Addictive disorders occupy a unique niche in our society and culture. The consequences of substance use disorders are widely known, yet ignorance of the biological basis of these disorders is common. Most people know family or friends with alcohol or drug problems, and the media is full of reports of well-known individuals. When viewed superficially, individuals with substance use problems often appear to be behaving illogically and making self-defeating choices, so it is easy to assume that the primary problem is a moral failing or a lack of willpower. This viewpoint leads to our society supporting punitive approaches for managing alcohol and drug addiction, rather than using a public health framework.
The risk of developing an addiction to alcohol or drugs is based on genetic, developmental, and environmental factors. Recent studies estimate that the proportion of risk in developing a substance use disorder due to genetic factors is at least 50 percent. These data suggest that behavioral disorders where the appearance of "choice" seems central are still highly determined by biology. Most people in the United States sample alcohol and other addictive substances at some point during their lifetime. What separates the people who go on to develop addiction from those who don't are a series of variables that were not in their control.
This is not to diminish the role of personal responsibility in managing addictive disorders. As with any health problem, optimal outcomes can only be achieved if the afflicted individual meaningfully participates in their treatment. For a diabetic, measuring blood sugar, taking prescribed medication, and following dietary recommendations is necessary to achieve the best outcomes. Likewise, an individual with a substance use disorder needs to follow treatment recommendations in order to live the happiest, healthiest life possible.
There are a wide variety of treatment options available to treat substance use disorders. Evidence-based behavioral therapies and medication treatments have been shown to improve the health of individuals with alcohol and drug addiction. Evidence-based behavioral treatments aim to increase motivation and develop skills for abstaining from substance use and managing distressing emotional states. Medication treatments tend to be more specifically directed at a particular substance. Effective medications are available for treating nicotine, alcohol, and opioid dependence. Research is ongoing to develop treatments for cocaine, methamphetamine, and cannabis dependence. In addition, other psychiatric disorders (e.g., depression, ADHD, anxiety disorders) frequently co-occur with addictive disorders. These co-occurring disorders need to be simultaneously treated along with the substance use problem in order to obtain the best possible outcomes.
There is a lot of controversy regarding "harm reduction" as a treatment goal. Examples of harm reduction include clean needle exchange, safe injection facilities, and treatments that are oriented toward reduction in substance use ("moderation"). Some authorities argue that anything short of complete abstinence from substance use is unsatisfactory, and in some cases harm reduction interventions promote drug use. My opinion is that this is a moralistic approach unsuitable for managing health care problems. The health consequences of alcohol and drug addiction are generally proportional to the amount of substance used. Reductions in substance use, without achieving abstinence, can result in improvements in physical health. Complete abstinence is clearly the optimal outcome for most individuals with substance use disorders. However, treatment that reduces harm and improves health can be valuable even when abstinence is not achieved. Even an intervention, such as needle exchange, that does not target drug use directly, can be extremely beneficial by reducing infectious disease risk and by providing a mechanism for engagement in treatment in general.
The hope is that is as science progresses, and as discoveries regarding the biological basis of addictive disorders, as well as the availability of effective treatment, becomes more widely known, the stigmatization and marginalization that individuals with addiction face will be reduced, and access to care will be improved.
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