Dr. Brensilver with a few thoughts on self-medicating...The idea that people initially seek drugs and then continue to abuse drugs to ward off painful feelings is frequently expressed within the addiction treatment community. People often speak of substances as an attempt to numb the pain of underlying emotional issues. The ‘self-medication hypothesis’ has had scientific proponents. In his 1985 article in The American Journal of Psychiatry, Ed Khantzian famously suggested that people abuse drugs as a way of blunting their particular brand of psychological pain. He hypothesized that individuals with narcotic addiction use the substance - at least initially - to effectively ‘treat’ their feelings of aggression while cocaine relieves mood problems. It is often noted that people who become addicted typically do have elevated levels of negative feeling and it is undeniable that intoxication temporarily alleviates acute emotional pain. Thus, it makes some intuitive sense to identify self-medication as the root cause of addiction. This conceptualization is the foundation for many treatment communities.
Despite the intuitive appeal of the self-medication hypothesis, several lines of evidence challenge this explanation. If self-medication is the primary cause of initial and persistent drug use, successful treatment of the negative affect should improve the situation. In fact, this has been the rationale for many experiments testing medications to treat addiction. For a range of pharmacological rationales, various anti-depressant and mood-stabilizing medications have been tested as candidate treatments for addiction. Although they have sometimes alleviated depressive symptoms of addicted people, they have largely failed to deliver even modest gains in terms of drug abstinence. This suggests that simply addressing background mood problems is ineffective in solving the problem of addiction. Second, a substantial proportion of people addicted to drugs initially exhibit no mood or anxiety disorder symptoms. This evidence is inconsistent with the notion that drug use is invariably an attempt to treat psychiatric symptoms. Third, the idea that people choose a particular drug because it addresses a specific kind of emotional pain is generally unsupported by research. The genetic and environmental risk factors that make a person more likely to initially use a drug or later become addicted are probably non-specific. What does ‘non-specific’ mean in this context? It means that a person’s risk for becoming dependent on heroin, for example, places them at higher risk for dependence on all other drugs. That is, there doesn’t seem to be an individual profile that places an individual at risk for one substance, while not placing them at risk for a range of other substances. While people may develop a favorite drug, the available evidence does not support the notion that drugs are used to target specific emotional symptoms. Fourth, the self-medication hypothesis posits the following conceptual framework: mood problems → drug abuse, but the reverse (drug abuse → mood problems) is more likely. George Koob, an addiction scientist at The Scripps Research Institute, formulated a model of substance use based on three phases: anticipation/preoccupation (concerned with getting the drug); intoxication (positive effects while using the drug) and withdrawal and negative affect (coming down off the drug). Over a period of repeated use, the brain adapts to the neural bombardment effected by drugs of abuse. In the brain’s attempt to maintain balance, a series of neurobiological changes take place and the third part of the cycle – the compulsion to relieve the withdrawal and negative affect – becomes predominant. These changes may lead to a state much like depression. Mood symptoms are common as people first establish abstinence. Thus, while the self-medication hypothesis is thus generally unsupported by the scientific evidence, this does not mean that there is no evidence exist for it. Rather, a reasonable conclusion is that its causal role in addiction is not critically important.
Why then, is the self-medication hypothesis so often invoked? This is just a speculation, but it seems to me like the self-medication explanation makes people feel less shame about addiction. Among the various explanations of addiction, this one seems to truly help people feel better about themselves as a person. And feeling less shame about addiction is definitely a worthy goal and probably important for treatment. I hope that whatever the causes of addiction, they are never a cause for shame.
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Tags: causes of addiction, matthew brensilver, self-medication, shame
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