William J. Udrow Jr. PsyD , LCP, CRADC, MISA I, PCGC Ecuador: 2012

1. Philosophies (Models) of Addiction II. History of Addiction: Evolution of the Disease ConceptIII. Disease Concept William J. Udrow Jr. PsyD, LCP, CRADC, MISA I, PCGC Ecuador: 2012

2. Models of Addiction Moral Model: Blames the drug user for lack of moral character and lack of self-control. An Egyptian wrier admonished his drunken friend with the slightly contemptuous “thou art like a little child.” Until the twentieth century addicted individuals were weak-willed, lazy, or immoral. (Ray & Ksir 2002) The Temperance and Prohibition movements were based on moral model. As Late as 1974, the New Hampshire Christian Civic League devoted an entire issue of its monthly newspaper to a passionate argument against the idea that alcoholism is a disease. In its view the disease concept gives reprieve to the “odious alcohol sinner.” (Kinny, J. 2000)

3. Models of Addiction Disease Model: Drug abuser requires medical treatment rather than moral exhortation or punishment. This requires a team of professionals: doctors, counselors, psychologists, social workers…. In1993, The American Society of Additive Medicine: “Alcoholism is a primary, chronic disease with genetic, psychological and environmental factors influencing its development and manifestations. The disease is often progressive and fatal.” (Kinny, J. 2000)

4. Models of Addiction Physical Dependence Model: sometimes called the withdrawal avoidance model, is based on the unpleasant withdrawal symptoms that occur when a person stops taking a drug that he or she has used frequently. In the 1960 a series of experiments in laboratory monkeys and rats were given intravenous catheters connected to a motorized syringes and controlling equipment so that pressing a lever would produce a single brief injection of morphine, a narcotic very similar to heroin. The monkeys would experience withdrawal symptoms when no longer allowed access to morphine. Thus, the monkeys had made “true” drug addicts of themselves.

5. Models of Addiction Positive Reward Model: The positive reward model of addictive behavior arose from animal research that was started in the 1950’s. Animals would furiously press a lever to self-administer cocaine and other stimulants that do not produce marked withdrawal symptoms. Drugs such as amphetamines and cocaine could easily be used as reinforces in laboratory experiments and they were known to produce strong psychological dependence in humans. (Ray & Ksir 2002)

6. Models of Addiction

7. The Evolution/History:Disease Concept Sin or Moral Model: Societies have come to grips with substance problems in a variety of ways. The Greek word for drunk, for example, means literally to “misbehave at the wine”. Noah’s drunkenness was not looked on kindly by his children. (Kinny, J. 2000) “Drunkenness excites the stupid to a fury to his own harm, it reduces his strength while leading to blows” (Bible, Ecclesiasticus 31) The Koran, the holy book of Islam refers to the drinking of wine to be frowned upon. (Inaba & Cohen, 2000).

8. The Evolution/History:Disease Concept In America drinking in the colonies was largely a family affair and remained so until the beginning of the nineteenth century. Around the 1830’s Dr. Samuel Woodward and Dr. Eli Todd, did not see inebriates in the same class with criminals, the indigent, or the insane. Their efforts were taking place against the background of the temperance movement. The Washington Temperance Society was organized in much the same ways as the ordinary temperance groups except in was founded on the basis of one drunkard helping another.

9. The Evolution/History:Disease Concept Early Classifications: Dr. Benjamin Rush, physician, medical educator, patriot, reformer and the first U.S. Surgeon General. He published the first American treaties on alcoholism in 1804-An Inquiry into the Effects of Ardent Spirits on the Human Body and Mind. It was a collection of current attitudes toward abuse of alcohol.

10. The Evolution/History:Disease Concept Temperance and Prohibition: The temperance movement coincided with the rise of social consciousness, a belief in the efficacy of law to resolve human problems. Temperance (temp a rance) the idea that people should drink beer or wine in moderation but drink no hard liquor. (Ray & Ksir 2002) In August 1917, the U. S. Senate adopted a resolution that submitted the national prohibition amendment to the states and in January 1920 a national prohibition was stated in the amendment. Soon people were buying and selling alcohol illegally: bathtub gin. Organized crime flourished.

11. The Evolution/History:Disease Concept 1940’s, Alcoholics Anonymous: The concept of Dr. William Silkworth, one of AA’s early friends is sometime cited by AA members:…”an obsession of the mind and an allergy of the body.” (Alcoholics Anonymous, 2001) AA was having mores success in treating people with alcohol problems than was any other group. AA grew with a current estimated membership of over two million in both America and abroad. Lawyers, business people, teachers, people from every sector of society began to recover. (Kinny, J. 2000)

12. The Evolution/History:Disease Concept 1952 Disease Concept Introduced: Dr. Jellinek charted the signs and symptoms associated with alcohol addiction. Dr. Jellinek was a pioneer in modern alcohol studies. “Alcoholism is any use of alcoholic beverages that causes any damage to individual or to society or both.” (Kinny, J. 2000) 1970 NIAAA: Senator Harold Hughes, himself a recovering person established the “bill of rights” for those with alcoholism. This bill the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act was a protection against discrimination in hiring recovering alcoholics.

13. Dr. Jellinek’s Phase of Addiction Prealcoholic Phase: According to Jellinek’s formulation, the individual’s use of alcohol/drug using is socially motivated. The individual may soon experience psychological relief in the drinking/drug using situation. He or she may not have other ways to manage tension and stress. Therefore, the drinking/drug using behavior may become the standard means of handling tension and stress. This phase can extend for several months to 2 or more years. An increase in tolerance gradually develops.

14. Dr. Jellinek’s Phase of Addiction Prodromal Phase (Experimental): This phase means warning or signaling disease. Noted by the beginning of *Blackout (amnesia-like periods). During blackouts the person seems to be functioning normally but later has no memory of what happened (neurological damage). This phase includes sneaking extra drinking/using before or during parties, gulping the first drink or two and guilt about the drinking/drug using behavior. This period can last from 6 months to 4 or 5 years depending on the persons circumstances. (Kinny, J. 2000)

15. Dr. Jellinek’s Phase of Addiction Crucial Phase: The key symptom that ushers in this phase is loss of control. The person can no longer control the amount consumed after taking the first drink/drug. The drinking and drug using is now clearly different. It requires explanation, so rationalization, excuses and lying begin. Deliberate periods of abstinence; changing drinking/using patterns; or geographical changes to escape/avoid; job changes occur. Life had become alcohol/drug centered. Family life and friendships deteriorate. (Kinny, J. 2000)

16. Dr. Jellinek’s Phase of Addiction Chronic Phase: Intoxication is an almost daily, day-long phenomenon. The individual may also go to places/dives and drink and/or use drugs with persons outside his/her normal peer group. When the drug of choice is unavailable, other substitutions are the alternative. During this phase, marked physical changes occur. Tolerance for alcohol/drugs drops sharply. The long-used excuses are revealed as just that----excuses. Drinking and/or using is likely to continue because the person can not imagine a way out (feelings of hopelessness).

18. ADDICTION AS A DISEASE

19. CHARACTERISTICS OF DEPENDENCE Let’s look at four important dimensions of addiction. Addiction is: • Chronic • Primary • Progressive • Incurable Let’s review each concept in turn so that we know what this means.

20. 1. ADDICTION IS CHRONIC A disorder that is CHRONIC continues for a long time. The opposite of chronic is “acute,” which means relatively sudden and short. Let’s look at other examples of chronic vs. acute disorders. Acute disorders Chronic disorders Notice that “acute” disorders are treated once and they’re gone. “Chronic” disorders are managed, not cured.

21. 2. ADDICTION IS PRIMARY A disorder that is PRIMARY means that it is not the “result” of something else. It is a disorder in its own right, requiring specific treatment. For example, a man may start drinking to control the painful feelings of depression. However, when that man becomes an alcoholic (addicted to alcohol), he now has a separate and “primary” disorder that needs treatment. Treating the depression does not mean the alcoholism will also go away.

22. 3. ADDICTION IS PROGRESSIVE A disorder that is PROGRESSIVE tends to get worse over time. With drug addiction, we see that the consequences of the addiction tend to worsen over time. One important mechanism of this progressive quality is tolerance, which we’ve discussed. The development of tolerance tends to ensure that a person has to get more, spend more, hide more, and use more over time. Later we’ll look at some of the particular consequences of progression, including medical problems.

23. 4. ADDICTION IS INCURABLE We say that addiction is INCURABLE because the biological changes involved in addiction tend to be permanent. As a result, an addict will never be able to safely use the drug of abuse (or any other drugs of abuse). An alcoholic will never be able to “drink normally.” Likewise, a cocaine addict will never be safe using stimulating drugs (for example, ephedra, which is an over-the-counter stimulant). A person addicted to one drug can easily switch over the another drug and still be an addict. This is called cross-addiction (more on this later).

24. BIOLOGICAL BASES: THE REWARD CENTER Clinical File First let’s take a look at a part of the human brain which has been called the “reward center” deep in the brain. This area includes specialized neural pathways which process experience of pleasure. • 3 elements of the reward center: • Medical forebrain bundle • Nucleus accumbens • Ventral tegmental

25. BIOLOGICAL BASES: THE REWARD CENTER

26. BIOLOGICAL BASES: THE REWARD CENTER The reward center seems to process many experiences of pleasure, such as eating and sex. Experimental rats trained to stimulate their own reward centers with electric switches have been known to press on the switches thousands of times per hour! They neglect all other activities in order to keep stimulating themselves. (11) Does this kind of behavior sound familiar?

27. BIOLOGICAL BASES: THE REWARD CENTER Now, you may not be surprised to learn that many drugs of abuse stimulate the reward centers. As a result using mind-altering drugs is pleasurable. The addict is almost like one of those experimental rats, stimulating itself again and again, neglecting anything else.

28. THE PROBLEM IS THIS: WHILE THE DRUGS ARE STIMULATING ALL THIS PLEASURE, THEY ALSO CAUSE PERMANENT CHANGES. Repeated use of certain drugs of abuse can result in depletion of brain chemicals that allow the experience of pleasure. What happens next is this: more and more of the drug becomes necessary to generate pleasure, and other sources of pleasure lose their effects. Eventually, the addict can’t even feel just normal without the drug. As a result, the addict needs the drug to feel normal, and without it, they feel bad! It’s no longer a matter of pleasure… it’s a matter of avoiding pain. This is the mechanism for tolerance.

29. SPOTLIGHT: DOPAMINE The brain chemicals that help generate pleasure are called dopamine, a brain chemical belonging to a group called neurotransmitters. For example, both alcohol and heroin result in a build-up of dopamine, resulting in (temporary) pleasure. Neurotransmitter A “messenger chemical” in the brain, which have many different effects.

30. NEUROADAPTATION As we discussed above, the brain adapts to this higher level of dopamine in the system. It’s almost as if the body tries to “normalize” the new levels of pleasure by “raising the bar” to experience pleasure. These changes are referred to as neuroadaptation. In other words, neuroadaptation means that it gets harder and harder to experience pleasure as you use more drugs. Addicts get the point that only their drug…in ever-increasing amounts…makes them feel good. (12)

31. THE TRAP OF ADDICTION In a sense, get trapped by their own drug. They started using it to feel good, but end up needing it just to avoid feeling bad. But can’t the addict ever go back to normal? Even if he quits?

32. THE TRAP OF ADDICTION (CONTINUED) Addicts can learn to experience pleasure in ways other than using. Unfortunately, research and clinical experience shows that the biological changes are permanent. This is why addiction is considered incurable, as we discussed before.

33. IMPLICATIONS OF ADDICTION We’ve seen now how repeated drug use causes permanent biological changes in the brain. An important implication of the changes is this: An addict can never assume it’s safe to resume using addictive drugs. Using even once will get the addict back to Square One. 12-Step programs call this “waking the tiger.” Once an addict, always an addict.

34. References Alcoholics Anonymous Big Book 4th Edition (2001). New York :Alcoholics Anonymous World Services, Inc. Inaba, S. D. & Cohen, E. W. (2000). Uppers, Downers, All Arounders: Physical and Mental Effects of Psychoactive Drugs. Oregon: CNS Publications, Inc. Kinny, J. (2000). Loosening the Grip: A Handbook of Alcohol Information. United States: The McGraw-Hill Companies, Inc. Ray, O. & Ksir, C. (2002). Drugs, Society and Human Behavior: New York, New York: The McGraw-Hill Companies, Inc The Bible, Ecclesiasticus, 27. The Discovering Alcoholic. (September 6, 2012). Update on the Jellinek Curve: http://discoveringalcoholic.com/alcoholism/update-on-the-jellinek- curve