Defining Drug Addiction

Sweet Jesus, Aunt Bettyaˆ¦ the white ladys riding a white horse. Heroin, heroin aˆ¦ heroin and heroin, these are all slang words for one thing, heroin. It is back in full force. Heroin used to be predominantly used by poor, urban youth, but in recent years, it has grown more popular in the middle class, and affects suburban people of all ages. It is here and it is in your neighborhood. There is no one single causal change for drug abuse. A range of individual, family, social, environmental and other risk factors have been identified. Males are more likely to use illicit drugs at earlier ages than females, and more prone to use them to try to cope with problems (Spooner, 1999). Individuals who struggle with personality disorders often have trouble dealing with others. They often tend to be solemn in nature and almost unbendable in their ways and unable to manage change well. This causes an inability to respond to the normal changes and demands of living. People with personality disorders often feel that they are “normal”, but tend to have a narrow view of life. They find it exceedingly difficult to participate in the routine daily activities of living. The repercussions of drug abuse are vast yet all encompassing and affect people of all ages. Treatment is the only answer regardless of whether one chooses to become a drug addict or it is, as believed, a disease. This paper will explore the psychology of addiction and examine the relevant research, and psychological theories as it pertains to the issues of drug addiction and propose two solutions to address this problem with a final solution being chosen by the writer, as the best course of action for addicted individuals.

Defining Drug Addiction:

The National Institute on Drug Abuse (NIDA) defines addiction as a chronic, often relapsing brain disease that causes compulsive drug seeking and use, despite the harmful effects to the user and to those around them. It is a brain disease because it actually changes the structure of the brain and the way in which is functions. The American Society of Addiction Medicine (ASAM) released a new definition of addiction last year, stating, in part that addiction is a chronic brain disorder and not simply a behavioral problem. For the first time, the ASAM has taken an official position that addiction is not solely related to behaviors and lack of control. The actual short definition reads as follows:

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by the inability to consistently abstain, impairment in behavioral control, and craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death (Definition of Addiction (2011, April 19).

While the decision to take drugs is voluntary for most people, the brain then changes over time, and those changes challenge a person’s self-control and ability to resist the urge to use. This is why addiction classifies as a brain disease; the drug actually changes the brains structure and the way in which it functions. These changes can be long lasting and lead to harmful behaviors in people who abuse drugs (National Institutes of Health National Institute on Drug Abuse, 2011). Because of these changes, quitting is often difficult for those that are ready try, and it often takes more than one attempt. Addiction can occur despite a person’s strength of character and once it occurs, repeated use changes the delicate and complex systems of the brain. According to Drs. N. Volkow and H. Schelbert, of NIDA, the brain imaging studies from drug-addicted individuals show actual physical changes in those areas of the brain critical to judgment, decision-making, learning, memory, and behavior control. This is just another reason why researchers believe that these changes alter the actual function of the brain and may help to explain the compulsive, destructive behaviors, which go along with addiction. Drugs of abuse contain chemicals, which actually tap into the brain’s communication system and actually disrupt the way nerve cells normally send, receive and process information. There are at least two ways that this disruption happens: by imitating the brain’s natural chemical messengers and by over stimulating the “reward circuit” of the brain (National Institutes of Health National Institute on Drug Abuse, 2011).

misc_volkow.gif

Image: National Institutes of Health National Institute on Drug Abuse.

Repeated drug exposure changes brain function. Positron emission tomography (PET) images are illustrated showing similar brain changes in dopamine receptors resulting from addiction to different substances – cocaine, methamphetamine, alcohol, or heroin. The striatum (which contains the reward and motor circuitry) shows up as bright red and yellow in the controls (in the left column), indicating numerous dopamine D2 receptors. Conversely, the brains of addicted individuals (in the right column) show a less intense signal, indicating lower levels of dopamine D2 receptors (Volkow, N. D. (Medical Imaging Scan). (2012). PET Images of Brain Changes after Repeated Drug Exposure).

Reduced dopamine production eventually leaves the user incapable of feeling any sense of pleasure, even from the drugs that feed the addiction. Scientists can now visualize this, in the above scan, the lack of dopamine receptors do not show up as bright red and yellow in the right column as they do on the left, in the control group. Drugs of abuse also affect the regions of the brain that help to control desires and emotions which results in a lack of control, and leads the addict to pursue the drug compulsively despite the lack of pleasure produced.

Researchers in China at the Mental Health Institute also conducted an imaging study to investigate the gray matter volume in 20 former IV heroin users at three days after abstinence, and again at one month after abstinence. They also used 20 normal subjects used as the control group. They found that at the three-day mark, decreased gray matter density was found in the frontal cortex and occipital regions of the brain but at the one-month mark, there were no significant differences in those regions in the brains of the heroin addicts and the control group. While this was a small study and would need to be replicated in a larger group, what they found was that the changes occurring in the brain were, at least in part, reversible. They had initially, based on previous studies, hypothesized that the heroin dependent subject would have decreased gray matter density permanently (Wang X., 2012).

Understanding the Addicted Brain:

Illicit drugs (drugs), the term used to describe drugs which are under international control and that are produced, trafficked and/or consumed illicitly(UNODC: Information about drugs, 2012), use affects every part of the brain and it’s functioning. Drugs and alcohol interfere with the exchange of information in your brain, which actually produce changes that promote drug use. Just seeing a drug or its paraphernalia can bring anticipatory pleasure. This paper will identify just a few of the parts that are affected. The addicted brain is distinctly different from the non-addicted brain, as manifested by changes in metabolic activity, receptor availability, gene expression, and responsiveness to environmental cues. The activation of the brains reward system seems to be the common element in what hooks individuals on drugs.

Drugs alter the central nucleus of the almond shaped part of the brain, known as the amygdala. The amygdala has a key function in the acute reinforcing actions of drugs of abuse. The amygdala is a part of the limbic system and is responsible for regulating emotions, fear and pleasure (Koob & Volkow, 2009). Drugs also alter the part of the brain involved in impulse control, the prefrontal cortex, which makes it more difficult for addicts to resist taking drugs. This finding may help to explain why adolescents are more susceptible to addiction – the prefrontal cortex does not become fully developed until people reach their mid-20s.

The brain becomes used to these changes caused by the drug and begins altering its normal production and release of neurotransmitters (Harryman, 2011). The addict begins to lose control and has difficulty limiting drug intake, the need to consume becomes compulsive because the drug has affected the regions of the brains controlling impulse, craving and behavior. The individual is addicted. Initially, interfering with this system makes the user feel good but it leads to seeking the behaviors, which give pleasure at any cost. Chronic drug use causes changes in the structure and function of the neurons that can last for years, even after the user is clean. These changes to the brains structure and functions over time actually reduce the pleasurable effects of the drugs but also increase the cravings resulting in a destructive spiral.

Scientists are learning how genetics and environmental factors, like stress, contribute to these neural disruptions and increase the risk of addiction. This ongoing research is allowing researchers to understand how addictive substances affect the brain’s reward system, and allowing for the development of more effective therapies for treating addiction. When a person takes an addictive drug, from nicotine to heroin, chemicals travel swiftly through the blood stream into certain key brain regions known as the reward system, the nucleus accumbens, which regulates the ability to feel pleasure. With continued drug use, the circuitry of this system becomes flooded with dopamine.

Dopamine, a brain chemical, or neurotransmitter, activates specific sites on brain cells called receptors to increase pleasure and reward. Over time, the brain adjusts to the excess dopamine by decreasing the number of dopamine receptors and the overall amount of dopamine in the brain. Users must then consume more and more of the drug to achieve the same “high.”

Disruption to the brain’s reward system is only part of the reason why drug addictions are so difficult to overcome, and why relapses can occur even after years of abstinence. Neuroscientists have also discovered drugs alter connections in brain circuits that regulate learning and memory, causing strong associations between the drug’s pleasurable sensation and the circumstances under which it is taken. In fact, scientist are beginning to postulate that the whole action surrounding the “getting high”, is just as addictive than the actual drug itself. The “rush” for the addict often comes from pursuit of the activity. Drug addicts tend to be risk takers and thrill seekers and expect to have a pleasurable reaction to their substance of abuse before they use it. Some experts in the field of addiction today prefer the term addictive behaviors, to addiction. The biological, psychological, and social processes by which addictions occur have common pathways. All addictions have roots in genetic predispositions and biological traits. Many in the field say that addictions have characteristics in common and so do addicts. Regardless of the source of addiction, the effects are mainly concentrated in the brain: physically, chemically, and psychologically affecting emotions and energy levels. Addicts have distinct preferences for one substance over another and for how they go about using the substance they abuse. Many addicts have problems with self-regulation and impulse control, they tend to use drugs as a coping strategy in dealing with both stress and their everyday lives in general. They do not seek a way to escape so much, but more as a way to manage their lives.

Heroin – The Sequel:

Across the nation, heroin use is increasing at an alarming rate and affecting a surprising population, kids in the suburbs. Heroin is a highly addictive drug and the most rapidly acting of the opiate class. The kids in the cities know not to touch it but it seems that message never made it to the kids in the suburbs. The biggest connection seems to be between prescription painkillers and heroin. The opiate ‘high’ that kids get from drugs such as OxyCodone is much like the one that they get from heroin use. The kicker is that heroin is much cheaper and more easily obtained and the ‘high’ is more intense. A small bag of heroin is cheaper than a six-pack of beer in some places and is estimated to be 15 times purer than it was in the 1970s. The increased purity means that it is easier for users to it. Many teens have a mistaken idea that snorting the drug makes them less likely to become addicted to it. “Kids are going to believe that this is not a problem, and parents are going to continue to leave their prescription opioids unattended if they don’t know about the risks,” said Wesley Clark, director of the Center for Substance Abuse Treatment at the Department of Health and Human Services (Drug Enforcement Agency, 2012).

According to the 2008 National Survey on Drug Use and Health, the number of current (past-month) heroin users aged 12 or older in the U.S. increased from 153,000 in 2007 to 213,000 in 2008. There were 114,000 first-time users of heroin aged 12 or older in 2008. This number keeps climbing (National Institutes of Health, 2010).

heroin_use_2009.png

Image from National Institutes of Health

Like most parents in upper-middle class neighborhoods, parents do not realize that there is a problem out there and continue to leave their prescriptions out and unmonitored. Heroin used to be used by predominantly poor, urban youth, read: black. In recent years, it is growing more popular in the middle class suburban areas, read: white. In truth, close to 90% of teen heroin addicts are white (Department of Drug Enforcement, 2012). In 2010, there were 140,000 persons aged 12 or older who had used heroin for the first time within the past 12 months. This estimate was similar to the estimate in 2009 (180,000) and to estimates during 2002 to 2008 (ranging from 91,000 to 118,000 per year). The average age at first use among recent initiates aged 12 to 49 was 21.3 years, significantly lower than the 2009 estimate (25.5 years) (National Institutes of Health National Institute on Drug Abuse, 2011).

Heroin’s most important ingredient is morphine. Morphine is derived from the sap of the Papaver somniferum, the scientific name for the opium poppy. Afghanistan is the number one opium poppy producer in the world, and supplies more than 90% of the world’s opium.

poppy.gif seedpod.jpg

The opium poppy, papaver somniferum and the seed pod, showing the exudates/sap.

Image: Morphine & Heroin.

It would not be a far stretch to think that the war in Afghanistan and the increase in heroin use in the United States are somehow related. According to a CNN news report, there have been eight Americans who have died from overdoses involving heroin, morphine or other opiates in Afghanistan from 2010 to 2011. These overdoses were revealed in documents that showed that the Army had officially investigated 56 soldiers, including the eight that died, on suspicion of possession, use and distribution of heroin and other opiates. Heroin use is on the rise in the Army overall, military statistics show that the number of soldiers testing positive for heroin has increased from ten in 2002 to 116 in 2010. Army officials did not respond to questions, but official records from the Criminal Investigation Command show how soldiers bought drugs from Afghan juveniles. The report also reveals that soldier lingo for the drug is “Afghan dip”(CNN, Martinez, M., 2012). USA Today, reported that medical officials estimated that 25% to 35% of about 10,000 ailing soldiers assigned to special wounded-care companies or battalions are addicted or dependent on drugs – particularly prescription narcotic pain relievers, according to an Army inspector general’s report made public in January of 2011(CNN, Retterbush, T., 2012)

Since the US Invasion of Afghanistan, the heroin output has increased over 5000 percent, according to Glenn Greenway of the Drug Truth Network. Immediately following the 2001 invasion, opium prices spiraled and by 2002, the opium price was almost ten times higher than in 2000, the United Nations Office of Drug Control (UNODC) acknowledged. Heroin use in the United States and Europe are at epidemic proportions (CNN, Retterbush, T., 2012).

In East Alton, there have been twelve heroin overdoses before the year is even half over. This places the county on track for a record number of heroin overdoses. This places the county on track for a record number of heroin overdoses. Fatalities from all drug overdoses are currently at 22 cases for 2011 (Occaisionalplanet.org, Mike Davis, 2011). East Alton is a Village, with a U.S. Census total population of 6,301 in 2010. There have been so many documented cases of drug activity in the community, the Police Department has now made a form available online to citizens so that they may anonymously report a house suspected in or near their neighborhood, or any suspected drug activity (Village of East Alton, 2012). Fatalities from all drug overdoses are currently at 22 cases for 2011. The US is not alone in this epidemic, Russia estimates that one in every 50 people of working age is addicted to heroin. South Wales has seen a jump of 180% in heroin addiction rates. In 2008, the European Union, (EU) estimated that a young European died every hour from a drug overdose. What is the cause for this epidemic across the planet? Last year, Russia publicly blamed the US and NATO for refusing to eradicate poppy production by US allied warlords, resulting in an estimated 30,000 heroin deaths in Russia in a single year. The US Congressional Research Service estimates that Afghanistan currently accounts for 90% of the world’s illicit opium (the essential ingredient of all narcotics) supply. Opium revenues for Afghanistan are equivalent to 7% of the licit GDP for the nation with 10% of the population actively participating.

According to the progressive online news site, Occasional Planet, “the ultimate cause of the heroin epidemic destroying much of the world and local youth is the Afghanistan war and the shortsighted policies involved there”. This flood of heroin is a direct result of the war efforts.

afghanistan-drug-chart.jpg

Image taken from occasionalplanet.org

Theorists and Theories – Applied:

The most common type of dual diagnosis is a connection between a mental or personality disorder and a substance abuse disorder such as alcoholism or drug addiction. The reason that these two disorders go hand in hand is that drug addiction and alcohol addiction are often caused by depression, anxiety and other personality disorders. According to researchers at the University of Manitoba, Winnipeg Department of Psychiatry, using drugs or alcohol to reduce emotional distress or self-medicating is common among people with mood disorders and the general population as a whole. Researchers found that 24.1 percent of people used drugs or

alcohol to relieve their symptoms. In essence, the people knew they had mental illnesses, and they took drugs and alcohol in order to make those symptoms less palpable. By taking drugs and adding dopamine to their systems, they were able to mask their mental illness symptoms. Dual diagnosis is should be the expectation and not the exception.

Dr. Marvin Zuckerman, at the University of Delaware, has conducted research on an aspect of personality that he calls sensation seeking. This trait has large hereditary components. Zuckerman describes sensation seeking as a desire for “varied, novel, complex, and intense sensations and experience, and the willingness to take physical, legal, and financial risks for the sake of such experiences. His theory points out that those identified as antisocial risk takers are usually drug addicts. Zuckerman’s theory has commonsense appeal. It is easy to accept the idea that people differ in their need for excitement and risk, change and adventure. During an interview with BigThink.com, Mr. Zuckerman had this to say in response to a question posed by the interviewer:

Question: Are risk-seekers more prone to becoming addicted to drugs?

Marvin Zuckerman: Well, there are four types of risk taking which form the core you might say, smoking, drinking, drugs and sex. Now you can see three of those are substance abusers, and they act through the central nervous system. They act on centers in the central nervous system that give intrinsic pleasure. Particularly stimulant drugs like cocaine. They provide pleasure. They provide the kick that activities provide, as sex provides, for the sensation seeker. They are all correlated because they are all aspects of intensity seeking sensation and the novelty too. There is a difference, for instance, in drug users between those who are high

sensation seekers and those that are low. I found this out when I was treating drug abusers. The low sensation – well the average sensation-seeking drug abuser tries one drug, which he enjoys particularly and sticks to it. The low’s try many different drugs. So, invariably they get into odd drugs like LSD that affect their minds as well as they provide unusual sensations as well as arousal, the low’s stay away from those drugs.

Question: What is a specific link between high sensation seeking and drug use?

Marvin Zuckerman: You find for instance that high sensation seekers – there are not many men, who love war and combat, but there are a few, there are some who really find that exciting and will re-volunteer simply because they are bored with military life outside of combat. In addition, there are various substances, which are interesting as they stimulate the same sensors that are stimulated by intense and novel external stimulation. Drugs do that more directly, particularly drugs like cocaine.

Control theory, or Perceptual Control Theory (PCT), takes a different path, it view variability at the essence of behavior. The heart of control theory is that the organisms control and what they control is not behavior at all but perception(Powers M. A., 2005 (1994)). To put it simply, behavior is the control of perception(Powers W. T., 2009). According to Bill Powers, the developer of PCT, “the living thing is in the driver’s seat, driving the car.” The control theorist would say that deviance arises when the adolescent/young adult, lack sufficient ties with conventional groups, such as family, schools and religious organizations; the alienation from those prevailing values that those groups instill are associated with drug use. This lack of social bonding has been found to be predictive of early or frequent drug use and resistance to traditional

authority and normlessness(Spooner, 1999). Raymond L. Calabrese offers a definition of alienation in general, as the relationship of individuals to their environment and specifically, it describes the relationship in terms of isolation, meaninglessness, normlessness and powerlessness (pg. 14). This and other personality traits have been found to be associated with drug abuse.

Self-efficacy is the concept that lies at the center of Albert Bandura’s Social Cognitive Theory. Self-efficacy is “the belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations” (Self-Efficacy in Changing Societies, Bandura, 1995, p. 2). Bandura also mentions that developing strong self-efficacy is through “mastery experiences” ((Fletcher, 2003). These experiences are a double-edged sword. If completed, they improve one’s self-efficacy. If failed, they weaken it. Individuals with low self-efficacy often abandon their goals at the first signs of even a minor obstacle. They tend to have all-or-nothing patterns of thinking. There is no room for being “human”, nor the possibility for mistakes. According to Caron, a non-profit provider of drug and alcohol treatment in PA, current statistics show relapse rates for addictive diseases usually are in the range of 50% to 90%; however, these rates vary by definition of relapse, severity of addiction, which drug of addiction, length of treatment, and elapsed time from treatment discharge to assessment, as well as other factors. SAMHSA, Substance Abuse and Mental Health Service Administration regularly collect and publish this information.

According to supporters of Addictive Personality theory, a distinct trait predisposes individuals to addictions. Much of the established medical community does not accept addictive personality as a diagnosis used to explain why some people become addicted to alcohol, drugs, activities or even emotions. Stephen Mason, PhD, said in his article “Look at it this way” in Psychology Today, “A major misconception involving addiction is the idea that certain substances are, all by themselves, addicting”. He goes on to add, “Addiction depends, first and foremost, upon having an addictive personality. Such people, estimated at perhaps 10%-15% of the population, simply do not know when to stop.

The nature and existence of this trait is still hotly debated in medical, neurobiological and psychological communities, there are definite implications in the brain that contribute to addictions. Dr. Alan Leshner, PhD of the National Institute on Drug Abuse describes addictions instead as “a brain disease” and “a chronic relapsing disease”, in that there are visible alterations in the brains of addicts and the effects are long lasting within their neurological patterns. Dr. Leshner also addresses the types of addiction and substance abuse that are often accredited to the addictive personality. He explains that there are two primary forms of addiction, one being the substance-based, the second being behavior-based.

The substance-based addictions such as to alcohol, nicotine, narcotics are more easily explained and can be identified neurologically. Certain drugs like crack and heroin cause massive dopamine surges in the brain with different sensations ranging from invincibility or strength to euphoria or perceived enlightened states. The use of these substances almost

immediately changes particular aspects of the brains behavior, making most individuals immediately susceptible to future abuse and addiction.

Also common is the behavioral aspect of addictions. These are not easily explained neurologically, but generally are included in the addiction susceptibility characterized by the personality trait (Leshner, 2001). Moreover, combined addictions, addictions that include both the substance as well as the behavior are also common. The physical act of indulging in the “steps” involved and repetitive behavior essentially succeeds at making the invisible, visible.

Cognitive Behavioral Therapy, (CBT), is the method used by many today as a single source method for helping people get over emotional upsets in their lives. This type of therapy gives them the tools needed should they arise again. CBT teaches people how to change the way they think about things. In issues of addiction, the goal is to teach the person to recognize situations in which they are most likely to use, and identify situations that make them more vulnerable. It teaches them to avoid these circumstances if possible, and how to cope with other problems and behaviors which may lead to their substance abuse. CBT has two main components, functional analysis in which the therapist and client work together to identify the feelings, and give the client insight into what led to their abuse in the first place. The second component is skills training. The goal is to get the person to learn or re-learn better coping skills. This is achieved through a process of unlearning old habits and learning and developing healthier skills and habits. The main premises are to educate, to identify and to change.

Some therapist mix different orientations and teachings. They are eclectic in their therapy styles, and “pick and choose” from different orientations. This “pick and choose” method is probably the most controversial style as it is, more often than not, of no benefit to the client and may be detrimental. Rational Emotive Behavior Therapy, (REBT) was formulated in the 1950’s by Dr. Albert Ellis. REBT and CBT are similar but slightly different approaches to psychotherapy. REBT teaches that outside elements, the world around you, do not create emotions but the interactions with such and the beliefs and expectations, which we hold which give rise to the emotions we feel. When your beliefs become ‘rigid’, then emotional disturbance is the result. REBT teaches clients to modify the belief so that it is not so rigid and therefore less likely to create emotional upset. Example of rigid beliefs – Everyone should agree with me and when that is modified, it becomes It would be nice if everyone agreed with me, but I realize that not everyone will. REBT is based on the premise that whenever we become upset, it is not the events taking place in our lives that upset us; it is the beliefs that we hold that cause us to become depressed, anxious, enraged, etc.

Immediate Short Term Effects of Heroin:

Soon after using, abusers report feeling a surge of pleasurable sensations, the rush. The intensity of this rush depends on how much of the drug is taken and how quickly the drug enters the brain and binds to the natural opioid receptors. One of the reasons why heroin is so addictive is because of the speed at which it enters the brain. The effects of heroin are almost immediate and last typically, from three to five hours. This rush is accompanied by a warm flushing sensation, dry mouth, slight nausea, itching, and a heavy feeling in the extremities (AstriCon 2012: Hooked on heroin: Dane County’s deadliest drug, 2010). Some users report that they enter a dream-like state where nothing matters, they equate this to “bliss” (Weyant, 2012). The user may also experience severe nausea, vomiting, and severe itching, which is usually the case with first use. “I got so sick the first time I “banged up” (injected), I actually puked but then right after that, this warm feeling came all over me and wow, I was gone. It was like this warm, rolling orgasm but it was my whole body. I can’t explain it, this is so weird talking about this with you, but you asked. Sometimes I still get sick but that’s when I know its good dope, you don’t mind vomiting behind smack” (Weyant, 2012). After this initial rush, abusers usually will be drowsy for several hours, they call this “getting a nod on” (Weyant, 2012). Mental function is clouded by heroin’s effect on the central nervous system. Cardiac function slows, and breathing is severely slowed, sometimes to the point of death. The goal of the addict is to recreate this rush, but with each use it becomes harder and harder to obtain. “It is never like the first time, no matter how much I do. Mom, it’s like this – It’s an identity, vocation, and pastime, a lover, master, and my best friend. It makes me sick sitting here admitting all of this to you but it is what it is. Heroin is just everything to every addict, all the time.” (Weyant, 2012). This is the vicious cycle of addiction.

5522_2 brain_nih.gif

Brain on Drugs.

Image: National Institutes of Health, National Institute on Drug Abuse

Heroin Hits Home

Heroin has killed more people in Dane County than any other drug in the past five