Mental health articles

continuum of use alcohol & drugs Alcohol is a psychoactive drug that has been around for thousands of years
and has been the drug of choice on America’s college campuses according
to virtually every national study on college students’ alcohol and drug use
(Johnston, O’Malley, & Bachman, 1998; Meilman, Cashin, McKillip, & Presley,
1998; Presley, Meilman, Cashin, & Lyerla, 1996; Wechsler, Davenport,
Dowdall, Moeykens, & Costillo, 1994). Used appropriately, it is not a problem
except insofar as it may present legal problems for underage drinkers.
But used in risky ways, alcohol is hazardous to physical and mental
health. Serious injuries and accidental deaths due to alcohol misuse occur
every year on the nation’s campuses. In addition, alcohol has the potential
to create, mimic, or exacerbate psychological and psychiatric difficulties
and to wreak havoc on students’ lives, academic careers, and future plans
(Meilman & Gaylor, 1989). Other illegal drugs and the abuse of prescription
medications can do the same. This chapter addresses the use of these
substances and briefly comments on addictions to sex, gambling, the
Internet, and food. Alcohol will generally be used as the model, but many
of the same principles apply to these other addictions.

Alcohol consumption for any given individual can be placed on a continuum
ranging from abstinence to late-stage alcoholism. At one end, there is complete
avoidance; about one in fi ve college students report being nondrinkers
(Presley, Meilman, & Leichliter, 2002). Students may abstain for any number
of reasons, including dislike of the taste or the burning sensation in the throat,
dislike of the mental or physiological eff ects, interference with prescription
medications, the desire to be in control, or bad associations with alcohol use
in the family. When conducting a substance use assessment, it is a good idea to
learn a student’s specifi c reasons for abstinence: “You say that you don’t drink
at all. I wonder what your reasons have been for abstaining?”
Next on the continuum is alcohol use that is social, in moderation, and
without any ill eff ects. In such nonproblematic cases, alcohol may serve as a
pleasant adjunct to social situations but is not the primary activity or focus; it
is incidental or secondary to the interpersonal interaction and does not take center stage. Slightly further along on the continuum are isolated problematic
incidents such as a single episode of driving while intoxicated (DWI), a single
blackout (the inability to remember something that happened under the infl uence
of excessive alcohol consumption), or a single embarrassing social incident.
While not necessarily a cause for great concern at the time of evaluation,
it should be noted that even a single incident of alcohol misuse can result in
serious injury or death.
Problem drinking, or alcohol abuse, next on the continuum, is defi ned by
an accumulation of alcohol-related incidents. It is helpful to think about abuse
as “abnormal use,” or “ab-use”; normal drinkers do not experience repeated
negative incidents. If, for example, a student’s drinking has led to several
blackouts, an emergency room visit, and trouble with campus authorities, it
would fall into the category of substance abuse. While such problem drinking
may be uncommon in the general population, it is readily apparent in the
college environment, where upward of 30% of the population might meet the
criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth
edition (DSM-IV), for alcohol abuse (Knight et al., 2002).
Further along on the continuum, alcohol abuse shades over into alcohol
dependence. An observer senses that the drinker has developed something
akin to a working relationship, a bond, with alcohol. Typically, the student
has lost control over the amount of alcohol consumed, or loses control over
behavior when drinking. Drinkers also display protectiveness with respect to
their drinking, responding with anger when drinking problems are discussed,
minimizing the eff ects, or rationalizing the usage, all verbal strategies to fend
off others’ concerns and to keep drinking. For example, a dependent drinker
might say, “I don’t drink half as much as my friends do.” Students in this category
are sometimes hard to detect, since out-of-control behavior is normative
in some college circles (for example, fraternity parties), and so their pattern of
use may resemble run-of-the-mill misbehavior. And yet it is something more:
early stage dependence, or what laypersons label alcoholism. Since there is a
common misperception among students that one needs to drink every day or
experience withdrawal symptoms to be defi ned as alcoholic, it’s oft en best to
avoid this term. More valuable are psychoeducational strategies that focus on
identifying what is and isn’t abuse and dependency.
As drinking progresses over time, the drinker develops greater tolerance;
he or she must drink more to obtain the same eff ects once obtained at lower
levels. Drinking may begin to aff ect work and relationships. Middle-stage
alcoholism is characterized by frequent drunkenness, and relationships typically
become seriously troubled or lost. Interestingly, academic performance
is oft en the last thing to go. Some middle-stage alcoholics are able to perform
satisfactorily in their course work while the rest of their lives fall apart.
In late-stage alcoholism, the drinker’s life is typically troubled in most every
domain. Th e body’s organ systems break down from having been awash in an alcohol bath for years, and overall health is oft en severely impaired. Friendships,
marriages, and other relationships dissolve. Sometimes these individuals
demonstrate reverse tolerance, needing less alcohol to become intoxicated
than in the past because the liver’s ability to metabolize alcohol is compromised.
If they stop drinking, late-stage alcoholics risk delirium tremens (DTs),
complete with hallucinations and seizures, and so detoxifi cation needs to take
place in a controlled setting and be carefully managed. Th ough infrequent,
we have actually seen college students in their early to mid-20s who, aft er a
5-, 10-, or even 15-year history of heavy drinking, match the description of
late-stage alcoholism.
Technically speaking, a diagnosis of dependence on alcohol or other drugs
can be made when there is a maladaptive pattern of use within a 12-month
period with at least three of the following symptoms: increased tolerance,
withdrawal symptoms, consumption of more of the substance or over longer
time periods than intended, a persistent desire to or unsuccessful attempts to
cut down, substantial time spent using a substance or experiencing its aft ereff
ects, reduction of important activities due to use, and continued use despite
knowledge that it causes physical or psychological harm (American Psychiatric
Association, 2002).
While this continuum is useful in understanding alcohol problems, an
individual’s drinking may not always show a “progression” from one stage to
the next. In our experience, some who drink very occasionally may still pose
signifi cant challenges. On the infrequent occasions when they do drink, they
experience loss of control or predictability, and perhaps a blackout or another
negative consequence. In many cases, they have innate tolerance, and so can
consume large quantities very early in their drinking history, which can
sometimes lead to dangerous behavior and consequences. Th us some female
students report unwanted sexual experiences under the infl uence, some males
can be verbally or physically aggressive, and both males and females may
engage in suicidal behaviors that are absent when they are sober. Th e fact that
these drinkers may drink less frequently than their peers complicates their
recognizing and resolving their alcohol problems. College drinking games,
which promote excessive and rapid consumption of alcohol, are risky for all
students, but especially for these students who have innate tolerance.

We have seen female students who, following a blackout, discovered missing
clothing articles and being in another student’s bed, with no knowledge of
whether or not they had engaged in sexual activity. We have also seen male students
who unpredictably exhibit aggressive or even violent behavior, sometimes
directed at professional staff who attempt to intervene. While such diffi cult
behavior is rarely life threatening, such students run the risk of being removed
from the university for misbehavior they don’t even remember. Th eir memory
loss insulates them from truly experiencing the seriousness of their behavior.

Tags: alcohol use