Scientific Article | Special Issueutilization of short screens similarto the CAGE 16 questionnaire, theAUDIT, 17 and the MAST 18 applieddur<strong>in</strong>g a medical evaluationfollowed with the application ofstandardized diagnostic criterionhas been proven reliable. 19,20 Thesewell-known multiple questionscreen<strong>in</strong>g tools vary <strong>in</strong> degrees ofusability <strong>in</strong> the primary care sett<strong>in</strong>gand <strong>in</strong> their ability to identify moresevere unhealthy dr<strong>in</strong>k<strong>in</strong>g (i.e.,dependence). A s<strong>in</strong>gle-questionscreen: “How many times <strong>in</strong> thepast year have you had X or moredr<strong>in</strong>ks <strong>in</strong> a day?” (where X was4 dr<strong>in</strong>ks for women and 5 dr<strong>in</strong>ksfor men); was 82% sensitive and79% specific for unhealthy alcoholconsumption. A positive result is>1 occasion for both males andfemales. This screen is a useful tool<strong>in</strong> the busy primary care sett<strong>in</strong>g, 21similar to us<strong>in</strong>g a f<strong>in</strong>ger-stick glucosemeasurement <strong>in</strong> diabetes screen<strong>in</strong>g.It has been shown that screen<strong>in</strong>gfollowed with brief <strong>in</strong>terventionsby physicians can affect themotivational change among patientsand positively impact the long-termhealth outcomes. Studies specificto substance abuse and addictionhave shown abst<strong>in</strong>ence <strong>in</strong>creasedand HIV seroconversion decreased<strong>in</strong> opiate dependent <strong>in</strong>dividualswhen provided motivationalcounsel<strong>in</strong>g from a health educator. 22The presence of coca<strong>in</strong>e <strong>in</strong> theur<strong>in</strong>e of pregnant mothers gett<strong>in</strong>gsome treatment for addiction andcounsel<strong>in</strong>g <strong>in</strong> the context of theirprenatal visits has been shownto be significantly decreased atdelivery compared to addictedpregnant mothers who receivedrout<strong>in</strong>e prenatal care only. 23The treatment of addictionrequires both long-term managementand acute <strong>in</strong>terventions. Similarly,asthma and diabetes are managedchronically with the utilization ofma<strong>in</strong>tenance measures and acutelywith more immediate treatment.This pr<strong>in</strong>ciple should also be applied<strong>in</strong> the management of the addictedpatient where relapse occurs ata rate of 40-60% <strong>in</strong> the first yearfollow<strong>in</strong>g treatment. 24,25 Treatmenteffectiveness is dependent uponcompliance with the treatmentrecommendations. Accord<strong>in</strong>g toMcLellan, et al, there is a significantdegree of non-compliance withmedication and behavioral treatmentrecommendations which contributesto relapse rates of 30-50% and 50-70% of adult patients with diabetesand asthma respectively. 19 Noncompliancelead<strong>in</strong>g to relapse isknown to occur <strong>in</strong> both addictiveand non-addictive illnesses andshould be managed rather thanviewed as treatment failure.Nature and NurtureEvidence shows a significantgenetic contribution to the riskof addiction comparable to otherchronic illnesses. A multitude of tw<strong>in</strong>studies have shown significantlyhigher rates of dependenceamong tw<strong>in</strong>s than non-tw<strong>in</strong>sibl<strong>in</strong>gs. There is a higher rate ofdependence among monozygoticthan dizygotic tw<strong>in</strong>s. 26,27 Tw<strong>in</strong>studies of hypertension, diabetesand asthma show a significantcomponent of heritability. 28,29,30As with other chronic illnessesa genetic predisposition and theenvironmental trigger must oftenco-exist before disease occurs. Forexample, exposure to asbestos <strong>in</strong> apatient with a genetic predispositionto lung cancer is more likely to result<strong>in</strong> the development of carc<strong>in</strong>oma ofthe lung than the exposed patientwithout this genetic predisposition. 31The voluntary <strong>in</strong>itiation of druguse does not dist<strong>in</strong>guish drugdependence from other medicalillnesses. Many other diseasesare affected by voluntary choiceespecially when tak<strong>in</strong>g <strong>in</strong>to accountgenetic, environmental and culturalfactors. Excessive salt <strong>in</strong>take, forexample, can contribute to thedevelopment of hypertensionwhen comb<strong>in</strong>ed with the geneticpredisposition for salt sensitivity,cultural stress and exogenous obesity.The <strong>in</strong>itiation of alcohol use canbe extremely pleasurable to some<strong>in</strong>dividuals (or not). The pleasantsensation <strong>in</strong>duced by a casual dr<strong>in</strong>kat the end of the day is familiar andsafe for many people. However,this recreational usage progressesto tolerance and dependence forsome <strong>in</strong>dividuals. Studies haveshown sons of alcohol dependentfathers have a higher degree oftolerance to alcohol and are lesslikely to experience hangovers thansons of non-alcoholic dependentfathers. 32 Conversely, the “flush<strong>in</strong>g”response to alcohol <strong>in</strong> the <strong>in</strong>heritedpresence of aldehyde dehydrogenasegenotype (associated with alcoholmetabolism) leads to an unpleasant<strong>in</strong>itial reaction to voluntary alcoholuse result<strong>in</strong>g <strong>in</strong> very few alcoholicsbe<strong>in</strong>g found with this genotype. 33Environmental and other<strong>in</strong>fluences such as comorbid mentalillness, low-self-esteem, poor socialskills, poor cop<strong>in</strong>g mechanisms,exposure to physical or sexualabuse, poor parental <strong>in</strong>fluences,poor school performance, peerswho abuse substances, male gender,and poverty 7,19 can lead <strong>in</strong>dividualsto seek pleasure by reactivat<strong>in</strong>gthe dopam<strong>in</strong>ergic system (seeNeurobiology). In patients withoutthe genetic predisposition foraddiction, it is less likely that thisdisease will be established even <strong>in</strong>the presence of at risk behaviors.The overall addiction vulnerabilityis related to genetic <strong>in</strong>fluences,environmental conditions, othercomplex personality traits, stressresponses and comorbid issues<strong>in</strong>clud<strong>in</strong>g self-medication ofundiagnosed psychiatric illness,codependency, family of orig<strong>in</strong>issues, poor cop<strong>in</strong>g skills, etc.The NeurobiologyChronic exposure to an addictivedrug can “hi-jack” the neuralcircuits of the susceptible bra<strong>in</strong>28 <strong>West</strong> Virg<strong>in</strong>ia <strong>Medical</strong> Journal
Special Issue | Scientific Articlecaus<strong>in</strong>g enhanced “plasticity” <strong>in</strong> theneural circuits related to reward,motivation, and learned behavior.This circuit is conta<strong>in</strong>ed <strong>in</strong> theventral tegmental area connect<strong>in</strong>gthe limbic cortex through the midbra<strong>in</strong>to the nucleus accumbens.Although by different mechanisms,alcohol, opiates, coca<strong>in</strong>e and nicot<strong>in</strong>eactivate the dopam<strong>in</strong>ergic system,result<strong>in</strong>g <strong>in</strong> the euphoria associatedwith drug use. Adm<strong>in</strong>istration ofan addictive substance <strong>in</strong>creasessynaptic dopam<strong>in</strong>e levels <strong>in</strong>the bra<strong>in</strong> creat<strong>in</strong>g euphoria andenhanced sense of well-be<strong>in</strong>g. 34,35,36This occurs predom<strong>in</strong>antly by theneurons of the ventral tegmentalarea (VTA) releas<strong>in</strong>g dopam<strong>in</strong>e<strong>in</strong>to the nucleus accumbens and theprefrontal cortex. 4,35,36,37 Volitionalbehaviors become habits and thencompulsions through pavlovianlearn<strong>in</strong>g. The bra<strong>in</strong> adapts replac<strong>in</strong>gappropriate reward for survivalactivities like quench<strong>in</strong>g thirst,satisfy<strong>in</strong>g hunger, sleep<strong>in</strong>g and sexwith the drive for activation of thedopam<strong>in</strong>ergic system. Repeatedactivation eventually leads to chronicchanges <strong>in</strong> the neuroregulatorymechanism. 34,35,36 This neuro-adaptivetransformation occurs at a higherrate if the <strong>in</strong>itial’s substance exposureoccurred dur<strong>in</strong>g adolescence whenthere is a greater degree of synapticplasticity. 37 Other neuroendocr<strong>in</strong>esubstances and structures <strong>in</strong>volved<strong>in</strong>clude, but not limited to, seroton<strong>in</strong>,norep<strong>in</strong>ephr<strong>in</strong>e, N-methyl-Daspartatereceptors, opioid peptidereceptors, γ-Am<strong>in</strong>obutyric acid(GABA) systems, dynorph<strong>in</strong>,acetylchol<strong>in</strong>e, corticotroph<strong>in</strong>releas<strong>in</strong>g factor, adrenocorticotropichormone, and corticosterone. 34,36,37PharmacotherapyIncreased understand<strong>in</strong>g of thepathophysiology of addiction hasled to medications useful <strong>in</strong> thetreatment of addiction. 38 Nicot<strong>in</strong>e,bupropion and varenicl<strong>in</strong>e are goodexamples of pharmacologic agentsutilized <strong>in</strong> the treatment of cigarettesmok<strong>in</strong>g. Opioid dependence hasbeen successfully treated with thepartial agonist buprenorph<strong>in</strong>e, 39and methadone is known to reduceopiate use, the spread of <strong>in</strong>fectiousdiseases and crime. 38 The opioidantagonist naltrexone competitivelyblocks the actions of hero<strong>in</strong> result<strong>in</strong>g<strong>in</strong> neither dysphoria or euphoria <strong>in</strong>abst<strong>in</strong>ent patients. 40,41 The GABAagonist acamprosate has beenshown to decrease crav<strong>in</strong>g andrelapse to alcohol use. 42 Disulfiramis well-known to be useful <strong>in</strong> theprevention of relapse <strong>in</strong> <strong>in</strong>dividualsFor a free brochure on our nationally recognized addictionprofessionals alcohol and drug treatment program visit usat: www.FarleyCenter.com/Journey or call 877-389-4968The Farley CenterAT WILLIAMSBURG PLACESUBSTANCE ABUSE IN <strong>WV</strong> | Vol. 106 29
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