Addiction as a Disease

Arlin J.Silberman D.O.,FAOAAM Certified in Addiction Medicine Certified in Addiction Psychiatry Fellow of the American Osteopathic

Academy of Addiction Medicine

Abuse vs Dependence

There is a difference between intentional drug abuse and pathological drug dependence.

The latter is what is referred to as addiction.

Chemical Abuse

Maladaptive pattern of drug use leading to impairment or distress,presenting as one or more of the following over a 12 month period-failure to fulfill obligations,use that is physically hazardous,drug related legal problems,and continued use despite social/interpersonal problems.

Chemical Dependence

3 or more of the following:tolerance,withdrawal,drug used more than intended,inability to control use,effort to obtain drug,important activities replaced by drug use,use despite negative consequences.

Present Understandings

Drug abuse causes short-term and long-term changes in brain function.

Medial forebrain bundle(mesolimbic dopamine system)

History

References made in the civilizations of ancient Egypt and Greece,called ‘drink madness’.

In colonial America, Anthony Benezet noted drunkenness to self accelerate.

In 1784 Dr.Benjamin Rush wrote a pamphlet describing an ‘odious disease’and a ‘disease induced by a vice.’

History cont.

Rev.Lyman Beecher’s sermons in 1825 describes ‘intemperance is a disease as well as a crime.’

Dr.Samuel Woodward recommended special asylums for the treatment of inebriates.(1830’s)

First Treatment Facility

In 1864 the New York State Inebriate Asylum founded by Dr.Joseph Turner.

Disease Concept

Dr.William Sweetser described intemperance causing a ‘morbid alteration’ in nearly all the major structures and functions of the human body.(1829)

Concept of Alcoholism

Biological predisposition Drug toxicity Morbid craving Tolerance Disease progression Loss of volitional control over quantity

Opiate Addiction

In the 1870’s dope fiends where caricaturized as Chinese immigrants when the majority were white middle-aged women using patent medicines laced with opium.

Criminalization

Dr.CW.Earle led the first anti-drug campaign.”It is becoming altogether too customary in these days to speak of vice as disease”

In the 1880’s the term ‘drug vice’ used.

Disease Concept

American Association for the Cure of Inebriety formed in 1870.

Founding principles-disease concept,curable,constitutional susceptibility which maybe inherited or acquired.

Moral Treatment

Franklin Reformatory for Inebriates in Phila. recognized ‘drunkenness as a habit,sin,and crime.’(1874)

Alternative views of alcohol and drug use

Source of the problem was in the person in terms of vice and sin.

Source of the problem was the product. Aggressive promotion of the product.

Disease Concept Abates

By the end of the 1800’s the disease concept faded away.

Disease Concept Returns

E.M.Jellinek presents disease model in 1960.

American Psychiatric Assoc. uses the term disease to describe alcoholism in 1965.

American Medical Assoc. follows in 1966.

Present Understandings

Drug abuse causes both short-term and long –term changes in brain function.

This makes it nearly impossible for users to stop on their own.

The biology of the brain changes may never return to preuse state.

Our Understandings

‘Dependence’brain areas are parts of the brain that govern unconscious thought.

Medial forebrain bundle,also known as mesolimbic dopamine system.

Neurotransmitters involved in dependence.

Our understandings

Functional dysregulation-they aren’t working right.

One or more neurotransmitter chemicals involved.

Neurotransmitters

Dopamine(affected by cocaine, amphetamines or alcohol).

Serotonin(alcohol or LSD) Endorphins(alcohol or opiods)

Neurotransmitters

GABA(alcohol or benzodiazepines) Glutamate(alcohol) Acetylcholine(alcohol or nicotine)

Genetic Factors

Abnormal genes lead to abnormal proteins.

This results in abnormal transmitter-synthesizing enzymes,abnormal transmitter breakdown enzymes,or abnormal receptors.

Genetic Factors

The above factors lead to neurotransmitter dysregulation.

This is why scientists believe that dependence is a chronic medical brain disease.

Needs Long Term Treatment

As chronic relapsing disease like heart disease,diabetes and schizophrenia,disease management,not one shot treatment,is the most promising approach. Alan Leshner PhD.,Director NIDA.(1997)

Treatment Modalities

Behavioral approaches change brain chemistry.

Medications to treat withdrawal and cravings.

Medications Approved for Alcohol Treatment

Antabuse(disulfiram) Naltrexone Acamprosate

Critics of the Disease Model

Stanton Peele-disease concept has spread to include eating,child

abuse,gambling,shopping,premenstrual tension,compulsive love affairs,and almost every form of self destructive behavior.

Critics

Herbert Fingarette states alcohol industry itself contributes to the public perception of alcoholism as a disease.(Heavy Drinking:The Myth of Alcoholism as a Disease.1988 Univ.of Calif.at Berkeley Press)

Bibliography

William L.White(1998).Slaying the Dragon:The History of Addiction Treatment and Recovery in America. Bloomington,Ill.Chestnut Health Systems

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)1994.

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