Integrating Psychological and Pharmacological Treatments for Addictive Disorders

An Evidence-Based Guide

James MacKillop, George A. Kenna, Lorenzo Leggio, Lara A. Ray, James MacKillop, George A. Kenna, Lorenzo Leggio, Lara A. Ray

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781317405856
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Integrating Psychological and Pharmacological Treatments for Addictive Disorders distills the complex literature on addiction, offering a curated toolbox of integrated pharmacological and psychotherapeutic treatments in chapters authored by leading experts. Introductory chapters on the epidemiology, etiology, and fundamentals of addiction treatment provide a concise overview of the state of the field. Subsequent chapters then focus on the treatment of specific substance use disorders and on gambling disorder. Finally, a chapter on the treatment of addiction in primary care addresses the opportunities for clinical care in non-specialist outpatient settings. Physicians, psychologists, social workers, and other mental health professionals will come away from the book with an essential understanding of evidence-based practice in treating addiction and the scientific foundations of those approaches.

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Part I
Epidemiology, Etiology, and Treatment of Addictive Disorders

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Chapter 1
The Epidemiology and Public Health Burden of Addictive Disorders

Kevin D. Shield, Sameer Imtiaz, Charlotte Probst, and Jürgen Rehm

Competing interests: The authors have declared that no competing interests exist

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Scope of the Chapter

The use of addictive substances and engagement in addictive behaviors have taken place since the beginning of recorded history, are postulated to have contributed to human evolution [1], and occur worldwide. Furthermore, compulsive and addictive behaviors that are characterized by an impulse, drive, or temptation to perform the behaviors are also hypothesized to be the result of evolutionary pressures [2]. It is theorized that people engage in the use of addictive substances and in addictive behaviors for pleasure, to feel better, as a social lubricant, out of curiosity, and “because others are doing it” [3]. After initiating substance use or engaging in an addictive behavior, an individual’s vulnerability to becoming addicted to the substance or behavior is dependent on numerous complex and interacting genetic and environmental factors [4]. The harms caused by the use of addictive substances are dependent on the substance used, as well as the amount and patterns of substance use [5, 6].

The following chapter provides an overview of the epidemiology (mainly prevalence) and burden of disease associated with the use of alcohol, tobacco, and illicit drugs, and the use disorders associated with these substances. Current medical definitions of addictive behaviors (see the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 [7]) include gambling and consider Internet/gaming addictions as potentially addictive behaviors. Specifically, in the DSM-III, pathological gambling was introduced as a disorder of impulse control [8], suggesting an intrapersonal difficulty in controlling one’s actions. In the DSM-IV, similarities to the phenomena of substance use disorders were discussed [9], namely similarities in the neurological activation of the reward system [10], genetic similarities [11], and similarities of specific symptoms such as craving and tolerance [12]. These discussions led to the inclusion of gambling disorders in the category of substance-related and addictive disorders in the DSM-5 [13]. In addition, in the DSM-5 [7], Internet Gaming Disorder was identified as a condition warranting more clinical research and experience before being formally included in the DSM as a disorder.

Data are scarce on the epidemiology and burden of addictive behaviors such as gambling or gaming disorders. For example, ALICE RAP (Addiction and Lifestyles in Contemporary Europe Reframing Addictions Project; www.alicerap.eu) aimed to provide such data for countries in the European Union (EU), but did not find data on the prevalence of gambling disorders for these generally data-rich high-income countries.

This chapter also provides an overview of the various definitions of addictive disorders. Although there are medical (psychiatric) definitions found in the DSM-5 and in the tenth revision of the International Classification of Diseases (ICD) [14], these definitions are rarely used in fields other than medicine. For example, in the case of tobacco, medical classifications of tobacco use disorders are not used in the field of epidemiology, and are not included in the burden of disease classifications. With respect to illicit drug use disorders, other systems of classification are more important, such as the category of problem drugs found in the World Drug Reports ([15] as the most recent example). For a recent general discussion of how best to define addictive disorders comprising both substance use disorders and other behavioral addictions, see the overview of ALICE RAP [16, 17].

The overview of the burden of disease caused by addictive disorders presented in this chapter is restricted to the health burdens caused by such disorders (i.e. mortality, years of life lost to premature mortality (YLL), years of life lost to disability (YLD), and/or disability adjusted life years (DALYs) lost attributable to addictive disorders; see [18]). The most important measure of the health burden caused by addictive disorders is the DALYs lost [19], which is the sum of YLL and YLD (i.e. a summary measure of health) [19]. All estimates of the health burden caused by addictive disorders were obtained from the most recent iteration of the Global Burden of Disease and Injury (GBD) study (for the last relevant publication on the topic, see [20] and http://vizhub.healthdata.org/gbd-compare/). Although other estimates of the burden of addictive disorders exist, estimates from the GBD study are presented in this chapter, as they are comparable estimates across substances; however, the GBD study estimates do have limitations. Substance use disorders as defined by the GBD 2010 included only dependence as defined by the DSM-IV [21] or ICD-10 [14], and not abuse (DSM-IV: [19]) or harmful use (ICD-10: [14]). Thus, it is implicitly assumed that the disability weight [22] for people with “abuse” or “harmful use” is the same as for similar people without those disorders. Lastly, the GBD study does not provide explicit estimates for tobacco use disorders, but is restricted to smoking as a risk factor.

Alcohol Use Disorders

Alcohol has been used by societies for thousands of years [23]. Furthermore, the industrialization of alcohol production and the globalization of alcohol marketing and promotion led to an increase in alcohol consumption worldwide in the 20th century [24]. Alcohol consumption is causally associated with both positive (at low levels of alcohol consumption for people who do not engage in heavy episodic drinking) and negative medical consequences [25], and is the fifth leading risk factor for the global burden of disease [26]. Alcohol use disorders (AUDs) in general, and alcohol dependence (AD) specifically, are some of the most severe health effects caused by the prolonged harmful use of alcohol [7]. Furthermore, with a prevalence of approximately 4%, AUDs are some of the most common mental disorders worldwide [20]. Due to the detrimental effects of the chronic heavy use of alcohol, people with an AUD have a life expectancy that is more than 10 years lower than people without an AUD [27, 28]. Additionally, AUDs are often linked to the majority of the alcohol-attributable burden of disease and death [29, 30] since the risk relationship between the average volume of alcohol consumed and most disease and injury endpoints is exponential [25]. However, despite the prevalence of AUDs and the burden they cause, AD was only first suggested in 1976 by Edwards and Gross [31].

The following section on AUDs provides an overview of the diagnostic criteria for AUDs, the epidemiology of alcohol use and AUDs (data for this section were obtained from the Global Status Report on Alcohol and Health [24]), and the burden of disease attributable to alcohol use and AUDs (data for this section were obtained from the GBD 2010 study [20]).

Epidemiology of Alcohol Use and Alcohol Use Disorders

The consumption of alcohol is a common behavior in most high-income countries; the average prevalence of lifetime abstainers in high-income countries is below 20% [24]. However, in low- and middle-income countries, lifetime abstinence from consumption of alcohol is more common [24]. Additionally, in countries with a high proportion of Muslims (i.e. 80% and more), lifetime abstention rates are often as high as 80%, even among people with high socioeconomic status [24].

Similar to the prevalence of alcohol consumption, the prevalence of AUDs varies considerably between countries due to religious, economic, and other differences [24]. In 2010, an estimated 95 million people worldwide met the criteria for AD [20]. The lowest prevalence of AUDs (...