Study analyzes etiology of substance use disorders and their associations with family systems

It's no secret that substance use disorders (SUDs) can negatively impact the individual struggling, even putting their life in jeopardy.

"For persons with SUDs, their brain is telling them this lie that, 'You've got to use to stay alive,'" said Sterling Shumway, chair of the Texas Tech University Department of Community, Family & Addiction Sciences and director of the Institute for the Study of Addiction, Recovery & Families.

Likewise, groundbreaking new research now indicates that the same thing is happening in the brains of the people caring for those with addiction.

"To further understand the etiology of SUDs and their associations with family systems, research must expand beyond examining the individual struggling with an SUD," said Shumway, co-principal investigator (P.I.) for the ongoing project. "This includes research that helps us understand the neurological impact of stress, fear and the impairment found in the family system."

The original hypothesis was that if the person struggling with an SUD's brain is compelling them to use as a survival mechanism, perhaps the family member's brain is doing the same thing as it relates to their loved one's survival, thus leading to the mostly ineffective and compulsive attempts to rescue their loved one.

"It's really first-of-a-kind research," Shumway said, "looking to see if the person and their family member have become similarly, what we call, 'co-impaired.'"

Looking inside the brain

Over the last four years, Shumway and co-P.I. Spencer Bradshaw, director of the Center for Addiction Recovery Research and an assistant professor in the department, have been using functional near-infrared spectroscopy (fNIR) to monitor reactions in the frontal cortex of both those in recovery from an SUD and family members as they participate in a research protocol presenting certain audio and visual cues meant to stimulate the prefrontal cortex (PFC).

For the person who struggles with alcoholism, this protocol involves sounds and a variety of images that evoke strong emotional responses, including images associated with alcohol. We look at how their brain lights up differently in response to these various images.

When family members come in, they aren't presented a picture of a glass of alcohol, they see instead a current image of their loved one seeking recovery. That's what makes this research groundbreaking, in that a family member's PFC lights up in a similar way when looking at their addicted loved one as the PFC of someone with an SUD when looking at their substance of choice."

Sterling Shumway, Chair of the Texas Tech University Department of Community, Family & Addiction Sciencesies

When the fNIR results showed that family members often exhibited similar impairment and decision-making difficulties as those with an SUD, Shumway and Bradshaw realized they needed to look deeper inside the brain to explain this phenomenon.

"This is the next step in our research: to look at the family member brain at the level of the midbrain – a much deeper, more primitive part of the brain – and compare it with the brains of those struggling with an SUD," Shumway said. "We want to know if a similar process is also occurring there with respect to these deeper brain structures and their interaction with the PFC."

Now, with the help of the Texas Tech Neuroimaging Institute, the two are using functional magnetic resonance imaging (fMRI) to do just that.

"What comes from the midbrain is what causes addicts to use – it's this intense pain associated with craving. Craving is the means by which the brain compels a person to do something they wouldn't normally do as part of a survival response – that is, to use despite harmful consequences," Shumway said. "In relation to a person struggling with an SUD, their brain is telling them, 'You must use drugs and alcohol, or you're going to die.'"

This message becomes so intrusive that it overrides the more rational frontal cortex, which is attempting to get them to consider the negative consequences. Unfortunately, when the disease of addiction is present, the midbrain wins the battle.

"With family members, particularly those who've been fighting the longest to keep their loved one alive, we believe similarly that their midbrain begins to compel them toward behaviors that may enable rather than resolve SUD behavior," Shumway said. "In other words, they're reacting to keep their loved one alive. They may know it's not helping, but they're going to do it anyway just like the person with an SUD is going to find and use their substance. This, because the midbrain is requiring it of them out of a perceived need for survival."

Testing the hypothesis

Shumway and Bradshaw will use the fMRI to examine different parts of the brain, how they are connected to one another and which parts are being activated by different activities or presentations.

"Brain structures, their connectivity and their functioning are key to what we now understand about the brain of the person with an SUD and are what we are similarly interested in examining with respect to the family member brain," Bradshaw said.

As before, Shumway and Bradshaw intend to include a control group.

"With a control group, we'll be able to compare those who have never been around addiction, never been impacted by addiction, and never have had to make the difficult decisions like those in families where addiction is present," Bradshaw said.

Shumway emphasized the research is likely one-of-a-kind.

"We're probably the only ones, perhaps in the world, who have looked at the frontal cortex of family members related to the way it is responding," he said. "And we probably will be one of the first to look at family members and functioning of the midbrain when given certain stimuli."

'They need help, too.'

One of the biggest reasons for this research is to try to help the family members of those with an SUD find their own recovery, which also gives their loved one a better chance.

"You've got two brains – the family member's and the loved one's brain – that are trying to keep one person alive. The problem is the family members also suffer," Shumway said. "They don't take care of themselves, and they struggle as well. We're not very good at taking care of those who struggle with substance use disorders; we're even worse at taking care of the family members."

Because dynamics differ between families, the person who is the primary caregiver differs as well – and sometimes that role switches between people within a family.

"It's often those who have cared for these people the longest who have the most personal investment in their lives and their success," Bradshaw said. "This person could, at times, be a grandparent, a parent or even a sibling. While we usually find this person to be a close family member, it may include a wide umbrella of people who care about this person."

This so-called "systems approach" to addiction recovery values everybody in the system. The idea is that if the parents, siblings, etc., are doing well, the person with the disorder has a better chance of doing well. And, reciprocally, if the person with the disorder is doing well, that helps the others in the system do well.

"With SUDs and recovery, it's a team sport," Shumway said. "The more people on the team who are healthy makes a big difference in terms of the trajectory of success."

While the researcher say society if often most concerned about the identified patient with the SUD, and that's important, it's not the whole story.

"The health of every family member is important," Bradshaw said. "Research shows that when family members are impacted by the stress of addiction, they go to the doctor more often, they have higher medical claims and services and they get diagnosed with higher rates of depression."

Therefore, resources are needed for both the loved one with the SUD and the family member.

"Both deserve happiness and quality of life," Bradshaw said.