CES in the Treatment of Addictions: A Review and Meta-Analysis
For decades, our national anti-drug motto was “Just Say No!" It has never served as anything other than a catchy public relations phrase. In fact, the motto itself became an instant hit among the purveyors of illicit substances during decades of anti-establishment activities. The motto has also been a grim disguise for many years of chronic human destructiveness involving both legal and illegal substances, and has even been a political invective foisted against various candidates for political office. Agencies for detoxification, “rehabilitation," and other types of addiction treatment tried unsuccessfully to replace “just say no” with “just say yes” to positive lifestyle alternatives, but it never worked unless the treatment program itself was powerful and had very long-term follow-up.
Volumes have been written about addiction and billions of dollars have been spent on the problem. But the definition of addiction is far from clear. Not understanding a complex addiction problem often results in unnecessary hospitalization, increased medical costs, and patients who develop a distrust of both healthcare practitioners and “rehabilitation” organizations. Conversely, without a universally-accepted definition of addiction, many people on destructive life paths fail to receive the care they require. Nevertheless, realistic practice guidelines for the addictions are either unavailable or equivocal. This produces difficulties with both patient management and reimbursement.
Addictive behaviors present confusing and complex patterns of human activity.1 While most people think of alcohol and other drug (substance) dependence as the primary addictions, these addictions are definitely surpassed in number by dependence upon excessive sugar, caffeine, and nicotine. It has also been said that eating disorders, compulsive gambling, excessive sexual behavior, and other intemperate behavior patterns might also be considered as behavioral dependencies or addictions. While prevalent in many cultures, such behaviors have historically defied explanation. Nevertheless, these behavioral dependencies often also have specially-designed supportive programs that incorporate a 12-Step Program similar to what has been a sine qua non of effective treatment programs that focus on alcoholism and the abuse of other substances. Just as there is an Alcoholics Anonymous, there are also groups such as Gamblers Anonymous and Overeaters Anonymous. The American Psychiatric Association considers a diagnosis of Pathological Gambling to be a form of “Impulse-Control Disorders Not Elsewhere Classified” in the DSM-IV-TR.2
|Substance Use Disorders
The DSM-IV-TR also divides substance-related disorders into two broad categories, Substance Use Disorders and Substance-Induced Disorders (see Table 1).
From a psychiatric point of view, Table 1 illustrates the broad complexity and the wide-ranging, protean manifestations of addiction. Addiction can occur as part of many different psychiatric disorders, but can also induce them as the Table indicates. Addiction does not usually just happen, “out of the blue." There is a progression through use, habituation, abuse, dependence, intoxication, and withdrawal. Individual vulnerabilities interact with various psychopharmacologic facets of one or more substances to produce both immediate and, occasionally, persistent and long-term destructive effects. The DSM-IV-TR groups all substances into 11 classes and gives detailed criteria sets of Intoxication and Withdrawal for each substance class. The main DSM-IV-TR classes of substances of abuse are listed in Table 2.
DSM-IV-TR actually lists two other classes of substances, which are labeled as “Polysubstance" and “Other." Clinically-active professionals from any discipline will understand the importance of these two additional categories. Polysubstance abuse often presents the most puzzling and challenging sets of symptoms that can appear completely refractory to treatment when the multiple substances are not recognized or admitted by history. The “other" category gives not so silent testimony to the waves of newer designer drugs and novel but dangerous homemade combinations of substances that may be relatively innocuous and readily available over the counter in most drug stores and pharmacies. In the year 2007, Western ingenuity has produced a frequently deadly combination of heroin and Tylenol® P.M. known as “cheese." This finely ground up powder can be sold inexpensively and snorted (inhaled) or injected.
Despite the apparently robust medical nosology of addiction, there is an uncomfortable gap between the medical certainty of naming and classifying addictions and the vexatious problems of devising most effective treatment methodologies. There is such distance between the theory and clinical practice of dealing with addiction that many successful long-term programs have minimal medical input only during the acute phase of withdrawal and focus instead on the psychosocial aspects. Ideally, adequate therapeutics focus on both medical and psychosocial aspects, as well as providing long-term follow-up.
A substantial number of “rehab" programs are administered by recovered addicts and eschew medical input, except for emergencies. One value of these “indigenous" rehab programs is that they illustrate the spectrum of ideas about addiction. Very robust non-medical components of modern addiction treatment often highlight the element of self-help. In the 21st century, self-help almost universally includes the processing of both reliable and unreliable internet-based information. A search of the web provides a variety of definitions for addiction, and reveals the diversity of thinking about addictions: