case study essay about drug addiction

Module 9: Substance-Related and Addictive Disorders

Case studies: substance-abuse disorders, learning objectives.

• Identify substance abuse disorders in case studies

Case Study: Benny

The following story comes from Benny, a 28-year-old living in the Metro Detroit area, USA. Read through the interview as he recounts his experiences dealing with addiction and recovery.

Q : How long have you been in recovery?

Benny : I have been in recovery for nine years. My sobriety date is April 21, 2010.

Q: What can you tell us about the last months/years of your drinking before you gave up?

Benny : To sum it up, it was a living hell. Every day I would wake up and promise myself I would not drink that day and by the evening I was intoxicated once again. I was a hardcore drug user and excessively taking ADHD medication such as Adderall, Vyvance, and Ritalin. I would abuse pills throughout the day and take sedatives at night, whether it was alcohol or a benzodiazepine. During the last month of my drinking, I was detached from reality, friends, and family, but also myself. I was isolated in my dark, cold, dorm room and suffered from extreme paranoia for weeks. I gave up going to school and the only person I was in contact with was my drug dealer.

Q : What was the final straw that led you to get sober?

Benny : I had been to drug rehab before and always relapsed afterwards. There were many situations that I can consider the final straw that led me to sobriety. However, the most notable was on an overcast, chilly October day. I was on an Adderall bender. I didn’t rest or sleep for five days. One morning I took a handful of Adderall in an effort to take the pain of addiction away. I knew it wouldn’t, but I was seeking any sort of relief. The damage this dosage caused to my brain led to a drug-induced psychosis. I was having small hallucinations here and there from the chemicals and a lack of sleep, but this time was different. I was in my own reality and my heart was racing. I had an awful reaction. The hallucinations got so real and my heart rate was beyond thumping. That day I ended up in the psych ward with very little recollection of how I ended up there. I had never been so afraid in my life. I could have died and that was enough for me to want to change.

Q : How was it for you in the early days? What was most difficult?

Benny : I had a different experience than most do in early sobriety. I was stuck in a drug-induced psychosis for the first four months of sobriety. My life was consumed by Alcoholics Anonymous meetings every day and sometimes two a day. I found guidance, friendship, and strength through these meetings. To say early sobriety was fun and easy would be a lie. However, I did learn it was possible to live a life without the use of drugs and alcohol. I also learned how to have fun once again. The most difficult part about early sobriety was dealing with my emotions. Since I started using drugs and alcohol that is what I used to deal with my emotions. If I was happy I used, if I was sad I used, if I was anxious I used, and if I couldn’t handle a situation I used. Now that the drinking and drugs were out of my life, I had to find new ways to cope with my emotions. It was also very hard leaving my old friends in the past.

Q : What reaction did you get from family and friends when you started getting sober?

Benny : My family and close friends were very supportive of me while getting sober. Everyone close to me knew I had a problem and were more than grateful when I started recovery. At first they were very skeptical because of my history of relapsing after treatment. But once they realized I was serious this time around, I received nothing but loving support from everyone close to me. My mother was especially helpful as she stopped enabling my behavior and sought help through Alcoholics Anonymous. I have amazing relationships with everyone close to me in my life today.

Q : Have you ever experienced a relapse?

Benny : I experienced many relapses before actually surrendering. I was constantly in trouble as a teenager and tried quitting many times on my own. This always resulted in me going back to the drugs or alcohol. My first experience with trying to become sober, I was 15 years old. I failed and did not get sober until I was 19. Each time I relapsed my addiction got worse and worse. Each time I gave away my sobriety, the alcohol refunded my misery.

Q : How long did it take for things to start to calm down for you emotionally and physically?

Benny : Getting over the physical pain was less of a challenge. It only lasted a few weeks. The emotional pain took a long time to heal from. It wasn’t until at least six months into my sobriety that my emotions calmed down. I was so used to being numb all the time that when I was confronted by my emotions, I often freaked out and didn’t know how to handle it. However, after working through the 12 steps of AA, I quickly learned how to deal with my emotions without the aid of drugs or alcohol.

Q : How hard was it getting used to socializing sober?

Benny : It was very hard in the beginning. I had very low self-esteem and had an extremely hard time looking anyone in the eyes. But after practice, building up my self-esteem and going to AA meetings, I quickly learned how to socialize. I have always been a social person, so after building some confidence I had no issue at all. I went back to school right after I left drug rehab and got a degree in communications. Upon taking many communication classes, I became very comfortable socializing in any situation.

Q : Was there anything surprising that you learned about yourself when you stopped drinking?

Benny : There are surprises all the time. At first it was simple things, such as the ability to make people smile. Simple gifts in life such as cracking a joke to make someone laugh when they are having a bad day. I was surprised at the fact that people actually liked me when I wasn’t intoxicated. I used to think people only liked being around me because I was the life of the party or someone they could go to and score drugs from. But after gaining experience in sobriety, I learned that people actually enjoyed my company and I wasn’t the “prick” I thought I was. The most surprising thing I learned about myself is that I can do anything as long as I am sober and I have sufficient reason to do it.

Q : How did your life change?

Benny : I could write a book to fully answer this question. My life is 100 times different than it was nine years ago. I went from being a lonely drug addict with virtually no goals, no aspirations, no friends, and no family to a productive member of society. When I was using drugs, I honestly didn’t think I would make it past the age of 21. Now, I am 28, working a dream job sharing my experience to inspire others, and constantly growing. Nine years ago I was a hopeless, miserable human being. Now, I consider myself an inspiration to others who are struggling with addiction.

Q : What are the main benefits that emerged for you from getting sober?

Benny : There are so many benefits of being sober. The most important one is the fact that no matter what happens, I am experiencing everything with a clear mind. I live every day to the fullest and understand that every day I am sober is a miracle. The benefits of sobriety are endless. People respect me today and can count on me today. I grew up in sobriety and learned a level of maturity that I would have never experienced while using. I don’t have to rely on anyone or anything to make me happy. One of the greatest benefits from sobriety is that I no longer live in fear.

Case Study: Lorrie

Figure 1. Lorrie.

Lorrie Wiley grew up in a neighborhood on the west side of Baltimore, surrounded by family and friends struggling with drug issues. She started using marijuana and “popping pills” at the age of 13, and within the following decade, someone introduced her to cocaine and heroin. She lived with family and occasional boyfriends, and as she puts it, “I had no real home or belongings of my own.”

Before the age of 30, she was trying to survive as a heroin addict. She roamed from job to job, using whatever money she made to buy drugs. She occasionally tried support groups, but they did not work for her. By the time she was in her mid-forties, she was severely depressed and felt trapped and hopeless. “I was really tired.” About that time, she fell in love with a man who also struggled with drugs.

They both knew they needed help, but weren’t sure what to do. Her boyfriend was a military veteran so he courageously sought help with the VA. It was a stroke of luck that then connected Lorrie to friends who showed her an ad in the city paper, highlighting a research study at the National Institute of Drug Abuse (NIDA), part of the National Institutes of Health (NIH.) Lorrie made the call, visited the treatment intake center adjacent to the Johns Hopkins Bayview Medical Center, and qualified for the study.

“On the first day, they gave me some medication. I went home and did what addicts do—I tried to find a bag of heroin. I took it, but felt no effect.” The medication had stopped her from feeling it. “I thought—well that was a waste of money.” Lorrie says she has never taken another drug since. Drug treatment, of course is not quite that simple, but for Lorrie, the medication helped her resist drugs during a nine-month treatment cycle that included weekly counseling as well as small cash incentives for clean urine samples.

To help with heroin cravings, every day Lorrie was given the medication buprenorphine in addition to a new drug. The experimental part of the study was to test if a medication called clonidine, sometimes prescribed to help withdrawal symptoms, would also help prevent stress-induced relapse. Half of the patients received daily buprenorphine plus daily clonidine, and half received daily buprenorphine plus a daily placebo. To this day, Lorrie does not know which one she received, but she is deeply grateful that her involvement in the study worked for her.

The study results? Clonidine worked as the NIDA investigators had hoped.

“Before I was clean, I was so uncertain of myself and I was always depressed about things. Now I am confident in life, I speak my opinion, and I am productive. I cry tears of joy, not tears of sadness,” she says. Lorrie is now eight years drug free. And her boyfriend? His treatment at the VA was also effective, and they are now married. “I now feel joy at little things, like spending time with my husband or my niece, or I look around and see that I have my own apartment, my own car, even my own pots and pans. Sounds silly, but I never thought that would be possible. I feel so happy and so blessed, thanks to the wonderful research team at NIDA.”

• Liquor store. Authored by : Fletcher6. Located at : https://commons.wikimedia.org/wiki/File:The_Bunghole_Liquor_Store.jpg . License : CC BY-SA: Attribution-ShareAlike
• Benny Story. Provided by : Living Sober. Located at : https://livingsober.org.nz/sober-story-benny/ . License : CC BY: Attribution
• One patientu2019s story: NIDA clinical trials bring a new life to a woman struggling with opioid addiction. Provided by : NIH. Located at : https://www.drugabuse.gov/drug-topics/treatment/one-patients-story-nida-clinical-trials-bring-new-life-to-woman-struggling-opioid-addiction . License : Public Domain: No Known Copyright

Substance Abuse: Case Study Analysis Essay

• To find inspiration for your paper and overcome writer’s block
• As a source of information (ensure proper referencing)
• As a template for you assignment

Introduction

Treatment model and conceptualization, dsm5 diagnosis, treatment plan.

Andrew, a Hispanic man of 26, lives with his mother and elder sister. He works part-time since he is currently enrolled at a nearby community college. Andrew was suspended from school and placed on academic probation for his involvement with marijuana. In addition, he was doing a number of part-time gigs, all of which ended in his dismissal after a few months of bad performance. One of Andrew’s four siblings, a brother, lost his life in a terrible childhood drowning. He has not sought either therapy or a solid support network. Andrew, though, has admitted to consuming marijuana and drinking alcohol and has sought professional help.

A decade of fighting Major Depression, it is finally revealed after he attends many therapy sessions. Andrew says he can drink heavily without becoming drunk. He freely admits to having tried and failed on several occasions to kick his weed and alcohol habits. Andrew has a higher chance of being fired again since he keeps skipping work. Multiple prescriptions for antidepressants were written for Andrew’s mum by her Physician. In addition, her sister gives off a gloomy vibe but insists she is well. To this end, the self-medication model will be applied to Andrew’s case to establish the root of her addiction and the best means of treating it.

Under the self-medication theory, drug use is a symptom of a deeper problem. For some people, drug abuse is a means of coping with difficult feelings, mental health issues, and stressful situations. Drug use is a coping mechanism for the distress of mental illness (Parvinro et al., 2022, p.20). Individuals may feel better in the short term, but the underlying substance misuse problem remains. Substance addiction problems are strongly linked to self-medication, suggesting that people engage in this approach because they believe it would cure their underlying disease. The use of substances provides a means for those who have suffered trauma to divert their focus away from their feelings and toward something else, which is why addiction and trauma occur together. In addition, drug use is perpetuated because it provides users with temporary relief from unpleasant experiences.

Pain, whether mental or physical, that persists over a long period of time is a major factor in the development of drug misuse disorders. Self-medication is a coping mechanism used to alleviate both emotional and physical suffering (Hawn et al., 2020, p.5). Relaxation and pain reduction from any source are two of the many benefits of using marijuana or opioids. The paradigm of self-medication is crucial to understand because it may lead to improved methods of treating substance abuse problems(Hawn et al., 2020, p.8). Substance misuse typically manifests as a symptom of a more severe problem. Substance addiction treatment often ends in relapse since so many things might trigger an individual to start abusing drugs or alcohol in the first place.

Andrew’s been using marijuana and alcohol as a kind of self-medication for his mental health issues. Over the past decade, Andrew has been medicating his significant depressive disorder using it. This suggests that Andrew’s decision to self-medicate in order to deal with his grief is a symptom of a deeper mental health issue. Since Andrew’s mom used antidepressants and her sister seems down in the dumps, it is possible that Andrew has a family history of depression. Andrew’s mental difficulties run in the family; both his sister and her mother suffer from depression. Even more importantly, Andrew is hiding his feelings of despair by consuming drugs. From Andrews’s case, it is evident that people turn to drugs as a means of relieving tension and gaining security against the unknown.

Andrew suffers from significant depression and addiction. A person with symptoms consistent with DSM-F33, IV’s major depressive disorder, recurrent episode, typically has recurring episodes of depression without a concurrent history of periods of increased activity or improved mood (Jongsma, 2022, p.6). A recurrence after two months should have been expected, and the last episode ought to have been two weeks. A lack of previous mania or hypomania is a common feature of this condition. Andrew has admitted to having serious depression for the past decade but insists he does not require treatment. The relationship he shares with his brothers is strained, but he is happy with his fiancée.

Andrew has been allowed a number of part-time positions owing to subpar performance. His lack of focus shows in his inconsistent performance at work and subsequent terminations. Despite his lack of a pre-existing depressive disorder, Andrew satisfies the diagnostic criteria for severe depression. He admits he does not need aid since Andrew thinks he is OK on his own. Andrew claims he has tried and failed to give up both alcohol and marijuana. Andrew’s drinking has been worse recently, and he brags about being able to consume large quantities of alcohol without seeing any effects.

It is clear that Andrew has a drug use disorder according to the DSM-IV criteria. Due of his dependency and abuse, he describes the experience of cravings. Andrew has a severe craving for both weed and alcohol. He freely admits to having tried and failed to kick his nicotine and alcohol habits. Because he does not seem to cut down on his drinking, Andrew also satisfies the requirements for dependency. Fearing he may fail in his job as a result of his absences, he is unable to take any significant action. He fits the abuse criteria since he has been using drugs and alcohol to cope with his major depressive disorder for a decade.

Problem Presentation

Andrew suffers from significant depression and addiction, he opens out about his heavy use of both marijuana and alcohol. His girlfriend had been encouraging him to see a counselor, and he finally did. A decade of significant depression and alcohol abuse were revealed after he attended numerous sessions. Recently, Andrew has been bragging about drinking excessively without becoming drunk. Andrew’s drinking has gotten out of hand, and he is tried several times to cut back without success.

Treatment Goal

Long-term planning for Andrew should focus on improving both the quality and the duration of his life. Goals include relieving Andrew’s severe depressive symptoms and helping him give up drinking. Andrew is depressed and uses marijuana and liquor to self-medicate. Evidence of extreme reliance and misuse is his recent pattern of drinking heavily without becoming intoxicated. Andrew has tried several times to cut back on his drinking but to no avail. Short-term targets for Andrew include cutting back on drinking and consuming marijuana and increasing his attendance at work.

Therapeutic Intervention

In order to alleviate Andrew’s substantial depressive symptoms, cognitive-behavioral therapy (CBT) should be suggested. Zayfert & Becker (2019, p.5) found that clients suffering from both depression and substance misuse responded positively to CBT. In comparison to other types of psychiatric drugs or psychological therapy, the therapy has proven to be more effective. That is why CBT is the best option for helping Andrew overcome his significant depression since he will have access to new and healthier coping mechanisms. The reduction of his depressive symptoms should help him become more productive. Andrew will be better able to handle difficult situations after doing CBT since he will have acquired the necessary problem-solving abilities. Behavioral modifications are the focus of treatment in CBT.

The second strategy is connecting Andrew with abuse support groups. The support group will assist him in giving up alcohol and drugs as coping mechanisms. In these gatherings, Andrew may hear from others and gain insight into how they have dealt with similar situations. Those who take part in support groups have less cause for worry, anxiety, and despair (Shaari, & Waller, 2022, p.10). A common theme in the group’s communication is honesty and openness about members’ internal experiences. Therefore, Andrew will be able to stick with the different treatment options that have been proposed to him and maintain his motivation to quit drinking and smoking.

Andrew suffers from serious depression, which has led him down the path of substance misuse. Andrew’s drinking and smoking habit is best explained by the self-medication theory. Upon participating in therapy, he said that he had suffered from serious depression for the previous decade, which had led him to turn to alcohol and marijuana for relief. Andrew will be able to overcome his alcohol and drug addiction with the aid of cognitive behavior therapy and connection to substance abuse support groups.

Abu Hassan Shaari, A., & Waller, B. (2022). Self-help group experiences among members recovering from substance use disorder in Kuantan, Malaysia . Social Work with Groups , 1-17. Web.

Hawn, S. E., Bountress, K. E., Sheerin, C. M., Dick, D. M., & Amstadter, A. B. (2020). Trauma-related drinking to cope: A novel approach to the self-medication model . Psychology of addictive behaviors , 34 (3), 465. Web.

Jongsma Jr, A. E. (2022). The addiction treatment planner . John Wiley & Sons.

Parvinroo, S., Rouhi Khalkhali Pargam, H., Hosseinzadeh Asli, R., Rafiei, E., & Nemati, S. (2022). Frequency and causes of self-medication in patients with chronic rhinosinusitis, North of Iran, 2018–2019. European Archives of Oto-Rhino-Laryngology , 279 (8), 3973-3980.

Zayfert, C., & Becker, C. B. (2019). Cognitive-behavioral therapy for PTSD: A case formulation approach . Guilford Publications.

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Substance Use Disorders and Addiction: Mechanisms, Trends, and Treatment Implications

Information & authors, metrics & citations, view options, insights into mechanisms related to cocaine addiction using a novel imaging method for dopamine neurons, treatment implications of understanding brain function during early abstinence in patients with alcohol use disorder, relatively low amounts of alcohol intake during pregnancy are associated with subtle neurodevelopmental effects in preadolescent offspring, increased comorbidity between substance use and psychiatric disorders in sexual identity minorities, trends in nicotine use and dependence from 2001–2002 to 2012–2013, conclusions, information, published in.

• Substance-Related and Addictive Disorders
• Addiction Psychiatry
• Transgender (LGBT) Issues

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Home — Essay Samples — Nursing & Health — Public Health Issues — Drug Addiction

Drug Addiction Essay Examples

Hook examples for drug addiction essays, the personal story hook.

Start your essay with a personal story or anecdote related to drug addiction. Share an experience or the journey of someone who has struggled with addiction to create an emotional connection with your readers.

The Shocking Statistics Hook

Begin with alarming statistics or data about drug addiction rates, overdoses, or the economic impact of addiction. Highlight the gravity of the issue to capture the reader's attention.

The Historical Perspective Hook

Explore the historical context of drug addiction. Discuss the evolution of drug policies, societal perceptions, and the impact of substances on different cultures and time periods.

The Celebrity Case Study Hook

Examine the stories of well-known individuals who have battled drug addiction. Discuss their struggles, treatment, and how their experiences shed light on the broader issue of addiction.

The Societal Consequences Hook

Highlight the societal consequences of drug addiction, such as family breakdowns, crime rates, and the burden on healthcare systems. Explain why addressing addiction is essential for the well-being of communities.

The Brain Science Hook

Introduce the science behind addiction by discussing how drugs affect the brain's reward system. Explain the neurological aspects and why addiction is considered a complex brain disorder.

The Recovery Success Hook

Share stories of individuals who have successfully recovered from addiction. Emphasize the themes of resilience, rehabilitation, and hope to inspire readers and showcase the possibility of recovery.

The Policy and Legislation Hook

Discuss drug policies and legislation related to addiction. Explain how policies have evolved and their impact on addiction treatment, prevention, and societal attitudes.

The Prevention and Education Hook

Highlight the importance of prevention and education programs. Discuss initiatives aimed at raising awareness, providing resources, and educating the public about the dangers of drug addiction.

The Personal Reflection Hook

Begin with a thought-provoking question or reflection on the broader implications of drug addiction. Encourage readers to consider their own perspectives and attitudes toward addiction.

Treatment Methods in Addiction Recovery in "A Million Little Pieces"

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Substance Abuse: Drug Types, Alcohol, Tobacco, and More

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Drug Addiction in Our Brain

An examination of the genetic risk factors in drug addiction, biological basis of addiction, the drug abuse problem, teenage drug abuse in the united states, impact of drug abuse on today's society, the theme of drug and alcohol abuse in books and films, investigating causes of drug abuse /effects /intervention strategies in kenya, technology addiction among youth and its impact, the negative consequences of drugs consumption, the effects and possible solutions of drug abuse in society, the addiction of america with drugs, analysis of substance abuse through biological, psychological and sociological perspectives, prescription drug abuse among teenagers, arguments against legalization of illicit street drugs, a view of the usage of suboxone in the battle against dependency on opioid, the downtown eastside community of people, important ideas on perceptions & attitude of youth towards narcotic drugs, hate being sober: why african americans experience substance abuse in their community, drug abuse in kenya.

Contrary to the popular belief, drug addiction is an issue that is not only met among famous rock stars or people living in the streets with no home or shelter of any kind. In truth, since the evolution of synthetic drugs, even middle school children have become the victims of drug addiction. The same can be said about people who tend to live with the help of strong painkillers and medication that contains narcotic substances. Finally, we can take the ongoing issue of recreational marijuana, which is also addictive. It shows that once you start exploring this social issue, it goes way further than we initially think.

While the subject of drug addiction can be met all over the world for decades, it does not get enough coverage or statistics regarding the range or scope of the problem. It has always been in discussion since the famous Opium Wars that you might have heard of while at school or in college. Still, the modern side of the problem has been linked to the nightclubs and entertainment among young people. You can see some of our free samples on this subject to get a better idea. Regardless if you take the past or the modern times, it will have enough to write about.

Starting with the World Federation Against Drugs (an international NGO) to famous celebrities who have battled addiction, we have several people who have started an international movement to show young people how a person cannot battle the woes of addiction alone without professional medical help. The examples include Robert Downey Jr, Demi Lovato, Ben Affleck, Bradley Cooper, Drew Barrymore who has announced that she was an addict while being only 13, Elton John, Jamie Lee Curtis, a famous children’s book author, Keith Urban, Daniel Radcliffe, Eric Clapton, Carrie Fisher (Star Wars), and many others.

• Mental and physical degradation.
• Violation of the federal laws.
• Inability to recover without ruining one’s body.
• The physical danger of overdose.

Even if you have not faced any person with an addiction in your life, it is still something that we should not ignore. As a college student and a responsible person, you can make a major difference by protecting people from this awful situation with the help of education and social help. It also relates to people in recovery who require help and support. As the social stigma is quite strong, the addicts are usually left on their own and rarely ask for help, not only because they do not realize that they need help. By providing better information and exploring this subject, you can make a difference and save lives.

It does not matter what topic you may be given or have the freedom to choose for your college essay, you can explore the economical state, criminal situation, and many other aspects of life. For example, one of our paper samples talks about Bangladesh and drug addiction among young people while the other one explores the process of overcoming this problem. You can also start a debate regarding recreational marijuana and all those dangerous cocktails in modern nightclubs. The possibilities are virtually endless, which is why this topic is often approached by colleges worldwide.

The most important aspect here is understanding that you (or your friend) cannot cope alone without professional medical help. One of the reasons why addiction rehabs are present in the life of the ex-addicts is the role of the chemical processes in one’s body, which means that a person receives special medication to decrease the reception of the elements that lead to dangerous consequences. In addition, providing mental support is also important, which is something you can do as a student. Finally, the best method is to prevent something bad from happening, which can be done with the help of educational materials and discussions with young people.

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• Eating Disorders
• Mental Health

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Addiction Research

Discover the latest in addiction research, from the neuroscience of substance use disorders to evidence-based treatment practices. reports, updates, case studies and white papers are available to you at hazelden betty ford’s butler center for research..

Why do people become addicted to alcohol and other drugs? How effective is addiction treatment? What makes certain substances so addictive? The Butler Center for Research at the Hazelden Betty Ford Foundation investigates these and other questions and publishes its scientific findings in a variety of alcohol and drug addiction research papers and reports. Research topics include:

• Evidence-based treatment practices
• Addiction treatment outcomes
• Addiction, psychiatry and the brain
• Addictive substances such as prescription opioids and heroin
• Substance abuse in youth/teens, older adults and other demographic groups such as health care or legal professionals

These research queries and findings are presented in the form of updates, white papers and case studies. In addition, the Butler Center for Research collaborates with the Recovery Advocacy team to study special-focus addiction research topics, summarized in monthly  Emerging Drug Trends  reports. Altogether, these studies provide the latest in addiction research for anyone interested in learning more about the neuroscience of addiction and how addiction affects individuals, families and society in general. The research also helps clinicians and health care professionals further understand, diagnose and treat drug and alcohol addiction. Learn more about each of the Butler Center's addiction research studies below.

Research Updates

Written by Butler Center for Research staff, our one-page, topic-specific summaries discuss current research on topics of interest within the drug abuse and addiction treatment field.

View our most recent updates, or view the archive at the bottom of the page.

Patient Outcomes Study Results at Hazelden Betty Ford

Trends and Patterns in Cannabis Use across Different Age Groups

Alcohol and Tobacco Harm Reduction Interventions

Harm Reduction: History and Context

Racial and Ethnic Health Disparities and Addiction

Psychedelics as Therapeutic Treatment

Sexual and Gender Minority Youth and SUDs

Health Care Professionals and Mental Health

Grief and Addiction

Helping Families Cope with Addiction

Emerging Drug Trends Report and National Surveys

Shedding New Light on America’s No. 1 Health Problem

In collaboration with the University of Maryland School of Public Health and with support from the Butler Center for Research, the Recovery Advocacy team routinely issues research reports on emerging drug trends in America. Recovery Advocacy also commissions national surveys on attitudes, behaviors and perspectives related to substance use. From binge drinking and excessive alcohol use on college campuses, to marijuana potency concerns in an age of legalized marijuana, deeper analysis and understanding of emerging drug trends allows for greater opportunities to educate, inform and prevent misuse and deaths.

Each drug trends report explores the topic at hand, documenting the prevalence of the problem, relevant demographics, prevention and treatment options available, as well as providing insight and perspectives from thought leaders throughout the Hazelden Betty Ford Foundation.

View the latest  Emerging Drug Trends  Report:

Pediatricians First Responders for Preventing Substance Use

• Clearing Away the Confusion: Marijuana Is Not a Public Health Solution to the Opioid Crisis
• Does Socioeconomic Advantage Lessen the Risk of Adolescent Substance Use?
• The Collegiate Recovery Movement Is Gaining Strength
• Considerations for Policymakers Regarding Involuntary Commitment for Substance Use Disorders
• Widening the Lens on the Opioid Crisis
• Concerns Rising Over High-Potency Marijuana Use
• Beyond Binging: “High-Intensity Drinking”

View the latest  National Surveys :

• College Administrators See Problems As More Students View Marijuana As Safe

College Parents See Serious Problems From Campus Alcohol Use

• Youth Opioid Study: Attitudes and Usage

About Recovery Advocacy

Our mission is to provide a trusted national voice on all issues related to addiction prevention, treatment and recovery, and to facilitate conversation among those in recovery, those still suffering and society at large. We are committed to smashing stigma, shaping public policy and educating people everywhere about the problems of addiction and the promise of recovery. Learn more about recovery advocacy and how you can make a difference.

Evidence-Based Treatment Series

To help get consumers and clinicians on the same page, the Butler Center for Research has created a series of informational summaries describing:

• Evidence-based addiction treatment modalities
• Distinctive levels of substance use disorder treatment
• Specialized drug and alcohol treatment programs

Each evidence-based treatment series summary includes:

• A definition of the therapeutic approach, level of care or specialized program
• A discussion of applicability, usage and practice
• A description of outcomes and efficacy
• Research citations and related resources for more information

View the latest in this series:

Motivational Interviewing

Cognitive Behavioral Therapy

Case Studies and White Papers

Written by Hazelden Betty Ford Foundation researchers and clinicians, case studies and white papers presented by the Butler Center for Research provide invaluable insight into clinical processes and complex issues related to addiction prevention, treatment and recovery. These in-depth reports examine and chronicle clinical activities, initiatives and developments as a means of informing practitioners and continually improving the quality and delivery of substance use disorder services and related resources and initiatives.

• What does it really mean to be providing medication-assisted treatment for opioid addiction?

Adolescent Motivational Interviewing

Peer Recovery Support: Walking the Path Together

Addiction and Violence During COVID-19

The Brain Disease Model of Addiction

Healthcare Professionals and Compassion Fatigue

Moving to Trauma-Responsive Care

Virtual Intensive Outpatient Outcomes: Preliminary Findings

Driving Under the Influence of Cannabis

Vaping and E-Cigarettes

Using Telehealth for Addiction Treatment

Grandparents Raising Grandchildren

Substance Use Disorders Among Military Populations

Co-Occurring Mental Health and Substance Use Disorders

Women and Alcohol

Prescription Rates of Opioid Analgesics in Medical Treatment Settings

Applications of Positive Psychology to Substance Use Disorder

Substance Use Disorders Among Legal Professionals

Factors Impacting Early Alcohol and Drug Use Among Youths

Animal-Assisted Therapy for Substance Use Disorders

Prevalence of Adolescent Substance Misuse

Problem Drinking Behaviors Among College Students

The Importance of Recovery Management

Substance Use Factors Among LGBTQ individuals

Prescription Opioids and Dependence

Alcohol Abuse Among Law Enforcement Officers

Helping Families Cope with Substance Dependence

The Social Norms Approach to Student Substance Abuse Prevention

Drug Abuse, Dopamine and the Brain's Reward System

Women and Substance Abuse

Substance Use in the Workplace

Health Care Professionals: Addiction and Treatment

Cognitive Improvement and Alcohol Recovery

Drug Use, Misuse and Dependence Among Older Adults

Emerging Drug Trends

Does Socioeconomic Advantage Lessen the Risk of Adolescent Substance Use

The Collegiate Recovery Movement is Gaining Strength

Involuntary Commitment for Substance Use Disorders

Widening the Lens of the Opioid Crisis

Beyond Binge Drinking: High Intensity Drinking

High Potency Marijuana

National Surveys

College Administrators See Problems as More Students View Marijuana as Safe

Risky Opioid Use Among College-Age Youth

Case Studies/ White Papers

What does it really mean to be providing medication-assisted treatment for opioid addiction

Are you or a loved one struggling with alcohol or other drugs? Call today to speak confidentially with a recovery expert. Most insurance accepted.

Harnessing science, love and the wisdom of lived experience, we are a force of healing and hope ​​​​​​​for individuals, families and communities affected by substance use and mental health conditions..

Psychology of Addictive Behaviors

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Journal scope statement

Psychology of Addictive Behaviors ® publishes peer-reviewed original articles related to the psychological aspects of addictive behaviors. The journal includes articles on the following topics:

• alcohol use and alcohol use disorders
• drug use and drug use disorders
• smoking and nicotine use and disorders
• eating disorders, and
• other addictive behaviors

Randomized trials, laboratory and prospective studies, and meta-analyses are given the highest priorities. Cross-sectional studies, especially those involving convenience samples, will need to make unique contributions to be competitive in this journal.

Disclaimer: APA and the editors of Psychology of Addictive Behaviors assume no responsibility for statements and opinions advanced by the authors of its articles.

Equity, diversity, and inclusion

Psychology of Addictive Behaviors supports equity, diversity, and inclusion (EDI) in its practices. More information on these initiatives is available under EDI Efforts .

Open science

The APA Journals Program is committed to publishing transparent, rigorous research; improving reproducibility in science; and aiding research discovery. Open science practices vary per editor discretion. View the initiatives implemented by this journal .

Editor’s Choice

This journal’s content is highlighted in the APA Editor’s Choice newsletter, a free, bi-weekly compilation of editor-recommended APA Journals articles. More information is available under the submission guidelines .

Author and editor spotlights

Explore journal highlights : free article summaries, editor interviews and editorials, journal awards, mentorship opportunities, and more.

To submit to the Editorial Office of Katie Witkiewitz, PhD, please submit manuscripts electronically through the Manuscript Submission portal Microsoft Word (.docx) or LaTex (.tex) as a zip file with an accompanied Portable Document Format (.pdf) of the manuscript file

All new manuscripts submitted should be prepared according to the 7 th edition of the Publication Manual of the American Psychological Association . APA Style and Grammar Guidelines for the 7 th edition are available.

Submit Manuscript

General correspondence may be directed to

Katie Witkiewitz, PhD Department of Psychology University of New Mexico MSC 03-2220, Logan Hall 1 University of New Mexico Albuquerque, NM 87131 Email: Editor's office

Every attempt will be made to review manuscripts rapidly and to keep publication lag at a minimum. The opinions and statements published are the responsibility of the authors, and such opinions and statements do not necessarily reflect the policies of the publisher or of Division 50 or the views of the editor.

In addition to addresses and phone numbers, please supply electronic mail addresses and fax numbers, if available, for potential use by the editorial office and later by the production office.

Psychology of Addictive Behaviors is using a software system to screen submitted content for similarity with other published content. The system compares the initial version of each submitted manuscript against a database of 40+ million scholarly documents, as well as content appearing on the open web. This allows APA to check submissions for potential overlap with material previously published in scholarly journals (e.g., lifted or republished material).

Each issue of Psychology of Addictive Behavior will highlight one manuscript with the designation as an “ Editor’s Choice ” paper. Selection is based on the recommendations of the editor, who considers the paper’s potential impact to the field, the distinction of expanding the contributors to, or the focus of, our science, or its discussion of an important future direction for science.

Manuscripts

All titles and degrees should be omitted from authors' names. All manuscripts should include the following footnote typed on a separate sheet in APA format: Correspondence concerning this article should be addressed to [give the author's full name and mailing address].

Psychology of Addictive Behaviors has firm page limitations on manuscripts. A full-length manuscript should contain no more than 40 pages inclusive of title page, abstract, text, references, tables, figures, and appendices. A brief report is 10 pages, excluding title page, abstract, author note, references, figures, and tables. Margins of 1 inch and font size of 12 point must be employed, per APA style.

Commentaries are also accepted in response to a single article recently published in Psychology of Addictive Behaviors . The primary purpose would be to provide a meaningful insight, concern, alternative interpretation, clarification, or critical analysis.

Commentaries should not exceed 5 pages, excluding title page, abstract, author note, references, figures, and tables. Margins of 1 inch and font size of 12 point must be employed, per APA style. The title of a Brief Comment should include a subtitle reflecting the actual title and year of publication of the article that engendered the comment. Commentaries should be submitted no later than 6 months after publication of the original article.

Registered reports and replications

In addition to full-length research papers and brief reports reporting novel findings, the journal publishes registered reports, negative findings, replications, commentaries, and reviews. Replication submissions should include “A Replication of XX Study” in the subtitle of the manuscript as well as in the abstract. Preregistration of replication studies is strongly recommended, but not required.

Registered reports require a two-step review process.

The first step is the submission of the registration manuscript. This is a partial manuscript that includes hypotheses, rationale for the study, experimental design, and methods. The partial manuscript will be reviewed for significance and methodological approach.

If the partial manuscript is accepted this amounts to provisional acceptance of the full report regardless of the outcome of the study. The full manuscript will receive rapid editorial review, for adherence to the preregistered design, and expedited production for publication in the journal.

All articles can be published as full-length articles or as brief reports. A registered report should contain no more than 40 pages inclusive of title page, abstract, text, references, tables, figures, and appendices. A brief report is 10 pages, excluding title page, abstract, author note, references, figures, and tables. Margins of 1 inch and font size of 12 point must be employed, per APA style.

The journal has partnered with the Peer Community In Registered Reports (PCI-RR) as an “interested” journal to encourage the publication of registered reports.

Psychology of Addictive Behaviors may offer to review or publish any Stage 1 or Stage 2 Registered Reports within the journal’s disciplinary scope that receives in-principle PCI RR acceptance or recommendation. Eligible registered reports will be subject to Psychology of Addictive Behaviors ’s additional criteria. Further details are available on PCI RR’s website .

Open science badges

Articles are eligible for open science badges recognizing publicly available data, materials, and/or preregistration plans and analyses. These badges are awarded on a self-disclosure basis.

At submission, authors must confirm that criteria have been fulfilled in a signed badge disclosure form (PDF, 33KB) that must be submitted as supplemental material. If all criteria are met as confirmed by the editor, the form will then be published with the article as supplemental material.

Authors should also note their eligibility for the badge(s) in the cover letter.

For all badges, items must be made available on an open-access repository with a persistent identifier in a format that is time-stamped, immutable, and permanent. For the preregistered badge, this is an institutional registration system.

Data and materials must be made available under an open license allowing others to copy, share, and use the data, with attribution and copyright as applicable.

Available badges are:

Note that it may not be possible to preregister a study or to share data and materials. Applying for open science badges is optional.

Registration of clinical trials

As of March 1, 2020 registration will be required for all clinical trials (studies designed to examine the efficacy or effectiveness of a treatment or preventive intervention) reporting primary outcome findings. Prospective registration (i.e., pre-registration) is required if recruitment began on or after March 1, 2020. Retrospective registration will be accepted only if recruitment began before this date.

Clinical trials must be registered at ClinicalTrials.gov or at another recognized registry. A complete list of acceptable trial registries can be found via the WHO International Clinical Trials Registry Platform. Differences between registered and reported methods or outcomes must be explained clearly and transparently in the manuscript.

Trial protocols, including statistical analysis plans, must be made available to readers. Both published and unpublished protocols are acceptable. Published protocols should be cited in the manuscript. Unpublished protocols may be provided in online-only supplements or made available by request.

Use of the Standard Protocol Items: Recommendations for Intervention Trials (SPIRIT) checklist is recommended.

For secondary analyses of existing data sets, where primary analyses have already been published (or are in press), registration is not required. For such analyses, registration status must be made transparent in the manuscript, and authors must follow guidelines about data transparency provided below. The article(s) reporting the primary outcomes, and the findings, must be cited in the manuscript.

Manuscripts reporting long-term outcomes of studies for which the primary outcomes have already been published also will not require registration, but authors must follow the guidelines above for secondary analyses.

For studies that are not clinical trials, registration is encouraged, but not required.

Authors must note registration status in their cover letter, in the manuscript, and in the submission portal.

Required use of JARS and MARS guidelines and the 21-Word Statement

In order to maintain consistency and fairness in the review process and in the reporting of scientific findings,  Psychology of Addictive Behaviors requires that ALL manuscripts conform to Journal Article Reporting Standards (JARS) and Meta-Analysis Reporting Standards (MARS) as described in Applebaum et al. (2018):

Applebaum, Cooper, Kline, Mayo-Wilson, Nezu, & Rao (2018).  Journal Article Reporting Standards for Quantitative Research in Psychology: The APA Publications and Communications Board Task Force Report . American Psychologist, 73, 3-25.

The editorial team will use consistency with the JARS/MARS guidelines as a review criterion, and manuscripts may be rejected if guidelines are not followed.

When deviating from JARS/MARS guidelines, authors must provide the rationale in their cover letter and describe the limitations of doing so in their manuscript. We also recommend checking reporting guidelines from the Equator Network for your particular study design.

Manuscripts must also report (1) how the sample size was determined, (2) all data exclusions, (3) all manipulations, and (4) all study measures. See Simmons, Nelson, & Simonsohn (2012) for details; include the following statement in the Method section:

• We report how we determined our sample size, all data exclusions (if any), all manipulations, and all measures in the study.

Title of manuscript

The title of a manuscript should be accurate, fully explanatory, and preferably no longer than 12 words.

If the paper reports a randomized clinical trial (RCT), this should be indicated in the title. Note that JARS criteria must be used for reporting purposes.

Abstract and keywords

All manuscripts must include an abstract containing a maximum of 250 words typed on a separate page. After the abstract, please supply up to five keywords or brief phrases.

Manuscripts published in the Psychology of Addictive Behaviors will include a structured abstract of up to 250 words.

For studies that report randomized clinical trials or meta-analyses, the abstract also must be consistent with the guidelines set forth by JARS or MARS guidelines, respectively. Thus, in preparing a manuscript, please ensure that it is consistent with the guidelines stated below.

Please include an abstract of up to 250 words, presented in paragraph form.

The abstract should be typed on a separate page (page 2 of the manuscript), and must include each of the following sections:

• Objective: A brief statement of the purpose of the study.
• Method: A detailed summary of the participants (N, age, gender, ethnicity) as well as descriptions of the study design, measures (including names of measures), and procedures.
• Results: A detailed summary of the primary findings that clearly articulate comparison groups (if relevant), and that indicate significance or confidence intervals for the main findings.
• Conclusions: A description of the research and clinical implications of the findings.

Author contributions statements using CRediT

The APA Publication Manual (7th ed.) stipulates that “authorship encompasses…not only persons who do the writing but also those who have made substantial scientific contributions to a study.” In the spirit of transparency and openness, Psychology of Addictive Behaviors  has adopted the Contributor Roles Taxonomy (CRediT) to describe each author's individual contributions to the work. CRediT offers authors the opportunity to share an accurate and detailed description of their diverse contributions to a manuscript.

Submitting authors will be asked to identify the contributions of all authors at initial submission according to this taxonomy. If the manuscript is accepted for publication, the CRediT designations will be published as an Author Contributions Statement in the author note of the final article. All authors should have reviewed and agreed to their individual contribution(s) before submission.

CRediT includes 14 contributor roles, as described below:

• Conceptualization: Ideas; formulation or evolution of overarching research goals and aims.
• Data curation: Management activities to annotate (produce metadata), scrub data and maintain research data (including software code, where it is necessary for interpreting the data itself) for initial use and later reuse.
• Formal analysis: Application of statistical, mathematical, computational, or other formal techniques to analyze or synthesize study data.
• Funding acquisition: Acquisition of the financial support for the project leading to this publication.
• Investigation: Conducting a research and investigation process, specifically performing the experiments, or data/evidence collection.
• Methodology: Development or design of methodology; creation of models.
• Project administration: Management and coordination responsibility for the research activity planning and execution.
• Resources: Provision of study materials, reagents, materials, patients, laboratory samples, animals, instrumentation, computing resources, or other analysis tools.
• Software: Programming, software development; designing computer programs; implementation of the computer code and supporting algorithms; testing of existing code components.
• Supervision: Oversight and leadership responsibility for the research activity planning and execution, including mentorship external to the core team.
• Validation: Verification, whether as a part of the activity or separate, of the overall replication/reproducibility of results/experiments and other research outputs.
• Visualization: Preparation, creation and/or presentation of the published work, specifically visualization/data presentation.
• Writing—original draft: Preparation, creation and/or presentation of the published work, specifically writing the initial draft (including substantive translation).
• Writing—review and editing: Preparation, creation and/or presentation of the published work by those from the original research group, specifically critical review, commentary or revision—including pre- or post-publication stages.

Authors can claim credit for more than one contributor role, and the same role can be attributed to more than one author.

Public health significance statements

Authors submitting manuscripts to Psychology of Addictive Behaviors are required to provide 2–3 brief sentences regarding the public health significance of their paper. This description should be included within the manuscript on the abstract/keywords page. It should be written in language that is easily understood by both professionals and members of the lay public.

When an accepted paper is published, these sentences will be used in dissemination by the journal, including e-mail alerts, the Society of Addiction Psychology website, and on social media (Twitter and Facebook). This new policy is in keeping with efforts to increase dissemination and usage by larger and diverse audiences.

Examples include the following:

• "This study indicates that vaping cannabis is increasing among adolescents and adolescent with lower perceptions of risk were more likely to use cannabis."
• "This review found that mindfulness-based interventions are increasingly being studied as a primary treatment for alcohol and other substance use disorders. The review also found that mindfulness-based interventions are as effective as other treatments."
• "This study highlights the importance of including measures of other substances, including alcohol, tobacco, cannabis, and other prescription and illicit drugs, in studies examining opioid use disorder and chronic pain."

To be maximally useful, these statements of public health significance should not simply be sentences lifted directly out of the manuscript.

Prior to final acceptance and publication, all public health significance statements will be carefully reviewed to make sure they meet these standards. Authors will be expected to revise statements as necessary.

Transparency and openness

APA endorses the Transparency and Openness Promotion (TOP) Guidelines by a community working group in conjunction with the Center for Open Science ( Nosek et al. 2015 ). Empirical research, including meta-analyses, submitted to Psychology of Addictive Behaviors must meet the “disclosure” level for all eight aspects of research planning and reporting and the “requirement” level for data citation and design and analysis transparency. Authors should include a subsection in the Method section titled “Transparency and Openness.” This subsection should detail the efforts the authors have made to comply with the TOP guidelines. For example:

• We report how we determined our sample size, all data exclusions (if any), all manipulations, and all measures in the study, and we follow JARS (Kazak, 2018). All data, analysis code, and research materials are available at [stable link to repository]. Data were analyzed using R, version 4.0.0 (R Core Team, 2020) and the package ggplot , version 3.2.1 (Wickham, 2016). This study’s design and its analysis were not pre-registered.

In order to reduce the likelihood of duplicate or piecemeal publication, authors are required to provide, in their cover letter, a list of published, in press, and under review studies that come from the same dataset as the one in the submitted manuscript, as well as a narrative description of how the submitted manuscript differs from the others.

This narrative description should include how the manuscript differs (or does not) in terms of research question and variables studied.

If requesting masked review (see below), then authors also are required to submit a masked version of the narrative description that can be provided to reviewers. Please add this as an appendix table on the last page of the submitted manuscript. Please base your description on the following examples, edited according to your specific data circumstances.

Narrative example: Multiple uses of data collected from the same sample

• The data reported in this manuscript have been previously published and/or were collected as part of a larger data collection (at one or more points in time). Findings from the data collection have been reported in separate manuscripts. MS 1 (published) focuses on variables 1, 2, and 3; while MS 2 (in press) focuses on variables 4, 5, and 6. MS 3 (the current manuscript) focuses on variables 8, 9, and 15. MS 4 (soon to be submitted) will focus on variables 10, 12, and 14.

Narrative example: Publicly available dataset

• The data reported in this manuscript were obtained from publicly available data, [name of project, along with website link to project description]. A bibliography of journal articles, working papers, conference presentations, and dissertations using the [name of project] is available at [website link to bibliography list]. The variables and relationships examined in the present article have not been examined in any previous or current articles, or to the best of our knowledge in any papers that will be under review soon. [Alternatively, clarify any overlap of variables, as done in the narrative example above].

Upon submission of the manuscript, authors will be required to attest to the provision of the required information described above.

Finally, upon acceptance of a manuscript, authors will be required to provide, as part of the author note, a list of related published papers that come from the same dataset, unless such papers are clearly described and referenced in the manuscript (specifically noting that findings come from the same dataset).

Data, materials, and code

Authors must state whether data and study materials are posted to a trusted repository and, if so, how to access them. Recommended repositories include APA’s repository on the Open Science Framework (OSF), or authors can access a full list of other recommended repositories . Trusted repositories adhere to policies that make data discoverable, accessible, usable, and preserved for the long term. Trusted repositories also assign unique and persistent identifiers.

In a subsection titled “Transparency and Openness” at the end of the Method section, specify whether and where the data and material will be available or include a statement noting that they are not available. For submissions with quantitative or simulation analytic methods, state whether the study analysis code is posted to a trusted repository, and, if so, how to access it.

For example: 

• All data have been made publicly available at the [trusted repository name] and can be accessed at [persistent URL or DOI].
• Materials and analysis code for this study are available by emailing the corresponding author. 
• Materials and analysis code for this study are not available. 
• The code behind this analysis/simulation has been made publicly available at the [trusted repository name] and can be accessed at [persistent URL or DOI].

Preregistration of studies and analysis plans

Preregistration of studies and specific hypotheses can be a useful tool for making strong theoretical claims. Likewise, preregistration of analysis plans can be useful for distinguishing confirmatory and exploratory analyses. Investigators are encouraged to preregister their studies and analysis plans prior to conducting their research via a publicly accessible registry system (e.g., OSF , ClinicalTrials.gov, or other trial registries in the WHO Registry Network). There are many available templates; for example, APA, the British Psychological Society, and the German Psychological Society partnered with the Leibniz Institute for Psychology and Center for Open Science to create Preregistration Standards for Quantitative Research in Psychology (Bosnjak et al., 2022).

Articles must state whether or not any work was preregistered and, if so, where to access the preregistration. If any aspect of the study is preregistered, include the registry link in the method section note.

• This study’s design was preregistered prospectively, before data were collected; see [STABLE LINK OR DOI]. 
• This study’s design and hypotheses were preregistered after data had been collected but before analyses were undertaken; see [STABLE LINK OR DOI]. 
• This study’s analysis plan was preregistered; see [STABLE LINK OR DOI]. 
• This study was not preregistered.

Optional masked review

If authors would like to have masked review of their manuscripts, then the authors must also submit a title page that shows the title of the manuscript, the authors' byline names and institutional affiliations in order of authorship, and the date the manuscript is submitted.

The title page must also include an author note that identifies each author's departmental affiliation at the time the reported research was conducted, any funding or other acknowledgments, details of any prior dissemination of the ideas and data appearing in the manuscript, and one current address that will provide a point of contact for the interested reader.

The first page of the manuscript should omit the authors' names and affiliations but should include the title of the manuscript and the date it is submitted.

It is the authors' responsibility to see that the manuscript itself contains no clues to the authors' identity, including grant numbers, names of institutions providing IRB approval, self-citations, and links to online repositories for data, materials, code, or preregistrations (e.g., Create a View-only Link for a Project ).

Please ensure that the final version for production includes a byline and full author note for typesetting.

Manuscript preparation

Prepare manuscripts according to the Publication Manual of the American Psychological Association using the 7 th edition. Manuscripts may be copyedited for bias-free language (see Chapter 5 of the Publication Manual ). APA Style and Grammar Guidelines for the 7 th edition are available.

In particular, Psychology of Addictive Behaviors recommends against the use of terminology that can stigmatize people who use alcohol, drugs, other addictive substances or who have an addictive behavior. Psychology of Addictive Behaviors is in agreement with the consensus statement on Addiction Terminology developed by the International Society of Addiction Journal Editors .

All empirical manuscripts are required to report on sex and gender, and race and ethnicity of the included samples. Studies that are limited by only including predominantly non-Hispanic and white participants need to acknowledge this limitation and note that findings may not generalize to non-White participants. Explicitly describing the study as relevant to primarily white participants could also be captured by the title of the manuscript and/or reflected in the abstract. The examination of race and ethnicity should not be reified as a biological factor and authors should incorporate and explicitly discuss how race and ethnicity may be proxy measures for systemic racism, as well as cultural, social, environmental, economic, and structural factors. For more information please see these standards for publishing on racial health inequalities (Boyd, Lindo, Weeks, & McLemore, 2020).

Review APA's Journal Manuscript Preparation Guidelines before submitting your article.

Double-space all copy. Other formatting instructions, as well as instructions on preparing tables, figures, references, metrics, and abstracts, appear in the Manual . Additional guidance on APA Style is available on the APA Style website .

Below are additional instructions regarding the preparation of display equations, computer code, and tables.

Display equations

We strongly encourage you to use MathType (third-party software) or Equation Editor 3.0 (built into pre-2007 versions of Word) to construct your equations, rather than the equation support that is built into Word 2007 and Word 2010. Equations composed with the built-in Word 2007/Word 2010 equation support are converted to low-resolution graphics when they enter the production process and must be rekeyed by the typesetter, which may introduce errors.

To construct your equations with MathType or Equation Editor 3.0:

• Go to the Text section of the Insert tab and select Object.
• Select MathType or Equation Editor 3.0 in the drop-down menu.

If you have an equation that has already been produced using Microsoft Word 2007 or 2010 and you have access to the full version of MathType 6.5 or later, you can convert this equation to MathType by clicking on MathType Insert Equation. Copy the equation from Microsoft Word and paste it into the MathType box. Verify that your equation is correct, click File, and then click Update. Your equation has now been inserted into your Word file as a MathType Equation.

Use Equation Editor 3.0 or MathType only for equations or for formulas that cannot be produced as Word text using the Times or Symbol font.

Computer code

Because altering computer code in any way (e.g., indents, line spacing, line breaks, page breaks) during the typesetting process could alter its meaning, we treat computer code differently from the rest of your article in our production process. To that end, we request separate files for computer code.

In online supplemental material

We request that runnable source code be included as supplemental material to the article. For more information, visit Supplementing Your Article With Online Material .

In the text of the article

If you would like to include code in the text of your published manuscript, please submit a separate file with your code exactly as you want it to appear, using Courier New font with a type size of 8 points. We will make an image of each segment of code in your article that exceeds 40 characters in length. (Shorter snippets of code that appear in text will be typeset in Courier New and run in with the rest of the text.) If an appendix contains a mix of code and explanatory text, please submit a file that contains the entire appendix, with the code keyed in 8-point Courier New.

Use Word's insert table function when you create tables. Using spaces or tabs in your table will create problems when the table is typeset and may result in errors.

Academic writing and English language editing services

Authors who feel that their manuscript may benefit from additional academic writing or language editing support prior to submission are encouraged to seek out such services at their host institutions, engage with colleagues and subject matter experts, and/or consider several vendors that offer discounts to APA authors .

Please note that APA does not endorse or take responsibility for the service providers listed. It is strictly a referral service.

Use of such service is not mandatory for publication in an APA journal. Use of one or more of these services does not guarantee selection for peer review, manuscript acceptance, or preference for publication in any APA journal.

Submitting supplemental materials

APA can place supplemental materials online, available via the published article in the PsycArticles ® database. Please see Supplementing Your Article With Online Material for more details.

List references in alphabetical order. Each listed reference should be cited in text, and each text citation should be listed in the references section.

Examples of basic reference formats:

Journal article

McCauley, S. M., & Christiansen, M. H. (2019). Language learning as language use: A cross-linguistic model of child language development. Psychological Review , 126 (1), 1–51. https://doi.org/10.1037/rev0000126

Authored book

Brown, L. S. (2018). Feminist therapy (2nd ed.). American Psychological Association. https://doi.org/10.1037/0000092-000

Chapter in an edited book

Balsam, K. F., Martell, C. R., Jones. K. P., & Safren, S. A. (2019). Affirmative cognitive behavior therapy with sexual and gender minority people. In G. Y. Iwamasa & P. A. Hays (Eds.), Culturally responsive cognitive behavior therapy: Practice and supervision (2nd ed., pp. 287–314). American Psychological Association. https://doi.org/10.1037/0000119-012

All data, program code and other methods must be cited in the text and listed in the References section.

Data set citation

Alegria, M., Jackson, J. S., Kessler, R. C., & Takeuchi, D. (2016). Collaborative Psychiatric Epidemiology Surveys (CPES), 2001–2003 [Data set]. Inter-university Consortium for Political and Social Research. https://doi.org/10.3886/ICPSR20240.v8

Software/Code citation

Viechtbauer, W. (2010). Conducting meta-analyses in R with the metafor package.  Journal of Statistical Software , 36(3), 1–48. https://www.jstatsoft.org/v36/i03/

Wickham, H. et al., (2019). Welcome to the tidyverse. Journal of Open Source Software, 4 (43), 1686, https://doi.org/10.21105/joss.01686

All data, program code and other methods must be appropriately cited in the text and listed in the references section.

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Katie Witkiewitz, PhD University of New Mexico, United States

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Special issue of APA's Psychology of Addictive Behaviors, Vol. 37, No. 1, February 2023. This special issue includes articles that focus on the scientific and applied fruits of molar behaviorism and behavioral economics as they pertain to understanding and changing addictive behavior.

Special issue of the APA journal Psychology of Addictive Behaviors, Vol. 36, No. 6, September 2022. The articles in this special issue address innovative methods and approaches that can be used to reduce AUD among young adults.

Special issue of APA’s journal Psychology of Addictive Behaviors, Vol. 35, No. 6, September 2021. The special issue was assembled to advance our understanding of the characteristics and consequences of combined use of alcohol and cannabis.

Special issue of the APA journal Psychology of Addictive Behaviors, Vol. 34, No. 1, February 2020. The articles span the multiple areas of addiction research to which Dr. Nancy Petry made key contributions, including behavior analysis and behavior pharmacology; contingency management; demographic predictors of outcomes across multiple clinical trials; reinforcer pathology and decision making; and gambling.

Special issue of the APA journal Psychology of Addictive Behaviors, Vol. 30, No. 7, November 2016. The articles profile emerging theory-driven science on PTSD and substance use disorders, specifically with regard to the biological, psychological, and social processes implicated in etiology and maintenance, as well as promising innovations in treatment approach.

Special issue of the APA journal Psychology of Addictive Behaviors, Vol. 27, No. 2, June 2013. Articles include integrative conceptual reviews and innovative empirical research on brain-based mechanisms that may underlie risk for addictive behaviors and response to psychotherapy from adolescence through adulthood.

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Psychology of Addictive Behaviors acknowledges the institutional and structural racism that is inherent in the United States drug policy and the disproportionate harm inflicted onto communities and individuals because of race, ethnicity, nationality, religiosity, socioeconomic status, ability status, gender identification, or sexual orientation. We acknowledge that we have been complicit in systemic oppression, and we are committed to using Psychology of Addictive Behaviors as a platform to promote justice and equity in research examining substance use, substance use disorder, and addictive behaviors.

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Psychology of Addictive Behaviors encourages addiction psychologists and authors to not only inform themselves but to also inform others about differences and similarities between and within individuals of all backgrounds, recognizing that diversity extends well beyond race and ethnicity, including but not limited to variables such as gender, ability status, sexual orientation, socioeconomic status, religion, language, and acculturation levels, and acknowledging the impact that the intersectionality of each of these aspects has on addictive behaviors. It is imperative that addiction psychologists be committed to cultural sensitivity and cultural humility, increasing our awareness and confronting structural oppression and the biases within our profession and ourselves, and developing the skills necessary to work with individuals of all backgrounds and identities.

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• Open access
• Published: 13 November 2021

Risk and protective factors of drug abuse among adolescents: a systematic review

• Azmawati Mohammed Nawi 1 ,
• Rozmi Ismail 2 ,
• Fauziah Ibrahim 2 ,
• Mohd Rohaizat Hassan 1 ,
• Mohd Rizal Abdul Manaf 1 ,
• Noh Amit 3 ,
• Norhayati Ibrahim 3 &
• Nurul Shafini Shafurdin 2  

BMC Public Health volume  21 , Article number:  2088 ( 2021 ) Cite this article

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Drug abuse is detrimental, and excessive drug usage is a worldwide problem. Drug usage typically begins during adolescence. Factors for drug abuse include a variety of protective and risk factors. Hence, this systematic review aimed to determine the risk and protective factors of drug abuse among adolescents worldwide.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was adopted for the review which utilized three main journal databases, namely PubMed, EBSCOhost, and Web of Science. Tobacco addiction and alcohol abuse were excluded in this review. Retrieved citations were screened, and the data were extracted based on strict inclusion and exclusion criteria. Inclusion criteria include the article being full text, published from the year 2016 until 2020 and provided via open access resource or subscribed to by the institution. Quality assessment was done using Mixed Methods Appraisal Tools (MMAT) version 2018 to assess the methodological quality of the included studies. Given the heterogeneity of the included studies, a descriptive synthesis of the included studies was undertaken.

Out of 425 articles identified, 22 quantitative articles and one qualitative article were included in the final review. Both the risk and protective factors obtained were categorized into three main domains: individual, family, and community factors. The individual risk factors identified were traits of high impulsivity; rebelliousness; emotional regulation impairment, low religious, pain catastrophic, homework completeness, total screen time and alexithymia; the experience of maltreatment or a negative upbringing; having psychiatric disorders such as conduct problems and major depressive disorder; previous e-cigarette exposure; behavioral addiction; low-perceived risk; high-perceived drug accessibility; and high-attitude to use synthetic drugs. The familial risk factors were prenatal maternal smoking; poor maternal psychological control; low parental education; negligence; poor supervision; uncontrolled pocket money; and the presence of substance-using family members. One community risk factor reported was having peers who abuse drugs. The protective factors determined were individual traits of optimism; a high level of mindfulness; having social phobia; having strong beliefs against substance abuse; the desire to maintain one’s health; high paternal awareness of drug abuse; school connectedness; structured activity and having strong religious beliefs.

The outcomes of this review suggest a complex interaction between a multitude of factors influencing adolescent drug abuse. Therefore, successful adolescent drug abuse prevention programs will require extensive work at all levels of domains.

Peer Review reports

Introduction

Drug abuse is a global problem; 5.6% of the global population aged 15–64 years used drugs at least once during 2016 [ 1 ]. The usage of drugs among younger people has been shown to be higher than that among older people for most drugs. Drug abuse is also on the rise in many ASEAN (Association of Southeast Asian Nations) countries, especially among young males between 15 and 30 years of age. The increased burden due to drug abuse among adolescents and young adults was shown by the Global Burden of Disease (GBD) study in 2013 [ 2 ]. About 14% of the total health burden in young men is caused by alcohol and drug abuse. Younger people are also more likely to die from substance use disorders [ 3 ], and cannabis is the drug of choice among such users [ 4 ].

Adolescents are the group of people most prone to addiction [ 5 ]. The critical age of initiation of drug use begins during the adolescent period, and the maximum usage of drugs occurs among young people aged 18–25 years old [ 1 ]. During this period, adolescents have a strong inclination toward experimentation, curiosity, susceptibility to peer pressure, rebellion against authority, and poor self-worth, which makes such individuals vulnerable to drug abuse [ 2 ]. During adolescence, the basic development process generally involves changing relations between the individual and the multiple levels of the context within which the young person is accustomed. Variation in the substance and timing of these relations promotes diversity in adolescence and represents sources of risk or protective factors across this life period [ 6 ]. All these factors are crucial to helping young people develop their full potential and attain the best health in the transition to adulthood. Abusing drugs impairs the successful transition to adulthood by impairing the development of critical thinking and the learning of crucial cognitive skills [ 7 ]. Adolescents who abuse drugs are also reported to have higher rates of physical and mental illness and reduced overall health and well-being [ 8 ].

The absence of protective factors and the presence of risk factors predispose adolescents to drug abuse. Some of the risk factors are the presence of early mental and behavioral health problems, peer pressure, poorly equipped schools, poverty, poor parental supervision and relationships, a poor family structure, a lack of opportunities, isolation, gender, and accessibility to drugs [ 9 ]. The protective factors include high self-esteem, religiosity, grit, peer factors, self-control, parental monitoring, academic competence, anti-drug use policies, and strong neighborhood attachment [ 10 , 11 , 12 , 13 , 14 , 15 ].

The majority of previous systematic reviews done worldwide on drug usage focused on the mental, psychological, or social consequences of substance abuse [ 16 , 17 , 18 ], while some focused only on risk and protective factors for the non-medical use of prescription drugs among youths [ 19 ]. A few studies focused only on the risk factors of single drug usage among adolescents [ 20 ]. Therefore, the development of the current systematic review is based on the main research question: What is the current risk and protective factors among adolescent on the involvement with drug abuse? To the best of our knowledge, there is limited evidence from systematic reviews that explores the risk and protective factors among the adolescent population involved in drug abuse. Especially among developing countries, such as those in South East Asia, such research on the risk and protective factors for drug abuse is scarce. Furthermore, this review will shed light on the recent trends of risk and protective factors and provide insight into the main focus factors for prevention and control activities program. Additionally, this review will provide information on how these risk and protective factors change throughout various developmental stages. Therefore, the objective of this systematic review was to determine the risk and protective factors of drug abuse among adolescents worldwide. This paper thus fills in the gaps of previous studies and adds to the existing body of knowledge. In addition, this review may benefit certain parties in developing countries like Malaysia, where the national response to drugs is developing in terms of harm reduction, prison sentences, drug treatments, law enforcement responses, and civil society participation.

This systematic review was conducted using three databases, PubMed, EBSCOhost, and Web of Science, considering the easy access and wide coverage of reliable journals, focusing on the risk and protective factors of drug abuse among adolescents from 2016 until December 2020. The search was limited to the last 5 years to focus only on the most recent findings related to risk and protective factors. The search strategy employed was performed in accordance with the Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) checklist.

A preliminary search was conducted to identify appropriate keywords and determine whether this review was feasible. Subsequently, the related keywords were searched using online thesauruses, online dictionaries, and online encyclopedias. These keywords were verified and validated by an academic professor at the National University of Malaysia. The keywords used as shown in Table  1 .

Selection criteria

The systematic review process for searching the articles was carried out via the steps shown in Fig.  1 . Firstly, screening was done to remove duplicate articles from the selected search engines. A total of 240 articles were removed in this stage. Titles and abstracts were screened based on the relevancy of the titles to the inclusion and exclusion criteria and the objectives. The inclusion criteria were full text original articles, open access articles or articles subscribed to by the institution, observation and intervention study design and English language articles. The exclusion criteria in this search were (a) case study articles, (b) systematic and narrative review paper articles, (c) non-adolescent-based analyses, (d) non-English articles, and (e) articles focusing on smoking (nicotine) and alcohol-related issues only. A total of 130 articles were excluded after title and abstract screening, leaving 55 articles to be assessed for eligibility. The full text of each article was obtained, and each full article was checked thoroughly to determine if it would fulfil the inclusion criteria and objectives of this study. Each of the authors compared their list of potentially relevant articles and discussed their selections until a final agreement was obtained. A total of 22 articles were accepted to be included in this review. Most of the excluded articles were excluded because the population was not of the target age range—i.e., featuring subjects with an age > 18 years, a cohort born in 1965–1975, or undergraduate college students; the subject matter was not related to the study objective—i.e., assessing the effects on premature mortality, violent behavior, psychiatric illness, individual traits, and personality; type of article such as narrative review and neuropsychiatry review; and because of our inability to obtain the full article—e.g., forthcoming work in 2021. One qualitative article was added to explain the domain related to risk and the protective factors among the adolescents.

PRISMA flow diagram showing the selection of studies on risk and protective factors for drug abuse among adolescents.2.2. Operational Definition

Drug-related substances in this context refer to narcotics, opioids, psychoactive substances, amphetamines, cannabis, ecstasy, heroin, cocaine, hallucinogens, depressants, and stimulants. Drugs of abuse can be either off-label drugs or drugs that are medically prescribed. The two most commonly abused substances not included in this review are nicotine (tobacco) and alcohol. Accordingly, e-cigarettes and nicotine vape were also not included. Further, “adolescence” in this study refers to members of the population aged between 10 to 18 years [ 21 ].

Data extraction tool

All researchers independently extracted information for each article into an Excel spreadsheet. The data were then customized based on their (a) number; (b) year; (c) author and country; (d) titles; (e) study design; (f) type of substance abuse; (g) results—risks and protective factors; and (h) conclusions. A second reviewer crossed-checked the articles assigned to them and provided comments in the table.

Quality assessment tool

By using the Mixed Method Assessment Tool (MMAT version 2018), all articles were critically appraised for their quality by two independent reviewers. This tool has been shown to be useful in systematic reviews encompassing different study designs [ 22 ]. Articles were only selected if both reviewers agreed upon the articles’ quality. Any disagreement between the assigned reviewers was managed by employing a third independent reviewer. All included studies received a rating of “yes” for the questions in the respective domains of the MMAT checklists. Therefore, none of the articles were removed from this review due to poor quality. The Cohen’s kappa (agreement) between the two reviewers was 0.77, indicating moderate agreement [ 23 ].

The initial search found 425 studies for review, but after removing duplicates and applying the criteria listed above, we narrowed the pool to 22 articles, all of which are quantitative in their study design. The studies include three prospective cohort studies [ 24 , 25 , 26 ], one community trial [ 27 ], one case-control study [ 28 ], and nine cross-sectional studies [ 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ]. After careful discussion, all reviewer panels agreed to add one qualitative study [ 46 ] to help provide reasoning for the quantitative results. The selected qualitative paper was chosen because it discussed almost all domains on the risk and protective factors found in this review.

A summary of all 23 articles is listed in Table  2 . A majority of the studies (13 articles) were from the United States of America (USA) [ 25 , 26 , 27 , 29 , 30 , 31 , 34 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ], three studies were from the Asia region [ 32 , 33 , 38 ], four studies were from Europe [ 24 , 28 , 40 , 44 ], and one study was from Latin America [ 35 ], Africa [ 43 ] and Mediterranean [ 45 ]. The number of sample participants varied widely between the studies, ranging from 70 samples (minimum) to 700,178 samples (maximum), while the qualitative paper utilized a total of 100 interviewees. There were a wide range of drugs assessed in the quantitative articles, with marijuana being mentioned in 11 studies, cannabis in five studies, and opioid (six studies). There was also large heterogeneity in terms of the study design, type of drug abused, measurements of outcomes, and analysis techniques used. Therefore, the data were presented descriptively.

After thorough discussion and evaluation, all the findings (both risk and protective factors) from the review were categorized into three main domains: individual factors, family factors, and community factors. The conceptual framework is summarized in Fig.  2 .

Conceptual framework of risk and protective factors related to adolescent drug abuse

DOMAIN: individual factor

Risk factors.

Almost all the articles highlighted significant findings of individual risk factors for adolescent drug abuse. Therefore, our findings for this domain were further broken down into five more sub-domains consisting of personal/individual traits, significant negative growth exposure, personal psychiatric diagnosis, previous substance history, comorbidity and an individual’s attitude and perception.

Personal/individual traits

Chuang et al. [ 29 ] found that adolescents with high impulsivity traits had a significant positive association with drug addiction. This study also showed that the impulsivity trait alone was an independent risk factor that increased the odds between two to four times for using any drug compared to the non-impulsive group. Another longitudinal study by Guttmannova et al. showed that rebellious traits are positively associated with marijuana drug abuse [ 27 ]. The authors argued that measures of rebelliousness are a good proxy for a youth’s propensity to engage in risky behavior. Nevertheless, Wilson et al. [ 37 ], in a study involving 112 youths undergoing detoxification treatment for opioid abuse, found that a majority of the affected respondents had difficulty in regulating their emotions. The authors found that those with emotional regulation impairment traits became opioid dependent at an earlier age. Apart from that, a case-control study among outpatient youths found that adolescents involved in cannabis abuse had significant alexithymia traits compared to the control population [ 28 ]. Those adolescents scored high in the dimension of Difficulty in Identifying Emotion (DIF), which is one of the key definitions of diagnosing alexithymia. Overall, the adjusted Odds Ratio for DIF in cannabis abuse was 1.11 (95% CI, 1.03–1.20).

Significant negative growth exposure

A history of maltreatment in the past was also shown to have a positive association with adolescent drug abuse. A study found that a history of physical abuse in the past is associated with adolescent drug abuse through a Path Analysis, despite evidence being limited to the female gender [ 25 ]. However, evidence from another study focusing at foster care concluded that any type of maltreatment might result in a prevalence as high as 85.7% for the lifetime use of cannabis and as high as 31.7% for the prevalence of cannabis use within the last 3-months [ 30 ]. The study also found significant latent variables that accounted for drug abuse outcomes, which were chronic physical maltreatment (factor loading of 0.858) and chronic psychological maltreatment (factor loading of 0.825), with an r 2 of 73.6 and 68.1%, respectively. Another study shed light on those living in child welfare service (CWS) [ 35 ]. It was observed through longitudinal measurements that proportions of marijuana usage increased from 9 to 18% after 36 months in CWS. Hence, there is evidence of the possibility of a negative upbringing at such shelters.

Personal psychiatric diagnosis

The robust studies conducted in the USA have deduced that adolescents diagnosed with a conduct problem (CP) have a positive association with marijuana abuse (OR = 1.75 [1.56, 1.96], p  < 0.0001). Furthermore, those with a diagnosis of Major Depressive Disorder (MDD) showed a significant positive association with marijuana abuse.

Previous substance and addiction history

Another study found that exposure to e-cigarettes within the past 30 days is related to an increase in the prevalence of marijuana use and prescription drug use by at least four times in the 8th and 10th grades and by at least three times in the 12th grade [ 34 ]. An association between other behavioral addictions and the development of drug abuse was also studied [ 29 ]. Using a 12-item index to assess potential addictive behaviors [ 39 ], significant associations between drug abuse and the groups with two behavioral addictions (OR = 3.19, 95% CI 1.25,9.77) and three behavioral addictions (OR = 3.46, 95% CI 1.25,9.58) were reported.

Comorbidity

The paper by Dash et al. (2020) highlight adolescent with a disease who needs routine medical pain treatment have higher risk of opioid misuse [ 38 ]. The adolescents who have disorder symptoms may have a risk for opioid misuse despite for the pain intensity.

Individual’s attitudes and perceptions

In a study conducted in three Latin America countries (Argentina, Chile, and Uruguay), it was shown that adolescents with low or no perceived risk of taking marijuana had a higher risk of abuse (OR = 8.22 times, 95% CI 7.56, 10.30) [ 35 ]. This finding is in line with another study that investigated 2002 adolescents and concluded that perceiving the drug as harmless was an independent risk factor that could prospectively predict future marijuana abuse [ 27 ]. Moreover, some youth interviewed perceived that they gained benefits from substance use [ 38 ]. The focus group discussion summarized that the youth felt positive personal motivation and could escape from a negative state by taking drugs. Apart from that, adolescents who had high-perceived availability of drugs in their neighborhoods were more likely to increase their usage of marijuana over time (OR = 11.00, 95% CI 9.11, 13.27) [ 35 ]. A cheap price of the substance and the availability of drug dealers around schools were factors for youth accessibility [ 38 ]. Perceived drug accessibility has also been linked with the authorities’ enforcement programs. The youth perception of a lax community enforcement of laws regarding drug use at all-time points predicted an increase in marijuana use in the subsequent assessment period [ 27 ]. Besides perception, a study examining the attitudes towards synthetic drugs based on 8076 probabilistic samples of Macau students found that the odds of the lifetime use of marijuana was almost three times higher among those with a strong attitude towards the use of synthetic drugs [ 32 ]. In addition, total screen time among the adolescent increase the likelihood of frequent cannabis use. Those who reported daily cannabis use have a mean of 12.56 h of total screen time, compared to a mean of 6.93 h among those who reported no cannabis use. Adolescent with more time on internet use, messaging, playing video games and watching TV/movies were significantly associated with more frequent cannabis use [ 44 ].

Protective factors

Individual traits.

Some individual traits have been determined to protect adolescents from developing drug abuse habits. A study by Marin et al. found that youth with an optimistic trait were less likely to become drug dependent [ 33 ]. In this study involving 1104 Iranian students, it was concluded that a higher optimism score (measured using the Children Attributional Style Questionnaire, CASQ) was a protective factor against illicit drug use (OR = 0.90, 95% CI: 0.85–0.95). Another study found that high levels of mindfulness, measured using the 25-item Child Acceptance and Mindfulness Measure, CAMM, lead to a slower progression toward injectable drug abuse among youth with opioid addiction (1.67 years, p  = .041) [ 37 ]. In addition, the social phobia trait was found to have a negative association with marijuana use (OR = 0.87, 95% CI 0.77–0.97), as suggested [ 31 ].

According to El Kazdouh et al., individuals with a strong belief against substance use and those with a strong desire to maintain their health were more likely to be protected from involvement in drug abuse [ 46 ].

DOMAIN: family factors

The biological factors underlying drug abuse in adolescents have been reported in several studies. Epigenetic studies are considered important, as they can provide a good outline of the potential pre-natal factors that can be targeted at an earlier stage. Expecting mothers who smoke tobacco and alcohol have an indirect link with adolescent substance abuse in later life [ 24 , 39 ]. Moreover, the dynamic relationship between parents and their children may have some profound effects on the child’s growth. Luk et al. examined the mediator effects between parenting style and substance abuse and found the maternal psychological control dimension to be a significant variable [ 26 ]. The mother’s psychological control was two times higher in influencing her children to be involved in substance abuse compared to the other dimension. Conversely, an indirect risk factor towards youth drug abuse was elaborated in a study in which low parental educational level predicted a greater risk of future drug abuse by reducing the youth’s perception of harm [ 27 , 43 ]. Negligence from a parental perspective could also contribute to this problem. According to El Kazdouh et al. [ 46 ], a lack of parental supervision, uncontrolled pocket money spending among children, and the presence of substance-using family members were the most common negligence factors.

While the maternal factors above were shown to be risk factors, the opposite effect was seen when the paternal figure equipped himself with sufficient knowledge. A study found that fathers with good information and awareness were more likely to protect their adolescent children from drug abuse [ 26 ]. El Kazdouh et al. noted that support and advice could be some of the protective factors in this area [ 46 ].

DOMAIN: community factors

• Risk factor

A study in 2017 showed a positive association between adolescent drug abuse and peers who abuse drugs [ 32 , 39 ]. It was estimated that the odds of becoming a lifetime marijuana user was significantly increased by a factor of 2.5 ( p  < 0.001) among peer groups who were taking synthetic drugs. This factor served as peer pressure for youth, who subconsciously had desire to be like the others [ 38 ]. The impact of availability and engagement in structured and unstructured activities also play a role in marijuana use. The findings from Spillane (2000) found that the availability of unstructured activities was associated with increased likelihood of marijuana use [ 42 ].

• Protective factor

Strong religious beliefs integrated into society serve as a crucial protective factor that can prevent adolescents from engaging in drug abuse [ 38 , 45 ]. In addition, the school connectedness and adult support also play a major contribution in the drug use [ 40 ].

The goal of this review was to identify and classify the risks and protective factors that lead adolescents to drug abuse across the three important domains of the individual, family, and community. No findings conflicted with each other, as each of them had their own arguments and justifications. The findings from our review showed that individual factors were the most commonly highlighted. These factors include individual traits, significant negative growth exposure, personal psychiatric diagnosis, previous substance and addiction history, and an individual’s attitude and perception as risk factors.

Within the individual factor domain, nine articles were found to contribute to the subdomain of personal/ individual traits [ 27 , 28 , 29 , 37 , 38 , 39 , 40 , 43 , 44 ]. Despite the heterogeneity of the study designs and the substances under investigation, all of the papers found statistically significant results for the possible risk factors of adolescent drug abuse. The traits of high impulsivity, rebelliousness, difficulty in regulating emotions, and alexithymia can be considered negative characteristic traits. These adolescents suffer from the inability to self-regulate their emotions, so they tend to externalize their behaviors as a way to avoid or suppress the negative feelings that they are experiencing [ 41 , 47 , 48 ]. On the other hand, engaging in such behaviors could plausibly provide a greater sense of positive emotions and make them feel good [ 49 ]. Apart from that, evidence from a neurophysiological point of view also suggests that the compulsive drive toward drug use is complemented by deficits in impulse control and decision making (impulsive trait) [ 50 ]. A person’s ability in self-control will seriously impaired with continuous drug use and will lead to the hallmark of addiction [ 51 ].

On the other hand, there are articles that reported some individual traits to be protective for adolescents from engaging in drug abuse. Youth with the optimistic trait, a high level of mindfulness, and social phobia were less likely to become drug dependent [ 31 , 33 , 37 ]. All of these articles used different psychometric instruments to classify each individual trait and were mutually exclusive. Therefore, each trait measured the chance of engaging in drug abuse on its own and did not reflect the chance at the end of the spectrum. These findings show that individual traits can be either protective or risk factors for the drugs used among adolescents. Therefore, any adolescent with negative personality traits should be monitored closely by providing health education, motivation, counselling, and emotional support since it can be concluded that negative personality traits are correlated with high risk behaviours such as drug abuse [ 52 ].

Our study also found that a history of maltreatment has a positive association with adolescent drug abuse. Those adolescents with episodes of maltreatment were considered to have negative growth exposure, as their childhoods were negatively affected by traumatic events. Some significant associations were found between maltreatment and adolescent drug abuse, although the former factor was limited to the female gender [ 25 , 30 , 36 ]. One possible reason for the contrasting results between genders is the different sample populations, which only covered child welfare centers [ 36 ] and foster care [ 30 ]. Regardless of the place, maltreatment can happen anywhere depending on the presence of the perpetrators. To date, evidence that concretely links maltreatment and substance abuse remains limited. However, a plausible explanation for this link could be the indirect effects of posttraumatic stress (i.e., a history of maltreatment) leading to substance use [ 53 , 54 ]. These findings highlight the importance of continuous monitoring and follow-ups with adolescents who have a history of maltreatment and who have ever attended a welfare center.

Addiction sometimes leads to another addiction, as described by the findings of several studies [ 29 , 34 ]. An initial study focused on the effects of e-cigarettes in the development of other substance abuse disorders, particularly those related to marijuana, alcohol, and commonly prescribed medications [ 34 ]. The authors found that the use of e-cigarettes can lead to more severe substance addiction [ 55 ], possibly through normalization of the behavior. On the other hand, Chuang et al.’s extensive study in 2017 analyzed the combined effects of either multiple addictions alone or a combination of multiple addictions together with the impulsivity trait [ 29 ]. The outcomes reported were intriguing and provide the opportunity for targeted intervention. The synergistic effects of impulsiveness and three other substance addictions (marijuana, tobacco, and alcohol) substantially increased the likelihood for drug abuse from 3.46 (95%CI 1.25, 9.58) to 10.13 (95% CI 3.95, 25.95). Therefore, proper rehabilitation is an important strategy to ensure that one addiction will not lead to another addiction.

The likelihood for drug abuse increases as the population perceives little or no harmful risks associated with the drugs. On the opposite side of the coin, a greater perceived risk remains a protective factor for marijuana abuse [ 56 ]. However, another study noted that a stronger determinant for adolescent drug abuse was the perceived availability of the drug [ 35 , 57 ]. Looking at the bigger picture, both perceptions corroborate each other and may inform drug use. Another study, on the other hand, reported that there was a decreasing trend of perceived drug risk in conjunction with the increasing usage of drugs [ 58 ]. As more people do drugs, youth may inevitably perceive those drugs as an acceptable norm without any harmful consequences [ 59 ].

In addition, the total spent for screen time also contribute to drug abuse among adolescent [ 43 ]. This scenario has been proven by many researchers on the effect of screen time on the mental health [ 60 ] that leads to the substance use among the adolescent due to the ubiquity of pro-substance use content on the internet. Adolescent with comorbidity who needs medical pain management by opioids also tend to misuse in future. A qualitative exploration on the perspectives among general practitioners concerning the risk of opioid misuse in people with pain, showed pain management by opioids is a default treatment and misuse is not a main problem for the them [ 61 ]. A careful decision on the use of opioids as a pain management should be consider among the adolescents and their understanding is needed.

Within the family factor domain, family structures were found to have both positive and negative associations with drug abuse among adolescents. As described in one study, paternal knowledge was consistently found to be a protective factor against substance abuse [ 26 ]. With sufficient knowledge, the father can serve as the guardian of his family to monitor and protect his children from negative influences [ 62 ]. The work by Luk et al. also reported a positive association of maternal psychological association towards drug abuse (IRR 2.41, p  < 0.05) [ 26 ]. The authors also observed the same effect of paternal psychological control, although it was statistically insignificant. This construct relates to parenting style, and the authors argued that parenting style might have a profound effect on the outcomes under study. While an earlier literature review [ 63 ] also reported such a relationship, a recent study showed a lesser impact [ 64 ] with regards to neglectful parenting styles leading to poorer substance abuse outcomes. Nevertheless, it was highlighted in another study that the adolescents’ perception of a neglectful parenting style increased their odds (OR 2.14, p  = 0.012) of developing alcohol abuse, not the parenting style itself [ 65 ]. Altogether, families play vital roles in adolescents’ risk for engaging in substance abuse [ 66 ]. Therefore, any intervention to impede the initiation of substance use or curb existing substance use among adolescents needs to include parents—especially improving parent–child communication and ensuring that parents monitor their children’s activities.

Finally, the community also contributes to drug abuse among adolescents. As shown by Li et al. [ 32 ] and El Kazdouh et al. [ 46 ], peers exert a certain influence on other teenagers by making them subconsciously want to fit into the group. Peer selection and peer socialization processes might explain why peer pressure serves as a risk factor for drug-abuse among adolescents [ 67 ]. Another study reported that strong religious beliefs integrated into society play a crucial role in preventing adolescents from engaging in drug abuse [ 46 ]. Most religions devalue any actions that can cause harmful health effects, such as substance abuse [ 68 ]. Hence, spiritual beliefs may help protect adolescents. This theme has been well established in many studies [ 60 , 69 , 70 , 71 , 72 ] and, therefore, could be implemented by religious societies as part of interventions to curb the issue of adolescent drug abuse. The connection with school and structured activity did reduce the risk as a study in USA found exposure to media anti-drug messages had an indirect negative effect on substances abuse through school-related activity and social activity [ 73 ]. The school activity should highlight on the importance of developmental perspective when designing and offering school-based prevention programs [75].

Limitations

We adopted a review approach that synthesized existing evidence on the risk and protective factors of adolescents engaging in drug abuse. Although this systematic review builds on the conclusion of a rigorous review of studies in different settings, there are some potential limitations to this work. We may have missed some other important factors, as we only included English articles, and article extraction was only done from the three search engines mentioned. Nonetheless, this review focused on worldwide drug abuse studies, rather than the broader context of substance abuse including alcohol and cigarettes, thereby making this paper more focused.

Conclusions

This review has addressed some recent knowledge related to the individual, familial, and community risk and preventive factors for adolescent drug use. We suggest that more attention should be given to individual factors since most findings were discussed in relation to such factors. With the increasing trend of drug abuse, it will be critical to focus research specifically on this area. Localized studies, especially those related to demographic factors, may be more effective in generating results that are specific to particular areas and thus may be more useful in generating and assessing local control and prevention efforts. Interventions using different theory-based psychotherapies and a recognition of the unique developmental milestones specific to adolescents are among examples that can be used. Relevant holistic approaches should be strengthened not only by relevant government agencies but also by the private sector and non-governmental organizations by promoting protective factors while reducing risk factors in programs involving adolescents from primary school up to adulthood to prevent and control drug abuse. Finally, legal legislation and enforcement against drug abuse should be engaged with regularly as part of our commitment to combat this public health burden.

Data availability and materials

All data generated or analysed during this study are included in this published article.

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The authors acknowledge The Ministry of Higher Education Malaysia and The Universiti Kebangsaan Malaysia, (UKM) for funding this study under the Long-Term Research Grant Scheme-(LGRS/1/2019/UKM-UKM/2/1). We also thank the team for their commitment and tireless efforts in ensuring that manuscript was well executed.

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Addiction as a brain disease revised: why it still matters, and the need for consilience

• Markus Heilig 1 ,
• James MacKillop   ORCID: orcid.org/0000-0003-4118-9500 2 , 3 ,
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• Louk J. M. J. Vanderschuren   ORCID: orcid.org/0000-0002-5379-0363 10  

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The view that substance addiction is a brain disease, although widely accepted in the neuroscience community, has become subject to acerbic criticism in recent years. These criticisms state that the brain disease view is deterministic, fails to account for heterogeneity in remission and recovery, places too much emphasis on a compulsive dimension of addiction, and that a specific neural signature of addiction has not been identified. We acknowledge that some of these criticisms have merit, but assert that the foundational premise that addiction has a neurobiological basis is fundamentally sound. We also emphasize that denying that addiction is a brain disease is a harmful standpoint since it contributes to reducing access to healthcare and treatment, the consequences of which are catastrophic. Here, we therefore address these criticisms, and in doing so provide a contemporary update of the brain disease view of addiction. We provide arguments to support this view, discuss why apparently spontaneous remission does not negate it, and how seemingly compulsive behaviors can co-exist with the sensitivity to alternative reinforcement in addiction. Most importantly, we argue that the brain is the biological substrate from which both addiction and the capacity for behavior change arise, arguing for an intensified neuroscientific study of recovery. More broadly, we propose that these disagreements reveal the need for multidisciplinary research that integrates neuroscientific, behavioral, clinical, and sociocultural perspectives.

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Introduction.

Close to a quarter of a century ago, then director of the US National Institute on Drug Abuse Alan Leshner famously asserted that “addiction is a brain disease”, articulated a set of implications of this position, and outlined an agenda for realizing its promise [ 1 ]. The paper, now cited almost 2000 times, put forward a position that has been highly influential in guiding the efforts of researchers, and resource allocation by funding agencies. A subsequent 2000 paper by McLellan et al. [ 2 ] examined whether data justify distinguishing addiction from other conditions for which a disease label is rarely questioned, such as diabetes, hypertension or asthma. It concluded that neither genetic risk, the role of personal choices, nor the influence of environmental factors differentiated addiction in a manner that would warrant viewing it differently; neither did relapse rates, nor compliance with treatment. The authors outlined an agenda closely related to that put forward by Leshner, but with a more clinical focus. Their conclusion was that addiction should be insured, treated, and evaluated like other diseases. This paper, too, has been exceptionally influential by academic standards, as witnessed by its ~3000 citations to date. What may be less appreciated among scientists is that its impact in the real world of addiction treatment has remained more limited, with large numbers of patients still not receiving evidence-based treatments.

In recent years, the conceptualization of addiction as a brain disease has come under increasing criticism. When first put forward, the brain disease view was mainly an attempt to articulate an effective response to prevailing nonscientific, moralizing, and stigmatizing attitudes to addiction. According to these attitudes, addiction was simply the result of a person’s moral failing or weakness of character, rather than a “real” disease [ 3 ]. These attitudes created barriers for people with substance use problems to access evidence-based treatments, both those available at the time, such as opioid agonist maintenance, cognitive behavioral therapy-based relapse prevention, community reinforcement or contingency management, and those that could result from research. To promote patient access to treatments, scientists needed to argue that there is a biological basis beneath the challenging behaviors of individuals suffering from addiction. This argument was particularly targeted to the public, policymakers and health care professionals, many of whom held that since addiction was a misery people brought upon themselves, it fell beyond the scope of medicine, and was neither amenable to treatment, nor warranted the use of taxpayer money.

Present-day criticism directed at the conceptualization of addiction as a brain disease is of a very different nature. It originates from within the scientific community itself, and asserts that this conceptualization is neither supported by data, nor helpful for people with substance use problems [ 4 , 5 , 6 , 7 , 8 ]. Addressing these critiques requires a very different perspective, and is the objective of our paper. We readily acknowledge that in some cases, recent critiques of the notion of addiction as a brain disease as postulated originally have merit, and that those critiques require the postulates to be re-assessed and refined. In other cases, we believe the arguments have less validity, but still provide an opportunity to update the position of addiction as a brain disease. Our overarching concern is that questionable arguments against the notion of addiction as a brain disease may harm patients, by impeding access to care, and slowing development of novel treatments.

A premise of our argument is that any useful conceptualization of addiction requires an understanding both of the brains involved, and of environmental factors that interact with those brains [ 9 ]. These environmental factors critically include availability of drugs, but also of healthy alternative rewards and opportunities. As we will show, stating that brain mechanisms are critical for understanding and treating addiction in no way negates the role of psychological, social and socioeconomic processes as both causes and consequences of substance use. To reflect this complex nature of addiction, we have assembled a team with expertise that spans from molecular neuroscience, through animal models of addiction, human brain imaging, clinical addiction medicine, to epidemiology. What brings us together is a passionate commitment to improving the lives of people with substance use problems through science and science-based treatments, with empirical evidence as the guiding principle.

To achieve this goal, we first discuss the nature of the disease concept itself, and why we believe it is important for the science and treatment of addiction. This is followed by a discussion of the main points raised when the notion of addiction as a brain disease has come under criticism. Key among those are claims that spontaneous remission rates are high; that a specific brain pathology is lacking; and that people suffering from addiction, rather than behaving “compulsively”, in fact show a preserved ability to make informed and advantageous choices. In the process of discussing these issues, we also address the common criticism that viewing addiction as a brain disease is a fully deterministic theory of addiction. For our argument, we use the term “addiction” as originally used by Leshner [ 1 ]; in Box  1 , we map out and discuss how this construct may relate to the current diagnostic categories, such as Substance Use Disorder (SUD) and its different levels of severity (Fig.  1) .

Risky (hazardous) substance use refers to quantity/frequency indicators of consumption; SUD refers to individuals who meet criteria for a DSM-5 diagnosis (mild, moderate, or severe); and addiction refers to individuals who exhibit persistent difficulties with self-regulation of drug consumption. Among high-risk individuals, a subgroup will meet criteria for SUD and, among those who have an SUD, a further subgroup would be considered to be addicted to the drug. However, the boundary for addiction is intentionally blurred to reflect that the dividing line for defining addiction within the category of SUD remains an open empirical question.

Box 1 What’s in a name? Differentiating hazardous use, substance use disorder, and addiction

Although our principal focus is on the brain disease model of addiction, the definition of addiction itself is a source of ambiguity. Here, we provide a perspective on the major forms of terminology in the field.

Hazardous Substance Use

Hazardous (risky) substance use refers to quantitative levels of consumption that increase an individual’s risk for adverse health consequences. In practice, this pertains to alcohol use [ 110 , 111 ]. Clinically, alcohol consumption that exceeds guidelines for moderate drinking has been used to prompt brief interventions or referral for specialist care [ 112 ]. More recently, a reduction in these quantitative levels has been validated as treatment endpoints [ 113 ].

Substance Use Disorder

SUD refers to the DSM-5 diagnosis category that encompasses significant impairment or distress resulting from specific categories of psychoactive drug use. The diagnosis of SUD is operationalized as 2 or more of 11 symptoms over the past year. As a result, the diagnosis is heterogenous, with more than 1100 symptom permutations possible. The diagnosis in DSM-5 is the result of combining two diagnoses from the DSM-IV, abuse and dependence, which proved to be less valid than a single dimensional approach [ 114 ]. Critically, SUD includes three levels of severity: mild (2–3 symptoms), moderate (4–5 symptoms), and severe (6+ symptoms). The International Classification of Diseases (ICD) system retains two diagnoses, harmful use (lower severity) and substance dependence (higher severity).

Addiction is a natural language concept, etymologically meaning enslavement, with the contemporary meaning traceable to the Middle and Late Roman Republic periods [ 115 ]. As a scientific construct, drug addiction can be defined as a state in which an individual exhibits an inability to self-regulate consumption of a substance, although it does not have an operational definition. Regarding clinical diagnosis, as it is typically used in scientific and clinical parlance, addiction is not synonymous with the simple presence of SUD. Nowhere in DSM-5 is it articulated that the diagnostic threshold (or any specific number/type of symptoms) should be interpreted as reflecting addiction, which inherently connotes a high degree of severity. Indeed, concerns were raised about setting the diagnostic standard too low because of the issue of potentially conflating a low-severity SUD with addiction [ 116 ]. In scientific and clinical usage, addiction typically refers to individuals at a moderate or high severity of SUD. This is consistent with the fact that moderate-to-severe SUD has the closest correspondence with the more severe diagnosis in ICD [ 117 , 118 , 119 ]. Nonetheless, akin to the undefined overlap between hazardous use and SUD, the field has not identified the exact thresholds of SUD symptoms above which addiction would be definitively present.

Integration

The ambiguous relationships among these terms contribute to misunderstandings and disagreements. Figure 1 provides a simple working model of how these terms overlap. Fundamentally, we consider that these terms represent successive dimensions of severity, clinical “nesting dolls”. Not all individuals consuming substances at hazardous levels have an SUD, but a subgroup do. Not all individuals with a SUD are addicted to the drug in question, but a subgroup are. At the severe end of the spectrum, these domains converge (heavy consumption, numerous symptoms, the unambiguous presence of addiction), but at low severity, the overlap is more modest. The exact mapping of addiction onto SUD is an open empirical question, warranting systematic study among scientists, clinicians, and patients with lived experience. No less important will be future research situating our definition of SUD using more objective indicators (e.g., [ 55 , 120 ]), brain-based and otherwise, and more precisely in relation to clinical needs [ 121 ]. Finally, such work should ultimately be codified in both the DSM and ICD systems to demarcate clearly where the attribution of addiction belongs within the clinical nosology, and to foster greater clarity and specificity in scientific discourse.

What is a disease?

In his classic 1960 book “The Disease Concept of Alcoholism”, Jellinek noted that in the alcohol field, the debate over the disease concept was plagued by too many definitions of “alcoholism” and too few definitions of “disease” [ 10 ]. He suggested that the addiction field needed to follow the rest of medicine in moving away from viewing disease as an “entity”, i.e., something that has “its own independent existence, apart from other things” [ 11 ]. To modern medicine, he pointed out, a disease is simply a label that is agreed upon to describe a cluster of substantial, deteriorating changes in the structure or function of the human body, and the accompanying deterioration in biopsychosocial functioning. Thus, he concluded that alcoholism can simply be defined as changes in structure or function of the body due to drinking that cause disability or death. A disease label is useful to identify groups of people with commonly co-occurring constellations of problems—syndromes—that significantly impair function, and that lead to clinically significant distress, harm, or both. This convention allows a systematic study of the condition, and of whether group members benefit from a specific intervention.

It is not trivial to delineate the exact category of harmful substance use for which a label such as addiction is warranted (See Box  1 ). Challenges to diagnostic categorization are not unique to addiction, however. Throughout clinical medicine, diagnostic cut-offs are set by consensus, commonly based on an evolving understanding of thresholds above which people tend to benefit from available interventions. Because assessing benefits in large patient groups over time is difficult, diagnostic thresholds are always subject to debate and adjustments. It can be debated whether diagnostic thresholds “merely” capture the extreme of a single underlying population, or actually identify a subpopulation that is at some level distinct. Resolving this issue remains challenging in addiction, but once again, this is not different from other areas of medicine [see e.g., [ 12 ] for type 2 diabetes]. Longitudinal studies that track patient trajectories over time may have a better ability to identify subpopulations than cross-sectional assessments [ 13 ].

By this pragmatic, clinical understanding of the disease concept, it is difficult to argue that “addiction” is unjustified as a disease label. Among people who use drugs or alcohol, some progress to using with a quantity and frequency that results in impaired function and often death, making substance use a major cause of global disease burden [ 14 ]. In these people, use occurs with a pattern that in milder forms may be challenging to capture by current diagnostic criteria (See Box  1 ), but is readily recognized by patients, their families and treatment providers when it reaches a severity that is clinically significant [see [ 15 ] for a classical discussion]. In some cases, such as opioid addiction, those who receive the diagnosis stand to obtain some of the greatest benefits from medical treatments in all of clinical medicine [ 16 , 17 ]. Although effect sizes of available treatments are more modest in nicotine [ 18 ] and alcohol addiction [ 19 ], the evidence supporting their efficacy is also indisputable. A view of addiction as a disease is justified, because it is beneficial: a failure to diagnose addiction drastically increases the risk of a failure to treat it [ 20 ].

Of course, establishing a diagnosis is not a requirement for interventions to be meaningful. People with hazardous or harmful substance use who have not (yet) developed addiction should also be identified, and interventions should be initiated to address their substance-related risks. This is particularly relevant for alcohol, where even in the absence of addiction, use is frequently associated with risks or harm to self, e.g., through cardiovascular disease, liver disease or cancer, and to others, e.g., through accidents or violence [ 21 ]. Interventions to reduce hazardous or harmful substance use in people who have not developed addiction are in fact particularly appealing. In these individuals, limited interventions are able to achieve robust and meaningful benefits [ 22 ], presumably because patterns of misuse have not yet become entrenched.

Thus, as originally pointed out by McLellan and colleagues, most of the criticisms of addiction as a disease could equally be applied to other medical conditions [ 2 ]. This type of criticism could also be applied to other psychiatric disorders, and that has indeed been the case historically [ 23 , 24 ]. Today, there is broad consensus that those criticisms were misguided. Few, if any healthcare professionals continue to maintain that schizophrenia, rather than being a disease, is a normal response to societal conditions. Why, then, do people continue to question if addiction is a disease, but not whether schizophrenia, major depressive disorder or post-traumatic stress disorder are diseases? This is particularly troubling given the decades of data showing high co-morbidity of addiction with these conditions [ 25 , 26 ]. We argue that it comes down to stigma. Dysregulated substance use continues to be perceived as a self-inflicted condition characterized by a lack of willpower, thus falling outside the scope of medicine and into that of morality [ 3 ].

Chronic and relapsing, developmentally-limited, or spontaneously remitting?

Much of the critique targeted at the conceptualization of addiction as a brain disease focuses on its original assertion that addiction is a chronic and relapsing condition. Epidemiological data are cited in support of the notion that large proportions of individuals achieve remission [ 27 ], frequently without any formal treatment [ 28 , 29 ] and in some cases resuming low risk substance use [ 30 ]. For instance, based on data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) study [ 27 ], it has been pointed out that a significant proportion of people with an addictive disorder quit each year, and that most afflicted individuals ultimately remit. These spontaneous remission rates are argued to invalidate the concept of a chronic, relapsing disease [ 4 ].

Interpreting these and similar data is complicated by several methodological and conceptual issues. First, people may appear to remit spontaneously because they actually do, but also because of limited test–retest reliability of the diagnosis [ 31 ]. For instance, using a validated diagnostic interview and trained interviewers, the Collaborative Studies on Genetics of Alcoholism examined the likelihood that an individual diagnosed with a lifetime history of substance dependence would retain this classification after 5 years. This is obviously a diagnosis that, once met, by definition cannot truly remit. Lifetime alcohol dependence was indeed stable in individuals recruited from addiction treatment units, ~90% for women, and 95% for men. In contrast, in a community-based sample similar to that used in the NESARC [ 27 ], stability was only ~30% and 65% for women and men, respectively. The most important characteristic that determined diagnostic stability was severity. Diagnosis was stable in severe, treatment-seeking cases, but not in general population cases of alcohol dependence.

These data suggest that commonly used diagnostic criteria alone are simply over-inclusive for a reliable, clinically meaningful diagnosis of addiction. They do identify a core group of treatment seeking individuals with a reliable diagnosis, but, if applied to nonclinical populations, also flag as “cases” a considerable halo of individuals for whom the diagnostic categorization is unreliable. Any meaningful discussion of remission rates needs to take this into account, and specify which of these two populations that is being discussed. Unfortunately, the DSM-5 has not made this task easier. With only 2 out of 11 symptoms being sufficient for a diagnosis of SUD, it captures under a single diagnostic label individuals in a “mild” category, whose diagnosis is likely to have very low test–retest reliability, and who are unlikely to exhibit a chronic relapsing course, together with people at the severe end of the spectrum, whose diagnosis is reliable, many of whom do show a chronic relapsing course.

The NESARC data nevertheless show that close to 10% of people in the general population who are diagnosed with alcohol addiction (here equated with DSM-IV “dependence” used in the NESARC study) never remitted throughout their participation in the survey. The base life-time prevalence of alcohol dependence in NESARC was 12.5% [ 32 ]. Thus, the data cited against the concept of addiction as a chronic relapsing disease in fact indicate that over 1% of the US population develops an alcohol-related condition that is associated with high morbidity and mortality, and whose chronic and/or relapsing nature cannot be disputed, since it does not remit.

Secondly, the analysis of NESARC data [ 4 , 27 ] omits opioid addiction, which, together with alcohol and tobacco, is the largest addiction-related public health problem in the US [ 33 ]. This is probably the addictive condition where an analysis of cumulative evidence most strikingly supports the notion of a chronic disorder with frequent relapses in a large proportion of people affected [ 34 ]. Of course, a large number of people with opioid addiction are unable to express the chronic, relapsing course of their disease, because over the long term, their mortality rate is about 15 times greater than that of the general population [ 35 ]. However, even among those who remain alive, the prevalence of stable abstinence from opioid use after 10–30 years of observation is <30%. Remission may not always require abstinence, for instance in the case of alcohol addiction, but is a reasonable proxy for remission with opioids, where return to controlled use is rare. Embedded in these data is a message of literally vital importance: when opioid addiction is diagnosed and treated as a chronic relapsing disease, outcomes are markedly improved, and retention in treatment is associated with a greater likelihood of abstinence.

The fact that significant numbers of individuals exhibit a chronic relapsing course does not negate that even larger numbers of individuals with SUD according to current diagnostic criteria do not. For instance, in many countries, the highest prevalence of substance use problems is found among young adults, aged 18–25 [ 36 ], and a majority of these ‘age out’ of excessive substance use [ 37 ]. It is also well documented that many individuals with SUD achieve longstanding remission, in many cases without any formal treatment (see e.g., [ 27 , 30 , 38 ]).

Collectively, the data show that the course of SUD, as defined by current diagnostic criteria, is highly heterogeneous. Accordingly, we do not maintain that a chronic relapsing course is a defining feature of SUD. When present in a patient, however, such as course is of clinical significance, because it identifies a need for long-term disease management [ 2 ], rather than expectations of a recovery that may not be within the individual’s reach [ 39 ]. From a conceptual standpoint, however, a chronic relapsing course is neither necessary nor implied in a view that addiction is a brain disease. This view also does not mean that it is irreversible and hopeless. Human neuroscience documents restoration of functioning after abstinence [ 40 , 41 ] and reveals predictors of clinical success [ 42 ]. If anything, this evidence suggests a need to increase efforts devoted to neuroscientific research on addiction recovery [ 40 , 43 ].

Lessons from genetics

For alcohol addiction, meta-analysis of twin and adoption studies has estimated heritability at ~50%, while estimates for opioid addiction are even higher [ 44 , 45 ]. Genetic risk factors are to a large extent shared across substances [ 46 ]. It has been argued that a genetic contribution cannot support a disease view of a behavior, because most behavioral traits, including religious and political inclinations, have a genetic contribution [ 4 ]. This statement, while correct in pointing out broad heritability of behavioral traits, misses a fundamental point. Genetic architecture is much like organ structure. The fact that normal anatomy shapes healthy organ function does not negate that an altered structure can contribute to pathophysiology of disease. The structure of the genetic landscape is no different. Critics further state that a “genetic predisposition is not a recipe for compulsion”, but no neuroscientist or geneticist would claim that genetic risk is “a recipe for compulsion”. Genetic risk is probabilistic, not deterministic. However, as we will see below, in the case of addiction, it contributes to large, consistent probability shifts towards maladaptive behavior.

In dismissing the relevance of genetic risk for addiction, Hall writes that “a large number of alleles are involved in the genetic susceptibility to addiction and individually these alleles might very weakly predict a risk of addiction”. He goes on to conclude that “generally, genetic prediction of the risk of disease (even with whole-genome sequencing data) is unlikely to be informative for most people who have a so-called average risk of developing an addiction disorder” [ 7 ]. This reflects a fundamental misunderstanding of polygenic risk. It is true that a large number of risk alleles are involved, and that the explanatory power of currently available polygenic risk scores for addictive disorders lags behind those for e.g., schizophrenia or major depression [ 47 , 48 ]. The only implication of this, however, is that low average effect sizes of risk alleles in addiction necessitate larger study samples to construct polygenic scores that account for a large proportion of the known heritability.

However, a heritability of addiction of ~50% indicates that DNA sequence variation accounts for 50% of the risk for this condition. Once whole genome sequencing is readily available, it is likely that it will be possible to identify most of that DNA variation. For clinical purposes, those polygenic scores will of course not replace an understanding of the intricate web of biological and social factors that promote or prevent expression of addiction in an individual case; rather, they will add to it [ 49 ]. Meanwhile, however, genome-wide association studies in addiction have already provided important information. For instance, they have established that the genetic underpinnings of alcohol addiction only partially overlap with those for alcohol consumption, underscoring the genetic distinction between pathological and nonpathological drinking behaviors [ 50 ].

It thus seems that, rather than negating a rationale for a disease view of addiction, the important implication of the polygenic nature of addiction risk is a very different one. Genome-wide association studies of complex traits have largely confirmed the century old “infinitisemal model” in which Fisher reconciled Mendelian and polygenic traits [ 51 ]. A key implication of this model is that genetic susceptibility for a complex, polygenic trait is continuously distributed in the population. This may seem antithetical to a view of addiction as a distinct disease category, but the contradiction is only apparent, and one that has long been familiar to quantitative genetics. Viewing addiction susceptibility as a polygenic quantitative trait, and addiction as a disease category is entirely in line with Falconer’s theorem, according to which, in a given set of environmental conditions, a certain level of genetic susceptibility will determine a threshold above which disease will arise.

A brain disease? Then show me the brain lesion!

The notion of addiction as a brain disease is commonly criticized with the argument that a specific pathognomonic brain lesion has not been identified. Indeed, brain imaging findings in addiction (perhaps with the exception of extensive neurotoxic gray matter loss in advanced alcohol addiction) are nowhere near the level of specificity and sensitivity required of clinical diagnostic tests. However, this criticism neglects the fact that neuroimaging is not used to diagnose many neurologic and psychiatric disorders, including epilepsy, ALS, migraine, Huntington’s disease, bipolar disorder, or schizophrenia. Even among conditions where signs of disease can be detected using brain imaging, such as Alzheimer’s and Parkinson’s disease, a scan is best used in conjunction with clinical acumen when making the diagnosis. Thus, the requirement that addiction be detectable with a brain scan in order to be classified as a disease does not recognize the role of neuroimaging in the clinic.

For the foreseeable future, the main objective of imaging in addiction research is not to diagnose addiction, but rather to improve our understanding of mechanisms that underlie it. The hope is that mechanistic insights will help bring forward new treatments, by identifying candidate targets for them, by pointing to treatment-responsive biomarkers, or both [ 52 ]. Developing innovative treatments is essential to address unmet treatment needs, in particular in stimulant and cannabis addiction, where no approved medications are currently available. Although the task to develop novel treatments is challenging, promising candidates await evaluation [ 53 ]. A particular opportunity for imaging-based research is related to the complex and heterogeneous nature of addictive disorders. Imaging-based biomarkers hold the promise of allowing this complexity to be deconstructed into specific functional domains, as proposed by the RDoC initiative [ 54 ] and its application to addiction [ 55 , 56 ]. This can ultimately guide the development of personalized medicine strategies to addiction treatment.

Countless imaging studies have reported differences in brain structure and function between people with addictive disorders and those without them. Meta-analyses of structural data show that alcohol addiction is associated with gray matter losses in the prefrontal cortex, dorsal striatum, insula, and posterior cingulate cortex [ 57 ], and similar results have been obtained in stimulant-addicted individuals [ 58 ]. Meta-analysis of functional imaging studies has demonstrated common alterations in dorsal striatal, and frontal circuits engaged in reward and salience processing, habit formation, and executive control, across different substances and task-paradigms [ 59 ]. Molecular imaging studies have shown that large and fast increases in dopamine are associated with the reinforcing effects of drugs of abuse, but that after chronic drug use and during withdrawal, brain dopamine function is markedly decreased and that these decreases are associated with dysfunction of prefrontal regions [ 60 ]. Collectively, these findings have given rise to a widely held view of addiction as a disorder of fronto-striatal circuitry that mediates top-down regulation of behavior [ 61 ].

Critics reply that none of the brain imaging findings are sufficiently specific to distinguish between addiction and its absence, and that they are typically obtained in cross-sectional studies that can at best establish correlative rather than causal links. In this, they are largely right, and an updated version of a conceptualization of addiction as a brain disease needs to acknowledge this. Many of the structural brain findings reported are not specific for addiction, but rather shared across psychiatric disorders [ 62 ]. Also, for now, the most sophisticated tools of human brain imaging remain crude in face of complex neural circuit function. Importantly however, a vast literature from animal studies also documents functional changes in fronto-striatal circuits, as well their limbic and midbrain inputs, associated with addictive behaviors [ 63 , 64 , 65 , 66 , 67 , 68 ]. These are circuits akin to those identified by neuroimaging studies in humans, implicated in positive and negative emotions, learning processes and executive functions, altered function of which is thought to underlie addiction. These animal studies, by virtue of their cellular and molecular level resolution, and their ability to establish causality under experimental control, are therefore an important complement to human neuroimaging work.

Nevertheless, factors that seem remote from the activity of brain circuits, such as policies, substance availability and cost, as well as socioeconomic factors, also are critically important determinants of substance use. In this complex landscape, is the brain really a defensible focal point for research and treatment? The answer is “yes”. As powerfully articulated by Francis Crick [ 69 ], “You, your joys and your sorrows, your memories and your ambitions, your sense of personal identity and free will, are in fact no more than the behavior of a vast assembly of nerve cells and their associated molecules”. Social and interpersonal factors are critically important in addiction, but they can only exert their influences by impacting neural processes. They must be encoded as sensory data, represented together with memories of the past and predictions about the future, and combined with representations of interoceptive and other influences to provide inputs to the valuation machinery of the brain. Collectively, these inputs drive action selection and execution of behavior—say, to drink or not to drink, and then, within an episode, to stop drinking or keep drinking. Stating that the pathophysiology of addiction is largely about the brain does not ignore the role of other influences. It is just the opposite: it is attempting to understand how those important influences contribute to drug seeking and taking in the context of the brain, and vice versa.

But if the criticism is one of emphasis rather than of principle—i.e., too much brain, too little social and environmental factors – then neuroscientists need to acknowledge that they are in part guilty as charged. Brain-centric accounts of addiction have for a long time failed to pay enough attention to the inputs that social factors provide to neural processing behind drug seeking and taking [ 9 ]. This landscape is, however, rapidly changing. For instance, using animal models, scientists are finding that lack of social play early in life increases the motivation to take addictive substances in adulthood [ 70 ]. Others find that the opportunity to interact with a fellow rat is protective against addiction-like behaviors [ 71 ]. In humans, a relationship has been found between perceived social support, socioeconomic status, and the availability of dopamine D2 receptors [ 72 , 73 ], a biological marker of addiction vulnerability. Those findings in turn provided translation of data from nonhuman primates, which showed that D2 receptor availability can be altered by changes in social hierarchy, and that these changes are associated with the motivation to obtain cocaine [ 74 ].

Epidemiologically, it is well established that social determinants of health, including major racial and ethnic disparities, play a significant role in the risk for addiction [ 75 , 76 ]. Contemporary neuroscience is illuminating how those factors penetrate the brain [ 77 ] and, in some cases, reveals pathways of resilience [ 78 ] and how evidence-based prevention can interrupt those adverse consequences [ 79 , 80 ]. In other words, from our perspective, viewing addiction as a brain disease in no way negates the importance of social determinants of health or societal inequalities as critical influences. In fact, as shown by the studies correlating dopamine receptors with social experience, imaging is capable of capturing the impact of the social environment on brain function. This provides a platform for understanding how those influences become embedded in the biology of the brain, which provides a biological roadmap for prevention and intervention.

We therefore argue that a contemporary view of addiction as a brain disease does not deny the influence of social, environmental, developmental, or socioeconomic processes, but rather proposes that the brain is the underlying material substrate upon which those factors impinge and from which the responses originate. Because of this, neurobiology is a critical level of analysis for understanding addiction, although certainly not the only one. It is recognized throughout modern medicine that a host of biological and non-biological factors give rise to disease; understanding the biological pathophysiology is critical for understanding etiology and informing treatment.

Is a view of addiction as a brain disease deterministic?

A common criticism of the notion that addiction is a brain disease is that it is reductionist and in the end therefore deterministic [ 81 , 82 ]. This is a fundamental misrepresentation. As indicated above, viewing addiction as a brain disease simply states that neurobiology is an undeniable component of addiction. A reason for deterministic interpretations may be that modern neuroscience emphasizes an understanding of proximal causality within research designs (e.g., whether an observed link between biological processes is mediated by a specific mechanism). That does not in any way reflect a superordinate assumption that neuroscience will achieve global causality. On the contrary, since we realize that addiction involves interactions between biology, environment and society, ultimate (complete) prediction of behavior based on an understanding of neural processes alone is neither expected, nor a goal.

A fairer representation of a contemporary neuroscience view is that it believes insights from neurobiology allow useful probabilistic models to be developed of the inherently stochastic processes involved in behavior [see [ 83 ] for an elegant recent example]. Changes in brain function and structure in addiction exert a powerful probabilistic influence over a person’s behavior, but one that is highly multifactorial, variable, and thus stochastic. Philosophically, this is best understood as being aligned with indeterminism, a perspective that has a deep history in philosophy and psychology [ 84 ]. In modern neuroscience, it refers to the position that the dynamic complexity of the brain, given the probabilistic threshold-gated nature of its biology (e.g., action potential depolarization, ion channel gating), means that behavior cannot be definitively predicted in any individual instance [ 85 , 86 ].

Driven by compulsion, or free to choose?

A major criticism of the brain disease view of addiction, and one that is related to the issue of determinism vs indeterminism, centers around the term “compulsivity” [ 6 , 87 , 88 , 89 , 90 ] and the different meanings it is given. Prominent addiction theories state that addiction is characterized by a transition from controlled to “compulsive” drug seeking and taking [ 91 , 92 , 93 , 94 , 95 ], but allocate somewhat different meanings to “compulsivity”. By some accounts, compulsive substance use is habitual and insensitive to its outcomes [ 92 , 94 , 96 ]. Others refer to compulsive use as a result of increasing incentive value of drug associated cues [ 97 ], while others view it as driven by a recruitment of systems that encode negative affective states [ 95 , 98 ].

The prototype for compulsive behavior is provided by obsessive-compulsive disorder (OCD), where compulsion refers to repeatedly and stereotypically carrying out actions that in themselves may be meaningful, but lose their purpose and become harmful when performed in excess, such as persistent handwashing until skin injuries result. Crucially, this happens despite a conscious desire to do otherwise. Attempts to resist these compulsions result in increasing and ultimately intractable anxiety [ 99 ]. This is in important ways different from the meaning of compulsivity as commonly used in addiction theories. In the addiction field, compulsive drug use typically refers to inflexible, drug-centered behavior in which substance use is insensitive to adverse consequences [ 100 ]. Although this phenomenon is not necessarily present in every patient, it reflects important symptoms of clinical addiction, and is captured by several DSM-5 criteria for SUD [ 101 ]. Examples are needle-sharing despite knowledge of a risk to contract HIV or Hepatitis C, drinking despite a knowledge of having liver cirrhosis, but also the neglect of social and professional activities that previously were more important than substance use. While these behaviors do show similarities with the compulsions of OCD, there are also important differences. For example, “compulsive” substance use is not necessarily accompanied by a conscious desire to withhold the behavior, nor is addictive behavior consistently impervious to change.

Critics question the existence of compulsivity in addiction altogether [ 5 , 6 , 7 , 89 ], typically using a literal interpretation, i.e., that a person who uses alcohol or drugs simply can not do otherwise. Were that the intended meaning in theories of addiction—which it is not—it would clearly be invalidated by observations of preserved sensitivity of behavior to contingencies in addiction. Indeed, substance use is influenced both by the availability of alternative reinforcers, and the state of the organism. The roots of this insight date back to 1940, when Spragg found that chimpanzees would normally choose a banana over morphine. However, when physically dependent and in a state of withdrawal, their choice preference would reverse [ 102 ]. The critical role of alternative reinforcers was elegantly brought into modern neuroscience by Ahmed et al., who showed that rats extensively trained to self-administer cocaine would readily forego the drug if offered a sweet solution as an alternative [ 103 ]. This was later also found to be the case for heroin [ 103 ], methamphetamine [ 104 ] and alcohol [ 105 ]. Early residential laboratory studies on alcohol use disorder indeed revealed orderly operant control over alcohol consumption [ 106 ]. Furthermore, efficacy of treatment approaches such as contingency management, which provides systematic incentives for abstinence [ 107 ], supports the notion that behavioral choices in patients with addictions remain sensitive to reward contingencies.

Evidence that a capacity for choosing advantageously is preserved in addiction provides a valid argument against a narrow concept of “compulsivity” as rigid, immutable behavior that applies to all patients. It does not, however, provide an argument against addiction as a brain disease. If not from the brain, from where do the healthy and unhealthy choices people make originate? The critical question is whether addictive behaviors—for the most part—result from healthy brains responding normally to externally determined contingencies; or rather from a pathology of brain circuits that, through probabilistic shifts, promotes the likelihood of maladaptive choices even when reward contingencies are within a normal range. To resolve this question, it is critical to understand that the ability to choose advantageously is not an all-or-nothing phenomenon, but rather is about probabilities and their shifts, multiple faculties within human cognition, and their interaction. Yes, it is clear that most people whom we would consider to suffer from addiction remain able to choose advantageously much, if not most, of the time. However, it is also clear that the probability of them choosing to their own disadvantage, even when more salutary options are available and sometimes at the expense of losing their life, is systematically and quantifiably increased. There is a freedom of choice, yet there is a shift of prevailing choices that nevertheless can kill.

Synthesized, the notion of addiction as a disease of choice and addiction as a brain disease can be understood as two sides of the same coin. Both of these perspectives are informative, and they are complementary. Viewed this way, addiction is a brain disease in which a person’s choice faculties become profoundly compromised. To articulate it more specifically, embedded in and principally executed by the central nervous system, addiction can be understood as a disorder of choice preferences, preferences that overvalue immediate reinforcement (both positive and negative), preferences for drug-reinforcement in spite of costs, and preferences that are unstable ( “I’ll never drink like that again;” “this will be my last cigarette” ), prone to reversals in the form of lapses and relapse. From a contemporary neuroscience perspective, pre-existing vulnerabilities and persistent drug use lead to a vicious circle of substantive disruptions in the brain that impair and undermine choice capacities for adaptive behavior, but do not annihilate them. Evidence of generally intact decision making does not fundamentally contradict addiction as a brain disease.

Conclusions

The present paper is a response to the increasing number of criticisms of the view that addiction is a chronic relapsing brain disease. In many cases, we show that those criticisms target tenets that are neither needed nor held by a contemporary version of this view. Common themes are that viewing addiction as a brain disease is criticized for being both too narrow (addiction is only a brain disease; no other perspectives or factors are important) or too far reaching (it purports to discover the final causes of addiction). With regard to disease course, we propose that viewing addiction as a chronic relapsing disease is appropriate for some populations, and much less so for others, simply necessitating better ways of delineating the populations being discussed. We argue that when considering addiction as a disease, the lens of neurobiology is valuable to use. It is not the only lens, and it does not have supremacy over other scientific approaches. We agree that critiques of neuroscience are warranted [ 108 ] and that critical thinking is essential to avoid deterministic language and scientific overreach.

Beyond making the case for a view of addiction as a brain disease, perhaps the more important question is when a specific level of analysis is most useful. For understanding the biology of addiction and designing biological interventions, a neurobiological view is almost certainly the most appropriate level of analysis, in particular when informed by an understanding of the behavioral manifestations. In contrast, for understanding the psychology of addiction and designing psychological interventions, behavioral science is the natural realm, but one that can often benefit from an understanding of the underlying neurobiology. For designing policies, such as taxation and regulation of access, economics and public administration provide the most pertinent perspectives, but these also benefit from biological and behavioral science insights.

Finally, we argue that progress would come from integration of these scientific perspectives and traditions. E.O. Wilson has argued more broadly for greater consilience [ 109 ], unity of knowledge, in science. We believe that addiction is among the areas where consilience is most needed. A plurality of disciplines brings important and trenchant insights to bear on this condition; it is the exclusive remit of no single perspective or field. Addiction inherently and necessarily requires multidisciplinary examination. Moreover, those who suffer from addiction will benefit most from the application of the full armamentarium of scientific perspectives.

Funding and disclosures

Supported by the Swedish Research Council grants 2013-07434, 2019-01138 (MH); Netherlands Organisation for Health Research and Development (ZonMw) under project number 912.14.093 (LJMJV); NIDA and NIAAA intramural research programs (LL; the content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health); the Peter Boris Chair in Addictions Research, Homewood Research Institute, and the National Institute on Alcohol Abuse and Alcoholism grants AA025911, AA024930, AA025849, AA027679 (JM; the content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health).

MH has received consulting fees, research support or other compensation from Indivior, Camurus, BrainsWay, Aelis Farma, and Janssen Pharmaceuticals. JM is a Principal and Senior Scientist at BEAM Diagnostics, Inc. DM, JR, LL, and LJMJV declare no conflict of interest.

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Heilig, M., MacKillop, J., Martinez, D. et al. Addiction as a brain disease revised: why it still matters, and the need for consilience. Neuropsychopharmacol. 46 , 1715–1723 (2021). https://doi.org/10.1038/s41386-020-00950-y

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Case Presentations from the Addiction Academy

Joan r. laes.

Division of Addiction Medicine, Hennepin County Medical Center, 701 Park Avenue, Mail Code G5, Minneapolis, MN 55415 USA

Timothy Wiegand

University of Rochester Medical Center & Strong Memorial Hospital, Rochester, NY USA

In this article, a case-based format is used to address complex clinical issues in addiction medicine. The cases were developed from the authors’ practice experience, and were presented at the American College of Medical Toxicology Addiction Academy in 2015. Section I: Drug and Alcohol Dependence and Pain explores cases of patients with co-occurring pain and substance use disorders. Section II: Legal and Policy Issues in Substance Use Disorders highlights difficult legal and policy questions in addiction medicine. Section III: Special Populations and Addictive Disorders delves into the complexity of addiction in special populations (pregnant, pediatric, and geriatric patients).

Introduction

The case studies described in this article were presented as panel and small group discussion sessions at the American College of Medical Toxicology “Addiction Medicine Academy” symposium in March 2015. The individuals who participated in the panel and led the group sessions are listed in the appendix. These cases were developed based on the practice experiences of the author and faculty participating in the discussions. The ensuing discussions are described in the question and answer style of the group sessions.

The cases in Section I: Drug and Alcohol Dependence and Pain describe issues that arise in the treatment of pain in patients with a history of, or concerning features for, substance use disorder. In Section II. Legal and Policy Issues in Substance Use Disorders , addiction medicine legal and policy perspectives are discussed through case-based format. In Section III: Special Populations and Addictive Disorders , the cases highlight the complex clinical issues medical providers face in the management of addiction in special populations including pregnant women, pediatrics, and the elderly.

Section I: Drug and Alcohol Dependence and Pain

A 54-year-old woman with chronic pain due to inflammatory arthritis presents to the emergency department (ED) stating that she is having a “flare” of her arthritis, but is out of her Oxycontin® and immediate-release oxycodone. She is aware that it is too early to fill her prescriptions, but she insists that she will be traveling out of state and “really needs” her medications. She presents on a Saturday when her clinic is closed, and her primary care physician is “on vacation.”

Question: How do you Approach This Patient in the ED?

Due to the escalation of opioid misuse in the USA, many EDs have instituted guidelines limiting refills of opioid medications for chronic pain concerns, particularly when there is no objective evidence of for an acute etiology of changes in pain [ 1 ].

Additional steps to the approach of this patient include:

• Conducting an evaluation for medical conditions causing the change in symptoms.
• Reviewing the prescription monitoring program database if available in the state of practice.
• Determining how early the refill request is, and her recent pattern of opioid use.
• Considering non-narcotic therapies.
• Determining risk of withdrawal or adverse events if the medication is not refilled.

In this scenario, several “red flags” suggest that the patient has a substance use disorder. She is using her prescribed opioid analgesics inappropriately by taking extra doses, and has subsequently run out of medications early. She is also presenting to the emergency department rather than returning to her physician for refills. Additionally, her “off-hour” presentation occurs at a time when her prescribing physician cannot be reached for verification and direction. Most physicians that provide opioid prescriptions use a contract that includes information about early refills and use of non-prescribed medications and illicit drugs. Some hospitals or physician groups include patient opioid contracts in their electronic health record (EHR).

Case 1 Alternate Scenario

The patient then presents to her primary care physician of 1 year with objective painful conditions (inflammatory arthritis, severe osteoarthritis, knee replacement, and a hip fracture associated with chronic prednisone use). She requests continued opioid therapy for these conditions. While this patient has been under her PCP’s care, the physician has received concerning information regarding her use of alcohol; a Driving Under the Influence charge, spousal complaints about her drinking, and a discharge summary from the emergency department visit related to injuries sustained after a fall from “mixing her pills with her drinks.”

Question: How do you Approach Management of This Patient in the Primary Care Setting?

Alcohol misuse is a contraindication to the prescription of opioid therapy for pain. The combination of alcohol and opioids synergistically increases the potential for sedation; a recent study found that the misuse of alcohol was a common feature in prescription opioid-related ED visits [ 2 ]. Many physicians obtain an “informed consent agreement,” or a “pain contract,” as the standard of care for treating patients with opioids. These agreements detail the risks of chronic opioid therapy and outline guidelines for treatment, including warnings that patients should not be using alcohol or illicit drugs while receiving opioids. Many providers will monitor for alcohol use in patients receiving chronic opioids, incorporating urine ethyl sulfate or ethyl glucuronide testing for ethanol use.

Approaches to the management of patients who abuse alcohol in the setting of chronic opioid therapy vary. Strategies include limiting or tapering opioid therapies, referral to pain management specialists, or offering screening, assessment, brief intervention, and referral to treatment (SBIRT) for alcohol use disorder.

When chronic pain patients abuse alcohol or other substances, specific pain and addiction program referral is available in some areas. These programs include personalized treatment aimed at the substance use disorder, as well as the complex nexus of pain and addiction. Alternatives to opioid analgesics include non-opioid medications (muscle relaxants, NSAIDs), physical therapy, mindfulness, biofeedback, and relaxation techniques.

A 30-year-old woman with a history of recent intravenous (IV) drug use is admitted to the observation unit for IV antibiotics after the incision and drainage of an antecubital abscess. She has a history of opioid and cocaine dependence.

She receives IV morphine followed by IV hydromorphone for acute pain, as she had a significant debridement performed. After the procedure, she is demanding increasingly higher doses of IV opioids, and the observation unit team is becoming uneasy regarding the dose and frequency of opioid medications that she is receiving. The nursing staff raises concerns that she has tampered with her IV tubing and may be using her IV to “inject something.”

Question: How do you Approach This Patient with Respect to her Pain and her Behavior?

Given her history of opioid dependence, this patient is tolerant to opioids; her physiological requirements for analgesia are higher than expected when compared to an opioid-naïve patient. Careful assessment of physical and psychological indices of pain, and evaluation for other conditions that may be contributing to pain (i.e., recurrent infection, thrombosis, etc.) are indicated. Symptoms of opioid withdrawal should also be assessed. In this setting, it is essential to discuss the pain management plan with the patient in a non-judgmental manner that describes the course of treatment. Anxiety concerning withdrawal or unmanaged pain can drive requests for additional opioid medications or unusual behaviors during treatment. A common pitfall in the management of pain in opioid-dependent persons is a lack of consideration for analgesic needs above their baseline opioid tolerance. Healthcare providers are often concerned about the potential respiratory depression secondary to high opioid doses, without recognizing the tolerance to respiratory depression that opioid dependence confers; the “amount” of opioid has less importance in pain management than close clinical monitoring of patient response. Monitoring in patients receiving high-dose opioids must include vital signs and overall level of arousal and wakefulness, as well as other clinical assessments like oxygen saturation and end-tidal carbon dioxide measurement (capnography). These tools may indicate either insufficient or excessive opioid dose.

The treatment plan should be coordinated with the primary care provider with involvement of a pain specialist, if available. Opioid-tolerant patients may have a prolonged recovery after a painful illness or injury. Some healthcare systems have dedicated committees of multidisciplinary specialists, including psychiatry, pain management, addiction medicine, internal medicine, and emergency medicine providers to convene and discuss management of these difficult cases. When a patient truly does not respond to (or worsens with) opioid analgesia, opioid-induced hyperalgesia must be considered, which would improve with the decrease/cessation of opioids—notably, this a difficult concept to implement in a patient at risk of opioid withdrawal. In hospitalized patients, additional options include simultaneous treatment with agents that enhance or otherwise modify the opioid effect, such as ketamine [ 3 ] and alpha-2 agonists [ 4 ]. Delivery of adjunctive treatments such as nerve blocks or administration of intrathecal opioids singly or alongside other medications by appropriately trained providers can also provide relief to selected patients.

Specific strategies:

• Using a combination of long-acting and short-acting opioids, scheduling both the long- and short-acting opioids, and informing the patient regarding the schedule.
• Switching to oral formulations as soon as possible.
• Maximizing non-narcotic therapies.
• Considering initiation of methadone in the hospital for management of baseline tolerance and opioid use disorder, with referral to an addiction medicine program that incorporates opioid agonist treatment.
• Urine drug testing for concerns about IV use of illicit drugs, such as heroin, in the hospital.
• Consider buprenorphine for both pain and addiction in appropriate hospitalized patients. However, provider experience and knowledge of buprenorphine pharmacology is critical to the success of buprenorphine therapy in this setting.

A 27-year-old woman on buprenorphine-naloxone (Suboxone®) for treatment of opioid dependence is admitted to the hospital with severe abdominal pain due to a perforated gastric ulcer. She received hydromorphone in the ED, and is urgently taken to the operating room. Postoperatively, she is on a patient-controlled analgesic (PCA) pump containing fentanyl. Her last dose of buprenorphine-naloxone was 20 h prior to the surgery; her daily dose is 16 mg.

Question: How can Pain be Managed in Patients who are Taking Buprenorphine-Naloxone? What Adjustments to her Medication Regimen can be Recommended?

Whether the patient is on methadone or buprenorphine-naloxone for treatment of opioid use disorder, clarification of patient history is critical for making management decisions regarding pain, as well as continuation of therapy for opioid dependence. Important clinical actions include the following:

• Understanding the medication history. What was the medication schedule? Once or twice daily use? Recent dose changes? How often are doses missed? How many doses are directly observed?
• Obtaining consent to discuss management with prescribing provider.
• Reviewing the prescription monitoring program records, if available, noting that methadone from an opioid treatment program is not documented in the databases.
• Identifying any concomitant use of additional opioids or sedating medications (prescribed or non-prescribed).

The article “Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy” by Alford et al. [ 5 ] provides an excellent summary of options for pain management:

• Continue buprenorphine maintenance therapy and titrate short-acting analgesics. Doses required to provide analgesia are higher than expected and should be titrated to response. High-potency analgesics, such as fentanyl or hydromorphone, are suitable choices.
• Divide the pre-surgery daily buprenorphine dose every 6–8 h, with consideration of supplemental doses as needed for additional analgesia.
• Discontinue buprenorphine therapy and use a combination of long- and short-acting opioid analgesics, again noting that a higher dose is needed to meet both baseline opioid tolerance and analgesia requirements. The half-life of buprenorphine is approximately a day; expect that 1–2 days after last buprenorphine dose, other opioids will start to have more effect at the opioid receptor. The patient should be closely monitored during this time period. Convert back to buprenorphine by re-induction methods when pain is resolved.
• Discontinue buprenorphine and treat opioid dependence with methadone 20–40 mg. Use additional short-acting opioid analgesics to treat pain, with consideration to schedule doses. Note that this is only an option for hospitalized patients.

Any of the above treatment plans should include additional psychosocial support, such as mutual help groups, increased frequency of visits to their treating physician, or brief counseling sessions from a licensed alcohol and drug counselor or peer support specialist.

For buprenorphine re-induction, management should occur in tandem with the patient’s buprenorphine prescriber, especially if the plan is to restart buprenorphine as an outpatient. Buprenorphine re-induction can proceed in the hospital or at home, with an abbreviated version of a typical induction regimen. Once acute pain needs related to surgery have improved, discontinue short-acting opioids for 16–24 h depending on the opioid. Then, administer sequential doses of 2 mg buprenorphine up to previous maintenance dose over a 4-h period. If the pain persists, a more frequent dosing regimen (e.g., every 6–8 h) is indicated instead of the standard daily or twice daily dosing that most buprenorphine maintenance patients receive. The patient must follow up with his/her regular buprenorphine provider soon after hospital discharge.

Question: If This Patient was on Methadone Maintenance for Treatment of Opioid Use Disorder, How Should Pain be Managed?

Treatment of pain in patients maintained on methadone tends to be less complicated than those receiving buprenorphine-naloxone. Continue the patient’s methadone at the normal maintenance dose if she can tolerate oral medications. If the patient is not able to take medications by mouth, IV methadone is a viable alternative. Treat pain with additional short-acting opioids as needed; doses are likely to be higher than expected to provide analgesia in opioid-naïve patients.

Question: What Options are Available for Pain Management if This Patient was Being Treated With Oral Naltrexone for Opioid Use Disorder?

First, the provider must determine which form of naltrexone the patient is receiving (e.g., Revia® PO or Vivitrol® IM). If a painful condition can be anticipated (such as an elective surgery), the oral form of naltrexone should be discontinued for 2–3 days prior, or the last dose of intramuscular naloxone should be given 30 days beforehand. Administer opioids in typical doses after that time. If pain is unanticipated (e.g., trauma), rapidly acting potent opioids like fentanyl should be carefully titrated to patient response, including respiratory rate, level of awareness, and level of analgesia. This management strategy requires close monitoring; respiratory support and reversal agents must be available. A second option is the use of non-narcotic analgesics, like non-steroidal anti-inflammatory drugs, ketamine, or local/regional/general anesthesia.

Before resuming naltrexone after receiving opioid analgesics for pain, it is recommended the patient be abstinent from opioids for at least 3 to 5 days although this may need to be longer for patients given long-acting agents such as methadone, oxymorphone or that have been on a fentanyl patch. This is to mitigate any potential for precipitated withdrawal symptoms developing when the antagonist, naltrexone, is administered too closely after the full agonist used for pain.

The emergency department contacts a medical toxicologist with a question regarding a patient seen frequently for pain complaints. His outpatient providers have been managing his opioid therapies for chronic pain, but the patient often runs out of pills early, misses scheduled pills counts, or has non-prescribed substances identified on urine drug testing. The patient denies that he has an “addiction problem,” and states his increased use is due to uncontrolled pain. The provider asks whether these behaviors are due to addiction or pain, and if this patient should be referred to addiction medicine.

Question: How is Opioid use for Pain Versus Addiction Differentiated?

This is a difficult question. Clinicians will encounter this conundrum frequently when treating patients who receive chronic opioids. Separating behaviors related to unmanaged pain versus an opioid use disorder can be very challenging. The Diagnostics and Statistics Manual (DSM)-V criteria for opioid use disorder [ 6 ] (see Table ​ Table1) 1 ) provide a useful framework. In addition to the DSM-V, several brief validated questionnaires are available to estimate the risk of opioid-related aberrant behaviors. The Opioid Risk Tool (ORT) is a five-question assessment that helps to identify patients at high risk for misuse that might benefit from other modalities of pain control besides opioids [ 7 ]. The ORT is primarily applicable to patients with chronic pain. The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) [ 8 ] is a slightly longer instrument which can also be used to predict opioid abuse in chronic pain patients. This tool includes aspects of self-report and observation as well as toxicology testing. The “Current Opioid Misuse Measure (COMM)” is a self-report assessment of past month aberrant medication-related behaviors [ 9 ]. The questions encapsulate signs and symptoms of inappropriate drug use, psychological issues, and compliance. Examples of aberrant behaviors include being more interested in opioids than other forms of treatment, seeking early refills, and requesting increasing doses of opioids. While the presence of aberrant behaviors can indicate a substance use disorder, patients may display aberrant behaviors for reasons other than addiction, such as misunderstanding instructions, seeking euphoria, using medications to deal with fear or stress, using medications to treat sleep problems, diverting medications for profit, coping with untreated psychiatric disorders, coping with undertreated pain, or general non-adherence. “Pseudoaddiction” is a controversial term of primarily historical significance thought to describe behaviors that mimicked those of addiction, but were actually due to severe, uncontrolled pain.

DSM-V criteria for substance use disorder

Section II. Legal and Policy Issues in Substance Use Disorders

A 20-year-old man is brought to the emergency department (ED) by his family for evaluation. His family reports that he failed out of school in his second year at a local community college. He admits to escalating struggles with prescription pain pills (prescription opioids), and then heroin use. He appears to be in opioid withdrawal; he describes anorexia and diarrhea, and is yawning and sweating on exam. He has a Clinical Opioid Withdrawal Scale (COWS) [ 10 ] (Fig.  1 ) score of 15, indicating moderate withdrawal. His provider orders clonidine, ondansetron, and 2/0.5 mg sublingual buprenorphine/naloxone, with a plan to observe him in the ED. The provider subsequently receives a concerned call from the hospital pharmacist.

Clinical opiate withdrawal scale

Question: The Pharmacist States That the Provider is Unable to Administer Buprenorphine in the ED Without an X-Waivered DEA Number. Is This Accurate?

In the ED setting, an X-waiver is not required. The distinction is that the providers are administering or dispensing buprenorphine, not prescribing it for outpatient use (please see Fig.  2 ). Under the Title 21 Code of Federal Regulations Section 1306.07 [ 11 ]: Administering or dispensing of narcotic drugs: “Nothing in this section shall prohibit a physician who is not specifically registered to conduct a narcotic treatment program from administering (but not prescribing) narcotic drugs to a person for the purpose of relieving acute withdrawal symptoms when necessary while arrangements are being made for referral to treatment. Not more than one day’s medication may be administered to the person or for the person’s use at one time. Emergency treatment may be carried out for not more than three days and may not be renewed or extended.” Section 1306.07 also declares that “This section is not intended to impose any limitations on a physician or authorized hospital staff to administer or dispense narcotic drugs in a hospital to maintain or detoxify a person as an incidental adjunct to medical or surgical treatment of conditions other than addiction or to administer or dispense narcotic drugs to persons with intractable pain in which no relief or cure is possible or none has been found with reasonable efforts.”

Title 21 Code of Federal Regulations 1306.07—Administering or Dispensing of Narcotic Drugs

This section of the Federal Regulations allows physicians in a hospital or ED to treat acute withdrawal with buprenorphine or methadone while the patient is attempting to access treatment. The patient may not receive more than 3 days of administered methadone in the emergency department or hospital unless there is a concomitant acute medical or surgical condition requiring treatment. Additionally, the patient may not be given a prescription for the medication upon discharge from the facility. For example, if the patient is hospitalized with an abscess, they may be treated for opioid withdrawal for the duration of their hospital encounter, but they may not be discharged with a prescription for methadone or buprenorphine. If a patient who is currently in a medication-assisted treatment program is hospitalized, their medication may be continued in the hospital, but they may not be discharged with a prescription. They must return to their prescribing provider for continued care. It is important to clarify their treatment plan with their provider and to verify the dose and schedule. Providers who administer buprenorphine in the ED for opioid withdrawal must follow standard buprenorphine induction guidelines [ 12  ]. An exception to the above rule exists when the treating provider is X-waivered (able to prescribe buprenorphine for the treatment of opioid dependence) and they are able to link the patient to either their own clinic or another provider who also has X-waiver certification and agrees to continue the buprenorphine prescription.

A provider is covering a county detoxification program (from alcohol and opioids) with 30 beds. The program is funded through the state’s Office of Alcohol and Substance Abuse Services, and operates under the Code of Federal Regulations (CFR) Title 42 Part 2 [ 13 ] guidelines regarding privacy and notification.

Question: What is CFR-42 Part 2?

Under federal law, there are restrictions concerning the use and disclosure of patient records pertaining to substance abuse treatment. CFR Title 42 Part 2 applies to any individual or entity that is federally assisted, and holds itself out as providing, and provides, alcohol or drug abuse diagnosis, treatment, or referral for treatment. Most drug and alcohol treatment programs are federally assisted. For-profit programs and private practitioners that do not receive federal assistance of any kind are not subject to the requirements of CFR Title 42 Part 2, unless the state licensing or certification agency requires them to comply. However, any clinician who uses a controlled substance for detoxification or maintenance treatment of a substance use disorder requires a federal Drug Enforcement Agency (DEA) registration, and becomes subject to the regulations through the DEA license. The restrictions under CFR Title 42 Part 2 apply to any information disclosed by a covered program that would identify a patient as a current or past alcohol or drug abuser, or as a participant in a covered program.

Case Continued

A woman calls the program, and identifies herself as the mother of one of the patients. She states that she does not want to intrude, but wants to confirm he actually made it to detox, saying “I just need to know if he’s there and safe.”

Question: Can the Provider Disclose his Presence at the Facility?

With limited exceptions, CFR Title 42 Part 2 requires patient consent for disclosures of protected health information even for the purposes of treatment, payment, or healthcare operations. Consent for disclosure must be documented in writing. Without consent, programs publicly identified as only a drug or alcohol diagnosis, treatment, or referral facility cannot disclose whether the person in question is a current or past patient. However, the regulations permit a provider to say that an identified individual is not, and never has been, a patient.

Case 6 Continued

Police arrive at the facility and state they have a warrant to arrest the patient. Apparently, his ex-girlfriend told the police that he was at this detoxification facility when they inquired about his location. The police will not discuss the charges, simply reiterating that they have an arrest warrant.

Question: What are the Obligations to Disclose Patient Information to Law Enforcement in This Setting?

If an immediate threat to the health and safety of an individual exists due to a medical emergency or crime on the program premises or against program personnel, information about a patient’s treatment may be disclosed without the patient’s consent to medical personnel in a medical emergency, or to law enforcement agencies. If there are threats to health and safety that do not involve medical emergencies or crimes on the program premises, reports can be made to law enforcement only if patient-identifying information is not disclosed. The restrictions do not apply to reporting incidents of child abuse or neglect to state authorities under state law; however, the restrictions continue to apply to the original alcohol or drug abuse records maintained by the program. Information may also be disclosed if there is both a court order to authorize disclosure, as well as a subpoena or similar legal mandate issued to compel disclosure. If presented with an arrest warrant, the healthcare provider cannot acknowledge the patient is on the premises unless the patient gives authorization, or if there is a court order authorizing disclosure. If law enforcement asks to speak with a patient, the provider may respond by informing them of a need to speak with supervisors, then discussing with the patient his willingness to provide written release if they are willing to speak with law enforcement.

A new patient presenting for buprenorphine-naloxone assisted treatment discloses that she is a PGY4 general surgery resident in a city 90 min away. She admits to intravenous heroin use (“20-30 bags a day”), along with cocaine and alprazolam. She reports that she is missing days of work due to heroin use, and has occasionally used heroin and cocaine while in the hospital, and before surgery just to “feel right.” She states that she presented to this distant provider because she did not want to be treated by anyone who might be affiliated with her training program.

Question: When is a Physician Considered “Impaired”? How Should Management of This Patient be Approached? Is There any Obligation to Notify Either the State Medical Board or her Residency Program Director?

When the health of the physician has declined to the point of causing interference with his or her ability to safely engage in professional activities, the physician is said to be impaired. Medical professionals have an obligation to intervene when it appears that the health of a colleague is compromised by addiction. In many states, it is legally permissible to report health professionals to the state’s impaired professionals program rather than to the professional licensing boards. Generally, impaired professional programs offer treatment programs while protecting confidentiality and the licensure of the professional. These programs also aim to prevent workplace safety concerns and harm to patients. Physicians caring for colleagues should not disclose patient information, except as required by law, ethical or professional obligation. Exceptions to the confidentiality of the physician and physician-patient relationship occur if the treating professional determines that the condition of the person constitutes a danger to public safety if the impaired colleague was to continue practice. In this case, the severity of the addiction with her self-reported use during patient care compels the treating physician to notify the state impaired professional program.

A 23-year-old woman attends an outpatient treatment program and office-based buprenorphine clinic. She has been doing well while maintained on 16 mg/day of buprenorphine. Recently though, she has missed group sessions and provided a urine for drug screening that tested positive for clonazepam and amphetamine. One of the other members in her group reported that they saw a “urine bottle fall out of her purse” as it spilled next to her chair in a group session; her counselor was unaware of this event.

Question: What are the Policies Regarding the use of Illicit Substances or Urine Adulteration or Substitution During Substance Abuse Treatment?

Policies should be determined by an individual provider or clinic. Typically, these policies provide balanced rules that seek to limit abuse, diversion, and harm from the administered medications, while providing the patient with direction, structure, and accountability. To increase awareness of program policies and expectations for patients, it is advisable to use special acknowledgment and treatment consent forms that describe program policies. Information regarding model buprenorphine policies and contracts for office-based buprenorphine programs are available from the Substance Abuse Mental Health Services Administration (SAMHSA) website [ 14 ].

Abnormal urine drug screens can be a first sign of dysfunction and relapse. The initial response is directed at helping the patient stabilize and recover their sobriety. For example, in many office-based buprenorphine programs, urine drug screens positive for non-prescribed or illicit substances prompt an increase in support services rather than a decrease (unlike a contract agreement for management of pain in primary care or specialty pain clinics). Increased support may include more therapeutic group attendance, individual counseling, referral to a more intensive treatment setting, or more frequent visits to the physician for medication management with enhanced accountability using observed dosing or additional “check-ins” with the patient’s counselor. Adulteration or substitution of urine is often considered a “positive urine drug screen.” Sometimes, if patients are not receiving enough of an opioid agonist to attenuate craving and withdrawal, dose increases can be helpful. This serves to both alleviate cravings for opioids, as well as limit the euphoria obtained from use.

The provider response also depends on the specific area of difficulty or conflict. Monitoring during buprenorphine treatment includes not only testing for illicit drug use in order to demonstrate effectiveness and sobriety, but also confirms compliance with the presence of buprenorphine, and adequate concentrations when levels or metabolite ratios are assayed. If there were signs that the patient was skipping doses or manipulating their dosing in order to use part way through a prescription, the response would be different. While providers avoid using a lower dose of a medication as a behavioral tool, limited circumstances (e.g., chronic non-compliance with treatment recommendations, or co-ingestion of sedatives or alcohol that can lead to overdose) may necessitate an “administrative” taper. Patients whose urine drug testing do not confirm appropriate buprenorphine levels may be diverting their medications. If there is concern for diversion of the medication, the response may be to limit the amount prescribed at one time, or to observe medication administration.

Responses to marijuana use, especially in states where medical marijuana or recreational marijuana is legal, vary widely. If the marijuana use does not interfere with treatment or the function of the patient, many programs do not address use as intensely as other drug use (such as heroin, non-prescribed opioids, or stimulants). Our panel would typically not sanction the patient for marijuana use, but direct more attention to counseling and focus on addressing the patient-reported motivation behind marijuana use. Patients who reported untreated pain as the reason behind marijuana use would be directed at alternative strategies to control the pain including mindfulness, physical therapy, yoga, and stretching. If the marijuana was used to regulate sleep or mood, the provider could recommend alternatives such as melatonin for insomnia, and confirm the patient has adequately addressed mental health resources.

Section III: Special Populations and Addictive Disorders

The toxicology service is consulted from the emergency department (ED) as the county jail staff has brought in a 21-year-old Hispanic woman who is 18 weeks pregnant. She was arrested on a warrant, and has been incarcerated for just over 24 h. During that time, she developed nausea, irritability, diaphoresis, anxiety, and yawning. She was noted to have stigmata of intravenous drug use (IVDU), and told the intake officers that she was going into heroin withdrawal.

Question: What is the Initial Approach to This Patient’s Care?

Heroin use during pregnancy is associated with fetal growth restriction, fetal death, and preterm labor [ 15 ]. Moreover, opioid withdrawal in pregnancy (especially during the first and third trimester) is associated with poor fetal outcomes, such as miscarriage and premature delivery [ 16 ]. Withdrawal symptoms in pregnant patients should be managed with medication. Initiation of methadone or buprenorphine is indicated during the acute care encounter, and can be initiated (or continued) by physicians even without a Drug Addiction Treatment Act (DATA) 2000 waiver (the waiver authority for physicians to prescribe buprenorphine in an office-based setting outside of a registered opioid treatment program). If a patient is hospitalized for reasons other than addiction (such as complications due to pregnancy, or delivery), physicians may administer opioids such as methadone or buprenorphine to initiate or continue maintenance treatment. Under these circumstances, the hospital treatment team does not require registration as an opioid treatment program, nor do they need a DATA 2000 waiver.

Pregnant patients must be connected to treatment resources prior to discharge from the ED or hospital. In most states, pregnant patients are prioritized for treatment; medication-assisted treatment programs will often initiate the intake process within 1–2 business days.

Question: What is the Safety of Methadone, Buprenorphine, or Buprenorphine-Naloxone Combination in Pregnancy and in Lactation?

Both buprenorphine and methadone, classified as category C drugs by the Food and Drug Administration, have been found in studies to be safe and effective when used in pregnant women [ 17 ]. While methadone has long been the standard of care for treatment of withdrawal and dependence in pregnancy, buprenorphine has a favorable profile, including less severe neonatal abstinence syndrome (NAS) after birth [ 17 ]. Additionally, buprenorphine has potential to be more accessible with both office-based settings and treatment programs, compared to methadone maintenance programs in clinic settings only. If buprenorphine is used, the induction can proceed after confirming that the patient is in withdrawal. The Clinical Opioid Withdrawal Scale (COWS) can be used to assess withdrawal symptoms, and to track improvement after treatment with methadone or buprenorphine.

In pregnancy, the buprenorphine-only formulation is recommended over the buprenorphine-naloxone co-formulation. Concerns have been raised about the safety of naloxone for the fetus. There are some data to suggest that naloxone causes maternal and fetal hormonal changes [ 4 ]; however, the clinical implications of this finding have not been demonstrated. There is additional concern over the possibility of inducing withdrawal if the mother injects buprenorphine-naloxone intravenously. Limited studies do suggest that the use of combination buprenorphine-naloxone is safe in pregnancy [ 18 ]; however, until the safety concerns have been adequately studied, patients on Suboxone® who become pregnant are recommended to transfer to buprenorphine-only formulations [ 15 ].

Post-partum, both buprenorphine and methadone are considered to be compatible with lactation [ 17 ]. Buprenorphine is excreted in breast milk; however, given the low oral bioavailability of buprenorphine, infant exposure is 10–20 % of available buprenorphine. The amount of methadone found in breast milk appears to be low (less than 1 % of the maternal dose) [ 19 ]. While studies do not demonstrate that buprenorphine in breast milk attenuates NAS, there are some reports describing attenuation in infants breast-fed by mothers taking methadone [ 6 ].

Question: What is the Approach to Diagnosis and Management of Neonatal Abstinence Syndrome (NAS)?

NAS is a generalized disorder characterized by signs and symptoms of irritability, gastrointestinal dysfunction, respiratory distress, and vomiting. NAS typically presents with 72 h after birth, in cases of in utero methadone or buprenorphine exposure; however, studies suggest that neonates exposed to buprenorphine require less medication and a shorter duration of treatment for NAS [ 20 ]. Many hospitals have protocols to treat NAS, using scale systems for severity and a combination of non-pharmacological and pharmacological treatments, with opioid and non-opioid medication options [ 21 ].

A 16-year-old boy is brought in to the Pediatric ED after his mother returned home and found him with slurred speech and “falling all over the kitchen!” He opens his eyes, sighs loudly, and turns away during the exam. The patient has been using marijuana, and has been caught drinking several times. When the patient is more awake, he and his mother have a loud and animated discussion about him “snorting her Xanax® again.” The mother asks for help with his continued drinking and drug use.

Question: What are Some Available Resources for Assessment and Treatment of Drug and Alcohol Abuse in Adolescents?

Adolescent substance use should be identified and addressed as early as possible. Drugs exert long-lasting effects on the developing brain [ 22 ]. The CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) questionnaire for alcohol and drug use disorders in adolescents (Fig.  3 ) is both validated and frequently used [ 23 ]. A total score of 2 or higher (5 questions, each “yes” is 1 point) indicates a positive screen and the need for additional assessment. Questions cover topics such as riding in a car with a driver under the influence of drugs or alcohol, using substances to relax or fit in or while alone, forgetting things while using substances, having others concerned about use, or getting into trouble while using alcohol or drugs.

CRAFFT questionnaire for alcohol and drug use disorders in adolescents

Adolescents can benefit from a drug abuse intervention, even if they are not “addicted” to a drug. Guides on treatment for adolescent substance use disorders indicate that motivational interviewing is a useful technique for discussing substance use, even with adolescents who are not interested in change or not ready to commit to change [ 24  ]. Treatment options include follow up with a primary care clinician, outpatient psychosocial addiction medicine treatment, family-based behavioral therapies, or pharmacological treatments. Several medications are approved by the FDA to treat addiction to opioids, alcohol, and nicotine. In most cases, though, little research has been conducted to evaluate the safety and efficacy of these medications for adolescents; however, some healthcare providers prescribe “off-label”, especially in older adolescents. Buprenorphine in particular has demonstrated potential efficacy in this population based on two research studies [ 25 , 26 ]. In some states, methadone is approved for adolescents between the ages of 16 and 18 after they have failed two other treatments, and with their parents’ approval.

The best approach to treatment includes supporting the adolescent’s life needs, such as those related to medical, psychological, and social well-being. Adolescents who abuse drugs frequently suffer from other conditions including depression, anxiety disorders, ADHD, oppositional defiant disorder, and conduct problems. Many adolescents who abuse drugs have a history of physical, emotional, and/or sexual abuse or other trauma. Tobacco use often accompanies other drug use and needs to be addressed as part of substance use disorder treatment [ 27 ]. Pharmacologic treatments for tobacco use disorder include bupropion, varenicline, or nicotine replacement therapies [ 28  ].

A 17-year-old boy is brought to the ED because his father states he has been “buying Suboxone® again, and I found it in his room!” The father is demanding that he be admitted to “detoxify” and referred to an inpatient treatment facility. The father refuses to take the patient home, saying, “I can’t have him around his younger brothers.” However, the father demands to be updated with information regarding his son’s care.

Question: How are Issues of Confidentiality Addressed for Adolescents With Substance Use Disorders?

Laws on various provisions can vary across states, including the definition of a minor (typically under age 18), the ability of a minor to consent to substance abuse treatment, parental notification of treatment, and the disclosure of medical records. HIPAA only allows parents to have access to the medical records of a minor child if that access does not conflict with a state or other confidentiality law. However, US Code §290dd-2 and 42 CFR Part 2.12 protect any information about an adolescent, if the adolescent has applied for or received any treatment related to his substance use disorder or referral services from a treatment program. Written consent from the adolescent is required to communicate with parents. Exceptions to the requirement for written consent can be made if the patient does not have the capacity to consent because of an extreme substance use disorder or a medical condition, or because disclosure is necessary due to substantial threat to the life or well-being of the adolescent or someone else.

A 66-year-old female presents to the ED somnolent and with myoclonus. Her sister found her unresponsive. She had an open bottle of Lyrica® (pregabalin) spilled on the bed, with other pills on her dresser and “around the room.” The patient has chronic kidney disease, diabetes mellitus, hypertension, chronic pain, and arthritis (status post-bilateral total knee arthroplasty), all of which has been “worsening” over the past month per her sister. She is arousable to painful stimuli, but confused and mumbling. She has myoclonus. Her respiratory rate is eight breaths per minute. Her creatinine is elevated to 2.3 mg/dL from baseline 1.4 mg/dL. She was in the ED the month prior for smoke inhalation after nearly burning her house down when “she fell asleep in a chair with her cigarette going.” She is on multiple medications, including long-acting morphine sulfate, pregabalin, gabapentin, cyclobenzaprine, metformin, glyburide, and lisinopril. She was also found with an empty bottle of her son’s tramadol.

Question: What Medication Regimen Changes are Warranted? What if the Patient is Resistant? For Example, if She States That She “Will Just Go to Another Doctor and Get the Same Pills…”

Benzodiazepines (especially those with long-acting metabolites and those metabolized by the CYP450 systems), antihistamines, and typical antipsychotics are among the medications not recommended for use in the elderly [ 29 ]. Opioid dose requirements decrease with age because of decreased gastrointestinal motility, decreased overall metabolism, decreased liver functioning, changes in kidney function, and changes in opioid receptor sensitivity. Due to decreased renal function, medications that have active metabolites or themselves are primarily excreted via the kidneys should be decreased or substituted: morphine sulfate, pregabalin, gabapentin. Care should be taken with glyburide, metformin, and lisinopril in the setting of decreased renal function. Cyclobenzaprine has sedating and anticholinergic effects and thus not recommended for extended use in the elderly population. Reasons that the patient may be taking her son’s tramadol should be explored, and subsequent management addressed. Before abruptly discontinuing medications, the potential for withdrawal should be addressed, as withdrawal may also cause delirium in the elderly.

Question: How are Elderly Patients Assessed for Substance Use Disorders?

Prescription drug abuse among older adults is prevalent; however, providers may be misled by their perceptions, and miss subtle clues that indicate substance misuse among the elderly. Concerning signs for substance abuse in the elderly include increased falls, increased daytime somnolence, self-medication, minor traffic accidents, and trauma without a known mechanism (bruises, scrapes, burns). Collateral reporting from family is often helpful. To screen the elderly for alcohol or substance use disorders, the CAGE [ 30 ] questionnaire or the Michigan Alcohol Screening Test [ 31 ] for older adults can be used. Providers should preface questions about alcohol or drug use with a link to a medical condition, and minimize use of stigmatizing terms. Providers should screen for cognitive functioning using an orientation, memory, and concentration test or the Mini Mental State Examination [ 32 ] with a drawn clock task; depression can be screened for using the Geriatric Depression Scale [ 33 ]. When planning for treatment, the ideal programs will involve the least intensive treatment options and cater to geriatric needs.

The management of co-occurring opioid use disorder and pain occurs frequently in both the emergency department as well as primary care settings. The treatment of chronic and acute pain with opioid therapies should be accompanied by careful monitoring for appropriate use of prescribed therapies and for the presence of relative contraindications to use of opioids therapies, such as alcohol misuse, diversion, or untreated opioid use disorder. Treatment of acute pain in patients receiving opioid-assisted therapy requires an informed plan by working with the patient and the healthcare providers involved in the care of the patient and knowledge of the pharmacokinetics and pharmacodynamics of opioids, including buprenorphine and methadone.

Understanding of policy and regulations surrounding treatment of substance use disorder is important for clinicians in a variety of clinical settings. In the emergency department or hospital setting, providers often encounter patients in opioid withdrawal; providers may use buprenorphine or methadone to treat withdrawal in these settings under CFR Section 1306.07. Special privacy protections at both the federal (42 CFR Part 2) and state level are afforded to patients with substance use disorders. These laws extend to the treatment of impaired physicians; however, there is an obligation to report to the appropriate regulatory bodies when there is a concern of danger to public health with continued practice. Policies at the clinic or provider level guide the approach to management of patients who continue to use illicit substances during substance use disorder treatment while simultaneously providing structure, direction, and balance for patients receiving treatment for their disorder.

Assessment and management of substance use disorders in pregnant, pediatric, or elderly requires an understanding of the unique needs of each population. Patients who are pregnant should be prioritized for treatment of substance use disorder due to the negative effects of illicit substances and withdrawal on both the mother and fetus. Adolescent substance use presents unique issues for confidentiality and treatment strategies. Elderly substance use requires careful clinical assessment and an understanding of the medical and social needs of this population. By using management strategies advised in the preceding cases, the clinician can develop a framework to navigate the complex management of addiction in these special populations.

JoAn R. Laes, MD

Petro Levounis, MD, MA, FASAM

Daniel L. Sudakin, MD, MPH, FACMT

Edwin A. Salsitz, MD, FASAM

Timothy Wiegand, MD, FACMT (Moderator)

Here’s how you know

• U.S. Department of Health and Human Services
• National Institutes of Health

Acupuncture: Effectiveness and Safety

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Acupuncture is a technique in which practitioners insert fine needles into the skin to treat health problems. The needles may be manipulated manually or stimulated with small electrical currents (electroacupuncture). Acupuncture has been in use in some form for at least 2,500 years. It originated from  traditional Chinese medicine but has gained popularity worldwide since the 1970s.

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According to the World Health Organization, acupuncture is used in 103 of 129 countries that reported data.

In the United States, data from the National Health Interview Survey show that the use of acupuncture by U.S. adults more than doubled between 2002 and 2022. In 2002, 1.0 percent of U.S. adults used acupuncture; in 2022, 2.2 percent used it. 

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National survey data indicate that in the United States, acupuncture is most commonly used for pain, such as back, joint, or neck pain.

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How acupuncture works is not fully understood. However, there’s evidence that acupuncture may have effects on the nervous system, effects on other body tissues, and nonspecific (placebo) effects. 

• Studies in animals and people, including studies that used imaging methods to see what’s happening in the brain, have shown that acupuncture may affect nervous system function.
• Acupuncture may have direct effects on the tissues where the needles are inserted. This type of effect has been seen in connective tissue.
• Acupuncture has nonspecific effects (effects due to incidental aspects of a treatment rather than its main mechanism of action). Nonspecific effects may be due to the patient’s belief in the treatment, the relationship between the practitioner and the patient, or other factors not directly caused by the insertion of needles. In many studies, the benefit of acupuncture has been greater when it was compared with no treatment than when it was compared with sham (simulated or fake) acupuncture procedures, such as the use of a device that pokes the skin but does not penetrate it. These findings suggest that nonspecific effects contribute to the beneficial effect of acupuncture on pain or other symptoms. 
• In recent research, a nonspecific effect was demonstrated in a unique way: Patients who had experienced pain relief during a previous acupuncture session were shown a video of that session and asked to imagine the treatment happening again. This video-guided imagery technique had a significant pain-relieving effect.

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Research has shown that acupuncture may be helpful for several pain conditions, including back or neck pain, knee pain associated with osteoarthritis, and postoperative pain. It may also help relieve joint pain associated with the use of aromatase inhibitors, which are drugs used in people with breast cancer. 

An analysis of data from 20 studies (6,376 participants) of people with painful conditions (back pain, osteoarthritis, neck pain, or headaches) showed that the beneficial effects of acupuncture continued for a year after the end of treatment for all conditions except neck pain.

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• In a 2018 review, data from 12 studies (8,003 participants) showed acupuncture was more effective than no treatment for back or neck pain, and data from 10 studies (1,963 participants) showed acupuncture was more effective than sham acupuncture. The difference between acupuncture and no treatment was greater than the difference between acupuncture and sham acupuncture. The pain-relieving effect of acupuncture was comparable to that of nonsteroidal anti-inflammatory drugs (NSAIDs).
• A 2017 clinical practice guideline from the American College of Physicians included acupuncture among the nondrug options recommended as first-line treatment for chronic low-back pain. Acupuncture is also one of the treatment options recommended for acute low-back pain. The evidence favoring acupuncture for acute low-back pain was judged to be of low quality, and the evidence for chronic low-back pain was judged to be of moderate quality.

For more information, see the  NCCIH webpage on low-back pain .

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• In a 2018 review, data from 10 studies (2,413 participants) showed acupuncture was more effective than no treatment for osteoarthritis pain, and data from 9 studies (2,376 participants) showed acupuncture was more effective than sham acupuncture. The difference between acupuncture and no treatment was greater than the difference between acupuncture and sham acupuncture. Most of the participants in these studies had knee osteoarthritis, but some had hip osteoarthritis. The pain-relieving effect of acupuncture was comparable to that of NSAIDs.
• A 2018 review evaluated 6 studies (413 participants) of acupuncture for hip osteoarthritis. Two of the studies compared acupuncture with sham acupuncture and found little or no difference between them in terms of effects on pain. The other four studies compared acupuncture with a variety of other treatments and could not easily be compared with one another. However, one of the trials indicated that the addition of acupuncture to routine care by a physician may improve pain and function in patients with hip osteoarthritis.
• A 2019 clinical practice guideline from the American College of Rheumatology and the Arthritis Foundation conditionally recommends acupuncture for osteoarthritis of the knee, hip, or hand. The guideline states that the greatest number of studies showing benefits have been for knee osteoarthritis.

For more information, see the  NCCIH webpage on osteoarthritis .

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• A 2020   review of nine studies that compared acupuncture with various drugs for preventing migraine found that acupuncture was slightly more effective, and study participants who received acupuncture were much less likely than those receiving drugs to drop out of studies because of side effects.
• There’s moderate-quality evidence that acupuncture may reduce the frequency of migraines (from a 2016 evaluation of 22 studies with almost 5,000 people). The evidence from these studies also suggests that acupuncture may be better than sham acupuncture, but the difference is small. There is moderate- to low-quality evidence that acupuncture may reduce the frequency of tension headaches (from a 2016 evaluation of 12 studies with about 2,350 people).

For more information, see the  NCCIH webpage on headache .

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• Myofascial pain syndrome is a common form of pain derived from muscles and their related connective tissue (fascia). It involves tender nodules called “trigger points.” Pressing on these nodules reproduces the patient’s pattern of pain.
• A combined analysis of a small number of studies of acupuncture for myofascial pain syndrome showed that acupuncture applied to trigger points had a favorable effect on pain intensity (5 studies, 215 participants), but acupuncture applied to traditional acupuncture points did not (4 studies, 80 participants).  

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• Sciatica involves pain, weakness, numbness, or tingling in the leg, usually on one side of the body, caused by damage to or pressure on the sciatic nerve—a nerve that starts in the lower back and runs down the back of each leg.
• Two 2015 evaluations of the evidence, one including 12 studies with 1,842 total participants and the other including 11 studies with 962 total participants, concluded that acupuncture may be helpful for sciatica pain, but the quality of the research is not good enough to allow definite conclusions to be reached.

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• A 2016 evaluation of 11 studies of pain after surgery (with a total of 682 participants) found that patients treated with acupuncture or related techniques 1 day after surgery had less pain and used less opioid pain medicine after the operation.

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• A 2016 review of 20 studies (1,639 participants) indicated that acupuncture was not more effective in relieving cancer pain than conventional drug therapy. However, there was some evidence that acupuncture plus drug therapy might be better than drug therapy alone.
• A 2017 review of 5 studies (181 participants) of acupuncture for aromatase inhibitor-induced joint pain in breast cancer patients concluded that 6 to 8 weeks of acupuncture treatment may help reduce the pain. However, the individual studies only included small numbers of women and used a variety of acupuncture techniques and measurement methods, so they were difficult to compare.
• A larger 2018 study included 226 women with early-stage breast cancer who were taking aromatase inhibitors. The study found that the women who received 6 weeks of acupuncture treatment, given twice each week, reported less joint pain than the participants who received sham or no acupuncture.

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• Chronic prostatitis/chronic pelvic pain syndrome is a condition in men that involves inflammation of or near the prostate gland; its cause is uncertain.
• A review of 3 studies (204 total participants) suggested that acupuncture may reduce prostatitis symptoms, compared with a sham procedure. Because follow-up of the study participants was relatively brief and the numbers of studies and participants were small, a definite conclusion cannot be reached about acupuncture’s effects.

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• A 2019 review of 41 studies (3,440 participants) showed that acupuncture was no more effective than sham acupuncture for symptoms of irritable bowel syndrome, but there was some evidence that acupuncture could be helpful when used in addition to other forms of treatment.

For more information, see the  NCCIH webpage on irritable bowel syndrome .

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• A 2019 review of 12 studies (824 participants) of people with fibromyalgia indicated that acupuncture was significantly better than sham acupuncture for relieving pain, but the evidence was of low-to-moderate quality.

For more information, see the  NCCIH webpage on fibromyalgia . 

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In addition to pain conditions, acupuncture has also been studied for at least 50 other health problems. There is evidence that acupuncture may help relieve seasonal allergy symptoms, stress incontinence in women, and nausea and vomiting associated with cancer treatment. It may also help relieve symptoms and improve the quality of life in people with asthma, but it has not been shown to improve lung function.

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• A 2015 evaluation of 13 studies of acupuncture for allergic rhinitis, involving a total of 2,365 participants, found evidence that acupuncture may help relieve nasal symptoms. The study participants who received acupuncture also had lower medication scores (meaning that they used less medication to treat their symptoms) and lower blood levels of immunoglobulin E (IgE), a type of antibody associated with allergies.
• A 2014 clinical practice guideline from the American Academy of Otolaryngology–Head and Neck Surgery included acupuncture among the options health care providers may offer to patients with allergic rhinitis.

For more information, see the  NCCIH webpage on seasonal allergies .

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• Stress incontinence is a bladder control problem in which movement—coughing, sneezing, laughing, or physical activity—puts pressure on the bladder and causes urine to leak.
• In a 2017 study of about 500 women with stress incontinence, participants who received electroacupuncture treatment (18 sessions over 6 weeks) had reduced urine leakage, with about two-thirds of the women having a decrease in leakage of 50 percent or more. This was a rigorous study that met current standards for avoiding bias.

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• Experts generally agree that acupuncture is helpful for treatment-related nausea and vomiting in cancer patients, but this conclusion is based primarily on research conducted before current guidelines for treating these symptoms were adopted. It’s uncertain whether acupuncture is beneficial when used in combination with current standard treatments for nausea and vomiting.

For more information, see the  NCCIH webpage on cancer .

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• In a study conducted in Germany in 2017, 357 participants receiving routine asthma care were randomly assigned to receive or not receive acupuncture, and an additional 1,088 people who received acupuncture for asthma were also studied. Adding acupuncture to routine care was associated with better quality of life compared to routine care alone.
• A review of 9 earlier studies (777 participants) showed that adding acupuncture to conventional asthma treatment improved symptoms but not lung function.

For more information, see the  NCCIH webpage on asthma .

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• A 2018 review of 64 studies (7,104 participants) of acupuncture for depression indicated that acupuncture may result in a moderate reduction in the severity of depression when compared with treatment as usual or no treatment. However, these findings should be interpreted with caution because most of the studies were of low or very low quality.

For more information, see the  NCCIH webpage on depression .

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• In recommendations on smoking cessation treatment issued in 2021, the U.S. Preventive Services Task Force, a panel of experts that makes evidence-based recommendations about disease prevention, did not make a recommendation about the use of acupuncture as a stop-smoking treatment because only limited evidence was available. This decision was based on a 2014 review of 9 studies (1,892 participants) that looked at the effect of acupuncture on smoking cessation results for 6 months or more and found no significant benefit. Some studies included in that review showed evidence of a possible small benefit of acupuncture on quitting smoking for shorter periods of time.

For more information, see the  NCCIH webpage on quitting smoking .

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• A 2021 review evaluated 6 studies (2,507 participants) that compared the effects of acupuncture versus sham acupuncture on the success of in vitro fertilization as a treatment for infertility. No difference was found between the acupuncture and sham acupuncture groups in rates of pregnancy or live birth.
• A 2020 review evaluated 12 studies (1,088 participants) on the use of acupuncture to improve sperm quality in men who had low sperm numbers and low sperm motility. The reviewers concluded that the evidence was inadequate for firm conclusions to be drawn because of the varied design of the studies and the poor quality of some of them. 

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• A 2018 review of 12 studies with 869 participants concluded that acupuncture and laser acupuncture (a treatment that uses lasers instead of needles) may have little or no effect on carpal tunnel syndrome symptoms in comparison with sham acupuncture. It’s uncertain how the effects of acupuncture compare with those of other treatments for this condition.    
• In a 2017 study not included in the review described above, 80 participants with carpal tunnel syndrome were randomly assigned to one of three interventions: (1) electroacupuncture to the more affected hand; (2) electroacupuncture at “distal” body sites, near the ankle opposite to the more affected hand; and (3) local sham electroacupuncture using nonpenetrating placebo needles. All three interventions reduced symptom severity, but local and distal acupuncture were better than sham acupuncture at producing desirable changes in the wrist and the brain.

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• A 2018 review of studies of acupuncture for vasomotor symptoms associated with menopause (hot flashes and related symptoms such as night sweats) analyzed combined evidence from an earlier review of 15 studies (1,127 participants) and 4 newer studies (696 additional participants). The analysis showed that acupuncture was better than no acupuncture at reducing the frequency and severity of symptoms. However, acupuncture was not shown to be better than sham acupuncture.

For more information, see the  NCCIH webpage on menopause .

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• Auricular acupuncture is a type of acupuncture that involves stimulating specific areas of the ear. 
• In a 2019 review of 15 studies (930 participants) of auricular acupuncture or auricular acupressure (a form of auricular therapy that does not involve penetration with needles), the treatment significantly reduced pain intensity, and 80 percent of the individual studies showed favorable effects on various measures related to pain.
• A 2020 review of 9 studies (783 participants) of auricular acupuncture for cancer pain showed that auricular acupuncture produced better pain relief than sham auricular acupuncture. Also, pain relief was better with a combination of auricular acupuncture and drug therapy than with drug therapy alone.
• An inexpensive, easily learned form of auricular acupuncture called “battlefield acupuncture” has been used by the U.S. Department of Defense and Department of Veterans Affairs to treat pain. However, a 2021 review of 9 studies (692 participants) of battlefield acupuncture for pain in adults did not find any significant improvement in pain when this technique was compared with no treatment, usual care, delayed treatment, or sham battlefield acupuncture.

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• Relatively few complications from using acupuncture have been reported. However, complications have resulted from use of nonsterile needles and improper delivery of treatments.
• When not delivered properly, acupuncture can cause serious adverse effects, including infections, punctured organs, and injury to the central nervous system.
• The U.S. Food and Drug Administration (FDA) regulates acupuncture needles as medical devices and requires that they be sterile and labeled for single use only.

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• Some health insurance policies cover acupuncture, but others don’t. Coverage is often limited based on the condition being treated.
• An analysis of data from the Medical Expenditure Panel Survey, a nationally representative U.S. survey, showed that the share of adult acupuncturist visits with any insurance coverage increased from 41.1 percent in 2010–2011 to 50.2 percent in 2018–2019.
• Medicare covers acupuncture only for the treatment of chronic low-back pain. Coverage began in 2020. Up to 12 acupuncture visits are covered, with an additional 8 visits available if the first 12 result in improvement. Medicaid coverage of acupuncture varies from state to state.

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• Most states license acupuncturists, but the requirements for licensing vary from state to state. To find out more about licensing of acupuncturists and other complementary health practitioners, visit the NCCIH webpage  Credentialing, Licensing, and Education . 

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NCCIH funds research to evaluate acupuncture’s effectiveness for various kinds of pain and other conditions and to further understand how the body responds to acupuncture and how acupuncture might work. Some recent NCCIH-supported studies involve:

• Evaluating the feasibility of using acupuncture in hospital emergency departments.
• Testing whether the effect of acupuncture on chronic low-back pain can be enhanced by combining it with transcranial direct current stimulation.
• Evaluating a portable acupuncture-based nerve stimulation treatment for anxiety disorders.

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• Don’t use acupuncture to postpone seeing a health care provider about a health problem.
• Take charge of your health—talk with your health care providers about any complementary health approaches you use. Together, you can make shared, well-informed decisions.

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Nccih clearinghouse.

The NCCIH Clearinghouse provides information on NCCIH and complementary and integrative health approaches, including publications and searches of Federal databases of scientific and medical literature. The Clearinghouse does not provide medical advice, treatment recommendations, or referrals to practitioners.

Toll-free in the U.S.: 1-888-644-6226

Telecommunications relay service (TRS): 7-1-1

Website: https://www.nccih.nih.gov

Email: [email protected] (link sends email)

Know the Science

NCCIH and the National Institutes of Health (NIH) provide tools to help you understand the basics and terminology of scientific research so you can make well-informed decisions about your health. Know the Science features a variety of materials, including interactive modules, quizzes, and videos, as well as links to informative content from Federal resources designed to help consumers make sense of health information.

Explaining How Research Works (NIH)

Know the Science: How To Make Sense of a Scientific Journal Article

Understanding Clinical Studies (NIH)

A service of the National Library of Medicine, PubMed® contains publication information and (in most cases) brief summaries of articles from scientific and medical journals. For guidance from NCCIH on using PubMed, see How To Find Information About Complementary Health Approaches on PubMed .

Website: https://pubmed.ncbi.nlm.nih.gov/

NIH Clinical Research Trials and You

The National Institutes of Health (NIH) has created a website, NIH Clinical Research Trials and You, to help people learn about clinical trials, why they matter, and how to participate. The site includes questions and answers about clinical trials, guidance on how to find clinical trials through ClinicalTrials.gov and other resources, and stories about the personal experiences of clinical trial participants. Clinical trials are necessary to find better ways to prevent, diagnose, and treat diseases.

Website: https://www.nih.gov/health-information/nih-clinical-research-trials-you

Research Portfolio Online Reporting Tools Expenditures & Results (RePORTER)

RePORTER is a database of information on federally funded scientific and medical research projects being conducted at research institutions.

Website: https://reporter.nih.gov

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• Befus D, Coeytaux RR, Goldstein KM, et al.  Management of menopause symptoms with acupuncture: an umbrella systematic review and meta-analysis . Journal of Alternative and Complementary Medicine. 2018;24(4):314-323.
• Bleck   R, Marquez E, Gold MA, et al.  A scoping review of acupuncture insurance coverage in the United States . Acupuncture in Medicine. 2020;964528420964214.
• Briggs JP, Shurtleff D.  Acupuncture and the complex connections between the mind and the body. JAMA. 2017;317(24):2489-2490.
• Brinkhaus B, Roll S, Jena S, et al.  Acupuncture in patients with allergic asthma: a randomized pragmatic trial. Journal of Alternative and Complementary Medicine. 2017;23(4):268-277.
• Chan MWC, Wu XY, Wu JCY, et al.  Safety of acupuncture: overview of systematic reviews. Scientific Reports. 2017;7(1):3369.
• Coyle ME, Stupans I, Abdel-Nour K, et al.  Acupuncture versus placebo acupuncture for in vitro fertilisation: a systematic review and meta-analysis. Acupuncture in Medicine. 2021;39(1):20-29.
• Hershman DL, Unger JM, Greenlee H, et al.  Effect of acupuncture vs sham acupuncture or waitlist control on joint pain related to aromatase inhibitors among women with early-stage breast cancer: a randomized clinical trial. JAMA. 2018;320(2):167-176.
• Linde K, Allais G, Brinkhaus B, et al.  Acupuncture for the prevention of episodic migraine. Cochrane Database of Systematic Reviews. 2016;(6):CD001218. Accessed at  cochranelibrary.com on February 12, 2021.
• Linde K, Allais G, Brinkhaus B, et al.  Acupuncture for the prevention of tension-type headache. Cochrane Database of Systematic Reviews. 2016;(4):CD007587. Accessed at  cochranelibrary.com on February 12, 2021.
• MacPherson H, Vertosick EA, Foster NE, et al. The persistence of the effects of acupuncture after a course of treatment: a meta-analysis of patients with chronic pain . Pain. 2017;158(5):784-793.
• Qaseem A, Wilt TJ, McLean RM, et al.  Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine. 2017;166(7):514-530.
• Seidman MD, Gurgel RK, Lin SY, et al.  Clinical practice guideline: allergic rhinitis. Otolaryngology—Head and Neck Surgery. 2015;152(suppl 1):S1-S43.
• Vickers AJ, Vertosick EA, Lewith G, et al. Acupuncture for chronic pain: update of an individual patient data meta-analysis . The Journal of Pain. 2018;19(5):455-474.
• White AR, Rampes H, Liu JP, et al.  Acupuncture and related interventions for smoking cessation. Cochrane Database of Systematic Reviews. 2014;(1):CD000009. Accessed at  cochranelibrary.com on February 17, 2021.
• Zia FZ, Olaku O, Bao T, et al.  The National Cancer Institute’s conference on acupuncture for symptom management in oncology: state of the science, evidence, and research gaps. Journal of the National Cancer Institute. Monographs. 2017;2017(52):lgx005.

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• Adams D, Cheng F, Jou H, et al. The safety of pediatric acupuncture: a systematic review. Pediatrics. 2011;128(6):e1575-1587.
• Candon M, Nielsen A, Dusek JA. Trends in insurance coverage for acupuncture, 2010-2019. JAMA Network Open. 2022;5(1):e2142509.
• Cao J, Tu Y, Orr SP, et al. Analgesic effects evoked by real and imagined acupuncture: a neuroimaging study. Cerebral Cortex. 2019;29(8):3220-3231.
• Centers for Medicare & Medicaid Services. Decision Memo for Acupuncture for Chronic Low Back Pain (CAG-00452N). Accessed at https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=295 on June 25, 2021.
• Chen L, Lin C-C, Huang T-W, et al. Effect of acupuncture on aromatase inhibitor-induced arthralgia in patients with breast cancer: a meta-analysis of randomized controlled trials . The Breast. 2017;33:132-138. 
• Choi G-H, Wieland LS, Lee H, et al. Acupuncture and related interventions for the treatment of symptoms associated with carpal tunnel syndrome. Cochrane Database of Systematic Reviews. 2018;(12):CD011215. Accessed at cochranelibrary.com on January 28, 2021.
• Cui J, Wang S, Ren J, et al. Use of acupuncture in the USA: changes over a decade (2002–2012). Acupuncture in Medicine. 2017;35(3):200-207.
• Federman DG, Zeliadt SB, Thomas ER, et al. Battlefield acupuncture in the Veterans Health Administration: effectiveness in individual and group settings for pain and pain comorbidities. Medical Acupuncture. 2018;30(5):273-278.
• Feng S, Han M, Fan Y, et al. Acupuncture for the treatment of allergic rhinitis: a systematic review and meta-analysis. American Journal of Rhinology & Allergy. 2015;29(1):57-62.
• Franco JV, Turk T, Jung JH, et al. Non-pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome. Cochrane Database of Systematic Reviews. 2018;(5):CD012551. Accessed at cochranelibrary.com on January 28, 2021.
• Freeman MP, Fava M, Lake J, et al. Complementary and alternative medicine in major depressive disorder: the American Psychiatric Association task force report. The Journal of Clinical Psychiatry . 2010;71(6):669-681.
• Giovanardi CM, Cinquini M, Aguggia M, et al. Acupuncture vs. pharmacological prophylaxis of migraine: a systematic review of randomized controlled trials. Frontiers in Neurology. 2020;11:576272.
• Hu C, Zhang H, Wu W, et al. Acupuncture for pain management in cancer: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine. 2016;2016;1720239.
• Jiang C, Jiang L, Qin Q. Conventional treatments plus acupuncture for asthma in adults and adolescent: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine . 2019;2019:9580670.
• Ji M, Wang X, Chen M, et al. The efficacy of acupuncture for the treatment of sciatica: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine.  2015;2015:192808.
• Kaptchuk TJ. Acupuncture: theory, efficacy, and practice. Annals of Internal Medicine . 2002;136(5):374-383.
• Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care & Research. 2020;72(2):149-162. 
• Langevin H. Fascia mobility, proprioception, and myofascial pain. Life. 2021;11(7):668. 
• Liu Z, Liu Y, Xu H, et al. Effect of electroacupuncture on urinary leakage among women with stress urinary incontinence: a randomized clinical trial. JAMA. 2017;317(24):2493-2501.
• MacPherson H, Hammerschlag R, Coeytaux RR, et al. Unanticipated insights into biomedicine from the study of acupuncture. Journal of Alternative and Complementary Medicine. 2016;22(2):101-107.
• Maeda Y, Kim H, Kettner N, et al. Rewiring the primary somatosensory cortex in carpal tunnel syndrome with acupuncture. Brain. 2017;140(4):914-927.
• Manheimer E, Cheng K, Wieland LS, et al. Acupuncture for hip osteoarthritis. Cochrane Database of Systematic Reviews. 2018;(5):CD013010. Accessed at cochranelibrary.com on February 17, 2021. 
• Moura CC, Chaves ECL, Cardoso ACLR, et al. Auricular acupuncture for chronic back pain in adults: a systematic review and metanalysis. Revista da Escola de Enfermagem da U S P. 2019;53:e03461.
• Nahin RL, Rhee A, Stussman B. Use of complementary health approaches overall and for pain management by US adults. JAMA. 2024;331(7):613-615.
• Napadow V. Neuroimaging somatosensory and therapeutic alliance mechanisms supporting acupuncture. Medical Acupuncture. 2020;32(6):400-402.
• Patnode CD, Henderson JT, Coppola EL, et al. Interventions for tobacco cessation in adults, including pregnant persons: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2021;325(3):280-298.
• Qin Z, Liu X, Wu J, et al. Effectiveness of acupuncture for treating sciatica: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine. 2015;2015;425108.
• Smith CA, Armour M, Lee MS, et al. Acupuncture for depression. Cochrane Database of Systematic Reviews. 2018;(3):CD004046. Accessed at cochranelibrary.com on January 20, 2021.
• US Preventive Services Task Force. Interventions for tobacco smoking cessation in adults, including pregnant persons. US Preventive Services Task Force recommendation statement. JAMA. 2021;325(3):265-279.
• Vase L, Baram S, Takakura N, et al. Specifying the nonspecific components of acupuncture analgesia. Pain. 2013;154(9):1659-1667.
• Wang R, Li X, Zhou S, et al. Manual acupuncture for myofascial pain syndrome: a systematic review and meta-analysis. Acupuncture in Medicine. 2017;35(4):241-250.
• World Health Organization. WHO Traditional Medicine Strategy: 2014–2023. Geneva, Switzerland: World Health Organization, 2013. Accessed at https://www.who.int/publications/i/item/9789241506096 on February 2, 2021.
• Wu M-S, Chen K-H, Chen I-F, et al. The efficacy of acupuncture in post-operative pain management: a systematic review and meta-analysis. PLoS One. 2016;11(3):e0150367.
• Xu S, Wang L, Cooper E, et al. Adverse events of acupuncture: a systematic review of case reports. Evidence-Based Complementary and Alternative Medicine. 2013;2013:581203.
• Yang J, Ganesh R, Wu Q, et al. Battlefield acupuncture for adult pain: a systematic review and meta-analysis of randomized controlled trials. The American Journal of Chinese Medicine. 2021;49(1):25-40.
• Yang Y, Wen J, Hong J. The effects of auricular therapy for cancer pain: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine. 2020;2020:1618767.  
• Yeh CH, Morone NE, Chien L-C, et al. Auricular point acupressure to manage chronic low back pain in older adults: a randomized controlled pilot study. Evidence-Based Complementary and Alternative Medicine. 2014;2014;375173.
• You F, Ruan L, Zeng L, et al. Efficacy and safety of acupuncture for the treatment of oligoasthenozoospermia: a systematic review. Andrologia. 2020;52(1):e13415.
• Zhang X-C, Chen H, Xu W-T, et al. Acupuncture therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials. Journal of Pain Research. 2019;12:527-542.
• Zheng H, Chen R, Zhao X, et al. Comparison between the effects of acupuncture relative to other controls on irritable bowel syndrome: a meta-analysis. Pain Research and Management. 2019;2019:2871505.

Acknowledgments

NCCIH thanks Pete Murray, Ph.D., David Shurtleff, Ph.D., and Helene M. Langevin, M.D., NCCIH for their review of the 2022 update of this fact sheet. 

This publication is not copyrighted and is in the public domain. Duplication is encouraged.

NCCIH has provided this material for your information. It is not intended to substitute for the medical expertise and advice of your health care provider(s). We encourage you to discuss any decisions about treatment or care with your health care provider. The mention of any product, service, or therapy is not an endorsement by NCCIH.

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Understanding Drug Use and Addiction DrugFacts

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.

What Is drug addiction?

Addiction is a chronic disease characterized by drug seeking and use that is compulsive, or difficult to control, despite harmful consequences. The initial decision to take drugs is voluntary for most people, but repeated drug use can lead to brain changes that challenge an addicted person’s self-control and interfere with their ability to resist intense urges to take drugs. These brain changes can be persistent, which is why drug addiction is considered a "relapsing" disease—people in recovery from drug use disorders are at increased risk for returning to drug use even after years of not taking the drug.

It's common for a person to relapse, but relapse doesn't mean that treatment doesn’t work. As with other chronic health conditions, treatment should be ongoing and should be adjusted based on how the patient responds. Treatment plans need to be reviewed often and modified to fit the patient’s changing needs.

Video: Why are Drugs So Hard to Quit?

What happens to the brain when a person takes drugs?

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 and 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.

Long-term use also causes changes in other brain chemical systems and circuits as well, affecting functions that include:

• decision-making

Despite being aware of these harmful outcomes, many people who use drugs continue to take them, which is the nature of addiction.

Why do some people become addicted to drugs while others don't?

No one factor can predict if a person will become addicted to drugs. A combination of factors influences risk for addiction. The more risk factors a person has, the greater the chance that taking drugs can lead to addiction. For example:

• Biology . The genes that people are born with account for about half of a person's risk for addiction. Gender, ethnicity, and the presence of other mental disorders may also influence risk for drug use and addiction.
• Environment . A person’s environment includes many different influences, from family and friends to economic status and general quality of life. Factors such as peer pressure, physical and sexual abuse, early exposure to drugs, stress, and parental guidance can greatly affect a person’s likelihood of drug use and addiction.
• Development . Genetic and environmental factors interact with critical developmental stages in a person’s life to affect addiction risk. Although taking drugs at any age can lead to addiction, the earlier that drug use begins, the more likely it will progress to addiction. This is particularly problematic for teens. Because areas in their brains that control decision-making, judgment, and self-control are still developing, teens may be especially prone to risky behaviors, including trying drugs.

Can drug addiction be cured or prevented?

As with most other chronic diseases, such as diabetes, asthma, or heart disease, treatment for drug addiction generally isn’t a cure. However, addiction is treatable and can be successfully managed. People who are recovering from an addiction will be at risk for relapse for years and possibly for their whole lives. Research shows that combining addiction treatment medicines with behavioral therapy ensures the best chance of success for most patients. Treatment approaches tailored to each patient’s drug use patterns and any co-occurring medical, mental, and social problems can lead to continued recovery.

More good news is that drug use and addiction are preventable. Results from NIDA-funded research have shown that prevention programs involving families, schools, communities, and the media are effective for preventing or reducing drug use and addiction. Although personal events and cultural factors affect drug use trends, when young people view drug use as harmful, they tend to decrease their drug taking. Therefore, education and outreach are key in helping people understand the possible risks of drug use. Teachers, parents, and health care providers have crucial roles in educating young people and preventing drug use and addiction.

Points to Remember

• Drug addiction is a chronic disease characterized by drug seeking and use that is compulsive, or difficult to control, despite harmful consequences.
• Brain changes that occur over time with drug use challenge an addicted person’s self-control and interfere with their ability to resist intense urges to take drugs. This is why drug addiction is also a relapsing disease.
• Relapse is the return to drug use after an attempt to stop. Relapse indicates the need for more or different treatment.
• Most drugs affect the brain's reward circuit by flooding it with the chemical messenger dopamine. Surges of dopamine in the reward circuit cause the reinforcement of pleasurable but unhealthy activities, leading people to repeat the behavior again and again.
• Over time, the brain adjusts to the excess dopamine, which 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, trying to achieve the same dopamine high.
• No single factor can predict whether a person will become addicted to drugs. A combination of genetic, environmental, and developmental factors influences risk for addiction. The more risk factors a person has, the greater the chance that taking drugs can lead to addiction.
• Drug addiction is treatable and can be successfully managed.
• More good news is that drug use and addiction are preventable. Teachers, parents, and health care providers have crucial roles in educating young people and preventing drug use and addiction.

For information about understanding drug use and addiction, visit:

• www.nida.nih.gov/publications/drugs-brains-behavior-science-addiction/drug-abuse-addiction

For more information about the costs of drug abuse to the United States, visit:

• www.nida.nih.gov/related-topics/trends-statistics#costs

For more information about prevention, visit:

• www.nida.nih.gov/related-topics/prevention

For more information about treatment, visit:

• www.nida.nih.gov/related-topics/treatment

To find a publicly funded treatment center in your state, call 1-800-662-HELP or visit:

• https://findtreatment.samhsa.gov/

This publication is available for your use and may be reproduced in its entirety without permission from NIDA. Citation of the source is appreciated, using the following language: Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.