The Case for Addicts

Introducing Drug Addiction

Whitney Houston, Heath Ledger, Janis Joplin, Philip Seymour Hoffman, and Chris Farley. What do each of these individuals have in common? Well, for one, they are all celebrities, and two, they have all died due to drug addiction. However, the list doesn't stop there, and it definitely isn't limited to celebrities only. Specifically, about 570,000 people die annually due to drug use, and that's deaths related to tobacco, alcohol, and illicit drug usage [1]. Secondly, according to the National Survey on Drug Use and Health, over 7 million Americans battled with drug addiction in 2014. Obviously, drug use and abuse is no small matter in this country, and it even costed the United States close to $200 billion in healthcare, criminal justice, legal, and loss of workplace production/participation costs in 2007 [3].

So, what exactly is drug addiction? Addiction is often defined as an ongoing use of mood-altering substances, including alcohol and drugs, despite harmful consequences. Genetic, psychosocial, and environmental factors influence both the development and manifestations of addiction. To the brain, alcoholism and drug addiction are one in the same, however there are some characteristics of each. According to Bettinardi-Angres and Angres, alcoholism is defined as, "continuous or periodic impaired control over drinking, preoccupation with alcohol, use of alcohol despite adverse consequences, and distortions in thinking—most notably denial" [ pg.31, 4]. On the other hand, the DSM-4 defines substance abuse and dependence as a " maladaptive pattern of substance use, leading to clinically significant impairment or distress, although they are manifested differently" [pg.31, 4].

Substance abuse is defined and manifested by one or more of the following in a 12-month period:

Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home
Recurrent substance use in situations in which it is physically hazardous
Recurrent substance-related legal problems
Continued substance use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance [4].

This chart summarizes several common illicit drugs, as well as their associated categories (i.e. stimulants) and effects.

Substance dependence and abuse are usually treated similarly by health professionals, but have varying diagnostic properties. Substance dependence is a more severe diagnosis, but substance abuse can often lead to dependence. Specifically, substance dependence is defined and manifested by three or more of the following in which the manifestations occur at anytime within the same 12-month period:

A need for markedly increased amounts of the substance to achieve intoxication or desired effects
A markedly diminished effect with continued use of the same amount of the substance
The characteristic withdrawal syndrome for the substance
The same substance taken to relieve or avoid withdrawal symptoms
The substance taken in larger amounts or over a longer period than was intended
A persistent desire or unsuccessful efforts to cut down or control substance use
A great deal of time spent in activities needed to obtain the substance, use the substance, or recover from the effects
Reduction in or absence of important social, occupational, or recreational activities because of substance use
Continued substance use despite knowledge of a persistent or recurrent physical or psychological problem caused or exacerbated by the substance [4].

The Tragic Death of an Up and Coming Star

Gustav Ahr, otherwise known by his stage name of Lil Peep, died at the young age of 21 on November 16 of 2017. He was a unique artist, combining sounds of rap and emo into his music, often in which he spoke of his opioid addiction as well as his struggles with depression. Obviously, many celebrities face death due to drug addiction, but Peep's story has created massive impact in that his death evoked conversation about the drug epidemic in the United States. It seems as though we live in a society that glorifies drug use in pop culture, but that also shames individuals addicted to drugs [5]. Negative connotations are often associated with addicted individuals, such as being a failure or having low motivation, and this shaming can keep addicts from seeking treatment at all. What drug addicts so desperately need is social support, and shaming hinders this from happening. In fact, based on previous research, lower levels of social support predict relapse in addicts, while higher levels of social support predict decreased substance use. In general, social support has been linked to better quality of life among substance users [6]. Not only was a definite cry for help evident in Peep's music (example below), but it was also evident in posts on social media sites. In the final hours of Peep's life, he posted this message on Instagram: "I just wana be everybody's everything I want too much from people but then I don't want anything from them at the same time u feel me I don't let people help me but I need help but not when I have my pills but that's temporary one day maybe I won't die young and I'll be happy? What is happy I always have happiness for like 10 seconds and then it's gone. I'm getting so tired of this" [5].

Most of the time, the way in which we talk about addiction in society is centered around the argument between choice and disease: is drug addiction a choice that people make or is this a disease that people cannot control without help? There is a simple answer to this question that some members of society may not want to accept, and that is that addiction is a disease of the brain. If society began to change its perceptions on drug addiction and addicts in terms of it being a medical disease, like cancer or heart disease, this may lead to progress. In November of 2016, the U.S surgeon general, Dr. Vivek Murthy, announced that American society needed to make a cultural shift in the way in which it thinks about substance addictions. Along with the commentary of Dr. Murthy, the U.S Surgeon General's Office, urged that findings from medical research be more widely used in prevention and intervention strategies surrounding drug addiction [7]. What exactly do findings state about drug addiction? What does the research reveal?

The Disease of Drug Addiction

During the 1930's, the time in which scientists were beginning to study addictive behavior, people addicted to drugs were thought to be "morally flawed and lacking in willpower". For much of the past century, these misconceptions shaped societies responses to drug abuse and "treatment". Individuals treated drug addiction as a moral failing, instead of an extreme health issue, which resulted in punishment of addicts rather than proper prevention/treatment. However, due to advances in science and research, views on addiction have changed dramatically, in that now we recognize addiction as a disease of the brain (as it should be recognized) [10]. Obviously, the first time an individual uses a drug, they do so by choice, in that they are choosing to take that drink or injection, and often they believe that they can control their usage. But with time, more and more of the drug is needed to achieve the same level of satisfaction that the individual received the first time they took the substance (now, various risk factors exist that influence the likelihood that someone will become addicted, which will be discussed later). Much of an addicts time thereafter is spent seeking out and taking the substance, while progressive changes in the brain drive the compulsive and uncontrollable addiction to the drug. When these changes in the brain occur, individuals can no longer voluntarily choose to stop taking the drug [9].

How Drugs Change Brain Structure & Function

Excerpt from, "Addiction is a Brain Disease, and It Matters", by Leshner (1997) : Explains why drug addiction is considered a disease as well as changes that occur in the brain...[12].

Pathways containing dopamine are where many drugs exert their effects
Healthy brains: dopamine is released in response to natural rewards (i.e. food or sex)
Drugs essentially hijack dopamine pathways (some drugs even have a structure similar to other chemical messengers in the brain, so this allows them to bind to brain cells in order to release dopamine) and this teaches the brain that drugs are good too, just as food is
Taking a drug=euphoric feeling=reinforces drug use
1. Drugs release 2-10 times more dopamine than natural rewards release
Continuation of substance use= the brain produces less dopamine and/or reduces the number of brain structures that receive dopamine
1. Less natural production of dopamine=decreased impact of dopamine on reward network as well as decreased feelings of pleasure
As a result of lack of natural production of dopamine, addicts appear tired, unmotivated, depressed, and report lack of pleasure
Substance use is increased in order to counter side affects of lack of dopamine and to attempt to feel the same amounts of pleasure that they used to
1. Tolerance=vicious cycle of needing more and more of the drug in order to regain adequate dopamine levels
Prolonged substance use changes the brain in ways that promote continued use --strengthens memory circuits associated with drug taking--can trigger a relapse despite amount of time abstinent (without being treated, of course) [9].

Addiction is a disease. We should treat it like one

Components of Drug Addiction

Go to (biology section) : http://learn.genetics.utah.edu/content/addiction/genes/

to learn more and to listen to Dr. Glen Hanson speak on susceptibility and the role of many genes influence on addiction.

A Case Study of Addiction

By examining a case study of drug addiction/substance abuse, one can learn to apply the specific factors that may have potentially helped cause the addiction (risk factors) as well as other implications.

Below is a case study presented on a pregnant woman with heroin dependence [10].

Based on this case, we can see that this woman was affected by changes in the brain that resulted in craving of the drug, as well as psychological and environmental related issues: being homeless, having to undergo a court case, poor family support (remember support is critical for drug addicts), and unemployment. This woman is also most likely being affected by pregnancy stress and what the future holds for her new role as a mother. What is particularly interesting in this case is that in order to protect both the mother and child, the woman must be given an effective, managed dose of the drug, because otherwise withdrawal symptoms would induce many risks.

Treating Drug Abuse: What Works?

Pharmacological & behavioral [19]:

For most opioid addiction treatment, pharmacological treatment, such as using methadone and buprenorphine, is routine.
It has been found that patients who have the most severe addiction, specifically to opioids, benefited more from drug counseling compared to those with less severe forms of the disease
Contingency management= a behavioral therapy approach that uses incentives in order to encourage patients to remain drug-free. Patients who achieve and maintain abstinence can earn the chance to win prizes involving cash (this approach has worked so well that the Department of Veteran Affairs is putting it into their own treatment clinics)--lower costing prizes work just as well as higher costing prizes in regards to motivating addicts to stay abstinent ("In one study, for example, Petry and colleagues found that $300 prizes worked just as well as $900 in incentives when it came to reducing cocaine use in methadone patients")-- costs of these reinforcement tactics can be less expensive compared to more traditional psychotherapy methods, and they often produce better outcomes
The current approach to making addiction treatment services available isn't working ("while 22 million to 23 million Americans each year meet criteria for dependence or abuse of alcohol or other drugs, just 3 million get treatment")--need to start integrating addiction treatment services into primary care
Web-based interventions= Marsch and colleagues found that substituting a web-based intervention in for some of the standard counseling methadone patients resulted in higher rates of abstinence for these patients compared to the standard treatment alone

Exercise [20]:

Individuals who engage in regular aerobic exercise are less likely to use/abuse illicit drugs
Based on studies conducted using lab animals, exercise reduces drug self-administration
Exercise produces protective effects within the transitional phases that occur during the development of and recovery from a substance use disorder
Exercise-based interventions reduce compulsive patterns of drug use in clinical and at-risk populations

Peer support groups [21]:

Defined as, "the process of giving and receiving nonprofessional, nonclinical assistance from individuals with similar conditions or circumstances to achieve long-term recovery from psychiatric, alcohol, and/or other drug-related problems"
Peer support groups included in the treatment of addiction shows much promise, however there is limited data relevant to this topic, resulting in a diminished ability to draw ultimate conclusions

(For research information regarding the effectiveness of the D.A.R.E program, visit https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448384/pdf/0941027.pdf)

Real Stories of Success:

Conclusions:

Drug addiction kills
Addiction is a disease
Biology, psychology, and environment all interact to influence vulnerability to addiction
Treatments do exist for drug abuse--especially effective is contingency management

References:

[1]= Drug facts chat day: Drug use. NIH. https://teens.drugabuse.gov/national-drug-alcohol-facts-week/drug-facts-chat-day-drug-use.

[2]= (2016). Celebrities who have died from addiction. USA Today. https://www.usatoday.com/story/life/people/2016/06/02/celebrities-who-have-died-addiction/85314450/.

[3]= Statistics on drug addiction. AAC. https://americanaddictioncenters.org/rehab-guide/addiction-statistics/.

[4]= Bettinardi-Angres, K. and Angres, D. H. (N/D). Understanding the disease of addiction. Journal of Nursing Regulation, 1(2), 31-37.

[5]= Zaru, D. (2017). Lil Peep’s death ignites a conversation about the addiction epidemic. CNN. http://www.cnn.com/2017/11/16/politics/lil-peep-death-opioid-epidemic/index.html.

[6]= Laudet, A. B., Morgen, K., and White, W. L. (2006). The role of social supports, spirituality, religiousness, life meaning and affiliation with 12-Step fellowships in quality of life satisfaction among individuals in recovery from alcohol and drug problems. Alcohol Treatment Quarterly, 24(1-2), 33-73. doi: 10.1300/J020v24n01_04.

[7]= Fikes, B. J. (2016). Treat alcohol and drug addictions as physical diseases, U.S. surgeon general urges. The San-Diego Union-Tribune. http://www.sandiegouniontribune.com/business/biotech/sd-me-addiction-report-20161117-htmlstory.html.

[8]= Jaffe, A. (N/D). What role does shame play in drug or alcohol addiction? Sharecare. https://www.sharecare.com/health/substance-abuse-addiction-recovery/what-shame-drug-alcohol-addiction.

[9]= Hardee, J. (2017). Science says: Addiction is a chronic disease, not a moral failing. Michigan Health. https://healthblog.uofmhealth.org/brain-health/science-says-addiction-a-chronic-disease-not-a-moral-failing.

[10]= https://www.drugabuse.gov/

[11]= https://www.youtube.com/watch?v=VI4KZWtROt0

[12]= Leshner, A. I. (1997). Addiction is a brain disease, and it matters. Science, 278, 45-46. DOI: 10.1126/science.278.5335.45.

[13]= Windle, M. (2010). A Multilevel developmental contextual approach to substance use and addiction. Biosocieties, 5, 124-136. doi:10.1057/biosoc.2009.9.

[14]= http://learn.genetics.utah.edu/content/addiction/genes/

[15]= Jedrzejczak, M. (2005). Family and environmental factors of drug addiction among young recruits. Military Medicine, 170, 688-690. http://militarymedicine.amsus.org/doi/pdf/10.7205/MILMED.170.8.688.

[16]= Google Images

[17]= https://www.youtube.com/watch?v=Tyb2v2bXFd4

[18]= https://www.youtube.com/watch?v=4T1F1UfXf_8&t=3s

[19]= Clay, R. A. (2015). Treating drug abuse. APA, 46(2), 46. http://www.apa.org/monitor/2015/02/drug-abuse.aspx

[20]= Smith, M. A. and Lynch, W. J. (2012). Exercise as a potential treatment for drug abuse: evidence from preclinical studies. Frontiers in Psychiatry, 2(82), 1-10. doi: 10.3389/fpsyt.2011.00082.

[21]= Tracy, K. and Wallace, S. P. (2016). Benefits of peer support groups in the treatment of addiction. Substance Abuse Rehabilitation, 7, 143-154. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5047716/pdf/sar-7-143.pdf.

[22]= West, S. L. and O’Neal, K. K. (2004). Project D.A.R.E outcome effectiveness revisited. American Journal of Public Health, 94(6), 1027-1029. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448384/pdf/0941027.pdf.

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