Understanding Addiction: The Pain Model
This is Part 3 in our series on Substance Use History.
Read Part 2: The Hidden Risks You Miss When You Don’t Take a Full Substance Use History for the previous component.
Before diving into the mechanics of taking a substance use history, we need to understand what we’re actually assessing. Addiction isn’t what most medical students have been taught to think it is. Understanding the scope of harm from inadequate assessment leads naturally to understanding why people use substances in the first place. This conceptual foundation transforms how we approach patients, interpret their substance use patterns, and formulate effective interventions.
This post establishes the pain-based model of addiction as the framework for all subsequent assessment techniques. Procedural guidance on chart review, interviewing, and documentation will follow in later parts of this series, building on this essential theoretical foundation.
Learning Objectives
After reading this section, you should be able to:
- Explain addiction as a response to psychological pain rather than moral failure
- Identify key components of the trauma-informed pain model of addiction
- Apply empathic understanding when approaching substance use assessment
- Distinguish between proximate triggers and underlying psychological wounds
- Connect the pain model to clinical assessment and treatment planning
Reframing Addiction: Not About the Substance, But About the Pain
Dr. Gabor Maté, who spent decades working with people suffering from severe addictions, offers us a lens that transforms how we see our patients (Maté, 2010):
“Not all addictions are rooted in abuse or trauma, but I do believe they can all be traced to painful experience. A hurt is at the centre of all addictive behaviours.”
That hurt might be obvious: childhood abuse, combat trauma, devastating loss. Or it might be subtle: chronic emotional neglect, the ache of never feeling quite good enough, the loneliness of growing up in a family where love was conditional. The wound may be hidden even from the person who carries it, but it’s there.
This reframes everything. When you sit across from someone who uses methamphetamine daily, or drinks a fifth of vodka every night, or can’t stop using benzodiazepines despite losing their job, they’re not making a series of bad choices. They’re not weak-willed or morally deficient. They’re solving a problem.
As Maté asks us to consider:
“It is impossible to understand addiction without asking what relief the addict finds, or hopes to find, in the drug or the addictive behaviour.”
What Relief Are They Finding?
Consider this question deeply when assessing substance use:
- The patient using opioids might be finding the first moments of peace they’ve felt since childhood, a warmth and safety they never experienced at home
- The person using cocaine might finally feel confident, capable, alive – emotions that eluded them when sober
- The individual drinking alcohol daily might be medicating unbearable anxiety, silencing the critical voice that’s been with them since they were small
- The person using cannabis constantly might find it’s the only way they can sleep without nightmares, or eat without nausea, or face another day
The substance isn’t the problem. It’s the solution they found to a problem that was unbearable. It just happens to be a solution that creates its own devastating problems.
Maté explains the temporal dimension:
“What seems like a reaction to some present circumstance is, in fact, a reliving of past emotional experience.”
This is crucial for psychiatric assessment. When a patient tells you they started drinking heavily after their divorce, or using stimulants when work stress increased, they’re giving you the proximate trigger, not the root. The divorce or job stress activated something much older, a pain that was always there, waiting. The substance allowed them to finally cope with feelings they’d been carrying, sometimes for decades.
Understanding this distinction prevents superficial assessment that mistakes recent stressors for underlying causes. The divorce didn’t create the pain; it awakened pain that predated the relationship. Treatment addressing only the proximate trigger misses the core wound requiring healing.
The Core Wound: Thwarted Love and Unmet Needs
Maté teaches us that “No human being is empty or deficient at the core, but many live as if they were and experience themselves as primarily that way.”
This is the tragic irony of addiction: people use substances to fill what feels like an emptiness inside them, not realizing that the emptiness itself is the wound. The internalized belief that they are somehow not enough, not worthy, not deserving of love and connection drives the desperate search for relief through substances.
This belief often began in childhood, when emotional needs weren’t met in the ways children require. As Maté explains:
“Addictions arise from thwarted love, from our thwarted ability to love children the way they need to be loved, from our thwarted ability to love ourselves and one another in the ways we all need.”
This doesn’t mean blaming parents or families. Most parents do the absolute best they can with the resources and awareness they have. But children need attunement, presence, unconditional acceptance. When that’s absent through no fault of the child, a void forms. And substances, for a brief moment, fill that void.
Understanding this developmental context informs assessment. Asking about childhood, early relationships, and family emotional dynamics isn’t tangential to substance use history. It’s central. The addiction makes sense only when understood within the context of unmet developmental needs and resulting internal emptiness.
Trauma Lives Inside
Here’s what makes this understanding so important for clinicians:
“Trauma is not what happens to you but what happens inside you.”
Two people can experience the same external event and have completely different internal experiences. One person might develop PTSD; another might not. One might turn to substances; another might not.
What matters isn’t just the event. It’s how isolated the person felt during it, whether they had support, whether they could make sense of it, whether they blamed themselves. The trauma lives inside, in how they learned to see themselves and the world.
This distinction transforms assessment. Rather than cataloging external traumatic events and assuming their impact, we must explore internal experience. How did the person make meaning of what happened? What did they conclude about themselves, others, and safety? What needs went unmet? These internal responses determine whether substances became necessary coping mechanisms.
The clinical implication: two patients with identical trauma histories (both experienced childhood sexual abuse, both witnessed domestic violence) may have completely different substance use patterns because their internal experiences differed. One had a supportive grandmother providing safety and validation; the other had no one. Assessment must explore not just what happened, but what happened inside the person in response.
A Forlorn Attempt to Solve Human Pain
When you’re taking a substance use history, you’re not just documenting quantities and frequencies. You’re witnessing a human being’s attempt to survive psychological pain that felt, and perhaps still feels, unbearable.
Maté puts it plainly:
“In short, it is a forlorn attempt to solve the problem of human pain.”
And this applies across the board: “This is no less true of the socially successful workaholic, such as I have been, than of the inveterate shopper, sexual rover, gambler, abject street-bound substance user or stay-at-home mom and user of opioids.”
The mechanism is the same across socioeconomic status, substance type, and social functioning:
- Unbearable internal experience (emptiness, shame, terror, rage, despair)
- Desperate search for relief from psychological pain
- Substance or behavior that temporarily works, providing escape or numbing
- Dependence on that relief as the only known way to manage pain
- Consequences that create more pain (health problems, relationship losses, legal troubles, financial ruin)
- Continued use to manage both the original pain and the new pain created by the addiction
This cycle explains why rational interventions (“just stop using”) fail. The substance isn’t the problem; it’s the only solution the person has found to unbearable pain. Removing it without addressing underlying suffering guarantees relapse.
Understanding this mechanism prevents moralistic judgment and enables therapeutic empathy. The patient isn’t choosing addiction over health. They’re choosing the only relief they’ve found over unbearable suffering. Treatment must provide alternative solutions to the pain, not just remove the substance.
Why This Information Matters
Understanding addiction through the pain model fundamentally transforms clinical assessment and treatment. This framework informs every aspect of substance use evaluation: how we ask questions, what we listen for, how we interpret responses, and what interventions we recommend.
For assessment approach: The pain model shifts focus from quantities and frequencies (though these remain important for medical management) to understanding function. “How much do you use?” still matters for withdrawal risk and medical complications. But “What does the substance do for you?” becomes equally critical. This question reveals what pain the substance addresses, what void it fills, what unbearable feelings it numbs. Without understanding function, we cannot provide alternatives.
For therapeutic alliance: Approaching patients with curiosity about their pain rather than judgment about their use builds trust. When patients realize you understand addiction as response to suffering rather than moral failure, they stop hiding. Shame dissolves. Honesty becomes possible. The therapeutic relationship shifts from adversarial (clinician trying to make patient stop using, patient defending their only coping mechanism) to collaborative (clinician and patient together addressing underlying pain while managing substance-related harm).
For diagnostic formulation: The pain model clarifies why substances are used, which informs diagnosis and treatment. Someone using cocaine to manage untreated ADHD needs stimulant medication, not just addiction treatment. Someone using alcohol to numb PTSD flashbacks needs trauma therapy. Someone using opioids to fill emotional emptiness from childhood neglect needs attachment-focused psychotherapy. The substance use disorder diagnosis remains accurate, but treatment must address underlying conditions or relapse is inevitable.
For treatment planning: Understanding what pain the substance addresses allows providing alternative solutions. You can’t just remove someone’s coping mechanism without offering something else. If alcohol manages social anxiety, treatment requires anxiety intervention (medication, therapy, skills training). If cannabis provides the only sleep the patient achieves, treatment needs sleep medicine consultation. If methamphetamine provides energy to manage depression, treatment requires depression treatment and possibly stimulant medication for energy. Effective treatment addresses the pain driving use, not just the use itself.
For prognostic assessment: The pain model predicts treatment outcomes. Patients whose substance use addresses unrecognized psychiatric disorders, untreated trauma, or chronic emptiness from developmental neglect have poor prognosis if only the addiction is treated. They relapse because the underlying pain remains. Conversely, patients whose use is recent, situational, and addresses temporary stressors have better prognosis because the underlying pain is less entrenched. Understanding what drives use predicts treatment complexity and duration needs.
For preventing moral judgment: The pain model protects against clinician burnout and contempt. When patients relapse repeatedly, miss appointments, or continue using despite consequences, clinicians without this framework become frustrated, viewing patients as unmotivated or manipulative. Understanding addiction as pain response maintains empathy. The patient isn’t choosing addiction; they’re choosing relief from unbearable suffering using the only method they’ve found. This understanding prevents countertransference reactions that damage therapeutic relationships.
For realistic expectations: The pain model clarifies that addiction treatment is slow because it requires addressing deep psychological wounds, not just stopping substance use. Expecting rapid abstinence without addressing underlying trauma, attachment injuries, or psychiatric conditions sets patients up for failure. Treatment must heal pain, not just stop using. This takes time, patience, and comprehensive intervention addressing root causes.
Clinical Application: Integration With Assessment
Now that you understand what addiction truly is – a response to pain, not a moral failing – you’re ready to approach substance use history with the right framework. The upcoming posts in this series will translate this conceptual understanding into systematic clinical practice: what to review in charts, how to structure interviews, what questions to ask, and how to document findings.
The pain model isn’t abstract theory. It’s the foundation for every clinical interaction with patients who use substances. When you ask “What does cocaine do for you?” with genuine curiosity informed by this framework, patients recognize that you understand. When you explore childhood experiences and emotional wounds, they sense you grasp that addiction makes sense in context. When you develop treatment plans addressing underlying pain rather than just stopping use, they experience hope that change is possible.
This understanding transforms you from someone who documents substance use to someone who understands human suffering and helps patients find healthier solutions to unbearable pain. That transformation is what allows you to actually help people recover rather than simply cataloging their failures to stop using.
Next in this series: Part 4 – Start With Chart Review: What to Look for Before the Interview
Previous post: Part 2 – The Hidden Risks You Miss When You Don’t Take a Full Substance Use History
