What is Addiction

and

how is it Treated?

by Steven R. Lee, MDRidgeview Institute

Preface

There are three principles that are essential to understand about addiction:

1. Addiction is a medical disease in the same way as hypertension or cancer are medical diseases. Addiction is a dysfunction of the pleasure centers of the brain.

2. Addiction is not a personality disorder or a moral problem (i.e. being a bad person). An addict did not decide one day that they would destroy their life and the lives of their loved ones through their obsessive-compulsive behavior.

3. Treatment works but it does not come in a pill nor does it end after detoxification. Recovery occurs when the addict makes the changes in their life necessary for them to have joy and happiness without their substance or behavior.

What is Addiction?

Addiction is a persistent, compulsive dependence on a substance or a behavior (i.e. gambling) even though the individual has experienced potentially harmful consequences while doing this substance or behavior. The compulsion to use a substance or to do a behavior comes from an involuntary biological drive located in the pleasure centers of the brain. Once an addict has had an experience that gives "pleasure" or relief, then the memory of this feeling is attached to the substance or behavior that caused it. This is called "biological conditioning". Addiction is a disorder of the brain's reward system.

"Pleasure", here, is defined as any feeling that gives someone a sense of well-being or relief from a bad feeling. Pleasure could be the ability to laugh when someone is depressed. It can also be an escape from a sense of dread when someone is under constant anxiety, stress, or fear.

Therefore, once the addict discovers that using a substance provides pleasure or relief, they are starting a process of biological conditioning. Whenever they are in an unpleasant or boring situation, they know that by using that substance they can get immediate relief.

Cigarettes are an example of this type of biological conditioning. A smoker smokes cigarettes when they drive their car. Assume they do this over 6 months or longer. Then one day they get into their car and they do not have a cigarette. Driving does not feel right without a cigarette. They can try to drive their car without a cigarette, but they feel that something is wrong without a cigarette. Smoking a cigarette has become, for the nicotine addict, a biological conditioned response. This patterning would be the same for someone who is compulsively dependent on alcohol, marijuana, OxyContin or whatever other substance is involved.

When an addict, who has been depressed for the past year, realizes that they are not depressed when they are using their substance, then their addiction has become, not just a recreational way to get high, but a “necessary” way to deal with their depression. This response will override any concerns about the consequences of using this substance such as the dangers of driving intoxicated or having unsafe sex. They now have a functional as well as a recreational reason to use their substance.

A co-occurring disorder is a psychiatric disorder that occurs in someone who also has a Use Disorder (addiction). Those addicts who also have a psychiatric disorder have a dual-diagnosis. The psychiatric disorder can be caused by the Use Disorder or it may have been there before the Use Disorder. It is important to make this distinction because if the psychiatric disorder is a separate diagnosis, then without aggressive

medical treatment of this psychiatric disorder, this will become the addict’s number one relapse risk factor. After the addiction has improved, the treatment of the psychiatric disorder must continue, and medications cannot be stopped.

You May be an Addict if ----

Someone who drinks a fifth of liquor a day for a year is an addict. Someone who uses heroin every day for 6 months is an addict. These are clear examples of addiction, but some people with an addiction, to avoid their need for treatment, will rationalize they are not as bad as these two examples. Here are a few examples: having two DUI charges over the past 5 years means that you have an addiction even though you only drink on the weekends. Falling down steps and breaking your leg while you were intoxicated along with being fired from a job because you are always too late in the mornings means that you have an addiction. Avoiding going to your grandparent’s funeral because you had gotten too intoxicated the night before along with having a history of one DUI means you have an addiction.

There are many more examples. Rationalization, minimization, and frank denial are our ways of avoiding the reality of the fact that we are powerless over our use of a substance or of repeatedly doing a behavior that is causing serious problems in our life. No one wants to admit that they cannot manage a part of their life but until you can admit this, you will not ask for help. You will continue to be controlled by your addiction which will cause problems in your life as well as the lives of those who love you.

Etiology

50% of Use Disorders have a genetic etiology. An alcoholic (someone who has an Alcohol Use Disorder) who has the variety of genes necessary to be an alcoholic may be able to drink a pint to a fifth of alcohol a day and not die from alcohol toxicity. An individual who is “genetically prewired” to have an Opioid Use Disorder can take a Percocet and become mentally clear; not worry about what is wrong in their life; feel comfortable and gregarious in groups even with an anxiety disorder; and be motivated to finish the term paper that is due tomorrow.

The other 50% of those who have an addiction are those individuals who were not born with the genes that cause a specific substance Use Disorder or an addictive behavior. These individuals develop an addiction because of what is going on in their lives. Examples of this include three groups of people: chronic pain patients; psychiatric patients; and young adults.

Patients with a chronic pain condition that is not adequately stabilized can abuse opioids. Even though they have overdosed on opioids in the past and almost died, they continue to abuse opioids trying to get pain relief because the pain is unbearable. They do not get a sense of wellbeing when they use the opioids like a “genetically prewired” opioid addict.

Someone trying to get relief from their Major Depressive Disorder may try stimulants, especially methamphetamine or cocaine, and become addicted to these substances because they get temporary relieve of their depression. With these drugs, intense cravings to use stimulants can develop such that they are unable to stop using these substances even when their life is shattered because of their use.

About 25% of all young adults meet the criteria for a Use Disorder. Once they mature past 26 years old, this percentage drops dramatically to that of other older adults. This is a cultural phenomenon of young adults in this generation. Just a generation ago, it was expected that by 21 to 25 years old, a male would be married and have a job supporting a family. Females were expected to marry earlier and to have children. All of this has significantly changed. The typical age of marriage is now around 28 years old and having children is 30 years old. Young adults have much less responsibility, are more educated, and believe they can do anything without getting hurt. Many are bored and looking for excitement and purpose, unfortunately, in the wrong way.

The last category of people with a Use Disorder is a smaller percentage of the population who are capable of being addicted to any substance and any behavior that can alter their consciousness so that they feel “high”. They will abuse Benadryl, alcohol, opiates, stimulants, inhalants such as glue or paint, hallucinogens, dissociatives (i.e. PCP, ketamine), sex, gambling, eating, and many more. We are not sure if these addicts have a series of genes that make them this way or if this is part of their personality structure. The treatment of this group of addicts is long and requires many different approaches to deal with the complexity of their life style.

Frequency

According to the National Institute of Health (NIH) in 2013, 8.6% (22.7 million people) of the United States aged 12 or older needed treatment for an addiction and this number does not include those with a Nicotine Use Disorder. Only 0.9% (2.5 million) received treatment. Only one out of 10 addicts obtain treatment. This means that about 90% of people

with an addiction will experience a lifetime of interpersonal and physical problems involved with their addiction and may die because of their addiction.

25% (80 million) of the United States has a Nicotine Use Disorder. Young adults ages 18 to 25 have the highest rate of use of tobacco products (35%). This is the worst addiction in the world. It earns the #1 position because of the loss of life caused by cardiovascular disease, cancer, and lung disease. According to the CDC in 2013, more than 480,000 deaths were caused by nicotine and cigarettes.

According to the World Health Organization in 2013, 7% of adults in the US (17 million) and 2.8% of ages 12 to 17 (700,000) had an Alcohol Use Disorder. Alcoholism directly resulted in 139,000 deaths and it reduced a person’s life expectancy by around ten years.

In 2015 the NIH said that 2 million people had an Opioid Use Disorder from pain relievers and 591,000 from heroin. This is about 0.8% of the 322 million people in the US. There were 33,000 deaths due to opioid overdose as per the CDC Injury Center. In 2017 there were 60,000.

Cannabis Use Disorder is the most common Illicit drug used in the United States. As this substance becomes more legalized throughout the country, more teenagers and young adults are spending their days getting high instead of taking charge of their life. About 9% of those who experiment with marijuana eventually develop a Use Disorder. According to a NIDA (National Institute on Drug Abuse) review, the rate goes up to 12.5% among those who begin use as a adolescent. The highest risk of cannabis dependence is found in those with a history of poor academic achievement, deviant behavior in childhood and adolescence,

rebelliousness, poor parental relationships, or a parental history of drug and alcohol problems.

Neuroanatomy of Addiction

Addiction is a medical disease. Usually an addiction involves an activity that gives pleasure or relief. Addicts have memories of what made them feel good in the past (i.e. alcohol, sex, etc.). These memories can be made conscious by events going on in the addict's life or by certain feelings experienced in the present. If they are sad, lonely, anxious or afraid, the brain remembers a solution that gives instant relief to deal with these bad feelings. That solution is the use of a specific substance or to do a specific behavior.

Brain has been sliced in half and you are looking at the right side of the brain. Limbic System is located inside the center of the brain. The Cortex is located outside of the Limbic System.

The part of the brain that initially responds to a bad situation or to a bad feeling is the limbic system. It does not necessarily care about the consequences of what may happen when the addict gets intoxicated as long as the individual gets relief from the bad feeling. In fact, the limbic

system does not even have memories of the consequences. It only remembers what gives relief.

The cortex is that part of our brain that remembers all past consequences of behaviors. The cortex also stores what the person has learned such as that lecture on unprotected intercourse. Normally, when a person experiences a bad feeling, the limbic system demands that the addict find immediate relief. The cortex filters these demands by flooding the person's consciousness (awareness) with all the memories of the problems that occurred when they got intoxicated in the past.

The person then must decide whether they will respond to the demands of the limbic system. Unfortunately, some substances (i.e. alcohol and Xanax) come with a mechanism called disinhibition. This disconnects the input of the cortex and does not allow the cortex to bring to consciousness the possible consequences of that behavior. The addict then proceeds with their addictive behavior.

The cortex does not fully develop before the age of 26. The limbic system is fully developed by the age of 18. This means that in the young adult, the more mature limbic system has more control over actions taken than someone over 26. Young adults and adolescents who have a Use Disorder will need a more “structured treatment” to keep them sober long enough so that they can begin their treatment. It is almost impossible to treat these individuals as an outpatient coming from home because they have such a high rate of relapse.

Aspects of Addiction

The Obsessive-Compulsive Drive Biological Conditioning Unmanageability PAWS Craving Use Disorders as a Medical Disease

The Obsessive-Compulsive Drive

The addict's repetitive use of their substance eventually causes tolerance which is a decrease in the response to their substance such that the addict must use larger amounts of their substance to get the same relief or high that they got the first time they used. With large doses of the substance (i.e. alcohol, Xanax, OxyContin), the awareness that usually would come from the mature part of our brain of potential danger (i.e. Do Not Drive at 100 MPH!) is blocked through disinhibition. The addict responds to the limbic system's need for gratification. The rational, objective part of our brain, the cortex, is ignored to experience that immediate gratification, regardless of the consequences.

Unfortunately, the drive to repeat the same behavior eventually takes top priority in the addict's life. Every other aspect of their life becomes secondary to the need to “get high”. Family, school, job, relationships, God, and the law all become secondary to the addictive behavior. Anyone who tries to prevent the addict from doing the compulsive behavior will be considered the enemy.

The addict’s rationalization, minimization, and frank denial become well refined responses to anyone's questions and concerns. Addicts convince themselves that they are righteous in their statements of how others are interfering in their life. They feel that others are trying to take away their

right to make their own decisions by questioning their judgment and treating them like children.

Addicts even become convinced that their behaviors and use of substances are necessary to deal with depression and anxiety, to calm down, to get to sleep, or to be able to focus. If OxyContin, alcohol, or marijuana were healthy treatments for anxiety, depression or attention deficit disorder, we would prescribe these substances as a standard of care for these problems, but they are not.

Many people in our society, who seem to be functioning well on the surface, suffer from addiction. You do not have to be passed out all the time secondary to alcohol or doing intravenous heroin to be an addict. You do not have to be a totally irresponsible person to be an addict. The reality is that most people with an addiction initially go about their lives as anyone else. The difference is their constant obsessions about when they can use their substance.

In the early phases of the disease the addict routinely goes to work or to school then at night uses their substance. This initial phase of the illness proves to addicts that they are in control of their use. They have proven to themselves that they can manage and control their compulsive behavior. Addicts use this fact to minimize, rationalize and deny that the behavior is dangerous. Rational, sane people would quickly admit that this behavior is dangerous and destructive. Addicts have a special type of insanity which is based on the delusion that they are in control of their behavior and that the behavior is essential to deal with life. They cannot or will not deal with life on life's terms without their substance.

Biological Conditioning

Even if an addict can stop the compulsive behavior temporarily, this does not mean that they are not an addict. The problem for any addict is not stopping but staying stopped. Most biological conditioning requires repetition of a stimulus/response behaviors based on receiving a reward for an action that was caused by the stimulus. Thinking about alcohol (stimulus) leads to taking a drink (response). This either gives a sense of wellbeing or relieves anxiety (reward). Once the response is reinforced through repetition they believe that to have a sense of wellbeing or relief from anxiety, the addict must take a drink.

Whenever the limbic system experiences a pleasure that is quick and efficient, it never forgets. A substance that can give essentially instant pleasure or relief of fear and anxiety fits that bill. In fact, some substances do this so efficiently that some people are addicted to a substance after doing that substance only once. Crack cocaine and methamphetamine can affect some people this way.

The problem here is that what takes one second start an addiction, takes at least a year to find alternative coping techniques that can at least equal the “benefits” of using that substance. Teaching the limbic system to use alternative ways to get relief from boredom, anxiety, depression and fear is like teaching a dog to walk on their hind legs. Not only do you have to teach the dog to walk on their hind legs, but you must help the dog to want to.

Unmanageability

After about 6 months of using a substance almost daily, most addicts begin to have unmanageability in their life because of their use. This unmanageability occurs in every aspect of their life. The addiction demands that using the substance is the primary purpose in their life.

Those people in relationship with the addict begin to feel rejected and abandoned as the addict begins to withdraw. Most jobs require that the employee is focused on their job instead of themselves. When the addict must use during the day or has been using much of the night and not resting right, the addict’s performance begins to wane and is noticed by their employer.

Eventually, something significant occurs such as an auto accident, a DUI, or being fired from a job. Bills do not get paid because the income goes to pay for the substance. Physically, the individual becomes weak because of not eating or sleeping right and not exercising. The list goes on. The addict is not able to manage the casual use of their substance without more unmanageability. Hopefully, when this significant event occurs, either the addict or the addict’s loved ones will realize the unmanageability that has been developing in that person’s life because of their addiction and seek treatment.

Without unmanageability in the addict’s life because of the use of the substance, the addict would never stop using the substance. Even with repeated unmanageability in an addict’s life, if the addict does not want to stop the use of a substance, nothing can make that addict stop. That person may die through the continued use of that substance.

PAWS

Post-acute-withdrawal syndrome (PAWS) describe a set of persistent impairments that occur after withdrawal from alcohol, opiates, benzodiazepines, antidepressants and other substances. In some cases, these substance-induced physical and psychological symptoms can persist long after detoxification, such as prolonged sleep disturbance, depression, irritability, and short frustration tolerance. A protracted

PAWS can also occur with symptoms persisting for months to a year after cessation of use.

The severity and longevity of PAWS depends on the potency of the drug and the length of time the drug was used. Drinking a fifth of alcohol a day for 10 years will result in a PAWS for about a year. Daily use of a gram of heroin a day for a year will result in about 6 to 8 months of a PAWS. Of course, the severity of a PAWS progressively decreases each day that the addict is not on their substance and eventually it stops all together. What is different from one person to another are the exact symptoms that make up the PAWS. Usually, disturbed sleep is a problem for at least a couple of months. This disturbance may differ from frequent awakening to vivid dreams all night which may include “using dreams” or horrible nightmares such that the person is afraid to go to sleep. PAWS is the cause of many relapses.

What can be controversial in the recovering community is the use of medication to manage the severity of PAWS. Trazadone, Vistaril, mood stabilizers (Seroquel), gabapentin, and antidepressants are all used to target specific symptoms. If these symptoms are not stabilized, many newcomers to the recovery process will relapse. Benzodiazepines (i.e. Xanax, Ativan, Klonopin) cannot be used because of how this chemically recreates the addicted state in the limbic system and can lead an addict back to their drug of choice.

Craving

As part of PAWS, craving is the uncontrollable desire to use a substance. The longer the addict uses a substance that gives pleasure or relief, the more their limbic system feels that they must have this substance. The limbic system will create an urgency that many addicts cannot resist.

Methamphetamine and crack cocaine addicts have some of the strongest cravings of any addiction though alcoholics and opiate addicts can also have just as severe cravings.

Use Disorder as a Medical Disease

A Use Disorder is a life-long medical disease. The cost of treating addiction over a lifetime is no different than any other medical disease. If a Use Disorder is believed to be just a weakness of character, then, of course, the amount of money it takes to treat this medical disease over a life time seems like a waste of money. The saying, “Addicts need to just say no!” is an oversimplification of what it takes to treat this major medical problem. We all wish it were this simple. This way of thinking is from someone who does not understand addiction and what it takes to manage the disease.

Major-medical illnesses require constant education and reassessment to keep the individual taking their medication, eating the right foods, doing the right exercise, and living the right life style. It is human nature that most of the population will not do all that they are supposed to do even with the best education. It takes the same amount of resources to treat addiction as it does to treat the other major medical problems.

Adherence Rate to medical treatment:

Diabetes - ~60% Hypertension - <40% Asthma - <40% Addiction - ~50%

Family

Addiction is a family disease. If one person in the family has an addiction, then everyone in the family is part of that addictive disease. Each family member who loves the addict is changed because of the addiction. Anger, depression, and fear are some of the most common feelings. Codependency, avoidance, minimization, rationalization, and denial are some of the common behaviors family members use to deal with their relationship with the addict. The family needs treatment as much as the addict to understand how to live life with addiction. This treatment can involve individual therapy, family therapy, and group therapy.

Alanon and Naranon are two 12 Step meetings for families of alcoholism and drug addiction, respectively. For some family members this is an essential activity to understand addiction and how to cope with having a family member who is addicted. It works if you will agree to go to at least five meetings and participate in the meeting. Do not try to deal with all of this by yourself.

Treatment

There are four stages of recovery from a Use Disorder; Acute, Subacute, Transition and Maintenance. The whole process takes at least a year to get into a full recovery if the addict is working their program of recovery every day. If they do not work their program of recovery, then the process takes longer with more frequent relapses. The reason it takes at least a year is because the changes that must happen in the brain to change the way the brain thinks are slow even with the best treatment for those willing to make the changes necessary. It took the addict a much longer time to develop their addiction and, during this time, the brain was changing slowly into the addicted brain.

Acute Phase of Recovery (one to two weeks)

Once the addict decides to stop using, their mind, their body, and their emotions react very much like a child that has had their candy taken away. Every addict will go through a “detox” stage and, for alcohol and sedatives, this is a medical emergency because of the potential for seizure, heart attack, and stroke. They must be admitted to a qualified medical detoxification unit so that they can be appropriately medicated and monitored by a medical team. The only thing that is required of the addict at this stage is the willingness to stop and to let people help them.

Opioid addicts need inpatient treatment as well so that they can get through their withdrawal without relapsing on their opioid. The danger here is if the person is physically debilitated and during the withdrawal loses too much fluid through vomiting and diarrhea, they could die. Healthy individuals are not in danger of death but will probably relapse if they are not in a contained inpatient unit because they feel so miserable both emotionally and physically.

Stimulant addicts, especially those abusing Methamphetamines, are usually physically debilitated through dehydration and lack of other nourishment. They may also be paranoid and convinced that you are going to either hurt them or try to humiliate them. They will need 3 to 5 days to sleep and to hydrate. Sometimes they are also physically weak and have lost a great deal of weight. Some individuals using crack (concentrated cocaine) may have the same symptoms.

Those stopping marijuana usually become irritable, have trouble sleeping and trouble with frustration tolerance. Their memory is not the best and they can be short winded so that exercise can be difficult.

With all of these substances, 3 days to a week will be necessary for the acute phase of detoxification. There is usually another week or two that

the individual is cognitively and physically slow. Those who start an addiction treatment program during this time will find that many principles of the recovery process will have to be repeated once their brain and body become healthier. They need emotional and physical nutrition to deal with their debilitated state caused by their addiction.

Subacute Phase of Recovery (4 to 6 weeks)

Once the brain, body and emotions have stabilized from the active addictive state, the addict is now able to start looking at the principles of recovery. Understanding the medical nature of their addictive disease is crucial for the addict to realize that they are totally powerless to deal with their substance by themselves. Powerlessness means that they cannot use their substance in moderation and manage their use because when they tried to do this, their life became unmanageable.

It takes a special ability to drink a pint of liquor a day or two six packs of beer. Most people cannot do this every day and be able to function. You must be genetically prewired to be able to metabolize that much alcohol daily. A small percent of the population will respond to an opioid with mental alertness, increased motivation, and decreased anxiety. When those who are not opioid addicts use an opioid, they are cognitively slow, have nausea, and it is not an enjoyable experience. Again, you must be genetically prewired for an opioid to give a positive feeling.

When you understand you are powerless over using your substance in moderation, you then can focus on finding a power greater than yourself that can help you to manage that powerlessness. This is not a statement of failure; it is an acceptance of our humanity and the medical disease of addiction. In fact, once an addict sorts out this step, they will open a door to a new and better life that they never knew existed. Willingness,

honesty, and open mindedness are the three essentials needed by the addict to respond to treatment.

Relapse is always possible during the recovery process. Understanding this helps patients and families to realize that a structured daily program is necessary. This is usually a PHP (Partial Hospitalization Program) followed by an IOP (Intensive Outpatient Program). Young Adults and many other adults also need to stay in a sober living facility as well as attend the PHP/IOP. They are not yet able to withstand the desire to use their substance and will relapse. All addicts must stay sober long enough to develop a foundation of recovery.

Transition

After 4 to 8 weeks of developing the foundation of recovery, the addict will have enough internal structure and connection with their higher power, that they can leave the PHP/IOP and move to either a sober living home outside of Ridgeview or in some cases their own home. They understand the third step of the 12 Steps. This does not mean that they are well enough to stop treatment. The brain is still in a state of addiction such that they can relapse without the right structure. Recovery will take at least another 10 months of going to meetings, working with a sponsor, and understanding and working the last 9 steps of the 12 Steps.

Maintenance

Addiction is a medical disease just like hypertension and diabetes. After the addict has worked all 12 steps, they are “in recovery”. We cannot cure addiction, but we can manage it. The addict will have to continue to work the steps regularly to stay in recovery. Once the addict stops

working the steps, they have a very high probability of relapse. This is no different than a diabetic that has finally gotten their weight right and is keeping their glucose normal.

Summary

Addiction is a devastating medical disease. Addicts do not decide to be addicts, they are either genetically predetermined to be an addict or there are circumstances in their life that predispose them to addiction. Once they have used a substance regularly or have repeatedly done a behavior (i.e. gambling) for at least 6 months, the brain changes such that life is not good unless they are active in their addiction. The addict is powerless by themselves to stop their active addiction, though this pattern of behavior can stop with the right kind of treatment. Once the addict has the willingness to get into treatment, addiction can be treated. The process of treatment takes time, but it works.