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- Basics on Drug Abuse and Addiction
- Treatment Philosophy
- Definitions
There are many reasons for substance abuse to develop. Once it begins, more and more aspects of life become involved in drug craving. Virtually any feeling, thought or memory may become associated with drug craving and drug use. When a severe psychological and physical addiction to opiate/opioid drugs develops, fear of withdrawal becomes the main factor maintaining drug seeking and drug use. At this point, methadone or buprenorphine maintenance treatment becomes an attractive option for the patient.
Opioid agonist treatment "cures" psychological addiction, i.e. the patient quickly feels "normal" and reverts to some abuse thinking with intermittent craving. This is similar to the state before the addiction developed. The patient may completely stop drug abuse behaviors. He/she can "take or leave" abusable drugs and usually no longer commits unethical acts to get drugs. However, unethical practices and psychological problems that preceded the drug addiction may return and may not change. For example, posttraumatic stress disorder (PTSD) symptoms may return when drug abuse stops. Prostitution is usually the result of sexual abuse occurring earlier in an individual's life, and may not stop as a result of opioid agonist treatment.
There are basically three ways of feeling good or three primary factors motivating behaviors: nature (instincts), culture (traditions, rituals, games, arts), and drugs. Abusable-addicting drugs bypass thoughts and actions, leading directly to rewarding, good feelings, as if the person would have done something of natural and/or cultural value. While cultural activities feel like "second nature", drugs function as "third nature", competing with culture and natural inclinations. Drug addiction leads to a severe disturbance of the emotional-behavioral system.
Drugs are self-reinforcing. They lead to a feeling of reward and craving for further use. It is "normal" for people to develop drug abuse and addiction when exposed to drugs. Virtually all animals used in experiments become quickly addicted to "hard drugs" and it is easy to teach animals to 'love' alcohol. People who do not get addicted to drugs, when exposed, benefit from protective factors, e.g. oversensitivity and fear of drug side effects, fear based on knowledge about drugs (insight), sense of wanting to be completely in control, religious and ethical beliefs, strong positive motivations that exclude the use of drugs, etc.; for people with strong positive life goals, insight into the problems of drug abuse/addiction may deter experimenting with drugs. Young people may be particularly prone to addiction if insecure, anxious, depressed, if suicidal, if there is an abuse/neglect history, and if there are other psychiatric conditions. Males are more likely to become addicted without major psychological stresses since young males are more likely to explore and take meaningless risks. Even if addiction appears to be caused by specific psychological problems, treating those problems will not treat the addiction-once addiction develops, it has its own life.
All drug abuse and addiction patterns interfere with a healthy and ethical life style. Drugs compete with healthy, natural inclinations, e.g. to take care of and nurture a child, to eat healthy food, to pursue artistic talents, or to be social and supportive with friends. Drugs are not only self-reinforcing, they also reinforce feelings and actions preceding the drug use, e.g. alcohol, when used in an anxious state, reinforces anxiety; heroin, taken after an unethical act, makes the unethical act seem acceptable, normal and natural. When addiction develops, family and loved ones suffer first; although life may become meaningless, the abuse behaviors are exciting and the addict feels mostly good. The European fairy tales about contracts with the devil, in which a poor man inadvertently sells his daughter or first-born to Satan, are metaphors for alcoholism.
Psychological addictions are similar to drug addictions, except that the good feeling is based on an inappropriately followed instinct or cultural behavior. Examples include eating because of boredom or for relaxation rather than because of hunger; gambling with the hope of "winning big", i.e. instantly becoming a wealthy, important person; seeking the physical excitement of sex in a non-loving relationship and/or with unjustifiable risk. Addictions may include significant, insignificant, or no physiological dependence, and drugs may lead to physiological dependence without being taken in an abusive or addictive way.
Addiction is a learned disordered pattern of feelings, thoughts, and behaviors. It involves many parts of the mind (or brain, nervous system). It can never be truly forgotten or unlearned, but when controlled or suppressed for an extended time, it is no longer "just below the surface", and the person leads a normal life. For people with a history of addiction, the danger of relapse is increased permanently. It appears that such learned behavior patterns stay side by side with other thought-behavior patterns but seem quite dominant even after not pursuing lapsing thoughts for over a year. With very strong positive motivation, people often stop addiction behaviors with little or no help, but they often relapse, when the motivation has weakened, or when there is major stress. Development and treatment of addiction may be compared to panic disorder. In panic disorder, a person who recently experienced major stress, may, in a potentially dangerous situation, slip into vicious cycles of catastrophic thinking with consequent adrenergic arousal symptoms. Once this reaction is learned, lesser and lesser triggers may start the disordered pattern. Studies showed, that if panic disorder is suppressed with benzodiazepine or antidepressant therapy, it is very likely to recur if the medication is tapered after nine months, but rarely reoccurs, if the medication is tapered after 18 months. Similarly, if a woman does not smoke for nine months because of pregnancy, she is very likely to relapse. Generally, the prognosis is best if positive motivation, psychological therapy and/or pharmacotherapy help to control or prevent the pathological responses for a long time.
We believe it is
important to address all issues of a client to the extent possible.
Client willingness to work on these issues is critical. Areas addressed
include: opiate/opioid and other substance and non-pharmacologic abuse/addiction
problems; psychiatric and psychosocial (including sex/gender and spiritual/religious)
issues and problems; general health issues, and chronic pain syndromes;
social and vocational problems.
The initial goal
of this opioid agonist treatment program is to move patients from an
extremely dysfunctional pattern of psychological and physical opiate
addiction and polydrug abuse to a managed opioid dependence that allows
normal functioning and meaningful psychological treatment. In a later
treatment phase, patients may be gradually withdrawn.
If clearly indicated,
not simply on patient's request, patients may be medically withdrawn
with short-term methadone or buprenorphine treatment, while being offered
individual therapy, group therapy, ear acupuncture, and follow-up narcotic
antagonist treatment, or they may be referred to a physician specialized
in medical withdrawal, possibly using experimental approaches. If patients
demand treatment that is not indicated, they are referred to other treatment
centers.
In contrast to "recovering"
drug users on no medication, patients in synthetic narcotic treatment
programs may have lapses into substance abuse without relapse into addiction.
A patient, while still physiologically dependent, can live an essentially
normal life and should show little or no symptoms of addiction. This
means there is little or no craving or withdrawal and the client has
the ability to cope with withdrawal-like symptoms or fear of withdrawal.
Patients should learn to deal with and prevent drug craving, and they
are helped to develop strong, positive motivation for a drug-free, healthy
life style. Relaxation, meditation, contemplation and self-hypnotic
techniques are taught in groups, which are offered to all clients. Many
younger patients, patients with a relatively short addiction history,
and patients who functioned well in the past greatly benefit from an
intensive style of treatment participation in the first few days and
weeks of therapy. This helps to prevent development of a pattern of
substance abuse while on methadone. The long-term goal for most patients
is to accomplish slow medical withdrawal while showing no substance
abuse behaviors, in addition to learning to cope with anxiety, depression,
drug craving, and life stressors.
The treatment team's
role is to help the patient clarify problems and goals, to show some
caring while being appropriately confrontive. This is particularly
important in the very early stage of treatment and during a crisis.
In addition, the treatment team works to move the patient into active
treatment when he/she is resistant but shows some signs of treatment
readiness. Both general psychiatric and substance abuse problems are
addressed in psychotherapy and in groups. Indicated psychotropic medications,
mainly antidepressants, are prescribed by a psychiatrist of this clinic,
unless the patient is presently treated by another psychiatrist. All
additional addiction problems are addressed, particularly smoking. General
health evaluations, teaching and referrals are important parts of treatment.
Group approaches are preferred over individual teaching and counseling
whenever possible. Significant others, including close friends, parents
and older teenage children of patients, may participate in groups and
other treatment. Counseling is primarily cognitive-behavioral and otherwise
eclectic. Groups emphasize tertiary abuse prevention, understanding
of psychological problems, dealing with stress, anxiety and mood disorders,
and use of a wide range of self-help approaches. Spirituality is valued
by many patients. However, it is recognized that 12-step self-help groups
(AA, NA, CA, etc.) are very helpful to some, but not necessarily most,
severely opiate-addicted persons. While emphasizing positive motivation
and relapse prevention, we like to stress the methadone client's health
rather than disease and slow recovery. Nurse-case managers often function
to some degree as social workers and may make appropriate referrals
for any type of problem.
Abuse behaviors are positively motivated (essentially pleasure-seeking) and often performed wholeheartedly, with little internal conflict at the time. This occurs despite the possible awareness of the individual that the behavior is in some way "bad". "Bad" may be defined as behavior that goes against the prevailing culture, is harmful to others, or is unhealthy to self, etc. The primary purpose of abuse behavior is to feel good or at least better. The abuser appears to exercise some control; i.e., abuse behaviors stand side by side with other positively perceived behavior options. If there is a special reason not to abuse, an individual will usually abstain. In other words, there are other choices the abuser perceives as comparably good.
Addiction is an essentially normal psychological response to exposure to abusable drugs "at the wrong time" with consequent increasing abuse. Addiciton develops when there are no protective factors; that is, when the person has no strong reason to refrain from the attractive abuse behavior. Addiction is not "compulsive." It is a pleasure-seeking (positively motivated) behavior pattern that dominates much of the addict's life and is continued despite negative consequences. To the addict, pleasure and avoidance of temporary withdrawal are more important than the negative effects of the abuse pattern. In addiction, the abuse behavior appears to have become a first priority. Addiction is often defined in terms of frequency of behavior. However, the severity of preoccupation is probably more important than actual frequency of use. There are often positively perceived, pleasurable obsessions individuals have, only their frustration and/or moral conflicts act as deterrents. Addiction is a learned, disordered-thought behavior pattern -- a core disturbance of the emotional-behavioral system. Addiction is not a disease in that it does not damage tissue. Normal behavior patterns still exist, are intact, and can be utilized when abuse/addiction behaviors stop; for example when treatment starts or when the patient finds powerful, positive motivation that acts as a deterrent.
Compulsions serve to avoid an irrationally feared occurrence. Insight is not helpful in stopping them. Compulsions are negatively motivated and ego-dystonic; i.e., they do not feel good. They are often performed repeatedly with only gradual or partial relief. Compulsivity usually includes negative obsessions with mental rituals occurring frequently.
Physical habits, such as nail biting, hair pulling, or skin picking, may represent exaggerated primitive inborn behaviors ("reptilian", "over-grooming behaviors"). Their frequency often increases with anxiety but seem automatic with little associated emotion. They do not relieve anxiety.
Habits are basically neutral -- not 'good' or 'bad'. Positive habits are often "compulsively" adhered to because the individual fears getting out of routine and losing benefits. Positive and neutral habits may be valued as part of the individual's personality. Damaging and destructive habits are generally part of psychopathology and/or abuse-addiction patterns.
Positive and non-damaging, neutral pleasurable habits are not addictions. For example, masturbation is an addiction if regularly pursued in spite of a belief that it is wrong or damaging, otherwise it is, generally, a neutral pleasurable habit.
Misuse refers to inappropriate use. Examples include self-medicating with a medication prescribed for another condition, and the use of alcohol or illicit drugs as psychotropic medications for psychiatric disorders.
Cultural use includes regular and structured use of alcohol and other drugs within specific contexts prescribed by the culture. In cultural use, the drug is not used for self-medication or as a form of pleasure-seeking. Cultures may encourage "acting out" and pleasure seeking behaviors during a specific festival or rite. For some people, such cultural drug use may lead to abuse and addiction patterns. Generally, the more structured a behavior is, the safer it is.
Dependence generally refers to a physiological adaptation to a drug, with tolerance and withdrawal occurring on discontinuation. In contrast, psychological addiction generally refers to regular abuse. Many non-abusable drugs lead to dependence, e.g. Aspirin and blood pressure medications, and many people are dependent on abusable drugs without being addicted. Examples include tranquilizer use for treatment of diagnosed anxiety disorders, or opiate pain medication use during prolonged treatment of major burns.
Non-pharmacological abuse and addiction patterns are frequent. Examples include gambling, consumption addiction, "perversions" (inappropriate ways of instinct fulfillment which are in some way damaging and used to relieve boredom and stress or for pleasure) (e.g., addictions to aberrant aggressive, sexual or eating behaviors). Money, representing most forms of instinct fulfillment, can be addicting. Sometimes dynamics are unclear: "workaholics" may possibly be avoiding family or addicted to material wealth rather than addicted to work.
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