{"id":84,"date":"2019-12-04T17:30:48","date_gmt":"2019-12-04T17:30:48","guid":{"rendered":"https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/chapter\/ch-3-name-2\/"},"modified":"2020-12-07T16:49:55","modified_gmt":"2020-12-07T16:49:55","slug":"ch-3-name-2","status":"publish","type":"chapter","link":"https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/chapter\/ch-3-name-2\/","title":{"rendered":"Ch. 3.3: Definition of Addiction, Historic Disease Model, Brain Disease Model, Bio-psycho-social-spiritual Aspects"},"content":{"raw":"<h2 class=\"import-Normal\"><strong lang=\"en-GB\" xml:lang=\"en-GB\">Defining Addiction<\/strong><\/h2>\r\n<span lang=\"en-GB\" xml:lang=\"en-GB\">There is more i<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">nvolved in<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> defining substance misuse and SUD than the clinical diagnostic protocols presented in the DSM-5 and ICD-11. As a start, consider the American Society of Addiction Medicine policy statement defining addiction (ASAM, 2011):<\/span>\r\n<p class=\"import-Normal\" style=\"margin-left: 36pt;margin-right: 36pt\"><em lang=\"en-GB\" xml:lang=\"en-GB\">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. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one\u2019s behavior and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death (p. 1).<\/em><\/p>\r\n<p class=\"import-Normal\" style=\"text-align: right\"><img class=\"aligncenter\" src=\"https:\/\/pressbooks.ulib.csuohio.edu\/bestpracticesinsubstancemisusetreatment\/wp-content\/uploads\/sites\/106\/2019\/12\/image11-1.png\" alt=\"\" width=\"489\" height=\"103\" \/><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">Important aspects of this definition <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">are recognition of:<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"><\/span><\/p>\r\n\r\n<ul>\r\n \t<li><span lang=\"en-GB\" xml:lang=\"en-GB\">the\u00a0<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">impact of addiction on biological, psychological\/emotional, social, interpersonal, and spiritual aspects of life<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">;<\/span><\/li>\r\n \t<li><span lang=\"en-GB\" xml:lang=\"en-GB\">the brain-behavior nexus in the development and maintenance of addictive behavior<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">;<\/span><\/li>\r\n \t<li><span lang=\"en-GB\" xml:lang=\"en-GB\">the common experience of cyclical relapse and remission, and <\/span><\/li>\r\n \t<li><span lang=\"en-GB\" xml:lang=\"en-GB\">the potential for problem progression. <\/span><\/li>\r\n<\/ul>\r\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">The ASAM definition reflects a <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">\u201c<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">disease model<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">\u201d<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> perspective\u2014a model popular in the United States and many other areas, but not without controversy and critics<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, particularly in other parts of the world<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">.<\/span><\/p>\r\n\r\n<h3 class=\"import-Normal\" style=\"text-indent: 36pt\"><strong lang=\"en-GB\" xml:lang=\"en-GB\">Original d<\/strong><strong lang=\"en-GB\" xml:lang=\"en-GB\">isease model of addiction.<\/strong><span lang=\"en-GB\" xml:lang=\"en-GB\"> <\/span><\/h3>\r\n<p class=\"import-Normal\" style=\"text-indent: 36pt\"><span lang=\"en-GB\" xml:lang=\"en-GB\">The original disease model of addiction emerged during the 1950s and 1960s regarding alcoholism, viewing addiction as a primary disease, not secondary to other psychological conditions (<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Hartje<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, 2009). The original disease model <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">of addiction <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">was hailed as an important, less stigmatizing alternative t<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">han the prevailing<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> moral model<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> that place<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">d<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> blam<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">e on <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">individuals for their addiction and<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> deem<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">ed<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> them<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> deserving of its consequences and punishment (Thombs, 2009). Viewing addiction as a disease, instead, allowed the person to <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">be seen as<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> the \u201cvictim\u201d of an illness, deserving of compassionate care and medically supervised treatment (Thombs, 2009). In th<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">e disease<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> model, an individual\u2019s choice to initially engage in substance<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> may have been freely<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> made; however, once initiated, the disease could take over: \u201cintense cravings are triggered via physiological mechanisms, and these cravings lead to compulsive overuse. This mechanism is beyond the personal control of the addict\u201d (Thombs, 2009, p. 561).<\/span><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">Research by E. Morton <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Jellinek<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> was credited with providing early support for a disease model of addiction (<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Hartje<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, 2009). Based on a non-random sample of surveys completed by 98 men responding to an Alcoholics Anonymous newsletter, later expanded to include 2,000 histories, <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Jellinek<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> (1952) identified four progressive phases of the disease: the <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">prealcoholic<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> symptomatic, prodromal, crucial, and chronic phases. The<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">\u00a0\u201c<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Jellinek<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> Curve\u201d reflects how specific behaviors and experiences relate to the disease\u2019s progression and recovery<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">\u2014i<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">ts very design reflects the perception of a person \u201chitting bottom\u201d before being able to recover from addiction<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> (from <\/span><a class=\"rId23\" href=\"https:\/\/www.in.gov\/judiciary\/ijlap\/files\/jellinek.pdf\"><span class=\"import-Hyperlink\">https:\/\/www.in.gov\/judiciary\/ijlap\/files\/jellinek.pdf<\/span><\/a>)<span lang=\"en-GB\" xml:lang=\"en-GB\">.<\/span><\/p>\r\n<p class=\"import-Normal\" style=\"text-align: center\"><span lang=\"en-GB\" xml:lang=\"en-GB\"><img class=\"aligncenter\" src=\"https:\/\/pressbooks.ulib.csuohio.edu\/bestpracticesinsubstancemisusetreatment\/wp-content\/uploads\/sites\/106\/2020\/09\/image12.jpg\" alt=\"Addiction and Recovery: The Jellinek Curve\" width=\"766\" height=\"558\" \/><\/span><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">Despite methodological weaknesses in the evidence, the original<\/span> <span lang=\"en-GB\" xml:lang=\"en-GB\">disease model became popular with many practitioners and Alcoholics Anonymous programs, introducing significant implications: <\/span><\/p>\r\n\r\n<ul>\r\n \t<li><span lang=\"en-GB\" xml:lang=\"en-GB\">alcoholism was viewed as a chronic, progressive, incurable disease;<\/span><\/li>\r\n \t<li><span lang=\"en-GB\" xml:lang=\"en-GB\">professional treatment was specified as necessary to control this incurable disease;<\/span><\/li>\r\n \t<li><span lang=\"en-GB\" xml:lang=\"en-GB\">abstinence was viewed as the only defense against recurrence and the only reasonable goal for a person with this disease;<\/span><\/li>\r\n \t<li><span lang=\"en-GB\" xml:lang=\"en-GB\">substituting a different drug for alcohol was expected to manifest the same disease symptoms and progression (<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Hartje<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, 2009).<\/span><\/li>\r\n<\/ul>\r\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">The original disease model and principles have greatly influenced assessment and treatment practices over the past 60 to 70 years.<\/span> <span lang=\"en-GB\" xml:lang=\"en-GB\">There exist several points around which the original disease model of addiction has been challenged.\r\n<\/span><\/p>\r\n\r\n<h4 class=\"import-Normal\"><strong lang=\"en-GB\" xml:lang=\"en-GB\">Heterogeneity challenge to the original disease model<\/strong><strong lang=\"en-GB\" xml:lang=\"en-GB\">.<\/strong><span lang=\"en-GB\" xml:lang=\"en-GB\"> <\/span><\/h4>\r\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">L<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">ongitudinal studies documenting the natural course of alcoholism demonstrated significant inconsistencies with a disease progression premise:<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> multiple patterns were observed among men still alive 60 years after beginning the study, including continued alcohol abuse, stable abstinence, and return to asymptomatic\/controlled drinking (Vaillant, 2003). Tremendous individual variation exists in patterns of addictive behaviors, as well as the severity of problems experienced by individuals at different points in time. <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Jell<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">i<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">n<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">e<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">k<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> (1952) admitted that his was an \u201caverage trend\u201d model in which individuals do not necessarily exhibit all of the symptoms associated with a phase, may differ in the sequencing of symptoms, and may differ in the duration of each phase; furthermore, \u201cnonaddictive alcoholic\u201d individuals may experience the identified negative consequences of alcoholism without experiencing a loss of control over drinking, and women may experience the disease differently. <\/span><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">This high degree of variability (heterogeneity) in expression called into question the perspective that alcoholism (or any<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> substance use disorder<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">) represents a single disease. Emphasis on the addiction\/dependence end of the continuum of substance misuse \u201chas resulted in a myopic view of substance abuse problems that has characterized them as progressive, irreversible, and only resolved through treatment\u201d (<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Sobell<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, 2007, p. 2). Observed heterogeneity <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">has <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">informed <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">the <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">diagnostic schedules\u2019 differentiations: different substances <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">(<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">and addictive behaviors <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">such as<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> gambling<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> disorder<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">) have distinct diagnostic codes. If \u201caddiction\u201d were a single uniform event there would be no need for multiple diagnostic categories<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">\u2014o<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">r different intervention strategies. <\/span><\/p>\r\n\r\n<h4 class=\"import-Normal\" style=\"text-indent: 36pt\"><strong lang=\"en-GB\" xml:lang=\"en-GB\">Subtypes versus stages of disease.<\/strong><\/h4>\r\n<p class=\"import-Normal\" style=\"text-indent: 36pt\"><span lang=\"en-GB\" xml:lang=\"en-GB\">There <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">exist marked differences in how <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">substance misuse\/SUDs<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> are expressed even within a single substance type. C<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">hallenging <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Jell<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">i<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">n<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">e<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">k\u2019s<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> stage model of alcoholism<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, for example,<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> is<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> evidence of heterogeneity in <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">\u201ctypes\u201d of alcoholism derived from <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">a national sample (U.S.)<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">. The investigators<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> based<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> their typology<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> on clinical characteristics of individuals meeting criteria for an alcohol <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">dependence per the DSM-IV-R criteria that preceded the DSM-5<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> (Moss, Chen, &amp; Yi, 2007). This analysis of U.S. National Epidemiological Survey on Alcohol and Related Conditions (NESARC) data led the authors to identify five \u201csubtypes\u201d of alcohol dependence, demonstrating <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">clinical <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">heterogeneity within the <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">single <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">diagnostic classification. The subtypes <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">they <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">identified were based on how participants clustered on diagnostic criteria, age of onset, family history, and presence of other co-occurring disorders. The five statistically determined clusters <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">they identified were<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> labelled<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">:<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> young adult, young antisocial, functional, intermediate familial, and chronic severe subtypes<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> (see Figure 1)<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">. The groups demonstrated differences in their patterns of drinking, help-seeking, and response to intervention, as well. This study, based on a large, nationally representative sample reflect<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">ed<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> heterogeneity among persons engaged in <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">a specific <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">addictive behavior, and the wisdom of avoiding stereotypes about them\u2014for instance, while the chronic severe subtype was the least common, it reflects a common stereotype of alcohol dependence.<\/span><\/p>\r\n<p class=\"import-Normal\"><strong><span lang=\"en-GB\" xml:lang=\"en-GB\">Figure 1. Subtypes of alcoholism (based on data from Moss, Chen, &amp; Yi, 2007).<\/span><\/strong><\/p>\r\n<img class=\"aligncenter size-full wp-image-76\" src=\"https:\/\/pressbooks.ulib.csuohio.edu\/bestpracticesinsubstancemisusetreatment\/wp-content\/uploads\/sites\/106\/2020\/09\/Fig-1-Subtypes-of-alcoholism-1.png\" alt=\"Subtype of Alcoholism: pie chart featuring the following numbers: Chronic\/Severe: 9%, Young adult: 32%, young antisocial: 21%, functional: 19%, intermediate familial: 18%\" width=\"996\" height=\"533\" \/>\r\n\r\n&nbsp;\r\n<h4 class=\"import-Normal\" style=\"text-indent: 36pt\"><strong lang=\"en-GB\" xml:lang=\"en-GB\">Treatment and the disease model. <\/strong><\/h4>\r\n<p class=\"import-Normal\" style=\"text-indent: 36pt\"><span lang=\"en-GB\" xml:lang=\"en-GB\">Additional important challenges to the disease model of addiction appear in the literature. <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">A<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">sserting that formal treatment for addiction is necessary has been challenged by evidence that many individuals experience significant, long-lasting improvement without engaging in formal treatment\u2014sometimes referred to as \u201cnatural recovery\u201d or \u201cself-change\u201d\u2014typically, persons whose alcohol misuse is not of the most severe dependant nature (<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Sobell<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, 2007). Little is known about natural recovery in other substance misuse, though some evidence for its existence appears in the literature (e.g., Chen, 2006; Erickson &amp; Alexander, 1989; Price, Risk, &amp; <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Spitznagel<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, 2001). Possibly, the necessity for engaging in formal treatment varies by individual, severity of the problem, and characteristics of the substances or addictive behaviors involved.<\/span><\/p>\r\n\r\n<h4 class=\"import-Normal\" style=\"text-indent: 36pt\"><span lang=\"en-GB\" xml:lang=\"en-GB\"><\/span><strong lang=\"en-GB\" xml:lang=\"en-GB\">Abstinence only based on disease model.<\/strong><span lang=\"en-GB\" xml:lang=\"en-GB\"> <\/span><\/h4>\r\n<p class=\"import-Normal\" style=\"text-indent: 36pt\"><span style=\"background-color: #ffffff\"><span lang=\"en-GB\" xml:lang=\"en-GB\">There are two parts of an abstinence only perspective that need to be unpacked. \u00a0The first pertains to controlled drinking, and the second pertains to medication used to treat substance use disorders.<\/span><\/span><\/p>\r\n<p class=\"import-Normal\" style=\"text-indent: 36pt\"><span style=\"background-color: #ffffff\"><span lang=\"en-GB\" xml:lang=\"en-GB\">V<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">iewing abstinence<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> from substance use<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> as the only defense against <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">\u201cdisease\u201d <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">recurrence and the only reasonable goal for a person experiencing a substance use disorder has been challenged. Complete abstinence from all psychoactive substances is at one end of a continuum in treatment strategies, commonly applied in U.S. medical practice (Glenn &amp; Wu, 2009). A debated position is that the continuum of recovery includes controlled substance use, including the type of substance which a person previously used problematically. For some individuals, their goal is\u00a0safer, more controlled use, and harm reduction.\u00a0<\/span><\/span><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">\u00a0 <strong>Controlled drinking<\/strong>. <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">T<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">he word \u201csobriety\u201d originally<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, historically<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> implied temperate, moderated indulgence, not necessarily complete abstinence\u2014an abstinence interpretation emerged during the 1900s (Glenn &amp; Wu, 2009). Evidence since the 1970s indicates that some individuals achieve controlled drinking despite having previously engaged in an \u201cout-of-control\u201d drinking pattern, contrary to \u201cthe prevailing belief that any alcohol consumption causes an inevitable loss of control over one\u2019s alcohol use\u201d (Klingemann, 2016, p. 436). The debate about \u201ccontrolled drinking,\u201d \u201creduced-risk drinking,\u201d and \u201cmoderation management\u201d continues, and it is unclear how the evidence for and against it might apply to other substances and addictive behaviors.\u00a0 Reduced-risk drinking (RRD) is seen in many Western European countries as one pathway out of addiction, and a legitimate treatment goal (Klingemann, 2016).\u00a0 Importantly, the ability to engage in controlled use following a substance use disorder may vary by individual, severity of the problem, and characteristics of the substances or addictive behaviors involved.\u00a0 Unsuccessful attempts at controlled use suggest the need for abstinence as a treatment goal.\u00a0 Conversely, if an individual is able to resolve the negative consequences of use, and sustain this change over a long period of time through controlled use, is this an acceptable resolution?<\/span><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\"><strong>Medication used to treat substance use disorders.<\/strong>\u00a0<\/span><\/p>\r\n<span style=\"background-color: #ffffff\">Closely associated with the abstinence issue lies an additional point of contention with the disease model of addiction--the belief that substituting medication for the primary addictive substance simply continues manifestation of the same disease of \"addiction.\"<\/span>\r\n\r\n<span style=\"background-color: #ffffff\">\u00a0This stance contributes to the hesitancy expressed by some practitioners to promote the use of medically assisted treatment (MAT) and pharmacotherapies to treat substance use disorders because they believe some medications maintain the disease rather than treating it. Of concern, this viewpoint sometimes serves as a barrier for those who would benefit from medication. \u00a0<\/span>\r\n\r\n<span style=\"background-color: #ffffff\">Indeed, some 12 step meeting attendees suggest that MAT is inconsistent with sobriety (<a href=\"https:\/\/www.statnews.com\/2017\/10\/04\/medication-assisted-therapy-12-step\/\">https:\/\/www.statnews.com\/2017\/10\/04\/medication-assisted-therapy-12-step\/<\/a>). \u00a0The American Society of Addiction Medicine (ASAM) has weighed in, saying, \"<span>this so- called \u201cadvice\u201d from well-intended but misinformed members is not founded in scientific or 12-step philosophy and violates a long held 12- step policy of 'AA members should not give medical advice to each other'\" (see here for detailed explanation <a href=\"https:\/\/www.asam.org\/Quality-Science\/publications\/magazine\/read\/article\/2014\/06\/12\/twelve-step-recovery-and-medication-assisted-therapies\">https:\/\/www.asam.org\/Quality-Science\/publications\/magazine\/read\/article\/2014\/06\/12\/twelve-step-recovery-and-medication-assisted-therapies<\/a>). ASAM posits, since substance use disorder is a brain disease, some people appropriately require medication in order to attai<span style=\"background-color: #ffffff\">n sobriety.\u00a0 Evidence supports this contention.\u00a0 For example, on the issue of the use of pharmacotherapy to assist in controlled drinking, recent meta-analysis concluded that three medications showed controlled drinking outcomes superior to a placebo (Palpcuer et al., 2018).<\/span><\/span><\/span>\r\n<h4 class=\"import-Normal\" style=\"text-indent: 36pt\"><strong lang=\"en-GB\" xml:lang=\"en-GB\">Loss of Control Concept.<\/strong><\/h4>\r\n<p class=\"import-Normal\" style=\"text-indent: 36pt\"><span lang=\"en-GB\" xml:lang=\"en-GB\">The <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">original<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> disease model of addiction <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">expresses another point with which scholars and practitioners have taken issue: applying \u201closs of control\u201d as a defining criterion. The prior moral model attributed individuals\u2019 use\/misuse of alcohol, tobacco, or other drugs to moral failure or personality weakness, holding them \u201cpersonally responsible for creating suffering for themselves and others\u201d (Thombs, 2009, p. 561). The original disease model, as previously discussed, did not take a position on a person\u2019s initial decision to use a substance, but argued that the \u201cdisease\u201d may take over, eventually rendering an individual helpless to control the behavior. Heather (2017) has argued against the \u201ccompulsion\u201d aspect of the disease model where addictive behavior \u201cis said to be carried out against the will,\u201d and \u201cmarks the turning point from normal, recreational drug use to addictive drug use\u201d (p. 15). His counter-argument does not support a moral failure\/blame stance toward addiction; instead, he emphasized the power of environmental, contextual, and reinforcement paradigms operating to influence behavioral <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">choices related to continued engagement in substance misuse (or other addictive behaviors)<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">.<\/span> <span lang=\"en-GB\" xml:lang=\"en-GB\">One problem with the loss of control concept is that individuals may reframe it in terms of, \u201cI can\u2019t help myself,\u201d excusing themselves from taking responsibility for the behavior or taking steps toward recovery. Reinforcing the notion of each individual's personal responsibility to manage their health, despite disease is an important counterpoint.<\/span><\/p>\r\n<p class=\"import-Normal\" style=\"text-indent: 36pt\"><strong>Contemporary brain disease model and bio-psycho-social-spiritual perspective.<\/strong><\/p>\r\nAs previously noted, recognition of the brain-behavior nexus in the development and maintenance of addictive behavior is important and necessary to understanding, intervening around, and recovery involving addictive behavior and related problems. Evidence concerning the neurobiology of substance use and mechanisms involved in the transition to substance use disorders has expanded in many directions over the past two decades, contributing to a widening variety of treatment and prevention intervention strategies (Volkow &amp; Koob, 2015; Volkow, Koob, &amp; McLellan, 2016).\r\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">Proponents of <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">a<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> contemporary brain disease model of addiction<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> argue that:<\/span> <span lang=\"en-GB\" xml:lang=\"en-GB\">\u201cAfter centuries of efforts to reduce addiction and its related costs by punishing addictive behaviors failed to produce adequate results, recent basic and clinical research has provided clear evidence that addiction might be better considered and treated as an acquired disease of the brain\u201d (Volkow, <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Koob<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, &amp; McLellan, 2016<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, p. 364). The U.S. National Institute on Drug Abuse applies the following definition of addiction:<\/span><\/p>\r\n<p class=\"import-Normal\" style=\"margin-left: 36pt;margin-right: 36pt\"><em lang=\"en-GB\" xml:lang=\"en-GB\">\u201cAddiction is defined as a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. It is considered a brain disorder, because it involves functional changes to brain circuits involved in reward, stress, and self-control, and those changes may last a long time after a person has stopped taking drugs. Addiction is a lot like other diseases, such as heart disease. Both disrupt the normal, healthy functioning of an organ in the body, both have serious harmful effects, and both are, in many cases, preventable and treatable. If left untreated, they can last a lifetime and may lead to death\u201d <\/em><span lang=\"en-GB\" xml:lang=\"en-GB\">(<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">NIDA, 2018).<\/span><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">Chronic, relapsing diseases like diabetes or high blood pressure often have a strong behavioral health component\u2014just as substance use disorders. While these disease conditions may worsen over time, the outcome is not immutable\u2014<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">outcomes<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> can be affected by behavioral health interventions<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, as well as self-directed changes in <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">behavior<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> and\/or environment<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">.<\/span><\/p>\r\n\r\n<h1 class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\" style=\"background-color: #ffffff\">Bio-psycho-social-spiritual<\/span><\/h1>\r\n<p class=\"import-Normal\"><span style=\"background-color: #ffffff\"><span lang=\"en-GB\" xml:lang=\"en-GB\">Biology and psychology intersect where substances altering the brain\u2019s reward and emotional circuits influence individuals\u2019 experiences, learning, memory, affect, executive function, decision-making, expectancies, withdrawal symptoms, and cravings, with profound implications for continued engagement in addictive <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">behavior<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, as well as strategies for changing addictive behavior patterns.<\/span> <span lang=\"en-GB\" xml:lang=\"en-GB\">Understanding brain-<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">behavior<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> processes is necessary; however, this alone does not impart <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">sufficient<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> knowledge. Biological and psychological processes do not occur in a vacuum, but within complex, impactful social and spiritual contexts and physical environments. For example, evidence that early exposure to alcohol and other substance misuse increases the odds of developing a substance use disorder later in life (Odgers et al., 2008) invokes mechanisms of multiple types: changes to the brain (biology); learning, social learning, and expectancies (psychology); social norms and access (social context\/environment). Not only does recovery occur within social contexts (Heather et al., 2018), biological, psychological, and social interventions all may play a role. Furthermore, social, psychological, and spiritual interventions can influence neurobiological processes (Volkow, <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Koob<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, &amp; McLellan, 2016); biology does not confer destiny but has a powerful iterative relationship with the other domains. Viewing addictive behaviors from an integrated biopsychosocial framework is required and reflected throughout this book. <\/span><\/span><\/p>\r\n*Note that some contents presented in this chapter are both adapted from and informed the writing of an introductory chapter by Begun and Murray (<em>in press<\/em>), to the <em>Handbook of Social Work and Addictive Behavior<\/em> from Routledge.","rendered":"<h2 class=\"import-Normal\"><strong lang=\"en-GB\" xml:lang=\"en-GB\">Defining Addiction<\/strong><\/h2>\n<p><span lang=\"en-GB\" xml:lang=\"en-GB\">There is more i<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">nvolved in<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> defining substance misuse and SUD than the clinical diagnostic protocols presented in the DSM-5 and ICD-11. As a start, consider the American Society of Addiction Medicine policy statement defining addiction (ASAM, 2011):<\/span><\/p>\n<p class=\"import-Normal\" style=\"margin-left: 36pt;margin-right: 36pt\"><em lang=\"en-GB\" xml:lang=\"en-GB\">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. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one\u2019s behavior and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death (p. 1).<\/em><\/p>\n<p class=\"import-Normal\" style=\"text-align: right\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter\" src=\"https:\/\/pressbooks.ulib.csuohio.edu\/bestpracticesinsubstancemisusetreatment\/wp-content\/uploads\/sites\/106\/2019\/12\/image11-1.png\" alt=\"\" width=\"489\" height=\"103\" \/><\/p>\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">Important aspects of this definition <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">are recognition of:<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"><\/span><\/p>\n<ul>\n<li><span lang=\"en-GB\" xml:lang=\"en-GB\">the\u00a0<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">impact of addiction on biological, psychological\/emotional, social, interpersonal, and spiritual aspects of life<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">;<\/span><\/li>\n<li><span lang=\"en-GB\" xml:lang=\"en-GB\">the brain-behavior nexus in the development and maintenance of addictive behavior<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">;<\/span><\/li>\n<li><span lang=\"en-GB\" xml:lang=\"en-GB\">the common experience of cyclical relapse and remission, and <\/span><\/li>\n<li><span lang=\"en-GB\" xml:lang=\"en-GB\">the potential for problem progression. <\/span><\/li>\n<\/ul>\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">The ASAM definition reflects a <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">\u201c<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">disease model<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">\u201d<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> perspective\u2014a model popular in the United States and many other areas, but not without controversy and critics<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, particularly in other parts of the world<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">.<\/span><\/p>\n<h3 class=\"import-Normal\" style=\"text-indent: 36pt\"><strong lang=\"en-GB\" xml:lang=\"en-GB\">Original d<\/strong><strong lang=\"en-GB\" xml:lang=\"en-GB\">isease model of addiction.<\/strong><span lang=\"en-GB\" xml:lang=\"en-GB\"> <\/span><\/h3>\n<p class=\"import-Normal\" style=\"text-indent: 36pt\"><span lang=\"en-GB\" xml:lang=\"en-GB\">The original disease model of addiction emerged during the 1950s and 1960s regarding alcoholism, viewing addiction as a primary disease, not secondary to other psychological conditions (<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Hartje<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, 2009). The original disease model <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">of addiction <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">was hailed as an important, less stigmatizing alternative t<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">han the prevailing<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> moral model<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> that place<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">d<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> blam<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">e on <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">individuals for their addiction and<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> deem<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">ed<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> them<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> deserving of its consequences and punishment (Thombs, 2009). Viewing addiction as a disease, instead, allowed the person to <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">be seen as<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> the \u201cvictim\u201d of an illness, deserving of compassionate care and medically supervised treatment (Thombs, 2009). In th<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">e disease<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> model, an individual\u2019s choice to initially engage in substance<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> may have been freely<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> made; however, once initiated, the disease could take over: \u201cintense cravings are triggered via physiological mechanisms, and these cravings lead to compulsive overuse. This mechanism is beyond the personal control of the addict\u201d (Thombs, 2009, p. 561).<\/span><\/p>\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">Research by E. Morton <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Jellinek<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> was credited with providing early support for a disease model of addiction (<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Hartje<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, 2009). Based on a non-random sample of surveys completed by 98 men responding to an Alcoholics Anonymous newsletter, later expanded to include 2,000 histories, <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Jellinek<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> (1952) identified four progressive phases of the disease: the <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">prealcoholic<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> symptomatic, prodromal, crucial, and chronic phases. The<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">\u00a0\u201c<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Jellinek<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> Curve\u201d reflects how specific behaviors and experiences relate to the disease\u2019s progression and recovery<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">\u2014i<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">ts very design reflects the perception of a person \u201chitting bottom\u201d before being able to recover from addiction<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> (from <\/span><a class=\"rId23\" href=\"https:\/\/www.in.gov\/judiciary\/ijlap\/files\/jellinek.pdf\"><span class=\"import-Hyperlink\">https:\/\/www.in.gov\/judiciary\/ijlap\/files\/jellinek.pdf<\/span><\/a>)<span lang=\"en-GB\" xml:lang=\"en-GB\">.<\/span><\/p>\n<p class=\"import-Normal\" style=\"text-align: center\"><span lang=\"en-GB\" xml:lang=\"en-GB\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter\" src=\"https:\/\/pressbooks.ulib.csuohio.edu\/bestpracticesinsubstancemisusetreatment\/wp-content\/uploads\/sites\/106\/2020\/09\/image12.jpg\" alt=\"Addiction and Recovery: The Jellinek Curve\" width=\"766\" height=\"558\" \/><\/span><\/p>\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">Despite methodological weaknesses in the evidence, the original<\/span> <span lang=\"en-GB\" xml:lang=\"en-GB\">disease model became popular with many practitioners and Alcoholics Anonymous programs, introducing significant implications: <\/span><\/p>\n<ul>\n<li><span lang=\"en-GB\" xml:lang=\"en-GB\">alcoholism was viewed as a chronic, progressive, incurable disease;<\/span><\/li>\n<li><span lang=\"en-GB\" xml:lang=\"en-GB\">professional treatment was specified as necessary to control this incurable disease;<\/span><\/li>\n<li><span lang=\"en-GB\" xml:lang=\"en-GB\">abstinence was viewed as the only defense against recurrence and the only reasonable goal for a person with this disease;<\/span><\/li>\n<li><span lang=\"en-GB\" xml:lang=\"en-GB\">substituting a different drug for alcohol was expected to manifest the same disease symptoms and progression (<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Hartje<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, 2009).<\/span><\/li>\n<\/ul>\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">The original disease model and principles have greatly influenced assessment and treatment practices over the past 60 to 70 years.<\/span> <span lang=\"en-GB\" xml:lang=\"en-GB\">There exist several points around which the original disease model of addiction has been challenged.<br \/>\n<\/span><\/p>\n<h4 class=\"import-Normal\"><strong lang=\"en-GB\" xml:lang=\"en-GB\">Heterogeneity challenge to the original disease model<\/strong><strong lang=\"en-GB\" xml:lang=\"en-GB\">.<\/strong><span lang=\"en-GB\" xml:lang=\"en-GB\"> <\/span><\/h4>\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">L<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">ongitudinal studies documenting the natural course of alcoholism demonstrated significant inconsistencies with a disease progression premise:<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> multiple patterns were observed among men still alive 60 years after beginning the study, including continued alcohol abuse, stable abstinence, and return to asymptomatic\/controlled drinking (Vaillant, 2003). Tremendous individual variation exists in patterns of addictive behaviors, as well as the severity of problems experienced by individuals at different points in time. <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Jell<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">i<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">n<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">e<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">k<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> (1952) admitted that his was an \u201caverage trend\u201d model in which individuals do not necessarily exhibit all of the symptoms associated with a phase, may differ in the sequencing of symptoms, and may differ in the duration of each phase; furthermore, \u201cnonaddictive alcoholic\u201d individuals may experience the identified negative consequences of alcoholism without experiencing a loss of control over drinking, and women may experience the disease differently. <\/span><\/p>\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">This high degree of variability (heterogeneity) in expression called into question the perspective that alcoholism (or any<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> substance use disorder<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">) represents a single disease. Emphasis on the addiction\/dependence end of the continuum of substance misuse \u201chas resulted in a myopic view of substance abuse problems that has characterized them as progressive, irreversible, and only resolved through treatment\u201d (<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Sobell<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, 2007, p. 2). Observed heterogeneity <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">has <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">informed <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">the <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">diagnostic schedules\u2019 differentiations: different substances <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">(<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">and addictive behaviors <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">such as<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> gambling<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> disorder<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">) have distinct diagnostic codes. If \u201caddiction\u201d were a single uniform event there would be no need for multiple diagnostic categories<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">\u2014o<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">r different intervention strategies. <\/span><\/p>\n<h4 class=\"import-Normal\" style=\"text-indent: 36pt\"><strong lang=\"en-GB\" xml:lang=\"en-GB\">Subtypes versus stages of disease.<\/strong><\/h4>\n<p class=\"import-Normal\" style=\"text-indent: 36pt\"><span lang=\"en-GB\" xml:lang=\"en-GB\">There <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">exist marked differences in how <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">substance misuse\/SUDs<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> are expressed even within a single substance type. C<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">hallenging <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Jell<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">i<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">n<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">e<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">k\u2019s<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> stage model of alcoholism<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, for example,<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> is<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> evidence of heterogeneity in <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">\u201ctypes\u201d of alcoholism derived from <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">a national sample (U.S.)<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">. The investigators<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> based<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> their typology<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> on clinical characteristics of individuals meeting criteria for an alcohol <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">dependence per the DSM-IV-R criteria that preceded the DSM-5<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> (Moss, Chen, &amp; Yi, 2007). This analysis of U.S. National Epidemiological Survey on Alcohol and Related Conditions (NESARC) data led the authors to identify five \u201csubtypes\u201d of alcohol dependence, demonstrating <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">clinical <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">heterogeneity within the <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">single <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">diagnostic classification. The subtypes <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">they <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">identified were based on how participants clustered on diagnostic criteria, age of onset, family history, and presence of other co-occurring disorders. The five statistically determined clusters <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">they identified were<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> labelled<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">:<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> young adult, young antisocial, functional, intermediate familial, and chronic severe subtypes<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> (see Figure 1)<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">. The groups demonstrated differences in their patterns of drinking, help-seeking, and response to intervention, as well. This study, based on a large, nationally representative sample reflect<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">ed<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> heterogeneity among persons engaged in <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">a specific <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">addictive behavior, and the wisdom of avoiding stereotypes about them\u2014for instance, while the chronic severe subtype was the least common, it reflects a common stereotype of alcohol dependence.<\/span><\/p>\n<p class=\"import-Normal\"><strong><span lang=\"en-GB\" xml:lang=\"en-GB\">Figure 1. Subtypes of alcoholism (based on data from Moss, Chen, &amp; Yi, 2007).<\/span><\/strong><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-full wp-image-76\" src=\"https:\/\/pressbooks.ulib.csuohio.edu\/bestpracticesinsubstancemisusetreatment\/wp-content\/uploads\/sites\/106\/2020\/09\/Fig-1-Subtypes-of-alcoholism-1.png\" alt=\"Subtype of Alcoholism: pie chart featuring the following numbers: Chronic\/Severe: 9%, Young adult: 32%, young antisocial: 21%, functional: 19%, intermediate familial: 18%\" width=\"996\" height=\"533\" srcset=\"https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-content\/uploads\/sites\/106\/2020\/09\/Fig-1-Subtypes-of-alcoholism-1.png 996w, https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-content\/uploads\/sites\/106\/2020\/09\/Fig-1-Subtypes-of-alcoholism-1-300x161.png 300w, https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-content\/uploads\/sites\/106\/2020\/09\/Fig-1-Subtypes-of-alcoholism-1-768x411.png 768w, https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-content\/uploads\/sites\/106\/2020\/09\/Fig-1-Subtypes-of-alcoholism-1-65x35.png 65w, https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-content\/uploads\/sites\/106\/2020\/09\/Fig-1-Subtypes-of-alcoholism-1-225x120.png 225w, https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-content\/uploads\/sites\/106\/2020\/09\/Fig-1-Subtypes-of-alcoholism-1-350x187.png 350w\" sizes=\"auto, (max-width: 996px) 100vw, 996px\" \/><\/p>\n<p>&nbsp;<\/p>\n<h4 class=\"import-Normal\" style=\"text-indent: 36pt\"><strong lang=\"en-GB\" xml:lang=\"en-GB\">Treatment and the disease model. <\/strong><\/h4>\n<p class=\"import-Normal\" style=\"text-indent: 36pt\"><span lang=\"en-GB\" xml:lang=\"en-GB\">Additional important challenges to the disease model of addiction appear in the literature. <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">A<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">sserting that formal treatment for addiction is necessary has been challenged by evidence that many individuals experience significant, long-lasting improvement without engaging in formal treatment\u2014sometimes referred to as \u201cnatural recovery\u201d or \u201cself-change\u201d\u2014typically, persons whose alcohol misuse is not of the most severe dependant nature (<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Sobell<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, 2007). Little is known about natural recovery in other substance misuse, though some evidence for its existence appears in the literature (e.g., Chen, 2006; Erickson &amp; Alexander, 1989; Price, Risk, &amp; <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Spitznagel<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, 2001). Possibly, the necessity for engaging in formal treatment varies by individual, severity of the problem, and characteristics of the substances or addictive behaviors involved.<\/span><\/p>\n<h4 class=\"import-Normal\" style=\"text-indent: 36pt\"><span lang=\"en-GB\" xml:lang=\"en-GB\"><\/span><strong lang=\"en-GB\" xml:lang=\"en-GB\">Abstinence only based on disease model.<\/strong><span lang=\"en-GB\" xml:lang=\"en-GB\"> <\/span><\/h4>\n<p class=\"import-Normal\" style=\"text-indent: 36pt\"><span style=\"background-color: #ffffff\"><span lang=\"en-GB\" xml:lang=\"en-GB\">There are two parts of an abstinence only perspective that need to be unpacked. \u00a0The first pertains to controlled drinking, and the second pertains to medication used to treat substance use disorders.<\/span><\/span><\/p>\n<p class=\"import-Normal\" style=\"text-indent: 36pt\"><span style=\"background-color: #ffffff\"><span lang=\"en-GB\" xml:lang=\"en-GB\">V<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">iewing abstinence<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> from substance use<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> as the only defense against <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">\u201cdisease\u201d <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">recurrence and the only reasonable goal for a person experiencing a substance use disorder has been challenged. Complete abstinence from all psychoactive substances is at one end of a continuum in treatment strategies, commonly applied in U.S. medical practice (Glenn &amp; Wu, 2009). A debated position is that the continuum of recovery includes controlled substance use, including the type of substance which a person previously used problematically. For some individuals, their goal is\u00a0safer, more controlled use, and harm reduction.\u00a0<\/span><\/span><\/p>\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">\u00a0 <strong>Controlled drinking<\/strong>. <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">T<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">he word \u201csobriety\u201d originally<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, historically<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> implied temperate, moderated indulgence, not necessarily complete abstinence\u2014an abstinence interpretation emerged during the 1900s (Glenn &amp; Wu, 2009). Evidence since the 1970s indicates that some individuals achieve controlled drinking despite having previously engaged in an \u201cout-of-control\u201d drinking pattern, contrary to \u201cthe prevailing belief that any alcohol consumption causes an inevitable loss of control over one\u2019s alcohol use\u201d (Klingemann, 2016, p. 436). The debate about \u201ccontrolled drinking,\u201d \u201creduced-risk drinking,\u201d and \u201cmoderation management\u201d continues, and it is unclear how the evidence for and against it might apply to other substances and addictive behaviors.\u00a0 Reduced-risk drinking (RRD) is seen in many Western European countries as one pathway out of addiction, and a legitimate treatment goal (Klingemann, 2016).\u00a0 Importantly, the ability to engage in controlled use following a substance use disorder may vary by individual, severity of the problem, and characteristics of the substances or addictive behaviors involved.\u00a0 Unsuccessful attempts at controlled use suggest the need for abstinence as a treatment goal.\u00a0 Conversely, if an individual is able to resolve the negative consequences of use, and sustain this change over a long period of time through controlled use, is this an acceptable resolution?<\/span><\/p>\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\"><strong>Medication used to treat substance use disorders.<\/strong>\u00a0<\/span><\/p>\n<p><span style=\"background-color: #ffffff\">Closely associated with the abstinence issue lies an additional point of contention with the disease model of addiction&#8211;the belief that substituting medication for the primary addictive substance simply continues manifestation of the same disease of &#8220;addiction.&#8221;<\/span><\/p>\n<p><span style=\"background-color: #ffffff\">\u00a0This stance contributes to the hesitancy expressed by some practitioners to promote the use of medically assisted treatment (MAT) and pharmacotherapies to treat substance use disorders because they believe some medications maintain the disease rather than treating it. Of concern, this viewpoint sometimes serves as a barrier for those who would benefit from medication. \u00a0<\/span><\/p>\n<p><span style=\"background-color: #ffffff\">Indeed, some 12 step meeting attendees suggest that MAT is inconsistent with sobriety (<a href=\"https:\/\/www.statnews.com\/2017\/10\/04\/medication-assisted-therapy-12-step\/\">https:\/\/www.statnews.com\/2017\/10\/04\/medication-assisted-therapy-12-step\/<\/a>). \u00a0The American Society of Addiction Medicine (ASAM) has weighed in, saying, &#8220;this so- called \u201cadvice\u201d from well-intended but misinformed members is not founded in scientific or 12-step philosophy and violates a long held 12- step policy of &#8216;AA members should not give medical advice to each other'&#8221; (see here for detailed explanation <a href=\"https:\/\/www.asam.org\/Quality-Science\/publications\/magazine\/read\/article\/2014\/06\/12\/twelve-step-recovery-and-medication-assisted-therapies\">https:\/\/www.asam.org\/Quality-Science\/publications\/magazine\/read\/article\/2014\/06\/12\/twelve-step-recovery-and-medication-assisted-therapies<\/a>). ASAM posits, since substance use disorder is a brain disease, some people appropriately require medication in order to attai<span style=\"background-color: #ffffff\">n sobriety.\u00a0 Evidence supports this contention.\u00a0 For example, on the issue of the use of pharmacotherapy to assist in controlled drinking, recent meta-analysis concluded that three medications showed controlled drinking outcomes superior to a placebo (Palpcuer et al., 2018).<\/span><\/span><\/p>\n<h4 class=\"import-Normal\" style=\"text-indent: 36pt\"><strong lang=\"en-GB\" xml:lang=\"en-GB\">Loss of Control Concept.<\/strong><\/h4>\n<p class=\"import-Normal\" style=\"text-indent: 36pt\"><span lang=\"en-GB\" xml:lang=\"en-GB\">The <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">original<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> disease model of addiction <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">expresses another point with which scholars and practitioners have taken issue: applying \u201closs of control\u201d as a defining criterion. The prior moral model attributed individuals\u2019 use\/misuse of alcohol, tobacco, or other drugs to moral failure or personality weakness, holding them \u201cpersonally responsible for creating suffering for themselves and others\u201d (Thombs, 2009, p. 561). The original disease model, as previously discussed, did not take a position on a person\u2019s initial decision to use a substance, but argued that the \u201cdisease\u201d may take over, eventually rendering an individual helpless to control the behavior. Heather (2017) has argued against the \u201ccompulsion\u201d aspect of the disease model where addictive behavior \u201cis said to be carried out against the will,\u201d and \u201cmarks the turning point from normal, recreational drug use to addictive drug use\u201d (p. 15). His counter-argument does not support a moral failure\/blame stance toward addiction; instead, he emphasized the power of environmental, contextual, and reinforcement paradigms operating to influence behavioral <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">choices related to continued engagement in substance misuse (or other addictive behaviors)<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">.<\/span> <span lang=\"en-GB\" xml:lang=\"en-GB\">One problem with the loss of control concept is that individuals may reframe it in terms of, \u201cI can\u2019t help myself,\u201d excusing themselves from taking responsibility for the behavior or taking steps toward recovery. Reinforcing the notion of each individual&#8217;s personal responsibility to manage their health, despite disease is an important counterpoint.<\/span><\/p>\n<p class=\"import-Normal\" style=\"text-indent: 36pt\"><strong>Contemporary brain disease model and bio-psycho-social-spiritual perspective.<\/strong><\/p>\n<p>As previously noted, recognition of the brain-behavior nexus in the development and maintenance of addictive behavior is important and necessary to understanding, intervening around, and recovery involving addictive behavior and related problems. Evidence concerning the neurobiology of substance use and mechanisms involved in the transition to substance use disorders has expanded in many directions over the past two decades, contributing to a widening variety of treatment and prevention intervention strategies (Volkow &amp; Koob, 2015; Volkow, Koob, &amp; McLellan, 2016).<\/p>\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">Proponents of <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">a<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> contemporary brain disease model of addiction<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> argue that:<\/span> <span lang=\"en-GB\" xml:lang=\"en-GB\">\u201cAfter centuries of efforts to reduce addiction and its related costs by punishing addictive behaviors failed to produce adequate results, recent basic and clinical research has provided clear evidence that addiction might be better considered and treated as an acquired disease of the brain\u201d (Volkow, <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Koob<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, &amp; McLellan, 2016<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, p. 364). The U.S. National Institute on Drug Abuse applies the following definition of addiction:<\/span><\/p>\n<p class=\"import-Normal\" style=\"margin-left: 36pt;margin-right: 36pt\"><em lang=\"en-GB\" xml:lang=\"en-GB\">\u201cAddiction is defined as a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. It is considered a brain disorder, because it involves functional changes to brain circuits involved in reward, stress, and self-control, and those changes may last a long time after a person has stopped taking drugs. Addiction is a lot like other diseases, such as heart disease. Both disrupt the normal, healthy functioning of an organ in the body, both have serious harmful effects, and both are, in many cases, preventable and treatable. If left untreated, they can last a lifetime and may lead to death\u201d <\/em><span lang=\"en-GB\" xml:lang=\"en-GB\">(<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">NIDA, 2018).<\/span><\/p>\n<p class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\">Chronic, relapsing diseases like diabetes or high blood pressure often have a strong behavioral health component\u2014just as substance use disorders. While these disease conditions may worsen over time, the outcome is not immutable\u2014<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">outcomes<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> can be affected by behavioral health interventions<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, as well as self-directed changes in <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">behavior<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> and\/or environment<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">.<\/span><\/p>\n<h1 class=\"import-Normal\"><span lang=\"en-GB\" xml:lang=\"en-GB\" style=\"background-color: #ffffff\">Bio-psycho-social-spiritual<\/span><\/h1>\n<p class=\"import-Normal\"><span style=\"background-color: #ffffff\"><span lang=\"en-GB\" xml:lang=\"en-GB\">Biology and psychology intersect where substances altering the brain\u2019s reward and emotional circuits influence individuals\u2019 experiences, learning, memory, affect, executive function, decision-making, expectancies, withdrawal symptoms, and cravings, with profound implications for continued engagement in addictive <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">behavior<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, as well as strategies for changing addictive behavior patterns.<\/span> <span lang=\"en-GB\" xml:lang=\"en-GB\">Understanding brain-<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">behavior<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> processes is necessary; however, this alone does not impart <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">sufficient<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\"> knowledge. Biological and psychological processes do not occur in a vacuum, but within complex, impactful social and spiritual contexts and physical environments. For example, evidence that early exposure to alcohol and other substance misuse increases the odds of developing a substance use disorder later in life (Odgers et al., 2008) invokes mechanisms of multiple types: changes to the brain (biology); learning, social learning, and expectancies (psychology); social norms and access (social context\/environment). Not only does recovery occur within social contexts (Heather et al., 2018), biological, psychological, and social interventions all may play a role. Furthermore, social, psychological, and spiritual interventions can influence neurobiological processes (Volkow, <\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">Koob<\/span><span lang=\"en-GB\" xml:lang=\"en-GB\">, &amp; McLellan, 2016); biology does not confer destiny but has a powerful iterative relationship with the other domains. Viewing addictive behaviors from an integrated biopsychosocial framework is required and reflected throughout this book. <\/span><\/span><\/p>\n<p>*Note that some contents presented in this chapter are both adapted from and informed the writing of an introductory chapter by Begun and Murray (<em>in press<\/em>), to the <em>Handbook of Social Work and Addictive Behavior<\/em> from Routledge.<\/p>\n","protected":false},"author":7,"menu_order":3,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[48],"contributor":[],"license":[],"class_list":["post-84","chapter","type-chapter","status-publish","hentry","chapter-type-numberless"],"part":60,"_links":{"self":[{"href":"https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-json\/pressbooks\/v2\/chapters\/84","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-json\/wp\/v2\/users\/7"}],"version-history":[{"count":23,"href":"https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-json\/pressbooks\/v2\/chapters\/84\/revisions"}],"predecessor-version":[{"id":1010,"href":"https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-json\/pressbooks\/v2\/chapters\/84\/revisions\/1010"}],"part":[{"href":"https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-json\/pressbooks\/v2\/parts\/60"}],"metadata":[{"href":"https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-json\/pressbooks\/v2\/chapters\/84\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-json\/wp\/v2\/media?parent=84"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-json\/pressbooks\/v2\/chapter-type?post=84"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-json\/wp\/v2\/contributor?post=84"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/wp-json\/wp\/v2\/license?post=84"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}