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Addiction—A Brief Primer
45 West 10th Street • St. Paul, MN 55102 Clinic: 651-232-3640 • Inpatient: 651-232-3644
Big Book Insights:

“ Men and women drink essentially because they like the effect produced by alcohol.
The sensation is so elusive that, while they admit it is injurious, they cannot after a time differentiate the true from the false. To them, their alcohol life seems the only normal one. They are restless, irritable and discontented, unless they can again experience the sense of ease and comfort which comes at once by taking a few drinks… ” [1] “ It helped me a great deal to become convinced that alcoholism was a disease, not a moral issue; that I had been drinking as a result of a compulsion, even though I had not been aware of the compulsion at the time; and that sobriety was not a matter of willpower. ” [2]
Addiction—Definition:

“ A primary, chronic, neurobiologic disease, with genetic, psychosocial, and
environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. ” [3]
Cravings—Some Definitions:

Positive Cravings
Type 1 Cravings
Desire for reward (intoxication, “buzz”, Induced by drugs or stimuli that have been Negative Cravings
Type 2 Cravings
Desire to relieve uncomfortable emotional Addiction—Differential Diagnosis:

Differential considerations
Defined as
• Fulfill some but not full criteria for substance • Substance-related health consequences • Does not fulfill full or partial criteria for substance • Substance use in excess of what is considered healthy but in the absence of physical harm • Does not fulfill full or partial criteria for substance • Taking a medication in a manner that is not • May signify another diagnosis appearing in this table • Taking a substance inappropriately to obtain • Obtaining medications under false pretenses to share • Behaviors that resemble addiction but are secondary • Pain that increases in severity and/or changes in character despite escalating doses of opioids • Symptoms and/or signs that occur after a substance is • Does not fulfill criteria for substance withdrawal associated with substance use • Disruptive behavior disorders‡ • Personality disorders, especially Cluster B¶ Adapted from References 6–12 * DSM-IV-TR = Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision § Examples include veisalgia (alcohol “hangover”), antidepressant discontinuation syndrome, various neonatal abstinence syndromes, et cetera † See, for example, Criterion 7 for Manic Episode ‡ Consider, for example, “Serious violation of rules” for Conduct Disorder ¶ See, for example, Criterion 4 for Borderline Personality Disorder Substance Dependence—Criteria Set:

A maladaptive pattern of substance 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:
Tolerance
Withdrawal
Impaired Control
• Substance is often taken in larger amounts or over a longer period than was intended
• There is a persistent desire or unsuccessful efforts to cut down or control substance use
• A great deal of time is spent in activities necessary to obtain the substance, use the
• Important social, occupational, or recreational activities are given up or reduced • Substance 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 the substance Adapted from DSM-IV-TR [13]
Substance Abuse—Criteria Set:

A maladaptive pattern of substance use, leading to clinically significant impairment or
distress, as manifested by one (or more) of the following, occurring within a 12-month
period:
Role Obligations
Recurrent substance use resulting in a failure to fulfill major role obligations at work,
Hazardous Use
Recurrent substance use in situations in which it is physically hazardous
Legal Problems
Recurrent substance-related legal problems
Social or Interpersonal Problems
Continued substance use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of the substance And the symptoms have never met the criteria for Substance Dependence for this class of substance [14] Substance Abuse Treatment—General Approach:

Substance abuse treatment occurs per the American Society of Addiction Medicine’s
framework; in brief, a patient’s clinical condition and needs are assessed in multiple
domains (Dimensions of Care); the patient is then placed in an appropriate treatment
environment (Level of Care) per their multidimensional profile [15]
Dimensions of Care:

Dimension Defined
Acute intoxication and/or withdrawal potential Emotional, behavioral or cognitive conditions and complications Relapse, continued use or continued problem potential
Levels of Care:

Level Defined
Intensive outpatient treatment or partial hospitalization Medically managed intensive inpatient treatment
Dimensions of Care—Contrasted with Other Charting Formats:

Dimension DSM-IV-TR Standard Medical Documentation
Transtheoretical Model—Stages of Change:

Stage Defined
Not currently considering behavioral change Serious evaluation of considerations for or against change Specific behavioral changes are attempted or made Work to maintain and sustain long-term change As per DiClemente and Velasquez [16]
Precontemplative Resistance to Change:

“ It can be helpful to think about precontemplators’ resistance to change in what can
best be summarized as the four R’s: reluctance, rebellion, resignation, and rationalization. Each of these patterns of thinking, feeling, and reasoning helps keep precontemplators not ready to change. Almost all precontemplators use a combination of these patterns… ” [16]
Motivational Enhancement Therapy—Definition:

“ We define motivational interviewing as a client-centered, directive method for
enhancing intrinsic motivation to change by exploring and resolving ambivalence.” [17]
Motivational Interviewing—General Principles:

Principle 1: Express Empathy
Principle 2: Develop Discrepancy
• The patient rather than the provider discrepancy between present behavior and important goals or values Principle 3: Roll with Resistance
Principle 4: Support Self-efficacy
• A patients’s belief in the possibility of • The patient is a primary resource in • The provider’s own belief in the patient’s Adapted from Miller and Rollnick [18] Motivational Interviewing—Patient Profiles:

Low Importance | Low Confidence
Low Importance | High Confidence
• Perceived ability to make change is low • Perceived ability to make change is high High Importance | Low Confidence
High Importance | High Confidence
• Perceived ability to make change is low • Perceived ability to make change is high Adapted from Miller and Rollnick [19]
Addiction Pharmacotherapy:

Diagnosis
FDA-approved Treatment Options
Acamprosate (Campral) Disulfiram (Antabuse) Naltrexone (ReVia, Vivitrol) Bupropion (Zyban) Nicotine (Nicorette and others) Varenicline (Chantix) Buprenorphine (Subutex, Suboxone) Methadone (Dolophine) Medications support but do not replace standard psychosocial supports (e.g., substance abuse treatment, * Consider an addiction medicine consultation to comment on possible unapproved (“off label”) therapies References:

1. Alcoholics Anonymous, 3d ed (7th imp). New York: Alcoholics Anonymous World
2. Alcoholics Anonymous, page 448. 3. Graham AW, et al., eds. Principles of Addiction Medicine, 3d ed. Chevy Chase: American Society of Addiction Medicine, 2003:1601. 4. Collins GB, et al. Drug adjuncts for treating alcohol dependence. Cleve Clin J Med 5. Koob GF, Le Moal M. Addiction and the brain antireward system. Annu Rev Psychol 6. Saitz R. Unhealthy alcohol use. N Engl J Med 2005;352:596. 7. Weaver M, Schnoll S. Addiction issues in prescribing opioids for chronic nonmalignant pain. J Addict Med 2007;1:2. 8. Cole BE. Recognizing and preventing medication diversion. Fam Pract Manag 9. Mitra S. Opioid-induced hyperalgesia: pathophysiology and clinical implications. 10. Wiese JG, et al. The alcohol hangover. Ann Intern Med 2000;132:897. 11. Warner CH, et al. Antidepressant discontinuation syndrome. Am Fam Physician 12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision. Washington, DC: American Psychiatric Association, 2000 [hereafter DSM-IV-TR]. 13. DSM-IV-TR, page 197. 14. DSM-IV-TR, page 199. 15. Mee-Lee D, et al., eds. ASAM Patient Placement Criteria for the Treatment of Substance-related Disorders, 2d ed, Revised. Chevy Chase: American Society of Addiction Medicine, 2001. 16. DiClemente CC, Velasquez MM. Motivational interviewing and the stages of change. In: Miller WR, Rollnick S, eds. Motivational Interviewing: Preparing People for Change, 2d ed. New York: Guilford Press, 2002:201ff. 17. Motivational Interviewing, page 25.
18. Motivational Interviewing, page 33ff.
19. Motivational Interviewing, page 54.
Revision history:

February 2009

Source: http://www.todayshospitalist.com/protocols/frenz_addiction_primer.pdf