Introduction
Addictions are a constellation of complex and chronic illnesses that affect multiple domains in a patient’s life, primarily for the worst. Nosologically, they are defined by use of an addictive agent and effects, rather than process, in contrast to many other diseases that are not defined primarily by chief complaint, but by etiology. As with other recurrent illnesses, multidisciplinary assessment and therapy improve chances of recovery, but perhaps no other diseases pose a greater variety of challenges, are met with more diverse and even opposite therapies, and are more neglected. Increasingly, people are reliant on web-based tools, direct-to-consumer self-help books and websites, and portable electronic devices when seeking solutions for lifestyle-related problems and health problems and risks that lie along a contiuum of risk factor to disease. Here, we propose a medically centered, generalized framework for the treatment of addictions, which can incorporate such new tools to deliver better assessment and interventions. We target multiple domains, which frequently involve severe, complex, and intractable problems that require a multidisciplinary team of expert providers. The treatment team integrates new measures and new interventions—some enabled by new technology and most not—that will hopefully be based on the pathophysiology of addictions. Individuals at risk, users, individuals with use disorder, and recovering patients represent different stages of the disease process, requiring assessments and interventions targeted to the stage. Multiple domains of vulnerability, use, addiction process, and consequence require evaluation and integration into a comprehensive treatment plan. Dramatic progress in the treatment of other chronic diseases for which etiologic-specific treatments are wanting, including cystic fibrosis and diabetes, indicates that a comprehensive approach, expensive though it may be, and incorporating appropriate technologies for at-home testing and intervention, can greatly improve the current prevalence and relapse statistics for addictions, which are diseases whose expense and impact on lives and communities justify the cost.
The Assessment
As with any medical evaluation, a detailed History and Physical (H&P) remains essential. One may ask why. For example, screening questionnaires such as the Fagerstrom (smoking) and Michigan Alcohol Screening Test (MAST) can ascertain most smokers and alcoholics. Furthermore, any heavy user of an addictive agent—be it a drug, gambling, or the Internet—is more than likely addicted and this can be readily ascertained by direct or indirect observation of use, and, for example, a blood alcohol level, or the reading from an electronic monitoring device. A person may enter mood or craving scores into an electronic device, or the information might be directly collected, for example, by recording their movements or changes in facial expression over time. However, such observations are insufficient to define a Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition (DSM-5), Use Disorder, and diagnosis of a DSM-5 Use Disorder represents only a starting point for understanding causes, process, and consequences of a patient’s addiction, and the beginnings of therapeutic engagement—the deep partnership that must be formed between patient and the multidisciplinary team. Fig. 13.1 highlights some of the key domains of addictions that need to be included in an H&P. All should be evaluated during the initial assessment to stage severity. It is important to understand the individual events that led a patient to this point in disease progression. This process will create the full clinical problem list, help to identify resources for recovery, and help to establish for the patient that their problems are of concern. This begins a therapeutic process, which includes the patient appreciating the relationship of their addiction to other causes and consequences. In line with a process-oriented conceptualization of addiction, this scheme includes at-risk individuals, understanding that addiction medicine needs to address its identifiable “precancerous lesions,” which may include escalating use or signs of progression to full disease; for example, in the way that physicians do not disregard infection or metabolic syndrome until a patient is actually septicemic or in renal failure. The complexity of initial assessment will only increase as new tools become available from multiple disciplines ranging from neuroimaging and genetics to electronic monitoring of substance use and emotional state. For example, in the domain of genetics , the heritability of addictions has been well established, suggesting that more clinically useful genetic variants in addition to ALDH2 (alcoholism/flushing/upper gastrointestinal [GI] cancer) and CHRNA5 and CYP2D6 (smoking, lung cancer) will be found. Many people are already receiving such genetic results direct-to-consumer, and websites devoted to the Asian flush , and inappropriate and potentially harmful treatments, have proliferated. For example, in the domain of addiction neuroscience, psychophysiological differences in executive cognition, emotion, and reward are being identified. Such measures offer the prospect of identifying at-risk individuals and offering early interventions. However, and actually as required by the diversity of assessments that may be required following whatever screening methods that may have been used, the true starting point of assessment is not an individual test—be it genetic, neuropsychologic, or behavioral—but the detailed H&P.
The Stages of Addiction
Addictions are chronic relapsing and remitting diseases, and although they are diverse, assessment will vary according to stage.
At-Risk Individuals
These individuals are not easily identified, except in the broader and more pessimistic sense that the population as a whole is at moderate-to-high risk of one addiction or another. Addiction medicine needs to move toward prevention and early intervention, and one component of that is identification of those at highest risk. Critically, addictions are common such that a large fraction of the population have either an addictive disorder or are at risk. For example, some 29.1% of adults in the United States meet criteria for Lifetime Alcohol Use Disorder according to the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) household survey of more than 36,000 people. Approximately 15% of Americans smoke cigarettes and most who do are addicted to nicotine. Easy availability of potent opioids such as oxycodone and fentanyl; legal tetrahydrocannabinol (THC)–enhanced marijuana; and gambling in many forms ranging from state-sponsored lotteries and casinos to sports-league–sponsored daily fantasy gambling, often delivered on handheld devices, will successfully addict larger segments of the population—addiction being an inherent component of the success of several of these products on the basis that addicts consume 50% or more of the product. Increasingly, it may be more useful to identify protective factors; for example, the ALDH2 polymorphism that protects against alcoholism via flushing, information about which is available by direct-to-consumer testing, as an experience in self-knowledge, and other nonmedical contexts such as testing of incoming university freshman, as a learning experience. On the other hand, genetic risk, as measured via specific genotypes or by family history, and environmental risk, in particular early life trauma, can be incorporated into risk assessment, and could be useful in many scenarios; for example, to assess addiction risk, and plan the tapering of the drug, when a patient requires an opioid over several weeks for pain management, or even to assess occupational hazards such as being a bartender or a physician.
Heavy Users Who Do Not Meet Criteria for Substance Use Disorders
As illustrated by the opioid epidemic initiated by heavy prescribing of oxycodone, any heavy user of an addictive agent is at high risk even if that person is innately resilient and under the care of a physician. Repetitive use of addictive substances and other addictive agents such as gambling create tolerance and allostatic changes that in some cases lead to “physiological” or “psychological” dependence. Following withdrawal, there will in many cases be no functional repercussions, and indeed, it can be conceded that in many cases a person’s life may have been enhanced by the experience be it a wine-tasting, relief of pain, or a horse race. The ability of a person to use an addictive agent heavily without some severe adverse outcome will be determined not only by factors and processes internal to them but by external factors: their employment, general health and nutrition, and social relationships, and by luck.
Patients with substance use disorder represent most of the individuals counted in studies and statistics. They are the cases where the use of a substance causes functional impairments such that they meet the criteria of a DSM-5 substance use disorder. In contrast to individuals at risk, patients with substance use disorder are easily identifiable and will occasionally ask for help. As has been well studied, only a minority of patients seek treatment and even fewer receive a therapy that has evidence of effectiveness. About 13.5% of Drug Use Disorder patients with a diagnosis in the last 12months received any form of treatment. For patients with a lifetime diagnosis of alcohol use disorder, only 19.8% were ever treated. Following the DSM-5 scheme, their substance use disorder (SUD) can be classified as mild (2–3 criteria), moderate (4–5 criteria), or severe (6–11 criteria). Traditionally we call the severe cases “dependent,” implying that it is difficult for the patients to make changes in their behavior without supervised care. Of the criteria for alcohol use disorder, two—#10 and #11—are related to tolerance or dependence: “Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before?” and “Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart, or a seizure? Or sensed things that were not there?.” However, tolerance and dependence are insufficient to define a “Use Disorder” and they only imply some of the etiological changes that we need to better understand. In total there are 1024 combinations of 6 or more DSM symptoms that can define a patient as “Severe.”
Patients in Recovery
Due to predisposing factors (e.g., genetics and early life trauma) and brain changes, most patients in recovery are at high risk for relapse. Some live with severe sequelae even if they maintain sobriety. End-organ damage, cancer, chronic infections, legal problems, unemployment, social dislocation and alienation, and stigma shape the lives of many patients in recovery. Recovery is not always equivalent to rehabilitation. We need to aim for higher functioning in the recovery group to achieve real rehabilitation. As ambitious as sobriety can be, due to the high percentage of relapses to different substances, and the potential for harm reduction even with failure to achieve abstinence, sobriety is insufficient as a marker for success in treatment.
The Domains
Genetics
Multiple genes have been identified as protective or risk factors for developing addictions and their complications. With advances in genetics, the identification of some of these genes in an individual at risk or with an SUD should become a standard practice. They can guide therapeutic approaches, from early intervention to pharmacotherapy, and relapse prevention. For example, at any stage of addiction to alcohol, any of 500 million people carrying the ALDH2 Lys 487 Asian flush allele can know that moderate alcohol consumption, with or without antihistamine drugs that can block flushing (and whose use is advocated on websites) would expose them to high risk of upper GI and other cancer risks.
Physiological Interface
As has been discussed, the repetitive behavior or use of a substance with addictive potential will change the brain, making the absence of this behavior or substance ego-dystonic. The changes in the body are not limited to the brain depending on the substance used. The continued use of a substance despite adverse consequences is a characteristic and symptom of an addiction.
End-Organ Damage
Traditionally the main area of assessment and treatment for addiction medicine has been limited to allostatic changes in brain physiology and their behavioral presentation. For some substances (primarily alcohol and tobacco) there has been detailed study of their effects on other systems (e.g., hepatic and pulmonary function). Nevertheless, treatments, when they exist, have targeted the brain. Changes in the reward circuitry, cue conditioning, and negative salience can be modified by medications or psychotherapeutic approaches like Cognitive Behavioral Therapy (CBT) and Motivational Interviewing (MI). Most patients would require a team of doctors, as many of our patients will have complications from their SUDs. Addiction medicine physicians frequently consult with dentists, cardiologists, hepatologists, infectious diseases specialists, and physiatrists.
Allostatic Changes
In an attempt to maintain functioning, the brain and other organs exposed to addictive substances gradually modify their baseline parameters, adjusting to the presence of the substance. If the substance is withheld, acute withdrawal may follow. Allostatic change also produces long-lasting deficits beyond the horizon of acute withdrawal such that a subsequent exposure to a specific cue or nonspecific stress can lead to relapse and rapid reinstatement to the highest levels of use. A classic example are the γ-aminobutyric acid (GABA)ergic and glutamatergic changes present in alcohol dependence, with benzodiazepine drugs capable of alleviating acute withdrawal, and long-lasting activations of the brain stress axis with changes in corticotropin-releasing factor (CRF) expression, and that thus far we do not know how to alleviate or reverse.
Neurocognitive Functioning
The brain is the main organ changed by addictive substances and behaviors, and addictions are diseases caused by changes in neuronal circuits. Some predisposing characteristics are seen in at-risk groups. However, SUDs have toxic consequences ranging from neuronal damage to changes in neuronal systems. From impulsivity and aggression to dementia, brain functioning changes with substance use. Some of these changes are postulated as the reason for the rapid reinstatement and reescalation of substance use once a patient relapses after a period of sobriety. Progress in characterizing neurocognitive functioning in addiction is likely to be rapid; such measures of function can guide and directly measure the effects of treatments, whether direct neurofeedback therapies and pharmacotherapies or indirect cognitive and behavioral therapies, that aim to modify the neurocircuitry of addiction and restore the addicted brain.
Family Interface
Addictions frequently disintegrate families, especially the relationships between close relatives who bear the brunt. The behavior of the patient, which may be erratic, aggressive, neglectful, criminal, or abusive, as well as the general deterioration of house and home, and economy, estrangement, loss, and accidents, all create difficult situations for dependents who may themselves to be at higher genetic risk. Via the family, addictions are transmitted both horizontally, and—in a transgenerational fashion—vertically. It is important to recognize that the addicted patient, who may have been initially ineffective and is now hampered by neurocognitive changes, can fail at ordinary family roles, even if the family is not estranged. Absent overt abuse or aggression toward loved ones, deficits in attention, reward, and motivation cause addicted individuals to neglect family duties and the needs of partners and dependents.
Work and Vocational Interface
Changes in the reward system alter productivity and engagement with work and other activities that give purpose and satisfaction. As addiction progresses, patients disengage from other passions, finding reward and pleasure only in the addictive agent of choice. As they develop tolerance, relief of withdrawal symptoms becomes their primary, and more immediate, goal. The need to prevent withdrawal leads to use while at work, or absenteeism. Negative work consequences are frequent, as are unemployment and underemployment. Some industries have a higher frequency of substance use due to exposure to trauma and stress (e.g., military, health care), exposure to addictive substances (e.g., bartender and other service industries), or in some cases the expectation of substance use as part of the job (e.g., sales, lobbying). For some patients, sobriety means restarting or rebuilding their professional life.
Community Interface and Legal Problems
Due—in part—to the punitive approach to SUDs and the stigma of addiction, legal consequences are common. Community support other than peer support groups (e.g., Alcoholics Anonymous [AA], Narcotics Anonymous [NA], Smart recovery) is rare for patients with SUDs. This leads to marginalization of our patients and obstacles to vocational, family, and social recovery. It is also important to recognize that many or most psychoactive addictive agents impair judgment and motor control, leading directly to aggression, bad decisions, and accidents that draw the attention of the criminal justice system.
Hedonic and Recreational Interface
For patients with addictions, finding recreational opportunities without their addictive agent of choice can be a challenge. In many cases, friends, loved ones, and even acquaintances use the same agent, making abstinence difficult. Alcohol is ubiquitous in most cultures and it can be difficult for some patients to even imagine having fun without it. Young Asian flushers may therefore use antihistamines to block alcohol-induced flushing but not the genotoxic effects. Because the reward system is modified by these substances, it might be difficult for some patients to reengage with earlier pleasures and passions when a facilitating substance or addictive agent has been removed from the equation.
Spiritual Interface
For many patients addiction is a sin or disgrace. For some, their system of values chastises use of addictive substances, creating negative connotations and shame. In some cases, shame leads to voluntary isolation or ostracism. However, it can also enlist the intervention of spiritual leaders and counselors. Many patients only seek help from religious figures because they see their illness as a “character defect” or “sin.” This has led to many support communities within religious establishments (e.g., most AA groups take place in churches or temples). Training on substance use counseling is a common skill for religious figures. Spiritual or religious practices like mindfulness have evolved into therapeutic approaches. Reintegration into religious communities can be a therapeutic tool in many cases.
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