Substance abuse

Substance abuse, also known as drug abuse, is a patterned use of a substance (drug) in which the user consumes the substance in amounts or with methods which are harmful to themselves or others. The exact cause of substance abuse is impossible to know because there is not just one direct cause. However substance abuse and addiction is known to run in families. One theory suggests there is a genetic disposition which predisposes certain individuals toward substance abuse. Another suggests substance abuse is learned there for people subjected to substance abuse by those around them begin to copy the same behaviors. Substance abuse might start out as a bad habit but when and if addiction develops it manifests as a chronic debilitating disease.

The terms have a huge range of definitions related to taking a psychoactive drug or performance enhancing drug for a non-therapeutic or non-medical effect. All of these definitions imply a negative judgment of the drug use in question (compare with the term responsible drug use for alternative views). Some of the drugs most often associated with this term include alcohol, substituted amphetamines, barbiturates, benzodiazepines (particularly alprazolam, temazepam, diazepam and clonazepam), cocaine, methaqualone, and opioids. Use of these drugs may lead to criminal penalty in addition to possible physical, social, and psychological harm, both strongly depending on local jurisdiction. There are many cases in which criminal or anti-social behavior occur when the person is under the influence of a drug. Long term personality changes in individuals may occur as well. Other definitions of drug abuse fall into four main categories: public health definitions, mass communication and vernacular usage, medical definitions, and political and criminal justice definitions. Substance abuse is prevalent with an estimated 120 million users of hard drugs such as cocaine, heroin, and other synthetic drugs.

Substance abuse is a form of substance-related disorder.

Public health definitions
Public health practitioners have attempted to look at substance use from a broader perspective than the individual, emphasizing the role of society, culture, and availability. Some health professionals choose to avoid the terms alcohol or drug "abuse" in favor of language they consider more objective, such as "substance and alcohol type problems" or "harmful/problematic use" of drugs.

The Health Officers Council of British Columbia — in their 2005 policy discussion paper, A Public Health Approach to Drug Control in Canada — has adopted a public health model of psychoactive substance use that challenges the simplistic black-and-white construction of the binary (or complementary) antonyms "use" vs. "abuse". This model explicitly recognizes a spectrum of use, ranging from beneficial use to chronic dependence (see diagram to the right).

Medical definitions
In the modern medical profession, the three most used diagnostic tools in the world, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM),the World Health Organization's International Statistical Classification of Diseases and ICRIS Medical organization Related Health Problems (ICD), no longer recognize 'drug abuse' as a current medical diagnosis. Instead, DSM has adopted substance abuse as a blanket term to include drug abuse and other things. ICD refrains from using either substance abuse or drug abuse, instead using the term "harmful use" to cover physical or psychological harm to the user from use. Physical dependence, abuse of, and withdrawal from drugs and other miscellaneous substances is outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Its section Substance dependence begins with: "Substance dependence When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped. These, along with Substance Abuse are considered Substance Use Disorders…"

However, other definitions differ; they may entail psychological or physical dependence, and may focus on treatment and prevention in terms of the social consequences of substance uses.

Drug misuse
Drug misuse is a term used commonly when prescription medication with sedative, anxiolytic, analgesic, or stimulant properties are used for mood alteration or intoxication ignoring the fact that overdose of such medicines have serious adverse effects. Prescription misuse has been defined differently and rather inconsistently based on status of drug prescription, the uses without a prescription, intentional use to achieve intoxicating effects, route of administration, co-ingestion with alcohol, and the presence or absence of dependence symptoms. Chronic use leads to a change in the central nervous system which means the patient has developed tolerance to the medicine that more of the substance is needed in order to produce desired effects.When this happens, any effort to stop or reduce the use of this substance would cause withdrawal symptoms to occur.

The rate of prescription drug abuse is fast overtaking illegal drug abuse in the United States. According to the National Institute of Drug Abuse, 7 million people were taking prescription drugs for nonmedical use in 2010. Among 12th graders, prescription drug misuse is now second only to cannabis. "Nearly 1 in 12 high school seniors reported nonmedical use of Vicodin; 1 in 20 reported abuse of OxyContin."

Avenues of obtaining prescription drugs for misuse are varied: sharing between family and friends, illegally buying medications at school or work, and often "doctor shopping" to find multiple physicians to prescribe the same medication, without knowledge of other prescribers.

Increasingly, law enforcement is holding physicians responsible for prescribing controlled substances without fully establishing patient controls, such as a patient "drug contract." Concerned physicians are educating themselves on how to identify medication-seeking behavior in their patients, and are becoming familiar with "red flags" that would alert them to potential prescription drug abuse.

As a value judgment
Philip Jenkins points out that there are two issues with the term "drug abuse". First, what constitutes a "drug" is debatable. For instance, GHB, a naturally occurring substance in the central nervous system is considered a drug, and is illegal in many countries, while nicotine is not officially considered a drug in most countries. Second, the word "abuse" implies a recognized standard of use for any substance. Drinking an occasional glass of wine is considered acceptable in most Western countries, while drinking several bottles is seen as an abuse. Strict temperance advocates, who may or may not be religiously motivated, would see drinking even one glass as an abuse. Some groups even condemn caffeine use in any quantity. Similarly, adopting the view that any (recreational) use of marijuana or substituted amphetamines constitutes drug abuse implies a decision made that the substance is harmful, even in minute quantities.

Signs and symptoms
Depending on the actual compound, drug abuse including alcohol may lead to health problems, social problems, morbidity, injuries, unprotected sex, violence, deaths, motor vehicle accidents, homicides, suicides, physical dependence or psychological addiction.

There is a high rate of suicide in alcoholics and other drug abusers. The reasons believed to cause the increased risk of suicide include the long-term abuse of alcohol and other drugs causing physiological distortion of brain chemistry as well as the social isolation. Another factor is the acute intoxicating effects of the drugs may make suicide more likely to occur. Suicide is also very common in adolescent alcohol abusers, with 1 in 4 suicides in adolescents being related to alcohol abuse. In the USA approximately 30 percent of suicides are related to alcohol abuse. Alcohol abuse is also associated with increased risks of committing criminal offences including child abuse, domestic violence, rapes, burglaries and assaults.

Drug abuse, including alcohol and prescription drugs, can induce symptomatology which resembles mental illness. This can occur both in the intoxicated state and also during the withdrawal state. In some cases these substance induced psychiatric disorders can persist long after detoxification, such as prolonged psychosis or depression after amphetamine or cocaine abuse. A protracted withdrawal syndrome can also occur with symptoms persisting for months after cessation of use. Benzodiazepines are the most notable drug for inducing prolonged withdrawal effects with symptoms sometimes persisting for years after cessation of use. Abuse of hallucinogens can trigger delusional and other psychotic phenomena long after cessation of use and cannabis may trigger panic attacks during intoxication and with use it may cause a state similar to dysthymia. Severe anxiety and depression are commonly induced by sustained alcohol abuse which in most cases abates with prolonged abstinence. Even moderate alcohol sustained use may increase anxiety and depression levels in some individuals. In most cases these drug induced psychiatric disorders fade away with prolonged abstinence.

Drug abuse makes central nervous system (CNS) effects, which produce changes in mood, levels of awareness or perceptions and sensations. Most of these drugs also alter systems other than the CNS. Some of these are often thought of as being abused. Some drugs appear to be more likely to lead to uncontrolled use than others.

Traditionally, new pharmacotherapies are quickly adopted in primary care settings; however, drugs for substance abuse treatment have faced many barriers. Naltrexone, a drug originally marketed under the name "ReVia," and now marketed in intramuscular formulation as "Vivitrol" or in oral formulation as a generic, is a medication approved for the treatment of alcohol dependence. This drug has reached very few patients. This may be due to a number of factors, including resistance by Addiction Medicine specialists and lack of resources.

The ability to recognize the signs of drug use or the symptoms of drug use in family members by parents and spouses has been affected significantly by the emergence of home drug test technology which helps identify recent use of common street and prescription drugs with near lab quality accuracy.

Treatment
Treatment for substance abuse is critical for many around the world. Often a formal intervention is necessary to convince the substance abuser to submit to any form of treatment. Behavioral interventions and medications exist that have helped many people reduce, or discontinue, their substance abuse.

Psychological
From the applied behavior analysis literature, behavioral psychology, and from randomized clinical trials, several evidenced based interventions have emerged: behavioral marital therapy, motivational Interviewing, community reinforcement approach, exposure therapy, contingency management

In children and adolescents, cognitive behavioral therapy (CBT) and family therapy currently have the most research evidence for the treatment of substance abuse problems. These treatments can be administered in a variety of different formats, each of which has varying levels of research support

Alcoholics Anonymous is one of the most widely known self-help organizations in which members support each other not to use alcohol.

Social skills are significantly impaired in people suffering from alcoholism due to the neurotoxic effects of alcohol on the brain, especially the prefrontal cortex area of the brain. It has been suggested that social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious, including managing the social environment.

Medication
Pharmacological therapy - A number of medications have been approved for the treatment of substance abuse. These include replacement therapies such as buprenorphine and methadone as well as antagonist medications like disulfiram and naltrexone in either short acting, or the newer long acting form. Several other medications, often ones originally used in other contexts, have also been shown to be effective including bupropion and modafinil.

Methadone and buprenorphine are sometimes used to treat opiate addiction. These drugs are used as substitutes for other opioids and still cause withdrawal symptoms.

Antipsychotic medications have not been found to be useful.

Epidemiology


The initiation of drug and alcohol use is most likely to occur during adolescence, and some experimentation with substances by older adolescents is common. For example, results from 2010 Monitoring the Future survey, a nationwide study on rates of substance use in the United States, show that 48.2% of 12th graders report having used an illicit drug at some point in their lives. In the 30 days prior to the survey, 41.2% of 12th graders had consumed alcohol and 19.2% of 12th graders had smoked tobacco cigarettes. In 2009 in the United States about 21% of high school students have taken prescription drugs without a prescription. And earlier in 2002, the World Health Organization estimated that around 140 million people were alcohol dependent and another 400 million suffered alcohol-related problems.

Studies have shown that the large majority of adolescents will phase out of drug use before it becomes problematic. Thus, although rates of overall use are high, the percentage of adolescents who meet criteria for substance abuse is significantly lower (close to 5%). According to BBC, "Worldwide, the UN estimates there are more than 50 million regular users of morphine diacetate (heroin), cocaine and synthetic drugs."



APA, AMA, and NCDA
In 1932, the American Psychiatric Association created a definition that used legality, social acceptability, and cultural familiarity as qualifying factors: "…as a general rule, we reserve the term drug abuse to apply to the illegal, nonmedical use of a limited number of substances, most of them drugs, which have properties of altering the mental state in ways that are considered by social norms and defined by statute to be inappropriate, undesirable, harmful, threatening, or, at minimum, culture-alien.""

In 1966, the American Medical Association's Committee on Alcoholism and Addiction defined abuse of stimulants (amphetamines, primarily) in terms of 'medical supervision': "…'use' refers to the proper place of stimulants in medical practice; 'misuse' applies to the physician's role in initiating a potentially dangerous course of therapy; and 'abuse' refers to self-administration of these drugs without medical supervision and particularly in large doses that may lead to psychological dependency, tolerance and abnormal behavior."

In 1973, the National Commission on Marijuana and Drug Abuse stated: "...drug abuse may refer to any type of drug or chemical without regard to its pharmacologic actions. It is an eclectic concept having only one uniform connotation: societal disapproval. ... The Commission believes that the term drug abuse must be deleted from official pronouncements and public policy dialogue. The term has no functional utility and has become no more than an arbitrary codeword for that drug use which is presently considered wrong."

DSM
The first edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (published in 1952) grouped alcohol and drug abuse under Sociopathic Personality Disturbances, which were thought to be symptoms of deeper psychological disorders or moral weakness.

The third edition, published in 1980, was the first to recognize substance abuse (including drug abuse) and substance dependence as conditions separate from substance abuse alone, bringing in social and cultural factors. The definition of dependence emphasised tolerance to drugs, and withdrawal from them as key components to diagnosis, whereas abuse was defined as "problematic use with social or occupational impairment" but without withdrawal or tolerance.

In 1987, the DSM-IIIR category "psychoactive substance abuse," which includes former concepts of drug abuse is defined as "a maladaptive pattern of use indicated by...continued use despite knowledge of having a persistent or recurrent social, occupational, psychological or physical problem that is caused or exacerbated by the use (or by) recurrent use in situations in which it is physically hazardous." It is a residual category, with dependence taking precedence when applicable. It was the first definition to give equal weight to behavioural and physiological factors in diagnosis.

By 1988, the DSM-IV defines substance dependence as "a syndrome involving compulsive use, with or without tolerance and withdrawal"; whereas substance abuse is "problematic use without compulsive use, significant tolerance, or withdrawal." Substance abuse can be harmful to your health and may even be deadly in certain scenarios

By 1994, The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) issued by the American Psychiatric Association, the DSM-IV-TR, defines substance dependence as "when an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed." followed by criteria for the diagnose

DSM-IV-TR defines substance abuse as:


 * A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
 * Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions or expulsions from school; neglect of children or household)
 * Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
 * Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
 * Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
 * B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

The fifth edition of the DSM (DSM-5), planned for release in 2013, is likely to have this terminology revisited yet again. Under consideration is a transition from the abuse/dependence terminology. At the moment, abuse is seen as an early form or less hazardous form of the disease characterized with the dependence criteria. However, the APA's 'dependence' term, as noted above, does not mean that physiologic dependence is present but rather means that a disease state is present, one that most would likely refer to as an addicted state. Many involved recognize that the terminology has often led to confusion, both within the medical community and with the general public. The American Psychiatric Association requests input as to how the terminology of this illness should be altered as it moves forward with DSM-5 discussion.

Legal approaches

 * Related articles: Drug control law, Prohibition (drugs), Arguments for and against drug prohibition

Most governments have designed legislation to criminalize certain types of drug use. These drugs are often called "illegal drugs" but generally what is illegal is their unlicensed production, distribution, and possession. These drugs are also called "controlled substances". Even for simple possession, legal punishment can be quite severe (including the death penalty in some countries). Laws vary across countries, and even within them, and have fluctuated widely throughout history.

Attempts by government-sponsored drug control policy to interdict drug supply and eliminate drug abuse have been largely unsuccessful. In spite of the huge efforts by the U.S., drug supply and purity has reached an all time high, with the vast majority of resources spent on interdiction and law enforcement instead of public health. In the United States, the number of nonviolent drug offenders in prison exceeds by 100,000 the total incarcerated population in the EU, despite the fact that the EU has 100 million more citizens.

Despite drug legislation (or perhaps because of it), large, organized criminal drug cartels operate worldwide. Advocates of decriminalization argue that drug prohibition makes drug dealing a lucrative business, leading to much of the associated criminal activity.

Cost
Policymakers try to understand the relative costs of drug-related interventions. An appropriate drug policy relies on the assessment of drug-related public expenditure based on a classification system where costs are properly identified.

Labelled drug-related expenditures are defined as the direct planned spending that reflects the voluntary engagement of the state in the field of illicit drugs. Direct public expenditures explicitly labeled as drug-related can be easily traced back by exhaustively reviewing official accountancy documents such as national budgets and year-end reports. Unlabelled expenditure refers to unplanned spending and is estimated through modeling techniques, based on a top-down budgetary procedure. Starting from overall aggregated expenditures, this procedure estimates the proportion causally attributable to substance abuse (Unlabelled Drug-related Expenditure = Overall Expenditure × Attributable Proportion). For example, to estimate the prison drug-related expenditures in a given country, two elements would be necessary: the overall prison expenditures in the country for a given period, and the attributable proportion of inmates due to drug-related issues. The product of the two will give a rough estimate that can be compared across different countries.

Europe
As part of the reporting exercise corresponding to 2005, the European Monitoring Centre for Drugs and Drug Addiction's network of national focal points set up in the 27 European Union (EU) Member States, Norway, and the candidates countries to the EU, were requested to identify labeled drug-related public expenditure, at the country level.

This was reported by 10 countries categorized according to the functions of government, amounting to a total of EUR 2.17 billion. Overall, the highest proportion of this total came within the government functions of Health (66%) (e.g. medical services), and Public Order and Safety (POS) (20%) (e.g. police services, law courts, prisons). By country, the average share of GDP was 0.023% for Health, and 0.013% for POS. However, these shares varied considerably across countries, ranging from 0.00033% in Slovakia, up to 0.053% of GDP in Ireland in the case of Health, and from 0.003% in Portugal, to 0.02% in the UK, in the case of POS; almost a 161-fold difference between the highest and the lowest countries for Health, and a 6-fold difference for POS. Why do Ireland and the UK spend so much in Health and POS, or Slovakia and Portugal so little, in GDP terms?

To respond to this question and to make a comprehensive assessment of drug-related public expenditure across countries, this study compared Health and POS spending and GDP in the 10 reporting countries. Results found suggest GDP to be a major determinant of the Health and POS drug-related public expenditures of a country. Labelled drug-related public expenditure showed a positive association with the GDP across the countries considered: r = 0.81 in the case of Health, and r = 0.91 for POS. The percentage change in Health and POS expenditures due to a one percent increase in GDP (the income elasticity of demand) was estimated to be 1.78% and 1.23% respectively.

Being highly income elastic, Health and POS expenditures can be considered luxury goods; as a nation becomes wealthier it openly spends proportionately more on drug-related health and public order and safety interventions.

UK
The UK Home Office estimated that the social and economic cost of drug abuse to the UK economy in terms of crime, absenteeism and sickness is in excess of £20 billion a year. However, the UK Home Office does not estimate what portion of those crimes are unintended consequences of drug prohibition (crimes to sustain expensive drug consumption, risky production and dangerous distribution), nor what is the cost of enforcement. Those aspects are necessary for a full analysis of the economics of prohibition.

US
The 2004 study The economic costs of drug abuse in the United States by the Executive Office of the President Office of National Drug Control Policy, lists the overall costs of drug abuse for the years 1992–2002 as follows:

These figures represent overall economic costs, which can be divided in three major components: health costs, productivity losses and non-health direct expenditures.


 * Health-related costs were projected to total $16 billion in 2002.
 * Productivity losses were estimated at $128.6 billion. In contrast to the other costs of drug abuse (which involve direct expenditures for goods and services), this value reflects a loss of potential resources: work in the labor market and in household production that was never performed, but could reasonably be expected to have been performed absent the impact of drug abuse.
 * Included are estimated productivity losses due to premature death ($24.6 billion), drug abuse-related illness ($33.4 billion), incarceration ($39.0 billion), crime careers ($27.6 billion) and productivity losses of victims of crime ($1.8 billion).


 * The non-health direct expenditures primarily concern costs associated with the criminal justice system and crime victim costs, but also include a modest level of expenses for administration of the social welfare system. The total for 2002 was estimated at $36.4 billion. The largest detailed component of these costs is for state and federal corrections at $14.2 billion, which is primarily for the operation of prisons. Another $9.8 billion was spent on state and local police protection, followed by $6.2 billion for federal supply reduction initiatives.

Process and context of migration
Governments, advocacy organizations, academics, and migrating persons often define the term "immigrant" differently, assigning unique meanings to the word, and often using the following terms somewhat interchangeably: aliens, immigrants, nonimmigrants, undocumented aliens, refugees, asylum seekers, and lawful permanent residents. The U.S. government classifies migrating persons into multiple categories based on both the type and legality of migration. "Lawful permanent residents" is the legal term for immigrants who have arrived in the United States through legal channels and with appropriate documentation. "Nonimmigrants" refers to students, tourists, short-term contract workers, and any person temporarily visiting the country while intending to return to their country of origin. "Illegal alien" is any immigrant who has entered the country illegally or who, although entering the country legally, has fallen "out of status." Illegal aliens may be deported at any time if brought to the attention of immigration authorities. The term "illegal alien" has drawn much criticism from advocacy groups as a label that is demeaning and dehumanizing. For this Wikipedia entry, the term "immigrants" will be used to refer to both documented and undocumented migratory persons.

The United States Immigration and Nationality Act of 1952 defines a "refugee" as any person who is outside his or her "country of nationality" and who is unable or unwilling to return to that country because of persecution or a well-founded fear of persecution, which must be based on the individual's race, religion, nationality, membership in a particular social group, or political opinion. The number of refugees allowed to enter the U.S. is restricted by quantity and geographic location of origin in accordance with federal policies. After one year of residence within the U.S., refugees may be eligible to obtain Lawful Permanent Residence status.

Despite the relatively short history of the nation, patterns and outcomes of immigration to the United States have been complex. Noted historians, journalists, educators, and scholars, such as Mindiola, Zinn, and Power, have extensively detailed the evolution of federal immigration and refugee policy within the U.S., signifying the economic, political, and social contexts and motivations shaping policy initiatives. The nation's earliest immigration legislation, such as the "Free White Persons Act" of 1790 and the Chinese Exclusion Act of 1882, reflected political manipulations of the economic incentives and social pressures of the times and provided a foundation for the codification of discriminatory practices based upon race and nationality within later policy designs. Further policy actions, including the Johnson-Reed Act of 1924, the "Bracero" guestworker program begun in 1942 and consequent Operation Wetback in 1954, and the USA Patriot Act of 2001 continued the process of selective immigration and detention according to racial and ethnic categories. Consequently, immigrant and refugee accessibility to the United States is limited according to fiscal, political, and humanitarian priorities; "numerical ceilings" for each fiscal year are determined by Congressional budget and appropriations.

Immigrant and refugee migration is often analyzed as a process consisting of three phases: 1) the pre-migration or departure phase, 2) the transit phase, and 3) the resettlement phase. Many economic, social, and psychological stressors are associated with each stage.  Physical trauma and depression and anxiety due to separation from loved ones often characterize the pre-migration and transit phases.  During the resettlement phase, "cultural dissonance," language barriers, racism, discrimination, economic adversity, overcrowding, social isolation, and loss of status regarding important social roles are just a few of the obstacles immigrants and refugees may encounter.  For undocumented immigrants, difficulty obtaining work and fears of deportation are common.  Refugees frequently experience concerns about the health and safety of loved ones left behind and uncertainty regarding the possibility of returning to their country of origin.

Cause
Many of the genetic, psychological, and environmental factors identified as potentially contributing to the development of substance abuse behaviors by multiple-generation by non-recent immigrants and refugees are similar for more recent immigrants and refugees. Heritable genetic, cognitive, and temperamental characteristics may signify increased risk or protective factors for biological family members. Psychological theories, such as the psychoanalytic, behavioral, cognitive, and social learning models may help to explain the role of environment in shaping substance abuse behaviors and patterns. Sociocultural models focusing on family interactions, peer influences, and social environments may describe the interpersonal mechanisms partially leading to substance abuse behaviors.

However, several models have been proposed that specifically apply to the development of substance abuse behaviors and disorders among immigrants and refugees. The majority of these models relate to individual experiences of migration and assimilation, integration, and segregation upon entry into a new culture.

One theory suggests that immigrants and refugees simply continue the substance use and abuse patterns and behaviors they maintained while residing in their country of origin, regardless of the stressors and any process of cultural adaptation they may experience in their new country.

Conversely, the acculturation (or assimilation) model proposes that substance abuse behaviors may be explained by examining the process in which recent immigrants and refugees adopt the attitudes, behaviors, and norms regarding substance use and abuse that exist within the dominant culture into which they are entering. With this theory, patterns of substance abuse among immigrants and refugees will more closely resemble the patterns of the dominant society than patterns existing within the culture of origin, if there are significant differences.

Similarly, the acculturative stress model suggests that substance abuse functions as a coping mechanism to attempt to deal with the stressors that result directly from the process of immigration, such as forced migration, involuntary settlement, "cultural conflict" and alienation, role transition and loss of status, economic insecurity, and the scarcity of resources.

Finally, the intracultural diversity model argues that universal theories attempting to explain substance abuse by immigrants and refugees fail to address diversity within and between cultural groups. This model proposes multiple pathways to addiction and recovery that cannot be generalized as applying to specific racial and ethnic populations. Proponents of this theory also point to intergenerational differences in substance abuse behaviors as evidence supporting the model and to identify potential risk and protective factors among individuals.

Empowerment social work and culturally competent practice
The National Association of Social Workers (NASW) provides standardized guidelines regarding professional values and codes of ethical conduct for individual social workers. The NASW identifies the following core values: service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence. Furthermore, the association provides detailed guidelines related to confidentiality, informed consent, self-determination, and many other aspects of practice with clients and colleagues. All social work values and ethics are implicated in direct practice with immigrants and refugees; however, special attention must be paid to codes of conduct regarding client self-determination, informed consent, cultural competent practice, and confidentiality.

A variety of strategies have been suggested for social work practice in the field of substance abuse recovery when working with immigrants and refugees.

In a literature review of the research on immigration, acculturation, and substance abuse, Leow, Goldstein, and McGlinchy (2006) recommend tailoring intervention and treatment services and materials for specific racial and ethnic cultures by utilizing language, images, values, and norms belonging to each culture and incorporating knowledge of cultural themes, attitudes, family structures, and service access points. However, before services can be provided, they contend, social workers should recruit and consult with members of the immigrant and refugee communities they are intending to serve regarding program development and implementation. Additionally, social work staff and volunteers should demonstrate cultural competency in two significant ways: 1) by possessing the "attitudes, knowledge, and skills" necessary when working with diverse groups, and 2) by continually evaluating their personal values and beliefs and recognizing differences in perspective.

Similarly, Pumariega, Rothe, and Pumariega (2005) focus on the overall accessibility, acceptability, and relevance of programs for immigrants and refugees coming from specific cultural backgrounds. Differences in "symptom expression" between various racial and ethnic groups may bias both social workers and diagnostic tools during assessment and intervention efforts. Ignorance of the role and significance of such factors as site location, documentation, language, social stigma, and treatment methods on individual and community perceptions regarding services may render intervention and treatment efforts largely ineffective. The authors also discuss the importance of incorporating the process of cultural transition into direct practice with immigrants and refugees by utilizing unique practices from a culture of origin into "Western-oriented" mental health services and re-evaluating characteristics and traditions within that culture that have been "negatively valued" in dominant, American culture. This includes recognizing and building on existing individual and cultural strengths to increase resilience.

When working directly with refugees, Adams, Gardiner, and Assefi (2004) emphasize the necessity of interpreters and advise the use of a preventive screening tool, such as an adaptation of the Harvard trauma questionnaire, to gather information regarding exposure to physical and psychological trauma, the presence of acute and chronic illnesses, use of alcohol and other drugs, and participation (voluntary and coerced) in specific cultural and medicinal practices, such as female genital surgery. Furthermore, they highlight the importance of contextualizing and understanding the migration process by inquiring as to an individual's country of origin and reasons for migration, experience of migration (time spent in refugee camps, circumstances surrounding travel, etc.), social roles and status prior to migrating (employment, education, etc.), and the status and location of close family members.

Street children
Street children in many developing countries are a high risk group for substance misuse, in particular solvent abuse.

Drawing on research in Kenya, Cottrell-Boyce argues that "drug use amongst street children is primarily functional – dulling the senses against the hardships of life on the street – but can also provide a link to the support structure of the ‘street family’ peer group as a potent symbol of shared experience." Cottrell-Boyce criticized agencies working with street children for ‘importing’ Western rehabilitation models emphasizing detachment from negative peer pressure, for failing to appreciate the different social context within which dependence took place.

Dependence, Moore argues, is too often understood as a ‘measurable psychobiological “it” which can be separated from the social context in which dependence occurs’. Moore challenges this tendency, proposing that manifestations of substance dependence which occur in different circumstances cannot be treated as the same phenomenon, ‘the concept of dependence’, Moore suggests, ‘makes little sense unless it is situated within a specific social context’.

Impulsivity
Impulsivity is characterized by actions based on sudden desires, whims, or inclinations rather than careful thought. Individuals with substance abuse have higher levels of impulsivity, and individuals who use multiple drugs tend to be more impulsive. A number of studies using the Iowa gambling task as a measure for impulsive behavior found that drug using populations made more risky choices compared to healthy controls. There is a hypothesis that the loss of impulse control may be due to impaired inhibitory control resulting from drug induced changes that take place in the frontal cortex. The neurodevelopmental and hormonal changes that happen during adolescence may modulate impulse control that could possibly lead to the experimentation with drugs and may lead to the road of addiction.

Musicians
In order to maintain high-quality performance, some performing musicians are prone to take chemical substances. They are therefore more prone to substance abuse. The most common chemical substance which is abused by pop musicians is cocaine, because of its neurological effects. Stimulants like cocaine increase alertness and cause feelings of euphoria, and can therefore make the performer feel as though they in some ways ‘own the stage’.

Another way in which substance abuse is harmful for a performer (musicians especially) is if the substance being abused is aspirated. The lungs are an important organ used by singers, and addiction to cigarettes may seriously harm the quality of their performance. Smoking causes harm to alveoli, which are responsible for absorbing oxygen.