Overview of Addiction
as a Medical Disease
by
Steven R. Lee, MD
Program Director
Young Adult Addiction Program
Ridgeview Institute
Goals of this lecture are to understand:
– The definition of Addiction
– Addiction as a medical disease with descriptions of each Use Disorder
– The standards of care for the treatment of Addiction
With an editorial –
The Interface of the Treatment of Chronic Pain with Addiction
Overview of Addiction as a Medical Illness
Table of Contents
What is Addiction? Page 1
Categories of Addiction - 4
Etiology - 4
Neuroanatomy of Addiction 6
Aspects of Addiction - 9
The Obsessive-Compulsive Drive - 9
Biological Conditioning - 10
Unmanageability - 10
PAWS - 11
Craving - 11
Use Disorder as a Medical Disease - 11
Specific Use Disorders - 12
Nicotine - 12
Alcohol - 14
Cannabis - 18
Opioid – 21
Harm Reduction Medication - 24
Naloxone - 25
Chronic Pain and Opioids – 25
Kratom - 28
Sedative/Hypnotics - 28
Stimulants - 31
Hallucinogen/Dissociatives - 32
Addiction Treatment - 34
Recovery - 35
Relapse - 35
Age - 36
Final Comments – 37
What is Addiction?
Addiction is a persistent, compulsive dependence on a substance or a behavior (i.e. gambling) even though the individual has experienced potentially harmful consequences while doing this substance or behavior. The compulsion to use a substance or to do a behavior comes from an involuntary biological drive located in the pleasure centers of the brain. Once an addict has had an experience that gives "pleasure" or relief, then the memory of this feeling is attached to the substance or behavior that caused it. This is called "biological conditioning". Addiction is a disorder of the brain's reward system.
"Pleasure", here, is defined as any feeling that gives someone a sense of well-being or relief from a bad feeling. Pleasure could be the ability to laugh when someone is actually depressed. It can also be an escape from a sense of dread when someone is under constant pressure or fear. Therefore, once the addict discovers that using a substance provides pleasure, they are starting a process of biological conditioning. Whenever they are in an unpleasant or boring situation, they know that by using that substance they can get immediate relief.
An addict generally uses their substance habitually at the same time of the day or in similar situations such as every happy hour, every evening, or every weekend. They develop a routine. After many repetitions, the brain develops an involuntary reaction to the initial stimulus (biological conditioning). When that time of the day or particular situation occurs, the addict has a very strong desire to use their substance. In fact, if they do not use their substance, they feel like something is wrong. If, in this routine, they find that their substance gives some sense of well-being or stress relief, then every time they are stressed, they feel that they have to have their substance to get relief.
Cigarette addiction is the best example of this type of biological conditioning. Let's say that whenever a smoker gets in their car, they have a cigarette. Assume that they do this multiple times over 6 months or longer. Then one day they get into their car and they do not have access to a cigarette. Driving in their car does not feel right without a cigarette. They can try to drive their car without a cigarette but they feel that something is wrong without that cigarette. Chances are they will go out of their way to find their brand of cigarettes. The same habitual reaction with cigarettes possibly develops after eating a meal, getting up in the morning, going to bed at night or dealing with a boring span of time. Smoking a cigarette has become, for the nicotine addict, a biological conditioned response to each of the above situations (stressors).
When the smoker realizes that they can get temporary relief of anxiety before a stressful event, such as taking a final examination in a college class, they have to have a cigarette to "calm down". For the cigarette addict, smoking is a compulsive act that has to be done to be able to deal with the anxiety of taking the test. This patterning would be the same for someone who is compulsively dependent on alcohol, marijuana, OxyContin or whatever other substance that is involved.
When an addict, who has been depressed for the past year, realizes that they are not depressed when they are using their substance, then their addiction has become, not just a recreational way to get high, but a “necessary” way to deal with their depression. This response will override any concerns about the consequences of using this substance (i.e. driving intoxicated, unsafe sex). They now have a functional as well as a recreational reason to use their substance.
A co-occurring disorder is a psychiatric disorder that occurs in someone who also has a Use Disorder (addiction). Those addicts who also have a psychiatric disorder have a dual-diagnosis. The psychiatric disorder can be caused by the Use Disorder or it may have been there before the Use Disorder. It is important to make this distinction because if the psychiatric disorder is a separate diagnosis, then without aggressive medical treatment of this psychiatric disorder, this will become the addict’s number one relapse risk factor. Also, after the addiction has improved, the treatment of the psychiatric disorder has to continue and medications cannot be stopped.
Also, addiction is not "caused by" an event or a situation. It is not the result of tragedy in someone's life. These situations may make an addiction worse, but they are not the cause of the addiction. There will be a discussion about the etiology of an addiction further in this paper.
Categories of Addiction
To simplify the present discussion, the focus will be about “substance” addictions also called Use Disorders. The behavioral addictions require a separate discussion since the treatment is different though these compulsive behaviors follow the same definition of addiction as presented above.
The behavioral addictions include:
· Gambling addiction
· Internet addiction including gaming and compulsively viewing pornography
· Sex addiction including compulsive masturbation, intercourse, or multiple sexual partners
· Eating Disorders including Compulsive Overeaters, Bulimia, and Anorexia
· Self-mutilation including cutting, burning, compulsive tattoos, and compulsive plastic surgery.
Etiology
Cognitive control, and particularly inhibitory control over behavior, is impaired in both addiction and Attention Deficit Hyperactivity Disorder (ADHD). Stimulus-driven behavioral responses that gives a reward tend to dominate one's behavior in an addiction.
The etiology of an addiction can be categorized into one of four categories:
· Genetic
· Epigenetic/Neural Plasticity
· Medical; Psychological; Environmental
· Polysubstance/Polybehavioral
50% of Use Disorders have a genetic (transcriptional) etiology. An alcoholic (someone who has an Alcohol Use Disorder) who has the variety of genes necessary to be an alcoholic can drink a pint to a fifth of alcohol a day and not die from alcohol toxicity. This is about 15% of the population. An individual who is “genetically prewired” to have an Opioid Use Disorder can take a Percocet and become mentally clear; not worry about what is wrong in their life; feel comfortable and gregarious in groups even with an anxiety disorder; and be motivated to finish the term paper that is due tomorrow. 10% of the population fit into this category.
In an epigenetic etiology, the addiction develops over time from chronically high levels of exposure to an addictive stimulus (e.g., morphine, cocaine, sexual intercourse, gambling, etc.) or from repeated behaviors. Epigenetics is the study, in the field of genetics, of cellular and physiological phenotypic (the expression of a gene such as black or blond hair) trait variations that are caused by external or environmental factors that switch genes on and off and affect how cells read genes.
We do not know the cause of Anorexia or Bulimia. Possibly under certain stressors, these individuals realize that losing weight or purging gives them some relief of their stress. Over time this obsessive-compulsive pattern becomes delusional (a false, fixed belief) and they cannot stop their behavior. Possibly this could be caused by some epigenetic process in the brain.
Epigenetics may be one etiology of some addictions. These alterations may or may not be heritable, although the use of the term "epigenetic" to describe processes that are not heritable is controversial. Unlike genetics based on changes to the DNA sequence (the genotype), the changes in gene expression or cellular phenotype of epigenetics have other causes.
Epigenetics may be part of the cause of the functional consequences of the addiction which may occur through altered neural plasticity in the brain. This may affect someone’s ability to think and to make decisions (lowered IQ) resulting in a decrease in functional productivity. Neural plasticity is how the function of a part of the brain (or of the function of an individual neuron) can change after repeated biological reconditioning that occurs through the use of a substance to obtain “pleasure” or of a behavior that is used to relieve stress.
In other words, when an addict repeatedly uses methamphetamine to get high or to deal with life, there may be changes in how parts of the brain functions through epigenetics and neural plasticity. You can see how the treatment of this addiction would require repetitive biological reconditioning for months to years to change the brain back to how it used to function (if this can be done at all).
The third etiology of addiction are those individuals who were not born with the genes that cause a specific substance Use Disorder or an addictive behavior. These individuals develop an addiction because of what is going on in their life. Possibly epigenetics is involved in these individuals that have genes that “switch on and off” because of a specific environment stimulus such that they develop an addiction.
Examples of this third category include three groups of people: chronic pain patients; psychiatric patients; and young adults. Patients with a chronic pain condition that is never adequately stabilized can abuse opioids. Even though they have overdosed in the past and almost died, they continue to abuse opioids trying to get pain relief because the pain is unbearable. They do not get a sense of wellbeing when they use the opioids like a “genetically prewired” opioid addict. Someone trying to get relief from their Major Depressive Disorder may try stimulants, especially methamphetamine or crack cocaine and become addicted to these substances because they get temporary relieve of their depression. Also, with these drugs, intense cravings to continue to use these substances develops in anyone using these drugs such that they are unable to stop using these substances even when their life is shattered because of their use.
Young Adults
About 25% of all young adults meet the criteria for a Use Disorder. Once they mature past 26 years old, this percentage drops to about 15%. This is a cultural phenomenon of young adults in this generation. Just a generation ago, it was expected that by 21 to 25 years old, a male should be married and have a job supporting a family. Females were expected to marry earlier and to have children. All of this has significantly changed so marriage is more around 28 years old and having children is 30 years old.
The “baby boomers” (children born after WWII) as a group have done well financially. As parents they want to give more to their children than they had as a child. These children, in general, have the best of everything and they believe that they are the privileged generation. They got the best education, cars, and clothes without having to work for these things on their own. Many young adults did not learn to appreciate what they have and feel entitled to more without having to work hard for it.
The spiritual void in young adults as a group is a set up for an addiction to become one of their gods. Young adults are usually not affiliated with the religions and the spiritual congregations of their parents. Science and common sense are their gods. The importance of the individual supersedes the importance of the group which leads to loneliness and separateness. For these young adults, having a spiritual experience is the high that the young adult obtains when they use a substance.
Just as we were producing the most knowledgeable and best educated men and women ever in the history of man (the young adult), there were no jobs available except for entry level jobs. Millennials with a master’s degree did not expect to start the work force working for Chick Fillet or as a gofer in an office in order to work their way up the ladder. Many of these individuals have ended up back at home with their parents in their old room. With too much time on their hands and no responsibilities of a mortgage or children, drinking, smoking marijuana, and doing other drugs becomes something to do.
The fourth etiology of people with a Use Disorder is a smaller percentage of the population who are capable of being addicted to any substance and any behavior that can alter their consciousness so that they feel “high”. They will abuse Benadryl, alcohol, opiates, stimulants, inhalants such as glue or paint, hallucinogens, dissociatives (i.e. PCP, ketamine), sex, gambling, eating, and many more. We are not sure if these addicts have a series of genes that make them this way or if this is part of their personality structure. The treatment of this group of addicts is long and requires many different approaches to deal with the complexity of their life style.