Substance use is multilayered, so why are we not treating it like it is?

Substance use and the biopsychosocial model of health

Substance use is a complex illness that involves a variety of health factors. When attempting to understand substance use, it’s beneficial to use a multilevel model of care. The use of the biopsychosocial model can help identify underlying causes of substance use in various aspects of life. By focusing on social and psychological factors that can contribute to an increased risk of use, it allows for better comprehension and treatment of the illness. People who use substances are a vulnerable, marginalized population who don’t receive adequate resources and support in the community due to a lack of understanding and often stigmatization. Society has deemed substance use as a deviant lifestyle choice when in reality, it's a serious illness that requires professional healthcare support. The use of the biopsychosocial model in the treatment of substance use, can help identify underlying causes, highlight appropriate treatment options, and provide support for future recovery.

The biopsychosocial (BPS) model of care refers to the consideration of biological, psychological, and social factors that influence the general health of individuals. This model of care is often connected to George Engel’s 1977 report, though there are many different works prior to this date offering similar insights. The BPS model was initially created to contradict the traditional biomedical approach and its limitations (Tramonti et al., 2021). This multi-level model provides a broader view of various factors that can contribute to the overall well-being of an individual. In comparison to the traditional biomedical approach that focuses on the physical factors of health, this model represents how typically there are multiple psychological and social factors that contribute to an increased risk of illness. The BPS model helps identify influential biological, sociological, and psychological aspects that contribute to health, thus aiding healthcare professionals to better understand various illnesses. The BPS factors that influence health, as seen below, can be described as both multi-sphered and interconnected. The purpose of this model is to highlight how important social and psychological aspects are in defining and understanding health (Tramonti et al., 2021).

Fig.1. (Gliedt et al., 2017)

The first sphere in this multilevel model is the biological factors. On a biological level, many people are predisposed to addiction. Gender, ethnicity, physical and mental illness can increase a person’s risk of using substances. Many people are also at a higher risk of addiction based on a number of neurochemical deficiencies and physical disabilities (Giordano, 2021). When an individual uses a substance, it creates a physical reaction that targets the body’s natural reward system. Dopamine levels will increase during use and over time, this reaction will be reinforced and result in cravings (Bujarski et al., 2018). In addition to the physical cravings one will exhibit, the substances used can impact the brain’s physical chemistry. Substances have the potential to cause permanent and dramatic changes in the structure and function of the brain, known as neuroadaptation (2018). As individuals progress in their substance use, the prefrontal cortex can become damaged, resulting in poor decision-making and impulse control (2018). Without intervention, substance use will develop into an addiction and result in increased tolerance and heavier use. This cycle can be described as physical dependence and has the potential to lead to detrimental effects on the well-being of the individual, effectively increasing the risk of overdose. According to the National Institute on Drug Abuse, substance users have a higher risk of developing cardiovascular disease, widespread infections, cancer, lung disease, stroke, HIV, and hepatitis (2020). Multiple treatments today are being used to combat the effects of substance use. Opioid agonist treatments, such as methadone, suboxone, and long-acting morphine are among some of the safe medications prescribed to help manage substance use and prevent withdrawal. Depending on the substance being used, individuals will likely require medical supervision to safely withdraw from the substance. The withdrawal period differs depending on the person and substance, having symptoms ranging anywhere from days to weeks. Whether or not substance use begins due to a biological component, it typically progresses into a biological dependence that requires professional treatment.

The second level of the BPS model is the psychological component. When we speak of the psychological factors that contribute to substance use, we can consider many mental health concerns. Substance use can often worsen or trigger many mental health conditions such as schizophrenia, depression, and anxiety (2020). Concurrent disorders are defined as those who suffer from both substance use and mental illness. Individuals with concurrent disorders are vulnerable and at a higher risk of health-related issues. Psychological aspects can also include personal experiences including trauma. Exposure to traumatic events such as physical or sexual abuse can lead to Post-Traumatic Stress disorder (PTSD), which is one of the leading comorbidities in substance use disorders (Bujarski et al., 2018). In order to best care for this population, the treatment must be highly specialized. In Vancouver, British Columbia, St Paul’s Hospital (SPH) is the main acute care setting supporting over 10,000 mental health and substance use-related cases annually (Imtiaz et al., 2021). Due to the high volume of substance use and the high number of substance use-related deaths, a specialized HUB was created to help target specific supports.

Fig .2. (BC Coroners Service, 2022)

The HUB consists of the Rapid Access Addiction Clinic (RAAC), the Overdose Prevention Site, and the Transitional Care Center (TCC), all located in the same building at SPH. RAAC is a low-barrier treatment clinic that offers a wide range of treatment options for those interested in abstaining from substance use (2021). For those who are not considering treatment, the Overdose Prevention site offers a safe, supervised, and sterile environment to consume substances (2021). This harm reduction model of care is open 7 days a week, hosts over 30 people a day, and offers free drug testing, take-home naloxone kits, and sterile consumption equipment (2021). The TCC targets housing issues by offering temporary housing resources. It also connects people to a number of social services such as income support, access to primary care, and counseling (2021). Without housing and mental health resources, the likelihood of successful participation in treatment is low. The HUB itself targets substance use by using a BPS approach, taking into consideration medical treatment and the psychosocial factors that influence its effects. It’s made evident by these programs how interconnected the three spheres of the BPS model are, and how relevant it is when discussing treating addiction.

The final sphere in the BPS model is the social aspect. This factor encompasses a variety of elements that contribute to substance use such as social expectations, relationships, status, and physical environment. According to a study by Hellman et al., society and what is considered societal norms can have significant effects on addiction (2015). Social relationships such as friends, family, or scarcity of both, can heavily influence the chances of using substances. Often substance use can stem from a learned behaviour of those around them. If the individual has family and friends that use substances, they are more likely to use themselves. Societal norms such as culture and occupational issues can cause increased stress which can lead to a higher risk of using substances (2015). People who struggle with addiction have a difficult time retaining employment, which can lead to strained relationships, homelessness, and further health issues. This study highlights how a substance, such as alcohol, can be viewed as socially accepted, and often the abstinence of use is viewed as a deviance from societal norms (Hellman et al., 2015). Controversially, the use of illicit substances is less socially accepted and is often related to criminal behaviours, therefore causing stress and isolation for the individual using. Whether or not the substance being used is socially accepted, the pressure exerted by society regardless has a heavy influence. On a broader level, income and social inequalities were found to lead to higher rates of mental illness and substance use (2015). Lower-income individuals tend to have less access to education and health-related resources which increases stress levels due to income disparities. In general, people who struggle with higher levels of stress are at greater risk of developing illness than those with lower levels. The physical environment also plays a large role in substance use. Often in lower-income populations, substances are more accessible and readily available (Giordano, 2021). If the goal is to successfully treat or manage substance use, the individual would best benefit from a change in environment. Short-term transitional housing should be considered to give the person some distance from possibly triggering environments. Being surrounded by other recovering substance users, and support staff will help positively influence the individual and increase the chance of recovery. Support around income and vocational resources will also contribute to an increased sense of accomplishment and purpose, in hopes of creating a healthier reward system. A social approach is important to promote further recovery as it includes direct and indirect factors that contribute to substance use.

Treating substance use is most effective when considering the biological, psychological, and sociological factors that contribute to use. When targeting the biological factors, one may consider medical treatment to help manage withdrawal and cravings. When considering the psychological factors, the use of appropriate mental health and substance use resources can help treat underlying causes of substance use and teach the individual alternate healthy coping strategies to use in the future. Finally, surrounding the individual with social supports such as safe housing, income assistance, and vocational resources, will open a new social circle that can serve as a support system. The BPS model illustrates how social and psychological spheres are interconnected with various biological components leading to substance use. This multi-level model of health is highly applicable to substance use, and when considered, has the potential of resulting in better comprehension and treatment of the illness. When an illness is better understood, the stigma surrounding it will decrease, and result in better health outcomes.

References

BC Coroners Service. (2022). Illicit drug toxicity deaths in BC: January 1, 2012-September 30, 2022

Bujarski, S., Lim, A. C., & Ray, L. A. (2018). Prevalence, Causes, and Treatment of Substance Use Disorders: A Primer. Judges’ Journal, 57(1), 10–15.

Giordano, A. (2021, July 10). What Exactly Is the Biopsychosocial Model of Addiction? | Psychology Today Canada. Psychology Today. https://www.psychologytoday.com/ca/blog/understanding-addiction/202107/what-exactly-is-the-biopsychosocial-model-addiction

Gliedt, J., Schneider, M., Evans, M., & King, J. (2017, June). Fig. 1 [2] An illustration of the biopsychosocial model comprised of... ResearchGate. https://www.researchgate.net/figure/2-An-illustration-of-the-biopsychosocial-model-comprised-of-biological-psychological_fig1_317415046

Hellman, M., Majamäki, M., Rolando, S., Bujalski, M., & Lemmens, P. (2015). What Causes Addiction Problems? Environmental, Biological and Constitutional Explanations in Press Portrayals From Four European Welfare Societies. Substance Use & Misuse, 50(4), 419–438. https://doi.org/10.3109/10826084.2015.978189

Imtiaz, S., Hayashi, K., & Nolan, S. (2021). An Innovative Acute Care Based Intervention to Address the Opioid Crisis in a Canadian Setting. Drug & Alcohol Review, 40(4), 553–556. https://doi.org/10.1111/dar.13193

NIDA. (2020, July). Addiction and Health. National Institute on Drug Abuse. https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/addiction-health

Tramonti, F., Giorgi, F., & Fanali, A. (2021). Systems thinking and the biopsychosocial approach: A multilevel framework for patient‐centred care. Systems Research & Behavioral Science, 38(2), 215–230. https://doi.org/10.1002/sres.2725