FIVE QUESTIONS : What is addiction? How do addicts differ from others?

2. FIVEQUESTIONS: What is addiction? How do addicts differ from others? What thinking causes addiction? 4. What cultures cause addiction? Is addiction decreasing/increasing?

3. MODELS OF ADDICTION

4. Disease Model of Addiction  Inbred/biological  Loss of control  Lifelong/permanent  Inevitable progression  Requires medical/spiritual treatment

5. Neurochemical Model  Addiction operates through dopamine  Drugs elevate dopamine  pleasure  Neuroadaptation  dependence  Requires treatment  chemical blocks  Leshner: “It's a myth that millions of people get better by themselves.”

6. ADDICTION IS… Understanding brain chemistry, not building up willpower, is the key to preventing adolescent alcohol and other drug addiction. Source: Nora Volkow, director, National Institute of Drug Abuse (NIDA).

7. Cognitive-Behavioral Model  Alter thinking  action  Present oriented  Skills oriented • - internal/cognitive • - external/practical • Coping/problem solving - applied to substance abuse - dysfunctional thinking  cycle

8. THE CONCEPT OF ADDICTION

9. Problems with the Addiction Concept Which drugs are addictive? • ILLICIT • cocaine • marijuana • LEGAL • nicotine • caffeine • antidepressants

10. Are Addictive Drugs Always Addictive • hospital patients • the clinical bias • Vietnam

11. What Happened in Vietnam? Of all those addicted… • 60% used narcotics stateside • 12% re-addicted any time • 6% addicted after three years

12. What is Addiction? Source: Stanton Peele, Diseasing of America, San Francisco: Jossey-Bass.

13. Vietnam vs. Home Environments • Fear and privation • -Control • -Positive options • -Social support • -Values of moderation

14. Addictive Criteria • Absorbing • Predictable • Sense of control / value • Illusory • Deepening / worsening

15. Gambling Example • Absorbing activity • “Predictable” • Sense of value and control • Growing penalties

16. ADDICTION IS… an absorbing activity that provides essential emotional rewards otherwise not available to one that entails growing life detriments. Source: Stanton Peele, The Meaning of Addiction, San Francisco: Jossey-Bass.

17. Sources of Addiction • Stressed environments • Lack of satisfaction • Lack of moderating influences • Lack of coping skills • Lack of self-efficacy

18. HOW CAN LOVE BE ADDICTIVE?

19. Causes of Relapse Two factors predicted relapse following treatment: “lack of coping skills and belief in the disease model of alcoholism.” Source: Miller, W.R., Westerberg, V.S., Harris, R.J., et al. (1996). What predicts relapse? Prospective testing of antecedent models. Addiction, 91 (Supplement), S155-171.

20. NATURAL RECOVERY & THE PROCESS OF CHANGE

21. What's the hardest drug to quit?

22. Did I ever tell you about my uncle Ozzie?

24. Illicit Drug Use Lifetime, Past Month, Ages 12+: Percentages, 2002 Lifetime Last Month Last Month/ Lifetime Cocaine 15 1 7 Crack 3 .3 9 Heroin 2 .1 6 Source: SAMHSA (2003, Table 1.1B)

25. Age 16-17 18-25 26-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ % Abuse/Dep 17 22 15 12 11 9 8 7 3 4 1 Addiction and Age

26. NESARC 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) : 43,093 in-person interviews 4422 DSM-IV alcohol dependent Source: Dawson, D.A., Grant, B.F., Stinson, F.S., & Chou, P.S., et al. (2005). Recovery from DSM-IV alcohol dependence: United States, 2001-2002. Addiction, 100, 281-292.

27. NESARC Past-Year Improvement Among Alcoholics (columns percentaged) TreatedUntreated Past Year Status(n=1,205) (n=3,217) Dependent 28 24 Abstinent 35 12 Drinking w/o dependence36 64 Source: Dawson et al. (2005)

28. Summarizing NESARC • Most alcoholics untreated • Treated alcoholics do no better • Most alcoholics cut back drinking • What were these people thinking? • Implications for treatment/policy

29. HARM REDUCTION THERAPY

30. What is harm reduction?

31. Principles of Harm Reduction  Consequences of behavior  Non-abstinence outcomes  Client-centered  Low threshold / low commitment • Pragmatic • Marlatt, A. (1996). Harm reduction: Come as you are. Addictive Behavior, 21, 779-788.

32. Is harm reduction accepted?

33. Why not?

34. SCIENTIFIC RESEARCH ON ALCOHOLISM

35. EFFECTIVE THERAPIES

36. Effective Alcoholism Treatments CES * Severity Brief interventions 390 2.47 Motivational enhancement 189 2.72 GABA (Acamprosate) 116 3.80 Community reinforcement 110 3.43 Self-help manual 110 2.59 *Cumulative Evidence Score Source: R.K. Hester and W.R. Miller (Eds.), Handbook of Alcoholism Treatment Approaches (3rd Ed.). Boston: Allyn and Bacon.

37. Ineffective Alcoholism Treatments CES* Severity Twelve-step facilitation -82 3.67 Alcoholics Anonymous -94 3.14 Confrontational counseling -183 3.00 General alcoholism counseling -284 3.22 Education (tapes, lectures) -443 2.44 * Cumulative evidence score Source: R.K. Hester and W.R. Miller (Eds.), Handbook of Alcoholism Treatment Approaches (3rd Ed.). Boston: Allyn and Bacon. (3rd Ed.). Boston: Allyn and Bacon.

38. HOW DO PEOPLE REALLY CHANGE?

39. BI/MI – What Is Common? • Minimal time in therapy • You must change • True to your values • Self-efficacy • Harm reduction

40. Patient Resources + Outcomes • Treatment or No • Stable marriage • Social/community stability • Higher socioeconomic functioning • Higher intellectual functioning • Employment - Job skills • Motivation to change • Ability to cope with stress

41. A Different View of Addiction • People change the more resources they have • They are helped by summoning the resources they possess • Treatment assists by helping them gather resources • Treatment not essential

42. Assessing Resources: • Intimacy and supportive relations • Work skills and accomplishments • Activities and interests • Coping with your world • Coping with yourself • Beating previous addictions

43. Stages of Change: How People Really Do It • Believe that the addictive involvement violates more important values. • Want to quit/ and believe you can. • Develop alternative rewards that are more meaningful than addiction. • Find/develop resources in life to maintain rewards.

44. Stages of Change: How People Really Do It (continued) • Rely on friends, family, and groups to help support the change in behavior. • Avoid situations and ways of thinking that provoke relapse. • Eventually develop a new self-image, a view of oneself as a former addict. • Develop higher goals than addiction.

45. ARE ALL SOCIETIES EQUAL? ALCOHOL

46. % of men who Drink every dayBinge 1+/week Ireland 2 48 Italy 42 11 Alcohol and Moderation Ireland vs. Italy Source: European Comparative Alcohol Study Norstöm, T. (Ed.). (2002). Alcohol in postwar Europe: Consumption, drinking patterns, consequences and policy responses in 15 European countries. Stockholm: SW: National Institute of Public Health, pp. 196-205.

47. Country% Drunk 10+/year Drunken 15-16 year olds • Denmark 39 • Finland 29 • U.K. 28 • Ireland 27 • Iceland 19 • + + + • Greece 4 • Malta 4 • Portugal4 • France 3 • Italy 2 Source: Plant, M., & Miller, P. (2001). Young people and alcohol. Alcohol & Alcoholism, 36, 513-515.

48. Non-Temperance Recipe  Regular consumption  With meals  Across gender, age groups  Drinking + / drunkenness -

49. Model for Moderation • Drinking is regular, accepted  Bad drinking, good drinking taught  Bad behavior not excused by drinking

50. PROTECTING AMERICAN YOUTH