On Friday, March 28, 2008, Dr. Mark Stanford presented SCV-CAMFT’s Mid Region luncheon, “Making the Difficult Possible: A Paradigm Shift — Treating Addiction as a Chronic Illness.”
Science shows us that drug abuse is a preventable behavior, and addiction is a treatable disease. Evidence from research demonstrates that addiction is a biologically-based brain disease. Prolonged drug use changes the brain in fundamental and lasting ways.
Nonetheless, myths persist: that addiction is a moral weakness; that you have to hit rock bottom to recover; that you have to want treatment for it to be successful; and that alcohol is not really a drug. We still presume (wrongly) that drug abuse is more common among minorities; that total abstinence from all psychoactive drugs is the goal of addiction treatment; and that methadone is just drug switching.
What is addiction, really? According to Dr. Nora Volkow, Director of the National Institute on Drug Abuse, a good working definition is “when you are unable to stop when you want to, despite being aware of adverse consequences...”
Addiction is a complex chronic illness, with both a genetic and environmental basis influencing development and manifestation. Recovery from it is a long-term process requiring repeated treatment. Relapses can occur during or after successful treatment episodes. Participation in self-help support programs during and following treatment can be helpful in sustaining long-term recovery.
People take drugs to feel good (to have novel sensations/experiences and share them) or to relieve symptoms such as anxiety, depression, and hopelessness. Initially, they take the drug hoping to change mood, perception or emotional state, i.e. to change the brain; later, they may not be able to stop because drug use rewires the brain.
Why do some people become addicted while others do not? Heredity and environment each play a part. If an individual has a family history of alcohol abuse, plus a lower-than-usual response to a normal dosage of alcohol when first trying it, studies show a long-term risk of alcohol dependency of 60%, versus 15% for a normal to high response (Marc Schuckit, University of California, San Diego, 2002).
There are many drugs available, but few with abuse potential: of the approximately 15 million substances in the world, about 55,000 are available for human consumption. Of these, only about 25 have the potential for abuse, because they mimic natural substances made in our bodies, but usually with far greater intensity. There are:
- Uppers (CNS stimulants) including amphetamine, methamphetamine, cocaine;
- Downers (CNS depressants) including alcohol, benzodiazepines (e.g. Valium), barbiturates (e.g. Seconal), inhalants, etc.;
- All-arounders (Hallucinogens): LSD, mescaline, MDMA (Ecstasy), psilocybin (magic mushrooms), PCP, etc.; and
- Pain Killers (Opioids) including heroin, codeine, morphine, Vicodin, Fentanyl, Oxycontin, and so on.
The substances that have abuse potential stimulate the brain’s natural reward system. The brain has pleasure circuits that reward the necessities for survival, such as water, food, sex, and nurturing. Drugs and alcohol affect the same areas in the brain’s reward pathways, but in a way that is dangerous and potentially fatal! Drugs feel better than sex, food, or nurturing.
Repeated use of drugs and/or alcohol saturates the brain’s reward pathway to the point that a person becomes conditioned to the intense level of drug-induced pleasure. Normal levels of natural rewards are no longer experienced as very pleasurable, and after chronic use, the brain’s reward system becomes depleted so nothing is pleasurable — not even the drugs!
The passage of time is the most important healer for addiction: within two-four weeks, the brain will have done a lot of recovery from drug use. However, for chronic high-dose drug use, expect six months to pass, and for chronic heavy marijuana use, one to three years, before the brain finally settles down. After chronic amphetamine use, the brain images look very much like clinical depression; furthermore, it will take two years before the forebrain begins to resemble baseline function levels. Note that the course and events of recovery vary greatly depending on the substance abused, the duration and intensity of use, and the individual’s biochemistry.
Prevention of relapse behavior is a critical part of addiction treatment. Drug craving behaviors are triggered by a conditioned response of the nervous system when re-exposed to an environmental cue it has associated with drug use. Memories appear to be a critical part of addiction. Relapse is usually triggered by external stimuli, people, places, and things. The conditioned responses can last a lifetime.
Decades of long-term studies show that substance abuse treatment is effective. It seems ineffective because we have been treating addiction as if it were only an acute condition — stabilize the patient, and discharge him. Compare what would happen if this were the standard treatment for other chronic diseases such as diabetes, hypertension, or asthma! Clearly, a disease-management approach is appropriate for addiction. Instead of looking only at outcomes immediately post-treatment, we need to look at the effect of ongoing interventions (meds, lifestyle changes, and self-management). In addictions, as with other chronic conditions, treatment effects are significant but don’t persist after discharge unless some level of continuous care is provided.
The standard of care for addiction has been as an acute care problem; the standard of care needs to be revised. HMOs and lawmakers both need to understand and change their perspective.
Improving chronic illness care requires a treatment model of Sustained Recovery Management (SRM): once the patient is stabilized, over time the provider can build the client’s personal responsibility and decrease treatment intensity. Truly, you can never close the case when treating addiction. Eventually, phone checkups can be an effective way of keeping the patient on track.
Lessons Learned:
- Having multiple acute care episodes is not a continuing care strategy — it’s expensive and wasteful. Patient education is necessary — client/therapist planning for some type of continuing care is essential.
- Patient retention is critical: make treatment attractive, offer options and alternatives, increase monitoring and management.
- Evaluations of continuing care should occur during treatment, including interim performance markers.
- Patients who are not in some form of post-treatment monitoring are at elevated risk for relapse.
- Monitoring is part of health care: phone and Internet contact is useful in reducing the number and severity of relapses.
- Frequent contact with the therapist is essential from both the outcomes and cost perspectives, as experiences in the care of other chronic illnesses demonstrates.
Useful Web Links:
Mark Stanford, Ph.D., is the Medical and Clinical Services Manager for the Addiction Medicine and Therapy Division of Santa Clara County Department of Alcohol & Drug Services. He is a member of the Association for Medical Education & Research In Substance Abuse (AMERSA). Dr. Stanford is also a clinical research educator in the behavioral neurosciences, Associate Professor in psychopharmacology at Cal State Hayward, UC Berkeley Extension, and Lecturer at Stanford University Department of Family and Community Medicine. He has been in the addictions treatment area since 1976 and has been a provider within the modalities of residential, day treatment, outpatient and medication-assisted treatment programs.
Author: Melissa Miller, MFT
Presented by: Dr. Mark Stanford
