Chapter 11: Substance Use and Addiction

Raskin provides an in-depth exploration of substance use and addiction, covering drugs, behavioral addictions, diagnostic systems, historical perspectives, biological and psychological theories, and treatment approaches. Case studies highlight alcohol abuse (Walter’s dependence and denial), opioid addiction (Ayesha’s withdrawal and theft), gambling disorder (Pedro’s compulsive betting), gaming disorder (Liam’s excessive online play), and compulsive shopping (Deanna’s financial collapse). Key terms such as addiction, abuse, and dependence are defined, with ICD-11 distinguishing “harmful use” from “dependence” and DSM-5-TR consolidating them into a single “substance use disorder.” The chapter reviews major drug classes: depressants (alcohol, barbiturates, benzodiazepines), stimulants (cocaine, amphetamines, MDMA, nicotine, caffeine), opioids (morphine, heroin, oxycodone, fentanyl, methadone), hallucinogens (LSD, psilocybin, mescaline, PCP, ketamine), and cannabis (THC, CBD), detailing their physiological effects, neurotransmitter systems, tolerance, withdrawal, and public health consequences. Concepts of polydrug use, cross-tolerance, and synergistic effects are explained, including the dangers of speedballing. Behavioral addictions beyond substances—gambling, gaming, sex, shopping, eating, and internet use—are evaluated, with DSM and ICD diverging on inclusion. Historical perspectives trace drug use from ancient societies to modern debates over the moral versus illness models of addiction, the founding of Alcoholics Anonymous (AA), and the spread of 12-step programs. Biological perspectives focus on dopamine hypotheses (reward deficiency syndrome, incentive-sensitization), the mesolimbic dopamine pathway, neurotransmitters (glutamate, serotonin, norepinephrine, GABA), genetics (heritability estimates 40–60%), evolutionary accounts (harmful dysfunction model), and immune system links (inflammation, gut microbiota). Treatments include detoxification, antagonist drugs (naltrexone, disulfiram, acamprosate, NAC), drug replacement therapies (nicotine replacement, methadone maintenance), and harm reduction strategies. Psychological perspectives include the self-medication hypothesis (substance use as coping with trauma or alexithymia), debates over the addictive personality, CBT methods (contingency management, social skills training, relapse prevention, cognitive therapy), and motivational interviewing (MI) combined with the transtheoretical model of change. Sociocultural perspectives highlight poverty, discrimination, systemic oppression, and social justice responses such as prevention programs, therapeutic communities, and Reclaiming Futures for juveniles. Service user perspectives examine stigma, debates over controlled drinking vs abstinence, harm reduction, and lived experiences of recovery. Systems perspectives, including multidimensional family therapy (MDFT), demonstrate the importance of family and community in addressing addiction. By integrating biological, psychological, social, cultural, and historical approaches, this chapter shows that addiction is not a single disorder but a complex interplay of brain, behavior, meaning, and context.