Addiction Today

I thought I was a bad boy who did stupid things. I got caught, charged, and convicted of possession of a CS with intent to sell. But I sweet-talked my social worker into letting me enroll in the Substance Treatment Program in jail. Seriously, though, I learned that I am not bad nor stupid. I have a mental health problem called addiction. It has something to do with my genes and brain. This helped explain some of my behavior and why I needed instant rewards like drugs, sex, or even crime to feel good. Lots of people are addicted to something. Chapter 1 looks at the many faces of addiction. It reviews the descriptive, diagnostic, and researched-based definitions of addiction; it discusses addiction severity and treatment intensity. The chapter also examines the incidence and prevalence of addiction.

The Faces of Addiction

We believe addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry, characterized by craving, loss of control, physical dependence, and tolerance Genetics, together with bio-psycho-social-spiritual factors, account for the likelihood one will develop an addiction or related disorder. Addiction jeopardizes the health and well-being of individuals, families, communities, even society itself. Addiction across the lifespan wears many faces.

• An infant born six weeks premature to a mother who is addicted to alcohol and cocaine.

• Two little girls playing dress-up and drawing red lines up their arms with lipstick to look like their mom: an IV drug user.

• Four high school seniors "high" on Adderall before taking their Scholastic Aptitude Tests (SATs).

• A 16-year old girl, "dumped" by her 25-year old boyfriend, admitted to the psychiatric unit after ingesting a quart of vodka and 50 Tylenol.

• "What do you have: gold or green OCs?" asks a teen to a street drug dealer.

• A young adult dead of cardiac arrest after a 40-hour marathon session of Diablo 3, an action role-playing game that features elements of the hack and slash, and dungeon crawl genres.

• An evening TV news anchor and sports gambler praying for a long commercial so he can check scores on his cell phone.

• A homeless soldier with four deployments to Iraq and Afghanistan admitted to a Veterans Administration (VA) Hospital with delirium tremens (DTs).

• A board-certified oncologist dismissed from his position at a prestigious University Hospital facing loss of license and incarceration for selling pain prescriptions to finance his gambling addiction.

• A hospice nurse, employee of the year, who has been suspended from work because she diverted narcotics to self-medicate her back pain.

• An executive vice president of a major insurance company admitted to a locked psychiatric ward for self-inflicted gun shots wounds, a botched suicide attempt, related to embezzlement to pay gambling debts.

• A retired electric utility worker who drinks himself into a stupor every evening to cope with his depression after the recent death of his wife.

• A 78-year old woman visiting her daughter and family who gets up during the night, falls, and breaks a hip. Her daughter discovers prescribed medications for Percocet, Xanax, and Ambien in her purse.

What is Addiction?

What do we really mean by addiction? Addiction is a broad, evolving construct that reflects a persistent, recurrent, maladaptive pattern of substance use, gambling, or other behavior that results in adverse consequences for self and others and can lead to clinically significant distress, marked impairment, or death. Substance use includes many legal products such alcohol, nicotine, prescription medications, over-the-counter (OTC) drugs, as well as a host of herbal and natural products that have brain altering properties. Marijuana, cocaine, methamphetamine, heroin, and "designer" drugs make up popular illicit drugs. Many household products like solvents, sprays, or glue have psychoactive effects, especially when inhaled.

Obsessive/compulsive/impulsive behaviors that can become addictive include gambling, eating, sex, and shopping; internet use and the cell phone; internet gaming and video games; and many more. Several terms describe gambling addiction—pathological gambling, compulsive gambling, problem gambling, or gambling disorder. Cross addiction or replacement addiction is common with substance use and other addictive behaviors.

Definitions of addiction are descriptive, diagnostic, and research-based. Many people in recovery, together with addiction professionals, consider addiction as a bio-psycho-social disorder; Howard J. Shaffer, a recognized addiction scholar, describes an addiction syndrome. The American Psychiatric Association and the World Health Organization offer diagnostic definitions respectively in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). Increasingly, definitions of addiction reflect basic research, for example the work of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute of Drug Abuse (NIDA), as well as the genetic research of Kenneth Blum and colleagues and the idea of a reward deficiency syndrome (RDS). The American Society of Addiction Medicine (ASAM) defines addiction as a brain-based chronic disease.

Addiction is a Bio-psycho-social Disorder

Addiction is a bio-psycho-social disorder in etiology, expression, treatment, and recovery. A bio-psycho-social perspective includes and integrates aspects of biological, psychological, and socio-cultural theories of addiction, reflecting a holistic view of individuals. Today, assessment, diagnosis, treatment planning, intervention, evaluation, and related documentation of addiction address bio-psycho-social variables. Best addiction practice models as well as program accreditation standards and criteria reflect a bio-psycho-social model of addiction.

The Addiction Syndrome

Howard J. Shaffer, editor of American Psychological Association publication Addiction Syndrome Handbook: Volume 1 Foundations, Influences, and Expressions of Addiction; Volume 2 Recovery, Prevention, and Other Issues (2012), has long held the idea of an addiction syndrome which recognizes the similarities in etiology, expression, and treatment response among different addictive disorders. Leading addiction scholars embrace the idea of an addiction syndrome model and write extensively about addiction from this perspective in these volumes.

American Psychiatric Association (APA)

For many years, addiction professionals have used the Diagnostic and Statistical Manuals developed by the American Psychiatric Association to diagnose substance-related disorders, pathological gambling, and other mental disorders: the widely-used DSM-IV-TR, published in 2000. Both general and specific changes in the DSM-5, published in 2013, affect addiction diagnoses. First, the multi-axial system has been removed. Second, the DSM-5 (2013) does not differentiate between substance abuse and substance dependence; instead, it suggests a continuum for substance-use disorders using the number of criteria to determine mild to moderate to severe problems. Substance-related disorders encompass ten separate classes of drugs including alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics, or anxiolytics; stimulants; tobacco; and other substances. Craving has been added as a diagnostic criterion for substance use disorders. Pathological gambling has been reclassified from an impulse-control disorder in the DSM-IV-TR to the category Substance-Related and Addictive Disorders in the DSM-5. Other areas of interest in the DSM-5 that relate to addiction include diagnostic criteria for binge-eating disorder and the emergence of internet gaming disorder. Although many addiction professionals work with individuals with compulsive sexual behaviors, sexual addiction or hypersexual disorder was rejected for inclusion as a disorder in the DSM-5.

World Health Association (WHO)

The official diagnostic system in the United States is based on the International Classification of Diseases and Related Health Problems (ICD) of the World Health Organization (WHO). The ICD is the global standard for diagnostic classification, health reporting, and clinical applications of mental disorders and other medical conditions.

Major mental health providers and many insurance companies use the ICD-10-CM, introduced in 2013, for third-party billing and reporting. At present, there are differences between the ICD-10-CM and the DSM-5. For example, the ICD includes codes for substance abuse and substance dependence. As stated above, the DSM-5 eliminates this difference and suggests a continuum for substance use disorders using a number of criteria to diagnose the problem as mild, moderate, or severe. It is important that people in recovery, who may need addiction services, and addiction professionals keep abreast of development of the ICD-11, expected in 2015, especially similarities or differences with the DSM-5 in diagnostic codes for substance-related and addictive disorders. Note: the DSM-5 cross references the ICD codes.

National Institute of Health (NIH)

The National Institute of Health (NIH), part of the U.S. Department of Health and Human Services (HHS) is the principal government agency for medical research. Two of its 27 Institutes and Centers focus on addiction research and its application to prevention, treatment, and recovery.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA), established in 1970, defines alcoholism as a disease that includes symptoms such as:

• Craving—a strong need, or urge, to drink.

• Loss of control—not being able to stop drinking once drinking has begun.

• Physical dependence—withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety after stopping drinking.

• Tolerance—the need to drink greater amounts of alcohol to feel the same effect.

NIAAA recognizes the enormous health, social, and economic consequences of the misuse of alcohol, alcoholism, and alcohol-related problems across the lifespan. NIAAA funds programs to prevent children and adolescents from beginning and continuing to drink alcohol. NIAAA supports basic research in genetics, neuroscience, epidemiology as well as many clinical studies to improve treatment. Initiatives include a fetal alcohol spectrum disorders program; an underage and college drinking program; medication development; the combined pharmacotherapies and behavioral intervention study (COMBINE); and the collaborative study on the genetics of alcoholism, designed to identify genes that affect the risk for alcohol dependence and alcohol-related behaviors (COGA).

The National Institute of Drug Abuse (NIDA), established in 1974, defines addiction as a chronic brain disorder characterized by the loss of control of drug-taking behavior, despite adverse health, social, or legal consequences of continued drug use. Addiction is characterized by relapses during recovery. NIDA's mission is to lead the Nation in bringing the power of science to bear on drug abuse and addiction. This charge has two critical components. The first is the strategic support and conduct of research across a broad range of disciplines. The second is ensuring the rapid and effective dissemination and use of the results of that research to improve prevention, treatment, and policy as they relate to drug abuse and addiction. NIDA works with a variety of government and private-sector institutions to further scientific knowledge about drug abuse and addiction.

NIAAA and NIDA research suggests that genetics, together with neurobiology and neurochemistry studies of the brain, demonstrates a predisposition toward addiction as well as a brain basis in its appearance. Other bio-psycho-social, even spiritual factors contribute to the manifestation of addiction. Neuro-scientific research also helps explain cognitive and emotional changes associated with addiction as well as behavioral manifestations and complications of addiction. Identified brain areas associated with reward, craving, stress, and cues for addiction increase the risk for relapse.

Reward Deficiency Syndrome (RDS)

Much of the research on reward deficiency syndrome (RDS) began with Dr. Kenneth Blum, a researcher in neuro-psychopharmacology and genetics. His 1990 study with Ernest Nobel, the former director of the National Institute on Alcohol Abuse and Alcoholism, published in the American Journal of the American Medical Association was titled, "Allelic Association of Human Dopamine D2 Receptor Gene in Alcoholism." Although the press has called his finding the "alcoholic gene," Blum believed his work to be of broader scope, calling this gene a "reward gene" which covers other addictive behaviors including drug addiction, smoking, overeating, and pathological gambling.

Blum and colleagues expanded their work and later described a "Reward Deficiency Syndrome (American Scientist, 1996) and more specifically, the "Reward Deficiency Syndrome: A Biogenetic Model for the Diagnosis and Treatment of Impulsive, Addictive, and Compulsive Behaviors" (Journal of Psychoactive Drugs, 2000). In 2005, Reuter and associates demonstrated that pathological gambling is linked to reduced activation of the mesolimbic reward system.

Although smoking rates have declined in the United States, adult smoking rates seem stuck or stalled at 20% of the population. Because Cytochrome P450 2A6 (CYP2A6) gene variants are known to metabolize nicotine and possibly influence nicotine dependence treatment, Akrodou (2014) studied their roles in the treatment of nicotine dependence. He suggests ways gene counseling and nicotine gene therapy can help individualize nicotine clinical treatment to increase smoking quit rates.

Today, reward deficiency syndrome (RDS) is considered as a gene-related condition characterized by compulsive, addictive, and impulsive behaviors. These repetitive behaviors contribute to a host of ailments such as drug addiction, adolescent/adult obesity, ADHD, smoking/smokeless tobacco use, pathological gambling, deviant sex addiction, excessive internet gaming, juvenile delinquency, pathological aggression, chronic pain (fibromyalgia) and other behavioral disorders. Individuals diagnosed with RDS are known to possess specific gene-phenotype variants that can be identified through genetic testing determining both resilience and vulnerability.

Genetic research supports the observation that "addiction runs in families," the heritability factor, and provides a basis for the widely accepted role genetics play in the etiology of addition. Diagnostic tests are being developed to determine individual genetic addiction risk. Genetic research lays the groundwork for current definitions of addiction.

American Society of Addiction Medicine (ASAM)

In August 2011, the American Society of Addiction (ASAM) advanced a definition of addiction as 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, as reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. According to ASAM:

Addiction is characterized by a. inability to consistently abstain; b. impairment in behavioral control; c. craving or increased "hunger" for drugs or rewarding experiences; d. diminished recognition of significant problems with one's behaviors and interpersonal relationships; and e. a dysfunctional emotional response.

Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. However, as with other chronic diseases, addiction can be managed effectively.

Addiction Severity and Treatment Intensity

Some of us are sicker than others. Recovering people and addiction professionals are familiar with the concepts addiction severity and treatment intensity. Diagnosis reflects addiction severity; services and level of care and suggest treatment intensity. A little history of these concepts follows. We need to consider addiction severity and management intensity when we manage addiction.

Addiction Severity

People with addiction informally talk about addiction severity:

• I hit bottom.

• I never shared needles.

• I don't work the streets.

• All kids steal from their parents; I needed the money to pay my bookies at school.

• I lost my job; my wife left me, and I got arrested for possession.

Most individuals usually minimize addiction severity and rarely seek treatment early in the disease process. Usually adverse consequences or some crisis precipitate a quest for professional help. Many of us were high functioning alcoholics/addicts (HAFs) who "functioned" at home, school, or work while we drank, used, or gambled; meanwhile, our addiction severity increased. We often call this progression.