Alcohol and Substance Use Disorders in Veterinary Medicine Part 2

In the previous article, Alcohol and Substance Use Disorders in Veterinary Medicine Part 1, we discussed the diagnostic criteria for alcohol and substance use disorders; the prevalence and costs associated with alcohol and substance use disorders; and the impact on veterinary medicine. Today, we’ll look at the history of addiction treatment in the U.S.; the advancements in the neurobiology of addiction; and the impact of the Americans with Disability Act of 1990 on addiction.

History of alcohol and substance use disorders in the U.S.

Many of us are familiar with the old stereotypes and language used to describe someone who has an addiction to mood-altering substances. These stereotypes no longer hold true. In fact, after examining the history of addiction and treatment in the U.S., we know those stereotypes were never true. 

The stigma created by those stereotypes likely did harm by stigmatizing people in need of help. Terms like lush, druggie, tweaker, junkie, and drunkard are belittling and emphasize personal weakness while ignoring the complex circumstances that contribute to a substance abuse disorder. Unfortunately, some of these words are still commonly used today. 

The U.S. has a well-documented history of AUD/SUD treatment that dates from 1784.[i] While beyond the scope of this article, many of the attitudes and approaches taken with AUD/SUD were rooted in a moralistic approach, that was at best naive and at worst dangerous. 

Examples of the AUD/SUD treatments in the U.S. from the 18th through the early 20th Century were voluntary sterilization, sedatives, spinal puncture, morphine (Carney Common Sense Opiate Cure, St. Anne’s Morphine Cure), and injections of glucose and insulin.[i] The “Swedish Treatment” was used in the late 1880s in sanatoriums to induce an aversion to alcohol by encouraging men to consume alcohol, including adding it to their beverages and food. Their clothing and bedding were saturated in alcohol with the overall goal of having them beg to be given water.

Fortunately, the 1990’s brought new advances in neurobiology and addiction with the advent of brain imagining, leaving no doubt that both alcohol and substance use disorders are diseases that affect the brain, rather than moral failings or personal shortcomings.

Neurobiology of addiction

Today, we know an alcohol or substance use disorder is influenced by biological and environmental factors (genetic influences, family, trauma, etc.) and there is no one primary factor that causes someone to have an addiction. Genetic variants and early life stress have been found to be associated with susceptibility and vulnerability to addiction.[ii]

Scientists and researchers can now use imaging studies to directly observe how the human brain is affected by alcohol and other mood-altering substances. Listed below are the brain imagining techniques used and a description of the images produced that help scientists and researchers understand the effects of alcohol and mood-altering substances on the brain. 

• Structural MRI: Map reduced gray matter in various regions of the brain as a result of drug use.  Chronic exposure to alcohol and drugs can enlarge or shrink some regions of the brain, helping to understand where drugs exert their effects;

• Functional MRI (fMRI): Measure blood flow and oxygen use.  Drug exposure can be seen activating brain regions affecting emotional processing and cognition;

• Magnetic Resonance Spectroscopy (MRS): Measure changes in biochemicals in the brain and detect drug metabolites.  Help identify drug-related biochemical changes that damage brain cells;

• Positron Emission Tomography (PET): Can see the effects of drugs on the various regions of the brain and which areas of the brain are inactive;

• Single Photon Emission Computed Tomography (SPECT): Shows toxic exposure to drugs and alcohol.[iii]

The neuroimaging techniques show how the brain is impacted by alcohol and various substances that directly affect a person’s decision-making ability and behavior.[iv] For example, we now know mood-altering substances help stimulate the release of dopamine (a neurotransmitter that plays a role in pleasurable reward and motivation) in the brain. Dopamine reinforces the desire to continue taking drugs, and also creates a learned response to alcohol or drug use.[ii]

The advent of neuroimaging helped increase our understanding of the physiological impact and debilitating effects of mood-altering substances in the brain. However, prior to 2008 AUD and SUD were not considered a disability and the economic implications of lost wages and careers was for many an impediment to seeking treatment.

American with Disabilities Act

The Americans with Disability Act of 1990 (ADA) was seen as a pivotal point for disability rights in the U.S. With its passage, the ADA banned discrimination based on disability and those with disabilities could no longer be denied access to employment, school, or transportation.  For a more information, please visit the U.S. Equal Employment Opportunity Commission (https://www.eeoc.gov/disability-discrimination).

By the end of the 1990’s, the ADA was seen as having a limited definition of “disability” as well as limiting the accommodations made to employees with disabilities.  The Americans with Disabilities Act Amendments Act (ADAAA) of 2008 broadened the “scope of protection” and the definition of “disability” as one that “substantially limits a major life activity” (p. 3).[v] With the neurological impacts of mood-altering substances documented through neuroimaging, addiction was also included in the definition of a disability. 

The ADAAA (2008) provides the criteria allowing a person to return to work who has an AUD and/or SUD. In order to return to work the employee must no longer be using mood-altering substances or misusing prescription medication such as opiates, anxiolytics, etc, and they must have completed treatment or be engaged in a drug rehabilitation program. Some employers may require toxicology tests to screen for mood-altering substances.  For a more detailed description of how the ADAAA applies to addiction and employment,[vi] please visit (https://adata.org/factsheet/ada-addiction-and-recovery)

Conclusion

We discussed the history of addiction treatment in the U.S.; the advancements in the neurobiology of addiction; and the Americans with Disability Act of 1990. We learned our early views of addiction and treatment were based on a moralistic approach that stigmatized the person suffering with an addiction. And finally, how our definition of disability has evolved to now include addiction.

In the third and final article, we’ll look at how addiction in safety-sensitive professionals such as veterinary medicine is addressed.  We’ll also explore the criteria used to make AUD/SUD assessments as well as the levels of care, and the role of Professionals Health Programs in monitoring.

Endnotes:

[i] White, W.L.  (1998).  Slaying the dragon: The history of addiction treatment and recovery in America.  Normal, IL, Chestnut Health Systems Publication.

[ii] Volkow, N.D. and Boyle, M.  (2018).  Neuroscience of addiction: Relevance to prevention and treatment.  American Journal of Psychiatry, 175: 729-740.  doi: 10.1176/appi.ajp.2018.17101174 

[iii] Fowler, J.S., Volkow, N.D., Kassed, C.A., Chang, L.  (2007).  Imaging the addicted brain.  Science & Practice Perspectives, 3(2), 4-16.  doi: 10.1151/spp07324

[iv] Volkow, N.D., Koob, G.F., and McLLean, A.T.  (2016).  Neurobiologic advances from the brain disease model of addiction.  New England Journal of Medicine, 374: 363-371.  DOI: 10.1056/NEJMra1511480

[v] O’Hara, R.J. and Regne, A.A.  (2020).  Is addiction a disability under the ADAAA?  Retrieved on May 16, 2022: https://www.ebglaw.com/wp-content/uploads/2020/11/OHara-Is-Addiction-a-Disability-under-the-ADAAA-Article-November-2020.pdf

[vi] ADA National Network.  (2021).  The ADA, addiction and recovery.  New England ADA Center. National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant numbers 90DP0087 and 90DP0086).  Retrieved on May 16, 2022: https://adata.org/factsheet/ada-addiction-and-recovery