Lecture 3 and 4

Question 1

Why do people use substances

Answer 1

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

Question 2

Why do people continue to use addictive substances

Answer 2

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

Question 3

Theories of addiction

Answer 3

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

Question 4

Psychological Theories

Answer 4

1. Disease theories
2. Behavioural theories (reinforcement)
3. Cognitive/Cognitive behavioural theories
4. Motivation and change theories
5. Family and systems theories

Question 5

The case of Mike

Answer 5

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.

Question 6

Disease Theories overview

Answer 6

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

Question 7

12 Steps models

Answer 7

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)

Question 8

Psychoanalytic View

Answer 8

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”

Question 9

Psychoanalytic Shared Assumptions

Answer 9

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)

Question 10

Jellinek 5 Types of Alcoholics ABGDE

Answer 10

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

Question 11

Cloninger, Wennberg 1987 Two Alcoholic Types

Answer 11

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*

Question 12

Personality Theory

Answer 12

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)

Question 13

Personality Predictors of Drug Use

Answer 13

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

Question 14

Personality characteristics are also related to drug of choice

Answer 14

• 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)

Question 15

Parts of the brain involved in addiction

Answer 15

• Cortex
• Limbic System
• Brain stem

Question 16

Endorphin-Deficiency Theory

Answer 16

Drugs of abuse target the brain’s pleasure centre

Question 17

Behavioural Theories

Answer 17

Only considers observable/measurable behaviour
Behaviour is a consequence of learning
Four main types of conditioning
Classical conditioning
Operant conditioning
Modelling 
Tension reduction

Question 18

Classical Conditioning Models

Answer 18

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

Question 19

Operant conditioning models

Answer 19

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

Question 20

Modelling behavioural theories

Answer 20

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)

Question 21

Cognitive Model

Answer 21

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

Question 22

Cognitive Dissonance

Answer 22

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)

Question 23

Cognitive Model

Answer 23

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

Question 24

Social Learning theory

Answer 24

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

Question 25

Expetancy Theory Bandura

Answer 25

Two specific cognitions: Outcome expectancy – beliefs about effects and outcomes of using Self efficacy – belief in ones own ability to effect change

Question 26

Implications for treatment: Relapse prevention

Answer 26

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

Question 27

Motivation and change theories

Answer 27

‘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

Question 28

Motivation and Change theories circle 6 things

Answer 28

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

Question 29

Family and systems theory

Answer 29

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.

Question 30

Deteminants

Answer 30

The range of risk and protective factors that make someone more or less likely to develop a drug use disorder

Question 31

Major risk and protective factors (Loxley et al., 2004) Prior to birth

Answer 31

``` Prior to birth Risk factors: -Social Disadvantage -Family breakdown -Genetic influences -Maternal smoking and alcohol use Protective factors: Birth outside of Australia ```

Question 32

Risk factor: Socio economic status

Answer 32

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

Question 33

Risk factors: Trauma

Answer 33

Children affected by abuse or neglect have a higher risk of problems later in life

Question 34

Risk factors: Genetics

Answer 34

Genetic / biological ``` Examples: Variations in the metabolism of substances Neurotransmitters Genetic temperament Personality factors ```

Question 35

Protective factors- Ethnicity?

Answer 35

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.)

Question 36

Aboriginal people who drink do so at harmful levels

Answer 36

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.”

Question 37

Major risk and protective factors: Infancy/pre school

Answer 37

Risk factors Parental neglect & abuse Protective factors Easy temperament

Question 38

Major risk and protective factors: Primary school 5-11

Answer 38

``` Risk factors: - Early school failure -Conduct disorder -Aggression Protective factors: -Social and emotional competence -Shy and cautious temperament ```

Question 39

Risk factors: Family factors

Answer 39

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

Question 40

Risk factors: Education

Answer 40

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

Question 41

Protective factors: Education

Answer 41

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

Question 42

Risk factors: Personality

Answer 42

Personality traits Rebelliousness, non-conformity, low sense of responsibility, resistance to authority… Sensation-seeking traits / adventurous personality

Question 43

Risk factors: Age of initiation

Answer 43

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

Question 44

Risk factors: Peer factors

Answer 44

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

Question 45

News reports

Answer 45

Youth already tried drugs more likely to be influenced by media coverage Other factors involved though (e.g. social norms and behaviour of friends)

Question 46

Major risk and protective factors: Adulthood 18-64

Answer 46

``` 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 ```

Question 47

Major risk and protective factors: Retirement/old age 65+

Answer 47

``` Risk factors: -Losing a spouse -Retirement -Loneliness and reduced social support -Poor health Protective factors: -Good health - Social support ```

Question 48

General protective factors

Answer 48

``` 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 ```

Question 49

Prevention

Answer 49

“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”

Question 50

What exactly are we trying to prevent

Answer 50

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?

Question 51

Prevention levels: Levels of prevention strategies (3)

Answer 51

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

Question 52

Prevention targets

Answer 52

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

Question 53

Clarifying Prevention Objectives

Answer 53

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

Question 54

Research Support for Prevention

Answer 54

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?

Question 55

APS Position

Answer 55

“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.”

Question 56

Research support for prevention

Answer 56

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…`