The Medical Model LECTURE TWO: ADDICTION

Let’s Look at the MAST

Michigan Alcoholism Screening Test (MAST) Scoring the Mast For each yes give yourself the score indicated except for questions 1,4, and 8. For 1,4, and 8, give yourself the score indicated if you give A NO Answer Zero points for a Yes answer 1,4,8. 12 or more points indicates a problem with alcoholism 5 and 10 suggestive of problem at risk

DSM IV-TR Criterion for: Alcohol Dependence - Diagnostic Code A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: (1) tolerance, as defined by either of the following: (a) a need for markedly increased amounts of alcohol to achieve Intoxication or desired effect (b) markedly diminished effect with continued use of the same amount of alcohol (2) Withdrawal, as manifested by either of the following: (a) the characteristic withdrawal syndrome for alcohol (b) alcohol (or a closely related drug such as valium) is used to relieve or avoid withdrawal symptoms (3) alcohol is often used in larger amounts or over a longer period than was intended

DSM criteria (cont.) 4) there is a persistent desire or unsuccessful efforts to cut down or control alcohol use (5) a great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects (6) important social, occupational, or recreational activities are given up or reduced because of alcohol use (7) alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol

Specifiers  With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 1 or 2 is present)  Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 1 nor 2 is present)  (Note--a diagnosis of Alcohol Dependence can never be changed to a diagnosis of Alcohol Abuse. A diagnosis of Alcohol Dependence is for life--it can never be removed from your medical chart not matter how much you improve.) Alcohol Abuse

Why do people abuse chemicals? The simplest answer is because it feels good! But why then are we not all addicts?

Is it not a choice?  What do folks think?

Is it simple a choice?

Physical reward potential Increased sense of pleasure Decreased discomfort Thus I use again and again  Pleasure center is not one a single center  Pleasure center across brain systems  Motivated to seek further stimulation

Social Learning Component  We learn how to use drugs and substances  In order to maximize their potential both physically and psychologically. Individual Expectation of Drug/Alcohol / Substance

Cultural influences on chemical use patterns  People’s decision to use or not can be a result of the community, subculture, family, and social group, to which you belong.  Peele [1985] holds that “cultures where use of a substance is comfortable, familiar, and socially regulated both as to style of use and appropriate time and place for such use, addiction is less likely and maybe practically unknown”.  And yet with new emerging addictions this may not hold as true as it did 20 years ago! What is Peele Smoking?Smoking We also can’t forget social groups within a culture

Individual Life Goals Present FuturePast It’s Important to remember that chemical abuse patterns are not fixed Moreover, no one sets out to become addicted

or Disease Model MEDICAL MODEL OF ADDICTION

Basic Tenet: Medical Model / Disease Model  A great deal of the individuals behavior is based on predisposition  However, there is no universally accepted disease model that explains addiction  Instead there exists loosely related theories that addiction is (unproven) a psycho-biomedical process that can be called a disease state.

Otto Jellinek (1952)  Influenced physicians  Shifted from moral disorder to medical disorder  Became recognized as formal disease in 1956 (by the AMA)  Proposed alcoholism to be a progressive / predictable disorder

Jellinek’s Four Stage Model Prealcoholic PhaseProdromal Phase Crucial PhaseChronic Phase Alcohol used for relief from social tension First Blackouts; preoccupation with use, development of guilt Loss of control; Physically dependent Loss of tolerance; obsessive drinking, alcoholic tremors, drinking with social inferiors PROGRESSIVE E COURSE LEADING TO DEATH

Jellinek’s Additions  Later classified different types of alcoholics  One hallmark of the alcoholic – they can’t predict how much they will drink after starting  His legacy – something worth studying (brain/biology)  Removes prejudices “the immoral alcoholic”  Wasn’t about will power was a “disease”

Genetic Inheritance Theories  Less sensitive to alcohol effects – (less neuronal firing)  Like / dislike certain substance(s)  Decision making (frontal cortex)  Make it harder to quit  Affect withdrawal syndrome  Different studies suggest that genes account for 20% to 58% of addiction risk  No signal gene causes addiction  Vulnerability not Destiny

Cloninger’s Type 1 and Type 2 Alcoholics  3,000 adoptees  Reared by non-alcoholic parents  Great deal of adoptees became alcoholic  Cloninger observed two distinct groups

Type 1 (larger subgroup)  ¾ children had biological parents who were alcoholic  These children drank in moderation in early adulthood  Later life developed dependence  Functioned in society as responsible adults  If raised in higher socio economic family less likely to become alcoholic

Type 2  Males  More violent than Type 1  Father’s were violent alcoholics  20% chance of becoming alcoholic regardless of SES  Later studies confirmed findings  10% of sample became alcoholics  Low Levels of MAO

Neuro-Biological Processes, Dopamine, and Drug Addiction  Addicts are biologically different from non-addicts  An addict’s brain acts differently before and after using  Addicts metabolize and bio-transform substances differently

Ego States and the Characterlogical Model of Addiction  Personality and its relationship with self and world (internal and external)  How we then deal with world  Addiction then helps to self-regulate via pharmacologic effects, attendant rituals, practices, and drug culture