Addiction is arguably one of world’s most pressing global health problems but is also among the least recognized. Approximately 40 million Americans – or 1 in 7 people over the age of 12 – have reported some type of substance abuse, nearly double the number of individuals who suffer from heart disease, diabetes or cancer. Similarly, 1 in 10 Canadians are thought to experience some type of substance abuse. While these numbers are staggering, only 10% of those affected receive treatment, making addiction a tragedy of the modern era.
Addiction first entered the English language in the late 16th century, and has its roots in the Latin word addictus, meaning an “individual who has surrendered oneself or become enslaved,” Substance and behavioural abuse has been documented since early civilization amongst Greek philosophers and in many religious texts. Today, addiction refers to the severest form of substance use disorder (SUD), as defined by the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5), the accepted principal authority in psychiatric diagnoses. SUD describes a disease spectrum based on eleven specific and defined symptomatic criteria that fall into four main categories: impaired control, social impairment, risky use, and pharmacological indicators such as tolerance and withdrawal. The number of criteria applicable to an individual is indicative of disease severity. However, addiction is more than just biological symptoms. Studying addiction through a psychosocial lens originated during the Industrial Revolution, an era associated with increased accessibility to new narcotics and recognition of addiction as a health crisis. Since then, hundreds of theories have arisen to describe drug dependency, evolution of addiction, and associated behaviours. Overall, it is critical to recognize addiction as a combination of biological and psychological phenomena that induce habitual changes, resulting in chronic disease.
Whether the addiction is behavioural or to a specific substance, the basic disease mechanism is similar. Reward centres in the brain become over-stimulated resulting in alterations of neurochemical pathways connected to reward, motivation and memory. The stimulus can become a requisite to feeling “normal”, with additional stimulation becoming required to achieve the same reward. Inhibition becomes diminished often resulting in harmful or risky behaviour, even when there is significant risk to the individual and their relationships. An example of the effect of substances on brain chemistry is alcohol’s ability to modulate behaviours of GABA receptors and dopamine release and uptake, producing withdrawal symptoms such as seizures as well as changes related to reward and memory. In addition, alcohol along with other drugs alter the transmission of glutamate, a powerful neurotransmitter associated with compulsive seeking of a substance, further reinforcing addictive behaviour. Many genes are associated with addictions, such as alcohol metabolism genes ALDH1B and ALDH2, mutations in the dopamine metabolizer COMT resulting in higher levels of dopamine in the frontal cortex, and variants of the serotonin receptor SLC6A4 that regulates mood and appetite. Genetic predispositions are further affected by social and environmental risks such as substance availability, early exposure and trauma. Early use is a significant factor as adolescents, whose brains are still undergoing development, are particularly susceptible to changes in the frontal cortex. There are many avenues by which addictive substances and behaviours hijack the brain’s natural chemistry, locking addicts into a cycle of abuse.
While understanding the underlying mechanisms of disease can be a powerful tool for the development of effective therapies, there remain other obstacles to treatments. Stigmatization of addiction still prevents many people from receiving proper help. In the early 20th century, the prevailing theories of addiction centred around the idea that a failure to abstain was simply a lack of willpower on behalf of the individual. Unfortunately, this established the notion that addicts choose to have an illness and be addicts, and recovering addicts are often stigmatized, frequently leading to restrictions of treatment options. An individual may choose to engage in risky behaviour, but it is no more a choice to develop a disease than poor diet or high-risk employment leading to disease being a choice. In reality, there are an enormity of factors and circumstances that contribute to an individual’s development of addiction and addictive behaviour.
Stigmatization is not only a reason for why so few people seek treatment, but it also affects the availability of evidence-based care and the ability of addicts to live without relapse. Prevalence of addiction-related stigma is associated with increased incarceration rates, adverse health effects and death in dependent populations. Evidence-based care methods are often controversial as they can involve the utilization of detox and drug replacement therapies in addition to psychosocial and family care. Accessibility becomes restrictive or at least not well known, whether due to political policy, geography or a lack of funding and resources, resulting in care often being delivered by individuals who are not qualified healthcare personnel. Therefore, while effective treatment may have been developed, underutilization due to societal pressures often reduces the wellbeing of addiction patients.
In reality, no single treatment will work for everyone but a shift towards acceptance and increased awareness of evidence-based care is critical. Historically, the abstinence model of recovery has been the standard of care. This model revolves around the idea of quitting drug use and using social care groups, such as Alcoholics Anonymous, to maintain sobriety. While effective in some cases, it fails to consider biological hurdles and in actuality has very low success rates for alcoholism in particular. Fortunately, many other approaches exist that address the physical, psychological and emotional reward patterns that lead to erratic and harmful behaviour. One such program is Canada’s Managed Alcohol Program (MAPS), which facilitates controlled access to small volumes of alcohol every hour. In conjunction with managing consumption, it facilitates enrollment in social care programs, behavioural therapies, and provides housing. Addicts learn addiction management strategies and can re-establish important connections with family and community. Programs like MAPS focus on re-establishing positive reward circuits disrupted by chronic drug abuse, with the aim of eventual cessation of drug use.
In addition to these unique programs, there are also an abundance of drug replacement therapies, such as suboxone or methadone, that mitigate dangerous and painful withdrawal phases, cravings and euphoria. Long-term use medications, such as Baclofen, which helps alcoholics manage triggers and anxiety, also face significant resistance despite their effectiveness. Like any medication, there are risks but these can be powerful tools when used properly. However, much like programs such as MAPS, drug replacement therapies face a great deal of stigmatization and are often viewed as agents that only encourage drug usage, thus hindering their availability and awareness. Unfortunately, at-risk communities are often the most restricted, making it even more challenging for the patients who need treatment the most to access these services. Many hit hard by the opioid crisis in rural northern and maritime communities have to travel many hours to find centres that are able to administer replacement therapies, making it nearly impossible for these individuals to access a potentially life-saving therapy. In addition to treatments that assist in managing physiological symptoms, there are a variety of unique therapies that can help manage the psychological manifestations of addiction. Behavioural and cognitive therapies help develop self-awareness and coping mechanisms and provide family care services that aid patients in reconnecting with families, while also helping families develop strategies for constructive care. Furthermore, even some forms of expressive therapies, such as music therapy, have shown to be beneficial in allowing addicts to manage disease long term. The challenge is to make all of these options available so that they can be used in a combination best suited for each individual.
Disease management is a lifelong process. There is no single treatment for all addictions. In Canada, there has been much effort to increase services for safe practices and addiction management, as well as to reduce stigmatization within communities. Needle exchanges and safe spaces for addicts are becoming part of communities, a service that is critical in keeping individuals safe until they are ready for treatment. The recent changes to the Controlled Drug and Substances Act has made it easier for healthcare practitioners to prescribe methadone, making the medication more accessible to patients in response to the devastating opioid crisis. Although these are steps in the right direction, more still needs to be done to help communities understand addiction and improve access and care for a much-ignored disease.
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