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By Bruce Springer, MD
What is addiction?
Most health care professionals would agree that addiction is a disease.
Like high blood pressure, diabetes, heart failure, and leukemia, it shares
many disease-defining characteristics and like these, if left untreated,
is often fatal. Unfortunately, addiction, whether to drugs or alcohol,
is also a relapsing disease that is all too common. Nearly 120,000 of
our friends, neighbors, and family will die of this disease within the
next year. If one considers nicotine an addictive substance, that number
swells to well over one-half million. Addiction finds its home in some
of the deepest parts of the human brain and yet reaches outward to affect
all of health, family life, law, and even history.
Terms used to describe and differentiate people's relationship to potentially
addictive substances are important to understand (please see definitions).
Frequently, these terms are used interchangeably and this adds confusion
to an already confounding topic. Most people using opiates for severe
pain relief may develop tolerance and require higher doses for
continued pain relief. Some of these same patients may become dependent
and experience uncomfortable withdrawal symptoms if the opiates were stopped
abruptly. The vast majority of these patients, however, will not develop
the disease of addiction.
A college freshman may abuse alcohol and drink to intoxication frequently
throughout his early college experience, but after failing an important
course, losing his driver's license, or frequent morning "hangovers,"
will decide that moderation and responsibility are important to his health
and future success. His best friend, however, may lose control over alcohol
consumption and develop addiction to alcohol, drinking despite
losing his family, friends, job, health, and, finally, his life (alcoholism).
How common is addiction?
Many studies to estimate the number of alcoholics and addicts in America
have taken place over the last several years. One such survey in the early
1980s found the prevalence of alcohol disorders (alcohol abusers
and alcoholics) among Americans around 13 to 14 percent! Alcoholism was
much more common among men than women. The prevalence of these disorders
among men was almost 24 percent and among women a little less than 5 percent.
These statistics indicate a number of men and women have some kind of
serious problem with alcohol during their lifetime. Recent studies have
shown a prevalence of drug use disorders in America around 6.2 percent
and some researchers have found lifetime prevalence about even for women
and men. The American Society of Addiction Medicine tells us over 10 million
Americans are addicted to alcohol or drugs.
Who are addicts?
The media announces, almost daily, the stories of famous people who have
entered treatment for their addiction to various substances. For a long
time our culture relegated addicts to city streets, back alleys, flop
houses, and homelessness. Just the opposite is true, however. The face
of the addict or alcoholic is one of a mother, father, teacher, athlete,
minister, doctor, lawyer, or politician. The addict can be anyone from
anywhere.
Just as there are risk factors for heart disease and lung cancer, there
are several characteristics that predict a greater chance for development
of addiction. One of the most fascinating lies within our DNA. Researchers
have found that children of alcoholics (especially sons of alcoholic fathers)
are many times more likely to become alcoholics themselves. Studies of
twins have shown a vastly greater chance of one developing alcoholism
if the other has the disease, even if they were raised in different homes.
There is a great deal of work the world over to find biochemical and molecular
processes that might contribute to this propensity in one person and not
in another.
There are several other risk factors including: growing up in a dysfunctional
family, having a history of certain psychiatric disorders such as antisocial
personality disorder and panic disorder, and having heavy drinking peers
and friends.
Some of the defining characteristics of an addict are a loss of control
over when and how much of a substance is used, plus spending an inordinate
amount of time thinking about and obtaining the substance. Another telling
trait in identifying the addict is one who uses the substance instead
of engaging in relationships, going to work, or living up to life's responsibilities
and commitments. The addict will use the substance despite physical, emotional,
spiritual, and social harm. A very frustrating component of addiction
is denial. As a matter of fact, part of the definition of alcoholism,
as put forth by the American Society of Addiction Medicine, includes denial.
Very often an individual with a serious drug or alcohol dependency problem
is not able to recognize it. One of the greatest human tragedies is when
a person loses everything he or she has and continues to drink alcohol,
blaming everything and everyone else instead of facing the disease of
alcoholism.
Addiction is a disease located in the brain
For most of time, alcoholism and addiction have been viewed as moral weaknesses
or diseases of the will or the spirit. We are now learning addiction begins
when significant changes take place deep within the human brain. The brain
is made up of billions of individual nerve cells that must be able to
communicate with each other. They do this with tiny appendages called
axons. These cellular appendages send chemical messages to each other
via neurotransmitters such as serotonin, dopamine, and norepinepherine.
Many medications and all substances to which human beings become addicted
affect the quantities of these chemicals and how they interact with nerve
cells.
Deep within the substance of the brain lie clusters of nerve cells which
allow us to feel joy, happiness, and satisfaction. These are known as
"pleasure centers" and are connected in a tract of nerve tissue
called the median forebrain bundle (MFB), running near the bottom
of the brain between the right and left hemispheres. It has been put forth
that people susceptible to addiction may experience changes in the interaction
of these neurotransmitters and their receptors. Perhaps there is too much
or too little neurotransmission or an abnormality in the production or
breakdown of neurotransmitters. There could also be changes in the receptors
and alterations in how they interact with the neurotransmitter molecule.
For persons having a predisposition to addiction, the introduction of
a substance bringing a pleasurable feeling may begin to disrupt the receptor/
neurotransmitter function of the nerve cells in the MFB when used again
and again. What once was a source of pleasure becomes a desperate need
for the substance bringing pleasure. The disease of addiction may bring
with it distinct molecular and biochemical changes in the human brain.
The price to be paid
Addiction takes a toll on the addict. Any drug of choice eventually begins
to destroy the physical and psychological health of its victim. Alcohol
is toxic to almost every organ in the human body. During an episode of
intoxication, the brain may be affected by an acute loss of memory (blackouts),
and with chronic use, injury may be more dramatic and long lasting. Many
chronic alcoholics coming to treatment have significant difficulty with
problem-solving and memory. Brain scans on many show noticeable shrinkage
of the brain, indicating loss of neural tissue. Alcoholic dementia is
virtually indistinguishable from Alzheimer's Disease and equally devastating
to the patient. A direct neurotoxic destruction of the balance centers
of the brain (cerebellar degeneration) frequently leaves the alcoholic
unable to walk or perform the simplest tasks. Other neurologic complications
of alcoholism include seizures, injury to peripheral nerves, trauma to
the brain in auto accidents and falls, plus damage secondary to lack of
essential vitamins such as thiamine. The latter can occur very rapidly
when a malnourished alcoholic is given nutrients lacking supplemental
thiamine.
Other serious effects involve the destruction of the heart and impairment
of its pumping function, chronic liver inflammation with cirrhosis and
liver failure, pancreatitis, and life threatening bleeding from the esophagus,
stomach, and duodenum.
The blood forming tissues in the bone marrow are not immune to alcohol's
toxic nature. Anemia is commonly seen and low levels of white blood cells
may impair the ability to fight infection. Sleep apnea, osteoporosis,
muscle destruction, and several types of cancer afflict the alcoholic
more commonly.
Narcotic overdose can cause depression of respiration leading rapidly
to death by asphyxiation. A few can even cause seizures. Cocaine use can
bring about severe hypertension, heart attacks, strokes, and muscle destruction.
It can also cause sudden death in a previously healthy person. Marijuana,
which is often abused by youngsters, has been found to cause dependence
and quickly impairs memory and learning.
Addicts frequently experience psychiatric complications as well. Most
alcoholics and addicts are depressed during the early days of their abstinence,
but this is usually self-limited. Cocaine, amphetamines, and phencyclidine
can cause psychosis, paranoia, and even violent or homicidal behavior.
Repeated cocaine use can so deplete the pleasure centers of neurotransmitters
that any joyful feelings are almost biologically impossible until cocaine
abstinence and time allow the brain to replete stores of dopamine. Some
addicts begin use of drugs and alcohol in response to a pre-existing psychiatric
condition and care must be given in evaluating which came first.
The physician and the addict
Health care professionals constantly come in contact with addicts and
alcoholics. It has been estimated that up to 20 percent of the inpatient
hospital populations are addicts. Physicians may see at least one a day
in their office. Most physicians would probably rather not deal with them.
This is not for lack of compassion, but rather for lack of understanding.
Very little time is spent in medical school or residency training discussing
addiction as a disease. Often a physician or nurse feels ill equipped
and rather hopeless when treating the addict or alcoholic. Sometimes the
doctor or nurse may feel uncomfortable because of the pain in his or her
own family caused by addiction. It is difficult for physicians to be in
the presence of an addict and not come away looking deeply within ourselves
and asking about our own relationship to alcohol or drugs.
Another frustration of health care professionals is the opiate-dependent
patient seeking narcotics. Pain is very difficult to gauge unless one
is personally experiencing it. The number one role for physicians, nurses,
and therapists is to ease pain, whether it is physical or emotional. Thus,
we are often easy targets for opiate addicts. Doctors frequently receive
phone calls on Friday nights from someone they have never met, explaining
they are a patient of another physician in the office and their brand
new prescription for morphine just fell in the toilet or was eaten by
the dog. This can present quite a dilemma for most health care providers.
The vast majority of people in pain do not become addicted and would
rather not be taking these medications in the first place. They find the
constipation, bloating, dizziness, and dry mouth irksome, to say nothing
of the cost. They would much rather be free of the pain once and for all
and get on with a normal life. These are the people who don't doctor shop,
go to only one pharmacy, bring all their unused medication to the physician
on each visit, and use it exactly as prescribed. They also call for refills
at appropriate times. The addicted patient experiences a decreased quality
of life using the medication, wants to increase the dose despite worsening
side effects, and never has any left over. Addicts may forge prescriptions
and often visit several physicians to acquire their opiates.
Busy physicians have precious little time to confront patients suspected
of being addicts. Most don't know how and avoid the time-consuming dialogue
and frustration. However, if we are to improve our ability to successfully
treat addiction, we must be willing to do just that. Studies have shown
that alcoholics who have been confronted by their physicians concerning
the medical complications of alcohol use are more likely to seek help
for their disease.
Conclusion
It is not difficult to see that if we are not ourselves victims of addiction,
we may well care about someone who is. The disease is all too common in
our society. Because it is felt by many to be our number one health problem,
it is important for health providers and the lay public alike to become
more familiar with addiction as a disease and not a moral weakness. People
with addiction are in great pain and their suffering can be lessened and
even eliminated through treatment. We must be willing to commit ourselves
to offering that treatment.
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