Addiction & Substance Use Disorders

The types of addiction and substance use disorders (SUD) fall into one of two categories: substance addictions and non-substance addictions, also known as behavioral addictions.

Individuals struggling with substance addictions, or SUD, have a dependance on drugs that have addiction potential, including prescription medications or non-medical drugs. Each of these substances target and activate the pleasure center of the brain, also known as the “reward center.” Substances that can cause addiction may include one or more of the following:

• Cannabis (marijuana)
• Nicotine and tobacco products (e.g., cigarettes, electronic cigarettes and vaping)
• Hallucinogens (e.g., LSD and PCP)
• Inhalants (e.g., gasses, nitrates, paint thinners, aerosol sprays)
• Alcohol
• Hypnotics, anxiolytics (anti-anxiety drugs) and sedatives (e.g., barbiturates, benzodiazepines, sleeping pills)
• Opioids: prescription and non-prescription (e.g., oxycodone, heroin and codeine)
• Stimulants: prescription and non-prescription (e.g., methamphetamine, cocaine and Adderall)

Like substance addictions, behavioral addictions also target and activate the brain’s reward system. Those suffering from behavioral addictions display compulsive behaviors beyond their control (e.g., eating disorders and obsessive compulsive disorder, or OCD). Research shows that any activity or habit that is beyond one’s control to stop, is all-consuming, and negatively impacts daily life and happiness qualifies as a behavioral addiction. Potentially addictive behaviors include:

• Internet use (either on one’s computer or handheld devices like phones and tablets)
• Video gaming
• Sexual activity
• Gambling
• Eating and food behaviors
• Exercise
• Shopping
• Risky behaviors, such as shoplifting

As with other diseases and disorders, the likelihood of developing an addiction differs from person to person, and no single factor determines whether a person will become addicted to drugs. In general, the more risk factors a person has, the greater the chance that taking drugs will lead to drug use and addiction. Protective factors, on the other hand, reduce a person’s risk. Risk and protective factors may be either environmental or biological.

Many people don’t understand why or how other people become addicted to drugs. They may mistakenly think that those who use drugs lack moral principles or willpower and that they could stop their drug use simply by choosing to. In reality, drug addiction is a complex disease, and quitting usually takes more than good intentions or a strong will. Drugs change the brain in ways that make quitting hard, even for those who want to. Fortunately, researchers know more than ever about how drugs affect the brain and have found treatments that can help people recover from drug addiction and lead productive lives.

Most drugs affect the brain’s "reward circuit," causing euphoria as well as flooding it with the chemical messenger dopamine. A properly functioning reward system motivates a person to repeat behaviors needed to thrive, such as eating and spending time with loved ones. Surges of dopamine in the reward circuit cause the reinforcement of pleasurable but unhealthy behaviors like taking drugs, leading people to repeat the behavior again and again.

As a person continues to use drugs, the brain adapts by reducing the ability of cells in the reward circuit to respond to it. This reduces the high that the person feels compared to the high they felt when first taking the drug—an effect known as tolerance. They might take more of the drug to try to achieve the same high. These brain adaptations often lead to the person becoming less and less able to derive pleasure from other things they once enjoyed, like food, sex or social activities.

Despite being aware of these harmful outcomes, many people who use drugs continue to take them, which is the nature of addiction. Long-term use also causes changes in other brain chemical systems and circuits as well, affecting functions that include:

• Learning
• Judgment
• Decision making
• Stress
• Memory
• Behavior

As with other diseases and disorders, the likelihood of developing an addiction differs from person to person, and no single factor determines whether a person will become addicted to drugs. In general, the more risk factors a person has, the greater the chance that taking drugs will lead to drug use and addiction. Protective factors, on the other hand, reduce a person's risk. Risk and protective factors may be either environmental or biological.

The following risk factors have been identified as precursors to drug addiction: 

• Aggressive behavior in childhood
• Lack of parental supervision
• Low peer refusal skills
• Drug experimentation
• Availability of drugs at school
• Community poverty

Biological factors that can affect a person's risk of addiction include their genes, stage of development, and even gender or ethnicity. Scientists estimate that genes, including the effects environmental factors have on a person's gene expression (called epigenetics), account for between 40 and 60 percent of a person's risk of addiction. Also, teens and people with mental disorders are at greater risk of drug use and addiction than others.

Environmental factors are those related to the family, school and neighborhood. Factors that can increase a person's risk include the following:

• Home and family. The home environment, especially during childhood, is a very important factor. Parents or older family members who use drugs or misuse alcohol, or who break the law, can increase children's risk of future drug problems.
• Peers and school. Friends and other peers can have an increasingly strong influence during the teen years. Teens who use drugs can sway even those without risk factors to try drugs for the first time. Struggling in school or having poor social skills can put a child at further risk for using or becoming addicted to drugs.

Other factors that increase the risk of addiction:

• Early use. Although taking drugs at any age can lead to addiction, research shows that the earlier people begin to use drugs, the more likely they are to develop serious problems. This may be due to the harmful effect that drugs can have on the developing brain. It also may result from a mix of early social and biological risk factors, including lack of a stable home or family, exposure to physical or sexual abuse, genes, or mental illness. Still, the fact remains that early use is a strong indicator of problems ahead, including addiction.
• How the drug is taken. Smoking a drug or injecting it into a vein increases its addictive potential. Both smoked and injected drugs enter the brain within seconds, producing a powerful rush of pleasure. However, this intense high can fade within a few minutes. Scientists believe this powerful contrast drives some people to repeatedly use drugs to recapture the fleeting pleasurable state.

Risk of drug use increases greatly during times of transition. For an adult, a divorce or loss of a job may increase the risk of drug use. For a teenager, risky times include moving, family divorce or changing schools. When children advance from elementary through middle school, they face new and challenging social, family and academic situations. Often during this period, children are exposed to substances such as cigarettes and alcohol for the first time. When they enter high school, teens may encounter greater availability of drugs, drug use by older teens, and social activities where drugs are used.

When individuals leave high school and live more independently, either in college or as an employed adult, they may find themselves exposed to drug use while separated from the protective structure provided by family and school.

A certain amount of risk taking is a normal part of adolescent development. The desire to try new things and become more independent is healthy, but it may also increase teens’ tendencies to experiment with drugs. The parts of the brain that control judgment and decision making do not fully develop until people are in their early or mid-20s. This limits a teen’s ability to accurately assess the risks of drug experimentation and makes young people more vulnerable to peer pressure.

Work with a specialist to use evidence-based screening and assessment tools that correlate specifically to the substance you are struggling to control. Some assessments are self-administered (such as for alcohol and tobacco) and others are clinician-administered.

Research-based or evidence-based prevention programs have been designed based on current scientific evidence, thoroughly tested, and shown to produce positive results. Scientists have developed a broad range of programs that positively alter the balance between risk and protective factors for drug use in families, schools and communities. Studies have shown that research-based programs, such as those described in NIDA’s Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide and Preventing Drug Use among Children and Adolescents: A Research-Based Guide for Parents, Educators, and Community Leaders, can significantly reduce early use of tobacco, alcohol and other drugs. Also, while many social and cultural factors affect drug use trends, when young people perceive drug use as harmful, they often reduce their level of use.

Prevention programs work to boost protective factors and eliminate or reduce risk factors for drug use. The programs are designed for various ages and can be used in individual or group settings, such as the school and home. There are three types of programs:

• Universal programs address risk and protective factors common to all children in a given setting, such as a school or community.
• Selective programs are for groups of children and teens who have specific factors that put them at increased risk of drug use.
• Indicated programs are designed for youth who have already started using drugs.

Drug, alcohol and substance use is not a disease or disorder. Once substance use is beyond the control of the individual and interferes with daily life and functioning in normal situations, it becomes pathological.

These behavioral signs are most common in those struggling to control their substance use:

• Unable to stop using or consuming the substance despite a desire to stop or regulate 
• Multiple attempts to stop using without long-term success
• Worrying about maintaining a constant supply, and obsessing over the next dose
• Intense cravings, particularly triggered in spots of previous use
• Spending large amounts of time obtaining, finding, taking or recovering from the substance
• Becoming unreliable in school, at work or at home; not meeting responsibilities
• Escalating interpersonal problems
• Isolating and withdrawing from friends and family, choosing to use the substance instead
• High-risk behavior around obtaining and using the substance
• Showing withdrawal symptoms (headaches, vomiting, sweating, shaking) when not using 
• Sneaky or secretive behavior around activities and relationships, including lying about location, absences and usage
• Neglect of appearance
• Stealing

The primary psychological sign of addiction is becoming powerless over use of the substance combined with overpowering, obsessive cravings.

Work with a specialist to use evidence-based screening and assessment tools that correlate specifically to the substance you are struggling to control. Some assessments are self-administered (such as for alcohol and tobacco), and others are clinician-administered. 

Research-based or evidence-based prevention programs have been designed based on current scientific evidence, thoroughly tested, and shown to produce positive results. Scientists have developed a broad range of programs that positively alter the balance between risk and protective factors for drug use in families, schools and communities. Studies have shown that research-based programs, such as described in NIDA’s Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide and Preventing Drug Use among Children and Adolescents: A Research-Based Guide for Parents, Educators, and Community Leaders, can significantly reduce early use of tobacco, alcohol and other drugs. Also, while many social and cultural factors affect drug use trends, when young people perceive drug use as harmful, they often reduce their level of use.

When someone has a SUD and another mental health disorder, it is usually better to treat both disorders at the same time rather than separately. People who need help for a SUD and other mental disorders should see a health care provider for each disorder. It can be challenging to make an accurate diagnosis because some symptoms are the same for both disorders, so the provider should use comprehensive assessment tools to reduce the chance of a missed diagnosis and provide the right treatment.

It also is essential that the provider tailor treatment, which may include behavioral therapies and medications, to an individual’s specific combination of disorders and symptoms. It should also take into account the person’s age, the misused substance and the specific mental disorder(s). Talk to your healthcare provider to determine what treatment may be best for you and give the treatment time to work.

Addiction is a treatable disorder. Research on the science of addiction and the treatment of substance use disorders has led to the development of research-based methods that help people to stop using drugs and resume productive lives, also known as being in recovery.

Like other chronic diseases such as heart disease or asthma, treatment for drug addiction usually isn't a cure. But addiction can be managed successfully. Treatment enables people to counteract addiction's disruptive effects on their brain and behavior and regain control of their lives.

The chronic nature of addiction means that for some people, relapse, or a return to drug use after an attempt to stop, can be part of the process, but newer treatments are designed to help with relapse prevention. Relapse rates for drug use are similar to rates for other chronic medical illnesses. If people stop following their medical treatment plan, they are likely to relapse.

Treatment of chronic diseases involves changing deeply rooted behaviors, and relapse doesn’t mean treatment has failed. When a person recovering from an addiction relapses, it indicates that the person needs to speak with their doctor to resume treatment, modify it or try another treatment.

While relapse is a normal part of recovery, for some drugs, it can be very dangerous—even deadly. If a person uses as much of the drug as they did before quitting, they can easily overdose because their bodies are no longer adapted to their previous level of drug exposure. An overdose happens when the person uses enough of a drug to produce uncomfortable feelings, life-threatening symptoms or death.

Research shows that when treating addictions to opioids (prescription pain relievers or drugs like heroin or fentanyl), medication should be the first line of treatment, usually combined with some form of behavioral therapy or counseling. Medications are also available to help treat addiction to alcohol and nicotine.

Additionally, medications are used to help people detoxify from drugs, although detoxification is not the same as treatment and is not sufficient to help a person recover. Detoxification alone without subsequent treatment generally leads to resumption of drug use.

For people with addictions to drugs like stimulants or cannabis, no medications are currently available to assist in treatment, so treatment consists of behavioral therapies. Treatment should be tailored to address each patient's drug use patterns and drug-related medical, mental and social problems.

Different types of medications may be useful at different stages of treatment to help a patient stop abusing drugs, stay in treatment and avoid relapse.

• Treating withdrawal. When patients first stop using drugs, they can experience various physical and emotional symptoms, including restlessness or sleeplessness, as well as depression, anxiety and other mental health conditions. Certain treatment medications and devices reduce these symptoms, which makes it easier to stop the drug use.
• Staying in treatment. Some treatment medications and mobile applications are used to help the brain adapt gradually to the absence of the drug. These treatments act slowly to help prevent drug cravings and have a calming effect on body systems. They can help patients focus on counseling and other psychotherapies related to their drug treatment.
• Preventing relapse. Science has taught us that stress cues linked to drug use (such as people, places, things and moods) and contact with drugs are the most common triggers for relapse. Scientists have been developing therapies to interfere with these triggers to help patients stay in recovery.

Behavioral therapies help people in drug addiction treatment modify their attitudes and behaviors related to drug use. As a result, patients are able to handle stressful situations and various triggers that might cause another relapse. Behavioral therapies can also enhance the effectiveness of medications and help people remain in treatment longer.

• Cognitive-behavioral therapy (CBT) seeks to help patients recognize, avoid and cope with the situations in which they're most likely to use drugs.
• Dialectical behavior therapy (DBT) uses concepts of mindfulness and acceptance or being aware of and attentive to the current situation and emotional state. DBT also teaches skills that can help control intense emotions, reduce self-destructive behaviors (such as suicide attempts, thoughts, or urges; self-harm; and drug use) and improve relationships.
• Assertive community treatment (ACT) is a form of community-based mental health care that emphasizes outreach to the community and an individualized treatment approach.
• Contingency management (CM) uses positive reinforcement such as providing rewards or privileges for remaining drug free, for attending and participating in counseling sessions, or for taking treatment medications as prescribed.
• Motivational enhancement therapy uses strategies to make the most of people's readiness to change their behavior and enter treatment.
• Family therapy helps people (especially young people) with drug use problems, as well as their families, address influences on drug use patterns and improve overall family functioning.
• Twelve-step facilitation (TSF) is an individual therapy typically delivered in 12 weekly sessions to prepare people to become engaged in 12-step mutual support programs. Twelve-step programs like Alcoholics Anonymous are not medical treatments, but they provide social and complementary support to those treatments. TSF follows the 12-step themes of acceptance, surrender and active involvement in recovery.
• Therapeutic communities (TC) are a common form of long-term residential treatment that focuses on helping people develop new and healthier values, attitudes, and behaviors.

Some effective behavioral treatments for children and adolescents include:

• Brief strategic family therapy (BSFT) therapy targets family interactions thought to maintain or worsen adolescent SUDs and other co-occurring problem behaviors.
• Multidimensional family therapy (MDFT) works with the whole family to simultaneously address multiple and interacting adolescent problem behaviors, such as substance use, mental disorders, school problems, delinquency and others.
• Multisystemic therapy (MST) targets key factors associated with serious antisocial behavior in children and adolescents with SUDs.

Stopping drug use is just one part of a long and complex recovery process. When people enter treatment, addiction has often caused serious consequences in their lives, possibly disrupting their health and how they function in their family lives, at work and in the community.

Because addiction can affect so many aspects of a person's life, treatment should address the needs of the whole person to be successful. Counselors may select from a menu of services that meet the specific medical, mental, social, occupational, family and legal needs of their patients to help in their recovery.

Addiction is a treatable disorder. Research on the science of addiction and the treatment of substance use disorders has led to the development of research-based methods that help people to stop using drugs and resume productive lives, also known as being in recovery.

Behavioral therapies help people in drug addiction treatment modify their attitudes and behaviors related to drug use. As a result, patients are able to handle stressful situations and various triggers that might cause another relapse. Behavioral therapies can also enhance the effectiveness of medications and help people remain in treatment longer.

• Cognitive behavioral therapy (CBT) seeks to help patients recognize, avoid and cope with the situations in which they're most likely to use drugs.
• Contingency management uses positive reinforcement such as providing rewards or privileges for remaining drug free, for attending and participating in counseling sessions, or for taking treatment medications as prescribed.
• Motivational enhancement therapy uses strategies to make the most of people's readiness to change their behavior and enter treatment.
• Family therapy helps people (especially young people) with drug use problems, as well as their families, address influences on drug use patterns and improve overall family functioning.
• Twelve-step facilitation (TSF) is an individual therapy typically delivered in 12 weekly sessions to prepare people to become engaged in 12-step mutual support programs. Twelve-step programs like Alcoholics Anonymous are not medical treatments, but provide social and complementary support to those treatments. TSF follows the 12-step themes of acceptance, surrender and active involvement in recovery.

Clinical trials are research studies that look at new ways to prevent, detect or treat diseases and conditions. The goal of clinical trials is to determine if a new test or treatment works and is safe. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at the National Institute of Mental Health (NIMH) and around the country conduct many studies with patients and healthy volunteers. We have new and better treatment options today because of what clinical trials uncovered years ago. Be part of tomorrow’s medical breakthroughs. Talk to your healthcare provider about clinical trials, their benefits and risks, and whether one is right for you.