Moral / Temperance Model * Addiction as Sin or Crime Personal Irresponsibility

1. MODELS OF ADDICTION: A SUMMARY • Moral / Temperance Model * Addiction as Sin or Crime • Personal Irresponsibility • Disease Model * Genetic and Biological Factors ** • 12-Step Framework; Abstinence • Education as Treatment • Behavioral and Cognitive- Conditioning and Reinforcement • Behavioral Models * Social Learning and Modeling • Drug Expectancies and other Cognitive Factors / RP • Family Models Family Disease • Family Systems • Behavioral Marital/Family Tx • Psychological / Psychoanalytic Disordered /Addictive Personalities • Sociocultural Models Cultural Factors • Socioeconomics/ Social Policy • Drug Subcultures • Public Health Model Agent, Host, Environment • Interactions • THE BIOPSYCHOSOCIAL MODEL: AN INTEGRATION • MODELS OF ADDICTION: A SUMMARY • Moral / Temperance Model Addiction as Sin or Crime • Personal Irresponsibility • Disease Model Genetic and Biological • Factors • 12-Step Framework; Abstinence, Education as Treatment • Psychological / Psychoanalytic Disordered /Addictive • Personalities • Behavioraland Cognitive- Conditioning and • Behavioral Models Reinforcement • Social Learning / Modeling • Drug Expectancies and other Cognitive Factors / RP • Family Models Family Disease • Family Systems • Behavioral Marital/Family • Therapy • Sociocultural Models Cultural Factors • Socioeconomic Factors • Drug Subcultures • Social Policy (e.g., drug control) • Public Health Model Interactions between • Agent • Host • Environment • THE BIOPSYCHOSOCIAL MODEL: • AN INTEGRATION

2. MODELS OF ADDICTION: A SUMMARY • Psychological / Psychoanalytic Disordered /Addictive Personality • Sociocultural Models Cultural Factors • Socioeconomics/ Social Policy • Drug Subcultures • Public Health Model Agent, Host, Environment • Interactions • THE BIOPSYCHOSOCIAL MODEL: • AN INTEGRATION

3. MODELS OF ADDICTION • Assumptions of Disease Model • addiction seen as a “primary” disease process • alcoholics qualitatively different from non • alcoholics: can’t drink in moderation • central symptom of addiction is loss of control • (e.g., one drink, one drunk) • addiction is chronic and progressive; no cure, • can only be arrested with total abstinence • (e.g. progression models - Johnson…learning & seeking the mood swing; harmful dependence; drinking to feel normal)

4. Disease Model - Treatment • Early identification • Education about diagnosis • Acceptance of disease and overcoming “denial” • Abstinence • 12-steps essential for real recovery

5. 12 Steps of Alcoholics Anonymous 1. We admitted we were powerless over alcohol - that our lives had become unmanageable. 2. Came to believe that a Power greater than ourselves could restore us to sanity. 3. Made a decision to turn our will and our lives over to the care of God as we understoodHim. 4. Made a searching and fearless moral inventory of ourselves. 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

6. 12 Steps of AA (con’t) 6. Were entirely ready to have God remove all these defects of character. 7. Humbly asked Him to remove our shortcomings. 8. Made a list of all persons we had harmed and became willing to make amends to them all. 9. Made direct amends to such people wherever possible, except when to do so would injure them or others. 10. Continued to take moral inventory and when we were wrong promptly admitted to it.

7. 12 Steps of AA (con’t) 11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. 12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

8. Disease Model - Research Support • Adoption study of Goodwin • 18% probands alcoholic vs. 5% controls • Twin Studies • male vs. female twin pairs • Metabolic Studies – an error in metabolism? Genetic variation does exist but…does it predispose or protect? The Asian and Native American flushing response • P3 Wave Studies

9. Data on Assumptions of Disease Model • addiction as “primary” • loss of control • chronic / progressive • alcoholics qualitatively different

10. CRITIQUE OF DISEASE MODEL Strengths - perception shift: from sin to TX - eases guilt, self-blame - disease is a good metaphor that fits the experience - 12-step support and framework works for many (prevalence of meetings; 24-hour support…) - Other strengths? _______________________

11. CRITIQUE OF DISEASE MODEL • Limitations • - not all data-based • - dichotomous thinking dangerous; no middle ground (you’re an alcoholic or not) • - loss of control and responsibility paradox • - Other flaws?

12. SUBSTANCE USE DISORDERS • GENERAL METHODS OF TREATMENT • Inpatient Detoxification and Rehabilitation • Outpatient Individual, Couple, or Family • Counseling • Self-help Groups (Alcoholics Anonymous; • NA, CA, OA, GA, Al-Anon etc.) • Residential Facilities & Therapeutic • Communities • Medications

13. TREATMENT OF SUBSTANCE USE DISORDERS • Addictive Behavior Meds • ETOH: antabuse, naltrexone, acomprosate; benzodiazepines • Opiates: • Methadone; LAAM • narcan/naltrexone; depot naltrexone • buprenophine • Nicotine: • Nicotine Replacement Therapies • Zyban, Wellbutrin (bupropion) • Effexor (venlafaxine)

14. Strength of Evidence of Pharmacotherapies for Alcohol Dependence • Naltrexone - GradeA: strong and consistent evidence of efficacy of studies of large size and/or high quality • Acomprosate – A: strong and consistent evidence of efficacy of studies of large size and/or high quality • Disulfiram – B: mixed evidence of efficacy • Serotonergic drugs –I: insufficient evidence • Lithium – C: evidence of lack of efficacy

15. Psychiatric Medications • Psychiatric Medications • The 3 revolutions in psychiatry • Schizophrenia & antipsychotic drugs • typical vs. atypical • Anxiety disorders and benzodiazepines • Mood disorders and antidepressants • (MAOIs; tricyclics; SSRIs; others -Wellbutrin) • Bipolar disorder: Lithium and anticonvulsants (Depakote, Tegretol, Lamictal)

16. TREATMENT OF SUBSTANCE USE DISORDERS TX myths 1. Nothing works 2. One approach is superior to all others (“one true light” tradition) 3. All treatment approaches work equally well for everyone - measuring outcomes - good studies use:________________________

17. TREATMENT OF SUBSTANCE USE DISORDERS • Outcome Studies • Hazeldon study: • N = 1,083 (71% retained)…53% abstinent at 1 yr. f/u • Drug Abuse Treatment Outcome Study (DATOS) – • natural tx in 4 settings: outpt. methadone clinics, outpatient drug-free, short-term inpatient, long-term residential: 1 year f/u data for outpt. methadone group • Pre F/U • N = 727 / 1,203 89.4%  27.8 heroin use • (60 %) 41.9%  21.7 cocaine use • *weekly or more drug use17.1%  13.9marijuana use • 14.8%  16.3 alcohol use, 5+ drinks • 28.6%  13.7 pred legal activity • 25.2%  12.9 sexual behavior risk

18. Type of Treatment Goal of Treatment Description Frequency CBT (Cognitive Behavioral Therapy) Learn skills to achieve and maintain sobriety Coping and drink-refusal skills taught by therapist to handle states and situations known to precipitate relapse 12 weekly sessions TSF (Twelve Step Facilitation) Acceptance of the disease of alcoholism and loss of control over drinking Patients introduced by therapist to the first steps of Alcoholics Anonymous and encouraged to attend meetings 12 weekly sessions MET (Motivational Enhancement Therapy) Mobilize the person’s own commitment and motivation to change Therapist applies motivational psychology to examine effect of drinking on patient’s life, and develop and implement a plan to stop drinking 4 sessions in 12 weeks Project MATCH Treatment Conditions

19. Project MATCH Results: N = 1,726 outpatients (n=952) and aftercare (n=774) at 5 sites (one of largest clinical trials ever) 25% were women; 15% were minority group members 10 client characteristics studied: severity etoh, sociopathy, cognitive impairment, gender, meaning seeking, motivation, psych severity, etc. 90% of the participants were assessed at 1-year follow-up pre-post differences in drinking days per month (25  6) and drinks per “drinking” day (15  3) each of the 3 treatments worked about equally well in reducing drinking

20. TSF outpatients more likely to remain sober (24%) at 1 yr. than outpatients in CBT or MET (about 15%) only 1 “matching” prediction supported: outpatients with few or no psychiatric problems had more abstinent days in TSF tx than in CBT At 3-yr. follow-up: 36% of TSF clients abstinent vs. 27% MET and 24% CBT clients *** strong correlation between abstinence rates and compliance with aftercare (“recovery” is a PROCESS).

22. Principles of Effective Treatmenthttp://www.nida.nih.gov/PODAT/PODAT1.html • No single treatment is appropriate for all individuals. • Treatment needs to be readily available. • Effective treatment attends to multiple needs of the individual, not just his or her drug use. Clients with coexisting mental disorders should have both disorders treated in an integrated way. • In order to meet the changing needs of the client, the treatment plan must be continually assessed and modified.

23. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. Counseling (individual, couple, and/or group) and other behavioral therapies are critical components of effective treatment for addiction... Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.

24. Treatment does not need to be voluntary to be effective Possible drug use during treatment must be monitored continuously. Treatment programs should provide assessment and counseling for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases to help patients modify or change behaviors that place themselves or others at risk of infection. Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment.