Foundations of Addictions

Unit 1

Glenn Maynard M.Ed., NCC, MAC, LPC

Overview of Addictions

• Debate in US continues on whether addiction is a disease, poor behavioral decision making or a moral failing

• Prior to Prohibition, Temperance Movement placed the cause in the substance and then in the user

• AA- moved the cause to the user and formed the basis of the disease model and behavioral model

Addictions Counseling

• Full cycle from mental health orientation to separate field and back to mental health under the name behavioral health

• Long history of people in recovery working as lay counselors

• Standards for addictions counselors began to evolve in the 1970’s

Addictions Certification

• 1972 JCAH developed accreditation standards that brought addictions into the mainstream

• NIDA and NIAAA developed standards for training including 2 years recovery; one year counseling experience and written examination

• Current certifications- CADC, NCADC, MAC

Reuniting Addictions and Mental Health

• Increased Federal and State interest in dual dx

• Behavioral health includes addictions as a focus of interest

• Administrative for AOD acknowledge licensed professionals as providers

Brickman SchemaIs the person responsible forchanging the AddictiveBehavior?

Is the person responsible forthe development of theAddictive Behavior?

Yes No

Yes Moral Model (War onDrugs)Lack of willpower

Spiritual Model (AA and12-Step)Loss of contact with higherpower

No Compensatory Model(Cognitive)Errors in judgement

Disease Model (Heredityand Physiology)Activation of disease state

Characteristics of Effective Counselors

• Meta analysis of tx outcomes show stronger therapist than tx effects

• Therapist attributes- few gross effects

• Recovery status does not predict tx outcome

• Positive relationship r with positive outcomes

• Adherence to a manual or technique improves outcomes

• Mixed research outcomes on confrontational tx

Overview of Epidemiology

• Study of disease in populations

• Groups studied in order to understand the etiology and prevention of disease

• Web of causation- agent (vector), host, environment

Prevalence and Incidence

• Prevalence= # of persons with a disease total number in population

• Incidence= # of persons developing disease

total population at risk

Lifetime Prevalence Rates for Substance Use Disorders

• Any Substance Use Disorder 16.7%

• Alcohol Abuse 5.6%

• Alcohol Dependence 7.9%

• Drug Abuse 2.6%

• Drug Dependence 3.5%

• Marijuana Dependence/Abuse 4.3%

• Cocaine Dependence/Abuse 0.2%

• Opiate Dependence/Abuse 0.7%

• Barbiturate Dependence/Abuse 1.2%

• Amphetamine Dependence/Abuse 1.7%

• Hallucinogen Dependence/Abuse 0.3%

Co-Morbidity Between Mental Disorders and Substance Use Disorders

• Any Substance Use Disorder and:– Schizophrenia 47%– Anxiety Disorder 23.7%– Antisocial Personality Disorder 83.6%

Co-Morbidity Between Mental Disorders and Substance Use Disorders

• Any Mental Disorder and:

– Any Alcohol 36.6%

– Any Drug 53.1%

• Schizophrenia and:

– Any Alcohol 3.8%

– Any Drug 6.8%

• Affective Disorder and:

– Any Alcohol 13.4%

– Any Drug 26.4%

• Anxiety Disorder and:

– Any Alcohol 19.4%

– Any Drug 28.3%

Alcohol Surveillance Data

• Per capita alcohol consumption in 1997 lowest in 35 years

• Consumption by state shows a consistent pattern of decreased consumption except for AR and MS

• Regional patterns: NE- decrease 0.5% South- decrease 0.9% Midwest- no change West- decrease 0.4%

• NIAAA goal for 2000 was annual consumption of 2 gals/capita

Trends in Alcohol Use

• 105 million Americans older that 12 reported current use of alcohol (30 day prevalence)

• 45 million engaged in binge drinking (30 day prevalence)

• 10.4 million are age 12-20

• 6.8 million of 12-20 engaged in binge drinking• 1999 National Household Survey on Drug Abuse

Epidemiologic Trends in Drug Abuse

• Data collection differs from alcohol due to all non-prescribed drugs being illegal

• Drug use more variable than alcohol use based on location and local customs about drug use

• 14.8 million 30-day prevalence in 1999

• Peak use of illicit drugs in 1979 was 25 million

Cocaine

• Peak use of 5.8 million in 1985

• 1.75 million users in 1996

• 1995 estimated incidence was 652,000

• Profile- most users are inner-city crack users, older users

• New trend- teenagers using crack and MJ (blunts)

Cocaine

• Decrease since 1985 has stabilized and may be on the rise for teenagers

• Women users are exceeding male users according to arrest records in some areas

• As m-amphetamine used declines, cocaine use may increase

Heroin

• Two types- Black Tar and White Powder

• Black Tar- used primarily in West and SW; injected; has more impurities

• White Powder- East Coast and SE; intranasal and smoked; appealing to teens

• Increasingly popular with college students

• Increasing use with other drugs

• Most CEWG cities report increased use

DAWN Heroin Data

• Seattle 97.5% IV

• San Francisco96.6% IV

• Los Angeles95.0% IV

• San Diego 93.3%IV

• Newark 43.6% IV

• Philadelphia66.8% IV

• Boston 73.3% IV

• New York City74.6% IV

Marijuana

• Incidence in 1995 was 2.5 million

• Drop in prevalence rate for 12th graders from 50.8% in 1979 to 23%

• Young adult use may account for incidence

• Considered less risky than other drugs

• MJ is being mixed with other drugs

• DAWN data for MJ have increased. See chart

M-Amphetamine

• DAWN data report sharp declines in m-amphetamine admissions from 1994-1998

• May be due to community prevention programs

• Aggressive legal action

• Precursor laws

• Decreased potency and purity

Developing Trends

• Rave or club drugs

• Ecstasy (MDMA)- 1996-7 14% of male and 7% of female 12th graders reported using MDMA at least once

• GHB (-hydroxybutrate)- too early to evaluate DAWN data

• Ketamine- as above

Epidemiological Correlates

• AOD abuse more common among men than women (note higher recent incidence of alcohol and cocaine use among young women

• Alcohol and drug prevalence decreases with age

• African-Americans begin abusive drinking later than Whites

• A-A have more health consequences than Whites

• Hispanics have higher life time prevalence for alcohol, lower for drugs

Epidemiological Correlates

• Twins typically show a 40-50% concordance for alcohol abuse

• Alcoholic are 6X more likely to come from homes with parental alcoholism

• 1/3 to 2/3 of people with alcohol disorders report no parental risk

• Prevalence rates for alcohol disorders increase for people unemployed for six months in 5 years

• Higher rates of alcoholism in entry level and blue collar jobs

Epidemiological Correlates

• ECA data do not show appreciable drug effect on employment

• Drug use among employed men is higher on low income jobs

• Leaving school r with increased risk

• Marital status- life-time prevalence for stable marriages is 8.9%; cohabitating is 29.2%

• For drug use- married men at 3.6% and women at 1.8%; cohabitating men at 30.2% and women 19.9%