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

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”

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)

% 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%

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

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

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

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?

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

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

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

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

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

Type Drug

% R

emis

sion

15%

30%

45%

60%

75%

90% ECA Survey, 1981-198NESARC Survey, 2001-2002

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

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

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

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

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

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

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

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?

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?

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”

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+