The Role of Stress in Alcohol Use, Alcoholism Treatment, and Relapse

Alcohol Research & Health, Winter, 1999 by Kathleen T. Brady, Susan C. Sonne

Addiction to alcohol or other drugs (AODs) is a complex problem determined by multiple factors, including psychological and physiological components. Stress is considered a major contributor to the initiation and continuation of AOD use as well as to relapse. Many studies that have demonstrated an association between AOD use and stress have been unable to establish a causal relationship between the two. However, stress and the body's response to it most likely play a role in the vulnerability to initial AOD use, initiation of AOD abuse treatment, and relapse in recovering AOD users. This relationship probably is mediated, at least in part, by common neurochemical systems, such as the serotonin, dopamine, and opiate peptide systems, as well as the hypothalamic-pituitary-adrenal (HPA) axis. Further exploration of these connections should lead to important pharmacological developments in the prevention and treatment of AOD abuse. Studies indicate that treatment techniques which foster coping skills, problem-solving skills, and social support play a pivotal role in successful treatment. In the future, individualized treatment approaches that emphasize stress management strategies in those patients in whom a clear connection between stress and relapse exists will become particularly important. KEY WORDS: psychological stress; causes of AODU (AOD use, abuse, and dependence); addiction care; AODD (AOD use disorder) relapse; neurobiological theory; animal model; AOD use initiation; AOD use susceptibility; AOD abstinence; AODU development; stress management skills; drug therapy; psychosocial treatment method; literature review

Clinicians and researchers consider the addiction to alcohol or other drugs (AODs) a complex problem determined by multiple factors, including psychological and physiological components. Many theories involving numerous variables (e.g., personality and access to AODs) have sought to explain the initiation and maintenance of AOD abuse and dependence. Most of those theoretical models consider stress a major contributor to the initiation and continuation of AOD use as well as to relapse. Accordingly, the relationship between stress and alcohol use has received much attention, as evidenced by the articles in this issue of Alcohol Research & Health.

The notion that exposure to stress-inducing factors in everyday life (i.e., life stressors) can cause susceptible people to initiate or relapse to alcohol use has intuitive appeal. (For more information on stress and the body's response to stress, see sidebar, p. 264.) Whereas the relationship between stress and AOD use can be studied fairly easily in laboratory animals, a definitive exploration of this connection in humans has been more difficult. Animal studies generally have supported the positive relationship between stress and alcohol use and abuse. Researchers also have begun to focus on an organism's response to stress and the consequences of AOD use and how it affects biological processes in the brain. These studies have identified several neurobiological connections between the changes produced by stress and the changes produced by both short-term (i.e., acute) and long-term (i.e., chronic) AOD use (Piazza and Le Moal 1998).

In the clinical arena, however, the relationship between stress and alcohol use has been more difficult to characterize. For example, human laboratory studies have not uniformly supported a prominent theory called the tension-reduction hypothesis of alcohol use, which posits that people use alcohol to reduce stress. Furthermore, studies of the relationship between stress and alcohol use are difficult to conduct in alcoholic patients and, as a result, have numerous inherent limitations. Study participants may recall only selective events that have contributed to alcohol use, may be inconsistent about which events to include as stressors, and may have difficulties distinguishing between events that precipitate alcohol use and those that result from alcohol use and relapse.

Because of these difficulties, many studies that have demonstrated an association between AOD use and stress have been unable to establish a causal relationship between the two. For example, heavy alcohol users frequently experience stress related to occupational, social, legal, and financial problems. When interpreting such observations, some investigators have chosen to classify stressful events as illness dependent or illness independent, depending on whether they are caused by the AOD use. This classification has not been consistently adopted, however, and many studies fail to determine the degree to which such stressors occur independent of alcohol use, cause alcohol use, or are a consequence of alcohol use.

The type of stressor studied also influences analyses of the relationship between stress and alcohol use. For example, many studies investigating the role of stress in relapse after treatment have limited their focus to stressors that occurred after treatment completion. Some stressful life events that affect the lives of alcoholics after treatment, however, may have occurred before treatment (e.g., a divorce or job loss). Moreover, stressors can range from dramatic and severe events (e.g., a divorce or death of a loved one) to chronic irritants of daily life (e.g., job hassles or financial worries). Both the temporal relationship between stress and alcohol use and the type of stressor studied, however, can profoundly affect study results.