Addictive Disease Concepts (HSV255)

1. Addictive Disease Concepts (HSV255) Fall Semester, 2006 Jim Wilwerding, M.Div., MA, LMHC, CADC, NCC

2. Substance Use • Is there a problem?

3. Substance Use • Is there a problem? • Is there a solution?

4. Substance Use • Is there a problem? • Is there a solution? • What is the solution?

5. Substance Use • Is there a problem? • Is there a solution? • What is the solution? • Why should society care?

6. Substance Use • Is there a problem? • Is there a solution? • What is the solution? • Why should society care? • Who provides/pays for treatment?

7. Substance Use • Is there a problem? • Is there a solution? • What is the solution? • Why should society care? • Who provides/pays for treatment?

8. Addictive Substances • The two most damaging addictive substances in terms of death, suffering and dollar cost are legal

9. Tobacco • $53-73 billion in direct medical costs per year • $47-82 billion in lost productivity per year (Anczak & Nogler, 2003; Patkar, Vergare, Batka, Weinstein, & Leone, 2003) • Globally, 3 million people die each year, 435,00 in the U.S. (approximately 1:5 deaths) (Mokdad, et al., 2004; Patkar, et al., 2003; Miller, 1999)

10. Alcohol • In the U.S., $26 billion per year in direct medical costs (Petrakis, Gonzalez, Rosenheck, & Krystal, 2002; Smothers, Yahr, & Ruhl, 2004) • $67.7-138 billion per year in lost productivity (Craig, 2004; Brink, 2004) • 20-50% of all hospital admissions are related to alcohol abuse/addiction (Greenfield & Hennessy, 2004; McKay, Koranda, & Axen, 2004) • 85,000-140,000 people die due to alcohol use/abuse each year (Mokdad, et al., 2004)

11. The Scope of the Problem • The most common cause of psychosis in young adults is alcohol/drug abuse (Cohen, 1995) • Recreational drug abuse is thought to increase the individual’s risk of ischemic stroke by 1,100% (Martin, Enevoldson, & Humphrey, 1997) • 10-30% of adults in the U.S. have a substance use disorder (Wilens, 2004)

12. American Way of Life? • The economic impact of illicit chemical use/abuse is estimated between $110 billion (Connors, Donovan, & DiClemente, 2001) and $276 billion (Stein, Orlando, & Sturm, 2000) per year in the U.S. • The annual expenditure for illicit chemicals in the U.S. was greater than the combinedincome of the 80 poorest Third World countries (Corwin, 1994)

13. Use, Abuse and Addiction • Use sometimes referred to as “social use” is defined by traditional social standards. What is acceptable or unacceptable in society. • Substance Abuse is defined as using a substance other than for its intended or socially acceptable standard use.

14. Abuse, Dependence and Addiction • Substance Abuse • Maladaptive substance use with clinically significant impairment as manifested by at least one of the following within any 1-year period: • Failure to fulfill major role obligations at work, school, or home • Recurrent use when physically hazardous • Recurrent legal problems • Continued use despite recurrent social or interpersonal problems • Patient has never met criteria for Dependence

15. Substance Dependence • Psychological Dependence—desire or craving to achieve the effects produced by the drug • Physical Dependence—Bodily processes have been modified by repeated use of a drug that continued us is required to prevent withdrawal symptoms

16. Substance Dependence (DSM-IV) • Substance Dependence • Maladaptive substance use with clinically significant impairment as manifested by at least three of the following within any 1-year period: • Tolerance • Withdrawal • Taken in greater amounts or over longer time course than intended

17. DSM-IV Continued • Substance Dependence • Desire or unsuccessful attempts to cut down or control use • Great deal of time spent obtaining, using or recovering from drug • Social, occupational, or recreational activities give up or reduced • Continued use despite knowledge of physical or psychological problem that is likely to have been caused or exacerbated by the substance

18. Addiction, Withdrawal, Tolerance • Addiction—broad term describing a compulsion to use a specific drug or engage in a certain activity • Withdrawal—Discomfort and distress, including physical pain and intense cravings, experienced after stopping the use of addictive drugs • Tolerance—decreased sensitivity to a drug brought on by its continuous use

19. Characteristics • Craving/compulsion • Loss of Control—Inconsistent control • Consequences

20. Why People Use Substances • Reward/Punishment systems • Operant Conditioning • Social Learning • Expectations • Cultural Norms/Taboos

21. Medical Model of Addiction • Jellinek (1952,1960) Proposed that alcoholism is a disease that was chronic, progressive and fatal. • According to Jellinek, alcoholism progressed through four stages.

22. Jellinek’s Four Stages • Prealcoholic Phase—alcohol is used for recreational purposes and to relieve social tension • Prodromal Phase—some severe symptoms, blackouts, etc. • Crucial Phase—Loss of control, withdrawal, etc. • Chronic Phase—Loss of tolerance, obsessive drinking, tremors, etc.

23. The “Jellinek Cycle” • Appendix 3 • Shows the progression from use through abuse and addiction and recovery.

24. Additional Models (Doweiko, 2006, p.30) • Moral Model—The individual chooses to use alcohol in a problematic manner • Temperance Model—Alcohol use in moderation • Spiritual Model—Drunkenness is a sign that the individual has slipped from his/her intended path in life.

25. Additional Models (Doweiko, 2006, p.30) • Dispositional Disease Model—The alcoholic is somehow different from the nonalcoholic such as in an allergy • Educational Model—Problems are caused by a lack of adequate knowledge about harmful effects of the chemical • Characterological Model—Problems are based on abnormalities in the personality structure of the individual

26. Additional Models (Doweiko, 2006, p.30) • General Symptoms Model—People’s behavior must be viewed within the context of the social system in which they live • Medical Model—The individual’s substance use is based on biological predispositions, such as his or her genetic heritage, brain physiology, etc.

27. A Disease of the Spirit • Mind-Body-Spirit connection • Priorities become misaligned • Manipulation—recreating my reality • Self-absorption • Denial, Rationalization, Projection and Minimization • Honesty as an essential component to recovery

28. Pharmacology • Drug Effects/Side-effects • Forms of administration • Enteral (Orally, sublingually, rectally) • Parenteral (injections—subcutaneous, intramuscular, intravenous) • Transdermal • Intranasal • Inhalation (smoking, inhaling)

29. Pharmacology • Bioavailability—concentration of the unchanged chemical at the site of action • Absorption/Distribution/Biotransformation/Elimination • Drug Half-Life (t1/2 )

30. Pharmacology • Dosage • Effective Dose (ED50) • Lethal Dose (LD50) • Therapeutic Index—ratio between ED50 and LD50 • Peak Effects

31. Pharmacology • Site of Action • Central Nervous System • Neurotransmitters, Neurons, etc. • Receptor Sites • Blood-Brain Barrier (BBB)