Instructions attached with the class readings and resources Topic 1: History, Etiology, And Substance And

Instructions attached with the class readings and resources
Topic 1: History, Etiology, And Substance And Process Addiction
Capuzzi, D. & Stauffer, M. (Ed.). (2019). Foundations of addictions counseling (4th ed.). Pearson ISBN-13: 9780135166932
Read Chapters 1, 2, and 3 in Foundations of Addictions Counseling.
Watch “Addiction Neuroscience,” in Addition video, by PBS (Producer), from the Films Media Group (2018).
Watch “The Addictive Personality,” from Films on Demand (2007).
Explore “Commonly Used Drug Chart,” on the National Institute on Drug Use website (2020).
Explore the “Drug Guide” on the Partnership to End Addiction website (2021).
Watch “From the CEO: Chris’s Story of Recovery – NAMI (National Alliance on Mental Illness),” from National Alliance of Mental Illness (2021). 
Read “Prescription Opioids (Oxy/Percs),” on the Commonly Used Drugs Charts webpage, of the National Institute on Drug Abuse (2020).
Watch “Screening and Treatment for Co-Occurring Mental Health and Substance Use Disorders,” from Substance Abuse and Mental Health Services Administration (2021).
Explore the Substance Abuse and Mental Health Services Administration (SAMHSA) website.
COMMENTARYArecenthistoryofopioiduseintheUS:ThreedecadesofchangeLindseyE.Dayer,JacobT.Painter,KelseyMcCain,JarrodKing,JuliaCullen,andHowellR.FosterDepartmentofPharmacyPractice,UniversityofArkansasforMedicalSciencesCollegeofPharmacy,LittleRock,Arkansas,USAABSTRACTBackground:TheopioidepidemicintheUnitedStatesisaproblemthathasdevelopedoverdecades.Whileclinical,regulatory,andlegislativechangeshavebeenimplementedtocom-batthisissue,changeswillnotbeimmediate.Moreover,thechangesthathavebeencarriedoutmayhaveunintendednegativeconsequencessuchasincreaseduseofillicitopioids(e.g.,heroinandsynthetics)andchallengesineffectiveandappropriatepainmanagement.Objectives:ThisreviewfocusesonthelastthreedecadesandpresentskeychangestheUnitedStateshasseenintheuseofopioids.Conclusions/Importance:TherehavebeennumerouspolicychangesandprogramsaimedatdecreasingopioiduseandabuseintheUnitedStates;however,itwilltakeamajorshiftinthemindsetofclinicians,thegeneralpublic,andpolicymakerstoalleviatethisepidemic.KEYWORDSOpioid;addiction;history;substanceabuse;opioidpolicy;opioidusedisorder;substanceusedisorderIntroductionOneofthemostprevalentpainconditionsintheUnitedStatesischronicpain,affectingcloseto100millionadults(Gaskin&Richard,2012;Tompkins,Hobelmann,&Compton,2017).Patientswithchronicpainandotherpainsyndromesmayhavedecreasedqualityoflifeandbeatanincreasedriskofdepres-sionandsuicide(Barry,Pilver,Hoff,&Potenza,2013;Fine,2011;Gerrits,vanOppen,vanMarwijk,Penninx,&vanderHorst,2014;Hassett,Aquino,&Ilgen,2014;Tompkinsetal.,2017).Therearemanyfactorsthatmaypredisposeapersontodevelopchronicpainincludingincreasingage(Rustoenetal.,2005;Shmagel,Foley,&Ibrahim,2016;Tsangetal.,2008),female(Johannes,Le,Zhou,Johnston,&Dworkin,2010),andpersonswithmentalillness(McWilliams,Cox,&Enns,2003).Also,ithasbeenreportedthatthosewithalowerhouseholdincomehavehigherchancesofreportingchronicpaincom-paredwiththosewithhigherannualincome(Shmageletal.,2016).Aswillbediscussedinthefollowingpaper,prescriptionsforopioidpainmedicationshaveincreaseddrasticallyinthelastthreedecadesduetoacompilationofreasonsdiscussedbelow.Althoughthisproblemhasledtounfortunateconsequenceswiththeopioidepidemic,thegoalsfocusingonpatientcareshouldremain:findthecauseofthepain,decreasethepain,andrepairfunctionandqualityoflife.Unfortunately,healthcareprofessionalsandthegeneralpublicintheUnitedStates(US)havebeenmisledbyopioidsonmorethanoneoccasion(Trickey,2018).Althoughopioidsdohaveanimpor-tantroleinthetreatmentofcancer-relatedpainandendoflifecare,theiruseinthetreatmentofnon-cancerrelatedchronicpainhavegrowntremendously(Daubresseetal.,2013).Hippocrates,theFatherofEarlyMedicine,describedthehealingpowersofopium(Booth,1999;Duarte,2005);Galen,theFatherofPharmacy,inthesecondcenturyadvocatedthepracticeofusingopium(Duarte,2005;Kritikos&Papadaki,1967);ParacelsustheFatherofToxicologyconcocteda“secretremedy”namedlaudanumandcalledopium“thestoneofimmortality”(Kapoor,1997).ThereweretwowarsfoughtbetweenBritishandtheChineseoverthetradeofopiuminthemid1800sandbytheendofthenineteenthcenturyitwasestimatedthatoneinfouradultmalesinChinawereusingopiumannually(UNODC,2008).BythelatenineteenthcenturyintheUS,opiateswerelegal,abundant,cheapandtheinjectionofmorphinewasconsiderednon-addictive(UNODC,2008).In1898,BayerPharmaceuticalbeganmarketingdiacetylmor-phineunderthebrandnameHeroin,evenmarketingitforcoughinchildren(MCCoy,2003).However,thetidebegantoturnandin1912Dr.JohnWitherspoon,laterpresidentoftheAmericanMedicalAssociation,CONTACTLindseyE.Dayerledayer@uams.edu;HowellR.FosterFosterHowellR@uams.eduDepartmentofPharmacyPractice,UniversityofArkansasforMedicalSciencesCollegeofPharmacy,4301W.Markham#522-1,LittleRock,AR72205,USA.2018Taylor&FrancisGroup,LLCSUBSTANCEUSE&MISUSE2019,VOL.54,NO.2,331–339https://doi.org/10.1080/10826084.2018.1517175
stated“saveourpeoplefromtheclutchesofthishydra-headedmonsterwhichstalksabroadthroughthecivilizedworld,wreckinglivesandhappyhomes,fillingourjailsandlunaticasylums,andtakingfromtheseunfortunates,thepreciouspromiseofeternallife”(Tracy&Acker,2004).Then,in1914,TheHarrisonNarcoticActwaspassedandthecompre-hensivecontrolofopiateswasestablishedintheUS(Garner,2014).Tenyearslater,Heroinwasmadeille-galforanyuse.ThewarondrugsintheUShadbegananditush-eredinaperiodoftimewherephysicianswerereluc-tanttoprescribeopiates.However,asthephilosopherGeorgeSantayanaoncesaid,“Thosewhocannotrememberthepastarecondemnedtorepeatit”(Santayana,1921).Inthe1980’s,safetyconcernspertainingtotheuseofopioidswereagain,minimalized.Small,poorlydesignedstudiesorextrapolationsofstudiesbeyondtheirintentandaggressiveadvertisingwereusedtochangeprescribingpracticesbyphysiciansanddrivepolicy(Moghe,2016).Somephysicianswerelegallychallengedovertheirstrictprescribingpractices.Thepharmaceuticalindustrypouredmoneyintopainedu-cationprograms.Asaresult,morbidityandmortalitywithopioidsweregrowingtoepidemicproportionsbytheturnofthecentury.Rightfully,stategovernmentsandtheUSDrugEnforcementAdministration(DEA)beganeffortstominimizethefloodofprescriptionopioidsreachingthestreets.OnewaythiswascarriedoutwasbyreducingtheamountofopioidcontrolledsubstancesthatmaybemanufacturedintheUS.Asthesupplyofprescriptionopioidsbegantodwindle,ariseinillicitopioidusebegantofillthevoid.TheresultwasskyrocketingheroinandsyntheticopioidabuseintheUS.Thelastthreedecadeshaveseentre-mendouschangeintheuseofopioidsintheUS;thisnarrativereviewaimstodescribethemajorshiftsthatoccurredinopioidprescribinganditsimpactonillicitopioidusefromthemid1980stopresent.Acallforaculturechange:1986–1996Priortothemid-1980s,literatureadvocatingopioiduseforthetreatmentofchronicpainwasscarce.Mostofthepublicationspriortoabout1987mostlyrecommendedopioidstotreateitheracutepaintypesorpainduetospecificdiseasescausingnociceptivetypesofpain.(Pawl,2008)IntheUSaslateasthemid-1980s,opioidswerefearedbyprofessionalsandthepublicbecauseofthepotentialforabuseand/oraddiction.In1987,Dr.RonaldMelzack,presidentoftheInternationalAssociationfortheStudyofPain(IASP),addressedtheorganization’smembershigh-lightingthe“growingbodyofevidence”thatopioidscouldbeusedsafelytotreatchronicnonmalignantpainandprovidedreassurancethat“mostpatientsinpainexposedtonarcoticsdonotbecomedrugabusers”(Pawl,2008).Inretrospect,thisspeechwasawatershedmoment,markingthebeginningofcallstominimizeculturalandsocialprejudicesregardingopioiduse,toprovideconsequencesforunderpre-scribing,andtomodifyregulationsallowingformoreliberaldispersalofopioidsforchronicpain.In1989,Wanzeretal.(1989)reflectedthatthelackofstandardizedclinicalpracticeforpaincontrolhas“moralimplications.”Theauthorsissuedastrongwarningwhichread:“Toallowapatienttoexperienceunbearablepainorsufferingisunethicalmedicalpractice.”In1995,TheStudytoUnderstandPrognosesandPreferencesforOutcomesandRisksofTreatments(SUPPORT)trialdescribedalackinstitu-tionalawarenessofpainanddemonstratedwidespreadundertreatmentofpain.Accordingtothisstudy,con-trollingpainwasalowpriorityforphysiciansresult-inginmoderatetoseverepaininoverhalfofcritically-illpatients.Acontrolledtrialtoimprovecareforseriouslyillhospitalizedpatients.Thestudytounderstandprognosesandpreferencesforout-comesandrisksoftreatments(SUPPORT).TheSUPPORTPrincipalInvestigators(1996)Somesmallpainmanagementgroupsbegantourgeeverymedicalboardinthecountrytoadoptaregulationthatstated“underprescribingandundertreatmentofpainisgroundsfordisciplinaryaction”(Martino,1998).Manyhealthcareprofessionalsstatedthatuntilpoli-cies,procedures,andenforcementregardingunder-prescribingofopioidswereadopted,theundertreatmentofpainwouldcontinuetoflourish(Martino,1998).Someinstitutionsadoptedqualityassurancemeasurestomonitorpaincontrolbypatientcomplaintsorothersubjectivemeasuresandprovidedphysicianswithpainmanagementscoresbasedonthesemetrics(Max,1990).Duringthisperiod,painmanagementandopioidusewerenotcommonlyfoundinhealthcarecurricu-lums,withprogramsfocusingalmostentirelyonavoidingrisk(e.g.,addictionanddiversion;Martino,1998).Manywereconcernedthatnewmedicalgradu-ateshadverylittleeducationregardingpainmanage-mentandthereforewouldbeinfluencedbyveteranphysicians’“traditionalview”ofopioids(Martino,1998;Max,1990).Becauseofthis,effortsadvocating332L.DAYERETAL.
forimprovedpre-andpost-graduatepainmanage-menteducationweretargeted(Max,1990).A1994nationalsurveyofphysicianspublicizedthatphysiciansintentionallyunderprescribedopioidstopatientswithpaintoavoidregulatoryinvestigation(Rich,2000).Collaborationshadbegunbetweenstatemedicalboards,painexperts,andprofessionalorgani-zationstoproducepoliciesthatbalancedtheriskofdrugdiversionwiththeneedforlegitimateopioidprescribing(Max,1990).Manyphysiciansexperienced“opiophobia”basedonfearsthatlegitimateopioidprescribingcoulddevelopintoillegaldruguseintheirpatients.Strategiestochallengethestigmaofusingandpre-scribingopioidswereimplemented.Forexample,Portenoystatedthatonlypatientswith“brainpatho-logy”wouldexperiencesomnolenceandmentalcloud-ing.Hewentontosaythatlong-termopioiduseinthemethadone-maintainedorcancerpopulationhavenotresultedinorgandamageortoxicityandhepointedoutthatthedrivingrecordsofmethadone-maintainedaddictsandotherdriversindicatenodif-ferenceinratesofinfractionsoraccidents.Thisexam-plewasusedtocombattheevidenceofcognitiveimpairmentfromlong-termopioiduseinthispopula-tion(Portenoy,1996a).Voicesadvocatingforexpandeduseofopioidsalsohadargumentstoaddressphysicianfearsofrespiratorydepression(Rich,2000)andtoreducestigmaandconfusionregardingaddiction,dependence,andtolerance(Portenoy,1996a).Martinosuggestedthatcliniciansshoulddescribepatientsas“physicallydependent”ratherthan“addicted”andshouldnotbeconcernedaboutthisclinicalpresentation(Martino,1998).Itisimportanttodistinguishbetweendependenceandaddiction.Dependenceismanifestedbyspecificwith-drawalsymptomsthatoccurwhenthemedication(e.g.,opioid)iswithheldabruptlyorthedoseisdecreasedrapidly,whereasaddictionisconsideredadiseasewithneurobiologicalandpsychologicalcharac-teristicsandisoftenassociatedwithdestructivebehav-iors(DefinitionsRelatedtotheUseofOpioidsfortheTreatmentofPain,2001).Highandlowpredictivefactorsofaberrantdrug-relatedbehaviorswerepub-lishedalongwiththechallengesofidentifyingless“egregious”behaviorsresultingin“pseudoaddiction”(Portenoy,1996a).Attheconclusionofhisrecom-mendation,Portenoydidincludeaclearwarningthatexposuretoopioidscaninduceaddictioninpatientswithoutasignificantpastmedicalhistory(Portenoy,1996a).Oneofthemostinfluentialstrategiesforexpandingtheuseofopioidswasbuildingacasesupportingtheuseoflong-termopioidsinnonmalignantpainbasedoninferencesfromfindingsinotherpatientsub-groups.Theseassertionsresultedinchangestolaws,regulatoryagencies,andsocietalbarriers.Thegreatsuccessofopioidsforpaintreatmentinpatientswithcancerwasthestrongestsupportforreexaminationoftheevidenceonopioidtherapy(Portenoy,1996b).Sinceopioidtherapytotreatmalignantpaincanrestorefunctionalityandqualityoflife,healthcareprofessionalsadvocatingforexpandedopioidusearguedthatopioidsusecouldbeutilizedforchronicnon-cancerpainaswell.Theyreasonedthattolerance,physicaldependence,developmentofdrugseekingbehavior,andaddictionwerenotconcernsfortreatingpatientswithcancer,soitmustbeaninternalculturalprejudicepreventingphysician’sfromprescribingtopatientswithoutcancer(Portenoy,1996b).In1989,theWisconsinStateControlledSubstancesBoardimplementedamalignantpainprogramthatenhancedmorphineprescribing10-fold(Max,1990).Thisinitiativeresultedinincreasedopioidprescribingandtheuseofamphetaminestocombatopioidseda-tioninpatientswithcancer.Thisopioidprescribingpracticewasquicklyadoptedandimplementedby20otherstatesduetopatientsinthisspecificprogramexhibitingalmostnoriskofaddiction(Max,1990).Despitethisdatabeingcollectedexclusivelyfromthetreatmentofmalignantpain,thedatafromthispro-gramwasusedtosupportimplementationofsimilarmodelsinnonmalignantpainpatients(Max,1990).Changesinopioidpracticesandprescribing:1996–2006Theideathatopioidscouldbeusedsafelyinthegen-eralpopulation,causedamajorshiftintheassessmentandmanagementofpain.In1996,theAmericanPainSocietyintroducedtheconcept“painasthefifthvitalsign”(Council,2001).Painasthefifthvitalsignincreasedhealthcareprofessionalfocusonpatientpain;cliniciansweretaughttoassesspainwiththesamefrequencyasvitalsigns.Amajorflawinthisconceptisthatpain,asubjectivemeasurement,wasassumedtohavethesamevalidityasobjectivemeas-ures,suchasbloodpressureandheartrate(Council,2001).Theadoptionof“painasthefifthvitalsign”alsocoincideswiththe1995approvalofPurduePharmaceutical’slong-actingOxyContin.From1996through2001Purdueheldmorethan40conferencesinwhichtheytrainedover5000physicians,SUBSTANCEUSE&MISUSE333
pharmacists,andnurses(PrescriptionDrugs:OxyContinAbuseandDiversionandEffortstoAddresstheProblem,2003;VanZee,2009).PurduealsoprovidedlucrativesaleincentivebonusestotheirsalesrepresentativestoencouragethemtoincreasethesalesofOxyContin,withbonusesrangingfrom$15,000toalmost$240,000annually.Afteraggres-sivelypromotingtheuseofOxycontinformanydif-ferentpaintypes,thenumberofprescriptionswrittenfornon-cancerpainincreasednearlytenfoldfromabout670,000in1997toabout6.2millionin2002,whereasprescriptionswrittenforcancerpainincreasedaboutfourfoldduringthisperiod(PrescriptionDrugs:OxyContinAbuseandDiversionandEffortstoAddresstheProblem,2003;VanZee,2009).Also,in1997,33statesadoptedIntractablePainTreatmentActs(IPTA)whichprovidedregula-toryreliefforphysiciansprescribingopioidsandreducedtheperceivedriskofprescribingopioids(Martino,1998).Thisnewattitudetowardopioidprescribingbypractitionerswascoupledwithdirecttoconsumeradvertisingthatmisrepresentedthebenefitsofopioidswhileminimizingthepotentialforabuseandaddic-tion.A2003letterissuedbytheFDAtoPurduePharmaceuticalsinstructedthecompanyto,“immediately[cease]thedissemination”ofadvertise-mentspertainingtoOxyContinthatappearedintheJournaloftheAmericanMedicalSociety(JAMA)(Abrams,2003).Purdue’sadvertisementsgeneralizedOxyContin’spatientpopulationbydepictingamanfishingwithaboyandthestatement,“Lifewithreliefispossible”inlargeprintacrossthepicture.TheadvertisementalsohighlightedOxyContin’sutilityinpatientswhorequireopioidsevery4–6h,despitetheproductonlybeingapprovedfor12-hdosing.TheadvertisementnotonlyattemptedtoexpandthepatientpopulationofOxyContin,butcompletelyomittedthepotentialriskofabuseandaddictionasso-ciatedwiththedrug(Abrams,2003).In1998,bioethicistEdmundPellegrinoexpressedhisopinion:“Nottorelievepainoptimallyistanta-mounttomoralandlegalmalpractice”(Pellegrino,1998),andprofessorandauthorDavidMorrisreportedthat:“Notrelievingpainbrushesdangerouslyclosetotheactofwillfullyinflictingit”(Morris,1991).In2004,apublicationbytheFederationofStateMedicalBoardsoftheUnitedStatesfurtheredtheideaofanepidemicofundertreatedpain.TheModelPolicyfortheUseofControlledSubstancesfortheTreatmentofPainpublishedbythisorganizationillustratedthattheprevalenceofundertreatedpainstemsfrom,“theperceptionthatprescribingadequateamountsofcontrolledsubstanceswillresultinunnecessaryscrutinybyregulatoryauthorities”anda“misunderstandingofaddictionanddependence”(Boards,2001).Thispolicyalsostatedthattheunder-treatmentofpainwasa,“departurefromanaccept-ablestandardofpractice”(Boards,2001).Thisphilosophy,combinedwithheightenedsensitivitytotheundertreatmentofpainduringthisera,leadtoamajorshiftintheopioidprescribingcultureduringthe1990sandearly2000s.However,despitesomeholdingviewstothecontrary,aswenowknowandhasrecentlybeenseenintheSPACERandomizedClinicalTrial,oftenthetreatmentofsometypesofchronicpainmaynotneedtoincludeopioidtreat-ment(Krebsetal.,2018).Theopioidepidemic:2007–2017Therehasbeenasurgeinoverdosedeathsassociatedwithopioids(Figure1;CDC,2016),resultinginwhathasbeencharacterizedasanopioidepidemic(CDC.gov,2016;CDC/NCHS,NationalVitalStatisticsSystem,Mortality,2016;Rudd,Seth,David,&Scholl,2016).Datashowopioidoverdoseisthecauseofdeathfor91Americanseachdayandmorethan1000peoplearetreateddailyinemergencyroomsacrossthecountryforinappropriateprescriptionopioiduse(CDC/NCHS,NationalVitalStatisticsSystem,Mortality,2016).Prescriptionsforopioidsincreasedfrom2002through2010;andthendecreasedsome-whatfrom2011through2013(Dartetal.,2015;Kolodnyetal.,2015).However,addictiontreatmentadmissions,overdosedeathrates,andotheradverseoutcomesassociatedwithopioidsdidnotfollowthesametrend,possiblyindicatinganincreaseintheuseofnonprescriptionopioids,suchasheroin(Kolodnyetal.,2015).Heroinisbecomingmorewidelyavail-ableandisrelativelyinexpensive,whichmaycontrib-utetothisincreaseduse(Cicero,Ellis,Surratt,&Kurtz,2014).Threeoutoffournewheroinusersreporttheyabusedprescriptionopioidspriortoher-oin(Jones,2013;Muhuri&Davies,2013).Deathsduetoheroinhavemorethanquadrupledsince2010anddeathsduetoothersyntheticopioids(e.g.,illegallymadefentanyl)otherthanmethadoneincreasedfrom5544deathsin2014to9580deathsin2015(CDC/NCHS,NationalVitalStatisticsSystem,Mortality,2016;Ruddetal.,2016).Nationally,emergencyroomnaloxoneusehastrendedupwardsince2006(Figure2),mirroringanincreaseinopioidoverdoserates(NationalHospitalAmbulatoryMedicalCare334L.DAYERETAL.
Survey,2006).Thisagentisanantidotetoapossiblelethalopioidoverdose.ManystatesnowhaveNaloxoneExpansionProgramsavailabletotryandpreventopioidoverdose.Thisincreaseinheroinusecoincideswiththereleaseoftheabuse-deterrentoxycodoneformulationin2010(Cicero&Ellis,2015).Astudyexaminingabusepatternsofpatientswithadiagnosisofopioidusedisorderandprimarydrugofabuseconsistingofaprescriptionopioidorheroinafterthereleaseofabuse-deterrentformulationOxyContinin2010foundthatsomeparticipantsswitchedtooraladministrationfromnonoralroutesordefeatedthenewformulation(Cicero&Ellis,2015).However,33%ofparticipantsindicatedthattheyreplacedOxyContinwithotherdrugsafterthereleaseoftheabuse-deterrentformula-tionand70%ofthosethatswitchedagentsreportedheroinastheirnewdrugofchoice(Cicero&Ellis,2015).Therehavebeenmanyattemptsto“correct”theopioidproblem.Implementationofprescriptiondrugmonitoringprograms(PDMPs)acrossthecountryhaveprovenbeneficial;however,somestateshavealsoseenproblemswiththeseprograms.Forexample,Kentuckyinitiallysawadecreaseintotalwrittenopioidprescriptionsby10.4%withinthefirstsixmonthsafterimplementationofitsPDMP.However,deathsrelatedtoheroininthestateincreasedfrom22casesin2011to143casesin2012and170casesinthefirst9monthsof2013(Huecker&Shoff,2014).Therehavebeenotherstateswhosawsimilarprob-lemswithheroinsubstitutingforprescriptionopioidsafterimplementationofregulationsthatreducedthesupplyofopioids(Huecker&Shoff,2014).SomestatesarealsomandatingthatphysicianscheckthePDMPpriortoprescribinganopioidforapatientwhoisnothospitalized(e.g.,emergencydepartment,outpatientclinic,andupondischarge).TheUSFDAalsoattemptedtocombattheprob-lemin2014bymovinghydrocodonecombinationmedicationsfromaScheduleIIItoaScheduleIIdrug.Thischangeledtostricterenforcementonthemedicationbecausepatientswouldnowhavetogetawrittenprescriptionandrefillswereprohibited.TheDEAhasalsocalledforareductionintheamountofopioidcontrolledsubstancesthatmaybemanufac-tured.Somesourcessaythisreductionwillbeasmuchas25%ormorein2017(Barrett,2016)andanother20%from2017to2018(DEAproposesreductiontoamountofcontrolledsubstancestobeFigure1.Overdosedeathsinvolvingopioids,UnitedStates,2000–2015(CDC,2016).SUBSTANCEUSE&MISUSE335
manufacturedin2018,2017).In2016theCentersforDiseaseControl(CDC)andPreventionalsorecom-mendedthatprovidersreduceprescribingforopioidmedicationsforchronicpain.Thiscallforachangeinprescribingpracticesparallelstheupdated,stricterguidelinesreleasedbytheCDCin2016fortheman-agementandtreatmentofpatientswithchronicpain.TheseguidelinespublishedinJAMAfocusonothermechanismsoftreatmentpriortoinitiatingopioidtherapyforchronicnonmalignantpain(Dowell,Haegerich,&Chou,2016).Theyalsocomplementarecentstudy,byShah,Hayes,andMartin(2017)whichfoundthatprescribingmorethanoneweekofopioidsinitiallyorauthorizingasecondrefillofanopioidprescriptionnearlydoublesthechancesofcontinuedopioiduseoneyearlater.Alsoin2016,theAmericanMedicalSocietyaskedfor“painasthefifthvitalsign”tobeabandoned(Johnson,2016).Manyoftheabovepolicychangesaredueinparttotheopinionsofothersoverthepreviousthreedeca-des.Theseopinionshavehelpedtodrivemanyofthechangesthathavetakenplace.Althoughtherehavebeenmechanismsputintoplacetodecreaseunsafeopioidprescribingpractices,suchasbetterprescriberandpatienteducationandupdatedprescribingguide-linestohelpreduceopioidexposure,decreasemisuseandabuse,andreduceaddiction,wearestilllackingadequatesolutionsandfacilitiesforhelpingthosewhoarecurrentlystrugglingfromchronicpainoranopioidusedisorder(OUD).Theremustbebettermechanismsfortreatingthiscomplexproblem.Asmentionedpreviously,chronicpainisaveryprevalentproblemandthereareoftenbarrierspatientsmustencounterwhentryingtoobtainadequatepainman-agement.Itisoftendifficultforpatientstofindeffec-tivepaintreatmentfacilitiesduetothelackofmultidisciplinarypaintreatmentcenters.Also,theoutofpocketexpensesfornon-pharmacologic/non-opioidtherapiescomparedwithprescriptionopioidsareoftenmuchhigherforthepatient(Tompkinsetal.,2017).Evenso,itisstillimportanttomakesurethatpatientsaretreatedappropriatelyandtheirpainismanagedeffectivelysothatapatient’spainisnotundertreated.Inaddition,theremustbeexpandedaccesstosubstanceabusetreatmentprogramsforthosewithOUD.Thesefacilitiesprovidemedication-assistedtreatment,inadditiontocounseling,behavio-raltherapy,andotherservicestothosewithsubstanceusedisorders;however,thesefacilitiesareinshortsupply,makingitdifficultforphysicianstomakethesereferrals.AccordingtodatafromtheSubstanceAbuseandMentalHealthServicesAdministration,in2013therewere22.7millionindividualsages12andolderwhoneededtreatmentforanillicitdrugoralco-holuseproblem.However,only11%or2.5millionactuallyreceivedtreatmentfromaspecialtyfacility(TheNSDUHReport:SubstanceUseandMentalHealthEstimatesfromthe2013NationalSurveyonDrugUseandHealth:OverviewofFindings,2014)Figure2.Emergencyroom(ER)naloxoneuseintheUnitedStates,2006–2013(NationalHospitalAmbulatoryMedicalCareSurvey).336L.DAYERETAL.
Theseprogramsareaneededserviceforthosewithsubstanceusedisorders.Healthcareprofessionalsmustbeabletocollaborateinordertotreatthepatientwithchronicpainwhomaybenefitfrompharmacologictherapy,butalsouti-lizenonpharmacologictreatment,suchasphysicaltherapy,exercise,cognitivebehavioraltherapy,aswellasothers(Nicol,Hurley,&Benzon,2017;Tompkinsetal.,2017;Veehof,Oskam,Schreurs,&Bohlmeijer,2011).Itisalsoimportanttonoteanddifferentiatethatopioiduseinthepalliativecaresetting,treatmentofmalignantpain,orotherseriousandlife-limitingdiseasearenotthefocusofthispaper.ConclusionsandfuturedirectionsTheopioidepidemicintheUSisaproblemthatdevelopedoverdecadesandisinnowaytheresultofanyoneindividualorgroup.Whileclinicalandpolicychangeshavebeenimplementedtocombatthisissue,changeswillnotbeimmediate.Moreover,changestopolicyandclinicalpracticemayhaveunintendedcon-sequencessuchastherisinguseofillicitopioids.Whileincreasedaccesstoaddictiontreatment,imple-mentationofPDMPs,andincreasedavailabilityofnaloxonearehelpful,itwilltakeashiftinmindsetonthepartofclinicians,thepublic,andpolicymakerstoalleviatethisepidemic.Itisimperativethathealthprofessions,whichcontributedtothedevelopmentofthisepidemic,takeresponsibilityforimplementingashiftbacktoresponsiblepractice.Thisshiftcanoccurasaresultofimprovedpainmanagementeducation,reducedstigmaaboutaddictionamonghealthcareprofessionals,andcontinuedpolicychangesthatempowerpractitionerstomakeresponsiblepainman-agementdecisions(Volkow&McLellan,2016)andasmentionedpreviously,utilizecautionagainstrepeatingthemistakesofourpast.AcknowledgmentThisresearchdidnotreceiveanyfundingfromfundingagenciesinthepublic,commercial,ornot-for-profitsectorsnordoesacommercialrelationshipexistintheformoffinancialsupportorpersonalfinancialinterest.Thismanu-scripthasnotbeenpublishedelsewhereandithasnotbeensubmittedsimultaneouslyforpublicationelsewhere.DisclosurestatementTheauthorsreportnoconflictsofinterest.Theauthorsaloneareresponsibleforthecontentandwritingofthepaper.ReferencesAbrams,T.(2003).WarningLetter[Pressrelease].Retrievedfromhttp://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/EnforcementActivitiesbyFDA/WarningLettersandNoticeofViolationLetterstoPharmaceuticalCompanies/UCM168946.pdf.Barrett,J.(2016).DEAReducesOpioidManufacturingin2017.Retrievedfromhttp://www.pharmacytimes.com/news/dea-reduces-opioid-manufacturing-for-2017Barry,D.T.,Pilver,C.E.,Hoff,R.A.,&Potenza,M.N.(2013).Paininterferenceandincidentmood,anxiety,andsubstance-usedisorders:Findingsfromarepresentativesampleofmenandwomeninthegeneralpopulation.JournalofPsychiatricResearch,47(11),1658–1664.doi:10.1016/j.jpsychires.2013.08.004Boards,S.M.(2001).ModelPolicyfortheUseofControlledSubstancesfortheTreatmentofPain.Retrievedfromhttp://dpr.delaware.gov/boards/medical-practice/documents/Model_Policy_Treatment_Pain.pdf.Booth,M.(1999).Opium:AHistory.NewYork:St.Martin’sGriffin.CDC(2016).Wide-rangingonlinedataforepidemiologicreserach(WONDER).RetrievedMarch31,2017,fromNationalCenterforHealthStatisticshttp://wonder.cdc.govCDC.gov.(2016).OpioidOverdose-OpioidBasics:UnderstandingtheEpidemic.Retrievedfromhttps://www.cdc.gov/drugoverdose/epidemic/index.html#CDC/NCHS(2016).NationalVitalStatisticsSystem,MortalityCicero,T.J.,&Ellis,M.S.(2015).Abuse-deterrentformula-tionsandtheprescriptionopioidabuseepidemicintheUnitedStates:Lessonslearnedfromoxycontin.JAMAPsychiatry,72(5),424–430.doi:10.1001/jamapsychiatry.2014.3043Cicero,T.J.,Ellis,M.S.,Surratt,H.L.,&Kurtz,S.P.(2014).ThechangingfaceofheroinuseintheUnitedStates:Aretrospectiveanalysisofthepast50years.JAMAPsychiatry,71(7),821–826.doi:10.1001/jamapsychiatry.2014.366Connors,A.F.,Dawson,N.V.,Desbiens,N.A.,Fulkerson,W.J.,Goldman,L.,Harrell,F.E.,…Wenger,N.S.(1996).Erratum:Acontrolledtrialtoimprovecareforseriouslyillhospitalizedpatients:Thestudytounderstandprogno-sesandpreferencesforoutcomesandrisksoftreatments(SUPPORT)(JournaloftheAmericanMedicalAssociation(November22/29,1995)274(1591–1598)).JournaloftheAmericanMedicalAssociation,275(16),1232.doi:10.1001/jama.275.16.1232Dart,R.C.,Surratt,H.L.,Cicero,T.J.,Parrino,M.W.,Severtson,S.G.,Bucher-Bartelson,B.,&Green,J.L.(2015).TrendsinopioidanalgesicabuseandmortalityintheUnitedStates.NewEnglandJournalofMedicine,372(3),241–248.doi:10.1056/NEJMsa1406143Daubresse,M.,Chang,H.-Y.,Yu,Y.,Viswanathan,S.,Shah,N.D.,Stafford,R.S.,…Alexander,G.C.(2013).AmbulatorydiagnosisandtreatmentofnonmalignantpainintheUnitedStates,2000–2010.MedicalCare,51(10),870–878.doi:10.1097/MLR.0b013e3182a95d86DEAproposesreductiontoamountofcontrolledsubstancestobemanufacturedin2018(2017).Online:DEAPublicSUBSTANCEUSE&MISUSE337
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InterpretivePhenomenologicalAnalysisoftheSpiritualCharacteristicsofRecoveryExperiencesintheContextoftheBrainDiseaseModelofAddictionKatieGivensKime1Publishedonline:25May2018#SpringerScience+BusinessMedia,LLC,partofSpringerNature2018AbstractSpiritualitypersistsasamechanismofbehaviorchangeforaddictionrecovery.Theaimofthisprojectwastocarefullyattendtohowthoseinrecoveryconstructmeaningoftheirexperienceofaddiction,regardlessoftheaddictiontreatmentmodalityorideologicalframework.Participantaccountsreflectedtheincreasedpublicinterestinandresearchfundingbasedonthebraindiseasemodelofaddiction(BDMA).Thequalitativestudyusedinterpretivephenomenologicalanalysistoinvestigatetheexperi-encesofsixadults(agerangefrom24to72)withatleastthreeyearsofsustainedrecoveryfromsubstanceusedisorders.In-depthkeyinformantinterviewstrackedtheirconstructionoftheirexperiencesandtheirunderstandingofaddiction.Participantswhoenteredrecoveryafter2010soughttointegrateBDMA-relatedconstructsintotheirunderstandingofaddictionandrecovery.AddictionrecoverynarrativesfeaturingBDMA-relatedconstructsintegratedneuroscience-relatedideaswithspirituality-relatedconstructsratherthancompletelyreplacingthelatter.Notableinnovationsandparadox-icaltensionswerefoundwithinparticipantaccounts.SuchfeaturesechotheinsightsonsecularityofHarvardphilosopherCharlesTaylor,particularlyhisnotionoftheBbufferedself,^whichoffersatheoreticalframeworkforunderstandingtheseshiftsinmeaning-making.Forpersonsenteringrecoveryinthetwenty-firstcentury,thebraindiseasemodelofaddictioncarriesmoreexplanatoryauthoritythanitdoesforpreviousgenera-tions,despitethelackofagreementacrossaddiction-relatedneuroscientificfindings.Asamodel,itengendersmoremechanistic,agential,brain-centered(Bbuffered^)sensesofself,ostensiblymakingitlesscompatiblewithspiritualunderstandingsofaddictionthanothermedicalmodelsofaddiction.However,thisstudy’sfindingsindicatethatthoseinrecoveryarelikelytodevisecomplexnarrativesoftheetiologyofaddictionthatcombineelementsfromvariousmodels.PastoralPsychol(2018)67:357–372https://doi.org/10.1007/s11089-018-0816-2*KatieGivensKimekgkime@gmail.com1UniversitätBern,Unitobler,Länggassstrasse51,CH-3000Bern9,Switzerland
KeywordsSpirituality.Addiction.Recovery.Neuroscience.Braindiseasemodelofaddiction.Substanceusedisorders.ReligiosityGiventheworldwideburdenofsubstanceusedisorders,itissignificantthatAlcoholicsAnony-mous(A.A.)programsandits12-stepderivationsareBubiquitous,effective,andfreeofcharge^(Kelly2017)andthattheyexplicitlyconsiderthemselvestobeBspiritualfellowships.^Thoughnotwithoutcontroversy,severallongitudinalmeasuresindicatethat12-stepprogramsproduceout-comescomparabletoorbetterthanotherinterventions(AshenbergStraussnerandByrne2009;Humphreysetal.2014;KellyandGreene2014).Severalstudiesinthefieldsofmedicineandthesocialsciencespointtopatternsofinverserelationshipbetweenspiritualityandsubstancemisuse(DermatisandGalanter2016;Geppertetal.2007;KatsogianniandKleftaras2015).However,cliniciansandprofessionalshaveexpressedconcernsregardingtheamorphousdefinitionsofBspirituality^(Cook2004),andthebiases,misunderstandings,andlackofeducationconcerning12-stepprograms’claimthatspiritualityistheircentralmechanismofbehaviorchange(DeAngelis2001;Johnson2013;Pargament2007).Concurrently,theso-calledbraindiseasemodelofaddiction(BDMA)isthelatestshiftinaddictionunderstandings,1andithashadanimmenseinfluenceonpopularandmedicaldiscourseandonresearchfunding.TheBDMAisbestunderstoodasanoverarchingparadigmratherthanasingularsetoffindingsortheories.Manyhavetraceditbackto1997,whenSciencepublishedalandmarkstudybyAlanLeshner,whowasatthetimethedirectoroftheU.S.government’sNationalInstituteonDrugAbuse(NIDA).TheSciencearticlecallsforashift:BAddictionisabraindisease,anditmatters,^arguingthataddictivedrugsBhijacktherewardcentersofthebrain^(Leshner1997,p.45).WithinseveralmonthsofthepublicationofLeshner’sarticle,BillMoyersusedthephraseBhijackedthebrain^in1998onalandmarkPBStelevisionseriesonaddiction,citingLeshner(Lewis2016,p.17).SeveralhistoriansandresearchersofaddictionhavenotedthewaythewordBhijack^stayedinthevocabularyofaddictionformanyyearsafterthat(Khantzian2003).AddictionresearcherNancyD.Campbell(2007)notesthattheBstayingpower^ofthehijackingmetaphorwasasignofBhowneuroscienceremadethesocialworldsofsubstanceabuseresearch^byimplyingthatBtheelusivesecretsofthis‘diseaseofthewill’wouldnowyieldtothepowerfulforceofbrainscience^(p.201).Indeed,ifpopulartitlesareanyindicator,theBDMAholdsgreatinfluenceoverpublicunderstandingsofaddiction(Earley2017;Lewis2016;O’Connor2015;Spiegelman2015;Szalavitz2016a,b).SeveralresearchersnotethatsocialscientistsrefertotheBDMAastheBNIDAparadigm^(Dunbaretal.2010,p.3),whichissignificantsinceNIDAfunds85%oftheworld’sresearchonaddiction(Vrecko2010b,p.55).Indeed,in2014NIDAdevoted41%ofitsfundingtobasicneuroscienceandafurther17%tothedevelopmentofnovelpharmacotherapiesbasedonthisneuroscience,yetonly24%toepidemiology,healthservices,andpreventionresearch(Field2015).Neuroscience-basedapproachestoaddictionmaybewellfunded,butdespitetheculturalperceptiontothecontrary,addictionresearchisBadisunifiedscience^(Campbell2011,p.195)withcriticaldifferencesandapproachesbetweenteams,suchastheirunderstandingofwhichneuromechanismsarerelevantforunderstandingaddic-tionandevenofhowsuchmechanismsoperate(cf.Kime2015b;KoobandMoal2005,1Inthisarticle,addictionservesasanumbrellatermforthefullrangeofsubstanceusedisorders(Miller2016,p.92).358PastoralPsychol(2018)67:357–372
pp.18–19).Regardingthisdiscord,Campbell(2010)pointsoutthatBneuroscienceisahighstakesinterpretivegame^(p.90).Inresponse,Lende(2012)callsforaneuroanthropologicaltheoryofaddictionratherthanaBbrain-driven^theory:Thepartsofthebrainwhereaddictionhappensarenotsingle,isolatedcircuits—rather,theseareashandleemotions,memory,andchoice,andarecomplexlyinterwoventomanagetheinherentdifficultyofbeingasocialselfinadynamicworld.(p.342)However,noinvestigationshaveexploredtheimpactthisBneuro^shifthashadonspiritualityasamechanismofbrainchangeinrecovery.Suchanoversightisasmallexampleofthebroadfragmentationandreductionofaddictionresearchintoisolatedcomponentsthattoooftenfailtoattendtothelivedexperiencesofpeopleinrecovery,despitecallsfromleadingvoicesinaddictionresearchforradicalinterdisciplinarity(Nadeau2014)andholisticattentiontosubjectivewell-being(MillerandMiller2009).Scholarsofreligionandtheologyhavebeenlargelyabsentfrommeaningfulinvolve-mentinthedesignorinterpretationofthevarioussocialscientificandempiricalstudiesofthespiritualorreligiousaspectsofrecoveryprograms,withsomenotableexceptions(e.g.,theHigherPowerProjectattheUniversityofChester[UnitedKingdom];seeDossett2013).Veryfewsuchstudiesappearinthescholarlyjournalsoftheologyandreligion(Sørensenetal.2015;SremacandGanzevoort2013;Stewart2004).Thoughnotconductingempiricalstudies,sometheologianshavecontributedinsightsaboutthespiritualandreligiouscharacteristicsofrecovery(Blevins2009;Clinebell1998;Cook2006;Doehring2006;Dunnington2011;Kime2015a;Lund2016;McDonough2012;Mercadante1996,1998,2009,2010;Nelson2004;Rohr2011).Nevertheless,thegapintheliteratureissignificant.Withexceptions(e.g.,Dossett2013;Flahertyetal.2014;Klingemann2011;Sørensenetal.2015),thevastmajorityofempiricalresearchonthespiritualaspectsofrecoveryfromsubstanceusedisordershasusedaquantitativemethodologicalapproach(DermatisandGalanter2016;Heinzetal.2010;KatsogianniandKleftaras2015;Robinsonetal.2003;Toniganetal.2013),relyinguponmeasurementsfeaturingdichotomies(e.g.,Bspiritual^orBnotspiritual^),closedquestions,classificationsystems,standardizedscales,and/orsinglecontinuousdimensions.Suchmethodsarevaluable,butitseemsappropriatetoalsoemployqualitativemethodsthatallowparticipantstovolunteerpreferredlanguage,symbols,meta-phors,andnarrativestructuresininterpretingtheirexperience.Severalscholars(Campbell2007;Keane2002;Vrecko2010b)havenotedtheimportanceofattendingtothenuancedconstructionsofmeaninggeneratedbypeopleinrecoveryabouttheirexperienceofaddiction.OthershavenotedthatBweliveinaworldofsmartpeople^whoareawareoftheparadoxandcomplexityofaddiction(Klingemann2011).Anoft-citedrecentstudyofpublicneurocentricunderstandingsofaddiction(Meurketal.2014)discovereddiffuse,complex,andvariedperspectiveswhenparticipantswerepromptedtophrasetheirowndescriptionsofaddictionetiologiesratherthancompletingaquestionnaireorotherinstrument.ThefindingsofWilliamsonandHoodJr.(2016)areanexceptionalexampleofalongitudinalqualitativestudyofthespiritualcharacteristicsofrecovery;itisfocusedparticularlyonstrategiesutilizingtheexhilarationofconversionsinPentecostaltraditions.Anyoneseekingtorecoverfromaddictioninthetwenty-firstcenturymustmakemeaningoftheirexperienceamidstacacophonyofcompetingmodels.ThisprojectseekstoinvestigatetheimpactofBDMA-relatedunderstandingsonthespiritualaspectsofrecoveryfromaddiction.PastoralPsychol(2018)67:357–372359
MethodThisqualitativestudyemployedtheguidelinesandintentionsofinterpretivephenomenolog-icalanalysis(IPA)andutilizedkeyinformantsemi-structuredinterviewstoinvestigatethespiritual/religiouscharacteristicsofrecoveryfromaddiction.IPAwasfirstimplementedinthefieldofhealthpsychologybyJonathanA.Smith,whonotedthatBIPAstudiesusuallydealwithsignificantexistentialissuesofconsiderablemomenttotheparticipantsandtheresearchers^(2004,p.49).Themethodfeaturesaphenomenologicaltheoreticalposition,agenerallyinductiveandhighlyidiographicapproach,andaninterrogativelyintentionedstancetowardsexistingliteratureandtherelevantfieldsofresearch;allthesecomponentsmakeIPAwellsuitedtothegoalsandresearchquestionsofthisstudy.Theresearchsampleforthisstudyconsistedofsixindividuals,asamplesizebaseduponthestandardparticipationinphenomenologicalresearchof1to10persons(StarksandTrinidad2007),guidanceforappropriatesamplesizesofIPAstudies(Smith2009,p.51),andthetimeandresourcesavailableforthecompletionofthisproject.ThestudybuiltupontherecentfindingsandstudystructureofFlahertyetal.(2014).Thelimitationsofthisstudyprecludedtheabilitytorepresentanyparticularracialorethnicpopulation,regionoftheUnitedStates,agegroup,gender,levelofeducation,sexualorien-tation,classidentity,orlifephase.However,diversitywassoughtintheparticipantselection,asillustratedinTable1.Somehomogeneitywasassumed;thisstudywaslimitedtoNorthAmericaandtothosewithstrongfacilitywiththeEnglishlanguageandexperiencewith12-steprecov-erycommunities.Allparticipantshadsustainedsobrietyforatleastthreeyears.Allidentifiedalcoholasasubstanceofabuse,andsomeidentifiednarcoticsaswell.Non-probabilisticsamplingwasmostappropriateforthisstudysincegeneralization,inastatisticalsense,wasnotagoal.Instead,purposefulsampling(themostcommonformofnon-probabilisticmethods)bestmatchedtheaimsandquestionsofthisstudy,sinceitassumesaresearchgoalofdiscovering,understanding,andgaininginsight(Merriam2009,p.77).Thisstudyutilizedastrategiccombinationofopportunisticandsnowballapproaches(Milesetal.2014,p.32)torecruitparticipants.Table1ParticipantCharacteristicsandDemographicsPseudonymGen-derAgeEthnicitySobrietyReligiousidentityRecoveryprogramsUrsulaF24WhiteAmerican4yearsSpiritual/NewAge,SBNR**A.A.BarryM38Palestinian-FilipinoAmerican4yearsCatholicA.A.,N.A.Sean*M44WhiteAmerican5yearsAgnostic,SBNRA.A.(some),RationalRecovery,RightTurnNavarroM52Mexican5.5yearsFormerCatholic,SBNRA.A.KarlM58AfricanAmerican27yearsChristianN.A.,A.A.ConnieF72WhiteAmerican37yearsProtestantA.A.*GiventhepublicdisclosureofhisaddictionnarrativeinTheWhiteChip(Kime2017),Seandeclinedtohavehisidentitymaskedbyapseudonymorotherwiseanonymized**BSpiritualbutnotreligious^360PastoralPsychol(2018)67:357–372
ThestudywasreviewedandapprovedbytheEmoryUniversityInstitutionalReviewBoard.AftertheprincipalinvestigatorwascertifiedviatheCollaborativeInstitutionalTrainingInitiative,andfollowingsubmissionofthefullstudydesign,includingprotocols,methods,riskandbenefitanalysis,andplansfordataanalysis,expeditedapprovalwasawarded.Keyinformantsemi-structuredin-depthinterviewscomprisedtheinstrumentationofthisstudy,buildingonthemethodofarecentAustralianstudy(Meurketal.2014)whoseauthorsfounditvaluabletodepartBfrompreviousliteratureinemployinganiterative,inductiveapproachtoderivecategorisationbasedontermsidentifiedwithintherespondents’discourse.^Participantsweresenttheinterviewquestions24hinadvancetoallowtimeforconsideration.AdaptedcloselyfromastudydesignedbyFlahertyetal.(2014,p.340),thequestionswerebroadlywordedpromptsregardingtheparticipants’narrativesofaddictionandrecovery.Innoinstancedidinterviewconversationsfollowthequestions;rather,participantswereencouragedtosimplytelltheirstory.Notably,nointerviewquestionsincludedanysuggestionofneuroscience-orBbrain^-relatedlanguage.Followingtheinterview,eachparticipantwaspermittedtoseeatranscriptofitforapproval.PertheguidanceofIPA,theinterviewprocesswasiterative,allowingtheresearchertoshifttheinterviewtemplatebasedoninsightsgainedfromapreviousinterview.Eachinterviewwasrecordedandfullytranscribed.Audiorecordingswereusedtoensureaccuracy;participantswerefullyinformedofandconsentedtothisprotocol.Thegoalofthephenomenologicallyorientedmethodofthisresearchprojectwastodiscoverandunderstandthelivedexperiencesofparticipants;therefore,aniterativeanddeductivecycleratherthanpreestablishedcodingwasusedtoselectsegmentsofdatafororganizationintocommonthemes.Althoughthisstudywasgroundedinthebroaderthemesandfindingsoftherecentliteratureandthecommonpremisesandsubjectsthatmightlendthemselvestoaprioricoding,theintentwastorefrainfrompreconceivedexpectations,allowingthedatatorevealcom-monalitiesandpatterns.ResultsIntheanalysisofthedata,thecommonalitiesandpatternsthatemergedsharedmanysimilaritiestothosefoundbyFlahertyetal.(2014),suchasprogressivestagesofrecovery.However,theflexibilityoftheIPAanalysisstageallowedanunanticipatedthemetoemerge:theintertwiningofBbrain^metaphorsandlanguagealongside(orwithin)descriptionsofthespiritualandreligiousaspectsofrecovery.Thus,thepoten-tiallyfruitfulfindingofthisprojectwasthatthefourparticipantswhohadenteredrecoveryafter2010(Sean,Ursula,Barry,andNavarro)soughttointegrateBDMA-relatedframeworksalongsidemoretraditionalspiritual,moral,andmedicalBdisease^models.Thetwoparticipants(KarlandConnie)whohadenteredrecoveryconsiderablyearlierthan2010hadfeworzeroinstancesofvolunteeringanyBDMA-relatedframe-workintheirdescriptionsoftheirexperiencesofaddictionandrecovery.Theparadoxicaltensionsandinnovationsthatemergedintheparticipantconstructionsoftheirexperi-encesofrecoveryofferawindowintothewaystheBDMAimpactsthespiritualaspectsofrecoveryfromaddiction.Sean,Ursula,Barry,andNavarroeachintegratedtheBbrain^alongsideorwithinspiritualcharacteristicsofrecovery.Sean’sconstructionofaBhigherpower^isnotable,particularlygivenhisidentificationasanatheist,whichhesourcedinhisnegativechildhoodandadolescentexperiencesinthePastoralPsychol(2018)67:357–372361
ChurchofLatterDaySaints.MorethanhisexperiencesinA.A.,SeanexperiencedabarelyveiledChristianagendabehindallhisencounterswithinrecoveryservices:Evenallthroughrehab,Icouldn’tgetit.Ijustcouldn’t…becauserehabisactuallymorereligiousthanjustyourstandardA.A.meeting.It’sreallypeoplebelievinginthepowerofGod….It’slikealmosteverybodyIencounteredwhoworksinrecoveryservicesisveryChristianandveryconservative.AlmostallRepublicans.Sothat,forme,wasalsothetrickypartofit,like,BWedon’tagreeonanything.Ourbeliefsystemsaresodifferent.^[But]evenwhenIwaslike,BIdon’tknowifIbelieveanyofthat,^theywerelike,BWell,thisisafaith-basedprogram.Thisiswhatwe’reherefor.^Igotinallthesefightswithmycounselor[Britt]justbecauseIfeltlikewhattheyweresayingwas,BYoudon’thavetobelieveinJesus.Youcanpickanything.^Buteverybody,eventually,believesinJesus.SoIfeltliketheywerejuststallingusupuntilthismomentwhenyou’deventuallycomearound.Unliketheotherstudyparticipants,SeanfoundtheBdoorknob^conceptofA.A.tobedisingenuousand,moreimportantly,unworkable.AcloseconfidantofSean’ssuggestedaBworkaround^HigherPowerconceptthatfunctionedforhim:Ihaveagreatfriend[inrehab]whoIwastalkingtoduringit,andhesaid…hepickedBtheocean^ashisthing,becausetheoceanisbiggerandmorepowerfulthanhim.ButIjustfeltlikeIdidn’tknow.I’mgivingupmypowertotheocean?Ijustcouldn’twrapmyheadaroundanyofit.Seanrelatesmuchofthesestrugglesthroughtheframeofhisrelationshipwithhiscounselorandsponsor,BarealtoughrecoveringcocaineaddictformerAirForceofficerturnedPreacherandAddictionSpecialist,namedBritt^(Daniels2016,p.80)whostatesthatifSeanwantsanychanceatsobriety,orevenatcontinuingtolive,hemustfindandsurrendertoaHigherPower.Inhisplayandinhisinterviewasaparticipantinthisstudy,SeanwasveryclearthatheagreedwithBrittthathislifewasatstake.Hehadenteredrehabilitationafterlosinghisspouseandhisjobandthencomingfrighteninglyclosetoattemptingsuicide.Seandescribeshisdesperationonedayneartheendofrehab:Idecideto,ugh,pray.I’mnotapray-er,butIwastold,whenthishappens,youhavetopray.So,Ido.Oldschool.Onmyknees.FirsttimesinceIwas15?16?IpraytheprayerIwastaught—andthewholetimeI’mhavingaMetasnobmoment—whoareyouprayingtoSean?Youdon’tactuallybelieveinanything.ButIpray.Ipray,thenIeat,thenIshower,thenIpray,andIeatagain…andthenIstopsweating.SuddenlyIrealizeIhaven’tthoughtaboutadrinkinafewminutes.ThenIrealize10minuteshavepassed.AndthenIamfine.Iamproud,andworriedaboutwhenthevoicesinmyheadwillreturn.(Daniels2016,p.85)Afteryearsoffailedrecoveryattempts,Seandescribedhisdesperationinhisfinaldaysofrehab,feelingsureheBwoulddie^becausehewasBnotanydifferent….I’vedetoxedproperly,butIhaven’tdoneanythingelse.^Atthesuggestionofhisrehabcounselor,SeanthenvisitedalocalmeetingofaparticularA.A.groupofpredominantlyJewishmenwhowereBveterans^ofA.A.Seandescribedthestrikingdifferenceheexperiencedbetweenthemedicalmodelcounselinghehadreceivedearlierinthehospitalwarninghimofphysiologicalandneurologicaldamageandtheexplanationofneurologicalmechanismsthathereceivedfromthemen’sgroup.362PastoralPsychol(2018)67:357–372
Butitwasn’tframed[thatway]untilImettheJewishguys,BHere’showyourbrainisoperating.Herearethethingsthatareoutofyourcontrol.^Soforme,thatwasthekeyintermsoffindingscience….Nooneeverexplained,BIt’snotinyourcontrol.Thisisthewaythatyourbrainissetup.^…Ihadbeentodetox.Ihadbeentocountlessmeetings.IhadtakenalcoholtrainingcoursesasrequiredwhenyougetanaggravatedDUIinKentucky.Noneofthishadcomeup.Ithadalwaysbeenreligion.IthadalwaysbeenlikeifyouhadbelievedinGodhardenough,youcoulddoit.ForSean,aneuroscientificaccountprovidedreleasefromhissenseoffailure,whereasothermedicalmodelaccounts(whichwarnedhimofliverandbraindamagewithoutexplainingthephysiologyassociatedwithcravingorimpulsecontrol)andcertainlyBreligion^hadfailedtoprovidehimsuchtoolsoropportunities.Furthermore,thecognitivemechanism(orBchemistry^asSeanoftenreferredtoit)wasseparatefromhisBwillpower^andhispersonhood:BIhavetorealize,‘Oh,that’sjustchemistry.That’snotlikemyself-willfailingme.’^Likemostpersonsexperiencingsevereaddictionofanykind,SeanreportedfeelingbewilderedanddisturbedbytheBnot-me^aspectofhisbehaviorwhileinthethroesofalcoholism.Inseekingtomakesenseofhowhediscoveredhimselfenroutetotheliquorstoreafterputtinghimselftobedfortheevening,cognitivescientificnarrativeshelpedSeanmakemeaning.Soyou’verewiredyourbraintoknowwehavetohaveenoughalcoholinthehousebefore2:00inthemorning,because2:00to10:00istheonetimeinthedaythatwecan’tgetit.Ithinklikethatmademefeelsomuchbetter,justthatIwasn’toutofcontrolandwatchingmyselffromafar.NoteworthyhereisSean’smixeduseofpronouns.ManyofSean’saccountsrevealedadualisticconstructionofhisself-agencyinoppositiontohisBbrain,^anexternalyetinternal,evenalien,entitywithagency,intention,goals,andbeliefsallBits^own.[Learning]aboutneuropathways….Yourbrainwantsthedopamineallthetime.Sothebraincanactuallyrewireitselftomakeyoudothingsthatwilleventuallygetitdopamine.InadditiontowhatByourbrainwants,^SeanofferedmanydescriptionsofthesortsofinnerdialogueheexperiencesashimselfinconflictwithhisBbrain.^IndescribinghowconfoundedhehadpreviouslyfeltbybehaviorandthinkingthatitBdidn’tmakeanysense,^SeandescribedhowlearningthewayinwhichhisBbrainequalizesdopamineexperiences^contin-uedtoofferhimclarityashelivedhislifeinrecovery:Evennow,I’llgetinabigfightwithmywife,andI’llthink,BIjustwanttodrinktoburnitalldown.^Thenit’sjustlike,BNo,I’mjustbeingself-destructive.I’mjustthinkingofthemostself-destructivethingIcando,^whichisn’treally…I’mnotreallyclosetodrinking.Mybrainstillflashesthatinmymindasathingthatcouldwork,butIkindoftrainedmyselftohavePavlovianresponses,soit’slikeIknowthat,thenI’mlike,BNope.Idon’t.That’sjustmybrainputtingthatthere.Idon’treallyhavetodothat.^SeandescribedseveraltimeshisprofoundtransformationuponlearningaBDMA-relatedaccountofaddiction,bothinhisplay(Daniels2016)(35)aswellashisaccountforthisstudy:SEAN:Peopleaskme,whydiditstickthattime?Itwasthefirsttimeitwaschemistryandscienceandnotshameandweakness.Ibelievedinsomethinglargerthanmyself.Myhigherpoweris:science.It’smyfaithinsciencethatkeepsmesober.ThoughitPastoralPsychol(2018)67:357–372363
seemstoworkforthevastmajority,andInevertrytotalkanybodyoutofit—evereverever—itdoesmakeyouthink,howmanypeoplearelikeme,andthendon’tmakeitbecauseweleadwithGodandnotwithscience?Doesbeliefinoneexcludetheother?(Daniels2016,pp.97–98)ForSean,Bscience^issufficientlypowerful,explanatory,andtrustworthy.NotablealsoisSean’ssuggestionthathisconstructionofscienceasaHigherPowerandmoretraditionallytheologicalconstructionsofaHigherPowermaynotbemutuallyexclusive.Thus,evenforSean,whowasthestudyparticipantmostaversetoanyspiritualorreligiouslanguageorframework,wordslikeBbelief^andBhigherpower^emergedasimportantterms.PerhapsmostnotableinSean’sstoryofsurrenderisthathedidnotseehisinabilitytoassenttoanysenseofaHigherPowerasamerephilosophicalortheologicaldiscrepancybutratherasamatteroflifeordeath.OncehehadaccesstoanBalternative^HigherPower,Seanfeltfreedfromhisnegativeexperiencesoforganizedreligionaswellasthemoralmodelofaddictioninwhichhefeltentirelytoblame.ItseemsBscienceasmyHigherPower^freedSeanintwoways:viahisBbrain^(orBbrainchemistry^)asthepartiallyculpableme-but-not-meagenticforcewithinhimandviaBscience^asanexternalforce(and/orsetofknowledge)morepowerfulthanhim.Sean’stermsandconceptsforhissenseofselfandhissenseofaHigherPowerarecomplex,slippery,andoverlapping—yetseeminglylife-saving.InNavarro’snarrationofhisrecoverypathway,hedescribedthedangeroushabitsofthoughtheexperiencedaspartofhisBfactorysettings.^Hedescribedtheimportanceofattending12-stepmeetingsandalsohisdailypracticeofmorningprayerandmeditationinmanagingself-destructiveirrationality.Withoutthispractice,NavarrosaidheobservestheimmediatereturnofunhelpfulmentalhabitsbecauseofhowBconditioned^hisBbrain^andhisBbehavior^seem:IfIgetup,Ijumpintheshower,getdressed,andwalkoutofthehouse,thenby10,11o’clockinthemorning,IjustfeellikeI’mreactionaryagain,likemyfactorysettingsaretakingoverandit’slike,BWhattheheck?^AndIgo,BOh,shoot,Ididn’tdomyprayerandmeditationtoday….ItrytostayinvolvedintheprogramasmuchasIcan.Itjustkeepsmeinthemind.Itkeepsmyfactorysettingsaway,whichisthewholepurposeofdoingthis,becausewhenIallowthefactory—Imean,theyimmediatelygoback.Imean,it’sunbelievablehowconditionedyourbehavior,yourbrainis,tothinkthatway.Clearly,termslikeBbrain^areimportantforNavarro’sself-understanding,thoughoverall,hisunderstandingofaddictionandrecoveryisbasedonatraditionalmixofthediseaseconceptofalcoholismandthespiritualapproachestypicalof12-stepprograms.ForUrsula,medical-modelandneuroscientificaccountsofaddictiondidnotemergeinourinterviewuntilsheturnedourconversationtoherobservationsasanaddictioncounselor.Upuntilthatpoint,herdescriptionofheraddictionandrecoverywasphrasedentirelyinspiritualterms.ThoughUrsula’sunderstandingofbothprayerandgraceincludedmultiplereferencestoherBbrain,^herframingoftheBhow^andBwhy^ofheraddictionandrecoverywasalmostentirelyspiritualintermsofphrasingandepistemology.Ursulahadfoundherselfunabletostopdrinkingandwasfacinghomelessness.AlthoughherexperienceofBrock-bottom^desperation,innerdivision,andfirmatheisticbeliefsarestrikinglysimilartoSean’sexperience,Ursula’sframingofherprayerexperienceismarkedlydifferentfromSean’sframingofhisprayerexperience.364PastoralPsychol(2018)67:357–372
Sothisiswheremyspiritualexperiencereallystarts,isbecauseIprayedforthefirsttime.Idon’tknowwhyIprayedinthatmoment.Iwasanatheist.Idon’tpray,butIwaslike,BDearGod,helpme,^youknow?Iguessbecause—whenIreadthisinTheBigBook,it’stheonlyreasonthatevermadesense.It’slike,deepdownineveryman,woman,andchildisthefundamentalideaofGod,youknow?Asa—asatheistasIwas,theoreticallyandinmybrain—likeintellectually,Iwaslike,BI’matheist.Iwillfightyoutothedeath.Iwillargueaboutit.^…Anditwasn’tsomelong,drawn-out,liketheLord’sPrayer.Itwasjustlike,BIneedf*ckinghelp,God.^Followingheraccountofherownstoryofrecovery,UrsulafirstraisedtheissueofhersenseofthedistinctionbetweenBspiritualmalady^andBbraindiseaseofyourneuralpathways^whenIaskedheraboutherpersonalviewofthenatureofaddiction:Spiritualmalady,Ithink,isreallytheinnatethingthatweallhaveincommon.Youknow,workinginthefield,there’salotof—Ikindofhavetoseparatemyopinionsoutofwhatbestpracticeandwhatsciencesaysisaddiction,whereit’slike,BOkay,it’sabraindiseaseofyourneuralpathwayshavedevelopedinthiscertainwayforyourrewardsystemtowork,^andIthinkofitmoreofaspiritualthing.Iwouldn’tsaythattoaclient.Imight—well,Imight,dependingonthesituation.ButIreallythinkthat’swhatitis,it’sa—IfeellikeIwasbornintothisworldbroken-hearted.Fromthispoint,UrsuladescribedtheBhandmodel^sheoftenusedwithclients,pointingtopartsofherfisttodescribetheprefrontalcortex,thefrontalcortex,cortex,midbrain(whichdecidesBthisisgood,thisisbad^),andbrainstem(Bsurvivalstuff^andBreptilianbrain^).ShebrieflydescribedsubstancemisuseasdamagingtheprefrontalcortexBthat’sinchargeofallrationalthought…beinganadult,really,lieshere.^Thus,theprefrontalcortexisdamagedandByoureallyliveinthisgoodandbadarea,themidbrain,that’savery—kindoflikeadog,youknow?^[Substancemisuse]releasesthedopamineinyourrewardpathwaythatwouldbenormallyreleasedforthingslikefood,water,shelter,sex.Allofthatgets—Imean,youreleasesomuchdopaminefromusingthatit’snotevencomparabletohavinganicemeal.It’snotinthesameballpark.Soitbecomestheultimatesurvivalthing,wherethatrewardpathwaywasdevelopedforustosurvive,youknow?Andwe’vehijackedit.Intermsofmodelsofselfhood,Ursula’sneuroscientificaccountsuggeststhatthedamageeffectedbyaddictiondiminishesone’shumanness(inwhichrationalityisprized),aswellasechoingmuchofthenarrativeofdopamineandrewardpathwaystowhichSeanwasattracted.UrsulastrictlyseparatedthemodelsshepresentedasanaddictioncounselorasopposedtoservingasanA.A.sponsor.Despiteherprofessionaldelineationbetweenthemodels,UrsulasawtheBDMAandthespiritualaspectsofrecoveryasmutuallyreinforcingandharmoniousratherthandiscordant.Theydon’treallyclashbecauseyoufindthatallofthethingsthatwe’vefoundwithneuroscienceofaddictionandthenthesolutionstothat,thebehavioralsolutionstothat,areveryinlinewithwhatwealreadyintuitivelydoinA.A.ButIthinktheGodpieceismissing,youknow?That’swhat’smissingwithinaveryscientificapproachtoaddiction,isthat,forme,IneededthatGodpiece.Istilldotothisday.PastoralPsychol(2018)67:357–372365
LikeUrsula,BarrysoughttoholdtogetherunderstandingsofaddictionthatwereBscientific^versusB12-steporiented.^Afterseveralattemptstomaintainsobriety,Barryfoundsuccessafteranear-deathvehicularcollisionandhissubsequentbriefimprisonmentandlengthy(498h)court-orderedoutpatienttreatment.Barry’sunderstandingofaddiction(likeUrsula’s)isanintegrationofspirituality-andBDMA-relatedframeworks:Butthecoindidn’treallyflipuntilmybrainalsohealed.Youmighthaveheardthathowtheprefrontalcortexgetsallmessedupfromlong-termalcoholuse.Itdoesn’treallyactuallybegintoheal,myunderstandingis,untilsixmonthsafterthelastdrink.Andfunnyenough,thatpartisresponsibleforoursenseofconsequencesandactionsandallthat.LikeUrsula,BarrysawtheBDMAandspirituallyrelatedaspectsasdistinctfromoneanotherbutnotconflicting.AlthoughBarryreportedfeelingdeeplyappreciativeofhisexposuretowhathecalledBthebestofbothworlds^fromhistwotypesofBteachers^—a12-stepapproachandanaddictionscienceapproach—hemadeapointofnotingthathethinkstoomuchBscience^isnothelpfulforaBnewcomer^inthefirststagesofrecovery:NowIlovegettingintotheotherstuff…thatgetsintomoreofachemistrylessonwithhowalcoholinteractswithmyliverandallthat.Butwhenyou’retalkingtoanewcomer,allthatstuffthat’sgoingtoturnintoclouds….Youhavetoreachdownatagut-wrenchinglevel,somethingthatwillgettheirattentionbecauseeverythingelseisjustknowledgethatcan’treallybeusedatthattime.Barry’sperspectiveandexperiencecontrastwiththoseofSean,whoreportedthatinformationaboutneurologicalmechanismandthedynamicsofdopamineasitrelatestoalcoholismwasfarmoreimportantforhisrecovery.Intherecoveryaccountsofthetwoparticipants(ConnieandKarl)whoenteredrecoverybefore1990,thetraditionaldiseaseconceptofalcoholismandaddictionfeaturedmoreprominentlythananyreferencestoneuroscientifictheories.BothparticipantsexplicitlyvolunteeredthevalueofrelinquishingwhattheyviewedastheimpossibleprojectofresolvingparadoxesofaddictionandrecoverysuchasBspiritualityandscience.^KarlclearlydescribedhisexperienceofthephysiologicalaspectsofaddictionbutalsostatedthathisBemotionalstateofmind^andBspiritualstateofmind^weredistinctfromtheBphysical,^whichislikeanBallergy.^Atonepoint,Karldescribedtheinnerstrugglewithaddictionasapullbetweenself,God,andtheBdemons^ofaddiction,allsubjectswithagencyandpowerasopposedtothesubstancesthemselves,whicharemereobjects.Youknowtheysaythatweonlyusetenpercentofourbrain.There’sawhole‘nother90percentthatwedon’tuse.Tome,that’sthatGodparttome.Otherthanthiscomment(apopularmisconception),theexperiencesandperspectivesKarlsharedwerecompletelydevoidoftermssuchasBbrain^orreferencestoneurologicalmechanismsofanykind.Intellingherownstoryofrecoveryandherunderstandingofaddiction,Connie’stestimonywassimilarlydevoidofBDMA-relatedterms,tendingtowardsconventional12-stepspiritualityconcepts.Conniewastheonlyparticipantinthisstudywhodidnotuseanyconceptsrelatedtoneuroscientifictheoriesofaddictionnoranyneurologicaltermsindescribingherexperienceofherself,noteventhewordBbrain.^Attheconclusionofourconversation,Iintroducedthetopicbybeginningtodescribeapopularnewspaperarticle,towhichConniequicklyresponded:366PastoralPsychol(2018)67:357–372
Interviewer:InTheNewYorkTimes,lastsummer,therewasanarticle—itwasin,like,thetoptenmostclicked-onarticlesinTheNewYorkTimesonline…itbasicallysaidthat,youknow,allthisstuff,everythingweknowaboutalcoholismandaddiction,itcannowbeexplainedneuroscientifically.AndI’mwonderingwhat—Connie:FirstthingI’dsayis,BBullshit.^[Laughs]No,Imean,really,Ijust,Ithinkthatthereissomethinginmethatisgenetic,somepredisposition,right?Butagain,howareyougoingtodefinealcoholism?Conniewentontodescribeexamplesofutterlyillogicalandself-destructivebehavior,notinghowBunexplainable^itwas.ThiswasapragmaticpointonwhichKarl,Connie,andNavarrowereinclearagreement,bothintermsofpursuingtheBhow^andBwhy^ofaddictionandintermsofcompletelyBgetting^theBGodstuff.^ConniesharedhowshetypicallyrespondstonewcomersstrugglingwiththeconceptofaHigherPower:Itellpeopleallthetime,BDon’tgettooburntoutaboutthisGodstuff,atfirst,becauseit’lljustdriveyoucrazythatyou’renotgoodenough,right?Don’tgetallwhoopedupaboutthat.Don’ttakeallthatstuffsoseriously.^Tome,thepointis,BIcan’tdothisbymyself;Iamnotthatpowerful.^FromUrsula’sBhandmodel^oftheneurologicalaspectsofaddiction,toSean’sreportsofinnermultiplicityunderstoodthroughaframingofhisBbrain^asaBnot-me^aspectofhimself,toBarry’sintegratingofhisBtwokindsofteachers^of12-stepandaddictionscience,toNavarro’sBfactorysettings,^theparticipantsinthisstudywhohadenteredrecoveryrelativelyrecentlyvolunteeredfarmoreBDMA-relatedconstructsofaddictionandrecoverythanthoseparticipantswhohadenteredrecoveryseveraldecadesearlier.DiscussionDevelopinginnovativeideologicalframeworksinordertomakemeaningofthebafflingexperienceofaddictionis,initself,nothingnew.Indeed,itisButterlybewildering^(Flanagan2011)tobeself-destructive,seeminglyincapableofstoppingoneselffromruiningone’sownlifeandeverythingoneholdsdear.Distortedthinking,whichcanbeakindofinnovativemeaning-making,isalong-recognizedattributeofaddiction.Similarly,theapparentparadoxofexpressingsurrendertoaHigherPowerasanempowering(ratherthandisempowering)actisnotnew,thoughcritiquesofthe12-stepmodelarearguablylouderthaneverintheBneuro-turn^(DodesandDodes2014;Glaser2015;Lewis2016;Szalavitz2016a,b).Furthermore,asnotedabove,Baself-constructedself-definedspiritualitythatisall-inclusive^(Kelly2017)hasalwaysbeenlauded(orcritiqued)asadefiningfeatureof12-stepprograms.Whatdistinguishestheinnovativeconstructionsofthisstudy’sparticipantsistheirintegrationofneurocentricself-conceptswiththeirspirituality/religiosity.ManyexcellentanalyseshaveemergedprobingthechangesinWesternsubjectivity(alongwithotherculturalcomponents,suchasgovernance,law,commerce,andeducation)thatseemtoaccompanytheneuro-turn,andtheyemploytermssuchasBbrainhood^(Vidal2009),Bneurochemicalselves^(RoseandAbi-Rached2013)andBcerebralsubject^(Ortega2009).Few,ifany,haveexploredtheimpactoftheneuro-turnonspiritualityandreligiosity.PastoralPsychol(2018)67:357–372367
ThecomplexemergenceofBDMA-relatedconstructswithinandalongsidethetranscen-dent,transpersonalfunctionsoftherecoveryaccountsofthisstudyseemlargelyreflectiveoftherecenttheoreticalproposalsaboutsecularitybyHarvardphilosopherCharlesTaylor,particularlytheconceptoftheBbufferedself^(2007).Severalresearchershavecapablynotedthetranscendent,transpersonalfunctionsofrecovery(KurtzandWhite2015),buttheTaylorianframeworkaddsahistoricizedaccountofthecurrentundergirdingoftheWesternsensibility,regardlessofanindividual’sprofessedreligiousorspiritualbeliefsorunbeliefs.Taylor’ssignificantcontributionisthedistinctionhemakesbetweenhisBsense^ofsecularityandpreviouslyidentifiedtheoriesofsecularity,whichhegroupsintotwosortsofBsenses.^Thefirstsense(S1)ofsecularityinvolvesthedepartureofreligionfrompublicspaces(politics,themarketplace,science,thearts).Thesecondsense(S2)ofsecularityismorepersonal,involvingtheinevitablewaningofreligiousbeliefandpracticeasaconsequenceofmodernity.TaylornotesthatS1andS2produceinsufficientBsubtractionstories^thatfailtoaccountforhowsecularityisproduced,notsimplydistilled.Taylor’sBbackground^senseofthesecular(S3)accountsforthecreationofparticularconditionsofbeliefandsharedcontextsofunderstandingthatalsoshapebothbeliefandBunbelief.^ForTaylor,theprimaryfeaturesofS3aretheawarenessthatanybeliefisalwaysoneoptionamongmanyandthatexclusivehumanismhasbecomeanoption.Thus,regardlessofhowonewouldrespondtoaPewResearchCentersurvey(BAreyoureligious?^),S3illustratesthatisimpossibletolackawarenessthattherearemultipleoptionsregardingbelief.Taylornotesthatwehaveshifted(permanently)fromacontextinwhichGodisunchallengedandunproblematictoacontextinwhichsuchbeliefisunderstoodasoneofmanyoptions.ThisisaBfeel^oftheworldweallshare,regardlessofourprofessedbeliefs.However,toconcludethatwearemovingtowardapost-religious,post-spiritualfuture(oreventhatsecularityishumanityminusreligion)istomissentirelythegiftsofTaylor’sinsightsandofthecomplexaccountsoftheexperienceofaddictionfromthoseinrecovery.IndisruptingourassumptionthatourinnerlifeBfeels^liketheinnerlifeofpeopleinothereras,Taylorcallsattentiontothehistoricizednatureofourinnermostsensesofself.Disruptingsuchassumptionsiscriticallyimportantforthestudyofaddiction,asCook(2010)notes:BWhileeachofusmightliketoimaginethatourownviewisthemostlogical,objectiveandimpartial,thatimaginationisinitselftherootoftheproblem^(p.760).Taylormasterfullyoutlinesthehistoricalforcesthathaveproducedanagethatisdistinctiveforitsprizingofself-governanceasahighandtreasuredgood.Fromthisvantagepoint,thepre-reflectivecontextofanyonelivinginWesternmodernity,regardlessofbeliefsorprinciples,includestheexpecta-tionthatonemaymasterone’sinnerexperience,includingone’sdesires.Nolongervulnerable(porous)tothedemonicorthetranscendent,thebufferedself(subject)expectstomasteritsowndesires(objects).Itfollowsthatoneshouldbeabletogovernandmanageone’ssensations,feelings,andemotionalstateswithanyavailabletoolsandstrategies,includingsubstances.Withinthisframe,addictionmayonlybecomprehendedintwoways:(1)as(moral)failure,onthepartofthebufferedself,toadequatelycontrolone’sdesires;and/or(2)asdisease,which,although(likedesire)aforceinternalbutnotidenticaltotheself,isanorganicBchemical^problemoverwhichtheaddictisunderstandablypowerlessandforwhichtheaddictisnot(orisless)responsible.Indeed,thetiredbifurcationbetweenBmoralfailure^andBdisease^isfurtherexacerbated,ratherthanabated,viapopularmediaengagementoftheBDMAasananswertoBwhycan’ttheyjuststop?^(Bogren2017;Campbell2013;Racineetal.2010;RobillardandIlles2012).AsCampbell(2011)notes,BTheaddictedbrainbecomestheprimeexampleofthebrain-based368PastoralPsychol(2018)67:357–372
self^(p.213).SallyL.SatelandScottO.Lilienfeld(2013,p.3)notethatthefamiliar1987Bthisisyourbrainondrugs^imageofanegg(thebrain)sizzlinginafryingpan(thedrugs)persists—onlynow,thefryingeggisreplacedwithcolorfulbrainimages.However,forSean,thesizzlingeggimagewasaninadequateexplanationofhisfailuretomasterhisdesires,whereasexplanationsofneuralpathwaysworked.Sean’sbrainwasaninternalagentialforcewithwhichhehaddialogue,aBme-but-not-me^partofhimwithdesiresandpowersthatheneededtomanage.Thus,perhapspartofthepoweroftheBDMAmodelisthewayinwhichasenseofagencyisparadoxicallyretained.Colorfulbrainimages,nowBliterallyrefashionedastoolsofsubjectivity^(Campbell2013p.257),fortifyamorecomplexandself-likemodelofbrainmechanisms,whereasarawegglackssuchcapacities.Campbell(2013)describesasimilarphenomenonamongstresearchersusingneuroimagingtechnologiesaswaystoBgetinside^theirpatients’heads(p.244),locatingaspectsofpersonhoodinparticularneuro-regions(Campbell2010,p.99)andperpetuatingaCartesiandualisminwhichthebrainitselfhasdesiresandwills.WhatFernandoVidal(2009)callsBthebeliefinbrain-selfconsubstantiality^andtheBreducibilityofselftoanorganofthebody^arethuswritlarge.AsNikolasRose(2007)putsit,BMindissimplywhatthebraindoes^(p.192).Therisingprominenceofneurocentricunderstandingsofaddictionmattersforthoseinrecovery,notonlybecauseitfurthermedicalizestheexperienceofaddiction(withoutsufficientscientificconsensusorevidence)butalsobecauseitevenmorefirmlyengendersasenseofthebufferedself,amodelofamoremechanistic,agentialanthropologyinwhichtheselfisinsulatedfromthetranscendentanddemonicandalsofromtheself’sowndesires.Whenaddictionisunderstoodtobesourcedinone’sbrain,alongwithanyaffective(orevenspiritual)experiences,theselfisevenfurtherreducedtolittlemorethanarationalmanager.Navarro’sBmyfactorysettings,^Sean’sBscienceismyhigherpower,^Ursula’sBGod-piece^reinforcingtheneuromechanicssheexplainedviaherfistmodel—suchframeworksofmeaningaremorethanpsycho-social-theologicalcuriositiesorinterestingphilosophicalconstructions.Inthecaseofrecoveryfromaddiction,theyarelife-savingconceptualframeworks.Asnotedabove,IconcurwithMeurketal.(2014,2016)andothers(BröerandHeerings2013;Buchmanetal.2013;O’ConnorandJoffe2013)whosuggestthatneurobiologicalunderstandingsofaddictionarenotabouttoutterlysurpassandextinguishothermodesofunderstanding,asissometimespredicted.And,certainly,theroleofspiritual/religiouschar-acteristicsinrecoveryseemstopersist.Theimplicationsforcaregivers,researchers,clinicians,faithleaders,andpolicymakersseemtobe(1)theneedtoprioritizemultidisciplinaryresearchonthespiritual/religiouscharacteristicsofrecovery,thoughsucheffortsarealwaysfraught;and(2)theknowledgethatunorthodoxmeaning-makinghappensandthatitcanbelife-saving.CompliancewithethicalstandardsCompetinginterestsNone.ReferencesAshenbergStraussner,S.L.,&Byrne,H.(2009).Alcoholicsanonymous:Keyresearchfindingsfrom2002–2007.AlcoholismTreatmentQuarterly,27(4),349–367.https://doi.org/10.1080/07347320903209665.Blevins,J.(2009).Wewerepowerless:Addiction,thewill,andtheEvangelicalrootsoftheTwelveSteps.http://religiondispatches.org/we-were-powerless-addiction-the-will-and-the-evangelical-roots-of-the-twelve-steps/.Accessed26May2015.PastoralPsychol(2018)67:357–372369
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GamblingwithGod:theeffectofgamblingonreligiousandspiritualstrugglesJenniferT.GrantWeinandyandJoshuaB.GrubbsDepartmentofPsychology,BowlingGreenStateUniversity,BowlingGreen,OH,USAABSTRACTReligionandspiritualityareoftenrelatedtovariousaddictivebehaviors,suchassubstanceusedisorders,excessiveinternetpornographyuse,andGamblingDisorder.However,presently,veryfewpublishedarticleshaveconsideredtherelationshipbetweenGamblingDisorderandnegativeaspectsofreligionandspiritualitysuchasreligiousandspiritualstruggles.Thisstudyaimedtobetterunderstandhowproblemgamblingseveritymaybeuniquelyassociatedwithreligiousandspiritualstruggles,bothcross-sectionallyandovertime.ThestudyusedsecondarydatafromalongitudinalMTurkSurvey(n=764;follow-upn=342)andcontrolledforneuroticism,age,gender,income,andgamblingpreference.Problemgamblingseveritywasuniquelyassociatedwithseveraltypesofreligiousandspiritualstrugglesatbaselineandmoststrugglesatasix-monthfollow-up,evenaftercontrollingforbaselinelevelsofsuchstruggles.Furtherresearchisnecessarytounderstandthenatureoftheselinksandhowtheymightinformclinicalcare.ARTICLEHISTORYReceived7October2020Accepted12January2021KEYWORDSReligion;spirituality;problemgambling;religiousandspiritualstruggles;gamblingdisorderGamblingwithGodGamblingDisorder(GD)isawidelyrecognisedbehavioraladdictionwhichnegativelyaffectsvariousaspectsofwell-beingandpredictsarangeofcomorbidities(seeLorainsetal.,2011).Therefore,understandinghowGDinteractswithotherfacetsofwell-beingrequiressustainedresearchinterest.Religious/spiritualfunctioningisanimportantdomainoflifeexperienceforamajorityofhumans(PewResearchCenter,2014).Yet,todate,thereislittleresearchexamininghowproblemgamblingmightinfluencereligiouswell-being.ThepresentworkinvestigatesthisbyexaminingGDsimpactonreligious/spiritualfunctioningbothimmediatelyandlongitudinally.GamblingwithinreligiousandspiritualtraditionsMostreligioustextsandcommunitiesengagewiththeproblemsandeffectsofsubstanceandgamblingaddictionsbothexplicitly(Proverbs20:1)andimplicitly.ThemodernCatho-lictraditionsuggestsgamblingisnotinherentlywrong,butharmingothersviagamblingorbecomingaddictedismorallyunacceptable(CatholicCatechism:2413).TheUnited©2021InformaUKLimited,tradingasTaylor&FrancisGroupCONTACTJenniferT.GrantWeinandyjtgrant@bgsu.eduSupplementaldataforthisarticlecanbeaccessedathttps://doi.org/10.1080/13674676.2021.1878491MENTALHEALTH,RELIGION&CULTURE2021,VOL.24,NO.5,437–449https://doi.org/10.1080/13674676.2021.1878491
MethodistChurch’sSocialPrinciplesstronglycondemnsgamblingwhileremindingfol-lowerstohelpthosewithaddictions(UnitedMethodistChurch,2016).IslamicteachingviewsgamblingasaworkofSatanandasinpunishableonJudgmentDay(SuraMa’idah5:90–91).IntheJewishtradition,gamblingisdoneprofessionally,compulsively,orforpersonalgainiscondemned(MishnahSanhedrin3:3).Hinduscriptureswarnagainstgamblingandthenegativeconsequenceswhichmayarise,bothforthegamblerandthosearoundthem(RigVedaMandala10,Sukta34).BuddhistteachingsfoundintheSigalovadaSuttaalsospeakofthedangerssurroundinggambling.Givensuchreligiousprohibitionsagainstgamblingacrossfaithtraditions,itisnotsur-prisingthatmanystudieshaveshownthatreligiousattendanceandbeliefsaliencepredictlowerlevelsofcompulsivegamblingbehaviors(e.g.,Braunetal.,2016;Caseyetal.,2011;Mutti-Packeretal.,2017)andthatreligiousdenominationmaybeprotectiveagainstdevelopingproblemswithgambling(Braunetal.,2016;Eitle,2011;Krauseetal.,2017).Further,religion/spiritualitymaybekeyaspectsoftherecoveryprocessfromgam-blingrelatedproblems,asseeninresearchwiththoseinGambler’sAnonymous(GA;e.g.,Walsh,2001),a12-steprecoveryorganisationthatcentresanindividual’sspiritualityasakeyelementofrecovery.Despitetheabovefindingsindicatingthatreligion/spiritualitymaybeabufferagainstgamblingproblems,morerecentresearchsuggeststhelinksbetweengamblingandreli-gionaremorenuanced.Higherreligiousnessmaybelinkedtogreatergamblingrelatedcognitivedistortionsinsomesamples(Kimetal.,2018),suggestingthattherearelikelycomplexrelationshipsbetweengamblingbehaviors,GD,andreligious/spiritualfunction-ing.Onepotentialrelationshipthathasbeenrelativelyignoredinpriorliteratureistheinfluenceofgamblingonreligiousandspiritualstruggles.ReligiousandspiritualstrugglesReligion/spiritualitycanpresentuniquechallengessuchasreligiousandspiritualstruggles(RSS;e.g.,Exlineetal.,2014).Priorwork(Exlineetal.,2014)hasnotedthatdivinestrugglesrefertonegativeemotionsaboutortowardadeity;demonicstrugglesfocusfeelingsofconcernaboutattacksfromevilspirits;interpersonalstrugglesarefocusedonfeelingsofconflictandantipathytowardreligiousadherents;moralstrugglesrefertofeelingsofstrugglearoundrightandwrong;doubtstrugglesarefeelingsofdis-tressaboutreligiousdoubts;andultimatemeaningstrugglesaredifficultieswithfeelingsofpurposelessnessorlackofmeaning.Importantly,RSSarepredictorsofavarietyofpro-blems,suchasanxietyanddepression(Stauneretal.,2016;Wiltetal.,2018),highermor-talityratesinchronically-illpatients(Pargamentetal.,2004),poorerrecoveryfromillness(Fitchettetal.,1999),morepsychologicalandmentalhealthproblems(Harrisetal.,2012),andneuroticism(e.g.,Grubbsetal.,2016;Wiltetal.,2017).TheseresultssuggestthatRSSareindicatorsoflowerpsychologicalandphysicalwell-beingoverallandthattheymaydrivedistressanddecreasedpsychologicalhealth(forareviewsee:Exline,2013).ReligiousandspiritualstrugglesandaddictionPastworksuggeststhatRSSareassociatedwithaddiction(e.g.,Johnsonetal.,2008;Krauseetal.,2017),especiallysubstanceusedisorders.Forexample,negativereligious438J.T.GRANTWEINANDYANDJ.B.GRUBBS
copingislinkedtodifficultiesmaintainingabstinence(Medlocketal.,2017)andcanbeabarriertotreatment(Pufferetal.,2012).Additionally,relationshipsbetweenRSSandproblemdrinkingseemtobestrongerthantherelationshipsbetweenproblemdrinkingandreligiouspractices(Krauseetal.,2017).Similarly,RSSarealsolinkedwithcompulsivesexualbehaviors(Griffinetal.,2016;Hooketal.,2015)andproblematicpornographyuse(Grubbsetal.,2017),withthelatterrelationshipsbeingevidentlongitudinallyaswell.Col-lectively,thesefindingssuggestaddictions–bothsubstancerelatedandbehavioral–areassociatedwithgreaterconcurrentandlongitudinalexperienceofRSS.Despitetheabovefindings,relativelylittleworkhasfocusedontheintersectionofRSSandGD.OnepriorstudyfoundpreliminaryassociationsbetweenRSSandgamblingaddiction(Faiginetal.,2014).However,thisworkwasacross-sectionalstudyofunder-graduatesonly.Anothermorerecentwork(Gutierrezetal.,2020)demonstratedthattherewererelationshipsbetweenhigherRSSandpathologicalgamblinginaclinicalsampleofUSveterans.Specifically,thisresearchnotedstrongassociationsbetweengam-blingrelatedproblemsandinterpersonal,moral,ultimatemeaning,anddoubtstruggles.However,thesefindingswerelimitedtoaveryuniquepopulation(USveteransreceivinginpatienttreatmentfordiagnosedGD).ThecurrentstudyBuildingonpriorresearch,thisstudyaimstounderstandtherelationshipbetweentheseverityofproblematicgamblingandRSSinamoregeneralsampleofUSadultsandtotesttheserelationshipsovertime.Previouscross-sectionalresearchhasshownthatgamblingisrelatedtoRSS(Faiginetal.,2014;Gutierrezetal.,2020).Buildingonthis,weexpectedthatproblemgamblingseveritywouldberelatedtoRSSandthisrelation-shipwouldcontinuesixmonthslater.Thatis,wewereinterestedinexaminingwhetherornotbaselinelevelsofproblemgamblingwereuniquelyrelatedtoRSSovertime,evenwhenbaselinelevelsofRSSwereheldconstant.RatherthanfocusingonchangeinRSS,ourprimaryaimwastosimplydeterminewhetherornotproblemgam-blingwasrelatedtoRSSovertime.Furthermore,indesigningthepresentwork,wenotedthat,aspreviouslyreviewed,neuroticismisaknowncorrelateofbothgamblingrelatedproblemsandself-reporteddifficultiesinreligious/spirituallife(i.e.,RSS;Grubbsetal.,2016;Potenzaetal.,2006;Wiltetal.,2017).Therefore,wecontrolledforneuroticisminallanalyses.MethodParticipantsandprocedureThisworkmadeuseofapre-existingdataset,collectedasapartofalargerprojectrelatedtoGDandPost-traumaticStressDisorder(forfulldetailssee:https://osf.io/n29xw/).Par-ticipantsfromtheUSwhoself-reportedgamblinginthepastyear(N=881adults)wererecruitedusingAmazon’sMechanicalTurk(MTurk)onlinelabourmarketplacethroughtheTurkPrimedataacquisitionplatform(Litmanetal.,2017).Respondentswerecompen-sated$7.00fortheirparticipation.Onlythosewhoperseveredthroughtheentirestudy,completingtheSouthOaksGamblingScreen(SOGS),theRSSScale,andthebaselineMENTALHEALTH,RELIGION&CULTURE439
demographicmeasures(gender,age,annualincome,neuroticism,andparticipationinonline,chance,orskill-basedgames)wereincluded,leavingafinalsampleof764partici-pants(finalinclusionrate=86.7%).Sixmonthsaftertheinitialsurvey,participantswereinvitedtocompleteafollow-upstudy.All764participantswerecontacted,ofwhich342completedallfollow-upmeasures(retentionrate=44.8%).Aftercompletingthesefollow-upmeasures,participantswerecompensated$5.00viatheMTurkmarketplace.DemographicsofparticipantsfrombothtimepointscanbefoundinTable1.Thisworkwasexemptfromreviewbytheauthors’InstitutionalReviewBoardbecauseitsolelyutilisedsecondarydata.Ofnote,portionsofthisdatahavebeenexaminedinpriorpublications(Grubbs&Chapman,2019;Grubbs&Rosansky,2019;Grubbsetal.,2018;Grubbs,Chapman,etal.,2019).However,nopriorworksbasedonthisdatahaveexam-inedtheroleofgamblinginthepredictionofreligious/spiritualfunctioning.MultivariateAnalysisofVariance(MANOVA)revealednodifferencesonbaselinemeasuresofkeyvariables(RSSandproblemgamblingseverity)betweenthosewhocom-pletedthefollow-upandthosethatdidnot(Wilk’sλ=.964,F[13,329]=.949,p=.502).There-fore,allthosewhocompletedthebaselinemeasureswereincludedinthebaselineanalyses,regardlessofwhethertheycompletedthefollow-upmeasures.Table1.Demographicsofparticipantsatbaselineandfollow-uptimepoints.BaselineaFollow-upbGenderFemale412(54%)185(54%)Male352(46%)157(46%)Age36.1(SD=11.2)37.4(SD=11.3)Race/EthnicityWhite/Caucasian584(76%)261(76%)African-American/Black89(12%)40(12%)Asian/PacificIslander66(9%)34(10%)Latino/Hispanic63(8%)29(9%)AmericanIndian/Native-American/AlaskaNative12(2%)3(1%)MiddleEastern3(0%)0(0%)Other10(2%)3(1%)SexualOrientationHeterosexual664(87%)302(88%)Homosexual33(4%)12(4%)Bisexual56(7%)25(7%)Asexual3(0%)1(0%)Pansexual5(1%)1(0%)Other4(0%)1(0%)Relationship/MaritalStatusMarried271(36%)138(40%)Single,notinacommittedrelationship241(32%)103(30%)Singleandinacommittedrelationship122(16%)45(13%)Livingwithapartner115(15%)46(14%)Divorced47(6%)29(9%)Separated9(1%)5(2%)Widowed6(1%)2(1%)AverageAnnualIncome$56,175$59,145(SD=$44,039)(SD=$48,935)PreferredgametypeChancegames448(59%)202(59%)Skill-basedgames168(22%)85(25%)Equalpreference148(19%)55(16%)Onlinegames59(8%)26(8%)Note:aN=764;bN=342.440J.T.GRANTWEINANDYANDJ.B.GRUBBS
MeasuresTable2showsmeans,standarddeviations,ranges,andinternalconsistencyvaluesforneuroticism,SOGSandeachRSSsubscaleatbaselineandfollow-up.ProblemGamblingSeverity.ProblemgamblingseveritywasassessedusingtheSouthOaksGamblingScreen(SOGS;Lesieur&Blume,1987).TheSOGScontains21-items,ofwhichonly20arescored,askingparticipantsquestionssuchas“Havepeoplecriticizedyourgambling?”and“Didyouevergamblemorethanyouintendedto?”.Responsescon-sistentwithGDweregivenavalueof1.Responsesweresummedandrangedfrom0to20.1ReligiousandSpiritualStruggles.The26-itemRSSScale(Exlineetal.,2014)includessixsubscales(Divine:fiveitems,Demonic:fouritems,Interpersonal:fiveitems,Moral:fouritems,UltimateMeaning:fouritems,andDoubt:fouritems)whichwereanalysedsepar-atelyforthisstudy,similartootherstudieslookingataddictionandRSS(e.g.,Stauneretal.,2019).Participantsratedeachstatementfrom1(notatall)to5(agreatdeal),andmeanscoreswerecalculatedforeachofthesubscales.Neuroticism.TheInternationalPersonalityInventoryPoolNEO120(IPIP-NEO-120;Maplesetal.,2014)wasincludedasameasureofneuroticism.ThesixfacetscoresoftheNeuroticismindex(Anxiety,Anger,Depression,Self-consciousness,Immoderation,andVulnerability)wereaveragedtocreateacompositeNeuroticismscalescore.TypeofGambling.Participantswereaskedtoindicatetheirpreferredmethodandtypeofgambling.Participantswerecodedasgamblingonlineiftheyrespondedthattheyhadmostoftengambledonlineinthepast12months,allotherswerecodedasnotprimarilygamblingonline.Participantswereadditionallycodedaseitherprimarilypreferringchancegames(i.e.,thelottery,bingo,dice,slots,tabs,keno,scratch-offs),skill-basedgames(i.e.,playedcards,betonhorse/dograces,sportsbetting,propbetting,stocks,fantasysports),orbothchance-basedandskill-basedgamesequally(equalpreference).Table2.Descriptivestatisticsforandcorrelationsbetweenneuroticism,SOGSandRSSsubscalemeasures.Mean(SD)αObservedRange12345678Baselinea1.Neuroticism2.71(.85).941–4.92-2.SOGS3.50(4.03).900–20.132-RSS3.Divine1.43(.84).931–5.277.319-4.Demonic1.42(.85).941–5.172.364.622-5.Interpersonal1.69(.89).871–5.298.215.537.421-6.Moral1.71(.99).921–5.278.337.611.661.476-7.UltimateMeaning1.89(1.06).891–5.520.244.573.386.546.527-8.Doubt1.57(.91).921–5.325.274.732.500.584.624.609-Follow-upbRSS9.Divine1.34(.74).951–5.261.369.644.463.381.365.355.42710.Demonic1.32(.70).941–5.168.394.414.604.344.386.224.30811.Interpersonal1.50(.74).871–4.60.330.267.350.379.642.337.388.37212.Moral1.54(.86).921–4.75.268.375.350.460.309.610.327.42813.UltimateMeaning1.76(.98).901–5.520.237.407.263.362.309.619.40914.Doubt1.43(.73).901–4.25.338.365.562.405.421.446.433.655Note:aN=764;bN=342;Allcorrelationsarestatisticallysignificant(p<.01).MENTALHEALTH,RELIGION&CULTURE441 PlanforanalysesForallvariables,wefirstcomputeddescriptivestatisticsandPearsoncorrelations.Totestkeyrelationships,wefollowedthesameanalyticstrategyemployedinpastworkonbehaviouraladdictionandRSS(e.g.,Grubbsetal.,2017).Wefirstconductedaseriesofcross-sectionalhierarchicalregressionsbetweenkeypredictorsatTime1andeachRSSatTime1.Inthefirststepoftheregressions,weincludedneuroticism,gender,age,annualincome,andpreferenceforonline,chance,orskill-basedgamesascontrolvari-ables.Baselinelevelsofproblemgamblingseverity(usingtheSOGS)wereenteredinthesecondstep.Againconsistentwithpriorwork(Grubbsetal.,2017),wethensoughttoexaminetheuniqueroleofgamblingproblemsinpredictingeachRSSscoreatTime2,whileholdingthesameRSSscoresatTime1constant,usinghierarchicalregressions.Giventhatonlytwotime-pointswereavailable,thatthevariablesmaynotbestableovertime,andthatouraimwastodeterminetheuniqueroleofgamblingproblemsinpredictingRSSovertime,ratherthanevaluatingtheeffectofaninterventionorchange,sucharesidua-lisedchangeapproachisadequate(Castro-Schilo&Grimm,2018;Gollwitzeretal.,2014).Inthefirststepoftheseregressions,weincludedthecontrolvariablesandbaselinelevelsoftheRSSbeingpredicted.2Inthesubsequentstep,baselinelevelsofproblemgamblingseveritywereentered.ResultsAlthoughthisstudyutilisedthewholesampleandaimedtouseanylevelofreportedgamblingproblems,mostparticipantsdidnotreportexperiencingclinicallysignificantlevelsofproblemgambling.Basedonpreviouslyestablishedcut-offpointsforclinicallysignificantgamblingproblemsontheSOGS(Goodieetal.,2013),27%scoredabovealiberalcut-offoffive,15%scoredaboveacut-offofeight,and6%scoredaboveacut-offof12,whichhasbeensuggestedforMTurksamples.Thesepercentagesareslightlyaboveratesfoundinthegeneralpopulation(e.g.,2.7%-5.6%:Welteetal.,2015).CorrelationalanalysesTable2showscorrelationsbetweenbaselinelevelsofneuroticismandproblemgamblingseverity,andallsixRSSatbothtimepoints.Analysesrevealedsmallpositivecorrelationsbetweenproblemgamblingseverityandneuroticism.Resultsshowedmedium-to-largepositivecorrelationsbetweenthevariousRSSandbetweenRSSatbaselineandfollow-up.EachRSScorrelatedhighlyandpositivelywithlaterreportsofthesameRSS.NeuroticismwaspositivelycorrelatedwithallRSSatbothtimepoints.Furthermore,problemgamblingseveritydemonstratedsmall-to-mediumpositivecorrelationswithallRSSatbothtimepoints.HierarchicalregressionsBaseline.Table3showsstandardregressionestimates(i.e.,betaweights)andfullregressionresultsforallhierarchicalregressionswithbaselinedata.442J.T.GRANTWEINANDYANDJ.B.GRUBBS Acrossallsixstruggles,neuroticismemergedasasignificantpredictorinthefirststepoftheregression.Inthesubsequentstep,SOGSscoresemergedasasignificantpredictorforallstruggles,accountingfor2.4%(interpersonalstruggles)to10.4%(demonicstruggles)ofuniquevarianceabovecontrolvariables.Longitudinal.Table4showsstandardregressionestimates(i.e.,betaweights)andfullregressionresultsforallfollow-uplevelhierarchicalregressionanalyses.Acrossallsixfollow-upstruggles,neuroticism(exceptfordemonicstruggles)andbase-linelevelsofthesamestruggleemergedassignificantpredictorsinthefirststepoftheregression.Inthesubsequentstep,SOGSscoresemergedasasignificantpredictorforallstrugglesexceptultimatemeaningstruggles,accountingfor.6%(interpersonalstruggles)to2%(doubtstruggles)ofuniquevarianceabovecontrolvariablesandbase-linelevelsofthesamestruggle.DiscussionThisworkaimedtobetterunderstandtherelationshipbetweengamblingandRSSintheUS,cross-sectionallyandlongitudinally.ProblemgamblingseveritywassignificantlyanduniquelyassociatedwithallsixRSSatbaselineandallRSS,exceptultimatemeaningstruggles,atthesix-monthfollow-up.Moreover,rawcorrelationsbetweenproblemgam-blingandRSSatbothbaselineandfollow-upwerehighlycomparable,suggestingrobustandconsistentassociationsbetweenthesedomainsovertime.BehaviouralAddictionsandReligiousandSpiritualStruggles.Priorworkshaveshownthat,withregardstoaddiction,valueinconsistentbehavioursoftenleadtoavarietyofintrapersonalproblems(e.g.,Grubbs,Kraus,etal.,2019).Forexample,previousresearchhasfoundthatperceivedproblemswithinternetpornographypredicteddivine,moral,Table3.SummaryofHierarchicalRegressionAnalysisofVariablesPredictingAllSixRSSatBaseline.STEP1VariableRSSDivineRSSDemonicRSSInterpersonalRSSMoralRSSMeaningRSSDoubtNeuroticism.267**.147**.298**.272**.528**.313**Gender.028−.027.062.045.096**.014OnlineGambler.119**.121**.089*.066.030.091**ChanceGames.010.046.019.020−.102*.005SkillGames.055.100*.002.076−.078.037Age.001−.019.001−.032.005−.006AnnualIncome−.079*−.097**−.044−.068−.081**−.077*R2.101.060.103.096.297.122FforR212.13**6.83**12.43**11.45**45.54**14.97**STEP2Neuroticism.232**.103**.276**.233**.506**.284**Gender.007−.053.050.023.083*−.002OnlineGambler.060.048.054.001.007.042ChanceGames.004.039.015.014−.105**.000SkillGames.026.064−.015.044−.096.*.014Age.005−.015.004−.028.008−.003AnnualIncome−.075*−.092**−.042−.065−.078**−.074*SOGS.270**.337**.163**.297**.171**.223**R2.168.163.128.176.323.167ΔR2.067.104.024.080.027.045FforΔR260.42**93.54**21.13**73.61**29.71**41.04**Note:**p≤.01;*p≤.05;N=764.Problemgamblingseverityinboldtypefaceforclarity.MENTALHEALTH,RELIGION&CULTURE443 andinterpersonalstrugglescross-sectionallyandmoralandinterpersonalstruggleslong-itudinally(Grubbsetal.,2017).Thepresentstudyextendsthosefindingstoanotherdomainofbehaviouraldysregulation:problemgambling.Moreover,thisstudyfoundlinksbetweenproblemgamblingandotherRSSovertime(i.e.,notjustmoralandinterpersonalstruggles).PreviouslyidentifiedcorrelationsspecificallybetweengamblinganddivineRSS(Faiginetal.,2014;Gutierrezetal.,2020)werereplicatedhere.Thisstudyextendsthesepriorworksfindingthatmostoftheserelationshipscontinuedatasix-monthfollow-up.ThissuggeststherelationshipbetweengamblingandRSSpersistsovertimeandmayprovidepreliminaryevidenceforpotentialcausalpathways.Althoughatwo-time-pointanalysisdoesnotallowustodrawcausalinferences,thelongitudinalnatureofthefindingssuggestarobustrelationshipbetweenthesetwodomains.Additionally,theonlinesampleofadultsusedinthisstudyincreasesgeneralisabilityoftheseresultsoverpriorworkswhichwerelimitedtoeitherundergraduates(Faiginetal.,2014)ortreat-mentseekingUSArmedForcesveterans(Gutierrezetal.,2020).Insum,thefindingsofthepresentwork,takenalongsidethecross-sectional,longitudinal,andclinicalsamplesdis-cussedabove,suggestthereareimportantlinksbetweenself-reportedaddictivebeha-vioursandtheexperienceofRSS.ImplicationsPreviousresearchsuggeststhatproblemgamblingcancausedistressinmultipleareasoflife,includingincreasingcriminalandsuicidalbehaviours,generalpsychologicaldistress,anddecreasingoverallwell-being(Battersbyetal.,2006;Blacketal.,2013;Kessleretal.,Table4.SummaryofHierarchicalRegressionAnalysisofVariablesPredictingAllSixRSSatFollow-upafterControllingforBaselineLevelsoftheSameRSS.STEP1VariableRSSDivineRSSDemonicRSSInterpersonalRSSMoralRSSMeaningRSSDoubtNeuroticism.098*.049.184**.100*.291**.146**Gender−.025−.030−.006−.037.062.012OnlineGambler.049.097*.080.102*.118**.091*ChanceGames−.123*.007−.042−.071.044−.078SkillGames−.012.015.013.024.047−.033Age.048−.090−.032−.030.034−.010AnnualIncome−.038−.032−.056−.033−.096*−.047BaselineRSS.608**.567**.590**.561**.459**.588**R2.438.391.464.407.465.466FforR232.47**26.71**36.01**28.57**36.24**36.32**STEP2Neuroticism.090*.037.176**.093*.286**.137**Gender−.025−.033−.007−.037.062.011OnlineGambler.012.059.053.063.092*.045ChanceGames−.129*−.001−.047−.078.038−.086SkillGames−.039−.014−.005−.002.030−.064Age.050−.089−.031−.031.035−.009AnnualIncome−.028−.021−.048−.023−.089*−.036BaselineRSS.569**.517**.576**.520**.450**.553**SOGS.141**.147**.087*.136**.078.157**R2.453.407.470.421.470.485ΔR2.015.016.006.014.005.020FforΔR29.19**8.85**3.88*7.96**3.1412.59**Note:**p≤.01;*p≤.05;N=342.Problemgamblingseverityinboldtypefaceforclarity.444J.T.GRANTWEINANDYANDJ.B.GRUBBS 2008;Laursenetal.,2016).Therefore,treatmenttendstofocusonthegambler’srelation-ships,mentalhealth,andfinancialwell-being.Unfortunately,thepublishedliteraturesuggeststhatthedomainofreligion/spiritualityhasbeenlargelyignoredintheclinicaltreatmentofGD.However,thefindingsofthisstudyandpriorstudies(i.e.,Gutierrezetal.,2020)suggestthatRSSmaybesalientforclinicians’treatmentofproblematicgam-bling.ThisisespeciallyclinicallyrelevantgiventhatRSSoftenpredictotherpsychologicalproblems.Morebroadly,thisworksupports,asmanypriorworkshavealsosuggested,theneedforspirituallyintegratedcareinmentalhealthtreatmentsettingsthatallowsfortheassessment,acknowledgment,andexplorationofclients’religious/spiritualbeliefs(e.g.,Pargament,2007).Furthermore,GA,whichalreadyhassometiestoaddressingreli-gion/spirituality,maybeparticularlypoisedtoaddresssomeoftheseconcerns.LimitationsandconstraintsongeneralisabilityThisstudyusedself-reportmeasures,whichhavewell-knownlimitations(Chan,2009).PotentialproblemswithMTurkdata,includingdataqualityissuesandconcernsaboutrepresentativeness,havebeennotedinpreviouswork;however,validitychecks,whichwereusedinthisdatacollection,maysomewhatmitigatethese(e.g.,Chmielewski&Kucker,2020).SincethissamplewasfromtheUS,cautionshouldbetakenwhengeneral-isingtheseresultstoothercountries.Thisstudyincludedonlytwotimepoints,precludinggrowthcurvemodellingorcausalinferences.Admittedly,theuseofhierarchicalregressionstopredictfutureRSSthroughresidualisedchangeisonlyoneofmanypossibleapproachestolongitudinaldata.Latentchangescores,differencescoremodels,andsimplepre-and-postcomparisonsareeachpotentialwaystoanalysethissamedata(Castro-Schilo&Grimm,2018;Gollwitzeretal.,2014).However,giventhatouraimwastodeterminewhethergamblingrelatedproblemspredicteduniquevarianceinRSSovertime,usingsimplehierarchicalregressionswasthemostparsimoniousapproach.Religiousness,includingreligiousattendanceandstrengthofbelief,wasnotincludedasacontrolvariableinthepresentstudy,asitwasnotincludedinthisdataset.Thisisaparticularconcernbecausepriorworkshaveshownthatreligiousnesshasasignificanteffectonanindividual’sparticipationingamblingandtheirexperiencesofRSS(Exlineetal.,2014;Lam,2006).However,priorworkhasnotedthatRSSarenotjustsymptomsofdistressinreligiouspopulations(Stauneretal.,2016).Rather,RSSareuniquephenom-ena,thatoccurmoreofteninreligiouspopulations,representdistinctdistress,andpredictsalientmentalhealthoutcomes,evenwhencontrollingforreligiousness(Exlineetal.,2014).Futurestudiesshouldbeawarethatthiswouldbeausefulcontrolvariableandmayhaveaccountedforasignificantamountoftheunexplainedvarianceinthisstudy.ThemeanvaluesoftheRSSScaleandSOGSwerelow(belowthemidpointofthescale).Assuch,theseresultsshouldbeviewedwithcautionastheymaynotberepresentativeofindividualswhoscorehighlyoneitherscale.ThismayalsoexplainthediscrepancybetweentheseresultsandthoseofGutierrezetal.(2020).Theamountofvarianceinstrugglesaccountedforbyproblemgamblingseverityintheregressionswassmall-to-moderate(i.e.,2.4%to10.4%atbaseline;.6%to2%overtime).Assuch,althoughgamblingbehaviourislikelyrelatedtoRSS,furtherresearchisnecessarytofullyunderstandthepracticaleffectofthisrelationship.Evenso,thelongitudinalMENTALHEALTH,RELIGION&CULTURE445 regressionanalyseswereconservativetests,astheycontrolledforbaselinelevelsofRSS,andthereforesmalleffectsizesshouldbeexpected.ConclusionBothgamblingandRSShavebeenshowntopredictsignificantpsychologicaldistress,suchasdepressionandanxiety(e.g.,Kessleretal.,2008).Historically,manyreligious/spiri-tualgroupshaveviewedgamblinginanegativelightandshunnedthosewhopartici-pated.Assuch,thosewhogamblemayfindthemselvesatoddswiththeirreligion/spirituality,leadingtofurtherdistress.ThisstudylookedathowmuchproblemgamblingseveritywasuniquelyassociatedwithRSSusingcorrelationalandhierarchicalregressionanalyses.TheresultsshowedthatgamblingproblemseveritywasuniquelyassociatedwithRSScross-sectionallyandcontinued,exceptforultimatemeaningstruggles,aftersixmonths.Overall,researchersshouldcontinuetoinvestigatehowtoreduceRSS,par-ticularlyinthosewithGD,andexaminehowreligiousnessmayaffectthisrelationship.Resultsfromthisstudysuggestthat,despitebeinglargelyignoredtodate,thedomainofreligion/spirituality,andinparticularRSS,shouldbegivenattentionwhenconsideringproblematicgamblingbehaviours.Notes1.Authorsalsoanalysedthedataafterexcludingallindividualswhoreportednoproblemgam-bling(SOGS<1),leavingasamplesizeof602.Theseresults(availableat:https://osf.io/srvd7/)wereverysimilartotheresultspresentedhere,thuswehavepresentedthosewiththehighestpower.2.AuthorsalsoanalysedtheRSSatTime2afterincludingallRSSatbaselineinstep1(Sup-plementaryTableS5:https://osf.io/srvd7/),resultsofwhichweresimilartothosepresentedhere.AcknowledgementsWearegratefulforHaroldRosenberg’sandDaraMusher-Eizenman’shelpfulcommentsonanearlierversionofthismanuscript.DisclosurestatementNopotentialconflictofinterestwasreportedbytheauthor(s).FundingWethanktheInternationalCenterforResponsibleGaming(ICRG)fortheseedgrantawardedtoJoshuaB.Grubbsthatfundedthecollectionofthisdataset.EthicsapprovalEthicalapprovalwaswaivedbytheInstitutionalReviewBoardatBowlingGreenStateUni-versityforthisworkbecauseitsolelyutilisedsecondarydataand,therefore,didnotmeetthedefinitionforhumansubjects’research.446J.T.GRANTWEINANDYANDJ.B.GRUBBS 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Title:Authors:Source:Document Type:Abstract:Full Text Word Count:Accession Number:Database:Record: 1Behavioral addiction.Montvilo, Robin KamiennySalem Press Encyclopedia of Health, 2020. 3p.ArticleThe terms behavioral addiction and process addiction are often usedinterchangeably. The criteria for behavioral addiction were published inthe American Journal of Preventive Psychiatry & Neurology in 1989. Abehavioral or process addiction is said to exist when a person repeatedlyengages in a behavior to a significantly greater extent than they hadintended. When such an addiction exists, the behavior occurs repeatedlyin spite of the person's attempts to control it. A person with a behavioraladdiction tends to be preoccupied with the behavior and spendsenormous amounts of time in activities dedicated to the behavior. Thiswill often interfere with the ability to perform other activities and fulfillobligations. The addictive behavior tends to persist in spite of the factthat it may have adverse effects on life and may cause social, financial,psychological, or physical problems for the person involved. Theindividual will often find that he or she must spend increasing amounts oftime devoted to the behavior in order to receive the desired effect. In thetwenty-five years since these criteria were established, many differenttypes of behavioral addictions have been researched. At this time onlygambling addiction has been recognized as a behavioral addiction in thefifth edition of the Diagnostic and Statistical Manual of Mental Disorders(DSM-5). As research of these process addictions continues, thecategory of behavioral addictions will continue to grow.1502115297524Research StartersBehavioral addictionType of psychology: Addiction; Clinical; Counseling; PsychopathologyWhile ancient history tells of compulsive behaviors involving activities like sex or gambling, the term behavioral addictionhas only recently come into use. Behavioral addiction refers to a persistent, compulsive dependence on a behavior.Addictions are chronic conditions that affect the brain's reward and motivational systems. In the case of behavioraladdictions, the reward is the result of experience rather than related to a chemical substance. When a behavior producesa potential reward in spite of threatened negative consequences and it is frequently repeated, it has likely become abehavioral addiction. In 2013, a form of behavioral addiction was included in the DSM-5 although it is in a categorydenoted as in need of additional research.Introduction The terms behavioral addiction and process addiction are often used interchangeably. The criteria forbehavioral addiction were published in the American Journal of Preventive Psychiatry & Neurology in 1989. Abehavioral or process addiction is said to exist when a person repeatedly engages in a behavior to asignificantly greater extent than they had intended. When such an addiction exists, the behavior occursrepeatedly in spite of the person's attempts to control it. A person with a behavioral addiction tends to bepreoccupied with the behavior and spends enormous amounts of time in activities dedicated to the behavior.This will often interfere with the ability to perform other activities and fulfill obligations. The addictive behaviortends to persist in spite of the fact that it may have adverse effects on life and may cause social, financial,psychological, or physical problems for the person involved. The individual will often find that he or she mustspend increasing amounts of time devoted to the behavior in order to receive the desired effect. In the twenty-five years since these criteria were established, many different types of behavioral addictions have beenresearched. At this time only gambling addiction has been recognized as a behavioral addiction in the fifthedition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). As research of these processaddictions continues, the category of behavioral addictions will continue to grow.Gambling addiction is the onlybehavioral addiction recognizedin the Diagnostic and StatisticalManual of Mental Disorders(DSM-5). pixabayExercise addicts spendexcessive time and efforts onphysical pursuits, at the expenseof other activities. pixabayTypes of behavioral addictionWhile the field of behavioral addiction still is in the midst of much ongoing research, many types of activitieshave been tentatively categorized as behavioral addictions. If an individual engages in an activity or behavior tosuch a great extent that it tends to not leave time for other activities or relationships, that behavior is consideredto be a behavioral addiction. In most cases, these behaviors adversely affect the individual and cause social,financial, psychological, or physical problems for the individual. Generally behavioral addiction involves behavior that is repeated persistently while seeking reward in spite of the fact that those rewards often do notmaterialize.The only form of behavioral addiction recognized in the DSM-5 is gambling addiction, though many addictionresearchers consider there to be a wide range of problematic, addictive behaviors that warrant clinicaltreatment. These other behaviors are also persistently repeated by individuals to their detriment and to theexclusion of other activities and social interactions. These behaviors generally fit the criteria for behavioraladdiction established in 1989 and are currently being researched as types of behavioral addiction. Examples ofsuch behavior that involve technology include television watching, video game playing, or using the computer.As is evident from these examples, a behavioral addiction can be active like playing video games or passivelike watching television.Moreover, addictive behavior may include various types of physical exercise. Exercise addiction, for example,may be seen in someone who spends an increasing number of hours at the gym or running or bicyclingincreasingly longer distances, leaving little time for other activities. People with exercise addictions often alsodemonstrate some type of eating disorder. Another common behavioral addiction is sex addiction, which againmay involve being an active participant (including exhibitionism or voyeurism) or an observer. Such an observermay have a pornography addiction, in which case they spend excessive amounts of time and money collectingpornographic pictures or magazines or accessing pornography on the Internet. Another commonly investigatedform of behavioral addiction is a shopping addiction (compulsive buying disorder). A person who is acompulsive shopper will spend money repeatedly and unnecessarily on virtually anything. Making purchasesprovides these individuals with pleasure so they tend to do it repeatedly, often spending money that they do nothave or should be devoting to other aspects of life. Finally, a person who is commonly dubbed a workaholicmay actually have a work addiction. People who have a work addiction are unable to stop themselves fromengaging in work to the extent that it interferes with the rest of their lives. Such behavior often starts out as adesire to succeed or get ahead and is often found in people who are viewed as perfectionists. While these arethe behaviors that are routinely considered to turn into addictive behaviors, any activity or behavior thatseemingly takes over one's life can become a behavioral addiction.Biological basis of behavioral addictionWhile substance use disorders or substance addictions have been recognized for much longer than behavioraladdictions have, all addictions seem to have the underlying common denominator of reward seeking. Thehuman brain seems to respond to rewards as equivalent whether they occur in response to a chemicalsubstance or as a result of a particular behavior. It is felt that behavioral addiction can affect the release ofneurotransmitters in the brain and that these neurotransmitters will then affect the brain as directly as chemicalsubstances that are ingested by the individual. This may then help explain why individuals with behavioraladdictions actually exhibit cravings and develop a tolerance requiring them to engage in ever increasingamounts of that behavior in order to feel the same effect. Neurotransmitters that are involved in addiction aremost likely to include serotonin, dopamine, and noradrenalin. Studies done with functional magnetic resonanceimaging (MRI) indicate that the same areas of the brain seem to be involved in both chemical addiction andbehavioral addiction. The ventral tegmental area, ventral striatum, and amygdala seem to play parts in bothtypes of addiction. It has also been found that families whose members exhibit substance addictions often alsoexhibit behavioral addictions. Research is currently ongoing to investigate whether there may be a genetic linkto any or all types of addiction. Diagnosis and treatment of behavioral addictionThere are currently a large number of scales and inventories available to help diagnose those forms ofbehavioral addiction that are not recognized in DSM-5. There currently are recognized scales available to helpdiagnose addictions to work, exercise, video game playing, Internet use, compulsive buying, problem gambling,sex, and binge eating. In 2010, the Behavioral Addiction Scale was developed as a means to screen forbehavioral addiction in general, rather than trying to screen for each individually.While gambling addiction is the only behavioral addiction recognized in the DSM-5, many of the abovementioned behaviors that are being researched as forms of behavioral addiction respond to the sametreatments as substance use disorders. These treatments range from self-help groups to behavior modificationand cognitive behavioral therapies. Medications have also been used to treat various forms of behavioraladdiction. Some of these medications are again the same drugs that have been used in treating chemicaladdictions. Potential for relapse is also something that all forms of addiction share. Relapse prevention andharm reduction models are commonly used with all forms of addiction.Similarities between substance addictions and behavioral addictionMuch of the current evidence indicates that there are many similarities between substance use disorders andbehavioral addiction. These similarities exist in terms of the onset and progression of the condition up to andincluding family history, the biological functioning of the brain and systems of neurotransmitters involved, typesof symptoms displayed, existence of cravings, development of a tolerance, and types of treatment that appeareffective in dealing with these disorders. The main distinguishing factor between substance addiction andbehavioral addiction is that the various forms of behavioral addiction involve only a psychological need whilesubstance addiction involves both a physical and psychological need. In spite of the fact that many forms ofbehavioral addiction are not yet officially recognized as such, it is believed that the category of behavioraladdiction is much broader than currently recognized and in most ways is equivalent to substance addiction.BibliographyAlavi, S. S., et al. “Behavioral Addiction Versus Substance Addiction: Correspondence of Psychiatric andPsychological Views.”International Journal of Preventive Medicine 3.4 (2012): 290–94. Print.Ascher, Michael S., and Petros Levounis, eds. The Behavioral Addictions. Arlington: Amer. Psychiatric Assn.,2015. Print.Banz, B. C., et al. "Behavioral Addictions in Addiction Medicine: From Mechanisms to Practical Considerations."Progress in Brain Research 223 (2016): 311–28. Print.Demetrovics, Z., and M. D. Griffiths. “Behavioral Addictions: Past, Present and Future.” Journal of BehavioralAddiction 1.1 (2012): 1–2. Print.Grant, J. E., et al. “Introduction to Behavioral Addictions”. American Journal of Drug and Alcohol Abuse 36.5(2011): 233–41. Print.Rosenberg, K. P., and L. C. Feder. Behavioral Addictions: Criteria, Evidence, and Treatment. Salt Lake City, UT:Academic, 2014. Print. Shaw, B. S., P. Ritvo, and J. Irvine. Addiction and Recovery for Dummies. Hoboken: Wiley, 2005. Print.Wilson, Stephen J. The Wiley Handbook on the Cognitive Neuroscience of Addiction. Malden: Wiley Blackwell,2015. Print.Copyright of Salem Press Encyclopedia of Health is the property of Salem Press. The copyright in anindividual article may be maintained by the author in certain cases. Content may not be copied or emailed tomultiple sites or posted to a listserv without the copyright holder's express written permission. However, usersmay print, download, or email articles for individual use.Source: Salem Press Encyclopedia of Health, 2020, 3pItem: 115297524 Topic 1 DQ 1 Read “Integrating Care for People with Co-Occurring Alcohol and Other Drug, Medical, and Mental Health Conditions” by Sterling, Chi, and Hinman. This week, you studied various theories and models of addiction and learned about the human body’s reaction to substances. With all the scientific knowledge we now have about addiction, why is there more than one etiology of addiction? What are some of those etiologies, including those that are Bible-based? How can an addiction counselor effectively contribute to the treatment of a client working with other healthcare professionals during their recovery process?   Topic 1 DQ 2 In preparation for this week’s assignment, review substance use disorders and process addictions. How do process addictions differ from substance use disorders? How does treatment vary between process addictions and substance use disorders? JournalofPsychoactiveDrugs,44(1),1–4,2012Copyright©Taylor&FrancisGroup,LLCISSN:0279-1072print/2159-9777onlineDOI:10.1080/02791072.2012.662105Editor’sNote:TheProcessAddictionsandtheNewASAMDefinitionofAddictionDavidE.Smith,M.D.,FASAM,FAACTaAbstract—Addictionisaprimary,chronicdiseaseinvolvingbrainreward,motivation,memoryandrelatedcircuitry;itcanleadtorelapse,progressivedevelopment,andthepotentialforfatalityifnottreated.Whilepathologicaluseofalcoholand,morerecently,psychoactivesubstanceshavebeenacceptedasaddictivediseases,developingbrainsciencehassetthestageforinclusionoftheprocessaddictions,includingfood,sex,shoppingandgamblingproblems,inabroaderdefinitionofaddictionassetforthbytheAmericanSocietyofAddictionMedicinein2011.Keywords—ASAMdefinitionofaddiction,brainchemistry,drugaddiction,neuroimaging,processaddictionsAsnewlydefinedbytheAmericanSocietyofAddictionMedicine(ASAM2011),theUnitedStates’addictionspecialtysocietyofphysicians,addictionisapri-mary,chronicdiseaseinvolvingbrainreward,motivation,memoryandrelatedcircuitry.Dysfunctioninthesecircuitsleadstocharacteristicbiological,psychological,socialandspiritualmanifestations.Thisisreflectedinpersonscom-pulsivelypursuingrewardand/orreliefbysubstanceuseandotherbehaviors.Addictioncannotbecuredbutcanbebroughtintoremissionthroughaprogramoftreatment,abstinencefromallpsychoactivesubstances,andsupportedrecovery.Alcoholandotherdrugshavelongbeenrecognizedasaddictivesubstancesandaddictionisnowgenerallyrecog-nizedasachronicdiseaseofthebrainthatinvolvesrelapse,progressivedevelopment,andthepotentialforfatalityifaPrincipal,DavidE.Smith,MD&Associates,SanFrancisco;Chair,AddictionMedicine,NewportAcademy,Orange,CA;MedicalDirector,CenterPoint,SanRafael,CA;Member,AdvisoryBoard,DominionDiagnostics,NorthKingstown,RI.PleaseaddresscorrespondencetoDavidE.Smith,M.D.,DavidE.Smith,MD&Associates,856StanyanStreet,SanFrancisco94117;phone:(415)933-8759;fax:(415)933-8674;email:DrSmith@DrDave.orgnottreated.Developingbrainsciencehassetthestageforinclusionoftheprocessaddictions,includingfood,sex,shoppingandgambling,inthisbroaderdefinitionofaddic-tion.TheDSM-VTaskForce,forexample,hassuggestedanewcategoryentitledAddictionsandRelatedDisorders(Grantetal.2010),whichwouldincludebothsubstance-relatedandnon-substance/behavioraladdictions.Thisexpansionoftheaddictiondefinitionisbasedonanunder-standingthatbothpsychoactivedrugsandcertainbehaviorsthatproduceasurgeofdopamineinthemidbrainarethebiologicalsubstrateforaddictivebehavior.Individualswhoaregeneticallypredisposedtoaddictionareathigherriskforthis“rewarddeficiencysyndrome”duetotheinterplayofgeneticandenvironmentalfactors(Smith2011a).Addictionischaracterizedbyaninabilitytoconsis-tentlyabstain,impairmentinbehavioralcontrol,craving,diminishedrecognitionofsignificantproblemswithone’sbehaviorsandinterpersonalrelationships,andadysfunc-tionalemotionalresponse.Likeotherchronicdiseases,addictioninvolvescyclesofrelapseandremission.Withouttreatmentorengagementinrecoveryactivities,addictionisprogressiveandcanresultindisabilityorprematuredeath(ASAM2011).JournalofPsychoactiveDrugs1Volume44(1),January–March2012 SmithTheProcessAddictionsAddictionisapathologicalprocesswithcharacter-isticsignsandsymptomsandapredictableprognosisifuntreated.Asabraindisease,itischaracterizedbytheindi-vidual’sinabilitytostopadysfunctionalbehaviorfueledbydrugsorotherrepeatedactivitiesdespiteadversecon-sequences.Thediseaseofaddictiondisruptstheareasofthebrainresponsibleformodulatingandcontrollingemotional,cognitiveandsocialbehaviors.Acceptanceofthismedicalmodelofaddictionhasallowedthefieldofaddictionmedicinetobeviewedlikethoseofotherchronicdiseases,whichareinfluencedbygeneticandenvironmentalfactors.Asaresult,addictionmedicineisnowaBoard-certifiedmedicalspecialtyintheUnitedStatesthroughtheAmericanBoardofAddictionMedicine.Thereisastronggeneticinfluence,withwell-studiedbiologicalmechanisms,particularlyforearlyonsetaddic-tioninadolescents.Theexpressionoftheaddictionpheno-typeisbasedonageneticpredispositionorgenotypethatisinfluencedbyenvironmentalfactors.Ifuntreated,addic-tionfollowsarelapsingandremittingcourse,buttreatmentcomplianceissimilartootherchronicmedicalconditions,suchasdiabetes,hypertensionandasthma.Addictionismosteffectivelymanagedasachronicdiseasewherebothmedicalandpsychosocialinterventionsareused.Largenumbersofpeoplewillbeexposedtopsychoactivedrugsbutonlyacertainpercentage,primarilytheat-riskpopulation,willprogresstoaddictivedisease.Itisimportanttoemphasizethattheonsetofaddictivediseaseisaninterplaybetweenthepsychologicalandphys-icalcharacteristicsofindividuals,includingtheirgeneticmakeup,theaddictivepotentialofthepsychoactivedrugsthey’reexposedto,andtheenvironmentinwhichthesevariablesinteract.Someofthekeyissuestounderstandaboutthepatho-physiologyofaddictionarewhyandhowpeoplegetaddictedtodrugsandwhysomepsychoactivechemicalsareaddictivewhileothersarenot.Thebodyhasverypre-cisemechanismsformaintainingbiologicalhomeostasis,forexamplepituitaryhormones,thyroid,insulin/glucose.Thesemechanismstitrateneurochemicalswithinthebodyandbraintomaintainthisbalance.Theintroductionofpotentoutsidepsychoactivedrugsaltersthisneurochemi-calbalanceanddisruptsthenormalhomeostaticsystemofcravingandsatiationforthebiologicalfunctionsnecessarytosustainlife,e.g.hunger,thirst,sex,sleep.Manypartsofthebrainworktogethertomaintainthishomeostasis.Themid-brainormesolimbicpathwayusesreward,whichisasenseofwell-beingorpleasure,topromotelifesustainingandlifefulfillingbehaviors,e.g.eating,drinking,nurturingtosustainpropagationofthespecies.Addictionoccursbydisregulationofthisnaturalprocess,suchthatthecravinganddrivefocusondrugsorcertainbehaviorsratherthannaturallifesustainingpro-cesses.Allhumanshavethisrewardpathwaybutnotalldrugsareaddicting,nordoallsubstanceusersbecomeaddicted.Thedrugsofaddictionareidentifiablebytheirabil-itytostimulatedopaminesecretioninthismesolimbicrewardpathway.Geneticallypredisposedaddictsareiden-tifiablebytheiruniqueresponsetoaddictivesubstancesthatproducehypersecretionofdopamineinthismesolim-bicrewardpathway.Recentbrainsciencestudiesusingvarioustypesofneuroimagingsupporttheconceptthattheprocessaddictionsalsostimulatedopaminesecretion,thusputtingthesebehaviorsonaparallelcoursewithdrugabuseasaddictivediseasesandleadingtoASAM’sinclud-ingtheminitsnewdefinitionofaddiction(Blum2012;Oberg,Christie&Tata2011;Potenzaetal.2011;Reynaud&Karila2011;Zhangetal.2011;El-Guebaly2010;Hanetal.2010).Repetitivedrugtakingbeginstochangeintoinvol-untarydrugtaking,atwhichpointthebehaviorisdrivenbycompulsiontousethedrugwithoutregardtoadverseconsequences.Fromaneurochemicalpointofview,cross-ingthelinefromhomeostasistoallostasiscanvaryintimefromtheonsetofdruguseandisstronglyinflu-encedbythegeneticpredispositionoftheindividual.Frequentdruguseinapersonwithgeneticpredispositionaltersthishedonicsetpointandcreatesanearliercrav-ingresponseforthedrugdespiteadverseconsequences.Thedrugorbehaviorlosesitspleasurableeffectsatstandard“doses”andtolerancedevelopssuchthathighlevelsofusagearewantedorneededtofeelnormal.Cravingsmaycontinueorevenincreasedespitecessationofdruguse,leadingtohedonichomeostaticdysregula-tion.Thisrewardpathwayisintimatelyconnectedvianeuralpathwaystoourjudgmentinemotionalareasbywayofprojectionstotheprefrontalcortex(thethinkingpartofthebrain)andthelimbicsystem(theprimitivepartofthebrain).Judgmentbecomesdistortedandthebrainbeginstotreatthedrugasnecessaryforhomeosta-sisandsurvival.Withhedonichomeostaticdysregulation,addictsarelogicallyawarethattheydonotneedthedrug,butsurvivaldrivestendtotakeprecedenceoverlogic.Continuedsubstanceusetakessurvivalprecedenceoverlifegoals,relationships,self-esteem,stability,safety,financesandhealth.Substituting“sex”or“food”or“gam-bling”for“drug”intheabovepresentsanequallyvalidscenario.Themedicalmodelfocusesonaddictionasabraindisease,emphasizingthatdrugshijacktherewardsys-tem,andalterthecognitiveandrewardprocesses,causingthepersontothinkthedrugsorprocessesareessen-tialforsurvival.Withtheprogressionofaddictivedis-ease,addictivesubstancescanalterthebrainchemistryandmimicoraggravatecomorbidpsychologicaldisor-dersincludingdepression,anxietyandpsychosis,com-plicatingthetreatmentpictureforsuchdualdiagnosispatients.JournalofPsychoactiveDrugs2Volume44(1),January–March2012 SmithTheProcessAddictionsTHENEWASAMDEFINITIONOFADDICTIONThenewASAMdefinitionofaddictionemphasizesthreebroadareas.Addictionisaprimary,chronicdiseaseofbrainreward,motivation,memoryandrelatedcircuitry.Addictionaffectsneurotransmissionandinteractionswithinrewardstructuresofthebrain,includingthenucleusaccumbens,anteriorcingulatecortex,basalforebrainandamygdala,suchthatmotivationalhierarchiesarealteredandaddictivebehaviors,whichmayormaynotincludealcoholandotherdruguse,supplanthealthy,self-carerelatedbehaviors.Addictionalsoaffectsneurotrans-missionandinteractionsbetweencorticalandhippocampalcircuitsandbrainrewardstructures,suchthatthememoryofpreviousexposurestorewards(suchasfood,sex,alcoholandotherdrugs)leadstoabiologicalandbehavioralresponsetoexternalcues,inturntriggeringcravingand/orengagementinaddictivebehaviors.Theneurobiologyofaddictionencompassesmorethantheneurochemistryofreward.Thefrontalcortexofthebrainandunderlyingwhitematterconnectionsbetweenthefrontalcortexandcircuitsofreward,motivationandmemoryarefundamentalinthemanifestationsofalteredimpulsecontrol,alteredjudgment,andthedysfunctionalpursuitofrewards(whichisoftenexperiencedbytheaffectedpersonasadesireto“benormal”)seeninaddiction—despitecumulativeadverseconsequencesexperiencedfromengagementinsubstanceuseandotheraddictivebehaviors.Thefrontallobesareimpor-tantininhibitingimpulsivityandinassistingindividualstoappropriatelydelaygratification.Whenpersonswithaddictionmanifestproblemsindeferringgratification,thereisaneuro-logicallocusoftheseproblemsinthefrontalcortex.Frontallobemorphology,connectivityandfunctioningarestillintheprocessofmaturationduringadolescenceandyoungadult-hood,andearlyexposuretosubstanceuseisanothersignificantfactorinthedevelopmentofaddiction.Manyneuroscientistsbelievethatdevelopmentalmorphologyisthebasisthatmakesearly-lifeexposuretosubstancessuchanimportantfactor.Geneticfactorsaccountforabouthalfofthelikelihoodthatanindividualwilldevelopaddiction.Environmentalfactorsinter-actwiththeperson’sbiologyandaffecttheextenttowhichgeneticfactorsexerttheirinfluence.Resilienciestheindivid-ualacquires(throughparentingorlaterlifeexperiences)canaffecttheextenttowhichgeneticpredispositionsleadtothebehavioralandothermanifestationsofaddiction.Culturealsoplaysaroleinhowaddictionbecomesactualizedinpersonswithbiologicalvulnerabilitiestothedevelopmentofaddiction.Otherfactorsthatcancontributetotheappearanceofaddic-tion,leadingtoitscharacteristicbio-psycho-socio-spiritualmanifestations,include:a)Thepresenceofanunderlyingbiologicaldeficitinthefunctionofrewardcircuits,suchthatdrugsandbehav-iorswhichenhancerewardfunctionarepreferredandsoughtasreinforcers;b)Therepeatedengagementindruguseorotheraddictivebehaviors,causingneuroadaptationinmoti-vationalcircuitryleadingtoimpairedcontroloverfurtherdruguseorengagementinaddictivebehaviors;c)Cognitiveandaffectivedistortions,whichimpairper-ceptionsandcompromisetheabilitytodealwithfeelings,resultinginsignificantself-deception;d)Disruptionofhealthysocialsupportsandproblemsininterpersonalrelationshipswhichimpactthedevelop-mentorimpactofresiliencies;e)Exposuretotraumaorstressorsthatoverwhelmanindividual’scopingabilities;f)Distortioninmeaning,purposeandvaluesthatguideattitudes,thinkingandbehavior;g)Distortionsinaperson’sconnectionwithself,withothersandwiththetranscendent(referredtoasGodbymany,theHigherPowerby12-stepsgroups,orhigherconsciousnessbyothers);andh)Thepresenceofco-occurringpsychiatricdisordersinpersonswhoengageinsubstanceuseorotheraddictivebehaviors.Addictionischaracterizedby:inabilitytoconsistentlyAbstain;impairmentinBehavioralcontrol;Craving;orincreased“hunger”fordrugsorrewardingexperiences;Diminishedrecognitionofsignificantproblemswithone’sbehaviorsandinterpersonalrelationships;andadysfunctionalEmotionalresponse.TheabovedefinitionisquotedfromASAM’sPublicPolicyStatement:DeÞnitionofAddiction(ASAM2011).SUMMARYASAMhasnowexpandedintotwonewareas—theprocessaddictionsandtheprescriptiondrugproblem,whicharethefocusoftwospecialforumsinthisissueoftheJournalofPsychoactiveDrugs.EachexpansionofthedefinitionofaddictionbyASAMhasbeenmetwithcontroversy.Therewasresis-tancetoincludingdrugsotherthanalcoholwhenASAMwasfirstfoundedinthe1950sanditwasn’tuntilthe1980sthatthediseasemodelofaddictionwasappliedtoalldrugsofaddiction.Sexaddictionwasparticularlycontroversialinthe1990sandwasrejectedbybothASAMandtheAMA(Robinson2011).ASAMhasaddressedtheprescriptiondrugproblemformorethanadecade(ASAM1989,rev.2000).Withthecurrentescalatingproblemsofprescriptiondrugsandthenonmedical,sometimeslethaluseofthembypartsofsoci-ety,muchofthecurrentoveralldrugproblememanatesfromthemedicalsystem.Prescriptiondrugoverdose,forexample,istheleadingcauseofdeathinadolescentsandyoungadults(Smith2011b;DuPont2010).REFERENCESAmericanSocietyofAddictionMedicine(ASAM).2011.PublicPolicyStatement:DeÞnitionofAddiction.Availableatwww.asam.org/research-treatment/definition-of-addictionAmericanSocietyofAddictionMedicine(ASAM).1989,rev.2000.PublicPolicyStatement:MeasurestoCounteractPrescriptionDrugDiversion.Availableatwww.asam.org/JournalofPsychoactiveDrugs3Volume44(1),January–March2012 SmithTheProcessAddictionsdocs/publicy-policy-statements/1prescription-diversion—rev-4-00.pdfBlum,K.;Garadner,E.;Oscar-Berman,M.&Gold,M.2012.“Liking”and“wanting”linkedtoRewardDeficiencySyndrome(RDS):Hypothesizingdifferentialresponsivityinbrainrewardcircuitry.CurrentPharmaceuticalDesignJanuary9[epubaheadofprint].DuPont,R.L.2010.Prescriptiondrugabuse:Anepidemicdilemma.JournalofPsychoactiveDrugs42(2):127–32.El-Guebaly,N.;Mudry,T.;Zohar,J.;Tavares,H.&Potenza,M.N.2011.Compulsivefeaturesinbehavioraladdictions:Thecaseofpathologicalgambling.AddictionOctober10[epubaheadofprint].Grant,J.E.;Potenza,M.N.;Weinstein,A.&Gorelick,D.A.2010.Introductiontobehavioraladdictions.AmericanJournalofDrugandAlcoholAbuse36(5):233–41.Han,D.H.;Kim,Y.S.;Lee,Y.S.;Min,K.J.&Renshaw,P.F.2010.Changesincue-induced,prefrontalcortexactivitywithvideo-gameplay.Cyberpsychology,Behavior,andSocialNetworking13(6):655–61.Oberg,S.A.;Christie,G.J.&Tata,M.S.2011.Problemgamblersexhibitrewardhypersensitivityinmedialfrontalcortexduringgambling.Neuropsychologia49(13):3768–75.Potenza,M.N.;Walderhaaug,E.;Henry,S.;Gallezot,J.D.;Planeta-Wilson,B.;Ropchan,J.&Neumeister,A.2011.Serotonin1Breceptorimaginginpathologicalgambling.WorldJournalofBiologicalPsychiatrySeptember22[epubaheadofprint].Reynaud,M.&Karila,L.2011.Fromsubstancedependencetoaddiction:Impactofaconceptualshiftontherapeuticapproaches?CurrentPharmaceuticalDesign17(14):1321–22.Robinson,M.2011.Thewagesofsexual-addictionpolitics.PsychologyTodayAvailableatwww.psychologytoday.com/blog/cupids-poisoned-arrow/201112/the-wages-sexual-addiction-politicsSmith,D.E.2011a.Theevolutionofaddictionmedicineasamedi-calspecialty.VirtualMentor13(12):900–05.Availableathttp://virtualmentor.ama-assn.org/2011/12/mhst1-1112.htmlSmith,D.E.2011b.Integrationofpharmacotherapyandpsychosocialtreatmentinopiate-addictedyouth.JournalofPsychoactiveDrugs43(3):175–79.Zhang,Y.;vonDeneen,K.M.;Tian,J.;Gold,M.S.&Liu,Y.2011.Foodaddictionandneuroimaging.CurrentPharmaceuticalDesign17(12):1149–57.JournalofPsychoactiveDrugs4Volume44(1),January–March2012 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