Chapter 1–Who Needs Treatment: An Overview of Addiction and Its Treatment

Almost everyone has had experience with addictive psycho active substances. Alcohol is a legal substance that is frequently used in social situations by people from all walks of life. Most people consume it occasionally and experience no adverse effects. Nevertheless, it can be addicting, and for those who reach this level of use, there are potential health and social consequences. In addition to alcohol, mood-altering drugs include a variety of illegal and legal substances that are highly addictive and often result in impaired physical, social, and psychological functioning of users.

Joseph A. Califano, Jr. (1992), president of the Columbia University Center on Addictions and Substance Abuse and former Secretary of the U.S. Department of Health, Education, and Welfare, reported the following estimates of the numbers of persons abusing alcohol and other drugs in the United States:

• approximately 18 million persons abuse or are addicted to alcohol;
• up to 1 million individuals use heroin;
• at least 2 million are addicted to cocaine or crack;
• 5.5 million get high on marijuana more than once a week; and
• 11 million persons abuse tranquilizers and other psychotropic drugs.

Because of the addictive properties of these substances, and the related physical, social, and psychological consequences they precipitate, treatment will be required for these individuals to recover from their addictions and achieve abstinence.

Those who have not had personal experiences using either socially acceptable or illicit drugs still may have been touched by the effects of these substances. Use and abuse of alcohol and other drugs has far-reaching effects. Family members, friends, coworkers, and others often are affected–sometimes tragically–by those who become involved in substance abuse.

In this chapter, the process of addiction–progressing from experimental and social use to dependency and addiction–will be examined. This process also includes recovery for many individuals who receive appropriate treatment interventions. Such recovery means a chance to return to productive roles in society that are not focused on procuring and using alcohol and other drugs at the expense of one's physical health and personal well-being. Recognized as a part of the disorder of addiction is its chronic and relapsing nature. Recovery from addictive illness necessitates sobriety and abstinence, relapse prevention programs, and continuing supportive intervention for those who become dependent on mood-altering chemicals.

The majority of persons who use drugs or alcohol from time to time will not need treatment. Those who are not dependent or addicted may be able to decide to stop using chemicals. However, finding a social climate that is intolerant toward drug use will be important for them. The threat of social, legal, or employer sanctions often is significant enough to persuade them away from continued drug use (Office of National Drug Control Policy [ONDCP], 1990b).

Treatment is for those who cannot or will not stop their use of alcohol or drugs without the help of a specific program–usually those who have become physically or psychologically dependent on alcohol or drugs. Without some form of intervention, compulsive alcohol and drug users usually are unable to stop their use for more than a few days at a time. Despite the personal and family consequences, of which they are usually aware, addiction makes it virtually impossible for them to abstain from abusing alcohol or other drugs (ONDCP, 1990b). Their need for chemicals often forces them to deny the negative consequences they are experiencing.

For youth, the criteria for those needing treatment services is somewhat different. In addition to illicit street drugs, the use of alcohol is also illegal for persons under the age of 21 in most States. Thus, lawfully, any use of these substances by adolescents can be considered abuse. Use of substances is also of particular concern for adolescents who are still developing, physically, socially, and emotionally. For youth, the stance is often taken that if use of alcohol or other drugs are creating problems in one or more areas of functioning, then assessment and intervention services should be provided (McLellan & Dembo, 1992). This affords a positive opportunity to prevent progression to more serious chemical dependency for many young persons.

Treatment is an essential and cost-effective factor in stemming the tide of substance abuse. Without treatment that is appropriate for the specific needs of individuals, the economic and human costs associated with substance abuse will continue to escalate. Treatment is vital for those whose use of alcohol and other drugs has progressed to the stage of dependence or addiction. This chapter will present a description of the five critical elements necessary for a comprehensive treatment approach.

The Process of Addiction

No one begins using a mood-altering substance with the intention of becoming addicted to it. For example, the use of alcohol begins with the notion that it will be used only on social occasions, with certain friends, or for specific purposes. In some cases, it is possible to maintain that level of use.

However, for persons who have progressed to dependence on alcohol or other drugs, the sojourn has been difficult. Once past a certain point, there is no turning back. Continuing the journey, with any expectation of health and well-being, will require substance abuse treatment.

Abstinence from alcohol and other drugs is typical for most people most of the time. Occasional use of psycho-active substances may begin because of curiosity or because of the influence of friends. Initial experimental use of mood-altering substances usually occurs during the adolescent years, most often between 12 and 15 years of age. The typical pattern is experimentation with tobacco and alcohol, followed by initial use of marijuana. As use continues, other illicit drugs that can be inhaled or ingested orally may be consumed. Use of more potent drugs, particularly those requiring hypodermic administration, begins somewhat later. During this initial period, use of drugs is intermittent, and most people return to periods of complete abstinence during which they do not seek or consume drugs and experience no adverse consequences from their use (Institute of Medicine, 1990). See Table 1-A for a brief summary of the characteristics of experimental and social use of alcohol and other drugs.

The metabolic effects of alcohol and other drugs alter the individual's chemistry because psycho-active drugs mimic, displace, block, or deplete specific chemical messengers between nerve cells in the brain. Certain areas of the brain control drives such as hunger, thirst, and sexual libido. When we are hungry we feel uncomfortable; when we eat, we feel satisfied–a positive reward. psycho-active substances act upon the same areas of the brain and they can produce euphoria, an extremely pleasurable feeling, or cravings for the drug, an unpleasant feeling. With gradually increasing use of a substance, the cycle of euphoria and cravings results in dependence or addiction to the drug (Dackis & Gold, 1992; Institute of Medicine, 1990).

Problem use or abuse of alcohol or other drugs is the second stage in the process of addiction (see Table 1-B). The frequency of administration, as well as the amount of the drug used, increases. Use to the point of intoxication occurs often. The pleasurable, euphoric feelings produced with earlier use are still sought, but after the effects of the drug subside, pain, depression, and discomfort may occur. Unlike earlier stages of use, individuals progressing through this stage are likely to begin encountering consequences for use. These may include:

• work- or school-related difficulties;
• changes in friends;
• family problems;
• physical illnesses;
• weight loss and other physical problems;
• financial and legal complications; and
• personality and emotional changes.

If substance abuse continues, the individual may reach the stage of dependency/addiction. Dependency occurs when a drug user experiences physical or psychological distress upon discontinuing use of the drug. Addiction implies compulsive use, impaired control over using the substance, preoccupation with obtaining and using the drug, and continued use despite adverse consequences (Morse & Flavin, 1992). Table 1-C summarizes the characteristics of this stage, including almost continuous use to avoid pain and depression. Dependent/addicted persons are unlikely to experience euphoria or other pleasant effects from the drug; continued administration is needed to achieve a state of homeostasis–feeling "normal" or not having pain.

The physical, social, occupational, financial, legal, and psychological consequences continue in a downward spiral. Those who persist in drug use to this stage often begin using injectable drugs. On average, it may take from 5 to 10 years following the first experimental use of drugs until a person progresses to the stage of dependency/ addiction. This means that many who initiate drug use in their early teens will be addicted by their late teens or early 20s. There are many personal and drug-related variables that can hasten or retard the process, but once dependent, obtaining and using a drug of choice is the focus of one's life (Institute of Medicine, 1990).

Figure 1-A graphically depicts the progression of drug use through the three stages of experimental/social use, problem use/abuse, and dependency/ addiction (Doweiko, 1990; Institute of Medicine, 1990). As the use of mood-altering chemicals progresses through these stages, related physical, social, and psychological problems increase. During earlier stages many people can manage their drug and alcohol use and may move back and forth from abstinence to problem use. Each stage entails some risk of progression to the next, but this course is not inevitable (Institute of Medicine, 1990). However, once the stage of dependency/ addiction is reached, the individual has acquired a chronic relapsing dis order that most professionals believe can never be "cured." Return to earlier stages of controlled use is no longer possible.

However, treatment helps addicted individuals enter a stage of recovery during which they abstain from substance use and experience improved physical, social and psychological functioning. Because of relapse, the recovery process may be interrupted by periods of return to substance use. This requires attention to relapse prevention and continuing supportive therapeutic interventions. Many treatment modalities (such as methadone maintenance or Alcoholics Anonymous) are viewed as potentially lifelong commitments to maintain the recovery process. Chapter 9 will provide more information on relapse prevention programming.

Knowledge of the mechanisms of substance abuse and addiction has not advanced enough to provide a cogent understanding of the reasons some people manage their use of alcohol or drugs while others progress to a problem stage of abuse or addiction. It is likely that a combination of physiological, environmental, and psychological factors converge to exacerbate the problem for some individuals. (Theories concerning the causes of addiction will be discussed further in Chapter 3.) Although found among all socioeconomic groups, persons already plagued by poverty, disease, and unemployment are over-represented among those afflicted by chemical addiction.

Recovery

Research indicates that, while it is not a curable disorder, treatment for substance abuse does work. With treatment, substance-dependent persons enjoy healthy and productive lives. Instead of creating health risks, committing crimes, and requiring public support, recovering individuals make positive contributions to society through their work and creativity. Recovery is the process of initiating and maintaining abstinence from alcohol or other drug use. It also involves making personal and interpersonal changes (Daley & Marlatt, 1992). Whether an individual is addicted to or abusing alcohol, illegal drugs, prescription drugs, or a combination of these, the most important goal is to discontinue the use of alcohol and/or drugs.

With relapse prevention programming and supportive treatment, recovery is a realizable goal. With improved treatment services and adequate resources, society also is protected from further consequences related to drugs and alcohol, including economic, social, health, and crime-related problems. Additional information on the consequences of substance abuse is presented later in this chapter and in Chapter 2.

Five Critical Components of Effective Treatment

Treatment is an effective tool in reducing drug abuse and rehabilitating those affected by it. It is particularly important that treatment strategies incorporate the following five critical components to enhance effectiveness (Messalle, 1992).

1. Assessment uses diagnostic instruments and processes to determine an individual's needs and problems. It is an essential first step in determining the possible causes of addiction for the person and the most appropriate treatment modality for his or her needs. More information on screening and assessment will be presented in Chapter 4.
2. Patient-Treatment Matching ensures that an individual receives the type of treatment corresponding with his or her personality, background, mental condition, and the extent and duration of substance abuse determined by the assessment. In Chapter 5, the importance of patient-treatment matching will be emphasized.
3. Comprehensive services include the range of services needed in addition to specific alcohol or drug treatment. The needs of addicted persons are often very complex, including health problems, financial and legal issues, psychological problems, and many others. Effective treatment must help people access the full extent of additional services needed to make their lives whole.
4. Relapse prevention is important because addiction is a chronic and relapsing disorder. Relapse prevention strategies are based on assessing an individual's "triggers"– those situations, events, people, places, thoughts, and activities–that re-kindle the need for drugs. Strategies for coping with these when they occur are then developed. Relapse prevention will be reviewed in more detail in Chapter 9.
5. Accountability of treatment programs is crucial for determining the success of specific approaches and modalities. The need for the program, its integrity, and its results, including abstinence, social adjustment, and reduction of criminal behavior by those treated in the program, must be evaluated. More information on accountability and program evaluation is contained in Chapter 10.

Throughout this text a variety of terms will be used frequently to describe the problem of chemical addiction and those who are affected by it. To avoid misinterpretation or confusion, several of these words are defined in Table 1-D.

Extent of Substance Abuse

Although some promising reports indicate a decline in drug use in the general population, other data indicate less encouraging results. Unfortunately, there is no single measurement that provides a clear picture of alcohol and drug use and its complex interaction with individual and social problems. Many large-scale studies use populations that are easily accessed, such as youth in high school or persons living at home who have telephones. However, these methods tend to overlook subgroups who are known to have high rates of substance abuse, such as those in prisons, homeless persons, and high school dropouts. Further, individuals may be reluctant to disclose alcohol and other drug use when they are questioned because they are concerned about potential punishment.

While these and other studies provide reason for optimism, there are some inherent problems. Those selected to take part in these studies are promised anonymity of their responses in return for their voluntary participation. However, it is likely that some decline because of fear of consequences for their behavior. National surveys also miss hard-to-reach subsections of the population. This includes youth and adults who are not living at home and are not attending school (e.g., school dropouts, incarcerated persons, the homeless). However, documented use of mood-altering substances is higher among such groups (ONDCP, 1990a).

Currently, estimates of the number of persons abusing or addicted to alcohol and other drugs range from 6.5 to 37.5 million. However, only about 300,000 of this number receive some form of treatment (Califano, 1992; Primm, 1992). It is estimated that nearly one-fifth of the population will experience substance abuse-related problems during their lifetimes. The use of illegal drugs in the United States has gradually increased from minimal levels in the 1940s and 1950s to 1985 levels at which approximately one-third of the population are thought to have used some drug(s) during their lifetimes (Frances & Miller, 1991).

Hospital Admissions Related to Drug Use
Between 1985 and 1988, while reported drug use was declining, the number of drug-related hospital admissions more than doubled (Frances & Miller, 1991). The Drug Abuse Warning Network (DAWN) examines the numbers and pattern of drug-related health emergencies and deaths in several cities. Cocaine-related emergency room cases increased 400 percent between 1985 and 1988. However, beginning in 1989, a gradual decline began. Deaths attributable to cocaine during the same period tripled. Corresponding patterns occurred with other illicit drugs during the same period; however, the increases in emergency room cases and deaths were not as dramatic with other drugs as they were with cocaine (ONDCP, 1990a).

Use of Drugs by Criminal Offenders
The Drug Use Forecasting Program (DUF) uses urinalysis to test a sample of arrestees in selected major cities around the country. Urine specimens are collected anonymously and voluntarily from both adult and juvenile arrestees. The DUF reports provide information about the criminal justice population that is under-represented in other drug surveys. The results indicate that the rate of drug use is as much as 10 times greater among those arrested for serious crimes than among the general population. Approximately three-quarters of arrestees committing crimes of burglary or robbery in 1989 tested positive for drugs, indicating a link between drugs and income-generating crimes. However, the data show that drug use is also prevalent among the majority of most other serious offenders (ONDCP, 1990a).

The association between drugs and crime can be made in at least three ways (Singer, 1992):

1. The criminal act of manufacturing or selling illegal drugs is undertaken for the extreme profits that can be made.
2. Some addicted persons engage in income-generating crimes to support their drug use habits. This includes crimes such as robbery, shoplifting, burglary, and prostitution.
3. Certain drugs increase aggressive or violent behavior in some individuals, resulting in violent crimes such as murder, manslaughter, rape, and other sexual assaults. Alcohol, cocaine, and phencyclidine (PCP) are particularly noted for this effect.

The National Narcotics Intelligence Consumers Committee Report also examines trends in drug availability and consumption. Cocaine continues to be widely available in the United States, although purity has declined and prices have increased according to recent reports. Heroin availability also increased during 1989. At that time, methamphetamine and MDMA ("Ecstasy") were readily obtainable and use remained high, while PCP use declined in major U.S. cities (ONDCP, 1990a).

These data indicate that drug use is a pervasive problem in American society, cutting across socio-economic, racial, and ethnic lines. Persons responsible for decision making and coordination related to treatment services should be attuned to the heterogeneity of the population (Singer, 1992).

The Response to Substance Abuse

The incidence of substance abuse remains unacceptably high, and both substance abusers and other persons are adversely affected by this disease. New information about the effectiveness and economic benefits of providing treatment are emerging rapidly. Efforts to evaluate treatment have led the Office of National Drug Control Policy (1990b, p. 30) to state unequivocally, "We now know on the basis of more than two decades of research that drug treatment can work."

Various perspectives have viewed addiction as a matter of personal choice, as a medical illness, or as deviant, criminal behavior. Thus, responses to addicted persons have ranged from ignoring them to hospitalization to imprisonment.

The medical view of addiction understands that addicted persons have a treatable disease, much like other diseases, such as diabetes. Addiction is a chronic disorder that is prone to relapse, even after significant periods of recovery. Thus, the individual needs treatment that is appropriate for his or her particular needs and problems based on an assessment of the cause and course of the disease. The mission of treatment agencies focuses on helping individuals make positive changes. Treatment approaches have evolved in two basic categories:

1. Pharmacological modalities, which affect physiological processes (such as detoxification and methadone maintenance), and
2. Behavioral modalities, which influence behavior or learning processes.

These often are combined to produce a greater effect (NIDA, 1991).

The criminal view of addiction defines drug use as a criminal behavior. The focus of intervention in the criminal justice system is first to protect the health, safety, and welfare of the public, and then to rehabilitate offenders, if possible. Prison crowding and an overwhelming drain on community corrections resources have resulted from increasing numbers of drug-involved offenders. However, as caseloads continue to rise, it is difficult to see that this approach, at least without concomitant treatment, has positively affected the problem of substance abuse.

Conclusion

Substance addiction is a chronic, progressive, relapsing disorder affecting all citizens in one way or another. If not directly involved, many have family members with alcohol or other drug-related problems. Highways and places of employment are sometimes unsafe because of the effects of alcohol and drugs on motorists and co-workers. It is a devastating disease to individuals, families, and communities. The exorbitant financial toll includes increased health care costs and reduced productivity, as well as higher law enforcement costs, thefts, and destruction of property. With the onset of HIV/AIDS and other infectious diseases for which transmission is directly or indirectly attributable to substance abuse factors, addiction is truly a deadly disease.

While prevention efforts are successful in lowering rates of substance abuse among some segments of the population, addiction is a pervasive problem among others. However, treatment is a cost-effective strategy for intervening to stop the cycle of destruction and despair. Treatment programs providing comprehensive services and attending to the continuing treatment needs of individuals are most beneficial. These programs include the five critical components of treatment– comprehensive assessment, patient-treatment matching, comprehensive services, relapse prevention, and accountability.

With coordination of efforts, appropriate application of resources, and a vision for a better future, great achievements in substance abuse treatment will occur.

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