FIVE QUESTIONS : What is addiction? How do addicts differ from others?
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FIVE QUESTIONS:
1. What is addiction?
2. How do addicts differ from others?
3. What thinking causes addiction?
4. What cultures cause addiction?
5. Is addiction decreasing/increasing?
MODELSOF
ADDICTION
Disease Model of Addiction
Inbred/biological
Loss of control
Lifelong/permanent
Inevitable progression
Requires medical/spiritual treatment
Neurochemical Model
Addiction operates through dopamine
Drugs elevate dopamine pleasure
Neuroadaptation dependence
Requires treatment chemical blocks
Leshner: “It's a myth that millions of people get better by themselves.”
ADDICTION IS…
Understanding brain chemistry, not building up
willpower, is the key to preventing adolescent alcohol
and other drug addiction.
Source:
Nora Volkow, director, National Institute of Drug Abuse (NIDA).
Cognitive-Behavioral Model
Alter thinking action
Present oriented
Skills oriented
- internal/cognitive
- external/practical
Coping/problem solving
- applied to substance abuse
- dysfunctional thinking cycle
THE CONCEPT OF
ADDICTION
Which drugs are addictive?
Problems with the
Addiction Concept
ILLICIT cocaine marijuana
LEGAL nicotine caffeine antidepressants
hospital patients
the clinical bias
Vietnam
Are Addictive Drugs
Always Addictive
What Happened in Vietnam?
Of all those addicted…
60% used narcotics stateside
12% re-addicted any time
6% addicted after three years
What is Addiction?
Source:Stanton Peele, Diseasing of America,
San Francisco: Jossey-Bass.
Vietnam
vs.
Home Environments
Fear and privation
-Control
-Positive options
-Social support
-Values of moderation
Addictive Criteria
Absorbing
Predictable
Sense of control / value
Illusory
Deepening / worsening
Gambling Example
Absorbing activity
“Predictable”
Sense of value and control
Growing penalties
ADDICTION IS…
an absorbing activity that provides essential emotional
rewards otherwise not available to one that entails
growing life detriments.
Source:Stanton Peele, The Meaning of Addiction,
San Francisco: Jossey-Bass.
Sources of Addiction
Stressed environments
Lack of satisfaction
Lack of moderating influences
Lack of coping skills
Lack of self-efficacy
HOW CAN LOVE BE
ADDICTIVE?
Causes of Relapse
Two factors predicted relapse
following treatment:
“lack of coping skills and belief in
the disease model of alcoholism.”
Source:Miller, W.R., Westerberg, V.S., Harris, R.J., et al. (1996). What predicts relapse? Prospective testing of antecedent models. Addiction, 91 (Supplement), S155-171.
NATURAL RECOVERY &THE PROCESS OF CHANGE
Lifetime, Past Month, Ages 12+: Percentages, 2002
Illicit Drug Use
Lifetime Last Month Last Month/Lifetime
Cocaine 15 1 7
Crack 3 .3 9
Heroin 2 .1 6
Source: SAMHSA (2003, Table 1.1B)
Addiction and Age
Age16-1718-2526-2930-3435-3940-4445-4950-5455-5960-6465+
% Abuse/Dep172215121198734
1
NESARC
2001-2002 National Epidemiologic
Survey on Alcohol and Related
Conditions (NESARC) :
43,093 in-person interviews
4422 DSM-IV alcohol dependent
Source:Dawson, D.A., Grant, B.F., Stinson, F.S., & Chou, P.S., et al. (2005). Recovery from DSM-IV
alcohol dependence: United States, 2001-2002. Addiction, 100, 281-292.
NESARC Past-Year ImprovementAmong Alcoholics
(columns percentaged)
Treated UntreatedPast Year Status (n=1,205) (n=3,217)
Dependent 28 24
Abstinent 35 12
Drinking w/o dependence 36 64 Source: Dawson et al. (2005)
Summarizing NESARC
Most alcoholics untreated
Treated alcoholics do no better
Most alcoholics cut back drinking
What were these people thinking?
Implications for treatment/policy
HARM REDUCTION THERAPY
What is harm
reduction?
Principles of Harm Reduction
Consequences of behavior
Non-abstinence outcomes
Client-centered
Low threshold / low commitment
Pragmatic
Marlatt, A. (1996). Harm reduction: Come as you are. Addictive Behavior, 21, 779-788.
Is harm reduction
accepted?
Why not?
SCIENTIFIC RESEARCH ON ALCOHOLISM
EFFECTIVE THERAPIES
Effective Alcoholism Treatments CES *
Severity
Brief interventions 390 2.47
Motivational enhancement 189 2.72
GABA (Acamprosate) 116 3.80
Community reinforcement 110 3.43
Self-help manual 110 2.59
*Cumulative Evidence ScoreSource: R.K. Hester and W.R. Miller (Eds.), Handbook of Alcoholism Treatment Approaches (3rd Ed.). Boston: Allyn and Bacon.
Ineffective Alcoholism Treatments CES*
Severity
Twelve-step facilitation -82 3.67
Alcoholics Anonymous -94 3.14
Confrontational counseling -183 3.00
General alcoholism counseling -284 3.22
Education (tapes, lectures) -443 2.44
* Cumulative evidence scoreSource: R.K. Hester and W.R. Miller (Eds.), Handbook of Alcoholism Treatment Approaches (3rd Ed.). Boston: Allyn and Bacon. (3rd Ed.).
Boston: Allyn and Bacon.
HOW DO PEOPLE REALLY CHANGE?
BI/MI – What Is Common?
Minimal time in therapy
You must change
True to your values
Self-efficacy
Harm reduction
Patient Resources + Outcomes Treatment or No
Stable marriage
Social/community stability
Higher socioeconomic functioning
Higher intellectual functioning
Employment - Job skills
Motivation to change
Ability to cope with stress
A Different View of Addiction
People change the more resources they have
They are helped by summoning the resources they possess
Treatment assists by helping them gather resources
Treatment not essential
Assessing Resources:
Intimacy and supportive relations
Work skills and accomplishments
Activities and interests
Coping with your world
Coping with yourself
Beating previous addictions
Stages of Change:How People Really Do It
Believe that the addictive involvement violates more important values.
Want to quit/ and believe you can.
Develop alternative rewards that are more meaningful than addiction.
Find/develop resources in life to maintain rewards.
Stages of Change:How People Really Do It
(continued)
Rely on friends, family, and groups to help support the change in behavior.
Avoid situations and ways of thinking that provoke relapse.
Eventually develop a new self-image, a view of oneself as a former addict.
Develop higher goals than addiction.
ARE ALL SOCIETIES EQUAL? ALCOHOL
Alcohol and ModerationIreland vs. Italy
Ireland 2 48 Italy 42 11
% of men whoDrink every day Binge 1+/week
Source: European Comparative Alcohol Study
Norstöm, T. (Ed.). (2002). Alcohol in postwar Europe: Consumption, drinking patterns, consequences and policy responses in 15 European countries. Stockholm: SW: National Institute of Public Health, pp. 196-205.
Drunken 15-16 year olds
Country % Drunk 10+/year
Denmark 39Finland 29U.K. 28Ireland 27Iceland 19
+ + +Greece 4Malta 4Portugal 4France 3Italy 2
Source: Plant, M., & Miller, P. (2001). Young people and
alcohol. Alcohol & Alcoholism, 36, 513-515.
Non-Temperance Recipe
Regular consumption
With meals
Across gender, age groups
Drinking + / drunkenness -
Model for Moderation
Drinking is regular, accepted
Bad drinking, good drinking taught
Bad behavior not excused by drinking
PROTECTING AMERICAN YOUTH
Monitoring the Future 2004Drinking by U.S. H.S. Seniors
Behavior
Drank in last year 71%
Drunk in last year 52%
Drunk in last month 33%
Attitudes
Disapprove of 1 or 2 drinks/daily 76%
Disapprove 5+ drinks weekends 66%
Source: Johnston, L.D.. National Results on Adolescent Drug Use: Overview of Key Findings, 2004. Bethesda,
MD: National Institute on Drug Use, 2005.
What are kids most likely to be addicted to?
Are children not sufficiently protected?
Heavily protected
Echo boomers are the most watched-over
generation in history. Most have never
ridden a bike without a helmet, ridden in a
car without a seat belt, or eaten in a
cafeteria that serves peanut butter.
Source: 60 Minutes, “The Echo Boomers”
Not independent
“Sometimes, they don't know what to do if
they're just left outside and you say, ‘Well,
just do something by yourself for a while’
They'll look around stunned.”
Source: 60 Minutes, “The Echo Boomers”
Not independent
"Parents feel as if they're holding onto a piece of
Baccarat crystal or something that could
somehow shatter at any point. They have a sense
their kids are fragile. Parents therefore are
protecting them, inflating their egos, massaging
them, fighting their battles for them."
Source: 60 Minutes, “The Echo Boomers”
Immediate gratification
“Everything has to be immediate, like a video game.
And they have a lot of trouble doing things in a
stepwise fashion, delaying gratification.”
Source: 60 Minutes, “The Echo Boomers”