Transcript DEBATE: Heyman

AMERSA “spicy” debate: Is Addiction
REALLY Like other Chronic Illnesses?
“Yes”: it has a biological basis
“No”: it is typically not chronic
“No”: it is not like illness because the factors that
influence drug use in addicts have little or no direct
influence on disease symptoms
Evidence:
– Everyday speech (idioms)
– Research findings
Everyday expressions that distinguish
addiction from chronic illnesses
“kicking the habit”
“going cold turkey”
Is addiction a chronic disorder?
These findings
are derived from
Remission in Representative Samples of
Dependent (Addicted) Drug Users (N approx. 2700)
80%
National
Epidemiological
Survey of
Alcohol and
Related
Syndromes
(NIAAA, DHHS)
60%
40%
20%
NE
SA
R
C
20
01
-2
00
2
20
01
-0
3
NC
S
19
90
-9
2
0%
NC
S
% in Remission
100%
National
Comorbidity
Surveys (NIMH,
NIDA) and
Remission % for Opiate Addiction:
"Prospective, Intensive" Studies
80%
60%
40%
20%
S
In t Lo
ne u
r C is
it y
0%
% of "Cases" Who No Longer
Met Criteria for Drug Dependence
100%
80%
60%
40%
20%
-0
2
3
01
-0
20
01
20
C
S
AR
C
N
ES
N
C
S
19
90
-9
2
0%
N
% Cases Remitted
Vi
e
Ve tna
ts m
% in Remission
100%
Why do we say that addiction is a “chronic”
disorder, when the data say otherwise?
Our understanding of addiction is based largely
on clinical experience
But most addicts do not seek treatment
Hypotheses:
– Drug use persists longer in clinic populations
– Clinic populations tend to have additional problems
that interfere with recovery
Is addiction like other illnesses?
A distinguishing feature of illnesses is that the symptoms
are involuntary
How to measure “voluntariness”?
Behaviors vary in the degree to which they are susceptible
to the influence of ideas, values, costs and benefits
(consequences). One possible continuum:
– reflexes
– satisfying an essential biological urge (hunger, thirst)
– whether to play tennis, read a novel or write a new paper
Thus, we can test whether addiction is
like other illnesses
Do ideas, values, costs, and benefits influence drug use
in addicts?
– That so many addicts quit on their own suggests “yes”
Voluntary behavior is not a synonym for free will
We are investigating a causal relationship
Information and
Smoking
Per Capita Cigarette
Consumption*
4500
First Surgeon
General's Report
4000
3500
3000
2500
First Cancer Alert
2000
Approx.
1500
1000
The Depression
500
1920 1930 1940 1950 1960 1970 1980 1990 2000
Year
* Fiore et al., 1993, Natural Hist & Epid of Tobacco Use...,
Does expert
opinion
(information)
influence drug
use?
Differences in Likelihood of Psychiatric Disorders
as Function of Differences in Year of Birth (ECA)
10%
on
si
ep
re
s
0%
Psychiatric Disorder
Historical influences and addiction
Sc
hi
zo
D
C
O
ni
c
Pa
M
an
ia
2%
An
4%
xie
ty
6%
D
8%
Af
f
D ect
is iv
or e
de
r
Likelihood
12%
Born 1917-1936
Born 1952-1963,
Ab
D us
ep e/
14%
0.16
*National Comorbidity Study
0.12
0.08
0.04
Year of Birth
19
66
-1
97
5
19
56
-1
96
5
19
46
-1
95
5
0.00
19
36
-1
94
5
Probability that Drug Use Leads
to Dependence by Age 20
Historical Variation in the Transition
From Drug Use to Drug Dependence*
Choice-based
voucher treatment: Cocaine
Incentives,
dependent
users
prosocial
% Cocaine Abstinent
activities, and
drug use in
cocaine addicts
100%
80%
Vouchers
Counseling
Higgins et al.
1995
60%
40%
20%
0%
6
9
12
Months Since Treatment
Summary:
Most addicts stop using drugs and usually do so without
professional assistance
The primary factors that bring drug use to a halt are those that
influence choice: familial concerns, economics, values
We cannot make a similar summary for “chronic illnesses”
Choice is critical to the distinction between disease and nondisease.
Thus, addiction, is not “Really like chronic diseases”
This doesn’t make addiction less of a problem, but it does
help us frame the problem
Current Cases as Function of Age
NCS Survey, 1990 - 92
ECA Survey, 1980-1984
% "Current" Cases
5%
4%
Abuse & Dependence
3%
2%
1%
Dependence Only
0%
20
30
40
Age
50
90%
ECA Survey, 1981-198
NESARC Survey, 2001-2002
60%
45%
30%
Type Drug
s
im
St
O
pi
od
s
15%
M
ar
ij
% Remission
75%
Remission
as %
a function
whether
Remission
for Heroinof
Addiction
Asclinic
a
Function
of How
Subjects Were
Selected
For Study
treatment
determined
subject
recruitment
Random Selection, Independent
of Treatment Status
80%
60%
Treatment Follow
Up Study
40%
20%
S
& tep
C he
ot n
tre s
ll
S
In t Lo
ne u
r C is
ity
V
V e ie
ts tna
in m
Tx
0%
Vi
e
Ve tna
ts m
% in Remission
100%
80%
Drug Depend
& Tx Seeking
70%
60%
50%
40%
Drug Depend &
Not Tx Seeking
NotDrug
Dependent
30%
20%
10%
Tx
Se
Tx ek
Se Op
ek ia
Tx Co te
Se ca
ek ine
N An
y
ot
Tx Dr
An g
N
ot yD
r
D
ru g
gD
ep
Freq of Additional
Psych Disorders
Treatment Seeking is Corrrelated
With Higher Comorbidity*
* Regier et al., 1990; Rounsaville et al., 1991
Religious Values and Heredity
0.2
0.0
Identical Twins
Fraternal Twins
R
m
Va
lu
es
R
el
ig
io
us
en
ta
lis
Fu
nd
am
el
ig
io
us
In
te
re
st
s
-0.2
R
el
ig
io
us
Correlation
0.4
Vietnam Vets In Treatment
% Relapsed After
Treatment
80%
70%
60%
50%
40%
30%
20%
10%
0%
0
10
20
30
40
50
Weeks Since Release
*Robins, 1993
Relapse Following Treatment
(Resumption of Drug Use)
% Relapse
75%
60%
Hunt et al., 1971
45%
Alcohol
Smoking
Heroin
30%
15%
0
2
4
6
8
Months
10
12
Suspended
MDs
and Pilots:Use
Random
Clinic Success
Stories:Drug
CouldDrug
LeadTests
and Threat of
Loss of(MDs
License
to Loss of Professional
License
and Pilots)
% Abstinent
100%
No Monitoring
80%
60%
40%
20%
0%
1
2a
2b
3
4
5
6
7
Study Code, See Footnote n
Setting Influences Opiate Use& Addiction:
Same Individuals--Different Settings
In Vietnam
40%
30%
20%
Pre-Vietnam
(USA-Home)
Back
in the
USA
10%
te
d
Ad
di
c
te
d
Ad
di
c
se
U
te
d
Ad
di
c
se
0%
U
Percentage Use
and Addiction
50%
Remission Rates for Psychiatric Disorders
NCS (1990-1992)
60%
All psychiatric disorders,
not counting drug and
alcohol dependence.
45%
30%
Al
lD
is
U
or
de
rs
se
15%
Su
bs
t
% in Remission
75%
Do all psych
disorders
have high
remission
rates?
80%
Ever Used
Ever Dependent
60%
40%
20%
ga
re
tte
s
Al
co
O
ho
th
l
er
Dr
ug
s
M
ar
iju
an
a
Co
ca
Am
in
ph
e
et
am
in
e
He
ro
in
0%
Ci
% of US Population,
National Comorbidity Study
100%
Addictive Drugs: Experimentation
and Dependence
What accounts
for these
differences?
Common themes in biographical
accounts:
Stories are laced with explicit and implicit values:
–
–
–
–
“I wasn’t put on earth to be an addict”
“I wanted my parents to be proud of me again”
“I didn’t want to embarrass my children”
“I was sick of the hassles”
Ordinary concerns:
–
–
–
–
Fear of arrest
Finances and occupational concerns
Familial relations
Taking stock: “hitting bottom,” “conscious weighing of costs and
benefits”
% PERSONS REPORTING
COCAINE USE PAST MONTH
Age 12-17
Age 18-25
26+
8%
6%
4%
2%
YEAR
TABLE 2.10, 2.11, & 2.12 NHSDA
MAIN FINDINGS 1990
1992
1990
1988
1985
1982
1979
1977
1976
1974
0%
1972
% National Population
Household Survey
10%