Q&A With Addiction Treatment Specialistis, Joseph R. Volpicelli, MD, PhD, and Tracy Steen, PhD

How would you define addiction?

TS: I define addiction in terms of the criteria used in the DSM-IV-TR for substance dependence. The criteria include tolerance, withdrawal,

drinking more than intended, drinking in spite of known physical or psychological consequences, and spending a lot of time drinking or recovering from drinking. Disruption to one’s personal or professional life is another characteristic of addiction, as are repeated unsuccessful efforts to cut down or “control” drinking. I talk with patients about addiction as a brain disease. Alcoholism is a disease that affects the brain’s natural reward pathways and causes them to become disrupted over time. It is important that both patients and healthcare professionals understand this concept.

JV: While the DSM-IV-TR criteria are helpful in presenting the symptoms of addiction, from my perspective the

cardinal feature of addiction is impaired control over the frequency and quantity of alcohol or drug use. This impaired control often leads to serious complications such as difficulty with social relationships, work difficulties, legal problems, emotional disorders, and physical complications. The DSM-IV-TR uses the term dependence to define alcohol and drug addiction, but I believe this term is misleading. Dependence can refer to the physiological adaptation that some people experience when they use a drug over time. This can refer to tolerance, when the drug has less effect over time or withdrawal symptoms when the drug is stopped or used less frequently. While physiological adaptation can occur when people are addicted to a drug, it is not a necessary or sufficient condition of addiction, since one can have physiological adaptation to medications such as betablockers but not be addicted to them. Similarly, one can be addicted to alcohol or other drugs and not show any physiological adaptation. From my perspective, addiction essentially comes down to the fact that drug use begets more drug use.

Are there unique characteristics that differentiate alcohol addiction or dependence from other forms of addiction?TS: There are more similarities than differences between alcohol dependency and the other addictive disorders. We see genetic predispositions to alcohol as well as other addictive substances, and there is overlap in the brain structures involved. Tolerance, withdrawal, loss of control, drinking or using in spite of serious interpersonal, health, or professional consequences…all of the criteria I mentioned earlier are hallmarks of addiction to alcohol, stimulants, opiates, or other addictive substances. But the fact that alcohol is legal and ubiquitous certainly makes a difference in assessment and treatment. Because moderate drinking is so acceptable in society, alcoholics are reluctant to accept total abstinence as a treatment goal. Even family members of alcoholics may encourage an (ill-fated) return to “normal” drinking after a brief period of abstinence. And because heavy drinking is the norm in certain settings—like college, for example—it may take longer for people to identify a problem.

JV: All addictions have in common the characteristic that drug use begets more drug use. People will continue to use these substances despite adverse consequences. Alcohol is somewhat unique in terms of its biochemistry. Alcohol is sort of a “dirty drug” because it affects a variety of neurotransmitter systems. For example, alcohol stimulates the opioid system and produces a pleasant, opiatelike “high.” People, particularly those with a strong family history of alcohol addiction, will drink alcohol because it stimulates a release of endogenous opioids, which in turn stimulates the release of dopamine into the nucleus accumbens,

the so-called pleasure center of the brain. Medications, such as naltrexone, that block opioid receptors also block the high that people experience when they drink or use opiates. Naltrexone also blocks the addictive cycle in which one drink sets the occasion for the next drink.

Alcohol also has effects on other neurotransmitters such as the GABA system. Alcohol enhances the GABA system and this effect gives alcohol its sedative properties. With chronic use of alcohol, there is an adaptation so that there is an increase in the excitatory neurotransmitter system. Medications such as acamprosate (Camprel) block the excitatory neurotransmitter system

and thus help balance the inhibitory and excitatory neurotransmitters and reduce the craving for drinking. Research suggests other important effects of alcohol on a variety of neurotransmitter systems. This has led to new areas of research to find effective treatments.

How important is it to change the perception that alcoholism is purely a psychological condition?TS: The perception of alcoholism as a character weakness rather than a disease contributes to the stigma associated with it. And this stigma creates very real barriers to treatment. Individuals are less likely to seek professional help for something they think they should be able to manage using willpower alone. In addition, family members and the community at large are less likely to be supportive of individuals struggling with a stigmatized disease. Community resources for treating addiction are inadequate—especially for adolescents. It’s not uncommon to find communities that have no options for treating adolescents with addictive disorders, and insurance plans that provide inadequate coverage for addiction treatment.

Increasing educational efforts to help people understand the biological basis for the disease concept is our best bet for reducing the stigma associated

with the disease and increasing

empathy for individuals with addictive

disorders. When patients and their family

members understand addiction as a

brain disease, they tend to make better

decisions. When patients understand,

for example, the biological basis of cueinduced

or stress-induced cravings, they

are more likely to take active steps to

avoid temptation and manage stress.

Understanding the disease concept

improves treatment outcome.

JV: It is important to stress the physical

component of addiction because

too often when we think of addiction

in psychological terms a morality judgment

is involved. Many people still

think that people who are addicted to

alcohol have a character defect or lack will power. Clearly, there are biochemical changes in the brain which are brought on by drinking alcohol that lead to thoughts, feelings, and behaviors that lead to impaired control over its use.

Furthermore, it is likely that genetic

factors have a strong influence. Some

people can drink one or two drinks of

alcohol and not experience a desire to

keep drinking. However, my patients

invariably tell me that after they have

a couple of drinks the desire to have

the third and fourth drink is even higher than the desire to have the first drink.

When I see that kind of pattern—even though the person doesn’t exhibit all the other classic symptoms of alcohol addiction—

it tells me that the person has a

problem and needs further evaluation

and treatment.

Does that stigma and resistance to change include healthcare professionals?TS: Definitely. Many medical schools

offer their students only a few hours of instruction on this topic, and this results in an inadequate supply of physicians well-trained to deal with the addictions they may encounter in their practice.

Penn’s medical school is a notable

exception—medical students at Penn

receive over 18 hours of instruction

in an addiction course, but this is the

exception to the rule. Currently, addiction

training is still very specialized, and

it is not uncommon to find healthcare

professionals who view alcoholism as a willpower failure or character flaw.

JV: It has been a difficult transition to

move beyond a moral failing model of

addiction to a chronic disease model

of addiction for healthcare professionals.

I have been training primary care

residents for several years now and I

have seen where residents often view

addiction as a moral failing. The good news, however, is that this attitude is changing. Last week, a medical resident called and ask my advice on how to carry out an outpatient alcohol detoxification. This came from someone who was part of a program that had thousands of patient visits without one visit being coded for an alcohol use disorder.

Clearly, people who are involved with

addiction research agree that alcohol

addiction is a chronic relapsing disorder not unlike most medical disorders. This awareness needs to extend beyond the specialists in addiction and filter out to the general medical community.

What are the hallmarks of an effective approach to treatment and management?TS: First there has to be engagement and a strong therapeutic alliance. In an outpatient setting it’s a particular challenge to encourage ambivalent patients to engage in a treatment program that often requires them to make difficult lifestyle changes. Clinicians must walk a fine line as they confront individuals about the seriousness of their problems while still expressing empathy and hope.

Another hallmark of effective treatment

would be the availability of psychiatric

services. Anxiety, depression, and

other mental disorders often co-exist

with alcohol addiction, and it is important to untangle and treat these co-existing concerns. An effective treatment program is one that offers patients access to the pharmacological agents available for treating alcoholism: Antabuse, Acamprosate, Naltrexone, and Vivitrol.

I also think it’s critical to involve the

patient’s family early on in treatment. It

is important to do this not only to get

the whole story regarding the patient’s

addiction, but also to educate the family

members. They need to resolve any

misconceptions about addiction and

then learn how they can be supportive

throughout the patient’s treatment and

beyond. Addiction treatment is different

from traditional psychotherapy in that

it’s much more prescriptive. There are

right things to do and wrong things to

do. There are things that family members can do to be helpful, and there are things that well-meaning family members can do that actually compromise the recovery process.

JV: I often tell my students that the

most important goal in treatment is

to make sure the patient returns. It is

important that the patient feels understood

and respected. I understand the

time pressure that many physicians feel

in private practice, but we cannot ignore

the importance of spending the time

to talk with patients. This is an area

where the nursing staff can help. I have

developed a psychosocial approach that

doctors and nurses can use called the

BRENDA approach. It describes how the

medical staff can approach and counsel

patients who have addictions and then

combine that with medications to help

people stay motivated for treatment. The

BRENDA approach encourages patients

to look at the consequences of their

drinking instead of focusing solely on

why they drink. It talks about what they can do to control or stop their drinking.

It’s a very matter-of-fact, non-judgmental,

supportive approach. I’ve found that

when you take that approach, people

tend to stay in treatment.

How important is it to combine

medication with counseling and

psychosocial support?

JV: I think it is very important that we

combine medication with psychosocial support in alcohol addiction treatment.

The research clearly shows that medications

improve treatment outcomes,

but I think medications alone are not

enough. While medications may help

the patient refrain from drinking, over

time the motivation to stay in treatment can wane. Feeling improved, patients without psychosocial support may stop taking medications or fail to replace the “high” associated with drinking with other pleasurable activities. This can lead to relapse. However, with psychosocial support, patients can learn to use all their time and energy on healthy and productive activities. In general, I like to offer patients weekly visits with me or a nurse until they are stable in their recovery.

TS: : I think counseling or support via self-help groups like AA is critical. At the O’Brien Center for Addiction Treatment here at Penn, we recommend both pharmacological and nonpharmacological treatment. Our patients engage in some combination of individual therapy, group therapy, and family or couples therapy along with any pharmacological treatment. In order to maintain their sobriety, it is essential that patients learn strategies for coping with cravings, managing stress, and identifying and avoiding triggers. I believe that the social support obtained in group therapy or self-help groups like AA helps patients maintain their resolve when confronted with common challenges in recovery—challenges such as feelings of resentment, boredom, or loneliness; unsupportive family members; missing alcohol as a reliable short-cut to relaxation, etc.

What are the biggest obstacles

to successful treatment?

TS: Stress is a big obstacle; life

stressors tend to predict relapses.

Interestingly, celebration can also trigger

relapse. It is not uncommon for

people to relapse just after a major

milestone—like attending 90 AA meetings

in 90 days. The accomplishment

lulls them into thinking that perhaps

they can control their drinking after all. During times of celebration, people often report that they want to continue the “buzz,” and they fall back on drinking to do this.

Cue-induced cravings (or triggers)

are another cause of relapse. Alcohol

becomes associated with particular

people, certain settings, and even time of day or mood. It’s very hard to unlearn these triggers, and alcohol itself is omnipresent in our society.

Another obstacle is the societal

stigma against alcoholism, which

manifests itself in many ways, including

disparities in insurance coverage

of addiction treatment compared to

other diseases. The resulting lack of

resources, in addition to the lack of

awareness and understanding, the stigmatization,

the criminalization—all are

obstacles to treatment. And of course

a patient’s personal burden of denial

or shame regarding his or her addiction can be a major obstacle in treatment and recovery.

JV: Currently, only about 10% of

people who have an alcohol use disorder

receive any treatment, and most

of those receive treatment in self-help

groups like AA. It is disheartening

to see how few patients are taking

advantage of the new pharmacologic

advances in treatment, such as acamprosate

and naltrexone (both oral and

sustained release). So one important

obstacle to effective treatment is the

failure of healthcare professionals to

assess for alcohol addiction and offer

treatment options. We need to inform

physicians and patients about the

recent medical advances in addiction

treatment. If we can raise awareness

of this, then I think a lot more people

would start and stay in treatment.

A second major obstacle to successful

treatment is finding a source to

pay for treatment. Too often, motivated

patients who desire treatment are simply

not able to afford medication or psychosocial

support because their insurance

will not cover the expense. Since

research shows that addiction treatment

saves money in the long run, it is unfortunate

that costs should continue to be

a major barrier.

Finally, perhaps the biggest obstacle

to effective treatment is the general

perception that addiction is a moral

failing. All too often patients feel

embarrassed to seek treatment and

even when they do seek treatment,

they encounter an appalling lack of

understanding from employers, family,

and in some cases healthcare

professionals. Perhaps a publication

such as this can move us toward

understanding addictions in a more

non-judgmental way. The good news is

that the prejudice toward addictions is

beginning to erode and people are better

educated toward understanding the

cardinal features of addiction and its

effective treatment