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Models of Addiction

Competency #3Midwest Regional Fetal Alcohol Syndrome Training Center

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Competency 3: Models of Addiction

• This competency applies concepts and models of addiction to women of childbearing age, including those who are pregnant, to provide appropriate prevention services, referral, and case management.

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Learning Goals

• Explain past and current theories of alcohol use.

• Describe the categories of alcohol use in women.

• Describe stages of alcohol use/dependence/addiction and individual interventions.

• Explain the “stages of change” model in alcohol use treatment.

• Address psychiatric co-morbidities related to alcohol use.

• Recognize characteristics of alcohol dependent families.

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Past and Current Models of Alcohol Use

• Moral Model

• Sociocultural Models

• Psychological Models

• Addictive Disease Model

• Biomedical Model

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Past and Current Models of Alcohol Use: Moral

• Personal choice whether to drink or abstain.

• Individual doesn’t have the moral strength to resist alcohol’s temptation.

• Punishment of behavior is important.• Blame is placed on the alcohol-

dependent individual.

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• Abuse is facilitated by society.

• Problem due to lack of economic opportunity and positive role models.

• Treatment involves education, economic opportunity and reintegration back into society.

Past and Current Models of Alcohol Use: Sociocultural

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Past and Current Models of Alcohol Use: Psychological

• Heavy drinking is promoted by observing others and is used to numb pain or achieve pleasure.

• Problem due to lack of other coping skills to deal with stress.

• Treatment involves learning positive coping skills, reducing stressors, and resolving emotional problems.

• Conditioning model is sometimes used (drinking is punished and abstaining is rewarded).

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• Sometimes confused with biomedical model.

• Promotes idea that addiction is a disease that is progressive and curable.

• Loss of control over drinking and denial of problem are indicators of disease.

• Abstinence is first step to treatment. Other options include AA, outpatient and residential detoxification.

Past and Current Models of Alcohol Use: Addictive

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• Most widely supported in scientific literature

• Alcohol dependence is a brain disorder

• Genetic and environmental basis for dependency

• Abstinence advisable but not seen as necessary for all people with dependency

• Favors harm-reduction approach, drug substitution, craving reduction medication and brief psychotherapy

Past and Current Models of Alcohol Use: Biomedical

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Alcoholism-Definition

• Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by continuous or periodic impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial.

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Alcoholism-Characteristics

• Alcoholism is an addictive disease process characterized by: Craving and compulsions Loss of control Continued use despite adverse

consequences

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Alcohol AbuseDSM IV Criteria

• One of more of the following occurring in the past twelve months: Role failure (interference with homework or school

obligations). Risk of bodily injury. Drinking while driving (operating machinery or

swimming). “Run-ins” with the law (arrests or near arrests). Relationship trouble (with friends and family).

• If yes to one or more, your patient abuses alcohol.

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• Tolerance

• Withdrawal

• Impaired control

• Drank more or longer than intended

• Spent a lot of time drinking

• Neglect of activities

• Kept drinking despite problems

Three or more of the following occurring in the past twelve months:

Alcohol DependencyDSM IV Criteria

If yes to three or more, your patient has alcohol dependency.

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Categories of Alcohol Use in Women

• Statistics show that Over 50% of women report alcohol use One in eight women report binge drinking 10% of pregnant women report any alcohol use; 2-4%

of them report binge drinking

• Standard drink: contains about 14 grams of pure alcohol which is equivalent to: One 12-ounce beer or wine cooler One 5-ounce glass of wine 1.5 ounces of 80-proof distilled spirits

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Drinking Patterns and Risk of Alcohol Dependence

1: Abstainers (0%)

2: Low-risk drinking (<1 in 100)

3: At-risk drinking (1 in 5)

4: Problem drinking (1 in 2)

5: Alcohol dependent drinking (100%)

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• Loretta comes to your office today to determine if she is pregnant. She is a 28 y.o. single mom with a 6 y.o. child. She uses alcohol, smokes, and sporadically uses marijuana.

• Drinking Amount: 2-3 standard drinks (beer) per night, up to 6 on a Saturday night.

• Problems : Becomes nervous if stops drinking for more than a day and has insomnia. Has difficulty raising her child who has ADHD and holding down a job. No trouble with the law.

• Tolerance: Takes 3 drinks to feel high, no control issues.

• What is Loretta’s drinking pattern?

The Case

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• Stage 1: Tolerance – ability to drink without becoming intoxicated

• Stage 2: Physical dependency – motivates the large bulk of alcoholic drinking; drinks to alleviate symptoms

• Stage 3: Major organ change – alcohol has done measurable damage to the body

Stages of Alcohol Use/Dependence/Addiction

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Stage One: Tolerance

• Occasional use

• One drug/two gateway drugs (nicotine or marijuana)

• Tolerance

• Occasional hangover

• Anxiousness

• Disruptive sleep patterns

• Mild depression• Frequent

colds/infections• Reduced sexual

inhibitions• Mild tremors/shakes • Vivid dreams • Pleasant memories of

use • Occasional blackouts

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Stage One Tolerance: Outside influences

• Family problems

• In trouble with the law (close calls)

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Stage Two: Physical Dependency

• Daily, usually a.m. use

• Variety of drugs

• Increase tolerance

• Withdrawal symptoms: headache/nausea

• Irritability/mood swings/paranoia

• Sleeplessness

• Sexual problems

• Depression and other psychiatric diagnoses

• Intention tremor

• Nightmares

• Preoccupation/cravings

• Development of blackout patterns

• Disease pathology developing in major organs

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Stage Two Physical Dependency: Outside influences

•School/work problems

•DWI/DUI/unlawful possession

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Stage Three: Major Organ Changes

• Maintenance use

• Multiple drug addiction

• Change in tolerance

• Migraines/vomiting

• Mood disorders/

paranoia

• Insomnia

• Suicidal ideation/attempts

• Impotence

• Delirium tremens

• Night sweats

• Compulsion/use despite consequences

• Longer more frequent duration of memory loss

• Major organ damage

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Stage Three Major Organ Changes: Outside influences

Loss of job/family/school Incarceration

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The Case

• What stage of addiction characterizes Loretta?

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Interventions: Advise and Assist

• State your conclusions and recommendations clearly:

• “I believe you have an alcohol use disorder and I strongly recommend you quit drinking.”

• Relate alcohol use to the patients concerns and medical findings if present.

• Negotiate a drinking reduction goal.

• Abstinence is the safest course for patients with alcohol abuse/dependence and pregnancy/breast feeding.

• Patients who have at-risk, problem drinking or milder forms of abuse or dependency and are unwilling to abstain may be successful in cutting down, use a brief intervention.

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Interventions: Advise and Assist

• Consider referral for additional evaluation by an addiction specialist, especially if the patient is dependent.

• Consider referring to a mutual help group.

• For patients who are dependent, consider:medically managed withdrawal (detoxification)prescribing a medication for alcohol dependent

individuals who endorse abstinence as a goal

• Arrange follow up appointments.

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Medications for Alcohol Use Disorders

• Disulfiram 250-500mg po qd– Produces an unpleasant flushing reaction when patients drink alcohol.

• Naltrexone 50mg po qd – Blocks opioid receptors that are involved in the rewarding effects of drinking alcohol and the craving for alcohol after establishing abstinence.

• Acamprosate 666mg po tid, 333mg po tid if renal impairment - Probably works by reducing symptoms of protracted abstinence such as insomnia, anxiety and restlessness.

(Greater effectiveness is achieved if use of these agents are combined with AA or counseling).

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The Case

• What treatment would you recommend for Loretta?

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Stages of Change

• Stages of change model arose out of smoking cessation research.

• Behavioral change is not a single discrete event, but involves phases which are clearly identifiable.

• Characteristic clinician actions during each stage can move the patient forward in the process.

• Relapses are inevitable, normal and are a part of the process.

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Stages of Change and Clinician Actions

Stage-Definition Characteristic Clinician ActionsPre-contemplation:

not considering change

Motivate through emotional appeal to a better if change occurs.

Contemplation:

thinking about change

Help the patient assess risks and benefits for change and not changing in their lives.

Preparation:

planning to change

Help the patient prepare a specific behavioral plan.

Action:

actively changing

Provide support and encouragement. Help in judging effectiveness of plan. Modify plan if not working.

Maintenance/Relapse:

trying to maintain change

Normalize relapse, assess upsetting emotional events or mental illness, such as depression, and treat it promptly as these emotional events are a big cause of relapse.

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The Case

After giving Loretta advice and assistance,Loretta consented to a brief intervention butfound it difficult to set a drinking reductiongoal or form a plan. While she was convincedshe needed to make a change, she didn’tknow how she was going to do it given herlifestyle. In what stage of change is Lorettaand what should the clinician do?

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Psychiatric Co-morbidities

• Definition: Refers to the co-occurrence of two disorders. Co-morbidity is often marked by greater functional impairment and self destruction and chronic treatment is often more difficult.

• Alcoholism is one of the most common psychiatric disorders, with a prevalence of 8 to 14%. The most common co-morbidities among women are anxiety and mood disorders.

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• Dis-inhibitions and feeling of sadness/irritability contribute to suicide attempts and completed suicides.

• Anti-social personality disorder may be associated with alcohol-related disorders. The presence of this diagnosis will increase the likelihood of criminal behavior.

• For adolescents, one might find conduct disorders and repeated antisocial behavior as well as depression and suicide, eating disorders and hormonal imbalances.

Psychiatric Co-morbidities

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• In assessing co-morbidities the clinician discovered symptoms of depression in Loretta. After 3 months of treatment with a selective serotonin reuptake inhibitor, Loretta seemed to put more energy into changing her alcohol use, including joining an Alcoholics Anonymous group.

The Case

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Characteristics of the Alcohol Dependent Families

• Genetics

• Environmental family factors

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Role of Genetics

• Whether women drink in the first place is more determined by environmental factors; however, genetic factors play a larger role in determining whether alcohol use will develop into abuse or dependency.

• Genes determine how quickly alcohol metabolizes, tolerance to alcohol, and craving for alcohol all of which are linked to the chance of developing alcohol addiction.

• An estimated 5 to 10% of female relatives and 25% of male relatives of alcoholics will themselves develop alcohol dependency suggesting that alcoholism can be transmitted from generation to generation.

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Family Factors that Contribute to Alcohol Use

• Stress, isolation and low self esteem in the household. One study determined that the death of a spouse, divorce, or either a member of the family moving in or out were three of many stressful experiences that alcoholics have linked to need for consumption.

• High levels of emotional abuse, parental alcoholism, constant parental conflict, feeling unwanted or unloved.

• A parent/caregiver’s lack of involvement or negative involvement in the lives of their children in the formative years.

• A parent’s consumption of alcohol is thought to be associated with their child’s initiation and continuation of alcohol consumption.

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Characteristics of Chemically Dependent Families

• Family members have low self esteem.

• Family rules are rigid or nonexistent.

• Blaming and defensiveness.

• Isolated family members.

• Feelings are not expressed openly or appropriately.

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• Roles may be confused with children acting as parents and parents acting as dependent children.

• Stress related illness is common

• Denial is present at every level.

• Compulsive behaviors appear in an effort to defend against stress or chemical dependency.

Characteristics of Chemically Dependent Families

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Intervention: Family Factors

• Family therapy to uncover and change dysfunctional dynamics.

• Al – Anon for family members.

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The clinician uncovered Loretta’s unhappiness with her relationship with herboyfriend. She felt her boyfriend was notsupportive of her desire to gain control overher addiction, as he was a very heavy drinkeralso. He often bought alcohol for Loretta andencouraged her to drink. What intervention isindicated?

The Case

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Conclusion

• Alcoholism, dependency or abuse, is a chronic illness requiring follow up, multiple modalities of treatment and consideration for the person’s stage of change, co-morbidities, and family factors.

• Alcoholism, dependency or abuse, are treatable disorders, the earlier the better.

• The case: Loretta was successful in treating her addiction, (unfortunately she had to find a new boyfriend).