Substance Abuse and Addiction Issues The Science Behind Addiction. John B. Woods. Recovery Specialists, LLC

Transcription

1 Ethics: Substance Abuse and Addiction Issues The Science Behind Addiction John B. Woods Recovery Specialists, LLC PO Box Jackson, TN (731)

2 John B. Woods, MD, FASAM, DABAM, is an addiction-medicine specialist based in Jackson, Tennessee. A graduate of the University of Tennessee College of Medicine, Dr. Woods practiced internal medicine in in Middle and West Tennessee for more than 26 years. After his own struggle with addiction, however, Dr. Woods obtained board certification in addiction medicine approximately five years ago. Since obtaining board certification in addiction medicine, Dr. Woods has specialized in the practice of addiction medicine in both outpatient and residential-treatment settings. He is the owner of Recovery Specialists, LLC. Dr. Woods also works at Cumberland Heights, a drug and alcohol treatment facility in Nashville, Tennessee.

3 Ethics: Substance Abuse and Addiction Issues The Science Behind Addiction Table of Contents I. Introduction...5 II. Defining Addiction...5 III. Explaining Addiction...5 IV. Lawyers and Addiction...6 V. The Stigma of Addiction...6 VI. The Reward Pathway and Dopamine...6 VII. High Risk Factors...7 VIII. DSM 5 Criteria for Substance Abuse Disorder...7 IX. Treating Addiction...8 A. Treatment Options...8 B. Medications...8 C. Length of Treatment...8 X. Conclusion...8 Ethics: Substance Abuse and Addiction Issues The Science Behind Addiction Woods 3

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5 Ethics: Substance Abuse and Addiction Issues The Science Behind Addiction I. Introduction Many people believe addicts lack will power, motivation, or moral principles. In reality, however, the science behind addiction reveals that it involves a complex neurobiology that permanently alters brain chemistry. Overcoming addiction takes more than good intentions. Addiction can affect anyone. Addiction does not discriminate. It affects all socioeconomic classes, genders, occupations, and ages. The 2015 National Survey on Drug Use and Health found that approximately 20.8 million people aged 12 or older had a substance abuse disorder related to alcohol or illicit drugs in the last year. Unfortunately, in 2015, only 2.3 million people aged 12 or older who needed treatment received treatment at a specialty facility. Substance Abuse and Mental Health Services Administration (SAMHSA), Key Substance Abuse and Mental Health Indicators in the U.S.: Results from the 2015 National Survey on Drug Use and Health (available at FFR1-2015/NSDUH-FFR pdf) (last accessed on March 20, 2017). Fortunately, researchers of addiction know more about this disease than ever before. Treatment options are expanding, and society s acceptance of addiction as a disease of the brain is also increasing. In this presentation, I will cover some general principles about addiction, including its definition and diagnosis. I will also discuss the neurology of addiction and certain risk factors that make addiction more likely. Lastly, I will briefly discuss treatment options and recovery rates. II. Defining Addiction The American Society of Addiction Medicine (ASAM) defines addition as the primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations.... [A]ddiction often involves cycles of relapse and remission. III. Explaining Addiction How we choose to explain addiction can take several forms. The most common models of addiction include: (1) brain disorder; (2) matter of will, or disorder of choice; (3) bad character; or (4) self-medication. First, according to the ASAM, addiction is a brain disorder. According to Dr. Michael Miller, ASAM s past president: At its core, addiction isn t just a social problem or a moral problem or a criminal problem. It s a brain problem whose behaviors manifest in all these other areas. Dr. Miller further stated: Many behaviors driven by addiction are real problems and sometimes criminal acts. But the disease is about brains, not drugs. It s about underlying neurology, not outward actions. Second, some explain addiction as a voluntary act because it typically begins with voluntary behaviors. This model considers addiction a disorder of choice. Gene Heyman, Addiction: A Disorder of Choice, Harvard University Press (Oct. 2010). According to Mr. Heyman, addictive behaviors all begin with a voluntary behavior, even if they later develop into involuntary, self-destructive behavior. The third explanation is that addiction is a result of bad character. This view unfortunately gained endorsement between 1996 and Bernice A. Pescosolido, Ph.D., et al., A Disease Like Any Other?: A Ethics: Substance Abuse and Addiction Issues The Science Behind Addiction Woods 5

6 Decade of Change in Public Reactions to Schizophrenia, Depression, and Alcohol Dependence, 167 Am. J. of Psych (Nov. 2010). Lastly, addiction has been explained as self-medication. In this model, the addict usually first experiences some type of trauma, such as abuse, neglect, loss, or other type of emergency. The addict then develops some type of post-traumatic stress disorder, depression, or anxiety that he or she attempts to soothe through substance use. Marc Lewis, Ph.D., Addiction as Self-Medication, Psychology Today (Aug. 2012), (available at (last accessed on March 20, 2017). IV. Lawyers and Addiction A study by the American Bar Association and the Hazelden Betty Ford Foundation found that lawyers suffer from depression, alcoholism, and anxiety more commonly than other professionals. The study included more than 12,000 lawyers in nineteen states throughout the United States. That study revealed: Problem drinkers: One in three lawyers reported being problem drinkers, compared to 15% of surgeons revealed in a prior study by the American College of Surgeons. Depression: Twenty-eight percent suffer from depression; Anxiety: Nineteen percent show symptoms of anxiety. Lawyers who work in law firms reported the highest rates of alcohol abuse. And it breaks down from highest rate of abuse to the lowest: junior associates, senior associates, and junior partners. This study shows a correlation between being in the early stages of your legal career and problem drinking. Elizabeth Olson, High Rate of Problem Drinking Reported Among Lawyers, N.Y. Times, February 4, 2016 (available at (last accessed on March 21, 2017). V. The Stigma of Addiction Most people have felt stigmatized at some point in their lives. This is especially true for those suffering with addiction. The general public is more likely to have a negative attitude toward those dealing with addiction than with other diseases. Those suffering from addiction may be perceived as weak, bad, irresponsible, depressed, or immoral. See Stephanie Desmon & Susan Morrow, Drug Addiction Viewed More Negatively than Mental Illness, John Hopkins Study Shows, JHU HUB (Oct. 2014), (available at edu/2014/10/01/drug-addiction-stigma/) (last accessed on March 20, 2017). People suffering from addiction are not bad people; they are sick people. As such, society often unfairly mischaracterizes those with addiction problems. VI. The Reward Pathway and Dopamine Addictive drugs activate the reward pathway. Dopamine is the best studied and most important neurotransmitter involved in the neurobiology of addiction, but its actions are very complex and there remains a great deal of debate over exactly how altered dopamine levels lead to the compulsive behaviors associated with addiction. Dopamine acts on the reward pathways located in the nucleus accumbens and ventral tegmental area, located deep in the midbrain (unlike areas in the frontal lobe, this part of the brain the lizard brain lies outside of conscious control). Dopamine can be viewed as a stimulant, similar to 6 Employment and Labor Law May 2017

7 adrenalin, and addictive drugs can either directly stimulate its release or inhibit other neurotransmitters that block dopamine. While a thorough discussion of the neurobiology involved in these neural pathways is beyond the scope of this presentation (and, truthfully, beyond my understanding) one fairly straightforward and simplified but useful way to understand addiction is to look at how addictive substances (or other stimuli) affect dopamine release. Dopamine release feels good. Once dopamine levels are released there is a subsequent dysphoria (bad feeling) due to depleted dopamine levels until the body synthesizes more. Repeated surges of dopamine release somehow reset the threshold level of dopamine needed to produce the pleasurable feeling, thus making it harder and harder to achieve the same good feeling. Some substances, such as cocaine, stimulate dopamine release directly, while others, such as alcohol and benzodiazepines (Valium, Xanax), generally speaking, block an inhibitory neurotransmitter called GABA, resulting in a net increase in dopamine levels. Even worse, for some substances, such as opioids, repetitive use of the addictive substance causes an upregulation an increase in the number of receptors in the midbrain. Therefore, more receptors must be filled with the drug (higher doses) in order to achieve the same high over time. And when those opioid receptors are not filled with opiates, the addict experiences extreme dysphoric symptoms. The opioid receptors will decrease in number over time if the addict abstains from opioid exposure, but it takes on average roughly eighteen months for those receptors to decrease to a more normal level. It also seems that those pathways are FOREVER more sensitive to upregulation than before the opioid exposure, with obvious implications for the risk of relapse with exposure even after many years of abstinence. A common and heartbreaking occurrence involves opioid addicts with several months of sobriety, often after extended residential treatment, who relapse. Thinking that they require the same opioid dose to get high that they most recently required when they were using, they flood their downregulated opioid receptors to the point of inducing respiratory arrest and death with a dose that a few months ago would not have caused such an effect. VII. High Risk Factors Certain sectors of the population tend to be at a higher risk for developing an addiction. Having one or more of these factors does not mean that a person will become addicted, but it does mean his or her odds are greater. Risk factors include: having a genetic predisposition; beginning use at a younger age; being exposed to childhood trauma (e.g., violence, sexual, etc.); having a learning disorder (e.g. ADD or ADHD); or having a mental illness (e.g., depression, bipolar disorder, psychosis, personality disorder, etc.). VIII. DSM 5 Criteria for Substance Abuse Disorder The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5) is the latest edition of the American Psychiatric Association s text on names, symptoms, and diagnostic features of all recognized mental illnesses. Addiction is included in the DSM 5. The DSM 5 lists the following criteria for substance abuse disorders: 1. Pattern of increasing use; 2. Inability to stop, despite a desire to stop; 3. Preoccupation with obtaining the substance; 4. Craving; 5. Continued use despite adverse consequences; Ethics: Substance Abuse and Addiction Issues The Science Behind Addiction Woods 7

8 6. Recurrent use resulting in failure to fulfill major life obligations; 7. Recurrent use in physically hazardous situations; 8. Tolerance; 9. Withdrawal symptoms; and 10. Important social, occupational, or recreational activities are given up because of use. IX. Treating Addiction A. Treatment Options The addicted person must first recognize that he or she has a problem, and the next step is to seek treatment for the problem. There are several types of treatment available. Some examples of treatment options include outpatient addiction treatment programs, residential treatment programs, psychotherapy, self-help groups, and medication. While mutual help groups, such as AA are not technically treatment, they have pointed many addicts and alcoholics to recovery. B. Medications Medications can be an important part of a treatment plan for someone with an addiction. Typically, medication must be combined with counseling and other behavioral therapies to be useful. For alcohol addiction, examples of medication include Naltrexone (oral and injectable), Disulfiram, and Acamprosate. For opiate addiction, examples of medication include Naltrexone, Methadone, and Buprenorphine. Nicotine addiction may be treated through nicotine replacement products (e.g., gum, patches, sprays, inhalers), Bupropion, or Varenicline. Unfortunately, medication options for those addicted to stimulants are essentially nonexistent. C. Length of Treatment The length of treatment can vary from patient to patient. It will depend on the patient s problems and needs. For residential or outpatient settings, fewer than 90 days is of limited effectiveness. For methadone maintenance, a minimum of 12 months is required. Longer treatment often increases the chance of success. Please note, however, that addiction recovery is an ongoing, long-term process because addictions are permanent. As such, addicts must anticipate and avoid situations or circumstances that may cause a relapse. An addiction is not cured just because an addict completes a course of treatment. Instead, a constant effort is required for addicts to remain sober and clean and, thus, avoid relapse. X. Conclusion You cannot always identify an addict by his or her appearance, but you can often identify one by his or her actions because the disease will lead addicts to lie, steal, and hide in order to feed the addiction. You generally are not helping an addict in the long run by ignoring or covering for the addict s lapses and indiscretions because the nature of the disease is one of progression and they generally just become sicker without help. In my experience, the earlier the intervention, the less severe the consequences. 8 Employment and Labor Law May 2017