Many of the origin stories for compulsive behaviors including substance abuse begin with stress. Some chronic substance abusers are “thrill-seeking” and often have impulse control issues. They experiment with prohibited substances earlier in life, when the brain is still forming and substance abuse can have long-lasting impacts. A large study involving 248 adult college students and 224 adult non-college students found those scoring higher for thrill-seeking also scored higher for stress. It is possible that thrill-seeking behavior is a response to stress.

Other chronic substance abusers are “avoidance users,” using substances or behavior to mask pain or depression. They tend to start later in life than “thrill-seekers” but also find it harder to give up because the behavior or substance treats pain. The majority of opioid addicts first get hooked on pills prescribed for pain. Pain causes stress which is temporarily relieved by painkillers. 

For people with substance use disorder, the stress of not having access to medication becomes the biggest pain they need to treat. Even for those in recovery, the stress of thinking about substance use and the fear of relapse never completely go away.

In a review for European Neuropsychopharmacology, Dr. Nicholas Goeders, Head of Pharmacology, Toxicology & Neuroscience at Louisiana State University’s Health Science Center, writes, “[E]xposure to stress has a significant impact on drug addiction.” Specifically, Dr. Goeders writes that stress increases the reward experienced from the use of stimulants, “possibly through a process similar to sensitization.” Dr. Goeders elaborates:

One explanation for the high concordance between stress-related disorders and drug addiction is the self-medication hypothesis, which suggests that a dually diagnosed person often uses the abused substance to cope with tension associated with life stressors or to relieve symptoms of anxiety and depression resulting from a traumatic event.

Dr. Goeders points to the “hypothalamo-pituitary-adrenal (HPA) axis,” which is aroused when contemplating proscribed behaviors. During abstinence, the HPA is aroused by stress and drug-associated cues, resulting in cravings and often leading to relapse. His conclusion, back in 2003, is that:

Stress reduction, either alone or in combination with pharmacotherapies targeting the HPA axis may prove beneficial in reducing cravings and promoting abstinence in individuals seeking treatment for addiction.

In his “Unified Theory of Addiction,” Dr. Robert Pretlow, publisher of AddictionNews, explains how the buildup of stress leads to its displacement, providing a dopamine surge that temporarily mitigates the pain or stress. If continued, this displacement leads to compulsive behavior which itself becomes a source of stress. The gambler uses gambling to block stress and the losses become an additional source of stress that is mitigated by more gambling in what Dr. Pretlow calls a “vicious circle.”

The drug addict is continuously stressed by the need to secure an adequate supply, ruminating on how to find drugs, how to pay for them, and how to hide their behavior. The addict in recovery is stressed by environmental cues that cause urges and cravings. 

Many recovering addicts do not have the means or desire to change their employment, change where they’re living, or change who their friends are, and must cope in an environment loaded with triggers and cues. That, in itself, is extremely stressful for recovering addicts.

Solutions to Stress During Recovery

Stress is what brings people to compulsive and addictive behaviors. Stress is what sabotages recovery and causes relapse. It appears there is no way out of these disorders without dealing with stress. Pharmaceutical solutions by themselves have a lousy success rate, according to Dr. Reinout W. Wiers, who points out that they’re barely better than placebo. Pharmaceutical solutions make a significant difference to less than one in 10 recovering addicts.

Perhaps it seems obvious, but if you want to stop the use of painkillers, you have to stop the pain. Otherwise, it’s cruel to withhold medicine. The physical addiction to substances can often be successfully broken using pharmaceuticals in 30 days. After that, you have to deal with the psychological pain, which can be much deeper and harder to mitigate. That psychological pain is augmented, in fact, by abstinence, which adds to the pain of withdrawal and cravings.

How, then, do you eliminate the stress underlying compulsive behavior and magnified by withdrawal? Twenty years after Dr. Goeders identified stress as a major factor in addiction, the preferred methodology is mindfulness.

In 2022, the scientific journal, Bioinformation, published a study of mindfulness techniques at a residential de-addiction center in Tamil Nadu, India. The researchers divided 60 patients evenly into a control group that did not receive the intervention, and a group that received mindfulness-based stress reduction (MBSR) training. Cortisol levels were measured at the start of the program and again at the conclusion. The results:

The mean level of blood cortisol in the experimental group was 18.08 before the intervention [and] dropped to 7.54. The mean cortisol level in the experimental group differs by 10.54 between pre and post intervention.

What did the MSBR training consist of? An eight-week course, two one-hour sessions each day, which adds up to over 100 sessions! Pretty intensive. In addition, “Patients were asked to keep a diary of their practice time for activities like meditation, walking meditation, and body scans for six days a week for eight weeks after the orientation.” They were also expected to formally practice meditation for 15 to 45 minutes each day.

The intervention leans heavily on the work of Jon Kabat-Zinn and the Massachusetts Medical Center’s Stress Reduction and Relaxation Clinic. The researchers summarize, “MBSR teaches participants how to self-regulate their arousal in response to stressful situations or symptoms.” The researchers summarize very eloquently the plight of drug addicts in rehab:

When someone enters an addiction treatment facility, receives treatment, and achieves relapse, the possibility of relapse looms over them constantly, haunting them like a phantom. As a result, anxiety and stress continue to be a normal part of life even after recovery.

In addition to the significant impact on cortisol levels, researchers cited the self-reported results of MBSR patients: “Drug misuse patients receiving treatment in addiction treatment facilities reported considerably lower levels of felt stress than the control group.” An earlier study of MBSR in a community-based addiction treatment center found, “MBSR can be implemented successfully for relapse prevention in early recovery. Client ratings indicated high levels of acceptability and satisfaction.”

The earlier survey was conducted at the Center for Mindfulness in Medicine, Healthcare, and Society in Worcester, Massachusetts. The team found they had to “reshape” MBSR into “a mindfulness-based relapse prevention program whose central focus is the role of stress in relapse.” In particular, the focus shifted to:

• refine self-regulatory skills
• increase relaxation and awareness skills
• decrease symptoms of stress and stress reactivity
• increase an overall sense of well-being

Patients were taught coping skills in facing cravings, how to “observe” a craving without acting on it, how to recognize cues and triggers, and how to respond by refocusing attention on the moment. “[T]he role of stress in the curriculum,” explain researchers, “was reoriented to relate specifically to its impact on substance use, cravings, and relapse and its prevention.” Patients responded favorably to the changes, resulting in better attendance, better attentiveness during class, and better evaluations upon conclusion.

We are a long way from unlocking the relationship between stress, addiction, and recovery. We’ll continue to examine this subject in the coming days and weeks on AddictionNews.

Written by Steve O’Keefe. First published September 16, 2024.

Sources:

“T behavior: Psychological implications of thrill-seeking/risk-taking,” Current Psychology, December 2019.

“The impact of stress on addiction,” European Neuropsychopharmacology, December 2003.

“A Unified Theory of Addiction, Preprint 5” by Robert A. Pretlow, MD, MSEE, FAAP, March 2023.

“Mindfulness based stress reduction among substance abuse patients at de-addiction center,” Bioinformation, November 2022.

“Adaptation of Mindfulness-Based Stress Reduction Program for Addiction Relapse Prevention,” The Humanistic Psychologist, April 2009.

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