Reasons for Initiation and Maintenance of Drug Use and Alcohol Use Among Dually-Diagnosed Individuals
Objectives: The objectives of the study were:
- To determine the reasons why subjects initiated substance use;
- To examine the determinants of patterns of substance use over time;
- To study the circumstances surrounding relapses, including attributions for cravings, urges and drug dreams and how they lead to substance use (i.e., when strategies to cope with cravings or urges are unsuccessful); and
- To examine the association between substance use and mental illness (from subjects' perspectives as well as from patterns of substance use and symptoms) to derive conclusions about the role of mental health disorders in substance use among the dually-diagnosed.
Significance: A large percentage of persons with an alcohol or drug
use disorder have a comorbid psychiatric disorder. Compared to those
with a "single" disorder, these "dually-diagnosed" individuals
are more impaired, seek treatment services more often and tend to have
a poorer prognosis. Dually-diagnosed individuals working on their recovery
report significantly more difficulty dealing with substance use-related
issues (e.g., fear of relapse) than with mental health. (e.g., symptoms
and medication side-effects. This emphasizes the need to understand
the causes of drug and alcohol abuse in this population.
Most theoretical formulations of the causes of substance abuse among
the dually-diagnosed have received, at best, modest support from empirical
investigations; the majority of such studies have been conducted among
clients with a psychotic disorder, chiefly, schizophrenia. One potential
area that remains largely unexplored is substance users' stated reasons
why they use drugs and alcohol (what they believe drives them to use).
These perceptions, however inaccurate, may themselves drive drug-taking
behavior and thus merit further investigation because what substance
users believe about the effects of drug and alcohol use is a crucial
determinant of whether they maintain (or return to) substance use.
Methods: Participants (N = 310) were members of a dual-recovery self-help group (Double Trouble in Recovery -DTR) held in community-based service agencies and treatment programs in New York City between from Jan. to Dec. 1998. They were interviewed using a semi-structured instrument
Key Findings: Study participants were predominantly male and ethnic minority members. Their experiences with drugs and alcohol were extensive, starting with their first use in early adolescence. Primary substances were crack/cocaine and alcohol, primary psychiatric diagnoses were schizophrenia, bipolar disorder and major depression. One-half of participants started using drugs before experiencing mental health symptoms, 38% showed the reverse pattern; and 12% started experiencing symptoms and using drugs or alcohol at the same age.
- Initiation of Substance Use Alcohol and marijuana were most often cited as substances used first. Fifty-percent reported using daily or almost daily when they started.. The most often cited reason for starting to use was the desire to fit in ("to belong," "to be accepted").
- Abstinent Periods: Reasons to Quit and Strategies. Nearly two third of participants reported having had one or more drug-free periods of one month or longer outside of being in a closed controlled environment (e.g., hospital or jail). The desire to have a better life and the negative consequences of drug use (e.g., severe threat to health, fear of losing custody of children, frequent car wrecks) were the most often cited reasons to stop. The most frequently used strategies used to stop were 12-step recovery groups, drug treatment and 'cold turkey.'
- Triggers to Relapse Forty-two percent of those who had reported having had one or more drug-free periods of one month or longer outside of being in a closed controlled environment had returned to substance use. The two most frequent internal reasons for returning to substance use were loneliness/boredom and the desire to use (cravings). Stress and increased responsibilities, and temptation to use were the most frequently cited environmental triggers to relapse.
- Perceived Association between Mental Illness and Substance Use In structured (forced-choice) items, two-thirds of participants reported that their symptoms get worse if or when they are using drugs and 44% of participants said they felt like using 'very much' if/when they experienced symptoms.
The exploration of reasons for substance use and its relationship to their mental health disorder among dually-diagnosed individuals' can elucidate the interaction between the two disorders as well as provide valuable information of therapeutic relevance, particularly with respect to relapse prevention. Learning what individuals believe causes them to use drugs and alcohol will help identify triggers as well as any erroneous or irrational beliefs about substance use; both can then be addressed explicitly in the therapeutic context; positive coping strategies for dealing with triggers and cravings can be introduced as alternative to substance use. Moreover, learning clients' stated reasons for substance use can also yield information about issues that may not typically be addressed yet play an important part in clients' lives such as boredom, low self-esteem or the need for social contact. Finally, both substance dependence and psychiatric disorders are often viewed as chronic, relapse-prone disorders it is important to understand the interplay between the two disorders over time. Doing so will yield information that can contribute not only to substance use relapse prevention efforts but also potentially, to improving clients' mental health (if, for instance, data were to show that a substance use relapse triggers a recurrence or aggravation of mental heath distress). In addition, learning about the reasons for substance use among the dually-diagnosed can contribute to the development or refinement of prevention program for mentally ill individuals who are not substance users.
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