Substance Use Problems

2 The Biopsychosocial Model of Drug Problems (p. 21-22)

Etiological work on substance-related problems can inform treatment in helpful ways. It has generated prevention and intervention efforts that address issues as large as international policy and as small as pharmacotherapies that focus on individual neurotransmitter systems. Theories of drug problems have a long history, beginning with conceptualizations that relied on evil spirits, moral weakness, and complex intrapsychic conditions that proved impossible to measure. Many early theories emphasized a particular domain of contributors to the exclusion of others, making them inadequate in their account of problems. A myopic, restricted focus on any one dimension, whether spiritual, medical, psychological, or societal, led to missing important aspects of problems. Treatments based on these theories invariably neglected aspects of the person and failed to improve associated problems. An alternative approach designed to encompass more of the potential contributors to drug problems developed in an effort to account for the multifaceted nature of human experience – the biopsychosocial model (Mosey, 1974; Skewes & Gonzalez, 2013).

The predominant model of drug problems attempts to incorporate findings from disparate literatures ranging from the cellular to the societal. These efforts to explain substance use and related problems have interesting implications for prevention and treatment, and advantages over previous work that focused exclusively on single domains. The heterogeneity of drug-related disorders makes constructing an all-encompassing model quite challenging. The different interacting biological, psychological, and social contributors can be easier to understand in light of different stages of drug use (see Figure 2). Different facets of each contributor can have a different effect on each of these stages and the transition from one stage to the next.

One way to view stages of drug use begins with no use and extends to problematic use as well as treatment outcome. The vast majority of people begin life with little exposure to drugs. A subset of those initiate drug use depending upon various factors. A group of those people continues subsequent use of drugs. A subset of this group then develops problems. A handful of these people receive treatment, with a variety of outcomes. The transitions from no use to problematic use to treatment outcome each rest on different kinds and degrees of biological, psychological, and social variables.

2.1 Interacting Components As the name suggests, the biopsychosocial model rests on potentially heritable physiological components. Some research suggests that substance use disorders can run in families, and twin studies support a contribution of genetics (Agrawal & Lynskey, 2008; Hicks et al., 2007). The heritable component might include genes that contribute to out-of-the-ordinary neurotransmitter function, drug metabolism, or sensitivity to stimuli. These qualities alone need not be deficits; in fact, they may provide distinct advantages in certain settings. Inheriting a novel desire for adventure or a tendency to avoid harm might prove adaptive in some environments but lead to drug problems in others (Advokat et al., 2014). Because substance-related disorders are among a handful in the DSM-5 that require something outside of the individual (in this case, drugs) for the diagnosis, the psychological, social, and societal components can prove particularly important. Currently, there is no research to support that a single gene or biological factor predicts the future occurrence of drug problems (Buckland, 2008). In addition, some situations might lead to drug problems regardless of an individual’s biological makeup such as familial and behavioral factors. Repeated exposure to some drugs, particularly the opiates, almost invariably leads to small increases in tolerance and withdrawal regardless of physiological variation among people. Diagnosable symptoms only arise as a result of a combination of these physiological, psychological, and social factors.