Addiction 101: History, Etiology, & Treatment - PowerPoint Presentation

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Addiction 101: History, Etiology, & Treatment

Thomas M. Workman, PhD, LPC, NCC, ACSKevin Caridad, PhD, LCSW

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Objectives

To identify the primary historical shifts in the conceptualization of addictionDevelop a basic understanding of the genetic and neuropsychological factors influencing addiction

To identify common risk factors influencing addiction

To identify effective and evidence-based treatments, including barriers

Discuss applications & opportunities for advancement

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History of Addiction

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Before the Disease

Humans have been seeking highs for a very long timeWe can argue that we start from a very young age

The Moral Model

Prior to the Disease Concept addiction was a moral failing

The individual was seen as

Bad

Weak

Responsible for the problems of societyLacking values and moralsStill apparent in some aspects of society today

(Miller, 2015)

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The Disease of Addiction

Formulated in the late 1800’s - Magnus HussInstead of bad, the alcoholic was sick

Provided easy concept of addiction to grasp

E. M.

Jellinek

– wrote on the disease model in 1900’s and brought it more mainstream

Provided bridge between AA & treatment centers

Provided information on the stages of addiction/progressionConcept of recoveryEncouraged the creation of self-help groups.Members of AA began employment in treatment facilities

(Miller, 2015)

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Evolution of Treatment

Lay therapy began in 1913Within Boston’s Emmanuel ChurchLay counselors were typically in recoveryAA came around in 1935 & looked at alcoholism as an allergy to alcoholNear the same time of AA

Research funded by government started

Also started 2 treatment programs in prisons

1973 HMO act passed

Decreased legal restrictions & provided loans

1980’s increased counseling demand & less money pressured more efficient/less costly counseling

(Miller, 2015)

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Etiology

Basic NeuropsychologyGenetic ContributionsPersonal & Systemic Factors

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Basic Neuropsychology

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PlasticityKey in development of addictionsBrain’s ability to change & adapt to accommodate learning

More & new neural connectionsDisconnect & death of existing connectionsStronger synapsesStrengthening of current neuronsDrugs remodel the brain’s structure in reward pathways

(Hall & Walker, 2017)

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Some Key Players

Dopamine (DA) – movement, goal-directed behavior, cognition, attention, and rewardMesocorticolimbic DA system – primary reward circuit is divided into 2 parts mesolimbic pathway

Reward prediction

mesocortical

pathway

Executive functions: working

memory, behavioral flexibility,

decision makingPleasurable sensations following drug use linked to increased levels of DA in mesolimbic pathway

(Hall & Walker, 2017)

Lister Hill National Center for

Biomedical Communications

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Cravings & Discomfort

CravingsHippocampus - memory formation & consolidation

When stimulated by enough firing, individual forms associations between reward cues & environmental stimuli

Conditioned response, based on expectation of reward

Frequency and intensity of DA exposure associated with stimuli have implications for this process to take place

Prefrontal cortex is impaired, habit pathways supersede executive function

Discomfort & tolerance

Positive hedonic & negative hedonic states are inversely relatedThe Amygdala - emotional response to environmental stimuliThe more drugs excessively stimulate natural (primary) reward system, the Amygdala has an anti-reward response

Less sensitive one becomes to drugs the more sensitive one becomes to unpleasant stimuli

(Hall & Walker, 2017)

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Genetic Contributions

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Genetic Factors

Unlike disorders such as Down Syndrome, no single gene has been identified (Duncan, 2012)Over 1,500 genes have been linked to addiction (Duncan, 2012)There is a cumulative effect with regard to genetic transmission (Duncan, 2012)The basic premise to understand is that there is not one addiction gene. Genes related to addiction can be in various domains (Hall & Walker, 2017)

Planning and decision making

Impulse control

Compulsivity

Social competence

Emotion Regulation

Sensitivity to specific substancesExtinction LearningOther mental health dx (Depression, Bipolar, Anxiety, and others)Coaction

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Twin StudiesPredispose an individual to becoming addicted ranges from 40% to 70%

Alcohol: 50%Cocaine 60%Opioids 70%Increased risk if first-degree relative has a substance abuse disorder (4 – 8x)Increased risk if a first-degree relative has a process addiction

(Duncan, 2012)

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Alcohol Metabolization Example

Alcohol is metabolized by several processes or pathways. The most common of these pathways involves two enzymes—alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH). These enzymes help break apart the alcohol molecule, making it possible to eliminate it from the body.

First, ADH metabolizes alcohol to

acetaldehyde

, a highly toxic substance and known carcinogen

Acetaldehyde

is further metabolized down to another, less active byproduct called

acetate, which then is broken down into water and carbon dioxide for easy elimination.High levels of acetaldehyde make drinking unpleasantresulting in facial flushing, nausea, and a rapid heart beat

Different versions of these enzymes are present in different ethnic groups are may contribute to, or protect against, alcoholism

(NIH, 2007)

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Co-occurring Disorders

Estimated that nearly 40% of individuals with substance use disorders also meet the criteria for another co-occurring mental health diagnosis (Gros,

Milanak

, Brady, & Back, 2013; SAMHSA, 2017)

Possible genetic contribution to addiction

Individuals who have a co-occurring mental health diagnosis may require additional treatment to help them cope with other variables in their lives.

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Interventions & Evidence-Based Treatments

Early Intervention & PreventionHarm Reduction

Evidence-Based Treatments

Treatment-Related Issues

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Early Intervention & Prevention

Prevention and early intervention are the most promising means (NIH, 2014)

Early as preschool to address specific risk factors that eventually lead to drug use: emotion regulation, aggressive behaviors, and poor social skills (Webster-Stratton, Reid, & Hammond, 2001)

O'Connell, Boat, and Warner (2009) provide a list of effective components:

Interaction among participants

Direct and indirect influences on drug use

Emphasize social norms that involve a commitment to not use drugs

Community components and peer leadersTraining in life skills and social resistance skills Positive effects of these efforts tend to wane if interventions are not built systematically into the child’s development (

Scheier

&

Botvin

, 1999)

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Harm Reduction

As opposed to abstinence-based treatment models, harm reduction focuses on reducing the amount of drug use or reducing the harm associated with drug use. (Little &

Franskoviak

, 2010).

Harm reduction recognizes and supports abstinence while acknowledging the progressive steps that the individual has taken towards a healthier lifestyle (Little &

Franskoviak

, 2010)

Needle distributionDesignated driversIgnition Interlock DeviceWound care educationNon-abstinence goals

Distribution of naloxone

Safe use areas

Embedding professionals in high-risk communities and buildings

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Recommended Treatment Approaches

Cognitive Behavior Therapy (NIH, 2014)

Contingency Management (NIH, 2014)

Motivational Enhancement Therapy (NIH, 2014)

Family Therapy (NIH, 2014)

Medication-Assisted Treatment

Approaches are not implemented with fidelity (Olmstead et al., 2012)

Most treatment centers do not provide ongoing training and monitoring in the implementation of evidence-based practices, and they do not require new professionals to have a working knowledge of these practices (Olmstead et al., 2012)Ongoing training, education, and accountability are necessary to assure that the approaches that research has shown to be effective are implemented and with fidelity (Beidas

& Kendall, 2010)

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Medication-Assisted Treatment

Suboxone, Subutex, Buprenorphine, Vivitrol, Naltrexone, Methadone

Added to existing treatments and are show to enhance outcomes (van den Brink, 2012)

Treatment with Naltrexone, which only blocks opioid receptors, is shown to be effective with only a small number of patients who are highly motivated for treatment (van den Brink, 2012)

Use of MAT is far from perfect as dropout rates remain high (van den Brink, 2012)

Risk factors for dropout include:

Co-occurring diagnoses (Clark, et al., 2015;

Ferri et al., 2014)Concurrent other substance use (Clark, et al., 2015; Ferri

et al., 2014)

More previous treatment episodes (Clark et al., 2015)

First degree relative with substance abuse (

Evren

, 2014)

Involvement in probation (

Evren

, 2014)

History of suicide attempts (

Evren

, 2014)

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In Conclusion

Goal for today: Provide a basic overview of addiction regarding history, etiology, and treatment

Apparent that risk and opportunity exist in multiple domains across the life span

We will likely need to work across professional groups in order to develop more effective systemic and systematic solutions

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References

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Clark, R. E., Baxter, J. D.,

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medicaid

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