74088842 addictive behaviours psyb10 for prof page gould on 2011-11-13 at university of toronto

7/29/2019 74088842 Addictive Behaviours PSYB10 for Prof Page Gould on 2011-11-13 at University of Toronto

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PHP3002: Psychology of Addictive BehavioursWeek 1: History of Drug Use

Miles Cox

Introduction

Staff

Module organiser and lecturero Professor Miles Cox

Seminar Leaders

o Steve Hosier

o Simon Viktor

Assessment

30% intervention essay, so it is important to go to the seminarsessions.

70% final exam. 50 MCQs and 3 short answer questions out of achoice of 5. 1 hour is allowed for each section.

Required reading

It is important to read these as they will be covered in the final exam,so make sure you keep up with them.

They are very easy to access as most of them can be downloaded andthe links are on blackboard.

The book chapters are available on short term loan from DeiniolLibrary.

A large part of the course will be based on alcohol with brief coverageof some other drugs.

How do we measure alcohol consumption?

Alcohol consumption is measured by frequency x total units per day. This can also be used to measure atypical drinking. E.g. Binge drinking

or special occasions. Everyone was given a sheet to fill in to measure your own alcohol

consumption and drinking habits. Keep the sheet as you will be doingthe same exercise at the end of the course so you can compare themand see if they have changed.

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Reefer Madness DVD

This film is about the perceptions of marihuana in America (New York)75 years ago.

Things to consider in the film:-o What are the differences between then and now, with society and

in general?o What were peoples perceptions of drugs?o What is the government doing to control drug abuse? What are the

advantages and disadvantages of the approach?

DVD...

Marihuana was seen as a violence inducing narcotic and leading to

uncontrollable laughter and incurable insanity. The governmentreferred to it as a ghastly menace and the scourge of society It was thought to be worse than, and harder to combat than cocaine

and heroin due to the fact that it was a naturally occurring drug. Schools were attempting to bring in compulsory education on narcotics

and this was supported by the Department of Narcotics inWashington.

The film portrayed marihuana as inducing people to commit crimessuch as hit and run driving and murder.

It also showed dealers in organised gangs targeting school children byusing women to lure them in and deceive them into smoking a reefer (amarihuana cigarette).This then lead to the students academic andpersonal life going downhill.

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PHP3002: Psychology of Addictive BehavioursWeek 2: Basic Principles of Drug Use and

PsychopharmacologyMiles Cox

Key definitions

Drug:

o Any natural or artificial substance, other than food, that by itschemical nature alters the structural function of the livingorganism.

Illicit Drug:

o A drug that is illegal to use meaning it is forbidden by thegovernment. It can also be prescription drugs that are sold ormanufactured illegally. It is also an illicit drug if alcohol or tobaccois sold to minors and glue and paint if they are used to get high.

Deviant Drug Use:

o This refers to the use of a drug in a way other than directed, andin a way that deviates from the norms of a social group

Drug Misuse:

o Using a prescriptiondrug in a way other than directed. E.g. takingthe drug in a higher dose than prescribed.

Drug Abuse:

o The use of a drug in a manner, amount or situation that is likely tocause problems for the person or society.

Drug Addiction:

o When a drug takes over a persons life and becomes the mostimportant thing at the cost of everything else. This includes the

neglect of family, their job and their physical health because ofbeing preoccupied with a drug.

The Drug Problem

There are several things to consider when determining if a person hasa drug problem.

Who?

o Who is taking the drug? E.g. a 40yr old drinking vs. a 10yr old. Weneed to look at who is taking the drug to learn if they have aproblem.

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What?

o What drugs are being taken? There is a big difference betweendrinking alcohol and taking heroin.

When/Where?

o When is the drug being taken? It may be accepted in certain socialsettings but not in others, for instance drinking in a pub or in a car.

Why?

o Are the drugs being taking because they are a prescription or arethey just to make you feel good?

How?

o How is the drug being taken? Chewing cocoa leaves is accepted insome societies, however if they are smoked in Britain it is cocaine.

Psychoactive drugs refer to drugs that are mind altering. Principles behind these:

o They alter a persons consciousness or mood.o They can combat negative feelings and make people feel good or

less bad.o They all have multiple effects on the mind and the body.o The size and quality of the drug depends on the amount taken.o The effect depends on peoples expectations. People have been

known to get high on oregano leaves thinking that it was marijuana.

Historical advances in psychopharmacology

There has been much advantageous progress made inpsychopharmacology, including:

Vaccines

o E.g. Louis Pasteur. Involves injecting a mild form of a disease toprevent the fully blown form of it later on.

Antibiotics

o E.g. Penicillin. Antibiotics changed the character of hospitals. Theybecame a place where people would go to get well, not just to bequarantined or to die.

Psychotherapeutic drugs

o Used for those suffering from a mental illness.o For schizophrenics, there used to be nothing that could be done

and they were just sent away and held in institutes.o In the 1950s there came the development of anti-anxiety drugs,

antipsychotics, antidepressants and lithium for manic depression.

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These could still have undesirable effects, however they changedour attitudes towards mental illness.

Oral contraceptives

o These changed sexual practice and family planning.

Drugs and drug use today

Getting accurate information is very difficult as questionnaires havebiased answers and people are unlikely to volunteer themselves.

Surveys are the most popular method of collecting this informationand shows that cannabis is the most widely used drug and this usepeaks between the ages of 18 and 25.

Alcohol consumption by country

o

The countries with the highest alcohol consumption are allEuropean. Britain is 9th in the world.o Sweden is very low due to alcohol being very expensive and widely

prohibited. Alcohol consumption in the UK over time

o It was very high in the 1900s.o Consumption drops during the two world wars.

Characteristics of drug users

o Marijuana and alcohol are the most commonly used drugs and are

therefore used as indicators of drug habits.o There are age effects the highest use being between the ages of

18 and 25.o There are also gender effects. Males use more drugs although the

gender gap is narrowing.o The worst abuse comes from non-conformist societal groups. They

use them to regulate emotions. Motives for drug use

o Enhancement pleasure seeking, increasing good feelings.

o Coping strategy social lubricant.o Reinforcement chemical effects reinforce the behaviour.o Rebellion against parents, authority and societal values.o Dependence becomes the most important thing in your life.

Pharmacology

Psychoactive drugs and their actions

Sources:o Natural plants

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o Chemically manufactured Names:

o Brand name (e.g. valium).o Generic name (diazepam)

o Chemical name the exact chemical compounds to enableduplication.

Categories of psychoactive drugs:

o Stimulants arousing drugs.o Depressants relaxing drugs.o Opiates from opium poppies. Very good pain killers but also

euphoric side effects. Cough suppressants.o Psychotherapeutic stop the negative effects of psychosis.o Hallucinogens alter consciousness and how reality is viewed.

Drug effects:o Non-specific placebo effects the effect of expectancy. It is a

very real effect.o Specific effects pharmacological effects.o Very difficult to separate the two and so single-blind and double-

blind studies are carried out. Dose-response relationships

o The size of response is dependent on the amount of drugo The threshold is the lowest dose of a drug needed for an

observable effect.o All-or-none is when a drug needs a very specific amount to produce

an effect and the wrong dose produces no effect at all.o Margin of safety is the difference between an effective dose and

a lethal dose. Routes of administration

o Topical application cream on the skin.o Oral ingestion slow method.o Inhalation very quick into the blood stream.o Subcutaneous injected just under the skin.o Intramuscular injected into the muscle.o Intravenous quickest route directly into the blood stream.

Blood-brain barrier

o This is a membrane surrounding the brain to protect it. It is a builtin biological barrier.

o It develops between 1 and 2 years of age.o It only allows certain chemicals into the brain.

Elimination of drugs from the bodyo Excretion in the urine via the kidneys. It is very slow.

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o Chemical metabolism through the liver. Tolerance and dependence

o Tolerance means when a drug is continually taken it comes to haveless and less of an effect. The body adapts and becomes

accustomed.o Dependence is when the body comes to depend on a drug and

therefore producing withdrawal effects if the body is deprived ofit.

The Brian and the Nervous System (NS)

The divisions of the Nervous System. The Central Nervous Systemconsists of the brain and spinal cord.

The Peripheral Nervous System (outside the main stream) consists of: Somatic NS

o Muscles over which we have voluntary control Autonomic NS (automatic, e.g. respiration)

o Sympathetic NS excitatory system, e.g. fight or flighto Parasympathetic NS inhibitory system, relaxing, slow heart rate.

Pathway for the sensation of/reaction to pain

o Impulse travels down the spinal cord to the brain into the thalamus.

It travels from this relay station to the primary sensory cortexand onto the primary motor cortex. This travels back down throughthe thalamus and down the spinal cord to make a response.

There are two types of chemical messengers: Hormones

Neurotransmitters:

o Acetylcholine for voluntary movements.o Norepinephrine (noradrenaline) arousal.

o Dopamine motivation, wanting.o Seratonin emotions, lack of this leads to depression.o GABA Inhibition.o Endorphins well being.

Synapse and synaptic transmission:

o Neurotransmitters jump over a synapse and binds to theappropriate receptor. It is then released again and reuptakeoccurs back into the pre-synaptic membrane to be use again.

Reward Pathway:

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o Stimulated when we feel good.o Involves the prefrontal cortex, nucleus accumbens and the VTA.

These are all stimulated during activities such as nurturing,kindness and sexual activity. This can also be achieved with drugs.

o Opiates bind to the reward pathway and increase the release ofdopamine.

Brain imaging techniques

fMRI (functional magnetic resonance imaging)

o Show what is being activated when a particular stimulus ispresented.

o For light drinkers there is greater activation in the reward

pathway for non alcohol related stimuli such as food.For heavy drinkers there is greater activity in the reward pathway foralcohol related stimuli.

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PHP3002: Psychology of Addictive BehavioursLecture

Week 3:Alcoholic Beverages and their EffectsLecturer

What is Alcohol?

Related liquids that are odourless and colourless Isopropyl alcohol:

o This is used in surgeries for sterilising skin and cleaning.o This alcohol cannot be drunk.

Ethyl alcohol (ethanol):

o This is the alcohol that is found in beverages. It is made from grainproducts e.g. barley and rice.

Methyl alcohol (methanol):

o Generally for commercial use.o It is used in solvents, fuels and antifreeze.o It is denatured ethyl alcohol to make it unable to drink. It can

cause blindness if drunk.

Production of Alcohol

Fermentation:

o Sugar, water and yeast.o Yeasts are living organisms and can be found everywhere in the air.o These yeasts are ingested in the water and sugar, then excreted

through the sugar into alcohol.o This method cannot produce alcohol above 15% as the yeasts die

off after this. Distillation:

o The water and alcohol are heated to evaporation and thencondensed.

o The boiling point of alcohol is lower than water. This creates astronger solution of 15%+.

Types of Alcohol

Beer (4-6% alc.):

o The most commonly consumed alcohol in the UK is lager.

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o This can have up to 10% alcohol in other European countries such asBelgium.

o It starts with a grain product such as barley or rice, which have nosugars in them. This creates an extra step in the fermentation

process.o The grain is heated in water to allow the starch to be converted

into sugar, and then they are put in a new solution with the yeast. Wine (11-18% alc.):

o One of the oldest types of wine is mead the sugars of which comefrom honey.

o Now, white wine comes from white grapes and red wine from redgrapes. Ros comes from red grapes that have had their skinsremoved and are therefore paler.

Champagne (12% alc.):o Champagne is bottled before the fermentation process is finished

and so still contains carbon dioxide.o Carbon dioxide moves quickly into the small intestine where it is

absorbed and is quickly acting. Distilled Spirits (40-95% alc.):

o These start as wine and then is further distilled.o E.g. Brandy is also referred to as burnt wine due to the heating

process during distillation. Fortified Wines (17-21% alc.):

o This includes port, sherry and madeira, and they are a mixture ofwine and brandy.

Liqueurs, Cordials and Desert Wines (20-65% alc.):

o These occur when other herbs and spices are added to the alcoholto give them their distinct flavour.

Congeners

Congeners give alcohol their distinct taste and appearance. They are the result of:

o Useless by-products of production process.o Added during production to enhance the flavour.

They are what a hangover is attributed to. The darker the colour, thehigher the congeners and therefore the greater the hangover.

Absorption and Distribution of Alcohol

Absorption begins in the stomach, but only a small amount occursthere and the rest happens in the small intestine.

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There are definite gender differences Gender Differences:

o It is very dependent on average body weight.o Men have a much higher average body weight then women.

Therefore they have more room for alcohol to be passed aroundthe body which means it has less of an effect on men than onwomen.

o Similarly, the relative proportions of fat to muscle are importantas men have more muscle and women have more fat.

o The amount of alcohol dehydrogenase also varies in men and women.This is the enzyme that is necessary for alcohol metabolism. It ismostly in the liver but also in the stomach and men have a greaterquantity of it in their stomach. Therefore, more gets into a

womans blood stream where it takes longer to break down.

Rate of Absorption

This is determined by various things, such as... Type of Beverage:

o The higher the concentration, the quicker the rate of absorption.

Carbon Dioxide:

o If there is carbon dioxide in the alcohol it moves quickly into the

small intestine and is therefore absorbed more quickly. How is Beverage Drunk?:

o If the drink is drunk slower, it is absorbed slower. Condition of the Stomach:

o The absorption is slower if there is food in the stomach as itprevents the alcohol from getting into the small intestine.

Metabolism of Alcohol

Intoxication does not last forever and is chemically broken downbefore it leaves the body. Alcohol needs no digestion and is directly absorbed. This means that it

cannot be stored or turned into energy and this is why alcohol makesyou gain weight.

A very small amount is excreted through the skin, breath and urinebut 90% is metabolised through the liver.

metabolism:-

o Alcohol dehydrogenase converts alcohol into acetaldehyde. This is

what is toxic to the body and contributes to a hangover.

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o This is converted into acetic acid and water allowing it to beexcreted.

o This conversion process is slow, constant and fixed and thereforecannot be changed with hangover cures.

o Caffeine is thought to help, however it merely counteracts thedepressive effects rather than any physiological effects.

Effects

Acute:

o These are the effects that occur when alcohol is in the bloodstream.

Chronic:

o

These are the long-term effects on the body when the alcohol hasbeen removed. CNS Effects (acute):

o Alcohol depresses the CNS like a general anaesthetic.o The initial high effect is deceptive at first due to loss of

inhibition.o It used to be used intravenously as a general anaesthetic. However

this was very dangerous as there is a very narrow margin of safetybetween being sleep inducing and being fatal. It can interfere with

blood clotting and you are unable to turn off the effects ofalcohol and you have to wait for it to be metabolised.

o As the level of blood-alcohol concentration rises, so does thedepressive effects.

o The inhibitory GABA receptors are involved in the calming andstress relieving effects of the alcohol.

o Dopamine is also released creating the pleasurable effect. Other Acute Effects:

o Dilation of the peripheral blood vessels. This releases heat and

makes us feel warmer. This can be dangerous as we may not protectourselves even in severe cold.

o Fluid imbalance. Alcohol is a diuretic and can cause dehydration.o Hormonal effects. Testosterone is reduced, and this can have

permanent effects including the loss of hair and the growing ofbreasts in men.

o Blackouts in excessive drinking. We may continue to interact withpeople when are not able to recall it when we have sobered up.However, if we continue drinking the next day it has been found

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that we are able to recall the periods that we were not able towhen sober.

Stress Reduction:

o Alcohol appears to reduce stress when there is a pleasant

distracter and drinking before a stressor occurs can also reducethe stress of the stressor.

o However, drinking after a stressor occurs has no effect and caneven increase the stress.

Expectancy Effects:

o By using a balanced 2x2 factorial placebo design, we are able toseparate which effects are pharmacological and which are justbased on the expected effects of alcohol.

o Aggressive behaviour appears to be culturally determined. It is

very common in western society. We believe alcohol is having thateffect, but aggression is not a pharmacological effect.

o There is a big effect on sexual behaviour although this decrease ininhibitions is not a pharmacological effect either. Alcohol appearsto provoke desire yet remove performance!

Determinants of a Hangover

Blood-alcohol Concentration:

o The more you drink, the worse the hangover tends to be. Congeners:

o The more congeners there are , the greater the hangover is.o This effect was identified by Chapman in 1970. University students

had to stick to either vodka or whiskey for one night and the nextmorning their symptoms and the severity of them were recorded.The conclusion was that the whiskey drinkers had more hangoversymptoms and they were also more severe, and these results weredue to the quantity of congeners.

Alcohol Withdrawal

Withdrawal is similar to a hangover although the symptoms are muchmore severe and can be life threatening.

Body Tremors:

o This shows increased heart rate, increased blood pressure andinsomnia. The tremors appear to be the result of stimulationcounteracting the depressive effects

Hallucinations:o These include auditory, visual and tactile hallucinations.

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Delusions:

o People feel delirious and suffer amnesia and paranoia.

Seizures:

o Violent convulsions of the body.

The withdrawal from alcohol is much more severe than other drugssuch as opium and cocaine.

Chronic Alcohol Toxicity

Liver cirrhosis can occur as it stops metabolising. Brain damage can also occur, although it can recover if it is caught in

time.

Heart disease and cancer of the mouth, throat and oesophagus arealso by-products of excessive alcohol consumption. All of these can compromise the immune system as all of the organs

are affected. Liver:-

o Fatty tissue can build up causing enlargement.o Liver fibrosis occurs when scar tissue forms, although recovery is

still possible.Liver cirrhosis is the final stage that can be counteracted with a liver

transplant.

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Week 4: Measuring and Problem DrinkingMiles Cox

Physical Damage (week 3 cont.....)

Liver damage:

o Fatty liver the metabolism of alcohol takes precedence over food.o Liver fibrosis scar tissue forms, but the damage is reversible.o Liver cirrhosis the tissue damage is irreversible.

Brain damage:

o Impaired abstract reasoning the inability to make properjudgements and form concepts.

o Wernicke Korsakoff Syndrome extreme confusion, ataxia. Lackof limb control and gaps in memory. Sufferers make things up to fillin the gaps and this is known as confabulation. There is norecovery from this condition.

o These cognitive deficits are the result of vitamin B deficiency and

the direct toxic effects of the alcohol. Foetal alcohol syndrome:

o This is an impairment to a child when the mother drinks duringpregnancy causing irreversible physical and behaviouralabnormalities.

o Alcohol crosses the placenta where the baby cannot metabolise itand this creates permanent damage.

o This syndrome is detected by growth and CNS retardation thatnever catches up after birth, and abnormal features in the head

and face.o This is caused by excessivedrinking during pregnancy, but how can

we gauge what is safe? The best advice is therefore not to drink atall or take any psychoactive drugs.

Sensible Drinking

Sensible drinking does not appear to have a subjective answer. Department of Health:

o Men should drink no more than 3 or 4 units a day. This is approx.2pints.

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o Women should drink no more than 2 or 3 units a day.o These limits also depend on an individual regarding age, health and

size of body. Royal college of Psychiatrists:

o Men should drink no more than 21 units a week.o Women should drink no more than 14 units a week.o This means that it is healthy to have one or two alcohol free days a

week and avoid binge drinking. What is binge drinking?

o The British Office of National Statistics (ONS) states that bingedrinking for men is greater than 8 units a day, or for women it isgreater than 6 units in a day.

Hazardous, Harmful and Dependent Drinking

Guidelines as set by the Department of Health. Hazardous drinking:

o Above the sensible level of alcohol but not harmful.o For men this is between 22-50 units per weeko For women this is between 15-35 units per week.

Harmful drinking:

o Drinking above the sensible level of alcohol and causing physical

harm and social harm to others.o For men this is 50 + units per week.o For women this is 35 + units per week.

Dependent drinking:

o Drinking above the sensible level, causing harm and showingsymptoms of dependence such as withdrawal.

Consequences of Intoxication

The consequences of intoxication depend highly on the individual. Social consequences:

o Interpersonal.o Inappropriate sexual behaviour.o Unsafe sex and unwanted pregnancy.o Accidents.o Criminal behaviour

Medical consequences:o Disturbed sleep.

o Acute alcohol poisoning.o Gastritis irritation of the stomach lining.

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o Cardiac arrhythmias (irregular heartbeat) and pancreatitis. Drinking excessively:

o Social consequences:

o Absenteeism from work and loss of a job.

o Impaired social relationships.o Psychological problems, such as anxiety.o Sexual problems.o Criminal behaviour.o Medical consequences:

o Hypertension.o Liver damage.o Brain damage.o Cardiomyopathy.o Cardiovascular.

Alcohol dependence:

o Social consequences

o Family problems and the inability to fulfil roles.o Morbid jealousy and paranoia.o Financial problems.o Unemployment.o Social disintegration.o Medical consequences

o Withdrawal symptoms.o Hallucinations, tactile and auditory.o Dementia and early senility.

Are you Drinking Too Much?

There are various tests to measure problem drinking. AUDIT (Alcohol Use Disorders Identification Test):

o This is a quick screening test which is widely used to identify

excessive drinking.o It uses various questions to identify the amount and frequency of

drinking, any symptoms of a problem and any social problems causedby the drinking.

o The minimum score for non-drinkers is 0 and the maximum score is40.

o Anybody who scores above 8 shows signs of harmful or hazardousdrinking.

Drink Monitoring:

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o This can be performed by using a drink diary where the exacttime, how much and what alcohol is drunk is recorded over a certainperiod of time.

o There is also the method of the timeline follow-back where

drinking is recorded retrospectively by using a calendar as aprompt.

Drinkers check-up:

o This can be used as an intervention to motivate people to drink less.o Firstly, there is a comprehensive assessment that tests cognitive

functioning, physical functioning and psychological tests.o One week later there is a feedback session in which a person is

given the previous test results.o They are shown how they fit in with the general population to

demonstrate that their drinking is out of line and unhealthy.o The damage that is being done to their health and social life is also

demonstrated.o Hopefully, this motivates people to cut down on their drinking,

however it is not such an effective method with very severedrinking problems that may have already progressed todependence.

Problem Drinking: Formal Diagnosis

There are two types of diagnoses defined by the DSM IV. Substance abuse:

One or more of the following criteria should be manifested within atwelve month period for a current diagnosis or at any point insomeones life for a lifetime diagnosis:o Substance becomes a major role at the expense of other things.o The substance is used in hazardous situations.o Legal problems with a substance e.g. drink driving.

o Continual use despite negative effects.o Never having met the criteria for substance dependence.

Substance dependence:

Three or more of the following criteria should have manifested for apositive diagnosis:o Tolerance. More and more of a substance is needed to get the same

effect.o Withdrawal when substance taking stops.o Preoccupation with a substance and the inability to control it.o A lot of time and effort is spent on obtaining the substance.

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o Other activities are given up to pursue a substance.

Video

Facts about drinking in the UK:

o

It takes 5 minutes for alcohol to reach every part of the body.o One in three men and one in five women binge drink, of which the

UK has the highest rates in Europe.o 29% of women binge drink, the highest percentage in Europe.o There are over one million incidences of alcohol related violence

every year.o One thousand people suffer facial injuries each week due to

alcohol, wine glasses and beer bottles being the most commonlyused weapon.

o Ten people a week die from drink driving.o 30billion a year is spent on alcohol.o Twenty-two thousand premature deaths are caused by alcohol each

year e.g. brain, heart and liver disease.o Liver damage has gone up 900% in the last thirty years.

It kills more people a year than any other drug, including heroin.

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Week 5: Brief Interventions for Substance

Misuse.Dr Lee Hogan, NW Wales NHS Trust (guest lecturer)

Introduction to Brief Interventions (BIs)

The idea goes back 30 years to Edwards et al. (1977). They used 100alcohol dependent males.

Controlled trial of treatment and advice. One group was given the standard treatment and 63% of them showed

improvement. The other group had the responsibility in their ownhands and 58% of these showed an improvement.

However, this study looked at stable married men. Change within-self seemed to be the most important factor when

looking at changing drinking behaviour. BI take-off:

o Meta-analyses report brief interventions as more effective than no

treatment and even some more extensive treatments.

Brief Interventions

There are two different types: Opportunistic:

o This is delivered by a non-specialist and involves a screeningprocess.

o It is usually for those who are not dependent on a substance and is

used as an early intervention.o It can take between 5mins and 1hr to administer.

Brief Treatment:

o This is conducted by a specialist when an individual has beenidentified as an excessive drinker and is seeking help.

o The goal is usually abstinence and this is a longer treatment.

Content of Brief Interventions

FRAMES:

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o Feedback showing an individual what the problem is and theconsequences.

o Responsibility getting them to take responsibility for theirbehaviour.

o Adviceo Menu of options giving the possible choices that could be pursued.o Empathyo Self-efficacy showing that they are able to make the change,

giving them belief in themselves.

Brief Treatment form of Brief Intervention

Motivational Enhanced Therapy (MET).

Motivational interviewing. Looking at peoples values and building uptheir motivation to change. Two studies:

o Project MATCH (1997) and UKATT (2005).o Both studies showed the same findings, that MET had no different

effects to other types of longer therapy. It may be more costeffective as it is shorter, but it is no better.

NHS alcohol strategy recommendations:

o Early detection of hazardous drinking should be made through

screening and brief interventions can be used for those with thepotential to cause harm to themselves and others.

The computerised Brief Intervention

Combining the opportunistic BI and the brief treatment approach. This is also based on motivational interviewing and providing personal

feedback and using the adverse consequences as motive for change. Motivational Interviewing:

o

This draws heavily on basic counselling skills.o It is non-confrontational and is good for those who are ambivalent

about change. Principles:

o Showing empathy towards the individual and not passing judgement.o Developing discrepancy between the values in someones life.o Avoid arguing as this may prompt an individual to argue for the

sake of it.o Go with resistance and work with it. Let them have their views.

o Support self-efficacy and try to instil in people that they have theability to change.

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Readiness to Change Model

This is the idea that people pass through discrete stages for change

to occur; pre-contemplation, contemplation, action and maintenance. Interventions are developed so that they fit into these stages. They

are needed to fit in with those who are not ready to change as well asthose are trying to maintain that change.

They are given printed feedback and this can be delivered within 20minutes.

The feedback consists of things such as a calculation of alcoholconsumption, blood alcohol concentration and how a high tolerance canbe dangerous. This gives them a reason to change.

Individuals are given a graphic representation of their drinking habitsin comparison to the general population to build up a picture of howtheir drinking fits in with others.

An objective view is then taken where individuals list the good thingsand the bad things about drinking and then weigh them up to decidewhich side out-weighs the other.

Then people are asked what they think would happen if they continueto drink the way they are, would they like to do anything about thisand if so what would they like to happen or change?

They are then given strategies to help them dependent on theiranswers and are asked which of the strategies they would considertrying.

Finally, they are asked what support services they think would helpand are given a complete summary of everything.

Another method of intervention:

o Substance use, quantity and frequency.o This uses a harm reduction approach and looking at rules people

use, such as only using good quality substances and not using whilst

around family members.o This attempts to make people look at it in a different way.o It looks at possible triggers for substance use and what strategies

could be adopted to help avoid these situations where influencesoccur and prevent the substance use.

o Thinking about what life will be like in five years time if we do ordont make a change. Is there a significant difference between thetwo?

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Lifestyle Review

This is used to get a good baseline for what is going on in a personslife to help motivate them to change.

The interview takes around 1 hrs. They describe their home, employment and finances, friends and

family, education and social activities. They then say whether they are satisfied with each area in their lives

and what they would like in each area for the future. These are allshowed to them afterwards and they are asked how they thinkcontinued drug use will affect their hopes for the future.

Personal Concerns Inventory (PCI):

o This was established before the lifestyle review and considers the

goals we have in life.o How committed are we to the goal, how much joy do you think will

be gained from it, when do you think you think you will be able toachieve it and how much do you believe that alcohol will interferewith achieving it?

o These goals can be explored at different levels as to whyindividuals believe their goals achievable or not achievable.

o A goal ladder is set up with discrete stages and definite times asto when each stage should start and finish.

Brief Interventions with Bangor University

Study 1:

o 88 participants that drink above low risk or are binge drinkers.60% were females.

o A diary method was used to assess their drinking behaviour andanother group had an extensive baseline assessment. Thehypothesis was that the intervention groups would have a reduction

in alcohol consumption.o The most common negative consequences reported were hangovers,

embarrassment, cost and vomiting.o The results showed that the interventions for the males had an

immediate effect but experienced the same negative consequences.The females showed a reduction in consumption just from being inthe study regardless of whether they were in and interventiongroup. They also experienced less negative consequences.

Study 2:

o Using brief interventions with general hospital patients byscreening them when they enter hospital.

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o However, only 26 were followed up as they are harder to trackonce they leave hospital.

o Heavy male drinkers consumed an average of 154 units and theysuffer a lot more negative consequences such as family, health and

psychological problems.o Those who took part in an intervention had a reduction in their

alcohol consumption, but the controls actually appeared to increasetheir consumption when they left hospital. As this was notsignificant it only shows a trend.

GWLAD Pilot Study

Sample 1:

o

Sample was taken from a local quarry, however there were only 9participants who were all management. This is because if any of theworkers were found positive for drug or alcohol use they would losetheir job.

Sample 2:

o 25 participants who had used a substance within the last 3monthswere asked to rate their quality of life.

o After the intervention the individuals had reduced substance andincreased well being.

o This is a more real to life study, although there was no controlgroup used.

Conclusions:

o Computerised interventions are an effective method of motivatingsubstance uses to change.

They work best in hospital-based services, clinic-based services, pre-detoxification, arrest-referral schemes and in occupational services.

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Week 6: Models of AddictionMiles Cox

Historical Models of Addiction

Drunkenness The Moral Model:

o In the late 1700s alcohol was drunk like water and was deemedsafer to drink.

o Ministers stated that it was a gift from God.o Drunkenness however, was seen as a sin and was the indication of

moral weakness and lack of will power. The deficit was with theindividual and the sinner was entirely to blame.

Demon Alcohol Model:

o Alcohol was the first psychoactive drug to be considered as anactive source of evil and was often used as a scapegoat for societalproblems.

o Temperance was advocated, but this lead to prohibition. Thisshowed a short improvement but then alcohol started to bemanufactured and sold illegally so the problems became even biggerthan they were before prohibition.

Disease Model of Addiction

The idea that it goes through stages like any other disease. It can bediagnosed and therefore should be able to be cured.

Dr Benjamin Rush:

o Drunkenness is a loss of control.o Rush was the first to use the term addiction.o He suggested that those with addiction should abstain from alcohol

completely. This is similar to the Alcoholics Anonymous approachthat the only way is total abstinence.

Dr Thomas Trotter:

o The first person to characterise it as a disease.

Dr Magnus Huss:

o Classified the physical damage of alcohol and described it as achronic disease.

E Morton Jellinek:

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o Coined the phrase disease concept of alcoholism.o His studies however did not use a strict control and does not use

representative samples.o He described five types of alcoholism (named after the first five

letters of the Greek alphabet). Only gamma is classified as adisease and involves lack of control i.e. an alcoholic.

o Delta is common in continental Europe as they drink alcohol on aday to day basis. They do not drink enough to become intoxicatedbut it takes its toll on the body and if examining their internalorgans they would show similar symptoms to alcoholics.

Alcoholics Anonymous (AA):

o Came out of the disease concept.o It was formed by two severe alcoholics who got together to talk

about their problems and support each other suggesting ways thatcould help.

o They have something called the Big Book which contains 12 stepsand 12 traditions. The philosophy is that alcoholics are unable todrink without developing a craving and therefore there must becomplete abstinence.

Current Models of Addiction

The disease model is still very popular and wide spread in NorthAmerica.

The Cognitive-Behavioural Model attempts to alter faulty thinking andbehavioural patterns. How can reinforcements be altered?

Motivational Models look at why people find drinking so attractive.

Cognitive-Behavioural Model

What is a persons goal for drinking? Do they want to cut it out

completely, moderate their drinking or abstain for a while just toprove that they can? Self-monitoring individuals record the number of drinks they have

and the circumstances under which they drink them. Rate-control encouraged to drink slower and make the drink last or

alternate with non-alcoholic drinks. Setting rewards for reaching goals. There is a functional analysis of drinking. What leads up to it, how

does it feel? What can help to avoid these high-risk situations?

Learning alternative coping skills such as other ways to relax.

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Motivational Approaches

Stages of Change (Prochaska and DiClemente):

o On the way to changing any addictive behaviour people must pass

through discrete stageso Precontemplation (having not even thought about change),

contemplation (think about the possibility), determination orpreparation (making the decision and preparing to change), action(actively trying to control alcohol use) and maintenance(maintaining abstinence) or relapse (go back to the beginning ofthe cycle).

o But is it this simple? Motivational Interviewing:

o

Getting people to recognise the problem and motivate them tochange.o It focuses on the behaviour.o Involves expressing empathy to show that you are aware of where

the person is coming from and that there are both positives andnegatives.

o Develops a discrepancy between where they are now and wherethey would like to be in the future.

o Avoids arguing and this lets them know that their arguments are

legitimate.o You roll with the resistance that they express and then they may

argue the opposite.o Emphasises self-efficacy by showing them that they have the

capacity to change. Motivational Model (Cox and Klinger):

o This integrates the biological (e.g. metabolism), psychological (e.g.anxiety) and sociological determinants.

o It takes motivational principles into account and bears in mind that

different variables carry different weights for different people.o What degree of satisfaction does the drinker get from other areas

of their life? Feelings of frustration?o Things may vary in importance over time.o Treatments should be matched to individual needs.

Attentional and Motivational Interventions for Reducing

Excessive Drinking

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With addiction there must come goals as that is what motivationrefers to.It may help people cope with negative feelings or enhancepositive feelings.

These are the motivations, otherwise they wouldnt be drinking.

Relapse rates after treatment:o Around 60% of patients relapse after 3 months of apparently

successful treatment.o Patients say that they have no more positive satisfaction in their

life and that things are still the same. Motivation:

o An internal state that leads to goal directed behaviour. Past experience:

o Positive and negative consequences reinforce our motivation to

drink or not drink.o There are also biological factors. Some are more physically

affected by alcohol than others.o And environmental factors, as we have different habits in

different cultures and we model our behaviour on other people.o Bingeing appears to be more detrimental to your health than

spreading the amount of alcohol out, as it produces a serious jolt onthe body.

Current Factors:

o Motivation to drink is closely tied in with satisfaction in otherareas of our life.

Current Concern: A Motivational State

When we are trying to reach a goal, we form it and then become achanged individual as our goal changes what we pay attention to.

Distracters are everywhere food if we are concerned about eatingor shopping if we are concerned about money.

We make automatic responses but we need to learn to ignore these asthey can get us into trouble. For instance having a car crash becauseyou were talking on the phone.

Brain reward pathway:

o Associated with the release of dopamine.o fMRI results show that heavy drinkers show a significant response

in the insular cortex as opposed to light drinkers.The insular cortex is associated with cravings.

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Week 7: Attention Alcohol BiasMiles Cox

Alcohol Stroop Test

Classic Stroop Test:

o It was developed by J. R. Stroop (1935) and shows very consistentresults.

o It uses congruent stimuli (word and font colour are thesame/compatible) and incongruent stimuli (word and font colour aredifferent and conflicting.

o You just have to respond to the colour of the word and not theword itself, and slower response times are seen for the incongruentstimuli.

Alcohol Stroop Test:

o There are no congruent and incongruent stimuli, but rather alcohol-related stimuli and emotionally neutral stimuli.

o Similarly, all of the words appear in different colours.o Heavy drinkers show consistently slower response times to the

alcohol-related stimuli as they are more distracted by them. Measurement:

o Interference.o The average response time for the incongruent stimuli minus the

average for the congruent stimuli.o For the alcohol-related stroop it measures the average response

time to the alcohol-related words minus the average for the

neutral words. This gives us the attentional distraction to alcohol-related stimuli. Fadardi and Cox (2004):

o Alcohol abusers are slower to react to the alcohol-related stimuli.o Non-abusers show no difference in average response time between

the alcohol-related words and the neutral words. Importance of attentional bias:

o Heavy drinkers are unable to resist the influence of addictive cues.o This bias sets an automatic (and possibly unconscious) chain of

events into motion, which leads someone to drink. Literature on the alcohol stroop test:

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o Fadardi and Cox, 2004 (as previously mentioned).o Attentional bias is accompanied by physiological symptoms

(Stormark et al, 2000).o Greater attentional bias is predictive of relapse (Cox, Hogan,

Kristian and Race, 2002). When the alcohol stroop wasadministered to patients in a rehab clinic, some showed increasedattentional bias as they become more preoccupied with alcoholwhen withdrawal occurs. This increase was predictive of those whowere likely to relapse.

Clinical importance:

o An important factor in relapse.o Interventions can target this unconscious process through training

people to disattend to certain alcohol stimuli.

Alcohol Attention Control Training Programme (AACTP)

This aims to reduce the time needed for people to avert theirattention from alcohol-related stimuli and help them gain control ofthis attentional bias.

It attempts to do this through reducing response times and errors inalcohol-related stroop stimuli.

They are also given feedback.

The participants choose their favourite types of alcoholic and non-alcoholic drinks to be included in the stroop test.

In the first set of test the participant are required to respond to thesurrounding colour of a drink picture, the second set was similar butthe there was less colour around the pictures and the third set oftask showed two pictures of drinks and participants had to respond tothe colour around the non-alcoholic drink.

University experiment 1:

o This looked at social, excessive and abusive drinkers. Does training

have an effect? 2:

o Looking at alcohol specificity in AACTP with excessive drinkers.This showed the development of cognitive flexibility and adecrease in attentional bias.

3:

o The effectiveness of AACTP with abusive drinkers.o Alcohol interference decreased as well as alcohol consumption

which appeared to be maintained et a 3 month follow-up.o Readiness to change increased along with positive affect.

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o There was also a decrease in self-inventory problems.

Incentive Value of Alcohol Versus Other Life Areas

There are certain differences between those who do and those who do

not relapse. Those who dont, report positive changes in other life areas and are

able to develop substitute activities for drinking which give everydaymeaning and satisfaction without alcohol.

Fluctuations in drinking are often associated with satisfaction in otherareas of life and extra-treatment activities are very important.

Why do people not strive for these?

o Some people may not know how to go about achieving these things.o People may also feel ambivalent about their goals and not know if it

will make them happy.o They also have a pessimistic attitude and dont believe that they

can achieve it.

Personal Aspirations and Concerns Inventory (PACI)

Success and happiness with other goals can affect outcome. Measuring motivational structure:

o People are presented with a list of areas of concern where theymay have goals and then are asked to describe those goals in theirown terms.

o They then rate each of them in terms of things such asachievability, the happiness it will bring (value), how long it will taketo achieve and your perceived control over it.

PACI profiles:

o This determines the extent to which a persons profile is adaptive(e.g. commitment to goals, strong sense of control and high value)or maladaptive (e.g. low value, knowledge of achieving a goal and

lack of determination).

Video Systematic Motivational Counselling (SMC)

The Addiction Files The social aspect:

o What makes one sibling addicted and another not?o No two people have the same environment.o E.g. The Army is a macho culture where drinking is subsidised.o Peer influence or a neighbourhood where there is nothing else to

do.

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The psychological level:

o Drinking for the buzz, gaining confidence and enabling you tointeract.

o Alcoholics need to relearn their beliefs about alcohol.

o A profile is drawn up around beliefs of achievability and control.o Social support is very important.

The physiological level:

o Neurotransmitters greater release of dopamine when drugs aretaken.

o Alcoholics adapt to deal with the amount of alcohol that wouldmake the average person comatose.

The genetic level:

o DNA. Are there problematic genes that make us especially

sensitive to withdrawal?o It is expected that many genes are involved such as the gene

involving thrill-seeing behaviour.o A set that produce complex behaviours.

Putting it all together:

o Our present is a result of the pastAs we plan for the future we can alter our past trends.

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Week 10: Medical Management of Substance

AbuseJulian Race

Drug Use

The majority of drug use is by men and there has been an explosion ofcocaine use in the last 10-15 years.

The most common drugs used are cannabis and benzodiazepines. Heroin is the most clinically treated. Social cost:

o Results in theft to feed the habit.

We use disease-orientated classifications for treating drug use.

Effects

Opiates/opioids:

o

The most common effect is euphoria.o Most people dislike the drug when they first use it, but they still

go back.o 50% inject and therefore clinics give out clean needle to avoid

fatal diseases such as septicaemia. Opiate withdrawal:

o Symptoms of a cold or rhinorrhoea.o Insomnia, colic, nausea, vomiting, diarrhoea, irritability and pain.

Cocaine:

o Creates huge cravings and used to be used as an anaesthetic.o It eventually causes delusions and hallucinations and general

psychotic symptoms. It often causes mental disorders. Amphetamines:

o This is similar to cocaine but to a lesser degree and can causepsychosis in the same way.

o A variant is methamphetamine, which is much more like cocaine andcommon in the Far East.

Cannabis:

o This is currently a class C drug and is not regarded as dangerous.However it is as carcinogenic as the tobacco it is mixed with.

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o There is an ongoing debate as to whether it causes psychosis, butthere is no real evidence for this.

o There can be drug induced psychotic states but once it not beingtaken again, this stops.

Addiction

Involves looking at what happens when people go without the drug(habituation). You need to be aware of the difference between misuseand abuse.

Characteristics:

o Drugs become all important to the exclusion of everything else andthey are constantly preoccupied with it. They feel compelled to use

the drug and often relapse. Developmental factors:

o Family history, such as whether the parents are drug users or adysfunction family.

o If ADHD is not treated, individuals can develop personalitydisorders and this may cause them to drift towards drug use.

Social learning:

o Positive and negative reinforcement through the side effects ofthe drugs and withdrawal.

Psychological Treatments

Prochaska and DiClemente. Precontemplation, contemplation, actionand maintenance.

Why give drugs?

o Diamorphine for example, may sort out a heroin habit but you canthen become addicted to something else.

Historical perspective:

o

1900-1940 Electro-convulsive therapy and abrupt rapidwithdrawal were used. These did not work and were potentiallyfatal.

o 1940-1970 Dole and Nyswander were the first to givemethadone. Vaillant followed up drug users and found that if theycould get through 10/15 years with substitutes they turn out OKand can lead a normal life.

Treatment

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People tend to use lots of drugs i.e. if they are using heroin they arelikely to also be taking cocaine. They are poly-drug users and if you tryto reduce their use of one drug, they will increase the use of another.

Therefore we try to reduce their risk and increase their safety

through clean needles. Once this has been sorted, the drug use itselfcan then be dealt with.

New guidelines regarding this come out every 10 years and theybecome more and more stringent limiting the drugs that can be used.

Therapeutic drugs:

o Substitutes are used to improve the individuals lifestyle.o Opiates, such as methadone and buprenorphine are used and are

synthetic drugs drawn from opium. These cannot be given in tabletform, as they will be crushed up and inhaled producing chalk in the

lungs. Success:

o High doses and strict monitoring usually yield good results.o One of the most important things however, is the relationship

between the patient and therapist. Duration:

o The best success rates occur when treatment is long-term, meaningthat it lasts longer than a year.

o Subutex is very successful as it can be reduced very quickly with

fewer negative side effects. Detoxification:

o Methadone and buprenorphine are used, as are sedatives, which arenot ideal but help with agitation.

Objectives of detoxification:

o It is nota cure as the problem comes when a patient goes home andis surrounded by drug users and dealers.

o It only has a short-term aim to interrupt heavy or regular drug use.o It occurs mostly in hospitals or specialist units.

Abstinence:

o Naltrexone blocks opioid receptors and is a complete agonistagainst opiates.

Challenges:

o It is difficult getting so many people into treatment and a lot ofpeople have to be left waiting.

o The long-term aim for 2010-2030 is getting people throughtreatment and helping them to maintain it afterwards.

o

People dont want to go back to drugs, but they are left to stagnateand end up with no apparent choice.

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Alcohol

Depression is the highest cause of disability worldwide. Britain is renowned for binge drinking whereas there is high

abstinence in Ireland and low abstinence in Denmark. History of guidelines:

o 1917 start of the drinking guidelines as men were found to bedrunk in the afternoons after working in munitions factories.

o 1976 The Royal College of Psychiatrists said that you should drinkno more than 56 units per week.

Effects

Harmful:

o Alcohol has many physical effects such as liver fibrosis andcirrhosis, pancreatitis, cancer of the gut, foetal alcohol syndrome,gastritis and oesophageal varices (veins in the oesophagus that cancause acute haemorrhages and can be fatal.

Beneficial:

o Can reduce cholesterol, but otherwise can have very littlebeneficial effects if you are not a male over forty drinking twounits of wine a week.

Psychological Symptoms

40% of people show anxiety and depression Delirium tremens 15% mortality rate if not treated. Alcoholic hallucinations:

o These are non-violent and often involve the person believing theyhave a very friendly pet.

Wernickes encephalopathy:

o Vitamin B and thiamine can help with 80/90% recovery if caught

early. Korsakoffs psychosis:

o If Wernickes encephalopathy is unresolved it can develop intoKarsakoffs Psychosis, which is irreversible. This involves severememory loss and the inability to create new memories.

o These individuals will often end up in nursing homes.

Alcoholic dementia:

o This is the global deterioration in skills, but is quite hard todistinguish from Korsakoffs syndrome.

Alcohol dependency syndrome:

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o These individuals have a few specific drinks that they will rely on.They then become dependent on the drink and show withdrawalsymptoms.

o The body gets rid of approximately 1 unit of alcohol each hour and

therefore if you drink 1 bottle of spirits a day your body will notget rid of it.

Misplaced detoxification:

o Doctors want to help people and will therefore tend to give drugsthat they may not need.

Preparation:

o It is important to do activities that do not involve certain friendsor situations associated with drugs or alcohol. This produces bettereffects of treatment.

Treatments that are probably ineffective:o Psychodynamic psychotherapy.o Confrontational counselling.o Education (the only thing to have worked recently is the drink

driving campaign).o Relaxation therapy.o Supportive counselling.

Neurochemistry:

o There are no actual alcohol receptors in the brain, but it works on

GABA receptors.o Benzodiazepines also work on these receptors.o Chlordiazepoxide is also good as it is less habit forming than

diazepam and good for anxiety. You are able to gradually decreasethis drug within a week and patients are more tolerant to this thanthey think they will be and cope well with it.

Outcomes:

o 80-90% of in-patients complete treatment and only 50-60% ofoutpatients complete it. This also produces a 50-60% relapse rate.

Relapse prevention:

o Antabuse this was first used in the rubber industry forvulcanization and it was noticed that workers were sick if theydrank afterwards. However, this is a very bad drug to give todepressed people.

o Acomprosate This works on the frontal lobes to reduce thefrequency of drinking and stop craving (stimulates GABA).

o Naltrexone blocks opiate receptors.o

Lithium supposed to stabilise mood but is not very effectiveh ld l d f h ll d d

74088842 addictive behaviours psyb10 for prof page gould on 2011-11-13 at university of toronto

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