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Rethinking Substance Abuse: What the Science Shows and What We Should Do About It

David F. Rubenstein, Psy.D., M.S.W.

This is an exciting new book that seeks to solve a problem that has generally plagued the substance abuse field; that is, understanding what the research says about substance abuse and treatment and how we understand this in terms of application to clinical practice. This book is unusual and useful in its accessibility to both the substance-abuse research and clinical audience. The information provided by editors within this book comes from the results of a "think-tank" the authors attended at the Conference on Approaches for Combating the Troublesome Use of Substances (CACTUS) in 2004.

The authors have attempted to make the presentation of information in this book much smoother by dispensing with the presence of ongoing scientific citation, relying on senior-scientist peer critique and revision of the material at this meeting to ensure accuracy. The authors were asked to "set aside... brand-name treatments and familiar service models and systems and to refrain from making specific recommendations for interventions," allowing the readers to "draw their own conclusions."

What results from this collection of effort is a series of 18 chapters, broken up into five categories: 1) defining substance abuse; 2) understanding biological factors that contribute to addiction; 3) psychological factors present in addiction; 4) social and environmental contexts for understanding addiction; and 5) substance-abuse interventions. At the end of each chapter, there is a succinct set of emerging critical questions and answers, a set of "robust principles," and a wealth of academic resources.

In their introduction, Carroll and Miller correctly point out the wide disparity between substance-abuse research and practice, and describe the impact of dwindling systemic financial resources for treatment and the ongoing stigmatization of this population. They illustrate the importance of understanding the individual, biological, and social context as critical to the understanding of the behavior of substance abuse. Moreover, they are able to explain that our understanding of the manifestation and recovery from substance abuse in one individual may be completely different in another individual and that it is the understanding of the context in which the substance abuse occurs that is the key to successful treatment.

This book reviews various knowledge approaches in the neurobiology of addiction, focusing on brain changes through the addiction cycle, how we understand genetic contributions, and what the latest advancements in brain imaging can tell us. A clear picture is given of specific substances of abuse, the processes of reinforcement and addiction, and which neurotransmitter systems and areas of the brain are involved. A presentation of how brain imaging can help us to understand addiction simplifies an otherwise complex process. Also addressed are the genetic vulnerabilities during different periods of individual development, environmental interaction, prevention, and treatment implications. The discussion on genetic factors is particularly clear; it begins with a review of terminology to help the reader understand the concepts of genetic research, and then presents a review of adoption studies and twin studies, followed by a discussion of the genes involved in the metabolism of substances and the neuronal pathways that affect substance-related behaviors.

The editors present a review of psychological factors involved in addiction and an insightful discussion of how and why some individuals develop substance abuse or dependence whereas others do not. Ethnicity, culture, gender, developmental issues, social stigma, and psychological factors are also all discussed in helping the reader to gain a fuller picture. The "self-change" process is reviewed in terms of understanding how some people are able to embark more successfully on recovery over time. The role of family is also explored in terms of its influence on addiction and in the treatment and recovery process. Also examined are gender differences, ethnicity, and the impact of secular trends and birth-cohort effects. Social factors such as friends, family, peer group, work, and neighborhoods are also explored more fully as factors that can exacerbate or protect against substance use/abuse. Epidemiology of the comorbidity between substance abuse and mental illness and their effect on each other are also reviewed. Theories that attempt to explain the reasons behind their increased comorbidity are explained and categorized into four clear models and associated empirical findings.

The authors also categorize the development of treatment approaches for dual diagnosis into two separate models: 1) the integrated treatment approach; and 2) a quadrant model (categorizing patients with co-occurring disorders and their respective treatment by the severity of each disorder into quadrants). Empirical evidence of elements within both models are reviewed. Also included is a discussion of how we understand comorbidity during adolescence. The phenomenon and role of motivation in substance abuse and recovery is explored in some detail. Interpersonal factors and facilitation of the change process are discussed, along with other "contextual" factors. On the other hand, processes that do not influence motivation for change and that have been used for years in the treatment field are also presented. Factors that do appear to positively affect motivation for change are also described.

Finally, this text discusses interventions and puts forth "fundamental processes" of addiction and then discusses treatment and dissemination within that framework in the hope that this would increase dissemination into clinical practice. They do this by identifying a set of "core principles" for changing behavior and identification of "key skills" that can be conveyed to clinicians. Pharmacotherapies aimed at treating substance abuse are also reviewed, with major substances of abuse and current treatment approaches and their efficacy identified, along with new pharmacotherapies currently being investigated. The text does a nice job of illustrating the role and elements of efficacy of religion and spirituality in the recovery process and the protective elements of prevention they can have. The editors close by bringing the intent of this book full circle, to begin a process of bringing the science to bear more directly on practice by outlining 10 principles of understanding substance-abuse behavior and, given these principles, 10 recommendations to effectively translate the science into practice.

FOOTNOTES

 
David Rubenstein, Psy.D., M.S.W., is Clinical Director of the Institute for Addictive Disorders and Clinical Associate Professor of Psychiatry and Psychology, Drexel University College of Medicine, Philadelphia, PA.

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