in the brain, where all addictive drugs increase dopamine, especially with habitual use (Stahl, 2020; Wise & Jordan, 2021). Arising in the ventral tegmental area (VTA), it projects into the nucleus accumbens (NA) and prefrontal cortex (PFC). The psychology of substance use disorders reflects psychodynamic theories dating back 100 years (Boland & Verduin, 2022). Disturbed ego functions, self-medication, and alexithymia (inability to describe feelings) are common among substance users. Aside from pharmacologic effects, positive reinforcement is gained from paraphernalia and associated behaviors with drug use (Boland & Verduin, 2022). Conditioned responses (similar to Pavlovian phenomena), such as cravings and withdrawal, promote relapsing behaviors (Boland & Verduin, 2022). Individuals aged 18-24 years have a high prevalence rate for every substance disorder. Healthcare Considerations: Every member of our community may help to lessen stigma and prejudice against those who suffer from drug use disorders by: ● Understanding substance use disorders are chronic, treatable medical conditions. ● Changing stigmatizing language with more empowering, preferred language that does not equate people with their condition or have negative connotations. ● Addressing systemic racism, sexism, and other forms of discrimination leads to multiple layers of stigma for many people with addiction. (NIDA, 2022)
use based on neurocircuitry, namely impulsivity and compulsivity (Stahl, 2020). These endophenotypes are found trans-diagnostically present across many psychopathologies. Impulsivity causes the individual to act without forethought and with lack of reflection on previous behavior. Compulsivity is characterized by inappropriate actions which persist regardless of the situation (Stahl, 2020). Over time, impulsive substance use becomes compulsive addiction as this dysregulation becomes a dependent conditioned response. The impulses in the ventral loop of reward and motivation migrate dorsally because of neuroplasticity and engage in a habit system, creating the conditioned response of addiction (Stahl, 2020). Impulsive drug use produces a high , which, if experienced too often, cause the migration to compulsive use (addiction) to reduce the unpleasant effects of withdrawal. The mesolimbic pathway is hypothesized to be the final common pathway of reward and reinforcement Implicit bias and stigma in substance use disorders The language used by clinicians, such as addicts , can stigmatize individuals with substance use disorders reflecting misconceptions that these behaviors are choices rather than compulsions (NIDA, 2022). Negative biases can dehumanize individuals and affect the therapeutic alliance, and, ultimately, the course of recovery (NIDA, 2022). Clinicians who stereotype drug use as a criminal activity marginalize disadvantaged groups and negatively influence treatment plans, which may increase drug use (NIDA, 2022.) Stigma and implicit biases impact fear of disclosing substance use, decreased quality of care, or reduced access to care (NIDA, 2022). To this end, the word addiction has been eliminated from the DSM-5® (Diagnostic and Statistical Manual of Mental Disorders , 5th ed.) in favor of the more neutral term substance use disorder (APA, 2013).
Risk factors for substance use disorders Adult risk factors for substance use disorders include the following:
• Poor health status. • Significant drug burden/polypharmacy. • Unexpected or forced retirement. • Social isolation (living alone or with nonspousal others). • History of alcohol problems. • Previous or concurrent substance use disorder. • Previous or concurrent psychiatric illness. (Kuerbis, 2020)
• Ability to afford drugs. • Avoidant coping style. • Bereavement. • Caucasian ethnicity, • Chronic pain.
• Chronic physical illness/comorbidity. • Physical disabilities or reduced mobility. • Transitions in care/living situations.
Evaluating Substance Use Disorder (Abbreviated)
Instrument
Purpose
Interpretation
Addiction Severity Index
• Assessment tool. • The clinician administers the semi- structured interview. • Screening tool. • Clinician/self-administered. • Evaluates the quantity and frequency of drinking.
200 items, normed national data.
Alcohol Use Disorders Identification Test (AUDIT) Alcohol Use Disorder Identification Test-Consumption (AUDIT-C)
10 items.
Cage Questionnaire
• Screening tool. • Clinician/self-administered. • Identifies the presence of problematic drinking. • Assessment tool. • Clinician administered. • *Gold standard for alcohol withdrawal assessment.
4 items: • positive score ≥ 2.
Clinic Institute Withdrawal Assessment-Alcohol Revised (CIWA-Ar)*
10 items: • <10, mild withdrawal. • 10-18, moderate withdrawal. • >18 severe withdrawal.
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