Our language shapes and reveals attitudes that can be quite subtle. Because we are in the business of using language, our choice of words in describing what we do and who we treat becomes very important. This is particularly true in the treatment of addiction disorders.
Despite the scientific advances we have seen in our understanding of the biological and cognitive aspects of abuse and addiction, people (including treatment professionals) still think of addiction as a choice, not an illness.
A core concept that has evolved over the last 10 years is that drug addiction is a brain disease that develops over time as a result of the initially voluntary choice of using drugs (including alcohol and tobacco). Addiction professionals now know that there are fundamental changes in the structure and function of the brain when exposed to addictive substances. These changes are long-lasting and persist well beyond abstinence from drugs of abuse. This explains why many people, once addicted, are never able to return to limited “controlled” drinking or drug use.
The point is that while addiction may begin through a voluntary choice to use, once a person becomes addicted, he or she has moved into a different state of being. This change at the molecular level involves the brain’s “pleasure pathway”, mediated by neurotransmitters, and results in a disease expressed in the form of uncontrollable, compulsive drug craving, seeking, and use. These cravings overwhelm all other motivations. This is why the addicted person continues to use in spite of severe health, legal, and social consequences. It is beginning to appear that all substances of abuse (including food) operate under similar biological processes in the brain.
Yet we persist in blaming the patient for his disease. One reason for this is that not everyone who uses drugs or alcohol becomes addicted. Individuals show different susceptibilities to addiction, in how quickly they become addicted and to what substances they may be most vulnerable. Our prejudice is showing when we ask what the person’s “drug of choice” is. Once the person has developed the addiction, it has become their drug of necessity, not choice.
We contribute to the stigma of this illness by calling people with addictions “substance abusers”, or even worse, “addicts” (which conjures up even more negative images). Another pejorative phrase is used with drug screens. The person is either “clean” or “dirty” based on a positive or negative drug screen result. These labels imply that the full responsibility of the addiction is the individual’s. It discounts the role that environmental factors, genetics/biology, and the drugs themselves play. But old concepts are giving way to more effective strategies.
Therapists no longer terminate clients because they relapse. The idea that we won’t treat you as long as you are ill no longer makes sense. Do we stop treating someone with schizophrenia because they hallucinated? Given the stigma that even professionals frequently attach to addiction, is it any wonder that addicted persons will minimize and lie about their illness (to themselves as well as others) and avoid seeking help? The shame and guilt associated with addiction is well known. Treatment helps the client overcome this shame through an understanding of the disease process and to develop skills necessary to cope with cravings, environmental cues, and intense emotional stresses.
A myth associated with addiction is that treatment does not work. Outcome studies have shown that addiction treatment is on par with other medical/behavioral disorders such as diabetes and heart disease. Successful outcomes in these chronic illnesses often require behavioral changes. Relapse and “compliance” (another pejorative term) issues are not unique to addictions treatment and can be expected.
Treatment works. Research suggests that the longer the person participates in some form of treatment—any treatment—the better the outcome. Positive results rely less on frequency or intensity of sessions and more on being actively involved in a recovery effort over time. Such efforts can include counseling, aftercare, medication, and external self-help support groups such as Narcotics Anonymous.
Another aspect of addictions is the frequency in which it is found with clients suffering from mental illnesses such as depression, schizophrenia, bipolar disorder, and personality disorders. More than half of all individuals who have a serious mental illness (SMI) will also have a co-occurring substance abuse disorder at some point. This is why, when treating individuals with emotional/behavioral disorders, addiction is the expectation, not the exception. Addiction is not to be “discovered”. It is to be ruled out. Dedicated treatment for co-occurring disorders is now an accepted and necessary part of our continuum of care.
Substance abuse is prevalent in adolescence as well as in adults. It is the rare adult who did not begin the addiction process when he was a teenager. Consider the fact that four out of five teens in the juvenile justice system are under the influence of alcohol or drugs while committing their crimes.
Treatment of addictions has led the way in the development of evidence-based practice. The widely accepted “stages of change” and models for motivational interviewing are based in addictions treatment. Medication management of cravings or blocking of the euphoric buzz is an expanding area of treatment, with such drugs as Naltrexone, Buprenorphine (Suboxone), and Campral.
As the scientific understanding of addictions has increased and treatment strategies have become more research-informed, the need for addictions professionals trained in effective methods of care has increased. This need has resulted in the recently passed Indiana licensure bill establishing the Licensed Clinical Addictions Counselor and Licensed Addictions Counselor, to begin in 2010. The requirements for state licensure will demand a professional level of preparation and expertise that reflect our increasing knowledge and optimism for effective treatment of addiction disorders.
Substance Abuse Facts and Figures
- Through PET scans and similar technologies we are now able to peer inside the addicted person’s brain to study the long term neurological consequences. One study was able to show how certain neurotransmitters were activated when the subject was shown pictures of drugs in rapid succession. While the subject was not consciously aware of the images the brain was and reacted to these “triggers” by producing drug cravings. Drug cravings may be well out of the conscious awareness. Basically, anything can become an association to drug use and trigger cravings which can lead to compulsive drug seeking and use.
- Studies have shown long lasting structural impairment in brain functioning well past the point of discontinuing the drug. Again, individual differences occur. The individual may have persistent difficulty with concentration, mood regulation (moodiness, anger, depression), ability to process information, or memory. This is particularly worrisome with adolescents whose brains are still developing, i.e. brain damage.
- Only 1.5% of 22 million people in the U.S. needing treatment for alcohol or illicit drug use actually seek help without being forced to do so. A conservative estimate is 80% of the clients we treat for addiction/abuse disorders are court-ordered or are coming in as a preemptive strike prior to a court hearing. It’s closer to 100% if we also consider pressure and threats from family or the workplace.
—About the author: Dan Brown is Director of Outpatient Services at Aspire Indiana’s Willowbrook office in Indianapolis. Follow Dan on Twitter: @DannyCBrown. Learn more about Aspire Indiana at http://www.aspireindiana.org/ or on Facebook at https://www.facebook.com/AspireIndiana.