Substance addiction: characteristics, causes and treatment

Substance addiction: symptoms

Substance addiction is defined by the WHO (World Health Organization) as “a psychic and sometimes physical state, deriving from the interaction with a substance , which determines changes in behavior and the need to take this, to obtain the same psychic effects and avoid the withdrawal syndrome “. The concept of ” addiction ” can take on different meanings, depending on whether it is physical or psychological but, in both cases, the core of the addiction lies in the “need” to take on the substance of abuse and, often, these two facets are difficult to distinguish.       

Physical addiction is induced by some, but not all, substances of abuse , and occurs when repeated drug use changes the way our brains distinguish between pleasant and unpleasant sensations. Withdrawal symptoms are the consequence of this change, when the brain feels the lack of it. Withdrawal symptoms such as tremors, nausea, and aches, therefore, confirm the presence of a physical addiction .      

Psychological addiction , on the other hand, is defined as the uncontrollable need to use the substance: when the latter is used to change one’s mood and create feelings of joy or increase one’s self-esteem, the addicted person needs to continue using the substance . which gives her the aforementioned sensations.     

Behaviors or symptoms of substance abuse include:  

• You need to make use of the substance frequently  
• Need to increase the dosage over time to achieve the same effect
• Make sure you don’t run out of an escort
• Spending money to procure the substance , even in cases where it is difficult to afford the expense 
• Continue to abuse the substance while being aware of the physical and psychological problems and damage it causes  
• Try unsuccessfully to break free from addiction 
• Ignoring obligations and responsibilities, work or relationship, due to drug use 
• Experience withdrawal symptoms when trying to stop using the substance 

The substances of abuse are numerous and very different from each other in effect. Among the most commonly used we find:  

• Cocaine
• Alcohol
• Heroin
• Hallucinogens
• Inhalants
• MDMA
• Opiates
• Methamphetamine
• Steroids
• Tobacco
• Marijuana

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM – 5) updated the criteria used up to that point to diagnose substance abuse disorder . According to DSM 5, a substance use disorder represents ” a problematic pattern of substance use that leads to clinically significant distress or impairment .” In order to diagnose a substance abuse disorder , at least 2 of the following 11 symptoms must be present, manifesting over a 12-month period:      

• Consumption of the substance in larger quantities than planned  
• Desire to stop taking it or unsuccessful attempts to control its use
• Large amount of time spent in taking the substance or in actions aimed at obtaining it  
• Failure to fulfill one’s role at home, at work or at school due to substance 
• “ Craving ”, or uncontrollable desire or urge to obtain the substance 
• Failure to stop drug abuse despite the resulting health problems 
• Failure to stop using the substance , despite its negative effects on interpersonal relationships 
• Repeated use of the substance in dangerous circumstances  
• Abandonment or reduction of daily activities due to the substance of abuse   
• Development of substance tolerance , defined in the following ways: 
• You need to use increasing amounts of the substance to achieve the desired effect  
• Decrease in the effect of the substance over time 
• Withdrawal symptoms upon cessation of use, typically: 
• Anxiety
• Irritability
• Nausea / vomiting
• Tremors
• Exhaustion

The causes of substance addiction

The causes of addiction are not unique and, as with many other psychological disorders, can only be analyzed by taking into account various risk factors, which can contribute to the onset of an addiction . However, it is still unclear what distinguishes a person who becomes addicted to a substance from one who will never develop drug abuse .          

Generally, the factors that increase the risk of addiction are divided into biological, environmental and developmental factors (ie related to some particular and critical phases of a person’s development). Among the factors that, of course, can influence the likelihood of developing an addiction we can list:    

• Compresence of mental disorders. People who have already been diagnosed with a mental disorder, such as depression or post traumatic stress disorder, are more likely to become addicted to a substance , used as a way to manage painful emotions such as anxiety , depression , and loneliness.        
• Family history of addictions . Substance abuse occurs more commonly in individuals from certain families, due to a probable genetic predisposition and, at the same time, an environmental influence.    
• Early use. The younger the age of first use, the more likely it is that the substance will be abused in a brain that is still developing . 
• Pressure from peers. For younger people in particular, peer group influence can exert a strong influence on drug use and abuse .  
• Lack of family support. Both a family situation of emotional distress and a lack of parental control can increase the risk of an addiction . 
• Type of substance . Some types of drugs, such as painkillers or cocaine, produce a rapid development of addiction , as well as the way they are taken can influence its course.  

The treatment of addictions

Treating an addiction means helping the individual to stop taking the substance , avoiding relapses, and to regain one’s role in the family, at work or in society. There are several evidence-based approaches for the treatment of addictions, which can be grouped into the macro-categories of psychotherapies and drug treatment: depending on the patient and the type of substance used, one of the two forms of treatment will be chosen, or a combination of both.       

Drug therapy is used primarily to manage withdrawal symptoms and prevent relapses. In the first place, therefore, the drugs help to eliminate the painful symptoms that occur during cessation and to prevent the drug from being taken again : this is not, in itself, the treatment, but it represents an indispensable first step for change. Furthermore, possibly coexisting psychological disorders could contribute to the maintenance of addiction : their treatment is a further objective that facilitates cessation.  

Among the psychotherapies used for the treatment of substance addiction , in particular Cognitive – Behavioral Therapy (CBT), the Motivational Approach and Dialectical – Behavioral Therapy ( DBT ) have proved to be among the most effective in achieving results and in preventing of relapses.   

Cognitive – Behavioral Therapy for the treatment of addictions

The CBT approach considers addiction as a dysfunctional behavior learned and maintained over time: the aim of therapy is the correction of the addictive behavior and, therefore, the acquisition of new, more functional behaviors in the person’s life.    

The cognitive – behavioral model of substance addiction is based on some fundamental assumptions:   

• Addiction is a learned behavior . In behavioral theory , there are two key concepts behind learning, both of which can be found in substance abuse behaviors :    
• Classical conditioning, which describes how an originally neutral stimulus can produce a conditioned response, through its association with a significant stimulus (in addiction , for example, objects associated with intake, such as syringes or spoons, become capable of provoke the desire for the substance yourself )  
• Operant conditioning, which describes how the consequences of a particular behavior can influence the frequency of the emission of that behavior (in addiction , this mechanism can explain the continued use of the substance as a way to stop withdrawal symptoms).   
• Dependence emerges within the environmental context. There are numerous environmental factors associated with the development of substance addiction , such as social deprivation, substance availability, peer influence.   
• Addiction develops and is maintained by specific thought processes . Recognizing the cognitive components of addictive behaviors is fundamental in the patient’s understanding and acquisition of control. Thoughts related to substance addiction include, for example, expectations of relief from negative states and emotions, or minimization of the negative consequences of abuse .      

The techniques underlying cognitive-behavioral therapy for substance addiction require, as a first step, the formation of a solid therapeutic alliance and the profound understanding of the case by the professional, together with the unconditional acceptance of whatever emerges, to the inside and outside the therapy sessions. Through the therapeutic relationship and the conceptualization of the case, therefore, the pain and fear and, in some cases, the patient’s hostility, can be understood and framed.      

With a view to collaboration, patient and therapist:

• they decide the objectives, times and methods of the intervention
• agree on the tasks to be performed outside
• they analyze possible difficulties and risk situations
• evaluate the patient’s strengths and resources
• they examine and restructure beliefs

CBT has two fundamental components:

• functional analysis
• learning skills

Functional analysis identifies the thoughts, emotions and circumstances that occur before and after using the substance . In the early stages of treatment, in particular, functional analysis plays a critical role in helping the patient and therapist to examine high-risk situations and in providing food for thought on the reasons that lead the person to be dependent on a drug . Even in the later stages, however, functional analysis is used to highlight those situations or emotional states that are still difficult to manage. The first step of CBT for substance addiction , therefore, is to help patients recognize why they are using a certain type of drug and, at the same time, determine what actions to take to avoid or learn to manage situations – urge to use the substance . All these elements can be investigated through the analysis of the patient’s history of addiction and the therapeutic goals that the latter considers desirable. Through the functional analysis, therefore, a “map” is created which shows:            

• Situation management skills and patient strengths
• Potential barriers to change and factors of vulnerability
• Factors determining the use of the substance (when, how, where, with whom, for what reason, for what purpose)

When it comes to learning new skills, or Skills Training, CBT helps addicted patients unlearn old behaviors associated with substance abuse and learn, or relearn, healthier habits and skills. Especially patients who have a long history of ineffective cessation attempts, in fact, can be extremely pessimistic about their abilities: learning to consider their own abusive behavior as a “skill” learned over time can facilitate trust in themselves about the possibility of learning other different ones.       

Furthermore, when therapeutic help is sought, the level of use of the substance is often pervasive, and the person is likely to use it as the main, or only, way of dealing with a great variety of problems, personal and relational. This can be due to several reasons:  

• The person may never have learned effective strategies for dealing with the challenges and problems of adult life, particularly when substance abuse begins in adolescence   
• Any acquired strategies may have been abandoned over time and replaced by drug abuse  
• The person’s ability to use more functional strategies may have been weakened by other concomitant problems such as, for example, the presence of other psychological disorders.

The first skills that are taught concern the control of substance use ; once these are learned and mastered, the training also extends to other possible problem areas of the person’s life (for example, work or interpersonal relationships).   

In the cognitive-behavioral theoretical model, it is believed that the learning of addictive and abuse behavior is established due to the processes of modeling , classical conditioning and operant conditioning . Likewise, each of these processes is used to help the patient stop the aforementioned behaviors.        

• Modeling ( or learning by imitation) is used in order to make the patient learn new behaviors, through his participation in role – playing during the sessions. The patient, therefore, learns to emit different responses first by observing the therapist and, subsequently, by putting into practice the new strategies, within the protected context provided by the therapeutic setting .     
• Operant conditioning explains that some behaviors are emitted more frequently if they produce a pleasant effect ( positive reinforcement ). This is used to examine the circumstances of abuse and establish the role of the substance in the patient’s life and, at the same time, build positive reinforcement alternatives to drugs (relationships, work, hobbies).        
• Classical conditioning , i.e. the establishment of an association between a stimulus capable of causing a response ( unconditioned ) and a neutral ( conditioned ) stimulus, is used to help the patient understand and recognize the conditioned stimuli that facilitate the assumption of drugs , avoid exposure to the aforementioned stimuli and manage the craving for the substance , so that, over time, the conditioned craving is reduced.     

Finally, in the Cognitive – Behavioral Therapy for substance addiction , the fundamental steps to be reached for an effective treatment are the following: 

• Reinforce motivation to maintain substance abstinence 
• Learn coping skills, to be used to recognize situations with a high risk of relapse and manage moments of difficulty or stalemate  
• Learn to manage painful emotions
• Improve interpersonal functioning and social support network

The motivational interview

The motivational interview for the treatment of addictions is a type of counseling created with the aim of reinforcing the patient’s motivation to change a self-destructive behavior, especially in cases where the lack of motivation to change is the main obstacle to the process of breakdown.  

The model of addictive behaviors , defined trans -theoretical , is made up of different stages, each of which is characterized by a different level of motivation to abandon substance abuse : this theoretical model has laid the foundations for the development of the motivational interview. The first stage is defined by the authors as precontemplation , that is, the complete refusal to admit the existence of a problem; the second is the stage of contemplation , in which the perception of having a problem begins to take shape, without the ability to undertake actions to solve it; the third stage is defined as determination , and sees the person begin to formulate a concrete plan for his own change; after the latter, the stage of action can begin , in which the effective abandonment of the substance of abuse occurs and, finally, maintenance , in which changes in lifestyle and behavior and attitudes can be maintained or lost, resulting in a relapse.        

At the base of the Motivational Interview there is the thought that every person who finds himself addicted to a substance is, at least in part, aware of the negative consequences deriving from his own drug abuse : through this type of interview, the therapist facilitates the achievement a willingness to get involved and change one’s behavior, overcoming ambivalence or fear of change. More than “convincing” the person, in fact, it can be more useful and effective to try to understand what he wants or fears, because this could be the basis of dysfunctional behavior.       

In the Motivational Interview, therefore, the key points are:

• The motivation must come from the patient, not from external sources (e.g. family, employers, justice system)
• The patient is solely responsible for resolving his or her ambivalence
• Ambivalence cannot be overcome through an attempt to persuade
• The therapist obtains all the information he needs from the patient, in an empathic way and with full acceptance of everything that emerges from the interviews
• The therapist acts as a guide to recognize and resolve ambivalence
• Being ready for change is the result of a process that will see several fluctuations and which, therefore, must be constantly monitored
• The relationship between patient and therapist is configured as a real cooperation aimed at achieving the objectives

Dialectical Behavioral Therapy (DBT) for the treatment of substance addiction

DBT ( Dialectical behavioral therapy) is a branch of Cognitive – Behavioral Therapy, to which several changes and additions have been made, and which was initially developed by M. Linehan for the treatment of Borderline Personality Disorder ( BPD ), but which Over time, it has also been recognized as effective in the treatment of conditions related or independent of BPD , such as:     

• Mood disturbances
• Bipolar disorder
• Post-Traumatic Stress Disorder
• Anxiety Disorders
• Food disorders
• Substance Abuse Disorders

DBT is a form of psychotherapy whose ultimate goal is to help the patient build a full life for himself and lived as worthy: he, in fact, learns to conceive and pursue goals independent of his own history of uncontrollable behaviors.  

The treatment, in general, includes some fundamental steps:

• Improve patient motivation for change
• Increase the skills of the person
• Learning new behaviors
• Restructure your living environment

Particularly for people suffering from addiction , substance abuse is the first and fundamental behavior that interferes with the patient’s quality of life. The behavioral goals of DBT for substance abuse , therefore, include:     

• Decrease substance abuse , whether it is illegal drugs or drugs taken without a prescription      
• Relieve the physical pain associated with withdrawal symptoms
• Decrease the uncontrollable urge to take the substance 
• Avoid any occasions and circumstances in which abuse may be more likely, for example by cutting out contact with certain people or by getting rid of materials or objects that resemble or relate to taking the substance  
• Increase support from the environment, for example by encouraging the development of new friendships or the rehabilitation of those lost due to addiction, engaging in new activities and researching social environments unrelated to drug use 

In this path towards abstinence, DBT requires a permanent and immediate cessation of any type of substance intake , combined with the understanding that a possible relapse does not represent a failure: through the learning of non-judgmental problem solving modalities, the patient learns to focus his energies only on the aspects that can be changed, accepting those that, on the contrary, cannot be changed