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Addiction

Addiction



Dr. C. Ramasubramanian MD. (Psy) DPM.,
Consultant Psychiatrist,
Madurai

Introduction

The burden of mental, behavioral and substance abuse disorders are both due to the increasing numbers and significant disability resulting from disorders. Alcohol abuse is a common public health problem with substantial impact on family and society. The lifetime prevalence of alcohol use (not abuse/ dependence) ranges from 34 % to 42 % and of other drugs (excluding tobacco) 7-12 %, the current (1 month) prevalence of opiate use: 0.7-1.6 %, cannabis: 0.4-1.7 % and minor tranquilizer: 0.1-0.2 % (Country Profile – India, 1998). 

Definition:
Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain — they change its structure and how it works. These brain changes can be long lasting and can lead to the harmful behaviors seen in people who abuse drugs.

The following statements can be used to identify addiction.
Answer yes or no to the following seven questions. Most questions have more than one part, because everyone behaves slightly differently in addiction. You only need to answer yes to one part for that question to count as a positive response.

  1. Tolerance. Has your use of drugs or alcohol increased over time?
  2. Withdrawal. When you stop using, have you ever experienced physical or emotional withdrawal? Have you had any of the following symptoms: irritability, anxiety, shakes, sweats, nausea, or vomiting?
  3. Difficulty controlling your use. Do you sometimes use more or for a longer time than you would like? Do you sometimes drink to get drunk? Do you stop after a few drink usually, or does one drink lead to more drinks?
  4. Negative consequences. Have you continued to use even though there have been negative consequences to your mood, self-esteem, health, job, or family?

Neglecting or postponing activities. Have you ever put off or reduced social, recreational, work, or household activities because of your use?
Spending significant time or emotional energy. Have you spent a significant amount of time obtaining, using, concealing, planning, or recovering from your use? Have you spend a lot of time thinking about using? Have you ever concealed or minimized your use? Have you ever thought of schemes to avoid getting caught?

  1. Desire to cut down. Have you sometimes thought about cutting down or controlling your use? Have you ever made unsuccessful attempts to cut down or control your use?

If you answered yes to at least 3 questions, then you meet the medical definition of addiction. This definition is based on the American Psychiatric Association (DSM-IV) and the World Health Organization (ICD-10) criteria.

Different Types of Substance Addictions

Substance addictions are those addictions where a person tends to ingest or administer himself with a certain substance. These substances may include drugs, alcohol, LSD, etc. Most of the time these substances are used for recreational or medicinal purposes. The psychological feelings and euphoria they seem to impart tends to make a person get addicted to these substances.

Caffeine Addiction:

One of the commonly observed addictions today is caffeine addiction. People tend to drink coffee and tea as a socially accepted beverage. However, caffeine tends to have stimulant effects and helps a person stay awake. It gives mental alertness and imparts calming effects on the mind. But, when one tends to drink more than 4-5 cups of coffee or tea in a day he/she may be addicted to caffeine. These people cannot work till they do not have a cup of their favorite caffeine beverage, they become restless to have it, they can’t concentrate without it, they seek relief only in downing their favorite drink.

Alcohol Addiction:
Alcohol addiction is one of the most common addictions plaguing society. People from all walks of life tend to suffer from alcohol addictions. Most of the alcoholics tend to drink to overcome their feelings of anxiety, depression and low self confidence. A person tends to develop tolerance to alcohol and begins to drink more to achieve the same stimulation feelings. They spend more time drinking alcohol and are unsuccessful trying to give up drinking.

Nicotine Addiction:
Smokers are addicted to nicotine addiction, an alkaloid found in tobacco. The nicotine addiction is the second leading cause of death around the world. Nicotine is drugs that causes euphoria and makes the person get used to the feeling. It also helps reduce anxiety and has sedative effects on the mind.
Cocaine Addiction:
One of the most expensive drugs in the market is cocaine. It is one of the most widely abused substances in the United States as well as other parts of the world. This drug causes euphoria and increases sexual desire. It leaves the user filled with energy and gives them a feeling that they can achieve anything in the world. It tends to make a shy person more outgoing. Addicts find all their five senses heightened. It also suppresses appetite that makes users who want to lose weight more attracted to it. Soon, a person loses control over his/her life and tends to rob his own family. These addicts may take up other criminal jobs just to earn money. As I have mentioned, cocaine is a very expensive drug and highly addictive. The obsession to the drug makes the user dependent on it and even brings them to the brink of suicide.
Opiate Addiction:
One of the most common addictions in the United States is abuse of prescription drugs. Patients are given painkillers that contain opiates, a type of narcotic drug. It is usually given to people who are in great pain due to serious injuries and have undergone some major surgery. These opiates give the patient a feeling of well being, happiness, in other words, make the patient ‘feel good’. The patient begins to develop a strong desire or compulsion to take the drug. He/ she feels that without the drug the pain will intensify. Their body begins to grow tolerant to the drug and the patient begins to take high doses to achieve the effect. This drug abuse leads to liver damage, change in mood and impairment of cognitive function.

Heroin Addiction:
Heroin is one of the most addictive drugs that give an instant high to the user. It gives a certain ‘rush’ to the brain that gets people hooked to it after single use. It can either be injected, snorted or smoked. It tends to affect the central nervous system and slows down respiration. Over a period of time, regular use of heroin addiction lowers the respiratory rate so much, that it leads to instant death. The body tends to adapt very quickly to the drug and an addict needs to regularly ‘up’ the doses to achieve the effect. However, one will never experience the same effects they had the first time, how much ever they try increasing the dose.

Methamphetamine Addiction:
Methamphetamine addiction or meth addiction is a very dangerous addiction. It is a street drug that is called ‘speed’ or ‘chalk’. This drug is also available in crystallized form and looks like ice. It can be inhaled by smoking and therefore called as ‘crystal’, ‘ice’, ‘glass’, etc. It induces euphoria and helps people lose weight. However, it soon becomes addictive and regular use damages the central nervous system. Crystal meth effects include sleep disorders, physical exhaustion, failure to regulate body temperature, etc. The drug induces a feeling of superiority in the user and its effect can last for 3 to 18 hours.

Marijuana Addiction:
You may recognize marijuana by names such as ‘pot’, ‘weed’, ‘herb’, ‘chronic’, etc. It is the most widely used illegal drug in America. Marijuana causes problems with concentration, inflammation of the whites of the eyes, paranoia, stupor, etc. It has a major impact on one’s life as well as health.

Principles of Effective Treatment

Scientific research since the mid – 1970s shows that treatment can help patients addicted to drugs stop using, avoid relapse and successfully recover their lives. Based on this research, key principles have emerged that should form the basis of any effective treatment programs:

  • Addiction is a complex but treatable disease that affects brain function and behavior.
  • No single treatment is appropriate for everyone.
  • Treatment needs to be readily available.
  • Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.
  • Remaining in treatment for an adequate period of time is critical.
  • Counseling — individual and/ or group — and other behavioral therapies are the most commonly used forms of drug abuse treatment.
  • Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.
  • An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs.
  • Many drug–addicted individuals also have other mental disorders.
  • Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long–term drug abuse.
  • Treatment does not need to be voluntary to be effective.
  • Drug use during treatment must be monitored continuously, as lapses during treatment do occur.
  • Treatment programs should assess patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases as well as provide targeted risk–reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases.

Effective Treatment Approaches

Medication and behavioral therapy, especially when combined, are important elements of an overall therapeutic process that often begins with detoxification, followed by treatment and relapse prevention. Easing withdrawal symptoms can be important in the initiation of treatment; preventing relapse is necessary for maintaining its effects. And sometimes, as with other chronic conditions, episodes of relapse may require a return to prior treatment components. A continuum of care that includes a customized treatment regimen — addressing all aspects of an individual’s life, including medical and mental health services — and follow–up options (e.g., community – or family-based recovery support systems) can be crucial to a person’s success in achieving and maintaining a drug–free lifestyle.

Medications

Medications can be used to help with different aspects of the treatment process.

Withdrawal: Medications offer help in suppressing withdrawal symptoms during detoxification. However, medically assisted detoxification is not in itself “treatment” — it is only the first step in the treatment process. Patients who go through medically assisted withdrawal but do not receive any further treatment show drug abuse patterns similar to those who were never treated.

Treatment: Medications can be used to help reestablish normal brain function and to prevent relapse and diminish cravings. Currently, we have medications for opioids (heroin, morphine), tobacco (nicotine), and alcohol addiction and are developing others for treating stimulant (cocaine, methamphetamine) and cannabis (marijuana) addiction. Most people with severe addiction problems, however, are polydrug users (users of more than one drug) and will require treatment for all of the substances that they abuse.

  • Opioids: Methadone, buprenorphine and, for some individuals, naltrexone are effective medications for the treatment of opiate addiction. Acting on the same targets in the brain as heroin and morphine, methadone and buprenorphine suppress withdrawal symptoms and relieve cravings. Naltrexone works by blocking the effects of heroin or other opioids at their receptor sites and should only be used in patients who have already been detoxified. Because of compliance issues, naltrexone is not as widely used as the other medications. All medications help patients disengage from drug seeking and related criminal behavior and become more receptive to behavioral treatments.
  • Tobacco: A variety of formulations of nicotine replacement therapies now exist —including the patch, spray, gum, and lozenges — that are available over the counter. In addition, two prescription medications have been FDA–approved for tobacco addiction: bupropion and varenicline. They have different mechanisms of action in the brain, but both help prevent relapse in people trying to quit. Each of the above medications is recommended for use in combination with behavioral treatments, including group and individual therapies, as well as telephone quitlines.
  • Alcohol: Three medications have been FDA–approved for treating alcohol dependence: naltrexone, acamprosate, and disulfiram. A fourth, topiramate, is showing encouraging results in clinical trials. Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking and in the craving for alcohol. It reduces relapse to heavy drinking and is highly effective in some but not all patients — this is likely related to genetic differences. Acamprosate is thought to reduce symptoms of protracted withdrawal, such as insomnia, anxiety, restlessness, and dysphoria (an unpleasant or uncomfortable emotional state, such as depression, anxiety, or irritability). It may be more effective in patients with severe dependence. Disulfiram interferes with the degradation of alcohol, resulting in the accumulation of acetaldehyde, which, in turn, produces a very unpleasant reaction that includes flushing, nausea, and palpitations if the patient drinks alcohol. Compliance can be a problem, but among patients who are highly motivated, disulfiram can be very effective.

Behavioral Treatments

Behavioral treatments help patients engage in the treatment process, modify their attitudes and behaviors related to drug abuse, and increase healthy life skills. These treatments can also enhance the effectiveness of medications and help people stay in treatment longer. Treatment for drug abuse and addiction can be delivered in many different settings using a variety of behavioral approaches.

Outpatient behavioral treatment encompasses a wide variety of programs for patients who visit a clinic at regular intervals. Most of the programs involve individual or group drug counseling. Some programs also offer other forms of behavioral treatment such as —

  • Cognitive–behavioral therapy, which seeks to help patients recognize, avoid and cope with the situations in which they are most likely to abuse drugs.
  • Multidimensional family therapy, which was developed for adolescents with drug abuse problems — as well as their families — addresses a range of influences on their drug abuse patterns and is designed to improve overall family functioning.
  • Motivational interviewing, which capitalizes on the readiness of individuals to change their behavior and enter treatment.
  • Motivational incentives (contingency management), which uses positive reinforcement to encourage abstinence from drugs.

Residential treatment programs can also be very effective, especially for those with more severe problems. For example, therapeutic communities (TCs) are highly structured programs in which patients remain at a residence, typically for 6 to 12 months. TCs differ from other treatment approaches principally in their use of the community — treatment staff and those in recovery — as a key agent of change to influence patient attitudes, perceptions and behaviors associated with drug use. Patients in TCs may include those with relatively long histories of drug addiction, involvement in serious criminal activities and seriously impaired social functioning. TCs are now also being designed to accommodate the needs of women who are pregnant or have children. The focus of the TC is on the re-socialization of the patient to a drug-free, crime–free lifestyle.

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