This post recaps a continuing education event hosted by The Dorm, in collaboration with Dr. Kevin McCauley, MD, Senior Fellow with The Meadows.
Today, more than one in six Americans live with substance use disorder— equating to 48 million individuals. And this number doesn’t fully encompass those who struggle with other addictive patterns, such as vaping, screen dependence, and gambling.
“Substance use disorder, addictions, and compulsive behaviors have touched all of us, either directly or indirectly,” shared The Dorm’s Founder & CEO, John McGeehan, LCSW, CADC, as an introduction to our collaborative event with Dr. Kevin McCauley, Senior Fellow at The Meadows.
Having delivered more than 2,000 lectures on addiction neuroscience and recovery management, Dr. McCauley joined us to share the latest research on addiction science, highlighting the importance of looking beyond the brain disease model to consider how a client’s community and environment impact long-term recovery outcomes.
The Brain Disease Model of Addiction
Dr. McCauley began his presentation by introducing the brain disease model of addiction, which is still one of the leading models of addiction today.
The brain disease model stems from the idea that all things that create addiction pass through the dopamine system. This is also known as the dopamine hypothesis. For some individuals the sudden increase of dopamine that accompanies substances or addictive behaviors more easily leads to addiction.
Known as the “feel-good” hormone, dopamine is a neurotransmitter, or a chemical messenger in the brain, that plays a role in the brain’s “reward center,” which is evolutionarily designed to reward us with positive signals after completing a task needed for survival, such as eating food or achieving goals.
The risk of substances and addictive behaviors is tied to this reward system.
As Dr. McCauley put it, “Intoxicants create large spikes in the concentration of dopamine. If you understand this concept, you will understand so much about addiction: it is not just the amount of dopamine, it is also how fast it comes on.” For instance, different delivery methods of a substance can lead to quicker spikes in dopamine and increase vulnerability to addiction.
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Dr. McCauley explained that humans have evolved to seek behaviors that stimulate dopamine release, and the dopamine hypothesis suggests that individuals who struggle with addiction seek substances and addictive behaviors to initiate this dopamine release. Under this model, addiction is explained solely through the lens of neuroscience and brain physiology, and is seen as a disease that can be treated through medicine.
Beyond the Brain Disease Model: 4E Cognition
While empirical and well-researched, the brain disease model does not consider all facets of addiction. Dr. McCauley, from his own experience with substances, posited three questions that were asked of him during his recovery journey:
- Who are your friends?
- Where do you live?
- Can you work or go to school (build a future)?
These are all critical questions that emphasize the role of a person’s environment in addiction.
Are you experiencing changes in your relationship with alcohol, substances, or coping behaviors? These experiences could be symptoms of a substance use disorder.
“Housing Matters”
Dr. McCauley highlighted the importance of one’s living situation and social environment through the Rat Park study, conducted by Bruce K. Alexander and his colleagues in 1978. This study examined two groups of rats, one housed in isolation, and the other in a “rat park,” where they were free to roam, socialize, and play.
Both groups were exposed to morphine, and while both groups drank plenty of morphine, the isolated group still had a higher level of morphine ingestion than the socialized group. This study demonstrated that housing plays a key role in substance use, and is an important consideration for addiction study.
“If I relapsed, and I had a dollar to spend on my recovery […] I’d spend it on housing,” said Dr. McCauley. “Housing is such a powerful social determinant of health that if you have it, everything else works better—AA works better, methadone works better, buprenorphine works better, CBT works better. If you don’t have it, nothing really works all that well.”
Here, Dr. McCauley introduced a model that encompasses not just the biological parts of addiction but also the social, environmental, and behavioral aspects: the 4E cognition model.
4E Cognition
The 4E Cognition model argues that cognition is not just a product of the brain, it is also:
- Embodied: Body shapes cognition. For example, trauma is held in the body, and the immune system acts as a stress receptor for the brain—this allows us to understand stress and trauma as a cause for mental health and addiction.
- Embedded: Cognition exploits environmental opportunities. We understand ourselves and our brains through the context of the environment we live in.
- Extended: Affordances (tools) and skilled action shape cognition. Through the lens of addiction, this can be framed in the idea that it is a mental decision to stay sober.
- Enacted: Our actions in the world determine our cognition. In terms of addiction, this could look like declining a drink or joining sober communities.
Environmental Toxicology: The Importance of “Exposure”
Throughout the presentation, Dr. McCauley emphasized the key role of exposure in addiction and how decreasing exposure reduces the risk of addiction.
When thinking about exposure within our work with clients, there are four main considerations:
- How much: What is the dosage, concentration, or time spent using the substance?
- What route: How is the drug administered? Is it topical, inhaled, or injected?
- How fast: How is the drug processed by our bodies? Does it go straight into the bloodstream, or pass through the digestive tract?
- To whom: Who is the person using? What is their developmental stage, previous exposure, or degree of compromise?
Intoxicant Example: Cannabis Through the Lens of Exposure
As an anecdote to illustrate the complexity of exposure, Dr. McCauley cited the growing popularity of cannabis, a substance that is becoming more readily available and prevalent in our daily lives. The cannabinoid system is present in multiple areas of the body, including reward, inflammation, and the constriction and dilation of blood vessels—“there are very few systems in the body that don’t have some input from the cannabinoid system,” Dr. McCauley explained.
He also described the risk of cannabis use through the four aspects of exposure:
- How much: A key trend in recent cannabis use has been the rapid increase in THC concentration in cannabis products. Dr. McCauley observed, “What we tend to see is that people don’t just stay at the spliff. They concentrate the drug (through vaping or dabbing, for example). And what you’re really talking about is the use of a drug that is really almost a different drug.”
- What route: Smoking brings THC to the brain much faster than an edible, for example. In a case where people are smoking concentrated cannabis, “you’re talking about a very, very big dose delivered very, very quickly to the brain, and that carries much greater risk than an edible would.”
- How fast: Dr. McCauley highlighted that one of the interesting aspects of cannabis is that it’s post-synaptic, which means that it doesn’t directly affect a specific neurotransmitter, but rather magnifies the effect of that signal. For example: “If what comes in feels very good, cannabis says, ‘Oh, it’s even better than that!’”
- To whom: Effects will also differ based on who the user of cannabis is. Dr. McCauley spoke to developmental “risk periods” and their importance in addiction formation. “If you first use cannabis when you’re nine, that’s a very serious problem. But if you first use cannabis when you’re 29, well, that carries much less and perhaps even no risk of forming addiction.”
Decreasing Risk of Addiction Through Decreasing Exposure
Dr. McCauley also provided some tips on how to decrease the risk of addiction, especially in substances or behaviors that we are readily exposed to in daily life, such as screens, cannabis, caffeine, and nicotine. Out of the four elements of exposure, it is perhaps simplest to address “how much” and “to whom.”
- How much: Being aware of the dosages as labeled on cannabis and nicotine products, as well as the amount of time spent in relation to these substances or addictive behaviors (such as screen-time) is a great first step in bringing awareness and attention to the addiction cycle.
- To whom: Another consideration is delaying the onset of use. Studies have demonstrated that from 2013 to 2022, cannabis use had increased in adults but remained constant for youth. This is important to note, especially with regards to the legalization of cannabis in many states. Similarly, the answer to the emerging question of “at what age should my child get a smartphone?” could be to delay that exposure to decrease the risk of media or screen addiction.
Supporting Recovery Through Connection
In closing the presentation, The Dorm’s Partner & Chief Clinical Officer, Dr. Amanda Fialk, LCSW, LICSW, joined in for an interactive Q&A session with Dr McCauley, sharing, “People often refer to the opposite of addiction as sobriety or recovery. While these are admirable treatment goals, at The Dorm, we like to think of the opposite of addiction as connection.”
Dr. McCauley went on to emphasize the importance of a person’s social sphere in addiction recovery, providing a personal example on how the people he surrounded himself with acted as buffers during his own recovery experience. “I kind of buffered myself against exposures that were stressful or traumatic by the people that I had in my world,” Dr. McCauley shared.
Conclusion
We were grateful to welcome Dr. McCauley to The Dorm, as his research closely aligns with our holistic and integrative model of care. At The Dorm, 93% of our clients arrive with multiple diagnoses, often managing co-occurring mental health and substance use disorders. Our approach prioritizes treating the whole person, providing clients with an affirming community environment where they can focus on their healing. According to our third-party validated research outcomes, this model has led to a 138% increase in overall client well-being.
Additionally, community is at the heart of our program, and we take pride in fostering meaningful relationships that support lasting healing and growth. As a result of our community-based approach, 67% of clients remain sober post-discharge—a rate 86% higher than the average population. Discover how our evidence-based care leads to long-term, sustained outcomes for young adults.
We sincerely thank Dr. McCauley for sharing his experience and insights into the important topic of substance use and addiction. Visit our YouTube to watch the full presentation.
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