Recovery from Severe Substance Addiction: Understanding different models and interventions in supporting the recovery journey.

In this blog, we are asking, what are the particular considerations in discussing recovery from severe substance addiction, such as alcohol and opiates. And specifically the role of medical and pharmacological interventions in supporting the recovery journey.

Additionally, we want to bring into view the ‘Learning Model of Addiction' that proposes: ‘while the brain has the capacity for addiction, it also has the capacity for behaviour change, shifting the emphasis to recovery.’

About Substance Dependence

In this blog, we explore recovery from severe substance addiction, specifically focusing on alcohol and opiates. We examine a variety of medical and pharmacological interventions, such as Methadone and Naltrexone, that support the journey towards recovery. Additionally, we delve into the 'Learning Model of Addiction,' which posits that just as the brain has the capacity for addiction, it equally possesses the ability to change behaviours, thereby emphasising recovery possibilities.

How do these interventions and models interact in real-world recovery scenarios? What does current research say about the effectiveness of combining medical treatments with psychological models like the Learning Model? Join us as we unpack these complex interactions and consider what they mean for individuals on the path to recovery.

Defining Addiction and its Impact

Addiction introduces a significant risk for increased 'years lived with disability,' a key concern reflected in the DSM-5 diagnostic criteria for diagnosing and classifying substance use disorders. The impact on quality of life and years lived with disability is considerable, highlighting the urgency of this discussion. But what do we mean by addiction?

Addiction theories characterise the transition from controlled to "compulsive" drug-seeking and drug-taking behaviors. Here’s how addiction is defined:

“Risky substance use refers to quantity/frequency indicators of consumption; Substance Use Disorder (SUD) refers to individuals who meet criteria for a DSM-5 diagnosis (mild, moderate, or severe); and addiction refers to individuals who exhibit persistent difficulties with self-regulation of drug consumption [despite harmful consequences]. Among high-risk individuals, a subgroup will meet the criteria for SUD and, among those, a further subgroup would be considered to be addicted to a substance. The boundary for addiction is intentionally blurred to reflect that the dividing line for defining addiction within the category of SUD remains an open empirical question” (Heilig et al, 2021).

Moral Model and Learning Model of Addiction

The 'Moral Model of Addiction,' historically predominant up to the 1980s, discusses recovery through shame and humiliation, reflecting a poor societal response. This model has now been largely replaced by the ‘Learning Model of Addiction' which argues that, "while the brain has the capacity for addiction, it also has the capacity for behaviour change, shifting the emphasis to recovery" (Heilig et al, 2021). This model accounts for changes in the brain without removing hope in the possibility of flourishing after addiction through supported recovery.

There is much work being done, in the area of ‘recovery-oriented approaches and drug treatment interventions’, including therapeutic and also medicalised treatment methods and objectives (NIDA) (Drug Strategy, 2010) (Wangensteen and Hystad, 2021).

Neurobiological basis of Substance Addiction

Research has shown that addiction involves changes to the brain's reward centres and frontal lobes, when under the influence of substances. The ‘brain disease model of substance addiction’ characterises addiction as a chronic, relapsing, and remitting illness driven by compulsive drug-seeking behaviours, affecting some individuals more than others. This model, however, sometimes overlooks the crucial roles of individual heterogeneity and environmental factors in remission and recovery.

Historically, before the adoption of the brain disease model, the ‘moral model of substance addiction’ dominated up to the 1980s. This earlier model viewed addiction as a choice, leading to societal stigma against those suffering from substance dependencies. By suggesting that addiction resulted from moral failure or weak will, imposing shame and humiliation on individuals, exacerbating their challenges rather than a supportive environment for recovery. Made worse by challenging stereotypes of laziness and affliction, which is often still portrayed today in this moral model.

Both models emphasise a deterministic view of the compulsive/impulsive dimensions of addiction, where the sufferer is powerless, and so reliant on interventions, including pharmacological. The efforts of researchers evidencing the neurobiological basis of substance addiction in the brain disease model consider that addiction may have components of genetic and developmental risk.

They found clear evidence that brain changes do occur in the use of addictive substances, particularly in the reward centre of the brain and frontal lobes or pre-frontal cortex, changing the way that a person thinks, makes judgements, and is motivated to do things when under the influence, for example. They also found that environmental, social and socioeconomic conditions seemed to be ignored, despite implicating and influencing relapse, and treatment compliance.

Treatments and Interventions

Addiction to opiates, for instance, results in acute withdrawal symptoms if usage stops abruptly. Opiate Substitution Treatment (OST) has been proven effective in providing stability and safety during recovery. Drug Strategy (2010) describes the adoption of 'low threshold prescribing' not with the immediate goal of stopping heroin use but rather reducing harm over time by substituting OST.

Eventually, this may involve progressively coming off OST and leaving the structured treatment plan altogether. Although, exiting the use of OST earlier can cause harm, especially if it leads to relapse. These are important indicators of an individual’s recovery progress that must be factored in.

Tailored Interventions

Recovery is therefore seen as a broader and more complex process. OST is just one option, that includes working closely with a relevant support team. Incorporating support through increasing motivation, reducing risk-taking behaviour, helping overcome dependence, and improving general brain-physical-mental health, enhancing the personal wish for recovery—a voluntary choice.

Understanding the history of drug misuse is crucial in determining who might need medical treatment and addressing the question: Are all addictions curable? Notably, some individuals, known as 'high-functioning' addicts, may continue to use substances without apparent problems, complicating the approach to their treatment.

That is, they are able to hold down a job or run a business and perform well. But behind closed doors, alternating between heavy usage, abstinence and a return to using. Some may even stop on their own, known as ‘spontaneous recovery’ led by life events, such as getting married or starting a new job.

Being ‘ready’ to take up treatment may improve outcomes too, related to the concept of ‘hitting rock bottom’. Rock bottom is a narrative that comes from users themselves implying that treatment educates people; learning through the treatment journey, which includes putting support systems in place to make changes in real-life, or choosing to stop using altogether.

Self-detoxification in the case of opiates and alcohol is a common example. In this context, working closely with the relevant support team in obtaining medicalised treatment. For alcohol addiction, for example, the use of Naltrexone helps reduce cravings by mimicking the action of endogenous opioids. Naltrexone is an opioid receptor antagonist or a substance that binds to a relevant receptor inside cells or on the cell’s surface, causing the same action as the innate endogenous opioids that would normally bind to opioid receptors in the cells. So, Naltrexone ‘mimics’ this. It is also used in the management of opioid addiction by blocking the harmful effects of opioids and therefore reducing cravings.

Recent advances in the fields of molecular biology, behavioural neuropharmacology and Neuroscience, including brain imaging, have changed our understanding of the addictive processes in the brain, and why relapse can occur. Especially in the face of adverse consequences or life events.

The role of neuroscience in understanding the complex interactions between repeated exposure to drugs, and the biological (i.e., genetic and developmental), and environmental factors (i.e., drug availability, drug cues, social, and economic/education variables) are helping to unravel the complexities of addiction, sometimes referred to as an unpredictable illness.

This unpredictability means it is difficult to say what the tipping point is for user dependence, and how addictive states are likely to develop in determining a treatment plan, including medicalised treatment. The available research, and as reflected in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), concludes addiction to be on a continuum. That is a continuous sequence, where the extremes can be quite distinct, rather than binary (‘you are addicted or not’?). So, you are more or less addicted, depending on where you are on the continuum, and also depending on severity level.

Do interventions need to be tailored to individuals and contexts, therefore? Examples include alcohol addiction and the mentioned use of Naltrexone. However, the particular withdrawal syndrome for alcoholics can be dangerous, with the potential to cause seizures. In opiate addiction, ‘take-home’ naltrexone can be used by families and friends for users to ‘rescue’ from overdose or worse, to buy precious time to reach out for medical assistance.

Drug users, especially those injecting, are offered Hepatitis B vaccination, in order to prevent blood-borne viruses. In the context of club drugs, where psychological dependence may also feature, alongside physical dependence, interventions could include the potential of providing medical help onsite in clubs.

The concept of treatment penetration—that not all treatment systems engage everyone—highlights the importance of tailoring interventions to individual and contextual needs. The bad news is more than 80% of addicted individuals do not seek treatment and this may reflect a lack of recognition of the severity of the disorder by individuals, and a historical bias by the medical fraternity led by societal stigma (Goldstein et al, 2009).

This evolving understanding helps us appreciate the complex interactions between drug exposure, genetic factors, and environmental conditions, making addiction sometimes seen as an unpredictable illness. As research continues, the integration of medical treatments with psychological models promises to offer more effective approaches tailored to individual needs, reflecting the continuum of addiction.

The content presented in this blog incorporates factual information along with perspectives and opinions. It is designed to stimulate discussions and exploration of emerging research. However, it does not represent official advice or exhaustive factual claims. Readers of course consider multiple sources when forming a viewpoint. Alternative viewpoints are highly encouraged and welcomed at Blindspot.