Lecture 3 and 4 Flashcards
Why do people use substances
To enjoy the experience and short term effects To feel confident To “break the rules” To be part of the subculture To relieve boredom Peer influence Family factors Community factors
Why do people continue to use addictive substances
To counter the unpleasant effects of prescribed medications
To continue the habit
To avoid unpleasant feelings
To satisfy cravings
To avoid withdrawal symptoms
To counter the effects of other drugs (e.g., benzos after speed)
Gateway theory
Theories of addiction
Moral: sign of moral weakness, deviance
Disease: “sick role”, not reversible, genetic
Genetic/neuro-pharmacological: based on adoption and twin studies, limbic system, reward pathways/neurotransmitters
Psychological: classical/operant conditioning, positive reinforcement, associations
Socio-cultural: gender, age, SES, subculture
Bio-psycho-social: multiple contributing factors operate in combination
Psychological Theories
- Disease theories
- Behavioural theories (reinforcement)
- Cognitive/Cognitive behavioural theories
- Motivation and change theories
- Family and systems theories
The case of Mike
22 year-old male
Started binge drinking and cannabis when 15 yo
Currently drinking 10 standard drinks 5+ days/week
Cannabis use increased since failing uni and relationship break-up with his first serious boyfriend. Smoking cannabis nightly.
Reports feeling hopeless, depressed and anxious
States he was never close with his family. Sees them regularly, but things have become more difficult.
His father is a heavy drinker and is concerned to see his son making the same mistakes. High expectations to succeed from father.
Mike says drug use helps him to “feel better and forget”. He knows that his use is high and causing him harm, but feels there is nothing he can do about it.
He feels terrible after a heavy drinking session.
He believes he gets on better with people after he has had a few drinks, and can cope better with conflict with his family.
Disease Theories overview
Dependence is a symptom of physical or mental illness or disease
Dependence is caused by the presence of a specific gene or biochemical abnormality that precedes substance use
Inability to discriminate blood alcohol level
Increased sensitivity to alcohol
Abnormal brainwaves
Evidence comes from family, twin and adoption studies
12 Steps models
AA, NA, Al-Anon
Dependence as a “spiritual disease” and “lack of control”
Main premises (see Heather and Robertson 1997; Kaskutas, 2009)
Alcoholism is “all or nothing”. Problem or no problem.
Alcoholics are powerless over alcohol and experiences.
Alcoholism cannot be “cured”, only managed.
Disease is progressive and deterioration in condition is inevitable if drinking continues.
Support through attending groups, peer support, submitting to a higher power
Mechanisms of theory not well explained
Limited research evidence base
Heavy drinkers can control use, many dependant users do return to controlled use, no evidence that the disease is ‘progressive’.
This is an example of abstinence vs. harm reduction approaches.
Treatment outcomes from 12 step programs-associated with greater friends, spiritual connection, finding meaning in life (Kaskutas, 2009)
Psychoanalytic View
Nature and nurture Unconscious processes that govern the id, ego, & superego Importance of childhood experiences Variety of theories: Fixated at the “oral” stage Id –drive reduction theory. Ego – “self medication”
Psychoanalytic Shared Assumptions
Psychoanalytic shared assumptions:
Drug use is a symptom of an underlying psychological disorder
Indicates severe psychopathology
Psychological problems are assumed to cause substance abuse, but not usually recognised as a consequence of use
Addiction is considered a uniform disorder
Treatment via the therapeutic relationship and specific psychoanalytic techniques
Consumption provides relief from conflict generated by oral fixation; or repressed psychological conflict (see Rassool, 2011)
Jellinek 5 Types of Alcoholics ABGDE
alpha - pure psychological addiction
beta - continuous heavy drinking leading to medical complications, but psychological or physical dependence not evident
gamma - increased tolerance, withdrawals, cravings and loss of control
delta - as above with inability to abstain
epsilon - intermittent binge drinking interspersed with abstinence/controlled use
Cloninger, Wennberg 1987 Two Alcoholic Types
Type 1 (late onset): high reward dependency, high harm avoidance, and low novelty seeking Type 2 (early onset): lower reward dependence, low harm avoidance*, high novelty seeking Some research is inconsistent*
Personality Theory
Group of distinct personality characteristics that distinguish alcoholics from other individuals
Many ideas:
Predisposing factor (‘addictive personality’)
Consequence of dependence
Independent (personality trait and dependence)
Limited evidence of ‘addictive personality’ per se
Related to specific personality characteristics (e.g., sensation seeking)
Personality Predictors of Drug Use
Personality predictors of drug use (e.g., McGue 1995; Rassool, 2011)
Behavioural disinhibition (impulsivity)
Emotional negativity (negative mood, depressive PD)
Other personality features (e.g., narcissism)
Used to enhance sensation and avoid pain
Personality characteristics are also related to drug of choice
- Heroin patients show greater novelty seeking than alcohol patients (Le Bon et al, 2004)
- Some research considers internal vs. external stressors and uses MMPI personality profiles to categorise drug of choice (Lawson & Winstead, 2008)
Parts of the brain involved in addiction
- Cortex
- Limbic System
- Brain stem
Endorphin-Deficiency Theory
Drugs of abuse target the brain’s pleasure centre
Behavioural Theories
Only considers observable/measurable behaviour Behaviour is a consequence of learning Four main types of conditioning Classical conditioning Operant conditioning Modelling Tension reduction
Classical Conditioning Models
Classical conditioning models Sights, smells and sounds consistently associated with drug use elicit physiological and psychological responses that lead to drug seeking behaviour Conditioned stimuli (CS) – cues and triggers Conditioned response (CR) – physiological and psychological responses CS more important than CR
Operant conditioning models
Focuses on reinforcing properties of drugs, and the likelihood of people repeating immediately pleasurable experiences (and avoiding unpleasurable experiences)
Three main reinforcement types:
Positive reinforcement (i.e., drugs can cause pleasurable sensations)
Negative reinforcement
Punishment
Modelling behavioural theories
People learn favourable attitudes and expectation about drinking based on how the behaviour is modelled.
Lowers the risk of harm if one does not have to experience negative consequences personally
Increases the likelihood of pleasant experiences learned from others
Maintenance associated with past associations with drug-taking environments/situations (see Rassool, 2011)
Cognitive Model
Focuses on the thoughts/beliefs, and impact on behaviours and feelings
The way people interpret specific situations influences feelings, motivations and actions.
Layers of beliefs
Cognitive Dissonance
Conflicting beliefs (cognitive dissonance)
Conflict between the desire to use drugs and the desire to be free of drugs e.g. “I should not use alcohol” vs “It’s OK to have a drink just this one time”
Leads to a cycle of behavioural, emotional and thinking patterns
Cognitive-behavioural: thoughts and behaviours are learnt and therefore can be ‘unlearnt’ (CBT)
Cognitive Model
Circle -Activating stimulus: Internal cues External cues -Beliefs activated -Automatic thoughts -Cravings/urges -Facilitating beliefs (permission) -Focus on instrumental strategies (Action) -Continue to use or relapse
Social Learning theory
Triangle
Personal factors environment behaviour
Example: Adolescents who view substance use in a positive light, whose peers use drugs, and whose parents and peers have attitudes that condone substance use are more likely to use substances
Expetancy Theory Bandura
Two specific cognitions:
Outcome expectancy – beliefs about effects and outcomes of using
Self efficacy – belief in ones own ability to effect change
Implications for treatment: Relapse prevention
Interaction of high risk situations (cues/triggers) with coping response and expectancy (outcome and self-efficacy)
Aim is to reduce high risk situations and increase alternative coping strategies and self-efficacy
Motivation and change theories
‘Transtheoretical’
Stages of change (Prochaska & DiClemente, 1986)
Clients do not necessarily enter treatment committed to action and making changes
Popular model – growing evidence base
Motivational interviewing - intrinsic motivation is a necessary and sufficient factor to initiate behaviour change
Motivation and Change theories circle 6 things
Circle thing that was in lecture
1) Precontemplation: No intention of changing the behaviour
2) Contemplation: Aware a problem exists. No commitment to action
3) Preparation: Intent upon taking action
4) Action: Active modification of behaviour
5) Maintenance: Sustained change-new behaviour replaces old
6) Relapse: Fell back into old patterns of behaviour
Family and systems theory
Determinants of behaviour are based on an individuals role within a system
Family and other systems (e.g., peers) have role in starting/maintaining substance use
Many differing theories
Shared common elements:
Boundaries
Reciprocal causality
Homeostasis
Importance of placing emphasis on interventions for the system.
Deteminants
The range of risk and protective factors that make someone more or less likely to develop a drug use disorder
Major risk and protective factors (Loxley et al., 2004) Prior to birth
Prior to birth Risk factors: -Social Disadvantage -Family breakdown -Genetic influences -Maternal smoking and alcohol use Protective factors: Birth outside of Australia
Risk factor: Socio economic status
Low Social Status and the increasing disparity between the rich and the poor have been noted to impact upon morbidity, morality, and other health-risk behaviours such as drug use. This most likely arises through economic discrepancies producing personal and interpersonal insecurities, tensions, and conflict, which negatively influence physical and mental health, well-being, coping, and competence of individuals in the community
Risk factors: Trauma
Children affected by abuse or neglect have a higher risk of problems later in life
Risk factors: Genetics
Genetic / biological
Examples: Variations in the metabolism of substances Neurotransmitters Genetic temperament Personality factors
Protective factors- Ethnicity?
Depends on a number of factors
Some indication being born outside Australia is protective
family cohesion, rules and cultural norms, and parental supervision
Also can be a risk factor
Low SES communities, family trauma, social isolation
Indigenous risk factor
Not biological/genetic
http://blogs.abc.net.au/queensland/2008/09/indigenous-drin.html
Related to poverty, disadvantage, cultural dispossession & exclusion, & some other cultural factors (sharing culture, no traditional rules for alc.)
Aboriginal people who drink do so at harmful levels
While Aboriginal people generally drink less than non-Aboriginal people, those who do are more likely to drink at hazardous levels. Unfortunately, many reports focus on these results rather than the fact that generally they drink less.”
Major risk and protective factors: Infancy/pre school
Risk factors
Parental neglect & abuse
Protective factors
Easy temperament
Major risk and protective factors: Primary school 5-11
Risk factors: - Early school failure -Conduct disorder -Aggression Protective factors: -Social and emotional competence -Shy and cautious temperament
Risk factors: Family factors
Many family risk factors to consider
Harmony vs. conflict
Family relationships/support
Parent and family drug use
Parental role modeling risks
https://youtu.be/jJNNtsJmZb4
Modeling less influential than quality of relationships & parental family management techniques
Risk factors: Education
Academic failure / Learning or behavioural difficulties at school
May be both a contributor to and a result of drug use
Can result in detachment from school community
Impact on self-perception
Timing important
Grade 1 academic failure does not predict later delinquency
Grade 5 academic failure does predict later delinquency
Ongoing implications
Poor academic performance can reduce and lead to lack of training or employment opportunities
Protective factors: Education
Pro-social contact
Including positive relationships with adults
Minimises boredom
Enhances intelligence
Development and identification of talents
Explore future aspirations
Environment supporting positive health behaviours
Risk factors: Personality
Personality traits
Rebelliousness, non-conformity, low sense of responsibility, resistance to authority…
Sensation-seeking traits / adventurous personality
Risk factors: Age of initiation
Earlier initiation increases risk of later abuse
Developmental impact of drug use
Reasons for earlier onset?
Peer associations
Familial and societal norms
Trauma/mental health issues
Risk factors: Peer factors
Strong predictor of later drug abuse
Not “just” peer pressure
Peers have a strong immediate influence on choices
Peer modelling (social learning theory)
Shared sense of:
Alienation/Rebelliousness/Sensation seeking
News reports
Youth already tried drugs more likely to be influenced by media coverage
Other factors involved though (e.g. social norms and behaviour of friends)
Major risk and protective factors: Adulthood 18-64
Risk factors - Frequent drug use in adolescence -Unemployment in early adulthood -Mental health problems Protective Factors: -Well-managed environment for alcohol use -Marriage in early adulthood
Major risk and protective factors: Retirement/old age 65+
Risk factors: -Losing a spouse -Retirement -Loneliness and reduced social support -Poor health Protective factors: -Good health - Social support
General protective factors
Positive family relationships Clear, consistent boundaries Healthy attachments / social bonding Stability and connectedness Proactive problem solving - resilience Development of a special talent Can lead to pro-drug using peer groups though Personality and temperament Career goals / aspirations Above average intelligence
Prevention
“Prevention refers to measures that prevent or delay the onset of drug use as well as measures that protect against risk and reduce harm associated with drug supply and use”
What exactly are we trying to prevent
Drug use
Or at least delay initiation
Harm associated with drug use
Route of administration risks
Overdose/excessive use risks
Avoidance of help seeking – e.g. due to legal concerns
Risks of associated problems – e.g. accidents
Harm to others – e.g. Laws prohibiting smoking in public places
Rather than preventing something:
Increasing resilience/other protective factors?
Prevention levels: Levels of prevention strategies (3)
Levels of prevention strategies
Primary: Preventing uptake
Preventing non-users starting or delaying first use
E.g. Supply reduction methods, education on harms to developing body, school-based programs
Secondary: Preventing harm
Reducing risks to experimental/social users & avoiding transition to more regular use or possible harms
E.g. education on risks of addiction, advice on route of administration options
Tertiary: Reducing harm
Reducing use or potential harms among regular users
E.g. NSPs, controlled drinking, drink driving campaigns
Prevention targets
Targets of prevention strategies
Universal: targeting whole populations
National campaigns, advertising programs
Selective: subgroups with above-average risk
School-based programs, Alcohol free communities
Indicated: individuals with detectable symptoms
Counselling, advice lines, educational pamphlets
Clarifying Prevention Objectives
When to Target?
Early intervention
As early as possible in developmental pathway
What goals or purposes?
Attitudes
Knowledge
Expectancies
Behaviour associated with drug use (risks)
Targeting specific risk factors
Peer factors, educational involvement etc…
Best approach would be a combination of factors
Research Support for Prevention
Adolescent Interventions
Support for classroom based education programs
More effective if interactive, time-intensive and led by students
Support for regulation of price and availability of tobacco to young people
Lack of support for effectiveness of recent alcohol price increases
More research required?
APS Position
“While the ‘alcopop’ tax is an example of a targeted measure designed to offset the enticement of young people into an alcohol-soaked culture, such legislation—by itself—will not change Australia’s drinking culture.”
Research support for prevention
Universal interventions for illicit drug use
Diversion programs
Prohibition
May reduce drug use among non-users (Primary)
Not much evidence it affects current users
International changes to Cannabis laws have not been associated with significant increase in use
Other Universal Interventions
Good support for effectiveness of drink driving laws in Australia
Support for public education campaigns
Reductions in cigarette smoking and risky drinking
Multi-faceted campaigns (advertising, laws, taxes, etc…`
