Key Clinical Questions
Introduction
Patients with addiction can baffle and overwhelm even the most compassionate physicians, and these patients sometimes even deceive themselves into believing there is no problem. The symptoms of drug and alcohol use can mimic or co-occur with mental illness and chronic pain, complicating the diagnosis. Families can play a role in the development of addiction and also in its treatment. Fortunately, addiction is a treatable disease of the brain. Physicians have a unique opportunity to intervene in the addictive process and shepherd our patients—and our colleagues—into treatment when needed.
The brain is hardwired to reward behaviors that enhance survival of the individual or the species. The reward is pleasure, and it happens when dopamine levels rise in the limbic system. For example, eating when you are hungry, drinking water when you are thirsty, or having sex releases dopamine, which is subjectively experienced as pleasurable. People are motivated to seek pleasure and avoid pain in order to survive. Every behavior you perform is related to pain avoidance or short- or long-term pleasure reward.
Drugs of abuse—including alcohol, nicotine, illicit drugs, and some prescription medications—are potentially dangerous because they raise the dopamine in the limbic system faster, longer, and much higher than any natural reward (such as food, sex, or seeing your family). The brain, which is motivated to seek immediate reward, drives an individual’s behavior to repeat the intense pleasure as much as possible. Dopamine also enhances learning and classical conditioning, so a person with an addiction unconsciously learns the pleasurable “survival value” of the drug. If the drug use continues, it essentially hijacks the brain’s motivational dopamine system, tricking it into behaving as though the individual needs the drug to survive. At this point, the individual becomes dominated by seeking and repeating drug use. Changes take place in the brain that make it extremely uncomfortable to be without the drug. Natural dopamine production downregulates, and the brain becomes less responsive to dopamine presence. This is known as tolerance, meaning more of the drug is needed to produce a pleasurable sensation. It also means that previously pleasurable activities are no longer gratifying. The relative absence of dopamine leads to dysphoria in the absence of reinforcing drugs. Taking the drug is the fastest and easiest way for an addicted person in withdrawal to feel “normal” again. Eventually, continuing drug use overwhelms voluntary control and crowds out other relationships, becoming more important than an individual’s family, values, even food and sex. At this point, drug users isolate from other people to focus obsessively on drug use, and may use any means necessary—including manipulation, deceit, sometimes even violence—to obtain the drug of choice. Survival instincts can override judgment and moral values. This is why “drug seeking” patients can seem so difficult. The brain is motivated to survive, and following the brain changes of chronic drug use, survival equals continued use.
In late-stage addiction, a patient’s body has usually become so used to the presence of the drug that the patient reports needing the drug to feel “normal.” Without the drug, the patient will become increasingly uncomfortable and anxious until nothing in the environment can prevent the person from using. At that point, asking an addicted person to stop using is like asking you to stop breathing. If you were to voluntarily stop breathing, your hypoxic drive would make you increasingly anxious and uncomfortable until nothing in your environment could prevent you from taking a breath. And with the first breath you would begin to feel relief, begin to return to “normal.” After derangement of multiple brain systems, stopping breathing is what it feels like for an addicted person to stop using. That is why the relapse rate is so high if the disease of addiction is not treated properly.
Recognizing Addiction
Substance use occurs on a continuum from sporadic use to abuse to dependence and addiction. Rather than being defined by frequency of use, the hallmark of addiction is continued use despite consequences. Consequences may be social (damaged relationships), financial (money spent on drugs, or lost pay due to work absence), legal (driving under the influence or disorderly conduct), or medical (infections, overdoses, injuries while intoxicated, pancreatitis). In general, “if you’ve had problems because of drinking or using drugs, then you have an alcohol or drug problem.” This means that some alcoholic and addicted individuals use episodically, or in a “binge” pattern—not necessarily every day. The natural history of addiction is progressive, with a variable rate—some patients progress rapidly from abuse to severe addiction; others smolder for years with less severe consequences. Very few are able to stop permanently on their own. With each relapse to substance abuse, the addiction usually returns immediately to its worst point and progresses further. Depending on the substance(s) of choice, there can be a “shotgun effect” of end-organ damage involving every organ system (see subsequent chapters 233, 234, 235, 236 for sequelae of specific drugs).
Alcoholic and addicted patients are frequently in denial, meaning they honestly believe they do not have a problem; or they may desire very strongly to stop, but find they cannot because the biological motivation to use has become so strong. In addition, patients may not even remember some of the consequences of their use if they were intoxicated to amnesia (“blackouts”)—particularly with alcohol. They can also misinterpret the causal relationships with their drinking, for example, believing, “I drink a lot because my wife nags me,” when in fact the opposite is true. Addicted patients in denial frequently do not fully see the effects their use has on the lives around them.
Cognitive changes occur with chronic drug use, particularly with loss of ability to make decisions and weigh future consequences against immediate gratification—this is why addicted patients sometimes baffle us by leaving the hospital against medical advice. They do not make decisions the way nonaddicted people do. When the neurochemistry of the limbic system is altered in long-term drug use, decisions about drug use are driven by craving rather than by reason. In addition, many addicted people begin using during adolescence, around age 12 to 14. Individuals who rely on drug use as their primary coping mechanism do not learn any further coping skills that foster maturity. This means that a 46-year-old patient who has been using continuously since adolescence may have the emotional maturity and coping skills of a 13-year-old.
- Tolerance refers to homeostatic adaptations due to the repeated presence of a drug over an extended period. It is defined by emergence of physical symptoms (a withdrawal syndrome) when the substance is stopped. The body adapts in this way to many prescription medications, such as antihypertensives, SSRIs, and opioid pain medications; this is why clonidine, beta-blockers, and SSRIs need to be tapered slowly rather than stopped abruptly. Both tolerance and withdrawal are expected in patients with chronic pain on long-term opioid therapy, but neither defines addiction. That is why substance use disorders are diagnosed based on behaviors, not just physical tolerance and withdrawal.
- Pseudoaddiction. Imagine for a moment that a person has chronic or acute pain from, say, a femoral fracture. Imagine that the pain was not adequately treated with the medication prescribed at discharge. What strategies could the person employ to get the pain treated? The person might take larger doses of the prescribed pain medication, refill it early, leave repeated messages for the prescribing physician, even resort to an emergency department visit for pain medication. She might borrow a few Vicodin from a friend’s supply. Based on her behavior, she might correctly be labeled a “drug seeker.” This is pseudoaddiction, when untreated pain motivates a patient to seek relief in ways that resemble addictive behaviors. It can be difficult to unravel whether pain or addiction, or both, are causing the behaviors; thus pseudoaddiction should always be in the differential diagnosis list.
- Mental illness. Acute intoxication can mimic the symptoms of anxiety, depression, mania, paranoia, psychosis, even schizophrenia (specific substances in subsequent chapters 233, 234, 235, 236). Drug rebound and withdrawal can also imitate psychiatric conditions. Only a careful history with strict attention to the timing of onset of psychiatric symptoms and drug use can begin to elucidate the diagnosis. There is a strong association between substance use disorders and major depression, dysthymia, hypomania, social phobia, panic, and generalized anxiety; close to half of substance users may have some degree of concurrent personality disorder. Sometimes people with mental illness resort to illicit drug use in order to avoid unpleasant psychiatric symptoms; mental illness and drug use can then produce new psychiatric symptoms that result in more drug use. Drugs can precipitate new psychotic breaks that persist after intoxication in previously unaffected individuals. The two can be intimately entwined and fuel each other. Dual diagnosis or co-occurring disorder
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