Substance Abuse Treatment – What Really Works? (Part Two)

In the previous blog, I spoke about the importance of a thorough assessment to individualize a person’s treatment, the inclusion of group, individual, and family services, the use of education about the recovery process, and the utilization on an outpatient basis of consistent urine toxicology and breathalyzer screening.  In today’s blog, I will focus on the importance of medical care, psychiatric services, addiction medications, and community recovery support.

Many abusers of substances come to treatment with an array of medical issues, including malnutrition, infections, sexually transmitted disease, HIV, hypertension, or poor hygiene.  Many have not been seen by a medical professional in years.  It is a sign of good care that any patient entering substance abuse treatment be seen early in the process by a medical care professional.  This screening should determine what medical issues need to be addressed immediately and what issues need to be monitored throughout the treatment process.

Good treatment should also include a thorough screening of mental health concerns.  This may begin with completion of standardized screening tools used to pinpoint areas of concern around suicidal or homicidal thoughts, mood disorders, anxiety disorders, psychotic disorders, trauma, or personality disorders.  Any concerns identified would lead to a more specific exploration with a psychiatrist or other trained mental health professional.  This may lead further to a recommendation of medication to alleviate some of the symptoms of mental health disorders.

Another area of good practice is the inclusion of addiction medicine in the overall treatment plan.  Today, we are fortunate to have a variety of medications that can aid in reducing urges and craving for particular substances or to act as a better substitute for physical addiction to particular drugs.  For example, naltrexone seems to benefit many individuals dependent on opioids and/or alcohol.   Oral naltrexone acts as an opioid blocker in the brain, blocking the euphoric effects of opioids, and also seems to decrease the urges and cravings for alcohol.  For those who may not be compliant with taking the medication daily, there is now a monthly injectable version of naltrexone with the product name of Vivitrol.  Acamprosate, with the product name Campral, has also shown benefit in decreasing the urges and craving for alcohol in many users.  There are also medications to replace opioid dependence, such as methadone and the newer medication buprenorphine.  For nicotine dependence, there are now nicotine replacement aids, such as patches, gums, and even an electronic cigarette.  There is also an effective medication, Chantix, which appears to help decrease the cravings for nicotine.

Lastly, good treatment involves educating clients about the usefulness of participating in community recovery support services during and after leaving the treatment program.  Since substance use disorders are no longer considered to be an acute care disorder, but rather a chronic care condition needing a lifetime of monitoring, ongoing support is vital to arresting the disorder from reoccurring. This community recovery support may include participation in such programs as Alcoholics Anonymous and Narcotics Anonymous, or newer groups including SMART Recovery, Women for Sobriety, and Secular Organization for Sobriety (SOS).  There are now online support groups with chat rooms and videoconferenced services, such as Chat2Recovery.  Community recovery support can also include working with a particular professional specializing in helping people maintain a lifestyle free from substance use.  There are now even groups such as Moderation Management that support those who wish to attempt controlled use of substances.

High-quality substance abuse treatment can be very effective when it consists of the ingredients mentioned in the last two blogs.  Before entering any treatment program, ask specifically about the services offered and make certain that the program that you are considering includes many if not all of the services mentioned.


Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City. He has been in the field of substance abuse treatment for over 30 years. He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.  He can be reached at

Substance Abuse Treatment – What Really Works?

When I began working in the substance abuse treatment field over 30 years ago, the general philosophy seemed to be that the individual fit into the program model rather than the other way around.  There was little individualized care being offered.  While there are still treatment programs following this model of “one size fits all,” quality treatment programs today follow the philosophy of providing individualized care for each person based upon his or her particular needs or problems.  In order to provide effectively for this individualized care, programs today must have access to an array of treatment services to meet the particular needs of their patients, whether within the program itself or through links to specialized services outside of the program.

Since my expertise is in outpatient treatment settings, I will focus on effective services provided on an outpatient basis.  The array of services that should be offered on an outpatient basis includes, at a minimum, the following: a comprehensive assessment; individual, group, and family counseling; recovery education; toxicology and breathalyzer screening; psychiatric monitoring; medical care; addiction medicine; and access to community recovery support.

Effective treatment of substance use disorders begins with a thorough assessment of a person’s history.  The assessment should include a review of the individual’s substance use and treatment history, including use of objective screening tools to confidently ascertain that there is a diagnosable Substance Use Disorder (SUD).  The substance use history should attempt to understand whether the factors leading to an SUD are associated with physiological, psychological, social, environmental, or spiritual factors.  The assessment should include a review of mental health factors, including objective screening tools for signs of mood disorders, anxiety disorders, psychotic disorders, trauma, brain injury, and other compulsive behaviors (e.g., gambling, sex, eating).  A comprehensive assessment looks at the person’s physical health, and refers the individual for a physical examination as indicated.  A review of the individual’s family and social history is needed to understand the significance of relationships present and past, as well as the individual’s interpersonal functioning.  A review of education and employment history is important, including educational or vocational deficits.  Understanding a person’s living environment and leisure activities is very important.  It is also useful to be aware of any legal issues that may be impacting an individual’s life.  It is this comprehensive assessment that should be the basis of someone’s individualized treatment program.  I would recommend finding an alternative treatment program if this kind of assessment does not occur soon after enrolling in a program, or if the program offered to you appears to have no association to the problem areas identified in the assessment.

Effective treatment programs must include an array of individual, group, and family counseling services.  The counseling services offered should be associated with the assessment issues identified. If a patient is identified as ambivalent about complete abstinence from substance use, this factor should help determine the proper placement in particular groups or individual counseling that can address this ambivalence.  If the patient is found to have significant co-occurring mental disorders, this should also be taken into account in the placement of counseling services.  The frequency of group and individual sessions should be individualized to the particular issues of the patient.  Furthermore, family treatment and couple counseling should be provided either on-site or as a referral to outside resources when indicated.

Some degree of recovery education is expected in an effective treatment program.  This education should include: developing new coping skills to deal with urges and cravings; dealing with drug refusal skills; understanding the process of recovery; and understanding addictive disorders from biological, psychological, social, and spiritual perspectives.  This education should be provided by a qualified professional who is comfortable with the material covered and can answer questions effectively.

Effective outpatient programs should include toxicology screening and breathalyzer screenings as needed and on a random basis.  Many participants in outpatient programs report that the screenings were a helpful deterrent to continued substance use.  When they felt a strong urge to use a substance, believing that a toxicology screening or breathalyzer might be awaiting them at the treatment center helped them choose not to use the substance.  Also, fear and shame lead participants to hide or minimize substance use.  Regular toxicology and breathalyzer screenings allow the treatment team to monitor progress and dangerous relapse patterns. 

In Part Two of this blog, we will focus on the remaining services recommended as part of an effective treatment program.


Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City. He has been in the field of substance abuse treatment for over 30 years. He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.

What are the Options for Substance Abuse Treatment? (Part Two)

In Part One of this blog, I discussed the more intensive levels of care, namely inpatient detoxification services and residential treatment services.  In Part Two, I will review outpatient levels of care. Moving from the most intensive to least intensive, the first outpatient level of care (LOC) to consider is ambulatory detoxification services.  This LOC is considered for the person who is using a substance or substances daily and is physically addicted.  Physical addiction was explained in Part One as having developed tolerance for a substance and experiencing withdrawal symptoms when discontinuing that substance. Ambulatory detoxification typically involves going to a treatment center daily for a number of days to obtain medication, monitor vital signs, and assess the person’s comfort level during the detoxification process.  A professional addictions specialist would determine whether a person appears to be a good candidate for ambulatory detoxification or would need monitoring in an inpatient detoxification.

Intensive outpatient (IOP) involves non-residential services that typically meet a minimum of 3 hours per day and typically 9 to 12 hours per week.  The services often consist of daily educationally focused workshops, group counseling, individual counseling, and urine drug screens.  This level of care usually lasts about 4 to 8 weeks, with the average being about 6 weeks.  It is similar in its treatment approach to a 28-day inpatient treatment model, but the participant does not have to live away from home or even take a leave from his or her job.

The person who would benefit from IOP services is the individual who is using substances quite regularly, although is not physically addicted, and cannot seem to abstain from his or her substance use for any extended period of time.  This LOC is also suggested for the individual who lacks education about substance use disorders and the recovery process.

Outpatient treatment is the next less intensive LOC to consider.  Outpatient treatment includes any non-residential treatment services involving less than 9 hours per week or less than 3 hours in any day.  It includes structured outpatient programs or treatment in the office of a private practitioner.  An example of a structured outpatient program may include two 90-minute group sessions weekly, combined with a weekly individual counseling session.  The treatment can last for weeks or months, depending on the provider’s treatment philosophy.  The types of groups offered at this LOC also depend on the provider’s treatment philosophy, and can be oriented to a more traditional 12-step disease-model approach or geared toward more of a harm-reduction approach.  You should ask about a provider’s orientation towards treatment prior to enrolling.  In New York State, all licensed treatment programs are now rated by the Office of Alcoholism and Substance Abuse Services (OASAS) on a star system for their quality of treatment.  This system in New York is known as Scorecards and can be accessed at

The newest developing LOC for treatment of substance use disorders is online addiction treatment, such as the Inter-Care program, Chat2Recovery.  For those individuals who are either reluctant to enter face-to-face treatment (for whatever reason), cannot commit to being at a specific location on a set schedule due to work or travel commitments, or cannot find accessible quality outpatient services, this may be an alternative for treatment.  Chat2Recovery (C2R) has a 6-week program consisting of twice-weekly videoconferenced groups and bi-weekly videoconferenced individual sessions with a licensed clinician.  The program is geared toward providing support and education about the recovery process.  You can access it at

If the level of care that you enter is not working for you, you can always go to a higher or lower level.  If you are using your health insurance benefits to pay for treatment, your insurance provider will clearly have a say in which level of care you choose. 


Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City. He has been in the field of substance abuse treatment for over 30 years. He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.

What are the Options for Substance Abuse Treatment? (Part One)

Someone seeking treatment for a Substance Use Disorder for the first time can be confused about how to proceed. There are many options. If you ask for advice from someone who got help for themselves, they will often recommend what worked for them. That doesn’t necessarily mean that same treatment will be best for you. If you go to a treatment provider that only provides one option for treatment, guess what will likely be recommended for you. It’s important to be educated about making an informed choice that is best for you and will likely be effective. Let’s begin by discussing some of the more common treatment options or what we call levels of care. The options for treatment that I will be discussing include: medical detoxification, residential services, outpatient services, online treatment, addiction medicines, and self-help.

Let’s start with the most intensive and costly treatment options and progress to the least restrictive options. The most intensive option, or level of care, is known as medical detoxification or detox. This treatment is generally recommended for individuals who are heavy users or daily users of substances leading to physical addiction. A physical addiction is characterized by withdrawal symptoms (e.g., shakes, sweats, changes in blood pressure, fever) when discontinuing the substance and, when actively using the substance, high levels of tolerance (i.e., needing greater amounts of the substance to get to a state of intoxication). The setting for this treatment is typically a medical facility (e.g., hospital, private medical office) where your treatment is managed and monitored by medical staff, including doctors and nurses. Patients typically remain in this level of care for a few days (i.e., 2 to 5 days) depending on the severity of the medical condition. In our current health care model, insurance companies are often selective as to which substances are considered eligible for medical detox. Typically, the substances considered to lead to physical addiction with potentially harmful withdrawal symptoms include alcohol and sedatives from the benzodiazepine family (e.g., Valium, Xanax, Klonopin, Ativan). Opioids, which are pain killers, are also considered to lead to physical addiction. Opioids include heroin, codeine, morphine, methadone, oxycodone, hydrocodone, fentanyl, and buprenorphine, to name a few. However, because withdrawal from these substances, while unpleasant, is not considered life-threatening, many managed care companies will not authorize an inpatient medical detoxification for opioids, preferring treatment in what is known as an ambulatory or outpatient detoxification. Ambulatory detox involves going to a clinic each day for medication and monitoring of withdrawal symptoms for several days to a few weeks. Other substances, such as cocaine, methamphetamine, marijuana and hallucinogenic drugs, are not thought to lead to potentially harmful or life- threatening situations during withdrawal from heavy and chronic use patterns. Consequently, these substances are not usually authorized by managed care companies for inpatient medical detoxification.

Residential treatment services are the next option for care. Residential treatment involves entering a controlled environment where you will live for a specific duration of time, typically from 2 weeks to several months. There are a variety of residential treatment options. The most popular is the 28-day rehabilitation program, which has gotten a lot of publicity due to the number of celebrities who have participated in this form of treatment. The inpatient rehab model typically involves a daily, structured schedule of treatment activities, including specialized groups (e.g., cognitive-behavioral, trauma, relaxation, etc.), individual counseling, educational workshops on recovery-related issues, and reading and writing assignments. The quality of these programs, and the cost, varies greatly, and you will need to do a thorough review before choosing one. Your review should include what will and will not be covered by your health insurance plan, and you should obtain a copy of a typical schedule of activities, the current demographics of the population, the program’s treatment philosophy, and its reputation among former patients and addiction professionals. Usually, residential treatment is recommended for individuals who are unable to refrain from substance use for any extended period of time. If you are unable to abstain from a problem substance for at least three consecutive days, and are not exhibiting a physical addiction to alcohol, sedatives, or opioids, this level of care may be an option for you. Some residential programs combine medical detoxification services with the less intensive residential treatment services. Other residential services include an extended-care model, in which participants live in a sober environment for several months, and sober houses that do not provide treatment, but only provide a sober and supportive living environment. In Part Two of this blog, I will explore other, less intensive treatment options.


Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City. He has been in the field of substance abuse treatment for over 30 years. He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.

What Causes Substance Use Disorders? A Look at Spiritual Factors

What Causes Substance Use Disorders? 

A Look at Spiritual Factors

In previous blogs I have explored the physiological, psychological, social, and environmental factors contributing to substance use disorders.  Today, I will be writing about spiritual factors.  It’s not a coincidence that I write this blog just after returning from a vacation to my favorite place for reconnecting spiritually—a tiny island in the West Indies called Anguilla, a place of such natural beauty and loving people that it’s hard for me not to feel connected to something much larger.  On these trips, I also read spiritually based books that enhance my appreciation of being there or, more accurately, being here.

 It’s important that we feel a sense of purpose or meaning in our lives.  Without that, we feel a sense of emptiness—what is often termed a “hole in the soul.” In order to fill this hole, we often seek behavioral distractions, such as substance use, sex, work, food, or gambling, to fill this void. These behaviors, however, seem to help only temporarily at best.  We still feel empty, despite these distractions. I describe this state as having a spiritual deficit—the inability to feel purpose, meaning, or connection to something larger than ourselves.  This spiritual deficit is characterized by feeling alone, appearing depressed or apathetic, being involved in a variety of compulsive behaviors, having difficulty connecting to others, and suffering a variety of physical ailments.

Eckhart Tolle, in his classic book The Power of Now, succinctly depicts what it’s like to feel disconnected.  He writes, “The inability to feel this connectedness gives rise to the illusion of separation, from yourself and from the world around you. You then perceive yourself, consciously or unconsciously, as an isolated fragment.  Fear arises and conflict within and without becomes the norm.”  According to Tolle, feeling disconnected leads to a general sense of fear or dread.  It’s not surprising, then, that individuals with this spiritual deficit turn to drugs and alcohol to medicate the fear. 

How do we find purpose or meaning in our lives?  The simple answer is by finding passion for something.  This may include finding passion in our jobs, or through our roles, such as being a good parent.  However, many of us have not been able to find passion for anything.

One of the books that I took with me on vacation was The Art of Happiness.  A classic, it integrates our understanding of happiness from the perspective of the Dalai Lama’s Buddhism and that of Western science.  The Dalai Lama believes that our ultimate purpose in life is to simply find happiness.  He believes that the ways many of us seek happiness are often misguided.  He believes that the key to finding happiness and avoiding suffering is our state of mind.  He writes, “The greater the level of calmness of our mind, the greater our peace of mind, the greater our ability to enjoy a happy and joyful life.”  The way we develop this peace of mind is based upon the way we interpret the events in our life.  Cognitive therapy is a Western form of psychotherapy that challenges our irrational beliefs and helps us form new ways of thinking about situations in our lives.  The Dalai Lama believes that a systematic retraining of the mind by deliberately selecting and focusing on positive mental states (e.g., compassion, kindness) and challenging negative mental states (e.g., hatred, anger, greed, jealousy) can lead to happiness and the avoidance of suffering.

In my lecture with patients entitled “Spirituality: The Neglected Dimension,” I review common character weaknesses that foster unhappiness, including self-centeredness, irresponsibility, hatred, and resentment, and suggest ways to replace those responses with ones that lead to happiness and fulfillment.  For example, compassion can replace self-centeredness, discipline can replace irresponsibility, and compassion can replace hatred and resentment.

I truly believe that many individuals seeking treatment for substance use disorders are suffering from spiritual deficits and seeking something to replace their sense of isolation and lack of purpose.  It is our responsibility as practitioners to guide individuals toward greater fulfillment in their lives.


Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City.  He has been in the field of substance abuse treatment for over 30 years.  He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.

What Causes Substance Use Disorders? A Look at Social and Environmental Factors

In previous blogs, we looked at physiological and psychological factors that may contribute to the development of Substance Use Disorders (SUDs).  In this entry, we will focus on some social and environmental factors that may lead to the development of SUDs.

When discussing potential social factors contributing to the occurrence of SUDs, it seems reasonable to begin with the child’s primary social group—their family system, or their primary caretakers.  Obviously, the family’s attitude and behavior toward the use of alcohol and other drugs can have a significant impact on that child’s substance use patterns.  If the parents (or the primary caretakers) often abuse drugs and alcohol around the child, this may lead to the child modeling the behavior and repeating it later.  Sometimes, the modeling is not of the parents, but of other influential family members, such as siblings, uncles, aunts, or grandparents. 

Other family factors that have been found to contribute to the development of SUDs in a young person include poor supervision during the formative years, severe disciplinary practices toward the child, frequent family conflicts making the family system seem unsafe, and even economic deprivation or poverty in the household.  In recent studies attempting to identify factors leading to substance abuse in adolescents, the single most important factor for preventing SUDs was the frequency that children ate meals with their primary caretakers.  There seems to be a strong inverse correlation between eating meals with parents and substance use.  Children who frequently ate meals with parents abused substances less often than those who did not. 

Another important factor in a child’s life that contributes to the onset of SUDs is the school system.  Clearly, children with more conduct problems have a greater likelihood of developing SUDs.  This may not be entirely a social issue, as there is growing evidence that conduct disorders and SUDs may have genetic commonalities running in some families.  We do know that a low commitment to school, school failure, truancy, early dropout, and placement in special education classes are all correlated with an increased likelihood of developing SUDs.

A third system that plays an influential role in the life of an adolescent is the peer system.  It seems reasonable that an association exists between a strong acceptance of heavy drug and alcohol use by one’s peers and the development of heavy use in an adolescent.  Does an adolescent seek out peers with similar attitudes towards drug and alcohol use, or does the peer group influence the child’s attitude toward drugs and alcohol?  It seems to work both ways. 

Lastly, there are other environmental factors that appear to contribute to substance abuse, including poverty, unemployment, and a community or cultural leniency towards heavy drug and alcohol use.  Currently, there is a growing controversy as to the influence of television, movies, and video games that portray frequent use and abuse of substances on teen abuse of substances.  We will see what the growing research determines about these factors. 

In summary, there are many social and environmental factors that may contribute to the heavy use and abuse of drugs and alcohol.  Often, simply changing one’s environment and peer group can have significant, positive effects and reduce the likelihood of developing an SUD.

Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City.  He has been in the field of substance abuse treatment for over 30 years.  He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.

What Causes Substance Use Disorders? A Look at Psychological Factors

In the last blog, I discussed the physiological factors leading to Substance Use Disorders (SUDs). This time, I will focus on psychological factors that influence the abuse of and dependence on mood-altering chemicals.  There are two main psychological factors that I wish to focus on: self- medicating for mental health disturbances, and relying on maladaptive coping mechanisms.

Many individuals suffer from mental health disorders, including mood disorders (e.g., depression or bipolar disorder), anxiety disorders (e.g., panic disorder, post-traumatic stress disorder, generalized anxiety disorder), psychotic disorders (e.g., schizophrenia), and personality disorders (e.g., borderline, histrionic, dependent, etc.).  Many times these disorders go undiagnosed.  When people have one of these disorders, all they know is that taking a particular substance or substances makes them feel better.  As discussed in the last blog, many drugs of abuse affect naturally occurring chemicals in our brains and often alleviate distressful feeling states.  We often see individuals with specific mental health disorders choose to abuse particular classes of substances.

For example, people who are depressed or who have anxiety disorders often choose substances classified as depressants (e.g., alcohol, sedatives, sleep aids), whereas those with hyperactivity and attention-deficit disorders often choose drugs from the stimulant classification (e.g., cocaine, methamphetamine, Adderall).   We are also discovering that individuals who have been through severe trauma with suppressed rage commonly abuse pain killers, such as medications in the opioid family (e.g., heroin, hydrocodone, Oxycontin). Obviously, these mood-altering substances are helping people feel better. Unfortunately, use of these substances can quickly and easily turn into abuse and dependence.

Another psychological factor that can lead to the development of an SUD is associated with maladaptive coping mechanisms.  For example, if a child is growing up in a family system that is full of neglect or violence, the child may experience significant fear or anger and have no means of handling these feelings in an effective way.  In other words, the child has not developed adequate coping mechanisms to handle the feelings.  The child is then introduced to alcohol by friends and realizes that he doesn’t feel as upset when he drinks alcohol.  He quickly learns to deal with feelings by consuming alcohol, a pattern that continues well into his adult years.  Many individuals learn to cope with negative emotional states (e.g., depression, anxiety, boredom, anger) by getting high.  This becomes the only way they have of dealing with these distressing emotional states.  Oftentimes, treatment is a process of teaching more appropriate means of coping than the potentially dangerous strategy of medicating negative emotional states.

Let us know your thoughts—please comment.


Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City.  He has been in the field of substance abuse treatment for over 30 years.  He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.

What Causes Substance Use Disorders? A Look at Physiological Factors

 In previous blogs, I’ve defined Substance Use Disorders (SUD’s) and addiction. In this blog, we‘ll begin to explore the factors leading to SUD’s. Our most current understanding of SUD’s is that they develop from a variety of factors often with one or more factors being predominant. The factors commonly fall into 4 primary categories: physiological, psychological, social/environmental, and spiritual. In today’s blog, I‘ll primarily focus on the first category; physiological factors.

We‘ve developed an understanding that, for some individuals and families, SUD’s seems to be more common in some families than in others. Is it because substance abuse is learned within a family system or is it because something genetic is inherited? A few important studies seemed to suggest the latter. In one study, children adopted out of an addicted family system early in life and raised by non-substance abusing families still had higher rates of SUD’s compared to children who were born to non-abusing parents. In another important study, identical twins of the same genetic make-up were compared to fraternal twins who were born at the same time, but who did not share identical genetic material. This study attempted to remove differences often associated with learned behavior within a family system. The study reported that identical twins had higher rates of substance abuse as they matured than their fraternal twin counterparts providing more evidence of genetic traits being passed on from generation to generation.

The studies mentioned above seem to suggest that, for some individuals, something is being inherited or passed on genetically, that makes some more vulnerable to addiction than others. But, what is it that is inherited remains elusive. Scientists have not been able to simply locate a specific gene which leads to a susceptibility to addiction. This genetic susceptibility seems to involve an interplay of several genes. Individuals with this genetic vulnerability also seem to share other common psychological disorders such as antisocial personality and attention-deficit hyperactivity.

One of the most intriguing questions in treating SUD’s is why aren’t we all abusing the same substance or substances? In other words, why do some individuals abuse alcohol, while yet others prefer cocaine, or marijuana, or heroin, or any other particular substance? Why are there individual preferences for mood-altering chemicals? The answer to this may lead to our understanding of what is being genetically inherited. A theory as to what is being inherited is often termed the “Self-Medication Hypothesis”.

The Self-Medication Hypothesis suggests that some of us choose particular, mood-altering substances because they compensate for deficiencies in chemicals that are naturally found in our brains. For example, dopamine is a naturally occurring chemical in our brains that give us the feeling of pleasure when released. Dopamine is released when we have sex, eat a nice meal, gamble, exercise or get high. We also know that cocaine, for instance, releases very high levels of dopamine in the brain. The theory suggests that when a person with abnormally low levels of naturally activated dopamine uses a substance such as cocaine, that person will have a greater activation of dopamine than they have experienced before. This may actually make the person feel more “normal” than ever before setting up a pattern of continued use and possible abuse of cocaine. Other chemicals in the brain handle other psychological states. For instance the neurochemical, GABA , when released, is associated with decreases in anxiety; serotonin is associated with mood; endorphins are associated with managing pain (emotional as well as physical pain). Different drugs of abuse work on different neurochemicals. Thus, the Self-Medication Hypothesis suggests that we seek out specific drugs of abuse in order to compensate for deficiencies in naturally produced neurochemicals.

Why is the Self-Medication Hypothesis only a hypothesis? The answer is because our current technology is not yet sophisticated enough to accurately measure levels of neurochemicals in our naturally occurring brains. We cannot yet determine, for instance, how much dopamine is currently produced in our brains and what the normal levels should be. Our ability to accurately measure these neurochemicals has not yet occurred although significant progress is being made. It is believed that, one day in the near future, we’ll be able to measure these neurochemical levels , thus allowing for accurate forecasts as to who is likely to develop addictive potential for different drugs of abuse. One day, we may even be able to alter neurochemical deficiencies and significantly decrease the likelihood of SUD’s for many individuals and families. What are your thoughts and reactions to this blog? Let us know.

Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City. He has been in the field of substance abuse treatment for over 30 years. He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.

What is Chemical Addiction?

                      What is Chemical Addiction?

In the previous blog,   I defined the meaning of Substance Use Disorders.  However, the term “addiction” as it relates to substance use often connotes a subtle, but important difference. Whereas a Substance Use Disorder (SUD) is usually characterized by loss of control over a substance, addiction suggests more of a preoccupation to use.  That preoccupation to use can be associated with a psychological obsession to use or a physical compulsion to use.  Many times it can be both.

  Let’s first take a look at psychological addiction. Psychological addiction represents more of the obsessive qualities of substance use.  In other words, the incessant thoughts of using substances; the frequent and almost uncontrollable urges to use, distracting one from other activities of daily life. These preoccupations to use can be very powerful causing one to become irritable and psychologically unavailable to others until the obsession to use has been satiated with actual use.  Most individuals dependent on substances experience some degree of psychological addiction.   One of the best depictions of this psychological preoccupation was portrayed in the writing of J.R. Tolkien’s Lord of the Rings trilogy.  The power of the magic ring led to such mental preoccupation that the character Gollum would stare at it calling it “my precious.”   His life became completely obsessed with the ring.  Nothing mattered more than getting his hands on the ring.

Physical addiction is less common than psychological addiction.  That’s because not every substance is believed to lead to physical addiction.  This point is a matter of controversy. The substances that are currently associated with physical addiction fall into two categories:  depressants and opioids.  Depressants include alcohol, benzodiazepines (i.e., Valium, Xanax, Klonopin, and Ativan) and barbiturates (i.e., phenobarbital, Luminal).  Opioids include opium as a pure opiate, partially synthetic opioids such as heroin, codeine, and morphine and completely synthetic opioids like hydrocodone, oxycodone, and methadone.

Physical addiction is defined by two factors:  withdrawal and tolerance.  Withdrawal is defined as the body’s physiological response to the absence of ingesting the substance.  Withdrawal is usually associated with daily use of one of the substances mentioned above leading to characteristic, physiological symptoms for several days to several weeks when abstaining from the substance.  These symptoms can include sweating, nausea, shakes, agitation, even delusions and hallucinations.  In very heavy physical addiction to depressants like alcohol or benzodiazepines, there are even fatalities associated with withdrawal when going “cold turkey”.   Alternative medications are used to treat cases of physical withdrawal.  Tolerance is defined as needing more of the substance over time to achieve the same level of intoxication or desired effect.  For example, a person may initially find that six drinks would provide the adequate dosage of intoxication needed, but after months of daily use need two to three times that amount to obtain the same effect.  This same effect applies to many pills and opioid substances.  Many believe that even daily marijuana use can lead to withdrawal symptoms and tolerance.

In summary, chemical addiction can be exhibited through psychological addiction and/or physical addiction.  While every mood-altering substance can lead to psychological addiction, it is current belief that not every mood-altering substance leads to physical addiction.  Share your thoughts on this topic. I would love to hear.


Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City.  He has been in the field of substance abuse treatment for over 30 years.  He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.

Do I Have a Substance Use Disorder?

Do I Have a Substance Use Disorder?  It Begins with an Honest Self-Appraisal


In the last blog, I attempted to give you a simple description of Substance Use Disorders (SUDs).  In this blog, I will help guide you toward understanding whether you meet the criteria for one of these disorders.  The essential element here is self-honesty.  You will be completing some screening questions to ascertain your patterns of substance use.  You must be truthful with yourself in answering these questions and avoid minimizing the answers.  No one needs to know the answers to these questions besides you.  Your willingness to honestly take a look at your substance use patterns takes courage. It is often very painful for us to admit our shortcomings even to ourselves. Furthermore, your willingness to take an honest appraisal of your use patterns suggests some degree of personal concern over your behavior.  It is commendable that you’re willing to look at your behavior so honestly. This step alone may be one of the most significant you have ever taken towards self-improvement.

Among the screening instruments that we use at Chat2Recovery as part of our assessment process include the Alcohol Use Disorders Identification Test (AUDIT) for drinkers and the Drug Abuse Screening Test (DAST) for substances other than alcohol.  They are easy, short and scientifically validated tools for screening for SUDs.  While these instruments are the ones we prefer to use, there are many more available for you to consider, including the popular Michigan Alcoholism Screening Test (MAST),  the CAGE for alcohol, the Substance Dependence Severity Scale (SDSS), and the Severity of Dependence Scale (SDS) for substances other than alcohol.

If and when you’re ready, you can go to these instruments at the following e-mail addresses.  For the AUDIT, which will be automatically scored, go to For the DAST, which also is automatically scored, go to  At this site, you can also get access to other alcohol screening instruments mentioned above, namely, the CAGE and the MAST.  These questionnaires can all be completed anonymously, so there is no concern for your privacy.  While the scores to these screening tools may or may not suggest problem use of substances, it is highly recommended that you seek an evaluation with a licensed professional who specializes in treating substance use disorders for a more accurate view of your substance use patterns.  But, before you begin, remember, it all begins with an honest appraisal of your behavior.

In the next blog, I will review the difference between physical and psychological dependence to substances.  Please keep your comments and questions coming!  Speak soon.


Stay well,

Nick Lessa