from the text:

What Causes Substance Use Disorders?

CLINICAL THEORISTS HAVE developed sociocultural, psychological, and biological explanations for why
people develop substance use disorders. No single explanation, however, has gained broad support. Like
so many other disorders, excessive and chronic drug use is increasingly viewed as the result of a
combination of these factors.(pg 339)

Sociocultural Views

Sociocultural theorists propose that people are most likely to develop substance use disorders when
they live under stressful socioeconomic conditions. Studies have found that people in lower
socioeconomic classes have higher rates of substance use disorder than those in other classes. Similarly,
regions with higher unemployment levels have heightened rates of alcohol or opioid use disorder
(Thomas, 2020). And, in a related vein, 23 percent of unemployed adults currently use an illegal drug,
compared with 13 percent of full-time employed workers and 15 percent of part-time employees
(SAMHSA, 2020a, 2019b).

Sociocultural theorists also hold that people confronted regularly by other kinds of stress also have a
heightened risk of developing substance use disorders. A range of studies conducted with Hispanic,
African American, and LGBTQ individuals, for example, find higher rates of the disorders among those
participants who live or work in environments of particularly intense discrimination (Rose et al., 2018;
Slater et al., 2017).

Still other sociocultural theorists propose that people are more likely to develop substance use disorders
if they are part of a family or social environment in which substance use is valued or at least accepted.
Researchers have learned that problem drinking is more common among teenagers whose parents and
peers drink, as well as among teenagers whose family environments are stressful and unsupportive
(Thomas, 2020; Calhoun et al., 2018). In related work, lower rates of alcoholism are found among Jews
and Protestants, groups in which drinking is typically acceptable only as long as it remains within clear
limits, whereas alcoholism rates are higher among the Irish and Eastern Europeans, who do not, in
general, draw as clear a line (Ritchie & Roser, 2019).

Psychodynamic Views

Psychodynamic theorists believe that people with substance use disorders have powerful dependency
needs that can be traced to their early years (Wojtynkiewicz, 2018; Dodes & Khantzian, 2016). They
suggest that when parents fail to satisfy a young child’s need for nurturance, the child is likely to grow
up depending excessively on others for help and comfort, trying to find the nurturance that was lacking
during the early years. If this search for outside support includes experimentation with a drug, the
person may well develop a dependent relationship with the substance.(pg 340)

Some psychodynamic theorists also believe that certain people respond to their early deprivations by
developing a substance abuse personality that leaves them particularly prone to drug abuse. Personality
inventories, patient interviews, and even animal studies have in fact indicated that individuals who
abuse drugs tend to be more dependent, antisocial, impulsive, novelty-seeking, risk-taking, and
depressive than other individuals (Huey, 2020; Martino et al., 2017). However, these findings are
correlational (at least, the findings from human studies are) and do not clarify whether such traits lead
to chronic drug use or whether repeated drug use causes people to be dependent, impulsive, and the
like.

In an effort to establish clearer causation, a pioneering longitudinal study measured the personality
traits of a large group of nonalcoholic young men and then kept track of each man’s development
(Jones, 1971, 1968). Years later, the traits of the men who developed alcohol problems in middle age
were compared with the traits of those who did not. The men who developed alcohol problems had
been more impulsive as teenagers and continued to be so in middle age, a finding suggesting that
impulsive men are indeed more prone to develop alcohol problems. Similarly, in various laboratory
investigations, “impulsive” rats — those that generally have trouble delaying their rewards — have been
found to drink more alcohol when offered it than do other rats (Dalley & Ersche, 2019).

A major weakness of this line of argument is the wide range of personality traits that have been tied to
substance use disorders. Different studies point to different “key” traits. Inasmuch as some people with
these disorders appear to be dependent, others impulsive, and still others antisocial, researchers cannot
presently conclude that any one personality trait or group of traits stands out in the development of the
disorders (Soe-Agnie et al., 2020; Garofalo & Wright, 2017).

Cognitive-Behavioral Views

According to cognitive-behavioral theorists, operant conditioning may play a key role in substance use
disorders. They argue that the temporary reduction of tension or elevation of spirits produced by a drug
has a rewarding effect, thus increasing the likelihood that the user will seek this reaction again (Simpson
et al., 2020). Similarly, the rewarding effects may eventually lead users to try higher dosages or more
powerful methods of ingestion (see Table 11-3). Beyond these conditioning explanations, cognitive-
behavioral theorists further argue that such rewards eventually produce an expectancy that substances
will be rewarding, and this expectation helps motivate people to increase drug use at times of tension
(Wang et al., 2019).(pg 340)

In support of these views, studies have found that many people do drink more alcohol or seek heroin
when they feel tense (Strain, 2020a; Frone, 2016). In one study, as participants worked on a difficult
anagram task, a confederate planted by the researchers unfairly criticized and belittled them. The
participants were then asked to participate in an “alcohol taste task,” supposedly to compare and rate
alcoholic beverages. Those who had been harassed drank more alcohol during the taste task than did
the control participants who had not been criticized.

In a manner of speaking, the cognitive-behavioral theorists are arguing that many people take drugs to
“medicate” themselves when they feel tense. If so, one would expect higher rates of substance use
disorders among people who suffer from anxiety, depression, and other such problems. And, in fact, at
least 20 percent of all adults who suffer from psychological disorders also display substance use
disorders (SAMHSA, 2020a, 2019b; Dworkin et al., 2018). (pg 341)
A number of cognitive-behavioral theorists have proposed that classical conditioning may also play a
role in these disorders (MHN, 2020a; Goltseker et al., 2017). As you’ll remember from Chapters 3 and 5,
classical conditioning occurs when two stimuli that appear close together in time become connected in a
person’s mind, so that eventually, the person responds similarly to each stimulus. Cues or objects
present in the environment at the time a person takes a drug may act as classically conditioned stimuli
and come to produce some of the same pleasure brought on by the drugs themselves. Just the sight of a
hypodermic needle, drug buddy, or regular supplier, for example, has been known to comfort people
who are addicted to heroin or amphetamines and to relieve their withdrawal symptoms. In a similar
manner, cues or objects that are present during withdrawal distress may produce withdrawal-like
symptoms. One man who had formerly been dependent on heroin became nauseated and had other
withdrawal symptoms when he returned to the neighborhood where he had gone through withdrawal
in the past — a reaction that led him to start taking heroin again.(pg 342)

Biological Views

Over the past few decades, researchers have learned that biological factors play a major role in drug
misuse. Studies on genetic predisposition, neurotransmitters, and brain circuits have all pointed in this
direction.

Genetic Predisposition

For years, breeding experiments have been conducted to see whether certain animals are genetically
predisposed to become addicted to drugs (Kuhn, Kalivas, & Bobadilla, 2019; Logrip et al., 2018). In
several such studies, investigators have first identified animals that prefer alcohol to other beverages
and then mated them to one another. Generally, the offspring of these animals have been found to also
display an unusual preference for alcohol.

Similarly, research with human twins has suggested that people may inherit a predisposition to misuse
substances (NIDA, 2020b, 2019b; Stickel et al., 2017). Numerous studies have found an alcoholism
concordance rate of around 50 percent in identical twins; that is, if one identical twin displays
alcoholism, the other twin also does in 50 percent of the cases. In contrast, in these same studies,
fraternal twins have a concordance rate of only 30 percent. As you have read, however, such findings do
not rule out other interpretations. For one thing, the parenting received by two identical twins may be
more similar than that received by two fraternal twins.

A clearer indication that genetics may play a role in substance use disorders comes from studies of
alcoholism rates in people adopted shortly after birth (NIDA, 2020b, 2019b; Stickel et al., 2017). These
studies have compared adoptees whose biological parents abuse alcohol with adoptees whose
biological parents do not. By adulthood, the individuals whose biological parents abuse alcohol typically
show higher rates of alcoholism than those with nonalcoholic biological parents. (pg 342)

Neurotransmitters

Over the past few decades, some researchers have pieced together a neurotransmitter-focused
explanation of drug tolerance and withdrawal symptoms (Linnet, 2020; Lohani et al., 2017; Kosten et al.,
2011, 2005). They contend that when a particular drug is ingested, it increases the activity of certain
neurotransmitters whose normal purpose is to calm, reduce pain, lift mood, or increase alertness. When
a person keeps on taking the drug, the brain apparently makes an adjustment and reduces its own
production of the neurotransmitters. Because the drug is increasing neurotransmitter activity or
efficiency, the brain’s release of the neurotransmitter is less necessary. As drug intake increases, the
body’s production of the neurotransmitters continues to decrease, leaving the person in need of
progressively more of the drug to achieve its effects. In this way, drug takers build tolerance for a drug,
becoming more and more reliant on it rather than on their own biological processes to feel comfortable,
happy, or alert. If they suddenly stop taking the drug, their natural supply of neurotransmitters will be
low for a time, producing the symptoms of withdrawal. Withdrawal continues until the brain resumes its
normal production of the neurotransmitters.

To some extent, the abused substance dictates which neurotransmitters will be affected (Kashem et al.,
2020; Linnet, 2020). Repeated and excessive use of alcohol or benzodiazepines may lower the brain’s
production of the neurotransmitter GABA, regular use of opioids may reduce the brain’s production of
endorphins, and regular use of cocaine or amphetamines may lower the brain’s production of
dopamine. In addition, researchers have identified a neurotransmitter called anandamide that operates
much like THC; excessive use of marijuana may reduce the production of anandamide.

The Brain’s Reward Circuit

The neurotransmitter-focused explanation of substance abuse helps explain why people who regularly
take substances have tolerance and withdrawal reactions. But why are drugs so rewarding, and why do
certain people turn to them in the first place? Brain-imaging studies answer these questions by pointing
to the operation of a particular brain circuit — the circuit within which the neurotransmitters under
discussion do their work. As you’ve read earlier, a brain circuit is a network of brain structures that work
together, triggering each other into action to produce a distinct behavioral, cognitive, or emotional
reaction. The circuit that has been tied to substance misuse is the reward circuit, also called the reward
center and the pleasure pathway (Volkow, 2020; Volkow et al., 2019, 2018, 2016).

Apparently, whenever a person ingests a substance (from foods to drugs), the substance eventually
activates the brain’s reward circuit. This circuit features the brain structure called the ventral tegmental
area (in the midbrain), a structure known as the nucleus accumbens (also called the ventral striatum),
and the prefrontal cortex (see Figure 11-4). In addition, the circuit includes the amygdala, hippocampus,
and several other structures (Rappaport et al., 2020; Edmiston et al., 2019; Walker et al., 2018). The key
neurotransmitter in this reward circuit is dopamine. When dopamine is activated throughout the circuit,
a person feels pleasure. Music may activate dopamine in the reward circuit. So may a hug or a word of
praise. And so do drugs. Although other neurotransmitters also play roles in the reward circuit,
dopamine is the primary one. (pg 343)

Certain drugs directly stimulate the structures in the brain’s reward circuit. Remember that cocaine and
amphetamines directly increase dopamine activity. Other drugs seem to stimulate the structures in
roundabout ways. The biochemical reactions triggered by alcohol, opioids, and marijuana set in motion
a series of chemical events that eventually lead to increased dopamine activity in the reward circuit and,
in turn, excessive communications (that is, heightened interconnectivity) between the circuit’s
structures (Volkow et al., 2019, 2018, 2016). Some theorists further believe that as substances
repeatedly stimulate this reward circuit, the circuit develops a hypersensitivity to the substances. That
is, neurons in the brain circuit fire more readily when stimulated by the substances, contributing to
future desires for them — a notion called the incentive-sensitization theory (Moeller & Paulus, 2018).
Still other theorists suspect that people who chronically use drugs may generally suffer from a reward
deficiency syndrome: their reward circuit is not readily activated by the usual events in their lives, so
they turn to drugs to stimulate this pleasure pathway, particularly in times of stress. Abnormal genes,
such as the abnormal form of the D2 receptor gene discussed earlier, have been cited as possible
contributors to this syndrome (Blum et al., 2019).(pg343)

The Developmental Psychopathology View

Over the years, a list of factors that may contribute to substance use disorders has unfolded, but no
single factor fully predicts or explains the disorders. Thus, as with other psychological disorders, a
number of substance use theorists have tried to integrate the variables identified by each of the models.
Once again, developmental psychopathology theorists have been active in this effort.

According to this perspective, the road to substance use disorders often begins with genetically
inherited predispositions — predispositions characterized by a less-than-optimal reward circuit in the
brain and by a problematic temperament featuring some of the negative traits discussed earlier in this
chapter. Developmental psychopathologists suggest that such predispositions will eventually result in a
substance use disorder if the individual further experiences numerous stressors throughout childhood,
inadequate parenting (such as substance misuse modeling), satisfying substance use experiences,
relationships with peers who use drugs, and/or significant adult stressors (Waddell et al., 2020; Farnicka
& Bettin, 2019; Zucker et al., 2016). At the same time, individuals who experience manageable
adversities throughout childhood and adolescence can develop a level of resilience that may help
counter such unfavorable predispositions, stressors, and negative family and peer influences
(Rothenberg et al., 2019).

In short, the developmental psychopathology perspective provides a framework for understanding why
the factors discussed in this chapter sometimes lead to substance use disorders and sometimes do not.
But the perspective also does more than this: it offers an explanation for seeming contradictions in the
substance abuse research literature. Recall, for example, our earlier discussion of substance abuse
personalities (see page 340). As you read, a variety of personality traits have been linked to substance
use disorders — dependency, antisocial inclinations, impulsivity, novelty seeking, risk taking, and
depressive functioning — but different studies have tied different such traits to the disorders. These
findings are not conflicting at all, according to developmental psychopathology theorists.

The theorists propose that either of two very different temperaments may set the stage for later
substance abuse. On the one hand, some individuals may begin with a disinhibited temperament, also
called an externalizing temperament — featuring impulsivity, aggressiveness, overactivity, limited
persistence, low frustration tolerance, and inattention (Cicchetti & Handley, 2019; Zucker et al., 2016).
Such individuals have great difficulty controlling their behaviors, thus increasing their risk of having early
family conflicts, behavioral problems, and school difficulties — variables that may, in turn, lead to social
problems, relationships with undesirable peers, rewards from those peers for repeated drug use, and,
ultimately, the onset of substance use disorders. Studies have confirmed that this cluster and sequence
of variables do indeed precede many cases of substance use disorder (Cicchetti & Handley, 2019;
Chassin et al., 2016).(pg344)
On the other hand, according to the developmental psychopathology perspective, other individuals may
begin with a temperament of inhibition and negative affectivity, sometimes called an internalizing
temperament — characterized by multiple fears, depression, negative thinking, and dependence. This
temperament may contribute to worrying and sadness throughout the individuals’ development, low
self-concept, a sense of helplessness, and interpersonal rejections. These individuals may eventually
turn to alcohol and drugs largely because the substances reduce their emotional pain, quiet their
troublesome thoughts, and help them through interpersonal difficulties (see Figure 11-5). Studies have
indicated that this cluster and sequence of variables may also lead to substance use disorders (Cicchetti
& Handley, 2019; Chassin et al., 2016).(pg 345)