Chapter 11: Substance Use and Addiction

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Welcome to the Deep Dive.

We're here to make complex mental health topics really clear and hopefully quite useful.

Absolutely.

Today we're diving deep into something huge.

Substance use and addiction, it's, you know, everywhere in mental health discussions.

It really is.

And often so misunderstood.

Right?

Lots of judgment attached.

Exactly.

But it's way more complex than just willpower or morality.

It involves biology, our minds, our society, the whole picture.

So our mission today, especially for those of you studying mental health, is to give you a clear kind of engaging shortcut through a key chapter on this from psychopathology and mental distress.

We want to get beyond those simplistic views.

Really unpack addictions many facets, the brain science, the social stuff, everything.

Yeah.

We'll walk you through the big theories, how it's diagnosed, cultural points, treatments.

And always connect it back.

How does this theory look in the real world?

What does it mean for someone actually going through this or for you as a future clinician?

Right.

Because our understanding has shifted so much.

It's not just seen as a, you know, a moral failing anymore.

Hmm.

Not at all.

And we'll touch on how history shape things, the debates that are still happening, even in how we define it in the diagnostic manuals.

OK, let's start there then.

Definitions.

What about the word addiction itself?

It gets thrown around a lot.

It does.

And interestingly, it's often not a formal diagnostic label these days.

It's become, well, a bit loaded.

So how do professionals define it?

Well, you see different takes.

The American Society of Addiction Medicine calls it a treatable chronic medical disease.

Very much a brain and biology focus there involving genetics,

environment, life experiences.

OK, a medical disease.

But then look at the UK's NHS.

They say it's simpler.

Not having control over doing, taking, or using something to the point where it could be harmful.

Much more about control and harm.

Huh.

So different angles right from the start.

Exactly.

And historically, we mostly talked about drugs, right?

But that's broadened out massively.

Yeah.

Now we hear about gambling, shopping, internet use.

But before we get there, let's quickly revisit that older distinction.

Substance abuse versus dependence.

Still useful sometimes.

I think so, for understanding the history in some concepts.

Abuse was traditionally about the consequences of misuse.

Failing at work or school, doing risky things like drunk driving.

Like that case study, Walder.

The businessman drinking constantly gets a DUI.

Precisely.

His actions fit that abuse picture too much, too often, causing clear problems.

Okay.

And dependence.

Dependence was seen as needing the substance, physically or psychologically.

The big signs are tolerance.

Needing more to get the same effect.

Right.

Like needing more coffee just to feel awake.

And withdrawal, those nasty symptoms when you stop.

Headaches from stopping caffeine are a mild example.

So abuse is the negative impact.

Dependence is the inability to function without it, basically.

Yeah, that's a good way to put it.

The Hazelden Betty Ford Foundation said,

abuse is too much, too often.

Dependence is the inability to quit.

It captures that difference.

Got it.

And now, that concept of addiction has stretched beyond substances.

Behavioral addictions.

That started gaining traction.

In the 90s.

Around then, yes.

And the criteria sound familiar.

Disrupts your life, causes distress, potential harm.

You feel you can't control it, and it's not just a symptom of something else.

Like Pedro, the gambler.

Or Liam, with the video games taking over.

Exactly.

Or Deanna, whose shopping is causing debt and family issues.

These behaviors are causing real impairment.

But isn't this where it gets tricky?

The whole pathologizing everything debate?

Like, is eating too much chocolate an addiction?

That's the million dollar question.

Where's the line?

Experts really debate this.

Are these truly addictions like substance use disorders?

Or maybe more like impulse control problems?

Or even just extreme versions of normal behavior.

And that has real implications for diagnosis treatment.

Absolutely.

It affects everything.

Okay, let's do a quick tour of the major substance classes.

Not every detail, but the key effects and impacts.

Starting with depressants, they slow things down, right?

Yep.

Slow down the central nervous system.

And the big one, globally, is alcohol.

Been around forever, practically.

How does it work, generally?

It boosts GABA, an inhibitory neurotransmitter, makes you feel relaxed, less inhibited.

That's the initial buzz.

But it also messes with glutamate and dopamine.

As you drink more, judgment, coordination, speech, they all go downhill.

And the consequences can be severe.

Hugely.

Millions of deaths worldwide each year.

Then there's fetal alcohol syndrome in babies exposed in the wound growth issues, developmental delays, distinct facial features.

And for the person drinking long term.

Really serious risks.

Liver damage like cirrhosis, which is irreversible.

Korsakoff syndrome, where thiamine deficiency destroys memory.

And dangerous withdrawal like delirium tremens, the DTs.

Walter's story with the DUI and crumbling marriage really shows that impact on daily life.

What about other depressants?

Like sedatives?

Well, the older ones, barbiturates, were super addictive and dangerous.

Mostly replaced now by benzodiazepines, think Valium Xanax.

Safer, but still risky.

Definitely safer in overdose, but still habit forming.

They also work on GABA, used for anxiety, sleep, need careful monitoring.

Okay.

Switching track stimulants.

The opposite effect.

Right.

They speed up the central nervous system.

Think euphoria, alertness, energy boost.

But also restlessness, irritability, even paranoia, especially in high doses.

Like cocaine.

Cocaine's a powerful one.

From the coca plant.

Then you have lab -made amphetamines like meth.

They flood the brain with dopamine, norepinephrine, serotonin.

Intense highs, very addictive.

Though some amphetamines are used medically.

Yes, for ADHD, for instance.

And MDMA or ecstasy is even being researched for PTSD therapy, though it also carries risks and hallucinogenic properties.

What about more common stimulants?

Nicotine and tobacco.

Hugely addictive.

Major dopamine hit.

Massive health risks, cancer, heart disease.

And caffeine.

A coffee, tea, soda.

The world's favorite psychoactive drug.

It works differently, blocks adenosine, gives that mild alertness.

You can get tolerant and have withdrawal, those caffeine headaches are real.

Okay.

Next up, opioids.

Painkillers, right.

But more than that.

Much more.

They mimic our natural endorphins, cause euphoria, drowsiness, mess with memory, big potential for addiction.

You've got natural ones like morphine and codeine from opium.

Then semi -synthetics like heroin, incredibly addictive, nasty withdrawal.

And prescription ones like oxycodone, a huge part of the opioid crisis.

And fully synthetic ones like fentanyl, which are incredibly potent and driving up overdose deaths dramatically.

It's a terrible crisis.

Aisha's case really hits this home.

In jail, trembling, sweating, classic withdrawal.

Exactly.

Her story shows how opioid use can spiral, leading to desperate acts like stealing.

Alright, what about hallucinogens or psychedelics?

These fundamentally change perception.

Hallucinations, altered sense of self, sometimes paranoia, synesthesia, like hearing colors.

Things like LSD, magic mushrooms.

Cellicivan is mushrooms.

They mainly work on serotonin receptors.

Historically linked to the 60s counterculture, but now there's a renewed interest in their therapeutic potential for depression, trauma.

Are there risks?

Oh yes.

Bad trips, potential for flashbacks, lucid and persisting perception disorder, and others like PCP or angel dust are quite different, riskier, can trigger psychosis.

Catamine is related, used medically but also recreationally.

Okay, last big category,

cannabis,

marijuana.

Derived from the hemp plant.

The main psychoactive bit is THC.

It's complicated,

acts a bit like a stimulant, depressant, and psychedelic.

How does it work?

It affects GABA, glutamate, and definitely dopamine.

Gives that mild high relaxation, altered perception, but higher doses.

Can bring on paranoia, even psychosis in some people.

Is it addictive?

It's always debated.

The science says yes it can be.

Regular users build tolerance.

They experience withdrawal, irritability, anxiety, sleep problems, appetite loss.

And today's cannabis often has much higher THC levels, increasing that risk.

Which leads straight into the legalization debate.

It's heated.

Very.

On one side, people point to medical uses, pain, nausea from chemo, glaucoma, argue it's safer than alcohol or tobacco.

Saves money on prosecutions.

Might even reduce opioid use, though that's debated.

And the arguments against?

Concerns about increased car accidents, ER visits post -legalization, potential negative effects on teen brain development, links to depression, anxiety, the whole gateway drug idea, though evidence there is mixed.

So science gives us data,

but the decision is bigger than that.

It involves values, politics,

weighing different kinds of risks and benefits.

No easy answer.

One last thing here, poly drug use.

Using multiple drugs.

Super common.

And really ups the danger.

A huge chunk of overdose deaths involve more than one substance.

Why is it so dangerous?

Two main reasons.

Cross tolerance, being tolerant to alcohol, might make you tolerant to benzos, too.

And synergistic effects, the drugs combined have a much bigger impact than either alone.

Like alcohol and sedatives.

A classic deadly combo.

Or speedballing, mixing a stimulant like cocaine with an opioid like heroin.

Massive dopamine surge, massive overdose risk, like Katya Sukunova, the violinist, who died from that kind of mix.

Really tragic.

Wow.

Okay, so that's the landscape of substances.

How do the big diagnostic manuals, the DSM and ICD, actually classify these problems?

You mentioned they differ.

They do.

And it reflects those ongoing debates.

The ICD -11, the international classification, it still keeps a distinction.

It talks about harmful use,

basically.

Using in a way that causes damage, physically or mentally.

Like the old abuse idea?

Kind of, yeah.

Ongoing misuse causing problems.

And then it has dependence, where use becomes compulsive, takes priority, and you see tolerance and withdrawal.

That's closer to the old dependence idea.

So ICD separates using problematically from being dependent.

What about the DSM -5TR, used more in the U .S.?

The DSM took a different path.

Controversially, it merged abuse and dependence into one category.

Substance use disorder.

Just one diagnosis.

How do they differentiate, then?

By severity, mild, moderate, or severe.

Based on how many criteria someone meets out of 11.

These criteria cover things like loss of control over use, social problems caused by use, risky use, and the physical stuff like tolerance and withdrawal.

So Walter, with his drinking affecting his life and causing risky behavior like the DUI, he'd likely meet criteria for?

Alcohol use disorder.

Almost certainly.

And Aisha, with her opioid use, stealing, and clear withdrawal, that points strongly to opioid use disorder.

The criteria are pretty similar across different drugs.

And this difference between DSM and ICD, it actually matters in practice, right?

For diagnosis, treatment planning.

Absolutely.

And we should also remember, substance use disorders very often co -occur with other mental health issues.

Depression, anxiety, PTSD, personality disorders.

It's rarely just one thing.

What about those behavioral addictions we mentioned?

How do they fit into the manuals?

It's still evolving.

The DSM -5 -KR only officially includes gambling disorder.

Pedro's situation fits that persistent gambling causing major problems.

Only gambling?

What about gaming?

The DSM lists internet gaming disorder as needing more study.

But the ICD -11 did add gaming disorder, compulsive gaming taking over life, despite negative consequences, like Liam's case.

So the field is still figuring out how to classify these non -substance behaviors.

Definitely.

And other frameworks exist too.

HITA might see substance issues as part of a broader disinhibited externalizing pattern, impulsivity basically.

The PTMF framework might view it as a way people cope with trauma or social inequality through lenses.

Let's shift perspective again and look back at history.

How do we get to our current understanding?

Drug use itself isn't new.

Not at all.

It's ancient.

Across cultures.

Alcohol, psychoactive plants, used for rituals, medicine, recreation for millennia.

But how societies viewed problematic use, that's changed.

The moral model was dominant for a long time.

For centuries.

Addiction is a sin.

A weakness of character.

A crime.

Honestly, that view hasn't entirely disappeared.

It still fuels stigma and influences drug laws.

But then the illness model emerged.

Right.

The idea of addiction as a disease.

Dr.

Benjamin Rush, way back in the late 1700s, called alcoholism a disease, argued for compassion abstinence.

He was ahead of his time.

And that idea gained ground.

Slowly.

It influenced temperance movements.

Later, people like E .M.

Jelinek and Marty Mann really pushed to frame alcoholism as an illness in the public eye.

And that model is largely dominant now, at least in healthcare.

And this ties into the founding of Alcoholics Anonymous, AA.

Absolutely.

Bill W.

co -founded AA in the 20th century.

This is the first 12 -step program.

Views addiction as a disease, recovery through peers, spirituality, abstinence.

It wasn't immediately embraced by medicine, though.

No.

There was tension.

But its impact on recovery culture has been immense.

Okay, let's get into the why.

Biological perspectives.

What's happening in the brain?

Dopamine seems key.

Hugely important.

The dopamine hypotheses focus on the mesalamic pathway,

the brain's main reward circuit.

Addictive drugs tend to flood this pathway with dopamine.

There are different theories about how dopamine is involved.

Yes.

One idea, the reward deficiency syndrome, suggests some people might have naturally lower dopamine function.

So they use drugs to feel normal or get that reward hit they struggle to achieve otherwise.

Makes sense.

What's the other main theory?

The incentive sensitization theory.

This one's interesting.

It suggests that drug use doesn't just boost dopamine temporarily.

It makes the system itself more sensitive to drug cues and the wanting of the drug.

So the craving gets stronger, even if the pleasure decreases.

Exactly.

The wanting becomes disconnected from the liking.

The drug hijacks the system, creating this intense drive to seek it out, making relapse so common.

The brain itself changes.

But it's not just dopamine, right?

No, it's more complex.

Glutamate is involved, especially in relapse.

Serotonin, norepinephrine, GABA, they all play roles in reward motivation control.

And research is finding similar brain chemistry patterns in behavioral addictions, too, like gambling.

It points towards shared underlying mechanisms.

So how do we intervene biologically?

Detox is usually step one.

Often, yes.

Safely managing withdrawal, weaning someone off the substance usually needs medical support.

But detox alone is rarely enough.

What comes after medications?

Medications can help prevent relapse.

Antagonist drugs block the effects of the substance or reduce cravings.

Think now Trexone for alcohol or opioids.

What about making someone sick if they use, like, anti -abuse for alcohol?

Thisulfuram, yeah.

It causes nausea, vomiting if you drink alcohol.

The problem is people often just stop taking the pill.

Adherence is tough.

Are there drugs that substitute for the addictive one?

Yes.

Drug replacement therapies,

like nicotine replacement patches,

gum to gradually reduce nicotine dependence.

And for opioids,

methadone.

Methadone maintenance therapy, or MMT, is a key example.

Also buprenorphine.

You replace heroin or fentanyl with these medically supervised,

safer, longer -acting opioids.

Is the goal abstinence or something else?

Often it's harm reduction.

Stabilize the person, reduce illegal use, lower risks like HIV from needles, help them function better.

Abstinence might not be the immediate goal for everyone.

Does it work?

It can be very effective for harm reduction and stability.

But dropout rates can be high.

That's why combining it with therapy is so important.

For someone like Asha, MMP could keep her safer.

But therapy helps address the underlying issues and stick with treatment.

What about genetics?

How much does that play a role?

A significant amount.

Heritability estimates for addiction are often cited around 40 -60%.

If you have a close relative with a substance use disorder, your risk is substantially higher.

Maybe four to five times higher.

Are specific genes identified?

Researchers have found links to genes involved in dopamine pathways, alcohol metabolism, nicotine receptors, opioid receptors, lots of candidates.

But it's complex, not just one addiction gene.

And an evolutionary take.

The harmful dysfunction model suggests our brains evolved reward systems long before encountering potent modern drugs or stimuli like the internet.

These things hijacked the system in ways it wasn't designed for, leading to dysfunction, hence addiction as a disorder arising from these novel inputs.

This brings us back to that big debate.

Is addiction fundamentally a chronic, relapsing brain disease?

Yeah, it's a core tension.

Critics say calling it purely a brain disease removes personal responsibility, choice.

They argue people can choose to stop, that rewards don't compel behavior.

But the defenders of the model?

They'd argue that while choice isn't totally gone, the biological changes caused by vulnerability and drug use severely impair that ability to choose.

The brain changes disrupt self -control.

It's not about blaming, but understanding the biological constraints.

It echoes that old moral versus illness debate, really.

And a critique of purely biological models is they can ignore the context.

Right.

Critics say you can't understand addiction without looking at poverty, trauma, social pressures, the availability of drugs or gambling, etc.

The defenders agree context matters, but argue the brain is where all these factors ultimately converge and have their effects.

Okay, let's move into the psychological perspectives.

How do they explain addiction?

Psychodynamic views often mention self -medication.

Exactly.

The idea that people use substances to cope with underlying emotional pain, unconscious conflicts, maybe from childhood trauma or attachment issues.

They might struggle to even identify or express feelings, that's alexithymia.

So using alcohol to numb sadness or stimulants to combat boredom?

Something like that.

For Pedro the gambler, a psychodynamic lens might explore unconscious needs related to his father, feelings of inadequacy driving the risky behavior.

Therapy aims to bring those issues into awareness.

What about the addictive personality idea?

Does that hold up?

It's heavily debated.

Many experts argue there's no single personality type that predicts addiction, but others point to associated traits, impulsivity, sensation seeking, poor coping skills, high anxiety.

The debate continues, partly because the label can be stigmatizing.

Let's look at cognitive behavioral perspectives, CBT.

How do they view it?

Behaviorally, drugs are seen as powerful reinforcers, initially positive the high.

Later, negative reinforcement takes over using to avoid withdrawal.

Cognitively, it's about tackling the thoughts, beliefs, and expectations that few will use.

What are some key CBT techniques?

Contingency management uses rewards for staying clean, like vouchers for negative drug tests, quite effective while it's active.

Social skills training helps people handle social situations without needing substances.

And relapse prevention, that seems crucial.

Absolutely vital.

RP teaches people to identify their personal high -risk situations, specific people, places, feelings, events that trigger cravings.

Then you develop coping strategies.

Like for Aisha, seeing her old dealer.

Classic high -risk situation, RP would help her anticipate that, have a plan,

maybe avoid that area, practice saying no, call a sponsor, use distraction techniques.

It's about building self -efficacy belief in your ability to cope.

And cognitive therapy itself.

That digs into the automatic negative thoughts, I need a drink to relax, intermediate beliefs, if I don't drink I'll be awkward,

and core beliefs, I'm not good enough,

that drive the behavior.

Then you work on challenging and changing those thoughts.

Like Walter's thoughts about needing to be the life of the party or feeling unlovable.

Exactly.

CT would help him examine and revise those beliefs, maybe combined with social skills training and relapse prevention.

What about humanistic approaches, motivational interviewing, MI comes up a lot.

MI is huge.

It's very client -centered, empathetic, non -confrontational.

The therapist doesn't push change, but helps the person explore their own ambivalence, the gap between their values or goals and their actual behavior.

Using techniques like open questions, affirmations.

The ORS acronym, open questions, affirm, reflect, summarize.

It's often used with the trans -theoretical model of change.

Understanding where someone is in their readiness to change.

From pre -contemplation, not thinking about it, to maintenance,

sustaining change.

Like with Liam, the gamer.

Yeah, an MI therapist wouldn't argue about the gaming.

They'd listen, reflect his feelings, maybe help him see how his desire for friends clashes with spending all his time gaming.

It empowers him to find his own motivation.

And these psychological therapies, CBT, MI, they're effective.

Yes, they're strong evidence for them.

Often just as effective as medication for many people.

This brings up another big question.

What defines success?

Is it always total abstinence?

That's the traditional goal, especially in 12 -step programs.

But it's not the only view.

Controlled drinking or moderation management suggests some people can learn to reduce their use to non -problematic levels.

And harm reduction.

Harm reduction focuses on minimizing negative consequences, even if use continues.

Think needle exchanges for IV drug users.

Providing safe transport for drinkers.

The priority is safety and health.

Not necessarily immediate abstinence.

Is there evidence for these alternatives?

It's growing.

A big 2021 review suggested controlled drinking goals can be as effective as abstinence goals for some people with alcohol issues.

It challenges old assumptions and emphasizes tailoring goals to the individual.

Okay, finally, let's widen the lens again to use sociocultural perspectives.

How do things like poverty and discrimination fit in?

There are massive factors.

Stress from poverty, racism, lack of opportunity.

It significantly increases vulnerability to substance use as a coping mechanism.

We saw this starkly during the pandemic.

And it affects treatment, too.

Definitely.

People from marginalized groups often face more barriers to accessing care and can have worse outcomes.

Addressing these social inequalities is crucial for prevention and effective treatment.

That's where prevention and early intervention programs come in.

Like screenings, education, restricting access.

Yes.

And programs like Reclaiming Futures that work with youth in the justice system, addressing social factors alongside treatment.

What about therapeutic communities, TC's?

These are typically residential programs for people with serious, often co -occurring issues.

They focus on the whole person, therapy, medical care, job skills, family work.

The idea is re -socialization, learning healthier ways to live.

A place like that could be good for someone like Aisha after detox?

Potentially, yes.

Learning coping skills, communication, getting practical support in a structured environment.

We also have to talk about stigma.

It's huge with addiction.

Absolutely enormous.

People with addictions are often seen as reckless, unreliable, morally flawed.

That stigma gets internalized, makes people ashamed, less likely to seek help, and affects recovery.

Is it worse for behavioral addictions?

Often, yes.

There can be more blame.

You should just be able to stop shopping gambling.

Like with Deanna, feeling intense shame about her shopping, a therapist needs to actively counter that narrative.

And then there are the 12 -step programs, AA, NA, GA.

Self -help, peer -led groups.

Based on the idea of addiction as a disease, needing a spiritual solution, often a higher power,

rigorous honesty, making amends, helping others, and total abstinence, they follow the 12 steps.

How effective are they?

It's hard to study, right?

Anonymity?

Historically hard to study systematically.

But that big 2020 review by Kelly and colleagues actually found strong evidence that AA participation leads to higher rates of continuous abstinence compared to other treatments or no treatment.

Quite a significant finding.

Despite criticisms, like the spiritual focus, the disease model, the demographics sometimes being less diverse.

Yes, those criticisms exist.

Some find the spiritual angle off -putting or feel the model doesn't fit them.

But for millions, it's been lifesaving.

StuW's story in the text really highlights that journey of desperation, finding AA the struggle, but ultimately finding connection and sobriety.

That personal story is powerful.

Lastly, systems perspectives, like family therapy.

Yes, like multi -dimensional family therapy, MDFT, for adolescents.

It works not just with the teen, but with parents, the whole family, and even schools and courts.

Recognizes the problem exists within interconnected systems.

Good research support, too.

So sociocultural factors are clearly vital.

Absolutely.

Poverty, culture, family, stress.

They shape who uses, why, and how they fare.

But it's not deterministic.

Not everyone facing adversity develops addiction.

Individual biology and psychology are still critical pieces of the puzzle.

What an incredible journey through such a complex area.

We've covered so much from defining addiction, the different substances,

diagnostic debates, historical shifts.

To the biology of the brain, the power of psychological therapies like CVT and MI, and the crucial role of social context, stigma, and community support like AA.

It really drives home that understanding addiction needs this multifaceted lens.

You can't just look at one piece.

Truly.

Which leads to a final thought, perhaps for you listening.

Given everything we've discussed, the biology, the psychology, the social forces,

how can we as a society really move from seeing addiction mainly as a personal failing?

To treating it as the complex public health challenge it is.

One that needs integrated,

compassionate, evidence -based solutions.

What does that shift look like in practice?

That's a powerful question to sit with.

Especially for anyone planning a career in mental health, how do you bring all these perspectives together to truly help?

Exactly.

Well, thank you so much for joining us on this deep dive today.

We hope it's been insightful.

Keep exploring.

Keep questioning.

And keep learning.

We'll catch you next time.