An Evolving Understanding of Substance Use Disorders
Scientific breakthroughs have revolutionized the understanding of substance use disorders. For example, severe substance use disorders, commonly called addictions, were once viewed largely as a moral failing or character flaw, but are now understood to be chronic illnesses characterized by clinically significant impairments in health, social function, and voluntary control over substance use.3 Although the mechanisms may be different, addiction has many features in common with disorders such as diabetes, asthma, and hypertension. All of these disorders are chronic, subject to relapse, and influenced by genetic, developmental, behavioral, social, and environmental factors. In all of these disorders, affected individuals may have difficulty in complying with the prescribed treatment.4
This evolving understanding of substance use disorders as medical conditions has had important implications for prevention and treatment. Research demonstrating that addiction is driven by changes in the brain has helped to reduce the negative attitudes associated with substance use disorders and provided support for integrating treatment for substance use disorders into mainstream health care. Moreover, research on the basic neurobiology of addiction has already resulted in several effective medications for the treatment of alcohol, opioid, and nicotine use disorders, and clinical trials are ongoing to test other potential new treatments.5
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All addictive substances have powerful effects on the brain. These effects account for the euphoric or intensely pleasurable feelings that people experience during their initial use of alcohol or other substances, and these feelings motivate people to use those substances again and again, despite the risks for significant harms.
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As individuals continue to misuse alcohol or other substances, progressive changes, called neuroadaptations, occur in the structure and function of the brain. These neuroadaptations compromise brain function and also drive the transition from controlled, occasional substance use to chronic misuse, which can be difficult to control. Moreover, these brain changes endure long after an individual stops using substances. They may produce continued, periodic craving for the substance that can lead to relapse: More than 60 percent of people treated for a substance use disorder experience relapse within the first year after they are discharged from treatment,4,6 and a person can remain at increased risk of relapse for many years.7,8
However, addiction is not an inevitable consequence of substance use. Whether an individual ever uses alcohol or another substance, and whether that initial use progresses to a substance use disorder of any severity, depends on a number of factors. These include: a person’s genetic makeup and other individual biological factors; the age when use begins; psychological factors related to a person’s unique history and personality; and environmental factors, such as the availability of drugs, family and peer dynamics, financial resources, cultural norms, exposure to stress, and access to social support.9 Some of these factors increase risk for substance use, misuse, and use disorders, whereas other factors provide buffers against those risks. Nonetheless, specific combinations of factors can drive the emergence and continuation of substance misuse and the progression to a disorder or an addiction.
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