Current statistics show the immensity and seriousness of unrecognized substance abuse disorders and addictions.
An integrative psychiatry perspective looks beyond labels, symptoms, or a few illness characteristics to find understanding and positive treatment options for addictions.
Several questions arise about addictions.
Who is addicted and how is addictive illness defined?
Who is at risk?
How does addiction become a destructive disease with health and social consequences?
What are the indicators and early signs of addiction?
What are integrative psychiatry approaches to addiction, brain change, and neuroplasticity?
What resources are available if substance use is a problem?
How serious is the problem?
In a 1999 substance abuse survey, 14.8 million Americans used illicit drugs at least once during the prior month. About 3.5 million were dependent on illicit drugs, and an extra 8.2 million were dependent on alcohol. Only 8.1% of people with alcohol use disorders actually receive needed treatment. An estimated 30% of primary care patients with alcohol use disorders did not receive treatment. In 1992 alone, the total economic cost of addictions, alcohol, and drug abuse was estimated to be $245.7 billion - including:
Expense of treatment and preventive programs
Related health care costs
Reduced job productivity and loss of earnings
Increased crime with resulting personal and public costs
Social welfare needs
An addiction epidemic now exists to heroin, morphine and other prescription opioid pain relievers.
In the past decade, pain medicine prescriptions, like opiates, have increased 300%. It is estimated that two million people in the United States have substance use problems - most are from opioid pain relievers. About 26% of individuals, who are prescribed opioids for pain, develop opioid use disorders (Dr. Mercola, 2016). “In 2015, 52,404 Americans died from drug overdoses; 33,091 of them involved an opioid and nearly one-third of them, 15,281, were by prescription,” (Mercola, 2017); (SAMHSA); (Elinore F. McCance-Katz, MD, Ph.D., 2015).
Physicians and dentists in the past were taught to treat pain with drugs, which are now known to cause addiction. Patients were led to believe that pain would be controlled with a low risk of future addiction. As a result, we are now in a national healthcare crisis. In North Carolina, since 1999, more than 13,000 individuals have died from pain medication overdoses. Last year, North Carolina dispensed nearly 10 million opioid prescriptions (DHHS Secretary Mandy Cohen, MD, 2017).
“Since 1999, opioid overdose deaths have quadrupled, and opioid prescriptions have increased markedly – almost enough for every adult in America to have a bottle of pills. Yet, the amount of pain reported by Americans has not changed. Now, nearly 2 million people in America have a prescription opioid use disorder, contributing to increased heroin use and the spread of HIV and hepatitis C. As many as 1 in 4 receiving long-term opioid therapy in primary care settings struggle with opioid addiction.” (LETTER FROM THE SURGEON GENERAL, 2017 - The Surgeon General's Call to End the Opioid Crisis)
Addiction to refined carbohydrates, sugar, is now a major costly health crisis, contributing to obesity, diabetes, heart disease, and other significant health issues. Though a major problem, it is often overlooked, especially with the massive marketing of the sweetened products and their ready availability - as in soft drinks, and at many food outlets and restaurants. Some of the characteristics of sugar addiction are similar to cocaine addiction.
The American Society of Addiction Medicine, 2017 (ASAM) defines addiction as a "primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.” Addictions present characteristically in several ways:
Pathologically pursuing of reward and relief by substance use and other behaviors
Inability to consistently abstain
Impairment in behavioral control
Diminished recognition of significant problems with one’s behaviors and interpersonal relationships
Dysfunctional emotional response
Cycles of relapse and remission
The Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) from the American Psychiatric Association replaced the term addiction with "substance use disorder." The replacement was done because of the term, "addiction’s" uncertain definition and possible negative connotations. Also, it was felt that "substance use disorder" would be a more neutral term and describe a wider range of dysfunction, from mild to the severe state of “chronic relapsing compulsive drug taking and alcohol use.” However, the word "addiction" is still commonly employed in the USA and other countries where there is the persistence of severe substance abuse problems.
The DSM-5 describes alcohol and opioid in a similar manner as both are considered “use disorders with a problematic pattern of use leading to clinically significant impairment or distress.”
The manifestation is demonstrated by at least two significant occurrences within a 12 month period:
The substances are taken in larger amounts or over a longer period than was intended
There is a persistent desire or unsuccessful effort to cut down or control the substance use
Lots of time is spent in activities necessary to get the substance, use the substance, or recover from its effects
Craving or a strong desire to use the substance
Continued use, despite having persistent or recurrent social or interpersonal problems, caused or exacerbated by effects of the substance
Important social, occupational, or recreational activities are given up or reduced because of the substance use
Recurrent substance use in situations in which it is physically hazardous
Continued use despite knowledge of having a persistent or current physical or psychological problem that is likely to have been caused or exacerbated by the substance
Tolerance, which develops, is defined as a need for markedly increased amounts of the substance to achieve the desired effect. Also, there is the occurrence of a diminished effect with continued use of the same amount of the substance
The withdrawal shows the characteristics withdrawal syndrome for the particular substance
Related substances are used to relieve or avoid withdrawal symptoms (American Psychiatric Assoc. Publishing 2013) (DMS-5)
There are many factors that can increase the risk of developing an addiction.
A family history of addiction can increase the likelihood of substance use disorders in relatives. A National Co-morbidity Survey showed that individuals with a mood disorder are 2.3 times more likely to have a substance use disorder than those without a mood disorder. For bipolar disorder, there is 9.7
times greater chance of having alcohol dependence and 8.4 times higher chance of having another type of drug dependence problem. Trauma-related conditions, as the experience of a traumatic childhood or adult life events, are found to be a common substrate in addiction illness. Attention deficit (ADHD), anxiety, obsessive-compulsive, and schizophrenic disorders are associated with higher rates of substance abuse. Recognition and treatment of any condition that can potentiate or put one at risk for addiction need attention as soon as possible (see reference and resource page).
There are early warning signs of drug and alcohol abuse.
Increased drinking or use of other drugs
Changes in job or school performance
Changes in attitude and mood as depression, irritability, suicidal threats, or actions
Unexplained changes in eating, sleeping habits, physical appearance, physical complaints, blackouts, or temporarily memory loss
Behavioral problems as dishonesty, sexual promiscuity, and stealing
Change in relationships especially with new friends known to drink or use drugs
Alcohol on breath, slurred speech, staggering, appearing spaced out
Missing alcohol, medications, or money from around the house
The presence of drug paraphernalia as pipes, pill boxes, etc.
Recognition, early interventions, and treatment are critical.
The goal would be to reduce pain and suffering and the staggering cost to society. Because addictions can switch, all types of addictions need early recognition and intervention. Examples would be compulsive eating, gambling, the Internet, computer, sexual, and pornography addictions (see Addiction Reference and Resources page); (Hugh Myrick, MD, 2016).
There are valuable screening tools and questionnaires that are available to identify addictions. The AUDIT for alcohol (WHO) and the SBIRT (SAMSHA) for alcohol and substance abuse are helpful (Marc Schuckit, MD, 2014).
It is useful to learn how the brain develops, perpetuates addictions, and how it can heal itself. There are robust mechanisms in our nervous systems and brain that serve positive purposes. Theses critical brain operations are for survival, food, shelter, reward, gratification, and reproduction. The same processes are also the miraculous pathway for the achievement of success and accomplishments. Misdirection can occur however into debilitating addiction and substance use disorders (William Yvorchuk, MD, 2015).
New findings in brain research give promise for successful addiction treatment.
The brain can adapt, change, and lay down new neurocircuitry (nerve pathways). Less used neurocircuitry are removed in a healing and regenerative process. Information is needed about the brain's operations, functioning, and influencers. The application of gained knowledge in neuro research can lead to positive treatment outcomes. The goal would be for prevention, restoration of health, and addiction recovery.
"Neuroplasticity" is the descriptive name for the ability of the brain to change. This process represents the changes that can occur with training and to positive addiction treatment programs. Change in neurotransmitter patterns can result in new positive habits and behaviors. The training, repetition of positive experience in supportive social settings supports these brain changes (Ron Parks, MD, 2016); (Frank Lawlis 2015).
Other approaches as trauma-oriented therapies as EMDR and Spiritual Emergence are potentially valuable additions to treatment programs. The Center for Spiritual Emergence, as an example, aims to help people live to their fullest potential. A transpersonally-based, systems-oriented, body-centered, and trauma-integrated approach is provided to foster healing and spiritual emergence from spiritual emergencies, mental health issues, and substance use disorders. The physical, emotional, mental, social, and spiritual dimensions of patients' concerns as well as health and wellness are addressed as a pathway to wholeness.
Integrative and comprehensive approaches to addiction treatment are essential.
A thorough approach to addiction treatment looks at environmental, child to adulthood influences, psychosocial factors, trauma, and neuro-developmental issues. The importance of how other factors affect brain processes and human behavior need continuing investigation.
An intervention or treatment program can be set-up once a qualified individual or program completes an addiction assessment. An Integrative Psychiatrist and Addiction Specialist addition to the treatment team is recommended as there is a high degree of co-existing problems. Co-existing issues may need attention before addiction treatment can be successful or sustained. Treatment needs to be done for contributing medical and mental health concerns. Areas of concern may be nutritional, hormonal, allergy, immune, metabolic problems, trauma, behavioral, psychological, or emotional related conditions. Early medical interventions may look at nutritional deficiencies, inflammation, digestive, hormone, or metabolic problems as insulin resistance, early diabetes, or thyroid problems. Deficiencies of minerals or vitamins such as magnesium, copper, zinc, amino acids, essential fatty acids, B6, B12, or folic acid all can be corrected with appropriate assessment. (see Ten Holistic Steps for Mental Health)
Integrative psychiatry and addiction programs may include:
Cognitive behavioral therapy
Mutual help groups
Mind-body-spiritual and sensory-based therapies
Natural complementary therapies
Possible medication augmentation can be considered, especially when other interventions are not successful. Drugs that help reduce cravings and relapses are most effective for opioids and tobacco. The medications currently available are only moderately effective for alcohol and minimally useful for stimulants, cannabis, inhalants, other substances (Petros Levounis, 2015).
If you, or a significant other, such as a spouse, friend or employer, see early signs of addiction, do not ignore, as you may inadvertently be a contributor to the severity of the problem.
With the dramatic rise in death from heroin overdoses and the devastating effects of both drugs and alcohol on individuals, families, and children - addiction is a problem that can’t be ignored. Seek help and information for both recognition and treatment of addictions to prevent serious consequences.
Find resources locally, in your community, or on the Internet. Seek out or consult with:
Health care providers or your primary care physician
Addiction specialists, treatment centers, or programs
Integrative psychiatrists or, holistic health practitioners
Twelve-step programs as Alcoholics Anonymous or Narcotics Anonymous
Other resources as listed under addictions on our Resource page (see below)
The Substance Abuse Mental Health Service Administration (SAMHSA) can be contacted 24 hours a day at 1-800-622-HELP
By Ron Parks, MD & edited by Shan Parks