New Wrinkles to a Familiar Story

In some respects, the story of the misuse of drugs is the same today as in the past. Substance use is still rampant, often creating damaging psychological disorders. New drugs keep emerging, and the public goes through periods of believing, naïvely, that the new drugs are “safe.” Only gradually do people learn that these, too, pose dangers. And treatments for substance-use disorders continue to have only limited effect.

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Yet there are positive new wrinkles in this familiar story. Researchers have begun to develop a clearer understanding of how drugs act on the brain and body. In treatment, self-help groups and rehabilitation programs are flourishing. And preventive education to make people aware of the dangers of drug misuse is also expanding and seems to be having an effect. One reason for these improvements is that investigators and clinicians have stopped working in isolation and are instead looking for intersections between their own work and work from other models.

Perhaps the most important insight to be gained from these integrated efforts is that several of the models were already on the right track. Social pressures, personality characteristics, rewards, and genetic predispositions all seem to play roles in substance use disorders, and in fact to operate together. For example, some people may inherit a malfunction of the biological reward center and so may need special doses of external stimulation—which can be provided by, for example, gambling, intense relationships, an abundance of certain foods, or drugs—to stimulate their reward center. Their pursuit of external rewards may take on the character of an addictive personality. Such people may be especially prone to experimenting with drugs, particularly when their social group makes the drugs available or when they are faced with intense stress.

Just as each model has identified important factors in the development of substance use disorders, each has made important contributions to treatment. As you have seen, the various forms of treatment seem to work best when they are combined with approaches from the other models, making integrated treatment the most productive approach.

Yet another new wrinkle to the addiction story is that the clinical field has now formally proclaimed that substances are not the only things to which people may develop an addiction. By grouping gambling disorder with the substance use disorders and targeting Internet gaming disorder for possible inclusion in the future, DSM-5 has opened the door for a broader view and perhaps broader treatments of addictive patterns—whether they are induced by substances or by other kinds of experiences.