Comorbidity and Recovery

Published by
Ali Adyb
Publication Date
Drug Education and Skill Training
Ali Adyb - DTRC Hinmafushi

Imagine going through treatment numerous times but not being able to stop using. Imagine deciding not to use and doing everything you possibly can to stop using but relapsing despite all your efforts. If this sums up your situation or If this story keeps repeating in your journey of recovery from substance use disorder, then chances are you might be suffering from substance use disorder together with another disorder or comorbidity.

Comorbidity is the situation when a combination of conditions is present simultaneously in a patient, such as substance use disorder and depression or substance use disorder and anxiety disorder. Although other diseases like HIV, hepatitis C, cancer, cardiovascular disease can commonly co-occur with substance use disorder, In this article my focus will only be on the comorbidity of drug use disorders with other mental illnesses and trauma

A Substance use disorder or drug addiction treatment program needs to address patients who are suffering from signs of mental health disorders such as mood swings, panic attacks and anxiety, together with their substance use disorders. When these problems became intertwined patients often show signs of aggression and other none compliance behaviors which can be seen as refusal in adhering to treatment rules and regulations, and many times patients end up being evicted from treatment. Ignorance of or failure to treat a comorbid disorder can seriously jeopardize a patient’s chance of recovery and it is also now a known fact that patients’ need to be treated holistically if the goal of treatment is long-term recovery.

Substance use disorders and Mental Health. 

According to the National Institute on Drug Abuse, the high prevalence of comorbidity between substance use disorders and other mental illnesses does not necessarily mean that one caused the other, even if one appeared first. Establishing causality or directionality is difficult for several reasons. For example, behavioral or emotional problems may not be severe enough for a diagnosis (called subclinical symptoms), but subclinical mental health issues may prompt drug use. Also, people’s recollections of when drug use or addiction started may be imperfect, making it difficult to determine whether the substance use or mental health issues came first.

Three main pathways can contribute to the comorbidity between substance use disorders and mental illnesses: (1)

  • Common risk factors can contribute to both mental illness and substance use and addiction.
  • Mental illness may contribute to substance use and addiction.
  • Substance use and addiction can contribute to the development of mental illness.

Anxiety, Depression, Attention Deficit and Hyperactivity Disorder (ADHD), Obsessive Compulsive Disorder (OCD), Schizophrenia and Bipolar disorder are common mental health issues that often co-occur substance abuse disorders. 

(1). Santucci K. Psychiatric disease and drug abuse. Curr Opin Pediatr. 2012;24(2):233-237. doi:10.1097/MOP.0b013e3283504fbf.

Substance use disorders and Trauma

Scientific research has shown a strong link between traumatic events and substance use disorders. Many people who have experienced child abuse, violent attacks, disasters, or other traumatic events turn to substance use to help them deal with emotional pain, bad memories, poor sleep, guilt, shame, anxiety, or terror. Individuals seeking treatment for alcohol and substance abuse are likely to have a history of trauma (Wiechelt, 2014). In fact, there is a relation between increased trauma exposure and substance use (Shields, Delany, & Smith, 2015; Wolf, Nochajski & Farrell, 2015). In addition, as the severity of the experienced trauma increases, there is also an increase in severity of substance abuse, as well as other negative life outcomes (Wolf et al., 2015).  

According to the International Society for Traumatic Stress Studies, when a person is experiencing problems with both traumatic stress and substance abuse, he or she will often have other psychological or physical problems. As many as 50% of adults with both alcohol use disorders and PTSD also have one or more other serious psychological or physical problems. For example, traumatized people who also abuse substances are often troubled by anxiety disorders (such as panic attacks, phobias, incapacitating worry or compulsions), mood disorders (such as major depression or dysthymia), disruptive behavior disorders (such as attention deficit or antisocial personality disorder), and multiple addictive behaviors (alcohol abuse, use of illicit drugs and abuse of prescribed medication).

A recent German study found that 66% of the women with a diagnosis of opioid dependence also reported sexual abuse, whereas the figure for men was 11% (Schäfer et al., 2014). In a similar study among alcohol-dependent patients, 35% of the female patients and 6% of male patients were sexually abused as a child (Schäfer et al., 2009). In another study among treatment-seeking alcohol-dependent patients (80% male), the following figures were found: 24% sexually abused as a child, 15% physically abused as a child, 16% witnessed domestic violence as a child, 42% physically abused as an adult, and 11% sexually abused as an adult (Langeland, Draijer, & Van den Brink, 2002). 

Despite this well-documented relation, most substance abuse treatment program are ill equipped in addressing comorbidity. For example a patient who initiates substance use due to trauma induced anxiety disorder, which with continuous use develops into substance use disorder and has multiple encounters with the law, enters treatment for the third time because of a drug court intervention. The treatment center as usual, again focuses only on his substance use disorder, ignoring or failing to treat his underlying problem. He relapses while he is in the halfway house due to anxiety attacks. This kind of situations perpetuates negative self believes and hopelessness among patients, who tend to believe that no matter how much they try they are incapable of overcoming substance use disorders.

In a society such as ours this unfortunate situation adds to the already prevailing stigma within the community towards substance use disorder and instigates self-stigma among those who are suffering, especially those who have undergone treatment numerous times, demotivating them to such an extent that it takes many interventions for them to even think about treatment again. It is important to know that we have just one treatment center catering to every age group, including women. 

According to Principle 2 and 4 from the Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) by the National Institute of Drug Abuse;

Principle 2: No single treatment is appropriate for everyone. Treatment varies depending on the type of drug and the characteristics of the patients. Matching treatment settings, interventions, and services to an individual’s particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.

Principle 4: Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems. It is also important that treatment be appropriate to the individual’s age, gender, ethnicity, and culture.

Lets stop blaming the patients who relapse after treatment and instead ask if the treatment being provided is appropriate for the patients or does the treatment adhere to the patients’ needs and not the other way around.