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Substance Abuse Awareness: When Does Use Become Abuse?

Substance abuse is common, so common in fact that almost every American will have to deal with it at some point in their lives. Whether it’s something they struggle with personally or as an issue for someone close to them, it makes sense for everyone to be aware about substance abuse. Unfortunately, most of the data gathered on substance abuse is on individuals who have already met diagnostic criteria for substance dependence and are headed for intensive treatment. This blog is about the warning signs for everyone that their (or someone else’s) use of alcohol, illicit, or prescription drugs is about to become a problem.

Substance abuse in behavioral health patients is a big problem for two reasons; by itself substance abuse causes behavioral symptoms, it also adds symptoms to already existing behavioral health conditions. So when clinicians ask patients about their use of substances or their medication refill history, it’s not to punish, judge or blame, we’re just trying to understand what other factors are in play in the lives of our patients. In fact, one of the biggest warning signs there’s a problem to come is the need to conceal the use or misuse of alcohol, illicit or prescription drugs from a healthcare provider or family members.

The 3 Most Abused Substances

In primary care and general behavioral health settings, alcohol, marijuana and prescription drugs are the three most commonly abused substances that complicate treatment. Opioids, heroin and cocaine are certainly present but patients do not generally present for treatment until their use causes serious legal, employment or personal difficulties. The rest of this blog is about my professional experiences and opinions on patients who are misusing alcohol, illicit (mostly marijuana) and prescription drugs (mostly sedatives and stimulants) at a minimal level. Prevention is everyone’s responsibility.

Alcohol is part of American culture, we use it to unwind, relax and celebrate. For some it goes further and excessive and irresponsible use leads to problems with family, employers or the legal system. It’s pretty hard to define what constitutes family or employment problems from alcohol because they can occur even without the use of alcohol, and as a physician, I don’t want to accuse or judge. It’s a much easier discussion with patients around misuse of alcohol when it causes health or legal problems. Other signs that are attributable to alcohol use like blackouts, withdrawal symptoms or abnormal labs clearly show there’s a problem. Not everyone who is misusing alcohol needs detox, in fact most don’t. For many of the patients I treat, the realization that alcohol is being misused and a concerted effort to reduce alcohol use over time is all that is needed.

Discussion with patients around marijuana is easy. Illegal. And not likely to be legal in North Carolina anytime soon. Why risk it.  And let’s skip the discussion around marijuana’s natural healing properties and the inequity in the law. A positive drug test for marijuana can cause vast problems with current and future employers so I recommend patients stop. The good news is, compared to other substances, giving up marijuana seems pretty easy to do for most of my patients.

The most misused prescription drugs are the sedatives and the stimulants. Sedatives like Valium, Ativan and Xanax are used to treat severe anxiety and sometimes insomnia. Stimulants like Adderall and Ritalin are used to treat attention and hyperactivity disorders. All are controlled substances which means there is a risk of abuse or dependence and that controls are in place to minimize those risks. What gets lost in the discussion is how effective and life changing these medications are for many patients; basically the benefit of improved functioning makes managing the risks of abuse or diversion worthwhile. As humans we live in a natural state of anxiety and inattention. Anxiety is nature’s way of keeping us away out of dangerous situations and inattention for many is the friend of creativity; the goal of medications is not to be symptom free but to reduce anxiety and inattention to normal levels so they can be managed and used constructively. Coming up short on meds or testing positive for non-prescribed meds is not an immediate discharge or abrupt stop of controlled substances for my patients, I do however expect them to acknowledge the risk they are taking, understand the purpose of medication and to act responsibly going forward.

3 Questions to Ask Yourself or Your Loved Ones

So here’s my best advice for anyone who is using a substance that can lead to abuse or has risk of abuse even if it is a prescribed medication. First, ask yourself on a regular basis, is my use responsible? Second, are there any health or legal problems from my use? Third, am I concealing my use from others? If there’s a problem, think about the factors that led to misuse or that might be contributing to it and what you can do to change them. Finally, what’s the plan going forward. My job gets a lot easier when patients already realize there’s a problem and have an idea of what may have caused or contributed to it. We can usually sort out a recovery plan in a single visit.

One of the best parts of my job as a physician and psychiatrist is seeing people make changes to their behavior that improves their lives. I look forward to seeing patients who were misusing or abusing alcohol or drugs and managed to get back on track. Substance abuse is not the absolute, guaranteed downward spiral as portrayed in the media and on the internet. People can and do beat substance abuse. And there’s a lot to learn from these patients. Recognizing the problem themselves is a big first step. It’s always easier for someone to follow a plan they made themselves, not one imposed upon them. Successful long-term sobriety is mostly about understanding what led to misuse in the first place.

Have questions or concerns regarding substance abuse? If you live in North Carolina, please contact us to schedule an appointment to talk with a counselor.

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Dr. David Cowherd, MD, FACC - Pinehurst Medical Clinic

Carolina Behavioral Care has been my number one choice for my psychiatric referrals for the past 20 years. Their level of professionalism is unsurpassed and I have never been disappointed.

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