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Before substance abuse can be treated, it must be identified.
Making a distinction between a person who is capable of occasional use and someone who gets caught up in the cycle of compulsive substance use is crucial. Substance abusers will often minimize the extent of their use to make it sound recreational, and therefore under control.

In order to understand and treat substance abuse we need to have some understanding of the meaning of addiction. Technically, the term substance abuse applies to a pattern of continued use, despite adverse consequence. Substance dependence is the next stage in the progression of addiction and is characterized by "compulsive" use.

Addiction is a biological, psychological and social process. Four key components of addiction can be identified:




Compulsion
Compulsion means loss of control or loss of choice. The person feels compelled to use. Compulsive behavior has a driven quality, as though one is pulled along by forces out of one's control. Simply making a rational decision to not use is often not adequate to facilitate stopping a compulsive behavior. Compulsive use is often evident in a user's unsuccessful attempts to control or regulate use of a substance.




Continued use despite adverse consequences
Addiction involves continuing to use even though one knows it is causing problems. Substance abuse adversely affects relationships, job functioning, health, finances and the capacity to manage one's life on all levels. The activity of using assumes priority over other needs, including personal and financial security, comfort, relationships, health and employment.




Craving
Craving often occurs daily or, is experienced with regular binges. The user experiences intense psychological preoccupation with getting or using the substance.

Craving is dysphoric and agitating. With the exception of recalling the euphoria of the substance, craving feels very bad.




Denial
Denial involves a true distortion of perception caused by craving. The user, under the intense pressure of acute craving, is temporarily blinded to the risks and consequences of using.




Psychological aspects
Individuals sometimes choose to use substances in order to enhance the perceived rewards of other experiences.

When used for these reasons, the substance begins to fulfill multiple functions for the user such as serving to enhance sex, enhance social situations, boost the user's sense of self-worth, alleviate stress and tension and relieve painful feelings.

As the substance user becomes increasingly dependent upon the drug or alcohol to fulfill unmet needs and compensate for deficits in coping skills, their capacity to manage life's problems diminishes. The repetoire of coping skills which one develops and utilizes to manage stress and regulate self-esteem often atrophy as drug and alchohol use substitute for internal and interpersonal resources. The addict often becomes locked into a cycle of avoidance. He or she alleviates stress by using, medicates against painful feelings by using and deals with social anxiety by using.

As one increasingly relies upon the substance, one becomes less adept at coping. Confidence in managing one's moods and regulating self-esteem are lost.




Biological aspects
Drugs significantly affect the reward/pleasure centers in the brain's mesolimbic system, which plays a large part in experiencing pleasure in whatever people find rewarding, things such as chocolate, sex or a job well done. Addiction alters the pathways in the brain's pleasure centers, stealing the brain's normal ability to experience pleasure.

Many biological factors of substance use cannot be covered in this article, but neuroadaptation, tolerance, genetics and dual diagnosis all play a role in substance use.

When the reward/pleasure centers of the brain are bombarded with substances, the brain adapts to these high levels of stimulation. When the substance or substances are absent, the brain loses its natural capacity to create pleasure of a feeling of well being. In the chemically altered brain, a profound interference in the ability to experience pleasure occurs, causing the user to feel dysphoria, anxiety, frustration and craving.

Injury caused by insensitivity in pleasure centers causes the user to feel the opposite of the drug euphoria. Sobriety starts to feel the opposite of the euphoric drug-induced state. Sobriety starts to become associated with dysphoria and discomfort, and the drug-induced state can be perceived as the normal, balanced place to be.

Dual diagnosis is another important biological consideration. If a person suffers from depression or anxiety, they may use substances to medicate uncomfortable feelings. For the dual-diagnosed, receiving psychiatric treatment with medication often helps stabilize one's baseline mood, which in turn facilitates recovery or sobriety.

Tolerance of a substance is also a strong indicator of addiction. One needs increased amounts to get the same effect.




Social aspects
Due to the social networks woven between users, substances often become a crucial part of one's identity and social fabric.

A culture, sense of ritualized bonding and belonging develop around the substance and its users. The substance serves as a social lubricant, dissolving inhibitions, social discomfort and tension.

By understanding the biological, social and psychological factors that create powerful reinforcements of the addictive cycle, we can appreciate the immense challenge involved in breaking the cycle of addiction. Recovery means withstanding physiological and psychological discomfort, learning new skills and finding other sources of pleasure and self-worth.




Knowing the cycle of abuse
Many of us have watched friends or someone close to us deteriorate in the cycle of substance abuse or dependence. Rituals around using begin to consume more of their time and lifestyle. The substance assumes priority over other values.

We often start to see missed days at work. Bingers, for example, may start to miss work on Mondays following a weekend of substance abuse. Irresponsible behavior, enormous mood swings, irritability, health problems, and a generally chaotic life all become apparent as one devotes more time to using and recovering and neglects other aspects of self-care. One's lifestyle becomes chaotic and subject to constant crisis and instability.

While some symptoms of substance abuse are seen in a variety of substances, other symptoms are specific to a particular substance. Abuse of stimulants, for example, looks different than abuse of downers or opiates. Regardless of the substance, however, the end result of substance abuse is the same. Health, relationships, careers and lives are all affected, sometimes destroyed.




Commonly used substances
Crystal methamphetamine and cocaine are two of the most commonly used substance with members of the HIV community.

Characteristics shared by cocaine and amphetamine intoxication include grandiosity, hypervigilance, paranoia, agitation, impaired judgment and impaired social or occupational functioning. Physical symptoms that might be evident are rapid heart beat, dilated pupils, elevated blood pressure, perspiration or chills, nausea, tactile hallucinations.

Although cocaine use and amphetamine intoxication often look similar to the outside observer, each has distinct characteristics. Cocaine intoxication is much briefer than amphetamine intoxication, requiring more frequent dosing. Crystal may lead to more focused activity with the user intensely involved in projects, whereas cocaine may create more fragmented and scattered attention.

Withdrawal from these stimulants is also similar. Symptoms of withdrawal include fatigue, insomnia or hypersomnia, agitation, depression, irritability and anxiety. At times depression from stimulant withdrawal may be so severe that one feels suicidal. If this occurs, clients should seek psychiatric or medical attention, or both.




Responding helpfully
When someone is engaged in compulsive substance use, he or she frequently feels shame, cloaks their use in denial, withdraws or covers up or minimizes the behavior. A person's honesty about their substance use may be a sign that, on some level, they are ready for some help.

If we suspect a friend has a problem, we can only express concern and offer to be there when they are willing to get help.

A fine line separates enabling an individual's behavior and being supportive. Enabling means supporting the user's addiction by protecting the user from the consequences of their abuse. The enabler often makes excuses for the using party's behavior, such as calling in sick for their friend or partner or tolerating very irresponsible behavior and not confronting it.

Bailing out the substance abuser from perpetual crisis and the upheaval that addiction creates is a common pattern seen between addict and enabler. In attempting to support a friend who has substance issues we must ask ourselves whether we are supporting their addictive behavior or encouraging the development of healthier coping skills.

Supportive behaviors would include being directly honest about your concerns, confronting irresponsible and destructive behavior, encouraging your friend to get help and accompanying your friend to seek treatment or a 12-step meeting. Remember that you cannot "rescue" someone but you can support the part of the person who wants to get better.