Drug Treatment - Drug Abuse And/or Addiction

The Psychiatric View

Though not all experts agree on a single definition of drug addiction, the 2000 Diagnostic and Statistical Manual of Mental Disorders-IV Text Revision, or DSM-IV-TR (Washington, DC: American Psychiatric Association, 2000), is the most widely used reference for diagnosing and treating mental illness and substance-related disorders. In the current DSM, the nation's psychiatrists draw a distinction between "substance abuse" on the one hand and "substance dependence" on the other. They stress that these terms should not be used interchangeably.

According to the American Psychiatric Association, substance abuse can be diagnosed only when one of the following conditions has been observed in the past year: The patient has 1) repeatedly failed to live up to major obligations, such as on the job, at school, or in the family, because of drug use; 2) has used the substance in dangerous situations, such as before driving; 3) has had multiple legal problems due to drug use; or 4) has continued to use drugs in the face of interpersonal problems, such as arguments or fights caused by substance use.

The DSM requires that at least three of the following conditions be met in the previous year before a person can be said to be substance dependent: The patient has 1) experienced increased tolerance; 2) experienced withdrawal; 3) had a loss of control over quantity or duration of use; 4) had a continuing wish or inability to decrease use; 5) spent inordinate amounts of time procuring or consuming drugs or recovering from substance use; 6) given up important goals or activities because of substance use; or 7) has continued to use the substance despite knowledge that he or she has experienced damaging effects.

The psychiatric definition goes beyond the popular conception of addiction which, according to dictionary definitions, is characterized by habituation to an activity, including the consumption of drugs.

The Labeling Process

Since the 1960s one tradition in the field of sociology has been to study the "labeling process" by which people are identified and treated as addicts, a methodology also applied to the classification of mental disease and deviance. In this view a person's social status influences how the same behavior (e.g., drug consumption) is labeled by society. Persons of higher status are presumed to require treatment, and those of lower status are seen as out of control and requiring restraint. Sentencing data for whites and African-Americans give some support to this view: higher proportions of whites receive probation for drug possession violations than African-Americans. Data by race or income on persons sentenced to probation with mandatory treatment are not available, but of those admitted for treatment, non-Hispanic whites are present in lower proportion to their share in the population than non-Hispanic African-Americans. (See Table 8.1.) In 2002 whites admitted for drug treatment were 58.9% of the total admitted to treatment but represented 71.0% of the population; African-Americans were 24.0% of those admitted but 12.3% of the population. The closest match was experienced by Hispanics (who may be of any race): they were 12.7% of those admitted for treatment and 11.5% of the 2002 population.

TABLE 8.1
Percent distribution of admissions for drug/alcohol treatment, 1992-2002
SOURCE: "Table 2.9b. Admissions by Sex, Race/Ethnicity, and Age at Admission: TEDS 1992-2000 and U.S. Population 2002, Percent Distribution," in Treatment Episode Data Sets (TEDS) 1992-2002, Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, September 2004, http://www.dasis.samhsa.gov/teds02/2002_teds_rpt.pdf (accessed March 31, 2005)

The "Disease" Model of Addiction

In the last twenty years of the twentieth century, advances in neuroscience led to new understanding of how people become addicted and why they stay that way. The "disease model" of addiction has been proposed by psychiatric and medical researchers. Addicts, they say, respond to drugs differently than people who are not addicted. Much of the difference is associated with differences in brain functioning and can be linked to genetic factors. Current approaches to treatment emphasize that addiction must be treated in the same way as other chronic diseases.

The Journal of the American Medical Association published an article (A. McLellan, D. Lewis, C. O'Brien, and H. Kleber, "Drug Dependence, a Chronic Medical Illness," October 4, 2000) that likened drug dependence to chronic illnesses such as diabetes, hypertension, and asthma. The article reviewed scientific studies of twins and children of parents who were dependent on alcohol or other drugs. The authors reported high degrees of correlation between parental and sibling dependence, suggesting a strong genetic component in addiction and alcoholism. Moreover, people who used drugs over long periods had different patterns of brain function, which seemed to lead them to continue to use drugs.

The National Institute on Drug Abuse (NIDA) also views drug addiction (if not all substance abuse) as a disease. On its Frequently Asked Questions Web page (http://www.nida.nih.gov/tools/FAQ.html), the agency, which is part of the National Institutes of Health, answers the question "What is Drug Addiction?" as follows: "Drug addiction is a complex brain disease. It is characterized by compulsive, at times uncontrollable, drug craving, seeking, and use that persist even in the face of extremely negative consequences. Drug seeking becomes compulsive, in large part as a result of the effects of prolonged drug use on brain functioning and, thus, on behavior. For many people, drug addiction becomes chronic, with relapses possible even after long periods of abstinence."

Elsewhere the agency points out that drug addiction is not only a brain disease but leads to social "illness" as well—and other diseases (Principles of Drug Addiction Treatment: A Research-Based Guide, Rockville, MD: NIDA, October 1999, http://www.nida.nih.gov/PODAT/PODATindex.html). The agency states: "Addiction often involves not only compulsive drug taking but also a wide range of dysfunctional behaviors that can interfere with normal functioning in the family, the workplace, and the broader community. Addiction also can place people at increased risk for a wide variety of other illnesses. These illnesses can be brought on by behaviors, such as poor living and health habits, that often accompany life as an addict, or because of [the] toxic effects of the drugs themselves."

NIDA monographs also support the American Psychiatric Association definition that another range of behavior exists short of addiction, which the APA defines as "substance abuse." The view of Epidemiology of Heroin and Other Narcotics (NIDA Research Monograph 16, November 1977) regarding addiction is: "A single definition has limited application, and the solution may be to develop an array of alternative definitions to reflect the dispersion of experience. There are, for example, registered clients with methadone-maintenance programs legally addicted to a narcotic; persons who use heroin on weekends only; [and] users who interrupt their use from time to time."

The paper deals in part with analyzing this diversity of users in order "to predict which groups among them are likely to become addicts and, therefore, should be special targets for intervention."

Social and Cultural Influences

Researchers' insistence that a spectrum exists, extending from rare or occasional use all the way to compulsive behavior labeled addiction, is based in part on physiological and in part on sociological observations.

Changes in the brain occur after continued use of drugs and may cause individuals to continue using drugs; but these changes are temporary. Researchers have shown that they do not last more than a few months. Yet addicts are at risk of relapsing months, and even years, after they have quit using drugs—long after their brains have returned to normal functioning. Brain function is important, but sociologists and psychologists argue that it cannot explain why all, or even most, addicts become addicted.

American involvement in the Vietnam conflict in the 1960s and 1970s brought much evidence that social and cultural factors are also at work. Many American soldiers began using heroin while in Vietnam and came back addicted. Yet most of them stopped using heroin after returning. This phenomenon focused attention on users who either do not become addicted or who cycle between abstinence and relapse. Many people use morphine to mitigate pain after operations yet do not become addicted.

Norman Zinberg, a Harvard University professor of psychiatry, was the first to study "controlled users" of marijuana, opiates, and hallucinogens in the 1970s and 1980s (Drug, Set, and Setting, New Haven, CT: Yale University Press, 1984). He showed that the social situations in which people use drugs have a profound impact on whether or not they become addicted. People who use heroin with intimate groups of friends and do not interact with hard-core addicts often don't become addicted. Conversely, people who use drugs in risky environments—such as "shooting galleries" or "crack houses"—use drugs in ways that make it more likely that they will become addicts.

NIDA Research Monograph 12, Psychodynamics of Drug Dependence (NIDA, May 1977, http://www.drugabuse.gov/pdf/monographs/download12.html), reviews work conducted with drug-addicted adolescents in impoverished urban areas, showing that, in their case, "use of heroin was 'adaptive and functional,' helping them to overcome crippling adolescent anxieties evoked by the prospect of facing adult role expectations with inadequate preparation, models, and prospects."

An Integrated Approach to Treatment

The modern approach to treatment has come to reflect the complexity of the drug abuse/addiction spectrum and combines medical approaches, behavior modification, education, and social support functions intended to redress imbalances in the patient's total environment. Components of a comprehensive drug treatment approach are shown in Figure 8.1. Arrayed in the center are categories of treatment used alone or in combination and, on the periphery, social service functions that may have to be deployed to solve some of the patient's problems that led to drug use or addiction in the first place.