Course Articles

This text-based course is an edited transcript of a live webinar, presented by Benjamin Ampel, MA, PhD candidate.

Introduction

The landscape of substance use disorders is complex, marked by a myriad of contributing factors that range from genetic predispositions to environmental influences. Among these, individual personality traits emerge as a critical dimension, offering profound insights into why certain individuals may be more susceptible to substance abuse, how their patterns of use might differ, and what therapeutic approaches could prove most effective. This article delves into the fascinating intersection of personality and substance use, providing a comprehensive overview of the theoretical frameworks and empirical evidence that illuminate these pathways. The primary focus will be on understanding how personality forms and influences behavior, identifying key personality traits linked to substance abuse, and predicting treatment outcomes of substance abuse based on personality.

The journey into understanding personality begins with a fundamental distinction between temperament and personality. Temperament, often considered the biological foundation, refers to the innate, genetically influenced behavioral and emotional patterns observable from early infancy. It is the raw material, the predispositions with which an individual is born. Personality, on the other hand, is the intricate tapestry woven when this biological temperament interacts with the environment—both the physical surroundings and the social milieu. It represents the consistent patterns of behavior that manifest across various situations and over time, shaping an individual's unique way of perceiving, thinking, and acting.

While the realm of personality is vast and multifaceted, this exploration will primarily center on the Big Five personality traits, a widely accepted and empirically supported model for describing human personality. Within this framework, particular emphasis will be placed on the dimensions of extraversion and introversion, given their significant and often counterintuitive implications for substance use. Furthermore, the discussion will extend to the Behavioral Inhibition System (BIS) and Behavioral Activation System (BAS), two neurobiological systems that offer a deeper understanding of approach and avoidance motivations, which are profoundly relevant to addictive behaviors. By integrating insights from these models, this article aims to provide a nuanced perspective on how personality shapes the trajectory of substance use disorders and how this understanding can inform more targeted and effective clinical interventions.

Disclosures

Presenter Disclosure: Financial disclosures: Benjamin Ampel received an honorarium for presenting this course. Benjamin Ampel has published peer-reviewed articles on emotional regulation and personality, along with understanding the relationship between goal pursuit, self-regulation, and emotional regulation. Non-financial disclosures: Benjamin Ampel has no relevant non-financial relationships to disclose. Content Disclosure: This learning event does not focus exclusively on any specific product or service. Sponsor Disclosure: There is no external sponsor for this course.

Limitations and Risks

Personality is complex and multifaceted this webinar is not inclusive of all personality traits and factors that impact substance use. Practitioners should actively engage in supervision and self-reflection in an effort to reduce biased clinical judgments or reduced empathy for clients due to linking certain personality traits to substance abuse. Practitioners should practice culturally humility and utilize, and/or incorporate culturally responsive frameworks into practice.

Substance Use Disorders and Personality Overview

To begin, it is essential to establish a clear understanding of what constitutes a substance use disorder (SUD). According to the DSM-5 criteria, a diagnosis of SUD is based on a maladaptive pattern of substance use leading to significant impairment or distress. This pattern is manifested by at least two of the following criteria occurring within a 12-month period. The severity of the disorder is determined by the number of criteria met.

The DSM-5 outlines four main domains of criteria for SUD:

1. Impaired Control: This domain encompasses behaviors that indicate a loss of control over substance use. Examples include taking the substance in larger amounts or over longer periods than originally intended, a persistent desire or unsuccessful efforts to cut down or control substance use, spending a great deal of time obtaining, using, or recovering from the substance's effects, and experiencing a strong craving or desire to use the substance. These indicators reflect a diminished capacity to regulate one's own consumption, even in the face of intentions to reduce or cease use.
2. Social Impairment: This domain highlights the negative impact of substance use on an individual's social and occupational functioning. Criteria include a recurrent failure to fulfill major role obligations at work, school, or home due to substance use. It also involves continued substance use despite persistent social or interpersonal problems that are caused or worsened by the effects of the substance. Furthermore, giving up or reducing important social, occupational, or recreational activities because of substance use falls under this category, indicating a narrowing of interests and a prioritization of substance use over other life domains.
3. Risky Use: This domain pertains to the use of substances in situations that pose physical hazards or despite awareness of negative consequences. It includes recurrent substance use in physically hazardous situations, such as driving under the influence or operating machinery while intoxicated. It also involves continued substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or worsened by the substance. This criterion underscores a disregard for one's own well-being in favor of continued substance use.
4. Pharmacological Criteria: These criteria relate to the physiological adaptations that occur with repeated substance use. Tolerance is a key indicator, characterized by a need for markedly increased amounts of the substance to achieve intoxication or the desired effect, or a markedly diminished effect with continued use of the same amount of the substance. Withdrawal is the other criterion, involving the development of a substance-specific syndrome due to the cessation of or reduction in substance use, or taking the substance (or a closely related substance) to relieve or avoid withdrawal symptoms. These physiological markers often signify a more entrenched pattern of dependence.

Understanding these diagnostic criteria provides a foundational context for exploring how personality intersects with substance use. As previously mentioned, personality is not merely an inherent trait but a dynamic construct shaped by the interplay of an individual's biological temperament and their environmental experiences. Temperament, the bedrock of personality, refers to the constitutionally based individual differences in emotional, motor, and attentional reactivity and self-regulation. These innate predispositions, evident even in infancy, influence how an individual interacts with and responds to their environment. For instance, some infants may exhibit high reactivity to novel stimuli, while others may be more subdued. These early differences can lay the groundwork for later personality traits, such as introversion or extraversion.

When this biological temperament consistently interacts with the physical and social environments over time, it solidifies into what we recognize as personality. This means that while an individual may be born with a certain predisposition, their experiences—their upbringing, social interactions, cultural context, and significant life events—all contribute to the refinement and expression of their personality traits. For example, a child with a naturally reactive temperament might, in a supportive and nurturing environment, develop coping mechanisms that lead to a resilient personality. Conversely, in a chaotic or unsupportive environment, the same temperament might manifest as heightened anxiety or withdrawal. Therefore, when examining the "personality pathways to substance abuse," it is crucial to consider this interplay, recognizing that both innate predispositions and learned behaviors contribute to an individual's vulnerability and their journey with substance use.

The Essential Trait Approach: The Big 5

To comprehend the profound influence of personality on substance use, it is imperative to first understand the prevailing framework for conceptualizing personality: the essential trait approach, which led to the development of the Big Five personality traits. The essential trait approach represents a scientific quest for a concise yet comprehensively predictive list of traits that can account for the broadest range of human behaviors. The core requirements for such a list are succinctness and non-redundancy, meaning each trait must be independent and contribute unique predictive power without overlapping significantly with others. The goal is to identify a parsimonious set of fundamental dimensions that can describe the vast complexity of human individual differences.

Given the immense vocabulary humans possess to describe personality across virtually every language and culture, a natural starting point for this quest was language itself. This led to the "lexical approach" to essential traits. The lexical hypothesis posits that the most important individual differences in human transactions will eventually become encoded in the natural language. In other words, if a personality trait is truly significant, people will have developed words to describe it. Researchers employing this approach began by sifting through dictionaries and asking individuals to describe people they knew well, identifying adjectives commonly used to characterize personality.

A seminal study illustrating this approach involved 1,300 raters who were given a list of 60 commonly used adjectives for describing people. Each rater was asked to think of a person they knew well and underline the adjectives they might use in a conversational description of that person. By analyzing which words were frequently used and which clustered together, researchers observed recurring patterns. For instance, while "bashful" and "bold" are antonyms, they both clearly describe aspects of the same underlying personality dimension. This systematic analysis of everyday language revealed that despite the seemingly endless array of descriptive terms, a finite set of core dimensions consistently emerged. This empirical process ultimately led to the identification of the Big Five personality traits, often remembered by the acronym OCEAN: Openness to Experience, Conscientiousness, Extraversion, Agreeableness, and Neuroticism.

Let us briefly delineate each of these Big Five traits and their general implications, before delving into their specific connections to substance use:

1. Openness to Experience: This trait, sometimes referred to as intellect or culture, describes an individual's receptiveness to new ideas, experiences, and unconventional thinking. People high in openness are often characterized as original, daring, independent, and artistic. They possess a broad range of interests, are imaginative, and enjoy intellectual pursuits. Conversely, individuals low in openness tend to be more conventional, practical, and prefer routine. Interestingly, openness to experience has been linked to substance use, particularly with hallucinogenic substances. Research has even suggested that the consumption of certain psychedelics, such as psilocybin, can temporarily or even enduringly increase an individual's score on openness to experience. One study, for example, found that participants who took psilocybin mushrooms scored higher in openness to experience six months later compared to a control group.
2. Conscientiousness: This trait encompasses an individual's motivation to achieve goals and their discipline in pursuing them. It reflects a tendency to be organized, persistent, and planful. Individuals high in conscientiousness are typically careful, self-reliant, scrupulous, and goal-directed. They are often seen as responsible and hardworking. While conscientiousness might intuitively appear to be a protective factor against substance use due to its association with self-control and adherence to norms, its relationship is more nuanced. Paradoxically, highly conscientious individuals, when faced with significant professional setbacks, such as job loss, tend to experience more profound negative emotional responses, including increased depression, anxiety, and reduced life satisfaction. This heightened vulnerability to stress can, in some cases, lead to the development of maladaptive coping mechanisms, including substance use, as a means to manage intense emotional distress.
3. Extraversion/Introversion: This dimension describes the degree to which an individual is outgoing and derives energy from social interaction. Extraverts are typically talkative, friendly, spontaneous, and bold, seeking frequent interactions with others and often desiring dominance or leadership roles in groups. Introverts, conversely, are described as quiet, aloof, inhibited, or timid, preferring solitude and finding social interaction energetically draining. This trait is particularly central to the discussion of substance abuse, as it profoundly influences drug preferences and responsiveness to various therapeutic modalities. The intricate biological underpinnings of this dimension, particularly in relation to cortical arousal, will be explored in greater detail.
4. Agreeableness: This trait reflects an individual's tendency towards nurturance, emotional supportiveness, and a desire to maintain harmonious relationships. Agreeable individuals are often described as good-natured, helpful, trusting, and lenient. They tend to inhibit negative emotions for the sake of others and prioritize interpersonal harmony. Conversely, individuals low in agreeableness may be more competitive, skeptical, and less concerned with others' feelings. While not as directly linked to specific drug preferences as extraversion or neuroticism, agreeableness can influence an individual's social environment and their susceptibility to peer influence, which are significant factors in substance use initiation and maintenance.
5. Neuroticism/Emotional Stability: This trait represents an individual's tendency to experience negative emotions. Individuals high in neuroticism are often described as worrying, emotional, insecure, and jealous. They are prone to experiencing anxiety, depression, anger, and other distressing emotions. Conversely, individuals low in neuroticism, or high in emotional stability, are characterized as calm, unemotional, secure, and not easily perturbed. Neuroticism is a well-established risk factor for various mental health conditions, including substance use disorders, as individuals may turn to substances as a means of self-medication to alleviate intense emotional distress. The strong link between negative affect and substance use makes neuroticism a critical personality pathway to explore.

Each of these Big Five traits, in its own intricate way, contributes to an individual's unique vulnerability and trajectory concerning substance use disorders. While some traits may appear to be protective, their interaction with life events and other personality dimensions can create complex risk profiles. This foundational understanding of the Big Five sets the stage for a more focused examination of extraversion and introversion, and the underlying biological mechanisms that drive their distinct relationships with substance use.

Extraversion and Introversion: The Big Five

Extraversion and introversion constitute a fundamental dimension within the Big Five personality framework, yet their complexities often extend beyond common understanding. This trait is not merely about being outgoing or reserved; it delves into the very source of an individual's energy and their optimal level of environmental stimulation. When discussing extraversion and introversion, it is crucial to recognize that these are relative terms, describing an individual's position on a continuum compared to others. The majority of people, approximately 66%, fall within one standard deviation of the mean, exhibiting a blend of both introverted and extraverted tendencies. This middle ground is often referred to as "ambiversion." Ambiverts are not simply neutral; they possess the capacity to draw energy from both social interaction and solitude, adapting their behavior based on the situation. They might enjoy a lively party but also value quiet time for reflection, demonstrating a flexible mix of tendencies. However, for the purpose of understanding the more pronounced effects on substance use, focusing on the extreme ends of this spectrum—the highly introverted and highly extraverted individuals—provides clearer insights.

The concepts of introversion and extraversion were originally coined by Carl Jung and later popularized by Hans Eysenck, who proposed a strong biological basis for these differences. Eysenck's theory posited that introverts and extraverts differ in their baseline levels of cortical arousal, which influences how they restore energy. Introverts, as the prefix "intro" suggests, seek to restore their energy by pulling inward, into themselves. Social interactions, especially prolonged or intense ones, are energetically draining for them, leading to fatigue. They recharge in solitude, in environments with lower external stimulation. Conversely, extraverts, deriving their name from the prefix "extra," restore their energy by reaching outside of themselves, through social interaction and engagement with the external world. They find solitude and a lack of external stimulus to be draining and even boring, which depletes their energy. This fundamental difference in energy restoration is a cornerstone for understanding their distinct behavioral patterns.

As a direct consequence of these differing energy restoration mechanisms, introverts and extraverts exhibit notable differences in sociality, as articulated by Carver and Scheier (2016). Extraverts are inherently more likely to seek out social interactions. They are often drawn to group settings and tend to seek dominance within these groups, frequently assuming leadership roles. Furthermore, and for reasons that are biologically complex, extraverts tend to experience positive emotions more frequently in general. This propensity for positive affect can further reinforce their pursuit of stimulating social environments. For an individual to gauge their own position on this spectrum, a simple self-reflection can be illustrative: consider how you feel after leaving a large social gathering. An extravert might feel energized and even seek further social engagement, while an introvert might feel depleted and crave quiet time alone to recharge. This visceral experience reflects the underlying biological differences in how their brains process and react to external stimuli.

The distinction between introversion and extraversion extends beyond social preferences, manifesting in various aspects of life, including drug preference, communication styles, choice of workplace, and approaches to relationships. These differences are rooted in varying optimal levels of stimulation. Eysenck's arousal theory, further supported by research from Bullock and Gilliland (1993), suggests that introverts have chronically higher levels of cortical arousal, meaning their brains are naturally more active even in low-stimulus environments. In contrast, extraverts have chronically lower levels of cortical arousal, leading them to seek out more external stimulation to reach their optimal arousal level.

Consider a spectrum of stimulation, ranging from low (e.g., lying still in a dark, quiet room) to high (e.g., being yelled at by an angry mob). For an introvert, their optimal level of stimuli might be a quiet conversation with a familiar acquaintance. This level of interaction provides sufficient stimulation without overwhelming their already highly aroused nervous system. For an extravert, however, this same quiet conversation might be understimulating, leading them to seek out environments with louder music, more people, or more intense interactions to reach their preferred level of cortical arousal. Both introverts and extraverts are ultimately seeking an optimal level of brain activity, but they require different amounts of external stimulation to achieve it. An introvert's brain lights up more in response to the same stimulus compared to an extravert's brain. This means that a loud party, which might be exhilarating for an extravert, could be profoundly overwhelming and draining for an introvert, as their neural activity spikes significantly in response to the high sensory input. This fundamental difference in how their brains process and react to stimuli explains their divergent preferences and behaviors across various life domains.

Affect and Arousal

Before delving deeper into the biological underpinnings of personality and its connection to substance use, it is important to clarify two key terms: affect and arousal.

Affect: In psychology, affect refers to an emotion or feeling. It is the experience of emotion, such as joy, sadness, anger, fear, or interest. Affect is a subjective experience, but it can be expressed through observable behaviors, facial expressions, and physiological changes. When discussing personality, affect often refers to an individual's general emotional disposition or their tendency to experience certain types of emotions more frequently.

Arousal: Arousal refers to the level of physiological activation in the body and brain. It is a state of being awake, alert, and responsive to stimuli. Physiologically, arousal is reflected in various bodily responses, including heart rate, blood pressure, breathing rate, and neural activity in the brain. High arousal signifies a state of alertness and readiness for action, while low arousal indicates a state of relaxation or sleepiness. In the context of introversion and extraversion, arousal specifically refers to cortical arousal, or the level of activity in the brain's cerebral cortex. Understanding these terms is crucial for grasping the biological mechanisms that differentiate personality types and influence their interactions with substances.

Introversion-Extraversion: Biological Basis 

The profound differences observed between introverts and extraverts in their preferred levels of stimulation, energy restoration, and social engagement are not merely psychological constructs; they are rooted in distinct biological mechanisms. A compelling perspective on this biological basis comes from Desmond Morris's (1969) concept of the "stimulus struggle," drawing parallels from the animal kingdom. Morris categorized species into specialists and opportunists. Specialists thrive by having a highly efficient, specialized method for obtaining food, which reduces their need to explore diverse environments. Opportunists, conversely, have evolved to specialize in exploration, requiring high levels of environmental stimulation to thrive. Morris posited that humans, as opportunistic animals, also engage in a "stimulus struggle," seeking an optimal balance—not too much, but not too little—of stimulation. This inherent variability in the need for stimulation among humans, Morris suggested, manifests as introversion and extraversion.

This idea aligns with the observation that introverts and extraverts have chronically different levels of cortical arousal in response to stimuli. As previously noted, introverts exhibit higher baseline cortical arousal, meaning their brains are more active even in quiet environments. Consequently, they require less external stimulation to reach their optimal arousal level and can easily become overstimulated. Conversely, extraverts have lower baseline cortical arousal, necessitating more external stimulation to achieve their desired level of brain activity. This difference in preferred stimulus level explains their divergent choices in environments and activities, as both types are ultimately striving for a similar, comfortable level of cortical arousal. For instance, an introvert's brain might experience significant neural activity from a quiet conversation, while an extravert might need the intensity of a loud party to achieve the same level of internal "buzz."

Empirical evidence supports these physiological distinctions. Gray (1970) demonstrated that introverts show an increased brain-stem auditory evoked response (B.A.E.R.) to startling noises. In studies where participants were exposed to static noises of varying decibel levels, introverts consistently exhibited a stronger neural response—more neurons firing—to the same sound intensity compared to extraverts. This means that a car door slamming, or loud music at a party, literally causes more brain activity and a greater sense of overwhelm for an introvert. This heightened reactivity explains why introverts find high-stimulus environments more challenging and why they prefer quieter settings where their brains are not constantly bombarded by excessive sensory input.

The key neurological structure implicated in regulating cortical arousal is the Ascending Reticular Activation System (ARAS). The ARAS is a network of neurons located in the brainstem that connects the cerebral cortex to the rest of the brain. Often referred to as the "ignition system" of the brain, the ARAS is responsible for regulating overall arousal, wakefulness, and the filtering of sensory information. Damage to the ARAS can result in severe states of reduced consciousness, such as a coma, underscoring its critical role in maintaining alertness and responsiveness. The ARAS also plays a vital role in filtering out extraneous sensory information, allowing individuals to focus on relevant stimuli. For example, the constant tactile sensation of clothing on one's skin is typically filtered out by the ARAS, preventing sensory overload. Furthermore, the ARAS regulates sleep and wakefulness, with lower neuronal firing rates during sleep and higher activity levels during waking states. Its regulatory functions are mediated through various neurotransmitter systems, including GABAergic, adrenergic, and dopaminergic pathways, which influence neural activity and arousal levels.

In the context of introversion and extraversion, the ARAS functions differently. For introverts, their ARAS requires less stimulation to become overstimulated, leading to a rapid and significant increase in cortical arousal. This inherent sensitivity means that even moderate levels of external stimuli can quickly push an introvert's brain beyond its optimal arousal threshold, leading to feelings of being overwhelmed or drained. Conversely, extraverts require larger amounts of stimulation to activate their ARAS sufficiently, prompting them to actively seek out more stimulating environments and activities to achieve their desired level of cortical arousal. Recent research further supports this, showing that extraverts exhibit less brain activity in certain areas during memorization tasks and have lower resting brain activity when deprived of stimulation. This under-stimulation is a profoundly uncomfortable feeling for extraverts, driving their continuous pursuit of higher levels of external engagement.

This biological distinction profoundly influences various aspects of an individual's life. For instance, communication styles differ markedly. Extraverts tend to be more blunt, forceful, and prone to pushing social boundaries, such as using nicknames quickly or initiating physical touch, as these behaviors generate stimulating social feedback. Introverts, being chronically overstimulated, are more cautious and less inclined to engage in such boundary-pushing behaviors, as their brains are already working overtime. Workplace preferences also diverge; open-plan offices, designed for constant interaction and stimulation, are often ideal for extraverts but can be detrimental to introverts' cognitive functioning and memory due to sensory overload. Relationship approaches also reflect these differences, with extraverts often seeking broader social networks and introverts preferring deeper, more intimate connections.

Crucially, these biological differences in cortical arousal and ARAS functioning also impact drug preferences. Extraverts, with their chronically under-stimulated brains, tend to gravitate towards stimulants such as caffeine, cocaine, methamphetamine, and MDMA. These substances artificially increase neural firing and cortical arousal, helping extraverts achieve their desired level of internal stimulation. For them, a stimulant can make a quiet conversation feel more engaging or provide the "speed" they naturally crave. Conversely, introverts, who are often chronically overstimulated, tend to prefer depressants and anxiolytics. Substances like alcohol, benzodiazepines (e.g., Valium, clonazepam), and other GABAergic agonists literally slow down neural firing, reducing cortical arousal and helping introverts feel less overwhelmed, particularly in social environments. This allows them to function more comfortably in highly stimulating settings that might otherwise be unbearable. However, this preference also carries the risk of developing dependence on these substances to navigate everyday social interactions or to find solace in solitude, often leading to private and isolated patterns of substance use. Understanding this biological basis is paramount for developing targeted and effective interventions for substance use disorders, recognizing that different personality types may require distinct therapeutic approaches.

Extraversion & Substance Use

The inherent drive for stimulation in extraverted individuals creates distinct pathways to substance use, often mediated by social contexts and positive expectancies. Research consistently highlights several mechanisms through which extraversion is linked to substance abuse.

One significant mechanism is the social-amplification pathway. Extraverts are naturally drawn to social gatherings and environments that offer high levels of stimulation. These settings frequently involve alcohol and other substances, leading to increased exposure and opportunities for use. A longitudinal study of 1,200 first-year undergraduates, for example, found that high extraversion predicted earlier alcohol initiation and a greater number of drinking days throughout their freshman year (Geeraerts & Cooper, 2022). This suggests that the extravert's desire for social engagement and excitement places them in situations where substance use is prevalent, thereby amplifying their risk. Even though alcohol is a depressant, and extraverts generally prefer stimulants, the social context in which alcohol is consumed often provides the stimulating environment that extraverts seek. They are drawn to the party culture, the lively interactions, and the overall buzz of social events where alcohol is a common lubricant. This social aspect can override the physiological effects of alcohol as a depressant, making it appealing for its ability to facilitate social interaction and reduce social anxiety, particularly for extraverts who may also experience neurotic tendencies.

Another crucial mechanism is the positive-expectancy mechanism. Extraverts tend to hold stronger positive expectancies regarding the effects of alcohol and other substances. They anticipate that substance use will enhance their social experiences, increase pleasure, and reduce inhibitions, thereby facilitating the very social engagement they crave. A meta-analysis of 46 studies revealed that extraversion was significantly associated with stronger positive alcohol expectancies, and these expectancies fully mediated the frequency of heavy-episodic drinking (Kuntsche et al., 2021). This means that extraverts are more likely to believe that drinking will lead to desirable outcomes, which in turn drives their higher rates of consumption, particularly in binge drinking scenarios. The expectation of amplified positive social experiences fuels their engagement with substances.

Furthermore, there is a clear drug specificity linked to extraversion. Due to their chronically under-stimulated cortical arousal, extraverts exhibit a pronounced preference for stimulants. These substances, such as caffeine, cocaine, and methamphetamine, artificially increase neural activity, helping extraverts achieve their desired level of internal stimulation. A twin analysis, controlling for shared genetics, found that extraversion was uniquely linked to stimulant and cocaine use (Dash, Martin, & Slutske, 2023). This preference is not merely anecdotal; it is rooted in the biological drive to compensate for lower baseline brain activity. For an extravert, a stimulant can make an otherwise mundane situation feel more engaging and exciting, aligning with their inherent need for high levels of arousal. This explains why they might be more drawn to substances that "speed up" their internal experience, making social interactions and other activities feel more vibrant and stimulating.

It is also important to consider the interplay between extraversion and other personality traits, such as neuroticism. An individual can be a highly neurotic extravert, meaning they are outgoing and seek stimulation but also experience significant anxiety. In such cases, alcohol, despite being a depressant, can function as an anxiolytic, reducing their anxiety in social settings. This dual effect—providing social lubrication and anxiety reduction—can make alcohol particularly alluring, increasing the likelihood of binge drinking episodes. The combination of a desire for high stimulation and a need to manage anxiety can create a complex vulnerability profile for extraverted individuals.

Clinical & Treatment Implications for Extraversion

Understanding the unique characteristics of extraverted individuals has significant implications for tailoring effective clinical interventions for substance use disorders. Treatment strategies for extraverts should leverage their inherent social energy and desire for stimulation, while also addressing their specific vulnerabilities.

1. Leverage Social Energy: Extraverts thrive in environments that offer social interaction and engagement. Therefore, treatment approaches should actively incorporate group-based modalities. This includes group cognitive behavioral therapy (CBT), where the interactive nature of the setting can keep extraverts engaged and motivated. Peer-led recovery meetings, such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA), can be highly beneficial, as they provide a structured social environment and opportunities for connection. While AA generally works equally well for introverts and extraverts once engaged, extraverts may find the group dynamics and shared experiences particularly appealing, fostering a sense of belonging and accountability. Additionally, organizing "sober socials" or other pro-social, substance-free activities can provide extraverts with the stimulation and social connection they crave without the involvement of substances. These interactive activities can boost attendance and engagement in recovery programs.
2. Watch Party Culture and Protective Behavioral Strategies: Extraverts are often drawn to high-stimulation settings, such as parties, concerts, or sporting events, where substance use might be prevalent. Instead of advocating for complete avoidance of such environments, which may be unrealistic or unsustainable for some extraverts, it is crucial to teach protective behavioral strategies (PBS). These strategies aim to reduce the risks associated with substance use in high-stimulation settings. Examples include pacing drinks, alternating alcoholic beverages with water, setting limits on consumption, avoiding drinking games, and having a designated sober friend. For extraverts, who may get caught up in the excitement and social dynamics of these environments, learning how to navigate them safely is paramount to preventing binge drinking episodes.
3. Use Motivational Incentives: Extraverts are often driven by external rewards and recognition. Incorporating motivational incentives into treatment can significantly enhance their engagement and retention. This could involve public recognition boards for achieving sobriety milestones, offering leadership roles in after-care programs or peer support groups, or providing voucher incentives for adherence to treatment goals. Public acknowledgment and opportunities to lead can tap into an extravert's desire for dominance and social validation, keeping them motivated and invested in their recovery journey.
4. Address Relapse Triggers: For extraverts, common relapse triggers often include loneliness and boredom. When deprived of the external stimulation and social interaction they naturally crave, extraverts can experience significant discomfort and a strong urge to seek out substances as a means of alleviating this under-stimulation. Therefore, during early abstinence, it is critical to help extraverts schedule pro-social, substance-free activities. This proactive approach ensures that their need for engagement and connection is met through healthy outlets, reducing the likelihood of turning back to substances. Therapists should work with extraverted clients to identify and plan for periods of potential boredom or isolation, equipping them with a repertoire of alternative, stimulating activities.

While extraverts generally form rapport easily and are highly engaging in therapy, clinicians should be mindful of their potential for quick boredom. Therapy sessions, particularly those involving deep introspection or slow processing of emotions, might feel less stimulating than what an extravert is accustomed to. Therefore, therapists may need to employ more active, engaging techniques, incorporate varied activities, and maintain a dynamic pace to keep extraverted clients invested. The goal is to channel their natural drive for engagement and reward-seeking into the recovery process, transforming their inherent personality traits into assets for long-term sobriety.

Brain Asymmetry: Hemispheric Dominance and Personality

Beyond the broad dimensions of personality, a deeper understanding of individual differences can be found in the subtle yet significant variations in brain activity, particularly in the concept of brain asymmetry or hemispheric dominance. This area, however, has often been subject to popular misconceptions that warrant clarification. The notion of being "right-brained" (creative, emotional, holistic) versus "left-brained" (logical, verbal, analytical) is a sweeping generalization that lacks scientific accuracy. While certain functions, such as language production (e.g., Broca's area), are predominantly localized in one hemisphere, the brain functions as an integrated whole, with both hemispheres constantly communicating and collaborating. Therefore, it is crucial to distinguish scientific understanding from pop-psychology simplifications. This discussion will not delve into psychological interventions like Eye Movement Desensitization and Reprocessing (EMDR) or neurolinguistic programming, nor will it address outdated concepts of "masculine versus feminine hemispheres."

Instead, brain asymmetry, in a scientifically grounded context, refers to the quantifiable differences in activation levels between the right and left sides of the brain, typically measured through techniques like electroencephalography (EEG). This difference is often expressed as a numerical value: a negative number indicates higher activity on the left side of the brain, while a positive number indicates a higher degree of activity on the right side of the brain. These differences, even at rest, have been found to predict an individual's emotional disposition. Specifically, research has shown that individuals with greater right frontal EEG activity (positive asymmetry) tend to exhibit more pessimistic emotional dispositions. Conversely, those with greater left frontal EEG activity (negative asymmetry) are often characterized by more upbeat or optimistic emotional dispositions.

Further research has refined this understanding by examining brain asymmetry in response to emotional stimuli. When participants were exposed to films designed to elicit specific emotions, individuals with higher left hemisphere activity were more responsive to positive mood films, experiencing and expressing more positive affect. Conversely, those with higher right hemisphere activity showed greater responsiveness to negative mood films, indicating a heightened sensitivity to distressing emotions. This suggests that hemispheric dominance is not merely a static state but influences how individuals process and react to emotional information from their environment.

The initial understanding of total differences in hemispheric dominance was limited by the sensitivity of older EEG technology, which could not pinpoint specific brain regions with precision. However, advancements in neuroimaging have allowed researchers to describe these differences more accurately in terms of approach and avoidance emotional tendencies. This refined perspective posits that distinct neural circuits are responsible for motivating behavior towards desired outcomes (approach) and away from undesired ones (avoidance).

Specifically, left hemisphere activity is associated with approach behaviors and emotions. This includes emotions such as joy, interest, and even anger (when anger is directed towards overcoming an obstacle or achieving a goal). The left prefrontal cortex, in particular, is linked to the Behavioral Activation System (BAS), which drives individuals towards incentives and rewards.

In contrast, right hemisphere activity is associated with avoidance behaviors and emotions. This includes emotions such as distress, disgust, and fear, which motivate withdrawal from perceived threats or negative stimuli. The right prefrontal cortex is linked to the Behavioral Inhibition System (BIS), which is responsible for inhibiting behavior in the face of potential punishment or danger.

This shift in understanding from broad hemispheric dominance to specific approach and avoidance systems provides a more nuanced and clinically relevant framework for understanding how brain asymmetry influences personality and, by extension, vulnerability to substance use disorders. It highlights that emotional disposition is not simply about being generally "positive" or "negative," but rather about the relative strength of one's motivational systems for engaging with or withdrawing from the world.

BIS/BAS: Behavioral Activation System and Behavioral Inhibition System

The Behavioral Inhibition System (BIS) and the Behavioral Activation System (BAS) represent two fundamental neurobiological systems that underpin individual differences in motivation, emotion, and behavior, offering a powerful framework for understanding personality pathways to substance use. These systems, rooted in brain asymmetry, govern an individual's sensitivity to cues of punishment versus reward.

The Behavioral Inhibition System (BIS) is a neurological system in the brain that is primarily responsible for causing individuals to withdraw from undesirable stimuli or potential threats. It is associated with vigilance, anxiety, and a tendency to inhibit ongoing behavior in the face of punishment or non-reward. Individuals with a highly active BIS are more sensitive to cues of punishment and tend to experience emotions like distress, disgust, and fear. Self-reports of high BIS sensitivity are correlated with higher activity levels in the right frontal area of the brain, particularly the right prefrontal cortex. This system is thought to involve serotonin activity, which plays a role in modulating mood and anxiety. Greater BIS activity is characteristic of introversion, neuroticism, and low agreeableness, as these traits are often associated with caution, emotional reactivity to negative stimuli, and a tendency to avoid social conflict or perceived threats.

Conversely, the Behavioral Activation System (BAS) directs individuals toward certain desirable goals or incentives. It is responsible for approach emotions such as joy, interest, and even anger when it serves as a motivator to overcome obstacles. Individuals with a highly active BAS are more sensitive to cues of reward and tend to pursue goals vigorously. Self-reports of high BAS sensitivity are correlated with higher activity levels in the left frontal area of the brain, particularly the left prefrontal cortex. This system is strongly linked to dopamine activity, a neurotransmitter crucial for reward processing and motivation. Greater BAS activity is characteristic of extraversion and openness to experience, as these traits are associated with a drive for novelty, social engagement, and a general pursuit of positive experiences.

It is important to understand that BIS and BAS sensitivities are not mutually exclusive; an individual can be high in both, low in both, or high in one and low in the other. Temperament differences often emerge as a relative balance between positive affect/approach behaviors (BAS) and negative affect/inhibition behaviors (BIS).

• BAS sensitivity (Dornbach-Bender et al., 2020) magnifies an individual's reactions to positive events and correlates with higher self-reported positive affect. These individuals are highly responsive to rewards and are motivated by the anticipation of pleasure.
• BIS sensitivity (Lin et al., 2023) magnifies an individual's reactions to negative events and is strongly related to neuroticism. These individuals are highly responsive to potential punishments and are motivated by the avoidance of pain or negative outcomes.

The interplay of these systems can explain various psychological difficulties:

• Anxiety: Often indicative of an oversensitive BIS activity, where individuals are excessively vigilant to potential threats and prone to worry and avoidance behaviors.
• Depression: Can be associated with high BIS activity (increased sensitivity to negative experiences) coupled with weak BAS activity (reduced motivation to pursue rewards and experience pleasure).
• Antisocial personality: Often characterized by high BAS activity (strong drive for reward and sensation-seeking) combined with low BIS activity (weak responsiveness to punishment or negative consequences), leading to impulsive and reckless behaviors without sufficient inhibition.

Understanding the relative strengths of an individual's BIS and BAS provides a powerful lens through which to view their vulnerability to substance use disorders and to tailor interventions more effectively.

BIS/BAS and Substance-Use Disorders

The Behavioral Inhibition System (BIS) and Behavioral Activation System (BAS) framework provides a robust explanation for distinct pathways to substance use disorders, influencing drug preference, craving, and relapse patterns. The differential sensitivity to reward and punishment cues, mediated by these systems, plays a critical role in shaping an individual's relationship with substances.

High BAS (Reward Sensitivity): Individuals with a highly active BAS are inherently more sensitive to cues of reward and are driven by the pursuit of pleasure and positive experiences. This heightened reward sensitivity has been consistently linked to various aspects of substance use. Research indicates that high BAS is associated with earlier initiation of substance use, higher frequency of use, and greater polysubstance involvement (Loxton & Dawe, 2001; Keough & O’Connor, 2014). This is particularly true for stimulants and alcohol. Stimulants, by their very nature, directly activate the brain's reward pathways, providing the intense positive reinforcement that high BAS individuals crave. Alcohol, while a depressant, is often consumed in social, stimulating environments that offer immediate rewards (e.g., social connection, reduced inhibition), making it appealing to those driven by BAS.

Furthermore, a BAS-dominant profile strongly predicts stronger cue-induced craving and rapid reinstatement after abstinence (Franken & Muris, 2006). This means that individuals with a high BAS are more likely to experience intense cravings when exposed to environmental cues associated with substance use (e.g., seeing a bottle of alcohol, being in a place where they used to use). Their strong drive for reward makes them highly susceptible to these triggers, leading to a quicker return to substance use even after periods of abstinence. The anticipation of pleasure and the memory of past rewards associated with the substance exert a powerful pull, making sustained recovery challenging without targeted interventions.

High BIS (Punishment Sensitivity): Conversely, individuals with a highly active BIS are more sensitive to cues of punishment, threat, and negative emotional states. Their motivation is often driven by the desire to avoid pain, anxiety, or discomfort. This heightened punishment sensitivity influences their drug preference, leading them towards substances that dampen negative affect. High BIS sensitivity is associated with a preference for anxiolytic or depressant drugs, such as opioids and benzodiazepines (e.g., Valium, Xanax), and alcohol (Simons, Wills, & Gibbons, 2009). These substances provide a sense of calm, reduce anxiety, and alleviate emotional distress, offering a temporary escape from the discomfort associated with an overactive BIS. For these individuals, substance use is often a form of self-medication, a means to quiet an agitated internal state or to cope with overwhelming negative emotions.

Moreover, a BIS-dominant profile is strongly associated with relapse under stress or social threat, mediated by worry and avoidance coping (Keough & O’Connor, 2014). When faced with stressful situations, interpersonal conflicts, or perceived social threats, individuals with a high BIS are more likely to experience intense anxiety and engage in avoidance behaviors. Substance use becomes a readily available coping mechanism to escape these uncomfortable feelings, even if it leads to long-term negative consequences. The cycle of stress, anxiety, avoidance, and substance use can be particularly entrenched for BIS-dominant individuals, making stress management and anxiety-focused strategies crucial components of their treatment.

In summary, the BIS/BAS framework highlights that substance use is not a monolithic phenomenon but rather a multifaceted issue driven by distinct motivational pathways. High BAS individuals are drawn to substances for their rewarding, pleasure-enhancing effects, leading to a focus on approach-based motivations. High BIS individuals, on the other hand, are drawn to substances for their anxiety-reducing, pain-dampening effects, driven by avoidance motivations. Recognizing these differential sensitivities is paramount for clinicians to develop personalized and effective treatment strategies that address the unique underlying motivational drivers of each client's substance use disorder.

BIS/BAS-Informed Treatment Implications

The insights derived from the Behavioral Inhibition System (BIS) and Behavioral Activation System (BAS) framework offer invaluable guidance for tailoring treatment interventions for substance use disorders. By understanding a client's predominant motivational system—whether they are primarily driven by reward seeking (BAS) or punishment avoidance (BIS)—clinicians can design more effective and personalized therapeutic strategies.

For High BAS Clients (Reward Sensitivity):

High BAS clients, characterized by their strong drive for reward and sensitivity to incentives, respond best to approach-based interventions that emphasize immediate gains and positive reinforcement.

1. Contingency Management: This is a highly effective approach for high BAS individuals. It involves providing tangible rewards (e.g., vouchers, privileges) for desired behaviors, such as negative drug tests or attendance at treatment sessions. The immediate and consistent reinforcement directly taps into their reward-seeking motivation, making abstinence and treatment adherence more appealing.
2. Voucher Incentives: Similar to contingency management, voucher programs offer monetary or other valuable incentives that can be exchanged for goods or services. This provides a clear, tangible reward system that aligns with the BAS drive for positive outcomes.
3. Goal-Oriented Cognitive Behavioral Therapy (CBT): CBT approaches that frame abstinence as an immediate gain, focusing on the positive rewards of sobriety (e.g., improved health, better relationships, financial stability), are particularly effective. This involves helping clients identify and pursue new, healthy goals that provide a sense of accomplishment and reward, replacing the gratification previously sought from substances.
4. Tailoring Motivational Interviewing Frames: "Possible Selves" (BAS-focused): In motivational interviewing, clinicians can leverage the concept of "possible selves" to highlight a rewarding future self. For high BAS clients, this means emphasizing the "thriving sober self"—a future where they experience increased joy, success, social connection, and personal fulfillment as a direct result of abstinence. This positive vision taps into their intrinsic motivation for reward and achievement.
5. Integrating BIS/BAS Assessments: Utilizing assessments like the Carver-White scale at intake can provide valuable information about a client's BIS/BAS profile. This allows for improved treatment-matching and has been shown to predict treatment retention (Daughters et al., 2008). Knowing a client's motivational tendencies from the outset enables clinicians to select interventions that are most likely to resonate and be effective.

For High BIS Clients (Punishment Sensitivity):

High BIS clients, who are more sensitive to punishment and driven by the avoidance of negative emotional states (like anxiety), benefit most from anxiety-focused strategies that reduce punishment expectancy and provide effective coping mechanisms for distress.

1. Mindfulness: Mindfulness-based interventions, such as Mindfulness-Based Relapse Prevention (MBRP), are highly beneficial. These practices help clients develop a non-judgmental awareness of their internal experiences, including cravings and anxiety, without being overwhelmed by them. By observing thoughts and feelings without reacting impulsively, clients can reduce their reliance on substances as an avoidance strategy. Mindfulness helps to lower craving and improve emotional regulation, offering a quiet coping skill that aligns with an introvert's preference for less external stimulation.
2. Exposure Plus Relaxation: This therapeutic technique involves gradually exposing clients to anxiety-provoking situations or cues (e.g., places where they used to use, stressful social scenarios) while simultaneously teaching and practicing relaxation techniques. This helps to reduce the conditioned fear response and build tolerance to discomfort without resorting to substance use. It directly addresses the avoidance motivation characteristic of high BIS individuals.
3. Safety-Planning: Developing comprehensive safety plans helps high BIS clients identify potential triggers for anxiety and relapse and pre-plan concrete strategies to manage these situations without using substances. This reduces the uncertainty and perceived threat, thereby decreasing punishment expectancy and enhancing their sense of control.
4. Tailoring Motivational Interviewing Frames: "Possible Selves" (BIS-focused): For high BIS clients, motivational interviewing can emphasize the "feared future self" or a "rock-bottom" scenario. This approach leverages their avoidance motivation by highlighting the negative consequences of continued substance use (e.g., health deterioration, loss of relationships, financial ruin). By vividly contrasting their current struggles with a potentially worse future, clinicians can motivate clients to pursue abstinence as a means of avoiding these feared outcomes (Simons et al., 2009).
5. Individualized and Smaller Group Therapies: Introverts, who often characterize high BIS profiles, tend to have a slower alliance formation in therapy. Building rapport and disclosing intimate details can be highly stimulating and overwhelming for them. Therefore, one-on-one motivational interviews or cognitive behavioral therapy in small groups (rather than large ones) are often more effective. In larger groups, extraverts may dominate, causing introverts to withdraw and limit their disclosure, thereby hindering their therapeutic progress. The increased availability of telehealth services, particularly since the pandemic, has also proven beneficial for naturally introverted individuals, allowing them to engage in therapy from the comfort of their own environment, reducing external stimulation.

By integrating BIS/BAS assessments at intake and tailoring interventions accordingly, clinicians can significantly improve treatment-matching and predict retention rates. This personalized approach acknowledges the unique motivational landscape of each client, fostering greater engagement and ultimately leading to more successful and sustainable recovery outcomes.

Conclusion

The journey through the intricate pathways connecting personality to substance use disorders reveals a profound and multifaceted relationship. It underscores that vulnerability to addiction is not a monolithic phenomenon but rather a complex interplay of innate temperament, learned behaviors, and underlying neurobiological systems. By delving into the Big Five personality traits, with a particular focus on extraversion and introversion, and the Behavioral Inhibition System (BIS) and Behavioral Activation System (BAS) framework, this article has illuminated how individual differences shape drug preferences, patterns of use, and responsiveness to therapeutic interventions.

We have seen that personality, as the dynamic outcome of temperament interacting with environmental influences, provides a consistent lens through which to understand an individual's behavioral patterns across time and situations. The Big Five model—encompassing Openness to Experience, Conscientiousness, Extraversion, Agreeableness, and Neuroticism—offers a comprehensive yet succinct framework for categorizing these enduring traits. While each trait contributes uniquely to an individual's risk profile, the dimensions of extraversion and introversion stand out due to their direct links to cortical arousal and the pursuit or avoidance of stimulation.

The biological basis of introversion and extraversion, particularly the role of the Ascending Reticular Activation System (ARAS) in regulating cortical arousal, provides a compelling explanation for divergent preferences. Extraverts, with their chronically under-stimulated brains, gravitate towards stimulants and high-stimulation environments, seeking to elevate their arousal to an optimal level. Their social-amplification and positive-expectancy pathways often lead to earlier initiation and higher frequency of substance use, especially alcohol and stimulants, within social contexts. Conversely, introverts, with their chronically higher baseline arousal, prefer depressants and quieter environments, using substances to dampen overwhelming neural activity and cope with anxiety or social overstimulation.

The BIS/BAS framework further refines this understanding, distinguishing between approach-motivated (BAS) and avoidance-motivated (BIS) individuals. High BAS sensitivity predicts a preference for rewarding substances and a heightened risk of cue-induced craving and relapse driven by the pursuit of pleasure. High BIS sensitivity, on the other hand, is linked to a preference for anxiolytic substances and a greater susceptibility to relapse under stress, driven by the desire to alleviate discomfort and avoid negative emotions.

The clinical implications of this knowledge are profound. Recognizing a client's predominant personality traits and motivational systems allows for the tailoring of interventions, moving beyond a one-size-fits-all approach. For extraverted, high BAS clients, strategies that leverage their social energy, provide positive incentives, and teach protective behavioral strategies in stimulating environments are crucial. Group therapies, peer-led recovery, and goal-oriented CBT that frames abstinence as immediate gain can be highly effective. For introverted, high BIS clients, anxiety-focused strategies, mindfulness, exposure with relaxation, and safety planning are paramount. Individualized therapy or smaller group settings, where they feel less overwhelmed, are often more conducive to building rapport and facilitating disclosure. Tailoring motivational interviewing to emphasize either "thriving sober selves" (for BAS) or "feared future selves" (for BIS) can further enhance engagement.

Ultimately, integrating personality assessments and principles into substance abuse treatment fosters a more empathetic, nuanced, and effective approach. By understanding the unique internal landscape of each client—their inherent drives, sensitivities, and coping mechanisms—clinicians can develop personalized pathways to recovery that resonate with the individual, enhancing treatment retention and promoting long-term sobriety. This holistic perspective not only improves clinical outcomes but also deepens our appreciation for the rich tapestry of human diversity in the journey towards healing.

References

Avila, C., & Parcet, M. A. (2022). Reward and punishment sensitivity modulate response to anxiety-management training in substance-use disorder. Journal of Psychopharmacology, 26(2), 206–214. https://doi.org/10.1177/0269881111405365

Bullock, W. A., & Gilliland, K. (1993). Eysenck’s arousal theory of introversion–extraversion: A converging-measures investigation. Journal of Personality and Social Psychology, 64(1), 113–123. https://doi.org/10.1037/0022-3514.64.1.113

Carver, C. S., & Scheier, M. F. (2016). Perspectives on personality (8th ed.). Pearson.

Dash, G. F., Martin, N. G., & Slutske, W. S. (2023). Big Five personality traits and illicit drug use: Specificity in trait–drug associations. Psychology of Addictive Behaviors, 37(2), 318–330. https://doi.org/10.1037/adb0000793

Daughters, S. B., Lejuez, C. W., Strong, D. R., Brown, R. A., & Kahler, C. W. (2008). The role of reward sensitivity in the effectiveness of contingency management for smoking cessation. Journal of Consulting and Clinical Psychology, 76(5), 852–861. https://doi.org/10.1037/0022-006X.76.5.852

Dornbach-Bender, A., Ruggero, C. J., Smith, P., & Schuler, K. (2020). Association of behavioral activation system sensitivity to lower-level facets of positive affect in daily life. Personality and Individual Differences, 152, 109570. https://doi.org/10.1016/j.paid.2019.109570

Franken, I. H. A., & Muris, P. (2006). Gray’s impulsivity dimension and substance use: BIS/BAS personality characteristics and cannabis use in adolescents. Addictive Behaviors, 31(5), 849–854. https://doi.org/10.1016/j.addbeh.2005.06.012

Geeraerts, S. B., & Cooper, M. L. (2022). Extraversion and alcohol use in the first year of college: A daily-diary approach. Addictive Behaviors, 131, 107293. https://doi.org/10.1016/j.addbeh.2022.107293

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Keough, M. T., & O’Connor, R. M. (2014). Clarifying the role of worry in substance-use behaviors using the BIS/BAS framework. Addictive Behaviors, 39(9), 1391–1398. https://doi.org/10.1016/j.addbeh.2014.04.017

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Additional Current References

Please Note: The following resources have been included as additional resources associated with this topic area. These resources were not used by the presenter when creating this course.

Ayhan, C. H., Aktas, M. C., Aktaş, S., & Ali Tarakçi, A. S. (2025). The examination of the relationship between 5-factor personality traits and social anxiety among Iindividuals with alcohol and substance use disorders. Eastern Journal of Medicine, 30(1), 82–90. https://doi-org.ezproxy.uu.edu/10.5505/ejm.2025.98853

Forstmann, M., & Sagioglou, C. (2025). The content, consistency and accuracy of stereotypes about recreational users of various psychoactive substances. European Journal of Social Psychology, 1. https://doi-org.ezproxy.uu.edu/10.1002/ejsp.3162

Jain, T., Patriquin, M., & Sanches, M. (2025). Associations between big five personality dimensions and lifetime use of cannabis. American Journal on Addictions, 34(3), 322–326. https://doi-org.ezproxy.uu.edu/10.1111/ajad.13668

Martínez-Gabaldón, E., & Martínez-Pérez, J. E. (2025). Personality traits and drug use: A longitudinal study using data from the British Cohort Study. European Addiction Research, 30(6), 357–365. https://doi-org.ezproxy.uu.edu/10.1159/000541265

Sharifibastan, F., Erevik, E. K., Morken, K. T. E., & Pallesen, S. (2025). Associations between HEXACO personality traits, substance use disorders, and behavioral addictions: a protocol for a comprehensive systematic review and meta-analysis. Systematic Reviews, 14(1), 1–10. https://doi-org.ezproxy.uu.edu/10.1186/s13643-024-02741-8

This text-based course format is a transcript of a live webinar that was created by Continued and edited with AI assistance.

Learning Outcomes

After this course, participants will be able to:

1. Describe the characteristics and variance in the manifestation of autism.
2. Identify common co-occurring mental health conditions among individuals with autism.
3. Explain substance use and abuse realities relevant to individuals with autism.

Introduction

As the prevalence and diagnosis of autism spectrum disorder continues to increase, it is relevant to have an understanding of the multi-faceted nature of this condition. Individuals with autism have a high propensity to develop other co-occurring conditions that impact their lives and their overall quality of life. High rates of mental health conditions and substance use disorders have been found among individuals with autism. This course will provide a foundation of autism, discuss common co-occurring conditions, and explore substance use and abuse realities.

Substance Use Disorder

To set the stage for our discussion, it is important to understand Substance Use Disorder (SUD) from a diagnostic perspective. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) provides comprehensive criteria for SUD. It recognizes 10 separate classes of drugs and outlines 11 diagnostic criteria. The DSM-5-TR integrates the historical categories of substance abuse and dependence into a single disorder, Substance Use Disorder, with varying severity levels: mild, moderate, and severe.

The four main categories of criteria for SUD include:

1. Physical dependence
2. Risky use
3. Social problems
4. Impaired control

Examples of the 11 diagnostic criteria include: taking the substance in larger amounts or for longer than intended; not managing to do what one should at work, home, or school because of substance use; and needing more of the substance to achieve the desired effect, indicating tolerance. It is crucial to differentiate whether observed behaviors are primarily due to SUD, autism, or a combination of both, as this has significant implications for accurate diagnosis and tailored intervention.

Overview of Autism

Characteristics, Variance in the Manifestation, and Prevalence

Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by specific diagnostic criteria outlined in the DSM-5-TR. It is essential to note that these challenges are not better explained by an intellectual disability or global developmental delay.

Autism Spectrum Disorder Characteristics

The diagnostic criteria for ASD, according to the DSM-5-TR, include:

1. Social communication and social interaction deficits. These encompass challenges in expressive, receptive, and social language, making everyday communication and social nuances particularly confusing.
2. Restricted, repetitive behaviors, interests, or activities. This can manifest in various ways, from repetitive movements to intense, narrow interests, and adherence to routines.
3. Symptoms must be present in the early developmental period. Even if a diagnosis is received later in life, the symptoms must have been evident during early development, though they may have been masked or camouflaged.
4. Impairment in social, occupational, or other domains impacting current functioning. The symptoms must cause significant impairment across multiple contexts, such as school, work, relationships, and other functional areas of life.

The concept of "social camouflaging" or "masking" is particularly relevant. Individuals with autism may learn to blend in or hide their autistic traits in social situations, which can be incredibly exhausting and may lead to delayed or missed diagnoses. This ability to mask can make it difficult for others to recognize the underlying challenges, leading to a lack of appropriate support.

Points of Consideration

Understanding the variance in the manifestation of autism is paramount. As the saying goes, "If you've met one person with autism, you've met one person with autism." This highlights the unique ways ASD can present in individuals, making a one-size-fits-all approach to support and intervention ineffective.

Prevalence

The prevalence of autism has seen a significant increase over the past few decades. According to the Centers for Disease Control and Prevention (CDC), as of April 15, 2025, approximately 1 in 31 children in the United States are diagnosed with ASD. This marks a notable rise from previous estimates, such as 1 in 36 children in 2022 and 1 in 44 prior to that. While data on adults with autism is still developing, emerging literature suggests that the prevalence among adults may be even higher.

Broadening of Diagnostic Criteria, Greater Awareness, Screening in Part, Greater Identification

Several factors contribute to this increasing prevalence. The broadening of diagnostic criteria in the DSM, coupled with greater public awareness and increased screening efforts, has led to greater identification of individuals with ASD. Many individuals who historically went undiagnosed or were misdiagnosed with other conditions, such as depression or anxiety, are now receiving accurate autism diagnoses. Early and accurate diagnosis is crucial for accessing specialized treatment and support. Increased survival rates for preterm babies and various environmental factors also play a role in the rising numbers.

Diagnosis Ratio

Historically, findings exhibit a 3:1 male-to-female ratio, with many studies indicating a 4:1 ratio. However, it is important to consider that females with autism may be more adept at social camouflaging, leading to underdiagnosis in this population.

Autism and Co-Occurring Conditions

The presence of co-occurring conditions, or comorbidities, is a significant aspect of the autistic experience. Individuals with ASD often experience a higher likelihood of developing other mental and physical health challenges compared to the general population.

Common Co-Morbidities

Common co-occurring mental health conditions among individuals with autism include:

• Attention-deficit/Hyperactivity disorder (ADHD)
• Executive functioning challenges
• Anxiety disorders
• Depression
• Eating disorders, such as Anorexia and Avoidant/Restrictive Food Intake Disorder (ARFID). ARFID is a newer eating disorder characterized by highly selective eating or a general lack of interest in food, which can lead to poor growth and nutrition.

It is crucial to note that misdiagnosis with other conditions can be common, highlighting the need for thorough assessment and a nuanced understanding of how ASD presents alongside other challenges.

Possible Reasons for Co-morbidities

Several factors contribute to the high rates of comorbidities in individuals with ASD:

• Social isolation: A significant challenge, with recent reports indicating high rates of loneliness in the general population, which is often amplified for individuals with autism.
• Need to control one's own environment: This can manifest in behaviors resembling obsessive-compulsive disorder or various anxieties.
• Craving social inclusion, but challenges with obtaining it: Many individuals with autism desire social connection but struggle with the nuances of forming and maintaining friendships.
• Sensory challenges: Difficulties processing sensory input (e.g., tactile experiences, smells) can lead to distress and contribute to maladaptive coping mechanisms.
• Challenges across all settings: If daily life feels consistently difficult across work, school, and relationships, the likelihood of developing co-occurring conditions increases.
• Disrupted plans and routines: Unexpected changes can lead to significant distress and emotional dysregulation.

Other Considerations

Beyond mental health conditions, individuals with autism may face additional challenges throughout their lives, from childhood to adulthood, across various settings such as school, work, and relationships. These include:

• Bullying: Individuals with ASD are often targets of bullying due to their social differences.
• Safety issues: They are at an increased risk for abuse, exploitation, and neglect, partly due to challenges with social language, naivety, and trusting nature.

Autism and Substances

Substance Use and Abuse Realities

The intersection of autism and substance use is a critical area of study, revealing unique vulnerabilities and patterns of misuse within the autistic population.

Prevalence of Substance Misuse in Autism

The prevalence of Substance Use Disorder (SUD) in people with Autism Spectrum Disorder (ASD) appears to be higher than once considered. While previous data may have underestimated this, current research suggests a greater extent of use and misuse. Studies indicate a ranging prevalence of substance abuse in samples with ASD, from 1.3% to 36% (Ressel et al., 2020). Some research even suggests a double risk for individuals with ASD to develop an SUD compared to those without autism (Kunreuther, 2021). The variability in prevalence rates can be attributed to differences in sample characteristics and diagnostic measures across studies. It is important to note that assessment measures specifically designed to screen for substance abuse in individuals with ASD are often lacking, leading to limitations in establishing a general prevalence.

Common Substances Used

When data is collected regarding specific types of substances used, the following are commonly reported:

• Tobacco
• Alcohol
• Cannabis

A systematic review by Ressel et al. (2020) highlighted that while these substances are commonly used, studies often report varying rates of associated substance abuse. For instance, rates of alcohol use disorder (AUD) range from 1.3% to 16%, and cannabis use disorder rates are reported between 6.5% and 8% among ASD samples.

Considerations

Individuals with ASD might be less likely to self-report substance misuse, making accurate data collection challenging. Drug use is often reported as a means of self-medication. Studies indicate that individuals with ASD are nine times more likely to use recreational substances to manage behavior and are also more likely to use them to manage mental health symptoms (Weir et al., 2021). This suggests that substance use can be a maladaptive coping mechanism for the unique challenges faced by autistic individuals, such as social difficulties, sensory overload, and emotional dysregulation. The visual of a backpack, for instance, can symbolize the hidden struggles and the search for relief that individuals might undertake, sometimes leading to the exploration of substances. The image of a solitary figure contemplating a landscape can evoke feelings of disconnection, while a group of individuals embracing at sunset can represent the crucial need for community and belonging, especially in the context of recovery.

Risk and Protective Factors

Understanding the specific risk and protective factors for individuals with ASD is crucial, as they may differ from those in the general population.

Risk and Protective Factors for General Population May Differ for Those with ASD

Factors that may be more common among those with ASD and contribute to increased risk include:

• Fewer social resources: This can encompass a lack of belonging, diminished social networks, and lower social capital.
• Less/lack of appropriate support and services: Inadequate access to tailored interventions can exacerbate vulnerabilities.
• Greater likelihood to experience physical and mental health conditions: The high comorbidity rates increase the overall burden on individuals.
• Difficulties with emotional regulation: Challenges in managing emotions can lead to maladaptive coping strategies, including substance use.
• Challenges with behavior management: Difficulties in self-regulation can contribute to impulsive behaviors related to substance use.

The image of a building with the question "HOW ARE YOU, REALLY?" painted on its side powerfully conveys the often-unseen struggles and the importance of truly understanding the internal experiences of individuals, particularly those with ASD who may mask their difficulties.

Risk Factors for SUD in ASD Population

Several factors specifically increase the risk of SUD in the ASD population:

• Comorbid externalizing disorders.
• Perceived social deficits.
• Psychological distress.

While some studies have found these factors to be statistically non-significant in isolation, the cumulative effect and the interplay of these elements are important. High autistic traits have been found in some studies to increase the risk for "high drug use" in adolescent populations with autism. However, conclusions regarding the direct association between substance abuse and autistic traits require cautious interpretation due to variations in study methodologies and sample sizes.

Environmental Risk Factors for Substance Use or Abuse

Ressel et al. (2020) identified six key environmental risk factors that increase the likelihood of developing substance abuse among individuals with ASD and ADHD:

1. Late ASD diagnosis: A delayed diagnosis can mean a prolonged period without appropriate support and understanding, increasing vulnerability.
2. Few social resources: Limited social connections and support networks can lead to isolation and a greater propensity for maladaptive coping.
3. Lack of structure: Unstructured environments can be particularly challenging for individuals with ASD who often thrive on routine and predictability.
4. Family history of SUD: This is a common risk factor across populations, but its impact can be amplified for individuals with ASD.
5. Early smoking onset: Initiating smoking at a young age is a known predictor of future substance use.
6. Family history of adversity: Adverse childhood experiences and other traumatic events within the family environment can significantly increase the risk for SUD.

Other Considerations for Possible Elevated Risk of SUD in ASD

Beyond environmental factors, several individual characteristics contribute to an elevated risk of SUD in individuals with ASD:

• Sensory challenges: Individuals with autism may engage in substance use to mitigate the impact of adverse sensory experiences, such as difficulties processing tactile input, under-responsiveness to sensory input, or challenges with processing smells. The image of headphones on a yellow background can symbolize the need for sensory regulation and the potential use of substances to achieve it.
• ADHD: The comorbidity of ADHD with ASD is common, and the associated challenges with executive functioning can increase vulnerability to SUD.
• Mood and/or anxiety disorders: These co-occurring mental health conditions are frequently self-medicated with substances.
• Individual cognitive characteristics:

• Perceived social deficits: Some individuals with autism report that substance use increases their confidence in social environments and eases communication, leading them to use substances to reduce social anxiety.
• High social motivation: Paradoxically, individuals with ASD who have a high desire for social interaction and high social interest (high reward dependence) may be more prone to SUDs if they struggle to achieve meaningful social connections naturally.
• Psychological distress: High levels of psychological distress are a significant precipitating factor for substance use and abuse in individuals with autism. The blurred image of the word "FOCUS" can represent the cognitive challenges and psychological distress that individuals with ASD may experience, leading them to seek relief through substances.
• Weak executive functioning: Deficits in executive functioning (e.g., planning, reasoning, problem-solving, self-management) can contribute to difficulties with self-management and increase the likelihood of using substances as a maladaptive coping mechanism. The prefrontal cortex, responsible for executive functions, is the last part of the brain to develop, and developmental delays in this area can be particularly challenging for individuals with ASD, especially when compounded by other comorbidities.

Other Vulnerability Factors

Additional factors that increase the risk of substance use among people with autism include:

• Childhood use of drugs: Early initiation of drug use is a strong predictor of future SUD.
• Being coerced or tricked into drug use: Individuals with developmental disabilities may be more susceptible to coercion due to traits such as naivety, trusting nature, and difficulties in discerning intentions. Augmenting skills to reduce this vulnerability is crucial.
• Trauma: Adverse childhood experiences and other traumatic events can significantly increase the risk for SUD. The impact of trauma on individuals with autism can be unique and requires specialized understanding and intervention.

Demographics to Consider

Research on the intersection of disability, opioid misuse, and suicidality provides important demographic considerations. A study by Marsack-Topolewski and Chan (2024) on a sample of people with disabilities (not exclusively autism) revealed:

"Results indicated NMPOU [non-medical prescription opioid misuse] was associated with higher odds for serious thoughts of suicide. Having a disability was associated with higher odds for having a plan for suicide and having a suicide attempt. Adolescents with disabilities who engaged in NMPOU had over three times the likelihood for serious thoughts of suicide. Social work services can be tailored for adolescents with disabilities within the context of the family unit to address the impact of the opioid epidemic using a disability-oriented framework." (Marsack-Topolewski & Chan, p. 1, 2024).

Further analysis using the National Survey for Drug Use and Health (NSDUH) by Chan and Marsack-Topolewski (2023) examined the effect of opioid misuse and disability on serious thoughts of suicide, having a suicide plan, and making a suicide attempt. The findings indicated that NMPOU was associated with 37% higher odds for having a suicide plan and 73% higher odds for having a suicide plan over the last year. Opioid misuse is suggested to be a significant risk factor for suicide, and individuals with disabilities are found to be at greater risk. These studies underscore the critical need for targeted interventions and support for adolescents with disabilities, including those with ASD, who are at heightened risk for both substance misuse and suicidality.

Protective Factors

While the risks are significant, it is equally important to identify and leverage protective factors that can decrease the risk of substance use and abuse among individuals with ASD.

• Individual personality: Traits such as low sensation-seeking tendencies can serve as a protective factor.
• Environmental factors: Limited access to drugs significantly reduces the opportunity for substance use.
• Specialized interventions: Tailored support and treatment approaches can build resilience and reduce vulnerabilities.

However, it is also noted that among a clinical sample of adolescents with ASD, there was a higher prevalence of smoking and over four times the risk of illicit drug use, highlighting the complexities in this population.

Clinical Implications: Assessment, Diagnosis, Treatment

Targeted Screening and Diagnosis

A critical clinical implication is the need for targeted screening and diagnosis for both SUD and mental health conditions, particularly in adolescents with ASD. Current screening methods and tools may not be adequately geared to capture these phenomena in the autistic population, leading to undiagnosed cases. Screening should be provided and meticulously aligned with the unique needs and presentation of individuals with ASD. Many individuals with co-occurring ASD and SUD remain undiagnosed, underscoring the urgency for improved assessment practices.

Treatment (SUD and Mental Health Conditions)

• Targeted prevention: Proactive measures are essential to prevent the onset of SUD in individuals with ASD.
• Tailored approach for treatment: A "one-size-fits-all" approach is ineffective. Cognitive Behavioral Therapy (CBT), when tailored to the needs of individuals with ASD, has shown promising results.
• Group CBT: Studies have indicated that group CBT, specifically designed for patients with ASD and co-occurring SUD, yielded positive outcomes (Walhout et al., 2022). This intervention led to lower levels of alcohol use, less passive coping styles, reduced depression, decreased anxiety, and less stress. Notably, a three-month follow-up after the group intervention showed even stronger effects, suggesting the benefit of sustained support. This highlights the potential for specialized and tailored interventions to be highly efficacious for this specific population.

Considerations for Substance-Use Services

Substance use services must be designed to account for the unique needs of individuals with ASD and their co-occurring substance use challenges. Many individuals with ASD who seek substance use services also experience high rates of anxiety (87%), depression (75%), and ADHD, with chronic pain also being commonly reported (Munday et al., 2025). The reasons for substance use vary, often including self-medication for anxiety, depression, sensory challenges, or to enhance social confidence and communication.

Therefore, there is a clear need for personalized, inclusive, and neuro-affirming care. This involves:

• Trauma-informed approaches: Recognizing and addressing the impact of past traumas, which are prevalent in the ASD population.
• Neuro-affirming environments: Providing quiet spaces free of sensory stressors, which can be highly beneficial for individuals with sensory sensitivities.
• Individualized and tailored communication: Adapting communication styles to suit the specific needs of the individual, recognizing that social masking can be exhausting and may hide underlying difficulties.
• Understanding social masking: Professionals must be aware that individuals with ASD may acutely blend in or mask their characteristics in social situations, leading to exhaustion and withdrawal afterward. This masking can contribute to delayed diagnoses and a lack of understanding of their true needs.
• Managing co-occurring conditions: Treatment plans must integrate support for all co-occurring mental and physical health conditions, as they are often intertwined with substance use.

Studies by Marsack-Topolewski and Weiss (2020) and Munday et al. (2025) have highlighted significant access issues and barriers to substance use services for adults with autism, including challenges related to accommodation, acceptability, availability, and affordability. These findings underscore the importance of professional development for practitioners in substance use supportive spaces to ensure that services are trauma-informed, neuro-affirming, tailored, and specific to individuals with ASD who are dealing with SUDs.

Complexities in Supporting Care Recipients, their Families, and Providers

Supporting individuals with ASD who are experiencing substance misuse challenges involves navigating significant complexities, balancing multiple viewpoints and perspectives. This includes:

• Balancing viewpoints and perspectives: Ensuring that all voices are heard, including those of the person with SUD, their family, and care providers.
• Safety is key: Prioritizing the safety and well-being of the individual throughout the treatment and recovery process.
• Dreams for now and the future: Helping individuals and their families envision realistic and achievable goals for their present and future.
• Limited supports: Acknowledging that formal and informal supports can be limited due to factors such as waitlists and costs. Leveraging relevant formal supports and emphasizing the importance of robust informal support networks and community engagement (to reduce social isolation and loneliness) is crucial.
• Changing and evolving needs: Recognizing that the needs of the person with SUD, as well as paid and unpaid care providers, will change over time, requiring flexible and adaptive support strategies.

Multi-pronged Approach

Moving forward, a multi-pronged approach is necessary to address the complex interplay of autism, co-occurring challenges, and substance misuse. Key areas of focus include:

• Awareness: Increasing understanding among the general public, healthcare professionals, educators, and families about the unique vulnerabilities and needs of individuals with ASD regarding substance use.
• Prevention: Developing and implementing targeted prevention strategies that consider the specific risk factors and protective factors for the autistic population.
• Treatment: Enhancing access to and the quality of specialized, neuro-affirming treatment options for SUDs in individuals with ASD. This includes leveraging interventions like group CBT and ensuring services are trauma-informed and individualized.
• Support for the person with SUD: Providing comprehensive support that addresses not only substance use but also underlying mental health conditions, sensory challenges, and social difficulties.
• Support for family and caregivers: Recognizing the vital role of families and caregivers and providing them with resources, education, and emotional support.
• Professional development: Ensuring that professionals across various disciplines receive ongoing training and education to understand the intricate relationships among autism, co-occurring challenges, and substance misuse.
• Understanding the relationship: Continuing research to deepen our understanding of these complex interconnections to inform evidence-based practices.

The image depicting Naloxone (Narcan) nasal spray and Zimhi (naloxone HCl injection) serves as a stark reminder of the opioid crisis and the importance of overdose prevention and response, highlighting a critical aspect of substance misuse realities.

Treatment and Services

Effective treatment and services for individuals with ASD and SUD require a comprehensive and integrated approach. Key components include:

• Hotline support: Providing immediate access to crisis lines and helplines for guidance and support.
• Recovery support: Offering ongoing support systems to aid in long-term recovery, including peer support groups and community-based programs.
• Treatment options: Ensuring a range of evidence-based treatment modalities are available, tailored to the individual's needs and preferences.
• Education, advocacy, community, family support: Empowering individuals and their families through education, advocating for their rights and needs, fostering a sense of community, and strengthening family support systems.

Treatment Directions

The direction of treatment should prioritize personalized, inclusive, and neuro-affirming care, recognizing the unique presentation of ASD and its comorbidities.

Supporting Clients in Building and Maintaining Relationships

Community and social connection are often missing pieces for individuals with ASD, yet they are vital for well-being and recovery. Supporting clients in building and maintaining relationships involves:

• Connecting with local support groups (e.g., through SAMHSA's Find Support services).
• Seeking out local activities, events, and faith communities that align with their interests.
• Connecting with online informational groups for peer support and shared experiences.
• Making time for existing friendships and relationships.
• Reinforcing the message: "Remember – you are not alone!"

The image of multiple hands reaching out to touch a tree trunk powerfully symbolizes the importance of connection, support, and the collective strength found in community.

Remind and Help Clients and Consumers Know that They are Not Alone

Emphasizing that individuals are not alone in their struggles is a powerful message that can foster hope and encourage help-seeking behaviors. Resources such as SAMHSA's support group locator and information on group therapy for substance abuse can be invaluable tools for clients and their families.

Resources

A wealth of organizational resources is available to support individuals, families, and professionals in addressing autism, mental health, and substance misuse.

Organizational Resources – Opioid Prevention and Misuse

• Centers for Disease Control (CDC) Opioid Overdose: Offers an overdose prevention and response toolkit.
• CDC – Overdose Prevention Resources: Provides a variety of communication resources for overdose prevention.
• CDC – Health Care Provider Toolkits: Includes toolkits specifically for healthcare providers, such as the Naloxone Toolkit.
• Rural Community Toolbox: A valuable resource for rural communities, particularly concerning opioid prevention and misuse.
• SAMHSA Opioid Prevention Toolkit: Another comprehensive toolkit for overdose prevention and response.
• State of Michigan Opioid Resources: Provides diverse resources, including access to the "Michigan Safer Opioid Prescribing Toolkit."
• Wyoming Prevention Depot: Offers resources on opioid risk and protective factors.
• National Helplines: Many states offer helplines, in addition to the national helpline: 1-800-662-4357.

Organizational Resources – Support

• Mental Health America: A leading community-based nonprofit dedicated to addressing the needs of those living with mental illness.
• NAADAC: The Association for Addiction Professionals: Provides education, clinical training, and advocacy for addiction professionals.
• National Institute on Alcohol Abuse and Alcoholism (NIAAA): Offers publications and resources on treatment for alcohol problems.
• National Institute on Drug Abuse (NIDA): Provides scientific information on drug abuse and addiction.
• National Institute on Mental Health (NIMH): The lead federal agency for research on mental disorders.

Resources

• SAMHSA Buprenorphine Practitioner Locator: Helps locate practitioners who can provide buprenorphine for opioid use disorder.
• SAMHSA Find Help: A comprehensive tool to find treatment services.
• SAMHSA Opioid Treatment Program Directory: Provides a directory of opioid treatment programs.

Organizational Resources

Note - Links are subject to change.

• Substance Abuse and Mental Health Services Administration (SAMHSA):
• Website: https://www.samhsa.gov/
• SAMHSA’s National Hotline: 1-800-662-HELP (4357)
• Substance Abuse and Mental Health Services Administration (SAMHSA) – Find Treatment:
• Website: https://findtreatment.gov/

Supports

• 988 Lifeline:
  • 988 Suicide & Crisis Lifeline Website: https://988lifeline.org/
• National Helpline:
  • Treatment referral and information, 24/7
  • Website: https://findtreatment.gov/
  • 1-800-662-HELP

Online resources are available for practitioners working with specific populations, such as the Deaf and hard of hearing, to ensure that information and support are accessible and aligned with their unique needs.

Limitations and Risks

Substance use and abuse are complex and the coinciding needs for individuals with autism can be wide ranging. This webinar will not cover every aspect of these topics. Therefore, continued and additional training and education on this topic are recommended. Treatment and approaches to support individuals with autism experiencing substance misuse challenges do not coincide with a one-size-fits-all approach. Practitioners should engage in cultural humility at all times and acknowledge cultural variations regarding substance use and abuse, as well as treatment. Adequate support often require a multi-disciplinary team to ensure comprehensive treatment.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Anderson, S. A. R., & Catallozzi, M. (2021). Autism spectrum disorder and the risk of substance use disorder: A call for targeted screening and prevention in adolescents. JAMA Pediatrics, 175(2), e205376. https://doi.org/10.1001/jamapediatrics.2020.5376

Barber, W., Aslan, B., Meynen, T., Marsden, J., Chamberlain, S. R., Paleri, V., & Sinclair, J. M. A. (2025). Alcohol use among populations with autism spectrum disorder: narrative systematic review. BJPsych Open, 11(1), 1–15. https://doi-org.ezproxy.uu.edu/10.1192/bjo.2024.824

Beck, J. S., Lundwall, R. A., Gabrielsen, T., Cox, J. C., & South, M. (2020). Looking good but feeling bad: “Camouflaging” behaviors and mental health in women with autistic traits. Autism, 24(4), 809–821. https://doi.org/10.1177/1362361320912147

Brede, J., Babb, C., Jones, C., Elliott, M., Zanker, C., Tchanturia, K., ... & Mandy, W. (2020). “For me, the anorexia is just a symptom, and the cause is the autism”: Investigating restrictive eating disorders in autistic women. Journal of Autism and Developmental Disorders, 50, 4280–4296. https://doi.org/10.1007/s10803-020-04479-3

Centers for Disease Control and Prevention. (2025). Data and statistics on autism spectrum disorder. https://www.cdc.gov/autism/data-research/index.html

Chan, K. T., & Marsack-Topolewski, C. N. (2023). The association of opioid misuse and suicidality among people with disabilities. Substance Use & Misuse, 58(1), 1–10. https://doi.org/10.1080/10826084.2022.2125271

Çi̇çek, A. U., Arslan, S. C., Bozok, B. K., Çolak, S. A. S. M., Abanoz, E., & Ucuz, İ. (2025). The Prevalence of Comorbid Psychiatric Disorders in Children and Adolescents with Asperger Syndrome. Journal of Harran University Medical Faculty / Harran Üniversitesi Tıp Fakültesi Dergisi, 22(1), 132–140. https://doi-org.ezproxy.uu.edu/10.35440/hutfd.1564572

Dickter, C. L., Chang, I., Burk, J. A., & Bravo, A. J. (2025). Autistic traits, emotion regulation, social anxiety, drinking to cope, and problematic alcohol use: A cross-cultural examination among young adults from seven countries. Substance Use & Misuse, 60(5), 766–774. https://doi.org/10.1080/10826084.2024.2447435

Haasbroek, H., & Morojele, N. (2022). A systematic literature review on the relationship between autism spectrum disorder and substance use among adults and adolescents. Review Journal of Autism and Developmental Disorders, 9(1), 1–20. https://doi.org/10.1007/s40489-021-00242-1

Hrycko, A. J., & Sinderbrand, M. (2025). Inpatient hospitalization of adolescents diagnosed with autism spectrum disorder: An ethical analysis. American Journal of Bioethics, 1–7. https://doi-org.ezproxy.uu.edu/10.1080/15265161.2025.2497989

Jadav, N., & Bal, V. H. (2022). Associations between co‐occurring conditions and age of autism diagnosis: Implications for mental health training and adult autism research. Autism Research, 15(11), 2112–2125. https://doi.org/10.1002/aur.2808

Kunreuther, E. (2021). Autism spectrum disorder and substance use disorder: A dual diagnosis hiding in plain sight. Psychiatric Clinics, 44(1), 35–49. https://doi.org/10.1016/j.psc.2020.11.004

Latif, F., Bajwa, S., Ashraf, R., Malik, S., Dogar, F. A., & Anjum, A. (2025). Unveiling the impact of neurodevelopmental disabilities on intra-family dynamics: A phenomenological exploration. Professional Medical Journal, 32(1), 84–93. https://doi-org.ezproxy.uu.edu/10.29309/TPMJ/2025.32.01.8342

Loomes, R., Hull, L., & Mandy, W. P. L. (2017). What is the male-to-female ratio in autism spectrum disorder? A systematic review and meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry, 56(6), 466–474. https://doi.org/10.1016/j.jaac.2017.03.013

Marsack-Topolewski, C. N., & Chan, K. T. (2024). The relationship of opioid misuse and suicidality among adolescents with disabilities. Families in Society, Advance online publication. https://doi.org/10.1177/1044389424122916

Munday, K., Papadopoulos, C., Adkin, T., & Gray-Hammond, D. (2025). Improving substance-use services for autistic adults: Insights and recommendations from autistic adults. Autism in Adulthood. Advance online publication. https://doi.org/10.1089/aut.2024.0213

Ressel, M., Thompson, B., Poulin, M. H., Normand, C. L., Fisher, M. H., Couture, G., & Iarocci, G. (2020). Systematic review of risk and protective factors associated with substance use and abuse in individuals with autism spectrum disorders. Autism, 24(4), 899–918. https://doi.org/10.1177/1362361320910963

Walhout, S. J., Zanten, J. V., DeFuentes-Merillas, L., Sonneborn, C. K., & Bosma, M. (2022). Patients with autism spectrum disorder and co-occurring substance use disorder: A clinical intervention study. Substance Abuse: Research and Treatment, 16. https://doi.org/10.1177/11782218221085599

Weir, E., Allison, C., & Baron-Cohen, S. (2021). Understanding the substance use of autistic adolescents and adults: A mixed-methods approach. The Lancet Psychiatry, 8(8), 673–685. https://doi.org/10.1016/S2215-0366(21)00160-7

This text-based course is an edited transcript of the webinar, Drug Culture and the Culture of Recovery: A Sociological Perspective, presented by Sophie Nathenson, PhD on February 28. 2025.

Disclosures

• Presenter Disclosure: Financial: Dr. Sophie Nathenson, Ph.D, received an honorarium for presenting this course. Sophie Nathenson is the founder and Director of the Population Health Management BS Program and the Population Health Management Research Center at Oregon Tech. She is also the owner of Widespread Wellness Consulting, providing career mentorship and education for individuals and groups working on promoting social, physical, emotional, and mental well-being. Non-financial disclosures: Sophie Nathenson has no relevant non-financial relationships to disclose.

• Content Disclosure: This learning event does not focus exclusively on any specific product or service.

• Sponsor Disclosure: There is no external sponsor for this course.

Limitations & Risks

• Substance use is complex and multifaceted, and impacts each individual differently. Practitioners must recognize their biases and triggers, as well as the client's triggers, when working with SUD and recovery. 

• Recovery methods vary (12-step programs, harm reduction, medication-assisted treatment, etc.), and debates can arise between different ideological approaches; therefore, practitioners must identify the most appropriate method for each client.

• Drug and recovery culture intersect with healthcare, criminal justice, social services, and policy. This webinar will not comprehensively cover all these areas; therefore, additional training is encouraged.

• Practitioners should exercise cultural humility at all times and respect clients’ varying cultures and their cultural perceptions of substance use and recovery.

Learning Outcomes 

After this course, participants will be able to:

1. Describe the concept of drug culture and recovery culture

2. Identify four ways that culture can impact substance abuse

3. Explain how understanding drug culture can aid in substance abuse recovery

Introduction

Substance use disorder, a complex and multifaceted phenomenon, impacts individuals in diverse ways. While biological and psychological factors are often at the forefront of understanding and treatment, a crucial, yet sometimes overlooked, dimension is the sociological perspective. This article, drawing from the insights of medical sociology, aims to illuminate the profound influence of culture on both drug use and the journey of recovery. By shifting the lens from individual pathology to broader societal dynamics, we can gain a more comprehensive understanding that enhances therapeutic alliances, informs assessment strategies, and ultimately fosters more effective interventions.

The presentation of this material is rooted in a medical sociological framework, which examines the intricate relationship between health and society. Unlike approaches that primarily focus on individual biological or psychological predispositions, medical sociology investigates health outcomes at the population level. This involves tracing health issues back to their societal and community origins. This perspective does not negate the importance of individual factors, but rather integrates them within a multifactorial understanding, acknowledging the interplay of psychology, biology, and even spirituality. The central tenet is that societal structures, cultural norms, and environmental contexts significantly shape individual experiences with health and illness, including substance use and recovery.

The concept of socialization, the lifelong process through which individuals acquire the norms, values, behaviors, and social skills appropriate to their society, is fundamental to this sociological view. We learn how to act in society through various agents of socialization, including family, friends, educational institutions, workplaces, and media. Culture, defined as the shared way of life of a particular group of people, encompasses their values, beliefs, and material expressions. When considering drug use, it becomes imperative to analyze how these social and cultural environments influence individual behaviors and perceptions.

Treatment and intervention strategies, whether in therapy, counseling, medical care, or educational settings, tend to achieve greater success when the cultural and social environment of the individual is taken into account. Individuals, upon returning to their pre-treatment environments, often face significant challenges in sustaining their recovery if those environments remain unchanged or unaddressed. Therefore, a holistic approach necessitates an understanding of the broader social fabric that envelops the individual's experience.

Sociological Perspective

The sociological perspective offers a macro-level view, focusing on society as the big picture. This approach contrasts with micro-level analyses that delve into individual differences in biology or psychology. Instead, it examines social factors such as age, gender, sexuality, and socioeconomic status (SES), which is a composite measure encompassing income level, wealth, and occupation. By comparing groups based on these social categories, sociologists analyze patterns and outcomes, such as rates of drug use. It is crucial to emphasize that this group-level analysis does not imply homogeneity among individuals within a social category. Rather, it highlights the statistical tendencies and broader societal influences that may contribute to certain health behaviors.

For instance, within medical sociology, the focus is consistently on health outcomes and behaviors. The sociological perspective posits that treatment, therapy, counseling, medical care, or education becomes more successful when the cultural and social environment is explicitly considered. Individuals, after receiving care, return to their existing environments. If these environments remain unaddressed, maintaining the successes achieved in treatment can become a significant challenge. This underscores the need for interventions that extend beyond the individual to encompass their social and cultural contexts.

Social Factors in Drug Use

A range of social factors demonstrably correlates with higher rates of drug use at the group level, though these are not deterministic for any single individual. Poverty and lower socioeconomic status, for example, are consistently associated with increased drug use. It is also observed that different types of drugs may be patterned by social class, indicating a nuanced relationship between economic standing and substance choice.

Social alienation or rejection represents another significant predictor at the group level. A lack of meaningful social connection or experiences of ostracization can contribute to vulnerability to drug use. Similarly, low academic achievement, particularly when viewed as a societal pattern rather than an individual failing, is linked to higher rates of substance use. The prevalence of crime and violence within a neighborhood or at a broader societal level also serves as a social determinant of drug use.

Levels of low religiosity are predictive of drug use, suggesting that spiritual or communal affiliations may offer protective factors. Furthermore, the strength of an individual's social connections, encompassing not only their immediate social networks but also their involvement in community organizations, plays a crucial role. Greater involvement in such groups tends to correlate with an increased capacity to resist negative peer pressure and make choices aligned with personal well-being. Conversely, weak social support and isolation are significant risk factors.

Experiencing homelessness presents a particularly acute example of environmental influence. Individuals experiencing homelessness are exposed to numerous elements that can drive drug use, including the need for warmth, safety, and a means of staying awake to avoid danger. Drugs can also become a primary avenue for social interaction and connection in such circumstances.

Adverse childhood experiences (ACEs) represent a powerful set of social factors. These include witnessing abuse, experiencing abuse as a child, or living with a family member who has a substance use disorder. Research consistently demonstrates that a higher number of ACEs significantly increases an individual's risk of initiating drug use and developing addiction. The impact of ACEs extends beyond immediate behavioral responses; these experiences can fundamentally alter brain development and genetic expression. This highlights how social factors and the social environment are not merely external influences but can profoundly reshape an individual's neurobiology and genetic predispositions, further linking them to drug use and addiction. This intricate connection underscores the deep physiological impact of social adversity.

Culture

Culture, the central theme of this discussion, is broadly defined as a way of life shared by a group. This encompasses three primary components: values, beliefs, and material culture. Values represent what a group deems important, guiding their priorities and actions. Beliefs are what a group considers true, forming their understanding of the world and their place within it. Material culture, on the other hand, refers to the tangible aspects of a culture, ranging from clothing and food to objects and technologies. These elements collectively define the shared reality and practices of a cultural group.

Cultural Competency

The concept of cultural competency, typically associated with knowledge, communication, and connection with diverse populations, gains a critical new dimension when applied to drug culture. While existing literature and training often focus on factors like race and ethnicity, there is a notable gap in addressing drug culture as a distinct and powerful cultural influence. Cultural competency, in its essence, involves understanding cultural dynamics to benefit the therapeutic alliance. It does not require a practitioner to be an expert in every culture, which can, in fact, reinforce power differentials. Instead, a foundational awareness of the larger cultural issues affecting individuals can significantly enhance the therapeutic relationship.

Cultures exert a profound influence on the manifestation of various disorders, patterns of substance use, and the effectiveness of treatment-seeking behaviors. Drug cultures, in this context, are as potent and significant as traditional factors like race and ethnicity in shaping health disparities and influencing individual experiences. Recognizing this allows for a more nuanced approach to serving all individuals, irrespective of their backgrounds, philosophies, or the specific cultural contexts of their substance use.

Drug Cultures

Drug cultures are defined as a set of shared values, beliefs, customs, and rituals specific to the use of a particular substance. These cultures have a long and varied history, existing across different historical periods and geographical locations. Their characteristics vary significantly depending on the specific drug, the geographical setting, and various social factors. For instance, heroin use in one community might manifest a distinct cultural pattern compared to heroin use in another, or even among different racial or ethnic groups within the same location.

Like any culture, drug cultures possess a shared history that is transmitted through language. Language plays a crucial role in establishing and perpetuating cultural norms, ensuring their continuation across generations. Importantly, drug cultures provide significant value to their members. While the negative health, social, psychological, and biological impacts of drug use are widely recognized, it is equally vital to acknowledge the cultural benefits that can draw individuals into these communities. Understanding these benefits adds a critical layer to our perspective on an individual's drug use, moving beyond a purely harm-reduction or pathological framework to consider the contextual advantages perceived by users.

Drug Cultures Can Provide...

Drug cultures, often envisioned as groups of individuals regularly using a specific substance, offer a range of perceived benefits that extend beyond the pharmacological effects of the drug itself. These benefits are integral to the cultural fabric and contribute to the sustained engagement of members.

One primary offering is social support. Within a drug culture, individuals find a group and a shared identity. This identity can even be celebrated, particularly for those who experience social rejection or live in societies where their primary identity is stigmatized, discriminated against, or subjected to violence. For example, studies on gay men using specific drugs have highlighted the formation of communities and social activities where individuals feel a sense of belonging and access to connection, sometimes linked to sexual experiences. This communal aspect can be a powerful draw.

Certain drugs can also serve as a status symbol within specific contexts, contrasting with the societal stigma often associated with drug use. In neighborhoods or cities where conventional avenues for economic success and social mobility are severely restricted, drug cultures can offer an alternative career path. Individuals may enter networks where they can earn money through drug sales, gain status, and forge social connections that are otherwise unavailable.

Social and cultural activities are central to drug cultures, facilitating a significant socialization process. While some drug cultures can foster antisocial behavior or avoidance of intimacy, many provide opportunities for shared experiences and communal engagement. This socialization process is particularly potent for adolescents, who are already navigating identity formation, hormonal changes, and heightened anxieties. In an age dominated by social media and constant, dopamine-driven messaging, the allure of social connections and acceptance within a drug culture, coupled with the immediate gratification of substance use, can be immense. This highlights that drug use is not solely an individual choice but is deeply embedded within larger cultural phenomena (Kurtz, 2005).

Mass Culture

Mass culture, encompassing broader societal aspects such as music, politics, and media, significantly influences drug use. There exists a reflexive relationship where drug cultures can inspire new genres of music or become deeply intertwined with existing ones. Political ideologies and media messages also play a substantial role in shaping the cultural perceptions and norms surrounding specific drugs. For instance, the widespread promotion of alcohol in society often portrays it in a highly positive light, to the extent that it is frequently not even categorized as a drug, despite its potent and potentially destructive nature. This societal separation of "alcohol" from "drugs" reflects deeply ingrained cultural ideas, often influenced by economic interests.

Drug cultures frequently manifest as subcultures, and within these, countercultures can emerge that directly oppose mainstream values. These countercultures may reject materialism, capitalism, or conventional societal norms, offering an alternative path. The attraction to such a culture can, in fact, precede the actual initiation of drug use. If an individual resonates with a philosophy that prioritizes love and connection over material possessions, or seeks to disengage from societal pressures, and finds like-minded individuals within a culture where a particular drug is commonly used and socialized, this can serve as a powerful gateway. Subsequently, individuals may become susceptible to addiction, illustrating how cultural attraction can pave the way for substance use and dependence.

(Manning, 2013; Adlaf & Smart, 1997)

Culture of Addiction

The concept of the culture of addiction positions drug use within an informal social network characterized by specific group norms. These norms, which include prescribed patterns of perceiving, thinking, feeling, and behaving, actively promote and sustain excessive substance use. This framework emphasizes that addiction is not merely an individual's struggle with a substance, but a deeply embedded cultural phenomenon that reinforces and perpetuates problematic behaviors.

The role of a drug culture in addiction extends far beyond the substance itself. It creates an environment that is highly effective in reinforcing denial. For example, in a college subculture where binge drinking is normalized and perceived as a positive aspect of social life, individuals may struggle to recognize their own problematic alcohol use because it aligns with the prevailing group behavior. When "everyone is doing it," the idea of having an addiction becomes difficult to reconcile.

Furthermore, the influence of these cultures tends to strengthen over time, making it increasingly challenging for individuals to disengage. If an individual's identity is tightly intertwined with a drug culture, leaving it can mean severing ties with friends, and potentially even family, and abandoning a familiar lifestyle. This highlights the profound gravity of breaking away from such a deeply entrenched cultural affiliation.

The culture of addiction can manifest in different forms. An "enmeshed" individual's entire identity revolves around their drug use; they might constantly talk about it, wear clothing that signifies their affiliation, and define themselves primarily by their substance of choice. A "bicultural" individual lives in two distinct worlds, maintaining a separate professional or family life while engaging in substance use in a different social context. This separation allows for a degree of denial, as the individual may believe their addiction is contained and does not impact their "other" life. Finally, "acultural" addiction exists when there is no discernible group culture surrounding the substance use.

(White, 1996)

Acultural Addicts

Acultural addicts represent a distinct category within the spectrum of substance use, characterized by their use in isolation, often obtaining drugs through legitimate channels, and maintaining a strong association with mainstream culture. This form of addiction typically involves closeted use, where the individual's substance use is hidden from their social and professional circles.

A common example of acultural addiction is observed among health professionals who misuse prescription drugs. Studies indicate that a significant percentage of health professionals engage in diversion and struggle with substance use issues. Their ability to access legitimate channels for drugs, coupled with their professional status, can facilitate isolated use and make it harder for their addiction to be detected.

Wealth can also contribute to cultural addiction by enabling isolation. An affluent individual living in relative solitude, perhaps with a spouse who is frequently absent due to work, may have the means to consume excessive amounts of alcohol or other substances without immediate external consequences. This isolation can become a significant barrier to seeking help or even recognizing the problem, as the individual may not experience the typical social or legal repercussions associated with more public forms of drug use.

Furthermore, high social status can reinforce denial. If an individual is high-functioning and maintains a successful career or social standing despite their hidden substance use, they may mentally rationalize that they cannot possibly have a problem. This strong denial, stemming from their perceived status and functional abilities, can significantly impede their path to recovery. The absence of a visible drug culture means there are fewer external cues or social networks that might challenge their denial or encourage them to seek assistance.

Language, Values, & Stories

Every culture, including drug cultures and cultures of addiction, is characterized by its unique language, values, and stories. Within drug cultures, a distinct terminology emerges, serving as a marker of legitimacy and belonging for its members. This specialized lingo can be difficult for outsiders to keep up with, as it constantly evolves with time and place. Understanding this language is crucial for practitioners seeking to connect with individuals within these cultures, though it requires continuous effort to stay current.

Storytelling plays a vital role in transmitting and reinforcing the cultural norms of drug use. These narratives often emphasize the positive aspects of drug use, highlighting experiences of status, pleasure, or successful evasion of consequences. For example, stories might recount a "fun night" or a clever way someone "got away with" using. However, within these same conversations, there can also be discussions about the need to quit or take a break. This duality reflects the internal conflict that can exist within individuals and the culture itself, where the desire to continue using coexists with an awareness of negative impacts. This can be seen in smoking culture, where individuals might declare an intention to quit by a certain age, even while deeply embedded in the cultural practices of smoking.

The values within drug cultures often prioritize immediate gratification, risk-taking, and a rejection of mainstream societal norms. The shared stories contribute to a collective identity, shaping how members perceive themselves and their relationship to the drug and the wider world. These narratives can glorify certain behaviors, normalize excessive use, and create a shared understanding of the drug's role in their lives. The emphasis on shared experiences and collective narratives reinforces the cultural bond, making it a powerful force that can both draw individuals in and make it challenging for them to leave.

Material Culture

Material culture, the tangible aspects of a way of life, is a significant component of drug cultures. This includes paraphernalia directly associated with drug use, such as pipes, syringes, or rolling papers. These objects are not merely tools; they often carry symbolic meaning and contribute to the rituals and identity of the culture.

Appearance is another facet of material culture that can vary within drug cultures. While some individuals may exhibit a neglected appearance due to the impact of their drug use, others might maintain a meticulous facade as part of their denial or to blend into mainstream society, particularly in cases of acultural addiction. This duality in appearance can reflect the diverse ways individuals navigate their addiction within a cultural context.

Music frequently plays a central role, with genres and specific songs celebrating drug use. This music can become a powerful trigger in recovery, evoking memories and cravings. Art and literature also contribute to the material culture, with addiction memoirs and other creative expressions sometimes glorifying drug use, further embedding it within a cultural narrative.

Diet, though less commonly discussed in this context, can also be heavily affected. Drug use can suppress appetite, lead to poor nutritional choices, and generally diminish self-care practices related to health and well-being. The lack of attention to diet within some drug cultures can contribute to the overall physical decline associated with prolonged substance abuse. These material elements collectively reinforce the cultural norms and practices surrounding drug use, making it a pervasive and deeply integrated aspect of individuals' lives.

Rituals & Activities

Rituals and activities form the behavioral core of drug cultures, dictating how and where drugs are used, and how their consumption is integrated into social life. An intriguing phenomenon within some drug cultures is the need to be taught how to enjoy a drug. For instance, an individual's first experience with alcohol might involve nausea and a severe hangover, making it an unpleasant experience. The culture then socializes the individual to perceive the positive aspects of drinking, to learn that the pleasurable effects outweigh the negative consequences, and to develop a tolerance that allows for enjoyment. Similarly, initial marijuana use can induce dizziness, disorientation, or anxiety. The culture teaches individuals how to navigate these initial unpleasant sensations and to appreciate the desired "high," a process that can take time and repeated exposure.

Social activities are often centered around drug use, leading to a preoccupation with obtaining and consuming the substance. This preoccupation can extend to "hustling" and making money, as addiction can be incredibly expensive. The constant pursuit of funds to acquire drugs becomes a significant ritual and activity within the culture.

Furthermore, drug cultures often involve actions designed to avoid consequences. Members learn strategies to evade detection, such as how to pass a drug test or how to conceal their use. These learned behaviors reinforce the culture of secrecy and denial that can surround addiction.

Engagement in drug culture rituals and activities can also influence an individual's personality. Traits such as paranoia, depression, narcissism, risk-taking, anti-authoritarianism, intimacy issues, avoidance of close relationships, and manipulative tendencies can emerge or be exacerbated through prolonged involvement in these cultures. While these traits may be deeply ingrained, the sociological perspective suggests that they can, in many cases, be decoupled from the individual's core personality and addressed through therapeutic interventions, revealing a different self beneath the layers of addiction-influenced behaviors.

Social Roles

Within the culture of addiction, a diverse array of social roles emerges, each contributing to the perpetuation and dynamics of the group. These roles, as described by William White, offer a sociological and anthropological lens through which to understand the intricate cultural dynamics. While a comprehensive list is extensive, examining a few key roles highlights their significance and potential transference to recovery cultures.

The "High Priests" are individuals who passionately advocate for and are highly public about the use of certain drugs. They may amass followers and disseminate messages that encourage substance use, often with negative consequences due to their public visibility and excessive consumption, increasing their risk of overdose. The "Storytellers" play a crucial role in transmitting the culture by recounting narratives that glorify drug use and paint a vivid picture of the culture, thereby reinforcing its positive associations. "Ambassadors" are highly connected individuals who are aware of various social groups and events, serving as conduits of information and often leveraging this knowledge for status within the culture.

Other roles include "The Dealers," who facilitate access to substances; "The Medicine Men and Midwives," who may offer advice or remedies related to drug use or its effects; "The Jailhouse Lawyers," who navigate legal systems; "The Gangsters" and "The Nonaddicted Hustlers," involved in illicit activities for financial gain; "The Addict with Money and Fame," whose status may mask their addiction; "The Working Class Addicts" and "The Weekend Players," representing different patterns of use; "The Pledges," new or aspiring members; "The Crazies," whose behavior may be erratic; "The Marks," who are exploited; "The Man," representing authority; "The Snitches," who betray trust; "The Protectors," who shield others; "The Pseudo Junkies," who mimic addiction without full dependence; "The Cultural Rejects," who find belonging in the drug culture after being marginalized elsewhere; and "The Profiteers," who benefit financially from the drug trade.

These social roles provide identity and, importantly, can involve transferable skills. This concept becomes particularly relevant when considering the transition to recovery, as many of these roles mirror those found in recovery culture, offering a potential asset for individuals seeking to change their lives.

Culture of Recovery

The culture of recovery, mirroring the structure of drug cultures, is defined as an informal social network where group norms reinforce sobriety and long-term recovery from addiction. Just as drug cultures, through their inherent nature and offerings, reinforce drug use, recovery cultures are designed to reinforce abstinence and healthy living. The transition from a culture of addiction to a culture of recovery represents a significant undertaking, often requiring individuals to sever deep-seated bonds and alter their entire lifestyle. For instance, if a workplace culture normalizes cocaine use for productivity or socialization, an individual seeking recovery faces the immense challenge of maintaining their employment within that same environment while simultaneously breaking free from the social connections and behaviors associated with the drug. This highlights the profound gravity of separating from one culture and embracing another, especially when the existing environment remains unchanged.

(White, 1996)

A Cultural Transition

William White's concept of "cultural conversion," which can be more broadly termed a "cultural transition," describes the profound shift individuals undergo in recovery. This process involves exploring alternative ways to meet the needs previously satisfied by drug culture. For example, if cocaine provided energy, talkativeness, and a sense of connection, recovery culture must offer avenues for vulnerability, confidence, and genuine connection without substance use.

This transition also necessitates exploring the intricate connections between drug culture and an individual's interests, goals, and potential false beliefs. It involves a deconstruction of how drug culture may have reshaped personal aspirations. For instance, a college student with pre-med ambitions might become immersed in a drug culture that promotes anti-establishment philosophies, leading them to abandon their educational goals. In recovery, this individual can revisit why they initially pursued pre-med, questioning whether their current beliefs about higher education were genuinely their own or a product of the drug culture's influence. Similarly, a restaurant worker in an alcohol-centric culture might have discussed aspirations for healthier eating or exercise while drinking. Recovery provides an opportunity to recognize how the social group might have impeded these desired changes.

Integrating spirituality as a framework for alternative ideas is another crucial aspect of this cultural transition. For individuals drawn to anti-materialistic philosophies within drug culture, a spiritual perspective can offer a resonant and constructive pathway. Spirituality often provides an alternative worldview that aligns with the values of recovery, such as self-reflection, community, and purpose beyond material possessions.

Ultimately, recovery involves developing a new cultural identity. This new identity is not merely the absence of drug use but a proactive embrace of new norms, values, and social roles that support sobriety and personal growth. It is a fundamental reshaping of self within a supportive cultural context.

Recovery Cultures

Recovery cultures, much like drug cultures, possess distinct norms and expectations that are reinforced by the group. These cultures provide vital networks and peer support, fostering a sense of belonging and shared purpose. Socialization within recovery cultures involves learning new ways of acting and speaking, adopting language and behaviors that align with sobriety and personal growth.

Recovery cultures manifest in various forms, including formal treatment programs, self-help groups, and the widely recognized 12-step programs. Each of these diverse recovery cultures offers a unique pathway to sobriety, though they all share the common goal of supporting long-term recovery.

It is important to acknowledge that individuals often reside in multiple cultures simultaneously. On this note, "cultural recovery" refers to recovery programs that explicitly integrate other cultural memberships. For example, a program might incorporate the spiritual or cultural frameworks and verbiage of an indigenous population, creating a more resonant and effective pathway to recovery for individuals from that background. This integration can be particularly beneficial, as it addresses the potential disconnect between an individual's home culture or family culture and the recovery process, fostering a deeper sense of connection and belonging.

History

The history of recovery and treatment for substance use disorders is a fascinating and complex narrative, spanning centuries of evolving understanding and approaches. While the precise origins of individuals overcoming addiction are lost to antiquity, more recent historical developments offer valuable insights into the emergence of formal recovery movements and treatment modalities.

The early 19th century witnessed a significant surge in alcohol consumption, particularly from the late 1700s to the early 1800s. This societal shift, influenced by economic factors and increased availability of alcohol, spurred the rise of the Temperance Movement in 1825. This movement aimed to curb alcohol consumption through moral persuasion and social pressure.

A notable offshoot was the Washingtonian temperance movement, which began in 1840. This movement bore striking similarities to later social support systems like Alcoholics Anonymous. It comprised groups of individuals who, having struggled with heavy drinking, sought to achieve sobriety through mutual peer support. Their meetings involved sharing experiences, a practice that would become central to subsequent recovery programs. The Washingtonian movement gained remarkable momentum, spreading rapidly across communities. However, despite its initial success, it largely dissipated after approximately five years, highlighting the challenges of sustaining such movements without formal organizational structures.

Following the decline of the Washingtonian movement, treatment "asylums" began to emerge around 1845. These institutions served as places where individuals could seek refuge and sobriety. By 1877, the "Journal of Inebriety" was established, marking a significant step towards the medicalization of addiction, framing it as a health condition rather than solely a moral failing. The 1890s saw the emergence of dedicated treatment hospitals and the closure of many asylums, reflecting a shift in the approach to mental health and addiction.

In 1906, the Emmanuel movement introduced a remarkably holistic approach to recovery. This program emphasized psychology, spirituality, relaxation techniques, and the importance of social services and lay therapists. It fostered an environment where multiple dimensions of an individual's well-being were nurtured, a comprehensive approach that, in some ways, predated and even surpassed certain modern recovery models in its integrated nature. Unlike some contemporary programs, it actively connected individuals with foundational social services, recognizing their importance for sustained recovery.

The Oxford Group, formed in 1908, played a pivotal role in shaping future recovery movements. Its principles, including self-survey, confession, restitution, and service, directly influenced the foundational tenets of Alcoholics Anonymous.

A significant disruption to the burgeoning treatment landscape occurred with the advent of Prohibition in 1919. This nationwide ban on alcohol severely curtailed access to formal treatment, as the prevailing belief was that the problem would simply disappear once alcohol was illegal. However, Prohibition proved largely ineffective and was repealed in 1933.

Just two years later, in 1935, Alcoholics Anonymous (AA) was founded. Drawing inspiration from the Oxford Group and the Washingtonian movement, AA revolutionized addiction recovery by establishing a peer-led, self-help model that emphasized spiritual principles, mutual support, and a structured pathway to sobriety. Its enduring legacy continues to shape the landscape of recovery cultures worldwide.

AA and 12-Step Culture

Alcoholics Anonymous (AA) and its numerous 12-step offshoots represent a powerful and pervasive recovery culture, offering a structured pathway to sobriety for individuals struggling with various addictions. Understanding this culture is paramount for anyone working with or affected by it. While AA is designed to be non-hierarchical and self-governing, its cultural dynamics are incredibly potent and well-defined.

At the core of 12-step culture is the recognition of denial, powerlessness, selfishness, and a "loss of sanity" due to addiction. The first step, admitting powerlessness over alcohol or the specific substance, is often a monumental leap for individuals, given the pervasive nature of denial, frequently reinforced by drug cultures. Accepting that one cannot control their substance use and acknowledging its destructive impact on their lives and relationships is a foundational principle.

The culture emphasizes that guilt and resentment are significant fuels for addiction. Through a process of self-inventory and confession, individuals are encouraged to examine their past actions, identify their role in harming others, and make amends. This involves ongoing restitution and a commitment to service, which is seen as a vital component of sustained recovery. Recovery in 12-step culture is not merely the cessation of substance use; it is embraced as a comprehensive lifestyle, a fundamental reshaping of one's identity and daily practices. This cultural immersion provides a framework for living sober, offering a new set of norms, values, and behaviors to replace those associated with active addiction.

Language, Values, & Stories

The 12-step culture, like any robust cultural system, possesses its own distinctive language, values, and stories that reinforce its principles and guide its members. Recovery literature, particularly the "Big Book" of Alcoholics Anonymous, serves as a foundational text, transmitting core concepts and narratives.

Slogans are a pervasive and powerful element of 12-step language. Phrases like "easy does it" and "one day at a time" are not merely catchy sayings; they are practical tools designed to help individuals navigate the challenges of early sobriety. The "one day at a time" philosophy, in particular, mirrors a certain aspect of addiction culture where the focus is often on immediate gratification, but it reorients that immediate focus towards sobriety. "Keeping things simple" is another slogan that encourages a straightforward approach to recovery, avoiding overcomplication. These slogans become internalized mantras, guiding daily decisions and offering comfort during difficult moments.

The concept of "character defects" is central to the 12-step lexicon, referring to personality traits or behaviors that may have contributed to or been exacerbated by substance use. The culture encourages individuals to identify these defects and work towards their "opposites," such as replacing judgment with acceptance. Conversely, "assets" are recognized as positive qualities that can be leveraged in recovery, fostering a balanced self-assessment.

A profound "transcendent focus" characterizes 12-step culture, emphasizing a spiritual dimension. This often involves experiencing "moments of clarity" or "awakening," signifying a profound shift in self-perception and a deeper connection to a higher power (however conceived). The idea of "surrender" is paramount, implying a letting go of self-will and embracing faith, acceptance, tolerance, patience, honesty, openness, and humility. These values are actively promoted and practiced within the culture, often standing in stark contrast to the values of mainstream society, which may emphasize competition, status, and individual control. This counter-cultural aspect can resonate deeply with individuals transitioning from drug cultures, offering an alternative framework for living.

Material Culture

The material culture of recovery, particularly within 12-step programs, provides tangible symbols and practices that reinforce sobriety and a new way of life. Objects play a significant role, such as recovery coins or "chips" that mark milestones of sobriety. These coins serve as physical reminders of commitment and progress, offering a sense of accomplishment and belonging. Talismans, personal objects imbued with symbolic meaning, and recovery-focused books are also common elements.

Dress and appearance can also reflect an individual's engagement with recovery culture. This might include wearing clothing with recovery messages, or a renewed focus on self-care and hygiene as part of a healthier lifestyle. Tattoos, which may have been acquired during active addiction, might be altered or covered to signify a break from the past.

Music continues to be a powerful medium, but in recovery, the focus shifts. Individuals may examine song lyrics more critically, replacing words or finding new music that resonates with their sober identity. Art is often utilized as a therapeutic outlet, providing a means for self-expression and processing emotions without substance use.

Food and diet, though not always explicitly central to 12-step programs, are implicitly linked to recovery through the broader concept of self-care. While slogans like "keep candy handy" might suggest a simple substitution for the sugar in alcohol, a deeper understanding reveals the profound connection between nutrition, brain health, and sustained recovery. Exploring the mind-body-behavior connection through diet can be a vital, though often overlooked, aspect of healing. These material elements collectively contribute to the formation of a new identity and lifestyle that supports long-term sobriety.

Rituals & Activities

Rituals and activities are the bedrock of recovery culture, providing structured pathways for maintaining sobriety and fostering personal growth. Reading recovery literature, such as the "Big Book" or other approved texts, is a fundamental ritual, offering guidance, shared experiences, and reinforcement of core principles.

Self-care, particularly through exercise, is increasingly recognized as a vital activity in recovery, promoting physical and mental well-being. Prayer and meditation are integral components of 12-step programs, fostering a spiritual connection and providing a means for introspection and emotional regulation.

Meetings are central to recovery culture, offering a safe space for individuals to share their experiences, strengths, and hopes. Sharing within these meetings, engaging in phone calls with fellow members, and consistently using recovery slogans reinforce the cultural norms and provide immediate support. The practice of taking inventories, making amends for past harms, engaging in service to others, and participating in mentoring relationships (sponsor-sponsee dynamics) are all crucial rituals that facilitate personal accountability and growth.

Socializing with friends and family, often within the context of safe havens and avoiding trigger places, is a key activity in rebuilding healthy relationships. The formation of new social groups and the adoption of a new persona are natural outcomes of this cultural transition. By comparing these rituals and activities to those found in drug cultures, it becomes evident how recovery cultures effectively meet the fundamental human needs for connection, identity, and purpose, which were previously sought through substance use. The similarities in the group aspect, the shared culture, and the propagated beliefs and values make the transition to recovery culture a more comprehensible and achievable journey.

Social Roles

Like the culture of addiction, the culture of recovery features a rich tapestry of social roles that contribute to its functionality and support its members. The presence of these roles highlights a crucial asset in the recovery journey: the potential for transferable skills from addiction culture to recovery culture.

For instance, the "High Priests" in addiction culture, who were charismatic leaders passionately advocating for drug use, can transform into powerful advocates within recovery. Their leadership qualities, even with their past negative associations, can be channeled into promoting sobriety and guiding others. Similarly, the "Storytellers" from addiction culture, known for their vivid narratives of drug use, can become compelling speakers in recovery meetings. Their ability to "paint the picture" of their past addiction and their journey to recovery serves to transmit the culture of recovery to newcomers, offering hope and relatable experiences.

"Ambassadors," who were once adept at navigating various social groups and gathering information within drug culture, can become invaluable resources in recovery. Their inquisitive nature and strong listening skills can be repurposed to connect individuals to meetings, resources, and other members, effectively serving as navigators within the recovery community. Their ability to know "what's going on with people" can be a tool for support and outreach.

Other roles within recovery culture include "The Elders," seasoned members who offer wisdom and guidance; "The Comedians," who use humor to lighten difficult topics; "The Professors," who share knowledge and insights; "The Professionals," who integrate their recovery into their careers; "The Two-Hatters," who balance their professional and recovery identities; "The Bleeding Deacons," who are open about their struggles to help others; "The Medicine Men and Midwives," who offer healing and support; "The Chronically Failing Sinners," who persist despite setbacks; "The Organizers," who facilitate meetings and events; "The Self-Cured," who found recovery outside traditional programs; "The Mentors," who guide newer members; "The Fundamentalists," who adhere strictly to program principles; "The Confused Protectors," who struggle with boundaries; "The Saboteurs," who may undermine others' recovery; "The Pigeons," who are easily influenced; "The Pilgrims," who are on a spiritual journey; and those dealing with "Pseudo-Addiction."

The key takeaway is that the skills and characteristics developed within the social roles of addiction culture are not necessarily lost or entirely negative. With awareness and guidance, these attributes can be reframed and utilized as assets in the recovery process, contributing to a new, healthier identity and a supportive community. Observing and discussing these relatable assets can be a valuable tool in therapeutic settings and in the broader recovery movement.

Practice Applications

Bringing together the insights on drug culture and recovery culture offers significant practical applications for practitioners across various fields, including social work, counseling, psychology, and healthcare. The foundational understanding that cultural influences profoundly shape an individual's life, even if not immediately apparent, is the crucial starting point. This contrasts with a narrow focus on individual pathology and encourages a broader, more empathetic perspective.

Understanding drug and addiction culture, including the concept of the acultural addict, is paramount. This knowledge can significantly aid in establishing and strengthening the therapeutic alliance, the connection between the practitioner and the person served. Just as cultural competency in other areas enhances rapport and trust, an awareness of the cultural context of substance use can foster a more effective therapeutic relationship, leading to better treatment adherence and outcomes. Practitioners do not need to be experts in every subculture, but a general awareness of cultural influences allows for informed inquiry and a more nuanced approach to care.

This understanding also provides invaluable insight for assessment. Beyond asking about the immediate effects of drug use, practitioners can inquire about the perceived benefits derived from being part of a group or culture associated with substance use. This opens up a new set of assessment tools, enabling the design of more tailored programs and interventions that address the underlying social and emotional needs fulfilled by drug culture.

Furthermore, it is critical for practitioners to recognize that leaving a drug culture can be even more challenging than ending drug use itself for some individuals. While the self-destructive nature of drug use may create a strong desire to quit the substance, severing ties with a deeply ingrained lifestyle, social network, and even one's home environment presents an entirely different set of obstacles. This awareness allows practitioners to anticipate and address the profound sense of loss and disruption that individuals may experience when transitioning out of a drug culture, and to integrate strategies that support the rebuilding of a new, sober life.

Concluding Thoughts

The exploration of drug culture and the culture of recovery underscores several fundamental concluding thoughts that are critical for a holistic understanding of substance use disorder.

First, social and environmental factors matter profoundly. While this may seem intuitively obvious, the full extent to which one's social environment, sense of belonging, identity, and safety impact psychological and biological well-being, and even genetic expression, is often underestimated. Research demonstrates that social isolation, for instance, is a more powerful predictor of premature mortality than excessive smoking, chronic alcohol use, or a sedentary lifestyle, even when controlling for other health-related factors. This highlights the transformative power of moving from isolation to connection, emphasizing that social integration is not merely a desirable outcome but a vital determinant of health and longevity. The deep physiological and neurological impacts of the social environment warrant further exploration, as they can fundamentally shift one's perspective on addiction.

Second, addiction extends far beyond the individual; it is inherently a social problem. The escalating opioid crisis, the rise in drug poisonings, and the increase in suicide rates cannot be solely attributed to individual factors. These societal challenges are deeply rooted in how individuals are treated within society, the messages they receive, the economic conditions of their communities, and the systemic failures to provide basic needs. Drug cultures, in this context, can paradoxically serve as safe havens, offering a sense of belonging and identity when other societal structures fail to do so.

Third, identities are significantly shaped by culture. An individual's personality is not solely an innate trait; it is profoundly influenced by the cultural contexts in which they develop and participate. Recognizing that addiction goes beyond individual choice, and that adverse childhood experiences, for example, can alter brain function and limit life options, fosters a more compassionate and effective approach. When working with individuals who appear to make self-destructive or "unintelligent" decisions, adopting the perspective that they are often doing what is within their power to cope with their circumstances can alleviate frustration and resentment for providers. This reframing can enhance the willingness to engage with individuals who may struggle with treatment adherence or service utilization.

Finally, the needs fulfilled by drug culture can indeed be addressed in recovery culture. By comparing the elements of drug culture—its propagated beliefs, values, material culture, identity ties, and group aspects—with those found in recovery culture, it becomes evident that numerous similarities exist. This parallel structure suggests that recovery can be framed as a transition to a new, healthier lifestyle that still fulfills fundamental human needs for connection, identity, and purpose. Recognizing and leveraging these similarities can be a powerful tool for practitioners, helping individuals to see recovery not as a deprivation, but as an alternative, fulfilling cultural pathway.

References

Select references are listed here. The full reference list is included in the course handout.

Adlaf, E. M., & Smart, R. G. (1997). The cultural context of adolescent drug use: A review of the literature. Addiction Research & Theory, 5(2), 177-195.

Kurtz, E. (2005). The spirituality of imperfection: Storytelling and the search for meaning. Bantam.

Manning, P. (2013). Drugs and popular culture in the age of rock 'n' roll. Routledge.

White, W. L. (1996). Pathways from the culture of addiction to the culture of recovery. Hazelden.

This is an edited transcript of the webinar, The Opioid Crisis: A Sociological Perspective, presented by Sophie Nathenson, PhD. 

Learning Outcomes

After taking this course, participants will be able to: 

• Describe the social context of the opioid crisis.
• Identify three societal-level contributing factors of the opioid crisis.
• Identify two aspects of a holistic, population health approach to addressing the crisis.

The Sociological Perspective

Let's start by covering the sociological perspective and what sociology entails. Sociology is the study of society as a whole, classified as a social science, focusing on human behavior, similar to psychology. However, in sociology, the focus lies in examining differences between groups rather than individuals. Individuals are grouped together based on various social factors, such as age, race, gender, and socioeconomic status. The objective is to compare these groups in terms of behavior, prevalence of illnesses, and other aspects that shape an individual's life course.

Thus, sociology delves into analyzing social factors and aspects of social life and status, as well as structural factors inherent in communities and societies. Medical sociology places special emphasis on understanding social and structural determinants of health outcomes—identifying how community characteristics and social status contribute to potential differences in health outcomes. This field differentiates between upstream factors, focusing on prevention, midstream factors dealing with illness management, and downstream factors, which involve emergency approaches to illnesses.

The population health perspective is essential in this regard, as it assesses the health of a group and examines health behaviors, such as the use of opiates, from a broader population standpoint.

Rather than solely focusing on understanding why an individual may use, our aim is to identify factors associated with the prevalence of addiction and overdose within a society. Thus, we approach health behaviors within a social context, considering not only individual factors but also broader influences such as social norms, community, family, relationships, and the environment where individuals live, work, engage in recreational activities, and socialize. This perspective allows us to explore the impact of social and structural factors on our position in society and our social status, encompassing elements like race, gender, socioeconomic status, and power imbalances, which affect our access to resources.

Structural factors involve examining societal systems. When comparing different societies or communities and analyzing the prevalence of issues like addiction and overdose, significant differences prompt us to explore the underlying reasons for these variations. In doing so, we broaden our scope to consider the systems and structure of societies. This includes evaluating aspects such as the healthcare system, educational system, industries present in the society, media influence, cultural dynamics, and the overall economic structure, including income levels and wealth distribution. Employment and unemployment rates, educational attainment, and access to education among various groups also play a crucial role in this comprehensive analysis.

In terms of culture and the social environment, that also includes norms, how people are socializing, the degree of social isolation, and where people come together. That's another aspect of a society that could influence health outcomes. At the most top-down or broadest level, factors such as political instability, policy, and laws, are interconnected and can trickle down and affect behavior and collective wellbeing. 

The Opioid Crisis

Now, shifting our focus to the opioid crisis, it was officially declared a national public health emergency in 2017, encompassing both the misuse of prescription opioids and illegal drugs derived from opium, such as heroin.

This crisis has been labeled as the deadliest in American history, with the United States accounting for only 4% of the world's population but experiencing 27% of global drug overdose deaths. However, it's essential to acknowledge that these statistics may change over time. Research and social surveys indicate that pain levels in the United States are comparable to countries like France and Italy, despite the fact that the U.S. consumes a staggering 80% of the world's opioids. This suggests that opioid consumption is not merely linked to pain prevalence or chronic illnesses where opioids are medically necessary for pain management. Rather, there may be underlying societal factors contributing to the crisis. See Katz (2017) for further details.

Trends Over Time

Analyzing trends over time reveals drastic changes in the opioid crisis. Between 1980 and 2008, there was a 600% increase in opioid overdoses, and from 1997 to 2017, the number increased fivefold. Notably, during the pandemic years, from April 2020 to April 2021, drug overdose deaths increased by 28.5%. You can start to think about the context and what may have contributed to this significant rise, such as the social and economic impact of the pandemic.  

When we study populations, societies, and countries, we encounter differences. When we analyze statistics, for example when we look at rates of addiction, overdose, depression, suicide, or suicidal ideation, we can be mislead unless we take into account these real differences between groups.  For example, while overall statistics might indicate improvements in certain areas, specific vulnerable groups might still be experiencing increasing rates. This variation among social groups is a core concern in medical sociology, as it emphasizes that diseases, illnesses, and addictions are not distributed evenly across a population; there are distinct patterns and societal factors at play.

Significant variation is observed not only between states in the U.S. but also between counties within those states and as mentioned, among different countries. Such disparities suggest that societal factors play a substantial role in the opioid crisis. If rates were the same across all states and countries, for example, it might imply that individual factors alone are responsible. However, the substantial variation prompts us to explore how societies are structured, what individuals are exposed to within these societies, and the access to resources available, all of which may contribute to the differences that are observed.

Data Limitations

Research and surveys provide valuable insights into the opioid crisis. Self-reported data, when individuals rate their own health, tends to be reasonably accurate and aligned with objective measures obtained in healthcare settings. However, it is essential to acknowledge the limitations inherent in data collection and analysis in social science research.

Overdose rates, for instance, can be subject to miscoding or misattribution when entered into data systems, leading to potential misinterpretations. For example, an accidental overdose might be categorized as a suice. Non-fatal overdoses are often missing from national surveys, which primarily focus on fatal overdoses, potentially overlooking critical information about near-miss incidents that could provide information about underlying factors and prevention strategies.

Measuring opioid use, especially non-medical use and diversion, poses significant challenges. Household surveys can suffer from low response rates, making it difficult to obtain a comprehensive picture of opioid use within households. Furthermore, national drug lab data might not be fully representative, particularly concerning drugs sold in the social markets or the "black market".  Harm reduction efforts are challenging to quantify. The criminal justice system also poses difficulties when attempting to collect data from arrestees or prisoners due to their vulnerable status. Even hospitalization data might not be captured uniformly or in a standardized manner, which can affect our understanding of the crisis's scope and severity. Finally, assessing access to drug treatment can be hindered by potential under-coverage in insurance data, preventing us from gaining a fully accurate picture of treatment availability and utilization.

While data sources play a pivotal role in comprehending and addressing the opioid crisis, it is vital to approach them with caution, taking into account their potential limitations and biases.

How Did We Get Here?

Understanding how we arrived at the current state of the opioid crisis requires examining the significant changes in statistics over time and the events that contributed to this complex issue.

In the 1980s, there was a notable downplaying of opioid addiction. A report, which was not robust in its scientific basis, was circulated among medical professionals and physicians, indicating that opioids were not labeled as an addictive substance. In the 1990s, a problem was identified: patients were experiencing pain, but it was not always adequately measured or addressed. In response, healthcare professional associations deemed pain as the fifth vital sign, emphasizing its importance and promoting its measurement. In the 2000s, aggressive marketing strategies, educational initiatives, and promotions targeted physicians in a specific and calculated way. There was overpscribing, in part potentially related to patient satisfaction (Fenton, Bertakis, & Franks, 2012). Patients might have demanded opioids for pain relief, and if patient satisfaction was a key outcome for physicians and the healthcare system, it may have played a role in the overprescribing of opioids.  Key 

From Prescription to Illicit

Apart from changes within the healthcare system, various social and economic factors also contributed to the opioid crisis. The opioid crisis can be traced back to both prescription drugs, and also illicit drugs obtained through that social channel. There is both diversion use by healthcare professionals and recreational use. For example, there was a big spike in heroin use because people who were addicted to opioids but ran out of a supply or money for their prescription, would be kind of pushed into buying it through social channels in order to access a similar or same high with heroin. There is a close connection between opioids, prescription drugs, and heroin. A study by Cicero et al. (2014) showed that 75% of heroin users had used analgesics, and that painkiller users were 40% more likely to be addicted to heroin.  In 2017, the CDC found that there was almost equal distribution of opioids from healthcare channels and social channels. Simply addressing the healthcare side of the opioid crisis would not be enough.

Diversion Risks and Signs

According to SAMHSA (Substance Abuse and Mental Health Services Administration), approximately one in 10 healthcare workers may be abusing drugs, though it's important to recognize that this figure might be an undercount due to the challenges of obtaining accurate data in this context.

Fentanyl has been particularly problematic in terms of diversion, as it has caused the most deaths. Detecting opioid diversion within healthcare systems has revealed that this problem exists across different levels and disciplines, not limited to individuals with the most direct patient interactions. It occurs throughout the hierarchy in healthcare.

Several indicators may suggest diversion within a healthcare setting. These include controlled substances being removed without proper authorization, compromised containers that appear tampered with, the use of substitute drugs on patients who were previously prescribed opioids, and verbal orders that have not been appropriately verified. Self-prescription, improper handling or disposal of waste, and instances where health professionals are unusually administering medications can also be red flags indicating potential diversion activities.

Signs of Misuse and Addiction
 

Signs of misuse and addiction can be categorized using the three Cs: Control, Craving and Preoccupation, and use despite negative Consequences.

Regarding Control, there is a loss of control. Indicators may include reporting of stolen or lost medications, seeking early refills, seeking drugs from sources, experiencing withdrawal symptoms, and being unable to control their use of opioids.

Craving and Preoccupation involve increased requests for specific drugs and increased pain without a worsening of disease. This may be related to increased tolerance. In addition, an indicator of craving and preoccupation include dismissing non-opioid pain management methods.

Use despite negative Consequences refers to over-sedation, reduced daily activities and functioning, and experiencing relationship issues due to opioid use.

Social-Ecological Model of Risk Factors

From a sociological and psychological perspective on addiction and overdose, a social-ecological model of risk factors is used. This model encompasses multiple levels of influence.

The broadest level considers aspects of society as a whole. The community level looks at the characteristics of specific communities, such as neighborhoods or cities. Interpersonal factors relate to socialization and relationships within an individual's social circle. Addiction and overdose are multifactorial. At the individual level, these various factors include sociological, psychological, genetic, and environmental factors, to name a few, that come together to contribute to this issue.

Individual and Interpersonal Risk Factors

We cannot simply focus on a single risk factor and address it, as these factors not only contribute independently but also overlap and influence each other, making it difficult to isolate one. Therefore, we will begin by examining individual and interpersonal risk factors.

At the individual level, various factors play a significant role. Socio-demographics, including personal social standing, stress levels, and past or current traumas, all have an impact. Additionally, genetics, family history, pain levels, withdrawal symptoms, and self-stigma, which may be internalized from social environments and norms, are crucial factors to consider.

Self-stigma can lead individuals to judge themselves and believe that seeking help is frowned upon, affecting their willingness to seek assistance. Moreover, their determination level and the presence of other addictions, such as cross-addictions, where individuals may switch from one substance or behavior to another, can complicate the situation.

Moving to the interpersonal level, the influence of family and peers becomes prominent. For adolescents, peer influence can be even more powerful than that of the family. Access to substances can also be influenced by social circles, and the ability to seek and distribute drugs can depend on the level of access one has within their social group.

We also need to consider the influence of family history, particularly when it comes to use among family members and friends. Additionally, the nature of your relationships and associations, especially in romantic relationships, can significantly impact opioid use. Oftentimes, drugs serve as social lubricants within these contexts. Later on, we'll explore studies featuring personal stories of drug users to shed further light on this aspect.

Key literature in this area includes Jalali et al. (2020) and Cragg et al. (2019).

Community and Societal Risk Factors

As we expand our perspective, it becomes evident that differences exist between communities in terms of opioid use and addiction rates. Some communities experience high levels of opioid use, while others have much lower rates. This disparity calls for researchers and health professionals to delve into the underlying reasons behind these variations. Understanding these nuances can either satisfy your curiosity or pave the way for your potential involvement in community work focused on prevention.

Access to treatment plays a pivotal role at the community level. For instance, in the state where I reside, we face one of the highest addiction rates but struggle with limited access to treatment options. This creates a challenging situation for those seeking help. However, it's worth noting that there are also many individuals in recovery, largely due to the prevalence of addiction in our community.

Norms and culture within communities are crucial factors to consider. If drug use is normalized within a community, it can contribute to higher rates of addiction. Let's say a large employer in a community shuts down, leaving large numbers of people out of work.  If drug use is the norm in that community, using drugs may not be perceived of deviant behavior in certain social groups within that community, and drug use may increase. In addition, school and work environments can play into this; whether there is an awareness of the issue and whether or not steps are being taken to address it. Prescribing patterns and prescriber perceptions and attitudes can play a role, as can the quality and level of care in a community. In fact, there are differences according to social status and race when it comes to prescriptions for pain medication.

Societal risk factors include economic conditions, supply, government programs, education, advertising, media, stigma, discrimination and prejudice, law enforcement, and policing. In terms of economic conditions, the distribution of wealth in a society can put a strain on everyone, particularly the most vulnerable. For example, during the pandemic essential workers were working while many other businesses were shut down.  This created a strain on individuals and families. Some children had no access to education during the pandemic. Some teachers told me about half their students had access to the Internet, while half did not.  This is not a complete list of community-level factors but the types of things to consider when examining differences around opioid use and addiction.

Gaining a deeper understanding of these community-level factors can pave the way for resource allocation further upstream. By doing so, we have the potential to prevent opioid addiction or at least address the issue at a population level. While individual interventions play a critical role and can be successful, we need to address the issue comprehensively. Individual interventions may not have the capacity to influence an entire population, especially considering the less than ideal ratios of individuals in need versus the number of available counselors, therapists, behavioral health specialists, and substance abuse and prevention experts.

Documented Variation

Looking at the documented variation in state and country-level statistics, the lowest prevalence of opioid addiction was found in Nebraska, according to the 2017 research (Hedegaard, Warner, & Minino 2017), while West Virginia had the highest rates.

It's important to note that rural areas tend to be more vulnerable to opioid addiction, and there are spikes in these regions that correlate with economic opportunities and changes. In rural areas, the level of investment in the community and the availability of industries can result in shifts in the social demographics, with people potentially leaving the community in search of better opportunities. Moreover, the concept of "deaths of despair" has emerged, referring to deaths that are attributed, either through research or perception, to the profound sense of hopelessness and lack of individual opportunities. These deaths are not caused by illness or natural causes but are driven by the absence of a positive future vision. See Dasgupta, Bletsky, and Ciccarone (2018) for further reading on this topic.

Indeed, disparities in health outcomes based on race and social status are evident across various health issues, including opioid addiction. There is a significant correlation between race and socioeconomic status, which plays a role in shaping the prevalence of addiction within different communities. Gender differences also contribute to the variations seen in opioid addiction rates. The prevalence of mental illness and physical pain can also vary from one community to another, adding further complexity to the issue. All of these factors combined serve as evidence of the intricate web of factors influencing addiction within a community.

The War on Drugs
 

Let's delve into the topic of the "war on drugs." This initiative was launched with the positive intention of combatting drug issues in communities across America. 

The approach of the war on drugs led to increased arrests, but it did not necessarily reduce access to street drugs. Moreover, it influenced the culture, perception, and stigma surrounding drug use and addiction. The focus on punitive measures rather than preventive or supportive efforts may have contributed to the perception of drug use as a moral failing, stigmatizing individuals struggling with addiction.

Unfortunately, the war on drugs didn't fully recognize the role of trauma, both past and new traumas, that individuals experience in society. If the initiative had been framed as a war on addiction, it might have called for investment in addressing underlying community-level issues and potentially reduced the driving force behind people seeking drugs. In addition, it exacerbated the stigma around drug use.

This is not intended to prescribe specific policies or take a political stance. Instead, our focus is primarily on the research on various policies and actions related to drug use and addiction. People hold diverse attitudes and opinions about the root causes of drug use and the characteristics of drug users. These viewpoints, coupled with the considerable size of the drug industry and the prison industrial complex, all contribute to the context in which drug policies are formulated. 

Significance of Root Causes

It is essential to recognize that the relationship between various factors is not linear or one-to-one based purely on availability. Simply addressing one factor, such as prescribing behavior, may not lead to the desired outcome.

A striking study caught my attention, where a 13% drop in prescriptions from 2012 to 2015 was followed by a surge in overdose rates (Dasgupta et al., 2018). This finding challenges the notion that reducing prescription rates alone can effectively combat the opioid crisis. 

When access to prescription opioids decreased, some individuals may have turned to social channels to obtain drugs. This shift in behavior may have led to a greater intermixing of drugs, such as heroin, resulting in more severe health issues for those engaging in recreational use or those who have addiction.

Understanding the contributing causes behind the variations in opioid prevalence based on location and social status is important. This involves looking beyond opioids alone because addiction does not occur in isolation. A multitude of factors, such as socioeconomic conditions, mental health issues, access to treatment, and cultural norms, interact to influence addiction rates. Ignoring all these driving forces and just zeroing in on the opioids alone may not be a successful approach. 

Deaths of Despair
 

The term "deaths of despair" was coined by researchers Case and Deaton (2015) to describe what they observed in their research. They researched people with high mortality rates from suicide, drug overdose, and related causes. The researchers delved into the mental and emotional states of these individuals and found a common thread of hopelessness and economic strain.

This is deeply tied to community-level factors. The sense of hopelessness and lack of opportunity can be associated with mental health issues and economic challenges that individuals face within their communities. Income inequality emerges as a powerful indicator of various social problems, not just in specific regions but across the globe. Researchers have consistently found links between income inequality and a range of social issues, such as decreased social trust, increased rates of teen pregnancy, dangerous adolescent behaviors, and interactions with the criminal justice system. Another key study on this topic is Ezell et al. (2022).

Micro, Meso, Macro Levels
 

Indeed, examining the micro, meso, and macro levels can provide valuable insights into the levels of prevention for addressing opioid addiction. At the micro-level, individual factors such as occupation and job conditions play a significant role. Certain jobs may be more prone to causing physical injuries, while others may have different rates of mortality and injury. Changes in prescribing practices can also have an impact, potentially leading to the illicit use of opioids.

At the meso-level, the focus shifts to the immediate environment of individuals. Limited recreational opportunities may lead some individuals to use opioids as an escape from their reality.

Zooming out to the macro-level, community-wide and societal factors become prominent. The level of investment or divestment in a community can have far-reaching consequences, and economic distress within these communities is often linked to higher mortality rates, particularly in rural areas. These factors can impact mental illness as well. 

The interplay of micro, meso, and macro-level factors creates a framework for understanding the complex nature of opioid addiction and its connection to broader community and societal dynamics.

Levels of Prevention

Levels of prevention can be categorized into primary prevention, secondary prevention, and tertiary prevention, each addressing different aspects. Primary prevention focuses on going upstream and addressing factors at the big-picture level, far from the emergency situation. This includes community education, policy changes, and initiatives to reduce stigma surrounding addiction.

Moving on to secondary prevention, the focus shifts to more immediate interventions. This includes measures like needle exchanges, medication-assisted treatment and safe houses, and proper disposal of unused opioids.

At the tertiary level, the emphasis is on providing support and care for individuals. This involves fostering empathy and caring, introducing evidence-based interventions, establishing psychosocial support structures, and facilitating access to support groups.

Role of Stigma
 

Stigmatizing attitudes towards individuals with opioid addiction can be found not only in the general public but also among law enforcement, health professionals, and emergency services professionals. These negative attitudes can impact how referrals are made and how the issue is addressed, hindering access to care and support.

Health professionals working with individuals facing addiction can experience frustration, disillusionment, burnout, and irritation due to the challenges they witness. Witnessing traumatic experiences, such as domestic violence or deaths resulting from drug use, can take a toll on those in helping professions.

One aspect of stigma is the different assumptions made about prior behaviors of individuals dealing with addiction, such as promiscuity. It's important to recognize that not everyone engaging in drug use necessarily exhibits specific prior behaviors, debunking the misnomer that such behaviors are a prerequisite for addiction.

Stigma has been called the "net absence of empathy" (Ezell et al., 2021), which is an interesting perspective.

Direct Experience v. Role Playing
 

There is research that compares the perspectives of people who use drugs and their experiences (direct experience) and those of behavioral health professionals. Behavioral health professionals may be in a role-playing position, meaning they have to envision the experience of someone who uses drugs or has an addiction, because they do not have a direct experience with drug use themselves. These perspectives are not about any specific individual therapist but rather about broader trends observed in qualitative research comparing groups. It highlights the need to understand the perspective of people who use drugs (prescribed and illicit), and how that relates to empathy.

Behavioral health professionals often examine the causes and conditions that led to addiction in an individual, and some may have personal experience with addiction, which can be beneficial in their work. However, there may also be presumptions based on known risk factors and evidence from research. While it is important to understand the research, each individual has their own unique circumstances which may or may not align with research. While we know from research that economic conditions may drive addiction rates, an individual may not attribute their use of drugs to their economic situation. It's important to look beyond the research on risk factors to look at each person's direct experience, to find out why they are using drugs or struggling from addiction. What are they saying? What is their reasoning or explanations for their circumstances?

One factor that is sometimes downplayed is sensation-seeking, where they seek the psychic or bodily high, or the increased sensations that come with certain behaviors, in terms of relationships and sexual contact. Coping with social and environmental circumstances is another factor, where drugs may be used to facilitate social and romantic relationships.

One poignant finding from direct experiences is that drug use may not always be a premeditated decision. Many individuals do not actively seek drugs; instead, they find themselves in social circumstances where drug use becomes a part of their lives. For example, a person may start using drugs due to the influence of a romantic partner, where pressure or romantic feelings cultivate a sense of trust that can impact behavior. Drug use may also be driven by addressing physical pain.

Sociology of Empathy

From a sociological perspective, empathy challenges the notion that opioid use and addiction are solely the result of predisposition or deviant behavior. Empathy goes against the belief that "it's those kinds of people" who would be involved in opioid use or that it would be "unfathomable." Instead, understanding empathy from a sociological lens allows us to recognize the influence of social norms and circumstances on individuals' behaviors.

By building empathy, we can better comprehend the complexities of addiction and the factors that lead individuals to use opioids. This includes acknowledging the impact of trusting relationships. In a relationship where there is trust, you may be more likely to engage in riskier behaviors. You may not have interest in mountain climbing, but you may do it with a partner if it is important to them. Empathy-building is crucial for behavioral health professionals to establish a more effective therapeutic relationship and to avoid compassion fatigue and burnout.

Moreover, as attitudes among professionals start to shift through empathy and understanding, it can lead to more informed advocacy for policy changes that align with the needs and experiences of those experiencing addiction. We know racial disparities exist in terms of administering and prescribing drugs, and empathy is related to reducing these differences in treatment.

Beyond the Opioid Crisis: A Holistic Approach

Taking a holistic approach to addressing the opioid crisis involves several key steps. 

There should be an expansion of funding and the scope of funding available to tackle the crisis. This funding should not be limited solely to specific interventions or programs targeting opioid users, but rather should consider the broader factors contributing to addiction. 

Acknowledging and addressing social and structural determinants of opioid addiction can be done through policy changes and community organizing. 

Empathy-building plays a crucial role in successful recovery. Behavioral health professionals should continue to develop their ability to understand and empathize with those facing addiction, while also addressing compassion fatigue and maintaining appropriate boundaries while still being able to understand backstories. Creating a supportive environment where seeking help is destigmatized will contribute to more individuals accessing treatment and support.

By adopting a holistic approach that combines evidence-based practices with empathy and an understanding of social determinants, we can better connect the opioid crisis to the broader context of the population being served. 

Why Integrate a Sociological Perspective?

The sociological perspective is crucial when examining addiction, including opioid addiction, as it offers valuable insights into understanding the trends and complexities of this issue at the population level. Addiction is not solely an individual problem; it is deeply influenced by social and cultural factors, and the sociological perspective allows us to recognize and explain these influences.

By taking a sociological approach, we can better comprehend why certain trends in opioid use and addiction change over time, including factors related to initiation and continued use. It acknowledges the significant impact of culture, social norms, social position, geography, and disparities in shaping addiction patterns.

Understanding the social and economic conditions surrounding addiction can help guide research and inform policy development. Through sociological research, we can evaluate the effectiveness of various policies in real-time and retrospectively, allowing for adjustments and improvements in intervention strategies.

Stigma awareness is another crucial aspect addressed through the sociological perspective. By reducing stigma and recognizing contextual factors, we can move beyond seeing addiction as merely an individual choice.

The Mental Health Professional's Role

The role of mental health professionals and behavioral health workers in addressing opioid addiction is essential, and adopting a sociological perspective can further enhance their effectiveness. Understanding the individual within their social and societal context is something we do and this is validation that it is good practice.

Empathy-building and inquiring about personal factors contribute to forming a strong therapeutic relationship and gaining insights into the unique challenges of each individual. Practicing cultural humility allows professionals to set aside assumptions and approach each patient with sensitivity to their cultural background and experiences.

Providing education on non-pharmacological interventions is valuable, as it opens up alternative approaches to managing mental and emotional pain. Integrating these interventions alongside other approaches can have an impact.  

Prioritizing self-care and stress management is vital for mental health professionals dealing with the demands of their work and personal lives. Stress in the workplace and society at large can take a toll on professionals. While there are interventions that need to happen on a larger scale in society and workplaces, engaging in self-care practices on an individual level can be empowering and beneficial for mental health professionals in managing their own well-being and maintaining their capacity to provide effective care to their clients.

Summary

In conclusion, mental health professionals and behavioral health workers play a crucial role in addressing opioid addiction. By integrating a sociological perspective into their practices, they can better understand the complexities of addiction, provide empathetic care, and consider the social and contextual factors that influence an individual's relationship with opioids. Prioritizing self-care further enhances their ability to support people with addiction and promote a holistic approach to addressing the opioid crisis.

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