4 Special Considerations

Now that you have a sense of how to define addiction, along with a grasp of the role that drugs play in our society, it is time to turn our attention to additional issues. We call these special considerations because they are important to think about in the context of how addiction develops.

Addiction knows no boundaries. It doesn’t care about your gender, race, ethnicity, age, socioeconomic status, religion, or occupation. It can affect anyone at any point along the lifespan. However, a few populations have a special connection to or relationship with addiction.

This chapter examines drug use among older adults and issues unique to this population. It also explores gender differences in treatment services, highlighting factors to consider with female clients. The chapter then dives into information on conditions that impact the development of addiction, such as co-occurring disorders, trauma, and chronic pain. The chapter concludes by discussing how behavioral addictions like compulsive gambling, shopping, or internet use fit into our definition.

Substance Use in Older Adults

Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.

The scope of substance use in older adults
While illicit drug use typically declines after young adulthood, nearly 1 million adults aged 65 and older live with a substance use disorder (SUD), as reported in 2018 data.1 While the total number of SUD admissions to treatment facilities between 2000 and 2012 differed slightly, the proportion of admissions of older adults increased from 3.4% to 7.0% during this time.2

Are older adults impacted differently by alcohol and drugs?
Aging could possibly lead to social and physical changes that may increase vulnerability to substance misuse. Little is known about the effects of drugs and alcohol on the aging brain. However, older adults typically metabolize substances more slowly, and their brains can be more sensitive to drugs.3 One study suggests that people addicted to cocaine in their youth may have an accelerated age-related decline in temporal lobe gray matter and a smaller temporal lobe compared to control groups who do not use cocaine. This could make them more vulnerable to adverse consequences of cocaine use as they age.19

Older adults may be more likely to experience mood disorders, lung and heart problems, or memory issues. Drugs can worsen these conditions, exacerbating the negative health consequences of substance use. Additionally, the effects of some drugs—like impaired judgment, coordination, or reaction time—can result in accidents, such as falls and motor vehicle crashes. These sorts of injuries can pose a greater risk to health than in younger adults and coincide with a possible longer recovery time.

Prescription Medicines
Chronic health conditions tend to develop as part of aging, and older adults are often prescribed more medicines than other age groups, leading to a higher rate of exposure to potentially addictive medications. One study of 3,000 adults aged 57-85 showed common mixing of prescription medicines, nonprescription drugs, and dietary supplements. More than 80% of participants used at least one prescription medication daily, with nearly half using more than five medications or supplements,5 putting at least 1 in 25 people in this age group at risk for a major drug-drug interaction.5
Other risks could include accidental misuse of prescription drugs and possible worsening of existing mental health issues. For example, a 2019 study of patients over the age of 50 noted that more than 25% who misuse prescription opioids or benzodiazepines expressed suicidal ideation, compared to 2% who do not use them, underscoring the need for careful screening before prescribing these medications.6

Opioid Pain Medicines
Persistent pain may be more complicated in older adults experiencing other health conditions. Up to 80% of patients with advanced cancer report pain, as well as 77% of heart disease patients, and up to 40% of outpatients 65 and older. Between 4-9% of adults age 65 or older use prescription opioid medications for pain relief.7 From 1995 to 2010, opioids prescribed for older adults during regular office visits increased by a factor of nine.7
The U.S. population of adults 55 and older increased by about 6% between 2013-2015, yet the proportion of people in that age group seeking treatment for opioid use disorder increased nearly 54%.4 The proportion of older adults using heroin—an illicit opioid—more than doubled between 2013-2015,4 in part because some people misusing prescription opioids switch to this cheaper drug.4

Nine percent of adults aged 50-64 reported past year marijuana use in 2015-2016, compared to 7.1% in 2012-2013.10 The use of cannabis in the past year by adults 65 years and older increased sharply from 0.4% in 2006 and 2007 to 2.9% in 2015 and 2016.22
Medical Marijuana
One U.S. study suggests that close to a quarter of marijuana users age 65 or older report that a doctor had recommended marijuana in the past year.10 Research suggests medical marijuana may relieve symptoms related to chronic pain, sleep hygiene, malnutrition, depression, or to help with side effects from cancer treatment.11 It is important to note that the marijuana plant has not been approved by the Food and Drug Administration (FDA) as a medicine. Therefore, the potential benefits of medical marijuana must be weighed against its risks, particularly for individuals who have other health conditions or take prescribed medications.11
Risks of Marijuana Use
Regular marijuana use for medical or other reasons at any age has been linked to chronic respiratory conditions, depression, impaired memory, adverse cardiovascular functions, and altered judgment and motor skills.12 Marijuana can interact with a number of prescription drugs and complicate already existing health issues and common physiological changes in older adults.

The Centers for Disease Control and Prevention (CDC) reports that in 2017, about 8 of every 100 adults aged 65 and older smoked cigarettes, increasing their risk for heart disease and cancer.20 While this rate is lower than that for younger adults, research suggests that older people who smoke have increased risk of becoming frail, though smokers who have quit do not appear to be at higher risk.14 Although about 300,000 smoking-related deaths occur each year among people who are age 65 and older, the risk diminishes in older adults who quit smoking.13 A typical smoker who quits after age 65 could add two to three years to their life expectancy. Within a year of quitting, most former smokers reduce their risk of coronary heart disease by half.13

Nicotine Vaping
There has been little research on the effects of vaping nicotine (e-cigarettes) among older adults; however, certain risks exist in all age groups. Some research suggests that e-cigarettes might be less harmful than cigarettes when people who regularly smoke switch to vaping as a complete replacement. However, research on this is mixed, and the FDA has not approved e-cigarettes as a smoking cessation aid. There is also evidence that many people continue to use both delivery systems to inhale nicotine, which is a highly addictive drug.

Alcohol is the most used drug among older adults, with about 65% of people 65 and older reporting high-risk drinking, defined as exceeding daily guidelines at least weekly in the past year.16 Of particular concern, more than a tenth of adults age 65 and older currently binge drink,18 which is defined as drinking five or more drinks on the same occasion for men, and four or more drinks on the same occasion for women. In addition, research published in 2020 shows that increases in alcohol consumption in recent years have been greater for people aged 50 and older relative to younger age groups.21

Alcohol Use Disorder: Most admissions to substance use treatment centers in this age group relate to alcohol.2 One study documented a 107% increase in alcohol use disorder among adults aged 65 years and older from 2001 to 2013.16 Alcohol use disorder can put older people at greater risk for a range of health problems, including diabetes, high blood pressure, congestive heart failure, liver and bone problems, memory issues and mood disorders.16

Risk Factors for Substance Use Disorders in Older Adults

Physical risk factors for substance use disorders in older adults can include: chronic pain; physical disabilities or reduced mobility; transitions in living or care situations; loss of loved ones; forced retirement or change in income; poor health status; chronic illness; and taking a lot of medicines and supplements. Psychiatric risk factors include: avoidance coping style; history of substance use disorders; previous or current mental illness; and feeling socially isolated.19


How are substance use disorders treated in older adults?
Many behavioral therapies and medications have been successful in treating substance use disorders in older adults. Little is known about the best models of care, but research shows that older patients have better results with longer durations of care.7 Ideal models include diagnosis and management of other chronic conditions, re-building support networks, improving access to medical services, improved case management, and staff training in evidence-based strategies for this age group.7
Providers may confuse SUD symptoms with those of other chronic health conditions or with natural, age-related changes. Research is needed to develop targeted SUD screening methods for older adults. Integrated models of care for those with coexisting medical and psychiatric conditions are also needed.2 It is important to note that once in treatment, people can respond well to care.2


Answer the following questions about issues unique to older adults:

Key Takeaways

• While use of illicit drugs in older adults is much lower than among other adults, it is currently increasing.
• Older adults are often more susceptible to the effects of drugs, because as the body ages, it often cannot absorb and break down drugs and alcohol as easily as it once did.
• Older adults are more likely to unintentionally misuse medicines by forgetting to take their medicine, taking it too often, or taking the wrong amount.
• Some older adults may take substances to cope with big life changes such as retirement, grief and loss, declining health, or a change in living situation.
• Most admissions to substance use treatment centers in this age group are for alcohol.
• Many behavioral therapies and medications have been successful in treating substance use disorders, although medications are underutilized.
• It is never too late to quit using substances—quitting can improve quality of life and future health.
• More science is needed on the effects of substance use on the aging brain, as well as into effective models of care for older adults with substance use disorders.
• Providers may confuse symptoms of substance use with other symptoms of aging, which could include chronic health conditions or reactions to stressful, life-changing events.

Gender and Use of Substance Abuse Treatment Services

Carla Green, Ph.D, MPH

*Written for the National Institute on Alcohol Abuse and Alcoholism

Women are more likely than men to face multiple barriers to accessing substance abuse treatment and are less likely to seek treatment. Women also tend to seek care in mental health or primary care settings rather than in specialized treatment programs, which may contribute to poorer treatment outcomes. When gender differences in treatment outcomes are reported, however, women tend to fare better than men. Limited research suggests that gender-specific treatment is no more effective than mixed-gender treatment, though certain women may only seek treatment in women-only programs. Future health services research should consider or develop methods for (1) improving care for women who seek help in primary care or mental health settings, (2) increasing the referral of women to specialized addiction treatment, (3) identifying subgroups of women and men who would benefit from gender-specific interventions, and (4) addressing gender-specific risk factors for reduced treatment initiation, continuation, and treatment outcomes.

In the 1970s and 1980s, practitioners and researchers began to call attention to how little was known about providing appropriate care for women with substance abuse problems, particularly alcoholism (Schmidt and Weisner, 1995). Research traditionally had focused on how men fared in substance abuse treatment, and treatment programs were ill-equipped to help women. In response, government organizations began to support research and treatment for women, and significant numbers of researchers and practitioners focused on understanding and addressing gender differences in treatment access, treatment provision, and outcomes (Schmidt and Weisner, 1995). Researchers began examining the characteristics and social circumstances of women with substance abuse problems, identifying factors that interfered with detecting and diagnosing women who needed help. They also studied the barriers that prevented women from entering treatment and gender-specific issues related to women’s success in treatment. These efforts have resulted in a large body of research addressing gender differences in treatment-seeking, access to care, retention in care, and treatment outcomes.

Over this same period, many treatment programs also began to pay greater attention to the women in their programs and their special needs. Today many (although not all) treatment programs offer gender-specific or gender-sensitive services, such as gender-matching with counselors, mixed-gender treatment groups led by male and female co-leaders, gender-specific treatment groups, and gender-specific treatment content. Many programs also provide ancillary or wraparound services, such as child care and parenting groups, which facilitate women’s treatment entry and continuation. In addition, significant numbers of treatment programs serve women only, target pregnant women or adolescent girls, or offer specialized parenting services for women and their children.

These profound changes in research and treatment programs have occurred at the same time as other important social changes in the United States, such as women’s increased participation in the workforce, greater similarities in men’s and women’s patterns of substance use, and increased public knowledge about substance-abuse-related problems and their treatment. As a result, health services researchers who study gender and substance abuse treatment are finding it difficult to know whether findings from earlier research are still applicable in current settings. Consequently, the following review sometimes specifically distinguishes earlier research findings (i.e., from the 1970s and the 1980s) from more recent research findings.

This article examines gender differences in the prevalence of substance use and related problems, the identification of such problems, treatment-seeking and access, retention in treatment, and treatment outcomes.


Research on how gender influences substance use and substance-abuse-related problems has established clear differences between women and men in several important areas. Women typically consume less alcohol than men when they drink, drink alcohol less frequently, and are less likely to develop alcohol-related problems than men (Fillmore et al. 1997). Similarly, women are less likely than men to use illicit drugs and to develop drug-related problems (Greenfield et al. 2003a).

Conversely, when women do develop substance abuse problems, they tend to develop them faster than men do. For example, although women tend to be older than men, on average, when they begin a pattern of regular drunkenness, women’s drinking-related problems (e.g., loss of control over drinking, negative consequences of drinking) appear to progress more quickly than those of men (Randall et al. 1999). This faster progression also means that women experience shorter intervals than men between onset of regular drunkenness and first encountering the negative consequences of drinking, which include physical problems, interpersonal difficulties, negative intrapersonal changes (such as in personality or self-esteem), poor impulse control, and reduced ability to maintain normal social roles and responsibilities. Women also experience shorter intervals between first loss of control over drinking and onset of their most severe drinking-related consequences, and shorter intervals between onset of regular drunkenness and treatment-seeking (Randall et al. 1999). Women report more severe problems and experience more health-related consequences from substance use (Bradley et al. 1998), and their substance-related problems interfere with functioning in more life domains compared with men (Fillmore et al. 1997).

Recent narrowing of the differences in men’s and women’s substance use patterns and attitudes (McPherson et al. 2004) raises additional concerns because of women’s greater susceptibility to substance-related problems. Based on recent U.S. prevalence estimates, women make up about one-third of people with alcohol problems and slightly less than half of those who have problems with other drugs (Greenfield et al. 2003a).


Key Takeaways


Women are less likely than men to use illicit drugs and develop drug-related problems (Greenfield et al. 2003a).

Women drinkers tend to drink less alcohol less often than men do and are less likely than men to develop alcohol-related problems (Fillmore et al. 1997).

When women do develop substance abuse problems, they report problems of greater severity and experience more health-related consequences (Bradley et al. 1995).

Women’s problems related to substance abuse interfere with functioning in more areas of life than men’s do (Fillmore et al. 1997).

Women are older than men are when they begin drinking to intoxication, but once they develop a pattern of regular intoxication, they:

Encounter drinking-related problems more quickly than men (Randall et al. 1999)

Lose control over their drinking more quickly than men (Randall et al. 1999).

Recent research shows that women’s and men’s substance use patterns have become more similar in the past few years (McPherson et al. 2004).

Women make up about one-third of the population with alcohol problems and slightly less than half of those who have problems with other drugs (Greenfield et al. 2003a).

A person’s gender has the potential to affect several critical junctures along the pathway to seeking substance abuse treatment. Identification of a problem is the first step toward treatment, whether by the person needing treatment, or by a family member, health care professional, employer, or government agency. The likelihood that a person’s substance abuse problem will be identified appears to differ by gender in some settings. For example, compared with men, substance abuse problems among women, particularly older women (National Center on Addiction and Substance Abuse 1998), are less likely to be identified in health care settings (Brienza and Stein 2002). Women with substance abuse are more likely than men to be identified through contacts with child protective services (Fiorentine et al. 1997; Grella and Joshi 1999). Women also are less likely than men to be referred for substance abuse treatment by their employers or schools (Morgenstern and Bux 2003) and are more likely to have family members, friends, and partners who use drugs and support their substance use (Bendtsen et al. 2002; Grella and Joshi 1999; Center for Substance Abuse Treatment 1994; Kelley et al. 1996; Kline 1996).



Once people realize they have a substance abuse problem, they must decide or be convinced that they need help—through personal reflection, feedback from others, or legal, employer, or family mandates. Information about possible differences in how men and women go through these processes is limited. Little is known about how families interact when a family member has substance abuse problems, about how the gender of that person influences how families or employers communicate about or manage these problems (see Room et al. 2004 for an intriguing exception), or about how gender might influence reflection prior to treatment-seeking.

Researchers have determined that employed women seeking treatment for alcohol problems are less likely than men to be married and, if married, are less likely to have had spouses who played a role in referral to treatment (Blum et al. 1995). Men who receive suggestions to cut down or stop drinking are more likely to enter treatment, whereas such suggestions do not appear to predict treatment entry for women (Weisner 1993). Early research suggested that women were discouraged by family members from seeking treatment (Beckman and Amaro 1986), and an older Swedish study (Dahlgren and Myrhed 1977) found that women were more likely than men to enter treatment after serious acute complications of their substance use (e.g., unconsciousness, suicide attempts). Women and men do not appear to differ, however, in their perceptions about the need for treatment (Wu and Ringwalt 2004).

In the context of mandated treatment, sources of mandates differ for men and women (Grella and Joshi 1999), with men more likely to be mandated to treatment by employers, through the criminal justice system, and by their families. Women, in contrast, are more often referred by a social worker, suggesting family service agency involvement in their treatment entry (Grella and Joshi 1999). To date, researchers have not directly addressed how gender affects the processes leading to such mandates.


Once people recognize that they have a substance abuse problem and decide to seek treatment, they still must overcome a variety of barriers to finding and accessing treatment resources. Many studies provide evidence for gender differences in the type, strength, and number of barriers people encounter as they consider and attempt to access treatment. For example, Brady and Ashley (2005) reported that women are more likely than men to experience economic barriers when seeking treatment. They also are more likely to have trouble finding the time to attend regular treatment sessions because of family responsibilities and must overcome problems with transportation. Both men and women must overcome the stigma associated with seeking treatment, but women are particularly susceptible to feeling stigmatized (Brady and Ashley 2005).


Key Takeaways

Women are more likely than men to encounter barriers that prevent them from seeking or following through with treatment (Brady and Ashley 2005).

Women are more likely to experience economic barriers to treatment (Brady and Ashley 2005).

Women are more likely to have difficulty attending regular treatment sessions because of family responsibilities (Brady and Ashley 2005; Brady and Randall 1999).

Providing comprehensive services, such as housing, transportation, education, and income support, reduces post-treatment substance use among both men and women, but greater numbers of women need such services (Marsh et al. 2004, 2000).

Women are more likely to report feeling shame or embarrassment because they are in substance abuse treatment (Thom 1987).

Anxiety or depressive disorders, which tend to be more prevalent and severe among women, may prevent women from seeking help with substance abuse problems (Brady and Randall 1999).

Limitations in everyday functioning caused by substance abuse and dependence and common co-occurring conditions, such as mental illness, also can prevent people from accessing treatment. Although both men and women are likely to experience these functional limitations, anxiety and depressive disorders tend to be more prevalent (Hesselbrock and Hesselbrock 1997) and more severe among women with substance abuse problems. For this reason, women may be less likely to seek or follow through with care (Brady and Ashley 2005). Lack of information about treatment options—their availability and likelihood of success—is another barrier. Few studies have investigated whether men and women differ significantly in their knowledge in these areas.

Finally, women from some ethnic groups (such as Hispanic women) may experience cultural barriers (e.g., language problems [U.S. Department of Health and Human Services 2001]) to seeking treatment (Weiss et al. 2003). Moreover, older women are more likely than younger women to encounter physicians who do not believe substance abuse treatment is effective for them, and to have insurance carriers that deny them coverage for treatment (National Center on Addiction and Substance Abuse 1998).

In sum, women are more likely than men to encounter multiple barriers to treatment entry, making them less likely to seek care for their substance-related problems (Brady and Ashley 2005).


Consistent with these concerns, early research suggested that women with substance abuse problems were less likely to seek help than men with similar problem severity. More recent research suggests that rates of treatment access have improved, with women seeking care at rates similar to those of men, at least in the years following problem onset (Dawson 1996). Similar rates of treatment entry, however, may indicate that women continue to have reduced access compared with men because women consistently use more medical services in other settings than men do (Bertakis et al. 2000). Furthermore, although women’s access appears to have improved generally, some studies continue to find fewer admissions to substance abuse treatment among women (Westermeyer and Boedicker 2000; Arfken et al. 2002).

Various barriers experienced by women, particularly those related to stigma, may influence where women seek help, and whether they seek it from a health professional, a self-help group, or from another source, such as a member of the clergy. Women have been more likely than men to seek help in mental health and primary care settings rather than in substance abuse treatment settings (Weisner and Schmidt 1992). Recent research suggests that care obtained in these nonspecialty settings can lead to poorer treatment outcomes than those achieved at specialty treatment settings. For example, Mojtabai (2005) found that people receiving specialty substance abuse treatment services were less likely to continue substance use than those receiving mental health services. Other recent studies show that, consistent with the greater severity of women’s alcohol-related problems when seeking treatment, women have longer inpatient stays than men, and increasingly are more likely to use self-help programs such as Alcoholics Anonymous (with or without formal treatment) (Timko et al. 2002). Women also are more likely to benefit from these self-help programs than men are (Timko et al. 2002).

In sum, research findings indicate that help-seeking for substance abuse, dependence, and substance-related problems is affected by gender and gender-related characteristics (Weisner and Schmidt 2001). Research is needed to determine the relative value of improving substance abuse treatment services for women in the settings in which they currently seek care (such as in mental health and primary care settings) compared with the value of working to increase referrals to specialty addiction treatment. Improving the latter may be particularly important, given women’s greater needs upon entering treatment: Mental health and primary care settings may be significantly less prepared to manage women’s ancillary service needs and the complexity of their disorders.


Research has found that women seeking treatment for alcohol or other drug problems have more severe problems (Arfken et al. 2001), are younger, have lower education levels (Wechsberg et al. 1998), and have lower incomes (Brady et al. 1993) than men seeking treatment. Women are more likely to have experienced emotional, physical, and sexual abuse (Wechsberg et al. 1998); to have more severe depressive symptoms when depressed (Pettinati et al. 1997); and to be more hostile than men upon treatment entry (Robinson et al. 2001). Women also report more physical and mental health problems (Brady et al. 1993) and greater concerns about child-related issues (Wechsberg et al. 1998) than men do. In addition, women entering treatment for alcohol-related problems are more likely than men to identify factors other than drinking (e.g., stressful life events, mental health symptoms) as their primary problems and, at least as indicated by earlier studies, have been more likely to report shame and embarrassment at treatment entry (Thom 1987). These differences have led many to conclude that women would be less likely to seek, initiate, or complete treatment, and would therefore have poorer long-term outcomes.


Once they have made contact with a source of help, people may or may not proceed to the next step in the process—initiating treatment. They have many choices about initiation, including choice of setting—that is, whether in a formal substance abuse treatment program, another health care setting, within a support group, or with an individual helper. After a recommendation for continuation (often following assessment in a substance abuse treatment setting), people must decide whether to continue along the path they have chosen, seek other services, or decline help. Those who continue then must repeatedly choose whether or not to continue their involvement. This is true even if they have been mandated to treatment. People who select a formal treatment setting must decide whether or not they will complete the treatment program as it has been designed. Research has begun to assess the ways that gender affects the different steps in the treatment process: initiation, engagement and continuation in treatment, completion of the program, and subsequent outcomes.

Most recent studies suggest that gender either has no effect on initiation, or that if it does have an effect, women are more likely than men to initiate treatment (Weisner et al. 2001; Green et al. 2002; Timko et al. 2002). Similarly, research indicates that changes in the provision of care seem to have allayed concerns that women’s continuing engagement in treatment might be hindered by programs’ insensitivity to women’s needs. Women now appear at least as likely as men to engage in and complete treatment, although women from certain subgroups may be at risk for not completing treatment. For example, African American women— as well as women with lower incomes who are unmarried, unemployed, or have psychological problems of greater severity—are less likely to continue with treatment (Mertens and Weisner 2000). Research is needed to identify (1) subgroups at risk for not continuing treatment, (2) modifiable barriers to treatment completion among members of these groups, and (3) appropriate remedies for these barriers.


Many recent research efforts have addressed gender differences in treatment outcomes (which are defined in various ways, including abstinence rates and number of days substances were used in a particular period). Despite concerns that women would fare worse than men, current evidence suggests that, overall, women’s substance abuse treatment outcomes are as good as, or better than, men’s treatment outcomes. For example, one recent study found that men and women were equally likely to complete treatment, but women who completed treatment were nine times more likely to be abstinent than women who did not complete, whereas men who completed treatment were only three times more likely to be abstinent than men who did not complete treatment (Green et al. 2004).


Key Takeaways


Because of the characteristics of women with substance abuse problems and the obstacles to treatment they face, many researchers have suggested that women would be less likely to seek, begin, or complete treatment, and would therefore have poorer long-term outcomes (Schmidt and Weisner 1995).


Most recent studies suggest that gender either has no effect on treatment initiation or, if it has an effect, women are more likely than men to initiate treatment (Weisner et al. 2001; Green et al. 2002; Timko et al. 2002).

Women now appear at least as likely as men to engage in and complete treatment (Brady and Ashley 2005).

Men and women are equally likely to complete treatment, but women who complete are nine times more likely to be abstinent than women who do not; men who complete treatment were only three times more likely to be abstinent than men who do not (Green et al. 2004).

Current research suggests that women’s treatment outcomes are as good as, or better than, men’s.

Women in substance abuse treatment are less likely to relapse than men in treatment. When women relapse, their reasons for relapse differ from men’s:

Women are more likely to relapse when their romantic partners are substance users (Rubin et al. 1996).

Women are more likely to report personal problems before relapse (McKay et al. 1996).

Women who have been in treatment have better long-term recovery outcomes than men (Dawson et al. 2005; Weisner et al. 2003).

Research on the benefits of gender-specific treatment is less clear than evidence on the benefits of ancillary services, because few studies have compared gender-specific treatment with mixed-gender treatment (Orwin et al. 2001; Smith and Weisner 2000). One recent study randomly assigned female participants to women-only versus mixed-gender programs and found no differences in outcomes (Kaskutas et al. 2005).Researchers also have identified many factors that differ by gender and affect treatment outcomes in important ways—including income, education, employment, types of substances used, psychiatric disorders and symptoms, marital status, self-efficacy, history of sexual abuse, and children in the home (Green et al. 2004; Greenfield et al. 2003b, 2000, 1998, 2002). This suggests that addressing risks differentially, by gender, may help improve both the treatment process and outcomes for men and women. Recognizing these risks, and the potentially differential needs of men and women, has led to the development of gender-specific treatment programs and the provision of women-centered ancillary services. For example, evidence shows that providing services such as child care helps keep women in treatment (Brady and Ashley 2005).

Yet, as is true for other aspects of the treatment process, some subgroups of women may be more likely to benefit from gender-specific treatment. For example, substance-abusing women with post-traumatic stress disorder (PTSD) may benefit significantly more from gender-specific programs designed to address PTSD and addiction problems simultaneously. These programs provide gender-specific content and address, in a comfortable setting (i.e., with only female participants), traumatic experiences and sexual assault (Hien et al. 2004). (Men with PTSD resulting from combat experiences may similarly benefit from male-only groups.) Pregnant and perinatal women also have needs that may be more easily addressed in women-only programs. Although such programs are effective at improving outcomes (Orwin et al. 2001), important pregnancy, labor, delivery, and lactation concerns, as well as other needs (e.g., child care, service coordination, and mental health care) remain unaddressed among these women, particularly among those who also have mental health problems (Grella 1997). Finally, certain women may not seek treatment if women-only treatment programs are not available (Weisner 2005).

Rather than relying solely on gender-specific treatment, some researchers have examined ways to improve treatment by making it gender-sensitive. One approach is to match therapist and client gender or to match therapeutic modality to gender. Results of these efforts have been equivocal. Project MATCH found that matching gender and therapeutic modality had no effect on outcomes (Project MATCH Research Group 1997). Studies addressing therapist–client gender-matching have produced a range of outcomes—with some finding no effects, and others finding greater empathy and therapeutic alliance, longer treatment episodes, and higher rates of abstinence, but also more post-treatment psychiatric symptoms (Fiorentine and Hillhouse 1999; Sterling et al. 1998, 2001; McKay et al. 2003; Nurco et al. 1988). Additional research could help to determine the types of clients best served by same-gender or opposite-gender therapists, and to illuminate the mechanisms by which matching influences treatment process and outcomes.


Not surprisingly, women who have stopped using substances relapse under different circumstances than men do. For example, women are more likely to relapse in the presence of a romantic partner than men are, and are less likely to relapse when they are alone (Rubin et al. 1996). Women also are more likely to report interpersonal problems before relapse (McKay et al. 1996). Consistent with findings of women’s better outcomes in other domains (e.g., post-treatment abstinence, retention in treatment), women are less likely than men to relapse overall (Rubin et al. 1996), and women tend to have better long-term recovery outcomes (Dawson et al. 2005; Weisner et al. 2003). Such results suggest that future research on gender differences in treatment outcomes should focus on improving the understanding of the underlying factors which differ by gender and predict better outcomes (such as better therapeutic alliances among women in treatment) and reduced relapse. Such a focus might further improve treatment outcomes for both men and women.


Over the past two decades, health services researchers have successfully identified gender differences in patterns of substance use, health and social effects of substance use, pathways to treatment for substance abuse problems, and substance abuse treatment processes and outcomes. As a result of the efforts of treatment programs to address women’s needs, and the efforts of researchers to document the effectiveness of treatment for women, it is known that, in general, specialty addiction treatment is at least as effective for women as it is for men.

At the same time, this work has identified both different and common predictors of treatment access and outcomes for men and women. Now it is possible to target gender-specific factors that increase the risks that substance abuse problems will go undetected or lead to reduced treatment initiation and treatment completion. It also is possible to identify factors that could reduce relapse and improve outcomes. For example, because women continue to seek substance abuse treatment in primary care and mental health settings, care providers in these settings could be trained to identify and refer women to specialty addiction services. Conversely, integrated programs could be developed to provide care to women in places other than specialized treatment agencies or departments (e.g., primary care or mental health settings). Similarly, men who have been victims of domestic violence or forced sex might benefit from approaches developed for women with such histories.

Finally, this body of research suggests that a large proportion of men and women do well in mixed-gender treatment settings, and for these people, such settings will likely be more cost-effective than providing gender-specific treatment. However, some individuals or subgroups (female and male) may benefit in important ways from gender-specific treatment. Adequate assessment and appropriate treatment—whether in gender-sensitive mixed-gender programs or gender-specific programs—are critical to improving clinical outcomes for many people who currently are not well served.

1. Substance Abuse and Mental Health Services Administration. (2019). Results from the 2018 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/
2. Chatre S, Cook R, Mallik E et al. Trends in substance use admissions among older adults. BMC Health Services Research. 2017; 584(17). doi: https://doi.org/10.1186/s12913-017-2538-z
3. Colliver JD, Compton WM, Gfroerer JC, Condon T. Projecting drug use among aging baby boomers in 2020. Annals of Epidemiology. 2006; 16(4): 257–265.
4. Huhn AS, Strain EC, Tompkins DA, Dunn KE. A hidden aspect of the U.S. opioid crisis: Rise in first-time treatment admissions for older adults with opioid use disorder. Drug Alcohol Depend. 2018 Dec 1; 193: 142-147. doi: 10.1016/j.drugalcdep.2018
5. Qato DM, Alexander GC, Conti RM, Johnson M, Schumm P, Lindau ST. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA. 2008 Dec 24; 300(24): 2867-2878. doi: 10.1001/jama.2008.892
6. Schepis TS, Simoni-Wastila L, McCabe SE. Prescription opioid and benzodiazepine misuse is associated with suicidal ideation in older adults. Int J Geriatr Psychiatry. 2019; 34(1): 122-129. doi: 10.1002/gps.4999
7. Lehmann S, Fingerhood M. Substance-use disorders in later life, N Engl J Med. 2018 December 13; 379(24): 2351-2360. doi: 10.1056/NEJMra1805981
8. Galicia-Castillo, M. Opioids for persistent pain in older adults. Cleveland Clinic Journal of Medicine. 2016 June 6; 83(6). Retrieved from: https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/issues/articles/Galicia-Castillo_OpiodsForOlderAdults.pdf
9. Wu LT, Blazer DG. Illicit and nonmedical drug use among older adults: A review. Journal of Aging and Health. 2011; 23(3): 481–504. doi:10.1177/0898264310386224
10. Han BH, Palamar JJ. Marijuana use by middle-aged and older adults in the United States, 2015-2016. Drug Alcohol Depend. 2018; 191: 374-381. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/30197051
11. Abuhasira R, Ron A, Sikorin I, Noack V. Medical cannabis for older patients—Treatment protocol and initial results. Journal of Clinical Medicine. 2019; 8(11): 1819. https://doi.org/10.3390/jcm8111819
12. Volkow N, Baler R, Compton W, Weiss S. Adverse health effects of marijuana use. N Engl J Med. 2014 June 5; 370(23): 2219-2227. doi: 10.1056/NEJMra1402309
13. Centers for Disease Control and Prevention. Smoking and Older Adults. November 2008. https://www2c.cdc.gov/podcasts/media/pdf/HealthyAgingSmoking.pdf. Accessed March 12, 2020.
14. Kojima G, Iliffe S, Jivraj S, Liljas A, Walters K. Does current smoking predict future frailty? The English longitudinal study of ageing. Age and Ageing. 2018 January; 47(1): 126-131. https://doi.org/10.1093/ageing/afx136
15. Older adults fact sheet. National Institute on Alcohol Abuse and Alcoholism. https://www.niaaa.nih.gov/alcohol-health/special-populations-co-occurring-disorders/older-adults
16. Grant BF, Chou SP, Saha TD, et al. Prevalence of 12‐month alcohol use, high‐risk drinking, and DSM‐IV alcohol use disorder in the United States, 2001‐2002 to 2012‐2013: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiat. 2017; 74(9): 911‐923.
17. Kuerbis et al. Substance abuse among older adults. Clin Geriatr Med. 2014 Aug; 30(3): 629–654. doi:10.1016/j.cger.2014.04.008
Substance Use in Older Adults • July 2020 • Page 8
18. Han B, Moore A, Ferris R, Palamar J. Binge drinking among older adults in the United States, 2015-2017. Journal of the American Geriatrics Society. 2019 July 31; 67(10). https://doi.org/10.1111/jgs.16071
19. Bartzokis et al. Magnetic resonance imaging evidence of “silent” cerebrovascular toxicity in cocaine dependence. Biol Psychiatry. 1999; 45: 1203-1211.
20. Current cigarette smoking among adults in the United States fact sheet. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm
21. White A, Castle I, Hingson R, Powell P. Using death certificates to explore changes in alcohol‐related mortality in the United States, 1999 to 2017. Alcoholism Clinical and Experimental Research. 2020 January 7; 44(1): 178-187. https://doi.org/10.1111/acer.14239
22. Han BH, Sherman S, Mauro PM, Martins SS, Rotenberg J, Palamar JJ.
Demographic trends among older cannabis users in the United States, 2006-2013.
Addiction. 2017; 112(3): 516-525. doi:10.1111/add.13670

Part Two: Conditions that Impact the Development of Addiction

In 21st-century treatment centers, few clients are treated solely for a substance use disorder. In most cases, clients present with an extensive history that might involve mental health issues, trauma, attempts to manage chronic pain, or all of the above. It is critical for helping professionals, along with family members and friends, to understand the complex interaction of these problems.

We mentioned in Chapter 1 that addiction is a primary disorder, meaning that it requires its own treatment and is not simply a symptom of another problem. That said, addiction is rarely the only issue that someone is struggling with. Anxiety, depression, bipolar disorder, unresolved trauma, and severe pain are all commonly seen by helping professionals while treating addictive disorders.

The following interactive video explains the importance of treating co-occurring disorders in an integrated manner:

SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach

The convergence of the trauma survivor’s perspective with research and clinical work has underscored the central role of traumatic experiences in the lives of people with mental and substance use conditions. The connection between trauma and these conditions offers a potential explanatory model for what has happened to individuals, both children and adults, who come to the attention of the behavioral health and other service systems.

People with traumatic experiences, however, do not show up only in behavioral health systems. Responses to these experiences often manifest in behaviors or conditions that result in involvement with the child welfare and the criminal and juvenile justice system or in difficulties in the education, employment, or primary care system. Recently, there has also been a focus on individuals in the military and increasing rates of post-traumatic stress disorder.

SAMHSA’s Definition of Trauma

Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.

The six key principles fundamental to a trauma-informed approach include:

1. Safety

Throughout the organization, staff and the people they serve, whether children or adults, feel physically and psychologically safe; the physical setting is safe and interpersonal interactions promote a sense of safety. Understanding safety as defined by those served is a high priority.

2. Trustworthiness and Transparency

Organizational operations and decisions are conducted with transparency with the goal of building and maintaining trust with clients and family members, among staff, and others involved in the organization.

3. Peer Support

Peer support and mutual self-help are key vehicles for establishing safety and hope, building trust, enhancing collaboration, and utilizing stories and lived experiences to promote recovery and healing. The term peers refers to individuals with lived experiences of trauma. In the case of children, these may be members of their family who have experienced traumatic events and are key caregivers in their recovery. Peers have also been referred to as trauma survivors.

4. Collaboration and Mutuality

Importance is placed on partnering and the leveling of power differences between staff and clients and among organizational staff from clerical and housekeeping personnel, to professional staff to administrators, demonstrating that healing happens in relationships and in the meaningful sharing of power and decision-making. The organization recognizes that everyone has a role to play in a trauma-informed approach. As one expert stated, “one does not have to be a therapist to be therapeutic.”

5. Empowerment, Voice and Choice

Throughout the organization and among the clients served, individuals’ strengths and experiences are recognized and built upon. The organization fosters a belief in the primacy of the people served; in resilience; and in the ability of individuals, organizations, and communities to heal and promote recovery from trauma. The organization understands that the experience of trauma may be a unifying aspect in the lives of those who run the organization, who provide the services, and/ or who come to the organization for assistance and support. As such, operations, workforce development, and services are organized to foster empowerment for staff and clients alike. Organizations understand the importance of power differentials and ways in which clients, historically, have been diminished in voice and choice and are often recipients of coercive treatment. Clients are supported in shared decision-making, choice, and goal setting to determine the plan of action they need to heal and move forward. They are supported in cultivating self-advocacy skills. Staff are facilitators of recovery rather than controllers of recovery. Staff are empowered to do their work as well as possible by adequate organizational support. This is a parallel process as staff need to feel safe, as much as people receiving services.

6. Cultural, Historical, and Gender Issues

The organization actively moves past cultural stereotypes and biases (based on race, ethnicity, sexual orientation, age, religion, gender-identity, geography, etc.); offers access to gender-responsive services; leverages the healing value of traditional cultural connections; incorporates policies, protocols, and processes that are responsive to the racial, ethnic and cultural needs of individuals served; and recognizes and addresses historical trauma.

The Trauma-Addiction Connection

When a person fears for his/her safety, experiences intense pain, or witnesses a tragic or violent act, that person can be described as having experienced trauma. Levels of resiliency vary from person to person, so reactions to traumatic events are similarly varied. Although frightening experiences impact people at any age, adults will generally be more likely to manage through trauma than children will be. Further, some trauma is repeated or ongoing, such as that of child abuse or military combat. Other examples of traumatic events include car accidents, repeated bullying, street violence, sexual assault, domestic violence, growing up in an unstable home, natural disasters, or battling a life-threatening condition.

If trauma and the feelings associated with it are not resolved, serious long-term issues can develop. Post-traumatic stress disorder (PTSD) disrupts the lives of people who have experienced unresolved trauma by negatively impacting their relationships, emotions, physical body, thinking and behavior. PTSD sufferers may experience sleep disturbances, nightmares, anxiety and depression, flashbacks, dissociative episodes in which they feel disconnected from reality, excessive fears, self-injurious behaviors, impulsivity and addictive traits.

Researchers have been studying the connection between trauma and addiction in order to understand why so many drug and alcohol abusers have histories of traumatic experiences. Data from over 17,000 patients in Kaiser Permanente’s Adverse Childhood Experiences study indicate that a child who experiences four or more traumatic events is five times more likely to become an alcoholic, 60% more likely to become obese, and up to 46 times more likely to become an injection-drug user than the general population.  Other studies have found similar connections between childhood trauma and addiction, and studies by the Veterans Administration have led to estimates that between 35-75% of veterans with PTSD abuse drugs and alcohol.

The reasons behind this common co-occurrence of addiction and trauma are complex. For one thing, some people struggling to manage the effects of trauma in their lives may turn to drugs and alcohol to self-medicate. Post-traumatic stress disorder symptoms like agitation, hypersensitivity to loud noises or sudden movements, depression, social withdrawal and insomnia may seem more manageable through the use of sedating or stimulating drugs depending on the symptom. However, addiction soon becomes yet another problem in the trauma survivor’s life. Before long, the “cure” no longer works, and it causes far more pain to an already suffering person.

Other possible reasons addiction and trauma are often found together include the theory that a substance abuser’s lifestyle puts him/her in harm’s way more often than that of a non-addicted person. Unsavory acquaintances, dangerous neighborhoods, impaired driving, and other aspects commonly associated with drug and alcohol abuse may indeed predispose substance abusers to being traumatized by crime, accidents, violence and abuse. There may also be a genetic component linking people prone toward PTSD and those with addictive tendencies, although no definitive conclusion has been made by research so far.

First Things First

Sometimes, years of self-medicating through drugs and alcohol have effectively dulled the memory of trauma, so the only problem seems to be substance abuse and addiction. A person who has suppressed or ignored traumatic experiences may work very hard to get and stay sober, only to find other addictive behaviors eventually replacing the drugs and alcohol. These might include compulsive overeating, gambling, sexual promiscuity or any other compulsion-driven behavior. Unfortunately, continuing to avoid resolution of trauma will almost guarantee ongoing suffering.

However, dealing with traumatic experiences is challenging work. Under the influence of drugs and alcohol, it is a nearly impossible task. That is why therapists always recommend working first on recovery from drug addiction and alcoholism. Then, when the trauma survivor is stronger and more clear-minded, s/he can begin working with a therapist in individual or group counseling to address the underlying problem of unresolved trauma. Specific treatment modalities have been developed for people suffering long-term effects after traumatic experiences, including trauma-focused therapies, PTSD Intervention, Body Psychotherapy which targets the physiological response to trauma, and medications for depression and anxiety.

Considering the frequent link between trauma and addiction, anyone working on recovery from substance abuse and addiction could benefit from an assessment by a skilled therapist, to determine if there are underlying issues that should be addressed and to devise an appropriate treatment plan. The best approach is always to work first on living a sober life, then on resolving past trauma and learning positive coping skills, thereby breaking the trauma-addiction connection and finding a better life all around.

Hackensack Meridian Carrier Clinic. (2019). Trauma and addiction. Retrieved from https://carrierclinic.org/2019/08/06/trauma-and-addiction/

For more information, visit carrierclinic.org

The following video, produced by the Carrier Clinic, highlights the significant link between post-traumatic stress disorder and addiction.


The following video examines the ways trauma and addiction are linked. The issue of trauma has become one of the most important concepts in the treatment of addiction.



NAMI Guide to Dual Diagnosis

Dual Diagnosis

Dual diagnosis (also referred to as co-occurring disorders) is a term for when someone experiences a mental illness and a substance use disorder simultaneously. Either disorder—substance use or mental illness—can develop first. People experiencing a mental health condition may turn to alcohol or other drugs as a form of self-medication to improve the mental health symptoms they experience. However, research shows that alcohol and other drugs worsen the symptoms of mental illnesses. The professional fields of mental health and substance use recovery have different cultures, so finding integrated care can challenging.

How Common Is Dual Diagnosis?

According to a 2014 National Survey on Drug Use and Health, 7.9 million people in the U.S. experience both a mental disorder and substance use disorder simultaneously. More than half of those people—4.1 million to be exact—are men.


Because many combinations of dual diagnosis can occur, the symptoms vary widely. Mental health clinics are starting to use alcohol and drug screening tools to help identify people at risk for drug and alcohol abuse. Symptoms of substance use disorder may include:

  • Withdrawal from friends and family
  • Sudden changes in behavior
  • Using substances under dangerous conditions
  • Engaging in risky behaviors
  • Loss of control over use of substances
  • Developing a high tolerance and withdrawal symptoms
  • Feeling like you need a drug to be able to function

Symptoms of a mental health condition can also vary greatly. Warning signs, such as extreme mood changes, confused thinking or problems concentrating, avoiding friends and social activities and thoughts of suicide, may be reason to seek help.

How Is Dual Diagnosis Treated?

The best treatment for dual diagnosis is integrated intervention, when a person receives care for both their diagnosed mental illness and substance abuse. The idea that “I cannot treat your depression because you are also drinking” is outdated—current thinking requires both issues be addressed.

You and your treatment provider should understand the ways each condition affects the other and how your treatment can be most effective. Treatment planning will not be the same for everyone, but here are the common methods used as part of the treatment plan:

Detoxification. The first major hurdle that people with dual diagnosis will have to pass is detoxification. Inpatient detoxification is generally more effective than outpatient for initial sobriety and safety. During inpatient detoxification, trained medical staff monitor a person 24/7 for up to seven days. The staff may administer tapering amounts of the substance or its medical alternative to wean a person off and lessen the effects of withdrawal.

Inpatient Rehabilitation. A person experiencing a mental illness and dangerous/dependent patterns of substance use may benefit from an inpatient rehabilitation center where they can receive medical and mental health care 24/7. These treatment centers provide therapy, support, medication and health services to treat the substance use disorder and its underlying causes.

Supportive Housing, like group homes or sober houses, are residential treatment centers that may help people who are newly sober or trying to avoid relapse. These centers provide some support and independence. Sober homes have been criticized for offering varying levels of quality care because licensed professionals do not typically run them. Do your research when selecting a treatment setting.

Psychotherapy is usually a large part of an effective dual diagnosis treatment plan. In particular, cognitive-behavioral therapy (CBT) helps people with dual diagnosis learn how to cope and change ineffective patterns of thinking, which may increase the risk of substance use.

Medications are useful for treating mental illnesses. Certain medications can also help people experiencing substance use disorders ease withdrawal symptoms during the detoxification process and promote recovery.

Self-Help and Support Groups. Dealing with a dual diagnosis can feel challenging and isolating. Support groups allow members to share frustrations, celebrate successes, find referrals for specialists, find the best community resources and swap recovery tips. They also provide a space for forming healthy friendships filled with encouragement to stay clean. Here are some groups NAMI likes:

  • Double Trouble in Recovery is a 12-step fellowship for people managing both a mental illness and substance abuse.
  • Alcoholics Anonymous and Narcotics Anonymous are 12-step groups for people recovering from alcohol or drug addiction. Be sure to find a group that understands the role of mental health treatment in recovery.
  • Smart Recovery is a sobriety support group for people with a variety of addictions that is not based in faith.

Chronic Pain Management

Excerpted from SAMHSA TIP 54: Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders

Chronic non-cancer pain (CNCP) is a major challenge for clinicians as well as for the patients who suffer from it. The complete elimination of pain is rarely obtainable for any substantial period. Therefore, patients and clinicians should discuss treatment goals that include reducing pain, maximizing function, and improving quality of life. The best outcomes can be achieved when chronic pain management addresses co-occurring mental disorders (e.g., depression, anxiety) and when it incorporates suitable nonpharmacologic and complementary therapies for symptom management.

Treatment recommendations:

  • Treat chronic pain with non-opioid pain relievers as determined by pathophysiology
  • Recommend or prescribe nonpharmacological therapies (e.g., cognitive–behavioral therapy, exercises to decrease pain and improve function)
  • Treat comorbidities
  • Assess treatment outcomes
  • Initiate opioid therapy only if the potential benefits outweigh risk and only for as long as it is unequivocally beneficial to the patient
  • Therapeutic exercise
  • Physical therapy
  • Cognitive–behavioral therapy
  • Complementary and alternative medicine (CAM; e.g., chiropractic therapy, massage therapy, acupuncture, mind-body therapies, relaxation strategies)

Part Three: Behavioral Addictions

Luck, Lucky Number, 17, Roulette, Boiler, Casino

As you may know, the Diagnostic and Statistical Manual (DSM) is the source of psychiatric diagnoses in the United States. Its updated publications are eagerly anticipated and scrutinized throughout the field of mental health because it holds such significant influence. The language we use to discuss mental health issues, whether or not an insurance company will pay for a certain treatment, and whether a condition is even considered a disorder, are all part of the impact felt by this book. While the diagnostic manual has been criticized (Dr. William Glasser, founder of Reality Therapy, once called it “the most destructive book to human relationships ever written”), it maintains its prominent role in modern American psychology.

Currently, the DSM recognizes only one other addiction besides substance use disorder, and that is gambling disorder. The characteristics of compulsive gambling are quite similar to those found in substance use disorder.

Although other behaviors have yet to receive the same recognition, it is clear that the negative patterns associated with them match our present understanding of addiction. These can include shopping, spending, sex, internet gaming, relationships, eating, and other related behaviors.

As you will see in this section’s video, Dr. Robert Lefever has identified three clusters of addictive behaviors, which he labels as follows:

The Hedonistic Cluster:

  • Psychoactive substances such as alcohol, marijuana, heroin, cocaine, prescription pills, and methamphetamine
  • Caffeine
  • Nicotine
  • Gambling
  • Sex without regard for the other person

The Nurturement of Self Cluster:

  • Food, especially those containing sugar and refined flour
  • Bingeing/starving/purging/vomiting
  • Shopping and spending
  • Work
  • Internet and computer use
  • Exercise

The Relationship Cluster

  • Use of other people (intimate partner or co-workers)
  • Compulsive helping

Lefever notes that the outlets within each cluster are related in a way that makes it more likely that a person in recovery will relapse if he or she engages in any of the others in the same cluster. He also notes that people may have addictions in more than one cluster. This concept provides an excellent way of understanding the many faces of addiction. It also points toward the necessity of avoiding other behaviors within the same cluster.



Hoffman, J. & Froemke, S. (Producers). (2007). Addiction (DVD).

Kuerbis, A., Sacco, P., Blazer, D. G., & Moore, A. A. (2014). Substance abuse among older adults. Clinics in geriatric medicine30(3), 629–654. https://doi.org/10.1016/j.cger.2014.04.008

National Alliance on Mental Illness. (2015). Dual Diagnosis.

NIDA. 2020, June 2. Principles of Adolescent Substance Use Disorder Treatment. Retrieved from https://www.drugabuse.gov/publications/principles-adolescent-substance-use-disorder-treatment-research-based-guide/principles-adolescent-substance-use-disorder-treatment on 2020, September 20.

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