Understanding Substance Use: Insights from Dr Michael Smith at the 12 Months On Conference

As the Pro Patria Centre reflects on a year of progress, research, and community impact, our “12 Months On” Conference brought together leaders, clinicians, and advocates dedicated to the wellbeing of veterans and first responders. Among the highlights of this year’s event was an insightful presentation by Dr Michael Smith, who spoke with clarity and compassion on the medical aspects of substance use disorders, an issue deeply affecting both the veteran community and society at large.

Dr Smith began by acknowledging the significance of place and community, remarking, “It’s such a wonderful Wagga day, and I came down on the train last night, but it’s always good to come back here from Sydney.”

The Human Side of Substance Use

Reflecting on the personal stories that shape his practice, Dr Smith shared, “Everything I can appreciate from what veterans go through comes from the stories my dad would tell from his father, who served in the Royal Australian Navy… he learned the choicest swear words from his dad, who was a sailor, but also found that his dad had an issue with alcohol. And so hopefully we can sort of lift the lid on why that would occur.”

Dr Smith emphasised the need to view addiction as a disease, not a moral failing. “I’d like to help you guys understand the disease model that we can apply to addiction in the same way that we would look at hypertension or diabetes… we should look at addiction as applied to the disease model.”

He continued, “Most importantly, I think, in order to position ourselves as people who care about treatment, we do have to remove the stigma associated with substance misuse.”

The Realities Facing Veterans

Dr Smith underlined the increased stress and psychological challenges facing Australians in the 21st century. “The ABS showed that 15% of Australians aged 16 to 85 reported high or very high levels of psychological distress in 2020–2021, and this rose to 17%. That highest burden is 26% amongst 16 to 24 year olds. We’re getting less sleep. We’re less financially secure. We’re not drinking more than we used to drink… about one quarter of us are drinking too much.”

Bringing the focus to veterans, Dr Smith said, “Generally, they’re healthier than the average person, and whilst they’re in the force, they’re not abusing substances more than the average person. In fact, they’re abusing it less. But what we know, especially from the Royal Commission into veteran suicide, is that after people left the forces, they were 21% more likely to commit suicide. In males, and the females had a higher burden, at 81%.”

The Role of Dopamine and Motivation

“To survive, we need food, water, and—not oxygen—dopamine,” Dr Smith explained. “When you hear the word dopamine, just think about the word motivation… it’s actually possible to test this. You can deprive people from water, or food, and then put them in a functional MRI and see the territory of their brain that’s salient or relevant for food or water seeking, all those dopamine areas light up, so dopamine is very much responsible for motivation.”

He drew attention to the powerful effects some medications can have on the brain. “You could be prescribed a drug by a GP or a neurologist that could make you have a gambling problem, something you’ve never had before. And the basis for a lot of some of these drugs… is dopamine agonists. They activate the dopamine receptor.”

How Addiction Hijacks the Brain

Dr Smith described the neurobiology of addiction: “Addiction is a primary chronic disease of the brain involving reward, motivation and memory… it becomes pathological when you’re pursuing reward and seeking relief. We have an inability to abstain… and we have reduced insight into the fact that it’s causing a problem. It’s characterised by a cycle of relapse and remission.”

On the anatomical level, Dr Smith explained, “Let’s think about the brain as a hierarchical structure. At the top we have the cortex… as we get lower down, we get to the work horses. Right at the bottom we’ve got the amygdala, which is where fight or flight is often seen… the ventral tegmental area is basically the seat of motivation and reward.”

He illustrated how addictive substances can hijack the motivational circuitry of the brain. “Methamphetamine will give you an 11-fold increase in the amount of dopamine that hits your brain and your neural circuits in a very short period of time… by about the fifth use, you’re at 50 again. So now you have to use methamphetamine, or whatever it might be, just to feel normal. And so it becomes all-encompassing.”

A Holistic, Stigma-Free Approach

Dr Smith championed a holistic approach to treatment. “The Principles of Management are fairly well understood… detox is important, but it doesn’t predict for long-term abstinence. We also obviously need to treat the comorbid psychiatric disorders… management needs to be tailored and customised to our patients, and we need to remain in treatment.”

He concluded, “I think Pro Patria will be very successful in that, because they do approach a whole-person model of care.”

Dr Smith’s insights remind us that substance use is a complex health issue, not a failing of character. At the Pro Patria Centre, we remain committed to advancing evidence-based, compassionate care—supporting veterans and first responders on every step of their journey.

Pro Patria Centre, 12 Months On Conference Team