LITERATURE REVIEW FOR PDE1

Positive Psychology and Treatment for Substance Use Disorders in Nicaragua

Javier D. Ley

Mississippi College

Positive Psychology and Treatment for Substance Use Disorders in Nicaragua

Positive Psychology (PP)theory and interventions have a place in the treatment and recovery of individuals with SUD’s considering the negative affect and life situations that are a common consequence of this condition. In relation to the emotional aspect, Kooband Volkow (2010) describe drug addiction as being characterized by the “emergence of a negative emotional state” (p. 217) Also, research has shown that people in recovery from drug addiction scored higher on measurements of shame, depression, and maladaptive guilt (Meehan et al., 1996). Having been engulfed in these negative affective consequences for many years, it can prove a challenging task for the individual to identify and acknowledge positive aspects in their personalities and in their lives. In the following literature review, aspects related to concepts and definitions of addiction are described, as well as diagnostic criteria, screenings and assessments, prevalence and populations of interest, co-occurring disorders, suicides and mortality, development of the disorder, negative affect and emotions, evidence based practices, self-help or mutual-help, long term recovery, positive psychology and its possible integration with addiction.

Addiction – Concepts and Definitions

Theconceptualization of addiction as it relates to substance use disorders need to be considered. There are two relevant current definitions of addiction that are noteworthy. First is the definition of addiction utilized by the National Institute on Drug Abuse (NIDA), who, in their publication “Drugs, Brain, and Behavior: The Science of Addiction”, share that “addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences” (NIDA, 2010, p. 5). The relevance of NIDA and their definition stems from the fact that the agency is the largest funding source for research on the field (SatelLilienfeld, 2014). The second definition that isnoteworthy is the one utilized by the American Society of Addiction Medicine (ASAM). In a public policy statement adopted in 2011, ASAM shared as part of their short definition that

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors (ASAM, 2011, p. 1).

The relevance of ASAM is due to their being the largest professional group of medics specialized in the field (SatelLilienfeld, 2014).

Both definitions share the central role of the brain in their explanations. This view is a consensus generally accepted throughout the addiction science world (Levy, 2013). Imaging technology of the human brain has been at the forefront of this perspective on addiction. Significant increases in dopamine levels during drug use are related to the reinforcement effects of drugs (repetition of drug using behavior), while there are also effects on motivation (orbitofrontal cortex), memory (amygdala), and cognitive control (prefrontal cortex) (Volkow, Fowler, & Wang, 2003).

Specifically, it has been shown that drug addicted individuals, while not using drugs, present a reduction in dopamine activity, reduction in orbitofrontal activity (motivation and compulsivity), and in the cingulate gyrus (impulsivity). These reductions in dopamine lead to a decreased sensitivity to natural rewards or other non-drug rewards and also to an inappropriate functioning of the inhibitory frontal cortex. The value of the drug and related stimuli are increased in relation to these other rewards. When these individuals are presented with stimuli related to drugs, these areas and functions of the brain related to dopamine, motivation, and memory become hyperactive and strongly drive these individuals to seek drugs without the inhibitory control necessary to avoid a corresponding compulsive drug use. (Volkow, et al., 2003; Volkow, Fowler, Wang, Swanson, 2004).

Although the consensus stands among scientists that addiction is a brain disease, there are also some that are not in agreement with this perspective. Levy (2013) states that addiction is better understood as a disorder of a person within a social context and not as a brain disease. He goes on to argue that the neural adaptations and changes in the addicted person’s brain also occur in all behavior and the fact that it is true for an addict’s brain does not make it a brain disease. In relation to the involvement of the social context described above, Levy (2013) furthers his view by describing the social inabilities of the addicted person to remove himself or herself from the risky environment, the stress, demands, and even poor nutritional factors. He alsomentions the lack of other resources that can compete in value with the drugs.

Satel and Lilienfeld (2014) also argue against the brain disease model of addiction. They state that the brain is not the most relevant unit of analysis in the comprehension and treatment of addiction while adding that the brain disease model takes away focus on the following aspects: (a) a dimension of choice in addiction;(b) a capacity to be responsive to incentives; and (c) the fact that people have reasons to use drugs. In relation to the aspect of choice, they add that people can improve if they have a desire to get well, an aspect that is not shared by other diseases such as multiple sclerosis or schizophrenia.

In regard to the responsiveness of incentives, the authors share the examples of physicians who would have their licenses revoked if they do not present negative laboratory testing of drug use and the positive outcomes of contingency management in which participants receive a reward for drug free urine samples--something also that cannot be done with someone, for example, with Alzheimer’s. As for the fact that people use drugs for reasons, Satel and Lilienfeld (2014)describe examples of reasons to use drugsnot related to brain mechanisms, such as forgetting, and dealing with fear, anxiety, and doubt.

Diagnostic Criteria

The shift in 2013 from the Diagnostic and Statistical Manual of Mental Disordersfrom the American Psychiatric Association (APA) in their fourth edition and revised text (DSM-IV-TR) into the fifth edition (DSM-5) led into a change from two different disorders related to addiction in DSM-IV-TR-- those of substance abuse and substance dependence--towards one disorder in DSM-5: substance use disorder (SUD).DSM-5lists the essential characteristic of SUD as a “cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems”(APA, 2013, p. 483)The DSM-5description of SUD also has inclination towards the brain disease model, stating that another important characteristic of SUD is “an underlying change in brain circuits that may persist beyond detoxification, particularly in individuals with severe disorders” (APA, 2013, p. 483)

Categories of substances for which the DSM-5 has diagnostic criteria for SUD are: alcohol, cannabis, phencyclidine, other hallucinogens, inhalants, opioids, sedative (hypnotic or anxiolytic), stimulants, tobacco, and a category for other (or unknown) SUD. The diagnostic criteria are the same for each of the nine categories of substances mentioned above with 11 diagnostic criteria per substance. One difference is that there is no diagnostic criterion for withdrawal for phencyclidine, other hallucinogen, or inhalants; therefore these SUDs contain only 10 diagnostic criteria. The other categories contain all 11 criteria, with specific particularities for characteristic withdrawal symptoms of each substance or substance group (APA, 2013).

As an example of a specific substance, the diagnostic criteria for alcohol use disorders are described. The diagnostic criteria are the same for the other substances, with only the name of the substance changing in their specific criteria. In this case, an alcohol use disorder is described as a “problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

  1. Alcohol is often taken in larger amounts or over a longer period than was intended.
  2. There is persistent desire or unsuccessful efforts to cut down or control alcoholuse.
  3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
  4. Craving, or a strong desire or urge to use alcohol.
  5. Recurrent alcoholuse resulting in a failure to fulfill major role obligations at work, school, or home.
  6. Continued alcoholuse despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
  7. Important social, occupational, or recreational activities are given up or reduced because of alcoholuse.
  8. Recurrent alcoholuse in situations in which it is physically hazardous.
  9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
  10. Tolerance, as defined by either of the following:
  1. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
  2. A markedly diminished effect with continued use of the same amount of alcohol.
  1. Withdrawal, as manifested by either of the following:
  1. The characteristic withdrawal syndrome for alcohol.
  2. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms”(APA, 2013, p 490-491).

Other important specifiers for the diagnostic process of SUD include the current severity, state of remission, and if in a controlled environment. As for the current severity, SUD is now thought of as a continuum in which the individual can present a classification of the severity of their SUD in accordance to the number of criteria met. If the individual meets two to three criteria, the SUD is specified as “mild”. If the individual meets four to five criteria, the SUD is specified as “moderate” and if the individual meets six or more criteria, the SUD is classified as “severe”.

In relation to the state of remission, if the person with a SUD and who previously met criteria as such, has not met any of the criteria (except for Criterion 4: Craving) for at least three months but less than 12, then the diagnosis is specified as “in early remission.” If the person with a SUD and who previously met criteria as such has not met any of the criteria (except for Criterion 4: Craving) for 12 months or more, then the diagnosis is specified as “in sustained remission”. A final specification of “In a controlled environment” results if the person is in an environment where the substance related to their SUD is restricted (APA, 2013).

Knowledge of DSM-IV-TR criteria of abuse and dependence is also currently relevant since most research findings used in the present review of literature are based on these diagnostic criteria. Therefore, the inclusion of the diagnostic criteria for both disorders in DSM-IV-TR is needed for a better understanding in this literature review.

The criteria for Substance Abuse are defined as “a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

  1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g. repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household).
  2. Recurrent substance use in situations in which it is physically hazardous(e.g. driving an automobile or operating a machine when impaired by substance use).
  3. Recurrent substance-related legal problems (e.g. arrests, disorderly conduct).
  4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of the substance(e.g., arguments with spouse about consequences of intoxication, physical fights).” (APA, 2000, p. 228)

The criteria for Substance Dependence are defined as “a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring within a 12-month period:

  1. Tolerance, as defined by either of the following:

a. a need for markedly increased amounts of the substance to achieve intoxication or desired effect

b. markedly diminished effect with continued use of the same amount of the substance

  1. Withdrawal, as manifested by either of the following:

a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria set specific substances)

b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

  1. The substance is often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful efforts to cut down or control substance use.
  3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
  4. Important social, occupational, or recreational activities are given up or reduced because of substance use.
  5. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.” (APA, 2000, p. 223).

Screenings and Assessments

With the significant prevalence of SUD’s, their impact on the individual, on families, on morbidity, mortality, and society as whole, the importance of screening and assessment cannot be understated. Screening tools help with the identification of individuals with hazardous substance use. Other screening instruments also aid in categorizing a level of severity of problem use in the individual, while others also point towards level of care. A positive screen of a problem substance user also point towards more detailed assessments. These thorough assessmentsprovide a more complete context of the individual’s circumstances and areas of life impacted by the substance use, more information for diagnostic purposes, and a guide for treatment planning (Samet, Waxman, Hatzenbuehler, & Hasin, 2007).

Early detection of problem substance users is a main concern. There has been advancement in the early identification of problem drinkers of alcohol through brief intervention instruments such as the Alcohol Use Disorders Identification Test (AUDIT), which was developed by the World Health Organization (WHO). The AUDIT is a 10-item instrument which had been designed for use in primary health care settings. It has also been validated in relation to diverse languages and gender (Sims and Iphofen, 2003). Among the languages in which AUDIT has been officially translated is Spanish (Babor et al, 2001).

In relation to the screening of substances other than alcohol, the WHO also developed the

Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). This instrument has been validated for screeningof alcohol, but also for tobacco, cannabis, cocaine, amphetamine-like stimulants, inhalants, sedatives, hallucinogens, opioids, and other (unspecified) drugs (Humeniuk et al., 2008). The resulting score provided by the ASSIST is categorized in three levels of risk: low, moderate, high. The screening tool provides a maximum of eight items per substance. Not all items for a substance need to be answered if an individual does not use this particular substance.

There are other commonly used screening instruments utilized in the United States that are not known in Nicaragua. These include the Substance Abuse Subtle Screening Inventory (SASSI), the Michigan Alcoholism Screening Test (MAST), the Drug Abuse Screening Test (DAST), and the CAGE (Acronym for: Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers). All of these, except the MAST, are found in Spanish but none has been widely disseminated in Nicaragua. Other relevant information regarding these instruments includes the fact that the SASSI is one of the most widely used instruments in SUD treatment facilities because of addiction counselor preference to this instrument (Feldstein & Miller, 2007). Also, there is an importance to the DAST as it is one few instruments that are specific to drugs other than alcohol (Maisto, Carey, Carey, Gordon, & Gleason, 2000).

In relation to SUD assessments, the Addiction Severity Index (ASI) is one of the better known. It is utilized widely in research, as it is used in NIDA’s Clinical Trial and in clinical settings Networks (Samet et al., 2007). The format of the ASI is that of a semi-structured interview which focuses on diverse domains of life functioning, including medical, employment/support, alcohol and drug use, legal, family history, social, and the psychiatric domain. By the concentration in these domains, clinicians can better tailor interventions, areas of treatment, and referrals (Samet et al, 2007). The instrument is also found in Spanish but it has also not been widely disseminated in Nicaragua.

For a summary of the above mentioned screening and assessment instruments for SUD, see Table 1 below.

Table 1

Common screening and assessment instruments for SUD

Instrument / Description / Comments
Alcohol Use Disorders Identification Test (AUDIT) / - Screening for alcohol use
- 10 items
- Early identification of problem drinkers / - Developed by World Health Organization
- Available in Spanish for free
Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) / - Screening for alcohol, tobacco, cannabis, cocaine, amphetamine-like stimulants, inhalants, sedatives, hallucinogens, opioids, other drugs
- Maximum of 8 items per substance
- Classification of risk levels per substance: low, moderate, high / - Developed by World Health Organization
- Available in Spanish for free
Substance Abuse Subtle Screening Inventory (SASSI) / - Screening for SUD
- 93 items (adult version SASSI 3) / - Widely used in SUD treatment facilities
- Available in Spanish for purchase
Michigan Alcoholism Screening Test (MAST) / - Screening for alcohol use
- 25 item version and 10 item version (Brief MAST orbMAST) / - Not available in Spanish
Drug Abuse Screening Test (DAST) / - Screening for substance use other than alcohol
- 20 item version and 10 item version / - Available in Spanish
CAGE (Acronym for: Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers) / - Screening for alcohol use
- Version for screening other substance use CAGE-AID
- 4 items in both versions / - Available in Spanish
Addiction Severity Index (ASI) / - Semi-structured assessment interview
- Seven domains: medical, employment/support, alcohol and drug use, legal, family history, social, psychiatric / - Available in Spanish

Prevalence and Populations of Interest

SAMHSA sponsors a yearly survey called The National Survey on Drug Use and Health (NSDUH). To inform the public of its findings, SAMHSA published the “Results from the 2012National Survey on Drug Use and Health:Mental Health Findings” in 2013. In its introduction, the document states that “NSDUH is the primary source of statistical information on the use of illegal drugs,alcohol, and tobacco by the civilian, noninstitutionalized population of the United States aged 12 years or older” (SAMHSA, 2013, p. 3). Since 1971, the surveys have been conducted on a yearly basis and are administered in households throughout the United States (US). As a result of the 2012 survey and its 68,309 completed interviews, it was estimated that 22.2 million people 12 years or older fell under the category of substance abuse or dependence during the last year and based on DSM-IV criteria. This represented 8.5% of the 12 years and older population. The distribution of these 22.2 million people with SUD in relation to a broad category of substance use included 2.8 million people classified with abuse or dependence to both alcohol and illicit drugs (1.1%), 4.5 million people classified with abuse or dependence to only illicit drugs (1.7%), and 14.9 million people classified with abuse or dependence to only alcohol (5.7%)(SAMHSA, 2013).