43 Etiology and Treatment of Substance Use Disorders

Etiology

Section Learning Objectives

• Describe the biological causes of substance-related and addictive disorders.
• Describe the cognitive causes of substance-related and addictive disorders.
• Describe the behavioral causes of substance-related and addictive disorders.
• Describe the sociocultural causes of substance-related and addictive disorders.

Biological

     Genetics. Similar to other mental health disorders, substance abuse is genetically influenced.  With that said, it is different than other mental health disorders in that if the individual is not exposed to the substance, they will not develop substance abuse.

Heritability of alcohol abuse is among the most well studied substances, likely because it is the only legal substance (except cannabis in some states). Twin studies have indicated a range of 50-60% heritability risk for alcohol disorder (Kendler et al., 1997). Studies exploring the heritability of other substance abuse, particularly drug use, suggests there may be a stronger heritability link than previously thought (Jang, Livesley, & Vernon, 1995). Twin studies indicate that the genetic component of drug abuse is stronger than drug use in general, meaning that genetic factors are more significant for abuse of a substance over nonproblematic use (Tsuang et al., 1996). Merikangas and colleagues (1998) found an 8-fold increased risk for developing a substance abuse disorder across a wide range of substances.

Unique to substance abuse is the fact that both genetic and familial influence are both at play. What does this mean? Well, biologically, the individual may be genetically predisposed to substance abuse; additionally, the individual may also be at risk due to their familial environment where their parents or siblings are also engaging in substance abuse. Individuals whose parents abuse substances may have a greater opportunity to ingest substances, thus promoting drug-seeking behaviors. Furthermore, families with a history of substance abuse may have a more accepting attitude of drug use than families with no history of substance abuse (Leventhal & Schmitz, 2006).

     Neurobiological. A longstanding belief about how drug abuse begins and is maintained is the brain reward system. A reward can be defined as any event that increases the likelihood of a response and has a pleasurable effect. Most of the research on the brain reward system has focused on the mesocorticolimbic dopamine system, as it appears this area is the primary reward system of most substances that are abused. As research has evolved in the field of substance abuse, five additional neurotransmitters have also been implicated in the reinforcing effect of addiction: dopamine, opioid peptides, GABA, serotonin, and endocannabinoids. More specifically, dopamine is less involved in opioid, alcohol, and cannabis. Alcohol and benzodiazepines lower the production of GABA, while cocaine and amphetamines decrease dopamine. Cannabis has been shown to reduce the production of endocannabinoids.

Cognitive

Cognitive theorists have focused on the beliefs regarding the anticipated effects of substance use. Defined as the expectancy effect, drug-seeking behavior is presumably motivated by the desire to attain a particular outcome by ingesting a substance. The expectancy effect can be defined in both positive and negative forms. Positive expectations are thought to increase drug-seeking behavior, while negative experiences would decrease substance use (Oei & Morawska, 2004). Several studies have examined the expectancy effect on the use of alcohol. Those with alcohol abuse reported expectations of tension reduction, enhanced sexual experiences, and improved social pleasure (Brown, 1985). Additionally, observing positive experiences, both in person and through television or social media, also shapes our drug use expectancies.

While some studies have explored the impact of negative expectancy to eliminate substance abuse, research has failed to continually support this theory, suggesting that positive experiences and expectations are a more powerful motivator of substance abuse than the negative experiences (Jones, Corbin, Fromme, 2001).

Behavioral

Operant conditioning has been implicated in the role of developing substance use disorders. As you may remember, operant conditioning refers to the increase or decrease of a behavior, due to reinforcement or punishment. Since we are talking about increasing substance use, behavioral theorists suggest that substance abuse is positively and negatively reinforced due to the effects of a substance.

Positive reinforcement occurs when substance use is increased due to the positive or pleasurable experiences of the substance. More specifically, the rewarding effect or pleasurable experiences while under the influence of various substances directly impacts the likelihood that the individual will use the substance again. Studies of substance use on animals routinely support this theory as animals will work to receive injections of various drugs (Wise & Koob, 2013).

Negative reinforcement, or the increase of a given behavior due to the removal of a negative effect, also plays a role in substance abuse in two different ways. First, many people ingest a substance as an escape from their unpleasant life—whether it be physical pain, stress, or anxiety, to name a few. Therefore, the substance temporarily provides relief from a negative environment, thus reinforcing future substance abuse (Wise & Koob, 2013). Secondly, negative reinforcement is involved in symptoms of withdrawal. As previously mentioned, withdrawal from a substance often produces significant negative symptoms such as nausea, vomiting, uncontrollable shaking, etc. To eliminate these symptoms, an individual will consume more of the substance, thus again escaping the negative symptoms and enjoying the “highs” of the substance.    

Sociocultural

Arguably, one of the strongest influences of substance abuse is the impact of one’s friends and the immediate environment. Peer attitudes, perception of others’ drug use, pressure from peers to use substances, and beliefs about substance use are among the strongest predictors of drug use patterns (Leventhal & Schmitz, 2006). This is particularly concerning during adolescence when patterns of substance use typically begin.

Additionally, research continually supports a strong relationship between second-generation substance abusers (Wilens et al., 2014). The increased possibility of family members’ substance abuse is likely related to both a genetic predisposition, as well as the accepting attitude of the familial environment (Chung et al., 2014). Not only does a child have early exposure to these substances if their parent has a substance abuse problem, but they are also less likely to have parental supervision, which may impact their decision related to substance use (Wagner et al., 2010). One potential protective factor against substance use is religiosity. More specifically, families that promote religiosity may reduce substance use by promoting negative experiences (Galen & Rogers, 2004).

Another sociocultural view on substance abuse is stressful life events, particularly those related to financial stability. Prevalence rates of substance abuse are higher among poorer people (SAMHSA, 2014). Furthermore, additional stressors such as childhood abuse and trauma, negative work environments, as well as discrimination are also believed to contribute to the development of a substance use disorder (Hurd, Varner, Caldwell, & Zimmerman, 2014; McCabe, Wilsnack, West, & Boyd, 2010; Unger et al., 2014).

Treatment

Section Learning Objectives

• Describe biological treatment options for substance-related and addictive disorders.
• Describe behavioral treatment options for substance-related and addictive disorders.
• Describe cognitive-behavioral treatment options for substance-related and addictive disorders.
• Describe sociocultural treatment options for substance-related and addictive disorders.

Given the large number of the population affected by substance abuse, it is not surprising that there are many different approaches to treat substance use disorder. Overall, treatments for substance-related disorders are only mildly effective, likely due in large part to the addictive qualities in many of these substances (Belendiuk & Riggs, 2014).

Biological

     Detoxification. Detoxification refers to the medical supervision of withdrawal from a specified drug. While most detoxification programs are inpatient for increased monitoring, some programs allow for outpatient detoxification, particularly if the addiction is not as severe. There are two main theories of detoxification—gradually decreasing the amount of the substance until the individual is off the drug completely, or eliminating the substance entirely while providing additional medications to manage withdrawal symptoms (Bisaga et al., 2015). Unfortunately, relapse rates are high for those engaging in detoxification programs, particularly if they lack any follow-up psychological treatment.

     Agonist drugs. As researchers continue to learn more about both the mechanisms of substances commonly abused, as well as the mechanisms in which the body processes these substances, alternative medications are created to essentially replace the drug in which the individual is dependent on. These agonist drugs provide the individual with a “safe” drug that has a similar chemical make-up to the addicted drug. One common example of this is methadone, an opiate agonist that is often used in the reduction of heroin use (Schwartz, Brooner, Montoya, Currens, & Hayes, 2010). Unfortunately, because methadone reacts to the same neurotransmitter receptors as heroin, the individual essentially replaces their addiction to heroin with an addiction to methadone. While this is not ideal, methadone treatment is highly regulated under safe medical supervision. Furthermore, it is taken by mouth, thus eliminating the potential adverse effects of unsterilized needles in heroin use. While some argue that methadone maintenance programs are not an effective treatment because it simply replaces one drug for another, others claim that the combination of methadone with education and psychotherapy can successfully help individuals off both illicit drugs and methadone medications (Jhanjee, 2014).

     Antagonist drugs. Unlike agonist drugs, antagonist drugs block or change the effects of the addictive drug. The most commonly prescribed antagonist drugs are Disulfiram and Naloxone. Disulfiram is often given to individuals trying to abstain from alcohol as it produces significant negative effects (i.e., nausea, vomiting, increased heart rate, and dizziness) when coupled with alcohol consumption. While this can be an effective treatment to eliminate alcohol use, the individual must be motivated to take the medication as prescribed (Diclemente et al., 2008).

Similar to Disulfiram, Naloxone is used for individuals with opioid abuse. Naloxone acts by binding to endorphin receptors, thus preventing the opioids from having the intended euphoric effect. In theory, this treatment appears promising, but it is extremely dangerous as it can send the individual into immediate, severe withdrawal symptoms (Alter, 2014). This type of treatment requires appropriate medical supervision to ensure the safety of the patient.

Behavioral

     Aversion therapy. Based on respondent conditioning principles, aversion therapy is a form of treatment for substance abuse that pairs the stimulus with some type of negative or aversive stimulus. For example, an individual may be given a shock every time they think about or attempt to drink alcohol. By pairing this aversive stimulus to the abused substance, the individual will begin to independently pair the substance with an aversive thought, thus reducing their craving/desire for the substance. Some view the use of agonist and antagonist drugs as a form of aversion therapy as these medications utilize the same treatment strategy as traditional aversion therapy.

     Contingency management. Contingency management is a treatment approach that emphasizes operant conditioning—increasing sobriety and adherence to treatment programs through rewards. Originally developed to increase adherence to medication and reinforce opiate abstinence in methadone patients, contingency management has been adapted to increase abstinence in many different substance abuse treatment programs. In general, patients are “rewarded” with vouchers or prizes in exchange for abstinence from substance use (Hartzler, Lash, & Roll, 2012).  These vouchers allow individuals to gain incentives specific to their interests, thus increasing the chances of abstinence. Common vouchers include movie tickets, sports equipment, or even cash (Mignon, 2014).

Contingency management has been proven to be effective in treating various types of substance abuse, particularly alcohol and cocaine (Lewis & Petry, 2005). Not only has it been effective in reducing substance use in addicts, but it has also been effective in increasing the amount of time patients remain in treatment as well as compliance with the treatment program (Mignon, 2014). Despite its success, dissemination of this type of treatment has been rare. To rectify this, the federal government has provided financial resources through SAMHSA for the development, implementation, and evaluation of contingency management as a treatment to reduce alcohol and drug use (Mignon, 2014).

Cognitive-Behavioral

     Relapse prevention training. Relapse prevention training is essentially what it sounds like—identifying potentially high-risk situations for relapse and then learning behavioral skills and cognitive interventions to prevent the occurrence of a relapse. Early in treatment, the clinician guides the patient to identify any interpersonal, intrapersonal, environmental, and physiological risks for relapse. Once these triggers are identified, the clinician works with the patient on cognitive and behavioral strategies such as learning effective coping strategies, enhancing self-efficacy, and encouraging mastery of outcomes. Additionally, psychoeducation about how substance abuse is maintained, as well as identifying maladaptive thoughts and learning cognitive restructuring techniques, helps the patient make informed choices during high-risk situations. Finally, role-playing these high-risk situations in session allows patients to become comfortable engaging in these effective coping strategies that enhance their self-efficacy and ultimately reducing the chances of a relapse. Research for relapse prevention training appears to be somewhat effective for individuals with substance-related disorders (Marlatt & Donovan, 2005).  

Sociocultural

     Self-help. In 1935, two men suffering from alcohol abuse met and discussed their treatment options. Slowly, the group grew, and by 1946, this group was known as Alcoholics Anonymous (AA). The two founders, along with other early members, developed the Twelve Step Traditions to help guide members in spiritual and character development. Due to the popularity of the treatment program, other programs such as Narcotics Anonymous and Cocaine Anonymous, adopted and adapted the Twelve Steps for their respective substance abuse. Similarly, Al-Anon and Alateen are two support groups that offer support for families and teenagers of individuals struggling with alcohol abuse.

The overarching goal of AA is abstinence from alcohol. To achieve this, the participants are encouraged to “take one day at a time.” In using the 12 steps, participants are emboldened to admit that they have a disease, that they are powerless over this disease, and that their disease is more powerful than any person. Therefore, participants turn their addiction over to God and ask for help to right their wrongs and remove their negative character defects and shortcomings. The final steps include identifying and making amends to those who they have wronged during their alcohol abuse.

While studies examining the effectiveness of AA programs are inconclusive, AA’s membership indicates that 27% of its members have been sober less than one year, 24% have been sober 1-5 years, 13% have been sober 5-10 years, 14% have been sober 10-20 years, and more than 22% have been sober over 20 years (Alcoholics Anonymous, 2014).  Some argue that this type of treatment is most effective for those who are willing and able to abstain from alcohol as opposed to those who can control their drinking to moderate levels.

     Residential treatment centers. Another type of treatment similar to self-help is residential treatment programs. In this placement, individuals are completely removed from their environment and live, work, and socialize within a drug-free community while also attending regular individual, group, and family therapy. The types of treatment used within a residential program varies from program to program, with most focusing on cognitive-behavioral and behavioral techniques. Several also incorporate 12-step programs into treatment, as many patients transition from a residential treatment center to a 12-step program post discharge. As one would expect, the residential treatment goal is abstinence, and any evidence of substance abuse during the program is grounds for immediate termination.

Studies examining the effectiveness of residential treatment centers suggest that these programs are useful in treating a variety of substance abuse disorders; however, many of these programs are very costly, thus limiting the availability of this treatment to the general public (Bender, 2004; Galanter, 2014). Additionally, many individuals are not able to completely remove themselves from their daily responsibilities for several weeks to months, particularly those with families. Therefore, while this treatment option is very effective, it is also not an option for most individuals struggling with substance abuse.

     Community reinforcement. The goal for community reinforcement treatment is for patients to abstain from substance use by replacing the positive reinforcements of the substance with that of sobriety. This is done through several different techniques such as motivational interviewing, learning adaptive coping strategies, and encouraging family support (Mignon, 2014). Essentially, the community around the patient reinforces the positive choices of abstaining from substance use.

Community reinforcement has been found to be effective in both an inpatient and outpatient setting (Meyers & Squires, 2001). It is believed that the intrinsic motivation and the effective coping skills, in combination with the support of an individual’s immediate community (friends and family) is responsible for the long-term positive treatment effects of community reinforcement.

Module Recap

In this module, we discussed substance-related and addictive disorders to include substance use disorder, substance intoxication, and substance withdrawal. Substances include depressants, sedative-hypnotic drugs, opioids, stimulants, and hallucinogens. As in past modules, we discussed the clinical presentation, epidemiology, comorbidity, and etiology of the disorders. We then also discussed the biological, behavioral, cognitive-behavioral, and sociocultural treatment approaches.

3rd edition

“Etiology and Treatment of Substance Use Disorders” is adapted from Fundamentals of Psychological Disorders by Alexis Bridley and Lee W. Daffin Jr., used under Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.