Lecture 18: Addictions

Question 1

2009 web surveys

Answer 1

• 2500 undergrads
• 81% drank in last 4 weeks
• 68% drank a hazardous amount
• 37% binged in last week
• 33% had a blackout
• 6% had unprotected sex
• 5% were physically aggressive
• 10% drank + drove

Question 2

2012/13 NZ Alcohol Use Survey (in past 12 months)

Answer 2

• 80% NZ adults consumed alcohol
• 8% intoxicated weekly
• 12.2% experienced problems from their drinking
• 50% drink to intoxication

Question 3

NZ Health Survey 2017/18

Answer 3

• 20% drank alcohol in a way that could harm self or others
• Hazardous drinking rates higher in men than women
• Adults in most deprived areas were 1.3x as likely to be hazardous drinkers as adults in least deprived areas

Question 4

‘Safe drinking levels’

Answer 4

One standard drink equivalents

Question 5

Low Risk Drinking

Answer 5

For females:
- To reduce risk of injury no more than 4s.d at once
- To reduce long-term health risks, no more than 2 s.d daily (10 per week)
For males:
- To reduce risk of injury, no more than 5s.d at once
- To reduce long-term health risks no more than 3s.d daily (15 per week)

Question 6

NZ Substance Use (2015 Global Drug Survey)

Answer 6

• Alcohol 95%
• Cannabis 63.5%
• Synthetic cannabis 21%
• Cocaine 14%
• Meth 8.5%
• Opioids 6.8%

Question 7

Other addictions

Answer 7

• Sex
• Porn
• Food?
• Gambling
• Pills
• Internet gaming?

Question 8

Is this addiction frame helpful or harmful?

Answer 8

• Hard to accept addiction = stigma, blame, judgement from society
• Not their faulty but need to put in hard work

Question 9

Worldwide

Answer 9

• Cannabis, cocaine, MDMA, Amphetamines, LSD, magic mushrooms, Prescription opioids, E-cigarettes, Benzo, Nitrous oxide, ketamine

Question 10

DSM5: Substance-Related Disorders

Answer 10

1) Substance use disorders

2) Substance induced disorders = intoxication, withdrawal, substance-induced mental disorders

Question 11

DSM5: Addictive Disorders

Answer 11

1) Gambling disorders

Question 12

DSM5: Classes of substances covered

Answer 12

Alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, stimulants, tobacco, other

Question 13

Criteria: Substance use disorder (within a 12mnth period)

Answer 13

1. Using larger amounts than intended
2. Unsuccessful attempts to stop or control use
3. Spending a deal of time obtaining, using or recovering from effects
4. Craving or strong urge to use substance
5. Failure to fulfil obligations at work etc.
6. Continued use despite recurrent social or interpersonal problems
7. Important activities given up or reduced because of use
8. Use in physically hazardous situations
9. Continue use despite physical or psychological problems
10. Tolerance
11. Withdrawal

Question 14

DSM5 Severity & Specifiers

Answer 14

Severity:
 - Mild (2-3 symptoms)
 - moderate (4-5)
 - Severe (6 or more)
Specify remission:
 - In early remission (no criterai for 3-12 mnths)
 - In sustained remission (12+ months)
 - In a controlled env. (where access is limited)

Question 15

Gambling Disorder (at least 4 of following in 12 mnth period)

Answer 15

1. Needs to gamble with increasing amounts of money
2. Restless or irritable when attempting to cut down/stop
3. Has made repeated unsuccessful efforts to control or stop
4. Often preoccupied with gambling
5. often gambles when feeling distressed
6. After losing, returns to re-coup losses
7. Lies to conceal extent of involvement
8. Jeopardised or lost sig. job, relationship or opportunity because of it
9. Relies on others to provide money to relieve desperate financial situations caused by it

Question 16

Other places in DSM5

Answer 16

• Neurocognitive disorders - delirium = substance intoxication delirium
  = substance withdrawal delirium

Question 17

Aetiology of substance use disorders

Answer 17

• The Moral Model = a characterological flaw, immoral or lack of control (early 90s)
• The Disease Model = addiction is a medical disorder characterised by brain impairment whereby cravings are so strong (1930s)
  = a central premise for AA
• The Bio-psycho-social model = states many factors all contribute to substance consumption & should be taken into account for prevention + treatment

Question 18

Bio-Psycho-Social Model

Answer 18

• Bio = genetics, physiology, tolerance, withdrawal
• Psycho = personality, learned behaviour
• Social = society, culture

Question 19

Aetiology - Biological

Answer 19

• Genetic predisposition = adoption & twin studies show disorders have strong genetic component
• Dopaminergic reward system = use acts directly on brain’s reward systems
• Role of frontal lobrs = our ‘brakes’

Question 20

Biological - Role of brain (pleasure reward system)

Answer 20

• Dopamine plays a large role in neurochemistry of substance use
• Stimulation triggers release of dopamine (reward system)
• Drives use to do what is pleasurable (& important for survival)
• Substances stimulate same area of brain (as electrodes)
• The frontal lobes - our ‘brakes’ = play major role in decision-making & also in inhibiting or stopping unacceptable behaviour
  = For some, brakes are weak so more difficult to stop or not use

Question 21

Aetiology - Psychological Models

Answer 21

1) Personality theory = addictive personality - very little evidence
= Tri-dimensional personality theory - interaction between 1. harm avoidance, 2. novelty seeking, 3. reward dependence

Question 22

2) Psychological theories: Behavioural Theory

Answer 22

• Views substance use as a learned behaviour pattern
• Operant C = based on premises of reward + punishment
• CC = learning by association
• Social learning theory = modeled behaviour

Question 23

3) Cognitive Theory

Answer 23

• Emphasises importance of addictive beliefs & positive outcome expectancies and permission giving thoughts we have in relation to substance use

Question 24

Assessment

Answer 24

• Patterns of use
• Presence of physical dependence = tolerance, withdrawal
• Effects/harms = liver (physical), lover (relational), livelihood (work), law (legal)
• Function or theory of causation…why?
• Stage of change or motivation for change = pre-contemplation, contemplation, determination, action, maintenance, relapse

Question 25

Treatment

Answer 25

- Models: CADS guiding principles include = harm minimisation = a motivational approach = evidence-based practice

Question 26

1) Motivational Interviewing

Answer 26

- Counselling style for enhancing behaviour change - Client-centred approach by helping clients to explore + resolve ambivalence - MI usually brief-provided over 1-2 sessions - Relationship is collaborative - Empathy, genuiness, UPR - Client who must decide to change - Client needs self esteem & self-efficacy

Question 27

Principles of motivational interviewing

Answer 27

- Deploy discrepancy = awareness of consequences is important - Express empathy = avoid labelling - Avoid argumentation = counterproductive - Roll with resistance = momentum can be used to advantage as perceptions can be shifted - Support self-efficacy = belief in possibility of change

Question 28

Efficacy of motivational interviewing

Answer 28

- Meta-analysis = strongest support for MI was in altering substance abuse = Some reported large effects of MI in increased engagement in treatment & adherence to treatment recommendations

Question 29

2) CBT

Answer 29

- Often viewed as Relapse Prevention Therapy - Based on two models of relapse = Marlatt & Gordon (1985) = Beck (1993)

Question 30

CBT: Behavioural Contingency Management

Answer 30

- Based on principle that changing reinforcement contingencies that govern behaviour can modify behaviour - CC contingencies = cue exposure (cues without substance) = aversion procedure -> pair cue with negative outcome

Question 31

CBT: Behavioural Contingency Management (part 2)

Answer 31

- Operant Learning Contingencies = identify reinforcement patterns that are assessed as maintaining substance use &... - > reinforce other non-substance related behaviour - > might involve teaching & coaching non-substance related behaviour - > punish substance-related behaviour

Question 32

CBT: Add cognitive component ...(Relapse Prevention)

Answer 32

- Set goals - Identify factors that may prevent one from reaching goals - Coach client to avoid or manage these factors - Functional analysis of any lapses - Develop more non-drug taking strategies & keep going...

Question 33

CBT Model of Relapse (Beck)

Answer 33

High risk situation -> addictive belief activated -> craving/urge -> permissive thoughts & beliefs activated -> focus on using -> lapse -> rule violation effect -> relapse ->