Models of Addiction

1
Models of Addiction

• Competency 3
• Midwest Regional Fetal Alcohol
• Syndrome Training Center

2
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.

3
Learning Goals

• Explain past and current theories of alcohol use.
• Describe the categories of alcohol use in women.
• Describe stages of alcohol use/dependence/addictio
  n 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.

4
Past and Current Models of Alcohol Use

• Moral Model
• Sociocultural Models
• Psychological Models
• Addictive Disease Model
• Biomedical Model

5
Past and Current Models of Alcohol Use Moral

• Personal choice whether to drink or abstain.
• Individual doesnt have the moral strength to
  resist alcohols temptation.
• Punishment of behavior is important.
• Blame is placed on the alcohol-dependent
  individual.

6
Past and Current Models of Alcohol Use
Sociocultural

• 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.

7
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).

8
Past and Current Models of Alcohol Use Addictive

• 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.

9
Past and Current Models of Alcohol Use Biomedical

• 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

10
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.

11
Alcoholism-Characteristics

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

12
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.

13
Alcohol DependencyDSM IV Criteria
Three or more of the following occurring in the
past twelve months

• Tolerance
• Withdrawal
• Impaired control
• Drank more or longer than intended

• Spent a lot of time drinking
• Neglect of activities
• Kept drinking despite problems

If yes to three or more, your patient has alcohol
dependency.
14
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

15
Drinking Patterns and Risk of Alcohol Dependence

• 1 Abstainers (0)
• 2 Low-risk drinking (lt1 in 100)
• 3 At-risk drinking (1 in 5)
• 4 Problem drinking (1 in 2)
• 5 Alcohol dependent drinking (100)

16
The Case

• 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 Lorettas drinking pattern?

17
Stages of Alcohol Use/Dependence/Addiction

• 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

18
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

19
Stage One Tolerance Outside influences

• Family problems
• In trouble with the law (close calls)

20
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

21
Stage Two Physical Dependency Outside influences

• School/work problems
• DWI/DUI/unlawful possession

22
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

23
Stage Three Major Organ Changes Outside
influences

• Loss of job/family/school
• Incarceration

24
The Case

• What stage of addiction characterizes Loretta?

25
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.

26
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.

27
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).

28
The Case

• What treatment would you recommend for Loretta?

29
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.

30
Stages of Change and Clinician Actions
Stage-Definition Characteristic Clinician Actions
Pre-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.
31
The Case

• After giving Loretta advice and assistance,
• Loretta consented to a brief intervention but
• found it difficult to set a drinking reduction
• goal or form a plan. While she was convinced
• she needed to make a change, she didnt
• know how she was going to do it given her
• lifestyle. In what stage of change is Loretta
• and what should the clinician do?

32
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.

33
Psychiatric Co-morbidities

• Dis-inhibitions and feeling of sadness/irritabilit
  y 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.

34
The Case

• 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.

35
Characteristics of the Alcohol Dependent Families

• Genetics
• Environmental family factors

36
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.

37
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/caregivers lack of involvement or
  negative involvement in the lives of their
  children in the formative years.
• A parents consumption of alcohol is thought to
  be associated with their childs initiation and
  continuation of alcohol consumption.

38
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.

39
Characteristics of Chemically Dependent Families

• 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.

40
Intervention Family Factors

• Family therapy to uncover and change
  dysfunctional dynamics.
• Al Anon for family members.

41
The Case

• The clinician uncovered Lorettas
• unhappiness with her relationship with her
• boyfriend. She felt her boyfriend was not
• supportive of her desire to gain control over
• her addiction, as he was a very heavy drinker
• also. He often bought alcohol for Loretta and
• encouraged her to drink. What intervention is
• indicated?

42
Conclusion

• Alcoholism, dependency or abuse, is a chronic
  illness requiring follow up, multiple modalities
  of treatment and consideration for the persons
  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).