amersa “spicy” debate: is addiction really like other chronic illnesses? “yes”: it has a...
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AMERSA “spicy” debate: Is Addiction AMERSA “spicy” debate: Is Addiction REALLYREALLY Like other Chronic Illnesses? Like other Chronic Illnesses?
““Yes”: it has a biological basisYes”: it has a biological basis
““No”: it is typically not chronicNo”: it is typically not chronic
““No”: it is not like illness because the factors that No”: it is not like illness because the factors that influence drug use in addicts have little or no direct influence drug use in addicts have little or no direct influence on disease symptomsinfluence on disease symptoms
Evidence:Evidence:– Everyday speech (idioms)Everyday speech (idioms)– Research findings Research findings
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Everyday expressions that distinguish Everyday expressions that distinguish addiction from chronic illnessesaddiction from chronic illnesses
““kicking the habit”kicking the habit”
““going cold turkey”going cold turkey”
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Remission in Representative Samples of Dependent (Addicted) Drug Users (N approx. 2700)
% in
Rem
issi
on
0%
20%
40%
60%
80%
100%
Is addiction a chronic disorder?These findings are derived from
National Comorbidity Surveys (NIMH, NIDA) and
National Epidemiological Survey of Alcohol and Related Syndromes (NIAAA, DHHS)
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% of "Cases" Who No Longer
Met Criteria for Drug Dependence%
Case
s R
em
itted
0%
20%
40%
60%
80%
100%
Remission % for Opiate Addiction:"Prospective, Intensive" Studies
% in
Rem
issi
on
0%
20%
40%
60%
80%
100%
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Why do we say that addiction is a “chronic” Why do we say that addiction is a “chronic” disorder, when the data say otherwise?disorder, when the data say otherwise?
Our understanding of addiction is based largely Our understanding of addiction is based largely on clinical experienceon clinical experience
But most addicts do not seek treatmentBut most addicts do not seek treatment
Hypotheses:Hypotheses:– Drug use persists longer in clinic populationsDrug use persists longer in clinic populations– Clinic populations tend to have additional problems Clinic populations tend to have additional problems
that interfere with recovery that interfere with recovery
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Is addiction like other illnesses?Is addiction like other illnesses?A distinguishing feature of illnesses is that the symptoms A distinguishing feature of illnesses is that the symptoms are involuntaryare involuntary
How to measure “voluntariness”? How to measure “voluntariness”?
Behaviors vary in the degree to which they are susceptible Behaviors vary in the degree to which they are susceptible to the influence of ideas, values, costs and benefits to the influence of ideas, values, costs and benefits (consequences). One possible continuum:(consequences). One possible continuum: – reflexesreflexes
– satisfying an essential biological urge (hunger, thirst) satisfying an essential biological urge (hunger, thirst)
– whether to play tennis, read a novel or write a new paperwhether to play tennis, read a novel or write a new paper
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Thus, we can test whether addiction is Thus, we can test whether addiction is like other illnesseslike other illnesses
Do ideas, values, costs, and benefits influence drug use Do ideas, values, costs, and benefits influence drug use in addicts?in addicts?– That so many addicts quit on their own suggests “yes”That so many addicts quit on their own suggests “yes”
Voluntary behavior is not a synonym for free will Voluntary behavior is not a synonym for free will
We are investigating a causal relationshipWe are investigating a causal relationship
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Year
1920 1930 1940 1950 1960 1970 1980 1990 2000
Per
Cap
ita C
igar
ette
C
onsu
mpt
ion*
500
1000
1500
2000
2500
3000
3500
4000
4500
The Depression
First Cancer Alert
First SurgeonGeneral's Report
* Fiore et al., 1993, Natural Hist & Epid of Tobacco Use...,
Approx.
Information and Smoking
Does expert opinion (information) influence drug use?
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Psychiatric Disorder
Lik
elih
oo
d
0%
2%
4%
6%
8%
10%
12%
14%
Schizo
Abuse/
Dep
OCD
Panic
Depre
ssion
Man
iaAnx
iety
Disord
er
Affect
ive
Differences in Likelihood of Psychiatric Disorders as Function of Differences in Year of Birth (ECA)
Born 1952-1963,
Born 1917-1936
Historical influences and addiction
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Year of Birth19
36-1
945
1946
-195
5
1956
-196
5
1966
-197
5
Pro
ba
bili
ty t
ha
t D
rug
Use
Le
ad
s to
De
pe
nd
en
ce b
y A
ge 2
0
0.00
0.04
0.08
0.12
0.16
Historical Variation in the TransitionFrom Drug Use to Drug Dependence*
*National Comorbidity Study
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Months Since Treatment6 9 12
% C
oca
ine
Ab
stin
en
t
0%
20%
40%
60%
80%
100%
VouchersCounseling
Higgins et al.1995
Choice-based voucher treatment: Cocaine dependent users
Incentives, prosocial activities, and drug use in cocaine addicts
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Summary:Summary:
Most addicts stop using drugs and usually do so without Most addicts stop using drugs and usually do so without professional assistanceprofessional assistance
The primary factors that bring drug use to a halt are those that The primary factors that bring drug use to a halt are those that influence choice: familial concerns, economics, values influence choice: familial concerns, economics, values
We cannot make a similar summary for “chronic illnesses”We cannot make a similar summary for “chronic illnesses”
Choice is critical to the distinction between disease and nondisease. Choice is critical to the distinction between disease and nondisease. Thus, addiction, is not “Really like chronic diseases”Thus, addiction, is not “Really like chronic diseases”
This doesn’t make addiction less of a problem, but it does This doesn’t make addiction less of a problem, but it does help us frame the problemhelp us frame the problem
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Current Cases as Function of Age
Age20 30 40 50
% "
Cu
rre
nt"
Ca
ses
0%
1%
2%
3%
4%
5% NCS Survey, 1990 - 92ECA Survey, 1980-1984
Abuse & Dependence
Dependence Only
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Type Drug
% R
emis
sion
15%
30%
45%
60%
75%
90% ECA Survey, 1981-198NESARC Survey, 2001-2002
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Remission % for Heroin Addiction As a Function of How Subjects Were Selected For Study
% in
Re
mis
sio
n
0%
20%
40%
60%
80%
100% Random Selection, Independent of Treatment Status
Treatment Follow Up Study
Remission as a function of whether clinic treatment determined subject recruitment
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Fre
q o
f A
dditi
on
al
Psy
ch D
iso
rde
rs
10%
20%
30%
40%
50%
60%
70%
80%
Treatment Seeking is Corrrelated With Higher Comorbidity*
Drug Depend & Tx Seeking
Drug Depend & Not Tx Seeking
NotDrug Dependent
* Regier et al., 1990; Rounsaville et al., 1991
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Religious Values and Heredity
Religio
us In
tere
sts
Religio
us F
unda
men
talis
m
Religio
us V
alues
Co
rre
latio
n
-0.2
0.0
0.2
0.4
Identical TwinsFraternal Twins
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Vietnam Vets In Treatment
Weeks Since Release0 10 20 30 40 50
% R
ela
pse
d A
fte
rT
rea
tme
nt
0%
10%
20%
30%
40%
50%
60%
70%
80%
*Robins, 1993
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Relapse Following Treatment(Resumption of Drug Use)
Months
0 2 4 6 8 10 12
% R
elap
se
15%
30%
45%
60%
75%
AlcoholSmokingHeroin
Hunt et al., 1971
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Clinic Success Stories:Drug Use Could Lead to Loss of Professional License (MDs and Pilots)
1 2a 2b 3 4 5 6 7
% A
bstin
ent
0%
20%
40%
60%
80%
100% No Monitoring
Study Code, See Footnote n
Suspended MDs and Pilots: Random Drug Tests and Threat of Loss of License
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Setting Influences Opiate Use& Addiction: Same Individuals--Different Settings
Use
Addict
ed Use
Addict
ed
Addict
ed
Pe
rce
nta
ge U
se
an
d A
dd
ictio
n
0%
10%
20%
30%
40%
50%
Pre-Vietnam(USA-Home)
In Vietnam
Backin theUSA
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Remission Rates for Psychiatric DisordersNCS (1990-1992)
Subst
Use
AllDiso
rder
s
% in
Re
mis
sio
n
15%
30%
45%
60%
75%
All psychiatric disorders, not counting drug and alcohol dependence.
Do all psych disorders have high remission rates?
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Addictive Drugs: Experimentationand Dependence
% o
f US
Pop
ulat
ion,
Nat
iona
l Com
orbi
dity
Stu
dy
0%
20%
40%
60%
80%
100%
Ever UsedEver Dependent
What accounts for these differences?
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Common themes in biographical Common themes in biographical accounts:accounts:
Stories are laced with explicit and implicit values:Stories are laced with explicit and implicit values:– ““I wasn’t put on earth to be an addict”I wasn’t put on earth to be an addict”– ““I wanted my parents to be proud of me again”I wanted my parents to be proud of me again”– ““I didn’t want to embarrass my children”I didn’t want to embarrass my children”– ““I was sick of the hassles”I was sick of the hassles”
Ordinary concerns:Ordinary concerns:– Fear of arrestFear of arrest– Finances and occupational concernsFinances and occupational concerns– Familial relationsFamilial relations– Taking stock: “hitting bottom,” “conscious weighing of costs and Taking stock: “hitting bottom,” “conscious weighing of costs and
benefits”benefits”
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TABLE 2.10, 2.11, & 2.12 NHSDA
% PERSONS REPORTING COCAINE USE PAST MONTH
MAIN FINDINGS 1990
YEAR
1972
1974
1976
1977
1979
1982
1985
1988
1990
1992
% N
atio
na
l P
op
ula
tio
nH
ou
se
ho
ld S
urv
ey
0%
2%
4%
6%
8%
10%
Age 12-17Age 18-2526+