Social Media and Substance Use: What Clinicians Need to Know

SPECIAL REPORT: ADDICTION

Today, around the world, 4.9 billion individuals use social media, spending an average of 2.4 hours on platforms each day.¹ However, social media has a dark side. Not only can the platforms be addictive, but in many cases social media exposure can facilitate other addictive behaviors including substance misuse and alcohol abuse. Here, we will review research on both the addictive aspects of social media and its interconnection with substance-related problems. The relevant similarities and differences among social media, alcohol, and drugs are summarized in the Table.

Common Neural Pathways

Social media use and the use of addictive substances share some characteristics, as they are both activities that our brains may perceive as rewarding. Rewarding activities activate the brain’s mesolimbic dopaminergic reward pathway. Drives for primary rewards (eg, food) and secondary reward (eg, money) are essential for human survival.² Unfortunately, addictive substances like opiates, cocaine, alcohol, and others hijack these neural pathways in ways that lead to undesirable outcomes. Social media use activates these same reward areas in the brain by capitalizing on our preexisting drives for social rewards.³ For example, some individuals may receive a hit of dopamine through their reward pathway each time they receive an online like, which leaves them wanting more.²

Further, research on Instagram addiction shows not only activation of the reward pathway but also deactivation of the executive control network, which is important for decision-making, problem-solving, and goal-directed behavior.⁴ This pattern of neural changes (ie, activation of the reward pathway paired with deactivation of executive control) is common to a range of addictive behaviors, including social media addiction and substance-related problems. In addition, the timeline of important maturational changes in the prefrontal cortex, associated with executive control, may increase vulnerability to social media–related problems at either end of the lifespan. This is apparent in the frequent media reports of teens and older adults falling prey to misinformation and online scams.

Common Behavioral Trajectories

Social media addiction, while not yet a medically recognized disorder, is described as a hazardous commitment to social media that consumes a large amount of a person’s time, such that real-world activities and relationships receive inadequate attention compared with the constructed reality of social media.^5,6 Approximately 43% of social media users exhibit these symptoms,⁷ which can lead to negative consequences at school and work.⁸

There are significant similarities between the behavioral stages of social media addiction and those experienced in substance use disorder (SUD) or alcohol use disorder (AUD). For example, Koob et al describe drug addiction as a 3-stage cycle of binge/intoxication, withdrawal/negative affect, and preoccupation/anticipation.⁹ Similarly, Alexander and Delariarte describe the escalation of social media use from an exploratory stage to levels consistent with addiction.⁵ At the end stages, individuals engage in compulsive browsing and excessive social media use (up to 10 hours per day) and exhibit aggressive reactions when asked to quit.⁵ Relapses to social media use after periods of abstinence also occur.⁹ These trajectories of social media addiction and drug addiction—including impulsive and compulsive use, the narrowing of the user’s world to focus almost solely on their addiction, the psychological withdrawal symptoms (eg, aggression when asked to quit), and the periods of abstinence followed by relapse—are similar.^10,11 Note that we are not referring to the dangerous physical symptoms that occur in drug and alcohol withdrawal. Rather, Dickson suggests that social media addiction involves primarily psychological withdrawal, occurring when individuals are unable to access their devices or platforms.¹² However, a later study with a very similar design found increases in blood pressure and heart rate when participants were deprived of their mobile devices for short periods,¹³ suggesting that under some conditions, the psychological signs of social media withdrawal might also contribute to physical stress.

Psychiatric Comorbidity

Various maladaptive social media behaviors have been linked to preexisting psychiatric conditions, including features of cluster B disorders and AUD. In our work, we have found that the maladaptive online behavior of sadfishing (exaggerating one’s emotional state online to generate sympathy¹⁴) is significantly associated with the attention-seeking aspects of histrionic personality disorder, as well as the use of social media while intoxicated.¹⁵ Sadfishing may be particularly dangerous because it negatively affects mental health and exposes vulnerable individuals to online predators.¹⁶ Potential clinical interventions for sadfishing include developing healthy coping mechanisms and strengthening the client’s ability to self-soothe.¹⁷ In addition, the concurrent use of social media with alcohol or drugs is obviously problematic. The disinhibition of intoxication may lead to inappropriate online openness, such as posting embarrassing images or disclosing harmful personal information online.¹⁵ This intoxication-related loss of control over self-presentation often leads to regret and other negative consequences.¹⁸ Individuals who post about their own intoxication may also unintentionally influence others in their peer group to use addictive substances, thus spreading the problem.

Challenges for Clinicians

Social media hazards and addiction risk are clearly intertwined (see Figure). One challenge is that the algorithmic filtering in social media creates information bubbles that work to decrease exposure to diverse points of view and ensure that social media users are presented with a constant stream of new information tailored to their individual tastes and desires.¹⁹ Social media content may also work to assert virtual peer pressure by presenting highly curated or inaccurate portrayals of peer norms. For example, alcohol-related social media posts and advertising campaigns may lead college students to perceive that most of their peers are engaging in binge drinking, even if this is not the case.²⁰ Individuals who are already struggling with addiction may be triggered by visual cues on social media, eliciting cravings for addictive substances and causing FOMO (the fear of missing out²¹) for risky interactions that could lead to relapse.

However, addressing social media addiction, or treating an SUD or AUD in social media users, is challenging. In today’s world, it is nearly impossible to remain abstinent from social media. The maintenance of a positive social media presence is a social expectation for most and a career requirement for many. Researchers have suggested that the types of treatment approaches that are commonly used for eating disorders (eg, binge eating disorder), such as cognitive behavioral therapy, interpersonal therapy, and dialectical behavioral therapy, may also be useful for social media addiction, since food is another substance that is impossible to avoid completely.⁷ The aforementioned clinical approaches could be used to help social media users mitigate their use, increase their productivity outside of social media, and maintain healthier real-world relationships.⁷

Future Directions

Although social media has expanded our ability to communicate with others across the globe, in many ways it has simply reduced the entire world to a small town where anonymity is limited, fears of stigma are heightened, and the need for reputation management can be overwhelming. Numerous studies have documented how these specific conditions tend to hinder readiness to change and adversely impact addiction recovery.²² In the past, geographical changes could sometimes provide a fresh start. But now, “the internet is forever”²³ and there is nowhere to hide.

Yet, efforts are underway to harness the power of social media and use it as a force for good. For example, Jha and Singh²⁴ describe a public, open-source, web-based application named SMARTS that harvests real-time user-reported information from popular social media platforms and then uses it to identify individuals whose online activities mark them as being potentially open to a drug recovery intervention. As machine learning techniques advance, our ability to apply these predictive models in real time is expected to improve. Other researchers describe automated 2-way communication programs that similarly monitor content and intervene when an individual’s social media bubble contains information predictive of substance-related harm.²⁵

Finally, researchers also note that positive engagement with more traditional online “sober social networks” can help individuals build resilience, self-efficacy, and positive recovery identity, all of which are associated with effective and sustainable recovery.²⁶ However, the ever-changing landscape of social media makes it difficult to know where best to direct these efforts. One thing is clear: Age-differentiated strategies are needed. Data show that adolescents prefer very different platforms from middle-aged or older adults, and most importantly, teens tend to abandon platforms once they have detected the presence of other age groups in their space.¹ Keeping up with their migration would be a significant challenge for any social media-based intervention effort targeting adolescents.

Concluding Thoughts

Social media is here to stay, and its use must be a consideration in the treatment of psychiatric conditions, particularly SUD and AUD. This article has covered similarities and differences between excessive social media use and other types of addiction. As researchers gain a better understanding of how social media influences the mental health and well-being of individuals and groups, we will discover more effective ways to use this powerful tool for good and to limit its harms.

Dr Ceballos is chair of psychology at Texas State University. Ms Petrofes is a graduate of the department of psychology at Texas State University.

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