SelfCare: Substance abuse treatment and mental illness

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15 min read

Remember how years ago substance abuse was called ‘addiction’? The World Health Organisation concluded in 1964 that the term ‘addiction’ was not a scientific term and substituted it with “drug dependence’. The WHO defines ‘substance abuse’ as the harmful or hazardous use of psychoactive (any substance affecting the mind) substances, including alcohol and illicit drugs. They propose that the use of psychoactive substances can lead to a dependence syndrome (which we commonly understand as abuse or addiction) that includes:

  • a strong desire to take the drug
  • difficulties in controlling its use
  • persisting in its use despite harmful consequences
  • a higher priority is given to drug use than to other activities and obligations
  • increased tolerance
  • sometimes a physical withdrawal state

Adolescence is the riskiest time for picking up harmful habits. It’s the age where there is a desire to experiment with everything but not enough wisdom to choose wisely. “Feel good” factor and peer pressure governs most actions. So there isn’t much room for self-regulation or delaying gratification. A desire for the continued state of pleasure, a momentary feeling of invincibility, or an environment that encourages substance abuse makes it hard to stop after a few “hits”.

The most commonly abused substances are alcohol, tobacco, marijuana (cannabis) and opioids (to a small extent). Many studies also indicate that cannabis is a common substance of abuse during adolescence such as school and college-going students, street children and working adolescents. The most commonly used opioids are in the form of buprenorphine and codeine in cough syrups. Here are some statistics:

  1. About 20 million children of age ranging from 10-14 years were estimated to be tobacco addicted. To this shocking figure, about 5500 new users are added every year. 
  2. 3.8% of children were smokers while 11.9% were using smokeless tobacco. 
  3. 21.8% out of 8,587 people surveyed were found to be between 12 to 18 years. 
  4. About 3% of children and adolescents of ages ranged from 12 to 18 years abused cannabis and that only 4% of the Adolescent Drug Abuse in India abusers go for treatment of the problems arising from it. 

Types of substance abuse disorders

There are two groups of substance-use disorders according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5, 2013):

  • Substance use disorders – these are the patterns or clusters of symptoms resulting from the use of a substance that you continue to take, despite experiencing personal, social, health, or occupational problems as a result.
  • Substance-induced disorders – these include intoxication, withdrawal, and other substance/medication-induced mental disorders like short term memory and learning, impaired ability to focus, poor coordination, paranoia, mania, analgesia, feelings of dysphoria, flushing of the face, itchy skin, dry mouth, etc. are detailed alongside substance use disorders.

Signs and symptoms of Substance Abuse

Following are the diagnostic criteria for substance use disorders according to DSM5 which explains all the signs and symptoms of substance abuse disorders:

1. The substance is often taken in larger amounts and/or over a longer period than the patient intended. 

2. Persistent attempts or one or more unsuccessful efforts made to cut down or control substance use. 

3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from effects. 

4. Craving or a strong desire or urge to use the substance 

5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home. 

6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance. 

7. Important social, occupational or recreational activities given up or reduced because of substance use. 

8. Recurrent substance use in situations in which it is physically hazardous. 

9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. 

10. Tolerance, as defined by either of the following: 

  • Markedly increased amounts of the substance in order to achieve intoxication or desired effect; 
  • markedly diminished effect with continued use of the same amount; 
  • The characteristic withdrawal syndrome for the substance; 
  • The characteristic withdrawal syndrome for the substance; 
  • The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

Understanding the link between Substance Abuse and Mental Health

Substance abuse and mental health are very closely interconnected. A lot of times people develop a dependence on a substance to escape emotional or physical pain. Children from broken families and abusive childhoods are more likely to abuse psychoactive substances. A correlation has also been found between low self-esteem and substance abuse.

Dependence on a substance seems to be a coping mechanism known as ‘avoidance’ where the person seeks comfort in the haze or ‘high’ provided by these substances to avoid dealing with life. Once dependence develops, it leads to a lot of co-morbid mental illnesses like depression, bipolar disorder, anxiety disorders, and even psychosis. substance use disorders according to DSM5 (Diagnostic and Statistical Manual of Mental Disorders), leads to cognitive function loss,  irritability, anger issues, difficulties with concentration, and focus. In addition, substance abuse leads to work absence and problems in interpersonal relationships which in turn leads to further emotional problems.

Talking always helps to clear your mind, you can always talk to Wysa.

Substance Abuse and Mental Illness treatment

Treatment for substance abuse has to happen across many levels, sometimes simultaneously. The treatment aspects are:

  • Management of withdrawal symptoms during detoxification
  • Management of cravings and prevention of relapse after detoxification
  • Medications to substitute psychoactive substances to facilitate weaning off
  • Medications to manage and treat comorbid psychological disorders like mood and anxiety
  • Behavioral counseling
  • Psychotherapy
  • Modification of family and community environment to reduce cues that induce cravings

Steps in treating Substance Abuse

Treatment of substance abuse is a large-scale effort that involves many aspects of the patient as well as his/her environment to ensure continued prevention or avoid any relapse in behavior. The first step usually involves admission to a de-addiction center to under a detoxification period where the patient is monitored during withdrawal and sometimes managed with pharmacological aids to ease the physical discomfort and pain. After detoxification, depending on the substance being used, the patient is started on a substitute medication regime. 

Psychotherapy and counseling sessions are begun to build healthy coping skills and management of cravings. Group therapy has been found to be especially helpful in such cases because the patient finds resonance in fellow users and it helps to build a support system for him/her. Family counseling is also utilized to explain enabling (to unknowingly maintain addiction behavior at home by skirting around the issue), codependency or denial behaviors, and also to psychoeducation about the process of addiction so that the family members can create a conducive environment for the patient’s recovery. 

Commonly used Psychotherapeutic Techniques for the Treatment of Substance Abuse are:

Motivational Interviewing 

This technique encourages individuals to make positive and firm decisions toward recovery. It forms a pathway for growth by taking people forward from a place of indecision or uncertainty. The primary principles used are empathy and support. This technique has proved to be very useful in the treatment of substance use in a psychotherapeutic way because it targets the three major roadblocks to substance abuse recovery, which are:

Readiness

The motivational interviewing technique explores whether the patient is psychologically ready to make a change. It also deciphers at what stage they are because readiness can shift from time to time. The motivational interviewing technique encourages people and increases the resilience towards acceptance of the change.

Ambivalence

This implies the patient’s mixed feelings about making a change because they struggle between the relief they get from the substance use and the harmful effects it has on their life. The motivational interviewing technique can ease the confusion and constant battle in the minds of the people and can help them stay focused on their path of recovery.

Resistance 

This refers to the internal resistance the patient feels towards effective change because of internal as well as external factors (“I want to do it but I can’t”).

The motivational interviewing technique has been found to be especially effective with alcohol use and smoking.

Cognitive behavior therapy

This technique attempts to modify the thought processes and learned behavior patterns involved in the individual’s approach that lead to addictive behaviors. This is a very effective therapeutic technique because it brings about a lasting change in the thought processes of the user. 

After undergoing cognitive behavior therapy, the patient can expect to learn how to challenge negative automatic thoughts, cope with negative emotions and substance cravings in a healthy way. They can also prevent relapse by identifying triggers and controlling them by modifying thought processes. You can always use Wysa to reframe thoughts and practice CBT.

Psychodynamic therapy

This technique attempts to unearth the unconscious or suppressed motives behind addictive behaviors, the defense mechanisms used to uphold those behaviors and resolving any deep-rooted conflicts. 

Most of the time, early life experiences give rise to deep-seated unconscious conflicts within an individual which are too painful to be kept at the surface. So they get suppressed and certain defense mechanisms are utilized to keep the anxiety arising out of those internal conflicts at bay. People sometimes turn to substance use as a way to avoid dealing with those suppressed conflicts. Psychodynamic therapy can help to gradually bring those repressed thoughts to the surface and re-integrate them with the patient in the present. This helps unresolved emotions and past guilt or shame to be dealt with and the need for substance use to suppress those emotions fade away.

Conclusion

There can be many reasons for a substance abuse disorder, ranging from a personality disorder,  early exposure, family conflict, to psychological vulnerability. It needs to be treated as an illness and the patient should not be assumed to be acting voluntarily. If the perpetuating and maintaining factors are handled practically and continuous healthy support and monitoring are provided, it can yield some very promising results in the recovery of substance abuse.

What can substance abuse cause?

Substance abuse can cause many behavioral as well as health problems. Substance abuse can lead to depression, anxiety, mood disorders, and even psychosis. It can suppress the nervous system, lead to cardiovascular, liver and kidney disease and exacerbate existing health problems like blood pressure and diabetes. Along with individual impact, substance abuse also leads to interpersonal problems leading to family discord.

How common is substance abuse disorder?

1.5% of the global disease burden results from alcohol and illicit drug addiction; in some countries, it’s over 5%. In fact, More than half of those who die from alcohol or drug overdoses are younger than 50.

What are the forms of drug abuse?

Drugs can be abused by ingestion, inhalation or injection. The most commonly abused drugs and substances are alcohol, cannabis (bhang, ganja), opioids (heroin) and pharmaceuticals like sedatives.

How can you identify a drug user?

The Diagnostic and Statistical Manual for Mental Disorders lists provides an exhaustive to be able to diagnose people with substance use disorder. But, here are some observable signs that can help you identify a drug user:
-Erratic sleep cycles
-Redness in the eyes and allergy-like symptoms
-Irritability
-Secretive and avoidance behavior
-Injection marks on various parts of the body like arms and feet
-Flaring temper
-Stealing money or accumulating debt

What comes first: substance abuse or mental health problems?

This is a classic chicken and egg situation. In the case of substance abuse, both scenarios can be true. Someone suffering from an anxiety disorder or depression might turn to a substance to seek comfort and eventually become dependent. On the other hand, someone who becomes dependent on a substance might develop a psychological illness as an after effect.

What is the difference between substance use disorder and addiction?

There is no difference between the two. “Addiction” is a medically outdated term used earlier to describe substance use disorders. This term was declared unscientific by the World Health Organisation in 1964.

Is substance abuse causing you harm?

Yes, substance abuse harms you physically, socially, professionally and personally. Like other mental illnesses, this impacts all aspects of life. It leads to deterioration of cognitive function, damages liver, heart, and kidneys, creates conflict in the family, causes absence from work, and the distance you from friends and colleagues.

Is addiction a choice or disease?

Addiction is a psychological and physical dependence on a substance and therefore illness. It may start out as a voluntary ‘experiment’ to try certain substances but once dependence develops, it becomes a psychological illness with actual physical and neural correlates. Therefore, persons suffering from addiction must be treated as ill, provided proper medical and psychological assistance and not expected to just recover using sheer willpower.

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