Practical Skills and Clinical Management of Alcoholism and Drug Addiction

Samuel Obembe

• Publisher: Elsevier
• Year: 2012
• eBook ISBN: 9780124016613
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

This insightful book is a synoptic presentation of Causes and Treatment of Alcoholism and Drug Addiction. It gives an insight into Alcoholism and Drug Addiction genetic and/or acquired etiologies through researched studies that draw the conclusion that Addiction is a disease/ medical condition. It features the treatment from detox followed by psychotherapy with evidence based practices and supported by Aftercare programs to maintain sobriety and recovery. - An insight into Alcoholism and Drug Addiction - Psychotherapy with evidence based practices - Aftercare programs - Classification and effects of psychoactive drugs - Drug screening procedures - Motivational Interviewing - Causes and Treatment of Alcoholism and Drug Addiction - Life and clinical experiences - Culture and Drug Addiction - Levels of Care in Structured Programs

1

Addiction and its Etiology

The word “addiction” is loosely applied in social expression to indicate self-indulgence: cravings for food, drink, behavior, things, or places of interest. Basic human cravings are food, water, sex, and sleep. We frequently make these choices because of pleasures derived, but to a large extent within a normal range of consumption without dependency. But we shiver when faced with the intense, destructive consequences of addiction.

Some of the most devastating addictions involve gambling, alcohol, and psychoactive drugs. Other forms of addiction include eating, shopping, sex, the Internet, work, video games, and so forth. These behaviors may impact a person differently, but they can be just as devastating as alcohol and substance dependence.

The content of this literature directly and explicitly addresses the causes and treatment of alcoholism and drug addiction. Also, it places emphasis on practical skills that are essential in treatment management. The intent is to convey the message in synopsis but with clarity, which raises awareness to the causes and destructive effects of alcohol and drug addiction, contributes to the knowledge in management of the disease, dispels related social stigma through scientific insight into the nature of the disease, and provides proper guidance to achieving long-term, possibly life-time sobriety and recovery.

Compulsive consumption of alcohol and/or psychoactive drugs is defined as chemical dependence. This behavior is a shift from an impulsive (tendency to act on a whim—high vulnerability) to a compulsive behavior (a force-driven irrational impulse). The compulsion involves a loss of control in limiting intake of alcohol or psychoactive drugs of choice. This may involve impaired brain function, neuron damage, or synaptic dysfunction. The disease is found in the mesolimbic dopamine system, also referred to as the “pleasure pathway” or “reward system.”

The two primary indicators of alcohol and drug addiction are: (1) tolerance—an increase in the amount of intake to produce the same pleasure or a need for a higher dose to elicit the same effect; and (2) withdrawal symptoms—in the course of acute or chronic abuse of psychoactive drugs or alcohol, a physical or physiological adaptation occurs. A sudden or abrupt cessation of intake will precipitate acute physical or physiological symptoms: body pain, nausea, chills, vomiting, and depression. These can be devastating and are most often coupled with negative emotional state. Human compulsion is a pathological driving force which seeks attainment of “pleasure” feelings. The ultimate goal of this force is addiction and this state is sustained by a fear of withdrawal symptoms. This vicious cycle perpetuates addictive habit.

These are the primary operative elements of addiction. There are specific stages of chemical dependence which culminate into this disease state:

• Impulsive to compulsive behavior (loss of control of use) or neuronal damage.

• Psychobiological pathology: physiological and psychological dependence.

• Withdrawal stage—irritable discomfort from sudden cessation of use (“cold turkey” symptoms).

Formal addiction is an adaptation of the psychoactive substance into the “normal” physiology of the body. This dynamic involves physical compulsion by dramatic changes in brain function as a result of destructive effect due to constant and prolonged exposure to the chemical substance. Addiction is a pathological condition: a medical condition or a disease.

Causes could be intrinsic (genetic or familial) or extrinsic (environmental; unhealthy lifestyle, peer group, etc.) predisposing factors.

Griffith Edwards, DM, and Milton M. Gross, MD, provided a definition of chemical dependence syndrome in 1976. They described the essential elements of the syndrome as “a repertoire of drinking behavior; salience of drink-seeking behavior; increased tolerance to alcohol; repeated withdrawal symptoms; repeated relief or avoidance of withdrawal symptoms by further drinking; subjective awareness of a compulsion to drink; reinstatement of the syndrome after abstinence. All these elements exist in degree, thus giving the syndrome a range of severity; one clinical element may reflect underlying psychobiological happenings of several types and different clinical elements may be partial descriptions of the same underlying psychobiological process” (Edwards & Gross, 1976).

This is an explicit definition of chemical dependence syndrome—combined symptoms that characterize the disease. And it is this concept of clinical presentation by these experts that inspired a formal recognition of the syndrome. Multiple authorities agree with the syndrome as a clinical definition of alcohol and drug addiction: International Classification of Disease (ICD-10) and Other Health Problems Manual (World Health Organization, 1992) and Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision (DSM-IV TR).

Because addiction is interchangeable with the more specific terminology of chemical dependence, I may apply either term to convey the same meaning.

1.1 Definition and Characteristics of Alcoholism and Drug Addiction (Substance Dependence)

Many definitions have been given to addiction which sometimes lack the specific operative words, while some have done justice to it. Morse and Flavin’s (1992) definition of addiction published in the Journal of the American Medical Association (vol. 68, No. 8) states that addiction is a primary, progressive, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestation. The disease is often progressive and fatal. It is characterized by impaired control overuse of the substance, preoccupation with the substance, use of the substance despite adverse consequences, and distortion to thinking. This definition stands as the guiding principle of treatment centers and substance-abuse counselors.

Addiction could also be conceptualized as a demonstration of a pathological relationship with any mood-altering experience that results in ongoing, recurring life-damaging negative consequences. Pathologies such as denial, delusion entrenched with other defense mechanisms that are so crazy and irrational to the objective mind can occur. Life-damaging negative consequences and health problems due to alcoholism are depicted in Figure 2.1. Drug addiction is just as devastating, possibly more immediate, and often results in fatality. Legal problems are also most often consequences of abuse and addiction to drugs.

Loss of self-respect, respect of family or peers, jobs; irrational cognition, argumentative and negative attitude are social and economic downfalls due to alcoholism and drug addiction.

The American Psychiatric Association (APA) definition of alcohol and drug addiction is based on clinical symptoms. It states that addiction or dependence is present in an individual that demonstrates any three or more of the following symptoms at any time in the same 12-month period:

1. Tolerance: This is defined as a need to substantially increase the amount of intake of the psychoactive substance in order to achieve the same desired effect. This could be inversely expressed as a markedly diminished effect from same amount of substance that on prior intake had a desired effect.

2. Withdrawal: Abrupt cessation of substance intake manifests characteristic signs and symptoms of the withdrawal syndrome. Intake of same or closely related psychoactive substance could produce a relief or avoidance of withdrawal symptoms.

3. Larger amount of substance is taken for a longer period, indicating loss of control over setting limit of use.

4. Persistent desire to use psychoactive substance and inability or failure to quit or cut down on substance use.

5. Preoccupation or obsession with activities to obtain the substance, use of the substance, or failure of plan or intention to quit the use and recovery from the life-threatening symptoms of the psychoactive substance.

6. Consequential reduction or complete withdrawal from social, occupational, or recreational activities predicated on substance use.

7. The substance use is intensified as tolerance escalates in spite of the recurrent physical and psychological problems that are caused by the persistent use.

In view of these definitions and the characterization of addiction, it is essential to identify the differences among users of addictive/psychoactive substances. They could be classified into three groups:

1. Social user

2. Alcohol/substance abuser

3. Addict

Social user: He/She uses alcohol and/or drugs simply to enhance the pleasure of normally pleasurable situations. The social user experiences the following:

• No negative consequences

• No surprises or unpredictability

• No loss of control

• No complaints

• No thoughts of or need for limit setting

Alcohol/Substance abuser: He/She uses to enhance pleasure and/or compensate for something negative, such as physical or emotional pain, insecurity, fear, anger, and so on. The substance abuser experiences:

• Occasional negative consequences that are not repeated

• Limit setting that is adhered to

• Complaints are heard and dealt with

Addict: He/She uses to celebrate, compensate, or for any other reason, legitimate or not. The addict experiences some or all of the following:

• Negative consequences are recycled

• Limit setting and promises to self or others are broken

• Complaints are denied and/or not heard

• Reliable symptoms of addictive diseases become more evident

• Continued use despite negative consequences

• Loss of control, as in more use than planned (broken limits)

• Unpredictability, as in use despite plan not to use (broken promises)

• Compulsivity/preoccupation in thinking

• Denial; use of defenses to maintain denial

• Build up of (or ‘break’ in) tolerance

• Remorse and guilt about use or behavior when using

• Memory loss, mental confusion, irrational thinking

• Family history of addictive behavior

• Withdrawal discomfort (physical, mental, emotional, and/or psychological)

Courtesy of Roper (1999).

Addiction

There is an urgent need to treat the primary causative factor of the addiction as well as secondary clinical disease as reflected in axial diagnoses: peptic ulcer, avitaminosis, chronic pancreatitis, and so forth (see Section 3.3).

Chronic

Immediate treatment must commence on diagnosis of addiction. Chronic addiction may go into remission. But in the course of treatment, sometimes relapse is inevitable, especially among clients with poor coping skills and/or inconsistent treatment regimes. A prolonged treatment phase is often necessary to achieve long-term sobriety.

Progressive

The progression of addiction is often determined by the choice of psychoactive substance. Addiction can become aggravated rapidly, but with certain drugs such as alcohol, it may be a more gradual progression. Denial and enabling behaviors often facilitate and enhance the progression of addiction.

Terminal

This may stem from major organ destruction, as when cirrhosis of the liver progresses to liver failure and death. This progression is sometimes secondary to chronic alcohol addiction. The risks of contracting hepatitis B, hepatitis C, and human immunodeficiency virus (HIV) are very high. These are highly virulent diseases that could result in loss of life if not adequately managed. Exposure is especially high with intravenous (IV) administration of addictive drugs through contaminated IV needles. This risk could be minimized by supplying sterile needles and syringes to IV drug users called “harm reduction”; it also involves processes of discouraging IV use by supporting safer and less toxic alternative route (for further reading, see Chapter 2). Incidence of fatality due to drug overdose is very prevalent among IV drug users.

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Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Note to Readers
• My Story
• A Holistic Approach to Clinical Management
• Disclaimer
• Thanks
• 1. Addiction and its Etiology
• 2. Common Psychoactive Drugs
• 3. Management of Addiction
• 4. Theories of Treatment
• 5. The Impact and Treatment of Drug Addiction
• 6. Pharmacotherapy (Medication Therapy)
• 7. Crisis Intervention
• Inspired by: Life Events, Clinical Experience, and Intellectual Curiosity
• Bibliography