Introduction to Addiction Theory

Welcome! We appreciate your selecting our book, but even more so, we appreciate your interest in wanting to help and treat people who are impacted by substance use disorders (SUD) and related process addictions (e.g. gambling). As we are writing this book, the United States finds itself in the grips of an opioid epidemic which has killed approximately 72,000 Americans in 2017 and 60,000 in 2016 (Centers for Disease Control, 2018). Furthermore, in spite of increased treatment services, Narcan trainings and the like, there are few indications that the opioid epidemic will lessen anytime soon. And yet while federal budgets allocated to treat other diseases like cancer or AIDS have increased, the same has not held true for substance use disorders. For example, in 2016 the National Institutes of Health allocated S5.6 billion to research treatments for cancer and S3 billion in research funds to fight AIDS, while substance use disorders received only $1.6 billion in spite of the fact that more people suffer and die from addiction than from all other cancers combined (Hilgers, 2017). As authors, substance abuse counselors and addiction educators, who have both worked in the substance use disorder treatment field for over 25 years, we can attest to the fact that the United States has not witnessed an epidemic such as this in its history. It is estimated that 1 in 6 Americans know someone who has overdosed whether it’s a loved one, a friend or the sons and daughters of neighbors, co-workers and friends. So, you may be saying, “Why another book on substance abuse treatment or counseling?” Here’s why we wrote this book.

For years we would receive at our university campus offices, sample copies of textbooks to assign to our SUD counseling classes. We hate to sound negative or critical but you’ve probably have heard the old adage, “If you’ve seen one, you’ve seen them all.” Such was the case with many of the addiction counseling textbooks in that, they all contained chapters on ethics, assessment, individual counseling, group counseling, couples and family counseling, relapse prevention, and usually there was a chapter or two on working with people from diverse backgrounds, race/ethnicities or cultures. Some texts would even include an obligatory chapter on etiology' of addictions but, other than summarizing a few etiological or causal models of addiction (e.g. genetic models), there was not much information offered about why these models were important or how they connected to assessment or treatment of substance use disorders. Our goal in writing this book is to provide addiction studies students with practical information regarding addiction theories that would be relevant to any future counseling you may do with clients experiencing substance use disorders and process addictions. For example, nearly all addictions counselors are trained to do biopsychosocial assessments. Some structured interviews like the Addiction Severity Index (ASI) (McLellan, Kushner, Metzger, Peters, Grissom, & Argeriou, 1992) even have quite elaborate scoring systems, in which counselors are asked to count the number of items endorsed and also to rate their subjective confidence in the information he or she is hearing from the client as they progress through the biopsychosocial interview. We’ve often heard our students remark, “Why bother gathering all this information when the client is just going to deny everything or will just minimize or rationalize how their drinking or drug use has not been a problem that in any way impacts their lives?” Okay, that’s a valid criticism, but let’s take that a step further. It is common for clients to minimize when asked direct questions about their alcohol or drug use. So, while screening instruments such as the Michigan Assessment & Screening Test for Alcohol/Drugs (MAST-AD) (Westermeyer, Yargic, & Thuras, 2004); or Alcohol Use Disorders Identification Test (AUDIT) (Babor, de la Fuente, Saunders, & Grant (1992) or the Simple Screening Instrument for Alcohol and Other Drugs (SSI-AOD) (CSAT, 2004) (see Figure 1.1) are valuable in asking direct questions about alcohol and/or drug use, for someone who subjectively feels that their drinking or drug use is non-problematic, it’s pretty easy to figure out the nature of these direct questions and to “fake good” in order to avoid falling into the scoring range for being classified as someone who may have an alcohol or substance use disorder. This is where addiction theory comes in. Let’s take an example. One of the theories we’ll be presenting later in this text are genetic models of addiction. Most people accept that, like other diseases, SUDs tend to run in families, and that there may be a genetic link as evidenced by research that suggests that people who do not grow up with their biological parent who has an alcohol use disorder can still develop problems related to alcohol use in their teen or young adult years. Similarly, it is very common for people with SUDs to have experienced trauma. Trauma also becomes a risk factor for developing a substance use disorder. Therefore, when you’re asked to do a biopsychosocial assessment with a client, you’re essentially looking for risk factors that may place individuals at higher risk for developing SUDs. So, although clients who may be ambivalent or even resistant to being mandated to treatment will not be willing to tell us how their drinking or substance use has impacted their lives, they may be more willing to tell us about those factors that place them at risk for developing a substance use disorder. Here’s a quick example of where risk factors may help in screening individuals with substance use disorders. For several years, I (AAC) had done screenings of individuals who had DUI (Driving Under the Influence) offenses. The purpose of the screening was to determine those first offenders who were in need of further counseling beyond the usual educational programs mandated to first offenders. A 12-year follow-up study (Cavaiola, Strohmetz, & Abreo, 2007) we conducted found that while screening tests such as the Minnesota Multiphasic Personality Inventory (MMPI & MMPI-2) and the MAST were not found to be especially predictive of those who would go on to commit a second offense, one

Figure 1.1 Simple Screening Instrument for Alcohol and Other Drugs (SSI-AOD) of the risk factors we found to be significant was having a poor driving record (i.e. multiple moving violations for offenses other than DUI). So, although most DUI offenders were unwilling to admit to experiencing any alcohol problems on a direct measure such as the MAST, their poor driving records became a way to predict who would be likely to commit a second DUI offense.

A few things to keep in mind, however, as we explain various addiction theories or models. First, not all models are etiological or causal models. Genetic theories or models mentioned above are good examples of etiology models in that they claim that SUD can be predicted based upon having blood relatives who experienced alcohol or substance use disorders at some point in their lives. Yet, other theories or models we will be presenting are not about etiology or causes but rather are helpful in describing what maintains or sustains the addiction. Such would be the case with behavioral models, whereby the reinforcing or rewarding properties of alcohol or substances become “the fuel” that keeps the addiction going. You may be thinking, though, if alcohol or substances are reinforcing or rewarding why wouldn’t this be considered an etiological model or explanation for addictions? The problem is that since alcohol or drugs are inherently reinforcing or rewarding for most people, then why doesn’t everyone who has ever taken a drink or drug become addicted? For example, the Monitoring the Future survey (Johnston, O’Malley, Miech, Bachmann, & Schulenberg, 2014), which is a large epidemiological survey of high school students in 8th, 10th and 12th grade, indicates that 46.4% of those students surveyed had consumed alcohol at some point during their high school career. But the question remains, if nearly half of these students reported consuming alcohol, then why didn’t all of them become alcoholic? For this reason, we have divided the models or theories presented in this textbook to include etiological theories, sustaining theories, theories of change and relapse theories. Etiological theories include those theories or models that assert what factors will predict who will develop a substance use disorder (e.g. having a family history of alcoholism or having a personal history of trauma). Sustaining theories are those models that describe how substance use disorders are maintained over time (e.g. behavior theory claims that substances are rewarding or reinforcing or help to relieve tension, or, in the instance of negative reinforcement, a person may continue to drink or use drugs to avoid going into withdrawal). Theories of change examine the process by which individuals go from total denial of having problems related to substance use to a point where he or she is willing to seek help. Relapse theory examines the process by which people go from being abstinent or sober to where he or she resumes substance use (e.g. a relapse progression chain). If the models or theories we allude to here are unfamiliar to you, try not to become frustrated, as we will come back to these different types of models in the last chapter of this text. For the time being, just keep in mind that some models do a better job at describing what caused the SUD, others do a better job in describing what sustains or maintains the SUD over time, while the change models describe how one might transition from being an active SUD person to a recovering person.

This brings us to how to conceptualize what makes for a good or practical addiction theory. Bickel, Mueller and Jarmolowicz (2013), Edwards and Lader (1990) and Peele, (1985) have proposed several different explanations for what essential components make for a good and useful addiction theory. Accordingly, a sound or practical addiction theory should be able to explain: (1) why some substances are addictive and others are not; (2) why individuals with addiction, despite recognizing that their addiction is problematic and self-handicapping, continue to use and are unable to stop, cut down or remain abstinent from the addictive commodity or event; (3) the developmental sequence of addiction wherein addictive consumption most often begins in adolescence and, in some individuals, may end as they grow older (referred to as “maturing out”), or they get into recovery; (4) why addiction is highly comorbid with a wide variety of unhealthy behaviors and mental health disorders; and (5) how the theoretical view can directly inform effective therapeutic approaches (Bickel et al., 2013, p. 4). Similarly Kuhn (1962) describes five criteria that account for a theory’s effectiveness: (1) accuracy — the theory should be in agreement with existing observations and experiments; (2) consistency — a theory should be internally consistent as well as broadly consistent with other accepted theories in terms of compatibility; (3) broad scope — a theory’s consequences and implications should extend beyond the initial observations that led to its formation; (4) simplicity — the theory should bring order to observations that would otherwise be considered isolated, or collectively confusing (e.g. the theory of natural selection); (5) fruitful — a theory should lead to new and innovative research questions and experiments that enhance understanding of novel relationships between phenomena and/or uncover previously unknown phenomena.

We’d like you to conduct an informal survey with your family and friends. First, ask them if they’ve ever had a tooth pulled or some other major dental procedure like a root canal and if so, were they prescribed pain medication (e.g. Vicodin, Percoset, Tylenol with Codeine) to help manage their pain after the procedure? Now here’s the next important questions, ask if they experienced any difficulty with that medication either in terms of their reactions when taking it and did they have trouble when stopping the medication after taking it for a few days? These may seem like odd questions but, as you will see from reading this book, they’re not such unusual questions. Also keep in mind that the majority of today’s opioid epidemic originated with medical and/or dental patients being prescribed opioid pain analgesics. Here’s what you may have discovered in doing this brief informal survey. Generally, the vast majority of dental patients who are prescribed pain analgesics or pain medication after having a tooth removed or a root canal, do not become addicted or dependent on those medications. Most will say that that they stopped taking the pain medication as soon as the pain subsided, or that they switched to an over-the-counter pain reliever like Tylenol, Motrin or Aleve. Some might even tell you that they felt nauseous when they took the prescription pain analgesic. However, there may be those who took the pain medication beyond the prescribed dose or beyond the time period for which it was prescribed. There will be those who may have had trouble stopping the medication or who may report having become addicted or dependent on that medication, as evidenced by continued use, begging their oral surgeon or dentist for another refill.There may also be those who sought another pain medication prescription from another doctor or who may become involved in “doctor shopping” (i.e. making multiple visits to doctors in order to find one who will write a prescription). As most of you are aware, the current opioid crisis was fueled by three important factors: (1) doctors were told that pain medications had a very low (almost non-existent) potential to cause addiction; (2) pharmaceutical companies began heavily marketing strong opioid-based pain analgesics as a means of alleviating all types of pain (and thereby making huge profits); and (3) once prescribed opioid-based pain analgesics became too expensive (either through prescription or through illegal street dealers, people who had become addicted to pain meds found that heroin was a cheaper (albeit also illegal) alternative (Quinones, 2016). Now let’s go back to the informal survey you were asked to do earlier. Were you able to predict who had trouble with the medication and who did not? Were you able to predict the outcome your family member or friend experienced as a result of taking the pain medication? Were you surprised by any of your findings? What does your survey tell you about addiction theory? As you’re going through the various models or theories described in this textbook, are any of those theories able to predict and explain who had trouble stopping painkilling medication and who did not? The role of a good theory is that it will both predict and explain behavior. That’s another reason why we wrote this book.

Let’s look at this from a different perspective by examining some of the more recent epidemiological studies that are done in the United States pertaining to mental health and substance use disorders. According to the Monitoring the Future Survey (Johnston et al., 2014), which is a large epidemiological survey which examines alcohol and drug use among Sth, 10th and 12th grade students as well as college-age students, approximately 96% of 12th graders report that they drink alcohol while another 62% report that they smoke cannabis or marijuana. According to the Epidemiological Catchment Area Survey (ECA) approximately 24% of Americans experience a substance use disorder at some point in his or her lifetime. That’s nearly one in four Americans. Another large, national epidemiological study called the National Co-Morbidity Survey (NCS) also estimates that approximately 25% of Americans will experience a substance use disorder while another 26% will experience a mental health disorder at some point in his or her lifetime. Yet if we look at the rates of substance use disorders from the ECA and NCS surveys, it’s easy to see that not everyone who uses alcohol or marijuana as a teenager, will necessarily develop a full-blown substance use disorder as an adult. So, the question that has plagued researchers for decades is why do some people become addicted, while others do not? Why did over 60,000 Americans die of drug overdoses (primarily due to opioid use)? What was it about those individuals who became addicted to opioids that was different from all those people who were prescribed analgesic opioids (like Vicodin or Percoset) who did not become addicted?