Addiction and Mental Health Across the Lifespan: An Overview of Some Contemporary Issues

Throughout history, humans have discovered paths to pleasure, euphoria, and alternate realities through substances. Psychoactive substances that were ingested, chewed, inhaled, or smoked have played an important part in cultural rituals across the millennia. Early humans also discovered that substances derived from plants (e.g., opium from the poppy plant) can relieve the agonizing pain of acute and chronic medical conditions. All of these substances that benefited humanity also can be abused, either intentionally or inadvertently. New to the modern world are technological tools that can be misused and abused, such as the Internet. As Grossman noted, “The Internet, conceived as a research and productivity tool, has become a weapon of mass distraction” (Grossman, 2008, p. 52). In some countries in Asia (e.g., South Korea), Internet addiction is considered an issue of public health significance (Starcevic, 2013). The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013) includes Internet Gaming Disorder, in which individuals forgo meals, sleep, and even school or career opportunities to play games on the computer for countless hours. Clearly, this behavior activates the brain's reward system in a manner similar to taking a drug. Addiction is diagnosed when use of substances (or reward-seeking behaviors) continues despite adverse consequences (Boyd, 2017). Contemporary issues in addiction include its new manifestations, such as Internet Gaming Disorder, as well as the many complex and diverse contextual factors that can foster substance misuse and abuse across the lifespan, such as the grinding poverty and hopelessness of crowded slums; the residual traumas of interpersonal violence and wars; risky experimentation by children and adolescents; and sensation-seeking by affluent members of the “high society” in countries such as the USA (Califano, 2007). Access to evidence-based and affordable treatments for addiction is as much or more of an issue in the 21st century as in less-enlightened eras when addicts were stigmatized and shamed as immoral. Indeed, the stigma of addiction has not been extinguished.

Contemporary Issues in Addiction

Addiction is an issue across the entire lifespan, beginning with babies who are born addicted, either exhibiting neonatal abstinence syndrome (NAS) produced by prenatal exposure to opioids in utero or fetal alcohol syndrome (FAS) produced by prenatal exposure to alcohol. As children and adolescents, both syndromes have higher rates of mental health disorders (Rangmar et al., 2015; Uebel et al., 2015). NAS was first observed in babies whose mothers had used heroin or received methadone for their heroin addiction; another neonatal syndrome occurs in babies whose mothers have abused crack cocaine, and a more recent phenomenon is the dramatic increase in NAS because of pregnant women's abuse of opioid analgesics (see Jones & Fielder (2015) for a historical perspective on NAS and current information on its treatment).

Substance Misuse and Abuse in Childhood and Adolescence

Substance misuse and abuse is a grave concern for children, in a societal context where many dangerous products are cleverly marketed to appeal to them through colorful packaging and tasty flavoring. Flavored alcoholic beverages and alcoholic Jello shots are widely popular among teenagers. A product marketed with the harmless-sounding name “bath salts” contains synthetic cathinones that are 10 times more powerful than cocaine; packages of “bath salts” with appealing names such as “Cloud Nine” and “Vanilla Sky” can be purchased easily online and in drug paraphernalia stores (National Institute on Drug Abuse, 2016b). Another new product with high potential for detrimental consequences to youth is powdered alcohol. Mixing a packet of it would be as simple for children as mixing a pitcher of lemonade, yet a typical preparation is 50% alcohol; if mixed with the amount of liquid indicated on the packet, it yields a liquid that is 10% alcohol. Tragic consequences can ensue if children and adolescents consume such a preparation even if mixed correctly, but the likelihood of disobeying the mixing instructions is strong (Thomas, 2015a).

Cannabis (marijuana) is the most frequently used illicit drug by young people in countries with high incomes, and problems associated with use of the drug are now well established (Teesson et al., 2012; Thomas, 2015b). Cannabis has been linked to cognitive impairment and lower educational attainment of adolescents who use it frequently (Volkow, Baler, Compton, & Weiss, 2014). Cannabis use also heightens the risk of transient psychotic symptoms and psychiatric illness in predisposed individuals (Atakan, 2012). Especially in places where marijuana has been legalized, concerns are being raised about children's second-hand exposure to marijuana smoke, and about the rapidly rising number of children requiring treatment in emergency departments after ingesting it in baked goods prepared in their homes, such as brownies or cookies (Wang et al., 2016; Wang, Roosevelt, & Heard, 2013). Another disturbing trend is the production of synthetic cannabinoids (sold under brand names such as “Spice” or “K2”) which are chemically related to marijuana but much more powerful, resulting in a recent surge of hospitalizations and calls to poison control centers (National Institute on Drug Abuse, 2016a).

The epidemic of methamphetamine use (known as meth, ice, chalk, crystal) has also been prominent in recent addiction literature, and the harm of meth use becomes severe and intolerable early on due to the highly addictive nature of the drug (Colquhoun, 2015). Methamphetamine is rarely used medically, especially after its devastating consequences became known; chronic use produces molecular, structural, and functional changes in the brain (National Institute on Drug Abuse, 2014). Unlike many other substances that are expensive and somewhat difficult for youth to obtain, methamphetamine is easy to make, with ingredients such as the pseudoephedrine extracted from common over-the-counter decongestants, combined with household chemicals such as drain cleaner and antifreeze (Foundation for a Drug-Free World, 2016c). Children and youth are often burned or killed in explosions during meth-making in “labs” in their homes and neighborhoods. The toxic waste resulting from manufacture of methamphetamine in these primitive labs is disastrous to the environment as well as to the meth-makers and their families.

Methylenedioxymethamphetamine (MDMA, known as Molly or Ecstasy) was considered by adolescents as a harmless substance to enhance good feelings at “raves” and “techno parties;” its addictive potential was discounted. But similar to the trajectory of using so many other substances, dosage must be increased to achieve the desired effect, then other drugs such as heroin or cocaine are employed to “come down,” and soon young lives can sadly spiral out of control (Foundation for a Drug-Free World, 2016a). Other substances categorized as “club drugs,” such as rohypnol gamma-hydroxybuyrate and ketamine, are especially dangerous to adolescents and young adults because they can be ingested unwittingly at nightclubs in mixed drinks; some of these odorless and tasteless drugs are being used by predators to facilitate date rapes (Boyd, 2017).

The addictive potential of nicotine is now well known but tobacco use continues to be a public health concern across the globe, often beginning when children are in middle school. In addition to the harmful physical effects of nicotine, early adolescent smoking is concerning because it is strongly correlated with use of other drugs in high school and college. A large study (n = 864,443) of 18 cohorts of adolescents showed that cohorts with higher rates of smoking in 8th and 10th grade have a higher rate of marijuana and cocaine use in 12^th grade, even when controlling for trends in social norms (Keyes, Hamilton, & Kandel, 2016). Although the prevalence of smoking regular cigarettes has declined, use of other nicotine delivery modalities has escalated. Small cigars flavored like fruit or candy are smoked by 1 in 12 students by the senior year of high school (King, Tynan, Dube, & Arrazola, 2014), and water-pipe (hookah) smoking is popular among college students because of flavors like coffee and apple that have been added to the tobacco (Primack et al., 2008). Electronic cigarettes are the newest pathway to nicotine addiction, and “vaping” is mistakenly being viewed as less dangerous than regular cigarettes. Use of electronic cigarettes tripled among high school seniors from 2013 to 2014 (Keyes et al., 2016), and as the year 2017 begins, sales of electronic cigarettes are predicted to reach $10 billion in the USA alone (Gray, 2013).

Although cocaine is used by older individuals as well as youth, its use is most prevalent among late adolescents and young adults, many of whom begin using it while attending college. The progression from smoking to marijuana and cocaine reported by Keyes et al. (2016) was illustrated in a longitudinal study of students surveyed from pre-admission to their second year of college; those admitting cocaine use at Time 2 had used marijuana by age 15.8, tobacco by age 16.1, and cocaine by age 17–21 (Dodd & Moreno, 2015). Use of crack cocaine, a crystallized form sold by dealers in small quantities, reached epidemic proportions in the U.S. during the 1980s and somewhat later in the UK and Europe (Foundation for a Drug-Free World, 2016b). All forms of cocaine are extremely addictive; the “cocaine crash” is such a let-down that users quickly crave a new dose to restore well-being; among the dangerous consequences of cocaine use are convulsions, toxic psychosis, and respiratory failure (Boyd, 2017).

Internet addiction came into the scientific literature in the 1990s, mainly in papers emanating from Europe and Asia, and generated huge international attention in the ensuing years. Some social scientists argue that a distinction should be made between addictions on the Internet (excessive use of Internet because it affords access to social media, gambling, shopping, or gaming) and addictions to the Internet itself (Griffiths, Kuss, Billieux, & Pontes, 2016). Cultural factors are alleged to contribute to high prevalence rates of Internet addiction among young people in countries such as Korea, in which parents believe that any non-educational Internet use is a poor use of time that could be devoted to school-related or family activities (Kuss et al., 2014, cited in Griffiths et al., 2016). Debates continue regarding pathologizing high involvement in use of the Internet with the label “addiction,” and also regarding the appropriate amount of time children and youth should be online.

Less heavily researched is the new phenomenon of smartphone addiction, which includes specific addictions to particular social networking sites accessed via smartphones. Just as the Internet is a technology that provides convenient access to information and instant connectivity to other users across the globe, so too smartphones provide a variety of valued benefits to their users. However, Pearson and Hussain (2015) found that smartphones encourage narcissism, even in nonnarcissistic users, and that higher narcissism scores and neuroticism levels were linked to smartphone addiction. Addicts are compelled to use their phones even in areas where they have been banned. The researchers recommended that prospective buyers of smartphones be warned about their addictive potential. Undoubtedly, the science regarding all of the technological addictions is nascent and will continue to evolve.

Substance Misuse and Abuse in Adulthood and Older Age

There has been an unprecedented increase in morbidity and mortality associated with the use of opioid pain relievers [OPR], as overprescribing by physicians led to addiction and a consequent rise in deaths from overdose (Kolodny et al., 2015). In most of the 20th century, opioids were mainly used in cancer and other terminal illnesses, but sales of opioids such as oxycodone and hydrocodone quadrupled between 1999 and 2014 as they were increasingly prescribed for patients with chronic pain conditions (Gower, 2016). Reassured by pharmaceutical companies that these opioids were not addictive, physicians began to prescribe them to older adults for management of painful conditions such as arthritis. Regrettably, 1 in 10 patients do become addicted (Volkow, cited in Gower, 2016), and the largest increase in opioid-related morbidity and mortality rates has occurred in older adults (Kolodny et al., 2015).

Diversion for illicit use contributes to the widening epidemic of prescription drug abuse. Prescription medications such as opiates, fentanyl patches, and benzodiazepines are often stolen and sold on the street or obtained through fraudulent means, such as “doctor shopping” by addicts who skilfully feign painful conditions in visits to multiple prescribers (Worley & Thomas, 2014). In many communities, addict demand for “pain pills” has resulted in establishment of unscrupulous “pill mills” that liberally dispense prescriptions for opiates without requirement of physical examinations or diagnostic tests. Further compounding the opioid crisis is the manufacture of counterfeit pills that look like their prescription counterparts (e.g., Oxycontin, Xanax) yet contain fentanyl, resulting in a sharp increase in fentanyl-related overdose deaths (DEA Strategic Intelligence Section, 2016).

A very disturbing trend in the United States is the upsurge in heroin use, even in demographic groups with historically lower rates of use, such as women, and people with higher incomes (Centers for Disease Control and Prevention, 2016). The rise in heroin is attributed to addiction that began with prescriptions for opioids but then progressed to heroin because of its lower cost and wide availability; among new users, 3 out of 4 reported previous use of prescription opioids (Centers for Disease Control and Prevention, 2016). Heroin use has more than doubled among young adults (ages 18–25) in the past 10 years, and heroin-related overdose deaths have more than tripled since 2010 (Centers for Disease Control and Prevention, 2016), prompting some communities to provide police officers with naloxone (Narcan) for emergency administration. Naloxone is even available without prescription in many locales so that laypersons can purchase it to save lives of companions who have overdosed.

An overview of contemporary issues in addiction cannot omit the continuing widespread use and misuse of alcohol, perhaps the most socially acceptable addictive substance and one of the least expensive to purchase. Underage drinking is a longstanding problem that prompts many governments to set a legal drinking age (e.g., age 21), although adolescents can easily gain access to alcohol in their own homes or ask an older companion to purchase it for them. Young people who begin drinking before age 15 are four times more likely to become dependent on alcohol than those who commenced drinking when 21; furthermore, drinking is more hazardous for teenagers than for adults because it can result in brain damage (e.g., memory, motor skills) (Foundation for a Drug-Free World, 2016d). New attention is being given to binge drinking, because it is so prevalent in youth; the age group with the most common binge drinkers is the 18–34 age group, and more than 90% of the alcohol consumed by youth is during binge-drinking episodes (Centers for Disease Control and Prevention, 2015). These young binge drinkers are not yet alcoholics, but their chances of ultimately becoming ill and dying from alcohol-related diseases increase significantly, compared to individuals who use alcohol in a more moderate way (Centers for Disease Control and Prevention, 2015). Although the combined use of alcohol and other drugs is not a new issue to clinicians and researchers, it bears mentioning once again that countless preventable deaths still occur (e.g., combined use of cocaine and alcohol, Pilgrim, Woodford, & Drummer, 2013).

Comorbidity of Substance Use Disorders and Mental Health Disorders

After decades of separating individuals with substance use disorders (SUDs) from individuals with mental health disorders (MHDs) during hospitalization; notably during the era of the standard 28-day inpatient treatment delivered on “alcohol and drug units”—epidemiological studies have consistently demonstrated that this practice was unwise. Concurrent substance use disorders (SUDs) and mental health disorders (MHDs) are quite common (Lai & Sitharthan, 2012; Wüsthoff, Waal, Ruud, Røislien, & Gråwe, 2011). Since the 1990s, the high prevalence of SUDs comorbid with MHDs has emerged as a major concern for drug and alcohol and mental health services (Lai, Cleary, Sitharthan, & Hunt, 2015; Wüsthoff et al., 2011). Prevalence rates have been reported at 50% or more, but this varies, according to location, methodologies and the definitions used to define the disorders (Hunt, Siegfried, Morley, Sitharthan, & Cleary, 2013).

Estimates of current SUDs and lifetime prevalence vary (Horsfall, Cleary, Hunt, & Walter, 2009). For example, recent systematic reviews and meta-analyses which aimed to estimate the prevalence rates of SUDs in people diagnosed with bipolar disorder and mood and anxiety disorders reported comorbidity to be highly prevalent between SUDs, mood and anxiety disorders and highly prevalent in hospital and community-based samples (Hunt, Malhi, Cleary, Lai, & Sitharthan, 2016a; Hunt, Malhi, Cleary, Lai, Sitharthan, 2016b; Lai et al., 2015). This is acknowledged as a factor that influences the profile, course, patterns, severity, and outcomes of these disorders (Lai et al., 2015).

Different reasons are provided to account for the rates of comorbidity such as: one mental disorder may influence another (heavy alcohol use may cause depression), or substances may be used as a means of self-medication to relieve distress of a MHD, or that comorbidity may emerge from shared genetic predisposition or socioeconomic factors, such as poverty or trauma (Lai et al., 2015). There is much research documenting negative sequelae for those living with comorbidity in SUDs and MHDs, as these individuals are likely to experience greater rates of relapse and more hospital readmissions; treatment non-adherence; distorted perception and cognition and other positive symptoms of psychosis; greater levels of suicidal ideation; interpersonal stressors and difficulties; social exclusion–unemployment, living alone, or homelessness; more frequent use of aggression and physical violence and associated injury; and/or greater risk of HIV, cardiovascular, liver, and gastrointestinal disease (Horsfall et al., 2009; Hunt et al., 2013). Furthermore, it is highly likely that overall their subjective quality of life is poor. The trauma of relapse and admission to hospital alone can be distressing. When people become disabled by psychosis and hospitalised, more coercive treatments are likely to be utilised. This in turn increases the risk for a range of unpleasant and sometimes dangerous medication side-effects. Such experiences can be disturbing, demoralising and frustrating. Depression and suicidal ideas can ensue from a sense of despair and hopelessness. Anger may be fuelled by legally enforced hospitalisation or community treatment. The combination of psychosis, strong emotional responses and continuing use of readily accessible substances can lead to social alienation and increase the potential for aggressive responses (Horsfall et al., 2009). Family and friends may also experience distress and conflict within their relationships (Horsfall et al., 2009).

Increasingly, in recent times health professionals, researchers, economists, and policymakers have acknowledged the challenges associated with the identification and treatment of co-occurring MHDs and SUDs (Rosenthal, Nunes, & Le Fauve, 2012). Increased awareness of the importance of recognising SUDs and MHDs in different populations, can facilitate more effective comprehensive assessment to support treatment and recovery from MHDs or SUDs. The importance of identifying and treating SUDs and MHDs is underlined by research that demonstrates high comorbidity between SUDs, mood and anxiety disorders (Hunt et al., 2016a,b; Lai et al., 2015; Rosenthal et al., 2012)

Regardless of the model of service provision, effective services are contingent on collaboration, communication, coordination and accountability (Horsfall et al., 2009). Professional development across all disciplines is pivotal to interdisciplinary team work and the provision of best practice including person-centred care to support consumer and family recovery. A range of accessible programs are also required and should also incorporate long-term follow-up. Across the lifespan, people of all ages can benefit from early intervention strategies targeting problematic drug and alcohol use so that social networks are not fractured and the cycle of mental illness combined with substance abuse does not eventuate or perpetuate (Horsfall et al., 2009).

Continuing Debates and Issues in Addiction Treatment

Modern approaches to addiction treatment have ranged from religious/spiritual approaches to medical interventions (drug maintenance therapies, acupuncture) to individual therapies (mainly cognitive-behavioral and motivational interviewing) to group therapies (including therapeutic communities) and the classic 12-step self-help programs (Alcoholics Anonymous and Narcotics Anonymous); virtually all approaches recognize the importance of concomitant family therapy (Boyd, 2017). Debates are ongoing regarding brief versus long-term treatments, inpatient or outpatient program delivery, and how therapies can be tailored to the needs of various demographics (consider the vast differences between a teenager using Molly, a middle-aged arthritis patient using oxycodone, and an elderly widower using alcohol). As noted above, when addiction is comorbid with a mental health disorder, treatment must be interdisciplinary and multimodal. Relapse prevention strategies, management of craving, and ongoing follow-up are imperative.

It is important however that substance use is detected early and that treatment is provided. Traditionally, treatment has been difficult because of differing approaches and philosophies among mental health and drug services (Hunt et al., 2013). Less optimum care is related to treatment programs that are provided separately, in parallel or sequentially by different clinicians, versus the integrated treatment model where simultaneously mental health and substance use treatments are provided in the same setting and delivered in a coherent way. Elements include an assertive style of engagement, close monitoring, comprehensive services, supportive environments, flexibility and specialisation of clinicians, step-wise treatment, and a long-term perspective and therapeutic optimism (Drake, Mercer-McFadden, Mueser, McHugo, & Bond, 1998; Hunt et al., 2013).

There are many unresolved challenges for care providers. For example, challenges for therapeutic communities for clients with alcohol and substance abuse are outlined by Cutcliffe, Travale, Richmond, and Green (2016), in an article providing not only ample food for thought but many implications for future research. Among the challenges are (a) lack of a unifying definition of “therapeutic community” across diverse programs in settings ranging from prisons to psychiatric hospitals to community residential facilities; (b) diverse program aims, from harm reduction (as in needle-exchange programs for opiate addicts) to abstinence (as in programs for alcoholism); (c) scant empirical evidence of program effectiveness; (d) failure to define “recovery;” (e) inadequate preparation of clinicians for work with addicts; and (f) optimum length of stay in a therapeutic community. It is therefore encouraging to see the development of a recovery-oriented clinical tool to plan treatment and monitor progress toward dual recovery (see Noel, Woods, Routhier, & Drake, 2016)

Several reviews have also been undertaken. The following are some examples, and the list is in no way complete, but reviews include a systematic review of course and treatment of substance use disorder among people with first-episode psychosis (Wisdom, Manuel, & Drake, 2011), an extensive review of current psychosocial approaches to dual diagnosis (Drake & Mueser, 2000), a review of integrated mental health and substance abuse treatment for patients with dual disorders (Drake et al., 1998), a review of treatments for people with severe mental illnesses and co-occurring substance use disorders (Drake, Mueser, Brunette, & McHugo, 2004), an empirical, systematic and Cochrane review of psychosocial treatments for people with co‐occurring severe mental illness and substance misuse (Cleary, Hunt, Matheson, & Walter, 2009; Horsfall et al., 2009; Hunt et al., 2013), a review of dual diagnosis in older adults (Searby, Maude, & McGrath, 2015).

National Clinical Guidelines are also provided for Psychosis with coexisting substance misuse in adults and young people (National Institute for Clinical Excellence, 2011). These guideline recommendations are based on the best available evidence and are intended for clinicians and service commissioners to provide high-quality care for people with psychosis and coexisting substance misuse (National Institute for Clinical Excellence, 2011). Evidence-based guidelines are also available for substance use disorders in low-and middle-income countries (Dua et al., 2011). The mhGAP Intervention Guide (mhGAP-IG) for mental, neurological and substance use disorders for non-specialist health settings, is a tool developed by WHO through a systematic review of evidence followed by an international consultative and participatory process (World Health Organization, 2010). The mhGAP-IG presents integrated management of priority conditions using protocols for clinical decision-making and aims to increase the capacity of the primary health care system (World Health Organization, 2010).

Evidence-based guidelines are also available for the pharmacological management of substance abuse, harmful use, addiction and comorbidity with psychiatric disorders and these focus on pharmacological management and are presented as recommendations to aid clinical decision making for practitioners (Lingford-Hughes, Welch, Peters, Nutt, & expert reviewers 2012). These guidelines include the pharmacological management of withdrawal, short- and long-term substitution, maintenance of abstinence and prevention of complications, as well as comorbidity with psychiatric disorders in younger and older people. There are also a number of best practice guidelines available in the literature, and at professional and national organizational websites.

Further diverse research programs are continuing globally. Medication-assisted treatment (MAT) for example is currently being used with many people who are addicted to opiates; along with psychosocial support, they receive methadone (Lindgren, Eklund, Melin, and Graneheim, 2015). MAT is controversial, however, because critics assert that it simply substitutes one drug for another. Participants in a Swedish study by Lindgren et al. reported a double stigma, with regard to being both a drug addict and receiving MAT. Participants were forced to hide their participation in MAT from friends and employers. Group motivational interviewing was a useful addition to a methadone maintenance program in Iran; retention in treatment was higher, along with a reduction in drug craving (Navidian, Kermansaravi, Tabas, & Saeedinezhad, 2016).

Individuals with SUDs comorbid with MHDs are not a homogenous group and have many concerns and challenges. Women, especially those with a history of childhood trauma, and practical challenges associated with child raising, poverty, and intimate partner violence are particularly vulnerable to disorders (Caton, Xie, Drake, & McHugo, 2014; Dawson, Jackson, & Cleary, 2013). Findings from a comparative analysis suggest the need for gender-specific treatment programs (Caton et al., 2014). The need for gender-specific treatment, especially for women substance abusers with children, is recognized in the addiction literature, but appropriate treatment programs are still not available in many locales (Dawson et al., 2013). Even when therapies are available to mothers, their children are not usually considered in treatment planning (Lussier, Laventure, & Bertrand, 2010).

CONCLUSION

The enormity of addiction as a global health issue is unprecedented as exemplified in the foregoing selection of examples presented in this editorial. Before providing any intervention, an adequate substance use assessment and a mental status examination should be performed (Athanasos, 2016). Whilst there is limited evidence about the nature of best practice addiction, research suggests treating both MHDs and SUDS concurrently, using the integrated model of treatment is beneficial (Hunt et al., 2013). Given the immense scope and complexity of addiction issues across the life span, it is clear that much work remains to develop more enlightened public policies, greater access to evidence-based treatments, clinical guidelines and recovery programs, and increased societal compassion toward individuals with substance use disorders and/or comorbid mental health disorders.