Substance Use Disorders
Brief Background
Drugs, like alcohol, marijuana and opium have enhanced living and relieved suffering for millennium, and activities like eating, internet use, gambling and sex often provide similarly positive experiences. For some, however, drugs and/or activities like gambling are overused for purposes such as emotional regulation, to enhance performance or to change one’s perception of reality, and some individuals begin to depend almost exclusively on them, largely, because the desired effect is immediate and powerfully reinforcing. As the overuse of substances or activities continues, psychological and/or physiological dependence deepens. In cases of physiological dependence, the substance is needed to avoid dangerous and potentially fatal withdrawal symptoms. An example is seizures which can be part of alcohol withdrawal. Individuals in this category often say that they need the drug “to feel normal.” In cases of psychological dependence, the individual relies on the calming effect of drugs like alcohol or sedatives, for example, to such an extent that the development of new coping strategies is blocked.
What is the experience of an individual who has become dependent?
Initially, drug use, sexual experience, gambling or overeating elicits a sense of wellbeing and euphoria. Insecurities, isolation and painful emotions are quickly alleviated, and the drug or activity is repeated to obtain the desired effect. Unfortunately, there are costs associated with overuse of a substance or activity like gambling.
The individual may gain or lose weight, experience health problems, lose money and important relationships (Drug Facts) and develop tolerance. Tolerance means that more of the substance is needed to elicit the desired effect because it diminishes over time. As more of the substance is used, the social and/or medical costs increase. Divorce and the development of liver disease are good examples of this phenomenon. As the costs become more glaring and problematic, the individual may begin to feel ambivalent about the substance use. For example, an individual may understand that continued drinking will worsen their health, but a life without the numbing effect of alcohol may be difficult or impossible to imagine. Loss of control is another factor that deepens an individual’s mixed feelings about their use. For example, an individual may want to have two drinks, but with the introduction of alcohol an overwhelming urge to continue drinking overrides the person’s judgment and intention to limit its’ use. This phenomenon is called compulsion. A useful way to think about a compulsion is to imagine driving a car with faulty brakes. Sometimes the brakes work, but sometimes they do not. Now imagine how dangerous it would be to be in that car. This is how many people experience their substance use. It is at this point that some individuals seek treatment. At the same time, abstinence itself is frightening because it propels the addicted individual into an unfamiliar world. Many substance users describe this as “feeling like a turtle without its protective shell” and coping with everyday stress and painful emotions can feel overwhelming.
How are substance abuse disorders treated?
Most often, specialized treatment is required. Inpatient settings help the individual to safely withdraw from a substance, like alcohol, and intensive outpatient programs and residential treatment provide the education and support necessary for early sobriety. Twelve Step programs, like Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) provide free and lifelong support for the recovering individual, and Rational Recovery or SMART Recovery provide an alternative to AA or NA. Outpatient individual and group psychotherapy can be especially helpful for individuals with comorbid psychiatric disorders, and medication is often necessary to treat these underlying problems.
Once an individual is alcohol or drug free, continued support is vital because difficult lifestyle changes must be made. For example, drinking and drug associates must be replaced with sober friends and the individual will need ongoing support to cope with cravings and to develop new strategies for handling stress. The “Day at a Time” approach, espoused in the 12 Step programs, helps make these tasks feel more manageable, and provides hope to demoralized individuals who have experienced multiple relapses, which can be common. Exercise, sharing one’s pain with another, and meditation are examples of new coping strategies. Over time and with consistent practice these new skills become a reliable source of comfort and/or motivation. The development of a community that supports recovery is another vital ingredient for successful treatment. That community could be other AA members, sobriety coaches or religious organizations, to name a few. While daunting, these lifestyle changes are necessary for sustained long term recovery, but are made easier with the support from friends and family, and the example of individuals who have already made some of these changes during their own recovery. In this way, former gamblers or sober alcoholics serve as important role models and sources of necessary encouragement when times get hard, which they inevitably do. I want, however, to end on a positive note and affirm that treatment works and that relationships that were previously damaged by the overuse of substances can be repaired, begin to flourish again; and life can offer new experiences for learning and enjoyment. I think the AA community says it best when they assert that the purpose of recovery, and the hard work that is involved, is to develop “a capacity to feel joy in one’s relationships and work.”
Some Noteworthy Statistics:
The societal and personal costs associated with substance use disorders are considerable. For example, abuse of tobacco, alcohol and illicit drugs costs society approximately $740 billion annually due to lost work productivity, crime and health care costs (NIDA).
Incidents of abuse and dependence vary among different age groups. For example, one out of every six young adults between 18 and 25, or 16.3%, have a substance use related problem, which is the highest percentage of any age group. Approximately 14.5 million adults aged 26 or older struggle with a substance use disorder, and in the elderly population 15% develop problems, especially after retirement. Additionally, men have twice the rate of substance use related problems as women. While there is evidence to suggest that genetic factors may play a role posing a higher vulnerability for some to become addicted to substances, psychological and environmental factors also play a significant role in the development of substance use disorders. In addition, many people who have a substance use disorder also suffer from another psychiatric illnesses, like depression or anxiety, which may be undiagnosed. These individuals often use substances to self-medicate as a way to relieve the symptoms associated with these disorders (Khantzian, 1997). Lastly, about half of people who experience a psychiatric disorder will develop a substance use disorder (Drug Facts).
If you have concerns about your use of drugs and alcohol or about someone you care about, here are some invaluable resources:
SAMHSA’s National Helpline-1-800-662-4357.
Massachusetts Substance Use Helpline 800-327-5050.
National Drug Helpline-1-888-633-3239
Further Reading:
Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders. BF Grant, FS Stinson, DA Dawson. Archives of general…., 2004
The self- medication hypothesis of substance use disorders: reconsideration and recent applications. EJ Khantzian- Harvard review of psychiatry, 1997-
Taylor & Francis: Gender differences in substance use disorders. KT Bradley, CL Randal-Psychiatric Clinics of North America, 1999.