Understanding substance use disorders

A photo of John Saunders

A central disorder?

At one level understanding, substance use disorders is simple. These are disorders which are caused by the use of a psychoactive substance which has abuse and dependence properties. Whether there is a central mental or behavioural disorder of repetitive substance use is where debate, disagreement and controversy arise. Indeed, such are the varying opinions and philosophies (“models”) that a visitor from another planet might think human beings are incapable of coherent thinking about the nature of conditions that affect them.

Some people view persistent substance use as representing an underlying biological disorder where some people become “addicted” and are utterly different from the rest of the human race. Some regard substance-use-related problems as simply a consequence of the availability of particular substances in our society. Others view repeated substance use as a behaviour which is mostly driven by the same mechanism as other human behaviours and habits. Others regard them as an acquired disorder of addiction caused by abnormal brain processes.

Making sense of this

A highly influential construct is the “dependence syndrome,” introduced principally by Griffiths Edwards in the mid-1970s. This described what people with a long history of repetitive substance use experienced in terms of symptoms, behaviours, thoughts and observed physiological features. Importantly, it did not seek to ascribe a cause for the disorder other than substance use.

The dependence syndrome concept was taken up widely by the clinical community and incorporated into the two major international diagnostic systems, the International Classification of Diseases (10th Revision), published in 1992, and the US Diagnostic and Statistical Manual , 3rd Edition Revised and 4th Edition, published in 1987 and 1994 respectively. For nearly 30 years, these international diagnostic systems have formed the basis of disease characterisation and morbidity and mortality statistics. The concept of a dependence syndrome has been accepted for nearly all psychoactive substances which have abuse potential, and it has been supported by the burgeoning evidence on the neurobiological changes that underpin its clinical manifestations. I describe it as a “powerful internal driving force” to use and continue to use a psychoactive substance.

What has DSM-5 done?

It was a surprise to many when the latest version of the Diagnostic and Statistical Manual of Mental Disorders (the 5th Edition or DSM-5, published in 2013), amalgamated dependence with the non-dependence DSM-IV diagnosis of substance abuse. Now there is one central diagnosis for repeated substance use which is causing problems. Examples include “alcohol use disorder”, “cannabis use disorder” and “opioid use disorder”.

Does this composite disorder aid epidemiological and clinical practice? It is a very broad concept, although it is subdivided into “mild”, “moderate” and “severe”.

My view is that it is too broad. It also does not take into account our developing knowledge of the mechanisms of development of dependence. Some questions for consideration:

  1. Does it help communicate the nature and severity of the disorder amongst clinicians?
  2. Does this new diagnosis mean anything other than the person uses the substance repeatedly and periodically experiences problems?
  3. Does it alert the clinician to a patient who may develop a withdrawal state?
  4. Does it point to the goal of treatment (abstinence from the substance, controlled or moderated use or periodic use)?
  5. Does it assist the clinician in identifying appropriate treatments for discussion with the patient/client?
  6. Does it help identify whether patients who use heroin and other illicit opioids would be appropriately treated with agonist maintenance such as buprenorphine and methadone? As I have commented before, if an opioid user is not addicted to an opioid prior to treatment, they certainly will be addicted after they commence on methadone or buprenorphine!

These are some of the practical concerns that many clinicians and researchers have about the conceptualisation of substance use disorders in DSM-5. How these might be addressed and current developments in the next version of the International Classification of Diseases (ICD 11) will be the subject of my next commentary.

A photo of John Saunders

Author: John B. Saunders, Faculty of Medicine and Biomedical Sciences, University of Queensland; Disciplines of Psychiatry and Addiction Medicine, Sydney Medical School, University of Sydney, Australia.

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC.

Three surprising tips for a healthy pregnancy

The do’s and don’ts of pregnancy can be overwhelming at best. For an expectant parent who is using substances, the rhetoric is clear: just don’t.

But in hearing from parents themselves (during a study entitled Treatment and Prevention of Illicit Substance Use among Pregnant and Early Parenting Women), it is clear that there is a lot more to having a healthy pregnancy than abstaining from the likes of cigarettes, alcohol, opiates, etc.

Looking more closely, many parents who struggle to do the best they can for themselves and their growing families are caught in an awful web of intense and complex socioeconomic challenges, and their perspectives offer a much more nuanced understanding of health and the myriad of factors that impact our well-being.

So here are three fundamental tips for a healthy pregnancy, gleaned from the parents’ stories and lots of reading, which perhaps underlie all other choices for better health.

Tip 1: Break the cycle of poverty

Money may not buy love, but in many ways it can buy health. The numbers show that your chances of falling ill and dying sooner goes up as income goes down. Anyone who has struggled to buy fresh food, running shoes or medicine will know the link between money and health first hand. Parents in our study often saw substance use as a problem when it interfered with the ability to buy healthy food or pay rent – but rarely challenged the socioeconomic factors beyond their control.

The fact is, where you live may decide how soon you die. For example there is 10 year difference in life expectancy between Hope (75.5) and Richmond (85.6). It’s all about avoiding microcosms where opportunities, services and supports are lacking – where whole communities (socially or geographically defined) have slid between the cracks.

For struggling parents, who are often themselves born into disadvantage, the need for wraparound services that help with housing and comprehensive health and social supports is clear. Thankfully in Victoria, HerWay Home is able to meet some of this need, though safe and affordable housing in Victoria remains elusive.

And let’s not forget that one in five children in BC live in poverty (and half of single parents are poor) – with or without having substances in the house. Poor children suffer health consequences that may alter their entire lives. Cripplingly low income assistance payments, low-income thresholds for social service eligibility, and the high costs of housing and daycare are squeezing families in a big way.

Many of the potential harms of parental substance use on young and unborn child are virtually indistinguishable from the harms of poverty. Let it be known that the last word on the ‘crack baby’ epidemic was that poverty hurts kids more than being born to mothers with cocaine addiction.

Health and income inequity are big problems in BC, and any moral charge against mothers who use substances may be better spent advocating to give poor families a fighting chance.

Tip 2: Support healing from trauma

Trauma interferes with recovery from addiction. This is true for many new and expectant mothers, and dovetails with environmental, social and structural factors that make it harder to break the larger cycle of poverty and marginalization.

I’d love to advise avoiding trauma in the first place, but for half of Canadian women and one-third of Canadian men, it’s probably too late. Childhood trauma in particular strongly predicts:

  • Drug, tobacco and alcohol addiction
  • Depression, post-traumatic stress disorder (PTSD), and suicide attempts
  • Having >50 sexual partners, sexually transmitted infections (STIs), and teen pregnancies
  • Physical inactivity and severe obesity (ACE Study).

While pregnancy and becoming a parent can and do bring a lot of opportunities for joy and healing, it’s no panacea. Kate (a mom in our study, pseudonym) said:

“Just because you’re pregnant it doesn’t magically change what’s going on for you and how you’ve been brought up and all the shit that’s happened to you.

But seeking help is easier said than done. Our health and social services systems are only starting to become “trauma-informed” – which means service providers often overlook trauma as the root of the problem, or even re-traumatize patients with their insensitivity.

Tip 3: Community love bomb

The people around you (and the co-parent you choose) play huge roles in making or breaking your health habits. On the flip side, judgment, stigma and social exclusion can keep a new mom down.

For many parents in our study, keeping sober meant cutting ties with family and friends who were themselves mired in risky lifestyles. In the wake of these deep personal loses, mothers especially were coldly judged for using any substances at all.

Mothers who are struggling to make healthy choices for themselves and their families need to be given more credit for their love and commitment to their kids, and more appreciation for the immensity of the obstacles they face (often with roots in childhood trauma, and other circumstances beyond their control).

Fathers are only sometimes given credit for the role they play, and need to be more consistently acknowledged, encouraged and supported when this role can be a positive one.

Strong communities are built on trust and respect – nurturing these in our services will help support parents exactly where they are, and position us to reduce many complex barriers to health and well-being.

A photo of Samantha Magnus

Author: Samantha Magnus, Research Affiliate, Centre for Addictions Research of BC.

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC.