Transcript Disease Concept - Congresos en el Pacífico

I. Philosophies (Models) of
Addiction
II. History of Addiction:
Evolution of the Disease
Concept
III. Disease Concept
William J. Udrow Jr. PsyD, LCP, CRADC,
MISA I, PCGC
Ecuador: 2012
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Models of Addiction
Moral Model: Blames the drug user for lack of moral character
and lack of self-control. An Egyptian wrier admonished his
drunken friend with the slightly contemptuous “thou art like a
little child.” Until the twentieth century addicted individuals were
weak-willed, lazy, or immoral. (Ray & Ksir 2002)
The Temperance and Prohibition movements were based on
moral model. As Late as 1974, the New Hampshire Christian
Civic League devoted an entire issue of its monthly newspaper
to a passionate argument against the idea that alcoholism is a
disease. In its view the disease concept gives reprieve to the
“odious alcohol sinner.” (Kinny, J. 2000)
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Models of Addiction
Disease Model: Drug abuser requires medical
treatment rather than moral exhortation or punishment.
This requires a team of professionals: doctors,
counselors, psychologists, social workers….
In1993, The American Society of Additive Medicine:
“Alcoholism is a primary, chronic disease with genetic,
psychological and environmental factors influencing its
development and manifestations. The disease is often
progressive and fatal.” (Kinny, J. 2000)
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Models of Addiction
Physical Dependence Model: sometimes called the
withdrawal avoidance model, is based on the unpleasant
withdrawal symptoms that occur when a person stops
taking a drug that he or she has used frequently.
In the 1960 a series of experiments in laboratory
monkeys and rats were given intravenous catheters
connected to a motorized syringes and controlling
equipment so that pressing a lever would produce a
single brief injection of morphine, a narcotic very similar
to heroin. The monkeys would experience withdrawal
symptoms when no longer allowed access to morphine.
Thus, the monkeys had made “true” drug addicts of
themselves.
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Models of Addiction
Positive Reward Model: The positive reward model of
addictive behavior arose from animal research that was
started in the 1950’s. Animals would furiously press a lever
to self-administer cocaine and other stimulants that do not
produce marked withdrawal symptoms.
Drugs such as amphetamines and cocaine could easily be
used as reinforces in laboratory experiments and they were
known to produce strong psychological dependence in
humans. (Ray & Ksir 2002)
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Models of Addiction
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The Evolution/History:
Disease Concept
Sin or Moral Model: Societies have come to grips with
substance problems in a variety of ways. The Greek
word for drunk, for example, means literally to
“misbehave at the wine”. Noah’s drunkenness was not
looked on kindly by his children. (Kinny, J. 2000)
“Drunkenness excites the stupid to a fury to his own
harm, it reduces his strength while leading to blows” (Bible,
Ecclesiasticus 31)
The Koran, the holy book of Islam refers to the drinking
of wine to be frowned upon. (Inaba & Cohen, 2000).
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The Evolution/History:
Disease Concept
In America drinking in the colonies was largely a family
affair and remained so until the beginning of the
nineteenth century. Around the 1830’s Dr. Samuel
Woodward and Dr. Eli Todd, did not see inebriates in the
same class with criminals, the indigent, or the insane.
Their efforts were taking place against the background of
the temperance movement.
The Washington Temperance Society was organized in
much the same ways as the ordinary temperance groups
except in was founded on the basis of one drunkard
helping another.
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The Evolution/History:
Disease Concept
Early Classifications:
Dr. Benjamin Rush, physician, medical educator,
patriot, reformer and the first U.S. Surgeon
General. He published the first American treaties
on alcoholism in 1804-An Inquiry into the Effects
of Ardent Spirits on the Human Body and Mind. It
was a collection of current attitudes toward abuse
of alcohol.
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The Evolution/History:
Disease Concept
Temperance and Prohibition: The temperance
movement coincided with the rise of social
consciousness, a belief in the efficacy of law to resolve
human problems. Temperance (temp a rance) the idea
that people should drink beer or wine in moderation but
drink no hard liquor. (Ray & Ksir 2002)
In August 1917, the U. S. Senate adopted a resolution
that submitted the national prohibition amendment to the
states and in January 1920 a national prohibition was
stated in the amendment. Soon people were buying
and selling alcohol illegally: bathtub gin. Organized
crime flourished.
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The Evolution/History:
Disease Concept
1940’s, Alcoholics Anonymous: The concept of Dr.
William Silkworth, one of AA’s early friends is sometime
cited by AA members:…”an obsession of the mind and
an allergy of the body.” (Alcoholics Anonymous, 2001)
AA was having mores success in treating people with
alcohol problems than was any other group. AA grew
with a current estimated membership of over two million
in both America and abroad. Lawyers, business people,
teachers, people from every sector of society began to
recover. (Kinny, J. 2000)
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The Evolution/History:
Disease Concept
1952 Disease Concept Introduced: Dr. Jellinek charted
the signs and symptoms associated with alcohol
addiction. Dr. Jellinek was a pioneer in modern alcohol
studies. “Alcoholism is any use of alcoholic beverages
that causes any damage to individual or to society or
both.” (Kinny, J. 2000)
1970 NIAAA: Senator Harold Hughes, himself a
recovering person established the “bill of rights” for those
with alcoholism. This bill the Comprehensive Alcohol
Abuse and Alcoholism Prevention, Treatment, and
Rehabilitation Act was a protection against discrimination
in hiring recovering alcoholics.
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Dr. Jellinek’s Phase of
Addiction
Prealcoholic Phase: According to Jellinek’s
formulation, the individual’s use of alcohol/drug using is
socially motivated. The individual may soon experience
psychological relief in the drinking/drug using situation.
He or she may not have other ways to manage tension
and stress. Therefore, the drinking/drug using behavior
may become the standard means of handling tension
and stress.
This phase can extend for several months to 2 or more
years. An increase in tolerance gradually develops.
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Dr. Jellinek’s Phase of
Addiction
Prodromal Phase (Experimental): This phase means
warning or signaling disease. Noted by the beginning of
*Blackout (amnesia-like periods). During blackouts the
person seems to be functioning normally but later has no
memory of what happened (neurological damage). This
phase includes sneaking extra drinking/using before or
during parties, gulping the first drink or two and guilt
about the drinking/drug using behavior.
This period can last from 6 months to 4 or 5 years
depending on the persons circumstances. (Kinny, J. 2000)
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Dr. Jellinek’s Phase of
Addiction
Crucial Phase: The key symptom that ushers in this
phase is loss of control. The person can no longer
control the amount consumed after taking the first
drink/drug. The drinking and drug using is now clearly
different. It requires explanation, so rationalization,
excuses and lying begin.
Deliberate periods of abstinence; changing
drinking/using patterns; or geographical changes to
escape/avoid; job changes occur. Life had become
alcohol/drug centered. Family life and friendships
deteriorate. (Kinny, J. 2000)
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Dr. Jellinek’s Phase of
Addiction
Chronic Phase: Intoxication is an almost daily, day-long
phenomenon. The individual may also go to
places/dives and drink and/or use drugs with persons
outside his/her normal peer group. When the drug of
choice is unavailable, other substitutions are the
alternative.
During this phase, marked physical changes occur.
Tolerance for alcohol/drugs drops sharply. The longused excuses are revealed as just that----excuses.
Drinking and/or using is likely to continue because the
person can not imagine a way out (feelings of
hopelessness).
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ADDICTION AS A
DISEASE
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CHARACTERISTICS OF
DEPENDENCE
Let’s look at four important dimensions of addiction.
Addiction is:
Chronic
Primary
Progressive
Incurable
Let’s review each concept in turn so that we know what this
means.
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1. ADDICTION IS CHRONIC
A disorder that is CHRONIC continues for a long time. The
opposite of chronic is “acute,” which means relatively sudden
and short. Let’s look at other examples of chronic vs. acute
disorders.
Acute disorders
FLU
Food poisoning
Concussion
Chronic disorders
Diabetes
Hypertension
Epilepsy
Notice that “acute” disorders are treated once and they’re gone.
“Chronic” disorders are managed, not cured.
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2. ADDICTION IS PRIMARY
A disorder that is PRIMARY means that it is not the “result”
of something else. It is a disorder in its own right, requiring
specific treatment.
For example, a man may start drinking to control the painful
feelings of depression. However, when that man becomes
an alcoholic (addicted to alcohol), he now has a separate
and “primary” disorder that needs treatment.
Treating the depression does not mean the alcoholism will
also go away.
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3. ADDICTION IS PROGRESSIVE
A disorder that is PROGRESSIVE tends to get worse over
time.
With drug addiction, we see that the consequences of the
addiction tend to worsen over time. One important
mechanism of this progressive quality is tolerance, which
we’ve discussed.
The development of tolerance tends to ensure that a person
has to get more, spend more, hide more, and use more over
time.
Later we’ll look at some of the particular consequences of
progression, including medical problems.
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4. ADDICTION IS INCURABLE
We say that addiction is INCURABLE because the
biological changes involved in addiction tend to be
permanent.
As a result, an addict will never be able to safely use the
drug of abuse (or any other drugs of abuse). An alcoholic
will never be able to “drink normally.”
Likewise, a cocaine addict will never be safe using
stimulating drugs (for example, ephedra, which is an overthe-counter stimulant). A person addicted to one drug can
easily switch over the another drug and still be an addict.
This is called cross-addiction (more on this later).
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BIOLOGICAL BASES: THE
REWARD CENTER
First let’s take a look at a part of
the human brain which has
been called the “reward center”
deep in the brain. This area
includes specialized neural
pathways which process
experience of pleasure.
Clinical
File
3 elements of the
reward center:
–Medical forebrain
bundle
–Nucleus accumbens
–Ventral tegmental
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BIOLOGICAL BASES: THE
REWARD CENTER
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BIOLOGICAL BASES: THE
REWARD CENTER
The reward center seems to process many experiences
of pleasure, such as eating and sex. Experimental rats
trained to stimulate their own reward centers with electric
switches have been known to press on the switches
thousands of times per hour! They neglect all other
activities in order to keep stimulating themselves. (11)
Does this kind of behavior sound familiar?
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BIOLOGICAL BASES:
THE REWARD CENTER
Now, you may not be surprised to learn that many drugs of
abuse stimulate the reward centers. As a result using
mind-altering drugs is pleasurable. The addict is almost
like one of those experimental rats, stimulating itself again
and again, neglecting anything else.
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THE PROBLEM IS THIS: WHILE THE DRUGS
ARE STIMULATING ALL THIS PLEASURE,
THEY ALSO CAUSE PERMANENT CHANGES.
Repeated use of certain drugs of abuse can result in
depletion of brain chemicals that allow the experience of
pleasure.
What happens next is this: more and more of the drug
becomes necessary to generate pleasure, and other
sources of pleasure lose their effects. Eventually, the
addict can’t even feel just normal without the drug.
As a result, the addict needs the drug to feel normal, and
without it, they feel bad! It’s no longer a matter of
pleasure… it’s a matter of avoiding pain. This is the
mechanism for tolerance.
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SPOTLIGHT: DOPAMINE
The brain chemicals that
help generate pleasure are
called dopamine, a brain
chemical belonging to a
group called
neurotransmitters.
For example, both alcohol
and heroin result in a buildup of dopamine, resulting in
(temporary) pleasure.
Neurotransmitter
A “messenger
chemical” in the
brain, which have
many different
effects.
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NEUROADAPTATION
As we discussed above, the brain adapts to this higher
level of dopamine in the system. It’s almost as if the body
tries to “normalize” the new levels of pleasure by “raising
the bar” to experience pleasure. These changes are
referred to as neuroadaptation.
In other words, neuroadaptation means that it gets harder
and harder to experience pleasure as you use more drugs.
Addicts get the point that only their drug…in everincreasing amounts…makes them feel good. (12)
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THE TRAP OF ADDICTION
In a sense, get trapped by their own drug. They started
using it to feel good, but end up needing it just to avoid
feeling bad.
But can’t the addict
ever go back to normal?
Even if he quits?
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THE TRAP OF ADDICTION
(CONTINUED)
Addicts can learn to experience pleasure in ways other
than using. Unfortunately, research and clinical experience
shows that the biological changes are permanent.
This is why addiction is considered incurable, as we
discussed before.
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IMPLICATIONS OF ADDICTION
We’ve seen now how repeated drug use causes permanent
biological changes in the brain. An important implication
of the changes is this:
Once an addict, always an addict.
An addict can never assume it’s safe to resume using
addictive drugs. Using even once will get the addict
back to Square One. 12-Step programs call this “waking
the tiger.”
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References
Alcoholics Anonymous Big Book 4th Edition (2001). New York :Alcoholics
Anonymous World Services, Inc.
Inaba, S. D. & Cohen, E. W. (2000). Uppers, Downers, All Arounders:
Physical and Mental Effects of Psychoactive Drugs. Oregon: CNS
Publications, Inc.
Kinny, J. (2000). Loosening the Grip: A Handbook of Alcohol Information.
United States: The McGraw-Hill Companies, Inc.
Ray, O. & Ksir, C. (2002). Drugs, Society and Human Behavior: New York,
New York: The McGraw-Hill Companies, Inc
The Bible, Ecclesiasticus, 27.
The Discovering Alcoholic. (September 6, 2012). Update on the Jellinek
Curve:
http://discoveringalcoholic.com/alcoholism/update-on-the-jellinekcurve
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