Treating Addictions

The Four Components

An-Pyng Sun

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781317393535
• Edition: 1
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

Treating Addictions: The Four Components offers a unique and coherent understanding of addiction. The book begins with a chapter discussing the framework of addiction and the four essential components of treatments—the fundamentals of addiction, co-occurring disorders, quality of life, and macro factors—and subsequent chapters elaborate on each component. Most currently available addiction treatment books present knowledge and skills in separate chapters and fail to integrate all chapters within a single framework that can weave all concepts into a meaningful tapestry. Using a unified framework, this book offers students a comprehensive skill set for treating addictions.

1
Introduction

The ACQS Model: Considering Addiction, Co-Occurring Disorders, Quality of Life, and Social Factors

The phenomenon of addiction has been recognized since ancient times; however, it is still a controversial disorder today regarding its etiology and treatment. There were various historical landmarks that address, define, and explain addiction—for example, Nicolaes Tulp, a Dutch 17th-century physician, replaced sin with a medical disorder to account for addiction; Benjamin Rush, an early American physician, suggested in the 18th century that compulsive drinking is a disease wherein a person loses self-control; in the 19th century, professional journals in addiction medicine first appeared, including the Journal of Inebriety in the US and the British Journal of Addiction; and addiction-related diagnostic classifications and neurobiological research were first developed in the 20th century (Crocq, 2007). Nevertheless, today in the 21st century, we are still exploring and debating the nature of addiction and its treatment strategies and we are still unable to come to a consensus regarding policies related to addiction treatment and prevention. One example is the recent response, “Brain Disease Model of Addiction: Why Is It So Controversial?” by Volkow and Koob (2015) to the challenges of Hall et al. (2015), who criticized that too much emphasis has been placed on the biological aspect of addiction and not enough on its psychosocial aspect. Crocq stated that “the frequent pendulum swings between opposing attitudes on issues that are still currently being debated”—such as “is addiction a sin or a disease; should treatment be moral or medical; is addiction caused by the substance, the individual’s vulnerability and psychology, or social factors; should substance be regulated or freely available,”—questions reflecting the complex causes of addiction (p. 355).

The emergence of the concept of behavioral addiction (e.g., gambling disorder, internet gaming disorder, sex addiction, shopping addiction, and so on) in the past decades has provoked enormous opposition from both lay and professional communities, and further enlarges and intensifies the controversies related to addiction (Sun, 2013). Specifically, the grouping of gambling disorder together with substance use disorder (SUD) under the same umbrella, as well as inclusion of the internet gaming disorder (but not sex addiction) in its Section III by the Diagnostic Statistical Manual, 5th edition (DSM-5, American Psychiatric Association [APA], 2013), all have generated much disagreement among both sides of the professionals (Sun, 2013). On one hand, we have some scientists who affirm that the advanced technologies, like functional magnetic resonance imaging (fMRI), have enabled us to better understand behavioral addiction and its commonalities to, and close relationship with, substance addiction. On the other hand, others fear that the identification and targeting of behavioral addiction may pathologize everyday life behaviors and create “diagnostic inflation” and “false epidemics” (Sun, 2013).

Regardless, we continuously see patients seeking addiction treatment. It’s not uncommon to see mothers, whose cocaine or methamphetamine addiction has led to child neglect, seek treatment to gain back child custody; or husbands with alcoholism request treatment to save their marriage and keep employment; or to see heroin users apply for substitute or other treatments, as heroin has cost all their money and properties, and its satiation can never be achieved. In the past decade, we have also started seeing worried parents give ultimatums to their sons to get treatment, young men who have never abused alcohol or drugs but who have dropped out of college due to internet addiction (Sun & Cash, 2017). Some patients may hide behind the façade of defiance and be labeled as “involuntary” or “resistant” clients; most of them have drained all of their strength and confidence because of addiction and are in total despair. Still others, who are afflicted not only with addiction but also other severe psychiatric disorders and lack resources and social support, may end up on the streets and become chronically homeless (Sun, 2012).

Although some researchers have claimed that people can self-recover or achieve spontaneous remission from addiction, and that addiction is “a disorder of choice” (Heyman, 2009), the research has concurrently shown that it is those who have a lesser or less severe addiction that are likely to succeed in self-recovery (Klingemann et al., 2010). Individuals who end up in treatment programs or on the street are likely to have these factors: they have tried to quit but failed repeatedly; their addiction is moderate to severe rather than mild; they have a comorbid physical ailment or psychiatric disorder that prompts self-medication and exacerbates the addiction; they have low recovery social capital and resources, which weakens their motivation to get well and makes their abstinence unsustainable. These people, therefore, need most the external intervention and help from society and community. Addiction treatment is not only applicable to patients in treatment programs or tertiary prevention, it is critical to the primary and secondary prevention as well. Preventing addiction in the first place, and reducing the odds for a less severe addiction to advance into severe dependency, are equally as important as helping patients already afflicted with severe addiction to reach long-term recovery.

Although far more research is still needed, the clinical and science research communities have accumulated some insights and knowledge to help guide our practice. Based on my many years of research, as well as teaching and practice in the field of addiction, I developed the ACQS model to explain the nature of addiction and its treatments. The ACQS model proposes that a person’s addiction and treatment involves four essential components—understanding the fundamentals of addiction, considering the co-occurring disorders, taking account of the quality of life, and awareness of the social factors involved. Among the four components, I consider the “fundamentals of addiction” as the primary and unique feature to understanding addiction, and it is therefore placed first in the ACQS model. The other three components are also crucial to understanding addiction, but they may be relevant to many other phenomena or diseases as well, such as aging or depression, and are not unique to addiction. Nevertheless, to simply rely on the “fundamentals of addiction” without integrating the other three components would be incomplete and ineffective. Many people, when attempting to make sense of the occurrence of addiction and its recovery, focus only on one piece of the puzzle; even if that piece is necessary, it may never be sufficient to complete the puzzle.

Historically the general public, including many addicted people themselves and their families or even scholars, have had difficulty accepting “addiction” as a disease, especially as a brain disease. Volkow and Koob (2015) pondered “whether the difficulty relies in accepting as a bona fide disease one that erodes the neuronal circuits that enable us to exert free-will” (p. 678). This is consistent with society’s often loose application of the term “addiction” to any excessively engaged activities or consumed materials, whether or not they’ve had negative consequences. For example, someone may say jokingly, “I’m addicted to chocolate!” when she has eaten a great many fudge truffles recently. One night as I drove home listening to the radio I heard the DJ say, “I must be addicted to that song,” indicating she liked the song so much that she played it frequently. When a concept like “addiction” is used so lightly, it will be defined and perceived carelessly. Laypersons are unaware that real addiction involves a much more complex nature and course. They may see the impulsivity, in that the addicted person focuses only on seeking fun and pleasure, but they do not see compulsivity, in that the person may engage in the addictive behavior against his or her conscious wishes (Chamberlain et al., 2017; Koob, 2009; Koob & Volkow, 2010). They only see the person who gives up his or her job, marriage, and other meaningful life goals and relationships; they do not see his or her pain with regard to withdrawal, tolerance, craving, and multiple failures to quit. This could be the origin of the “moral model,” where people judge addicted individuals to be selfish, lazy, irresponsible, and immoral.

Some people—including those with an empathetic heart, general clinicians, and addicted people and their families—have become more receptive of the self-medication theory. This theory suggests that addicted people resort to alcohol and other drugs (AOD) and/or other addictive behaviors such as gambling or internet gaming to help them cope with pain and suffering, loneliness and alienation, dysfunctional interpersonal relationships, feelings of a meaningless and purposeless life, or other frustrations and unfulfilled needs. Knowing that my research area is addiction, some of my lay friends and colleagues will share with me their perspectives that addiction is caused by a lack of social support (a self-medication theory, too). As a matter of fact, Bruce Alexander wrote a book, The Globalization of Addiction: A Study in Poverty of the Spirit (2008), suggesting that addiction is “a substitute for an unbearable lack of psychosocial integration” (p. 326). He highlighted an ancient view, stating that “Socrates sees [addicts] as reacting to an impossible social situation in the best way they can” (p. 325). As a social worker and during my own early research career, I indeed felt the same way, and once wanted to title one of my manuscripts, “It’s about Life, Not about Drugs.” People self-medicate their dissatisfaction about life by abusing alcohol and other drugs, I concluded. However, the self-medication theory is relevant and significant, but insufficient to fully understand addiction. This theory implies that poor quality of life is the major factor contributing to addiction, and that addiction is only a by-product of and secondary to the poor quality of life. The rationale then is that once society provides treatment and helps people improve their quality of life, those who rely on alcohol and/or drugs to cope should be rid of addiction once and for all, as there is no reason to self-medicate any more. Society, and the addicted person’s significant others, cannot understand nor tolerate why the person relapses after treatment—not only once, but again and again—other than deciding the person to be immoral or weak-willed. Even addicted people may blame themselves and feel self-loathing for their repeated relapses. So, in an unexpected way, the self-medication theory brings people right back to the moral model.

Today, I still think quality of life and psychosocial integration are critical factors (which are covered in Chapter 4) in the occurrence of addiction and its recovery, especially long-term recovery; now, however, I will say, “It’s Not Only about the Life, It Is Also about the Drugs.” The addictive power and complexity of alcohol and other drugs, gambling, or internet gaming should not be ignored or underestimated. I have had clients or research participants—users of alcohol, heroin, cocaine, methamphetamine, or ketamine, as well as gamblers and gamers—tell me that although they are not using currently, “back in my brain,” they said, they are still thinking about the drugs. They missed the enormous pleasure the drugs brought to them; they were also in great fear of relapse (Sun, 2007, 2014; Sun et al., 2016). The craving or urge to use exists even after months and years post detox, and it may be triggered by stress or a cue (places, persons, or things associated with alcohol, other drugs, or gambling). Many addicted individuals wished that they had never used the drugs in the first place, because their addiction has haunted them a lifetime.

In the past several decades, advanced brain imaging technologies and research, such as positron emission tomography (PET) and functional magnetic resonance imaging (fMRI), have identified the addictive features of substance addiction and its effects on the brain’s activities and neuro pathways (Grant et al., 2010; Volkow et al., 2004; Volkow et al., 2002). Although more research is still needed, some brain imaging studies have also observed similar effects of addictive behaviors, such as gambling and internet gaming, on the brain’s activities and neurobiological mechanisms (de Ruiter et al., 2012; Grant et al., 2010; Ko et al., 2009; Ko et al., 2013; Luijten et al., 2014). Scientific data have suggested that addiction is a brain disease that involves the disturbance and neuro-adaptation of a person’s neurobiological systems. Overall, the research has identified three major characteristics of an addicted brain: a combination of impulsivity and compulsivity, neuroadaptation, and a chronic nature. A person’s addictive behavior is not only impulsive in nature—the “bottom-up” limbic system is heightened and dominant, whereas the “top-down” prefrontal cortex system is weakened and subdued—but also compulsive during the later stage of addiction, such that the person may engage in the addictive behavior against his or her own conscious wishes (Chamberlain et al., 2017; Koob, 2009; Koob & Volkow, 2010). Impulsivity drives a person to pursue pleasure, and addiction is positively reinforced during the initial stage; in contrast, compulsivity is related to negative reinforcement, in that the person no longer obtains pleasure from using the substances during the late stage of addiction, but rather engages in the addictive behavior in order to reduce anxiety (Koob, 2009). The neuro-adaptation resulting from the brain’s prolonged exposure to alcohol and other drugs (AOD) explains the chronic and relapsing nature of addiction. It is inaccurate, biased, and counterproductive to ignore the neurobiological fundamentals of addiction and to assume that once society has helped addicted people—offering detoxification and rehabilitation, healing the traumas, finding them a job, helping them regaining social support, and the like—they ought to be rid of their addiction once for all, and if they are not, they are a moral failure or weak-willed.

In Chapter 2, I discuss in details the fundamentals of addiction and its treatment strategies. Addiction, in and of itself, is a primary disease, not just a by-product from some other major diseases or main problems. To be more specific, drinking or doing drugs may be, initially, only a temporary by-product or secondary to a primary psychiatric disorder (e.g., depression, posttraumatic stress disorder [PTSD]) or other problems in life that the person attempts to self-medicate. But such coping behaviors may turn into a more permanent and difficult primary disorder, or an out-of-control addiction, if the brain is repeatedly exposed to AOD and the neuroadaptation is subsequently formed (Volkow et al., 2009). This could also happen to some people whose initial intention of drug use, gambling, or playing online games is curiosity, fun, or casual entertainment, but who find out later after routine usage that they have become addicted. Addiction is a chronic disease, such that relapse is the norm and relapse prevention should be part of the core treatment. Like other chronic illnesses, there is no cure for addiction so far, but it is treatable. To some people, especially patients with severe addiction, addiction is a lifetime battle and recovery demands a lifetime commitment. It is easier for the general public to accept illnesses such as cancer, diabetes, and hypertension as chronic diseases than addiction, perhaps because the presentation of addiction as a disease is relatively subtle and abstract. Although not all people with substance use disorder (SUD), or gambling or internet gaming disorder, are afflicted with severe addiction, for those who are, the fundamental neurobiological nature of addiction must be taken into consideration when helping the patients and their significant...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Preface
• Chapter 1 Introduction: The ACQS Model: Considering Addiction, Co-Occurring Disorders, Quality of Life, and Social Factors
• Part I
• Part II
• Appendix A1 The CRAFFT Questionnaire—Self Administered
• Appendix A2 The CRAFFT Questionnaire—Clinician Interview
• Appendix B The Alcohol Use Disorders Identification Test (AUDIT)—(Interview Version)
• Appendix C The Cannabis Use Disorders Identification Test—Revised (CUDIT-R) (Self Administration)
• Appendix D Clinical Institute Withdrawal Assessment For Alcohol, Revised (CIWA-Ar)
• Index