It is perplexing why some people become addicted to drugs while others can seem to use recreationally without significant consequence. It creates a discriminating environment where the addict is judged to be immoral or weak; lacking willpower or the discipline to simply stop on their own. However, drug addiction is a brain disease that is characterized by the individual compulsively seeking out drugs despite knowing the inevitable negative consequences. It is defined as such because of the way drugs affect and change the brain, in both structure and function. These brain changes can be temporary, long-lasting or even permanent, depending on the drug, the severity of the addiction and the length of use, and can lead to a wide variety of dangerous and destructive behaviors.
Initially, the decision to take drugs is voluntary for most people. Repeated use of drugs, however, can affect the brain and interfere your ability to resist the intense cravings to use the drugs. Drug addiction is chronic and even those in recovery from substance use disorders are at increased risk for relapsing back to drug use even after years of abstinence. Relapse, though common, does not mean that treatment does not work. On the contrary, it is the reason that treatment should be ongoing and customized to your needs. Comparable to people with chronic diseases like heart disease or diabetes, individuals who struggle with addiction must commit to lifelong changes to manage their disease.
Brain Changes
When you use drugs, the brain’s reward circuit is flooded with dopamine. Dopamine is a neurotransmitter that is responsible for feeling a rush of euphoria or “high”. These dopamine surges reinforce the pleasure derived from taking drugs, which is the impetus for repeated drug use since most drugs mimic the “high” that dopamine delivers.
The problem is that the drugs overstimulate the reward circuits, and the intense gratification is something that can only be replicated with continued drug use. Over time and continued use, the brain reduces the ability of the cells in the reward circuits to respond to the drugs. This leads to two problems. First, the body and brain develop a “tolerance” to the dosage, meaning you have to constantly increase the amount needed to achieve the desired effect. Second, because the drug is providing the brain with a constant flow of chemicals, it stops producing its natural feel-good neurotransmitters resulting in a crash when the effects of the drug have worn off.
The potential for long-lasting disruption to the brain’s neurotransmitter circuits after chronic drug use include: a) affects to the individual’s learning, b) judgment, c) decision-making, d) stress, e) memory, and f) behavior. Continued drug use despite the harmful consequences is the hallmark of addiction.
Criteria for a Substance Use Disorder
As described in the Alcohol Use Disorders section, the DSM-5 now integrates the symptoms that used to differentiate between substance abuse and substance dependence into one category – Substance Use Disorder with mild, moderate, and severe specifiers depending on how many of the diagnostic criteria you meet (2 or more are required). The following 11 DSM-5 criteria for a substance use disorder include:
- Taking the substance in larger amounts or for longer than you’re meant to.
- Wanting to cut down or stop using the substance but not managing to.
- Spending a lot of time getting, using, or recovering from use of the substance.
- Cravings and urges to use the substance.
- Not managing to do what you should at work, home, or school because of substance use.
- Continuing to use, even when it causes problems in relationships.
- Giving up important social, occupational, or recreational activities because of substance use.
- Using substances again and again, even when it puts you in danger.
- Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.
- Needing more of the substance to get the effect you want (tolerance).
- Development of withdrawal symptoms, which can be relieved by taking more of the substance.
The DSM-5 groups the symptoms associated with substance use disorders into four major groups:
A. Impaired Control – is associated to the first 4 criteria:
1. Using for longer periods of time or in larger amounts than intended.
2. Desire to cut down or stop using, yet unable to do so.
3. Spend excessive time getting, using, or recovering from the effect of drug use.
4. Intense cravings and obsessive thoughts about drug use.
B. Social Impairment – included in criteria 5, 6, and 7:
5. Not managing to do what you should at work, home, or school because of substance use.
6. Continuing to use, even when it causes problems in relationships.
7. Giving up important social, occupational, or recreational activities because of substance use.
C. Risky Use – included in criteria 8 and 9:
8. Using substances again and again, even when it puts you in danger.
9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.
D. Pharmacological criteria (tolerance and withdrawal) – criteria 10 and 11:
10. Tolerance occurs when you need to increase the amount of a substance to achieve the same desired effect. The “desired effect” might be to get high or avoid withdrawal.
11. Withdrawal symptoms can vary depending on the substance used and the degree of tolerance developed to those substances. The symptoms can be very unpleasant and sometimes fatal. It is important to seek the care of a medical professional prior to quitting drug use to ensure comfort and safety during the cessation process.
Treatment
Addiction treatment should be tailored to the individual. Different drugs, frequency and quantity of use, delivery methods, as well as social and environmental influences can influence treatment methods and outcomes.
Thankfully, treatment does work. The following information is provided to answer some basic questions about treatment and where to begin seeking it. If you need further clarification or guidance, please contact me. I’m here to help.
As I outlined in the Alcohol Use Disorder section, I recommend finding a physician who is certified in addiction medicine (ASAM or CSAM), as a starting point for recovering from drug addiction. They can evaluate the severity of or your addiction and recommend the appropriate level of care for supporting a safe recovery.
ASAM (American Society of Addiction Medicine) divides treatment into five levels.
Level 0 Early Intervention Services
Level 1 Outpatient Services
Level 2 Intensive Outpatient/Partial Hospitalization Services
Level 3 Residential/Inpatient Services
Level 4 Medically Managed Intensive Inpatient Services
Residential Treatment
Residential (inpatient) Treatment is needed for individuals with more severe or chronic cases of addiction. Not all residential rehabs are created equal, however, so it is important to make sure you find one suited to meet your needs, not necessarily your “wants”.
A Residential Treatment Center (RTC) will provide 24-hour care. Most (but not all) offer clinically managed high-intensity residential services (ASAM 3.5), which typically includes detox, medication management, individual therapy, group therapy, addiction education, couples or family therapy, skills building, aftercare planning, and referrals to support groups. Individuals who are more medically compromised (e.g. infections, diabetes, heart or lung diseases, wounds, vascular diseases, etc.) will need to consider residential or inpatient treatment offering ASAM 3.7 or 4.0 levels of care.
Treatment outcomes improve with increased lengths of treatment. A 28-30-45 day treatment stay is a foundation. The individual is learning and practicing new skills to maintain their recovery, however, they are doing so in a contained, regulated environment where they have constant support and oversight. Aftercare planning is a crucial component for transferring those skills to a less structured living environment. Success in maintaining sobriety hinges on continuity of care and on-going treatment.
Outpatient Treatment Programs
Outpatient programs are defined by their structure, type of services, and frequency of attendance.
- A Standard outpatient program is the least intensive. Typically they meet once or twice a week for a few hours in a group therapy format. They may offer one-to-one counseling with a counselor or licensed therapist. There is little or no medical supervision.
- An Intensive Outpatient Programs (IOP) is just that – more intensive. They meet typically between 9-20 hours per week. They treatment is composed of group counseling, individual counseling, drug testing, family groups, case management, and support group meetings. This is the typically the level of care recommended following discharge from a residential program, but it is also strongly recommended for those seeking treatment that may not need require a residential program.
- Partial Hospitalization Programs (PHP) are also known as “day treatment” programs. They may offer treatment up to seven days a week for 3-8 hours a day. Usually, they are offered in hospital or clinical settings. The services typically include medical and psychiatric care, medication management, group therapy, family therapy, recreational activities, and social services.
Medication
I know what you’re thinking. “Why would I want to trade one drug for another?” Medicated Assisted Treatment (MAT) is recommended in combination with therapy and/or counseling. According to SAMHSA, research finds it effective for the treatment of substance use disorders. Not everyone requires medication, but for some it increases their chances for survival and helps them stay in treatment longer.
Medication approved by the FDA for opioid overdose prevention is naloxone by reversing the effects of opioids. FDA approved medications for opioid dependency include buprenorphine, methadone and naltrexone and, for alcohol use disorders, medications include naltrexone, acamprosate, and disulfiram. Your physician can assess if any of these medications should be part of an appropriate course of treatment for you. While medication can be used alone, I believe treatment of any substance use disorder is most effective when it is combined with other treatment modalities.
Individual Therapy
Seeing a therapist who is experienced in the treatment of addictive disorders is a valuable resource to explore and identify underlying causes, or the “why” of substance use. They can provide a safe, non-judgmental space to talk about your substance use and any related issues.
- CBT (cognitive behavioral therapy) is typically used will help you identify relapse cues and manage the cravings and stress that call you to use.
- Motivational Enhancement strategies are used to help strengthen motivation to change substance use behaviors. Examining the pros and cons, identifying ambivalence, developing coping skills, identifying successes, and increasing confidence will create faith that the process is working. Having faith in the treatment instills hope for the future and improves motivation to stay the course in the present.
- Marital or Family Counseling can play a very important role in the success of substance use treatment. Interpersonal relationships are often damaged during the course of drug or alcohol use. Often, the spouse, partner, or children need education about substance use to better understand what you are experiencing. Relationships need repair, trust needs to be earned, and family support increases the potential for long term recovery.
- Brief Interventions by a psychotherapist are also beneficial. A supportive, non-judgmental therapist will establish a rapport of trust. Familiarity with your background enables the therapist to objectively identify behaviors that are potential risks for relapse. The therapist’s feedback and direction can help you make healthier choices.
Social Support Groups
12-Step Groups (NA, AA, CA, CMA, etc.) provide vital peer support. Finding new “like minded” friends who are on the same journey can be very reassuring that you are not alone. While often mistakenly confused with a purely religious philosophy, the 12-steps are merely suggestions and provide a behavioral road map for a life free from the ravages of alcohol. With some variations, the 12 underlying principles to the 12-steps are:
- Honesty
- Hope
- Faith
- Courage
- Integrity
- Willingness
- Humility
- Brotherly love
- Discipline
- Perseverance
- Spirituality
- Service
SMART Recovery is an abstinence-based program for those with addictive problems. Their approach utilizes a 4-Point Program to effect behavioral change. The 4-Points are:
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- Building and maintaining motivation to change,
- Coping with urges to use,
- Managing thoughts, feelings, &behaviors in an effective way without addictive behaviors,
- Living a balanced, positive, and healthy life.
Refuge Recovery is grounded and Buddhist beliefs. They believe the application of Buddhist teachings can relieve all suffering, including addiction. Refuge Recovery believes the recovery process begins when abstinence begins. They identify 4 Truths and an eight-fold path to recovery.
The Four truths are:
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- Addiction creates suffering,
- The cause of addiction is repetitive craving,
- Recovery is possible, and
- The path to recovery is available.
The eight factors are not meant to be done in any particular order, but all are to be developed at the same time and maintained throughout the course of life.
Eight-fold factors:
- Understanding
- Intention
- Communication/Community
- Action
- Livelihood/Service
- Effort
- Mindfulness/Meditations
- Concentration/Meditation
