ADDICTIVE BEHAVIOUR

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ADDICTIVE BEHAVIOUR

• Dr.M.Clark

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TOPIC A - THE CONSTRUCT OF ADDICTION

• RECENT PAST predominance of medical model
• 'ADDICT' - reserved for those who overindulged in
  certain behaviour, with associated loss of
  control, withdrawal symptoms and in whom a
  biological abnormality (disease) was suspected.
• Most readily applied to substance abuse - notion
  of disease

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BUT

• With the rise of social-psychological models
• Emphasis on biological element reduced
• Cultural, social and psychological factors have
  important role to play
• Addiction product of person- environment-activity
  interaction
• Allows for inclusion of non substance based
  behaviours as addictions

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Traditional concept of addiction highlights

• Tolerance effects
• Withdrawal symptoms
• Relief from withdrawal symptoms on resumption of
  involvement
• Emphasis on above factors criticised

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alternatively

• Addiction should be conceptualised in terms of
  the individuals attachment to the activity
  (Orford et al, 199648)
• Frequency
• Regularity
• Quality
• Preoccupation
• Subjective feelings of being addicted
• Harm caused
• Difficulty in reducing or giving up the behaviour

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Falling under the gamut of addictions

• Chemical dependency
• Gambling
• Sex
• Relationships
• food
• Work
• shopping
• Draw upon developments in the understanding and
  treatment of substance use to inform thinking and
  practice relating to non substance based
  addictions
• Substance use often concurs with other types of
  addiction
• Substitution

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THE UNITY OF ADDICTIVE BEHAVIOUR

• Dichotomy in the minds of many
• Miller (1980) - where professionals would once
  speak of alcoholism or drug addiction now speak
  of 'addictive behaviours'
• One common element, all involve 'some form of
  indulgence for short term pleasure or
  satisfaction at the expense of longer term
  adverse effects' (Miller, 19804)

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Social stratification process at work

• More readily label one form of behaviour as
  addiction than another
• The case of alcohol - Weil, 1986)
• Donovan (1988) evidence suggests a common
  foundation to all addictions, though final
  expression may be moulded by many different
  forces
• Khantzian (1986) - similar evolutionary processes
• Addicts use same defence mechanisms
• Similarity in self help programmes

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THE CONCEPT OF ADDICTION

• The idea that addiction or addictiveness is a
  property of substances is loosing ground
• Addiction is subject to cognitive and social
  processes rather than to purely biological ones
  (read extract from Peele)
• Non substance based theories beginning to appear
  (e.g. Peele 2001 - addiction to an experience
  Brown, 1986 addiction as an active strategy to
  manipulate emotional well being Walters, 2001 -
  addiction as a lifestyle choice )
• Consensus that addiction can be demonstrated
  where no substance is involved
• Not disillusionment for the concept but
  recognition of its power and utility

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Addiction as more than a physiological response
to drug use

• Reluctance to widen understanding of addiction
  based on reluctance to formulate scientific
  concepts about behaviour that include
• Subjective perception
• Cultural values
• Individual values
• Notions of self control
• Personality based differences

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HISTORY OF THE WORD ADDICTION

• Latin 'Addico' - giving over
• 'addictus' - a person given over as a slave or
  creditor
• Prior to 19th century rarely associated with
  drugs
• 'a formal giving over or delivery by sentence of
  court. Hence a surrender or dedication of anyone
  to a master. The state of being addicted or
  given over to a habit or pursuit devotion'
  (Oxford English Dictionary, 1933)
• Traditional meaning narrowed
• Linked addiction tightly to drugs
• Gave addiction an invariably harmful connotation
• Identified addiction with the presence of
  withdrawal symptoms or tolerance
• Resulting confusion excise the term from
  discussion of compulsive drug use e.g. DSM-IV
  eschews use of the term (dependence)

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ATTEMPTING A DEFINITION!!!!

• 'A behaviour pattern of compulsive substance
  abuse, relationships or other behaviours,
  characterised by over involvement with the
  relationship or abuse as well as a tendency to
  relapse after completion of withdrawal' (Freeman,
  1992)
• Compatible with the bio psychosocial model - the
  subjective compulsion to continue behaviour
  pattern
• Emphasis is on the process rather than on the
  substance
• 'pattern' refers to symptomatology
• addiction may be to a behaviour as well as a
  substance
• tendency to evaluate behaviour with loss of
  control but can only be inferred
• still no gold standard (Shaffer, 1999)

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Criterion clusters of

• progression
• preoccupation
• perceived loss of control
• negative long term consequences
• BUT
• Walters (1999) objects proposing an alternative
  concept emphasising personal choice
• Problem with Walters' conceptualisation -
  punitive
• Advantage - personal responsibility for recovery

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RESOLUTION

• addiction must not be seen in terms of rigid
  dichotomies
• points along a continuum
• progression is NOT inevitable
• those who present for treatment and often the
  sample in research studies are at the end of the
  continuum

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Four main components

• compulsion - desire
• dependence - need
• regularity - consistent
• destructiveness - varied degrees
• Hardiman (2000) combines the four elements
• 'a condition whereby an individual regularly
  takes a substance, or acts in a particular way,
  in response to a strong and sometimes
  overwhelming desire to do so and that, in the
  absence of doing so, he will experience negative
  feelings or actual illness. By taking the
  substance or carrying out the behaviour the
  addict causes harm to himself or others'
• not simply irresponsible people (moral model)
• responding to very strong driving force
• Alexander Schweighofer (1988) difference
  between positive and negative addictions
  (centripetal/integrative vs. centrifugal

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CRITICISM OF THE CONCEPT OF ADDICTION

• 'The addiction concept may well be the
  Frankenstein monster of modern American life'
  (Walters, 19991)
• has been overstretched
• relieve responsibility
• criticism of positivism generally - return to
  classical thought
• addiction is a nebulous concept
• operationality of terms is a necessary
  prerequisite for the development of research
  agenda

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MODELS OF ADDICTION

• MORAL MODEL
• ADDICTION A BIOLOGICAL CONSTRUCT (MEDICAL MODEL)
• ADDICTION AS A PSYCHOLOGICAL CONSRTUCT
• ADDICTION AS A SOCIOLOGICAL CONSTRUCT
• Addiction to a experience

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Why examine explanations for why people become
addicted?

• Explanations have different implications for
  dealing with person manifesting addictive
  behaviour
• Values and beliefs
• All explanations have some validity
• Fervour inflexibility controversy

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MORAL MODEL

• Addiction as a consequence of personal choice
• Morally weak - lack proper will power
• Adopted by religious groups and legal system
• Based on classical thought
• Important implications for what happens to people
  with addictive problems

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BIOLOGICAL CONSTRUCT

• Gained popular acceptance after Jellenik's text
  (1960)
• Implicit component of AA and NA programs
• Guiding model for many treatment programs
• Viewed as a primary disease
• Progressive
• Irreversible
• Complete abstinence
• Abuse liability

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TWO MAIN THEORIES

• 1. Genetic theory
• Genetic make up impacts the processing of a
  substance and/or the dose required to produce an
  ASC
• Genotypes associated with addictive behaviour
  have been studied using three primary methods
  family studiestwin studies adoption studies
• children of alcoholics children have patterns of
  alcohol consumption similar to natural parents
• 30 to 40 of COA become alcoholics versus about
  10 of general population
• alcoholism and the DRD2 gene
• Blum et al (1990) - identified a mutant allele
  (A1) of the D2 dopamine receptor(DRD2) in
  chromosome 11 to be three and a half times more
  prevalent in 35 patients, examined post mortem,
  who during lifetime had abused alcohol compared
  to the post-mortem results of 35 non alcohol
  abusers
• Various criticisms e.g. the A1 allele may be an
  effect rather than a cause of alcohol abuse
• Predisposition vs. cause (alcohol has less effect
  drink more more problems)

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Metabolic imbalance

• Specifically applied to narcotic addiction
• Dole Nyswander (19 ) certain addicts have a
  disease similar in action to diabetes
• Once take narcotic body develops a 'craving' like
  diabetics crave insulin
• No cure maintenance
• Some addicts behave 'as if' this were the case
• Physiological protection against addiction - the
  Oriental Flush

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cont

• Genetic components to this behaviour that put
  people at risk for future addictive involvement
  (Milam and Ketchan, 1983) e.g. DRD2 gene
• Physiological correlates - e.g. gambling - nor
  epinephrine is elevated and serotonin reduced in
  some problem gamblers
• Impossible to tell whether biochemical
  abnormalities are
• A cause of problem gambling
• An effect of problem gambling
• Consequence of some third variable

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Advantages

• Removes moral stigma
• Emphasis on treatment of illness
• Makes it easier for people to enter treatment

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disadvantages

• No inevitable and completely predictable
  progression of symptoms and stages
• No consistent lack of control
• Individuals may not fit the model
• May result in purely medical mode of treatment
• not really applicable to behavioural or activity
  addictions
• removal of responsibility
• sick role - promotes unnecessary treatment and
  hospitalisation
• Walters (1999) the simplicity of the model, once
  considered to be its strength - is now
  considered to be its weakness

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cont

• Thomas Szasz (1987) - products of
  neurophysiological discharges become behaviour
  when they are organised through intent
• 'Although simplicity clearly facilitates
  understanding, the summarisation of highly
  complex behaviours like those observed in the use
  of cocaine, the preoccupation with sex, or the
  binge-purge cycle of bulimia, may result in a
  superficiality of understanding'

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ADDICTION AS A PSYCHOLOGICAL CONSTRUCT

• Focuses on internalised processes
• 5 main constructions
• the self medication hypothesis
• addiction as a component of the obsessive
  compulsive spectrum
• addiction as a personality construct
• addiction as learnt behaviour
• Problem behaviour proneness

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self medication hypothesis

• ego deficit marks addictive behaviour
• roots in psychoanalytic theory
• addictive behaviour is engaged in to alleviate
  psychiatric symptoms and painful emotional states
• Criticisms
• anxiety and psychological distress play an
  important role in maintaining the addiction
• reduction in negative effect has minimal effect
  on drug use
• alleviation of drug use problems positive effect
  on PWB
• relationship is probably bi-directional
• a reciprocal effects model might be more useful

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Psychodynamic theory

• Symptom of some intrapersonal conflict
  outgrowth of the individuals attempt to come to
  terms with internal conflict
• Sullivan and Horney (1950s) deal with internal
  anxiety
• Edwards (1982) come to terms with helplessness
  and fear of abandonment
• Victims of incest Bradshaw (1988) escape the
  shame associated with the family of origin
• Coleman (1982) 32 68 of female alcoholics had
  suffered neglect or abuse in their family of
  origin
• Balzan (1998)
• Khantzian (1985) medicating emotional distress
• Brown (1985) illusion of control

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addiction as obsessive compulsive disorder

• OCD responds differentially to drugs that block
  serotonin reuptake in the CNS e.g. anafranil,
  Prozac
• Assuming that addictive behaviour lies along the
  OCD spectrum , they should respond to these drugs
• Good evidence for sexual preoccupation but not
  for other addictive behaviour

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Inadequate personality theory

• Addiction as a personality construct in which
  persistence is a featured element
• Use drugs as a means of coping self esteem
  and inferiority
• Emotional /psychic defect
• Escapism
• Inability to delay gratification drug use as a
  defense mechanism
• Addictive personality
• substantial overlap between different addictions
• addiction as learnt behaviour

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Learnt behaviour

• Reinforcement
• Underplays the idea of personality differences
• Even animals use certain drugs compulsively under
  the right experimental conditions (Wikler, 1990)
• No need to postulate psychodynamic variables
• positive and negative reinforcement
• Positive reinforcement
• The individual receives a pleasurable sensation
  and is motivated to repeat it.
• What is referred to as addiction is simply an end
  point along a continuum and indicates that a
  sufficient history of reinforcement has probably
  been acquired to impel a high rate of use in the
  user (McAuliffe and Gordon, 1980)
• Often partial intermittent /schedule
• Negative Reinforcement
• Removal of noxious stimulus pain withdrawals
• Focus on physical dependence criticism why
  use on methadone?
• Psychological dependency remove anxiety
• Explains craving the perception of withdrawal
  symptoms as being due to the absence of opiates
  will generate a burning desire for the drug

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• Two types of addicts
• Euphoria seekers motivated by intense pleasure
• compulsive
• expensive
• disruptive
• illegality
• Maintainers - stable
• often controlled use
• employed
• rational choice

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Problem Behavior Proneness

• nor reinforcement per se but risk taking
• deviant behavior not negative or pathological
  but different
• the person likely to get into trouble
• Continuum Conformity ------------------ Total
  non conformity
• I Vs Me
• Experimentation
• Traits rebellious, independent, open to new
  experiences, tolerant, accepting of deviance in
  others, pleasure seeking, peer oriented
• Transition prone

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Walters (1990)

• Drugs and crime in a lifestyle perspective
• a cognitive system develops in the individual
  which is dedicated to supporting, buttressing and
  perpetuating the irresponsibility and self
  indulgence of adolescence.
• learning eventually permits this thinking style
  to crystallize to the extent that the evolving
  lifestyle criminal finds shortsighted frivolity,
  unrestrained hedonism , intrusive action and
  rulelessness more rewarding than accountability,
  self discipline, interpersonal commitment and
  social conformity

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Walters (1990)

• Lifestyle Theory the presence of distorted
  cognitions can be traced back to earlier stages
  in the life of a person
• Developmental process
• Lifestyle evolves and unfolds in three distinct
  phases initiation (constructed) transitional
  (reinforced) and maintenance (solidified)
  (Walters, 2000)
• identifies 8 cognitive styles sustain,
  reinforce and supplement an entrenched deviant
  lifestyle

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errors

• Mollification- diverging responsibility
• Cutoff forget any potential risks incurred by
  illicit behavior
• Entitlement
• Power orientation
• Sentimentality
• Super optimism
• Cognitive indolence
• Discontinuity

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mollification

• Conveyed in statements that justify and
  rationalize drug seeking and crime oriented
  behaviors
• Similar to neutralization
• Victim stance seek to assuage guilt and anxiety
  consequential by adopting the mind set that they
  had no choice but to participate in thee
  activities because they were victims of nefarious
  socio-environmental circumstances
• Minimization of harm done to others
• Normalizing ones negative behaviors
• Transferring blame to the victim

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cutoff

• Develop the capacity to eliminate deterrents
  quickly from consideration
• Implosion flood of anger and emotion
  characterizes the cutoff process
• Fuck it mentality
• Drugs and alcohol

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entitlement

• Basis in the egocentricity of childhood
• Global sense of ownership and privilege
• Ownership, uniqueness and misidentification of
  wants as needs

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Power orientation

• Low self esteem
• Zero state impotent weak and powerless
• Eliminated by thoughts and actins designed to
  take control of a situation- power thrusting

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sentimentality

• Find ways to reconcile their discrepancies
  between their negative behavior and their
  positive self views
• Helping the weak
• Artistic or literary achievements

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Super optimism

• Most criminals realize that there is a chance
  that they will get caught but reason not this
  time
• Magical and superstitious thinking

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Cognitive indolence

• Eventually become lazier and uncritical of their
  thoughts and plans
• Swiftest possible results
• Short cuts
• nonvigilence

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discontinuity

• Lack of persistence and unpredictability
• Lack of integration
• Good intentions

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ADDICTION AS A SOCIOLOGICAL CONSRUCT

• Emphasize understanding of the individual located
  within specific social structures
• The group impacts on the individuals behaviour
• predisposing, initiating and maintenance
• addictive behaviour as a socialisation process
• addiction is a manifestation of failed or deviant
  socialisation
• person's helplessness in the face of outside
  influences (hence loss of control)
• three major sources family peers and media
• but selective socialisation
• Structural variables -

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• Anomie structural strain
• Goals- means disjuncture individual adaptation
• GoalsMeansConformistAcceptsAcceptsInnovatorAccepts
  Reject/blockedRitualistRejectAcceptRetreatistRejec
  tReject/blocked

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Social learning

• Edwin Sutherland (1939) differential
  association
• Behaviour is learned
• Behaviour is learned in intimate social groups
• Depends on priority, intensity and duration
• Involves techniques and motives

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Control Theory

• Internal control Reckless self efficacy
• External control Hirschi social bonds
• Involvement
• Commitment
• Attachment and
• Belief

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Subcultural Theories

• Stress the importance of
• Group socialisation
• Identity change
• Development of new value and normative systems
• Learn to obey a different set of norms and to
  define yourself in those terms
• Howard Becker becoming a marihuana user
• How Vs why?
• Learning socialisation subculture- identity
• Motive for continued behaviour evolves through
  participation in the behaviour in the company of
  others
• Learn to use the drug
• perceive its effects
• enjoy the effect
• access supply
• maintain secrecy
• neutralise stigma though identification with
  the subculture

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• Selective Interaction / Socialisation Denise
  Kandel
• Agents of socialisation
• Parents long term impact, basic values
• parental drug use some impact , opens up
  potential
• Peers peer drug use , very important factor
• - teens associate based on
  similarities in
• lifestyles
• imitation and social influence
• cohesive groups form
• friends are not chosen at random

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Conflict Theory

• macro
• structural
• class , income , power and neighbourhoods
• alienation drug use
• movement from recreational use to abuse more
  likely within impoverished populations (SES and
  Drug use Vs SES and drug use problems)

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Criticisms

• limited by simplistic approach to cause and
  effect
• Any perspective that considers people as victims
  of their circumstances

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GENERAL CONSIDERATIONS/ SUMMARY

• biological theories give us insight into specific
  mechanisms relevant for understanding a certain,
  rather small, segment of the population
• psychological theories help us understand
  willingness and potential for using drugs and the
  personality characteristics associated with users
• drug use is learned an reinforced within a
  particular group setting
• selective socialisation explains entrance into
  the group
• Involvement in the group provides rationale for
  escalation and continued behaviour
• Different influences are critical at different
  life stages

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INTEGRATED AND MULTIVARIATE MODELS

• ADDICTION TO AN EXPERIENCE (Peele, 1998)
• Addictive experiences stems from
• Pharmacological
• Physiological
• But takes its ultimate form from
• Cultural contructions
• Individual constructions
• What is addiction?
• - Dynamic social learning process
• - Rewarding
• - Ameliorates urgently felt needs
• - Damages ability to cope

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Elements of the addictive experience

• 1. Potent modifiers of mood and sensation
• Pharmacological action
• Learned and symbolic significance
• 2. Diminution of pain, tension and awareness
• 3. Enhanced sense of control, power and self
  esteem
• 4. Simplification, predictability and immediacy
  of experience

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Susceptibility to Addiction

• A. Social and cultural factors
• 1.Social class
• Social class differences in addiction appear to
  be persistent and substantial
• Based on differences in attitudes as well as
  behaviour
• Broadening of awareness of the forms of addiction
  indicate that higher SES addictions simply appear
  in different guises e.g. anorexics and compulsive
  runners middle class backgrounds
• 2. Peer and parental influence
• Influences not only initiation but more
  importantly patterns of use
• 3.Culture and ethnicity
• Where the use of a substance is comfortable and
  socially regulated both as to style of use and
  appropriate time and place for use, addiction is
  less likely
• E.g. drinking cultures
• Ethnic patterns for drinking are robust
• Achievement motivation Chinese and Japanese
  (high) vs. Indian and Eskimo (low)
• Societies that value demonstration of male power
  but that make such demonstration difficult
  drinking is heavier and associated with
  antisocial aggression
• The cultural stereotype for the drug infiltrates
  the kind of relationships people have with the
  substance
• Groups with lower drug or alcohol addiction rates
  express their distress and potential for
  addiction in other ways e.g. Jews obesity
  problems youth thinness

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Situational factors

• B. Situational factors
• Availability e.g. Vietnam (Lee Robins, 1978)
• Stress and control of stress
• Relapse precipitated by stressors and negative
  emotional reactions to them
• 3. Offers magical solutions
• Social support and intimacy
• 4. Opportunity for enterprise and positive rewards

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Individual factors

• Individual factors
• Lack of values towards moderation, self restraint
  and health
• Lack of achievement motivation and antisocial
  attitudes lifestyle
• Fear of failure, intolerance of uncertainty,
  belief in magical solutions and low self esteem
  (locus of control)

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CHEMICAL DEPENDENCY

• TERMINOLOGY - WHO definitions (cited in Ghodse,
  1989)
• What is a drug? 'Any substance that, when taken
  into the living organism, may modify one or more
  of its functions

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Terminology cont

• Drug Abuse - 'persistent or sporadic excessive
  use inconsistent with or unrelated to acceptable
  medical practice'
• Drug Dependence - a state, psychic and sometimes
  also physical, resulting from the interaction
  between a living organism and a drug,
  characterised by behavioural and other responses
  that always include a compulsion to take the drug
  on a continuous or periodic basis in order to
  experience psychic effect, and sometimes to avoid
  the discomfort of its absence. Tolerance may or
  may not be present'

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cont

• Psychological dependence a feeling of
  satisfaction and a psychic drive that requires
  periodic or continuous administration of the drug
  to produce pleasure or to avoid discomfort
• Physical dependence - an adaptive state
  manifested by intense physical disturbance
• Tolerance - 'a state of reduced responsiveness to
  the effects of a drug caused by its previous
  administration
• Interaction

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DSM-IV - DEFINITIONS

• Substance Abuse
• A maladaptive pattern of substance use, leading
  to clinically significant impairment or distress
  as manifested by one (or more) of the following,
  occurring within a twelve month period
• Recurrent substance use resulting in a failure to
  fulfil major role obligations at work, school, or
  home
• Recurrent substance use in situations in which it
  is physically hazardous
• Recurrent substance related legal problems
• Continued substance use despite having persistent
  or recurrent social or interpersonal problems
  cause or exacerbated by the effects of the
  substance (American Psychological Association,
  1994182-3)
• Substance Dependence see overhead

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THE PROCESS OF CHEMICAL DEPENDENCY

• Continuum
• Complete abstinence ? dependency
• Differ in intensity of use and consequences
• Cattarello et al (1995) 'some people never
  experiment some experiment and never use again.
  Others use drugs irregularly or become regular
  users, whereas others develop pathological and
  addictive patterns of use (p.152)
• No firm boundaries between the pints on a
  substance use continuum

65
MODELS

• Doweiko (2002) -
• Level 0 - total abstinence from drug use
• Level 1 - rare/social use of drugs
• Level 2 - heavy social use/early problem use of
  drugs
• Level 3 - heavy problem use/ early addiction to
  drugs
• Level 4 - clear addiction to drugs
• The focus is on physical dependency
• Doweiko does not accept behavioural or activity
  addictions because 'there is little evidence that
  non drug centred behaviours can result in
  physical addiction
• Addiction is viewed as
• A primary disease
• Multiple manifestations
• Progressive
• Potentially fatal
• Loss of control
• Preoccupation

66
Muisener (1994)

• Adolescent chemical use can be construed as
  occurring in different stages along a continuum.
  Young persons progress, regress through, or stay
  at different stages according to varied
  biological, psychological and social factors
• The Adolescent Chemical Use Experience Continuum
  (ACUE)
• Stage 1 experimental use - learning the mood
  swing
• Stage 2 social use - seeking the mood swing
• Stage 3 operational use - preoccupation with the
  mood swing
• Stage 4 dependent use - using to feel normal

67
Ungerleider Beigel (1980)

• Classification scheme for identifying different
  types of drug usage, excluding drugs used for
  therapeutic reasons
• Experimental drug use participated in primarily
  by youth and motivated by curiosity
• Recreational drug use indulged in by many for
  pleasure with one or more drugs
• Situational or circumstantial drug use ingested
  for specific effects for example use of
  stimulants
• Intensified drug use regular drug use that
  interferes with one's behaviour and relationships
  at home at work or at play
• Compulsive drug use obtaining drugs becomes the
  overriding concern of daily life

68
Parker et al (2000)

• Normalisation hypothesis
• Developed the concept of drug pathways. They
  identified 4 drug status' groups'
• Current users - use one or more illicit drugs
  regularly
• Former users - have tried, don't use now and
  dont expect o use again
• In transition - currently dont use, but expect
  to use in the future
• Abstainers - never tried, and dont expect to in
  the future
• - Actions and decisions made or chosen by young
  people can help shape the particular journeys
  they take
• there can be changes in drug behaviour along
  these pathways

69
Normalisation hypothesis

• The visible integration of recreational drug use
  into mainstream culture led to the proposal of a
  normalisation hypothesis based on the following
  criteria
• Drug availability
• Drug trying
• Drug use
• Being drug wise
• Future intentions
• Cultural accommodation of the illicit

70
THE ADDICTION CYCLE

• THE ADDICTION CYCLE
• Exposure
• People turn to experience to modify feelings
• Abandon all functional coping efforts
• Addictive experience becomes sole means for
  asserting control over addicts emotional life
• Remission
• Mix of addictive and functional coping shift
• Stress lessens, situations improve, successful
  experiences foster self efficacy addictive
  involvement becomes less necessary
• Change in a. external situations b. self efficacy
  and goals c. reward value attached to addictive
  experience
• Invest more heavily in activities that drug use
  interferes with and experience increased rewards
• Final stage rewards are firmly established no
  consideration of returning to lifestyle

71
THE ADDICTIVE CAREER

• TRANSITION FROM USE TO ADDICTION (ORFORD, 2002)
• Transition from appetitive beh that constitutes
  acceptable moderate indulgence to highly
  troublesome and noticeable excess
• From consumption that is manageable to one that
  is unmanageable
• Control is diminished
• Gradual development
• Conflict liking it but knowledge of the harm it
  is doing

72
Process of social change (Parker et al, 1988

• Deterioration of previous friendships
• Deterioration of previous recreational patterns
• Reduction of social options
• Identification with other drug users
• Financial deprivation
• Different pathways into addiction
• Contributing factor of consequence thereof

73
General Progression theory

• Change in patterns of use
• Change in motivation
• Change in norms regarding use
• Discrimination time and place
• Discrimination is eroded and behaviour
  generalized to additional stimuli and setting
• Preoccupation cognitive component
• Strong appetite has at least three components
• Enhanced affective attachment
• Increased mental commitment and orientation
  towards the object
• Increased regularity, volume or intensity of
  consumption or activity.

74
DRUG ACTION

• Pharmacology - the biochemical properties of
  drugs and how they interact with living tissue
• Not the whole story of drug use and effects
• While drugs have potential for specific effects
  on humans, whether potential is released is not
  simply a matter of pharmacology
• Interaction - 3 factors
• 4 crucial pharmacological dimensions
• drug action
• factors that influence drug action and drug
  effects
• drug classification
• drug dependence

75
DRUG ACTION BASICS

• interconnection between neurology and chemistry
• neurons - nerve cells that send electrical
  impulses or signals from one part of the body to
  another
• electrical impulses determine both autonomic and
  voluntary functions
• neurotransmitters -

76
neurotransmitters -

• 'chemical messengers'
• neurons release chemicals that are conveyed from
  one site to another
• released at the synapse
• extremely rapid
• 'lock and key ' hypothesis (Ray and Ksir, 1996)
• when neurons recognise specific neurotransmitters
  they translate signal into certain action
• they bind to a receptor
• E.g. heroin fits into the receptors that control
  breathing and heart rate. A sufficiently large
  does can shut down these functions overdose.THC
  does not bind to receptors in brain that control
  breathing and heart rate impossible to overdose
  on marihuana
• E.g. hippocampus and cerebral cortex control
  thinking and short term memory, rich in receptors
  that bind to THC THC can diminish user's short
  term memory and disorganise thinking process
• 'lock and key' bad fit
• Each effect of each drug is determined in large
  part by the fit between the drugs chemistry (the
  key) and the receptors located at specific sites
  in the brain (the lock)
• Imp to distinguish between drug action and drug
  effects which include
• - set
• Setting
• expectations

77
ROUTE OF ADMINISTRATION

• How a drug is taken influences drug effects
• 3 methods
• inhalation
• injection
• oral administration

78
DOSE

• ED effective dose
• ED's differ according to the effect under
  consideration and organism population
• LD - lethal dose
• With some drugs LD and ED are very close together
  e.g. heroin
• Combining drugs
• Addictive 112
• Antagonistic 110
• Synergistic 114 e.g. alcohol and barbs

79
TOLERANCE

• Diminishing effects
• Body adjusts to a given drug
• Requires larger doses
• Behavioural tolerance

80
BLOOD BRAIN BARRIER

• Presents materials from the blood from entering
  the brain
• Semi-permeable
• BBB has several important functions
• Protects the brain from foreign substances in the
  blood that may injure the brain
• Protects the brain from hormones and
  neurotransmitters in the rest of the body
• Maintains a constant environment for the brain
• Lipid (fat) soluble molecules rapidly cross
  through the barrier

81
FACTORS THAT INFLUENCE DRUG EFFECTS

• Pharmacological factors
• identity
• dose
• potency and purity
• drug mixing
• route of administration
• habituation
• the drug half life
• peak effects
• Psychological and social factors
• set
• expectations
• intelligence
• mental state
• personality
• setting

82
Drugs of abuse and their effects
83
ADOLESCENT SUBSTANCE ABUSE

• Adolescence as a period in the lifespan
• Boundaries of adolescence
• Transition risk and opportunity
• Late modernity expended period
• Status ambiguity
• Rites of passage
• Contexts of adolescent development family ,
  peer group and school
• Aspects of adolescent development
• physical and sexual
• cognitive
• social
• Identity moratorium and experimentation
• dependence and independence

84
Risk and Resiliency

• RISK
• Risk factors in relation to substance abuse are
  those factors that are associated with or are
  precursors of that abuse (Hawkins, Catalano and
  Miller, 1992).
• Several factors have been identified that
  differentiate those who use drugs from those who
  do not.
• Factors associated with greater potential for
  drug use are called risk factors.
• Stress might be considered a universal and
  comprehensive risk factor and it creates a large
  part in creating distress and vulnerability
  (Gullotta et al, 1995). Generally the more
  stressors that a child is exposed to, the more
  vulnerable he or she becomes.

85
RESILIENCY

• Those factors associated with reduced potential
  for drug use are called protective factors or
  resiliency factors.
• Resiliency factors are those influences that
  protect against vulnerability and enable
  sustained competent functioning even in the
  presence of major life stressors (Matsen, Best
  and Garmezy, 1990)

86
INTEGRATED DOMAINS

• Norman (1995) whether we are talking about risk
  or resiliency, it is crucial to explore at least
  three integrated systems
• (a) the characteristics of the individual
  associated with greater risk or resiliency
  (personal domain)
• (b) the family interaction system in which the
  young person is absorbed (family)
• (c) the school and community milieu in which the
  a1dolescent is embedded, including the peer
  domain.
• Thus risk and protective factors encompass
  psychological and behavioural, family and social
  (peer and school) characteristics.

87
PERSONAL FACTORS ASSOCIATED WITH SUBSTANCE
MISUSE.

• Four distinct aspects of the adolescent
  personality domain that should be considered
• (a) conventionality versus unconventionality,
• (b) emotional control,
• (c) personal functioning and
• (d) social relatedness.

88
RISK

• Brook et al (1990)having a difficult childhood
  temperament manifested by such factors as
  negative mood states, temper tantrums,
  irritability and withdrawal.
• Shedler and Block (1990) childhood emotional
  distress, depression and high anxiety.
• Block et al, 1988 Cloninger et al, 1988 Penning
  and Barnes, 1982 Shelder and Block, 1990
  behaviour problems such as hyperactivity,
  aggression and rebellion, poor impulse control,
  sensation seeking, low harm avoidance and
  inability to delay gratification.
• Jessor and Jessor (1977) Kandel et al, (1986)
  Unconventionality, expressed in lack of
  attachment or low commitment to school, having
  attitudes favourable to drug use and associating
  with drug using peers
• Penning and Barnes (1982) Alienation from
  dominant societal values, including low
  religiosity

89
RESILIENCY

• Genetic and biological factors easy temperament
  and intellectual capabilities have emerged in
  several studies as resiliency related (Werner and
  Smith. 1982 Garmezy, 1985 Masten et al, 1990).
• Sense of self-efficacy Rutter (1984) considers
  self-efficacy to be a feeling that one has
  worth, that one can deal with things that come
  up, and that one has at least some control over
  important events.
• Involves several related things a sense of
  self-esteem and self confidence and a belief in
  ones own ability to have an influence over ones
  internal and external environments.
• A realistic appraisal of the environment (Garmezy
  and Masten, 1986 Werner, 1986).
• Possessing a variety of social problem solving
  skills that reinforce ones sense of competency
  and self esteem (Werner and Smith, 1982 Pentz et
  al, 1989).
• Having a sense of direction or mission, being
  able to understand and respond to anothers
  feelings (empathy) and having a sense of humor
  (Kumpfer, 1983).
• Gender differences associated with resiliency
  Boys tend to be less resilient than girls in
  early childhood (Werner and Smith, 1982).
• Changes substantially in adolescence (Gullotta et
  al, 1995). In the second decade it is girls who
  become more vulnerable

90
FAMILY FACTORS

• Powerful socializing agent
• Quality of the attachment and bonding processes
  between parent and infant in the first few years
  of life are important for the later emotional
  health of the individual.
• Family relationships during adolescence have
  important flow on effects for a number of
  domains, such as autonomy and later independence
  of the individual (Coleman and Hendry, 1990)
  adolescent personality (Heaven, 1997), individual
  pathology (Scott and Scott, 1987) and problem
  behaviour (Peiser and Heaven, 1996 Shaw and
  Scott, 1991).

91
family domain

• The family domain may be further subdivided into
  
• the parental marital relationship domain,
• parental drug use and personality domains,
• parent adolescent relationship domain and
• sibling domain.

92
Parental marital relationship domain

• Family conflict is associated with the childs
  delinquency and drug use (Robins, 1980)
• Parental conflict may be greater risk factor than
  structural variables, such as parental absence
  (Farrington, Ghallager, Morley, Ledger, and West,
  1985).

93
Parental drug use and personality domains

• Parental drug use is related to the childs drug
  use.
• Parental attitudes toward drug use also play a
  role with parents who are tolerant of drug use
  being more likely to have children who use drugs
  (Barnes and Welte, 1986)

94
Parent adolescent relationship domain

• Parent adolescent relationship domain
• Mutual attachment influential in terms of
  adolescent drug use.
• Parents of non-users, report greater warmth (more
  child centeredness, affection and communication)
  and less conflict in their relationship with
  their children.
• Discipline structured discipline serves as a
  barrier to adolescent drug use (Kandel Andrews,
  1987)
• Appropriate parental monitoring is effective in
  reducing drug use (Patterson, Chamberlain Reid,
  1982).
• Authoritarian or power assertive techniques may
  be detrimental and permissiveness seems to have
  no effect (Brook Brook, 1986)

95
Sibling domain

• Several investigators have found that an
  adolescent with a sibling who uses drugs has an
  increased probability of drug use.
• Brook et al (1981) a sibling relationship
  characterized by conflict, less admiration, less
  satisfaction and less sibling identification is
  related to inner tension and psychic distress,
  less conventional attitudes and consequently more
  drug use.
• A good sibling relationship may buffer against
  the effects of a bad parental relationship.

96
Gulotta et al 1994

• highlight some of the main risk factors relating
  to the familial domain, leading to vulnerability
• Being born into poverty
• Living with chronic familial tension and discord
• Having dysfunctional parents who are physically
  or sexually abusive, who abuse substances and who
  suffer from serious mental illness
• Membership in a family where there is little
  warmth, support or positive bonding and there is
  parental non directiveness, permissiveness and
  inadequate supervision
• Experiencing the death of a significant adult
  before a child has reached the age of eleven
• Living in a neighborhood where there is a great
  1deal of violence and turmoil
• 
  (Gullotta
  et al, 199451)

97
Peer domain

• Risk
• Glantz and Pickens (1991) drug use appears to be
  a function of social and peer factors while abuse
  is more a function of biological and
  psychological processes.
• Peers provide models of use, access to drugs and
  the motive and support to initiate use.
• Associating with drug taking peers and having
  attitudes favourable to drug use
• Substance use takes place within the context of
  peer clusters, which consist of best friends or
  very good friends.

98
Resiliency

• peer warmth, conventionality, values and academic
  achievement can also be important in protecting
  against drug use. It is also important to
  understand and investigate the idea that the
  influence of peers changes as the adolescent
  matures.
• Maintaining successful friendships and peer group
  memberships in adolescence may be an important
  factor in the healthy social and psychological
  development of the young person.
• Gavin and Furman (1989827) Without being
  connected to the peer group, one may be left
  without an important source of support during a
  period of physical, emotional and social
  upheaval.

99
THE SCHOOL CONTEXT

• Schools have a major influence on adolescent
  development. Not only are many friendships formed
  there but, as society becomes more complex, with
  increasing influence paced on the acquisition of
  specialist skills and training for jobs, so the
  importance of the school as a social institution
  is gaining in importance
• 
  
  (Heaven, 2001)

100

• RISK
• young people experiencing a very important
  transition, that from primary to secondary
  school.
• accompanied by a move away from close friends and
  familiar surroundings
• associated with new expectations and teaching
  methods.
• new curricula to select from and new teachers to
  contend with.
• Moving into a large and impersonal school,
  separated from old friends and what is familiar
  may serve to lower the adolescents self esteem
  and confidence.
• Low self esteem may give rise to negative
  attitudes to school, which could increase truancy
  and other unacceptable behaviours (Rice, 1999).
• Schools that are rigid and authoritarian in their
  disciplinary policies tend to promote disrespect
  for authority.
• Low perceived peer affect towards school, low
  academic performance, low perception of freedom
  in school and negative attitudes towards school
  have been identified by Scheier and Newcomb
  (1991) as risk factors for experimentation with
  drug use

101
PREVENTION

• Risk and Resiliency factors
• Aimed at enhancing the individuals own
  responsibility for their health as well as that
  of others
• Directed towards the progress of public heath and
  mental health
• Can be carried out on diverse levels
• Most in particular within social sections like
  school, family and workplace (van der Stel, 1998)

102
Levels of Prevention

• Primary prevention
• Intervention before a health problem has arisen
• Breaking though the network of causal links which
  surround a problem by taking away one or more
  links in the chain
• Influencing the behaviour and views of the target
  group
• Education and information
• Utilises various strategies
• Holds various goals
• Emphasis on attitude to life and social skills
• Intermediary aim personal character building
• Intended result not using drugs
• Combined action by different people

103
Secondary prevention

• The early detection of an already developing but
  not yet clinically visible illness or health
  problem, in such a way that by early intervention
  the prognosis can be more favourable

104
Tertiary Prevention

• Preventing a relapse, or limiting the effects of
  residual symptoms in the case of a clinically
  overt illness or an overt behavioural problem in
  its early stage
• Closely allied to treatment activities

105
NEW CLASSIFICATION

• Universal approaches directed to the whole
  population
• Selected programmes designed for members of a
  whole at risk subdivision of the whole
  population, regardless of individual risks
• Indicated addressed at particular at risk
  individuals, who are showing early signs of
  problems

106
PRIMARY PREVENTION

• The goal of primary prevention in general is to
• anticipate problems
• reduce the no of new cases
• promote competencies that promote against the
  development of problems
• encourage optimal health
• The goals of primary prevention in the substance
  abuse field are to
• determine who is at risk for substance abuse
• reduce the number of people who abuse substances
• promote behaviours that protect against the use
  of substances
• encourage healthy behaviour that is incompatible
  with the use of substances
• developmental period that is targeted is early
  adolescence
• onset of gateway substances develops at this time
• also use interferes with essential maturational
  process and development

107
Mission Statement - sedqa

• "To ensure that all members of society are
  served with the right information about substance
  abuse and to provide training programmes
  regarding healthy living, appreciation, of one's
  abilities and self determination."

108
Primary Schools Programmes

• 'Tfal Favur Ambjent Liberu' (T.F.A.L.)This is a
  comprehensive programme targeting children from
  Kinder 2 through to Year 6. T.F.A.L workbooks are
  distributed to each child and class teacher. The
  workbooks are accompanied by lesson plans. Each
  workbook is age appropriate and regularly
  updated. It is a skills based programme which
  amalgamates formation and information based
  activities. The workbooks focus on three main
  topics, namely, 'Mental hygiene', 'Social
  relations' and 'Wise use of medicinals'.
• BABESThis is part of the T.F.A.L primary
  prevention programme. It targets Year 3 children
  (7/8 years) and is comprised of six one-hour
  classroom sessions, with approximately 20
  children in each class. sedqa-trained
  facilitators deliver the programme once weekly
  using visual aids such as puppets and flash cards
  to recount a succession of six stories. The Babes
  programme is a life skills based programme
  originally conceived in the United States and
  adapted for use in Malta. The purpose of BABES is
  to enable children to learn and practice
  living/loving skills and make positive early
  decisions about alcohol and other drugs.
• The BABES Follow-upThis programme is based on
  the same concept as the BABES. It is intended to
  compliment the BABES programme, to provide
  continuity and strengthen the skills that the
  children learn in year 3. The programme runs over
  three to four sessions each 60-90 minute. During
  the current scholastic year this programme is
  being reserved exclusively to Year 5 students in
  Government schools, and to a small sample of
  Church and Private Schools.
• 'Skola Sajf'Every year, sedqa Agency, together
  with the Skola Sajf coordinators from the
  Education Division organizes a special three day
  programme for year 4, year 5 and year 6 children
  attending Skola Sajf. The programme is delivered
  by the BABES facilitators.
• Special SchoolsThis project aims at reaching out
  to children with disabilities. Our target
  audience is children with disabilities in
  government, private and church schools, and
  schools for children with disabilities, including
  Guardian Angel, Eden Foundation, Wardija School
  and San Miguel. Rather than expecting individuals
  to try to adapt to sedqa's T.F.A.L prevention
  programme, our aim is to recognize and respect
  individual differences by making our programmes
  more flexible for the target audience. This
  requires that our programmes be tailor-made to
  suit such differences.

109
Secondary Schools Programmes

• CrossroadsSix sets of lesson plans and handouts,
  dealing with everyday issues vis--vis substance
  abuse and other addictions, for Form 1, 2 and 3
  teachers and students. Subjects include PSD and
  Social Studies.
• 'Jien u l-Ohrajn'Two-day non-residential
  seminars for Form 3 students coming from
  different schools where they explore, share, and
  learn different life-skills, research methods and
  public speaking skills.
• 'Ghini Nikber'A 3-hour course for Form 1, 2 and
  3 students in government schools and a sample of
  Church and Private schools Topics dealt with
  include team building, peer-pressure, feelings
  and self-esteem. Each group of students is
  visited 3 consecutive times for a one hour
  session per visit.
• Staff MeetingsRegular evaluation and updating
  meetings with teaching and other staff regarding
  sedqa's programmes in secondary schools. These
  meetings also serve to discuss and introduce new
  concepts and approaches.
• Prefects'/Leadership CourseOne-day leadership
  skills training course for prefects,
  sub-prefects, bus prefects, students' council
  members and other students who are potential
  leaders in all Forms.
• Information Awareness SeminarsTwo-and-a-half-ho
  urs seminars about alcohol, drugs and their
  effects. The sessions are divided into three
  parts, a film show, discussion in small groups,
  and a presentation about the effects of the
  substances in questions.

110
Secondary Prevention Programme

• Overview
• This mainstay of this Team is the STORM
  programme, which aims to provide students with
  information and skills on how to manage present
  and future problematic situations without
  resorting to substances or engaging in other
  risky behaviour. This outreach programme also
  aims to identify young persons at high risk of
  misusing substances or those who already started
  experimenting with substances. Further outreaches
  are conducted at parties and entertainment areas.
  The Team also deals with adolescents who seek
  sedqas help through the helpline or drop-in
  services. 
• Brochures
• Printed leaflet STORM booklet STORM programme
  material
•  
• Eligibility
• Young people who are at risk or started
  experimenting with substances. The STORM
  programme targets students in secondary schools
  at Form 4 level, and also post-secondary schools.
•  
• Procedure
• Young people who are at risk of substance abuse
  or have already entered the experimenting stage
  are identified by members of the Secondary
  Prevention Team during their outreaches or school
  interventions. Other referrals are made by the
  community services within sedqa, through the
  Helpline, the Court Services Team and also by the
  Safe Schools team within the Education
  Department.

111
PREVENTION TECHNOLOGIES

• Traditional intervention approaches
• information education
• fear arousal
• moral appeal
• affective education
• effectiveness of traditional approaches
• Psychosocial intervention approaches
• psychological inoculation
• resistance skills training
• personal and social skills training
• mass media approaches

112
EVALUATION

• Awareness of the extensiveness of substance use
  has led to numerous attempts at prevention,
  particularly in schools. Evaluation of prevention
  programs indicates that improvement in knowledge
  and some attitude change may occur however,
  there is little evidence that these programs
  serve to actually reduce or eliminate drug use
  (Bangert-Drowns, 1988). This lack of evidence of
  program effectiveness may be due to at least two
  factors the complexity of risk factors leading
  to adolescent substance abuse (Beman, 1995) and
  the difficulty of evaluating prevention programs.

113
INTERVENTIONS

• Matching Hypothesis (Miller and Huster, 1989)
• There is no single superior approach to
  intervention for all individuals
• Different individuals respond best to different
  intervention approaches
• It is possible to match individuals to optimal
  interventions thereby increasing treatment
  effectiveness and efficiency

114
PROCHASKA AND DICLEMENTE (1992)

• Transtheoretical model
• People are ultimately capable of making an
  informed choice in their own best interest
• Circular process that includes 6 stages (see
  graphic model)
• Identifying the stage of change is essential for
  deciding upon appropriate goals and the means of
  attaining these goals
• Ignoring the different stages of change often
  results in the offer of identical and usually
  inappropriate interventions to individuals with
  very different needs
• A person may proceed through each stage several
  times before achieving stable change

115
THE STAGES

• Precontemplation characterised by defensiveness
  about substance abuse
• Contemplation the person is aware that a
  problem exists but is ambivalent about making a
  change or has anxiety about what the change will
  mean.
• Preparation the person intends to make a change
  in the near future or has unsuccessfully taken
  action in the last year.
• Action the person takes action to change his or
  her behavior or environment to overcome a problem
  behaviour such as becoming abstinent or cutting
  down on drug use
• Maintenance where the person consolidates gains
  and works to prevent relapse
• Relapse - may occur repeatedly and is considered
  a normal part of the behaviour change process

116
CLIENT NEEDS

• Expressed needs
• Relief from symptoms of withdrawal
• Solution to medical complications
• Adjustment of chaotic life financial, legal,
  health, familial etc
• Prioritised needs
• Child care issues
• Financial difficulties
• Employment
• Relationships
• Legal problems
• Housing
• Sexual education

117
ASSESSEMENT

• Continuum of use
• Psycho-social history
• Drug use history
• Family history
• Social history
• Legal history
• Educational history
• Occupational history
• Medical history
• Psychological and behaviour problems

118
PHYSICAL EXAMINATION

• Tell tale signs
• Complications
• Mental status
• General behaviour
• Talk
• Mood
• Thought
• Cognitive state

119
TOOLS

• European Addiction Severity Index (Euro-ASI)
• clinical tool