Lesson 2

Lesson 2: Substance Use Disorders Overview

Attention

Learning Outcomes

Upon completion of this lesson's material, students will be able

Understand the brain basis for addiction
Understand and be able to state differences and similarities among various models of SUDs
Be able to state differences between DSM IV and DSM V in conceptualization of SUDs

Reading

Chapters 1, 2 and 3 in "The Thirteenth Step"

Teaching

Over the years a number of different perspectives on the nature of substance use have been developed. All have some validity, but one task you will have as astudent is to weigh tthe evidence for each model and critique how accurate and how helpful the model is. We begin with the Brain model which is the center of current research on not only addiction but all psychiatric disdorders.

Brain Basis for Addiction

We now understand more than ever how the brain is involved in all observed behavior

There is a final common pathway for most substances in the "Pleasure Center" of the brain (The limbic system including especially the Ventral Tegmental Area and the Nucleus Accumbens)
It is the effect of dopamine on the neurons in the limbic system that produces a sense of pleasure or reward
So, in the beginning, pleasure is at the center of substance use, and this pleasure is conveyed by the ability of the substance to evoke the release of dopamine in the limbic system. People use chemicals that stimulate the reward center of the brain.
Some people are genetically predisposed to develop problems with substances perhaps because of issues with the limbic system. We are beginning to think that people who get addicted have a limbic system which is broken from birth---they may have a genetic predisposition to have low levels of pleasure naturally which the addictive chemicals “fix” by giving them the stimulation they have been missing.
This genetic predisposition contributes 40 to 70% of the variance associated with substance dependence ( dependence is defined as loss of control, preoccupation with a substance and continued use despite negative consequences)
Generally genetic differences are more important when people have similar environments and less important when the environments are different. So for instance, two kids who both are raised in affluent families with loving parents and who are well treated at school will differ in their risk for SUDs mainly depending on their genetic inheritance. On the other hand, if one kid has a good environment and the other kid grows up poor and in a dysfunctional family and is treated badly at school, the second kid may develop a SUD even though his/her genetic predisposition isn't that strong. This is called "epigenetics" the study of how environment factors influence the development from genotype to phenotype.
Currently we think that genes influence both the sensitivity of the reward or pleasure center (limbic system) to dopamine (the brain chemical that causes the sense of pleasure in the limbic system) with those who are likely to develop SUDs paradoxically less sensitive but therefore getting the bigger kick from dopamine releasing substances
Heavy use of substances generally causes changes in the central nervous system (tolerance, withdrawal, craving) that make it difficult to stop
These facts---genetic differences in brain sensitivity to substances and brain changes induced by heavy use of substances--- form the basis for understanding addiction (substance dependence) as a medical issue

Over the years a number of different perspectives on the nature of substance use have been developed. These different models have had and continue to have influence on how the general public thinks of addiction.

Medical Model

The heart of the medical model is that the observed problem is due to physical issues in the body. The essential point is that the cause of the problem is physical (a virus, a bacterium, a broken bone, a malfunctioning organ, etc., etc.) and that we can cure the problem by fixing the physical issue. So with substances, the medical model assumes that an organ in the body is malfunctioning (most likely the brain, but it could be other organs like the pituitary or the thyroid) and that if we can fix it, the person will be ok.
Most medical issues (for example diabetes, heart disease, cancer) also involve choices and lifestyle factors that need to change as part of managing the disease. For example, a person with heart disease is generally counseled to reduce salt intake, lose weight, exercise and learn to manage stress. Or, as another example, even people who have the genes for Type 2 diabetes may avoid developing the disease by careful diet and exercise. Many cancers result from exposure to tobacco and other toxins and could be avoided.
All of this is true even though diabetes could be cured by fixing the pancreas---if that were possible---and cancer and heart disease could be cured by fixing the involved organs without any lifestyle changes at all.
Substance Dependence also includes the need to examine choices and make lifestyle changes. Although a person may have the genes for Alcohol Use Disorder (AUD), they will never develop the disorder if they remain abstinent. And once they have developed the disorder, they need to change relationships and behaviors in order to achieve and maintain sobriety. As with other medical problems, recovery is not just what the doctor does for you but what you do to work with the doctor.
But we need to remember that “choice” is no more and no less an issue in SUDs than it is in other human problems that are considered from the perspective of the medical model. If we could find the part of the body that needs to be fixed, the person suffering from SUDs would be cured without making any lifestyle changes at all.
Predisposing factors for Substance Use Disorders (SUDs): impulsive/compulsive paradox (that is to say that people who develop SUDS often try new things and fly against the radar and don't have a lot of respect for authority but once they find something that turns them on, they do it too much and even when it starts to make trouble for them); lonely, depressed, alienated; youth; male gender; mental illness
All of these considerations are part of the "Medical Model"---that the person is sick and their objectionable behaviors are symptoms of an underlying disease. The symptoms would go away if we cured the disease.
An early proponent of the Medical Model was a Philadelphia physician, Benjamin Rush, who was a signer of the Declaration of Independence.
The Medical Model came into vogue in the 20th Century and is advocated by Alcoholics Anonymous which says that alcoholics are powerless over their disease and will have it their whole life but can manage it and do better if they follow a recovery program embodied in the 12 steps.
The Medical Model destigmatizes alcoholism and has been associated with the decriminalization of drunkenness
Before 1970, drunks could be jailed just for being intoxicated; since then they have been referred for treatment
Drug use, on the other hand, still carries a lot of stigma and is illegal in itself. This is paradoxical since tobacco and alcohol (legal substances) cause a lot more sickness, death and suffering than drugs (illegal substances) while the underlying addiction mechanisms are exactly the same.
Whether rightly or wrongly, alcohol is simply more socially acceptable than other substances so that the general public has an easier time being sympthatic to people with drinking problems and seeing them as having a disease.

Moral Model

The Moral Model is the oldest and is still in vogue for judging drug users. It assumes that substance use is due to weak character and lack of will power and results from an overvaluing of pleasure that is sinful in itself and also causes sin.
An example of this is Paul's statement in I Corinthians 6.9,10 that "drunkards" will not be part of the Kingdom of God
Philosophy and religion have always been highly ambivalent about pleasure and see humans as needing to struggle against desire to live the good life.
AA is actually a combination of Medical and Moral Models. Alcoholism is a disease but the remedy is the 12 Step Program which is about taking a moral inventory and making changes with the help of God. AA says the alcoholic is powerless to change because of the disease but can find recovery through a Higher Power. The alcoholic finds the ability to change by turning their life and will over to the Higher Power. AA was closely connected to the Christian Moral Rearmament renewal movement of the early 20th Century---the Oxford Group
The moral model can be helpful in encouraging people to hope that they can do better but can also be associated with judgmentalism that stigmatizes people and makes them give up hope.
The moral model certainly applies to definitely immoral behaviors that substance users may commit such as lying, cheating, stealing, etc. Even though they probably wouldn’t commit such deeds if their SUD was cured, they are just as responsible for reprehensible behavior as anyone else and both AA and the legal system are right to ask them to take responsibility for and change such behaviors. Additionally AA says that doing this is part of “letting go and letting God” so that their Higher Power can restore them to sanity.

Disability Model

The Disability Model (associated with psychosocial rehabilitation and with which MHRT/Cs should be thoroughly familiar). Appropriate because SUDs are physically based, chronic, progressive and sometimes terminal disorders that require skills training and location of resources for coping. There also are handicaps that may require appropriate accommodations (e.g. for people on Suboxone therapy who should be allowed to engage in normal employment even though they test positive for buprenorphine, an opiate). The idea being that the person on Suboxone is not intoxicated and therefore not impaired and needs the accommodation of being allowed to work even though testing positive for a substance).
The disability model takes account of the idea that addiction is currently incurable but can be managed with recovery skills so that the person is able to live a productive life.
The disability model also applies to people with active SUDs who like people with schizophrenia or bipolar may be able to do better with help even though their symptoms are still active. For example, an alcoholic who is not currently able to stop drinking can learn not to drink and drive and may be able to cut back on drinking so that it’s less harmful.
Click HERE for a good resource regarding this model

Psychodynamic Model

In the Psychodynamic Model a person is coping based on their own personality and can be helped by learning to cope better with more adaptive behavior.
The Psychodynaminc Model is not widely used to help persons cease the use of substances because the physical basis of addiction is resistant to this methodology
But psychodynamic psychotherapy can be very helpful in Middle and Late Recovery after addicts have achieved initial abstinence. It can help them make the enduring changes that will lead to a happy life without substances.
The great psycholigist Carl Jung was sympathetic to AA and many recovering alcoholics have found his and other psychodynamic approaches to be helpful. Jungian and other psychodynamic psychotherapies work for people with SUDs the same as for other people: by helping them to find balance within themselves among the various forces at work, and by helping them to examine their values and choose new directions.
Not widely used any more in explaining or treating mental disorders.
Still has a lot of validity in helping people to understand themselves and gain insight and skills to act differently.

Learning Model

Learning Model (click HERE for an excellent article on this model): Person has learned behaviors which meet some needs but results in maladaptive outcomes. Recovery is through learning more adaptive habits. Cognitive behavioral approach to therapy.
Substance use is learned the same way all other non-instinctive behaviors are learned through classical and operant conditioning. Recovery is learning new habits that replace the old maladaptive habits. For example, learning to relax with a soda rather than with a beer or learning to resist a craving by just waiting it out or doing something to take your mind off it.
The Learning Model is often associated with controlled use approaches for persons with milder SUDs who do not want a goal of abstinence. The person learns to decrease use to reduce harm. For example, developing the habit of only drinking at the end of the day and keeping use down to no more than three standard drinks. Generally this does not work at more severe leevels of SUDs.
The Learning Model is also very useful in relapse prevention where the person learns to manage cravings and to discedrn and manage warning signs of relapse.
In the past there has been conflict between workers advocating the medical model and workers advocating the learning model. But now, most scientists accept that both models are helpful and complement one another, the medical model explaining more of the compulsion to use and learnin g model explaining more of the how, what, where, and when of use.
Learning model is often contrasted to the Medical Model (e.g. Stanton Peele)
Probably the best approach is to use both the learning and medical models rather than forcing a choice between them

Social Model

Social Model: drug and alcohol abuse is the result of dyssocial environments and can be corrected by changing them. Living in a bad neighborhood, peer pressure, poor parental modeling are seen as causes of experimentation and learning to use substances to deal with life problems.
War on Drugs, DARE (learning refusal skills based on fear of breaking the law), social reform (e.g. prohibition, liquor control measures such as hours of operation or limiting places of sale), helping families to do better are all seen as tools to change the way people interact with substances and therefore decrease the risk of addiction
The Social Model is helpful as a part of a balanced approach to dealing with substances but has caused harm in the past when it was advocated as the right or only approach. An example was the "War on Drugs" mass incarceration of a generation of a generation of (primarily black) young men for their involvement with drugs. Or the "Just say no!" advice to prevent drug addiction. Social approaches that discourage misuse without criminalizing it have been helpful. Examples would be be tax increases on alcohol and tobacco, built in breathalyzers in cars, and community policing that provides youth with alternatives to gangs.

Biopsychospiritual Model

Biopsychosociospiritual Model: all of the above.
Humans are complex and their problems require complex solutions. E.g. Ebola which is not only a virus that could be helped with a vaccine but also spread in Liberia because of distrust in the government and health agencies and which was compounded by overcrowding and poor sanitary practices.
Substance Use Disorders in this model are seen as medical problems which are influenced by the overall morality of the subculture in which the person lives, and which are disabilities, and which are influenced by the addicted person’s psychodynamics, and which require new learning for recovery and which occur in the context of a society that encourages or discourages addictive behaviors. Only this complex and interactive way of viewing the problem is likely to improve the addiction epidemic that is devastating 21st Century America.

Changes in the DSM

Changes in the conceptualization of SUDS in DSM V:primarily a movement to seeing SUDS as a continuous problem ranging from mild to severe rather than two different disorders---Abuse and Dependence with different causes and different treatment approaches.

The diagnosis of “Abuse” has been dropped because it lacked clinical validity: there was very low agreement between diagnosticians on whether a patient had “Abuse” or not.

Here are the current criteria for a Substance Use Disorder:

The new DSM describes a problematic pattern of use of an intoxicating substance leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

The substance is often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful effort to cut down or control use of the substance.
A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
Craving, or a strong desire or urge to use the substance.
Recurrent use of the substance resulting in a failure to fulfill major role obligations at work, school, or home.
Continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use.
Important social, occupational, or recreational activities are given up or reduced because of use of the substance.
Recurrent use of the substance in situations in which it is physically hazardous.
Use of the substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
Tolerance, as defined by either of the following:
1. A need for markedly increased amounts of the substance to achieve intoxication or desired effect.
2. A markedly diminished effect with continued use of the same amount of the substance.
Withdrawal, as manifested by either of the following:
1. The characteristic withdrawal syndrome for that substance (as specified in the DSM- 5 for each substance).
2. The substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.

Please note that any two of these are enough for a diagnosis of SUD unless the only two are #s 10 and 11 and the substance is legally prescribed and appropriately used by the patient.

Two or three symptoms are a “mild” SUD; four or five “moderate” and six are more “severe”.

Click HERE for a good resources on how the DMS has changed.s a good resource. The article explains changes from DSM IV but also contains another link with even more information: the link says "Criteria not displayed due to intellectual property and copyright regulations but can be found for free online here." Be sure to click on this second link also.

Assessment

Lesson 2 Quiz

Answer the following questions:

In 500 to 1000 words, compare (similarities) and contrast (differences) the first six models (Medical, Moral, Disability, Psychodynamic, Learning, Social) to one another with a paragraph for each. Finally write a paragraph or two discussing the biopsychosociospiritual model and your thoughts about this model (including at least one strength and one weakness) (25 points)
List four differences in Substance Use Disorders between DSM IV and DSM V. (25 points)
A patient presents with the following report: he has been drinking since his teen years and has always been able to drink more than anyone else. He drinks three beers every day and once a month may binge drink. He reports no problems as a result of drinking and his wife confirms this. He says he can stop and has stopped when he wants to “take a break”. His wife also confirms this. Does this patient have an SUD? Why or why not? (25 points)
According to DSM V, should we continue to use the term “substance abuse”. Why or why not?(25 points)

Lesson 2 Discussion

Review the different models described in this Lesson. Pick the one that you can relate to the most and explain why. Show that you understand the model and how the differences from other models make it more useful for you in explaining substance problems and helping those who have addiction issues.