Over 1.6 million people in England depend on alcohol; 1 in 5 children live with a parent who drinks harmful amounts of alcohol; 1 in 7 children under the age of one live with a substance-abusing parent.
These startling figures demonstrate the severity of addictions in the UK. Children of addicts are eight times more likely to develop an addiction. The problem crosses all socio-economic boundaries and addiction is now more common than diabetes.
Addiction can be defined as “the repeated involvement with a substance or activity, despite the substantial harm it causes, because that involvement was (and may continue to be) pleasurable or valuable.” Such substances and activities may include alcohol, drugs, food, gambling, shopping or sex.
This article discusses the causes of addictions, how to recognise a problem and offers advice on how you can best support at-risk patients.
The importance of early intervention
Recognising a problem and intervening early is extremely important in tackling an addiction. This also helps to reduce detrimental costs to society, and improve public health. Too often, individuals with an addiction believe that only severe cases require treatment, therefore many do not seek treatment when they should. In such cases, the addiction can rapidly cause significant social, economic, health, and/or legal consequences.
There are three key components of addiction:
The reward one receives from a pleasurable action is called ‘positive reinforcement’. People drink, for example, to feel good, confident and relaxed. All of these effects provide a ‘pay off’ or of course, a reward. The reward system is part of a human’s ‘survival kit’, which has evolved to ensure the survival of the species, making essential activities (such as eating, drinking and sex) pleasurable. The brain releases natural ‘reinforcers’ (opioid-like transmitters) which raise circulating dopamine levels and create a feeling of satisfaction.
Alcohol and other drugs of abuse are chemical surrogates of natural reinforcers but more powerful and persistent than that of natural reinforcers. Continuous exposure can initiate increased drug seeking behaviour and set the stage for addiction.
Drugs cause changes in the receptors to which they bind, making them less sensitive. This creates tolerance – the need to take sequentially larger amounts of a substance to produce the same effect/reward. If an individual progressively falls short of their reward/pay off, they will begin to abuse a substance more and more.
Dependence is the need for continued use to avoid withdrawal. If an addict stops using, they get the opposite effect to reward and go into withdrawal. Severe physical withdrawal symptoms are usually opposite in nature to the drug’s acute affect/reward and include anxiety, emotional agitation/depression, tremors and sweating. These effects are devastating and painful and starting the drug again brings prompt yet short-term relief.
Recognition can be difficult and denial is a big part of having a problem. However, providing someone with effective treatment as soon as possible will not only give them a better chance of long-term recovery but also stop the slide into any further addictions.
The intervention process
‘SBIRIT’ is a comprehensive, integrated, public health approach for achieving early intervention and delivering treatment services to people with, or at risk of developing an addiction. This stands for:
- Brief Intervention
- Referral to inpatient treatment
SBIRIT is designed to take place in general medical settings that people routinely visit, and to identify individuals with an addiction before their problems progress too far.
This quickly assesses the severity of substance use and identifies the appropriate level of treatment. A number of screening tools are available to help this process but the simplest to use is the modified ‘CAGE’ test:
- Have you ever thought you should Cut down your drug or alcohol use?
- Have you ever felt Annoyed when people have commented on your use?
- Have you ever felt Guilty about your use?
- Have you ever used drugs to Ease withdrawal symptoms, or to avoid feeling low after using?
Your score (one point for each ‘yes’ answer):
- If you scored 1, there is a 75% chance you're addicted
- If you scored 2, there is an 85% chance you're addicted
- If you scored 3, there is a 99% chance you're addicted
- If you scored 4, there is a 100% chance you're addicted
Advancements in neurobiological research now show an addiction is a problem of brain functioning. We become addicted to the chemicals our brain releases, not the substance or activity that cause this release. This emphasises even more that an addiction can be treated and can be overcome.
It remains controversial whether or not we should reduce addiction to a "chronic disease of the brain." Clearly, addiction does not develop merely because someone is weak-willed; an addicted person does not choose their genetics; they do not control whether they are at risk for developing an addiction. It can be also be argued that a traumatic experience of some kind can trigger an addiction.
People are certainly capable of choosing recovery over addiction. This makes addictive disorders very similar to other diseases and disorders as many health problems require lifestyle changes to restore health. For example, people with heart disease must choose a healthier diet and exercise – the same is true for people with addictions.
Based on the criteria of the American Psychiatric Association (DSM-V) and World Health Organisation (ICD-10), an addiction can also be identified by matching the following:
- Tolerance – Do you use more alcohol or drugs over time?
- Withdrawal – Have you experienced physical or emotional withdrawal when you have stopped using? Have you experienced anxiety, irritability, shakes, sweats, nausea, or vomiting? Emotional withdrawal is just as significant as physical withdrawal.
- Limited control – Do you sometimes drink or use drugs more than you would like? Do you sometimes drink to get drunk? Does one drink lead to more drinks? Do you ever regret how much you used the day before?
- Negative consequences – Have you continued to use even though there have been negative consequences to your mood, self-esteem, health, job, or family?
- Neglected or postponed activities – Have you ever put off or reduced social, recreational, work, or household activities because of your use?
- Significant time or energy spent – Have you spent a significant amount of time obtaining, using, concealing, planning, or recovering from your use? Have you spent a lot of time thinking about using? Have you ever concealed or minimised your use? Have you ever thought of schemes to avoid getting caught?
- Desire to cut down – Have you sometimes thought about cutting down or controlling your use? Have you ever made unsuccessful attempts to cut down or control your use?
If an individual matches any of the above criteria then it is important they seek help as soon as possible.
It is also important to recognise that some people aren't addicted to drugs or alcohol, but abuse them. The American Psychiatric Association definition of substance abuse is at least one of the following four criteria:
- Continued use despite social or interpersonal problems
- Repeated use resulting in failure to fulfil obligations at work or school
- Repeated use resulting in physically hazardous situations
- Use resulting in legal problems
This focuses on increasing a person’s awareness of substance use and encouraging changes in behaviour. If you have identified someone whose presentation is not so severe that they require residential treatment then offering them the opportunity of quick access to individual therapy may well be the answer.
Referral to in-patient treatment
This provides those who need more extensive treatment with a referral to specialty care. This is particularly true for those patients requiring a medical detox from alcohol or drugs. The quicker it is possible to get the client into treatment the easier it is to stop the problem form escalating.
Residential rehabilitation treatment
Residential ‘rehab’ provides a safe and supportive environment for detoxification and addiction treatment. It offers 24 hour care and support and includes input from a multidisciplinary team of consultant psychiatrists and psychologists, therapists and nurses.
In residential treatment a holistic treatment approach can also be delivered. There is evidence that a holistic approach supports the treatment process by empowering clients to develop the psychological, mental, emotional and physical resources to help with their recovery process.
A holistic approach vastly increases the chance of sustained recovery and good quality of life. Without this approach the individual is more likely to relapse, develop another addiction or disorder, and have a much poorer quality of life.
There is a strong evidence base that suggests having a holistic approach to addiction treatment reduces the risk of cross addiction, which can lead back into relapse.
Cross addiction follows the below premise:
- All addictions work in the same part of the brain, therefore one drug can lead patients back to any other drug and so on
- Even moderate drinking or smoking cannabis lowers a patient’s inhibitions, which makes it harder for them to make the right choices
- If patients stop using their drug of choice but continue to use alcohol or cannabis for example, new coping skills can’t be learnt and they don't want to change their life. They are saying that they want to continue to rely on drugs or alcohol to escape, relax, and reward themselves. But if they don't learn those new skills, then they won't have changed, and their addiction will catch up with them
Much of the work in residential rehab is group work, where inpatients can see that addiction can affect anybody. Usually a patient’s first reaction to addiction is to deal with it on their own but group work provides support from peers. Addiction is an isolating disease, so group work gives them the chance to reach out and ask for help.
Most addicts have difficulty sharing their emotions, partly because they're afraid nobody will understand them, and partly because they're afraid that they'll be criticised. This being the case means there is a real benefit of sharing with people that are going through the same thing that they are.
Support from Priory
As the UK’s leading independent provider of addiction treatment services, Priory provides professional, specialist treatment programmes for a wide range of addictive substances and behaviours at over 300 locations across the UK. We offer a nationwide network of specialist clinicians who will devise an individually tailored addiction treatment programme, ensuring all patients achieve the best possible outcomes with us.