Randall D. Ordovich Clarkson, MD
December 14, 2022
CLASSIFICATION OF ADDICTIVE DISORDERS
Not all addicts are built the same—some enjoy one too many drinks and others enjoy binge-watching pornography to the detriment of their day-to-day activities. Depending on the degrees of severity, such addictions could pose clinically significant disturbances or impairment. One interesting consideration that has plagued the field of behavioral health involves the ever-evolving definitions and classifications of addictive behaviors, among other mental illnesses. For instance, as of the publication of the DSM-V (2013), the decision was made to move Gambling Disorder from an impulse control disorder to a substance-related and addictive disorder. In that light, it is perhaps more appropriate to regard impulses vs. chemical dependence through a lens of process vs. chemical addiction.
The main difference between process addictions such as gambling and substance abuse is that in the latter, the patient is chemically dependent whereas in the former, the patient is addicted to the endogenous dopaminergic reward systems resulting from their behaviors. Such endogenous dopaminergic responses can be elicited through pathological gambling, sex addiction, shopping, etc. Alavi et al. (2012) state that behavior addictions such as impulsive internet use have similar constellation of signs as chemical dependence (salience, euphoria, tolerance, withdrawal, conflict, and relapse). However, the physiological aspects of drug addiction are fundamentally absent. In that, there is a clear demarcation in both process addiction and addictions involving substances insofar as each have different routes of administration—one creating a euphoric state through a specific behavior and the other creating a similar outcome through the use of chemicals. Despite the ever-evolving classification systems, the most prescient matter for clinicians concerns the severity of withdrawal symptoms
endogenous dopaminergic responses can be elicited through pathological gambling, sex addiction, shopping, etc.
WITHDRAWAL SYMPTOMS & TREATMENT CONSIDERATIONS
One of the greatest misconceptions of alcohol and opiate withdrawals involve the question of lethality. Can withdrawal symptoms kill you? The short answer is sometimes. Unlike opiate withdrawals, withdrawal from alcohol can have fatal consequences. Delirium tremens (DTs), which happens approximately 3 days after the last drink of ethanol in alcoholic patients, carries a mortality rate of 5-15% (DeBellis et al., 2005). This is primarily due to the autonomic hyperactivity resulting in elevated heart rate, respiratory rate, and blood pressure. Treatment for the prevention of DTs includes pharmacologic use of depressant anxiolytics such as benzodiazepines—diazepam and lorazepam being the most commonly used (Schuckit, 2014). One will never encounter such phenomenon in other forms of chemical dependence and withdrawal. However, therapists must also consider the mechanisms of opioid tolerance, which can have dire consequences if a patient in recovery were to relapse.
Delirium tremens (DTs), which happens approximately 3 days after the last drink of ethanol in alcoholic patients, carries a mortality rate of 5-15%
This is how many famous opioid users have overdosed. One notable example involved Sid Vicious of the Sex Pistols who was in jail at Rikers Island for fifty-five days where he underwent detoxification. He then relapsed after being released, ultimately overdosing in the process.
One of the key reasons for death due to chronic opioid use involves the question of tolerance. Several different mechanisms are involved in this process. As described by Bailey & Conner (2005), “alterations in receptor coupling, receptor number, the amount of effector protein or the capacity of an effector to be regulated by opioid receptors.” With increased exposure to opioid receptor agonists, the neuronal feedback mechanisms thereby reduce the receptor numbers and desensitize the patient from the chemical. Once ‘clean,’ opioid receptors return to their baseline number, and if the patient relapses, they administer quantities they had become previously used to, resulting in overdose. Therefore, it is important to address this risk to patients in recovery for opioid use disorder.
Asides from pharmacological considerations, there are other treatment modalities that can be used for addiction disorders. As stated by Alavi et al. (2012), “true addictions can exist even in the absence of psychotropic drugs.” In that, behavior addictions can be addressed by understanding the biological, psychological, and environmental underpinnings of such compulsions and attempt to overcome these through therapeutic modalities. Treatment approaches such as Cognitive Behavioral Therapy (CBT), for instance, state that thoughts create feelings which influence behaviors—actions that cycle back to influence thought formation (Tolin, 2016). In cases involving chemical dependence, the patient is best suited to overcome such challenges by developing positive social connectivity (e.g. 12 step programs or group sobriety living) and to acknowledge and avoid triggering events that result in subsequent relapse.
GENETIC PREDISPOSITIONS & EPIDEMIOLOGY
A critical consideration is the biological etiology of chemical dependence. As of today, there are no known genetic predispositions for specific process addictions. Having a sex-addicted father does not necessarily mean the child will also be predisposed to such behaviors. There is certainly a genetic linkage to chemical dependence. It is widely known in the scientific literature that there is a significant genetic component to substance use disorders including alcoholism. Take for instance Edenberg & Foroud (2013) who state that, "Abundant evidence indicates that alcoholism is a complex genetic disease, with variations in a large number of genes affecting risk. Some of these genes have been identified, including two genes of alcohol metabolism, ADH1B and ALDH2, that have the strongest known affects on risk for alcoholism." According to the authors study, there are several other genes that predispose individuals to alcoholism.
It is widely known in the scientific literature that there is a significant genetic component to substance use disorders including alcoholism.
The neurobiological predispositions may result in other addictive behaviors. For instance, it is known that addictive patients have similar structuring of the pre-frontal cortex, nucleus accumbens, the ventral tegmental area, as well as limbic areas including the amygdala, and hippocampus (Benbir et al., 2014; Shaffer et al., 2004). That said, in assessing patients, therapists may be more concerned about patients with a family history of alcoholism or other chemical dependence rather than focusing on relatives with, for instance, gambling addictions.
One interesting question is with regard to individuals who are born from mothers on drugs including methamphetamines, opioids, and alcohol. For fetal alcohol syndrome (FAS), the children will suffer from permanent cognitive, developmental, and even physical deficiencies. As for mothers who use opioids while pregnant, the child will be born and may develop withdrawal symptoms such as irritability, gastrointestinal disturbance, etc. (Stover & Davis, 2015). Asides from the withdrawal symptoms, there is certainly a genetic component to opioid use disorder as discussed by Wang et al. (2019). That being said, the fundamental concern of drug addiction is fetal exposure, while the question of genetic predisposition is a separate consideration. Of course, other environmental factors come into play in accordance with the biopsychosocial theory of disease.
With regard to different age cohorts, Koechl et al. (2012) state that, “substance use, abuse and addiction are not limited to a specific age group.” The researchers further state that, in cases of elderly populations, loneliness and lack of social support present significant risk factors for chemical dependence and that, “Alcohol use was far more frequent in subjects aged 50–64 years and among men” (Koechl et al., 2012). Indeed, addiction can effect patients at any age from adolescence and beyond. And, as argued by Crews et al. (2007), with cortical growth and development continuing throughout youth and adolescence, we must pay special attention to younger individuals engaging in neurologically damaging addictive behaviors.
CONCLUSION: LEGISLATION & ADVOCACY
In terms of legislation, the trend as of recent has been to medicalize rather than criminalize substance use disorders (SUDs). Methadone clinics can help to maintain patients on safer alternatives to street drugs, the latter of which may be contaminated with toxic additives as well as fatal levels of fentanyl. Furthermore, methadone may help to prevent SUD patients from relapsing. According to Williams (2012), “relapse rates are 70-90 percent among those who leave methadone maintenance treatment.” Following the trends of nations such as Portugal which have decriminalized illicit substances, choosing instead to provide medical treatment for SUDs, states such as Oregon have decided to experiment in decriminalization (Westervelt, 2021).
the trend as of recent has been to medicalize rather than criminalize substance use disorders...
At the end of the day, SUDs are a multifaceted dilemma. On the one hand, we want to help individuals towards recovery, becoming productive citizens of the community. On the other hand, we also want to make sure that communities are safe from criminal activity. Indeed, SUD can result in petty crimes including theft and burglary. Thus, the answer is likely an amalgamation of medical intervention and helping to reduce the burden of harmful street drugs. This may eventually take the form of what Columbia University psychologist and neuroscientist Dr. Carl Hart has advocated for in his seminal work Drug Use for Grown-Ups. In his book, Hart (2021) activates for both legalization and regulation of the production of heretofore illegal substances. This may help to reduce the burden of especially fatal substances such as fentanyl in the community. But at the end of the day, it will take a courageous culture to acknowledge that the ‘War on Drugs’ have caused more harm than good, and that a radical re-approach to SUDs may ultimately provide more benefit to the community, writ large.
REFERENCES
Alavi, S. S., Ferdosi, M., Jannatifard, F., Eslami, M., Alaghemandan, H., & Setare, M. (2012). Behavioral Addiction versus Substance Addiction: Correspondence of Psychiatric and Psychological Views. International journal of preventive medicine, 3(4), 290–294.
Bailey, C. P., & Connor, M. (2005). Opioids: cellular mechanisms of tolerance and physical dependence. Current opinion in pharmacology, 5(1), 60-68.
Benbir, G., Poyraz, C. A., & Apaydın, H. (2014). Diagnostic Approach to Behavioral or “Non-Substance” Addictions. Cytokine, 74, 78.
Crews, F., He, J., & Hodge, C. (2007). Adolescent cortical development: a critical period of vulnerability for addiction. Pharmacology Biochemistry and Behavior, 86(2), 189-199.
DeBellis, R., Smith, B. S., Choi, S., & Malloy, M. (2005). Management of delirium tremens. Journal of Intensive Care Medicine, 20(3), 164-173.
Edenberg, H. J., & Foroud, T. (2013). Genetics and alcoholism. Nature reviews. Gastroenterology & hepatology, 10(8), 487–494. https://doi.org/10.1038/nrgastro.2013.86
Hart, D. C. L. (2021). Drug Use for Grown-Ups: Chasing Liberty in the Land of Fear. Penguin Press.
Koechl, B., Unger, A., & Fischer, G. (2012). Age-related aspects of addiction. Gerontology, 58(6), 540-544.
Schuckit, M. A. (2014). Recognition and management of withdrawal delirium (delirium tremens). New England Journal of Medicine, 371(22), 2109-2113.
Shaffer, H. J., LaPlante, D. A., LaBrie, R. A., Kidman, R. C., Donato, A. N., & Stanton, M. V. (2004). Toward a syndrome model of addiction: Multiple expressions, common etiology. Harvard review of psychiatry, 12(6), 367-374.
Stover, M. W., & Davis, J. M. (2015). Opioids in pregnancy and neonatal abstinence syndrome. Seminars in perinatology, 39(7), 561–565. https://doi.org/10.1053/j.semperi.2015.08.013
Tolin, D. F. (2016). Doing CBT: A comprehensive guide to working with behaviors, thoughts, and emotions. Guilford Publications.
Wang, S. C., Chen, Y. C., Lee, C. H., & Cheng, C. M. (2019). Opioid Addiction, Genetic Susceptibility, and Medical Treatments: A Review. International journal of molecular sciences, 20(17), 4294. https://doi.org/10.3390/ijms20174294
Westervelt, E. (2021, June 18). Oregon’s Pioneering Drug Decriminalization Experiment Is Now Facing The Hard Test. NPR.org. https://www.npr.org/2021/06/18/1007022652/oregons-pioneering-drug-decriminalization-experiment-is-now-facing-the-hard-test
Williams, C. (2012, May 27). Clinicians say giving addicts maintenance methadone serves them and society best. Lewiston Sun Journal. https://www.sunjournal.com/2012/05/27/clinicians-say-giving-addicts-maintenance-methadone-serves-society-best/
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