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addiction
WHAT THE SCIENCE SAYS ABOUT SUBSTANCE USE DISORDERS
In just the last ten years, advances in science have brought tremendous insights to our understanding of drug addiction
and subsequently to improving treatment effectiveness. Based on this research, scientific evidence has defined addiction
as a chronic, and for many people, reoccurring disease characterized by compulsive drug seeking and use that results
from prolonged effects of drugs on the brain (Dennis, 2007). A range of scientific research has demonstrated that
chronic drug use changes the brain in fundamental ways that exist long after drug use has stopped. By using advanced
brain imaging technologies, we can see what we believe is the actual biological core of addiction. What the science shows
is that the brain of an addict is fundamentally different from that of a non-addict. Initially, when a person uses hard
drugs like heroin or cocaine, the chemistry of the brain is not much affected, and the decision to take the drugs remains
voluntary. But at a certain point, a “metaphorical switch” in the brain gets thrown, and the individual moves into a state
of addiction characterized by compulsive drug use and continued use despite adverse health consequences.
These brain changes can persist long after addicts stop using drugs, which is why relapse is so common. Research
has provided overwhelming evidence that not only do alcohol and other drugs interfere with normal brain functioning
by creating powerful feelings of pleasure, but they also have long-term effects on brain metabolism and activity.
Unfortunately, addiction as a chronic, relapsing disease
of the brain is a completely new concept for much of the
DISEASED BRAIN METABOLISM IN DRUG ABUSER
general public, for many policymakers, and sadly, for
many health care professionals. The consequence of this
High
informational gap is a significant delay in gaining control
over the drug abuse problem.
For example, there is a tendency for people to see addiction
as a social problem that should be dealt with only by social
solutions, and particularly via the criminal justice system.
Science has demonstrated that drug addiction is as much
a health problem as it is a social problem.
Low
Healthy Brain
Diseased Brain/
Cocaine Abuser
Source: NIDA
If we understand addiction as a chronic brain disease containing biological, behavioral, and social elements, treatment
strategies must include biopsychosocial methods using the principles of chronic illness care. Not only must the
underlying brain disease be treated, but the behavioral and social elements must also be addressed, as it is done with
other brain diseases, including stroke, schizophrenia, and Alzheimer’s disease (Leshner, 1999).
The science-based understanding of substance use disorders is discussed in this publication.
WHAT SCIENCE SAYS ABOUT ADDICTION
The emerging paradigm views addiction as a chronic, relapsing brain disorder to be managed with all the tools at
medicine’s disposal. The addict’s brain is malfunctioning, as surely as the pancreas in someone with diabetes. In both
cases, “lifestyle choices” may be contributing factors, but no one regards that as a reason to withhold insulin from a
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diabetic.“ We are making unprecedented advances in understanding the biology of addiction,” says David Rosenblum,
a public-health professor and addiction expert at Boston University.” And that is finally starting to push the thinking
from ‘moral failing’ to ‘legitimate illness’.”
Herbert D. Kleber, M.D., the medical director of the National Center on Addiction and Substance Abuse in New York,
says that the brain-disease concept fits with his experience with thousands of addicts over the years. “No one wants to
be an addict,” he says. “All anyone wants to be able to do is knock back a few drinks with the guys on Friday or have a
cigarette with coffee or take a toke on a crack pipe. But very few addicts can do this. When someone goes from being able
to control their habit to mugging their grandmother to get money for their next fix, that convinces me that something
has changed in their brain.” From the evidence of the new science of addiction, drug addiction is a brain disease
expressed as compulsive behavior.
In laboratories funded by the National Institute
on Drug Abuse (NIDA), MRI and PET scans
ADDICTION IS A BRAIN
DISEASE CHARACTERIZED BY:
are helping scientists discover more and more
• Compulsive behavior
about the neurobiology of addiction. Geneticists
have found the first few (of what is likely to be
• Continued abuse of drugs
despite negative consequences
many) gene variants that predispose people
• Persistent changes in the
to addiction, helping explain why only about
brain’s structure and function
one person in 10 who tries an addictive drug
Healthy
Drug User
Brain Activity
Brain Activity
Source: NIDA
actually becomes hooked on it. Neuroscientists
are mapping the intricate network of triggers
and feedback loops that are set in motion by the taste – or, for that matter, the sight or thought of a beer or a cigarette;
they have learned to identify the signal that an alcoholic is about to pour a drink even before he’s aware of it himself,
and trace the impulse back to its origins in the primitive midbrain. And they are learning to interrupt and control these
processes at numerous points along the way.
Among more than 200 potential medicines being developed or tested by NIDA are ones that block the intoxicating
effects of drugs, including vaccines that train the body’s own immune system to bar them from the brain. Other
compounds have the amazing ability to intervene in the cortex in the last milliseconds before the impulse to reach for
a glass translates into action. To the extent that “willpower” is a meaningful concept at all, the era of willpower-in-apill may be just over the horizon. “The future is clear,” says Nora Volkow, M.D., the director of NIDA. “In 10 years we
will be treating addiction as a disease, and that
means with an array of evidence-based addiction
TREATMENT REDUCES DRUG USE AND RECIDIVISM
medicines in addition to evidence-based
100
counseling therapy.”
Community-based Tx days
80
ADDICTION CAN BE
SUCCESSFULLY TREATED
% Opioid Test Positive
Addiction is a treatable disease and, like other
chronic diseases, can be managed successfully.
Treatment enables people to counteract
addiction’s powerful disruptive effects on brain
and behavior and regain control of their lives.
Overall, treatment of addiction is as successful
as treatment of other chronic diseases, such as
diabetes, hypertension, and asthma. According
to NIDA, drug treatment reduces drug use by
40 to 60% and decreases criminal activity during
60
Crime Days
40
sig. diff from referral
sig. diff from treatment
only on release
20
0
Release referral
to Methadone
Treatment
Methadone
Treatment
on Release
Methadone
both Pre- & Post
Release
Source: NIDA
Ventura County Behavioral Health, Alcohol & Drug Programs • White Paper
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and after treatment by that amount as well. Research shows that drug addiction treatment
reduces the risk of HIV infection by 6-fold and that interventions to prevent HIV are much
less costly than treating HIV-related illnesses. Treatment can improve the prospects for
employment, with gains of up to 40% after treatment. Combining treatment medications,
where available, with behavioral therapy is a best practice standard to ensure success for
most patients. Data from NIDA shows that drug abuse treatment has a significant effect on
reducing drug use. NIDA tracked 10,000 drug abusers in 100 treatment programs around
the U.S. from 2001 to 2003 and found that methadone treatment cut heroin use by 70%.
Only 28% of patients in outpatient methadone treatment programs reported weekly or
more frequent heroin use, down from 89.4% prior to admission. The study also found that
outpatient treatment resulted in a 50% reduction in weekly or more frequent cocaine use
after one year of follow-up. Reductions were greatest for those patients in treatment for at
least three months.
Treatment must
address the needs
of the whole
person to be
successful.
RELAPSE IS NOT A SIGN OF TREATMENT FAILURE
60
50 to 70%
0
50 to 70%
20
30 to 50%
40
40 to 60%
PERCENT OF PATIENTS WHO RELAPSE
The chronic nature of the disease means that relapsing to drug abuse is not only possible, but likely. Relapse rates
(i.e., how often symptoms occur) for drug addiction are similar to those for other well-characterized chronic medical
illnesses such as diabetes, hypertension, and asthma, which
RELAPSE RATES ARE SIMILAR FOR DRUG
also have both physiological and behavioral components.
100
ADDICTION AND OTHER CHRONIC ILLNESSES
Treatment of chronic diseases involves changing deeply
Source: NIDA
imbedded behaviors, and relapse does not mean treatment
80
failure. For the addicted patient, lapses back to drug abuse
indicate that treatment needs to be reinstated or adjusted,
or that alternate treatment is needed.
DRUG
ADDICTION
Type I
Diabetes
Hypertension
Asthma
Because addiction can affect so many aspects of a person’s
life, treatment must address the needs of the whole person
to be successful. This is why the best programs incorporate
a variety of services into their comprehensive treatment
regimens. Treatment counselors select from a menu of
services for meeting the individual medical, psychological,
social, vocational, and legal needs of their patients to foster
their recovery from addiction.
SUBSTANCE ABUSE TREATMENT REDUCES HEALTH CARE COSTS
About 22% of general health care patients report they have a comorbid substance use condition of some level of
severity (SAMHSA, 2005). This large percentage of patients is likely related to the pervasiveness of a myriad of physical
consequences that result from untreated substance misuse and dependency. Additionally, the presence of substance use
conditions often complicates the treatment of a variety of common medical disorders, such as diabetes.
As drug use patterns change, addiction specialty programs in the U.S. are seeing an increase in patients with serious
medical problems, including HIV, HCV and HCB related to intravenous drug use (CDC, 2008, 2009), as well as patients
with cardiovascular problems and lead poisoning associated with methamphetamine use (Burton, 1991).
A study of adolescents entering drug treatment also reflects a similar increase among their group in health problems
and health care costs (Mertens et al 2007). In addition to the health problems associated with persons with substance
use conditions and associated higher costs, research has show that family members of persons with substance use
conditions are also more likely to have medical conditions and to have higher medical costs as a result of living with
Ventura County Behavioral Health, Alcohol & Drug Programs • White Paper
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addicted persons (Ray, Mertens, Weisner, 2007). The data are clear that health care costs,
particularly the costs of chronic disease, substantially increase annually and over the lifetime
of persons with untreated substance use, alcohol and drug disorders. Substance abuse
treatment has been found to be associated with individuals’ decreased subsequent health
care costs, compared to the time before treatment. One study found a decline of more than
one-third in both per capita inpatient and emergency room costs following the receipt of
treatment. Other similar studies have reported more than a 50% drop in total per patient per
month medical costs (Weisner, Parthasarathy, Moore, and Mertens, 2010.).
Science has shown, beyond a reasonable doubt, that addiction is a disease of the brain, and
that our genes contribute close to half of the risk for becoming addicted. Addiction results
from profound disruptions in the function of specific neurotransmitters and brain circuits.
It involves an expanding cycle of dysfunction, first in areas of the brain that process reward,
followed by alterations in:
• complex cognitive functions, such as learning (memory, conditioning, habits);
• executive function (impulse inhibition, decision making, delayed gratification);
• cognitive awareness (interoception); and
• emotional functions (mood, stress reactivity).
Science has
shown, beyond a
reasonable doubt,
that addiction
is a disease of
the brain, and
that our genes
contribute close
to half of the risk
for becoming
addicted.
These circuits work together and change with experience. Eventually, with repeated drug
exposure, they become recalibrated, tilting the balance away from volitional control
over one’s behavior toward behaviors driven by drug cues and drug cravings. The result
is compulsive drug use, despite severe health and social consequences — which are the
hallmarks of addiction.
VENTURA COUNTY ALCOHOL & DRUG PROGRAMS (ADP) —
INNOVATIVE, EFFICIENT AND COLLABORATIVE
Improving the treatment and care of those suffering from addiction
Integrating the research based evidence to improve the treatment and care of those suffering from addiction continues
to be at the core of the ADP’s mission and purpose. We recognize that its mission of reducing the impact of substance
abuse in the County is part of, and supportive of, the larger County mission of promoting and maintaining the overall
health of the entire community. Substance use disorders need to be treated to enhance the health status of affected
individuals and their families. Dealing equally with health care for substance use and general health conditions
requires a fundamental change in how society and its health care system think about and respond to these problems
and illnesses. According to the Institute of Medicine, substance use problems should not be viewed as separate from
and unrelated to overall health and general health care, but rather an integral part of the same system (Institute of
Medicine, 2006).
The link between substance use problems and illnesses and general health and health care is very strong. This is especially
true with respect to chronic illnesses, which now are the leading cause of illness, disability and death in the U.S. As such,
ADP is building new projects to better interface with the larger health care system and create linkages with primary
medical care. These efforts include calling on primary care providers, and other specialty health care providers, and
components of our general healthcare system, to attend to the substance use health care needs of those persons they serve.
CONTACT US
For comments or feedback please contact:
Patrick Zarate, Division Manager
Ventura County Alcohol and Drug Programs
[email protected]
Adapted from the original publication by Santa Clara County Department of Alcohol and Drug
Services, with appreciation to Robert Garner, DADS Director, Mark Stanford and Judith Martin.
Ventura County Behavioral Health, Alcohol & Drug Programs • White Paper
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