Verified by Substance-Related Disorders
Substance-related disorders are common, affecting 40.3 million people over the age of 12 in the United States. Addiction may involve the use of prescribed drugs, such as opioid painkillers, common substances such as alcohol, or illicit substances such as heroin and cocaine. Problem behaviors such as gambling are typically included in this category because they share key neurobiological and behavioral features involving brain pathways of reward and reinforcement.
A person with an addiction uses a substance, or engages in a behavior, for which the rewarding effects provide a compelling incentive to repeat the activity, despite detrimental consequences to physical health, everyday activities, and social obligations and relationships. Substance-related disorders are diagnosed when the use of any substance or behavior leads to significant impairment or distress. Both substance use disorders and gambling behaviors are often accompanied by mental health conditions such as depression and anxiety. Because addiction affects the brain’s executive functions, individuals who develop an addiction may not be aware that their behavior is causing problems for themselves and others.
Although addictions often induce feelings of hopelessness and of failure, as well as of shame and guilt, recovery is the rule rather than the exception. There are many routes to recovery. Individuals can achieve improved physical, psychological, and social functioning on their own—so-called natural recovery. Others benefit from the support of community or peer-based networks. And still others achieve recovery with the help of clinical services of credentialed professionals.
Stopping substance use typically ushers in a period of acute and often all-consuming psychological and physical distress—generally referred to as withdrawal—that subsides in days or weeks. Withdrawal symptoms, ranging from anxiety, tremors, and nausea to hallucinations and frank seizures, differ significantly depending on the type of drug used, how long it is used, and how potent it is. The unpleasantness of withdrawal symptoms often drives continued use of drugs, and people undergoing withdrawal often need intensely supportive care.
Substance use disorders are currently defined according to the class of drug that is used, such as opioid use disorder, stimulant use disorder, sedative use disorder, and more. Although the DSM distinguishes 10 substance use disorders, all share the defining features of addiction: They directly and intensely involve reward and reinforcement systems of the brain, and they stimulate compulsive use that typically leads to the neglect of normal activities and negative consequences. With some variation, they also share common symptoms.
Alcohol use disorder is the most common substance use disorder, particularly among adult men, although rates are rising among women. Alcohol is the drug of choice among adolescents and young adults, who are especially prone to experience the ill effects binge-drinking.
Opioid use disorder includes addiction to the illicit drug heroin and to prescription pain-relievers such as oxycodone, codeine, morphine, and fentanyl. According to the American Society of Addiction Medicine, opioid-related overdoses are the leading cause of death in Americans under 50 years of age, and prescribed opioids are the “overwhelming initial source” of addiction.
Substance-related disorders are generally divided into two groups: substance-induced disorders and substance-use disorders. Substance-induced conditions include:
- intoxication
- withdrawal
- other mental disorders that can be caused by medication or other substances, such as psychotic disorders and sleep disorders
Substance use is not, by itself, a disorder. According to Diagnostic and Statistical Manual of Mental Disorders (DSM-5), it becomes a disorder when use of a substance eludes control and interferes with functioning. The DSM shuns the term addiction (but nevertheless refers to addictive disorders), instead preferring the term substance use disorder, and categorizes 10 distinct such conditions depending on type of drug involved—for example, Alcohol Use Disorder; Stimulant Use Disorder, including use of cocaine; Opioid Use Disorder, including heroin.
Whether the substance involved is crack cocaine or alcohol or a behavior such as gambling, the common denominator of all addictions is continued use despite the development of negative consequences—whether to self, relationships, finances, school or work performance—and the inability to control use. The DSM notes that all 10 substance use disorders “produce such an intense activation of the reward system that normal activities may be neglected.” Continued use also leads to changes in the brain’s wiring that, while ultimately reversible, make quitting difficult and underlie the repeated relapses and intense drug cravings experienced by many users attempting to quit.
How each of the 10 types of drug acts in the body is different, but the behavioral symptoms, including those associated with gambling, all overlap. Another common feature is the persistence of changes in brain circuitry well beyond the time it takes for all traces of the substance to leave the body; studies show that it can take months or more after stopping use for the brain to rewire itself so that it can respond to normal rewards.
Substance use disorder is marked by a pattern of pathological behaviors related to use of the substance. As listed in the DSM, they include:
• Being unable to stop taking a substance, even when wanting to cut down or regulate use or having tried several times
• Worrying about the next dose or getting a consistent supply of the substance
• Experiencing intense cravings at any time, but especially in places where the drug was once obtained or used
• Devoting considerable time to getting, taking, or recovering from drug
• Neglecting roles and responsibilities such as work, school or home obligations
• Experiencing interpersonal problems as a result of substance use
• Changing social patterns, withdrawing from family, friends and activities in order to use a substance
• Facing risky situations to become intoxicated or maintain a supply of drug
• Using a substance despite knowing it causes physical or psychological harm to oneself
• Developing tolerance, requiring more drug to get an effect; a common but not invariable feature of addiction, sometimes called adaptation
• Developing the unpleasant physiologic symptoms of withdrawal—shakiness, sweating, queasiness or vomiting, headache—when unable to take the substance. A highly variable sign of addiction; withdrawal occurs with use of some drugs (alcohol, for example) but not others (cocaine); however, it often drives continuing use. Withdrawal can require medical treatment when a person abruptly stops heavy substance use.
Along with the diagnostic signposts of addiction, those addicted typically display a number of other behavioral characteristics:
• Secretiveness about activities and relationships as well as private space, to conceal drug use
• Sudden changes in activity patterns, refusing participation in activities once enjoyed
• Lying about whereabouts, absences, consumption habits; making excuses for unusual behavior
• Loss of energy or motivation
• Neglect of appearance
• Stealing to support drug purchases.
A cardinal sign of addiction is the inability to control consumption of alcohol/drug—even when one wants to. In addition, addiction is typically marked by urges or craving—wanting a substance so badly it becomes difficult to think about anything else.
Intoxication has its own distinctive psychological manifestations—from belligerence and mood lability to impaired judgement and “absent presence.” They result from the effects of the substance on the central nervous system. Those who are high also display perceptual disturbances, problems with attention, disrupted thinking patterns and easy confusion, as well as difficulties relating to others.
Addiction can reveal itself in physical signs as well as psychological and behavioral ones, although they are not diagnostically specific for the condition. Substance users may have dilated pupils or glazed eyes, slurred speech, and ramble when they talk. They can show changes in movement patterns—depending on the type of substance involved, psychomotor retardation (heroin) or jumpiness (cocaine). Substances users often become so preoccupied with getting and using that they forego eating and suddenly lose weight. Another sign of addiction is a shift in sleep and wake patterns—sleeping too much or too little, or at unusual times.
By itself, substance use is not a disorder. It becomes an addiction when a person can no longer control the use, when they attempt to cut back but have difficulty doing so, and when use impinges on everyday activities—work, school, relationships. That point differs from person to person, and not everyone who uses a substance becomes addicted. Addiction does not hinge on the amount of drug consumed but on the ability to control its use.
Terminology about addiction can be confusing, and these terms are now synonymous. Terms that are used in common parlance may have more precise meanings within the medical world; moreover, officially sanctioned terms themselves undergo change, usually as a result of evolving understanding about the nature of disorders. With the publication of the fifth edition of the DSM in 2013, the American Psychiatric Association renamed substance abuse and substance dependence as substance use disorder. And while it officially eliminated the term addiction, it refers to substance use disorders as addictive disorders. The definitive terminology will not be written until neuroscience fully understands the nature of repetitive behaviors.
It can be hard for a person to admit they have an addiction: Most people feel great shame about having a problem that eludes their control. There are common behavioral signs suggesting that someone is struggling with a substance use disorder.
• Strained relationships with family and longstanding friends
• Problems with school or work responsibilities and performance
• Stealing drugs or alcohol or money to purchase them
• Lying to friends and family about whereabouts
• Negative changes in appearance
The DSM-5 identifies 10 distinct substance use disorders:
• Alcohol Use Disorder
• Caffeine-Related Disorders
• Cannabis Use Disorder
• Hallucinogen-Related Disorders, including Phencyclidine Use Disorder
• Inhalant Use Disorders
• Opioid Use Disorder, encompassing heroine, morphine, codeine, oxycodone, fentanyl
• Sedative-, Hypnotic-, or Anxiolytic Use Disorder, encompassing all prescription sleeping medications and almost all prescription antianxiety medications.
• Stimulant Use Disorder, encompassing amphetamine-type substances and cocaine
• Tobacco Use Disorder
• Other (or Unknown) Substance Use Disorder, encompassing substances from antihistamines and betel nuts to nitrous oxide and steroids—any psychoactive substance that is repeatedly used despite the development of serious problems from its use.
Research makes it clear: There is no single cause of substance abuse disorder. There is no way to predict who will develop compulsive substance use or gambling behavior. Addiction is a multi-faceted condition, arising from the confluence of many elements—the most obvious being exposure to an addictive agent. Risk factors for the development of substance abuse disorders include:
• Biological factors, among them variability in genes that determines the makeup of brain receptors for the neurotransmitter dopamine, the nature of the body’s hormonal response to stress; and variations in liver enzymes that metabolize substances.
• Psychological factors, including personality characteristics such as impulsivity; a history of trauma and other significant adverse experiences; and susceptibility to anxiety.
• Environmental factors, such as accessibility to substances; the nature of peer groups and social relationships; and employment status (unemployment is destabilizing and demoralizing).
Drug problems are linked to a person's age and life stage as well as to the availability of opportunities for the future. As a 2017 report by the National Academies of Sciences, Engineering and Medicine observed, “The opioid epidemic's toll is felt across the life span and in every sociodemographic group, but more heavily burdens vulnerable populations, such as those in economically depressed areas of the country.”
Surveys show that, in industrialized countries, illicit drug use is primarily a problem of young males between the ages of 18 to 25. Prescription drug use is a problem more among middle-aged and older women.
Many people with substance-use disorders have more than one addiction or mental health issue. Children of parents with substance-use disorders are at higher than average risk of developing the disorders themselves
When looked at through the largest and least judgmental lens, addiction is considered an attempt—a nonproductive attempt—to solve a problem: It offers relief from shyness, pain, relationship difficulties, shortage of life opportunities, losses and failures of any kind, and much more. From that perspective, it is a sign of inability to cope with a stressor; That is why acquisition of coping skills is always a component of successful treatment.
To some degree, biological factors play a role. Studies show that different strains of animals differ in how readily they develop addiction-like behaviors after they’re exposed to drugs. There may be natural variations the amount of dopamine, the reward chemical, released by pleasurable activities. A person’s environment plays an important part in addiction, too. For example, peer groups influence behavior, especially among teens. Studies show that some factors are actively protective: strong family ties, success in school or life, social skills, and good general problem-solving skills.
It is a myth that a particular personality trait—or some genetic factor or a particular experience—makes addiction likely. There are a number of common personality traits that indirectly influence the risk of developing problematic substance use. For example, people prone to thrill-seeking may be more likely than others to find themselves in situations where drugs are used. People who are high in the trait of neuroticism—they are prone to experiencing negative emotions—are often overwhelmed by minor frustrations and vulnerable to a wide array of mental health problems, from anxiety and depression to substance abuse.
It is also a myth that addiction causes personality change. The compulsive substance use that typifies addiction does alter patterns of behavior but it does not change personality structure. Studies show that as the drive for the drug and its reward becomes increasingly etched into brain circuity, the brain areas of judgment and control are weakened. As a result, people who are addicted can act in ways that even they do not like—lying, stealing, socially withdrawing, becoming suspicious and neglectful of obligations—and later feel great guilt and shame over their addictive behavior. It takes time for the brain to rewire itself after substance use is stopped or significantly reduced.
Substance use often co-occurs with other mental health problems—commonly called dual diagnosis in the addiction world— and treatment of the substance disorder can expose an underlying condition such as depression, anxiety, PTSD, or other emotional distress. Recovery from addiction typically hinges addressing and resolving the underlying mental health problem at the same time and in an integrated way. All good treatment programs screen new patients for co-existing mental health disorders.
Recovery from addiction is not only possible, it is the rule, rather than the exception. According to the latest annual U. S. National Survey on Drug Use and Health (NSDUH), more than 75 percent of people addicted to alcohol or drugs recover—their condition improves, and substance use no longer dominates their life. Recovery, however, is often a long-term process and may involve several attempts. Relapse is regarded as part of the process, and effective treatment regimens address prevention and management of recurrent use.
Since success tends not to occur all at once, any improvements are considered important signs of progress. Increasingly, programs are available that do not demand complete abstinence as a condition for receiving help. They are generally labeled harm-reduction programs.
Due to the nature of addiction, treatment is generally divided into to two distinct periods. The first is a preliminary phase, lasting days or weeks, that addresses the physiological effects of stopping a biologically active chemical. As the body eliminates a substance it had come to depend on and adapt to, supportive care is administered, aimed at managing the acute physical discomfort, drug cravings, and psychological distress that result. This period of detoxifying the body and managing withdrawal, which may be undertaken in a medically supervised setting, is just the prelude to recovery,
The second and generally more protracted phase of recovery addresses the many facets of an individual’s functioning, from the ability to tolerate frustration to establishing and maintaining a productive role in society, that addiction affects. Accordingly, good treatment focuses on improving self-management, social and family roles, and work skills as well as mental health. The components of treatment, which are often deployed in combination and typically change over the course of recovery, can include:
• Medication, sometimes used to reduce or counter use of illicit substances or to target co-occurring disorders such as anxiety and depression
• Motivational interviewing, a short-term counseling process that helps people resolve ambivalence about treatment and maintain incentives for change
• Cognitive Behavioral Therapy (CBT) to help people recognize and cope with situations that trigger the desire to use substances, and to provide them with general coping skills
• Group therapy and other peer-support programs, which leverage the direct experience of many to support individual recovery and prevent the recurrence of substance use
• Family therapy, which helps individuals repair the damage often done to family relationships and establish more supportive ones
• Life skills training, including employability skills.
There is no one pathway to recovery. Treatment is available in a variety of settings, from a doctor’s office or outpatient clinic to long-term residential facility. No one way will be right for everyone. Further, studies show that a person’s commitment to change is more important than the type of treatment program selected.
According to NSDUH, only 1.0 percent of people receive substance abuse treatment as an inpatient or outpatient at a specialty facility. Some people seek medical treatment at a hospital. Others seek help from an outpatient mental health facility. Many choose to recover without using any clinical services, while some people may use them only for the first phase of treatment. The single most popular path is the use of peer support groups in the community.
Recovery is neither easy nor fast. Relapse is likely— and while it may last anywhere from hours to days and even years, it does not preclude full remission. It’s a signal that there are coping strategies yet to be learned along with skills to outwit cravings. Researchers report that after five years of complete remission, the likelihood of relapse is no greater than is the risk of addiction among the general population.
It’s important to know that there are many treatment options, although it is challenging to know which would best work for any individual. One of the most comprehensive sources of help is SAMSA, the Substance Abuse and Mental Health Administration, an agency of the of the U.S. Department of Health and Human Services, which maintains a 24-hour helpline (1-800-662-4357) and website. The website features a list of treatment facilities searchable by zip code.
Psychology Today features an extensive registry of treatment centers, programs, expert clinicians, and support groups specializing in addiction recovery. The directory not only covers the full spectrum of care possibilities but provides detailed descriptions of each one. The Directory is searchable by city name and zip code.
There are many types of treatment facilities and programs. Several features mark effective programs. These include:
• comprehensive medical and psychiatric screening
• treatment addressing individual needs, including co-occurring conditions, whether chronic pain, anxiety, or hepatitis
• involvement of families in the treatment
• continuity of care so that patients are actively linked to resources in subsequent phases of recovery
• a respectful environment
• treatment services that are evidence-based and reflect best practices
• staff who are licensed and certified in the disciplines they practice
• treatment program accreditation by a nationally recognized monitoring agency
• monitoring of individual response to treatment and availability of collective outcome data on treatment performance.
Medication assisted treatment (MAT) is most commonly used for people seeking to overcome addiction to alcohol or opioids; it helps relieve the cravings and symptoms of withdrawal. Withdrawal from alcohol can create physical dangers, including rapid shifts in blood pressure and the possibility of seizures; drugs may be administered to counter those effects as well as the severe nutritional deficiencies that often accompany long-term heavy drinking. Specific pharmaceutical agents, notably buprenorphine, are available to counter the symptoms of withdrawal from opioids, such as heroin, oxycodone, and fentanyl.
Medication alone does not cure addiction. When it is used, medication is typically employed along with psychotherapy to help people understand what drew them into addiction, to help them discover more productive ways of solving life problems, and to rebuild a rewarding life.
Recovering from addiction usually involves an intensely personal struggle. Psychotherapy:
• helps people find and hold on to the internal motivation to change despite the difficulties
• helps people understand why they turned to substance use, so they can meet that need in healthier ways
• helps treat the depression, anxiety, and other mental disorders that commonly co-occur with addiction
• cultivates tangible coping skills that help people meet life’s challenges without drugs
• helps people to identify situations that serve as triggers to drug use and to develop workable ways to manage them.
Most people succeed in overcoming addiction—they regain the ability to control substance use, recover general well-being, and function as productive members of society. Recovery is a process involving the restoration of personal motivation and purpose, and it varies from individual to individual. Along the way, many people utilize some kind of help—often different kinds at different times, such as clinical inpatient or outpatient programs, individual or group psychotherapy, mutual-support groups, a coach, a job-training program, and more. The most effective treatment programs are those that help people believe in their own ability to succeed, no matter how many tries it takes.
References
American Psychiatric Association. Understanding Mental Disorders: Your Guide to DSM-5. 2015. American Psychiatric Publishing.
Hartz SM, Pato CN, Medeiros H et al. Comorbidity of severe psychotic disorders with measures of substance use. JAMA Psychiatry. 2014;71(3):248-254
National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse; Phillips JK, Ford MA, Bonnie RJ, editors. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. 2017. National Academies Press (US).
Substance Abuse and Mental Health Services Administration. (2021). Key substance use and mental health indicators in the United States: Results from the 2020 National Survey on Drug Use and Health (HHS Publication No. PEP21-07-01-003, NSDUH Series H-56). Rockville, MD: Center for Behavioral Health Statistics and Quality,
Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data.
