Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

222 III. SUBSTANCES OF ABUSE1. Intent. Is the substance used to treat a diagnosed medical problem, suchas anxiety or insomnia, or is it used to get high (or to treat the complications ofnonmedical use of other drugs)? Typical medical use of a benzodiazepine orother controlled substance occurs without the use of multiple nonmedicaldrugs, whereas nonmedical use of the benzodiazepines is usually polydrug abuse.Although alcoholics and drug addicts sometimes use the language of medicineto describe their reasons for using controlled substances nonmedically, “selfadministration”or “self-medication” of an intoxicating substance outside theordinary practice boundaries of medical care is a hallmark of drug abuse(DuPont, 1998).2. Effect. What is the effect of the controlled substance use on the user’slife? The only acceptable standard for medical use is that it helps the user live abetter life. Typical nonmedical drug use is associated with deterioration in theuser’s life, even though continued use and denial of the negative consequencesof this use are nearly universal.3. Control. Is the substance use controlled only by the user, or does a fullyknowledgeable physician share the control of the drug use? Medical drug use iscontrolled by the physician, as well as the patient, whereas typical nonmedicaluse is solely controlled by the user.4. Legality. Is the use legal or illegal? Medical use of a controlled substanceis legal. Nonmedical drug use of controlled substances, including benzodiazepines,is illegal.5. Pattern. What is the pattern of the controlled substance use? Typicalmedical use of controlled substances is similar to the use of penicillin or aspirin,in that it occurs in a medically reasonable pattern to treat an easily recognizedhealth problem other than addiction. Typical use of nonmedical drugs (e.g.,alcohol, marijuana, or cocaine), in contrast, takes place at parties or in othersocial settings. Medical substance use is stable and at a moderate dose level.Nonmedical use of a controlled substance is usually polydrug abuse at high and/or unstable doses (Juergens & Cowley, 2003).DRUG DEPENDENCE VERSUS PHYSICAL DEPENDENCESubstance use disorder is a mental disorder defined in the fourth revised editionof the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; AmericanPsychiatric Association, 2000). It includes out-of-control drug use, useoutside social and medical sanctions, continued use despite clear evidenceof drug-caused problems, and a drug-centered lifestyle. Physical dependence(including withdrawal on discontinuation), in contrast to addiction, is a pharmacologicalphenomenon in which the user experiences a specific constellationof symptoms for a relatively short period when use of the substance is abruptlydiscontinued. Physical dependence may, but often does not, accompany sub-