The medical model of addiction
The medical model of drug and alcohol addiction categorizes it as a disease. Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. (American Society of Addictive Medicine, 2011). A central thesis in Jellinek’s (1960) disease model of alcoholism was that alcoholics suffer from a loss-of-control such that any drinking leads to unregulated consumption and intoxication (George, Gilmore, ; Stappenbeck, 2012). This is the underlining philosophy medical/ disease theory of addiction which states that addiction is a progressive, incurable and chronic disease (Stevens, ; Smith, 2018)
Within the Alcohol Anonymous framing, alcoholism as a ‘disease’ is not associated with a specific biological etiology. Rather, it is viewed as a disease in the general sense of being an incurable individual affliction that can only be managed through complete abstinence from alcohol (Meurk, Carter, Partridge, Lucke, J., ; Hall, 2014). This is another major principle put forth by the diseased model.
The diseased model elucidates this philosophy with the reward center of the brain. Ouzir and Errami (2016) in their article Etiological theories of addiction: A comprehensive update on neurobiological, genetic and behavioral vulnerability states that “all addictive drugs elicit the excitation of the dopaminergic neurons in the ventral tegmental area (VTA) of the midbrain and in the shell of the nucleus accumbent.” They further explain this high level of neural dopamine release in an extremely convenient way, causing the reward system to become flooded with it and reinforcing the addictive cycle. Ross ; Peselow (2009) explains that repetitive substance abuse produces the activation of the reward pathways in the brain in unusual way causing neurophysiological and neuroplastic changes. This unnaturally high levels release of dopamine in reward system is associated with the generation of the Brain Derived Neurotrophic Factor (BDNF) as a compensatory mechanism to deal with oxidative stress in dopaminergic neurons (Vargas-Perez et al., 2014). Hence the medical model provides a shift of perspective from traditional moral theory which considered addiction as a moral downfall opening more room for treatment and recovery.
The Medical model primary treatment method is through a range of medication with abstinence at all times. The initiation of the treatment occurs with detoxification which is defined as the use of medications to treat withdrawal symptoms (Czapla, Simon, Richter, Kluge, Friederich, Herpertz, ;Loeber, 2016). Medication intervention addresses the on ongoing withdrawal symptoms, cravings and nutritional needs that accompanies the treatment process. Another useful intervention in the medical model is treatment for comorbidity. According to Newton, De La Garza, Kalechstein, Tziortzis, ; Jacobsen, (2009) the rates of relapse are higher if aftercare programs are not implemented. The medical model addresses aftercare in form of therapy, medication, and support group (Alcohol anonymous). The limitations to consider from the medical model is that it does not addresses the individuals needs who seeks to reduce consumption as it focuses on abstinence as the primary method of recovery (Stevens, ; Smith, 2018). Another major setback of this approach is that it does not probe into the environmental stimulus that might cause the onset or relapse of addictive behavior into treatment consideration. Overall the medical model focuses most of its attention on the treatment aspect of addiction. It leaves out the preventive measures and maintenance for the same.
Behavioral theory of addiction
Behavioral theory of addiction encompasses the behavioral models in psychology that emphasize the importance of learning; defined as the relatively permanent changes in behavior that result from the organism’s interaction with its environment. (Piazza, & Deroche-Gamonet, 2013). It explains the onset and continuation of addictive behavior through the lenses acquired learning. “Positive reinforcement, based on classical learning theory, is probably the most familiar preclinical model of addiction. Quite simply, this theory states that users will say they take drugs because they enjoy using them” (Spence 1956). Alavi, Ferdosi, Jannatifard, Eslami, Alaghemandan, and Setare, (2012) states psychoactive drugs (and many other activities) can be very potent reinforcers, both positive (euphoria, potency, sociability, peer acceptance) and negative (tension-reduction, escape from boredom, “drowning one’s sorrows,” etc.). Negative reinforcement provided one of the earliest theoretical explanations of addictive behavior. The basic premise is that drug use reduces withdrawal dysphoria (Newton, De La Garza, Kalechstein, Tziortzis, & Jacobsen, 2009). Relief from withdrawal symptoms by resumed use of drugs can be a very potent negative reinforcement (Alavi, Ferdosi, Jannatifard, Eslami, Alaghemandan, & Setare, 2012) Hill (2013) states that “the reinforcers of substance use might be stronger than their punishers ex: hangovers, arrests, social disapproval, getting fired, and the reinforcers are usually more immediate and certain while punishers are often delayed and uncertain.” The desire or craving can generalize to a variety of stimuli that prompt the behavior, and there might be a failure to discriminate when to use or not use, or when one has had too much. (Alavi, Ferdosi, Jannatifard, Eslami, Alaghemandan, & Setare, 2012). With so many reinforcers and conditioned stimuli, extinction can be hard to achieve, and relapse is common Ouzir and Errami (2016).
Behavioral theory implies several techniques that focuses on the breaking of cyclical pattern of substance use. Contingency management, in which patients receive incentives or rewards for meeting specific behavioral goals (e.g., verified abstinence). Contingency management approaches are based on principles of behavioral pharmacology and operant conditioning, in which behavior that is followed by positive consequences is more likely to be repeated (Carroll, and Onken, 2005).
Carroll, and Onken, (2005) in their article Behavioral Therapies for Drug Abuse provides CBT intervention for substance addiction. They state
Cognitive behavior approaches, such as relapse prevention, are grounded in social learning theories and principles of operant conditioning. The defining features of these approaches are 1) an emphasis on functional analysis of drug use, i.e., understanding drug use within the context of its antecedents and consequences, and 2) skills training, through which the individual learns to recognize the situations or states in which he or she is most vulnerable to drug use, avoid those high-risk situations whenever possible, and use a range of behavioral and cognitive strategies to cope effectively with those situations if they cannot be avoided.
Some other behavioral interventions are Motivational interviewing, teaching replacement behavior (spirituality, exercise) progressive desensitization, controlled-drinking programs called behavioral self-control training, etc. Drug counseling and couple and family therapy also comes under the umbrella of behavioral interventions. The defining feature of couples and family treatments is that they treat drug-using individuals in the context of family and social systems in which substance use may develop or be maintained. (Brown, & Coldwell, 2006). The limitation to address regarding the behavioral approach to addiction treatment is it fails to take into consideration the biological changes that addictive substance produces in the body. The techniques are solely utilized to change behavior and doesn’t acknowledge the already caused physical harm to the human body.
Medical Model Versus Behavioral Model of Addiction
The medical model and behavioral model have several distinctions in the group of ideas used to explain addiction disorder. Both the theories use the concept of reward center of brain a release of dopamine as the primary reason for continuation of addictive patterns. The medical model explains it as a positive experience of pleasure caused by the release of dopamine that further develops as a survival necessity. While the behavior model considers its as positive reinforcement promoting the likelihood of repeating the behavior. The primary difference in the two theories is that the medical model treats addiction of any kind as a chronic disease. On the other hand, behaviorist consider addiction as a result of acquired learning and thus a replaceable behavior.
The disease model treats addiction with medicinal interventions and thus use objective approach toward addiction treatment. The behavioral model focuses on interventions that takes into consideration the environmental, and intra-individual factors that plays into breaking the pattern of addictive behavior. it should be noted that medical model borrows some of their aftercare interventions techniques from the behavior model like counseling, support group etc. Another major difference between the two is the approach towards recovery. The behaviorist believe that complete abstinence is not necessary for recovery. Whereas the medical model operates with a belief that complete abstinence is the primary requirement towards recovery. Both the theories consider relapse as a normal part of recovery. The medical model explains the relapse as a cause of the illness of addiction causing a physical compulsion. Whereas the behavior model attributes relapse to the immediate reward experienced by the behavior. Overall, both the models use different lenses to explain the etiology of addiction disorder.
Personal Theory of addiction
Addiction causes several physical and psychological alteration to the human body. The intervention for the same should be able to address both the aspects to attain desirable outcome. Hence an integrated approach for addiction treatment will suit best for a holistic result. Borrowing from the behavioral model will be the idea that an addiction can be controlled with behavioral alteration. The motivation of change will be more if there is an attainability of the outcome. Hence setting an attainable goal that can be attained within a specific duration will be a part of my theory. The client does not have to be labeled as an addict for the rest of their lives. From my personal viewpoint initially learning the ‘why’ of the condition can help better understand the intervention to be put in place for the treatment. With consideration of the root cause of addiction and stage of addiction a client is at, a counselor can create a treatment plan for the same.
Borrowing from the medical model, if the client is at late stage of addiction, initiation of the treatment with medical detoxification will be beneficial which can be followed by the behavioral intervention to maintain recovery. With keeping in mind, the AA twelve step program and most of the therapeutic factors are behavioral techniques, medical intervention should be accompanied by behavioral techniques to fully address the issue. One example can be the use of spirituality as a replacement behavior. Also, both the models can be used to treat comorbidities that follows the same. It will be much more beneficial for the client to be receiving help with both physical and mental needs. The aftercare treatment will be maintained to teach client skills to be able to operate on their own and maintain recovery. An example can be using cognitive behavior techniques to teach new skills.