Psychologists are innovating to tackle substance use by building new alliances in treatment efforts

[This article is part of the 2024 Trends Report]

The latest trends in the United States for both illicit and legalized substances are sounding alarm bells for experts who track the harmful consequences of addiction. In 2022, more than 109,000 people in the nation died of drug overdoses—an estimated 54% jump from 2019, according to provisional data from the Centers for Disease Control and Prevention (CDC) (National Center for Health Statistics, 2023opens in new window). Roughly two-thirds of these deaths involved illicitly manufactured fentanyl, a synthetic opioid that is 50 to 100 times more potent than heroin (Morbidity and Mortality Weekly Report, CDC, Vol. 72, No. 26, 2023opens in new window).

Illicit drug makers are also increasingly mixing other substances with fentanyl, such as cocaine, methamphetamine, or xylazine, a sedative used in veterinary medicine. These combinations are creating a perfect storm of responses in the body that increases the risk of death, said Nora Volkow, MD, director of the National Institute on Drug Abuse (NIDA).

“The recreational drugs today are much more dangerous than what was available on the market 10 years ago, and we are seeing a dramatic increase in mortality,” Volkow said. “As we come out of the pandemic, there is also still a significant amount of distress in the population, and this increases the risk of substance use disorders.”

She is also concerned about the surge in regular cannabis consumption, especially as the availability of products with high levels of tetrahydrocannabinol (THC)—the main psychoactive compound in cannabis—continues to increase. Daily use in 2022 reached the highest level ever reported for young adults in NIDA’s Monitoring the Future survey (PDF, 1.45MB)opens in new window. Eleven percent of the respondents ages 19–30 reported using cannabis daily, and regular consumption of higher-content THC products can increase the risk of developing psychosis, cannabis hyperemesis syndrome (repeated and severe bouts of vomiting), suicidal ideation, and other conditions.

Although the statistics are alarming, psychologists are forging new pathways not only to offer support to more people who are misusing substances but also to improve the chances that they will successfully recover from substance use disorders. The strategies range from including probation officers in treatment efforts to advocating for programs that reward positive behavior.

The researchers pioneering this work are optimistic the innovations will help to slow or reverse worrisome trends, but societal biases have impeded progress. “There is remarkable stigma associated with substance use disorders in regulatory agencies, law enforcement, and health care, and psychologists need to use their position to develop and advocate for the programs that can assist patients,” said Rosemarie Martin, PhD, an experimental psychologist at Brown University and a principal investigator in the National Institutes of Health’s (NIH) Helping to End Addiction Long-term (HEAL) Initiativeopens in new window. “Increasing access to care for people struggling with substance use issues is a matter of social justice,” she said. NIH has invested $2.5 billion in more than 1,000 HEAL projects nationwide.

As an investigator for HEAL’s Justice Community Opioid Innovation Network, Martin is leading a program that equips probation officers to collaborate with community treatment providers. “Historically, treatment providers have not shared information with probation staff,” Martin said. “They are concerned about violating the patient’s privacy and that probation workers are looking for reasons to send people back to jail.”

Martin’s team recently invited probation staff and community health providers in Rhode Island to collaborate to identify gaps in care. They recognized that courts often do not mandate substance use treatment to reduce the number of restrictive conditions for probation. As a result, individuals misusing opioids were not accessing the care they needed. Now, probation workers in Rhode Island are screening individuals for opioid use at the outset of parole or probation. The community treatment providers are also communicating openly with probation officers when patients are struggling with opioid misuse. “If someone is going through a rough time, the probation officer can meet with the individual more often to provide referrals or other forms of support,” Martin said. She helped launch similar collaboration programs in Philadelphia and North Carolina.

Family members are another invaluable, often overlooked, resource in efforts to combat the opioid epidemic, said Marc Fishman, MD, medical director of Maryland Treatment Centers and a psychiatrist at the Johns Hopkins University School of Medicine. “When we think about any other subspeciality in health care, it is natural to involve family members if someone is ill,” he said. “With substance use disorders, loved ones are unsure what to do and there is a sense of shame and stigma.” He developed the Youth Opioid Recovery Support (YORS) intervention, in which one or more family members learn how to become allies who ensure youth in the program receive their monthly injections of medication for opioid use disorder—such as buprenorphine or naltrexone—to reduce cravings and block the effects of opioids. Family members also learn how to maintain the patient’s confidentiality and when to call the treatment team with concerns.

The program also uses an “assertive outreach” approach, which involves frequent communication with patients and family members about reminders, progress check-ins, and scheduling. “We are not passively waiting for the patient because motivation can fluctuate,” said Fishman. The medication is also delivered directly to the patient’s house. In the pilot study, nearly 50% of YORS patients did not relapse after 6 months, compared with 5% for the controls. The controls received treatment as usual, which included one dose of medication and an appointment to return to the clinic for subsequent doses (Journal of Substance Abuse Treatment, Vol. 125, 2021opens in new window).

New pharmacological treatments are also showing promise as a strategy to help people reduce drug use. For years, scientists have struggled to develop medications to treat cannabis use disorder, which occurs in about 1 in 5 cannabis consumers. One approach was blocking the specific cannabinoid receptors that are associated with the “high” caused by THC. But this method inhibits naturally occurring endogenous cannabinoids in the body, which leads to harmful side effects such as depression and suicidal ideation as well as withdrawal in individuals with cannabis use disorder. Recently, researchers discovered a drug currently called AEF0117 that inhibits only a subset of intracellular activity resulting from THC activation of the receptor. This medication does not produce negative side effects or withdrawal symptoms.

In a recent study, Margaret Haney, PhD, a professor of neurobiology at Columbia University Medical Center and director of the school’s Cannabis Research Laboratory, found that people who received the medication consumed less cannabis over a period of 4 days than those who did not receive the medication (Nature Medicine, Vol. 29, No. 6, 2023opens in new window). For Haney, one of the major advantages of this new pharmacological treatment is that it could help people who are interested in either abstaining or reducing their cannabis intake. “Many people are not open to quitting and want to control their use,” she said. “This is the first time we have found a medication that will help people use less by decreasing the high without side effects.”

Psychologists have also recently seen the benefits of a new pharmacological treatment that reduces a common withdrawal symptom: insomnia. People in treatment for opioid use disorder (OUD) often report that insomnia continues long after other withdrawal symptoms subside, but sedative medications typically used to treat insomnia are not recommended for people with OUD because these drugs can create a “high” sensation. Andrew Huhn, PhD, an associate professor in behavioral pharmacology at Johns Hopkins University School of Medicine, recently found that a drug called suvorexant—which inhibits wakefulness rather than promoting sedation—reduced insomnia in participants with OUD. The medication also helped to reduce other withdrawal symptoms such as vomiting and cravings (Science Translational Medicine, Vol. 14, No. 650, 2022opens in new window).

There are also signs that contingency management—or rewarding people for positive behavior—may be available to more patients soon. With this method, patients receive financial incentives such as gift cards as a reward for negative drug urine tests or other outcome measures, and there is overwhelming evidence that this strategy is highly effective in helping people recover from stimulant use disorders. But contingency management has not been used widely because the Centers for Medicare and Medicaid Services (CMS) has been unwilling to fund these programs, said Stephen Higgins, PhD, a behavioral pharmacology professor at the University of Vermont and founder of voucher-based contingency management for substance use disorders. “Regulators are concerned about fraud, such as providers who use the vouchers to draw people to a clinic who do not need treatment,” Higgins said. “But these programs can be designed to include safeguards that prevent this.”

In 2021, California became the first state to receive a waiver from CMS allowing regulatory approval to use a contingency management program for recovery from stimulants. In 2023, Washington state received a similar waiver. Michael McDonell, PhD, a professor in the Department of Community and Behavioral Health at Washington State University, has advocated for these programs, and he is encouraged by the increased openness to this evidence-based approach to treating addiction. “States are responding to the struggles that their citizens are having, and psychologists are leading the way to advocate for this strategy,” McDonell said.

Researchers are also working to address the underlying psychological and social conditions that perpetuate problematic drug use. Katie Witkiewitz, PhD, director of the University of New Mexico Center on Alcohol, Substance Use, and Addictions, believes it is critical to depathologize substance use behaviors. “If we recognize that people experience something positive when using these products, we can help them see the negative consequences and find different ways of getting their needs met,” she said.

Witkiewitz has been studying mindfulness-based treatment programs for people with alcohol use disorders. In 2022, rates of binge drinking in adults 35–50 reached an all-time high of 29%, according to the Monitoring the Future survey. For all age groups, the gaps are narrowing between males and females in consumption and related harms, such as emergency department visits and deaths.

Witkiewitz recently launched an online mindfulness group therapy program, known as THRIVE, that helps people with alcohol use disorder learn general life skills to cope with stress. In 60-minute virtual group meetings, participants explore how to feel stress and discomfort without trying to alter these emotions with alcohol, how to be mindful when things are going well, and how to savor moments. She plans to follow the participants for three years to track alcohol use and well-being.

[Related: Resources for families and significant others affected by opioid addiction]

Although new interventions like this hold promise, people who could benefit from them are missing opportunities for help because many clinicians do not screen patients for substance use, said Witkiewitz. “Most psychologists lack training in addiction medicine, and as a result, too many patients are treated solely for mental health conditions without receiving support for substance use disorders,” she said.

Volkow believes consistent screening will not only increase the chances of identifying people who are suffering from addictions but also help more individuals avoid substance use disorders altogether. “By screening more people, psychologists are in a unique position to do an intervention that can prevent patients from escalating to more frequent use,” she said. “It starts with telling patients how dangerous certain substances can be.”