From Stigma to Therapy: The Evolution of Psychiatry in Substance Use Disorders

Drug addiction has long been regarded as a disorder of the mind, with psychological, social, and economic factors underlying the origins of both a moral failing and a lack of willpower. As long as the word addiction bears a negative connotation, in fact, drug addicts will be regarded as weak individuals, where their frailty is to blame. As such, social exclusion and lack of assistance are the most important risk factors preventing a change in attitude towards the acute stigma associated to substance use disorders (SUDs). Considerable efforts have been made in the past century to understand biological bases of SUDs, which are nowadays taken for granted since the Diagnostic and Statistical Manual of Mental Disorders includes it. Today, SUD is defined as a chronic relapsing brain disease characterized by a wide range of mental, physical, and behavioral symptoms resulting in the loss of control towards drug seeking and intake despite harmful and adverse consequences. While structurally different substances produce specific molecular alterations, all in all they result in brain maladaptations of circuitries driving motivation, emotions and behavior. Converging evidence from preclinical research and psychobiology has shifted this paradigm in psychiatry in 80 s, thereby leading to the current notion that SUD is a brain disease. This important step in SUD nosology reduced the subjective moral judgement and improved the legal status of drug (ab)users. Finally, yet importantly, this extraordinary scientific progress has allowed for the development of both pharmacological and nonpharmacological therapeutics, which may improve treatment outcome.