Self-medication is a human behavior
in which an individual uses a substance or any exogenous influence to
self-administer treatment for physical or psychological ailments.
The most widely self-medicated substances are over-the-counter drugs used to treat common health issues at home, as well as dietary supplements. These do not require a doctor's prescription to obtain and, in some countries, are available in supermarkets and convenience stores.
The psychology of self-medicating with psychoactive drugs is typically within the specific context of using recreational drugs, alcohol, comfort food, and other forms of behavior to alleviate symptoms of mental distress, stress and anxiety, including mental illnesses and/or psychological trauma, is particularly unique and can serve as a serious detriment to physical and mental health if motivated by addictive mechanisms. In postsecondary (university/college) students, the use of self-medicating of study-drugs such as Adderall, Ritalin, and Concerta has been widely reported and discussed in literature.
Products are marketed by manufacturers as useful for self-medication, sometimes on the basis of questionable evidence. Claims that nicotine has medicinal value have been used to market cigarettes as self-administered medicines. These claims have been criticized as inaccurate by independent researchers. Unverified and unregulated third-party health claims are used to market dietary supplements.
Self-medication is often seen as gaining personal independence from established medicine, and it can be seen as a human right, implicit in, or closely related to the right to refuse professional medical treatment. Self-medication can cause unintentional self-harm.
The most widely self-medicated substances are over-the-counter drugs used to treat common health issues at home, as well as dietary supplements. These do not require a doctor's prescription to obtain and, in some countries, are available in supermarkets and convenience stores.
The psychology of self-medicating with psychoactive drugs is typically within the specific context of using recreational drugs, alcohol, comfort food, and other forms of behavior to alleviate symptoms of mental distress, stress and anxiety, including mental illnesses and/or psychological trauma, is particularly unique and can serve as a serious detriment to physical and mental health if motivated by addictive mechanisms. In postsecondary (university/college) students, the use of self-medicating of study-drugs such as Adderall, Ritalin, and Concerta has been widely reported and discussed in literature.
Products are marketed by manufacturers as useful for self-medication, sometimes on the basis of questionable evidence. Claims that nicotine has medicinal value have been used to market cigarettes as self-administered medicines. These claims have been criticized as inaccurate by independent researchers. Unverified and unregulated third-party health claims are used to market dietary supplements.
Self-medication is often seen as gaining personal independence from established medicine, and it can be seen as a human right, implicit in, or closely related to the right to refuse professional medical treatment. Self-medication can cause unintentional self-harm.
Definition
Generally
speaking, self-medication is defined as "the use of drugs to treat
self-diagnosed disorders or symptoms, or the intermittent or continued
use of a prescribed drug for chronic or recurrent disease or symptoms"
Psychology and psychiatry
Self-medication hypothesis
As
different drugs have different effects, they may be used for different
reasons. According to the self-medication hypothesis (SMH), the
individuals' choice of a particular drug is not accidental or
coincidental, but instead, a result of the individuals' psychological
condition, as the drug of choice provides relief to the user specific to
his or her condition. Specifically, addiction
is hypothesized to function as a compensatory means to modulate effects
and treat distressful psychological states, whereby individuals choose
the drug that will most appropriately manage their specific type of
psychiatric distress and help them achieve emotional stability.
The self-medication hypothesis (SMH) originated in papers by Edward Khantzian, Mack and Schatzberg, David F. Duncan, and a response to Khantzian by Duncan. The SMH initially focused on heroin use, but a follow-up paper added cocaine. The SMH was later expanded to include alcohol, and finally all drugs of addiction.
According to Khantzian's view of addiction, drug users compensate for deficient ego function by using a drug as an "ego solvent", which acts on parts of the self that are cut off from consciousness by defense mechanisms. According to Khantzian,
drug dependent individuals generally experience more psychiatric
distress than non-drug dependent individuals, and the development of
drug dependence involves the gradual incorporation of the drug effects
and the need to sustain these effects into the defensive
structure-building activity of the ego itself. The addict's choice of
drug is a result of the interaction between the psychopharmacologic
properties of the drug and the affective states from which the addict
was seeking relief. The drug's effects substitute for defective or
non-existent ego mechanisms of defense. The addict's drug of choice,
therefore, is not random.
While Khantzian takes a psychodynamic approach to
self-medication, Duncan's model focuses on behavioral factors. Duncan
described the nature of positive reinforcement
(e.g., the "high feeling", approval from peers), negative reinforcement
(e.g. reduction of negative affect) and avoidance of withdrawal
symptoms, all of which are seen in those who develop problematic drug
use, but are not all found in all recreational drug users.
While earlier behavioral formulations of drug dependence using operant
conditioning maintained that positive and negative reinforcement were
necessary for drug dependence, Duncan maintained that drug dependence
was not maintained by positive reinforcement, but rather by negative
reinforcement. Duncan applied a public health model to drug dependence,
where the agent (the drug of choice) infects the host (the drug user)
through a vector (e.g., peers), while the environment supports the
disease process, through stressors and lack of support.
Khantzian revisited the SMH, suggesting there is more evidence
that psychiatric symptoms, rather than personality styles, lie at the
heart of drug use disorders.
Khantzian specified that the two crucial aspects of the SMH were that
(1) drugs of abuse produce a relief from psychological suffering and (2)
the individual's preference for a particular drug is based on its
psychopharmacological properties.
The individual's drug of choice is determined through experimentation,
whereby the interaction of the main effects of the drug, the
individual's inner psychological turmoil, and underlying personality
traits identify the drug that produces the desired effects.
Meanwhile, Duncan's work focuses on the difference between recreational and problematic drug use.
Data obtained in the Epidemiologic Catchment Area Study demonstrated
that only 20% of drug users ever experience an episode of drug abuse
(Anthony & Helzer, 1991), while data obtained from the National
Comorbidity Study demonstrated that only 15% of alcohol users and 15% of
illicit drug users ever become dependent.
A crucial determinant of whether a drug user develops drug abuse is the
presence or absence of negative reinforcement, which is experienced by
problematic users, but not by recreational users.
According to Duncan, drug dependence is an avoidance behavior, where an
individual finds a drug that produces a temporary escape from a
problem, and taking the drug is reinforced as an operant behavior.
Specific mechanisms
Some mental illness sufferers attempt to correct their illnesses by use of certain drugs. Depression is often self-medicated with alcohol, tobacco, cannabis, or other mind-altering drug use. While this may provide immediate relief of some symptoms such as anxiety, it may evoke and/or exacerbate some symptoms of several kinds of mental illnesses that are already latently present, and may lead to addiction/dependence, among other side effects of long-term use of the drug.
Sufferers of posttraumatic stress disorder have been known to self-medicate, as well as many individuals without this diagnosis who have suffered from (mental) trauma.
Due to the different effects of the different classes of drugs,
the SMH postulates that the appeal of a specific class of drugs differs
from person to person. In fact, some drugs may be aversive for
individuals for whom the effects could worsen affective deficits.
CNS depressants
Alcohol and sedative/hypnotic drugs, such as barbiturates and benzodiazepines, are central nervous system (CNS) depressants that lower inhibitions via anxiolysis.
Depressants produce feelings of relaxation and sedation, while
relieving feelings of depression and anxiety. Though they are generally
ineffective antidepressants, as most are short-acting, the rapid onset
of alcohol and sedative/hypnotics softens rigid defenses and, in low to
moderate doses, provides relief from depressive affect and anxiety.
As alcohol also lowers inhibitions, alcohol is also hypothesized to be
used by those who normally constrain emotions by attenuating intense
emotions in high or obliterating doses, which allows them to express
feelings of affection, aggression and closeness. People with social anxiety disorder commonly use these drugs to overcome their highly set inhibitions.
Psychostimulants
Psychostimulants, such as cocaine, amphetamines, methylphenidate, caffeine, and nicotine, produce improvements in physical and mental functioning, including increased energy and feelings of euphoria. Stimulants tend to be used by individuals who experience depression, to reduce anhedonia and increase self-esteem. The SMH also hypothesizes that hyperactive and hypomanic individuals use stimulants to maintain their restlessness and heighten euphoria. Additionally, stimulants are useful to individuals with social anxiety by helping individuals break through their inhibitions.
Some reviews suggest that students use psychostimulants recreationally
to medicate for underlying deeper issues, such as depression or anxiety,
and that their chance of self-medicating of these drugs can be loosely
predicted using a variety of risk factors including childhood parental
monitoring, participating in a sports team, or through the DAST-10
(screening test).
Opiates
Opiates, such as heroin and morphine, function as an analgesic by binding to opioid receptors in the brain and gastrointestinal tract. This binding reduces the perception of and reaction to pain, while also increasing pain tolerance. Opiates are hypothesized to be used as self-medication for aggression and rage. Opiates are effective anxiolytics, mood stabilizers,
and anti-depressants, however, people tend to self-medicate anxiety and
depression with depressants and stimulants respectively, though this is
by no means an absolute analysis.
Cannabis
Cannabis is paradoxical in that it simultaneously produces stimulating, sedating and mildly psychedelic properties and both anxiolytic or anxiogenic properties, depending on the individual and circumstances of use.
Depressant properties are more obvious in occasional users, and
stimulating properties are more common in chronic users. Khantzian noted
that research had not sufficiently addressed a theoretical mechanism
for cannabis, and therefore did not include it in the SMH.
Effectiveness
Self-medicating excessively for prolonged periods of time with benzodiazepines or alcohol
often makes the symptoms of anxiety or depression worse. This is
believed to occur as a result of the changes in brain chemistry from
long-term use. Of those who seek help from mental health services for conditions including anxiety disorders such as panic disorder or social phobia, approximately half have alcohol or benzodiazepine dependence issues.
Sometimes anxiety precedes alcohol or benzodiazepine dependence
but the alcohol or benzodiazepine dependence acts to keep the anxiety
disorders going, often progressively making them worse. However, some
people addicted to alcohol or benzodiazepines, when it is explained to
them that they have a choice between ongoing poor mental health or
quitting and recovering from their symptoms, decide on quitting alcohol
or benzodiazepines or both. It has been noted that every individual has
an individual sensitivity level to alcohol or sedative hypnotic drugs,
and what one person can tolerate without ill health, may cause another
to suffer very ill health, and even moderate drinking can cause rebound
anxiety syndrome and sleep disorders. A person suffering the toxic
effects of alcohol will not benefit from other therapies or medications,
as these do not address the root cause of the symptoms.
Nicotine addiction seems to worsen mental health problems.
Nicotine withdrawal depresses mood, increases anxiety and stress, and
disrupts sleep. Although nicotine products temporarily relieve there nicotine withdrawal
symptoms, an addiction causes stress and mood to be worse on average,
due to mild withdrawal symptoms between hits. Nicotine addicts need the
nicotine to temporarily feel normal. Nicotine industry marketing
has claimed that nicotine is both less harmful and therapeutic for
people with mental illness, and is a form of self-medication. This claim
has been criticised by independent researchers.
Self medicating is a very common precursor to full addictions and
the habitual use of any addictive drug has been demonstrated to greatly
increase the risk of addiction to additional substances due to
long-term neuronal changes. Addiction to any/every drug of abuse tested so far has been correlated with an enduring reduction in the expression of GLT1 (EAAT2) in the nucleus accumbens
and is implicated in the drug-seeking behavior expressed nearly
universally across all documented addiction syndromes. This long-term
dysregulation of glutamate transmission is associated with an increase
in vulnerability to both relapse-events after re-exposure to drug-use
triggers as well as an overall increase in the likelihood of developing
addiction to other reinforcing drugs. Drugs which help to re-stabilize
the glutamate system such as N-acetylcysteine have been proposed for the treatment of addiction to cocaine, nicotine, and alcohol.
Infectious disease
Self-medication with antibiotics is commonplace in some countries, such as Greece. Such use is cited as a potential factor in the incidence of certain antibiotic resistant bacterial infections in places like Nigeria.
In a questionnaire designed to evaluate self-medication rates amongst the population of Khartoum, Sudan, 48.1% of respondents reported self-medicating with antibiotics within the past 30 days, 43.4% reported self-medicating with antimalarials,
and 17.5% reported self-medicating with both. Overall, the total
prevalence of reported self-medication with one or both classes of
anti-infective agents within the past month was 73.9%.
Furthermore, according to the associated study, data indicated that
self-medication "varies significantly with a number of socio-economic
characteristics" and the "main reason that was indicated for the
self-medication was financial constraints".
Similarly, in a survey of university students in Southern China, 47.8% of respondents reported self-medicating with antibiotics.
Physicians and medical students
In a survey of West Bengal, India undergraduate medical school students, 57% reported self-medicating. The type of drugs most frequently used for self-medication were antibiotics (31%), analgesics (23%), antipyretics (18%), antiulcerics (9%), cough suppressants (8%), multivitamins (6%), and anthelmintics (4%).
Another study indicated that 53% of physicians in Karnataka, India reported self-administration of antibiotics.
Children
A study of Luo children in western Kenya found that 19% reported engaging in self-treatment with either herbal or pharmaceutical
medicine. Proportionally, boys were much more likely to self-medicate
using conventional medicine than herbal medicine as compared with girls,
a phenomenon which was theorized to be influenced by their relative
earning potential.
Regulation
Self-medication is highly regulated in much of the world and many classes of drugs are available for administration only upon prescription by licensed medical personnel. Safety, social order, commercialization, and religion have historically been among the prevailing factors that lead to such prohibition.
