Doug Sellman is a professor of psychiatry and addiction medicine in New Zealand. In 2010 in the journal Addiction, a world leader, he attempted the difficult task of distilling the ten things you need to know about addiction from the research of the last thirty years. No mean feat.
Well, what are they? Ten things are way too many for any sane blogger to keep within his head at the same time, so I’m doing a two parter.
- Addiction is fundamentally about compulsive behaviour. In normal behaviours, the control in our brains is top down. In addiction the cortex (the decision making bit of the brain) becomes ‘eroded’ to a ‘dehumanised’ compulsion. Sellman outlines the well studied brain circuits involved, and points out how this view creates one of the defining marks of addiction: continuing to use despite negative consequences.
- Compulsive drug seeking starts outside conscious thought. The debate about free will (and as the prof says ‘free won’t’) gets complicated here. Apparently the conscious part of our brain is about a half second behind imprinted learned behaviours. The lag and its effects are exaggerated in addiction and well learned patterns including cues call the shots over the ‘higher’ brain’s ability to avoid damaging choices. Result, illogical self-harming behaviours continue.
- Addiction is about 50% inherited, but it’s much more complicated. Genetic and population studies show a strong genetic element for addiction with some folk being more vulnerable than others. It gets complicated because it’s not just about a single gene or even a few, but possibly hundreds, and even then they interact with infinite variations in environment. This is not about ‘nature versus nurture’, but represents a ‘new interactive model of nature via nurture’.
- Most people with addictions who come for help have other psychiatric problems as well. For those wanting to move away from the medically dominated model of treatment, this is a big obstacle. 75-90% of those asking for help from services have diagnosable mental health problems including depression, social phobia and post traumatic stress disorder. Alarmingly though, many of our big treatment studies have excluded people suffering from mental health problems. For those of us involved in providing help for those wanting to recover, we will need to ensure that mental health needs are not overlooked. On a personal note though: I do hold a hopefully healthy observation that many of the psychiatric labels patients pick up in active addiction melt away in recovery without the need for psychiatric treatment.
- Addiction is a chronic relapsing disorder in the majority. This was the hardest of the ten findings for me to swallow and the prof and I have to part company here. Prof Sellman says that fewer than 10% of those going through treatment will experience continuous long-term abstinent recovery. He does point out that life will be better for many after treatment and that we need to accept relapse as part of the deal for many. Not doing so will prevent folk coming back for help. There is a tension in this for me between instilling hope and optimism and being unrealistically positive. My observation at the moment is that many services are not getting anywhere near the hope and optimism bit yet, never mind overdoing the positivity, but that’s a personal point. The Centre for Substance Abuse Treatment looked at lifetime recovery rates across the literature in 2009 and found a recovery rate of 58%. Bill White looked at this more recently and came up with a similar figure. I wonder what that rate would be if everyone was using evidence based interventions and treatment of adequate intensity and duration.
Coming soon: Part 2
Sellman, D. (2010). The 10 most important things known about addiction Addiction, 105 (1), 6-13 DOI: 10.1111/j.1360-0443.2009.02673.x