Addiction

Addiction

Addiction is a brain disorder characterized by compulsive engagement in rewarding stimuli despite adverse consequences.^[8] Despite the involvement of a number of psychosocial factors, a biological process – one which is induced by repeated exposure to an addictive stimulus – is the core pathology that drives the development and maintenance of an addiction.^[1][9] The two properties that characterize all addictive stimuli are that they are reinforcing (i.e., they increase the likelihood that a person will seek repeated exposure to them) and intrinsically rewarding (i.e., they are perceived as being inherently positive, desirable, and pleasurable).^[1][3][7]

Addiction is a disorder of the brain’s reward system which arises through transcriptional and epigenetic mechanisms and occurs over time from chronically high levels of exposure to an addictive stimulus (e.g., eating food, the use of cocaine, engagement in sexual activity, participation in high-thrill cultural activities such as gambling, etc.).^[1][10][11] ΔFosB, a gene transcription factor, is a critical component and common factor in the development of virtually all forms of behavioral and drug addictions.^{[10][11][12][13]} Two decades of research into ΔFosB’s role in addiction have demonstrated that addiction arises, and the associated compulsive behavior intensifies or attenuates, along with the overexpression of ΔFosB in the D1-type medium spiny neurons of the nucleus accumbens.^{[1][10][11][12]} Due to the causal relationship between ΔFosB expression and addictions, it is used preclinically as an addiction biomarker.^[1][10][12] ΔFosB expression in these neurons directly and positively regulates drug self-administration and reward sensitization through positive reinforcement, while decreasing sensitivity to aversion.^{[note 1][1][10]}

Addiction exacts an “astoundingly high financial and human toll” on individuals and society as a whole.^[14][15][16] In the United States, the total economic cost to society is greater than that of all types of diabetes and all cancers combined.^[16] These costs arise from the direct adverse effects of drugs and associated healthcare costs (e.g., emergency medical services and outpatient and inpatient care), long-term complications (e.g., lung cancer from smoking tobacco products, liver cirrhosis and dementia from chronic alcohol consumption, and meth mouth from methamphetamine use), the loss of productivity and associated welfare costs, fatal and non-fatal accidents (e.g., traffic collisions), suicides, homicides, and incarceration, among others.^{[14][15][16][17]} Classic hallmarks of addiction include impaired control over substances or behavior, preoccupation with substance or behavior, and continued use despite consequences.^[18] Habits and patterns associated with addiction are typically characterized by immediate gratification (short-term reward), coupled with delayed deleterious effects (long-term costs).^[19]

Examples of drug and behavioral addictions include alcoholism, amphetamine addiction, cocaine addiction, nicotine addiction, opioid addiction, food addiction, gambling addiction, and sexual addiction. The only behavioral addiction recognized by the DSM-5 and the ICD-10 is gambling addiction. The term addiction is misused frequently to refer to other compulsive behaviors or disorders, particularly dependence, in news media.^[20] An important distinction between drug addiction and dependence is that drug dependence is a disorder in which cessation of drug use results in an unpleasant state of withdrawal, which can lead to further drug use.^[21] Addiction is the compulsive use of a substance or performance of a behavior that is independent of withdrawal. Addiction can occur in the absence of dependence, and dependence can occur in the absence of addiction, although the two often co-occur.

Drug rehabilitation is the process of medical or psychotherapeutic treatment for dependency on psychoactive substances such as alcohol, prescription drugs, and street drugs such as cannabis, cocaine, heroin or amphetamines. The general intent is to enable the patient to confront substance dependence, if present, and stop substance misuse to avoid the psychological, legal, financial, social, and physical consequences that can be caused.

Treatment includes medication for depression or other disorders, counseling by experts and sharing of experience with other addicts.^[1]

Psychological dependency[edit]

Psychological dependency is addressed in many drug rehabilitation programs by attempting to teach the person new methods of interacting in a drug-free environment. In particular, patients are generally encouraged, or possibly even required, to not associate with peers who still use the addictive substance. Twelve-step programs encourage addicts not only to stop using alcohol or other drugs but to examine and change habits related to their addictions. Many programs emphasize that recovery is an ongoing process without culmination. For legal drugs such as alcohol, complete abstention—rather than attempts at moderation, which may lead to relapse—is also emphasized (“One is too many, and a thousand is never enough.”)^{[citation needed]}

Whether moderation is achievable by those with a history of misuse remains a controversial point.^[2]

The brain’s chemical structure is impacted by addictive substances and these changes are present long after an individual stops using. This change in brain structure increases the risk of relapse, making treatment an important part of the rehabilitation process.^[3]

Types[edit]

Various types of programs offer help in drug rehabilitation, including residential treatment (in-patient/out-patient), local support groups, extended care centers, recovery or sober houses, addiction counselling, mental health, and medical care. Some rehab centers offer age- and gender-specific programs.^{[citation needed]}

In an American survey of treatment providers from three separate institutions (the National Association of Alcoholism and Drug Abuse Counselors, Rational Recovery Systems and the Society of Psychologists in Addictive Behaviors) measuring the treatment provider’s responses on the Spiritual Belief Scale (a scale measuring belief in the four spiritual characteristics Alcoholics Anonymous identified by Ernest Kurtz); the scores were found to explain 41% of the variance in the treatment provider’s responses on the Addiction Belief Scale (a scale measuring adherence to the disease model or the free-will model addiction).^[4]

Effective treatment addresses the multiple needs of the patient rather than treating addiction alone.^[5] In addition, medically assisted drug detoxification or alcohol detoxification alone is ineffective as a treatment for addiction.^[3] The National Institute on Drug Abuse (NIDA) recommends detoxification followed by both medication (where applicable) and behavioral therapy, followed by relapse prevention. According to NIDA, effective treatment must address medical and mental health services as well as follow-up options, such as community or family-based recovery support systems.^[6] Whatever the methodology, patient motivation is an important factor in treatment success.^[7]

For individuals addicted to prescription drugs, treatments tend to be similar to those who are addicted to drugs affecting the same brain systems. Medication like methadone and buprenorphine can be used to treat addiction to prescription opiates, and behavioral therapies can be used to treat addiction to prescription stimulants, benzodiazepines, and other drugs.^[8]

Types of behavioral therapy include:

• Cognitive-behavioral therapy, which seeks to help patients to recognize, avoid and cope with situations in which they are most likely to relapse.
• Multidimensional family therapy, which is designed to support the recovery of the patient by improving family functioning.
• Motivational interviewing, which is designed to increase patient motivation to change behavior and enter treatment.^[9]
• Motivational incentives, which uses positive reinforcement to encourage abstinence from the addictive substance.^[10]
• EEG Biofeedback augmented treatment improves abstinence rates of 12-step, faith-based, and medically assisted addiction for cocaine, methamphetamine, alcohol use disorder, and opioid addictions.^{[11][12][13][14][15][16][17][18][19][20]}

Treatment can be a long process and the duration is dependent upon the patient’s needs and history of substance use. Research has shown that most patients need at least three months of treatment and longer durations are associated with better outcomes.^[3] Prescription drug addiction does not discriminate. It affects people from all walks of life and can be a devastatingly destructive force.^[21]

Medications[edit]

Certain opioid medications such as methadone and more buprenorphine are widely used to treat addiction and dependence on other opioids such as heroin, morphine or oxycodone. Methadone and buprenorphine are maintenance therapies intended to reduce cravings for opiates, thereby reducing illegal drug use, and the risks associated with it, such as disease, arrest, incarceration, and death, in line with the philosophy of harm reduction. Both drugs may be used as maintenance medications (taken for an indefinite period of time), or used as detoxification aids.^[22] All available studies collected in the 2005 Australian National Evaluation of Pharmacotherapies for Opioid Dependence suggest that maintenance treatment is preferable,^[22] with very high rates (79–100%)^[22] of relapse within three months of detoxification from levo-α-acetylmethadol (LAAM), buprenorphine, and methadone.^[22][23]

According to the National Institute on Drug Abuse (NIDA), patients stabilized on adequate, sustained doses of methadone or buprenorphine can keep their jobs, avoid crime and violence, and reduce their exposure to HIV and Hepatitis C by stopping or reducing injection drug use and drug-related high risk sexual behavior. Naltrexone is a long-acting opioid antagonist with few side effects. It is usually prescribed in outpatient medical conditions. Naltrexone blocks the euphoric effects of alcohol and opiates. Naltrexone cuts relapse risk in the first three months by about 36%.^[22] However, it is far less effective in helping patients maintain abstinence or retaining them in the drug-treatment system (retention rates average 12% at 90 days for naltrexone, average 57% at 90 days for buprenorphine, average 61% at 90 days for methadone).^[22]

Ibogaine is a hallucinogenic drug promoted by certain fringe groups to interrupt both physical dependence and psychological craving to a broad range of drugs including narcotics, stimulants, alcohol, and nicotine. To date, there have never been any controlled studies showing it to be effective, and it is not accepted as a treatment by physicians, pharmacists, or addictionologist. There have also been several deaths related to ibogaine use, which causes tachycardia and long QT syndrome. The drug is an illegal Schedule I controlled substance in the United States, and the foreign facilities in which it is administered tend to have little oversight and range from motel rooms to one moderately-sized rehabilitation center.^[24]

A few antidepressants have been proven to be helpful in the context of smoking cessation/nicotine addiction. These medications include bupropion and nortriptyline.^[25] Bupropion inhibits the re-uptake of nor-epinephrine and dopamine and has been FDA approved for smoking cessation, while nortriptyline is a tricyclic antidepressant which has been used to aid in smoking cessation it has not been FDA approved for this indication.^[25]

Acamprosate, disulfiram and topiramate (a novel anticonvulsant sulphonated sugar) are also used to treat alcohol addiction. Acamprosate has shown effectiveness for patients with severe dependence, helping them to maintain abstinence for several weeks, even months.^[26] Disulfiram produces a very unpleasant reaction when drinking alcohol that includes flushing, nausea and palpitations. It is more effective for patients with high motivation and some addicts use it only for high-risk situations.^[27] Patients who wish to continue drinking or may be likely to relapse should not take disulfiram as it can result in the disulfiram-alcohol reaction mentioned previously, which is very serious and can even be fatal.^[26]

Nitrous oxide, also sometimes known as laughing gas, is a legally available gas used for anesthesia during certain dental and surgical procedures, in food preparation, and for the fueling of rocket and racing engines. People who use substances also sometimes use gas as an inhalant. Like all other inhalants, it is popular because it provides consciousness-altering effects while allowing users to avoid some of the legal issues surrounding illicit substances. Misuse of nitrous oxide can produce significant short-term and long-term damage to human health, including a form of oxygen starvation called hypoxia, brain damage and a serious vitamin B12 deficiency that can lead to nerve damage.^{[citation needed]}

Although dangerous and addictive in its own right, nitrous oxide has been shown to be an effective treatment for a number of addictions.^[28][29][30]

Residential treatment[edit]

In-patient residential treatment for people with an alcohol use disorder is usually quite expensive without insurance.^[31] Most American programs follow a 28–30 day program length. The length is based solely upon providers’ experience. During the 1940s, clients stayed about one week to get over the physical changes, another week to understand the program, and another week or two to become stable.^[32] 70% to 80% of American residential alcohol treatment programs provide 12-step support services. These include, but are not limited to AA, Narcotics Anonymous, Cocaine Anonymous and Al-Anon.^[32] One recent study suggests the importance of family participation in residential treatment patient retention, finding “increased program completion rate for those with a family member or significant other involved in a seven-day family program”.^[33]

Brain implants[edit]

Patients with severe opioid addiction are being given brain implants to help reduce their cravings, in the first trial of its kind in the US. Treatment starts with a series of brain scans. Surgery follows with doctors making a small hole in the skull to insert a tiny 1mm electrode in the specific area of the brain that regulates impulses such as addiction and self-control. This treatment is for those who have failed every other treatment, whether that is medicine, behavioral therapy, and/or social interventions. It is a very rigorous trial with oversight from ethicists and regulators and many other governing bodies.^[34]

Recovery[edit]

The definition of recovery remains divided and subjective in drug rehabilitation, as there are no set standards for measuring recovery.^[35] The Betty Ford Institute defined recovery as achieving complete abstinence as well as personal well-being^[36] while other studies have considered “near abstinence” as a definition.^[37] The wide range of meanings has complicated the process of choosing rehabilitation programs.^{[citation needed]}

The Recovery Model originates in the psychiatric survivor movement in the US, which argues that receiving a certain diagnoses can be stigmatizing and disempowering.^[38] While other treatment programs are focused on remission or a cure for substance abuse, the Recovery Model takes a humanistic approach to help people navigate addiction.^{[citation needed]} Some characteristics of the Recovery Model are social inclusion, empowerment to overcome substance use, focusing on strengths of the client instead of their deficits and providing help living more fulfilling lives in the presence of symptoms of addiction.^{[citation needed]} Another key component of the Recovery Model is the collaborative relationship between client and provider in developing the client’s path to abstinence. Under the Recovery Model a program is personally designed to meet an individual clients needs, and does not include a standard set of steps one must go through.^[39]

The Recovery Model uses integral theory:^[40] a four-part approach focusing on the individual, the collective society, along with individual and external factors. The four quadrants corresponding with each in Integral Theory are Consciousness, Behavior, Culture and Systems.^[41] Quadrant One deals with the neurological aspect of addiction. Quadrant Two focuses on building self-esteem and a feeling of connectedness, sometimes through spirituality. Quadrant three works on mending the “eroded relationships” caused by active addiction. Quadrant Four often involves facing the harsh consequences of drug use such as unemployment, legal discrepancies, or eviction.^[42] The use of integral theory aims to break the dichotomy of “using” or “not using” and focuses instead on emotional, spiritual, and intellectual growth, along with physical wellness.^{[citation needed]}

Criminal justice[edit]

Drug rehabilitation is sometimes part of the criminal justice system. People convicted of minor drug offenses may be sentenced to rehabilitation instead of prison, and those convicted of driving while intoxicated are sometimes required to attend Alcoholics Anonymous meetings.^[43] There are a great number of ways to address an alternative sentence in a drug possession or DUI case; increasingly, American courts are willing to explore outside-the-box methods for delivering this service. There have been lawsuits filed, and won, regarding the requirement of attending Alcoholics Anonymous and other twelve-step meetings as being inconsistent with the Establishment Clause of the First Amendment of the U.S. Constitution, mandating separation of church and state.^[44][45]

In some cases, individuals can be court-ordered to drug rehabilitation by the state through legislation like the Marchman Act.^{[citation needed]}

Counseling[edit]

Traditional addiction treatment is based primarily on counseling.

Counselors help individuals with identifying behaviors and problems related to their addiction. It can be done on an individual basis, but it’s more common to find it in a group setting and can include crisis counseling, weekly or daily counseling, and drop-in counseling supports. Counselors are trained to develop recovery programs that help to reestablish healthy behaviors and provide coping strategies whenever a situation of risk happens. It’s very common to see them also work with family members who are affected by the addictions of the individual, or in a community to prevent addiction and educate the public. Counselors should be able to recognize how addiction affects the whole person and those around him or her.^[46] Counseling is also related to “Intervention”; a process in which the addict’s family and loved ones request help from a professional to get an individual into drug treatment.^{[citation needed]}

This process begins with a professionals’ first goal: breaking down denial of the person with the addiction. Denial implies a lack of willingness from the patients or fear to confront the true nature of the addiction and to take any action to improve their lives, instead of continuing the destructive behavior. Once this has been achieved, the counselor coordinates with the addict’s family to support them in getting the individual to drug rehabilitation immediately, with concern and care for this person. Otherwise, this person will be asked to leave and expect no support of any kind until going into drug rehabilitation or alcoholism treatment. An intervention can also be conducted in the workplace environment with colleagues instead of family.^{[citation needed]}

One approach with limited applicability is the sober coach. In this approach, the client is serviced by the provider(s) in his or her home and workplace—for any efficacy, around-the-clock—who functions much like a nanny to guide or control the patient’s behavior.^[47]

Twelve-step programs[edit]

The disease model of addiction has long contended the maladaptive patterns of alcohol and substance use displays addicted individuals are the result of a lifelong disease that is biological in origin and exacerbated by environmental contingencies. This conceptualization renders the individual essentially powerless over his or her problematic behaviors and unable to remain sober by himself or herself, much as individuals with a terminal illness are unable to fight the disease by themselves without medication. Behavioral treatment, therefore, necessarily requires individuals to admit their addiction, renounce their former lifestyle, and seek a supportive social network that can help them remain sober. Such approaches are the quintessential features of Twelve-step programs, originally published in the book Alcoholics Anonymous in 1939.^[48] These approaches have met considerable amounts of criticism, coming from opponents who disapprove of the spiritual-religious orientation on both psychological^[49] and legal^[50] grounds. Opponents also contend that it lacks valid scientific evidence for claims of efficacy.^[51] However, there is survey-based research that suggests there is a correlation between attendance and alcohol sobriety.^[52] Different results have been reached for other drugs, with the twelve steps being less beneficial for addicts to illicit substances, and least beneficial to those addicted to the physiologically and psychologically addicting opioids, for which maintenance therapies are the gold standard of care.^[53]

SMART Recovery[edit]

SMART Recovery was founded by Joe Gerstein in 1994 by basing REBT as a foundation. It gives importance to the human agency in overcoming addiction and focuses on self-empowerment and self-reliance.^[54] It does not subscribe to disease theory and powerlessness.^[55] The group meetings involve open discussions, questioning decisions and forming corrective measures through assertive exercises. It does not involve a lifetime membership concept, but people can opt to attend meetings, and choose not to after gaining recovery. Objectives of the SMART Recovery programs are:^[56]

• Building and Maintaining Motivation,
• Coping with Urges,
• Managing Thoughts, Feelings, and Behaviors,
• Living a Balanced Life.

This is considered to be similar to other self-help groups who work within mutual aid concepts.^[57]

Client-centered approaches[edit]

In his influential book, Client-Centered Therapy, in which he presented the client-centered approach to therapeutic change, psychologist Carl Rogers proposed there are three necessary and sufficient conditions for personal change: unconditional positive regard, accurate empathy, and genuineness. Rogers believed the presence of these three items, in the therapeutic relationship, could help an individual overcome any troublesome issue, including but not limited to alcohol use disorder. To this end, a 1957 study^[58] compared the relative effectiveness of three different psychotherapies in treating alcoholics who had been committed to a state hospital for sixty days: a therapy based on two-factor learning theory, client-centered therapy, and psychoanalytic therapy. Though the authors expected the two-factor theory to be the most effective, it actually proved to be deleterious in the outcome. Surprisingly, client-centered therapy proved most effective. It has been argued, however, these findings may be attributable to the profound difference in therapist outlook between the two-factor and client-centered approaches, rather than to client-centered techniques.^[59] The authors note two-factor theory involves stark disapproval of the clients’ “irrational behavior” (p. 350); this notably negative outlook could explain the results.

A variation of Rogers’ approach has been developed in which clients are directly responsible for determining the goals and objectives of the treatment. Known as Client-Directed Outcome-Informed therapy (CDOI), this approach has been utilized by several drug treatment programs, such as Arizona’s Department of Health Services.^[60]