Welcome to this video about addiction and substance use disorder. We’ll start by examining our contemporary understanding of addiction and some of the theoretical foundations. We’ll also identify risk factors and provide a brief overview of evidence-based treatment practices.
The American Society of Addiction Medicine (ASAM) defines addiction as “a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences.” According to ASAM, “people with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases.”
The National Institute on Drug Abuse (NIDA) regards addiction as a chronic yet treatable brain disease, underscoring significant contributions of the brain circuits involved in reward, stress, memory, and self-control. Neuroadaptations, or changes in the brain’s structure and functioning, can sometimes persist years after a person has discontinued use, creating the potential for relapse. While relapse is common, addiction can be effectively managed with the right interventions.
Published by the American Psychiatric Association (2022), the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) has replaced the phrase “drug addiction” with “substance use disorder,” which conceptualizes substance use existing on a continuum, from mild to severe, with severe substance use negatively affecting several aspects of an individual’s cognitive, behavioral, and physiological functioning.
In 2023, only about 1 in 4 individuals over the age of 12 who needed treatment for substance use disorder actually received it. One significant contributing factor is the stigma or negative attitudes surrounding addiction. The use of terms like “addicts,” “drug abusers,” “junkies,” and “alcoholics” perpetuates harmful stereotypes, as do assumptions that individuals with substance use disorder are “pathological liars” or “dangerous.” Biases and stigma stem from outdated and erroneous conceptions of addiction, framing it as a moral failing, personal choice, or lack of willpower. These views are not only unfounded, but they impede access to care and contribute to discrimination, especially among marginalized populations and pregnant individuals with substance use disorder.
Person-first language is strengths-based and focuses on the individual rather than their condition. Using terms such as “a person with substance use disorder” reflects this approach. It views individuals as whole human beings, not just their diagnosis, and helps to increase hope and self-efficacy. Several organizations, including ASAM, have updated their definition of addiction to reflect advances in understanding addiction as a chronic brain disease with the potential for remission, creating new opportunities for prevention and harm reduction.
This next section will focus on the 11 diagnostic criteria for substance use disorder outlined in the DSM-5-TR. These diagnostic groupings include the following:
Impaired Control, which is exhibited in four ways:
- Using a substance in larger amounts or for longer periods than intended.
- Wanting to control substance use but being unable to.
- Spending significant time seeking or recovering from substance use, and
- Having cravings or a strong urge to use.
Social impairment, which can manifest in the following ways:
- Failing to fulfill roles at home, work, or school.
- Continuing use despite harming relationships, and
- Abandoning important social, job, or recreational activities.
Risky use, which involves:
- Using in dangerous situations, like driving, and
- The inability to stop despite adverse consequences.
Pharmacological criteria, which includes
- Tolerance
- Withdrawal
Tolerance is activated in either of the following:
- Requiring more of a substance to achieve the desired effect and
- Experiencing a reduced effect with continued use
Withdrawal occurs when one or more substances are discontinued after heavy or prolonged use. Withdrawal symptoms vary significantly among different classes of substances. Significant physiological symptoms are associated with alcohol, opioids, and other central nervous system depressants but not with inhalant and hallucinogen use.
The etiology of addiction is complex and multifaceted. No single theory fully explains why some individuals develop severe substance disorders while others do not. The theories chosen for this overview are empirically supported and provide a framework for evidence-based treatment practices.
Models of Addiction
Recent advancements in scientific research provide strong evidence for the neuropsychological model of addiction, which expands on the DSM-5-TR’s conceptualization of addiction. This model hypothesizes that variations in neurobiological systems affect the initiation, progression, and maintenance of substance use disorder. This is reflected in the cycle of addiction.
Targeted treatment interventions are associated with each stage in the cycle of addiction:
Stage 1: Binge/intoxication
The binge/intoxication stage begins in the basal ganglia and involves an intense rush or euphoria triggered by the release of dopamine. Dopamine is the primary neurotransmitter associated with emotionally heightened feelings of pleasure. Dopamine is produced in the ventral tegmental area (VTA) and carried to the nucleus accumbens and the prefrontal cortex. It accounts for the reinforcing and compulsive effects of substance use. When the brain’s reward centers are activated, incentive salience circuits gain motivational significance. Incentive salience refers to people, places, and things present during substance use. Other neurotransmitters the basal ganglia produce include glutamate, opioid peptides, and GABA.
Stage 2: Negative Affect and Withdrawal
The amygdala is involved in the negative affect and withdrawal phase, with symptoms varying by substance type and the severity of use. When a substance is discontinued, dopamine levels are diminished, causing intense dissatisfaction, negative emotions, and physiological symptoms.
The amygdala is the brain area associated with the body’s stress response. Activation of the stress response results in anxiety, irritability, and unease. The desire to remove the effects of withdrawal causes a person to compulsively seek the addictive substance. During this phase, a person no longer uses the substance for the pleasurable effects but to escape a negative emotional state. Neurotransmitters activated by the amygdala include norepinephrine, dynorphin, and corticotropin-releasing factor.
Stage 3: Preoccupation/Anticipation
The preoccupation/anticipation stage is marked by the pursuit of a substance after periods of abstinence. With severe substance use disorder, abstinence may be brief, lasting only hours for some. Preoccupation, cravings, and compulsive seeking coincide with the DSM-5-TR’s impaired control symptom cluster.
Changes in this stage are centered in the prefrontal cortex, which is responsible for thinking, planning, impulse control, and problem-solving. Impairment in executive functioning makes it difficult to resist cravings, especially in the presence of behavioral triggers, cues, or stressful situations. Activation of the neurotransmitter glutamate initiates cravings and incentive salience and disrupts the influence of dopamine.
Theories of Addiction
Principles of behavioral theories, including classical and operant conditioning, are reflected in elements of the addiction cycle. Ivan Pavlov’s classical conditioning experiment in the 1890s demonstrated that dogs could be conditioned to salivate at the sound of a bell after successive pairings with food. The bell, initially a neutral stimulus, became a conditioned stimulus, and salivation became a conditioned response. This theory applies to addiction in the areas of incentive salience and cravings. Environments where substances are used contain various stimuli, including people and drug paraphernalia, that, through repeated pairings, begin to elicit conditioned responses. These cue-induced cravings drive individuals with substance use disorder to re-enter the cycle of abuse.
Pavlov’s theory provides an understanding of stimuli-related responses but fails to answer how addiction develops in those without any previous pharmacological history. In the 1930s, B. F. Skinner developed operant conditioning theory, suggesting that consequences or environmental contingencies shape a person’s behavior. An individual’s functional relationship with the environment is influenced by positive reinforcement, negative reinforcement, and punishment. These processes are used to select and maintain behavior and form the basis of contingency management, an evidence-based practice in which vouchers or monetary incentives are used as rewards for behavioral change.
In 1977, Albert Bandura developed social learning theory, a key contribution to understanding the psychosocial and cognitive aspects of addiction. Bandura proposed that interactions with both the environment and other people can greatly impact behavior. Building on Pavlov and Skinner’s work, Bandura introduced cognitive appraisal as a mediating factor. Through social facilitation, individuals learn by observing, imitating, and modeling others’ behavior, especially if the perceived consequences are positive. Positive consequences, such as social inclusion and acceptance, are powerful determinants for adolescents’ initiation into drug and alcohol use. Bandura’s concept of reciprocal determinism in addiction suggests that substance use is determined by three factors: (1) observing influential role models, (2) cognitive appraisal and internal factors, including self-efficacy, attitudes, and beliefs, and (3) the act of substance use itself.
Integrating the neurobiological, social, cognitive, and behavioral components of addiction helps conceptualize addiction as a chronically evolving biopsychosocial disorder.
We’ll now turn our attention to biopsychosocial risk factors associated with developing substance use disorder:
- Adverse childhood experiences (ACEs), which are potentially traumatic events in early childhood, including abuse, exposure to violence, poverty, and having a parent with a mental or substance use disorder
- Genetics, which account for 40%-60% of a person’s risk
- Insecure attachment
- Age of initial use, with early use increasing a person’s risk
- Difficulty with emotional regulation
- Poor academic achievement
- Social isolation and disconnection
- Impairment in executive functioning
- Co-occurring mental disorders
- Marginalized groups, such as members of the LGBT community, women, and people of color
- Cultural acceptance and the availability of substances, and
- Administration of substances through smoking or injecting
Evidence-Based Practices for Substance Use Disorder Treatment
When considering treatment approaches for substance use disorder, evidence-based practices integrate empirically supported research, clinical expertise, and patient characteristics and preferences, including cultural values, spirituality, age, and gender. The combined use of pharmacotherapy, when appropriate, and psychosocial interventions are the most consistent predictors of successful client outcomes in this population. This brief overview will be limited to treatment interventions that coincide with the biopsychosocial factors discussed earlier.
Pharmacotherapy
Medications that are used to treat alcohol use disorder include the following:
- Naltrexone: Naltrexone which blocks the euphoric effects of alcohol and does not require complete abstinence. Individuals do not have to be abstinent from alcohol to begin.
- Acamprosate: Acamprosate decreases cravings for alcohol by restoring balance to inputs from the inhibition-excitation neurotransmitters (i.e., glutamate, GABA). It is used to help individuals with alcohol use disorder maintain abstinence.
- Disulfiram (Antabuse): Disulfiram produces unpleasant side effects when alcohol is consumed, including vomiting, headaches, and shortness of breath.
Medications for opioid use disorder include:
- Buprenorphine, which reduces cravings
- Naltrexone, which blocks the effects of opioids, and
- Methadone, which reduces cravings, blocks the effects of opioids, and helps with withdrawal.
Naloxone and nalmefene are medications for opioid overdose reversal.
Psychotherapy
Common evidence-based practices for substance use disorder include contingency management, which was touched on earlier, cognitive-behavioral therapy (CBT), motivational interviewing, and twelve-step groups. CBT works by identifying and changing maladaptive thoughts, emotions, and behaviors contributing to substance use. Behavioral strategies involve coping with cravings, identifying triggers, problem-solving, counter-conditioning, emotional regulation, and relapse prevention skills.
CBT in the context of relapse prevention includes
- Evaluating the client’s abstinence violation effect, which occurs when relapse is viewed as a complete failure rather than a temporary setback
- Investigating seemingly irrelevant decisions or turning points leading up to high-risk situations
- Recognizing covert antecedents, which are subtle cues or emotional states that may lead to a relapse, and
- Outcome expectancy, which is when positive expectations of substance use outweigh negative expectations, outcomes, or consequences.
One method for addressing any of these four areas is the RAP technique, a form of cognitive restructuring leading to realistic, adaptive, and positive thinking.
One form of CBT is dialectical behavioral therapy (DBT). DBT emphasizes creating a therapeutic alliance to help individuals overcome substance abuse and trauma associated with co-occurring mental disorders. This goal is accomplished by examining and synthesizing “black-and-white” or “all or nothing” dialects required for acceptance and change.
There are four core DBT modules:
- Mindfulness: The foundation of all DBT skills, mindfulness, focuses on nonjudgmental acceptance of the present moment. This helps individuals become aware of their thoughts, feelings, and actions without being overly reactive or overwhelmed by them.
- Distress Tolerance: Distress tolerance helps individuals manage and survive crises without making things worse. It involves techniques for tolerating pain and difficult emotions in stressful situations where immediate change is not possible.
- Emotion Regulation: Emotional regulation teaches individuals how to better understand and manage their emotions. It includes strategies to identify, reduce vulnerability to, and regulate intense emotions that might otherwise lead to destructive behavior.
- Interpersonal Effectiveness: Interpersonal effectiveness focuses on improving relationships and communication skills. It helps individuals assert their needs, set boundaries, and deal with conflict effectively, all while maintaining self-respect and healthy relationships.
These four modules together are designed to help individuals develop healthier ways of coping with stress, emotions, and interpersonal challenges.
Motivational interviewing (MI) is a strengths-based approach that explores client ambivalence toward abstinence, harm reduction, and recovery. MI is based on the principles of empathy, client autonomy, unconditional positive regard, and collaboration. Counselors collaborate with clients to determine differences between their current substance use and personal values and goals. This is accomplished by asking open-ended questions and providing affirmations, reflections, and summaries, which is represented by the acronym OARS.
Counselors using MI avoid confrontation and coercion, focusing instead on examining the individual’s resistance or what keeps them in the problem. They use flexible pacing to stay in sync with the client, resisting the urge to jump ahead or push them forward. Instead, counselors discuss the individual’s desire, ability, reasons, and need for change.
Mutual support groups, such as 12-step groups, are available online and in-person for various addictions, with Alcoholics Anonymous being the most common. The only requirement for AA membership is a desire to stop drinking. AA meetings are led by members on a volunteer basis, with rotation of service encouraged. Mutual support is developed as members share their experience, strength, and hope with one another. Concepts associated with social learning theory include observing and adopting coping skills, relapse prevention, and developing a healthy network of peers.
I hope this video was helpful in understanding concepts associated with addiction and substance use disorder.
Thanks for watching, and happy studying!
