Substance-related and addictive disorders

Carolyn Baird and Margaret Jordan Halter

Objectives

1. Describe the terms substance use, intoxication, tolerance, and withdrawal.

2. Define addiction as a chronic disease.

3. Describe the neurobiological process that occurs in the brain and neurotransmitters involved with substance use.

4. Identify potential co-occurring medical and psychological disorders.

5. Name the common classification of substances used.

6. Identify patterns of substance use

7. Apply the nursing process to caring for an individual who is using substances.

Visit the Evolve website for a pretest on the content in this chapter: http://evolve.elsevier.com/Varcarolis

Substance disorders are not disorders of choice. They are complex diseases of the brain represented by craving, seeking, and using regardless of consequences (National Institute on Drug Abuse [NIDA], 2010a). Continuous substance use results in actual changes in the brain structure and function of an area of the brain referred to as the reward or pleasure center. This area of the brain within the limbic system is also the part of the brain that is affected by other mental health disorders such as depression, schizophrenia, or anxiety. More than half the individuals with a substance use disorder can be expected to have some other co-occurring mental health disorder and vice versa, leading researchers to suspect that there is an underlying genetic vulnerability (McCauley, 2009).

Historically, these disorders have been treated in separate systems of care. Individuals received treatment for mental health problems in the mental health system and treatment for substance disorders in chemical dependency units or facilities. If both mental health and substance use disorders were present, the treatment might occur concurrently in different settings or as back-to-back treatment in one system followed by the other.

That care fragmentation began to change in 2001, when the Institute of Medicine (IOM) published a report on the status of the nation’s health care. Crossing the Quality Chasm: A New Health System for the 21st Century included recommendations for addressing the rising number of individuals with substance and addictive disorders with or without co-occurring mental health disorders. The IOM referred to the United States’ delivery of care as being uncoordinated and overly complex, resulting in patients” being handed off from one set of providers to the next. This fragmented care causes errors and slows the process down, wastes resources, and leaves tremendous voids in care.

These concerns are being addressed through a number of federal initiatives. These initiatives include integration of mental health and substance use treatment systems, cross training of health care professionals, and integrated screening and early intervention programs for identifying individuals with substance and addiction problems regardless of where they present for care.

It is important for all nurses regardless of their practice area to develop an understanding of the disease of addiction. Nursing curricula should include the content and practice the skills necessary for addiction screening, early detection, and referral to appropriate treatment. Without an accurate assessment for substance use and other mental health disorders, individuals will be unable to receive comprehensive treatment planning and quality care (Baird, 2011).

Clinical picture

A substance use disorder is a pathological use of a substance that leads to a disorder of use, intoxication, and, often, withdrawal if the substance is taken away. Substance use disorders encompass a broad range of products that human beings take into their bodies through various means (e.g., swallowing, inhaling, injecting). They range from fairly innocuous and innocent-seeming substances such as coffee to absolutely illegal, mind-altering drugs such as LSD. No matter the substance, use disorders share many commonalities, intoxication characteristics, and withdrawal attributes. The American Psychiatric Association (APA) (2013) identifies the following substance-related and addictive disorders:

• Sedative, hypnotic, anxiolytic

• Stimulant

• Tobacco

• Other substances

While substances are generally associated as the source of addiction problems, behaviors, too, are gradually being recognized as addictive. Internet gaming, the use of social media, shopping, and sexual activity are also considered to be addictive. Behavioral addictions are also referred to as process addictions. The first behavioral addiction, gambling, was officially declared a disorder in 2013 (APA). Gambling and other compulsive actions activate dopamine and glutamate in the reward or pleasure neural pathways of the brain’s limbic system the same as substances do (Potenza, 2008). The activities are reinforced through the dopamine glutamate cycle and may become dysfunctional for the individual, resulting in many of the same problematic behaviors and functional issues as the ingested substances.

See Table 22-1 for information on the commonly abused drugs.

TABLE 22-1

COMMONLY ABUSED DRUGS

CATEGORY AND NAME	COMMERCIAL AND STREET NAMES	DEA SCHEDULE/ADMINISTRATION*	**ACUTE EFFECTS/HEALTH RISKS**
Tobacco
Nicotine	Found in cigarettes, cigars, bidis, and smokeless tobacco (snuff, spit tobacco, chew)	Smoked, snorted, chewed	Increased blood pressure and heart rate Chronic lung disease; cardiovascular disease; stroke; cancers of the mouth, pharynx, larynx, esophagus, stomach, pancreas, cervix, kidney, bladder, and acute myeloid leukemia; adverse pregnancy outcomes; addiction
Alcohol
Alcohol	Found in liquor, beer, and wine	Swallowed	Low doses: Euphoria, mild stimulation, relaxation, lowered inhibitions High doses: Drowsiness, slurred speech, nausea, emotional volatility, loss of coordination, visual distortions, impaired memory, sexual dysfunction, loss of consciousness Increased risk of injuries, violence, fetal damage; depression; neurologic deficits, hypertension; live and heart disease; addiction fatal overdose
Cannabinoids
Marijuana	Blunt, dope, ganja, grass, herb, joint, bud, Mary Jane, pot, reefer, green, trees, smoke, sinsimella, skunk, weed	I/Smoked, swallowed	Euphoria; relaxation; slowed reaction time; distorted sensory perception; impaired balance and coordination; increased heart rate and appetite; impaired learning, memory; anxiety; panic attacks; psychosis/cough Frequent respiratory infections; possible mental health decline; addiction
Hashish	Boom, gangster, hash, hash oil, hemp	I/Smoked, swallowed
Opioids
Heroin	Diacetylmorphine: smack, horse, brown sugar, dope, H., junk, skag, skunk, white horse, China white; cheese	I/Injected, smoked, snorted	Euphoria; drowsiness; impaired coordination; dizziness; confusion; nausea; sedation; feeling of heaviness in the body; slowed or arrested breathing Constipation; endocarditis; hepatitis; HIV; addiction; fatal overdose
Opium	Laudanum, paregoric: big O, black stuff, block, gum, hop	II, III, V/Swallowed, smoked
Stimulants
Cocaine	Cocaine hydrochloride: blow, bump, C, candy, Charlie, coke, crack, flake, rock, snow, toot	II/Snorted, smoked, injected	Increased heart rate, blood pressure, body temperature, metabolism; feelings of exhilaration; increased energy, mental alertness; tremors; reduced appetite; irritability; anxiety; panic; paranoia; violent behavior; psychosis Weight loss; insomnia; cardiac or cardiovascular complications; stroke; seizures, addiction For cocaine: nasal damage from snorting For methamphetamine: severe dental problems
Amphetamine	Biphetamine, Dexedrine: bennies, black beauties, crosses, hearts, LA turnaround, speed, truck drivers, uppers	II/Swallowed, snorted, smoked, injected
Methamphetamine	Desoxyn: meth, ice, crank, chalk, crystal, fire, glass, go fast, speed	II/Swallowed, snorted, smoked, injected
Club Drugs
MDMA (methylenedioxy-methamphetamine)	Ecstasy, Adam, clarity, Eve, lover’s speed, peace, uppers	I/Swallowed, snorted, injected	Mild hallucinogenic effects; increased tactile sensitivity, empathic feelings; lowered inhibition; anxiety; chills; sweating; teeth clenching; muscle cramping Sleep disturbances; depression; impaired memory; hyperthermia; addiction
Flunitrazepam	Rohypnol: forget-me pill, Mexican Valium, R2, roach, Roche, roofies, roofinol, rope, rophies	IV/Swallowed, snorted	Sedation; muscle relaxation; confusion; memory loss; dizziness; impaired coordination Addiction
GHB	Gamma-hydroxybutyrate: G, Georgia home boy, grievous bodily harm, liquid ecstasy, soap, scoop, goop, liquid X	I/Swallowed	Drowsiness; nausea; headache; disorientation; loss of coordination; memory loss Unconsciousness; seizures; coma
Dissociative Drugs
Ketamine	Ketalar SV: cat Valium, K, Special K, vitamin K	III/Injected, snorted, smoked	Feelings of being separate from one’s body and environment; impaired motor function; analgesia; impaired memory; delirium; respiratory depression and arrest; death Anxiety; tremors, numbness; memory loss; nausea
PCP and analogs	Phencyclidine: angel dust, boat, hog, love boat, peace pill	I/II/Swallowed, smoked, injected	Feelings of being separate from one’s body and environment; impaired motor function; analgesia; psychosis; aggression; violence; slurred speech; loss of coordination; hallucinations Anxiety; tremors; numbness; memory loss; nausea
Salvia divinorum	Salvia, Shepherdess’s Herb, Maria Pastora, magic mint, Sally-D	Chewed, swallowed, smoked	Feelings of being separate from one’s body and environment; impaired motor function Anxiety; tremors; numbness; memory loss; nausea
Dextromethorphan (DXM)	Found in some cough and cold medications: Robotripping, Robo, Triple C	Swallowed	Feelings of being separate from one’s body and environment; impaired motor function; euphoria; slurred speech; confusion; dizziness; distorted visual perceptions Anxiety; tremors; numbness; memory loss; nausea
Hallucinogens
LSD	Lysergic acid diethylamide: acid, blotter, cubes, microdot, yellow sunshine, blue heaven	I/Swallowed, absorbed through mouth tissues	Altered states of perception and feeling; hallucinations; nausea; increased body temperature, heart rate, blood pressure; loss of appetite; sweating; sleeplessness; numbness; dizziness; weakness; tremors; impulsive behavior; rapid shifts in emotion Flashbacks, Hallucinogen Persisting Perception Disorder
Mescaline	Buttons, cactus, mesc, peyote	I/Swallowed, smoked	Altered states of perception and feeling; hallucinations; nausea; increased body temperature, heart rate, blood pressure; loss of appetite; sweating; sleeplessness; numbness; dizziness; weakness; tremors; impulsive behavior; rapid shifts in emotion
Psilocybin	Magic mushrooms, purple passion, shrooms, little smoke	I/Swallowed	Altered states of perception and feeling; hallucinations; nausea; nervousness; paranoia; panic
Other Compounds
Anabolic steroids	Anadrol, Oxandrin, Durabolin, Depo-Testosterone, Equipoise: roids, juice, gym candy, pumpers	III/Injected, swallowed, applied to skin	No intoxication effects Hypertension; blood clotting and cholesterol changes; liver cysts; hostility and aggression; acne; in adolescents – premature stoppage of growth; in males – prostate cancer, reduced sperm production, shrunken testicles, breast enlargement; in females – menstrual irregularities, development of beard and other masculine characteristics
Inhalants	Solvents (paint thinners, gasoline, glues); gases (butane, propane, aerosol propellants, nitrous oxide); nitrites (isoamyl, isobutyl, cyclohexyl): laughing gas, poppers, snappers, whippets	Inhaled through nose or mouth	Varies by chemical – stimulation; loss of inhibition; headache; nausea or vomiting; slurred speech; loss of motor coordination; wheezing Cramps, muscle weakness; depression; memory impairment; damage to cardiovascular and nervous systems; unconsciousness; sudden death

^*Drug Enforcement Agency Schedule I and II drugs have a high potential for abuse. They require greater storage security and have a quota on manufacturing, among other restrictions. Schedule I drugs are available for research only and have no approved medical use; Schedule II drugs are available only by prescription and require a form for ordering. Schedule III and IV drugs are available by prescription, may have five refills in six months, and may be ordered orally. Some Schedule V drugs are available over the counter.

National Institute on Drug Abuse. (2011). Commonly abused drug chart. Retrieved from http://www.drugabuse.gov/drugs-abuse/commonly-abused-drugs/commonly-abused-drugs-chart.

Concepts that are central to substance use disorders

A term that people commonly use to describe substance use disorders is addiction. The most current definition of addiction states that it is a “primary, chronic disease of brain reward, motivation, memory, and related circuitry” (American Society of Addiction Medicine, 2011, para. 1). It is a disease of dysregulation in the hedonic (pleasure seeking) or reward pathway of the brain (Koob, 2009). Characteristic manifestations usually include loss of behavioral control with craving and inability to abstain, loss of emotional regulation, and loss of the ability to identify problematic behaviors and relationships.

When people are in the process of using a substance to excess they are said be experiencing intoxication. Intoxication may manifest itself in a variety of ways depending on the physiological response of the body to the substance that is being abused. Substances may be classified according to their mechanism of action as sedative hypnotics, stimulants, depressants, and hallucinogens. They are often casually referred to as uppers, downers, and all arounders (Palladini, 2011). Individuals who are using substances are considered to be “under the influence,” intoxicated, or high. Terminology may vary depending on the substance and the population who is using. Alcohol causes intoxication, but cocaine makes you high. Stimulants cause hyperreactivity, and depressants dampen responses.

There are varying degrees of severity for substance use, and a variety of factors play into how severity is viewed. For example, in some cultures and religions alcohol use is not accepted, and any use would be considered aberrant; in other cultures, alcohol use is a regular part of everyday life, and the amount of consumption would be alarming to people outside the culture.

People with addictions experience tolerance to the effects of the substances. Tolerance is needing increasing amounts of a substance to receive the desired result or finding that using the same amount over time results in a much-diminished effect. Nursing students should know that some prescribed medications might have the same effect, such as some antianxiety medications, analgesics, and beta-blockers. Even antidepressants may result in tolerance (Fava & Offidani, 2011). This type of tolerance is not considered diagnostic when the individual is under medical supervision.

Withdrawal is a set of physiological symptoms that begin to occur as the concentration of the chemical decreases in an individual’s bloodstream. It is specific to the substance ingested, and each substance has its own characteristic syndrome. The same substance, or one with a similar action, may be taken to avoid or relieve withdrawal symptoms. Although alcohol is the drug with the greatest potential for and most serious symptoms of withdrawal, the rising numbers of individuals abusing prescription drugs has increased the concern for assessing for withdrawal complications (Office of National Drug Control Policy, 2011). Behavioral addictions such as gambling seldom have clearly identifiable intoxication or withdrawal symptoms, and tolerance is not an issue. Patterns of behavior and consequences are assessed to identify problematic behavior.

Epidemiology

The National Survey on Drug Use and Health is conducted annually on a randomly chosen segment of the population reflecting individuals 12 and older who reside in the United States. It is the primary source for national drug use statistics and trending. According to the 2010 survey, 22.6 million Americans used illicit substances, including the nonmedical use of prescription psychotherapeutics, in the month prior to the survey (Substance Abuse Mental Health Services Administration [SAMHSA], 2011).

While slightly more than half (50.8% or 130.6 million) of the nation’s population admits to drinking alcohol, almost a quarter (23.1%) reports binge drinking (five drinks on one occasion on one day in the last month) and about 7% report heavy drinking (five drinks on one occasion on at least five days in the last month). In 2010, 3 million individuals used illicit drugs for the first time, and nearly 5 million individuals tried alcohol; most (82%) of them were younger than 21 years of age (SAMHSA, 2011). Overall, more than 22 million individuals, or nearly 9% of the population of the United States, are estimated to have substance use disorders.

These numbers remained steady overall from 2002 to 2010. In 2010, marijuana had the highest percentage of misuse, followed by cocaine. Marijuana use has remained steady, with almost half of adolescents surveyed reporting that they have easy access to the drug. Cocaine use has been on the decline. It is the rise of prescription drug misuse that has prompted the greatest concern. Over half of individuals using prescription drugs nonmedically got them from a friend or relative for free, more than 10% percent paid a relative or friend for them, and another 9% percent stole them from a friend or relative (SAMHSA, 2011). More than 75% of these persons stated that their friend or relative had gotten them from just one doctor.

HEALTH POLICY

Bath Salts

Bath salts are a fairly new group of drugs; the salts are sold as tablets, capsules, or powder in sealed envelopes. They are purchased in such places as convenience stores, head shops, and on the Internet. These so-called bath salts are stimulants similar to cocaine, methamphetamine, methylenedioxymethamphetamine (MDMA, Ecstasy), and lysergic acid diethylamide (LSD).

Users of these drugs experience euphoria, elevated mood, and a pleasurable “rush”; however, tachycardia, hypertension, peripheral constriction, chest pain, hallucinations, paranoia, erratic behavior, inattention, lack of memory of substance use, and psychosis are also possible responses to the drugs. Health care workers, including nurses, have been faced with caring for hostile, belligerent, and paranoid patients high on bath salts.

On October 21, 2011, the U.S. Drug Enforcement Administration (DEA) exercised an emergency authority to name three key ingredients in bath salts—MDPV, mephedrone, and methylone—as Schedule I, thereby making them illegal to possess or sell in the United States. Drug sellers have gotten around the law by chemically tweaking the drug just enough to make them fall outside the bounds of the legislation while retaining their psychoactive properties.

In July 2012, President Barack Obama signed a bill that established a federal ban on bath salts, synthetic marijuana, the compounds from which these drugs are produced, and any versions that might be made in the future. This ban includes interstate and online sales and is a part of the Food and Drug Administration (FDA) Safety and Innovation Act (2012).

Data from U.S. Drug Enforcement Administration. (2011). Chemicals used in “bath salts” now under federal control and regulation. Retrieved from http://www.justice.gov/dea/pubs/pressrel/pr102111.html; FDA. (2012). Food and Drug Administration safety and innovation act. Retrieved from http://www.fda.gov/RegulatoryInformation/Legislation/FederalFoodDrugandCosmeticActFDCAct/Significant AmendmentstotheFDCAct/FDASIA/ucm20027187.htm.

Additional statistics are available for all substances abused according to demographics such as gender, race, age, geographic location, education, employment status, driving record, and incarceration status. According to statistics from the 2010 National Survey on Drug Use and Health, the younger the age of first use of drugs or alcohol, the greater the likelihood of misuse as an adult. Adults in their 20s have a higher rate of substance use and addiction than any other age group, and males are twice as likely as females to be represented. Around 16% of Alaska Natives and American Indians have substance use disorders as compared with other racial and ethnic groups who are fairly equal at 8% to 9%. Individuals who have higher education levels, are employed, and live in a non-metropolitan county are less likely to misuse substances.

CONSIDERING CULTURE

A Culture of Alcohol and Substance Use

The Monitoring the Future (MTF) survey has been collecting statistics since the mid-1970s on the use of, and attitudes toward, alcohol, tobacco, and other drugs by eighth, tenth, and twelfth grade students. The rate of illicit substance use has been rising and may be related to adolescents’ perceptions of risk. It has been suggested that media attention on medical marijuana, the attitude that Ecstasy is a safe drug (10% drop in twelfth graders who believed it was risky to use), and easy availability and nonregulation of synthetic marijuana are responsible for this perception change.

Other illicit drugs (methamphetamine, heroin, and hallucinogens) are increasing or holding steady. Nonmedical use of prescription and over-the-counter drugs, especially opiates such as Vicodin and the stimulant Adderall, is also a problem. Without a change in how the use of substances is viewed and a change in the attitudes voiced in the media, adolescents” perceptions about the risks associated with their behavior will remain unchanged, and their potential for current and future use of alcohol, tobacco, and other drugs will remain the same.

National Institute on Drug Abuse [NIDA]. (2012). Drug facts: High school and youth trends. Retrieved from http://www.drugabuse.gov/sites/default/files/drugfactshsyt.pdf.

Comorbidity

Comorbidity refers to two or more disorders occurring in the same person at the same time with the potential for interaction and exacerbation of symptoms. It may be two or more psychiatric disorders, two or more medical disorders, or a combination of medical and psychiatric disorders (NIDA, 2011b). Although surveys have shown that individuals with substance use disorders have more than a 50% chance of having other mental health disorders of mood and vice versa, it cannot be said that one disorder caused the other, and it is difficult to determine which is primary. It is important that all disorders be identified and treated with a comprehensive approach.

Psychiatric comorbidity

The high prevalence of psychiatric comorbidity is supported by statistics collected since 1980 using multiple national population surveys. Individuals with mood and anxiety disorders, antisocial behaviors, or histories of conduct or oppositional disorders as adolescents are more than twice as likely to have a substance use disorder (NIDA, 2010b). Three common representations of comorbidity have been identified:

1. The physiological response to certain drugs of abuse presents a cluster of symptoms similar to the symptoms of other mental health disorders (e.g., psychosis, and schizophrenia).

2. Subclinical symptoms from one mental health disorder may result in medication of those symptoms with a psychoactive drug (social anxiety and alcohol or marijuana).

3. Psychiatric illnesses and substance use disorders have common risk factors.

These shared risk factors are genetic vulnerabilities, underlying brain defects in common areas and pathways of the brain, and environmental factors, including exposure to stress or trauma during early developmental stages. Estimates suggest that 40% to 60% of an individual’s risk is in genetic vulnerabilities. For this reason, research on substance use and co-occurring disorders has been focusing on trying to identify any genes that may be implicated (NIDA, 2010b). Genes may act individually or in complex interactions of multiple genes to determine an individual’s level of susceptibility to risk-taking behavior, response to stress, or metabolism of substances. Research has also identified that the brain circuitry associated with the neurotransmitter dopamine is implicated in addictive disorders, depression, schizophrenia, and other mental health disorders. It has been proposed that deficits or dysfunction in this circuitry may predispose individuals to develop one or multiple psychiatric disorders.

The human brain undergoes dramatic growth from age 5 to 20 and most particularly in adolescence (NIDA, 2010b). Any insult (stress or trauma) during this time may alter the brain circuitry and cause long-term changes in the abilities of decision making, learning and memory, reward, and affect and behavioral control. Early drug use or mental health disorders, such as attention deficit hyperactivity disorder, conduct disorder, posttraumatic stress disorder, or schizophrenia, could be risk factors for all co-occurring disorders but at this time are not considered fully predictive. More research is indicated to determine the role of genetic vulnerabilities and the influence of environmental and psychosocial factors (NIDA, 2010b).

Medical comorbidity

According to the 2001-2003 National Comorbidity Survey Replication (NCS-R), 58% of all adults have some type of medical condition while 29% of these adults also have a comorbid psychiatric disorder. At the same time, 68% of adults with a psychiatric disorder have at least one medical disorder. These numbers suggest that 17% (34 million) of the adult population have psychiatric and medical comorbidities (Druss & Walker, 2011).

The more common co-occurring medical conditions are hepatitis C, diabetes, cardiovascular disease, HIV, and pulmonary disorders (NIDA, 2010b). The high comorbidity appears to be the result of shared risk factors, high symptom burden, physiological response to licit and illicit drugs, and complications from the route of administration of substances (Druss & Walker, 2011).

Etiology

Addiction is a primary and chronic disease that is related to reward, memory, motivation, and circuitry (American Society for Addiction Medicine, 2011). It is characterized by an individual’s compulsive seeking of drugs and use despite the amazingly harmful consequences (NIDA, 2009). The parts of the brain most affected by drug use are the brain stem, the limbic system, and the frontal cortex. The reward pathways for motivation and memory are located in the limbic system and are influenced by neurobiological as well as psychological and sociocultural factors (Koob, 2009).

Neurobiological factors

The human brain is composed of billions of nerve cells called neurons. Each cell has its own receptors and manufactures corresponding neurotransmitters and transporters to convey impulses or messages from cell to cell. In the center of the brain just above the brain stem is the most primitive part. This area is comprised of a number of structures that make up the limbic system and are responsible for survival through a reward system of pleasure and memory coupled with motivational reinforcement or salience (Wright, 2011).

The structures most identified with the reward system or pleasure center are the nucleus accumbens and the ventral tegmental area. The neural pathways between these areas are activated by the neurotransmitter dopamine. Normal activities such as eating, nurturing, and sexual activity are associated with pleasant feelings and cue the amygdala and hippocampus for memories of the experiences. The frontal cortex is stimulated, releasing glutamate and closing the circuit (Koob, 2009).

Psychoactive substances and certain behaviors can hijack this reward pathway circuit, releasing as much as 10 times the amount of dopamine as usual. Over time, the release of dopamine becomes more important than the reward of pleasure, and the increased saliency of the addictive process cancels the inhibitory function of the frontal cortex, leading to craving (McCauley, 2009; Wright, 2011). The brain responds to this imbalance by resetting the pleasure threshold, producing transporter chemicals, and decreasing or down regulating the number of receptors attempting to reach homeostasis. This is the mechanism that is responsible for drug tolerance.

Positron emission tomography (PET) scanning and magnetic resonance imaging (MRI) have made it possible to understand the underlying neurobiology of the brain through imaging studies (Wright, 2011). The brain’s response to various psychoactive drugs has been studied, and it has been possible to identify the involved areas of the brain by following the processes as they are activated. The results from these imaging studies also support the theory that other forms of psychopathology share the neurobiology of the same areas of the brain.

Psychological factors

Shared psychodynamics such as chronic stress and trauma have been identified in the histories of individuals with both substance use and mood disorders. Individuals who experienced abuse or neglect during childhood report more depression and suicidality. Chronic stressors such as poverty, the time and financial obligations of caring for children, and harmful relationships can lead to depression. Domestic violence, combat experience, and exposure to other forms of trauma may lead to posttraumatic stress disorder, major depression, generalized anxiety disorder, and substance use disorders (Druss & Walker, 2011). Many times, there are multiple addictive behaviors that seem to support a shared vulnerability or antecedent.

Sociocultural factors

Many chronic stressors have their roots in socioeconomic factors. Poverty raises the risk of an unfavorable living environment, lack of parental supervision, poor educational resources, and impaired support systems (Druss & Walker, 2011). A cycle of negative environmental events often begins within disadvantaged neighborhoods, increasing stress and anxiety along with lacking or negative social ties, which contributes to depression. Coping mechanisms may include drugs and acting out behaviors leading to destructive consequences and interaction with the legal system.