Elsevier

Disease-a-Month

Volume 54, Issue 10, October 2008, Pages 696-721
Disease-a-Month

The Disease of Addiction: Origins, Treatment, and Recovery

https://doi.org/10.1016/j.disamonth.2008.07.002Get rights and content

Introduction

Addiction can be defined as the continued use of mood-altering addicting substances or behaviors (e.g., gambling, compulsive sexual behaviors) despite adverse consequences. We have learned that alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by continuous or periodic impaired control over drinking, preoccupation with the alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial.1 This is a definition forwarded in JAMA in 1992, and includes the thinking of the American Society of Addiction Medicine and the National Council on Alcoholism and Drug Dependencies. Since that time, continued exploration of the nature of addiction includes other mood-altering substances aside from alcohol, as well as a number of highly reinforcing behaviors.

The common pathways in reward circuitry that affect memory and learning, motivation, control, and decision making are also involved in the addictive process. With the more global understanding of addiction come more treatment strategies, such as meditation and mindfulness training, psychosocial interventions, and pharmacologic approaches. Interestingly, our growing understanding of addiction as a disease has not diminished the value of the spiritually driven approaches, such as 12-step-oriented treatments, that are outlined in this article. An understanding of the disease of chemical dependency, and the multiple approaches to treatment, can assist the primary care physician (PCP) in the treatment of addiction. The PCP is an essential member of the extended treatment team and at the forefront of patient care.

Substance abuse negatively impacts public safety, reduces workers' productivity, and contributes to higher healthcare costs, premature deaths, and disability for millions of Americans.2 Despite this massive health problem, only a fraction of affected people get the help they need. A report released in September 2007, by the Substance Abuse and Mental Health Services Administration (SAMHSA), shows that, in 2006, 23.6 million persons aged 12 or older (9.6% of the population) required treatment for alcohol or drug problems with only 2.5 million receiving the help.3 The PCP is often the first (and sometimes only) clinician to interface with the active addict. This article supplements June 2007 Disease-a-Month, “Substance-related disorders in adults” by Jerold B. Leiken, MD,4 in which he outlines a practical approach to addressing various clinical presentations of substance abuse, including withdrawal states, potential toxicities, and pharmacologic management strategies. His overview assists the PCP with substance-abusing patients in an office, hospital, or medical setting. This article targets the addict in a mental health setting, such as an addiction treatment program.

The purpose of this article is to further educate the PCP and practitioner in their understanding of addiction and its treatment in a 12-step, abstinence-based treatment program. It will include an outline of the neurobiology of addiction, a brief history and description of Alcoholics Anonymous, the influence of personality on addiction and treatment, the impact on the addict's family and loved ones, and the ongoing need for spiritual growth and nonchemical coping skills to maintain long-term sobriety. A necessary addition describes Addiction Interactive Disorder which is a global understanding of addiction. It will also emphasize the treatment of addicted professionals: health-care professionals (e.g., physicians, dentists, pharmacists, and nurses), lawyers, executives, and those in safety-sensitive positions (e.g., airline pilots). This group of addicted patients has unique characteristics that may facilitate better treatment outcomes, but also offer certain challenges for the treatment team. The goal of treatment is to replace the addiction with growth in character and satisfaction with lifestyle, or a positive sobriety.

PCPs often complain about limitations and frustrations when treating addicted patients. Some of these patients are candidates for stabilization and treatment in a general hospital or office setting. Many others will require specialized, comprehensive treatment as described in this article. The PCP is often in a key position to initially diagnose and refer the addicted patient to the appropriate treatment program. The PCP needs more than a list of treatment providers or Alcoholics Anonymous meetings. The patient will rarely express eagerness for treatment that requires a solid commitment; therefore, an educated, empathic, and hopeful approach will have greater success in guiding the patient toward health and sobriety. The physician is often the one person an addicted individual will hear because of their role as a respected confidant.

Section snippets

An Overview of the Neurobiology of Addiction

Chemical dependency is defined as the compulsive use of mood-altering chemicals or continued engagement in addictive behaviors despite adverse consequences. Much research and clinical study has been done to further document and recognize chemical dependency as a disease. A percentage of the population has a biogenetic predisposition to chemicals and/or addictive behaviors; however, early life traumatic experience, such as isolation or abuse, can also contribute to a predisposition to addiction.

Addictive Interactive Disorders

As early as the 19th century, there are references in medical texts to the interaction between addictions. It was called “intemperance,” which states that the use of alcohol and tobacco will lead to excessive eating, sexual behavior, and other misadventures. Addiction Interactive Disorder (AID)15 implies that addiction has many forms, such as gambling, food, sex, work, certain financial behaviors, and even religiosity. Addictions do not just coexist; they reinforce, intensify, or become part of

The Role of Twelve-Step Recovery

Alcoholics Anonymous (AA) is the most widely used resource for alcoholism and addiction recovery utilized by addicts and treatment programs. AA meeting attendance is positively associated with long-term abstinence.18 Twelve-Step Recovery is a spiritual program that supports a healthier relationship with self, others, and ultimately a power greater than self. It is also a practical program that identifies three key components for sobriety: (1) what is the problem? (2) What is the solution? (3)

Chemical Dependency Treatment

The addicted brain struggling with deficits in reward, learning and memory, motivation, and decision making requires a comprehensive treatment approach. Physical, psychosocial, spiritual, and, in many cases, pharmacological interventions are necessary in treating addicted individuals. The disease model of addiction has promoted a number of effective pharmacological approaches to addiction; however, non-pharmacotherapeutic interventions are necessary as well. As mentioned earlier, most

Specific Treatment Strategies

A number of different therapeutic strategies in the treatment of addictions are available to patients. Project Match (1997) is the largest trial ever conducted for alcohol treatment methods. This trial evaluated 1726 clients at 9 sites matching patients to 3 types of treatment strategies: 12-Step Facilitation, Cognitive–Behavioral Skills Training, and Motivational Enhancement Therapy. Overall, Project Match participants showed significant and sustained improvement in decreased number of

Specialized Treatment for Professionals

Specialized treatment programs for health care and other professionals have specialized staff and programming that cater to a high-accountability population. They often have a peer group setting that both supports and confronts the feelings of uniqueness common to most professionals. Programs for professionals typically involve residential or partial programs with independent living and longer length of stays. As mentioned earlier, there is evidence that the longer the length of stay, the

Conclusion

Addiction constitutes a major health problem, yet so many addicts are left untreated. With the mounting evidence that verifies addiction as a disease, it is the hope of the authors that these individuals will be less harshly judged and have more access to treatment. The PCP is in a pivotal role to begin that process. Professionals with addictions are particularly sensitive to the stigma of the label of alcoholic or addict and desperately need their peers to understand and support their recovery.

First page preview

First page preview
Click to open first page preview

References (31)

  • K. Akiskal et al.

    Temperament profiles in physicians, lawyers, managers, industrialists, architects, journalists, and artists: a study in psychiatric outpatients

    J Affect Disorders

    (2005)
  • R. Morse et al.

    The definition of alcoholism

    J Am Med Assoc

    (1992)
  • C.M. Hughes

    Substance Abuse and the Nation's Number One Health Problem

    (2001)
  • Most who need addiction treatment don't receive it

    American Society of Addiction Medicine Newsletter

    (2007)
  • J. Leiken

    Substance related disorders in adults

    Dis Mon

    (2007)
  • G. Koob et al.

    Stress, dysregulation of drug reward pathway, and the transition to drug dependence

    Am J Psychiatry

    (2007)
  • C. Gianoulakis et al.

    Enhanced sensitivity of pituitary beta-endorphin to ethanol in subjects at high risk of alcoholism

    Arch Gen Psychiatry

    (1996)
  • E. van den Wildenberg et al.

    A functional polymorphism of the mu-opioid receptor gene (ORPMI) influences cue-induced craving for alocohol in male heavy drinkers

    Alcohol Clin Exp Res

    (2007)
  • Alcohol alert

  • P. Kalivas

    Predisposition to addiction: pharmacokinetics, pharmacodynamics, and brain circuitry

    Am J Psychiatry

    (2003)
  • A. Leshner

    Addiction is a brain disease, and it matters

    Science

    (1997)
  • P.W. Kalivas et al.

    The neural basis of addiction: a pathology of motivation and choice

    Am J Psychiatry

    (2005)
  • S.E. Hyman

    Addiction: a disease of learning and memory

    Am J Psychiatry

    (2005)
  • X. Noël et al.

    The neurocognitve mechanisms of decision making, impulse control, and loss of will power to resist drugs

    Psychiatry

    (2006)
  • R.Z. Goldstein et al.

    Drug addiction and it's underlying neurobiological basis: neuroimaging evidence for the involvement of the frontal cortex

    Am J Psychiatry

    (2002)
  • Cited by (52)

    • Early maladaptive schemas, behavioral inhibition system, behavioral approach system, and defense styles in natural drug abusers

      2016, Polish Annals of Medicine
      Citation Excerpt :

      Addiction is a state defined by compulsive engagement in rewarding stimuli. Despite adverse consequences, it can be thought of as a disease or biological process leading to such behaviors.1 A natural drug is a chemical compound or drug produced by a living organism that is found in nature.

    • In Silico Chemogenomics Knowledgebase and Computational System Neuropharmacology Approach for Cannabinoid Drug Research

      2016, Neuropathology of Drug Addictions and Substance Misuse Volume 3: General Processes and Mechanisms, Prescription Medications, Caffeine and Areca, Polydrug Misuse, Emerging Addictions and Non-Drug Addictions
    View all citing articles on Scopus
    View full text