Understanding Addictive Disorders

Posted on Friday, December the 28th at 6:32pm

Dr. Stephen F. Grinstead, LMFT, ACRPS, CADC-II

The definition for an Addictive Disorder used for this article is: a collection of symptoms (i.e., a syndrome) that is caused by a pathological response to the ingestion of mood altering substances and has ten major characteristics. These Characteristics are shown in the following table. The table is followed by a brief explanation of each characteristic.

Let’s look at each of these characteristics in a little more detail.

Euphoria

People use drugs because they work—they get some kind of need met. This is true of pain medications as well as other potential drugs of abuse. In addition to blocking physical pain, one of the side effects of some pain medications can be a sense of euphoria. If a person experiences this unique sense of well being or euphoria when they use a drug or medication, they are at high risk of becoming psychologically dependent and may even become addicted to that substance.

Recent research shows that when a person is genetically susceptible to being addicted to a specific drug, their brain will release large amounts of brain reward chemicals whenever that drug is used. It is this high level of brain reward chemicals that cause the unique feeling of well being that many addicts experience when using their drug of choice. In this book we will call this unique feeling of well being; euphoria.

It is important to distinguish between euphoria (the unique sense of well being experienced when using a drug of choice) and intoxication (the symptoms of dysfunction that occur when a person’s use exceeds the limits of their tolerance to a drug). Most addicts do not use their drug of choice to get intoxicated and become dysfunctional. The opposite is true. For instance, people who become addicted to prescription medication at first use it to manage physical pain, but at other times they use it to feel good and experience a unique feeling of well being that will allow them to function better—or in many cases experience the illusion of functioning better.

People can actually become addicted to this state of euphoria. They crave this unique sense of well being. They feel somehow empty or incomplete when they can’t feel this way. They feel deprived when they can’t experience this euphoria. They may even experience deprivation anxiety, which is a fear that if they can’t get their drug of choice (i.e. are deprived of it), they mistakenly believe that they won’t ever be able to feel good or function normally again.

This positive reinforcement is biopsychosocial in nature. Biologically the drug of choice causes a release of pleasure chemicals that create a unique sense of well being. Psychologically, “I come to believe the drug is good for me because it makes me feel good in the moment.” This is called emotional reasoning (“if it feels good it must be good for me”). They then begin adjusting their social network to accommodate these beliefs. “Anyone who supports the use of my drug of choice is my friend. Anyone who challenges the use of my drug of choice is my enemy.” The result is the development of a drug-centered lifestyle.

The stronger the positive reinforcement that is experienced when a person uses their medication, the greater the risk is that they will become addicted to that drug. This is true because strong biological reinforcement from drug use creates a craving cycle.

Craving

The addictive process starts when someone receives a reward, payoff, or gratification from taking a psychoactive (mood altering) drug. This reward may be the relief of pain or the creation of a sense of euphoria. Because the drug provides a quick positive reward, the person continues to use it.

With a pattern of consistent drug use some people come to rely heavily upon the drug to provide that reward. This leads to an addictive disorder, or what is called “substance dependence” by DSM-IV-TR. People need to use the drug to successfully accomplish one or more life tasks. Once people become addicted, they experience psychological distress when the thing they are dependent upon is removed. When people become addicted to medication for relief or euphoria, they experience anxiety when the drug is no longer available. Albert Ellis calls this deprivation anxiety. The person is anxious because he or she has been deprived of a drug that they believe they need in order to function normally.

This deprivation anxiety then causes the person to start thinking about the drug. Obsession is the out-of-control thinking about the reward that could be achieved by using the substance. Obsession can lead to compulsion—the irrational desire for the drug. Obsession and compulsion combine together to create a powerful craving or a feeling of need for the drug.

This cycle of obsession, compulsion, and craving creates a strong urge or pressure to seek out and use the medication even if the person consciously knows that it is not in his or her best interest to do so. Over time this reward continues to be reinforced, leading to an increased need for the drug. This leads to Tolerance.

Tolerance

There is a definite biological component to developing tolerance. The increased need for the substance leads to drug seeking behavior. There are also psychological and social components to this developmental process.

On the biological level, after drug-seeking behavior has been established, the brain undergoes certain adaptive changes in order to continue functioning despite the presence of the drug. This adaptation is called Tolerance. When tolerance occurs, the brain chemistry of the user actually changes, including the development of more receptor sites in the brain.

Psychologically the person starts believing that they need the drug. When people start to experience difficulty obtaining enough of the drug, they start feeling anxious and afraid. Socially they begin to experience difficulty with other people because of the time and energy they are expending which results in a Loss of Control.

Loss Of Control

The final stage of the craving cycle and development of tolerance is the loss of control people feel over their medication use and/or their behavior while using the drug. The person begins to develop an even higher tolerance for the drug. In other words, it takes more of the drug to get the same effect. Or, if the person keeps using the same amount of the drug, they experience less of an effect. So the person begins using more of the medication or seeking out stronger drugs, including alcohol, that will give the same—or better—reinforcing effect.

At times the medication and/or other drugs are taken in such large quantities that the person becomes intoxicated or dysfunctional. This dysfunction creates biopsychosocial life problems. At this point, if the person stops using the drug, they will experience uncomfortable physical and emotional problems. This leads to lowered motivation to stop the drug use.

Withdrawal

Withdrawal is marked by the development of a specific clinical syndrome upon the cessation of medication use. In some cases patients may use the same or a similar drug to relieve or avoid the withdrawal syndrome.

Once tolerance and loss of control take place, further abnormalities occur in the brain when drugs are removed. In other words, the brain loses it capacity to function normally when drugs are not present.

·         Low-grade abstinence-based brain dysfunction is distinct and different from the traditional acute withdrawal syndromes

·         Low-grade abstinence-based brain dysfunction is marked by feelings of discomfort, increased cravings, and difficulty finding gratification from other behaviors

·         Low-grade abstinence-based brain dysfunction creates a desire to avoid the unpleasant sensations that occur in abstinence.

·         The desire to avoid painful stimuli is called negative reinforcement

Inability To Abstain

A person eventually comes to believe that their drug of choice is good for them and that it will magically fix them or make them better as a result of their experiences created by the biological reinforcement and high tolerance. They start to develop an addictive belief system. They come to view people who support their drug use as friends and people who fail to support it as their enemies.

At this point the person is experiencing both positive and negative reinforcement to keep using. If they continue to use they experience euphoria and pain relief. This occurs because the brain releases large amounts of reward chemicals when they use their drug of choice. At this point they are totally unable and/or unwilling to adhere to the medication management plan that they agreed to follow with their healthcare provider.

If they stop using, they experience dysphoria or pain and suffering. They start to experience a sense of anhedonia that is marked by a low grade agitated depression and the inability to experience pleasure. They begin to believe that they have no choice but to keep using their drug of choice.

Addiction Centered Lifestyle

An addiction centered lifestyle develops when the person attracts and is attracted to other individuals who share strong positive attitudes toward the continued use of drugs (e.g., the problematic pain medication). These people usually have enabling support systems that condone and encourage their continued use. They become immersed in an addiction centered system.

Addictive Lifestyle Losses

The person distances themselves from people who support sobriety or effective medication management and surround themselves with people who support problematic medication use and/or alcohol and other drug use. The pattern of biological reinforcement has motivated the person to build a belief system and lifestyle that supports heavy and regular use.

The person is now in a position where they will voluntarily use larger amounts with greater frequency until progressive addiction and the accompanying physical, psychological and social degeneration occur. Their life becomes unbearable and unmanageable. They start experiencing a downward spiral of problems—addictive lifestyle losses.

Continued Use In Spite Of Problems

Unfortunately, this downward spiral leads to continued drug use in spite of the consequences. This inability to control drug use causes problems. The problems cause pain. The pain activates a craving. The craving drives people to start using the drug to get the relief that they believe they need.

As a result, when addicted people experience adverse consequences from their addiction, the adverse consequences cause cravings instead of correction. As a result, addicted people keep using drugs to gain the immediate reward or relief in spite of experiencing serious life problems.

Substance Induced Organic Mental Disorders

The progressive damage of pain medication and/or alcohol and other drugs on the brain create growing problems with judgment and impulse control. As a result, behavior begins to spiral out of control. The cognitive capacities needed to think abstractly about the problem have also been impaired, and the person is locked into a pattern marked by denial and circular systems of reasoning. There will be more about denial in a later chapter.

At this stage the person is now unable to recognize the pattern of problems related to their drug of choice. When problems do occur they begin to experience physical, psychological and social deterioration. Unless they develop an unexpected insight or are confronted by a motivational crisis or by concerned people in their life, the progressive problems are likely to continue until serious damage results.