Myth or Medicine
Major advancements in neurological science are changing the way experts understand and treat addiction. Learn from some of the country's leading experts what the latest medical research tells us about treating addictive behaviors in men and women.
What is addiction?
Addiction is not limited to certain social classes, nor to a person who fits a certain "profile." Neither does it refer exclusively to abuse of or dependence on illegal drugs or alcohol. It does refer to a condition in which people cannot control their craving for a substance. But while alcohol and illegal drugs grab all the headlines, one can be addicted to a wide range of substances or even activities. In this Second Opinion episode, the patient is a health-care professional addicted to a medication that helps her cope with headaches.
Addiction is a brain disease. Its causes are complex but its results are clear. The addicting substance changes the way the brain works. These changes lead to the behaviors we recognize as the symptoms of addiction. Like most other diseases, addiction can be treated. While treatment can be long and difficult and there are often relapses, it can be successful.
Symptoms of addiction
In the past, addiction and its symptoms, including the uncontrollable craving for the substance, willingness to go to extremes to get it, taking risks, acting undependably, and ignoring all responsibilities while under its influence, were seen as moral weaknesses or spiritual failings. That, and the idea that addicts are criminals who should be punished, are some of the many myths that shaped public policy about addiction and, unfortunately, still have a profoundly negative influence on it. Despite what some lawmakers believe, or think the public believes, most medical experts know that our national drug policies will be ineffective. The way it is being fought now, the "war on drugs" will never be won.
Addiction Quick Facts
- Addiction is not limited to certain social classes, nor to a person who fits a certain "profile."
- Addiction is a brain disease. Addicting substances change the way the brain works, especially its "reward circuits" or "pleasure pathways." These changes lead to the behaviors we recognize as the symptoms of addiction.
- It is estimated that about 3.6 million people in the U.S. are addicted to or dependent on a wide range of drugs. In addition, there are about 18.7 million alcoholics.
- The line between "substance abuse" and "addiction" can seem vague, but medical professionals have specific criteria they use to distinguish between the two. Both conditions are diagnosed by considering people's behavior. The American Psychiatric Association lists a number of behaviors it considers symptomatic of addiction, and says a person must do three or more of them within a twelve-month period to be considered "substance dependent."
- There are a variety of risk factors that make people more vulnerable to becoming addicted. These factors are both genetic and environmental. For example, at least 60 percent of alcoholics have family histories of alcoholism.
- Addiction is a chronic condition. Relapse is common among people with chronic conditions. In the case of people recovering from addiction, relapse occurs because the effects of addiction on their brains make them especially vulnerable to it.
- Treatment for addiction can be successful. It usually involves both medication and some form of psychotherapy--individual or group, including such well-known 12 Step groups as Alcoholics Anonymous
- Effective treatments recognize that, at first, taking the addictive substance makes the person feel better than they normally do.
- Treatment should be thought of as a three-stage process. The stages are:
- Continuing care
Addiction Ask Your Doctor
Asking your doctor the right questions about a condition is always important. But in the case of addiction, answering the doctor's questions may be even more important. Doctors diagnose substance abuse and addiction by considering a person's behavior, and how that behavior is being affected by the substances the person is using. Therefore, the doctor needs complete and honest answers to questions about your (or the suspected abuser's) behavior.
If you (or a loved one) is abusing a drug or in danger of becoming addicted, you might ask yourself, or have the doctor ask you:
- During the past year, how often did you fail to meet responsibilities (educational, professional, or social) because you were too busy trying to get the substance or were under its influence?
- During the past year, how often did you act recklessly or put yourself or others in danger while under the substance's influence?
- During the past year, have you had legal problems that were caused by your pursuit of or use of the substance?
- During the past year, did you continue to use the substance even though you felt that using it was causing you harm?
- During the past year, how often did you try but fail to stop using it?
- During the past year, did you try to stop using it and then felt withdrawal symptoms (physical or psychological)?
- During the past year, how often did you use more of it, or use it more frequently, than you planned?
- During the past year, how often did you need to use more of it than you had previously to feel its effects?
- During the past year, how often have you ignored friends, hobbies, work, school, or other activities because you were looking for or using it?
On the other hand, if you (or a loved one) are considering entering a treatment program (especially a residential program), these are some questions to ask:
- What kind of treatments do you use and how do they work?
- Do you have a credentialed psychiatrist on your treatment staff?
- Do you provide individual psychotherapy and/or counseling?
- Do you treat anxiety, mood disorders, and other psychological problems?
- Do you approve of and give medications?
- Are there studies that support the treatments that you use in your program?
- How do you monitor the quality/success of your program?
- How do you judge if the patient is getting better? What do you do if there are no signs of progress?
- Is the family involved in the treatment process? How?
- How will family members be prepared when the patient returns home?
- How do you test patients for substance abuse? Do you do urine tests?
- What continuing care options are available? How long do they continue?
- Do you try to connect patients to mutual help groups such as AA?
- Who pays for the treatment? How?
Key Point 1
Addiction affects millions of Americans. It's not simply a failure of will or character; it is a disease of the brain.
According to various estimates, about 3.6 million people in the U.S. are addicted to or dependent on a wide range of drugs. Many are addicted to more than one. In addition, there are about 18.7 million alcoholics. Millions more are functionally addicted to things we don't consider drugs, such as tobacco, caffeine and food, as well as to activities such as gambling, shopping, sex and spending time on the internet.
Of course, the term addiction can be used too loosely, so let's look at some definitions. Addiction is diagnosed by considering people's behavior. How much do they seem to need the substance (or addicting agent) to function? What are they willing to do to get it? How reckless and risky do they act while feeling its effects? How much do they ignore other things in their lives as they pursue what they're addicted to?
The line between addiction and substance abuse can seem vague, but medical professionals have specific criteria to distinguish them. Substance abuse causes harm to the user; people are considered to be abusing a substance if, during a twelve month period, they do any one of the following:
- Fail to meet responsibilities (educational, professional, or social) because of it
- Act in a reckless manner while under its influence
- Have legal problems because of it
- Continue to use it despite knowing the problems it causes
Addiction is a more severe condition, and involves doing more than one behavior. The American Psychiatric Association lists a number of behaviors it considers symptomatic of addiction, and says a person must do three or more of them within a twelve-month period to be considered "substance dependent." Among the symptoms are:
- Developing a "tolerance" for the substance. Tolerance means needing increased amounts of it to feel its effects or feeling a decreased effect when using the same amount
- Suffering withdrawal symptoms if one stops taking it or decreases the amount one takes. Withdrawal symptoms include an array of unpleasant effects, ranging from minor (such as sweating, anxiety) to the severe symptoms associated with withdrawal from narcotics (such as pain, cramps, tremors, and nausea)
- Losing control, as shown by:
- Taking more of the substance than planned
- Trying but failing (several times) to stop using it
- Spending a lot of time trying to get it, use it, or recover from its effects
- Ignoring other activities (educational, professional, social, or personal) because of its effects
- Continuing to use it despite knowing the physical and/or psychological problems it creates
In the past, this kind of behavior was seen as a moral weakness or spiritual failing. Today we know that addiction is a disease of the brain. What does this mean?
In recent years, clinical research into addiction has been greatly aided by sophisticated imaging technologies that let us look at the brain and see how it changes because of addiction. It appears that addictive substances alter the nerve cells (neurons) in the brain, which affects how they transmit and receive information. Addictive substances, therefore, are things that can create these changes in the brain. Obviously, not all drugs have this effect; therefore, not all drugs are addictive.
Each substance can cause different changes, but in general they seem to affect the "reward circuits" or "pleasure pathways," the information pathways that tell the brain when something (a substance or an event) is pleasurable. The changes can make normal, pleasure-producing things seem less pleasurable, while reinforcing the need to use the addicting agent.
Other parts of the brain can also be affected, including those that control the memory-making process, decision-making skills, judgment, desires, emotional responses, and motivation. The result of all these changes is that the brain is "re-wired" so that it produces an all-consuming, uncontrollable craving for the addictive substance, a craving that overwhelms the addict's normal needs, desires, and sense of values.
These changes in brain structure and function can last a long time, even after a person stops using the substance(s) that created them. But some changes may be reversible. That's why treating addiction is as important as treating any other disease.
Key Point 2
Addiction is a serious problem, but let's be clear. Not everyone who takes drugs or drinks alcohol will become addicted. Not everyone with the addiction gene becomes an addict. Genetics and environment together play a role.
Why do some people become addicts and others don't? The answers to this question are complex and not entirely understood. We do know that being vulnerable to addiction seems to result from a combination of genetics and environment. In other words, there are risk factors for addiction just as there are for other diseases and disorders. (Risk factors are things that increase your chance of developing a disease or condition, but they do not mean you definitely will get it.) The major risk factors appear to be:
- Genetics: most likely a number of genes are involved in making people more vulnerable to addiction. Studies of twins show that genetics explains perhaps 50 to 60 percent of the vulnerability. Children of alcoholics are four times more likely to develop alcoholism themselves than others and at least 60 percent of alcoholics have family histories of alcoholism.
- Psychological problems: people with attention-deficit/hyperactivity disorder, post-traumatic stress disorder, anxiety, depression, mood disorders, feelings of loneliness, and other psychological problems are at greater risk of developing addiction. Often drugs are used to cope with these problems, but then the drugs themselves become a greater problem.
- Social environment: peer pressure is a powerful influence in beginning drug use. People who live, go to school, or work in an area where drug use, abuse, and addiction are common are at greater risk of becoming drug users, abusers, or addicts.
- Type of drug: addictive substances affect the brain and brain chemistry in different ways. Some can create the changes in the brain that cause addiction much faster than others.
- Early drug use: using addictive substances at an early age can put one at greater risk of developing addiction.
- Early traumatic experiences: children who have had a history of neglect, abuse (psychological, physical and/or sexual), and other traumatic experiences are at greater risk of developing addiction. These experiences can affect a person's brain chemistry in ways that make them more vulnerable to addiction.
Key Point 3
While addiction is a disease of the brain, it can be successfully treated. Relapses are unfortunately sometimes part of the recovery process and the treatment does take time.
Perhaps the best way to understand why relapse is so common a problem among people with addiction is to think of addiction as a chronic disease. Chronic diseases are lifelong illnesses. They may never be cured, but they can be treated and managed so that their symptoms or negative effects are minimized. Sometimes the damage the disease has already caused makes the treatment difficult, and the patient may suffer relapses. And sometimes these relapses are caused, at least in part, by the person's behavior.
People with addiction have suffered changes in and damage to their brains that can linger for years. These long lasting changes are what make addiction a chronic condition and people with it vulnerable to relapse.
Even after they have stopped using the addictive substance for a seemingly long time, the combination of external situations (such as events that create stress or sadness, or the reverse, events that leave them excited or elated) and the damaged "wiring" in their brains can trigger cravings for it. Because their decision-making skills have been impaired, the cravings can overwhelm their better judgment. In other words, they give in to the craving even though they know it will harm them.
What is treatment for addiction? Because of the uniqueness of each human being, and because of the large variety of addictive substances, treatment must be tailored to the individual. But it usually does, and should, include both medications and psychological counseling.
The National Institute on Drug Abuse (NIDA), one of the National Institutes of Health, discusses thirteen principles of effective treatment for drug addiction. They are:
- No single treatment is appropriate for all individuals.
- Treatment needs to be readily available.
- Effective treatment attends to multiple needs of the individual, not just his or her drug use.
- An individual's treatment plan must be assessed continually and modified as necessary to ensure that the plan meets the person's changing needs.
- Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use.
- Treatment does not need to be voluntary to be effective.
- Remaining in treatment for an adequate period of time is critical for treatment effectiveness.
- Individual or group counseling and other behavioral therapies are critical components of effective treatment for addiction.
- Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.
- Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way.
- Possible drug use during treatment must be monitored continuously.
- Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection.
- Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment.
You can get detailed information about these principles, and about all other aspects of addiction, at NIDA
Many experts think of treatment for addiction as a three-stage process. The stages are:
- Detoxification/stabilization (also known as withdrawal): the goal of this stage is to get the drugs or alcohol out of the patients' system and eliminate or minimize the physical and emotional symptoms they have produced. This can involve slowly reducing the dose of the drug to zero and/or substituting one with less severe effects. "Cold turkey" is a slang term that means drugs are suddenly and completely withdrawn. This process of total, rapid withdrawal can produce strongly unpleasant withdrawal symptoms.
- Rehabilitation: this stage focuses on patients' psychological and emotional problems, on helping them make the personal changes (in lifestyle, attitudes, etc.) they need to fight their vulnerability to relapse. This stage of treatment can (and usually should) involve both medications and various forms of psychotherapy, including:
- Individual talk therapy with a wide range of therapists, such as
- Psychologists and psychiatrists
- Clinical social workers and counselors
- Group therapy programs, including 12-Step programs, such as Alcoholics Anonymous (AA) Group programs can be residential or outpatient. Currently, the "90-Day Rehab" model, which, as its name implies, tries to rehabilitate patients during an intense 90 day program, has been showing a lot of success.
- Individual talk therapy with a wide range of therapists, such as
- Continuing care: because of their vulnerability to relapse, people recovering from addictions need services that monitor their progress, their physical, psychological, and emotional health, their attempts to change their attitudes and lifestyle, etc. Patients may need help with issues such as work or school, legal problems, and relationships with family and friends. The form of treatment in this stage is similar to that of the second stage, that is, various forms of individual and/or group psychotherapy; however, it is usually not as frequent or intense as during the second stage.
Finally, we need to remember that people don't become addicted to drugs or alcohol because they want to ruin their lives. They become addicted because at first using them makes them feel good. To be effective, a treatment program must accept and deal with this fact.
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