Addiction: a Chronic Disease Requiring a Community Response

Health care approaches for chronic conditions include primary and secondary prevention, acute episodic interventions, and expansion of the care circle to recognize the role of caregivers and family. People with chronic conditions require care that is as seamless as possible as they move between primary, acute, specialty, and community care. In high-income countries, chronic diseases have long been the leading causes of death and disability. Health care systems need to realize that the complex chronic conditions affecting their patients’ health cannot be addressed successfully in the doctor’s office alone and that responsible health care isn’t just about the personal responsibility of patients but also requires that the health care system itself be responsible in providing health care consumers with appropriate options. These options can be provided by partnerships with local governments, community organizations, and other health and human service providers to develop strategies to address the social determinants of health.

Nietzsche called free will “a theologians’ artifice” that permits us to “judge and punish.” However, many thinkers believe, as Smilansky does, that institutions of judgment and punishment are necessary if we are to avoid a fall into barbarism. Today, people’s belief in free will is shown to influence the perception of personal control in self and others. The current studies tested the hypothesis that individuals who believe in free will attribute stronger personal blame to obese people and to people with mental illness (schizophrenia) for their adverse health outcomes. Free will beliefs are correlated with attribution of blame to people with obesity and mental health issues. The stigma of addiction is that people with substance abuse disorders are weak, immoral, and simply out for a good time at society’s expense. However, addiction impairs the brain. The earlier the drug exposure, or trauma to the brain, the greater the damage.

The challenge of stopping drugs has to do with deficiency of the prefrontal cortex which is the part of the brain involved with executive function. The job of the prefrontal cortex is self-monitoring, delaying reward, and integrating whatever the intellect tells you is important with respect to what the libido is telling you. The flood of intoxicating brain chemicals called neurotransmitters (chiefly dopamine) during drug use makes the brain relatively insensitive to normal sources of pleasure such as good conversation with a friend, or a beautiful sunset. Agonist medications such as methadone or bupropion can stabilize the craving brain while planning and reasoning processes get back in shape. The person who self-isolates themselves in order to use drugs without inhibition may need to work in a purposeful way to re-acquire habitual joy, such as social interactions, physical pleasure like a swim or bicycle ride, and other healthy enjoyable rewards.

In the healthy brain dopamine is released in response to natural reward, such as food or exercise. Some drugs are able to bind to brain cells and trigger the release of dopamine. Taking drugs produces a euphoria feeling, which in turn, re-enforces drug using behaviour. Drugs release 2 to 10 times the amount of dopamine that natural rewards release. As substance use continues the brain produces less dopamine and/or reduces the number of brain structures that receive dopamine. Thus, dopamine’s impact on the reward network diminishes along with the individual’s ability to experience pleasure. This can explain why individuals who chronically abuse drugs begin to appear lethargic, unmotivated and depressed and report a lack of pleasure in things that were once pleasurable. To counter, they increase their substance abuse in attempts to feel the same pleasure they use to. This creates a vicious cycle of taking increasing amounts of drugs that leads to tolerance.

The dopamine pathway is involved in mediating reward-motivated behaviour. However, biology is involved – a combination of personality and experiences over which they have no control. There is the challenge to deny the reward of craving – it is necessary to avoid the cues that set off cravings. People with addiction lose control over their actions. They crave and seek out drugs, alcohol, or other substances no matter what the cost – even at the risk of damaging friendships, hurting family, or losing jobs. People often describe drug addiction as a habit, and one that is difficult to break. When people attempt to discontinue an addiction like drug use, they can experience withdrawal. The memory of withdrawal is such an unpleasant experience that it serves as a powerful motivator (or cue) to resume the addictive behavior to avoid the unpleasant experience.  Eventually, the relief from withdrawal (by resuming use) becomes pleasurable in and of itself.

Both genetic and environmental variables contribute to the initiation of use of addictive agents and to the transition from use to addiction. Addictions are moderately to highly heritable. Many just appear to be at risk for addiction, then it makes addiction a chronic disease of the brain. Addictive drugs induce adaptive changes in gene expression in brain reward regions, including the striatum, representing a mechanism for tolerance and habit formation with craving and negative affect that persist long after consumption ceases. These neuroadaptive changes are key elements in relapse. Once an individual becomes addicted, the clinical options are untargeted and only partially effective. Counseling for addiction aims to help people change behaviors and attitudes around using a substance, as well as strengthening life skills and supporting other treatments. Some forms of treatment for addictive disorders focuses on the underlying cause of the addictive disorder in addition to behaviors characteristic of the addiction.

The rise in heroin use is believed to be linked to prescription drug abuse.  Many people who abuse painkillers switch to heroin for two reasons: It is cheaper and often easier to get. Over the past decade fatal opioid overdose has emerged as a major public health issue. Losses of tolerance and concomitant use of alcohol and other CNS depressants clearly play a major role in fatality; however, such risk factors do not account for the strong age and gender patterns observed consistently among victims of overdose. There is evidence that systemic disease may be more prevalent in users at greatest risk of overdose. Compton cautions against conflating all increased drug use directly with COVID-19. For example, shifts in drug availability may also be to blame for increased illicit opioid use deaths; if heroin isn’t easy to access, someone might take fentanyl, which is much stronger.

Existential crisis and dual diagnosis confound the response. An existential crisis is when questions about life, the universe, and humanity’s role in the scheme of things become so important to the individual that deep psychological pain occurs when there are no answers. And when this happens, some use illicit drugs to numb themselves to the profound pain they’re feeling. The qualifications for dual diagnosis are broad. Obviously struggling with depression and alcohol use disorder is a far cry in many ways from a schizophrenia diagnosis with a heroin addiction. However, both are dual diagnoses. Determining which disorder came first, and whether or not it caused the other, can be a tricky situation. Either substance abuse or mental illness can develop first. Someone with a mental health disorder may abuse drugs and/or alcohol as a self-medication for the initial mental problem. Drug and/or alcohol abuse only makes the symptoms of mental health disorders worse.

But experts agree based on research and clinical observation that pandemic-related pressures, from economic stress and loneliness to general anxiety about the virus, are a major driver for the increase. Fentanyl has been linked to many of these overdose deaths. Fentanyl is an opioid that is prescribed as a skin patch. It is 100 times more powerful than morphine and used to treat severe pain. Naloxone is a medication that can temporarily reverse the effects of an opioid overdose and allow time for medical help to arrive, is part of acute care. Harm reduction is part of long-term intervention in substance abuse. Safe injection sites complement existing services; they prevent death, not the problem. Essential to a harm reduction approach is that it provides people who use substances a choice of how they will minimize harms through non-judgemental and non-coercive strategies in order to enhance skills and knowledge to live safer and healthier lives.

Although there is much to learn, we do know that both primary and secondary prevention are crucial to reducing the harms of addiction. The social determinants of health are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems. Drug addiction is a chronic disorder typically characterized with intermittent relapses. Hence, a short-term one-time treatment is generally not sufficient. Research shows that addictions can be managed successfully. Individuals who enter and remain in treatment can manage their addiction and improve their quality of life. It is important to recognize addiction is not about moral failure, rather a chronic disease that requires community support for getting into and staying in recovery.

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