Overcoming Addiction: Is Admitting the First Step?
By: Cricia Rinchon
Dr. Benjamin Boshes, former neurology chairman emeritus at Northwestern University Medical School, once wrote, “the question of why some drug users become addicted and others do not is one which has defied understanding.”1 Six decades later, neuroscience and medical students are taught that addiction, the most severe form of substance use disorder, is a chronic brain disorder molded by biosocial factors with devastating consequences to individuals and society.2 Despite psychosocial factors, addiction’s core pathology is biological. For example, a variant in the gene encoding for the α-5 subunit of the nicotinic receptor (highly expressed in a brain area known as the habenula) has been associated with higher vulnerability to nicotine addiction.3 Ironically, in Canada, the extent that psychosocial or biological factors are emphasized in treatment depends on the type of addiction.
When you think of helping a person addicted to alcohol, what’s the first thing that comes to mind?
Alcoholics Anonymous (AA), an international self-help group, has been offering emotional support and a model of abstinence for people suffering from alcohol dependence since 1935, using a 12-step approach. It is the most common recovery resource in Canada;4 however, there is controversy surrounding its effectiveness since the Cochrane systematic review of eight trials involving 3417 people concluded that no experimental studies demonstrated the effectiveness of AA or the 12-step approach.5 Importantly, AA is a recovery resource and not an addiction treatment. Alcohol addiction, or alcohol use disorder (AUD), can be treated pharmaceutically using medications such as naltrexone, which blocks the pleasant effects of alcohol, or acamprosate , which reduces symptoms that occur in early withdrawal from alcohol such as cravings and discomfort. Both naltrexone or acomprostate are available to Ontario public drug plan beneficiaries with an AUD diagnosis. Still, a retrospective study found that between 2011 and 2012, very few beneficiaries (< 1%) are actually dispensed naltrexone or acamprosate in their subsequent year of diagnosis.6 These low rates of AUD medication may reflect lingering cultural views and medical teachings that substance problems are primarily psychosocial and not medical conditions.
Why is the opposite true with regards to people addicted to nicotine?
When it comes to a person addicted to smoking, there seems to be a general understanding that this person would need to take some sort of medication (i.e. a nicotine patch) in lieu of smoking in order to recover successfully. In a survey of over 100 physicians in Ontario, over 90% of family physicians felt knowledgeable enough to prescribe pharmaceuticals for tobacco dependencies.7 This contrasts greatly with the ~70% of physicians who felt uncomfortable prescribing pharmaceuticals for alcohol substance dependencies and attribute their lack of knowledge about the pharmacotherapies as the primary barrier. This statistic is concerning because approximately 21.6% of Canadians meet the criteria for substance use disorder during their lifetime, and alcohol is the most prevalent substance for which people meet the criteria for abuse or dependence.8
What is the first step then? Planning, together.
The purpose of this viewpoint article isn’t to discount the 12-steps mutual support group—nearly 80% of 785 respondents in a Canadian recovery survey believe that it is a very important recovery resource.4 Nor is the purpose to insist that pharmaceuticals alone are the answer. Instead, it is to highlight the importance of the Canadian healthcare system acknowledging substance use disorders as medical conditions that require multifaceted and personalized treatment approaches. Ultimately, a system is tragically flawed if it blames a patient for not getting “better” and propels them into a recovery program before they are in a position to “recover”. Science has progressed beyond attributing the cause of addiction to the will of individuals. The individual variations and mechanisms of addiction are progressively being revealed, and we are moving towards proving that addiction is not a condition that defies understanding.
Exciting new prospects for addiction science lay in the National Institute of Health’s long-term Adolescent Brain Cognitive Development (ABCD) study. The ABCD aims to recruit approximately 10,000 children ages nine to ten and follow them into early adulthood. The study’s goal is to increase our understanding of the many factors (sports, video games, social media, unhealthy sleep patterns, and smoking) that interact with each other and with a child’s changing biology to affect brain development, social, behavioural, academic health, and other outcomes. One of the fundamental questions this study hopes to answer is: how does the occasional versus regular use of substances (e.g., alcohol, nicotine, marijuana) affect learning and the developing brain? Many unanswered questions will hopefully be elucidated this coming decade—leading to a future where the conventional “first step” to overcoming addiction isn’t initiated by the patient, but by the healthcare system.
- Boshes B, Sewall LG, Koga M. Management of the narcotic addict in an outpatient clinic. American Journal of Psychiatry. 1956;113(2):158-62.
- Volkow ND, Boyle M. Neuroscience of Addiction: Relevance to Prevention and Treatment. The American journal of psychiatry. 2018;175(8):729-40.
- Fowler CD, Lu Q, Johnson PM, Marks MJ, Kenny PJ. Habenular alpha5 nicotinic receptor subunit signalling controls nicotine intake. Nature. 2011;471(7340):597-601.
- McQuaid RJ, Malik, A., Moussouni, K., Baydack, N., Stargardter, M., &, Morrisey M. Life in Recovery from Addiction in Canada. Canadian Centre on Substance Use and Addiction. 2017.
- Ferri M, Amato L, Davoli M. Alcoholics Anonymous and other 12‐step programmes for alcohol dependence. Cochrane Database of Systematic Reviews. 2006(3).
- Spithoff S, Turner S, Gomes T, Martins D, Singh S. First-line medications for alcohol use disorders among public drug plan beneficiaries in Ontario. Canadian Family Physician. 2017;63(5):e277-e83.
- Loheswaran G, Soklaridis S, Selby P, Le Foll B. Screening and Treatment for Alcohol, Tobacco and Opioid Use Disorders: A Survey of Family Physicians across Ontario. PloS one. 2015;10(4):e0124402.
- Mental Health Indicators. Statistics Canada; 2012.