What is Addiction?
The American Society of Addiction Medicine (ASAM) defines addiction as a chronic disease of brain reward, motivation, and memory. People can become addicted to many different substances including alcohol, tobacco, prescription opioids and stimulant medications, marijuana, heroin, hallucinogens (e.g., PCP, LSD), inhalants (e.g., paint thinner, glue), cocaine, and methamphetamines.
“Addiction” is a word used to describe the behavioral manifestation of a substance use disorder, characterized by a pattern of behaviors that impair a person’s ability to function effectively. Substance use disorders can affect learning, judgment, decision-making, memory, and behavior.
People develop substance use disorders because certain types of substances affect areas of the brain associated with reward (called the “reward circuit”). These substances trigger the release of dopamine, a chemical responsible for causing pleasant feelings. This pleasant effects of substances on the brain motivates people to repeatedly seek them out (positive reinforcement). With repeated use, people can build a tolerance to specific substances as the brain adapts to them. When people build a tolerance to a substance, they need to take greater doses to experience the same benefits, and when the body needs the substance to create those sensations, not using it may cause unpleasant symptoms or withdrawal (negative reinforcement).
Treatment for substance use disorders is based on the type of substance and the severity of use, and often requires a combination of medication and behavioral therapy. Treatment works best when it is tailored to an individual person’s needs. Treatment for addiction is similar to treatment for other chronic conditions. It is common for people recovering from addiction to experience relapse, and it is important to remember that treatment and recovery are ongoing processes.
More information is available from the National Institute on Drug Abuse.
Understanding Opioid Use Disorder
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association in 2013, defines Opioid Use Disorder (OUD) as: “A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period.”
To be diagnosed with an opioid use disorder, the DSM-5 specifies that a person must have at least two of the following criteria:
- Opioids are often taken in larger amounts or over a longer period than was intended.
- There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
- A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
- Craving, or a strong desire or urge to use opioids.
- Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
- Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
- Important social, occupational, or recreational activities are given up or reduced because of opioid use.
- Recurrent opioid use in situations in which it is physically hazardous.
- Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
Two additional criteria, Tolerance and Withdrawal are generally present with OUD, but can also be present when a person is treated regularly with opioids for chronic pain but does not have an opioid use disorder.
The DSM-5 defines Tolerance as either (1) a need for a markedly increased amounts of opioids to achieve a desired effect, or (2) a markedly diminished effect with continued use of the same amount. Withdrawal is manifested either by characteristic opioid withdrawal symptoms, or their avoidance by using opioids to relieve them.
The severity of OUD can be estimated based on the number of symptoms a person has which meet the DSM-5 criteria:
Mild OUD: Presence of 2–3 symptoms
Moderate OUD: Presence of 4–5 symptoms
Severe OUD: Presence of 6 or more symptoms
Assessing Opioid Withdrawal Symptoms
The Clinical Opioid Withdrawal Scale (COWS) may be used to measure severity of symptoms in a person who presents in acute withdrawal from opioids. A copy of the COWS can be downloaded here.
Treating Opioid Use Disorder
Treatment for opioid use disorders during pregnancy may occur at several levels of intensity and duration. Access to pregnancy specific treatment varies widely by region. Some programs may not accept pregnant women, and many do not allow children to accompany their mothers.
Office-based treatment combines behavioral treatment for substance use with buprenorphine/naloxone or buprenorphine monotherapy. Physicians can complete special training to be eligible for a waiver to prescribe buprenorphine for this purpose. Recent changes in Federal legislation allow Nurse Practitioners and Physicians Assistants to undergo similar training to obtain a buprenorphine waiver starting in 2017, with the addition of Certified Nurse Midwives in 2018.
Methadone maintenance programs combine behavioral treatment with daily observed treatment with methadone. In the United States, methadone can only be provided for the treatment of addiction at Opioid Treatment Programs certified by the Substance Abuse and Mental Health Services Administration.
Intensive Outpatient Programs (IOPs) usually consist of 9 hours of treatment for substance use disorders per week, although programs vary. People often begin treatment in IOP programs and graduate to weekly office-based treatment once doing well.
Residential Treatment Programs are substance use treatment programs which offer daily treatment in a residential setting. Residential programs may or may not be gender-specific. A few residential programs are also equipped to accommodate children whose mothers are seeking treatment.
More information about levels of treatment is available from the following sites:
http://asamcontinuum.org/knowledgebase/what-are-the-asam-levels-of-care/
https://www.samhsa.gov/medication-assisted-treatment/treatment/methadone
https://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine
