Dr. Roshan Jain
Consultant Psychiatrist & De-addiction Specialist
Throughout history those with addiction were thought to be morally flawed and lacking in willpower. Those views shaped society’s responses to alcoholism and drug abuse, treating it as a moral failing rather than a health problem, which led to an emphasis on punitive rather than preventative and therapeutic actions. Scientific advances and discoveries about the functioning of the brain altered views toward addiction and enabled us to respond effectively to the problem.
Addiction is a complex problem, perhaps a disorder or even a disease that affects the structure and function of the brain and individual’s behavior. It is characterized by intense and, at times, uncontrollable craving for the drug or an activity, along with compulsive behavior of seeking and use that persist despite devastating consequences for health, functioning, work and social life including relationship.
Scientific research has argued that addiction is a brain disease. While the path to addiction begins with the act of taking drugs or indulging in the activity, but over time a person’s ability to choose not to do so, is compromised, and seeking and consuming the drug/activity becomes compulsive. This behavior results largely from the effects of prolonged exposure (to drug or activity) on brain functioning. Whilst pleasure and enjoyment may have been originally sought with the drug or activity, but with habitual use/involvement it will be needed to feel normal. Many individual may indulge to reduce unpleasant feelings or emotions. Addiction affects multiple brain circuits, including those involved in reward and motivation, learning and memory, and inhibitory control over behavior. Simple biological or genetic basis cannot explain heritability of addiction or addictive behavior, and it is established that vulnerability is multi-factorial with interplay of genetic makeup, age of exposure to drugs (and activity), environmental influences (including stress from work, relationship and social milieu), and psychological status. Associated medical and psychiatric illnesses are common and there has been argument whether they are the cause or effect of specific addiction.
Are there different types of addiction? Well it’s indeed a very broad concept but to simplify, addiction can be broadly divided under the headings of chemical or drug addiction and behavioral addiction. This divide somewhat explains that behavioral element is important for turning an infrequent habitual behavior into compulsive/ dependent one, and that specific chemical property is required for physiological withdrawal state.
In behavioral addiction there can be withdrawal state but with prominent psychological component.
Common forms of drug addiction especially in India, is to alcohol, tobacco (cigarettes and gutka) and opium. Perhaps the misuse of prescribed, and illegally available over the counter anti-anxiety and hypnotic medication (such as Anxit, Valium, Librium – containing Alprazolam, Diazepam, and Chlordizepoxide, and sleeping pills – Zolpidem, Zopiclone), is underestimated. Indeed these particular individual may be the tip of iceberg.
Behavioural addiction is a growing epidemic. So far, diagnostic manuals (Diagnostic and Statistical Manual Version 4 and International Classification of Diseases Version 10) have only recognized sexual disorders under category of impulse control disorders and disorder of adult personality and behavior such a Pathological gambling and betting. This section includes a behavioral pattern of clinical significance, which tends to be persistent and appear to be the expression of the individual’s characteristic lifestyle and mode of relating to himself or herself and others. With increasing recognition of other behavioral disorders, categorized by compulsions or compulsive repetitive behaviour that are not substance (or drug)-related, subtypes such as Internet addiction will be included in upcoming version of Diagnostic and Statistical Manual, Version 5. This category includes addiction to chat rooms, online multiplayer gaming and gambling, compulsive surfing and online shopping and cyber sex and cyber pornography, social networking sites. Other types include sexual addiction, and addiction to video game, food, sex, work and television.
Alcoholism or Alcohol Dependency Syndrome:
To put it in perspective we will discuss in context of most common addictive disorder, alcoholism, or clinically addressed as alcohol dependency syndrome.
Before we do that it’s worth looking at some statistics of alcoholism in India, and its consequences on health. According to Indian Alcohol Policy Alliance (IAPA), alcohol intake is on the rise across the world and this is a major public health concern. There has been a steady increase intake in developing countries since 1980s, with drinking to intoxication is more prevalent in these countries. The per capita consumption of alcohol increased by 106.7 % over the 15-year period and there are over 62 million alcohol users in India. Over 80 % of alcohol consumption is in the form of hard liquor or distilled spirits and branded liquor accounts for about 40 % of alcohol consumption. Worryingly people are drinking at an earlier age than previously with mean age of initiation of alcohol intake reduced from 23 to 19.
Alcohol affects every organ of the body. It impairs coordination and judgement, disinhibits individual making him prone to impulsive behaviour and affect memory including causing dementia. It damages the liver causing fatty enlargement to cirrhosis. There is an increasing presentation of alcoholic with disturbed heart rhythm (arrhythmia), enlarged heart (cardiomyopathy) and high blood pressure (hypertension). Associated gastric problem include ulcers, gastritis and cancer. Alcohol significantly disturbs sleep and commonly causes sexual disorder including erectile problem leading to relation difficulties and breakdown. Most importantly it can contribute to the development of psychiatric problems especially depression, anxiety and psychosis. It elevates the risk of suicide to 10- 15 %. According to IAPA, about 17.6% of all psychiatric emergencies are caused by alcohol.
So, what are the characteristic features of Alcohol Dependency? Alcohol dependence syndrome is seen as a cluster of seven elements that concur, and it is argued that not all elements may be present in every case, but the picture is sufficiently regular and coherent to permit clinical recognition.
According to the DSM 4 criteria for alcohol dependence, at least three out of seven of the following criteria must be manifest during a 12 month period: Tolerance (needing more alcohol to sustain a buzz or high), Withdrawal symptoms (includes symptom such as sweating, shaking, nausea and anxiety), Use in larger amounts or for longer periods than intended, Persistent desire or unsuccessful efforts to cut down on alcohol use, Time is spent obtaining alcohol or recovering from effects, Social, occupational and recreational pursuits are given up or reduced because of alcohol use, Use is continued despite knowledge of alcohol-related harm (physical or psychological).
There are warning signs to identify alcoholic and alcoholism. Individual will be drinking a lot without becoming drunk, needing to drink more and more to get the same effect, feeling unwell without a drink, or need a drink to start the day, experiencing shakes, sweats, and anxiety/ tense a few hours after your last drink, unable to stop drinking (loss of control), carry on drinking even though it is interfering with work, family and relationships, “memory blanks” where you can’t remember what happened for a period of hours or days. By and large similar warning signs will apply to drug addiction.
Although features of different addiction may vary, there are common symptoms, namely persistence despite negative consequences, increasing tolerance, and specific withdrawal symptoms. For Internet addiction, individuals may report loosing track of time online, feel guilty or defensive about Internet use, perhaps a sense of euphoria or relief from stress when using Internet.
Addiction is a complex but treatable disorder. Addiction has many dimensions and disrupts so many aspects of an individual’s life, so treatment is not simple. Effective treatment programs Alcohol treatment programs must incorporate many components, each directed to a particular aspect of the illness and its consequences. Careful consideration should be given to approaches most fitting, likely to elicit the desired effect, and compatible with a particular culture. Addiction treatment programme must help the individual stop drug or activity, maintain a drug/guilt free lifestyle, and achieve productive functioning in the family, at work, and in society. Because addiction is a disease, people cannot simply stop using drugs for a few days and be cured. In modern times it may be unrealistic, for example, to expect Internet addicts to abstain from computer altogether, and emphasis of treatment would be on identifying and addressing underlying core issues feeding a behavior, reducing computer usage. Most individuals with addiction will require ongoing advice, support and structured care and support/ therapy to achieve desired goal, of sustained abstinence, harm minimization, change in patterns of behavior and balanced lifestyle.
It is my opinion that any treatment programme must incorporate 3 steps: Intervention, treatment and rehabilitation. These three steps will include an effective combination of early identification, medicinal and psychological intervention (counselling or psychotherapy/ talking therapy, behavior modification, support groups, etc) and ongoing support.
The following is an overview of some of the commonly used approaches to treatment of addiction, in particular alcohol dependency.
Early detection and Brief Intervention: Effective early detection can be done with detailed account of alcohol, drugs and behavior in question from the individual. Speaking with spouse and family member is important as addicts may underestimate their problem due to subjective shame and guilt. Brief intervention involves 5-10 minutes of information and advice, with 2-3 short session of motivation intervention to encourage change of behavior. It can be conducted in general health settings, designed for health professional who do not specialize in addiction treatment. It aims at reducing drinking, and behavior rather than abstinence. However it has been used in dependent individuals to motivate to enter specialized treatment programme. Freemantle and his colleagues (1993) demonstrated effectiveness of brief intervention with 24% reduction in alcohol intake by the end of the year.
Motivational Interviewing (MI): Initially description by William Miller (1983), this technique focuses on exploring and resolving ambivalence and centers on motivational processes within the individual that facilitate change. It centers on the idea that individual with problem drinking or behavior may recognize it but will require assistance in addressing their ambivalence for change. It uses specialized psychotherapeutic technique to encourage the individual to set realistic goals, using positive feedback to encourage and sustain progress and change. Psychotherapeutic approaches like Brief Intervention and Motivational Enhancement Therapy (MET) is underpinned by Motivational Interviewing.
Cognitive Behavioral Therapy (CBT): A form of psychotherapy or talking therapy initially developed for treatment of anxiety and depression. It is based on the idea that feelings and behaviors are caused by a person’s thoughts, not on outside stimuli like people, situations and events. People may not be able to change their circumstances, but they can change how they think about them and therefore change how they feel and behave. In the treatment of various addictions, the goal of cognitive behavioral therapy is to teach the person to recognize situations in which they are most likely to indulge in drink, drug or behavior, avoid these circumstances if possible, and cope with other problems and behaviors which may lead to their said habit.
General Counselling and Supportive Therapy: It centers on addressing emotional issues and problems that may be contributing to addictive behavior. It can be used as an effective method to enable individual develop insight and understanding of problem and associated issues, and help considering specialized intervention.
Medicinal Therapy: Commonly used to assist individuals with drug dependence especially alcohol and opioid dependence. It centers on the idea that by easing the symptoms of withdrawal and craving one may assist individuals in achieving drug free status and encouraging further engagement in motivational processes for sustaining change. This intervention must always be done along side of psychological intervention described above. Various form of medicinal treatment is used in hospital and out-patient setting for alcohol and drug detoxification. Choice of setting is guided by severity of dependence, successes of any previous treatment approaches, available support from family and friends, associated psychiatric and medical illness, besides individual personal resource to engage in therapeutic processes. For alcohol dependency, a reducing dose of minor tranquilizing medication like Diazepam and Chlordiazepoxide are commonly used for detoxification. Other drugs like Disulfiram (Antabuse), naltrexone, and acamprosate are among the most common drugs used for treatment of alcohol dependency, as they enable aversion, reducing euphoric effect of alcohol and craving respectively.
In some individuals who has experienced recurrent relapses to addiction and those with severe underlying mental illness, prolonged residential rehabilitation may be required for effective deliver many of the above-mentioned intervention, and enable development of lasting personality change and alternative coping strategies.
For all behavioral addiction the above psychological strategies applies, with importance of practical advice, support and strategies. It is important to recognize medical and psychiatric co-morbidities, which will require specific treatment. Unattended underlying illness and psychological problems are important factor in relapse.
Addiction is a treatable disease. Highly structured and empathic approach is required when dealing with individuals presenting with drug or behavioral dependency, as it is likely that they will be plagued with guilt and shame, and be suffering from ambivalence or skepticism about change. There is no substitute for being thorough in evaluating the said behavior and habit, and all treatment should be patient centered. It is important to recognize that motivation fluctuates, and to err is human! Therefore relapse should not be seen as a failure of the individual or treatment modality, but rather as an opportunity to further individual understanding of the addiction and associated issues.
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