No quick fix for sub­stance ad­dic­tion

Post - - Opinion - Dr Ab­dul Kader Domingo is a Spe­cial­ist Psy­chi­a­trist and Se­nior Lec­turer at Stel­len­bosch Uni­ver­sity.

“IT’S bet­ter if an ad­dict dies, that way fam­ily mem­bers en­dure less suf­fer­ing and over a shorter pe­riod of time.”

That was the gist of my very first lec­ture on drug ad­dic­tion dur­ing my child­hood.

It was said with such con­vic­tion that I have to ad­mit it stuck with me for a num­ber of years.

“It’s only by the grace of God that I’m not an ad­dict to­day. I don’t seem to have a ge­netic pre­dis­po­si­tion. I was not ex­posed to sub­stances dur­ing my ado­les­cent years. I was not ne­glected or abused as a child and I grew up in an en­vi­ron­ment where drugs were nei­ther ac­ces­si­ble nor ac­cept­able.”

My su­per­vi­sor said this to me on the first day of my ad­dic­tion ro­ta­tion as a doc­tor spe­cial­is­ing in psy­chi­a­try.

Over the past few years I’ve had the priv­i­lege of hearing first hand the ac­counts of in­di­vid­u­als strug­gling with a chronic ad­dic­tion, what had led them to this point, and I’ve wit­nessed the courage and de­ter­mi­na­tion re­quired to change that path.

The risk of de­vel­op­ing a chronic ad­dic­tion is not equal. The same could be said for other chronic con­di­tions. Our risk of de­vel­op­ing dis­or­ders such as asthma, di­a­betes and hy­per­ten­sion de­pend on our ge­netic sus­cep­ti­bil­ity, our ex­po­sure to risk fac­tors and the role our en­vi­ron­ment plays.

While we have cri­te­ria to di­ag­nose an ad­dic­tion, di­a­betes and hy­per­ten­sion, we are still not ca­pa­ble of pre­dict­ing which in­di­vid­u­als will de­velop these dis­or­ders.

Ad­dic­tion dif­fers from other chronic med­i­cal dis­or­ders in many ways, the most ob­vi­ous be­ing that in­ten­tion and in­sight were present dur­ing ini­ti­a­tion, dur­ing ev­ery episode of us­ing a sub­stance and with ev­ery re­lapse. So why then should this be con­sid­ered a chronic med­i­cal dis­or­der?

Sub­stance ini­ti­a­tion of­ten oc­curs dur­ing ado­les­cence.

Phys­i­cal changes as­so­ci­ated with pu­berty, the emo­tional shifts, so­cial tran­si­tions and in­creased risky be­hav­iours make this a vul­ner­a­ble pe­riod.

Re­search has shown that our brain de­vel­op­ment con­tin­ues to oc­cur un­til our early twen­ties.

Our abil­ity to screen our en­vi­ron­ment, as­sess op­tions and weigh up con­se­quences as­so­ci­ated with our de­ci­sions are not fully de­vel­oped dur­ing this pe­riod of neuro-de­vel­op­ment.

Teenagers are there­fore still in the process of de­vel­op­ing their ca­pac­ity to make the best pos­si­ble de­ci­sion in the en­vi­ron­ment they find them­selves in.

While peer pres­sure has been found to be the most com­mon cause for sub­stance ini­ti­a­tion, it is the sub­jec­tive ben­e­fit ob­tained from the sub­stance that is most likely as­so­ci­ated with con­tin­ued use.

Our ge­netic pro­file has the abil­ity to de­ter­mine the way we ex­pe­ri­ence var­i­ous sub­stances.

Some may find the ex­pe­ri­ence of in­tox­i­ca­tion as re­ward­ing, while oth­ers may ex­pe­ri­ence it in a neg­a­tive man­ner.

For many in­di­vid­u­als, sub­stance in­tox­i­ca­tion of­fers more than just euphoria or re­ward though, it also of­fers an es­cape from a tu­mul­tuous in­ter­nal en­vi­ron­ment.

The en­vi­ron­ment we find our­selves in and the way we per­ceive that en­vi­ron­ment are two other crit­i­cal risk fac­tors to­ward the de­vel­op­ment of an ad­dic­tion.

Ed­ward Khantzian hy­poth­e­sised that an in­di­vid­ual’s drug of choice was based on their form of dis­tress or suf­fer­ing, that it was used as a means of self-med­i­cat­ing that dis­tress.

The Na­tional Youth Risk Be­hav­iour Sur­vey was con­ducted dur­ing 2011 and it sur­veyed 10 997 pupils in grades 8 to 11 across the nine prov­inces of South Africa.

This study found that 7% of pupils re­ported car­ry­ing weapons on school prop­erty, 21% felt un­safe at school dur­ing the past month and 12% were threat­ened or in­jured by some­one with a weapon while on school prop­erty. In the six months pre­ced­ing the sur­vey, 25% of pupils re­ported hav­ing ex­pe­ri­enced feel­ings of sad­ness or hope­less­ness, 18% had con­sid­ered sui­cide and 18 had at­tempted sui­cide.

In terms of al­co­hol use, 49% re­ported ever hav­ing drunk al­co­hol and 25% hav­ing en­gaged in binge drink­ing.

These statis­tics of­fer only a glimpse of the dif­fi­cul­ties our youth strug­gles with to­day.

Ad­dic­tion there­fore of­ten be­gins by means of vul­ner­a­ble in­di­vid­u­als find­ing them­selves ex­posed to sub­stances, of­ten start­ing in their youth, and ex­pe­ri­enc­ing a re­lief from their in­ter­nal or ex­ter­nal en­vi­ron­ment.

With re­peated ex­po­sure these in­di­vid­u­als are likely to ex­pe­ri­ence brain changes that fa­cil­i­tate the feel­ing of re­ward ob­tained from drugs, de­crease the sen­sa­tion of re­ward ob­tained from other means, re­quir­ing larger quan­ti­ties to main­tain that sen­sa­tion and ex­pe­ri­enc­ing dif­fi­cult with­drawal symp­toms when at­tempt­ing to cut down.

These brain changes have also ex­plained why en­vi­ron­men­tal cues are able to in­duce strong crav­ings and why in­di­vid­u­als strug­gling with an ad­dic­tion are prone to im­pul­sive ac­tions when crav­ing drug use.

This “med­i­cal model” of ad­dic­tion does not mean to stig­ma­tise an in­di­vid­ual as hav­ing another “chronic dis­ease”. It does how­ever pro­vide us with in­sight into cur­rent ev­i­dence within this grow­ing field, it ac­knowl­edges that these were once highly vul­ner­a­ble in­di­vid­u­als and that the act of main­tain­ing so­bri­ety re­quires so much more than just “a de­ci­sion to stop us­ing”, so­bri­ety re­quires knowl­edge and skills.

These “skills” re­quire in­put and guid­ance from trained pro­fes­sion­als who are ca­pa­ble of of­fer­ing ev­i­dence-based treat­ment. This model high­lights the im­por­tance for on­go­ing pro­tec­tion and care of our youth.

This pe­riod of de­vel­op­ment pro­vides care­givers the op­por­tu­nity to in­stil resilience and an abil­ity to man­age in­ter­nal con­flict. With­out this emo­tional buf­fer, ado­les­cents may re­sort to other means of man­ag­ing dis­tress.

The med­i­cal model pro­vides us with one fur­ther in­sight.

Like other chronic dis­or­ders that re­quire reg­u­lar re­views, as­sess­ments and ad­just­ments to treat­ment, those who have strug­gled with a chronic ad­dic­tion should al­low for reg­u­lar “check-ins” as well.

Af­ter-care groups of­fer a means for on­go­ing sup­port and should be ca­pa­ble of high­light­ing any changes in be­hav­iour that war­rant more ur­gent in­ter­ven­tion.

Many seem to be un­der the im­pres­sion that in­di­vid­u­als should be “cured” af­ter an ad­mis­sion to a drug re­ha­bil­i­ta­tion unit, that any re­lapse af­ter such a process in­di­cates a fail­ure or weak­ness of the in­di­vid­ual, not ac­knowl­edg­ing our in­cor­rect as­sump­tion that a chronic dis­ease can be cured by means of an acute, short term treat­ment.

Ado­les­cent drug ad­dic­tion is all about coping, fit­ting in and mak­ing adult-level de­ci­sions be­fore the brain is even fully formed.

AB­DUL KARIM DOMINGO

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