Substance use disorder background

This post is jointly authored by Steve Pizer and Austin Frakt. We should have posted this before the other recent substance use-related posts were published. Better late than never. Numbered references appear at the end of the post.

Substance use disorders (SUDs) are chronic, relapsing diseases of the brain.  They are characterized by the compulsive search for and use of drugs of abuse despite harmful physical, emotional, and social consequences.  Each year, at least 3.8% of the U.S. population suffer from an SUD [1,2].

In recent years, neurobiological research has improved our understanding of SUDs in important ways.  We now know that repeated use of drugs of abuse leads to physically observable changes in the brain, in effect “teaching” the brain to seek out regular and increasing quantities of that substance [3].  In many cases, brain-related changes remain even after prolonged periods of abstinence from a substance, which contributes to the frequent relapse experienced by individuals with substance use disorders.

In a seminal paper regarding the chronic nature of addiction, McClellan and colleagues demonstrated that SUDs compare similarly to common chronic conditions including Type I diabetes, hypertension and asthma [4].  The incidence of each condition is related to both genetic factors and to environment.  In each case, rates of relapse are high, and compliance with treatment in the population is below recommended levels.  Thus, like other chronic conditions, treatment for SUDs typically helps to manage the condition, and to prolong the time before relapse, rather than to “cure” it.

One important way in which SUDs differ from other physical conditions is the high economic costs of illness.  Of the estimated $190 billion in costs of substance abuse each year, the greatest cost stems from lost productivity and criminal involvement.  However, SUDs also inflict substantial increases in medical costs both directly related to the condition, such as injuries or infections sustained while using drugs of abuse, and because SUDs interfere with the maintenance of other serious medical conditions.  The last factor is important because individuals with SUDs have high rates of co-occurring physical and psychiatric disorders.

Despite the chronic nature of SUDs and the high social costs associated with them, many successful treatments do exist to manage these conditions.  The two primary types of treatment for SUDs include behavioral and pharmaceutical therapy.  Behavioral therapy can take many forms, can be delivered in various settings by a range of providers, and may be done at the individual, family, or group level, depending on the situation.  However, all behavioral therapies involve some type of counseling.  There are many evidence-based behavioral therapies that demonstrate both efficacy in clinical trials and effectiveness when delivered in the community, and evidence suggests that when delivered appropriately a wide range of approaches are equally effective [5].

The second type of therapy that can complement behavioral therapy is pharmaceutical therapy.  Pharmaceutical therapies can be used to help mitigate withdrawal symptoms that may drive on-going use, to help maintain clients in treatment, to reduce the rewarding effects of the misused substance, and to help reduce cravings for a drug after sustained abstinence by reducing the effect of “triggers” that activate cravings even among abstinent individuals [3].  For example, two therapies, Naltrexone to treat alcohol disorders and Buprenorphine to treat opioid disorders have recently demonstrated promising rates of success in trials and some community settings, though in practice use of these therapies is low.  Consensus exists in the scientific community that where available, a combination of behavioral and pharmaceutical therapy achieves the best treatment effects [3].


1. Kessler RC, Chiu W, Demler O, et al. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Arch Gen Psychiatry. 2005; 62:617-27.

2. Grant BF, Compton W, Crowley TJ., et al. Errors in Assessing DSM-IV Substance Use Disorders, Arch Gen Psychiatry. 2007; 64(3): 379-80.

3. National Institute on Drug Abuse, National Institutes of Health. Drugs, Brains, and Behavior: The Science of Addictions, 2007.

4. McLellan, A.T., Lewis, D.C., O’Brien, CP, Kleber, HD, Drug Dependence, a Chronic Medical Illness:  Implications for Treatment, Insurance, and Outcomes Evaluation. JAMA. 2000; 284(13): 1689-1695.

5. Project MATCH Research Group. Treatment Matching in Alcoholism, Thomas F. Babor and Frances K. Del Boca, Editors. New York: Cambridge University Press; 2003.

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