Predisposing Factors in Addiction
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Predisposing Factors in Addiction Predisposing Factors in Addiction Document Transcript

  • Donald West Predisposing Factors in Addiction The essence of Addiction is compulsive drug seeking and use even in the face of negative health and social consequences. I. Definitions: A. Substance dependence: (Essentially addiction...more severe disorder than substance abuse) A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by : 1. Signs of physical dependence a. Tolerance: result of physical adjustment to regular use of a substance in which the brain requires increasing amounts of the substance to achieve the desired effect. b. Withdrawal: physical symptoms which occur on when a substance on which a person has become physically dependent is rapidly discontinued. Withdrawal symptoms vary with the substance being abused. Dangers of withdrawal also vary according to the substance. 2. Loss of control of use 3. Drug interferes with important life activities B. Substance abuse: a maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one or more of the following within a 12 month period: 1. Recurrent use resulting in failure to fulfill major role obligations. 2. Recurrent use in situations in which use is physically hazardous. 3. Recurrent substance use-related legal problems. 4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the use. II. The Disorder (Disease) of Addiction A. Why addiction can be considered a Disease. 1 .Identifiable symptoms 2. Predictable course 3. Has an effective treatment. B. Why Addiction can be considered a Brain Disease. 1. All substances of abuse have common effects either directly or indirectly on a single pathway win the brain, the mesolimbic reward system. Activation of this system appears to be a common element in what keeps drug users taking drugs. In this way acute drug use alters brain function. 2. Prolonged drug and alcohol use causes pervasive changes in brain
  • function that persist long after the drug taking stops, Significant effects of chronic drug use have been identified the molecular, cellular, structural and functional levels. The addicted brain is distinctly different from the non-addicted brain as manifested in brain metabolic activity, receptor availability, gene expression and responsiveness to environmental cues. 3. That addiction is tied to changes in brain structure and function is what makes it fundamentally a brain disease. C. Public Health Model of Disease Agent Host All needed for a disease to manifest itself Environment 1. The Agent: Alcohol/Cocaine/Heroin Nicotine a. Alcohol: A sedative drug, relieves inhibitions initially, later simply sedates. 1.).Metabolized at fixed rate of about 1 to1.5 oz./ hour. 2). To reach legally drunk (0.8 mg./cc) blood alcohol level, it is estimated that it takes approximately 4 drinks in an hour for men and 2.5 drinks per hour for women. 3). Women metabolize differently because of low levels of an enzyme in the stomach which breaks down alcohol before it enters the bloodstream. This results in more effect per drink higher Blood Alcohol with fewer drinks: and less time to develop serious physical long term consequences with less alcohol. b. Cocaine: extremely reinforcing (Pleasurable experience sought over and over) In animal experiments has been found that animals will seek (lever push) to get cocaine to the exclusion of food, water and sex. c. Heroin: Pleasurable--makes everything OK; takes away the chaos. d. Nicotine: the only substance that both stimulates and relaxes. 1/2 of those who try become addicted. Self -injection experience similar to cocaine. In one study found to be more difficult to stop than heroin. 2. The Environment: the USA, New England, the Upper Valley, Dartmouth. a. Drinking is accepted. b. Drinking is expected. c. Drinking is a major form of recreation and lubricant for other activities (conversation, dancing, sex). d. Drunkenness is tolerated and amusing. e. The non-drinker is suspect. f. Drinking is illegal until a certain age when (suddenly) one is
  • supposed to know how to drink. g. In few families do children learn to drink at meals and celebrations as in some European cultures. 3. The Host: One who uses the substance Why do some people become alcoholic and not others? A .Genetic Substrate or Predisposition 1). Twin studies: If a monozygotic twin is alcoholic, his/her twin is twice as likely to become dizygotic twin or regular siblings. 2). Adoption Studies: In studies where children born to alcoholic parents and adopted out to and raise in non-alcoholic families were compared with the opposite situation, those with the biologically alcoholic parents were most likely to become alcoholic. 3).Having a biologic parent who is alcoholic puts one at least four times greater risk of becoming alcoholic than having an non- alcoholic parent. 4). Alcohol-naive sons of alcoholic parents (male) when compared to alcohol-naive sons of non-alcoholic parents and given a fixed dose of alcohol show: less body sway, less obvious intoxication and can drink more without severe hangovers. 5). Same comparison studies without alcohol involved show differences in EEG waves between sons of alcoholics and non- alcoholics, difference in evoked potentials. 6). Personality Factors as etiology—Controversial) Vaillant’s research: No evidence for addictive personality however. Rather the characteristics associated with the alcoholic seem to be more a result of the disorder than the pre-existing personality. Tarter and colleagues from reviewing evidence suggest that the genetic factors in alcoholism exercise their effects through behavior and temperament. And –as a result of these - are predisposed to behaviors and reactions that become associated with excessive alcohol use. Differences they suggest are important include: Activity level (high) Attention span (deficient) Soothability (unable) Emotionality (labile) Reaction to food (Extreme) Sociability (disinhibited and non-conforming)
  • 7.)Cloninger: Type I a. either parent can abuse alcohol b. can be men or women c. develops later in life . drink for reward an or in response to stress e. harm avoiding /non-impulsive. Type II (25% of alcoholics) a. men only , transmitted from alcoholic father to son. b. drink like fathers. c. early onset of drinking and problems. d. impulsive, thrill-seeking, e. less concerned with consequences of actions. 2. Non-genetic Developmental Contributors: Khantzian: Problems with need satisfaction and self-care. Need to self –sooth, defend against painful affect, confusing affect or lack of affect. 3. Development of Primary Psychiatric Problems and Secondary Substance Abuse Anti-social personality disorder Depression Bi-Polar disorder Post Traumatic Stress Disorder III.Treatment Outcome Macy Foundation Study (2000) CASA National survey of Primary Care Physicians and Patients on Substance Abuse; Only 3.6% of surveyed physicians think treatment for alcoholism if very effective and 2.1% thing drug abuse treatment is. A.Chronic Disease Concept; (See reading List) Problem with assessing treatment is partially based on the fact that caregivers do not see addiction as a chronic relapsing disorder, much the same a hypertension, diabetes, asthma. Because patients relapse, even after rehabilitation, caregivers often base their opinion of the entire addict population on those who relapse and ignore research, which has very positive outcomes. Caveats: 1. It is unreasonable to expect a single intervention to bring about abstinence. 2. Many patients attain abstinence/sobriety after multiple relapses and treatment failures.
  • 3. .Addiction requires ongoing care 4. Harm Reduction concept 5. “Brick in the Wall” concept. B. Assessing treatment outcome for substance abuse sounds, initially, like a simple task. It is in fact extraordinarily complex. Treatment modalities, length of treatment, treatment setting (in-pt vs. out-pt.) assessing AA (is it treatment?) and designing controlled studies are just a few of the problems confronting those who attempt to asses outcome. The literature is large with over 1000 studies reporting, in one way or another, that "treatment works." Yet skepticism remains because of the above confounding factors. “…Research to date has conclusively established that treatment can be effective, but there are only preliminary indications at this time as to why treatment is effective or what it is within treatment that makes it effective.” McLellan and McKay 1998 C.What is known from research studies includes: 1.. Results from primary care medicine, brief intervention studiesd ata showing that treatment of alcoholism is as or more effective than that for diabetes, hypertension and asthma 2, Brief Interventionswork:: a. Two large randomized, controlled studies have shown effectiveness. b,Borne out by systematic review of literature and meta-analysis. Bien et. al 1993:, Wilk et. al. 1997 c. Effectiveness of Brief Interventions in Primary Care Settings increased with : 1)Lower severity of both addiction and psychiatric symptoms at time of admission. 2)Motivation beyond the “precontemplation" stage of change. 3(Being employed or self-supporting. 4)Having family and social supports for sobriety. D. Regarding Heroin addiction and Methadone Maintenance Treatment From the beginning (1960’s) in all areas where treatment was made available: 1)Crime rates decreased 2 2)Employment among those in treatment increased. 3 3)Ability to parent increased among those in treatment. 4)Medical related disorders decreased (HIV, Hepatitis C etc)
  • Buprenorphine seems to work as well but no good outcome data E. CATOR Data [Comprehensive Assessment and Treatment Outcome Research] Mostly alcoholic patients 1. Outcome Data from Minnesota Model treatment programs. Sample was 8000 patients from in and outpatient programs where abstinence was the goal. 2. CATOR Data relies on self-report regarding sobriety and that of a significant other to confirm. (When patient reported abstinence, the significant other agreed in 88% of cases.) CATOR data is only on followed cases. Those lost to follow- up not included (a potential problem). Sample largely white employed males between ages 20 and 50. 3. Conclusions: General outcome rates: One year abstinence rates were slightly greater than 60%. An additional 25% reported at least 6 months abstinence. The data is very similar to that previously reported on similar samples. Abstinence rates also varied with amount of aftercare and continuous AA attendance. Those with less than 6 mos. of aftercare and no continuous AA had a 45% abstinence rate at 1 yr. Those with weekly AA and one year of aftercare had a 90% abstinence rate. Treatment was also found to lower post treatment medical costs (see Holder below) and decrease post treatment work problems. 4. In a subset of the data, coerced (mandatory) DWI offenders required to attend outpatient treatment had a 68% one year abstinence rate as compared to a 60% for non-coerced outpatients. (Hoffman. 1994) D. Reduction of Medical Costs as a Result of Treatment A. Holder (1986) did a six year longitudinal study to determine if the treatment of alcoholism as a primary diagnosis results in the reduction of health care cost and/or utilization for the alcoholic as well as other nonalcoholic family members. All health care costs and utilization were tracked for a group of 90 families representing 245 individuals, enrolled with Blue Cross/Blue shield through the Health Benefits Division, California Public Employees Retirement System. At least one member in each family received treatment under a specific diagnosis of alcoholism from July 1, 1974 to December 1, 1975. All health care utilization costs were obtained for a 12 month period before initial treatment for alcoholism and up to July 1, 1979. In addition a matched group of 83 comparison families with no alcoholic members and covering 291 persons were selected to reflect family composition, age, and
  • sex. Total health care data were obtained over the same time period for these families. The results indicated that utilization and costs of all forms of inpatient care for both non alcoholic family members as well as the alcoholic family members dropped after alcoholism treatment began and ultimately reached a level similar to the matched comparison group. B. .In a second study Holder (1992) followed 3729 alcoholics covered by health plan of a large Midwestern manufacturing plant for 14 years. 3068 got treatment. 661 did not. Among those treated, health care costs post-treatment declined by 23 to 55% from their highest pre-treatment levels (including the cost of treatment). Costs rose for those alcoholics identified, but not treated. C. In a third study Holder (1986) demonstrated that health care costs for the family rose in the six months prior to treatment of the alcoholic member and (as above) fell in the follow-up treatment years. Conclusion: Treatment reduced overall family health costs even when cost of treatment is included. E. Harm Reduction: A more recent concept in the treatment area—and quite controversial is “Harm Reduction” where actions are taken and policies adopted “to decrease the adverse health, social and economic consequences of drug use without necessarily diminishing drug consumption. This approach has its roots in the relative ineffectiveness of many treatment efforts which have appeared ineffective, expensive and counterproductive.” (Wodak 1999) Though methadone maintenance and needle exchange programs are the most often mentioned and most often debated examples of harm reduction, perhaps the most effective example has been the widespread promotion and the relative acceptance of the “Designated Driver” concept coupled with the “ Friends don’t let friends drive drunk” and the lowering of the accepted level of blood alcohol for DWI in many states. However simply helping addicts achieve even limited periods of sobriety is also harm reduction. Reduced overall consumption of alcohol? —Unlikely for many. Damage control?? Almost certainly! References: Treatment Outcome
  • 1. Fleming M, Cotter F, Talboy E. Training Physicians in Techniques for Alcohol Screening and Brief Intervention NIAAA/NIH/USPHS. 1997 Available from NIAAA. 2. Bien TH, Miller WR. Breif interventions for alcohol problems: a review. Addiction 88:315-335. 1993 3. Fiellin DA, Carrington R O,’Connor PG Outpatient management of patients with alcohol problems. Ann. Intern. Med. 2000;133:815-837. November 2000. 4. Finney JW, Moos RH What works in treatment :effect of setting, duration and amount.Principles of Addiction Medicine. Chevy Chase, MD American society of Addiction Medicine. 1998. 5. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers: a randomized , controlled trial in community-based primary care practices. JAMA 277:1039-45. 1997 6. S, Haines A. Randomized controlled trial of general practioner intervention in patient with excessive alcohol consumption. BJM: 297:663-67.1988 7. Hester RK Outcome research: alcoholism In The American Psychiatric Press Textbook of Substance Abuse Treatment. Washington, DC. American Psychiatric Press. 1994. 8. Holder HD, Hallan JB. Impact of alcoholism treatment on total health care costs: a six year study. Advances in Alcohol and Substance Abuse 6:1-15 1986.. 9. Holder HD, Blose JO. The reduction of health care costs associated with alcoholism treatment: a 14 year longitudinal study. J. of Studies on Alcohol. 53:293-302. 1992. 10. Wilk AI, Jensen NM, Havighurst TC. Meta-analysis of rendomized, controlled trials addressing brief interventions in heavy alcohol drinkers. J. Gen Intern,. Med. 12:274-83. 1997. 11. Wodak A. Harm reduction as an approach to treatment. . Principles of Addiction Medicine. Chevy Chase, MD American society of Addiction Medicine. 1998.