People use the terms “dependence” and “abuse” interchangeably when talking about 
illicit drugs, but are they really the same thing? Some researchers would say they are not the same thing at all because abuse refers to behaviours, whilst dependence refers to psychological and physical changes brought on by substance use. The simplest way to look at it is that some people can abuse drugs or alcohol for years and never develop dependence on either. As a result, researchers developed criteria for defining dependence, which has implications for employers. For example, should an employer treat two workers differently when the person is not physically addicted to the drug and could simply choose to change behaviours, whilst the other person is dependent and has lost control? These are the types of difficult questions that employers are faced with when dealing with substance use in the workplace and makes having a drug and alcohol policy in place even more important.
Instead of just saying “dependence”, it is better to say “chemical dependence” or “substance dependence” because the implications are more obvious. A typical misunderstanding is that withdrawal and chemical dependence are the same things. That is not necessarily true. Cocaine is an addictive drug, but users may experience few observable withdrawal symptoms. Yet the person could be dependent. In reverse, a person may go through withdrawal but that still does not necessarily mean the person is substance dependent. Some people stop using illicit drugs and experience physical symptoms, but never mentally crave the drugs again. They no longer believe the drugs and alcohol are necessary for functioning and decide to stay away from the substances.
Dual Nature of Dependency
Substance or chemical dependency has both a psychological and physical component. The dual nature of dependency is what sets it apart from abuse. A person who is a chemical dependent has physical and psychological dependence but does not necessarily experience withdrawal symptoms when chemical use ends. The physical dependency symptoms are noticeable when the body begins to experience unpleasant side effects as the drugs or alcohol wear off or the substances are used less frequently. The physical symptoms of withdrawal are different for each person and depend on the drug. Effects include nausea, crawling sensations under the skin, difficulty breathing, excessive sweating, tremors, and many others. The psychological effects associated with withdrawal include anxiety, irritability, poor concentration, depression, and so on. In some cases, the withdrawal symptoms indicate a dangerous health situation, like someone having grand mal seizures (physical) or hallucinations (psychological).
Though employers need to be familiar with withdrawal symptoms, they do not determine whether a person is an abuser or dependent. As mentioned, someone can withdraw from drugs or alcohol and not experience withdrawal symptoms. Chemical dependency is best summarised with three words: Obsessive, Compulsive, Excessive. This translates into a person who believes that it is impossible to function without using the drugs or alcohol. There is a continuum of substance use that goes like this: non-use, experimental use, recreational use, problematic use, and dependent use. A person reaching a condition of dependency feels a loss of control and experiences intense cravings both psychologically and physically. The life focus becomes ensuring there is always a supply of drugs or alcohol ready for consumption or that can be easily obtained.2
Signs, Signs, Everywhere are Signs
Before a person becomes chemically dependent, there will be signs the employer may notice without realise what is happening. For example, problematic users begin to have relationship, financial and health problems. Drug and alcohol tolerance increases, but the substance user is avoiding admitting the problem exists. Tolerance for the substances increases. A drug abuser can often learn to change behaviours in a short-term treatment or counselling program. However, a person who is dependent is always “recovering” after stopping drug and alcohol use. The person can stay off drugs and alcohol but may need a stronger, ongoing support system. An abuser may be able to take a drink or use cannabis (not advisable, of course) and not devolve into addiction. A truly dependent person cannot use chemicals under any circumstances because they trigger the life-altering cravings. Health professionals are learning that some people recidivate over and over again because they are chemical dependents and not just chemical abusers.
Dependence may or may not include withdrawal symptoms. However, it always has characteristics that include the inability to control use, expended effort to obtain the drug, greater drug use than was intended, drug use time replacing time for important activities, continued use despite awareness of personal physical or psychological problems. Each chemically dependent person does not necessarily have all of these issues. A dependent person is defined as having three or more of these characteristics with withdrawal symptoms and increased drug tolerance possibly accounting for one or two of the symptoms.3
Drugs of Choice
Dependency is not limited to illicit drugs. South Australia has a Drugs of Dependence Unit (DDU) with drugs of dependence defined as prescription medicines that have a higher potential than other drugs for misuse, abuse and dependence. The drugs are recognised as having therapeutic value. The list of drugs of dependence is long, and of real interest to employers is the fact the prescription drugs contain some of the same ingredients as illicit drugs. They include opioids like oxycodone and stimulants like cocaine.1 However, the important fact employers need to keep in mind is that a legal opioid threatens workplace safety as much as an illicit opioid.
Most employers are not qualified to assess whether a worker is a drug and alcohol abuser or a chemical dependent. The random drug and alcohol testing program is a means of identifying who is using harmful substances in the workplace. Once it is determined an employee is using substances that impact workplace health and safety, possessing knowledge about the complexity of substance use and its impacts helps employers make better decisions about the next steps to take.
The first step in identifying abusers and dependents is implementing a quality random drug and alcohol testing program at all employer locations. That is where Mediscreen can offer invaluable services. Mediscreen (mediscreen.net.au) routinely provides screening services aligned to workplace needs wherever those needs exist.
Resources
1 SA Health, Drugs of dependence, (24 October 2013) Government of South Australia: http://bit.ly/19yZ1YS
2 Identifying mental health problems and conditions, (11 Oct 2013) Curtin University: http://bit.ly/1f7sst9
3 Carlton Erickson (Director), Exploding Drug Myths, (15 March 2007), adapted from Diagnostic and Statistical manual of Mental Disorders (Fourth Edition), Addiction Science Research and Education Center: http://bit.ly/17FvSAN
