Substance Use Disorders

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Substance Use Disorder (SUD) is the current formal terminology to describe familiar syndromes such as alcoholism, drug abuse, and addiction.  

SUD covers a broad range of substances, including alcohol, tobacco, cannabis, opioids, cocaine and others. Each has distinct properties, with different intoxication syndromes, withdrawal symptoms, and addiction potential.  But they all activate the brain reward systems, leading to reinforcement of use, and therefore the potential to result in a common syndrome of unhealthy and/or compulsive use. Over time, higher doses are required to achieve the same feeling as tolerance develops.  Continued use is also driven by attempts to avoid painful withdrawal symptoms. People continue to use the substance despite significant negative consequences—in work, physical health, relationships, finances, leisure activities and psychological health.

“At first, addiction is maintained by pleasure, but the intensity of the pleasure gradually diminishes and addiction is then maintained by the avoidance of pain.” 

– Frank Tallis, Psychologist and Author

The specific disorders are named, for example, Alcohol Use Disorder (AUD), Opioid Use Disorder (OUD), Cannabis Use Disorder (CUD) etc.

Despite differences between the substances, there are some common categories of a SUD diagnosis.  According to the DSM-5 (The Diagnostic and Statistical Manual of Mental Disorders), a formal diagnosis involves a certain number of symptoms from the list below, along with associated impairment in functioning and/or distress:

Difficulty controlling use:

  • Using larger amounts or for longer periods of time than intended
  • A persistent desire and/or unsuccessful attempts to cut down or stop use
  • Spending a lot of time obtaining, using or recovering from the effects of the substance
  • Craving: intense desire for substance or urge to use, especially with exposure to triggers (people, places and things associated with using)

Social impairment:

  • Failure to fulfill major role obligations: home, work, school
  • Continued use despite persistent social or interpersonal problems 
  • Stopping or reducing important activities due to substance use (family, recreational, occupational)

Risky use:

  • Persistent use when physically hazardous 
  • Persistent use despite known negative physical and/or psychological impacts

Pharmacological:

  • Tolerance- increased dose needed to achieve the desired effect
  • Withdrawal symptoms when without the substance

Many of the withdrawal symptoms of a specific substance are, in general, the opposite of the effects of intoxication. Withdrawal from stimulants, such as cocaine, can cause sedation, depression, and slowed thinking. Withdrawal symptoms from sedatives such as alcohol and benzodiazepines (Valium, Ativan and others) include elevated blood pressure and heart rate, insomnia and tremor.

To be sure, there are levels of problematic substance use that do not fully meet these formal criteria and yet are still risky. 

There are several known risk factors for developing a substance use disorder, although it remains unclear how these factors may lead to addiction in some people and not others. And we don’t fully understand the complex ways in which these risk factors influence each other. The risk of developing a problem, therefore, is very individualized, and one person should not compare themselves to another for reassurance. Two college friends can both drink alcohol to the same degree, with one developing a SUD while the other does not. 

In general, the more risk factors, the greater the chance for developing a problem.

One of the strongest known risk factors is genetic predisposition (family history). People with relatives who have struggled with alcohol or drug problems, or are heavy users, should be extra cautious about their own use. Some signs of genetic risk include having a higher tolerance, having trouble cutting down on use, and difficulty coping with stress. Having family members with mental health disorders, such as bipolar disorder or schizophrenia, can also increase your risk of addiction.

There are many psychological, cultural and social risk factors as well, including community norms, peer pressure, and ease of access to the substance. For example, the widespread legalization of marijuana may increase rates of addiction related to cultural factors (people may think that if marijuana is legal, it must not be risky or addictive) and increased access to the drug.  

Other social and environmental risk factors include poverty, exposure to trauma and stress, and less family involvement and support.

Biological and psychological risk factors (in addition to family history) include having a mental health disorder (such as bipolar disorder, anxiety or depression), using highly addictive substances, heavy use, and starting at a younger age.

These risk factors interact with each other in complex ways.  For example, if someone grows up in a household with an actively drinking alcoholic father, both genetics and environment contribute to the risk of developing an addiction.

Substance Use Disorders Are Treatable Illnesses

There are many treatment options, often used in combination: psychotherapy (different kinds of individual, group and family therapies), recovery programs (such as AA and NA), support communities and sober housing, and Medication-Assisted Treatment (MAT).  Relapses are common along the path to recovery, so it is important not to give up. There are different levels of care, depending on the person’s specific needs and resources:  outpatient, intensive outpatient, partial hospitalization, acute detox and residential treatment.

MAT consists of a range of approaches, with options differing by substance.  Some medications are approved by the Food and Drug Administration (FDA); some are used “off label” if there is some evidence for their efficacy but they may not be FDA-approved for that specific purpose. Medications can be used on a shorter-term basis to decrease risk of relapse by reducing withdrawal symptoms and/or cravings. Examples include nicotine patches and Chantix to help quit smoking, clonidine for opioid withdrawal, and benzodiazepines for alcohol withdrawal. There are also medications that can be used longer-term to reduce cravings, prevent a “high,” and as safer alternatives to the drug of abuse. Examples include acamprosate, disulfiram (Antabuse), and naltrexone (Revia, Vivitrol) for alcohol use disorder. For opioid addiction, methadone, naltrexone and buprenorphine (Naloxone) are the main medications used. They can significantly reduce harm and mortality by decreasing the risks of overdose, HIV/hepatitis from sharing of needles, and legal, financial and social repercussions of addiction.

Because substance use and other mental health disorders often occur together, it is important that treatment systems integrate care for both, with “no wrong door” to access help. In the past especially, people with both substance abuse and bipolar disorder, for example, might be excluded from care at a “mental health” clinic because of the substance use, being told to get sober first. And at the same time, they might be ineligible for treatment in a substance abuse program due to having an active mood disorder, leaving them with few-to-no options. Given high rates of SUD and the toll it takes on people, families and society, we need many more affordable treatment programs throughout the U.S.

Prevention and early recognition and intervention are also crucial in reducing the negative personal and societal impacts of substance abuse. Addressing community risk factors by, for example, reducing neighborhood poverty, providing financial and other supports to families, and increasing affordable access to safe structured activities for children is crucial to these efforts.

For more information, here are a few helpful resources (including treatment resources):

  • U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration: www.samhsa.gov
  • National Institute on Drug Abuse (NIDA): nida.nih.gov
  • Alcoholics Anonymous: www.aa.org
  • Narcotics Anonymous: na.org 

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