Addictive Behaviours and their Health Outcomes

Question 1

What is addiction?

Answer 1

Addiction can be described as not having control over doing, taking or using something to the point where it could be harmful to you, and from which reward/pleasure is sought/derived..

Commonly associated with drugs, alcohol, nicotine, gambling but it’s possible to be addicted to just about anything, work, internet, exercise…

Question 2

Describe the concepts of harmful use and dependence.

Answer 2

There are specific criteria for the diagnosis of substance problems and dependence.

The International Classification of Diseases (ICD-10) and the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-V)

ICD-10 defines ‘harmful use’ of a substance separately from ‘dependence’ on a substance, the DSM-V criteria link these two concepts together as a single disorder measured on a continuum from mild to severe.

Question 3

What is ICD-10 criteria for harmful use? (WHO, 1992).

Answer 3

• A pattern of psychoactive substance use that is causing damage to either physical or mental health.
• Diagnosis requires that damage should have been caused to the mental or physical health of the user.
• Harmful patterns of use are often criticized by others and frequently associated with adverse social consequences of various kinds.
• Acute intoxication or “hangover” is not sufficient evidence of the damage to health required for coding harmful use.

Question 4

What is ICD-10 criteria for Dependence Syndrome? (WHO, 1992).

Answer 4

• A definite diagnosis of dependence should only be made if 3 or more of the following have been present together at some time during the last year:
• Strong desire or sense of compulsion to take the substance
• Difficulties in controlling substance-taking behaviour – wanting to stop but not able to
• Physiological withdrawal state when substance use has ceased or been reduced, as shown by either of the following: the characteristic withdrawal syndrome for the substance, or use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms
• Evidence of tolerance, such that increased doses of the psychoactive substance are required in order to achieve effects originally produced by lower doses
• Progressive neglect of alternative pleasures or interests because of psychoactive substance use and increased amount of time necessary to obtain or take the substance or to recover from its effects
• Persisting with substance use despite clear evidence of overly harmful consequences (physical or mental)

Question 5

What are some of the determinants for the development of substance problems or ‘addiction’?

Answer 5

• Social factors – cost, availability and accessibility of drugs influence use.
• Economic conditions - deprivation and affluence may affect public health and lead to an escalation of problems.
• Pressure & stressful nature of certain occupations too may act as a stimulus to heavy use.
• Personal, environmental and biological factors such as age, gender and genes shape substance use.
• Predisposition to mental health issues, may use substances as a coping mechanism.

Question 6

What are the models of health behaviour in regards to addiction?

Answer 6

• Trans-theoretical Model – based on an individual’s readiness to take adopt a new health behaviour
• Motivational Interviewing - a guiding style to engage with patients, clarify their strengths and aspirations, evoke their own motivations for change, and promote autonomy of decision making.
• Health Belief Model -designed to understand the likelihood that someone would perform a health protective behaviour
  
  • – And depends upon four factors: (i) the perceived threat of the disease that the behaviour might protect against (ii) the perceived effectiveness of the preventive behaviour (iii) the person’s general health motivation and (iv) cues to action that reflect immediate situational determinants 9 (e.g. warnings on cigarette packets).

Question 7

Describe the Stage of Change model.

Answer 7

Movement is not always in one direction. Individuals, when quitting, may move back through the changes (eg – relapse) as well as forward.

This model informs the focus of cessation therapy: eg – on health risks or cessation techniques.

The model has proved valuable in predicting the success of smoking interventions (DiClemente et al., 1991)

Question 8

What is Motivational Interviewing and when is it used?

Answer 8

• Major intervention used in smoking cessation/addiction work in clinical settings
• MI is a structured talking therapy involving directive counselling
• Its technique is to recognise and overcome ambivalence
  Gentle art of changing attitude
• Involves assessing readiness to change, so uses principles from stage of change model

Question 9

What is the prevalence of smoking in the UK?

Answer 9

• In 2019, 14.1% of people aged 18 years and above smoked cigarettes, which equates to around 6.9 million people
• 15.9% of men smoked compared with 12.5% of women
• The proportion of current smokers in the UK has fallen significantly from 14.7% in 2018 to 14.1% in 2019.
• 5.7% of respondents in 2019 said they currently used an e-cigarette, which equates to nearly 3 million adults in the population with proportion of vapers significantly increased since 2014
• Of the constituent countries, 13.9% of adults in England smoked, 15.5% of adults in Wales, 15.4% of adults in Scotland and 15.6% of adults in Northern Ireland.

Question 10

Why do people smoke?

Answer 10

Smoking is a highly addictive substance

“Cigarettes are highly efficient nicotine delivery devices and are as addictive as drugs such as heroin or cocaine.” Royal College of Physicians, 2000.

View that adults smoke to cope with life- personal reasons

Children/adolescents smoking is motivated by attempts to achieve the status of cool and hard, and to gain group membership –social reasons.

Young people – way of rebelling or getting at those in authority

Myths – re loss of weight, relaxing etc

Question 11

What is the impact of smoking on your health?

Answer 11

Smoking harms nearly every organ of the body, causes many diseases, reduces quality of life and life expectancy

Smoking is the leading cause of preventable death and disease in the UK.

The three main diseases associated with cigarette smoking and death are: lung cancer, chronic obstructive lung disease (bronchitis and emphysema) and coronary heart disease.

People that breath second-hand smoke are at risk of the same diseases as smokers, including cancer and heart disease.

Children are particularly affected by second-hand smoke because their bodies are still developing.

Smoke in the air contains about 4,000 chemicals & over 50 of these chemicals are carcinogens

Question 12

How many deaths did smoking cause in the UK?

Answer 12

Smoking is a leading cause of preventable death in the UK.
- Between 2016 and 2018, 77,600 deaths
were attributable to smoking per year in England.

Estimates from the devolved countries
Wales 5,000 deaths each year,
Scotland 10,000 deaths per year
Northern Ireland, 2,300 deaths per year

Question 13

Describe the study by Doll et al 2004 – Mortality in relation to smoking.

Answer 13

Longitudinal study of UK male doctors who smoke - studied for 50yrs

Recorded all deaths for 50 years (1951-2000)

Smokers on average lose 10 years of life

Stopping smoking works, stopping smoking at age 35-44 gains about 9 years of life

Question 14

What are the Key Legislations for smoking?

Answer 14

• Health Act 2006 and five sets of smokefree regulations set out the detail of the smokefree legislation
• Smoking ,Health and Social Care (Scotland) Act 2005 – implemented March 2006
• The Smoke-free Premises (Wales) Regulations 2007 implemented April 2007
• The Smoking (Northern Ireland) Order 2006 implemented April 2007
• Smoking in enclosed public places was banned in England from 1 July 2007
• Sale of tobacco products to under 18s illegal from Oct 2007
• 1 October 2015 – Smoking banned in cars with anyone under 18 years in them

Question 15

Describe the law regarding alcohol.

Answer 15

• Drinking age laws - restricting the availability of alcohol to children in some form.
• Hours of trading
• Drink Driving

And in Scotland:The Alcohol (Minimum Pricing) (Scotland) Act 2012 is an Act of the Scottish Parliament, which introduced a statutory minimum price for alcohol, initially 50p per unit, as an element in the programme to counter alcohol problems. https://www.gov.scot/policies/alcohol-and-drugs/minimum-unit-pricing/

Question 16

How prevalent is alcohol in the UK?

Answer 16

• In England there are an estimated 586,780 dependent drinkers. Less than 18% are receiving the treatment.
• In 2018 in England, 44% of pupils aged 11-15 in England reported having ever drunk alcohol. Of these, 14% of 11 year-olds reporting ever having drunk an alcoholic drink, compared to 70% of 15 year-olds
• In Scotland in 2018, 9.9 litres of pure alcohol were sold per adult (16 years old and above), equivalent to 19 units per adult per week. This is a 3% decrease from 2017 and the lowest level in Scotland since 1994. This coincides with the introduction of Minimum Unit Pricing in Scotland in May 2018
• 19% of adults in Wales were drinking above the weekly guidelines in 2016/17-2017/18

Question 17

Describe alcohol mortality in the UK.

Answer 17

• There were 7,551 deaths registered in the UK in 2018 that related to alcohol-specific causes, lower than 7,697 deaths in 2017 but still the second highest since the time series began in 2001.
• Rates of alcohol-specific deaths in males have been more than double those in females (16.4 and 7.6 deaths per 100,000 in 2018 respectively) since the beginning of the time series in 2001.
• Alcohol-specific death rates were highest among men aged 55 to 59 years and women aged 60 to 64 years in 2018.
• Scotland had the highest rate of alcohol-specific deaths registered in 2018, followed by Wales and England with 20.8, 13.1 and 10.7 deaths per 100,000 people respectively
• Northern Ireland - 303 alcohol-related fatalities in 2017, an increase over the last decade

Question 18

What are the long-term health risks of alcohol misuse?

Answer 18

• high blood pressure
• stroke
• pancreatitis
• liver disease
• liver cancer
• head, neck and mouth cancer
• breast cancer
• bowel cancer
• alcohol-related brain damage

Question 19

What are the psychological and medical treatments of alcohol misuse?

Answer 19

• 12 Step programs - Alcoholic Anonymous
• Counselling / psychotherapy –CBT
• Brief Interventions/Advice
• Social Support – Groups for both drinkers and families - ADFAM
• Detox and withdrawal symptoms – medications
• Self –help, groups to help you to change your drinking? Club Soda- mindful drinking

Question 20

Describe the drinking trends in the UK?

Answer 20

Over the last century, the overall amount of alcohol consumed per person in the UK has risen and fallen repeatedly.

It peaked in the mid-2000s,

But now consumption has been falling steadily – especially among young people.

Average consumption now per adult is about 9.7 litres of pure alcohol per year – or about 18 units a week – still more than recommended limits

COVID-19 impacts?

Question 21

What are brief interventions and why should we screen and give it?

Answer 21

Brief interventions are usually ‘opportunistic’ – that is, they are administered to patients who have not attended a consultation to discuss their drinking”

“……the giving of information, advice and encouragement to the patient to consider the positives and negatives of their drinking behaviour, plus support and help to the patient if they do decide they want to cut down on their drinking.” from the 2004 Alcohol Harm Reduction Strategy for England.

Early intervention and prevention of medical and social harm but also more severe dependence

Research/reviews have shown that opportunistic screening and brief interventions are effective in reducing excessive alcohol consumption.

Department of Health evidence shows that for every eight people receiving brief advice one cuts down their drinking.

Contribution to public health – broadening the base of interventions against alcohol-related harm

Question 22

Describe what FRAMES is

Answer 22

FRAMES is a model of brief intervention.

Feedback: about personal risk or impairment
Responsibility: emphasis on personal responsibility for change.

Advice: to cut down or abstain if indicated because of
severe dependence or harm.

Menu: of alternative options for changing drinking pattern and, jointly with the patient, setting a target; intermediate goals of reduction can be a start.

Empathic interviewing: listening reflectively without cajoling or confronting; exploring with patients the reasons for change as they see their situation.

Self efficacy: an interviewing style which enhances peoples’ belief in their ability to change

Question 23

What is the summary of the drug situation in the UK?

Answer 23

• Drug use reported in the UK has remained relatively stable
• Recent surveys covering England and Wales, and Scotland are reporting an increase in drug use in the past 10 years.
• Drug use among 15 year olds has increased
• Cannabis is the most prevalent, followed by powder cocaine, MDMA, ketamine and amphetamine.
• 3,284 drug-related deaths (DRDs) occurred in Great Britain in 2017

Question 24

What is a drug or substance?

Answer 24

The term ‘drug’ covers licit/legal (e.g. tobacco and alcohol) and illicit substances:-

• Central nervous system depressants such as opiates and opioids (e.g. heroin and methadone),
• Stimulants (e.g. cocaine, crack, amphetamine and ecstasy), and LSD, khat and magic mushrooms.
• Prescription and over-the-counter drugs, such as benzodiazepines and codeine-based products (e.g. cough medicines, decongestants) are also included.

Question 25

What are the different definitions of drugs?

Answer 25

• A medicine or other substance which has a physiological effect when ingested or otherwise introduced into the body. – e.g. Aspirin
• A substance taken for its narcotic or stimulant effects, often illegally.
• Examples of psychoactive substances include caffeine, alcohol, cocaine, ecstasy and cannabis, and the newer novel psychoactive substances

Question 26

What are some New or Novel Psychoactive Substances?

Answer 26

• Novel/new psychoactive substances
• Research chemical
• Designer drugs
• Bath salts, plant food, herbal incense
• Various definitions (WHO, EMCDDA, ACMD)
• Can be thought of simply as a new recreational drug
• Come in a variety of forms

Question 27

What do typical drugs of abuse do in the brain?

Answer 27

They change levels of neurotransmitters e.g. dopamine and serotonin leading to psychological changes

Cocaine		stimulant & euphoric effects
LSD		hallucinations
Ketamine		dissociative, dream-like effects
Alcohol		relaxation
Cannabis		relaxation and dream-like

Question 28

What are the physical and mental harm that drugs do?

Answer 28

PHYSICAL:

• bleeding in muscles and internal organs
• swelling of brain
• unconsciousness
• sweating/overheating
• difficulty breathing
• shaking all over
• ridgity of body
• fitting/foaming at mouth

MENTAL:

• acute psychoactive effects: canges in mood, anxiety, perception, thinking, memory and attention
• Agitation, jittery, fidgety, distress, confuson , disorientation
• paranoid thoughts

Question 29

What are the UK drug laws?

Answer 29

The laws controlling drug use are complicated but there are three main statutes regulating the availability of drugs in the UK:
The Misuse of Drugs Act (1971)
The Medicines Act (1968) and
The Psychoactive Substances Act (2016)

Question 30

Expand on The Misuse of Drugs Act.

Answer 30

classifies drugs into classes and has sanctions for each class

Class A: Amphetamines (speed) (if prepared for injection), Ecstasy, LSD, Heroin, Cocaine, Crack, Psilocybin mushrooms (magic mushrooms), .
Class B: Amphetamines, Cannabis (marijuana), Methylphenidate (Ritalin), Pholcodine, mephedrone, methoxetamine (mexxy),
Class C: Benzodiazepines (tranquilisers), some painkillers, Gamma hydroxybutyrate (GHB and GBL), Ketamine.
Not classified: Alcohol, Tobacco, caffeine, salvia, poppers, nitrous oxide

Question 31

What is the law regarding different classes of drugs if you are in possession or trafficking them?

Answer 31

Class A:Up to 7 years’ imprisonment or a fine or both
Class B:Up to 5 years’ imprisonment or a fine or both
Class C:Up to 2 years’ imprisonment or a fine or both

Question 32

What is gambling?

Answer 32

Gambling is a common, socially acceptable and legal leisure activity in most cultures across the world.

It involves wagering something of value (usually money) on a game or event whose outcome is unpredictable and determined by chance (Ladouceur et al, 2002).

Question 33

What is the Gambling Regulation and The Law?

Answer 33

Regulated by the Gambling Commission under the Gambling Act 2005 –its objectives are to

prevent gambling from being a source of crime or disorder, being associated with crime or disorder or being used to support crime,

ensure that gambling is conducted in a fair and open way, and protect children and other vulnerable persons from being harmed or exploited by gambling.

Question 34

What are the stats for gambling and young people?

Answer 34

11% of 11-16 year olds say they spent their own money on gambling activities in the seven days prior to taking part in the survey. This is down from 14% in 2018.

5%of 11-16 year olds say they have placed a private bet for money (e.g. with friends) in the past seven days, with a further 3% playing cards for money with friends in the past seven days.

4%of 11-16 year olds report playing on fruit or slot machines in the past seven days.

3%of 11- 16 year olds say they have played National Lottery scratch-cards and 2% say they have played the Lotto (the main National Lottery) draw in the past seven days.

1.7%of 11-16 year olds are classified as ‘problem’ gamblers, 2.7% as ‘at risk, using the DSM-IV-MR-J-screen. In 2018, 1.7% of 11-16 year olds were classified as ‘problem gamblers’ and 2.2% were classified as ‘at risk’. The 2019 results do not represent a significant increase over time.

69%of 11-16 year olds say they have seen or heard gambling adverts or sponsorship with 83% of those saying that it had not prompted them to gamble.

Question 35

What is problem gambling defined as?

Answer 35

Is defined as behaviour related to gambling which causes harm to the gambler and those around them.

Like substance use, gambling behaviours too exist on a scale of escalating severity and adverse consequences, ranging from no gambling, normal/recreational gambling, through problematic/sub-syndromal gambling to gambling addiction or gambling disorder

Question 36

How is problem gambling and at risk identified?

Answer 36

The Problem Gambling Severity Index (PGSI) identifies people who are at risk of problems related to their gambling behaviour but who are not classified as problem gamblers.

DSM - 5 Diagnostic Criteria for Gambling Disorder – where persistent and recurrent problematic gambling behaviour leads to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12-month period:

• Gamble with increasing amounts of money in order to achieve the desired excitement.
• Restless or irritable when attempting to cut down or stop gambling.
• Repeated unsuccessful efforts to control, cut back, or stop gambling.
• Often gambles when feeling distressed, guilty, anxious, or depressed.
• Lies to conceal the extent of involvement with gambling.
• Has jeopardized or lost a significant relationship

Question 37

What are some consequences of gambling?

Answer 37

Problem gamblers suffer high rates of psychiatric comorbidity, including depression, anxiety, substance misuse and personality disorders (Petry et al, 2005).

Severe gambling disorder is also associated with several stress-related and other medical disorders (e.g. cardiovascular, musculoskeletal, gastrointestinal), with resultant increased use of medical services (Morasco et al, 2006).

Excessive gambling often results in financial losses, leading to debts and bankruptcy. Individuals may commit crime to fund their addiction.

As the gambling addiction takes hold,employment and employability may suffer significantly.

Moreover, it is estimated that for every pathological gambler, between 8 and 10 others are also directly affected, including family, friends and colleagues (Lobsinger et al, 1996).

Question 38

What are some interventions and treatments for gambling?

Answer 38

Treatment – until recently services for those with Gambling Problems have been very scarce.

Specialist face-to-face NHS treatment for gambling addiction has only been available in London but is being made available across the country as part of the NHS Long Term Plan.

NHS clinics now exist: NHS Northern Gambling Service in Leeds, followed by Manchester and Sunderland.
The National Problem Gambling Clinic in London will also offer specialist help for children and young people aged 13 to 25 as part of an expansion which will also ramp up treatment for adults.

Help and Support Groups –such as GamCare offers free information, support and counselling for problem gamblers in the UK. Gambling Therapy website, which offers online support to problem gamblers and their friends and family.

Question 39

What are some ongoing issues regarding smoking, drugs and alcohol?

Answer 39

Vaping and E-Cigarettes – debates about safety, health issues,cessation tool..

Medicinal Cannabis On the 1st of November 2018, medicinal cannabis products were removed from schedule 1 and placed in schedule 2 of the Misuse of Drugs Regulations 2001. This change in the law has left patients, medical professionals and law enforcement perplexed about who should and who should not have access to medicinal cannabis. https://drugscience.org.uk/medical-cannabis-educational-slides/

Older people – risky drinking patterns https://theconversation.com/theres-a-binge-drinking-boom-among-older-people-and-heres-what-that-could-be-doing-124544

COVID -19 – impact on behaviours – smoking, alcohol and gambling.

Question 40

What are the drinking trends in the UK?

Answer 40

Public Health England
• a rise in the proportions of both non-drinkers and higher risk drinkers
• similar proportions of people are drinking more than before and less than before

IAS analysis of numerous sources highlights

• addiction treatment services have seen a decrease in the number of clients starting alcohol or other drug treatment this financial year,
• concerns from elsewhere that relaxation of regulations on availability designed as temporary measures for the duration of the pandemic become embedded and permanent as a result of industry activities. If this is the case, there is a possibility such activities could undermine longer term progress on alcohol harm.

Question 41

Expand on smoking/vaping and COVID-19.

Answer 41

Researchers from University College London Study: Twice as many people completely quit smoking after the COVID-19 lockdown began in March as did before the restrictions, a study has found. https://www.ucl.ac.uk/news/2020/jul/million-people-have-stopped-smoking-covid-19-pandemic-hit-britain

A million people around the country have quit during the pandemic. ASH https://ash.org.uk/media-and-news/press-releases-media-and-news/pandemicmillion/

Does vaping spread COVID-19?
Professor Caitlin Notley, of Norwich Medical School at the University of East Anglia, said :“Someone infected with coronavirus clearly would be emitting viral [particles] in their vape if they were vaping, just the same as they would if they were breathing out or singing,” she said. “The thing with vaping is it makes breath visible and so when you are outside you can see huge clouds of vapour floating away in the wind.”