Substance use disorder

The relationship between substance use and other mental health illnesses is complex and a person can have more than one diagnosis. Substance use disorders are often seen with other mental health conditions and the term “concurrent disorder” is used to identify this combination. A significant risk factor for developing a problem with substance use is having symptoms, or a family history, of another mental health condition such as depression, anxiety or bipolar disorder.

In some instances, people may use drugs or alcohol to try to control symptoms of these other conditions. In the long run, this can lead to problems with substance use and make symptoms of mental illness worse.

Although one condition may be identified as most problematic, all require treatment. The treatment for concurrent disorders addresses the symptoms of substance use disorder and other mental health conditions at the same time. The treatment for substance use disorders should include learning to recognize symptoms of anxiety or depression, learning skills and strategies to manage these symptoms, and developing different ways to cope with unpleasant thoughts and feelings.

People can become dependent on different types of substances, and although the physical effects of those substances may differ, the symptoms of substance use disorder are generally the same for different substances.

The diagnosis of substance use disorder is based on a set of behaviours or criteria related to the use of the substance. The criteria relate to impaired control of use of drugs or alcohol, social impairment related to use, risky behaviours related to use and pharmacological effects. The severity of the condition is determined by how many criteria are met. A mild condition meets two or three criteria, moderate condition meets four or five criteria, and a severe substance use problem meets six or more of the following criteria.

• Larger amounts may be used over a longer period
• Persistent desire to stop using the drug or cut down but inability to stop or control use
• Significant time is spent on activities to obtain, use or recover from using the substance
• Craving, strong desire or urge to use

• Failure to fulfil major role obligations at work, school or home
• Continued use despite problems caused by use of the substance
• Social, occupational or recreational activities are given up, reduced or disrupted

• Recurrent use in unsafe situations
• Persistent use despite knowing that it is causing or worsening a physical or psychological problem

• Tolerance – need for larger amounts or a decreased effect from the use of the same amount
• Withdrawal – physical symptoms are experienced when use of the substance is stopped

Often, people with a substance use disorder will downplay the problem and try to conceal their symptoms and at times the people around them - including family, friends and co-workers - may notice warning signs.If you see these warning signs in someone you know it’s important to speak up and address them without being judgmental. People often need help to recognize that their substance use is a problem.

• Bloodshot eyes
• Changes in appetite or sleep patterns
• Deterioration in physical appearance or personal grooming habits
• Unusual smells, tremors, slurred speech, impaired coordination
• Drop in attendance or performance at work or school
• Arriving late or frequent breaks without explanation
• Unexplained financial problems
• Secretive or suspicious behaviour
• Change in friends, hangouts, hobbies
• Frequently getting into trouble, or having accidents
• Unexplained change in personality or attitude
• Sudden mood swings, irritability, or angry outbursts
• Unusual hyperactivity or agitation
• Reduced motivation
• Looks anxious or fearful for no reason

An assessment and recommendations by an addictions counsellor or doctor may help to determine which type of treatment may be appropriate for an individual.

Treatment usually begins by managing withdrawal symptoms. After withdrawal, there is generally an intensive period of treatment ranging from one to three months in duration which consists of psycho-education and counselling. This treatment focuses on learning alternate habits and how to resist cravings. This is followed by a period of aftercare which can be life-long. Aftercare may include counselling or attending peer support groups in the community. During this period of aftercare, most people are able to return to their usual work or school with the support of their treatment providers.

Even after long periods of abstinence people may continue to crave alcohol or drugs and may begin to use again. That is why treating this condition can be very challenging and most people require long-term or repeated care to regain productive functioning in the family, at work and in society.

There are a wide variety of treatment approaches which are included in accredited treatment programs, because different people respond best to different types of treatment. These may include residential or outpatient treatment, individual or group therapy, as well as self-help or peer led support groups. In addition, there are also medications that may be helpful.

Medication may help to control withdrawal symptoms. However, this is only the first step in treatment and will not help a person to stop using a drug. Medication can sometimes also be used to re-establish normal brain function or curb cravings. There are different medications that are used for various substances and supervised by a treatment program.

These programs provide intensive treatment, including group and individual counselling that may help people find alternatives to substance use.

These programs incorporate a wide range of group and individual counselling modalities, similar to residential programs, that people can access on an outpatient basis.

Different types of counselling may help individuals recognize the need to change behaviour and to manage their addiction. These may include:

• Cognitive behaviour therapy – The goal is to help people recognize, avoid, and cope with situations where they are most likely to abuse drugs.
• Motivational interviewing – Focuses on the readiness of individuals to change their behaviour and begin treatment.
• Positive reinforcement – Uses incentives/rewards to encourage abstinence.
• Family therapy or couples therapy – May help to address relationship influences on drug abuse patterns.

Maintaining adequate nutrition, regular physical activity and sticking to a proper sleep schedule can help relieve tension and stress. This is important to help maintain the strength that is needed to apply the skills and techniques learned in treatment. Taking care of ourselves also leaves us less vulnerable to depression and mood changes.

The urge to use the drug or drink alcohol may not go away and may be triggered by certain situations. Planning ahead for these situations can be helpful. Work with your treatment provider to develop a plan to follow when faced with an urge to use or if you find yourself in a situation where it is difficult to control the urge.

It is easier to make positive lifestyle changes with the support of others. Involving friends and family in a “get-better” plan may be helpful if a person is comfortable discussing their goals and treatment plan with them. For example, exercise with a friend, make healthy recipes for the entire family at mealtimes and participate in group activities.

Arrange for continued support. Self-help groups organized by mental health advocacy associations are a great resource for information, counselling and support. Self-help workbooks and websites (from a trusted source such as a national mental health association) can also provide practical advice.

Here are some self-care activities that may help to develop and maintain a heathy lifestyle and/or help other treatments work more effectively.

• Stick to a regular sleep routine
• Establish a regular, consistent time for sleeping and waking
• Do something relaxing before going to sleep like reading (in a different room) or taking a warm bath
• Don’t use the bedroom for non-sleep activities (e.g., watching TV or eating in bed)
• Avoid strenuous exercise, caffeine or tobacco a few hours before bedtime
• Avoid naps during the day. Get outdoors for some activity (e.g., a short walk) to refresh
• Talk to a health care provider about using a sleep medication
• Choose activities that are enjoyable
• Plan activities for the times when they can be performed consistently
• Be active on a regular basis. Aim for 10 minutes of continuous activity, three times a week, as a start. As fitness increases, the duration and intensity of activity can be increased
• Take advantage of opportunities to be more active by making small changes each day (e.g., take stairs instead of an elevator, exit a bus one stop earlier than a destination and walk)
• Keep up with proper nutrition

The urge to use the drug or drink alcohol may not go away and may be triggered by certain situations. The good news is that planning ahead for these situations can be helpful to keep you on the right track.

• Continue with self-care. Anything that helps maintain a healthy lifestyle should be continued on a regular basis. This might mean reading, going for short walks, going to bed at regular times, talking with friends, attending counselling sessions and doing counselling homework.


• Learn to manage stress. Stress can lead to increased urge for substance use, or decreased ability to resist the urge. Learn ways to avoid or manage stressors.


• Follow health care provider advice. Your health care providers can help you plan for difficult or stressful situations so you are prepared with a strategy to help you stop using. They will also help you maintain a healthy lifestyle.


• Take medication as prescribed. Medication should not be discontinued if symptoms improve or if they are no longer a problem. Always consult a health care provider before making any treatment or medication change.


• Take part in social activities. But avoid situations where the activity focuses on substance use.


• Stay connected to others. Connect with people who can support you in recovery and on the path to a substance-free life. Developing relationships with people who share healthy interests and activities and who can support you in making healthy choices will help you on your road to recovery.


• Take it slow. If roles and responsibilities have been reduced, return to them in a gradual, step-by-step fashion rather than all at once.


• Create an action plan. Develop a plan including specific words that you will say, what you will do, how you will act, if the urge to use presents itself. Also arrange to have someone to call when you have the urge to use.


• Arrange for continued support. Self-help groups are a great resource for information, counselling, and support. Self-help workbooks and websites (from a trusted source such as a national mental health association) can provide practical advice.

If there was an absence from the workplace, preparing to return to work may seem overwhelming, especially after being away for an extended period of time. To help make the return to work successful, the following tips may help.

• Write and rehearse your back to work explanation. This means prepare the words you will say when colleagues see you and ask how you are. Planning this response can help to reduce anxiety about returning to work.


• Think about what helps the most. Each person is different. Some people need more flexible work arrangements (e.g., reduced hours, modified job duties) and others feel capable of returning to full capacity immediately.


• Clearly understand the return to work plan and be an active participant in its creation. What are the hours? What are the expectations, roles, and responsibilities? Who needs to be informed?


• Understand privacy rights and be prepared for any disclosure (if necessary). Details of an absence are private and confidential. However, there may be workplace policies that require that certain kinds of information be reported (e.g., safety sensitive positions, information needed for job accommodation purposes). If any disclosure is required, plan what to say and how much information to share. Questions about who to disclose information to, and how much information to disclose, should be directed to a third party such as a human resources representative or employee health professional.


• Learn about support options. Good support is essential to a successful return. Find out what resources are available.


• Continue self-care efforts.


• Watch for signs of stress or triggers for substance use and apply your plan to stay healthy.


• Apply the tools developed in counselling or treatment.


• Be aware that it is normal to feel anxious about returning to work and agitation and worry may fluctuate throughout the return to work process. Adjustments in the return to work plan may be necessary.

With the right help, the right information, and the right support, people with substance abuse problems can maintain a productive and rewarding life. Change takes time and may be a lifelong process.