recommendations for screening tools for substance misuse in pregnancy include that they take less than 10 minutes, should be used routinely, include an educational component. tools suitable for pregnant women include i.a. 4ps, t-ace, tweak, tqdh (ten-question drinking history), and audit. treatment 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 they help suppress cravings and mental anxiety, improve focus on treatment and new learning behavioral skills, ease withdrawal symptoms and reduce the chances of relapse. in children and adolescents, cognitive behavioral therapy (cbt) and family therapy currently has the most research evidence for the treatment of substance abuse problems. well-established studies also include ecological family-based treatment and group cbt. these treatments can be administered in a variety of different formats, each of which has varying levels of research support research has shown that what makes group cbt most effective is that it promotes the development of social skills, developmentally appropriate emotional regulatory skills and other interpersonal skills. a few integrated treatment models, which combines parts from various types of treatment, have also been seen as both well-established or probably effective. a study on maternal alcohol and other drug use has shown that integrated treatment programs have produced significant results, resulting in higher negative results on toxicology screens. additionally, brief school-based interventions have been found to be effective in reducing adolescent alcohol and cannabis use and abuse. motivational interviewing can also be effective in treating substance use disorder in adolescents. alcoholics anonymous and narcotics anonymous are widely known self-help organizations in which members support each other abstain from substances. social skills are significantly impaired in people with 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 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 but they facilitate the tapering off process in a controlled fashion. when a person goes from using fentanyl every day, to not using it at all, they will experience a point where they need to get used to not using the substance. this is called withdrawal. antipsychotic medications have not been found to be useful. acamprostate is a glutamatergic nmda antagonist, which helps with alcohol withdrawal symptoms because alcohol withdrawal is associated with a hyperglutamatergic system. heroin-assisted treatment opiates v opioids illustrated with diagrams and sub-classifications three countries in europe have active hat programs, namely england, the netherlands and switzerland. despite critical voices by conservative think-tanks with regard to these harm-reduction strategies, significant progress in the reduction of drug-related deaths has been achieved in those countries. for example, the us, devoid of such measures, has seen large increases in drug-related deaths since 2000 (mostly related to heroin use), while switzerland has seen large decreases. in 2018, approximately 60,000 people have died of drug overdoses in america, while in the same time period, switzerland's drug deaths were at 260. relative to the population of these countries, the us has 10 times more drug-related deaths compared to the swiss confederation, which in effect illustrates the efficacy of hat to reduce fatal outcomes in opiate/opioid addiction. dual diagnosis main article: dual diagnosis it is common for individuals with drugs use disorder to have other psychological problems. the terms “dual diagnosis” or “co-occurring disorders,” refer to having a mental health and substance use disorder at the same time. according to the british association for psychopharmacology (bap), “symptoms of psychiatric disorders such as depression, anxiety and psychosis are the rule rather than the exception in patients misusing drugs and/or alcohol.” individuals who have a comorbid psychological disorder often have a poor prognosis if either disorder is untreated. historically most individuals with dual diagnosis either received treatment only for one of their disorders or they didn't receive any treatment all. however, since the 1980s, there has been a push towards integrating mental health and addiction treatment. in this method, neither condition is considered primary and both are treated simultaneously by the same provider. epidemiology disability-adjusted life year for drug use disorders per 100,000 inhabitants in 2004. no data <40 40–80 80–120 120–160 160–200 200–240 240–280 280–320 320–360 360–400 400–440 >440 the initiation of drug use including alcohol 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 with 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 un estimates, there are "more than 50 million regular users of morphine diacetate (heroin), cocaine and synthetic drugs." more than 70,200 americans died from drug overdoses in 2017. among these, the sharpest increase occurred among deaths related to fentanyl and synthetic opioids (28,466 deaths). see charts below. drug use is higher in countries with high economic inequality total recorded alcohol per capita consumption (15+), in litres of pure alcohol total yearly u.s. drug deaths. us yearly overdose deaths, and the drugs involved. history apa, ama, and ncda 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 1972, 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 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 other 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 defined 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 health and may even be deadly in certain scenarios. by 1994, the fourth edition of the dsm issued by the american psychiatric association, the dsm-iv-tr, defined 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", along with criteria for the diagnosis. the 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) the symptoms have never met the criteria for substance dependence for this class of substance the fifth edition of the dsm (dsm-5), was released in 2013, and it revisited this terminology. the principal change was a transition from the abuse-dependence terminology. in the dsm-iv era, abuse was seen as an early form or less hazardous form of the disease characterized with the dependence criteria. however, the apa's dependence term 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 requested input as to how the terminology of this illness should be altered as it moves forward with dsm-5 discussions. in the dsm-5, substance abuse and substance dependence have been merged into the category of substance use disorders and they no longer exist as individual concepts. while substance abuse and dependence were either present or not, substance use disorder has three levels of severity: mild, moderate and severe. society and culture legal approaches related articles: drug control law, prohibition (drugs), arguments for and against drug prohibition, harm reduction 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. 1991 indian postage stamp bearing the slogan – beware of drugs 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