Why do some people become addicts, and others do not?

Imagine an alcoholic parent who has four children. Each of those children would be considered at higher than normal risk for developing an addiction themselves – but only one does. That one might carry an addictive gene that is not present in their siblings’ DNA.

Or, the child with the addictive gene could also have suffered abuse, and gotten involved with friends who used drugs or drank copiously. Often it is a combination of triggers that sends one sibling into battle with an addiction, while brothers and sisters manage to steer clear.

“There are more pathways to addiction than people in the field might acknowledge,” said John Clapp, interim dean of the USC Suzanne Dworak-Peck School of Social Work. “Predisposition doesn’t necessarily mean it’s going to manifest.”

Over the years, addiction has been described as an individual moral failing, a disease of the brain, or a genetic inheritance. However, modern research says addiction is not an issue that can be reduced to one cause alone.

Clapp, one of the nation’s foremost addiction researchers in the field of social work, studies alcohol problem prevention. He notes that the very word “addiction” is thrown around to encompass everything from a tendency to overconsume caffeine to an obsessive attachment to a smartphone. But for a behavior to rise to the level of addiction, it must meet two standards: first, a growing tolerance ― one needs progressively more of the substance to achieve the desired effect. And second, withdrawal ― when one stops using the substance, there are negative consequences, such as serious cravings or becoming physically ill.

Abuse of drugs and alcohol generally meets those standards, according to Clapp. Gambling, on the other hand, is one of those practices that some in the addiction field believe meets the standard, and some do not. “It continues to be a healthy debate,” he said.

Not always as it appears

It is almost impossible to predict who will become an addict and who will not. But Jordan Davis, assistant professor in the Department of Children, Youth and Families, has surveyed people entering treatment, looking for the most likely predictor for their addiction. “The main predictor, the highest increase in odds of entering treatment for substance abuse, is post-traumatic stress disorder,” he said.

That means addiction casts a wide net in society.

“Addicts come in all shapes and sizes,” said Amber Richert, adjunct lecturer in the Department of Nursing.

Richert is a nurse practitioner in Baltimore, Maryland, and provides care largely to the city’s homeless population. Her clients, she said, generally fit the addiction stereotype: poor, minority, limited education. “But an addict can also be a Redondo Beach mom,” she said.

Although Richert’s patients live in desperate circumstances, their struggles are not profoundly different from those of clients with more resources who, 3,000 miles away, attend group and individual therapy at CAST Centers, a West Hollywood, California, outpatient treatment center where Cecelia Mylett, MSW ’92, is the clinical director.

Like Richert, who treats addiction as part of her primary care work, Mylett’s approach at CAST “is we treat the whole person. Where they are, what got them here and what they want to change. People are coming in here in pain, shame and suffering that they may not be aware of, but they know it’s affecting their lives and loved ones.”

Because some individuals seeking help from CAST come from affluent backgrounds, they may have used substances for quite a while before being confronted about the problem, according to Robert Oppenheimer, MSW ’92, a clinical therapist at CAST. “The nature of addiction,” Oppenheimer said, “is a lot of secrecy.”

The more power and money individuals with substance use disorders have can work to their detriment. Someone with wealth “can get their hands on whatever they want,” Mylett said. Furthermore, individuals who hold positions of power and authority are less likely to get called out on their addiction, at least in the workplace, because colleagues who might notice a problem are probably in subordinate positions and fear retribution.

Common denominators

For those living in impoverished communities, a lack of options can lead to a real struggle to stay sober.

Clapp recalls doing field work in a rural Ohio county where as much as 70 percent of the adult population was addicted to opioids. One of the main culprits was a lack of hope ― there were very few jobs in the region and there was widespread poverty. “In cases like that, it quickly becomes clear that who you are, where you are and how you live help determine how vulnerable you are to addiction,” he said.

Through her research with impoverished Mexican-American women victims of intimate partner violence in Texas, Alice Cepeda, associate professor in the Department of Adult Mental Health and Wellness, has witnessed a similar situation to that in rural Ohio. “They use heroin because it makes them forget about the everyday struggles they have to deal with,” she said.

Cepeda takes issue with the word “addiction,” as does her colleague in the Department of Adult Mental Health and Wellness, Professor Avelardo Valdez. Although addiction is a scientific term, Valdez said, there is often disagreement on what it actually means. He and Cepeda prefer to talk about different levels of dependence and the structural factors that contribute to it, including high rates of incarceration, lack of employment and education opportunities and limited treatment services.

There are particularly high levels of substance abuse dependence among the Texas women that Cepeda studies. The use of heroin and other illegal drugs has been intergenerational and present in these communities for decades. However, statistics are scarce. “We can’t say they are not dealing with the issue of dependence; it just has not been accurately assessed, documented and reported,” she said.

Valdez has found the same issues throughout the Latino communities he studies. Neuroscientists are looking to the brain for answers, but Valdez maintains that his research suggests that brain chemistry “pales in comparison” to the social climate and the emotional trials that can drag someone down the pathway to addiction.

“At the core of addiction,” Valdez said, “are people who have a dissatisfaction with their lives. However, the source of this dissatisfaction is not necessarily personal, but more at the structural level.”

A path forward

The university has recently created the USC Institute on Addiction Science, a joint venture between the Suzanne Dworak-Peck School of Social Work and the Keck School of Medicine of USC (with various other schools contributing expertise as well). The idea is to create a large research center solely to study addiction. In addition, social work researchers are working on new and novel approaches to improve outcomes for those affected by addiction.

Jordan Davis is presently working on three separate research initiatives on substance abuse. He is conducting studies on the practice of mindfulness with at-risk youth, and has found that those who received mindfulness training, such as meditation, lowered their probability of relapse at nearly double the rate of those who did not receive the training.

Together with the National Center for PTSD, part of the U.S. Department of Veterans Affairs, Davis, in collaboration with colleagues at the RAND Corporation and the Veterans Administration of San Francisco, is developing an app that will deliver mindfulness interventions to veterans suffering from both PTSD and substance abuse who cannot or choose not to seek treatment.

Finally, Davis is researching treatment outcomes for heroin and opiate use, to see which types of treatment work best for which people. He notes that many substance abusers are also dealing with mental health issues. “Hopefully,” he said, “one day we’ll have individualized care.”

Like Davis, John Clapp is also involved in the development of mobile applications to address substance abuse. With a team of engineers and computer scientists, he is studying the system dynamics of drinking events, trying to understand why and how people get drunk. The hope is to create apps that will let people know when they or their friends are at risk of slipping into drunkenness, preventing problems like drunk driving and alcohol-fueled violence and sexual assault.

At the heart of all of this research is improving care and saving lives. As society changes, so does the scope of its problems and solutions. The issue of addiction is evolving, and its diagnosis and treatment must evolve along with it.