Learn more about Substance Abuse

This page is full of comprehensive information to help you learn more about substance abuse.  Sections covered include:

General Description of Substance Abuse
Causes of Substance Abuse
The Purpose of Substance Abuse
Ways to treat Substance Abuse
Blog Posts about Substance Use and Abuse
Screening Tools for Substance Abuse
Overview of “Substance Abuse” from Substance Abuse and Mental Health Services Administration

Note: In the case of a medical or psychiatric emergency, such as a possible drug overdose, dial 911 or take the person to the nearest hospital immediately.

General Description of Substance Abuse

Substance abuse occurs throughout the world and cuts across all socioeconomic statuses, ages, genders, and ethnicities. The substances abused by individuals vary in legality, potency, addictive potential, and form. Although anyone can abuse substances and most adults have (for example, many clinicians consider a common hangover to qualify as substance abuse), some individuals may be predisposed to abuse substances (more about this in the “causes” section below). Unfortunately, many harmful drugs are extremely addictive (for example, alcohol, crack cocaine, methamphetamine). Many are illegal, yet some of the biggest killers, nicotine and alcohol, are legal. And ironically, many drug abuse stories begin with a medicine prescribed by a medical doctor.

It is often unclear when exactly an individual’s substance use becomes substance abuse, as many people who abuse substances are still able to function adequately in their lives and in society, at least on the surface. A person is engaging in substance abuse when the consequences of the drug or alcohol abuse become problematic (for example, physiologically, psychologically, and/or socially). This can happen slowly, over many years, or suddenly (for example, a person discovers a new drug that makes him or her feel great). If untreated, the effects of substance abuse can cause death (for example, death due to overdose). Substance abuse is common. There are many drugs, and any of them can be abused.

If you suspect that substance abuse is occurring, call your doctor today and ask for help. Seek a second opinion if the doctor is not concerned, because if you think there’s a problem, there probably is. Likewise, if those who care about you suspect you might have a problem with substances, take their concerns seriously by looking into the matter further. When a person is in the middle of an addiction, it’s difficult to know what is normal. Typically, individuals use the psychological defenses of rationalization (for example, “Well, I know plenty of other people who drink more than me.”) and denial (for example, “I simply don’t have a problem!”), which serve to preserve the person’s addiction. These defensive maneuvers can be incredibly clever and sophisticated. The addict’s life becomes more and more organized around the habit, which can continue for years despite negative consequences of which the individual typically denies or rationalizes away.

The popular “Transtheoretical Model” (Prochaska & DiClemente, 1992) suggests five stages of change an individual in recovery will go through:

  • Pre-comtemplation: not considering change
  • Comtemplation: being ambivalent or “on the fence” about change
  • Preparation: trying to change
  • Action: practicing new behavior
  • Maintenance: continued commitment to sustaining new behaviors

Often, individuals will linger in one stage for months or even years before being ready to move to the next stage. Further, the stages of change can become a cycle if the person has a relapse or “slip” with the drug(s) of choice. Regardless of this, there is hope for those who abuse drugs, as substance abusers can and often do recover from their addiction.

Many non-experts mistakenly believe that substance abuse is merely the person’s own fault or that the person lacks willpower, but this is an over-simplification. Accepting responsibility for one’s actions is important in recovery, but the person abusing drugs should not be merely blamed; this only increases feelings of shame. Those who are willing to honestly accept they have a problem have made a very important step in recovery. A person who is committed to recovery can make positive life changes in a relatively short period of time. However, for those with a deep addiction, recovery can also move slowly and become the most work of a person’s lifetime.

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Common Causes of Substance Abuse

Generally speaking, people use substances in an attempt to manage painful or uncomfortable feelings. Similarly, a desire to feel some type of pleasure – happier, more relaxed, energized or focused – can also be a motivating factor. Often, these two are intertwined (e.g., a person feels anxious about socializing, so drinks to feel more ease).

The ultimate causes of substance abuse, however, are complex and vary from person to person. Biological, psychological and environmental factors all come into play. For example, some studies suggest there’s a genetic predisposition to addiction, but again, this relationship is complex, involving the interaction between the person (biology) and their environment (stressors, lifestyle, etc.). In other words, science has yet to uncover a gene or other physical marker that guarantees addiction, but genes that appear to increase susceptibility have been discovered.

With that said, below are some of the common factors that can lead to substance abuse. As you can see, these items aren’t mutually exclusive:

  • Exposure to traumatic events or other stressors (e.g., violence, loss)
  • Emotional pain (due to any cause, including depression, anxiety and low self-esteem) (i.e., ‘self-medicating’)
  • Physiological and/or psychological sensitivity
  • Poor impulse control
  • Self-destructive tendencies
  • Boredom
  • Lack of social community, isolation
  • Family and cultural influences (e.g., growing up in an environment in which substance abuse is normal may teach the individual that drugs are a standard way to cope with stress; peer pressure can also contribute to use).

Why do you use drugs or alcohol? To relax? To have fun? Because everyone else is doing it? To forget about something? Whether or not you abuse substances, answering this simple question can help you cultivate some compassion for those who do abuse drugs – we’re all pretty similar, really. We all try to minimize our pain and make ourselves feel good. People who abuse drugs are usually following a natural inclination to try to feel better. Unfortunately, drug abuse is a problematic way to try to do so.

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The Purpose of Substance Abuse

It would probably take some creativity to say that substance abuse has a purpose. However, in the short-term, a drug or alcohol can make people feel better. A person strung out on heroin will tell you they need more of the drug to keep from getting sick (known as acute and post-acute withdrawal). It turns out that drug abuse is a misguided and ultimately destructive way of self-medication.

For those who accept they have a problem and are willing to do the difficult work of recovery, substance abuse can lead to a radically positive reformation of one’s life. This generally happens after a low point in a person’s life – when a person hits “rock bottom” with regards to their personal health, relationships or career. Rock bottom can include developing an illness related to using the substance, or nearly dying from a drug overdose.

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Ways to treat Substance Abuse

There are differing philosophies of substance abuse treatment. There is no one-size-fits-all treatment; individuals respond differently to different approaches. Often, people enter substance abuse treatment only to find they’re not ready to give up their drink or illicit drug(s). Individuals who do not believe they have a problem will not make any deeply beneficial changes. To truly be “in recovery” is a mental state of humility in which you honestly accept you have a problem. If you’re new to recovery, here are some basic categories that countless numbers of people use to seek help:

  • 12-step support groups. Alcoholics Anonymous, Narcotics Anonymous, Overeaters Anonymous, and many others exist worldwide
  • Non-12-step support groups. (e.g. LifeRing)
  • Psychotherapy is often used in conjunction with other approaches (e.g. medication, and/or a 12-step group). There are many theoretical orientations used in psychotherapy, including behavioral treatments such as CBT, mindfulness training, motivational interviewing, psychodynamic, and many others.
  • Recovery programs. Recovery programs can be inpatient and/or outpatient and vary widely in their level of treatment philosophy, intensity, size, cost and location. Treatment philosophies vary, but the two basic types are abstinence or harm-reduction. Harm-reduction models are relatively tolerant of continued drug use, whereas abstinence-based models take a drug relapse or “slip” more seriously. Recovery programs typically use urinalysis to detect substance use.

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Blog Posts about Substance Use and Abuse

Mindfulness training may reduce deficits in natural reward processing during chronic pain or drug addiction (by National Institute of Mental Health-NIMH)

H.A.L.T. (Hungry, Angry, Lonely and Tired): A Self-Care Tool (by Gudrun Zomerland, MFT-Therapist)

Robin Williams (by Thomas Insel, Director of NIMH)

Drinking Diaries (an interesting blog about women and drinking)

Prescription Drugs More Deadly than Car Accidents, Guns and Suicide (by Charlotte Lytton as the Daily Beast)

More Older Adults are Struggling with Substance Abuse (by Abby Ellin at NYTimes)

The “Rat Park” experiments demonstrate the importance of community when it comes to substance abuse.

A Different Path to Fighting Addiction (by Gabrielle Glaser at NYTimes)

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Screening Tools for Substance Abuse

Note: the purpose of any type of screening or assessment tool is to gain more information about the type and degree of symptoms one is experiencing.  It’s not a definitive answer on whether somebody meets the criteria for a particular clinical diagnosis, but is one of several factors to consider, and doesn’t replace the type of comprehensive assessment you’d receive from a mental health professional.

AUDIT (Screening for Alcohol Abuse)

CAGE (Screening for Alcohol and Drug Abuse)

List of many screening tools for different types of substances, from the National Institute on Drug Abuse

Overview of Substance Abuse from SAMSHA

Note: the following information is from the Substance Abuse and Mental Health Services Administration (SAMSHA) – a division of the Dep’t of Health and Human Services of the US Gov’t. 

“According to SAMHSA’s National Survey on Drug Use and Health (NSDUH), more than half of all adults drink alcohol, with 6.6% meeting criteria for an alcohol use disorder. Among Americans aged 12 or older, the use of illicit drugs has increased over the last decade from 8.3% of the population using illicit drugs in the past month in 2002 to 9.4% (24.6 million people) in 2013. Of those, 8.2 million people met criteria for a substance use disorder in the past year. The misuse of prescription drugs is second only to marijuana as the nation’s most common drug problem after alcohol and tobacco, leading to troubling increases in opioid overdoses in the past decade. An estimated 25.5% (66.9 million) of Americans aged 12 or older were current users of a tobacco product. While tobacco use has declined since 2002 for the general population, this has not been the case for people with serious mental illness where tobacco use remains a major cause of morbidity and early death.
Additional data from SAMHSA’s Behavioral Health Barometer – 2013 show that:

  • Men reported higher rates of illicit drug dependence than women, 3.8% to 1.9%.
  • American Indians and Alaska Natives have the highest rates of illicit drug dependence at 6%, followed by African Americans at 3.6%. Asian Americans reported the lowest rate at 1%.
  • About 14% of adults with illicit drug dependence reported receiving treatment in the past year, which did not vary by gender.
  • Each year, approximately 5,000 youth under the age of 21 die as a result of underage drinking.
  • In 2012, 58.3% of people who tried alcohol for the first time were younger than 18.
  • More than 50% of people aged 12 or older in 2011-2012 who used pain relievers for non-medical reasons in the past year got them from a friend or relative.”
Treatment Recommendations from the SAMSHA

Source: http://www.samhsa.gov/treatment/substance-use-disorders

The treatment system for substance use disorders is comprised of multiple service components, including the following:

  • Individual and group counseling
  • Inpatient and residential treatment
  • Intensive outpatient treatment
  • Partial hospital programs
  • Case or care management
  • Medication
  • Recovery support services
  • 12-Step fellowship
  • Peer supports

A person accessing treatment may not need to access every one of these components, but each plays an important role. These systems are embedded in a broader community and the support provided by various parts of that community also play an important role in supporting the recovery of people with substance use disorders.

Individual and Group Counseling

Counseling can be provided at the individual or group level. Individual counseling often focuses on reducing or stopping substance use, skill building, adherence to a recovery plan, and social, family, and professional/educational outcomes. Group counseling is often used in addition to individual counseling to provide social reinforcement for pursuit of recovery.

Counselors provide a variety of services to people in treatment for substance use disorders including assessment, treatment planning, and counseling. These professionals provide a variety of therapies. Some common therapies include:

  • Cognitive-behavioral therapy teaches individuals in treatment to recognize and stop negative patterns of thinking and behavior. For instance, cognitive-behavioral therapy might help a person be aware of the stressors, situations, and feelings that lead to substance use so that the person can avoid them or act differently when they occur.
  • Contingency management is designed to provide incentives to reinforce positive behaviors, such as remaining abstinent from substance use.
  • Motivational enhancement therapy helps people with substance use disorders to build motivation and commit to specific plans to engage in treatment and seek recovery. It is often used early in the process to engage people in treatment.
  • 12-step facilitation therapy seeks to guide and support engagement in 12-step programs such as Alcoholics Anonymous or Narcotics Anonymous.

Some forms of counseling are tailored to specific populations. For instance, young people need a different set of treatment services to guide them towards recovery. Treatments for youth often involve a family component. Two models for youth that are often used in combination and have been supported by SAMHSA grants are the Adolescent Community Reinforcement Approach (ACRA) and Assertive Continuing Care (ACC). ACRA uses defined procedures to build skills and support engagement in positive activities. ACC provides intensive follow up and home based services to prevent relapse and is delivered by a team of professionals.

Inpatient and Residential Settings

Treatment can be provided in inpatient or residential sessions. This happens within specialty substance use disorder treatment facilities, facilities with a broader behavioral health focus, or by specialized units within hospitals. Longer-term residential treatment has lengths of stay that can be as long as six to twelve months and is relatively uncommon. These programs focus on helping individuals change their behaviors in a highly structured setting. Shorter term residential treatment is much more common, and typically has a focus on detoxification (also known as medically managed withdrawal) as well as providing initial intensive treatment, and preparation for a return to community-based settings.

An alternative to inpatient or residential treatment is partial hospitalization or intensive outpatient treatment. These programs have people attend very intensive and regular treatment sessions multiple times a week early in their treatment for an initial period. After completing partial hospitalization or intensive outpatient treatment, individuals often step down into regular outpatient treatment which meets less frequently and for fewer hours per week to help sustain their recovery.

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Medication

Using medication to treat substance use disorders is often referred to as Medication-Assisted Treatment (MAT). In this model, medication is used in combination with counseling and behavioral therapies. Medications can reduce the cravings and other symptoms associated with withdrawal from a substance by occupying receptors in the brain associated with using that drug (agonists or partial agonists), block the rewarding sensation that comes with using a substance (antagonists), or induce negative feelings when a substance is taken. MAT is has been primarily used for the treatment of opioid use disorder but is also used for alcohol use disorder and the treatment of some other substance use disorders.

Medications for Alcohol Use Disorders

Medications also exist that can assist in the treatment of alcohol use disorder. Acamprosate is a medication that reduces symptoms of protracted withdrawal and has been shown to help individuals with alcohol use disorders who have achieved abstinence go on to maintain abstinence for several weeks to months. Naltrexone, a medication used to block the effects of opioids, has also been used to reduce craving in those with alcohol use disorders. Disulfiram is another medication which changes the way the body metabolizes alcohol, resulting in an unpleasant reaction that includes flushing, nausea, and other unpleasant symptoms if a person takes the medication and then consumes alcohol.

Medications for Tobacco Use Disorders

There are three medications approved by the Food and Drug Administration (FDA) to treat tobacco use disorders (cigarette smoking). Nicotine replacement medications assist with reducing nicotine withdrawal symptoms including anger and irritability, depression, anxiety, and decreased concentration. Because nicotine delivered through chewing of gum containing nicotine, via transdermal patch, or in lozenges has a slower onset of action than does the systemic delivery of nicotine through smoked tobacco; these medications have little effect on craving for cigarettes. These medications are available over-the-counter. However, the nicotine inhaler and nasal spray deliver nicotine more rapidly to the brain and so are available only by prescription. Bupropion is a medication originally developed and approved as an antidepressant that was also found to help people to quit smoking. This medication can be used at the same dose for either cigarette smoking or depression treatment (or both). Varenicline is a nicotine partial agonist that reduces craving for cigarettes and has been helpful in smoking cessation for many. Bupropion and varenicline are prescription medications.

Medication for Opioid Use Disorders

Medication-assisted treatment with methadone, buprenorphine, or extended-release injectable naltrexone plays a critical role in the treatment of opioid use disorders. According to the latest survey of opioid treatment providers more than 300,000 people received some form of medication-assisted treatment for an opioid use disorder in 2011.

Opioid agonist therapies with methadone or buprenorphine reduce the effects of opioid withdrawal and reduce cravings. They have been shown to increase retention in treatment and reduce risk behaviors that lead to transmission of HIV and viral hepatitis such as using opioids by injection.

Medication-assisted treatment with extended-release injectable naltrexone reduces the risk of relapse to opioid use and helps control cravings. Extended-release injectable naltrexone is particularly useful for people exiting a controlled setting where abstinence has been enforced such as jail or residential rehabilitation or in situations where maintenance with an opioid agonist is not available or appropriate. People who misuse prescription opioids benefit from medication assisted treatment as much as people abusing heroin.

There are no other FDA-approved medications for the treatment of other substance use disorders.

More information about medication-assisted treatment is available through SAMHSA’s Addiction Technology Transfer Center Network.

Recovery Support Services

Recovery support services are non-clinical services that are used with treatment to support individuals in their recovery goals. These services are often provided by peers, or others who are already in recovery. Recovery support can include:

  • Transportation to and from treatment and recovery-oriented activities
  • Employment or educational supports
  • Specialized living situations
  • Peer-to-peer services, mentoring, coaching
  • Spiritual and faith-based support
  • Parenting education
  • Self-help and support groups
  • Outreach and engagement
  • Staffing drop in centers, clubhouses, respite/crisis services, or warmlines (peer-run listening lines staffed by people in recovery themselves)
  • Education about strategies to promote wellness and recovery

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Peer Supports

Peers are individuals in recovery who can use their own experiences to help others working towards recovery. Peer supports are a critical component of the substance use disorder treatment system. Many people who work in the treatment system as counselors or case managers are in recovery, and peers are central to many recovery support efforts.

Peers also play a powerful role as a part of mutual-support groups. These groups, including Alcoholics Anonymous or Narcotics Anonymous and other 12-step programs, provide peer support for ending or reducing substance use. They provide an international support network which is relied upon by many people in recovery from substance use disorders. Mutual-support groups are often intentionally incorporated into treatment plans and can provide a ready community for individuals who are trying to change their lifestyles to get away from alcohol and other drugs. While mutual-support groups do not work for everyone and are not a necessary part of recovery, they are a fundamental component of the substance use disorder treatment system, even if they are not considered formal treatment.

Resources for Specific Substance Use Disorders

Alcohol Use Disorder
Learn more about medications that can be used to treat alcoholism from the SAMHSA publication Incorporating Alcohol Pharmacotherapies into Medical Practice – 2009.

Cannabis Use Disorder
The Cannabis Youth Treatment Series is a five-volume resource for substance abuse treatment professionals that provides a unique perspective on treating adolescents for marijuana use.

The Brief Marijuana Dependence Counseling (BMDC) program is an evidence-based program and a 12-week intervention designed to treat adults with a diagnosis of cannabis dependence.

SAMHSA also developed the Brief Counseling for Marijuana Dependence: A Manual for Treating Adults – 2005, which guides practitioners on how to help adult patients reduce or stop marijuana use through skill building.

Stimulant Use Disorder
One of the best-known treatment interventions is the Matrix Model, an outpatient treatment approach that was developed during the mid-1980s. SAMHSA has developed a set of materials about the Matrix Model.

SAMHSA’s Treatment Improvement Protocol (TIP) #33: Treatment for Stimulant Use Disorders – 2009 contains comprehensive information on all aspects of stimulant abuse, including treatment.

Opioid Use Disorder
Two volumes in the SAMHSA Treatment Improvement Protocol (TIP) series focus on opioid treatment:

Other SAMHSA materials also provide information about treatment for opioid use disorder:

Find Treatment through the SAMHSA services locator:

http://findtreatment.samhsa.gov/MHTreatmentLocator/faces/quickSearch.jspx

This online search tool can help you locate the following services near you:

  • Public mental health facilities that are funded by the State
  • Mental health treatment facilities administered by the Department of Veterans Affairs
  • Private for-profit and non-profit mental health facilities that are licensed by the State or accredited by a national accreditation organization

End Source: Substance Abuse and Mental Health Services Administration (SAMSHA) – a division of the Dep’t of Health and Human Services of the US Gov’t.

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