The Trajectories of Addiction

By Jeanene Swanson 12/09/14
Who really needs treatment? And how should this be tailored to better incorporate the severity and specificity of addiction?

Current epidemiological studies have shown that most people will remit—on their own, without formal treatment—from addictions to nicotine, alcohol, marijuana, cocaine, and prescription pills. However, the common belief among treatment centers and medical professionals is that addiction is a chronic, relapsing disease—once an addict, always an addict, as they say at 12-step meetings.

Should I get treatment? Do I need to? What kind of treatment should I be looking for? These are questions likely everyone with a substance or behavioral addiction asks. The answers are elusive. The fact is there aren’t many studies looking at the trajectories of drug use—how long it lasts, and how the severity and specificity (choice of drug) influence remission rates and therefore, treatment expectations. Understanding the patterns of substance abuse is essential for developing more effective prevention and treatment strategies.

Aging out

NESARC, or the National Epidemiologic Survey on Alcohol and Related Conditions, was a large study designed to determine the magnitude and progression of alcohol use and related substance use and comorbid psychiatric disorders among the general population. Out of 43,000 people interviewed between 2001 and 2002, and then again from 2004 to 2005, it found that the majority of individuals dependent on nicotine, alcohol, cannabis, and cocaine achieved remission at some point in their lives. The half-life, or the time it took for half the people to remit, was 26 years for nicotine, 14 for alcohol, 6 for cannabis, and 5 for cocaine. In another analysis, scientists found that most prescription drug addicts come clean, with a half-life of between 4 and 5 years. The drawbacks to a self-reported study are obvious: our memories often don’t serve us well. Plus, how many people sought “informal” treatment, even along the lines of simply asking family and friends for support? Finally, the numbers are different for those who sought formal treatment—which might suggest that severity influences who will and will not remit without treatment. SAMHSA data says that duration from first use to treatment for alcohol is 20 years, cocaine is 14.5, heroin is 12.5, stimulants is 12, marijuana is 12, and prescription drugs is 8.

The “aging out” theory is well researched—in fact, it dates back to the 1960s. NESARC data simply backs it up. People grow up, and they either have to choose between adult responsibilities—leaving home, getting married, having kids—and getting loaded; or they can no longer afford to, whether financially, physically, or emotionally. “The maturing out process is believed to result when people enter ‘young adulthood’ (18 to 25 years old) and take on the roles and responsibilities of adulthood, [for example] marriage, parenthood, labor market entry,” says Elizabeth Evans, who conducts research into drug use over the life course at UCLA’s Integrated Substance Abuse Programs. Attitudes change, and people become less apt to act impulsively.

Natural recovery is recovering without formal treatment or mutual support groups. About three-fourths of people in recovery did not make use of formal treatment or mutual help groups to achieve remission; however, those with less severe problems, fewer comorbidities, and more social support have a greater chance of recovering without formal treatment, says the Recovery Research Institute. The concepts of treatment and mutual support are changing, too, in light of the numerous online resources available today. Online support networks like SMART Recovery, virtual 12-step meetings, and web-based recovery forums, not to mention the sober blogging community, are changing the way people relate—providing them with more tools and improving the chances for success.

Trajectories of drug use

Not all addicts will age out, or mature away from their addiction. “The maturing out phenomenon has been less well-documented for substances other than marijuana and alcohol,” Evans says. “Instead, a growing amount of evidence—much of it generated by the work that has been done here at our organization—indicates that individuals who engage in problematic use of methamphetamine, cocaine, and particularly heroin, tend to persist in their use over many years of the adult life course.”

In one study not conducted at UCLA, scientists found that one-third of adults continued using narcotics into middle age. “The few long-term follow-up studies have generally shown that severe or dependent users tend to persist in their drug use, often for substantial periods of their lifespan,” writes UCLA’s Dr. Yih-Ing Hser, lead author of multiple papers on drug use trajectories. “For example, data from our 33-year follow-up study of heroin addicts has shown that heroin addiction is characterized by long periods of regular use and tends to persist over the life course.”

In a recent study, Hser found that heroin was used more often and for longer periods of time than cocaine or meth. “In general, heroin is characterized by a greater liability for physical dependence than other substances,” Evans, who was a co-author, says. “To avoid physical withdrawal symptoms, heroin users need to use consistently. This is not the case for other substances.”

It’s also been shown that early onset means worse outcomes. One in four Americans who began using any addictive substance before age 18 end up addicted, compared to one in 25 who started using at age 21 or older. Hser found that users in the high use group also had earlier onsets of drug use and crime, longer periods of incarceration, and were the least employed. In general, first use that happens before age 15 is associated with a more severe course of substance use disorders and poorer health and social consequences over time, Evan says.

Specificity of addiction

This idea of specificity of addiction—what you get addicted to—is even more understudied than drug use trajectories, yet has just as much relevance to improving treatment programs. In one paper, USC’s Dr. Steve Sussman, a professor of preventive medicine and psychology, outlines that addiction clusters divide into two general categories: “hedonistic” such as drug use, sex, love/relationships, and gambling; and “nurturing” such as food, shopping, work, and exercise. “Overall, different people appear to show unique patterns of addiction and, while they struggle with one or more addictive behaviors, they may not have difficulty with other potentially addictive behaviors,” he writes. 

His group has developed model, or framework, to better address addiction specificity. Called “PACE”—pragmatics, attraction, communication, and expectations—it is meant to help treatment providers understand how addiction might develop. Pragmatics is how accessible the drug is, attraction relates to how rewarding or good it feels, communication is about code words, and expectations function to keep someone hoping for the desired outcome. 

Improving treatment

Who really needs treatment, then? And, how should this be tailored to better incorporate severity and specificity of addiction? While some people do recover on their own, others benefit from treatment, especially for those with longer trajectories.

Improved treatment might consider the PACE framework, or in general, personalizing treatment more. “Tailoring treatment to meet the needs of individual patients is something that treatment programs generally aim to achieve,” Evans says. “How might resources be better allocated to help them to do that?”

Evans, like many, believes that treatment programs should be aware of and make use of the relatively new medications to treat opioid dependence. “A combination of medications and therapy and use of other services are usually the most effective,” Evans says. The rise of addiction to prescribed opioids has created a new type of patient that is “different in many ways from heroin users.” Treatment programs should be sure to be equipped to treat this population. Recent changes in the Affordable Care Act are expected to bring more people with substance use disorders into primary care settings. “This is a big change,” she says.

Dr. Christopher La Riche, medical director at the Lucida Treatment Center in Florida, uses the common anti-craving medication naltrexone to treat both alcohol and opioid use disorders. Another treatment provider says it depends on the patient’s drug use trajectory whether she uses anti-craving meds or replacement therapies: sometimes it’s better to use substitution medications for heroin addiction if there is a history of relapse. “Outcomes are better with use of antagonist/anti-craving treatments,” like naltrexone, Antabuse, and acamprosate, La Riche says, allowing for longer periods of sobriety and less heavy drinking during relapses. However, remission takes time—sometimes decades—and relapse is common. “Anti-craving and antagonist medicines work as one modality in a comprehensive and integrated approach to recovery.”

Utilizing the PACE framework might lend depth to the current treatment landscape. “Various therapies may function by confronting perceived attraction and expectations of an addiction, creating equivocation, and resolving the equivocation through reduced attraction or realization of the lack of functionality of the addiction,” Sussman says. “One may also help the participant pursue other positive avenues to address enjoyment or life expectations.”

Jeanene Swanson is a regular contributor to The Fix. She last wrote about substituting addictions and addiction among Hispanics.

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Jeanene Swanson is a science journalist who specializes in mental health and addiction. As a science writer with a background in biotechnology, she enjoys turning complex subjects into stories that everyone can understand—and apply to their lives. You can find Jeanene on Linkedin.