Chapter 8 (Lecture) Flashcards
How do drugs cause harm?
health harms through:
- intoxication (accidents, violence, injury)
- acute harms (drug-induced psychosis, overdose)
- chronic harms (long term use –> organ damage)
- dependence or substance use disorders (leads to prolonged use in a high risk pattern): which are counted as mental disorders and part of the mental health burden
Also:
- social problems (unemployment, partner/child abuse, role failure
- indirect harm (incarceration for drug offences, blood borne virus transmission)
mechanisms of harm
risk of a specific substance vary in relation to the:
- particular substance
- dose
- patterns of use (amount and frequency)
- route of administration
3 mechanisms:
1. toxic/biochemical effects
2. psychoactive actions producing intoxication
3. dependence
Addiction - terminology and conceptualisation
Addiction - repetitive consumption of a substance (or repetitive engagement in an activity) that is considered to be problematic
- this definition has evolved, but the core concept is that the behaviour associated with the substance use causes problems for the individual or the people/community around that individual - the problematic component is key
illicit drugs
controlled/prohibited substances (heroin, cocaine, cannabis, etc.) and diverted pharmaceuticals (prescription, opioids, etc.)
drugs misuse, harmful use or problematic use
consumption that causes social, psychological or health problems/harms for individual or society
drug dependence
psychobiological syndrome involving impaired control of use, increased tolerance, continued use despite negative consequences, and withdrawal symptoms - has replaced “drugs addiction” in the ICD
psychoactive drugs
defined as a substance capable of influencing brain systems linked to reward and pleasure - “drug” for simplicity
People who use drugs (PWUD)
person-centred, descriptive, neutral
people who inject drugs (PWID)
injection as mode of administration
addict
pejorative and stigmatising, but some people identify with the label and it may be part of their recovery journey
addiction
lack precision and clarity, a debated term
drug use
transparent, neutral, and free of judgement - includes approved or disapproved forms of consumption
substance use - increasingly the term in public health
two parallel models developed in 1880s
Addiction stemmed from physical or psychological predispositions in some individuals - this model led to beliefs about individual degeneracy and solutions such as institutionalisation and sterilisation
Addiction related to the characteristics of the substance itself - this model was associated with the “temperance movement” which identified the substance (alcohol) as the source of the problem and advocated for severe restrictions or prohibitions (laws making production and sales illegal) on the availability of alcohol
How was the tension between a medical model focusing on the person w addiction and a focus on dangerous substances influenced our response to addiction?
- if we see addiction as a disease, we are likely to favour medical responses to addiction
- if we see addiction as bad behaviour (moral view), we are likely to favour criminal justice responses to addiction
- if we consider social determinants of health, we might look at systemic or social drivers (causes) of addiction
Disease model vs the moral model
temperance movement: main problem/cause is the properties of substance itself (rather than the individual)
- pushed for restrictions on the availability and consumption of alcohol
- one of the largest social movements at the time (early 1900s) in the English speaking world, part of Christian religious movements
- basic tenet persists: some substances are inherently dangerous and addictive, leading to health and social problems
what term was abandoned by WHO in 1964 and what was it replaced with?
Addiction was abandoned by WHO in 1964 due to imprecision - replaced addiction with dependence
DSM-5 - medical model of addiction
- DSM-5 uses the term “addiction” and includes non chemical, behavioural addictions in the relevant sections
- this emphasises psychological aspects of dependence, rather than physical/biological (substances) - though physical dependence is key component of SUDs
- implications: this leads to inclusion of “addictions” that do not involve physiological dependence (as substances do), but some biologically/brain focused researchers would say these problem behaviours similarly alter brain function/chemistry
More on the medical model of addiction
- viewing behavioural addictions as similar to substance use disorders if founded upon view of addiction as involving compulsion, loss of control, continued use/behaviour despite knowledge of negative consequences (these are key criteria for SUDs)
- advocates for this model point to neurological research into the reward systems of the brain … what was rewarding or pleasurable, becomes compulsive due to neurological changes in the brain (common between chemical and non-chemical dependencies)
- language around substance use continues to shift and evolve and reflects our beliefs around mortality and choice in substance use
- some addictive behaviours are now thought to operate psychologically and like substance dependence
- it is argued that there are similar neurochemical changes in the brain when the behaviour is engaged in - related to the reward system in the brain
Hi-jacked brain model of addiction
- very much adopted and mobilised by the US national institute on drug abuse (NIDA)
- important to acknowledge that this view perhaps expands the mandate/mission of NIDA, as behavioural addictions wouldn’t fall under into their mandate (drug abuse)
research on addiction and substance use is full of debate, disagreement and controversy
- discovering addiction (2007): historian Nancy Campbell argues that relying on science to explain craving, intoxication, and dependence has powerfully shaped political and medical responses to drug use
- if addiction is a disease, then medical interventions (and rehabilitation) will be prioritised
- if it is a moral/behavioural problem, punishment in the form of incarceration (imprisonment) should deter people from using drugs
The disease model may bring a more humane approach to managing addictions, but there are consequences related to medicalisation:
- arguably reduced individual responsibility and imperative to improve/reform (compulsion stems from medical condition)
- decreases emphasis on social, economic, and cultural contexts in shaping substance use and outcomes
- less attention to systemic and underlying issues, like the social determinants of health, if we view it solely as medical problem
Public health - models of addiction
Medicine tends to adopt a very biological, individually-focused and brain based view (individual biology or psychology)
Public health: more focus on individuals in context and the role of socio-cultural influences in shaping behaviour and outcomes
- social determinants of health and systemic factors
- ethnicity, neighbourhoods characteristics, gender, sexual orientation, income (SES), education: all influence mental health and substance use
- environment is centrally important and structures issues related to addiction
DSM-5 view of substance use disorders
specific to the substance involved in problematic use, but common features:
- loss of control of use
- cravings and compulsion to use the substance, reduction in other activities
- inability to stop or reduce use
- problems: social/interpersonal role failures
- continued use despite physical/psychological problems
- presence of tolerance and withdrawal
Explanation of the “brain disease model” of addiction
- mesolimbic dopaminergic pathway (pleasure centre of the brain) with dopamine as the pleasure neurotransmitter
- reward system and the major structures: the ventral tegmental area (VTA), the nucleus accumbens and the prefrontal cortex
- information travels from the VTA to the nucleus accumbens and then up to the prefrontal cortex
- pathway gets activated when a person receives positive reinforcement for certain behaviours (having sex, spending time with loved ones)
NIDA brain disease or “high-jacked” brain model
chronic exposure to high doses of alcohol produces counter-adaptive neural changes that affect the motivation of the individual and drive subsequent alcohol-seeking behaviour and use
addiction as a compulsive brain disease
enduring changes to reward pathways is the mechanisms common to both:
- substance “addictions”
- behaviour “addictions”
Similar pathways whether we are talking about cocaine use, video games, shopping, gambling, etc.
what is drug addiction?
addiction is defined as a chronic, relapsing brain disease that is characterised by compulsive drug seeking and use, despite harmful consequences
it is considered a brain disease because drugs change the brain - they change its structure and how it works
these changes can be long-lasting and can lead to the harmful behaviours seen in people who abuse drugs
addiction involves multiple factors
biology/genes
environment
implications of this reconceptualisation
- frames behavioural addictions as similar SUDs - but are they progressive and fatal diseases
- perhaps problematic assumption that addictions are always chronic, relapsing conditions
- downplays personal agency and foster assumptions that those who are addicted will always continue to be (perhaps overly deterministic)
- de-emphasizes social and moral factors shaping behaviours
- overlooks how cultural influences on diagnostic categories (hazardous consumption as part of SUDs)
workaholic = work addiction
- working hard and valuing work is valorised in society (viewed very positively)
Is work addiction beneficial/admirable? - or should it be viewed as an illness due to its impacts on individual health, family relations, etc.
Can be viewed as a classic example of ignoring other priorities and responsibilities to engage in one particular behaviour (think of the reward pathway)
philosophical considerations
viewing addiction as a “disease of the will” brings up philosophical questions
- is free will truly usurped and destroyed by addiction?
The common understanding is as a disease that robs individuals of their ability to control behaviour and exercise will may not be entirely accurate:
- people who live with dependencies may describe them as a choice (or not) in a situationally dependent way (e.g., who is asking the question)
- individuals balance short term agin against short and long term risk in relation to their addictive habit (situated risk perceptions)
- medical view of addiction as disease that overrules willpower and controversial because of counter evidence (some people stop and recover) and philosophical implications regarding human behaviour
compulsive buying disorder (CBD)
excessive shopping cognitions and buying behaviour that leads to distress and impairment
emphasises:
- distress/impairment
- preoccupation (obsession)
- compulsion (loss of control)
- relief/euphoria
strong similarities to SUD features, emphasis on altered reward system
can lead to a number of problems however it is not recognised as a distinct behavioural addiction in DSM-5
alcohol as a toxic substance
toxic substance (poison) - direct and indirect effects on organs and organ systems
categories of harm:
- acute intoxication or binge drinking - adverse health impacts like alcohol poisoning, acute pancreatitis, acute cardiac arrhythmias
- chronic disease from long term exposure to high does of alcohol - cancers and cirrhosis
mechanisms of harm from wider range of drugs
risks of a specific substance vary in relation to the:
- particular substance
- dose
- pattern of use (amount and frequency)
- route of administration
3 mechanisms:
- toxic/biochemical effects
- psychoactive actions producing intoxication
- dependence
3 aspects of use shaping risk/harm
Dose - ranges from barely intoxicating to lethal and is related to purity
- greater doses increase potential for acute effects like intoxication or overdose
Patterns of use (frequency/variability of consumption) - may be intermittent or daily
Mode of administration - non-oral routes may have potential for infectious disease transmission, and increased risk of overdose
- dose can exceed tolerance leading to overdose/poisoning or death
- regular use can lead to chronic effects on tissues/organs: heavy cannabis use can lead to lung conditions
- intoxication: impaired judgement/coordination and potential for injuries - can also contribute to pain, disorientation, violence, and medical/psychological problems
3 dimensions to consider in relation to each substance
- natural or synthetic form
- route of administration
- medicinal or non-medicinal use
Natural or synthetic
modern chemistry has led to:
- production of potent extracts (morphine, cocaine)
- concentrated forms of drugs (heroin, crack cocaine)
- new or more potent substances (LSD, opioids, benzodiazepines)
- synthetic opioids (fentanyl, fentanyl analogues)
Trend toward increased potency, portability (due to purity/concentration) and dependence potential in the evolution of substances, particularly with trend toward synthetic substances
Example: fentanyl and carfentanil = increasingly potent opioids
route of administration
- taken orally (both natural and synthetic substances)
- insufflated (snorted) intake via mucous membranes in nasal passage (cocaine)
- inhalation - smoking (crack, crystal meth, cannabis)
- via injection - intravenous, muscular or subcutaneous injection (herion, cocaine)
trend toward more rapid delivery/effects
injection: increasing potential for physical harms and dependence/SUD
medicinal or non-medicinal use
- many substances originally developed for medical purposes now restricted under prescription system (sedatives, opioids)
- some are still medical, but strictly controlled (morphine, amphetamines, benzodiazepines)
- others no longer regarded to have medicinal purposes (cocaine)
medicinal substances are often misused (potential for physical, psychological, or legal problems)
- used by people who have not been prescribed them (diversion)
- used for reasons other than their medical purpose
- taken in larger doses than intended/preescribed
- taken through other routes of administration (snorted, injected)
3 dimensions (1. natural or synthetic form, 2. route of administration, 3. medicinal or non-medicinal use) - these distinctions are cubical but not sufficient to fully comprehend the complexities of drug use
must also consider the diversity, role, and specific risks of:
- different consumption patterns
- effects of drug combination (e.g. overdose)
- situational risks (e.g. impaired driving, or injecting in public venues)
- behavioural risk-taking (e.g. unprotected sex during the high experienced after amphetamine use, or disinhibition stemming from alcohol)
individual who uses substances
- lack of social context in model
- lack of recognition of ecological forces in shaping patterns of use, potential for risk/harm
- highly psychological explanations of behaviour
overly individual focus on individuals in production of risk, interventions, and research
risk environment framework
Policy
- legislation and drug policy (availability of substances and risk-reduction)
Social
- influence of peer networks or prevailing cultural norms
Legal and Economic
- neighbourhood level deprivation
Physical
- geographic locale or micro-environment where drugs are consumed
All of these point to the individual
risk environment framework - premise and definition
premise: risk/harms of drug use are driven by interactions between individuals and diverse social and structural factors (an ecological model)
definition: the space - whether social or physical - in which a variety of factors interact to increase (or decrease) the change of drug-related harm occurring
historical perspective
social science and history can provide helpful perspective and a correct lens
addiction sometimes viewed as a “modern plague”, without recognition of historical contexts
- we can see cycles of drug scares and moral panics related to different substances
- reefer madness concerns about LSD (1960s), PCP (1970S), crack cocaine (1980s) - even alcohol in 1920s
drug epidemics - Virgina berridge
virginia verridge: draws attention to context and changes in understanding of addiction over time
- consumption of substances is linked to broader
- sometimes brought on by medicine (like Milton), fostering use and dependence
- “Frankenstein narrative” (Mike Jay 200): medicine/doctors promote a substance, then later restrict it - particularly true for pharmaceutical drugs (like alcohol, cocaine, morphine) which were subsequently demonised
- history helps us see that addiction is not solely an individual-level phenomena, but a societal problem and issue, and this shapes how we use language about addiction and how we define the term
drug epidemics - rapid increases in drugs use in localised areas
- 1940s inner-city Chicago - dramatic increase in heroin users, then declined in the 50s
- Merseyside, UK - prevalence of heroin users increased from almost zero to 4000 over a 6 year period in the early 80s
2 simultaneous processes in these cases
- micro-diffusion: spread social networks through personal contact between experienced and novice users (drug use as a learned social behaviour)
- macro-diffusion: supply side changes (trafficking and dealer expansion) to geographical areas influence availibility
Alcoholics Anonymous
- AA and similar groups (NA) have fostered a predominant narrative regarding treatment and recovery in relation to addiction
- the emergence of AA coincided with the medicalisation of addiction and reliance on doctors to treat it
- the AA model claims that people with addiction are intrinsically predisposed to addiction, and different from “normal” people
- AA suggests that a actions such as prayer, self-reflection, and self-improvement are ways to help oneself heal (or recover) from addiction
- the model has been adopted for a wide variety of addictive substances and behaviours, beyond alcohol and other substances to include gambling, shopping, etc.
- AA founded in the 1930s
- controversial as a frontline response to problematic alcohol use
AA - History of the medical model of addiction begins with US “inebriate reformatory” movement
- doctors adopted the medical model, capitalising on the temperance movement and increasing public concern about alcohol
Drawing on 2 visions noted earlier: - alcohol as an inherently addictive substance leading certain people to need medical intervention
- alcoholism as a disease that affects particular people
put doctors in central position in countering alcohol problems
AA - Tension between medical and temperance model: was the alcoholic unique, or is alcohol so powerful?
AA adopts former perspective: alcoholics are constitutionally different, characterised by an inherent alcoholism (intrinsically predisposed to addiction) - central principle of AA since 30s onward
AA - roots in Oxford Group, a popular religious movement at the time
- self-improvement, self-reflection, admitting wrong-doings, making amends, praying, meditating, preaching message to others (see 12 steps of AA)
Rowland Howard (an alcoholic from Rhode Island) sought help from psychoanalyst Carl Jung - who said Rowland was “medically hopeless” and believed that only a spiritual experience could help him, suggesting the Oxford Group
- was able to avoid drinking by following Oxford Group principles
AA founded by Bill and Dr Bob Smith
1939 manual describing path to sobriety: “Alcoholics Anonymous: the story of how many thousands of men and women have recovered from alcoholism” (known as “The Big Book”
- popularised the 12-step approach, later adopted and adapted for other addictions - beyond alcohol and other substances to include gambling, shopping
- AA suggests that actions such as prayer, self-reflection, and self-improvement are ways to help oneself heal (or recover) from addiction
AA 12 step approach
- we admitted we were powerless over alcohol - that our lives had become unmanageable
- came to believe that a power greater than ourselves could restore us to sanity
- made a decision to turn out will and our lives over to the care of God as we understood him
- made a searching and fearless moral inventory of ourselves
- admitted to God, to ourselves, and to another human being the exact nature of wrongs
- were entirely ready to have God remove all these defects to character
- humbly asked Him to remove all these defects of character
- made a list of all persons we had harmed, and became willing to make amends to them all
- made direct amends to such people wherever possible, expect when to do so would injure them or others
- continued to take personal inventory and when we were wrong promptly admitted it
- sought through prayer and meditation to improve our conscious contact with God, as we understood Hi,, praying only for knowledge of His will for us and the power to carry that out
- having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affaris
Criteria for Substance Use Disorder from DSM-5
Impaired Control:
- substance often taken over a longer period of time or in larger amounts than was intended
- unsuccessful efforts to stop, reduce, or control use
- a great deal of time spent to obtain, use, or recover from use of the substance
- overwhelming cravings or desire for the substance
Social Impairment:
- use may lead to failure to fulfil major obligations
- use continues despite persistent or recurrent interpersonal or social problems causes or exacerbated by use
- important occupational, social, or recreational activities are given up or reduced due to substance use
Risky Use:
- recurrent use in physically dangerous situations
- continued use despite physical or psychological problems that are caused or exacerbated by substance use
Pharmacological Dependence:
- tolerance to the effects of the substance
- withdrawal symptoms when not using or using less
SUDS:
- specific to the substance
- mild, moderate, severe categories
- severe SUD = presence of 6 or more
Dependence - ICD-11 focuses on 3 criteria (any 2 qualify as a diagnosis)
- impaired control over substance use
- substance use becoming an overriding priority in the user’s life (other activities decline or are ignored)
- tolerance (increased doses required) or withdrawal symptoms from the drug (upon reduced use or cessation)
DSM-5; dependence replaced with substance use disorder, diagnosed on presence of 2/11 criteria related to use: mental states, repeated behaviours, and reactions of others
Dependence - alternate emerging epidemiological perspective
The crucial dimension can be described in behavioural terms, “heavy substance use over time”
Note: principles of drug dependence do not apply equally to all psychoactive substances (partially due to differing pharmacological properties)- differing substances have been identified as having differing levels of “dependence potential”
