Week 1: History, Course and Environmental Factors
1.1 Course
Martin, C. S., Chung, T., & Langenbucher, J. W. (2016). Historical and cultural
perspectives on substance use and substance use disorders.
Introduction
• Substance use and problems had varied conceptualization/understanding between and within
historical eras and cultures
• Very nature of substance abuse problems, symptoms and syndromes is controversial → moral
failing vs medical disease vs psychological syndrome (or a combination).
o Disagreements extend to key terms used by scientists/clinicians and the general
public
Psychoactive substance use: history, patterns and cultural variation
History of • People have been using psychoactive substances for millennia → alcohol widely from about
substance use 1000BC. Ancient historical and literary references to opium and marijuana
• Indigenous patterns of substance use; plus spread of alcohol and other drugs through trade,
war and migration
o eg- Columbus found Native Americans smoked dried tobacco → practise spread to
Europe
o eg- Napoleon’s French troops in Egypt found hashish and introduced it to Parisian
(and Western) societies
Patterns of • Many patterns of substance use which vary according to the type of substance, the route of
substance use drug, and the frequency and quantity of use. For majority of people, substance use is not
harmful, but it does provide foundation for understanding the compulsive and pathological
substance use behaviours that characterize many of those with SUDs.
• Huge variety of substances that have psychoactive (produce subjective feelings of
intoxication or reward)
o No two drugs identical, but may exert similar physiological changes in the user
o Classification systems vary (eg- molecular structure, clinical use, potential for abuse
etc)
o DSM-IV has eleven classes: alcohol, amphetamines, caffeine, cannabis, cocaine,
hallucinogens, inhalants, nicotine, opiates, phencyclidine, and
sedatives/hypnotics/anxiolytics.
▪ Also “other”: given that number and types of drugs is not static and many
new designer drugs will continue to be developed and distributed
• Varied routes of administration for ingesting drugs, including eating, chewing, smoking,
snorting and injection.
o Some drugs primarily ingested through one route (eg- drinking alcohol) while others
have multiple common routes that correspond with level of involvement (eg- heroin
can be snorted, but greater potential for addiction when injected).
o Different chemical preparations of same drug to facilitate route of admin (eg-
snorting cocaine vs. smoking crack)
o Routes vary with: speed of absorption to the brain (assoc with subjective high).
o Route of drug administration can have social meaning (eg- many who snort cocaine
look down on those who smoke crack)
• Differences in topography: dimensions of quantity and frequency
o Frequency can range form one lifetime use to use that daily or multiple times per
day. Frequency level that is considered problematic by professionals and the public
varies according to culture and the substance of choice (eg- Western culture OK with
small alcohol use per day, but would view any heroin use as problematic)
o Quantity = amount of substance that is used during a use episode or during a day in
which use occurred. Concentration and purity can vary (from highly controlled
pharmaceuticals to “street drugs”)
, o Patterns of use are very important above and beyond overall “Q/F” estimates – i.e.,
the health and safety implications of consuming one drink per day differ from
consuming seven drinks once per week
• Simultaneous poly-drug use (SPU): use of two or more psychoactive substances in
combination. Some combinations can produce novel psychoactive metabolites = new effects
from precursors alone. Danger comes from additive or interactive effects on intoxication and
impairment (eg- opiates + alcohol and benzodiazepines are much more lethal)
Cultural variation • Culture is a system of shared beliefs, attitudes and norms for behaviours that are specific to a
in substance use group.
patterns o Cultural norms reflected in attitudes regarding substance use, including regulatory
policies related to alcohol and drug control
• The meanings and functions associated with use of a particular substance can vary by culture,
among subgroups within a larger culture and over time within a culture (eg- the enactment
and repeal of Prohibition in the US)
• The degree to which, and ways in which, newly introduced substances have been
incorporated into cultures has varied, sometimes taking on meanings and functions in the
newly adoptive culture that differed from the originating culture.
• Cultural norms can:
o Dictate generalized abstinence from psychoactive substances generally
o Include substance-specific norms regarding acceptable patterns, contexts and
purposes of a given substance (eg- opioids for palliative care, but not recreation)
o Play a protective role in helping to regulate the use of specific substances within a
group, via cultural norms around acceptable patterns and contexts of use
o In cultures that do not advocate generalized abstinence, substance use in and of itself
is not considered to be disordered/dysfunctional in and of itself → historically only
until it was associated with particular context or behaviours (eg- use among lower
classes and associated criminality)
• Prevalence and specific types of substance use varies across countries and cultural groups.
o Uneven distribution of substance use not systematically related to a country’s
drug control policy (eg- US has more strict drug control policies than Netherlands,
but also has higher levels of illicit substance use)
o Despite uneven prevalence, some individual predictors of use (eg- higher SES and
male gender) are consistent across most cultures
• Reasons for differences in cross-cultural and cross-country substance use patterns:
o Regional and geographic variation in drug availability. Eg- Coca plant can only be
effectively grown in certain altitudes and climates → consumption in high-grow
areas may be close to 100%
o May reflect biological differences in acute drug effects between different racial or
ethnic groups → eg- Asian “flushing” response to alcohol, from specific enzyme;
might act as protective factor against alcohol problems in Asian cultures compared to
Western.
Historical perspectives on SUDs
Historical • Understanding and concept of SUDs have been influenced by historical developments in
developments in understanding and classifying those with mental and psychological problems
understanding • Timeline:
and classifying o Hippocrates and Galen → mental and physical problems in terms of presumed
mental disorders aetiology related to imbalance of various elements in the body
o Paracelsus → syndromal diagnosis: group of co-occurring signs and symptoms
represent a particular disease state (even if etiology is unknown)
o Pinel → syndromal diagnosis elaborated into hierarchical classification system for
mental problems
o Kraepelin (19th / early 20th century) → emphasised careful observation of signs and
symptoms, differential diagnosis and understanding mental illness as brain disease
• Modern thinking about psychiatric diagnosis is within neo-Kraeplinean tradition
o Mental disorders are evolving constructs that serve to describe and organise a
constellation of associated pathological signs and symptoms
o Goal is to describe meaningful types to guide research and clinical practiser
, • Controversy about how to define a mental disorder
o DSM-IV-TR: clinically significant behavioral or psychological syndromes that are
associated with distress and impairment, are not merely an expected reaction to a
particular event, and are considered a manifestation of some underlying dysfunction
in the individual
o Wakefield: mental disorders are “Harmful Dysfunction” – the failure of an
internal mechanism to perform its naturally selected evolutionary function, causing
harm to the individual
o Similarities between DSM/Wakefield’s approaches:
▪ Emphasis that disorder is attribute of an individual, whereby something has
gone wrong in the functioning of an internal mechanism
▪ Each excludes dysfunction that does not cause sufficient harm or distress
▪ Each excludes distress not caused by dysfunction but instead by social
deviance or conflict with society
Historical • Excessive alcohol consumption and the social and health problems it engenders have long
descriptions of been decried by some clergy, physicians, philosophers and social activists
substance o Old Testament references
problems o Concept of intemperance. “Discovery” of concept of addiction in 1787 by Rush,
who found that some patients were unable to discontinue drinking. Led to large
social movement of 1800s → intemperance movement which ultimately led to the
establishment of Prohibition
▪ Variety of viewpoints about causes and nature of substance problems, but
some took moralistic view, seeing excessive use as a sign of poor moral
character
▪ Controversy about individual volition and values in substance problems
versus disease processes out of individual’s control continue until the
present day
Jellinek’s • Described numerous signs and symptoms of the “disease” of alcoholism related to the
description of domains of “pathological patterns” of use, negative consequences of use, and physiological
alcoholism features such as tolerance and withdrawal
syndromes • Important:
o illness progression and developmental staging of signs and symptoms related to
alcohol problems (pre-alcoholic, relief, prodromal, crucial and chronic phases)
o description of different subtypes (“species”) of alcoholism. Data did not support
subtypes, but influenced description of research diagnostic criteria and subsequent
descriptions of SUDs
DSM-I and DSM- • DSM (1952) and DSM-II (1968) were very similar
II SUD criteria o DSM used global term “alcoholism” where drinking was severe enough to cause
impairment
o DSM-II characterised alcohol and other drug problems among a larger class of
personality disorders/nonpsychotic forms of mental illness. Three classifications
of alcoholism (episodic, habitual and addiction), but had low validity and were not
empirically validated
The Alcohol • Edwards and Gross (1976) emphasised
Dependence o compulsive use patterns and the incentive salience of (i.e., motivational drive
Syndrome (ADS) toward) alcohol use
o together with physiologic features of tolerance and withdrawal
• Removal of symptoms related to negative consequences that might be culturally or
historically bound → syndrome thus not defined or overly influenced by social and cultural
circumstances, instead aiming to define and “illness core” that was focused on pathological
or compulsive substance use behaviours and signs
• Seven ADS dimensions: tolerance, withdrawal, use to avoid withdrawal, subjective
compulsion to use, salience of use in person’s life, stereotyped use patterns and rapid
reinstatement of frank addiction upon return to use after a period of abstinence
• Influential concepts that have been used to also describe other types of substance dependence
and behavioural compulsions
, DSM-III SUD • Major advance → attempted to operationalize diagnostic criteria to make the system more
criteria reliable than its predecessors
o Dropped alcoholism; described substance “abuse” and “dependence”
o New category of “substance use disorders” rather than with personality disorders
• Substance abuse required evidence of either pathological patterns of use, remaining
intoxicated throughout the day or negative social consequences of use
• Substance dependence required one of these above domains (as well as tolerance or
withdrawal → i.e., physiologic features)
• Limitations: inadequate coverage of the diverse symptoms that accompany compulsive
patterns of substance use; the system was not entirely consistent with the polythetic view of
ADS, where none of a set of a criteria is either necessary or sufficient for diagnosis
DSM-III-R SUD • Substance abuse was defined by hazardous use or continued use despite social consequences
Criteria (1987) • Substance dependence defined by broader criterion array than predecessor. Polythetic, so
that no symptom was necessary or sufficient for a diagnosis.
o At least 3/9 symptoms related to physiologic features (i.e., tolerance and
withdrawal), incentive salience of substance use (e.g., great time spent using),
compulsive use patterns (eg- unsuccessful quit attempts) and negative consequences
of use
• Limitations:
o As with DSM-III, abuse implied to be milder than dependence, but the association
between these categories was not described (ie- are they distinct disorders, or is
abuse a prodromal form of dependence?)
o Certain symptoms overlapped as criteria for both disorders – confusing!
Research on • Subtypes of persons with alcohol dependence were researched mainly in 1980s-90s
Alcohol • Two main types were proposed (eg- Babor):
Dependence o Type A: moderate heritability; milder course with fewer medical or social
Subtypes consequences; less psychopathology, particularly less antisociality; and about as
common in men and women
o Type B: stronger familial and genetic risk; earlier onset; greater severity of
dependence; more dyscontrolled drinking, more polysubstance use; greater
psychiatric comorbidity and male gender dominance
• Problems with subtype research:
o Based on treatment groups so may oversample severe and multi-problem cases
o Does not adequately describe community and adolescent samples
o LCA analysis has consistently found classes that differ in severity rather than
clinical profile → differences in subtype can be more parsimoniously described in
terms of illness severity
o SUD subtypes are illustrative prototypes, but most persons with substance problems
do not fit cleanly into the described categories. Most people tend to show mix of
clinical features that vary dimensionally
Cultural Perspectives on SUDs
• The meaning, norms and values of a particular culture determine whether a pattern of
substance use is considered disordered or dysfunctional behaviour
• Role of culture: in defining illness, shaping symptom manifestation and content, influencing
the interpretation of symptoms, and determining the need for intervention
• Two perspectives:
o Universalistic: focuses on the common elements among cultures (e.g., ADS)
o Relativistic: emphasises the influence of culture on the manifestation and content of
illness (e.g., at the extreme, culture leading to culturally specific syndromes)
• Universalistic perspective allows for cross-cultural comparisons, however culture-specific
manifestations of illness may be neglected or ignored.
• Global burden of mental illnesses estimated by WHO in 2004 (universalistic perspective)
o 12-month prevalence of DSM-IV alcohol and other drug disorders (abuse or
dependence) ranged from low of 0.4% to high og 6.4%
o Unsure if cross-cultural differences in prevalence represent true differences or reflect
artifacts (eg- respondent misunderstanding of items and concepts; the effect of social
