Addiction - Reducing Addiction

Question 1

What are the key features of drug therapy as a way of reducing addiction?

Answer 1

• aversive drugs pair addictive stimuli with unpleasant consequences
• agonists replace addictive drug by producing a similar effect
• antagonists block the effects of the addictive drug
• smoking: NRT helps to avoid withdrawal symptoms
• gambling: opioid antagonists reduce release of dopamine
• drugs not officially approved for gambling addiction

Question 2

What do aversive drugs do?

Answer 2

The main effect of aversive drugs is to pair the behaviour with unpleasant consequences such as vomiting (classical conditioning).

For example, disulfiram is a drug therapy that creates the effects of a severe hangover just minutes after alcohol is drunk.

The idea is that the addict will associate the alcohol with these unpleasant effects rather than the ones they enjoy.

Question 3

What do agonists do?

Answer 3

Agonists bind to the neuron receptors and activate them.

This produces a similar effect to the addictive drug and controls the withdrawal effects.

For example, methadone is used to treat heroin addiction but has fewer harmful side effects than heroin itself.

Question 4

What do antagonists do?

Answer 4

Antagonists treat addiction by binding to the receptor sites and blocking them.

Therefore the drug of dependence cannot produce its usual addictive effects.

For example, naltrexone is used to treat heroin addiction.

Question 5

How does NRT help to avoid withdrawal symptoms of smoking?

Answer 5

Nicotine replacement therapy comes in the forms of gum, inhalers and patches to deliver nicotine in a less harmful fashion.

Dosage can be reduced over time, decreasing the aversiveness of withdrawal symptoms.

NRT operates neurochemically by:

• binding to nicotinic acetylcholine receptors in the mesolimbic pathway of the brain
• stimulating the release of dopamine in the nucleus accumbens, just as it does in cigarette smoking

Question 6

How do opioid antagonists reduce the release of dopamine for gambling?

Answer 6

Gambling addiction taps into the same dopamine reward system as heroin, nicotine, etc.

Therefore the same drugs used to treat heroin are used with gamblers.

Opioid antagonists (such as naltrexone) dampen the cravings to gamble by:

• enhancing the release of neurotransmitter GABA in the mesolimbic pathway, which…
• reduces the release of dopamine in the nucleus accumbens, which…
• reduces the craving to gamble

Question 7

Have drugs been officially approved for gambling addiction?

Answer 7

Despite the research, there is not yet a drug that is thought good enough to be officially approved.

Even if naltrexone was prescribed for gambling addiction, people probably wouldn’t use it because of the unpleasant side effects.

Question 8

What are the strengths of drug therapy to reduce addiction?

Answer 8

• research support

- removal of addiction stigma

Question 9

What are the weaknesses of drug therapy to reduce addiction?

Answer 9

• side effects of drug therapy
• drug therapy requires motivation
• there are individual differences

Question 10

What research support is there for drug therapy?

Answer 10

Stead et al. (2012) concluded that NRT is more effective in helping smokers quit than either placebo or no treatment. NRT users were up to 70% more likely to have still abstained from smoking after six months.

Research also indicates two extra benefits of NRT: it is safer than cigarette smoking because it eliminates the harmful effects of tobacco smoke, and it does not appear to foster dependence.

This shows that NRT is a useful treatment.

Question 11

How does drug therapy lead to the removal of addiction stigma?

Answer 11

Drug therapy encourages a growing perception that drug addiction is a medical problem. Research is rapidly revealing the neurochemical and genetic basis of addiction.

This is changing the view that addiction is a form of psychological or moral failure. Addiction therefore becomes less stigmatised as more people accept that it may not be the addict’s fault.

This is a strength because in turn it could encourage more addicts to seek treatment.

Question 12

What side effects are there of drug therapy?

Answer 12

Common side effects are sleep disturbances, dizziness and headaches. In relation to gambling, the dose of naltrexone required leads to side effects worse than would be the case when using it to treat opiate addiction.

Such side effects mean there is a risk that the patient will discontinue the therapy, especially when they have also lost the pleasurable effects of the addiction.

The risk of side effects should be carefully weighed up against the benefits of the drug therapy and psychological therapies such as covert sensitisation.

Question 13

Why does drug therapy require motivation?

Answer 13

Drug therapy is often seen as more convenient than making changes to thought processes but it requires compliance and people with addictions may be too disorganised to take medicine regularly.

Drug therapy is therefore probably best suited to a relatively small subset of addicts who are extremely motivated and who are not leading chaotic lifestyles.

This means, paradoxically, that drug therapy is not effective for everyone despite its perceived convenience.

Question 14

How are there individual differences to drug therapy?

Answer 14

Drugs do not work in the same way for everyone and genetic variations between people have a significant impact on treatment success.

For example, alcoholics with one gene variant respond more readily to naltrexone treatment than those with a different version of the gene.

As Chung et al. (2012) point out, drug treatments need to become more tailored to individual genetic profiles if they are to be more effective.

Question 15

What are the key features of behavioural interventions as a way of reducing addiction?

Answer 15

• aversion therapy associates the addiction with unpleasant consequences
• disulfiram used to associate alcohol with severe nausea
• electric shocks used to associate gambling with pain

Question 16

What is aversion therapy?

Answer 16

Aversion therapy is a behavioural intervention based on classical conditioning. According to learning theory, an addiction can develop through repeated associations between a drug and the pleasurable state of arousal caused by it.

It follows that the addiction can be reduced by associating the drug with an unpleasant state (counterconditioning).

Question 17

How is disulfiram used?

Answer 17

Aversion therapy has been used in treating alcoholism.

The client is given a drug such as disulfiram (UCS) which causes a person drinking alcohol to experience an instant hangover with severe nausea and vomiting (UCR).

The client learns to associate the alcohol (NS and then CS) with the unpleasant symptoms (CR) and the fear of the symptoms can prevent the client from drinking.

Question 18

How are electric shocks used?

Answer 18

Electric shocks have been used in place of drugs for behavioural addictions such as gambling.

The gambler selects phrases that relate to their gambling behaviour and others that do not.

They read out each phrase and whenever a gambling-related phrase is read (NS and then CS) they receive a two-second electric shock which is painful (UCR and then CR) but not too bad.

Question 19

What are the key features of covert sensitisation as a way of reducing addiction?

Answer 19

• imagined not real
• nicotine: therapist asks client to vividly imagine vomiting
• technique may involve imagining snakes or faeces

Question 20

What is covert sensitisation?

Answer 20

Traditional aversion therapy has been largely superseded by covert sensitisation.

This is a type of aversion therapy, but in vitro rather than in vivo, in that the unpleasant stimulus is imagined rather than actually experienced.

Question 21

How are patients with a nicotine addiction treated with covert sensitisation?

Answer 21

Patients with nicotine addiction are first encouraged to relax, then conjure up a vivid image of themselves smoking a cigarette (CS), followed by the most unpleasant consequences (CR) such as vomiting (including graphic details of smells, sights, etc.).

The association formed (classical conditioning) should reduce smoking behaviour.

They may also imagine being forced to smoke a cigarette covered in something unpleasant. Towards the end of the session, the client imagines turning away from cigarettes and experiencing the resulting feelings of relief.

Question 22

What are the strengths of behavioural interventions to reduce addiction?

Answer 22

• research support for covert sensitisation

Question 23

What are the weaknesses of behavioural interventions to reduce addiction?

Answer 23

• aversion studies suffer from methodological problems
• treatment adherence issues
• short-term effectiveness
• ethical issues

Question 24

What research support is there for covert sensitisation?

Answer 24

McConaghy et al. (1983) found that after one year, gambling addicts who had received covert sensitisation were much more likely (90%) to have reduced their gambling activity than those who received aversion therapy (30%).

The participants also reported experiencing fewer and less intense gambling cravings than the aversion-treated participants.

This is one of many studies suggesting covert sensitisation is a highly promising treatment for addiction to alcohol, nicotine and gambling.

Question 25

How do aversion studies suffer from methodological problems?

Answer 25

Hajek and Stead (2001) reviewed 25 studies of aversion therapy for nicotine addiction, claiming it impossible to judge effectiveness because the studies suffered from errors.

In most studies, ‘blind’ procedures were not used, so the researchers who evaluated the outcomes of the studies knew which participants received therapy or placebo.

Such inbuilt biases generally make therapy appear more effective than it actually is, which challenges the validity of the findings.

Question 26

What treatment adherence issues are there of aversion therapy?

Answer 26

Given the unpleasant nature of the treatment, many patients and research participants avoid the stimuli and drop out of treatment before it is completed.

It is therefore difficult to judge overall effectiveness as there may be a pattern to which patients and participants drop out - leaving those who are willing to be conditioned.

If this is the case, then research is probably overoptimistic about the efficacy of aversion therapy.

Question 27

How is aversion therapy only effective in the short-term?

Answer 27

McConaghy et al. (1983) found that aversion therapy was more effective in reducing gambling behaviour after one month than after one year.

In a long-term follow-up, it was found that aversion therapy was no more effective than a placebo and covert sensitisation was more beneficial.

This suggests that any benefits of aversion therapy seem to be mostly short-term and that there is no long-term effectiveness.

Question 28

What ethical issues are there to aversion therapy?

Answer 28

Inflicting nausea and pain can be seen as unethical and patients could lose their dignity by vomiting in social situations.

Covert sensitisation is often preferred as it does not induce vomiting or other self-shaming behaviours, allowing patients to retain their dignity and self-esteem.

This means that the limitations of aversion therapy can also be seen as a strength of covert sensitisation.

Question 29

What are the key features of the cognitive behaviour therapy for addiction?

Answer 29

• CBT aims to tackle distorted thinking and develop coping behaviours
• 1. cognitive = functional analysis, therapist deals with distorted cognitions
• 2. behaviourist = skills training, replacing poor coping behaviours

Question 30

How can CBT be used to reduce addiction?

Answer 30

Cognitive behaviour therapy has two key elements:

• cognitive: identify, tackle and replace cognitive distortions that underlie the addiction (functional analysis)
• behaviourist: skills-training helps the client develop coping behaviours to avoid the high-risk situations that trigger the addiction-related behaviour

Question 31

What is functional analysis (cognitive)?

Answer 31

CBT starts with the client and therapist together identifying the high-risk situations that lead to the client’s drug use or gambling.

The therapist reflects on what the client is thinking before, during and after such a situation.

The therapist’s role in the relationship is to challenge the client’s cognitive distortions.

This process of functional analysis continues throughout the treatment, not just at the beginning of the therapy.

Question 32

What is skills training (behaviourist)?

Answer 32

People seeking treatment for addiction may have a huge range of problems but only one way of dealing with them - their drug of choice.

CBT helps to replace this strategy with more constructive ones by developing new skills.

Question 33

What are the key features of developing new skills?

Answer 33

• cognitive restructuring confronts and challenges faulty beliefs
• specific skills are taught (e.g. to deal with danger)
• social skills training can help with social anxiety

Question 34

How does cognitive restructuring confront and challenge faulty beliefs?

Answer 34

For example, a gambler may hold faulty beliefs about probability, randomness and control in gambling.

In the initial education phase, the therapist may give the client information about how to challenge these faulty beliefs.

Question 35

What specific skills are taught in CBT?

Answer 35

CBT focuses on the wider aspects of the client’s life related to the addiction.

For example, in the case of a lack of skills to cope with situations that trigger alcohol use:

• anger may trigger addictive behaviour, and anger management training may be appropriate
• interpersonal conflicts may trigger addictive behaviour, and may be dealt with through assertiveness training

Question 36

What specific skills are taught in CBT?

Answer 36

CBT focuses on the wider aspects of the client’s life related to the addiction.

For example, in the case of a lack of skills to cope with situations that trigger alcohol use:

• anger may trigger addictive behaviour, and anger management training may be appropriate
• interpersonal conflicts may trigger addictive behaviour, and may be dealt with through assertiveness training

Question 37

How can social skills training help with social anxiety?

Answer 37

Most clients can benefit from developing skills that allow them to cope with anxiety in social situations (e.g. trying not to drink alcohol at a wedding).

Social skills training helps the client to refuse alcohol in order to avoid embarrassment (e.g. making eye contact and being firm).

The therapist and client may model coping strategies using role play.

Question 38

What are the strengths of cognitive behaviour therapy to reduce addiction?

Answer 38

• research support

- relapse prevention

Question 39

What are the weaknesses of cognitive behaviour therapy to reduce addiction?

Answer 39

• lack of long-term advantages
• lack of treatment adherence
• difficult to know which elements work

Question 40

What research support is there for CBT?

Answer 40

Petry et al. (2006) found that gamblers assigned to a treatment condition (Gamblers Anonymous meetings + CBT) were gambling less than a control group (GA meetings only) 12 months later.

An important feature of this study is that the participants were randomly allocated to the CBT group or the control group, and there were no significant differences in the extent of their gambling at the start.

Therefore, the findings are strong evidence that CBT is effective in treating gambling addiction, from a methodologically-sound study.

Question 41

How does CBT prevent relapse?

Answer 41

CBT incorporates the likelihood of relapse into treatment, viewing it as a further opportunity for learning and cognitive restructuring.

Relapse, rather than being seen as a failure, may be seen as an inevitable part of the addict’s life, but acceptable as long as improvement continues.

CBT’s effectiveness at preventing relapse is a strength of the therapy.

Question 42

How does CBT lack long-term advantages?

Answer 42

Cowlishaw et al. (2012) found CBT has definite beneficial effects for up to three months after treatment. However, after 9-12 months, there were no significant differences between CBT and control groups.

In addition, the researchers also concluded that the studies they reviewed were of such poor methodological quality that they probably overestimated the efficacy of treatment with CBT.

Therefore, CBT may be effective in reducing gambling behaviour, but the ‘durability of therapeutic gain’ is unclear.

Question 43

How does CBT lack treatment adherence?

Answer 43

Cuijpers et al. (2008) indicate that the drop-out rates in CBT treatment groups can be up to five times greater than for other forms of therapy.

Even when clients continue in treatment, their commitment to homework and attendance wanes. Clients often seek CBT during a life crisis and give up once the crisis ends.

Lack of treatment adherence suggests that CBT may not be an effective long-term treatment strategy because clients see it as too challenging.

Question 44

Why is it difficult to know which elements of CBT work?

Answer 44

CBT uses a variety of techniques to reduce addictions and can now be delivered in many ways (e.g. online and with telephone support). This allows CBT to be tailored to the individual.

However, this flexibility and variety of use means it is difficult for researchers to identify which elements of CBT are most useful in reducing addiction because there is no standard treatment.

So, whilst CBT’s flexibility is a strength of the therapy, it also makes it difficult to draw conclusions about its efficacy.