Understanding Substance Use Disorders: Causes and Contributing Factors

Introduction

Substance use disorders can cause significant health and socioeconomic issues. These disorders are classified dependent on the substance abused and result in physical and mental dependence. Different substances have ranging effects that may lead to the desire to abuse them including but not limited to euphoria, sedation, and increased energy. Initially, an individual may view these effects as benefits and continue abusing the substance leading to addiction. Once the individual becomes addicted to the substance, then the substance is abused to reduce negative withdrawal symptoms. Studies show that individuals that abuse one substance are more likely abuse multiple substances (Jahan & Burgess, 2023).

A simple definition for substance abuse is the misuse of any substance potentially resulting in addiction (Carlson et al., 2009). Drugs are classified as narcotics, depressants, stimulants, hallucinogens, and cannabis (Gossop, 2006). Substance abuse can have detrimental effects on the mind, body, and social aspects of life. Despite simplifying the definition of substance abuse, specific criteria must be met for a diagnosis.

For an individual to be diagnosed with a substance use disorder, varying from mild to severe, they must meet several criteria as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Criteria Type 1 is impaired control over the substance use: consumes the substance for longer than needed or intended, unsuccessful attempts and/or inability to regulate use, excessive time spent seeking and/or recovering from the substances and experiencing cravings or desires. Criteria Type 2 is social impairment: substance use impairs obligations, continued use even with personal or social problem, and/or reduced or withdrawn activities due to the substance abuse. Criteria Type 3 is risky use: continued use even with physical or psychological issues and/or recurrent use in unsafe environments. Criteria 4 is pharmacologic: tolerance and/or withdrawal. The substance use disorder may be mild, moderate, or severe based upon the number of criteria that are fulfilled (McNeely & Adam, 2020).

Interactions between many factors including biological, psychological, and environmental are believed cause of most drug use (Al-Kandari et al., 2001). It has been shown that individuals with certain mental illnesses are at higher risk of substance use. Some individuals may be predisposed to issues with addiction based upon genetics. Also, traumatic childhood experiences are increased risk factors for substance abuse (Jahan & Burgess, 2023). This literature review will explore the role of the brain, contributing factors, treatment options, and social implication of substance use disorders.

Theories on Substance Abuse

Addiction and substance abuse have been an ongoing issue for many years. Theories explaining substance abuse are continuing to evolve. Research indicated that chronic substance abuse is linked to social concerns, as well has biological and psychological makeup. Thus, the theories explain substance use are based upon these factors (Butorac, 2010).

Sociological theories suggest that individuals have drug issues based on their social interactions or their social structures. These theories do not focus on physical traits. (Wiatrowski et al., 1981). Social control theory is an example of a sociological theory that is used to explain substance use and addition. This theory details the idea that lack of control contributes to an individual to participating in actions they have been conditioned to (Groff, 2014).

Biological theories focus on the assumption that people have internal mechanisms, such as the brain, which influence them to experiment with drugs. Some biological theories include genetic theories and metabolic imbalances. These theories explain that an individual’s genetic predisposition may explain addiction. Metabolic imbalances are believed to be directly related to the use of opioids. Opioids may produce feels of happiness or well-being reinforcing the urge to use for those with metabolic disorders (Altman et al., 1996).

Contributing Factors

Many factors contribute to substance abuse. Some believe that peer pressure may be an initial contributing factor to substance abuse. Teens may experiment with drugs leading to an addiction that carries over into adulthood. Environmental factors such as drug use in the home increases accessibility. In addition, women are more likely than men to abuse drugs for certain ailments such as depression and pain. Women are more likely than men to use drugs for weight loss and pressure from their sexual partner. Also, mental illness is believed to increase the likelihood of addiction (Al-Kandari, et al, 2001).

Individuals that abuse substances are twice as likely to have a cooccurring mental health disorder as compared with the general population. Likewise, people with certain mental health disorders, such as depression and anxiety, are more likely to have a substance use disorder (National Institute of Drug Abuse., 2018). Iqbal et al (2019) contents that individuals are “2.9 times more likely to have an anxiety disorder and abuse substances. The study, also, reported that children with attention deficit hyperactivity disorder (ADHD) are more likely to develop substance use disorder. Najt et al (2010) contends that individuals with major depressive disorder and post traumatic stress disorder (PTSD) have poorer outcomes when also suffering from SUD. McCauley et al (2012) also reports that PTSD and SUD are commonly cooccurring with increase negative outcomes such as higher health risks and suicide attempts.

Another contributing factor to substance use disorders are Adverse childhood experiences (ACES). ACES have been shown to increase the risk of harmful behaviors, substance abuse, and mental illness. Negative childhood experiences such as domestic violence, mental illness, and household substance abuse have a significant impact on the lifelong health and wellbeing of the individuals. ACES have been shown to have a lasting effect on physiological and neurological systems of developing children (Hughes et al., 2019). In addition to abuse being a risk factor, a child exposed to drugs at a young age can lead to depression, anxiety, and other mental disorders (National Institute of Drug Abuse., 2018).

ACES and poor home life may contribute to poor coping skills. A lack of coping skills to deal with the stress, trauma, or abuse may lead to substance abuse. Unfortunately, this can contribute to worsening of pre-existing mental disorders caused by abuse, creating a vicious cycle. In addition, the increased substance abuse may cause damage to the brain and hamper an individual’s capability to stop the substance abuse (National Institute of Drug Abuse., 2018).

Social stigma is an ongoing issue surrounding addiction. However, choosing to quit using drugs is a challenging task and requires long-term treatment to correct. The struggle with abstinence is believed to be largely contributed to due alterations in the functioning and structure of the brain. Substance use imitates chemical messengers and results in overstimulation of the reward circuit in the brain (Squeglia et al., 2009).

Methamphetamine and cocaine contribute to the brain underproducing dopamine, the chemical responsible for joy and pleasure. The decrease of dopamine may contribute to continued use for a sense of normalcy (National Institute of Drug Abuse, 2018). Psychoactive substances disrupt the brain effecting decision making, learning, behavior, and judgment, and may eventually cause permanent damage to these areas or even lead to death (National Institute of Drug Abuse, 2018).

Squeglia et al (2009) report that brain imaging shows that substance use in adolescents in linked to abnormalities in brain functions effecting neurocognition. These images show changes in white matter, volume, and cognitive tasks with alcohol use. Wydra et al., (2020) noted interaction between A2ARs and the use of cocaine at both the molecular and behavior levels.

Picci et al (2021) reported a link between the “opioid receptor mu 1 (OPRM1) and dopamine receptor d2 (DRD2) genes” and substance use disorders. This study shows that these receptors and substance use are related to changes in structure in the anterior cingulate, nucleus accumbens, and putamen areas.

Another idea is that self-awareness contributes to whether an individual suffers with drug addiction and addictive behaviors. Studies show that cocaine use disorder impairs basic metacognition based upon self-reported confidence. Gray matter volumes in the rostral anterior cingulate cortex were decreased with individuals that were in active cocaine use disorder and in remission (Moeller et al., 2016). Despite studies showing the link between substance use and structure, this may not be applicable to all individuals. Turner et al (2018) reported that individuals with schizophrenia have “reduced gray matter volume in the bilateral precentral gyrus, right medial frontal cortex, right visual cortex, right occipital pole, right thalamus, bilateral amygdala, and bilateral cerebellum regardless of substance use history.” They found that substance abuse does not significantly impair the gray matter in individuals with schizophrenia.

Substance Use Disorder is a serious public health issue. There is a need for continued studies to show how all aspects of people may contribute to this disorder. Studies show that genes and the environment interact and play a role on various aspects of SUD, including addiction, drive to use, metabolism, and drug processing (Prom-Wormley, 2017).

Alcohol metabolizing genes ADH1B and ALDH2 affect alcohol-related traits. Genetic factors greatly influence substance abuse and heavy alcohol use. ALDH2 has been shown to be linked to alcohol dependence. The Dopamiergic Receptor D2 (DRD2), Klotho Beta variant, and the GCKR gene have also been linked to alcohol consumption (Prom-Wormley, 2017).

CHRNA5-CHRNA3-CHRNB4 gene cluster influences nicotine-related traits. Genetic studies show that both the environment and genetics influence cannabis use. Perhaps an even greater genetic influence occurs with opioid dependence. Genetics are believed to be 50% liable for opioid dependence. KCNG2, KCNC1, APBB2, CNIH3, RGMA, and OPRM1 have all been associated with opioid. Further Copy Number Variations (CMV) studies show three common CNVs (18q12.3 deletion, a Xq28 deletion, and a 1q21.3 duplication) and several rare CNVs associated with opioid use (Prom-Wormley, 2017).

Treatment Options

Treatments may include outpatient or inpatient treatment, recovery at home, supervised detoxification, and/or opiate maintenance treatment. Cooccurring illness will need to be identified and treatment will need to take a holistic approach. Depending on the severity of the substance use, individuals may need monitored by a medical provider for detoxification (Simpson et al., 1997). Dating back to the 90’s it was been acknowledged that treatment needs to focus on disease management and relapse prevention (McCartney, 1999).

Social support services, including family support, employment, housing, nutrition, and legal services need provided for better success outcomes. These social support services should evaluate both past and present social issues (Simpson et al., 1997). Traditional options for treatment focus on one substance use addiction. These treatment options focus on goals such as abstinence and harm reduction. However, it has become increasingly apparent that many people that suffer with substance use disorder have addictions to multiple substances. Treatment options need to be multifaceted and target psychological, economic, social, and physical impairments (Körkel, 2021).

Interventions include detoxification, intensive outpatient programs, outpatient therapy, pharmacological, residential treatment options that focus on abstinence. Harm reduction programs are another option for treatment. Harm reductions focuses on reducing social, economic, and health impacts of substance abuse. Examples of harm reduction include syringe programs and hygiene programs (Körkel, 2021).

One common therapeutic technique for substance use disorders is cognitive behavioral therapy (CBT). CBT is a technique that involves using cognitive and motivational elements to learn new skills and reframe thinking. CBT has been shown to be moderately effective on various substance use disorders. CBT has been shown to be more effective with cocaine and opioid use disorders when compared with polysubstance abuse. This therapeutic technique can be used individually, in groups, or in family settings. It has also been shown to be effective in pharmacological methods (McHugh et al., 2010).

Pharmacological options vary dependent upon the substance use disorder. The focus of treatment with medication is reducing cravings and management of withdrawal symptoms. Replacement nicotine is used with tobacco cessation. Treatment of alcohol use disorder has shown success with the use of disulfiram, acamprosate, and naltrexone. Methadone and buprenorphine have both been shown to be successful with treatment of opioid use disorders (Douaihy et al., 2013).

Neurotransmitters are dysregulated from substance use disorder and pharmacological methods target the brain receptor of neurotransmitters. Pharmacological options generally fall in three categories: antagonists, partial agonists, or full agonists medications. Methadone is example of a full agonist medication that binds to the opiate receptors in the brain. Partial agonists, such as Buprenorphine, may be used for detox and maintenance purposes. They do not stimulate the brain receptors to the same extent as a full agonist. Naltrexone is an example of an agonist medication which binds the brain receptor without stimulating it. This medication prevents agonists from binding with the receptors. A combination of pharmacological and behavioral therapies may be the best approach to treat substance use disorders (Douaihy et al., 2013).

Implications to Social Work and Public Policy

Substance use disorder is a widespread problem in the United States leading to an increased need for mental health professionals, including social workers. The social consequences of substance abuse can lead failure of relationships, economic issues, legal issues, and intergenerational dysfunction in families. Substance use disorder directly correlates with abuse and neglect of children (Al-Kandari, et al, 2001). Social workers are considered to be one of the primary providers of service to individuals with substance use disorder (Wells et al., 2013).

Substance abuse, including alcohol, narcotics, and cocaine continue to be problematic in families in the United States. It is estimated that 8.7 million children in the United States live in homes that have substance abuse issues. 20.2 million adults have reported issues with substance abuse in the past year. There is a great need for providers specializing in treatment of substance use disorder for the best outcome for children and their families (Lapari et al., 2017).

Social workers act as direct care providers, advocates, case managers, and administrators in agencies that provider substance use disorder treatment. Despite the continued prevalence of this disorder, history shows a lack of training related to SUD. This includes in education, field placement, and employment. These shortcomings have resulted in nationwide training initiatives that will need to continue (Wells et al., 2013).

Another relevant implication to social work is human rights. Our judicial system often times fails to acknowledge the severity of substance use disorder. SUD can contribute to risk taking behavior and criminal activity. Social workers will need to advocate to protect the rights to treatment for these individuals. Despite the criminal activity, inmates need access to evidence based treatment (Chigangaidze et al., 2023).

SUD and the need for social workers is increased in rural areas. Rural areas have less providers and less public resources to access the available providers (Fortney & Booth, 2002). Polysubstance abuse and other mental illnesses have been rising in rural areas without an increase in services. COVID has loosened the requirements for SUD treatment. However, some believe that the treatment requirements need to be tightened, rather than loosened (Warfield et al., 2020).

Given the implications to social work and need for increased treatment options in rural, there is a need for focus on public policy. A significant number of children and families are affected by substance use disorder. A failure to address appropriate treatment needs and accessibility can have significant negative impact on families and the future of children. Also, advanced research and imaging studies have shown that substance use disorders and addiction is correlated with the brains and genetics. Public policy needs to follow suite with these discoveries to ensure treatment options are available and take a holistic bodily approach.

The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 has had a significant impact in the United States on substance use disorder treatment and tracking (Peterson & Busch 2018). However, there has been little conducted in individual states about substance abuse treatment. Studies show a need for increased public policy and awareness surrounding prenatal care and substance abuse treatment (Kozhimanni et al., 2019). Additionally, there has been very little research on the effects of COVID19 on substance abuse treatment options in individual states (Andraka-Christou et al., 2021).

References

• Al-Kandari, F. H., Yacoub, K., & Omu, F. (2001). Initiation factors for substance abuse. Journal of Advanced Nursing, 34(1), 78-85. doi: 10.1046/j.1365-2648.2001.3411731.x

• Altman, J., Everitt, B. J., Robbins, T. W., Glautier, S., Markou, A., Nutt, D., Phillips, G. D. (1996). The biological, social and clinical bases of drug addiction: Commentary and debate. Psychopharmacology, 125(4), 285-345. doi:10.1007/bf02246016

• Andraka-Christou, B., Bouskill, K., Haffajee, R. L., Randall-Kosich, O., Golan, M., Totaram, R., Gordon, A. J., & Stein, B. D. (2021). Common themes in early state policy responses to substance use disorder treatment during COVID-19. The American Journal of Drug and Alcohol Abuse, 47(4), 486–496. https://doi.org/10.1080/00952990.202.1903 023

• Blume, A. W. (2001). Negative reinforcement and substance abuse: Using a behavioral conceptualization to enhance treatment. The Behavior Analyst Today, 2(2), 86-90. doi:10.1037/h0099916

• Butorac, K. (2010). SOME PERSONALITY FEATURES AS PREDICTIVE FACTORS OF DRUG AND ALCOHOL ABUSE AND DEPENDENCY. Kriminologija & Socijalna Integracija, 18(1), 79

• Carlson, R. G., Singer, M., Stephens, R. C., & Sterk, C. E. (2009). REFLECTIONS ON 40 YEARS OF ETHNOGRAPHIC DRUG ABUSE RESEARCH: IMPLICATIONS FOR THE FUTURE. Journal of Drug Issues, 39(1), 57-70.

• Chigangaidze, R. K., Noel Garikai, M., & Samuel Lisenga, S. (2023). How deep is the cancerous cut of substance use disorders on human rights? the effects of substance use disorders from a human rights perspective: The thinking of Developmental Clinical Social Work. Social Work in Health Care, 1–15. https://doi.org/10.1080/00981389.2023.2221706

• Douaihy, A. B., Kelly, T. M., & Sullivan, C. (2013). Medications for substance use disorders. Social work in public health, 28(3-4), 264–278. https://doi.org/10.1080/19371918.2013.759031

• Gossop, M. (2006). Classification of illegal and harmful drugs. Bmj, 333(7562), 272-273. doi: 10.1136/bmj.38929.578414.80

• Groff, E. R. (2014). Informal Social Control and Crime Events. Journal of Contemporary Criminal Justice, 31(1), 90-106. doi:10.1177/1043986214552619

• Fortney, J., Booth, B.M. (2002). Access to Substance Abuse Services in Rural Areas. In: Alcoholism. Recent Developments in Alcoholism, vol 15. Springer, Boston, MA. https://doi.org/10.1007/978-0-306-47193-3_10

• Hughes, K., Bellis, M. A., Sethi, D., Andrew, R., Yon, Y., Wood, S., Ford, K., Baban, A., Boderscova, L., Kachaeva, M., Makaruk, K., Markovic, M., Povilaitis, R., Raleva, M., Terzic, N., Veleminsky, M., Włodarczyk, J., & Zakhozha, V. (2019). Adverse childhood experiences, childhood relationships and associated substance use and mental health in young Europeans. European Journal of Public Health, 29(4), 741–747.

• Iqbal, M. N., Levin, C. J., & Levin, F. R. (2019). Treatment for substance use disorder with co-occurring mental illness. The Journal of Lifelong Learning in Psychiatry, 17(2), 88–97. https://doi.org/10.1176/appi.focus.20180042

• Jahan, A., & Burgess, D. (2023, January). Substance use disorder. National Center for Biotechnology Information. https://pubmed.ncbi.nlm.nih.gov/34033404/

• Körkel, J. (2021). Treating patients with multiple substance use in accordance with their personal treatment goals: A new paradigm for addiction treatment. Drugs and Alcohol Today, 21(1), 15-30. doi:https://doi.org/10.1108/DAT-10-2020-0065

• Kozhimannil, K. B., Dowd, W. N., Ali, M. M., Novak, P., & Chen, J. (2019). Substance use disorder treatment admissions and state-level prenatal substance use policies: Evidence from a National Treatment Database. Addictive Behaviors, 90, 272–277. https://doi.org/10.1016/j.addbeh.2018.11.019

• Lapari, R., & VanHorn, S. (2017). Children who live with parents with substance use disorder . Substance Abuse and Mental Health Service Administration. https://www.samhsa.gov/data/sites/default/files/report_3223/ShortReport-3223.html#:~:text=The%20annual%20average%20of%208.7,to%20prevention%20and%20supportive%20services

• McHugh, R. K., Hearon, B. A., & Otto, M. W. (2010). Cognitive behavioral therapy for substance use disorders. The Psychiatric clinics of North America, 33(3), 511–525. https://doi.org/10.1016/j.psc.2010.04.012

• McCauley, J. L., Killeen, T., Gros, D. F., Brady, K. T., & Back, S. E. (2012). Posttraumatic stress disorder and co‐occurring substance use disorders: Advances in assessment and treatment. Clinical Psychology: Science and Practice, 19(3), 283–304. https://doi.org/10.1111/cpsp.12006

• McCartney, J. (1999). Reflections on Volatile Substance Dependency Treatment. Journal of Substance Abuse Treatment, 16(3), 255-264. doi: 10.1016/S0740-5472(98)00055-5

• McNeely, J., & Adam, A. (2020, October). Substance use screening and risk assessment in adults. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK565474/

• Moeller, S. J., Fleming, S. M., Gan, G., Zilverstand, A., Malaker, P., d׳Oleire Uquillas, F., Schneider, K. E., Preston-Campbell, R. N., Parvaz, M. A., Maloney, T., Alia-Klein, N., & Goldstein, R. Z. (2016). Metacognitive impairment in active cocaine use disorder is associated with individual differences in brain structure. European Neuropsychopharmacology, 26(4), 653–662. https://doi.org/10.1016/j.euroneuro.2016.02.009

• Najt, P., Fusar-Poli, P., & Brambilla, P. (2010). Co-occurring mental and substance abuse disorders: A review on the potential predictors and clinical outcomes. Psychiatry Research, 186(2–3), 159–164. https://doi.org/10.1016/j.psychres.2010.07.042

• National Institute of Drug Abuse (2018). Understanding Drug Abuse and Addiction Retrieved from http://www.drugabuse.gov/publications/drugfacts/understanding-drug-abuse-addiction

• Peterson, E., & Busch, S. (2018). Achieving Mental Health and substance use disorder treatment parity: A quarter century of policy making and research. Annual Review of Public Health, 39(1), 421–435. https://doi.org/10.1146/annurev-publhealth-040617-013603

• Prom-Wormley, E. C., Ebejer, J., Dick, D. M., & Bowers, M. S. (2017). The genetic epidemiology of substance use disorder: A review. Drug and alcohol dependence, 180, 241–259. https://doi.org/10.1016/j.drugalcdep.2017.06.040

• Picci, G., Fishbein, D. H., VanMeter, J. W., & Rose, E. J. (2021). Effects of OPRM1 and DRD2 on brain structure in drug-naive adolescents: genetic and neural vulnerabilities to substance use. Psychopharmacology, 239(1), 141–152. https://doi.org/10.1007/s00213-021-06030-3

• Turner, S., Mota, N., Bolton, J., & Sareen, J. (2018). Self-medication with alcohol or drugs for mood and anxiety disorders: A narrative review of the epidemiological literature. Depression and Anxiety, 35(9), 851–860. https://doi.org/10.1002/da.22771

• Simpson, D., Joe, G. W., & Brown, B. S. (1997). Treatment retention and follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology Of Addictive Behaviors, 11(4), 294-307. doi:10.1037/0893-164X.11.4.294

• Squeglia LM, Jacobus J, Tapert SF. (2009). The influence of substance use on adolescent brain development. Clinical EEG and Neuroscience. 2009;40(1):31-38. doi:10.1177/155005940904000110

• Volkow, N. D. (2020). Drugs, brains, and behavior: the science of addiction. National Institutes of Health. https://nida.nih.gov/research-topics/addiction-science/drugs-brain-behavior-science-of-addiction

• Warfield, S., Pack, R., Degenhardt, L., Larney, S., Bharat, C., Ashrafioun , L., Marshall, B., & Bossarte, R. (2020). The next wave? mental health comorbidities and patients with substance use disorders in under-resourced and Rural Areas. Journal of Substance Abuse Treatment. https://www.sciencedirect.com/science/article/pii/S0740547220304463

• Wells, E. A., Kristman-Valente, A. N., Peavy, K. M., & Jackson, T. R. (2013). Social workers and delivery of evidence-based psychosocial treatments for substance use disorders. Social work in public health, 28(3-4), 279–301. https://doi.org/10.1080/19371918.2013.759033

• Wiatrowski, M. D., Griswold, D. B., & Roberts, M. K. (1981). Social control theory and deliquency. Retrieved from http://www.jstor.org/stable/2094936

• Wise, R. A., & Bozarth, M. A. (1987). A psychomotor stimulant theory of addiction. Psychological Review, 94(4), 469-492. doi:10.1037/0033-295x.94.4.469

• Wydra, K., Gawliński, D., Gawlińska, K., Frankowska, M., Borroto-Escuela, D. O., Fuxe, K., & Filip, M. (2020). Adenosine a2a receptors in substance use disorders: A focus on cocaine. Cells, 9(6), 1372. https://doi.org/10.3390/cells9061372