Module 17 – Substance-Induced Disorders

3rd edition as of August 2022

Module Overview

In Module 17, will cover matters related to substance-related and addictive disorders to include their clinical presentation, prevalence, comorbidity, etiology, assessment, and treatment options. Our discussion will include substance intoxication, substance use disorder, and substance withdrawal.  We also list substances people can become addicted to. Be sure you refer to Modules 1-3 for explanations of key terms (Module 1), an overview of the various models to explain psychopathology (Module 2), and descriptions of the therapies (Module 3).

Module Outline

• 17.1. Clinical Presentation
• 17.2. Prevalence and Comorbidity
• 17.3. Etiology
• 17.4. Assessment
• 17.5. Treatment

Module Learning Outcomes

• Describe how substance-related and addictive disorders present.
• Describe the prevalence and comorbidity of substance-related and addictive disorders.
• Describe the etiology of substance-related and addictive disorders.
• Describe how substance-related and addictive disorders are assessed, diagnosed, and treated.

17.1. Clinical Presentation

Section Learning Objectives

• Define substances and substance abuse.
• Describe properties of substance abuse.
• Describe how substance use disorder presents.
• Describe how substance intoxication presents.
• Describe how substance withdrawal presents.
• Define depressants and describe types.
• Define stimulants and describe types.
• Define hallucinogens/cannabis/combination and describe types.
• Describe the effects of using drugs in combination.

17.1.1. Defining Terms and Adding Context

Substance-related and addictive disorders are among the most prevalent psychological disorders, with roughly 100 million people in the United States reporting the use of an illegal substance sometime throughout their life (SAMHSA, 2014). It is worth noting that the DSM-5 shifted terminology from drug addiction to substance use disorder, “…to describe the wide range of the disorder, from a mild form to a severe state of chronically relapsing, compulsive pattern of drug taking.” The DSM-5 acknowledges that many clinicians will use the term drug addiction to describe more severe presentations, but it is omitted from the DSM-5 due to “…its uncertain definition and its potentially negative connotation” (APA, 2022, pg. 543).

What are substances? Substances are any ingested materials that cause temporary cognitive, behavioral, or physiological symptoms within the individual. The DSM uses 10 classes of substances: alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, stimulants, tobacco, and other (or unknown).

Repeated use of these substances or frequent substance intoxication can develop into a long-term problem known as substance abuse. Abuse occurs when an individual consumes the substance for an extended period or must ingest large amounts of the substance to get the same effect a substance provided previously. The need to continually increase the amount of ingested substance is known as tolerance. As tolerance builds, additional physical and psychological symptoms present, often causing significant disturbances in an individual’s personal and professional life. Individuals with substance abuse often spend a significant amount of time engaging in activities that revolve around their substance use, thus spending less time in recreational activities that once consumed their time.

Sometimes, there is a desire to reduce or abstain from substance use; however, cravings and withdrawal symptoms often prohibit this from occurring. Common withdrawal symptoms include, but are not limited to, cramps, anxiety attacks, sweating, nausea, tremors, and hallucinations. Depending on the substance and the tolerance level, most withdrawal symptoms last anywhere from a few days to a week. For those with extensive substance abuse or abuse of multiple substances, withdrawal should be closely monitored in a hospital setting to avoid severe consequences such as seizures, stroke, or even death.

According to the DSM-5-TR (APA, 2022), the substance-related disorders are divided into two groups: substance use disorders and substance-induced disorders which include substance intoxication and substance withdrawal. While there are some subtle differences in symptoms, particularly psychological, physical, and behavioral symptoms, the general diagnostic criteria for substance use disorder, substance intoxication, and substance withdrawal remains the same across substances. These criteria are reviewed below, with more specific details of psychological, physical, and behavioral symptoms in the Section 11.1.5.: Types of Substances Abused.

17.1.2. Substance Use Disorder

The essential feature of substance use disorder, is a “…cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems” (APA, 2022, pg. 544) and can be diagnosed for all the substance classes except caffeine. Distress or impairment can be described as any of the following: inability to complete or lack of participation in work, school or home activities; increased time spent on activities obtaining, using, or recovering from substance use; impairment in social or interpersonal relationships; use of a substance in a potentially hazardous situation; psychological problems due to recurrent substance abuse; craving the substance; an increase in the amount of substance used over time (i.e., tolerance); difficulty reducing the amount of substance used despite a desire to reduce/stop using; and/or withdrawal symptoms (APA, 2022). While the number of these symptoms may vary among individuals, only two symptoms are required for a diagnosis of substance use disorder.

17.1.3. Substance Intoxication

For a diagnosis of substance intoxication, the individual must have recently ingested a substance. Immediately following the ingestion of this substance, significant behavioral and/or psychological change is observed. In addition, physical and physiological symptoms present as a direct result of the substance ingested. As stated above, these behavioral, physical, and physiological symptoms are dependent on the type of substance that is ingested and, therefore, discussed in more detail within each substance category (i.e., depressants, stimulants, hallucinogens/cannabis/combination). This said, the most common changes involve disturbances of perception, wakefulness, attention, thinking, psychomotor behavior, interpersonal behavior, and judgment (APA, 2022).

17.1.4. Substance Withdrawal

Finally, substance withdrawal is diagnosed when there is cessation or reduction of a substance that has been used for a long period of time. Individuals undergoing substance withdrawal will experience physiological and psychological symptoms within a few hours after cessation/reduction. These symptoms cause significant distress or impairment in daily functioning (APA, 2022). As with substance intoxication, physiological and psychological symptoms during substance withdrawal are often specific to the substance abused and are discussed in more detail within each substance category later in the module.

17.1.5. Types of Substances Abused

For our purposes, the most abused substances will be divided into three categories based on how they impact one’s physiological state: depressants, stimulants, and hallucinogens/cannabis/combination.

     17.1.5.1. Depressants. Depressants include alcohol, sedative-hypnotic drugs, and opioids are known to have an inhibiting effect on one’s central nervous system; therefore, they are often used to alleviate tension and stress. Unfortunately, when used in large amounts, they can also impair an individual’s judgment and motor activity.

While alcohol is one of the only legal (over-the-counter) substances we will discuss, it is also the most commonly consumed substance. According to the 2015 National Survey on Drug Use and Health, approximately 70% of individuals drank an alcoholic beverage in the last year, and nearly 56% of individuals drank an alcoholic beverage in the past month (SAMHSA, 2015). While the legal age of consumption in the United States is 21, approximately 78% of teens report that they drank alcohol at some point in their life (SAMHSA, 2013).

Despite the legal age of consumption, many college-aged students engage in binge or heavy drinking. In fact, 45% of college-aged students report engaging in binge drinking, with 14% binge drinking at least 5 days per month (SAMHSA, 2013). In addition to these high levels of alcohol consumption, students also engage in other behaviors such as skipping meals, which can impact the rate of alcohol intoxication and place them at risk for dehydration, blacking out, and developing alcohol-induced seizures (Piazza-Gardner & Barry, 2013).

The “active” substance of alcohol, ethyl alcohol, is a chemical that is absorbed quickly into the blood via the lining of the stomach and intestine. Once in the bloodstream, ethyl alcohol travels to the central nervous system (i.e., brain and spinal cord) and produces depressive symptoms such as impaired reaction time, disorientation, and slurred speech. These symptoms are produced due to the ethyl alcohol binding to GABA receptors, thus preventing GABA from providing inhibitory messages and allowing the individual to relax (Filip et al., 2015).

The effect of ethyl alcohol in moderation allows for an individual to relax, engage more readily in conversation, and in general, produce a confident and happy personality. However, when consumption is increased or excessive, the central nervous system is unable to metabolize the ethyl alcohol adequately, and adverse effects begin to present. Symptoms such as blurred vision, difficulty walking, slurred speech, slowed reaction time, and sometimes, aggressive behaviors are observed.

The extent to which these symptoms present are directly related to the concentration of ethyl alcohol within the body, as well as the individual’s ability to metabolize the ethyl alcohol. There are a lot of factors that contribute to how quickly one’s body can metabolize ethyl alcohol. Food, gender, body weight, and medications are among the most common factors that affect alcohol absorption (NIAAA,1997). More specifically, recent consumption of food, particularly those high in fat and carbohydrates, slow the absorption rate of ethyl alcohol, thus reducing its effects. Regarding gender, women absorb and metabolize alcohol differently than men, likely due to the smaller amount of body water and the lower activity of an alcohol metabolizing enzyme in the stomach. Another factor related to gender is weight—with individuals with more body mass metabolizing the alcohol at a slower rate than those who weigh less. Finally, various medications, both over the counter and prescription, can impact the liver’s ability to metabolize alcohol, thus affecting the severity of symptoms that present (NIAAA, 1997).

Sedative-Hypnotic drugs, more commonly known as anxiolytic drugs, have a calming and relaxing effect on individuals. When used at a clinically appropriate dosage, they can have a sedative effect, thus making them a suitable drug for treating anxiety-related disorders. In the early 1900s, barbiturates were introduced as the main sedative and hypnotic drug; however, due to their addictive nature, as well as respiratory distress when consumed in large amounts, they have been largely replaced by benzodiazepines which are considered a safer alternative as they have less addictive qualities (Filip et al., 2014).

Commonly prescribed benzodiazepines— Xanax, Ativan, and Valium—have a similar effect to alcohol as they too bind to the GABA receptors and increase GABA activity (Filip et al., 2014). This increase in GABA produces a sedative and calming effect. Benzodiazepines can be prescribed for both temporary relief (pre-flight or before surgery) or long-term use (generalized anxiety disorder). While they do not produce respiratory distress in large dosages like barbiturates, they can cause intoxication and addictive behaviors due to their effects on tolerance.

Opioids are naturally occurring, derived from the sap of the opium poppy. In the early 1800s, morphine was isolated from opium by German chemist Friedrich Wilhelm Adam Serturner. Due to its analgesic effect, it was named after the Greek god of dreams, Morpheus (Brownstein, 1993). Its popularity grew during the American Civil War as it was the primary medication given to soldiers with battle injuries. Unfortunately, this is also when the addictive nature of the medication was discovered, as many soldiers developed “Soldier’s Disease” as a response to tolerance of the drug (Casey, 1978).

In an effort to alleviate the addictive nature of morphine, heroin was synthesized by the German chemical company Bayer in 1898 and was offered in a cough suppressant (Yes, Bayer promoted heroin). For years, heroin remained in cough suppressants as well as other pain reducers until it was discovered that heroin was more addictive than morphine. In 1917, Congress stated that all drugs derived from opium were addictive, thus banning the use of opioids in over-the-counter medications.

Opioids are unique in that they provide both euphoria and drowsiness. Tolerance to these drugs builds quickly, thus resulting in an increased need of the medication to produce desired effects. This rapid tolerance is also likely responsible for opioids’ highly addictive nature. Opioid withdrawal symptoms can range from restlessness, muscle pain, fatigue, anxiety, and insomnia. Unfortunately, these withdrawal symptoms, as well as intense cravings for the drug, can persist for several months, with some reports up to years. Because of the intensity and longevity of these withdrawal symptoms, many individuals struggle to remain abstinent, and accidental overdoses are common (CDC, 2013).

The rise of abuse and misuse of opioid products in the early-to-mid 2000s is a direct result of the increased number of opioid prescription medications containing oxycodone and hydrocodone (Jayawant & Balkrishnana, 2005). The 2015 report estimated 12.5 million Americans had abused prescription narcotic pain relievers in the past year (SAMHSA, 2016). In an effort to reduce such abuse, the FDA developed programs to educate prescribers about the risks of misuse and abuse of opioid medications.

     17.1.5.2. Stimulants. The two most common types of stimulants abused are cocaine and amphetamines. Unlike depressants that reduce the activity of the central nervous system, stimulants have the opposite effect, increasing the activity in the central nervous system. Physiological changes that occur with stimulants are increased blood pressure, heart rate, pressured thinking/speaking, and rapid, often jerky behaviors. Because of these symptoms, stimulants are commonly used for their feelings of euphoria, to reduce appetite, and prevent sleep.

Similar to opioids, cocaine is extracted from a South American plant—the coca plant—and produces feelings of energy and euphoria. It is the most potent natural stimulant known to date (Acosta et al., 2011). Low doses can produce feelings of excitement, talkativeness, and euphoria; however, as the amount of ingested cocaine increases, physiological changes such as rapid breathing, increased blood pressure, and excessive arousal can be observed. The psychological and physiological effects of cocaine are due to an increase of dopamine, norepinephrine, and serotonin in various brain structures (Hart & Ksir, 2014; Haile, 2012).

One key feature of cocaine use is the rapid high of cocaine intoxication, followed by the quick depletion, or crashing, as the drug diminishes within the body. During the euphoric intoxication, individuals will experience poor muscle coordination, grandiosity, compulsive behavior, aggression, and possible hallucinations and delusions (Haile, 2012). Conversely, as the drug leaves the system, the individual will experience adverse effects such as headaches, dizziness, and fainting (Acosta et al., 2011). These negative feelings often produce a negative feedback loop, encouraging individuals to ingest more cocaine to alleviate the negative symptoms. This also increases the chance of accidental overdose.

Cocaine is unique in that it can be ingested in various ways. While cocaine was initially snorted via the nasal cavity, individuals found that if the drug was smoked or injected, its effects were more potent and longer-lasting (Haile, 2012). The most common way cocaine is currently ingested is via freebasing, which involves heating cocaine with ammonia to extract the cocaine base. This method produces a form of cocaine that is almost 100% pure. Due to its low melting point, freebased cocaine is easy to smoke via a glass pipe. Inhaled cocaine is absorbed into the bloodstream and brain within 10-15 seconds suggesting its effects are felt almost immediately (Addiction Centers of America).

Crack is a derivative of cocaine that is formed by combining cocaine with water and another substance (commonly baking soda) to create a solid structure that is then broken into smaller pieces. Because of this process, it requires very little cocaine to make crack, thus making it a more affordable drug. Coined for the crackling sound that is produced when it is smoked, it is also highly addictive, likely due to the fast-acting nature of the drug. While the effects of cocaine peak in 20-30 minutes and last for about 1-2 hours, the effects of crack peak in 3-5 minutes and last only for up to 60 minutes (Addiction Centers of America).

Amphetamines are manufactured in a laboratory setting. Currently, the most common amphetamines are prescription medications such as Ritalin, Adderall, and Dexedrine (prescribed for sleep disorders). These medications produce an increase in energy and alertness and reduce appetite when taken at clinical levels. However, when consumed at larger dosages, they can produce intoxication similar to psychosis, including violent behaviors. Due to the increased energy levels and appetite suppressant qualities, these medications are often abused by students studying for exams, athletes needing extra energy, and individuals seeking weight loss (Haile, 2012). Biologically, similar to cocaine, amphetamines affect the central nervous system by increasing the amount of dopamine, norepinephrine, and serotonin in the brain (Haile, 2012).

Methamphetamine, a derivative of amphetamine, is often abused due to its low cost and feelings of euphoria and confidence; however, it can have serious health consequences such as heart and lung damage (Hauer, 2010). Most commonly used intravenously or nasally, methamphetamine can also be eaten or heated to a temperature in which it can be smoked. The most notable effects of methamphetamine use are the drastic physical changes to one’s appearance, including significant teeth damage and facial lesions (Rusyniak, 2011).

While we are sure you are well aware of how caffeine is consumed, you may be surprised to learn that in addition to coffee, energy drinks, and soft drinks, caffeine can also be found in chocolate and tea. Because of the vast use of caffeine, it is the most widely consumed substance in the world, with approximately 90% of Americans consuming some form of caffeine each day (Fulgoni, Keast, & Lieberman, 2015). While caffeine is often consumed in moderate dosages, caffeine intoxication and withdrawal can occur. In fact, an increase in caffeine intoxication and withdrawal have been observed with the simultaneous popularity of energy drinks. Common energy drinks such as Monster and Red Bull have nearly double the amount of caffeine of tea and coke (Bigard, 2010). While adults commonly consume these drinks, a startling 30% of middle and high schoolers also report regular consumption of energy drinks to assist with academic and athletic responsibilities (Terry-McElrath, O’Malley, & Johnston, 2014). The rapid increase in caffeinated beverages has led to a rise in ER visits due to the intoxication effects (SAMHSA, 2013).

     17.1.5.3. Hallucinogens/Cannabis/Combination. The final category includes both hallucinogens and cannabis- both of which produce sensory changes after ingestion. While hallucinogens are known for their ability to produce more severe delusions and hallucinations, cannabis also has the capability of producing delusions or hallucinations; however, this typically occurs only when large amounts of cannabis are ingested. More commonly, cannabis has been known to have stimulant and depressive effects, thus classifying itself in a group of its own due to the many different effects of the substance.

Hallucinogens come from natural sources and have been involved in cultural and religious ceremonies for thousands of years. Synthetic forms of hallucinogens have also been created—most common of which are PCP, Ketamine, LSD, and Ecstasy. In general, hallucinogens produce powerful changes in sensory perception. Depending on the type of drug ingested, effects can range from hallucinations, changes in color perception, or distortion of objects. Additionally, some individuals report enhanced auditory, as well as changes in physical perception such as tingling or numbness of limbs and interchanging hot and cold sensations (Weaver & Schnoll, 2008). Interestingly, the effect of hallucinogens can vary both between individuals, as well as within the same individual. This means that the same amount of the same drug may produce a positive experience one time, but a negative experience the next time.

Overall, hallucinogens do not have addictive qualities; however, individuals can build a tolerance, thus needing larger quantities to produce similar effects (Wu, Ringwalt, Weiss, & Blazer, 2009). Furthermore, there is some evidence that long-term use of these drugs results in psychosis, mood, or anxiety disorders due to the neurobiological changes after using hallucinogens (Weaver & Schnoll, 2008).

Similar to hallucinogens and a few other substances, cannabis is also derived from a natural plant—the hemp plant. While the most powerful of hemp plants is hashish, the most commonly known type of cannabis, marijuana, is a mixture of hemp leaves, buds, and the tops of plants (SAMHSA, 2014). Many external factors impact the potency of cannabis, such as the climate it was grown in, the method of preparation, and the duration of storage. Of the active chemicals within cannabis, tetrahydrocannabinol (THC) appears to be the single component that determines the potent nature of the drug. Various strains of marijuana have varying amounts of THC; hashish contains a high concentration of THC, while marijuana has a small concentration.

THC binds to cannabinoid receptors in the brain, which produces psychoactive effects. These effects vary depending on both an individual’s body chemistry, as well as various strains and concentrations of THC. Most commonly, people report feelings of calm and peace, relaxation, increased hunger, and pain relief. Occasionally, negative symptoms such as increased anxiety or paranoia, dizziness, and increased heart rate also occur. In rare cases, individuals develop psychotic symptoms or schizophrenia following cannabis use (Donoghue et al., 2014).

While nearly 20 million Americans report regular use of marijuana, only 10% of these individuals will develop a dependence on the drug (SAMHSA, 2013). Of particular concern is the number of adolescents engaging in cannabis use. One in eight 8th graders, one in four 10th graders, and one in three 12th graders reported use of marijuana in the past year (American Academy of Child and Adolescent Psychiatry, 2013). Individuals who begin cannabis abuse during adolescence are at an increased risk of developing cognitive effects from the drug due to the critical period of brain development during adolescence (Gruber, Sagar, Dahlgren, Racine, & Lukas, 2012). Increased discussion about the effects of marijuana use, as well as psychoeducation about substance abuse in general, is important in preventing marijuana use during adolescence.

     17.1.5.4. Using drugs in combination. It is not uncommon for substance abusers to consume more than one type of substance at a time. This combination of substance use can have dangerous results depending on the interactions between substances. For example, if multiple depressant drugs (i.e., alcohol, benzodiazepines, and/or opiates) are consumed at one time, an individual is at risk for severe respiratory distress or even death due to the compounding depressive effects on the central nervous system. Additionally, when an individual is under the influence of one substance, judgment may be impaired, and ingestion of a larger amount of another drug may lead to an accidental overdose. Finally, the use of one drug to counteract the effects of another drug—taking a depressant to combat the effects of a stimulant—is equally as dangerous as the body is unable to regulate homeostasis.

17.2. Prevalence and Comorbidity

Section Learning Objectives

• Describe the epidemiology of depressants.
• Describe the epidemiology of stimulants.
• Describe the epidemiology of hallucinogens.
• Describe the comorbidity of substance-related and addictive disorders.

17.2.1. Prevalence of Substance-Related and Addictive Disorders

It has been estimated that nearly 9% of teens and adults in the United States have a substance abuse disorder (SAMHSA, 2014). Asian/Pacific Islanders, Hispanics, and African Americans are less likely to develop a lifetime substance abuse disorder compared to non-Hispanic white individuals (Grant et al., 2016). Native Americans have the highest rate of substance abuse at nearly 22 percent (NSDUH, 2013). Additional demographic variables also suggest that overall substance abuse is greater in men than women, younger versus older individuals, unmarried/divorced individuals than married, and in those with an education level of a high school degree or lower (Grant et al., 2016). With regards to specific types of substances, the highest prevalence rates of substances abused are cannabis, opioids, and cocaine, respectively (Grant et al., 2016).

     17.2.1.1. Depressants. Concerning depressant substances, men outnumber women in alcohol abuse 2 to 1 (Johnston et al., 2014). Ethnically, Native Americans have highest rate of alcoholism, followed by White, Hispanic, African, and Asian Americans. With regards to opioid use, roughly 1% of the population has this disorder, with 80% of those being addicted to pain-reliever opioids such as oxycodone or morphine; the remaining 20% are heroin (SAMHSA, 2014).

     17.2.1.2. Stimulants. Nearly 1.1% of all high school seniors have used cocaine within the past month (Johnston et al., 2014). Due to the high cost of cocaine, it is more commonly found in suburban neighborhoods where consumers have the financial means to purchase the drugs. Methamphetamine is used by men and women equally. It is popular among biker gangs, rural America, and urban gay communities, as well as in clubs and all-night dance parties (aka raves; Hopfer, 2011).

A growing concern is the abuse of stimulant medication among college students as 17% of college students reported abusing stimulant medications. Greek organization membership, academic performance, and other substance use were the most highly correlated variables related to stimulant medication abuse.

     17.2.1.3. Hallucinogens. Up to 14% of the general population have used LSD or another hallucinogen. Nearly 20 million adults and adolescents report current use of marijuana. Men report more than women. Sixty-five percent of individuals report their first drug of use was marijuana—labeling it as a gateway drug to other illicit substances (APA, 2022). Due to the increased research and positive effects of medicinal marijuana, the movement to legalize recreational marijuana has gained momentum, particularly in the Pacific Northwest of the United States.

17.2.2. General Comorbidity

Substance abuse, in general, has a high comorbidity within itself (meaning abuse of multiple different substances), as well as with other mental health disorders. Researchers believe that substance abuse disorders are often secondary to another mental health disorder, as the substance abuse develops as a means to “self-medicate” the underlying psychological disorder. In fact, several large surveys identified alcohol and drug dependence to be twice as more likely in individuals with anxiety, affective, and psychotic disorders than the general public (Hartz et al., 2014). While it is difficult to identify exact estimates of the relationship between substance abuse and serious mental health disorders, the consensus among researchers is that there is a strong relationship between substance abuse and mood, anxiety, PTSD, and personality disorders (Grant et al., 2016).

17.3. 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.

17.3.1. Biological

     17.3.1.1. 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).

     17.3.1.2. 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.

17.3.2. 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 expectancies are thought to increase drug-seeking behavior, while negative expectancies 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).

17.3.3. 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.    

17.3.4. 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).

17.4. Assessment

Section Learning Objectives

• Outline the assessment process for substance-use disorders.

Overall, assessment is based on verbal report from caregivers, teachers, and the individual themselves. It is very important to be clear to the adolescent about who will have access to the information. Moreover, it may be helpful to discuss with parents the importance of transparency in the interview, and thus, the need for assurance that punishment for behaviors will not occur. Essentially, the adolescent can report on their behaviors without fear of repercussions. Nevertheless, full reports on use can be difficult to obtain. At times, using objective screeners and measures may also help. There are a host of them, some that target general substance use behaviors such as the CRAFFT, others that target specific drug use such as the Cannabis Use Disorders Identification Test (CUDIT). Additionally, screening for other risky behaviors, delinquent peer groups, and other serious mental health conditions should occur. Family history of substance use disorders should be obtained due to its strong etiological relevance and may inform prognosis.

17.5. 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).

17.5.1. Biological

     17.5.1.1. 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.

     17.5.1.2. 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).

     17.5.1.3. 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.

17.5.2. Behavioral

     17.5.2.1. 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.

     17.5.2.2. 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).

17.5.3. Cognitive-Behavioral

     17.5.3.1. 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).  

17.5.4. Sociocultural

     17.5.4.1. 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.

     17.5.4.2. 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.

     17.5.4.3. 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

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

We hope you enjoyed the book and learned a lot.

3rd edition