Blending Perspectives and Building Common Ground

A Report to Congress on Substance Abuse and Child Protection
April 1999

Chapter 2

Understanding Addiction, Substance Abuse Treatment, and Recovery

Substance abuse is a major public health problem that affects millions of people and places enormous financial and social burdens on society. It destroys families, damages the economy, victimizes communities, and places extraordinary demands on the education, criminal justice, and social service systems. To understand the connections between substance abuse problems and the child welfare system, it is important that substance abuse and the medical, social, and economic problems that are associated with the use and misuse of alcohol and other drugs, as well as addiction to these drugs, be clearly understood.

The Spectrum of Substance Use, Abuse, and Addiction

The use of alcohol and other drugs is a multifaceted phenomenon, varying with the individual's level of use and the dysfunction he or she experiences as a result of his or her use. The range includes the following:

Drug experimentation: The use of alcohol or illicit drugs at any time for experimentation. While in and of itself experimentation may not appear to be abusive, even a single episode of experimentation can result in harm to self or to others. For example, the use of alcohol or other drugs at all during pregnancy could result in harm to the fetus, the experimental use of alcohol or other drugs while driving can result in harm to the user as well as others, or a child may be injured when left unsupervised while a parent is intoxicated. Also, if experimental use continues or serves as a gateway to additional use, as often it does, patterns of alcohol and other drug abuse may develop.
Social use of drugs: Use of any drug or combination of drugs in social situations, or for social reasons. If such social use causes any harm, physical or otherwise, to the user or others, it is also considered abuse. Social use of alcohol or other drugs often leads to further and elevated use.
Binge drinking: Heavy use of alcohol periodically. This can result in harm to the physical health of self and others, and negative behavioral consequences, which may result in bodily harm to self or others. For example, harm may be caused by heavy periodic use of alcohol or other drugs while pregnant, driving while intoxicated, or either neglecting or inflicting violence on self and others while under the influence. The National Household Survey on Drug Abuse defines binge alcohol use as drinking five or more drinks on the same occasion at least one day in the past 30 days.
Substance abuse: The characteristic feature of abuse is the presence of dysfunction related to the person's use of alcohol or other drugs. One standard definition (U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration [HHS/SAMHSA], 1994) describes it as "the use of a psychoactive drug to such an extent that its effects seriously interfere with health or occupational and social functioning." Abuse may or may not involve physiologic dependence or tolerance. For example, use of substances in weekend binge patterns may not involve physiologic dependence; however, it may have adverse affects on a person's and possibly others' lives. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) produced by the American Psychiatric Association is used across the medical and mental health fields for diagnosing both substance abuse and mental health disorders. According to the DSM-IV, substance abuse is "a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by" a variety of possible symptoms of impairment. Neglect of children is specifically listed as a potential symptom of substance abuse (American Psychiatric Association, 1994).
Addiction or Chemical Dependency: With continued use, many persons' use or abuse of alcohol or other drugs becomes addiction, a disease in which the substances have caused changes in a person's body, mind, and behavior. As a result of this disease, addicted persons are unable to control their use of substances, despite the bad things that happen when they use them. Addiction may be a chronic, relapsing disorder and if the disease process progresses, recovery becomes more difficult. Chemical dependency occurs most frequently in those who have a family history of the disease. Chemical dependency may cause death if the person does not completely abstain from using alcohol and other mood-altering drugs (HHS/SAMHSA, 1996a). The DSM-IV distinguishes dependence from abuse primarily by the presence of more abuse symptoms (three or more rather than at least one), and the possible presence of tolerance (needing more of the substance for the same intoxicating effect) or withdrawal (physical symptoms when the substance is not used).

The American Society of Addiction Medicine describes drug dependence as having two possible components: 1) psychological dependence and 2) physical dependence. Psychological dependence centers on the user's need of a drug to reach a level of functioning or feeling of well-being. Due to the subjective nature of this term, it is not very useful in making a diagnosis. Physical dependence, however, refers to the issues of physiologic dependence, establishment of tolerance, and evidence of an abstinence syndrome or withdrawal upon cessation of alcohol or other drug use. Tolerance, dependence, and withdrawal develop differently depending on the particular substance (HHS/SAMHSA, 1994).

Myths and Facts About Addiction and Treatment

Myth:: Addiction is a bad habit, the result of moral weakness and overindulgence.
Fact:: Addiction can be a chronic, life-threatening condition, like atherosclerosis, hypertension or adult diabetes. Addiction has roots in genetic susceptibility, social circumstance, and personal behavior.

Myth:: If an addicted person has enough willpower, he or she can stop abusing alcohol or other drugs.
Fact:: Most people addicted to alcohol and other drugs cannot simply stop using them, no matter how strong their inner resolve. Most need one or more courses of structured substance abuse treatment to reduce or end their dependence on alcohol and/or other drugs.

Myth:: Many people relapse, so treatment obviously doesn't work.
Fact:: Like virtually any other medical treatment, addiction treatment cannot guarantee lifelong health, although nearly one-third of clients achieve abstinence from their first treatment attempt. Relapse, often a part of the recovery process, is always possible and treatable. Even if a person never achieves perfect abstinence, addiction treatment can reduce the number and duration of relapses, minimize related problems such as crime and poor overall health, reduce impact of parental addiction on children, improve the individual's and his or her family's ability to function in daily life, and strengthen the individual's ability to cope with the next temptation or craving. These improvements reduce the health, social, and economic costs of addiction.

Substance Abuse Treatment and Recovery

In order to understand the treatment that is needed for addiction, it is important to emphasize that medical experts today generally consider alcohol and other drug addiction to be a disease that, while treatable, is chronic and relapsing. Because dependency on alcohol and other drugs creates difficulties in one's physical, psychological, social, and economic functioning, treatment must be designed to address all of these areas. Addiction and its related problems can be treated successfully, but no single treatment works for all substances, nor for all substance abusers.

It is important to note that not all persons in recovery for substance abuse relapse. Nearly one-third achieve permanent abstinence from their first attempt at recovery. An additional one-third have brief periods of substance use but eventually achieve long-term abstinence, and one-third have chronic relapses that result in premature death from chemical addiction and related consequences. These statistics are consistent with the life-long recovery rates of any chronic lifestyle-related illness (HHS/SAMHSA, 1996a).

Substance abuse treatment refers to a broad range of activities or services, including identification of the problem (and engaging the individual in treatment); brief interventions; assessment of substance abuse and related problems including histories of various types of abuse; diagnosis of the problem(s); and treatment planning, including counseling, medical services, psychiatric services, psychological services, social services and follow-up for persons with alcohol or other drug problems (Institute of Medicine, 1990).

Substance abuse treatment may be based on one of several traditional approaches: the Medical Model which focuses on the recognition of addiction as a bio/psycho/social disease, the need for life-long abstinence, and the use of an ongoing recovery program to maintain abstinence; the Social Model which focuses more on the need for long-term abstinence and the need for self-help recovery groups to maintain sobriety; and the Behavioral Model which focuses more on diagnosis and treatment of other problems or conditions that can interfere with recovery (HHS/SAMHSA, 1996a). Many programs use a combination of some aspects of the various models in order to facilitate the most appropriate treatment for the individual and to give patients options. Others also include innovative non-traditional models of treatment such as acupuncture and traditional healing practices associated with specific cultural groups.

Treatment may occur in various settings, such as inpatient, hospital-based programs; short- and long-term residential programs; or outpatient programs; and may be augmented by self-help/12-step and other support groups. Treatment may also use a combination of therapies, such as pharmacological therapy to treat certain addictions (for example the use of methadone for heroin addiction or the use of antabuse to treat alcoholism); use of psychological therapy or counseling, education and social learning theories; and non-traditional healing methods such as acupuncture. Treatment may extend over the course of weeks, months, or years, depending on the severity of the problems and the level of burden created by clients' multiple disorders such as alcoholism, other drug addiction, HIV/AIDS, mental illness (especially depression), and serious physical illnesses. The type and intensity of treatment depend on the patient's psychological, physical, and social problems; the stage (or severity) and type of addiction; personality traits; and social skills before the onset of addiction (HHS/SAMHSA, 1996a).

The concepts of treatment and recovery are not one and the same. However, treatment is a very important part of the recovery process. When the formal treatment component (s) are completed, whether it be outpatient, inpatient or short- or long-term residential treatment, this is not the end for anyone with an addiction problem, much less for an addicted woman with children. Recovery is a lifelong process that takes place over time and often in specific stages. In addition to abstinence, recovery includes a full return to bio/psycho/social functioning (HHS/SAMHSA, 1996a).

One widely accepted model of recovery, known as the Developmental Model, identifies six stages that addicted individuals must undergo for long-term recovery:

Transition, the period of time needed for the addicted individual to come to grips with the realization that safe use of alcohol or other drugs for them is not possible;
Stabilization, during which the chemically dependent person experiences physical withdrawal and other medical problems and learns how to separate from people, places and things that promote substance abuse;
Early recovery, when an individual faces the need to establish a chemical-free lifestyle and build relationships that support long-term recovery;
Middle recovery, seen as time for the development of a balanced lifestyle where repairing past damage is important;
Late recovery, during which the individual identifies and changes mistaken beliefs about oneself, others and the world that caused or promoted irrational thinking; and
Maintenance, the lifelong process of continued growth, development, and managing routine life problems.

Recovery is very complex, is not exempt from vulnerabilities, and requires a long-term commitment. This important part of the treatment continuum must be taken into account in the design of training programs for providers of substance abuse treatment and those of child welfare services. The complexities of recovery must be understood as well as the compelling need to address the issues of children and addicted parents and other family members. It is often said in the recovery communities that the whole family is in recovery because many changes affecting the entire family system will necessarily occur as the recovering person embarks on this lifelong journey of well being. However, many programs do not include a specific focus on parenting and family dynamics.

With respect to women in particular, additional problems emerge in early recovery, including problems related to parenting, to trauma resulting from physical or sexual abuse, or to mental illness. Together with the model described above, a woman's recovery will only be successful to the extent that the other issues which precipitate or relate to the abuse of alcohol or other drugs are also ameliorated. That is to say, if a woman who is newly drug-free returns to a hostile, abusive environment, to high levels of stress in raising one or more children alone, to unsafe housing and insecurity in the employment arena, and with minimal resources for physical and mental health care and other basic needs, recovery will be difficult. Under such circumstances recovery will require ongoing counseling, attendance in self-help and other support groups and accessibility to other available resources. Child welfare workers must become aware of the implications and critical importance of these factors to overall treatment for women, in particular as they relate to identifying proper services for them and their children.

Understanding Relapse and Factors Associated with Relapse

Relapse is not an isolated event, but rather a process whereby an individual becomes dysfunctional or unable to cope with life in sobriety, and thus can no longer avoid using alcohol or other drugs. This process of becoming dysfunctional may lead to renewed alcohol or other drug use, physical or emotional collapse, or even suicide. The process is marked by predictable and identifiable warning signs that begin long before the return to use or collapse occurs. Progressively increased distress levels in any one of the problem areas — physical, psychological or social — can lead to physical or emotional collapse, resulting in relapse. These symptoms increase and intensify unless the individual returns to the use of alcohol or other drugs (HHS/SAMHSA, 1996a). One particular warning in early recovery occurs when a recovering person begins to seek out situations involving people who use alcohol or other drugs.

Given that addiction can be a chronic, progressive disorder often characterized by relapse, and given the fact that women who relapse may be in particular need of intensive treatment and continued support, the opportunity to reenter treatment must remain open. Continued relapse may point to a more serious disorder that was not initially diagnosed, such as post traumatic stress syndrome resulting from past sexual or physical abuse or current abuse. In order to address these and other issues in women's lives, such as stress connected with being a single parent, low income, being identified as a maltreating parent, and having few social resources, any or all of which may bring about relapse, separate attention to these issues is needed — attention that extends beyond the substance abuse treatment process. In order to prevent relapse, the client may have to continue addressing these issues for years after leaving treatment. Formal relapse prevention components that offer means for early detection of relapse and tools for intervention should be included in every treatment program.

Impact of Substance Abuse on the Individual, Family, and Community

Substance abuse affects and costs the individual, the family, and the community in significant, measurable ways including loss of productivity and unemployability; impairment in physical and mental health; reduced quality of life; increased crime; increased violence; abuse and neglect of children; dependence on non-familial support systems for survival; and expenses for treatment. The physical and mental health and social consequences of alcohol and other drug use by women can seriously affect their lives and those of their families (HHS/SAMHSA, 1997a). Not only are women, especially young women, beginning to close the gap between female and male consumption of alcohol and other drugs, they suffer earlier and more serious consequences. Women become intoxicated and addicted more quickly than men and develop related diseases earlier (National Center on Addiction and Substance Abuse, 1996). As will be described more fully in Chapter 5, children also bear the burden of biological and environmental consequences of parental substance abuse.

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