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 303.90

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.)

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?

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 Expecta

tion of

Drug/Alco

hol / Substa

nce

Individual Expecta

tion of

Drug/Alco

hol / Substa

nce

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?

We also can’t forget social groups within a culture

Individual Life Goals

Present Future

Past

• 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 Phase

Prodromal Phase

Crucial Phase Chronic 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

PROGRESSI

VEE

COURSE

LEADING

TO DEATH

PROGRESSI

VEE

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