Drug Addiction Is a Disease—So What Do We Do about It? (Page 1 of 2)
At a Glance
Photo courtesy of Gray Wolf Ranch Wilderness Recovery Lodge.
Students make predictions about the success rate for treatment of addiction compared with treatment for other chronic diseases. Then students evaluate case studies of individuals with different diseases to compare and contrast how the diseases are similar to, or different from, the others.
Drug addiction is a recurring chronic disease that can be treated effectively, similar to other chronic diseases.
By the end of these activities, the students will
- understand that addiction is a chronic disease that is likely to recur;
- recognize that treatment is most effective when it combines medication and behavioral treatments;
- be able to explain how treatment for addiction is similar to that for other chronic diseases, such as diabetes or heart disease; and
- recognize that even though we may think that treatment could be more effective when people who are addicted to drugs, like people with other chronic diseases, choose to participate actively in their treatment, research shows that treatment can be very effective even when it is compulsory.
Basic Science–Health Connection
Addiction has many dimensions and disrupts many aspects of a person’s life. Scientific research and clinical practice have yielded a variety of effective approaches to treatment for addiction to certain drugs, such as heroin. Continuing research is yielding new approaches to developing medications to treat addiction to other drugs, such as cocaine, for which no medications are currently available.
Drug abuse and addiction lead to long-term changes in the brain’s chemistry and physiology. The changes in the brain cause drug-addicted people not only to lose the ability to control their drug use, but their addiction also changes all aspects of their lives. People with drug addiction often become isolated from family and friends and have trouble in school or work. In addition, the compulsive need for drugs can lead to significant legal problems. While the biological foundation for drug addiction does not absolve an individual from the responsibility of his or her actions, the stigma of drug addiction needs to be lifted so individuals may receive proper medical treatment, similar to that for other chronic diseases.1
Addiction is a recurring chronic disease. No cure is available at this time, but addiction can often be treated effectively. Drug addiction is often viewed as a lapse in moral character. This value judgment influences how society deals with the disease, both socially and medically. Unfortunately, because people, including physicians, have often viewed addiction as a self-inflicted condition, drug-addicted people have not always received the medical treatment common for other chronic diseases. Treating addiction requires more than a “just say no” approach.2
Treatment for addiction can be very effective. Treatment is successful when the addicted person reduces or abstains from drug use, improves his or her personal health or social function, and becomes less of a threat to public health and safety.3 Certain addictions, such as heroin addiction, can be treated with medications.4,5 Methadone, the most common medication, prevents craving and withdrawal symptoms in heroin addiction. Methadone is an opioid-receptor agonist. That is, methadone binds to the opioid receptor just as heroin does. Methadone, however, does not produce the euphoria or “high” that results from heroin use. When taken orally as indicated, it does not produce the rapid increase in opioid-receptor occupancy that comes from injecting or snorting heroin, but it does maintain sufficient opioid-receptor activity to prevent withdrawal and cravings for opioids.
Methadone can be part of an effective treatment plan for addiction to opiates. Photograph
of pills by, and used with permission of, Roxane Laboratories, Inc. All Rights Reserved.
A second medication prescribed for heroin addiction is naltrexone. Unlike methadone, naltrexone is an opioid-receptor antagonist. Instead of competing with or mimicking heroin for the opioid receptor, naltrexone prevents heroin from binding to the receptor, thereby preventing heroin from eliciting the euphoric high (see Figure 5.2). Buprenorphine is also used to treat heroin addiction. It is a long-acting partial opioid-receptor agonist. It acts on the same receptors as heroin but does not produce the same intense “high” or dangerous side effects. Buprenorphine has some advantages over other medications for treating heroin addiction. Unlike methadone, buprenorphine can be prescribed in physicians’ offices. It is also less likely to be toxic or abused than methadone.
Agonists are chemicals that bind to a specific receptor to elicit a response, such as excitation or inhibition of action potentials. Methadone is an agonist that, like heroin, binds to opioid receptors. Unlike heroin, however, methadone does not produce the same level of euphoria. Buprenorphine is a partial agonist that also binds to opioid receptors. Partial agonists are chemicals that are similar to full agonists, but at higher doses their effect is not as great as a full agonist’s. Buprenorphine does not produce the euphoria seen with heroin. Antagonists are chemicals that bind to a receptor and block it, producing no response and preventing other chemicals (drugs or receptor agonists) from binding or attaching to the receptor. Naltrexone is an antagonist that binds to the opioid receptor and blocks heroin from binding.
Table 5.1 outlines the different medications used to treat addiction. The development of medications to treat drug addiction has been difficult because the brain, the main target of addictive drugs, is such a complex organ. Until scientists understand how drugs affect the chemistry of the brain, they cannot develop medicines that will alter their effects.
Table 5.1: Medications for Addiction4
||Treatment for addiction to
||Mixed opioid-receptor agonist
|Nicotine gum, patches
||Provide low doses of nicotine
Medication, if available, is rarely sufficient for effective treatment. Behavioral treatment in combination with medication is the most effective way to treat drug addiction.6,7 People recovering from drug addiction need to address the behavioral and social consequences of their drug use and learn to cope with the social and environmental factors that contribute to their illness.7 Behavioral treatments can be provided either individually or as a group.
Principles of Effective Drug Addiction Treatment
- Addiction is a complex but treatable disease that affects brain function and behavior. Drugs of abuse alter the brain’s structure and function, resulting in changes that persist long after drug use has ceased. This may explain why drug abusers are at risk for relapse even after long periods of abstinence and despite the potentially devastating consequences.
- No single treatment is appropriate for everyone. Matching treatment settings, interventions, and services to an individual’s particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.
- Treatment needs to be readily available. Because drug-addicted individuals may be uncertain about entering treatment, taking advantage of available services the moment people are ready for treatment is critical. Potential patients can be lost if treatment is not immediately available or readily accessible. As with other chronic diseases, the earlier treatment is offered in the disease process, the greater the likelihood of positive outcomes.
- Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems. It is also important that treatment be appropriate to the individual’s age, gender, ethnicity, and culture.
- Remaining in treatment for an adequate period of time is critical. The appropriate duration for an individual depends on the type and degree of his or her problems and needs. Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment. Recovery from drug addiction is a longterm process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug abuse can occur and should signal a need for treatment to be reinstated or adjusted. Because individuals often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment.
- Counseling—individual and/or group—and other behavioral therapies are the most commonly used forms of drug abuse treatment. Behavioral therapies vary in their focus and may involve addressing a patient’s motivation to change, providing incentives for abstinence, building skills to resist drug use, replacing drug-using activities with constructive and rewarding activities, improving problemsolving skills, and facilitating better interpersonal relationships. Also, participation in group therapy and other peer support programs during and following treatment can help maintain abstinence.
- Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. For example, methadone and buprenorphine are effective in helping individuals addicted to heroin or other opioids stabilize their lives and reduce their illicit drug use. Naltrexone is also an effective medication for some opioid-addicted individuals and some patients with alcohol dependence. Other medications for alcohol dependence include acamprosate, disulfiram, and topiramate. For persons addicted to nicotine, a nicotine replacement product (such as patches, gum, or lozenges) or an oral medication (such as bupropion or varenicline) can be an effective component of treatment when part of a comprehensive behavioral treatment program.
- An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. A patient may require varying combinations of services and treatment components during the course of treatment and recovery. In addition to counseling or psychotherapy, a patient may require medication, medical services, family therapy, parenting instruction, vocational rehabilitation, and/or social and legal services. For many patients, a continuing care approach provides the best results, with the treatment intensity varying according to a person’s changing needs.
- Many drug-addicted individuals also have other mental disorders. Because drug abuse and addiction—both of which are mental disorders—often co-occur with other mental illnesses, patients presenting with one condition should be assessed for the other(s). And when these problems co-occur, treatment should address both (or all), including the use of medications as appropriate.
- Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. Although medically assisted detoxification can safely manage the acute physical symptoms of withdrawal and, for some, can pave the way for effective long-term addiction treatment, detoxification alone is rarely sufficient to help addicted individuals achieve long-term abstinence. Thus, patients should be encouraged to continue drug treatment following detoxification. Motivational enhancement and incentive strategies, begun at initial patient intake, can improve treatment engagement.
- Treatment does not need to be voluntary to be effective. Sanctions or enticements from family, employment settings, and/or the criminal justice system can significantly increase treatment entry, retention rates, and the ultimate success of drug treatment interventions.
- Drug use during treatment must be monitored continuously, as lapses during treatment do occur. Knowing their drug use is being monitored can be a powerful incentive for patients and can help them withstand urges to use drugs. Monitoring also provides an early indication of a return to drug use, signaling a possible need to adjust an individual’s treatment plan to better meet his or her needs.
- Treatment programs should assess patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases. Typically, drug abuse treatment addresses some of the drug-related behaviors that put people at risk of infectious diseases. Targeted counseling specifically focused on reducing infectious disease risk can help patients further reduce or avoid substance-related and other high-risk behaviors. Counseling can also help those who are already infected to manage their illness. Moreover, engaging in substance abuse treatment can facilitate adherence to other medical treatments. Patients may be reluctant to accept screening for HIV (and other infectious diseases); therefore, it is incumbent upon treatment providers to encourage and support HIV screening and inform patients that highly active antiretroviral therapy (HAART) has proven effective in combating HIV, including among drugabusing populations. 9
Source: NIDA. 2009. Principles of Drug Addiction Treatment: A Research-based Guide, 2nd edition. 2009. National Institute on Drug Abuse.
Relapse is a common event for people recovering form drug addiction. In many ways, relapse should be thought of as a normal part of the recovery process. A person in recovery is more likely to experience a relapse if he or she also has other psychiatric conditions, experiences stress, or lacks the support of family and friends.
Despite the preconceptions and value judgments many people place on addiction, it is, in many ways, similar to other chronic diseases such as diabetes and coronary artery disease. Genetic, environmental, and behavioral components contribute to each of these diseases. Some people may argue that drug addiction is different because it is “self-inflicted.” As presented in Lesson 4, the initial choice to use drugs is voluntary, but, once addiction develops, drug use is compulsive—not voluntary. Moreover, voluntary choices do contribute to the onset or severity of other chronic diseases as well. For example, a person who chooses to eat an unhealthy diet and not exercise increases his or her risk for coronary heart disease.
Successful treatment for any chronic disease necessitates patient compliance with the prescribed treatment regimen. Adhering to a treatment plan is difficult for those with any chronic disease. Less than 50 percent of people with diabetes follow their routine medication plan, and only 30 percent follow their dietary guidelines.2 Problems adhering to a treatment plan lead to about 50 percent of diabetic people needing additional medical care within one year of diagnosis and initial treatment. Similar statistics hold true for other chronic diseases: approximately 40 percent of patients with hypertension need emergency room treatment for episodes of extreme high blood pressure, and only about 30 percent of adult asthma sufferers take their medication as prescribed. People treated for drug addiction also commonly relapse during treatment and recovery, resuming drug use. The difficulties in following a treatment plan and coping with the stresses of a chronic disease illustrate how difficult changing human behavior is. The challenge of adherence is particularly severe in the case of addiction because this disease implicates and coopts the very same brain substrates that underlie what we call free will.8 Activities 2 and 3 of this lesson provide more insight into this topic.
Scientific research is likely to change how drug addiction is treated. Research to understand how the brain works and how drugs cause changes in the chemistry and function of the brain may lead to new medications to treat disease. Scientists continue to work on developing medications that relieve the cravings experienced when drugs are withdrawn. Also, scientific advances may reveal ways to reverse the long-term functional changes to the brain that drugs inflict.
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