Everybody is talking a lot about causes and cures for substance abuse, but like the weather, so little of the talk ends up changing the situation much at all. This short, informal paper outlines a simple lens for viewing, thinking about, and talking about what is really causing substance abuse, whether it be drug abuse or alcoholism.
The main point is to avoid a one-size-fits-all characterization that does a disservice to most people.
From observation of reports over the years, I have concluded that the primary drivers of substance abuse are:
- Experimentation and thrill-seeking.
- Peer pressure.
- Chronic pain.
- Environmental distress.
- Mental illness.
Those drivers are in fact order by increasing level of severity, so that the primary driver is the highest level of severity that is in play for a given individual.
Another main point is that it can be very counterproductive to attempt to use a solution to one of those categories when the primary driver for an individual is another of the categories.
It is also important to realize that superficial symptoms of one of the drivers may mask a more significant underlying driver. In fact, in extreme cases, it is very possible for an individual to be the victim of all five categories, and not so uncommon for individuals to be victims of two or three of the drivers at the same time.
My primary motivation for this paper has been the growing media attention to so-called opioid addiction, the purported “Opioid Epidemic” sweeping the country. Not that there isn’t a real problem, but the media coverage seems more intent on generating heat and anxiety than enlightenment, let alone help to move towards a solution.
The usual touted solution is merely to spend more money, without very much concern for effectiveness.
My point is that if you don’t have a good handle on the underlying problem (root cause for the substance abuse), then you are unlikely to offer a truly effective solution.
Hence, my focus here on identifying the primary driver of substance abuse for any given individual.
Drugs vs. alcohol
This paper focuses on substance abuse, regardless of whether the substance be drugs or alcohol.
In addition, this paper makes no attempt to distinguish the abuse of prescription pharmaceuticals and illegal drugs.
They are all substances and all subject to abuse.
Ultimately, most substance abuse is about escape, whether escape from pain, unpleasant relationships, boredom, mental delusions, or whatever. People simply want to escape from a bad place and get to what they think will be a good or at least better place.
Not that this simple explanation points us to a solution, but simply that if drugs or alcohol are providing an escape that works for an individual, to some degree, then any real solution will need to provide a comparable escape or release from the anxiety that is necessitating the desire for escape in the first place.
Not to disparage counseling and talk therapy per se, but although counseling can be very effective for many forms of substance abuse, particularly when environmental distress is involved, it may be particularly ineffective or counterproductive when chronic pain or mental illness are the primary drivers.
It’s just a phase, they’ll grow out of it
Clearly chronic pain and mental illness are not things that you will necessarily “grow out of it”, but… some of the more mild drivers of substance abuse really can be grown out of and don’t merit overly-heavy treatments that could cause much more harm than any good. The trick is to discover which it is.
Simple, traditional, teenage experimentation and thrill-seeking, maybe simply as an act of rebellion against parental authority may indeed be no cause for alarm. Ditto for peer pressure where kids graduate from high school, graduate from college, and start families, with each stage having its own baggage that will tend to get left behind as the individual matures and moves on to new peer groups, each hopefully more mature than the last.
Again, the trick is to look past the superficial driver and sense whether some more powerful, darker, underlying driver may be in play. Maybe a normal teenager can skate on from a one-time thrill, but someone with mental illness or severe relationship problems may not be so lucky, even though the initial experience is the same for both.
In contrast with chronic pain and mental illness, environmental distress is any factor outside of the individual which is causing them great distress. Common sources include:
- Relationship problems — parents, children, spouse or significant other, other family members, romantic breakups, marriage problems.
- Unstable home environment — missing parent, dysfunctional parent, physically, sexually, or emotionally abusive parents, no parents, homeless, disruptive presence of non-parental adults.
- Parental substance abuse.
- Parental mental illness.
- Parental work, health, or financial issues.
- Work issues — conflicts with boss or coworkers, loss of job, chronic unemployment.
- School issues — problems with authority, academic performance, poor relationships with classmates, bullying, cognitive difficulties.
- Loss — death in the family, traumatic accident.
- Health problems — personal or in the family.
- Gender identity conflicts or anxiety.
- Financial difficulties — making ends meet, rising expenses, lost job, reduced income, medical expenses.
Many forms of environmental distress have practical solutions that don’t involve substance abuse, especially professional counseling, but it may also be true that some element of environmental distress may trigger an underlying primary driver of substance abuse such as mental illness. Not that environmental distress might cause mental illness per se, but simply that it could trigger an underlying mental instability that up to that point may have been dormant or at least unnoticed or unnoted.
Difficulties with relationships can be powerful triggers for substance abuse.
Counseling can be a big help.
Underlying mental illness can be a major, underlying driver, so just because the obvious problem is difficulty with a relationship, one needs to dig deep enough to see if the relationship difficulty is the real, source problem or simply the trigger for an underlying mental illness issue.
Severe substance abuse
This paper covers all substance abuse, but not all abuse is necessarily severe.
Moderate medication for legitimate chronic pain may not rise to the level of severe substance abuse.
Bouts of experimentation or thrill-seeking by teenagers will tend not to be severe substance abuse problems.
Occasional substance use as a result of peer pressure will not tend to indicate a severe substance abuse problem. It could be a yellow flag and bear watching more closely, but unless occasional becomes frequent for an extended period of time, it may not be a true, severe problem.
There may be a subtle distinction between substance abuse and addiction that makes sense to medical professionals, but for practical purposes it is simply abuse that matters in the context of this paper. Actual addiction may make the matter much worse, but abuse is what is of concern here. In fact, if one addresses the driver(s) of the abuse and then maybe the addiction either vanishes or is more readily treated.
For the purposes of discussion here, I would define simple substance abuse as having a specific triggering condition, while addiction would be abuse that is initially triggered but then takes on a life of its own, long after the initial trigger has abated. The point is that simple substance abuse can be cured by removing the trigger (and dealing with any lingering, lagged effects), while a true addiction would typically have a more complex resolution even after the trigger is safely removed.
There is the hybrid condition where the trigger persists for an extended period or even indefinitely, such as chronic pain, a disruptive home environment, or an abusive relationship, such that the otherwise simple substance abuse superficially persists as if an addiction. The resolution would be to either address the underlying trigger or to provide the individual with coping mechanisms to mitigate the effect of the trigger even if the trigger itself cannot be cured.
Chronic pain vs. temporary pain
My heart goes out to anyone who suffers from chronic, untreatable pain. That said, it is all too easy to segue from the short-term necessity of drugs for a temporary pain to an imagined but long-term dependence, even long after the original cause of pain may have been eliminated.
If the individual truly does have long-term chronic pain, or a terminal illness, then their drug use probably doesn’t constitute abuse per se. But, all to commonly, that is not the case — a short term issue ends up becoming a long-term substance abuse problem.
Even then, one must dive deeper to discern whether some more significant factor is at work that is driving the abuse more than any short-term or chronic pain, such as mental illness, relationship problems, or a dysfunctional home environment. Put simply, pain may simply be the excuse rather than the root cause of the substance abuse.
Physical addiction vs. psychological addiction
Physical drug addiction may seem a lot scarier and more difficult to cope with, and maybe that’s true, at least to some extent, but ultimately it is the psychological addiction that is most problematic. Rehab programs and medications can indeed address physical addiction, but even then there is most typically a psychological addiction in play as well.
So commonly, an individual successfully completes a rehab program, but shortly thereafter relapses. Clearly there is something more at work than the mere physicality of the addictive power of a given substance being abused.
In any case, even once physical addiction is taken out of the picture, the question remains which of the various drivers is the primary cause of the psychological addiction.
Address the primary driver of the psychological addiction and the physical addiction will most likely be a non-problem.
Mental illness really is the 800-pound gorilla or elephant standing in the middle of the room. Sure, outright, severe mental illness is an easy diagnosis, but a lot of lesser but still severe mental illness, not to mention borderline mental illness can go undetected, unnoticed, even unnoted, and unfortunately untreated, making it a primary candidate for driving the kind of substance abuse that enables the sufferer to escape their inner demons, at least in some superficial sense.
Mental illness is a huge problem. This paper is not intended to suggest any cures, but simply to note and highlight how significant a primary driver for substance abuse it can be.
I’ll go out on a limb and suggest that mental illness is the primary driver for most substance abuse.
Rehab and counseling simply can’t make a dent on substance abuse that is primarily driven by mental illness.
Use the lens
Again, the primary message of this paper is not that there is a magic bullet solution or that substance abuse is an insoluble problem, but simply that the first step should be to use the proposed lens and get a handle on what the primary driver of the substance abuse really is:
- Experimentation and thrill-seeking.
- Peer pressure.
- Chronic pain.
- Environmental distress.
- Mental illness.
Start at the highest level, mental illness, and work downward to find the highest level of primary driver that applies to a given individual.
Even for severe physical addiction such as opioids and chronic alcoholism, my claim is that as a general proposition if you address the primary driver of the substance abuse, you will be tackling the psychological component of the addiction, rendering any physical addiction a non-problem. Sure, physical addiction does require its own treatment, but focus on the psychological component first, otherwise the physical addiction will quickly return.
Not that I am suggesting or recommending that any reader engage in diagnosing or treating a suspected substance abuse problem, but I am strongly suggesting the use of this lens or model for general discussion of substance abuse as a social problem that needs to be addressed by society in general, and to use this lens when discussing and evaluating proposed public policy decisions for solutions to substance abuse problems, such as the purported Opioid Epidemic.
So, when someone proposes a public policy or treatment program or even a prescription for treatment of a single individual, we can ask: Which primary driver of substance abuse is being addressed?