Substance Use Disorder

Understanding the Condition

Substance use disorders represent a major and pressing problem in the United States. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), 46.3 million people age 12 years and older in the U.S. met the criteria for a substance use disorder in 2021.

The “common denominators” for all SUDs are that, whatever the substance is which is abused, the person has an impaired control over its use, and often takes greater and greater quantities of this substance over time. In addition, people experience a social impairment in that because of the use of the substance, they can no longer adequately fulfill their key roles as a worker, a parent, a spouse or partner, or other roles that were formerly important to the individual.

People with SUDs also may engage in risky behaviors, such as using the substance when it is dangerous to do so. For example, drinking a large quantity of alcohol when individuals know that they must drive themselves home later is extremely risky behavior. It is possible that another person at the party or other situation may recognize that the individual is intoxicated and take away their car keys, but this also may not happen. As a result, the person could drive in a drunken state and cause a car accident, harming themselves and others.

Researchers have also found that people with SUDs have an elevated risk for suicide. For example, people with tobacco use disorder have twice the risk of suicide of a person without this disorder. People who have tobacco use disorder, a drug use disorder, and an alcohol use disorder have more than an 11 times greater risk for suicide compared to a person without these disorders.

Individuals with a substance use disorder may experience withdrawal symptoms when they fail to use a substance that they commonly use, experiencing physical and psychological symptoms. Withdrawal from some substances, such as opioids or alcohol, can be physically and psychologically very painful.

There are multiple substances on which a person may become excessively reliant, both psychologically and physically.

Disorders that are substance use disorders may include the following:

• An alcohol use disorder
• A cannabis (marijuana) use disorder
• An opioid use disorder
• A stimulant use disorder
• A sedative or anti-anxiety substance
• A tobacco use disorder
• A hallucinogen use disorder

With each of these disorders, over the course of at least a year, the individual is using greater amounts of the substance or for a longer time frame than originally intended. Often the person has tried and has failed to cut back on the amounts of the substance.that was used. If the substance is a prescribed medication, such as an opioid for pain or an anti-anxiety medication, the use of the drug becomes problematic when the individual exceeds the amount that is recommended by the prescriber, and the individual may begin seeking ways to obtain an earlier than indicated medication. The person may also ask friends or relatives for their medications or may purchase drugs illegally from dealers.

Both a medical and a mental health condition

A substance use disorder (SUD), is both a medical and a mental health condition that is characterized by an inability to decrease or discontinue the consumption of substances, even when distress and adverse consequences occur as a result. As mentioned, the substance may be alcohol or it may be opioids, marijuana, cocaine, or other substances. In addition, many people consume multiple substances. The continued use of a substance regardless of the consequences, is indicative of a substance use disorder.

More than half of those with an SUD also have another mental health condition.

Many people develop substance use disorders in an effort to self medicate the underlying condition. Mental illness causes high levels of distress, driving individuals to desperation to achieve relief. They may also consume multiple substances to excess. This pairing or clustering of conditions is often referred to as, “dual diagnosis,” or “co-occurring disorders.” Many people who have multiple substance use disorders, also have multiple underlying psychiatric diagnoses.

It is also important to note that an SUD often presents with other psychiatric problems, particularly major depressive disorder (MDD). There may be a bidirectional relationship in that the abuse of substances often causes depression. In addition, depression itself may lead to the abuse of substances in an ineffective attempt for an individual to try to feel better. Many intoxicating substances of choice yield some immediate relief, yet cause severe rebound effects, leading to repeated abuse and increased amounts needed to achieve relief.

There are several reasons why mental health conditions often occur together. First, the presence of an SUD can set in motion a constellation of new symptoms. For example, opioids are central nervous system depressants, so it stands to reason that opioid use disorder (OUD) and depression are often found together. Attention Deficit Hyperactivity Disorder is a common underlying cause of opioid abuse as well. These patients are deficient in dopamine in the prefrontal cortex of the brain, where judgment and decision making reside. The effects of opioids so closely resemble native dopamine, that patients who lack dopamine tend to crave “dope.” An OUD can also lead to heightened symptoms of anxiety, thus OUD and anxiety are frequent companions. The same can be said of an alcohol use disorder (AUD) and an array of other conditions across the mental health spectrum.

On the other hand, untreated mental health symptoms can set the stage for individuals engaging in self-medicating with alcohol or other substances, in a misguided attempt to alleviate their distressing symptoms. Ultimately, consuming drugs or alcohol to excess is not a long-term solution and instead, compounds the problem.

The question of whether chronic substance use causes mental health conditions, or whether untreated mental health symptoms lead to an SUD is often debated. The resolution to this chicken or egg conundrum is best sorted out with the help of a professional addiction or mental health treatment provider. Psychiatric professionals deem three months of sobriety necessary, to make a true and accurate diagnosis.

What it looks like

A substance use disorder (SUD) is a progressive medical and psychiatric condition. It is characterized by an inability to decrease or discontinue the problematic substance, despite significant distress or impaired functioning in important areas. These include social, occupational, academic and legal domains, as well as the development or worsening of medical and psychological conditions.

Common behaviors of a person with an SUD include the following actions:

• Consuming more of a substance or for a longer period than the person planned
• Failed attempts to decrease or stop using the substance
• Excessive time spent obtaining, consuming, becoming intoxicated, or recovering from the effects of the substance
• Craving the substance or an urgent desire to use that makes it difficult to think of other things, often resulting in more use.
• The inability to fulfill important obligations to family or function at school or work; impairmed social functioning and relationships, academic problems, or problems at work due to absenteeism or poor functioning.
• Continuing to use the substance, despite relationship or social problems that are created or worsened due to drug/alcohol use
• Neglecting family, work, or hobbies in order to make more time for consumption of the substance and recovering from its effects.
• Abusing the substance despite knowing that it causes or worsens medical problems; psychological problems, such as anxiety or depression; social/relationship problems, such as violent arguments with family members or child abuse, or legal problems.
• Consuming the substance when it is physically hazardous, including driving, operating machinery, or engaging in sports, such as swimming.
• Having withdrawal symptoms from not using the substance for any reason. Such symptoms may include hallucinations and seizures.
• Symptoms of withdrawal can occur approximately 4-12 hours after prolonged or heavy consumption of the substance. Withdrawal symptoms are uncomfortable and sometimes painful and can motivate continued drinking or drug abuse to alleviate the discomfort.
• Tolerance: requiring greater quantities of the substance to produce the same effect,

A substance use disorder can range from mild to severe. In general, the more symptoms a person has, the more severe the SUD is considered to be.

It should be noted that, in some cases, the severity of the SUD can progress from mild to moderate to severe in a relatively short period of time. An example of this is the high school or college student who engages in binge drinking, drinking games, or other activities where tolerance is quickly built. This progression can be disrupted with treatment.

Having a substance use disorder is nobody’s fault

The stigma of substance abuse remains powerful and prevalent. The message of stigma is one of shame and blame for the fact of having an SUD. Sadly, those suffering from such a disorder often internalize these negative messages and suffer for far too long before they are able to break through the grip of stigma and reach out for treatment.

In the past, many of those working in the field of addictions, bought into and perpetuated this destructive stigma. With antiquated attitudes and limited treatment options to offer, it is not surprising that people are still reluctant to seek treatment. But times are changing, and addiction is one area of medicine that caring, supportive providers can improve outcomes for patients.

Fortunately, today’s addiction’s treatment has evolved to one of a compassionate, respectful, and structured approach with a range of proven medications and therapies available. Look for a shame-free treatment environment that offers well researched and proven comprehensive treatment options. Look for providers who understand that addiction is a disease and not a series of poor choices, driven by poor intentions.

Outlook

We are living in an exciting time of exploration into the workings of the brain and the addictive impact of some substances on brain chemistry. Recent discoveries in neuroscience have led to innovative and effective treatment protocols for an SUD. The gold standard of SUD treatment is a complete psychiatric evaluation and concurrent treatment of the SUD together with any other condition that may be present. An integrated treatment plan, consisting of psychotherapy and medication management, where indicated, is the standard of care. Group therapy is also important, to establish a trusting community of supportive individuals who have experienced similar challenges.

In good company

Many prominent people reportedly have/had an SUD, such as actor Ben Affleck, singer Tim McGraw, and actress Edie Falco, among many other luminaries. Janis Jopiln, Jimi Hendrix, and John Belushi, are all great examples of why saving these patients is worth it, in each and every case. Addiction chooses and claims some of the most brilliant and creative individuals in our society.

The current thinking on what causes SUDs

In the past, healthcare professionals have explained conditions such as substance abuse disorders as a “chemical imbalance” that causes an increased risk for dependency on a substance such as alcohol or opioids. This may make it seem like an SUD is similar to a vitamin or mineral deficiency, and that simply taking the right medication will easily cure someone. Unfortunately, an SUD is more complicated, and it’s unclear whether an imbalance causes SUDs or if other intervening factors are more prominent as causal.

There is also disagreement over whether a person is born with the “chemical imbalance” or if there is a potential to develop this imbalance – or if it gets triggered by the person's environment. Most likely, the primary risks for an SUD are a combination of genetics, environment, and personal choice. Risk factors for developing AUD have been identified and are listed below. Before beginning a discussion of risk factors, it is important to note that having one or more risk factors does not mean that an SUD is inevitable. Neither is it a life sentence or reason to succumb to SUD. Effective tools for mitigating and treating the impact of these factors are available.

Genetics

Key among these risk factors is genetics. The role of genetics has been studied extensively. Identical twin studies and adoption studies suggest that genetics increases the likelihood of developing an SUD considerably. If a parent or sibling has an SUD, then the risk for an individual is increased. It is never 100 percent, even in identical twins, but it is elevated.

It’s a complicated issue. Some people have multiple family members with SUDs, and they never develop an SUD themselves. In other cases, there is no one in the extended family known to have an SUD, but a person develops such a disorder anyway. Researchers are constantly studying the causes of SUDs and potential ways to mitigate the effects of common conditions. For example, the age when a person starts abusing substances is directly relevant to the increased risk for long-term substance use disorder. The younger a person is when starting drinking or using drugs, the higher the lifetime risk is of an SUD. According to a study from the National Institute of Alcohol Abuse and Alcoholism (NIAAA) , people who begin drinking before age 15 have more than a five times greater risk of AUD when compared to those who delayed alcohol consumption until after age 21.

Environment

Environment is another risk factor. Growing up in an environment where family members abuse substances such as alcohol or drugs can normalize the behavior. The interplay between genetics and environment compounds the risk.

Having an untreated mental health condition

Having an untreated mental health condition, such as Major Depressive Disorder, Generalized Anxiety Disorder, ADHD, Post Traumatic Stress Disorder, Bipolar Disorder, Insomnia, and others, plays an important role in the development of an SUD. On a positive note, treating the other condition and alleviating the symptoms can significantly decrease that risk.

Trauma and coping with stress

Problems coping with stress, difficulty communicating boundaries, and the inability to manage strong emotions are additional drivers of the development of an SUD. Trauma is also a catalyst for the development of an SUD, because people are driven to numb the pain caused by the event.