Substance Abuse and Mental Health

Introduction

Science Stuff. Addiction is all about DOPAMINE (DA). It is our reward hormone/neurotransmitter and drugs can horribly dysregulate the system in multiple ways, it’s also a primary neurotransmitter for (motor) balance so if that’s off, everything can seem off. DA is also why your medications become scheduled, regulated, and addictive. It’s why sometimes chemicals are needed for treatment (see the table above). We get reasonable surges of DA with food, love, a new job, etc. However, with drugs such as cocaine, that DA is surging into another galaxy, and then you get serious problems trying to regulate that level of chaos.  It’s this explosion of DA that leads to risky behaviors, strokes, deaths, etc. A few strategies for dealing with patients struggling with addiction:

  • Empathy and Relating: Reflecting on personal struggles (e.g. how you don’t do the same things from 5, 10, 15+ years ago…) can help build empathy and hope for patients. The focus is on guiding them to overcome challenges, learning from past mistakes, and instilling optimism.
  • Consequences of Addiction: Addiction often involves masking underlying issues, creating cycles of guilt, shame, and chronic relapses. Patients may develop multiple addictions as they attempt to fill the void caused by this DA dysregulation.
  • Managing Recovery: Addiction impairs rational thinking, reducing decision-making to impulsive, emotional, and primitive behaviors. Recovery requires patience and a strategy akin to retraining a toddler’s brain—recognizing emotional volatility and promoting gradual healing.
  • Treatment Goals: Effective care focuses on preventing further damage, promoting brain regeneration, and helping patients rebuild their lives despite potentially long-term effects. Goals should be consistent and realistic (small steps).

Treat the Mood or SUD first?

The consensus in most literature is to treat the most critical issue first. If the mood disorder involves suicidal, psychotic, or severe symptoms, prioritize stabilizing it. Otherwise, address the substance use disorder (SUD) first, as sobriety is essential for effective treatment. Once the person is stable and sober, focus on treating the other condition.

Quick Definitions

  • Aberrant Behavior: Medication-related behavior that departs from adherence to the prescription plan.
  • Addiction: Chronic neurobiological disease characterized by impaired control over drug use, compulsive use, and continued use despite harm and/or craving.
  • Abuse: Use of a drug/medication for non-medical purposes 
  • Dependence: Pharmacological adaptation characterized by drug class-specific withdrawal 
  • Tolerance: State of adaptation in which exposure to a given dose of a drug induces biological changes that result in the drug’s diminished effects over time; often leads to escalation

Substance Use Disorder by DSM

The DSM-5 has helped change how we think about addictions by not overly focusing on withdrawal. “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.” There are 3 Basic Substance-Related Categories:

  1. Substance Use Disorder: The user has taken a substance frequently enough to produce clinically significant distress and/or impaired functioning.
  2. Substance Intoxication: This is an acute condition resulting from a recent overuse of a substance.
  3. Substance Withdrawal: The user experiences a collection of symptoms that occur when the user has frequently used a substance and discontinues or markedly reduces the amount used.

Drug craving has been added to the list, and problems with law enforcement have been eliminated due to cultural considerations that make the criteria difficult to apply internationally. The DSM-5 uses ten groupings of individual disorders. The ten specific disorders are 1. Alcohol 2. Caffeine 3. Cannabis 4. Hallucinogen Related Disorders 5. Inhalant Related Disorders 6. Opioid-Related Disorders 7. Sedative, Hypnotic, or Anxiolytic Disorders 8. Stimulant Related Disorders 9. Tobacco-Related Disorders 10. Other (or Unknown) Substance-Related Disorders, Generally speaking, the substance-related categories are the same for the majority of the categories.

Nearly all substances are diagnosed based on the same overarching criteria. In this overarching categorization of substance abuse disorders, the criteria have not only been combined but strengthened. Whereas a diagnosis of substance abuse previously required only one symptom, mild substance use disorder in DSM-5 requires two to three symptoms from a list of eleven. Regardless of the particular substance, the diagnosis of a substance use disorder is based upon a pathological set of behaviors related to the use of that substance. These behaviors fall into four main categories:

  • Impaired control: (1)Using for longer periods of time than intended, or using larger amounts than intended; (2) Wanting to reduce use, yet being unsuccessful in doing so; (3) Spending excessive time getting/using/recovering from the drug use; (4) Cravings that are so intense it is difficult to think about anything else.
  • Social impairment: (5) People may continue to use despite problems with work, school, or family/social obligations. This might include repeated work absences, poor school performance, neglect of children, or failure to meet household responsibilities. (6) Addiction may also be indicated when someone continues substance use despite having interpersonal problems because of the substance use. This could include arguments with family members about the substance use; or, losing important friendships because of continued use. (7) Important and meaningful social and recreational activities may be given up or reduced because of substance use. A person may spend less time with their family, or they may stop playing golf with their friends.
  • Risky Use: The key issue of this criterion is the failure to refrain from using the substance despite the harm it causes. (8) Addiction may be indicated when someone repeatedly uses substances in physically dangerous situations. For instance, using alcohol or other drugs while operating machinery or driving a car. (9) Some people continue to use addictive substances even though they are aware it is causing or worsening physical and psychological problems. An example is a person who continues to smoke cigarettes despite having a respiratory disorder such as asthma or COPD.
  • Pharmacological indicators (tolerance and withdrawal): (10) Tolerance occurs when people need to increase the amount of a substance to achieve the same desired effect. Stated differently, it is when someone experiences less of an effect using the same amount. The “desired effect” might be the desire to avoid withdrawal symptoms. On the other hand, it may be the desire to get high. People experience tolerance differently; i.e., people vary in their sensitivities to different substances. Specific drugs will vary in terms of how quickly tolerance develops and the dose needed for tolerance to develop. (11) Withdrawal is the body’s response to the abrupt cessation of a drug, once the body has developed a tolerance to it. The resulting cluster of (very unpleasant and sometimes fatal) symptoms is specific to each drug. We discuss these specific symptoms in each substance category. Although withdrawal is very unpleasant, it does not usually require medical assistance. However, withdrawal from some drugs can be fatal. Therefore, consult with a medical professional before attempting to stop drug use after a period of heavy and continuous use. This will ensure that quitting is as safe and comfortable as possible.

–Mental Help

The Severity of Substance Use Disorders

The DSM 5 allows clinicians to specify how severe or how much of a problem the substance use disorder is, depending on how many symptoms are identified. Two or three symptoms indicate a mild substance use disorder;1 four or five symptoms indicate a moderate substance use disorder, and six or more symptoms indicate a severe substance use disorder. –Very Well Mind  & Addiction Policy Forum also has a nice graphic.

Also Read: New Diagnostic Codes for Substance Use Disorders to reflect stages of use and remission, etc. –Psychiatric Times 

Specific Addictions & Medication Management

Other (Substance Abuse Topics)

Recovery and Maintenance

Blog Posts and Pages about Substance Abuse

General Resources of Substance Abuse & Treatment

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