January 26, 2012

• Defining the Problem
  • Who is taking the drug?
  • What drug is being used?
  • When and where is the drug being used (in what situation/context)?
  • Why does someone take a drug? (Can be answered by looking for consistency in the situations in which the behavior occurs)
  • How is the drug being taken?
  • How much of the drug is being used?
• Terminology
  • What do we mean by “psychoactive substance”?
    • Ingested substances that work on the central nervous system
  • Why do we say “alcohol and other drug abuse”?
    • Make it explicit that alcohol is a drug
  • Why do we say “use and abuse” or “problematic use”?
    • There are some drugs that are used theraputically, and some use is not problematic (ex. one glass of wine during dinner)
• Four Principles of Psychoactive Drugs
  1. Drugs are not good or bad. It does not contain evil intent, but the user might use it abusively.
  2. Every drug has multiple effects. The same drug can be a painkiller and a substance causing psychological problems. It can affect both the brain and the body.
  3. Both the size and the quality of a drug’s effect depend on the amount the individual has taken.
  4. The effect of any psychoactive drug depends on the individual’s history and expectations.
• Motives for Drug Use
  • Humans are social animals that try to impress others, so we do things that we know we should not do
  • Adolescents who know adults or peers who use drugs, or feel as if the adults or peers around them are not a source of support, are more likely to use drugs
  • Some people begin young to identify themselves with a deviant subculture
  • Individuals having difficulty impressing others use drugs and exhibit dangerous behavior to demand attention
  • Once use begins, drugs have a reinforcing effect that encourages users to continue using
  • Some high schoolers use drugs for the experience or because they are bored
• Conceptual Frameworks
  • Impose a pattern on reality
  • Provide a general sense of cohesion, direction, and purpose
  • Aid in identifying and organizing one’s thinking
  • Provide a shortcut for understanding from what perspective an argument is coming from
  • Questions they may answer:
    • How and why do some people use substances?
    • What defines problematic use?
    • Why is it that some people use without problem, and other people develop problems?
    • Fundamentally, what is the cause of problematic use?
    • How should we respond to problematic use
  • Questions to aid our evaluation of conceptual frameworks:
    • What does it say about the environment (things that are right around the user, as well as the macroenvironment) in which people use the substance?
    • What does it say about the substance?
    • What does it say about the person using the substance?
  • Conceptual frameworks are not static entities
    • Have changed over time
    • May have changed and developed in response to a specific substance or group of substances
    • Example: Nixon was the first to declare war on drugs
• Four Broad Conceptual Frameworks for Alcohol and Other Drug Use/Abuse
  • Moral/Legal Perspective
    • Substance is active, the primary culprit or cause, legal/illegal distinction is important
    • User is ignorant, unwilling, deviant, victim
    • Environment is of little interest
    • Responses: punishment, threat, control availability, increase cost (taxes), persuasion and drug education (scare tactics)
  • Medical/Pharmacological Perspective
    • Substance is active; dependence-producing potential is of interest
    • User is vulnerable or not vulnerable due to their biology and knowledge
    • Environment is favorable or not to development of problems
    • Responses: detoxification, drug solutions, drug education (about drug effects)
  • Psychosocial Perspective
    • Substance is less important
    • User is active, meaning and function of use to the individual is important, may be psychologically vulnerable
    • Environment: family, peers, immediate community influence is important
    • Response: counseling, therapy, drug and skills education (values, decision-making, relapse prevention, etc.)
  • Sociocultural Perspective
    • Substance gains meaning by society’s definition
    • User may have problems due to own behavior and society’s response
    • Environment is active; poverty, discrimination, and lack of opportunity lead to increased risk
    • Response: social policy, advocacy, legislation
• Comprehensive Conceptual Framework: Public Health Model
  • Substance = Agent
  • User = Host
  • Environment = Environment
  • Recognition that all three (and interactions between the three) are causal factors in understanding and intervening with any disease or health problem

January 31, 2012: Terminology

• Agent
  • Drug, substance, chemical
  • Definition: psychoactive substance that has an impact on sensation, thinking, mood, or behavior, and does this through its effect on the central nervous system (alters structure or function)
• Host
  • User, alcoholic, addict
  • “People First” Language: Person with an alcohol problem, person with a substance use disorder, etc.
  • They are not defined by their disorder as a whole – there is much more to them
  • Sometimes, identity as an alcoholic, etc. can be important/empowering to an individual during recovery
• Field
  • Addictions Field
  • Alcohol and Other Drug Abuse (AODA)
  • Alcohol, Tobacco, and Other Drug Abuse (ATODA)
  • Chemical Dependency Field
  • Substance Abuse Field
• Range of Use
  • Use
  • Abuse (used very broadly)
  • Troublesome use
  • Problematic use (two categories)
    • Problematic use not meeting criteria for diagnostic disorders
    • Problematic use that does meet criteria for diagnostic disorders: substance use disorders
• Substance Abuse Disorder
  • Maladaptive (does not help someone adapt to their environment) pattern of substance use leading to clinically significant (in need of medical attention, recurrent) impairment or distress, as manifested by one or more of the following, occurring within a 12 month period:
    • Recurrent use resulting in failure to meet major role obligation (school, work, family, social)
    • Recurrent use in situations in which it is physically hazardous
    • Recurrent substance-related legal problems
    • Continued use in spite of social/interpersonal problems
• Substance Dependence Disorder
  • More severe diagnostic disorder
  • Maladaptive pattern of use, leading to clinically significant impairment or distress, as manifested by 3 or more of the following:
    • Tolerance
    • Withdrawal
    • Substance taken in larger amounts or over longer time period than intended
    • Persistent desire / unsuccessful efforts to cut down or quit
    • Great deal of time spent in activities to obtain the substance, use the substance, or recover from its effects
    • Important social, occupational, or recreational activities are given up or reduced because of use
    • Continued use of substance despite knowledge of having a persistent/recurrent psychological or physical problem that is caused or exacerbated by the use
  • These substance disorders are more focused on behavioral symptoms than they are physical.
• Other Use Terms
  • Misuse: use of prescribed drugs in amounts greater than, or for different purposes than, what is prescribed. Or, use of substances other than their intended use (paint, glue, solvents, etc.)
  • Deviant Use: use that is not common or accepted within a social group
  • Addiction: imprecise, often used interchangeably with dependence

February 02, 2012

• Terminology
  • Processes
    • Intoxication: reversible state caused by recent use of a substance that is typically characterized by substance-specific constellation of physiological, behavioral, and cognitive-emotional changes
    • Withdrawal: typically involves the opposite experiences that are associated with intoxication of the substance consumed (e.g., the euphoria of cocaine intoxication is countered by feelings of depression in cocaine withdrawal)
      • Does not occur for all psychoactive substances.
      • Sometimes a distinction is made between physical/psychological withdrawal symptoms.
      • Can be caused by a disruption in balance because of the body abruptly not needing something for which it compensated. Example: heroin causes intestines to move slower, so the body compensates by speeding it up. If heroin is no longer used, the intestines are now moving too fast.
    • Craving: intense desire to use the substance (often occurs during the state of withdrawal)
    • Tolerance: the process of needing to use more of a substance in order to achieve the same effect previously achieved with a smaller amount.
  • Drug Effects
    • Dependence: state of needing the drug; difficult to get along without it
      • Physiological (presence of physical withdrawal symptoms) and psychological
      • At first we thought it was impossible to get cocaine dependence because it had no physiological symptoms
      • Now we think that the distinction between physiological and psychological symptoms are insignificant as we discover more about the mind-body connection
      • Psychological dependence is more important than physical dependence. The consequences of physical dependence (withdrawal symptoms) are not seen as severe by drug users, who soemtimes voluntarily go through them so they can user lower and more affordable doses of the drug.
      • Dependence on a substance varies not only by what the drug is, but also how the drug is used.
  • Substance Categories
    • Legal / illegal (illicit)
    • Schedule of controlled substances: substances that have a higher level of control have greater legal ramifications
    • According to their chemical properties
    • According to their effect on the central nervous system (depressant, stimulant, etc.)
    • “Street” versus other drugs
  • Drinking Behavior
    • Binge use: consuming 5 or more drinks on the same occasion in the past 30 days
    • Heavy use: consuming 5 or more drinks on the same occasion at least 5 different days in the past 30 days
    • For women, a more conservative approach takes body size and metabolism into account and lowers the requirement for binge use from 5 to 4 drinks
    • Although this does not directly translate to problematic use, it increases the risk of problematic use
    • “The same occasion” is generally considered to be one drinking session within a few hours
  • A “drink” is…
    • 12 oz. of beer or cooler
    • 8-9 oz. of malt liquor
    • 5 oz. of table wine
    • 3-4 oz. of fortified wine
    • 2-3 oz. of cordial, liqueur, or aperitif
    • 1.5 oz. of brandy
    • 1.5 oz. of spirits
• Use and Abuse…
  • Where is the line for you?
  • What criteria might you use to know when the line is crossed? What factors play a role?
• Historical Perspective
  • Themes
    • Our behavior and response to drug use is not static over time
    • Drugs of choice have alternately been glorified and vilified
    • There was a point in time when cocaine and heroin were okay drugs while alcohol was an evil drug
    • Ambivalence is reflected in the roles we ascribe to substances
    • Different reactions to the same drug over time
    • Rising potency of drugs tends to follow whenever they are banned or are more strictly controlled
    • After prohibition, distilled liquor became more popular than beer and wine
    • Substance use associated with immigrants/slaves became a mechanism for hysteria, racism, and discrimination
    • Drugs that were associated with immigrants (such as beer and wine with Europeans and opium with Chinese) were considered more evil
  • Across Time
    • There is no civilization whose citizens have not tried to escape from tedium or stress through altering their consciousness with alcohol, tobacco, tea, other plants
    • Animals of various species have been observed seeking out fermented berries
    • Human use of substances is unique in the ritual surrounding the use of the substance, planning involved in acquiring the substance, and social regulation
  • Colonial America and Beyond
    • Our Puritan founding fathers and mothers imbibed (drank alcohol)… a lot!
    • Both in Europe and early America, alcohol was often safer than water.
    • The tavern was the center of family, social, economic, and political activity.
    • Strong drink was thought to protect against disease, was used as a painkiller and as an antiseptic (medicinal).
    • There was more beer than water on the Mayflower. Beer was considered safer than water due to its fermentation and germ killing, and was consumed by children and pregnant women.
    • New Englanders distilled rum from Jamaican molasses. Used it for trade and consumed it themselves in large quantities.
    • Alcohol was measured in barrels.
    • Laborers digging the Erie Canal were allotted a quart of whiskey a day.
    • As long as social norms were followed, drinking excesses were tolerated.
  • Beginning of Changing Views Towards Alcohol (1785-1835)
    • As availability of cheap spirits increased, there was also an increase in solitary & binge drinking.
    • Alcohol use became intertwined with family breakdown.
    • Dr. Benjamin Rush, surgeon general during the American Revolution, observed the devastation wrought on soldiers by rum rations, and provided a scientific voice calling for an end to distilling and drinking whiskey and other spirits.
    • Call was echoed by concerned Puritan family members and clergy.
    • Solitary and binge drinking were not as a socially accepted form of excessive drinking.
  • Mid 1800s
    • Alcohol consumption cut in half. Beginning of “temperance” movement.
    • New attraction to patent medicines with high opiate content.
    • 1900 saw the prohibition of tobacco; selling it was illegal in 14 states.
    • Opium, morphine, and heroin were sold over the counter.
    • Temperance is the idea of moderate use of a substance
    • Temperance was focused on distilled liquor rather than beer or wine
    • Free cigarettes were provided to immigrants on Ellis Island in an attempt to get people more interested in smoking
  • Early 1900s
    • Warnings about danger of morphine began to appear, and in 1909, import of opium was banned.
    • Heroin (injected) became more popular.
    • Intolerance of tobacco dissolved.
    • As prohibition of alcohol spread, use of cocaine (in cola drinks, etc.) increased.
    • Pure Food and Drugs act of 1906 prohibited trade of misbranded foods and drugs, which allowed the government to enter and monitor the marketplace
    • Harrison Act in 1914 severely limited the amount of opioids or cocaine in any remedy without a prescription.
    • Tobacco: free distribution of cigarettes to World War I soldiers
    • The Harrison Act set the stage for modern-day drug control
    • By arresting physicians and pharmacists who were prescribing morphine and opioids to dependent users, the government narrowed the possibility of getting these drugs down to only the illegal market
    • The Jones-Miller act of 1922 increased penalties for illegal drug trade
    • The government started looking into methods of treatment rather than punishment because the prisons were filling up quickly with drug trade violators
    • In the 1980s, more laws were passed making punishments for drug use harsher, including minimum prison sentences, and aiming to reduce the demand for drugs
  • Prohibition of Alcohol
    • Grew out of temperance movement.
    • Attitudes toward alcohol use became more extreme, and attached to immigrant use.
    • 18th Amendment in 1919 outlawed alcohol.
    • Repealed in 1933.
    • The forbidden nature made it more attractive; it became associated with glamorized crime
  • Concerns Today
    • Toxicity
      • Poisonous, deadly, or dangerous
      • Behavior toxicity: the results of a drug causing normal activities (such as swimming or driving) to become dangerous
      • Acute: short-term effects of a single dose
      • Chronic: long-term effects of repeated use
    • Crime
      • Drug use leads to criminal personality
      • It is possible that drug use changes the individual’s personality in a lasting manner, turning him/her into a criminal type
      • People engage in criminal behavior to support their habit (stealing money to purchase more drugs)
      • Marijuana is not useful for committing a crime, but other stimulating drugs may be
      • Altered psychological state resulting from drug use leads to criminal behavior
      • Drug use, in and of itself, is criminal behavior
    • Dependence

February 07, 2012

• Follow-up from last class…
  • Is dependence on a substance, in and of itself, problematic?
  • Dependence is defined as having a craving for the substance to stay in physiological balance. It does not refer to needing a substance to stay alive, such as insulin for diabetics.
• Methadone example
  • “Methadone suddenly grows as a killer drug.” –NY Times, February 9, 2003
  • Government response: “Methadone-associated mortality: report of a National Assessment.” -SAMHSA publication #04-3904
  • Bourgois, P. (2000). Disciplining addictions: The bio-politics of methadone and heroin in the United States. Culture, Medicine, and Psychiatry, 24, 165-195.
  • Someone would take methadone instead of heroin because methadone is a less dangerous substance.
  • It becomes problematic when it is used as an ongoing treatment with no intention to eventually wane the patient off methadone.
• History of Treatment/Intervention
  • Disease Model / 12-step Programs (ex. Alcoholics Anonymous, Narcotics Anonymous)
    • Alcoholics are fundamentally different
    • Through fellowship with other alcoholics, must abstain from all alcohol
    • Requires a fundamental change in all aspects of one’s life
    • Not all of it is necessarily professionally-provided treatment
  • Cognitive-Behavioral Approaches
    • People lack basic skills to stop using and to avoid relapse
    • Antecedents of and thoughts associated with use are key
    • Does not necessarily mean they don’t have the motivation to stop using the substance
    • Take a look at the smaller units of the individual’s life (thoughts, behaviors)
    • Breaking it down into smaller units removes some of the personal blame
  • Motivational Enhancement
    • Built on theory of “stages of change”
    • Recognizes the similarity between change processes of all kinds of behaviors
    • Focus on increasing a person’s motivation to make a change
    • Successful behavioral change: pre-contemplation → contemplation (thinking about change) → preparation → action → maintenance
    • Recognizes that people sometimes have not finalized a decision to change
    • Older models would say that there’s nothing they can do until the person has a true desire to change; this model focuses on the steps leading up to the desire to change
  • Harm Reduction
    • Recognizes that there are things that can be done to reduce possibility of harm associated with use
    • Controversial, and yet, there are many examples of socially accepted harm reduction
    • Example: needle exchange program. Its main purpose is to reduce the chances of getting blood-transferrable illnesses. It is controversial because it provides a means for a person to use drugs in a safe way.
    • Example: designated driver. Allows people to drink a lot safely because they don’t have to worry about driving.
    • Example: smoking section. Allows people to smoke, but decreases the amount of harm other people receive as a result of others’ smoking.
    • Example: sex education. By giving children sex education and teaching them how to have safe sex, we may be encouraging sexual activity.
    • Evidence tends to show that giving people information about how to act safely does not necessarily encourage them to engage in the act.
• Drug and biology basics
  • Dosage: the drug’s effect is affected by the amount and strength of the dosage.
  • Potency: amount of drug that must be taken to get a certain effect. Example: alcohol has low potency because it takes a lot to go into effect, but LSD is highly potent (dosages are measured in micrograms). Potency does not necessarily reflect danger. Alcohol is less potent, but it is more dangerous.
  • Composition: what the drug is made up of, including active and inactive ingredients. Inactive ingredients include binders and fillers; they are not intended to have an effect on the person, but sometimes they do.
  • Frequency of use: how often someone uses a drug
  • Route into the body
    • The route determines how fast the substance is taken into the body
    • Swallowing: slightly slower because it must be ingested
    • Sublingual ingestion: ingest underneath your tongue; effective more quickly because the tissue under your tongue is more rich in blood
    • Injection
      • Subcutaneous: below the skin, not absorbed as quickly
      • Intramuscular
      • Intravenous: directly into the blood stream
    • Inhalation: quick; smoking takes 7-19 seconds for the substance to reach the brain
    • Snorting: mucus membrane
    • Transdermal: through the skin, much slower and longer-acting
• The Nervous System
  • Components of the Nervous System
    • Neurons: analyze and transmit information. All neurons contain a cell body (contains nucleus), dendrites (contain receptors that respond to chemical signals), axon (conducts electrical signal), and presynaptic terminals (chemical messengers).
    • Glia provide firmness/structure to the brainget nutrients into the system, eliminate waste, and form myelin (form blood-brain barrier for toxin protection). They take up about 90% of the cells in the brain
  • Neurotransmission
    • The action potential is an electrical signal that initiates neurotransmitter communication by positively charging the cell
    • Blocking Na+ channels prevents the cell from becoming more positively charged, reducing pain
  • The Nervous System
    • Somatic nervous system: peripheral nerves that input sensory information and output voluntary movement
    • Autonomic nervous system: controls visceral (involuntary) movement. Sympathetic branch is “fight or flight”; parasympathetic branch counteracts this to relax the organism
    • Central nervous system: brain and spinal cord. Sensory information comes in, movement goes out. This is where most information processing occurs.
    • The same neurotransmitter can have a different effect on different parts of the body; the receptor determines what the neurotransmitter does
  • The Brain
    • Dopamine controls reward signals. Overstimulation can cause hallucinations (ex. schizophrenia); understimulation (due to loss/damage of dopamine pathways) can cause movement problems (ex. Parkinson’s disease)
    • Acetylcholine: neurotransmitter found in parasympathetic branch. Deficiency can lead to Alzheimer’s disease due to damage to nucleus basalis (important for learning and memory)
    • Norepinephrine: controls level of arousal, attentiveness, and wakefulness; important for food intake, energy balance, and body weight
    • Serotonin: for food intake, body weight regulation, aggression and impulsivity, and depression
    • GABA: found in most areas of CNS; has inhibitory functions
    • Glutamate: makes cells more excitable
    • Endorphin: produce similar effects as morphine and opium; contributes to pain relief
    • Cortex: processing sensory information, control muscles
    • Basal ganglia: maintain muscle tone
    • Hypothalamus: hormonal output for feeding, drinking, temperature, sex
    • Limbic system: emotions, memory, physical activity
    • Brain stem: reflexes, neurotransmitter release, vomiting center
  • Drugs and the Brain
    • Drugs disperse in the body through blood equilibrium
    • Uptake: cell uses energy to take in needed molecules
    • Synthesis: making a neurotransmitter with enzymes
    • Neurotransmitters are stored in vesicles until they’re needed, then released all at once
    • Drugs alter the availability of neurotransmitters in the synapse, or act directly on the receptor
  • Chemical Theories of Behavior
    • Monoamine theory states too little causes depression and too much causes mania
    • Drugs are only slightly more effective than placebos, implying that depression is far more complicated
  • Brain-Imaging Techniques
    • PET: radioactive chemical injected into bloodstream
    • MRI: apply magnetic field and measure energy release; fMRI shows real-time data, while MRI only shows structural information
    • Research has found structural differences in drug users versus non-users, but not performance differences
• The Actions of Drugs
  • Sources of Drugs
    • Most drugs are from plants or chemically derived from plants
    • This is due to plants’ survival of the fittest
    • Chemical names display the drug’s entire composition, generic names are official and registered, and brand names are company trademarked
    • A drug can be patented for 20 years
  • Categories (based on effects to user)
    • Stimulant: produce wakefulness, energy, well-being; mania, excitement, paranoia, hallucinations
    • Depressant: disinhibition, relaxation, talkativeness, recklessness; slowed reaction, uncoordination, unconsciousness
    • Stimulants and depressants do not hard counter each other (ex: taking a stimulant and a depressant together will not make you normal)
    • Hallucinogens: altered visual perceptions and sensations
    • Psychotherapeutics: prescribed for mental problems. Antipsychotic: calm psychotic patients; antidepressants: recover mood
  • Drug Effects
    • Placebo: inactive drug that works through deception, primarily useful for depression and pain
    • Dose-response: some symptoms / side effects only occur when a particular amount of the drug is used (drug threshold, resistance to certain effects)
    • ED = effective dose, LD = lethal dose; numeric subscript is percent of animals tested that showed that result. Usually, LD₁ is much greater than ED₉₅
    • Potency: amount of drug needed for a response; getting the same effect with less drug amount = more potent
    • Time course: timing of onset, duration, and end of drug’s effects; time release distributes the drug’s release and extends its duration
  • Getting the drug to the brain
    • Oral: slowest and most complicated entry into bloodstream; might be metabolized before taking effect
    • Intravenous injection: very fast effect, able to inject high concentrations; may cause veins to weaken or collapse, introduces bacteria into body
    • Intramuscular: muscles have good blood supply, release of substance can be prolonged
    • Subcutaneous: under skin, similar to intramuscular, may cause irritation
    • Inhalation (smoking, huffing): efficient delivery with rapid effects – capillary walls thin, blood moves directly to brain; no storage system
    • Topical: very long-term release
    • Blood-brain barrier causes some drugs to act outside the central nervous system
  • Drug deactivation
    • Excreted from body, or changed so it has no effect
    • Enzymes can change the drug’s chemical structure (ex. CYP450)
  • Mechanisms of tolerance and withdrawal
    • Drug tolerance usually takes the form of positive feedback loops
    • Behavior tolerance is like practicing and getting better at tasks while intoxicated
    • Pharmacodynamic tolerance: nervous system becomes less sensitive

February 09, 2012

• Follow-up from last class…
  • Notion that there is something different about the brains of adolescents who become substance-dependent and that this difference predates the drug use
  • Idea that the brain changes and adapts to repeated exposure to substances
  • Idea that the brain matches or agrees with people’s subjective report of drug craving/desire
• Etiology
  • Relates to an understanding of the roots and origins of a specific problem, the factors that shape its development, and the influences that might interfere with or ameliorate its course
  • Importance of etiology of substance use disorders
    • Helps us to identify persons who are at risk
    • Helps us to understand why they are at risk
    • Helps us in our strategies to alleviate risk
    • Helps us to determine treatment strategies that are likely to be effective
• Biological Theories
  • Genetic — pedigree, twin, and adoption studies
    • Most studies have examined alcohol use disorders because it is frequently used and people are willing to admit use of alcohol because its legal
    • Pedigree studies: examination of extended family history
      • Although rates vary from study to study, higher rates of alcohol dependence (AD) are consistently found among family members of persons with AD
      • Positive association between rate of AD and pedigree position (higher rates among closer relatives). Risk for developing AD is 4 to 7 times greater for first degree relatives when compared to general population.
      • Small amount of evidence for the genetic transmission of other drug use disorders
    • Twin studies: comparison of rates of disorders among monozygotic (identical; twins share the same genes) and dizygotic (fraternal; do not share a complete set of genes, but more than regular siblings) twins
      • Majority of studies report increased concordance of AD among monozygotic twins compared to dizygotic twins
      • Several studies have also reported similarity in alcohol consumption patterns among twins raised apart
    • Adoption studies: comparisons of rates of disorders for biological parents and adopted children
      • Studies in Scandinavia and US of adopted infants being raised by adoptive parents without AD
      • Adoptees who have biological parents with AD develop AD as adults at rates higher than adopted children who have biological parents without AD
    • What we can conclude…
      • Difficult to separate biological (genetic) factors from possible environmental influences in family studies. For example, consider that political ideology is often “passed on” among family members.
      • Genetic factors are NOT determiniistic
      • No single gene has been identified. Rather, it is likely that there is a combination of genes that are responsible for increased vulnerability.
      • Also likely that there are genes that are responsible for increased protection
    • Mechanism of Heritability: Gene-Environment Interaction
      • Many researchers have stressed the importance of the interaction between genetic vulnerability and environmental risk factors
      • Environmental factors, although not definitively identified, are thought to contribute either increased risk or increased protection
      • Synergistic relationship between genetic and environmental factors
      • Even if someone has an extremely high genetic vulnerability, they do not always have the increased risk, so it shows that another factor is playing a role
      • Protective factors include involvement in alternatives to alcohol-related activities (such as religious affiliations)
  • Neurobiological — brain imaging, neurocognitive testing, brain wave measurement
    • “Go!” System
      • Primitive reward system
      • Limbic and mesolimbic system
      • Relatively well-developed during adolescence
      • System is activated in a much stronger way in response to drugs of abuse than to other natural rewards (food, sex, etc.)
      • Cocaine dependent individuals show fewer dopamine receptors
      • Was thought to be a result long history of cocaine use, but there is new evidence suggesting that low dopamine receptors may predate drug use (and thus, be considered a risk factor)
    • “Stop!” System
      • Inhibitory or “put on the brakes” system in prefrontal cortex
      • Has more reasoning and logic; helps someone think through potential consequences of behavior
      • Less developed in adolescents
      • Adults who are substance dependent show important deficits in the effectiveness of the “stop!” system
      • Poorer performance on tests of long-term strategy and decision making
      • Brain-imaging data of persons with cocaine or alcohol dependence demonstrate lower frontal cortex activity (blood flow and glucose metabolism are reduced) and structural difference (fewer nerve cells)
• Additional Etiological Models
  • Psychological models
    • Behavioral: environmental conditioning
    • Cognitive: beliefs, expectancies
    • Social learning: we do what we see
  • Sociocultural models
    • Family
    • Peer
    • Social environment

February 14 & 16, 2012: Tobacco

• History and Evolution of Use
  • Used as medicine: “the holy plant” and “the plant against all evils”
  • Nicotiana tobacum grew well and was used for products; it became an important component of the economy
  • Products varied from pipes, snuff, chew, cigars, and cigarettes
  • After tobacco became under attack, production companies tried to:
    1. Undermine scientific evidence against tobacco
    2. Produce a “safer” filtered type
  • Tobacco companies came to a $205 billion settlement for a cap on legal liability
  • Reducing nicotine and other safety implementations just causes people to compensate and use more
  • An alternative to cigarettes called Eclipse was rejected by government agencies
  • The FDA is now able to somewhat regulate tobacco as a drug, but this might give off the impression that it is FDA approved and that it is safe
  • Cigarette use among high schoolers has declined; higher level of education reduces smoking rates, but not because of knowledge, but because of social context
  • Smokeless tobacco use is on the rise (ex. moist snuff, chewing tobacco); causes less problems to lungs and others, but causes more problems to the mouth
  • Hookahs are water pipes used for milder smoking
• Basics
  • More than 4000 chemicals found in tobacco smoke
  • Nicotine is the primary reinforcing/addictive component
  • Multiple other chemical components are responsible for ill health effects
• Mechanisms of Addiction
  • Nicotine activates the reward (“go!”) system by increasing dopamine levels by both activating and inhibiting nicotine-related neuron receptors
  • Tobacco smoke is related to decreased level of monoamine oxidase (MAO), an enzyme that breaks down dopamine, thus, increasing dopamine levels
  • Nicotine’s pharmokinetic properties also enhance its abuse potential: via smoking, drug level peaks in 10 seconds, but acute effects (including reward) wear off in a few minutes, causing the smoker to administer another dose
• Pharmacology
  • Nicotine is one of the most toxic drugs known
  • Primarily deactivated in the liver
• Immediate Physiological Effects
  • Nicotine stimulates the adrenal glands, resulting in a rush of epinephrine (adrenaline) which causes a sudden release of glucose and increases blood pressure, respiration, and heart rate
  • Nicotine suppresses insulin output from pancreas which means that smokers are always slightly hyperglycemic
  • Nausea, dizziness, weakness; tremors, convulsions, suffocation; lack of hunger, decreased skin temperature, increased blood pressure
• Immediate Psychological/Behavioral Effects
  • Smokers report seeking both activation/stimulation and tranquilizing/calming effects
  • Some studies suggest that smokers are able to sustain attention to a task requiring rapid information processing if allowed to smoke before beginning the task
  • Strong possibility that calming effects reported and increased performance are related to interference with withdrawal symptoms
  • Withdrawal symptoms include irritability, craving, sleep disturbance, cognitive disturbance, and increased appetite
• Health Effects
  • Responsible for death of 440,000 US persons each year
  • Smoking kills an estimated 5 million people per year worldwide
  • Since 1964, more than 12 million Americans have died prematurely from smoking
  • 25 million American smokers alive today will most likely die of a smoking-related illness
  • Cigarette smoking accounts for 1/3 of all cancer deaths
  • Death rates from cancer are twice as high among smokers as nonsmokers, and four times as high for heavy smokers
  • Cigarette smoking is linked to 90% of all lung cancer, which is the number one cancer killer for men and women
  • Cigarette smoking also linked to other cancers: mouth, esophagus, stomach, pancreas, kidney, bladder, etc.
  • 90% of all deaths from chronic obstructive pulmonary diseases (COPD) such as bronchitis and emphysema are linked to cigarette smoking
  • Cigarette smoking substantially increases risk of heart disease, including stroke, heart attack, vascular disease, and aneurysm; estimated that smoking is responsible for 21% of deaths from coronary heart disease each year
• Effects of Cigarette Use by Pregnant Women and Parents
  • Smoking during pregnancy increases risk of premature delivery, low birth weight infants, and, in some cases, spontaneous abortion, sudden infant death syndrome, as well as some learning/behavior problems in childhood
  • Smoking more than a pack a day during pregnancy nearly doubles the risk that the affected child will become addicted to tobacco if that child starts smoking
  • Children raised in households with smokers are at greater risk for developing asthma & other health problems
• Costs
  • Tobacco use is the leading preventable cause of death in the US
  • More than $75 billion in total US healthcare costs are directly attributable to smoking
  • Does not include the costs of burn care, perinatal care for low birth weight infants, and healthcare related to second hand smoke
• How to Stop
  • Quitting is difficult because of the reinforcing effect
  • Nicotine can be prescribed without toxins and tars
  • Combining with counseling increases chances of quitting
  • People tend to quit better if they quit by themselves, but these people have also been smoking for shorter periods of time
• Clinical Practice Guidelines (Treating Tobacco Use and Dependence, 2008 Update)
  1. Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective treatments exist, however, that can significantly increase rates of long-term abstinence.
  2. It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health care setting.
  3. Tobacco dependence treatments are effective across a broad range of populations. Clinicians should encourage every patient willing to make a quit attempt to use the counseling treatments and medications recommended in this Guideline.
  4. Brief tobacco dependence treatment is effective. Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective in this Guideline.
  5. Individual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity. Two components of counseling are especially effective, and clinicians should use these when counseling patients making a quit attempt:
     • Practical counseling (problem solving / skills training): How are you going to get through your day without a cigarette? What time of day do you want a cigarette the most? How do you refuse a cigarette when someone offers it to you? How do you stop the urge to buy cigarettes?
     • Social support delivered as part of treatment: someone out there who cares
  6. Numerous effective medications are available for tobacco dependence, and clinicians should encourage their use by all patients attempting to quit smoking—except when medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents).
     • Seven first-line medications (5 nicotine and 2 non-nicotine) reliably increase long-term smoking abstinence rates: Bupropion SR (anti-depressant), nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, Varenicline
  7. Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either alone. Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication.
  8. Telephone quit line counseling is effective with diverse populations and has broad reach. Therefore, both clinicians and health care delivery systems should ensure patient access to quit lines and promote quit line use.
  9. If a tobacco user currently is unwilling to make a quit attempt, clinicians should use the motivational treatments shown in this Guideline to be effective in increasing future quit attempts.
  10. Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders. Providing coverage for these treatments increases quit rates. Insurers and purchasers should ensure that all insurance plans include the counseling and medication identified as effective in this Guideline as covered benefits.
• Brief Intervention – 5 As
  • Ask about tobacco use
  • Advise to quit
  • Assess willingness to make a quit attempt
  • Assist in quit attempt
  • Arrange a follow-up
• Policy and Regulation
  • Taxing tobacco products
    • In Wisconsin:
      • 2001 – 2007: $0.77/pack
      • Jan. 2008 – Aug. 2009: $1.77/pack
      • After Dec. 2009: $2.52/pack
  • Regulating where smoking is allowed
    • Example: there used to be a smoking section in airplanes
    • There have historically been smoking sections in many places, but that has been reduced now
  • Advertising
  • Warning labels on products

February 21 & 23, 2012: Alcohol

• Overview
  • World’s most important psychoactive drug
  • Alcoholic beverages have been consumed for thousands of years, perhaps as far back as 8000 BC
  • A central nervous system depressant
  • Society’s love-hate relationship wth alcohol: social lubricant? adjunct to a fine meal? demon rum?
• Fermentation Products
  • Fermentation: the production of alcohol from sugars through the action of yeasts; forms the basis of all alcoholic beverages
  • Mixing fruits and yeast will cause fermentation to begin (fruits naturally contain sugar
  • Cereal grains contain starch, which must be converted to sugar by malt before fermentation can begin
  • Yeast has a limited tolerance for alcohol – when alcohol concentration reaches 15%, the yeast dies and fermentation ceases
• Distilled Products
  • Distillation: evaporation and condensing of alcohol vapors to produce beverages with alcohol content higher than 15%
    • First used in Arabia around 800 AD
    • Introduced into Europe in about the 10th century
    • In U.S., began on a large scale at the end of the 18th century
  • Proof: alcohol content of a distilled beverage, twice the percentage of alcohol by weight
    • 90-proof whiskey is 45% alcohol
• Alcohol Use: Early Views
  • Before American Revolution
    • People drank more alcohol than water
    • Drunkenness was viewed as misuse of positive product
  • After American Revolution
    • Alcohol itself viewed as the cause of serious problems, an active agent of evil
    • Alcohol was first psychoactive substance to become demonized in American culture
• Temperance Movement
  • Benjamin Rush (1745-1813)
    • Heavy drinking = health problems
    • Alcohol use damages morality
    • Alcohol addiction is a disease
  • Temperance societies
    • Initially promoted abstinence from distilled spirits and moderate consumption of beer and wine
    • Later promoted total abstinence
  • Became fashionable to “take the pledge”
• Prohibition
  • States began passing prohibition laws in 1851
    • By 1917, 64% of Americans lived in “dry” territory
    • Laws reflected issues of class, ethnicity, religion, immigration, and politics
    • People still drank illegally in speakeasies and private clubs and legally through purchase of patent medicines
  • Federal prohibition
    • 18th Amendment of the U.S. Constitution, banning the sale of alcohol, was ratified in January 1919
    • National prohibition went into effect in January 1920
    • People continued to buy and sell alcohol illegally, and enforcement was challening and expensive
    • Organized crime became more organized and profitable
    • Alcohol dependence and alcohol-related deaths declined
  • Prohibition Repealed
    • Concerns that widespread disrespect for prohibition laws encouraged a general sense of lawlessness
    • Taxation: alcohol taxes had been a major source of revenue
    • Repealed by the 21st Amendment (ratified in 1933)
    • Alcohol per capita sales and consumption increased slowly until after World War II, when they returned to pre-prohibition levels
• Who Drinks and Why?
  • Cultural influences on drinking – ethnic and social factors
  • Trends in U.S. alcohol consumption
    • Use peaked in 1981, followed by a decline, mirroring patterns of illicit drug use
    • Decline particularly significant for distilled spirits
    • About one-third of Americans abstain
    • Average consumption among drinkers is about three drinks per day, but most drink far less
    • Half of all alcohol consumed in the United States is consumed by about 10% of the drinkers
  • Regional differences in the United States
    • Stress index: drinking rates higher in states where people experience a great deal of social stress and tension
    • Drinking norms: drinking rates higher in states where people tend to approve of the use of alcohol to relieve stress
  • Defining Alcohol Consumption
    • Prior to 1970, per capita consumption = total alcohol beverage sales / total population over age 15 years
    • Since 1970, per capital consumption = total alcohol beverage sales / total population over age 14 years
    • The 1997 per capital consumption was 2.18 gallons of ethanol per person
  • U.S. Alcohol Consumption
    • Gender differences: males more likely to drink than females, and more likely to drink more
  • Drinking among college students
    • College students drink more than their non-student peers
    • Many campuses have banned sale and advertising of alcohol, and many fraternities have banned keg parties; alcohol use and drinking behavior hasn’t changed significantly in response
    • Today’s college students are less likely to drink and drive compared to students in the early 1980s
• Definitions of Drinking Behavior
  • Binge alcohol use: drinking 5 or more drinks on the same occasion (at the same time or within a couple of hours of each other)
  • Heavy alcohol use: drinking 5 or more drinks on the same occasion on each of 5 or more days in the past 30 days
• Alcohol Pharmacology
  • Absorption
    • Some absorbed in the stomach, most in the small intestine
    • Absorption is slower if there is food or water in the stomach
    • Absorption is faster in the presence of carbonated beverages
  • Distribution
    • Blood alcohol concentration (BAC) is a measure of the concentration of alcohol in the blood, expressed as a percentage in terms of grams per 100 mL
    • Alcohol is distributed throughout body fluids
    • Alcohol is less distributed in fatty tissues, so a lean person will have a lower BAC than a fatter person
  • Metabolism
    • Liver metabolizes about 0.25 oz. of alcohol per hour
    • If rate of intake = rate of metabolism, BAC is stable
    • If rate of intake exceeds rate of metabolism, BAC climbs
    • About 2% of alcohol is excreted unchanged; about 90% is metabolized in the liver
    • Exercise, coffee, and other strategies do not speed up the rate of metabolism
    • Liver responds to chronic intake of alcohol by increasing enzyme activity; contributes to tolerance among heavy users
• Gender Differences
  • Women tend to be more susceptible than men to the effects of alcohol after consuming the same amount
  • Stomach enzyme that metabolizes a small amount of alcohol is more active in men
  • Women absorb a greater proportion of the alcohol they drink
  • Women tend to weigh less and have a higher proportion of body fat
  • “Tank” into which alcohol is added is smaller
• Mechanism of Action
  • Central nervous system depressant
  • Used as anesthetic until the late 19th century
  • Alcohol has many effects on the brain and the mechanisms are difficult to pin down
  • Similar to barbiturates and benzodiazepines, it enhances the inhibitory effect of GABA at the GABA-A receptor
  • At high doses, it blocks the effects of the excitatory transmitter glutamine
  • It affects dopamine, serotonin, and acetylcholine neurons
• Blood Alcohol Concentration and Behavioral Effects
  • 0.05: Lowered alertness, release of inhibitions, impaired judgment
  • 0.10: Slower reaction times, impaired motor function, less caution
  • 0.15: Large, consistent increases in reaction time
  • 0.20: Marked depression in sensory and motor capability, intoxication
  • 0.25: Severe motor disturbance, staggering, great impairment
  • 0.30: Stuporous but conscious – no comprehension of what’s going on
  • 0.35: Surgical anesthesia; about LD1, minimal level causing death
  • 0.40: About LD50 (letal dose 50%)
• Alcohol Toxicity: Long-Term Risks and Effects
  • Brain tissue loss and intellectual impairment
  • Liver disease: hepatitis, fatty liver, cirrhosis
  • Heart disease: cardiomyopathy, heart attack, hypertension, stroke; alcohol’s effects on HDL may reduce heart attack risk among moderate drinkers
  • Cancer
  • Impaired immunity
• Fetal Alcohol Syndrome (FAS)
  • A collection of physical and behavioral abnormalities caused by the presence of alcohol during fetal development
  • Diagnostic criteria: growth retardation before and/or after birth, pattern of abnormal features of the face and head, evidence of central nervous system abnormality
  • Fetal alcohol syndrome: related to peak BAC and to duration of alcohol exposure; prevalence of 0.2 to 1.5 per 1,000 births
  • Fetal alcohol effects: all alcohol-related developmental abnormalities associated with prenatal alcohol exposure; prevalence of 80-200 per 1,000 births
  • Drinking during pregnancy increases the risk of spontaneous abortion
  • Data do not prove that low levels of alcohol use during pregnancy are safe or that they are unsafe
• Alcohol and Violence
  • Alcohol is related to both aspects of violence – perpetration and victimization
  • Offenders were drinking in 86% of homicides, 60% of sexual offences, 37% of assaults, 27% of females and 57% of males involved in marital violence, 13% of child abuse cases
  • Risk factors for becoming violent include history of violence, multiple drug use, co-morbid psychiatric disorder
  • Rates for alcohol-related violence are hard to find because rates of alcohol involvement may vary across studies making comparison difficult, and it is hard to establish a causal reationship due to other factors (e.g., interaction between personality factors and alcohol)
• Alcohol-Related Hospitalizations
  • Hospital discharges (1997): alcohol-related diagnosis was first-listed (primary) diagnosis for 20.2/10,000 population aged 15+; all listed alcohol-related diagnosis was 64.5/10,000 population
  • Alcohol-related morbidity episodes not appearing as a first-listed (primary) diagnosis: 69%

February 28, 2012 & March 01, 2012: Marijuana

• Overview
  • Most widely used illicit substance in the US – 41.9% of persons 12 and older have used in lifetime
  • Most controversial – can find cited information based stating that significant harm is associated with use, and that using is relatively harmless
  • Issues of legalization
• Grass: Fact, Fiction, Belief, Bias?
  • As we watch this film, take notes and look for evidence to consider the following questions:
    1. What information presented seems factual?
    2. What information seems biased or slanted to promote a particular position?
• Contrasting Messages
  • “In contrast to its supposed medical benefits, the negative health effects of are well known and have been proven in scientific studies: among other things, the drug is addictive, impairs brain function, and when smoked greatly increases the risk of lung cancer.” –Marijuana and Medicine … Subcommittee on Criminal Justice (April 2004)
  • “Recent findings confirm that marijuana activates the very receptors in the increase of appetite…has medicinal value in the treatment of cancer and AIDS patients…regrettably, the US Supreme Court has ruled…that even for ill patients, there is no exception…classifying the drug as illegal” –Van Wormer and Davis (2003)
  • “The use of marijuana can produce adverse physical, mental, emotional, and behavioral changes, and –contrary to popular belief—it can be addictive.” -NIDA Research Report Series, Marijuana Abuse (July 2005)
  • “Compared to alcohol, the purely physiological effects of marijuana and hashish use are relatively few.”
  • “No conclusive evidence supports damage to other organs related to marijuana usage” -McNeese and DiNitto (2005)
• What We Know
  • Several varieties of the cannabis plant
  • THC is the primary psychoactive ingredient
  • Absorbed rapidly from the lungs – peak blood levels occurring in 10 minutes, but rapidly declines
  • Absorbed more slowly via ingestion – may take about 1 hour – may last as long as 5 hours
  • THC is readily stored in fat cells (related to long half-life); traces may be detected for weeks or even months after chronic use
  • Blood levels of THC do not show strong correspondence to subjective intoxication or “high”
  • Peak high typically occurs after blood levels begin to fall
  • Neuropharmacology was poorly understood until fairly recently (late ’80s)
  • Specific receptors for cannabinoids were discovered
  • Related to the mesolimbic dompaminergic pathway (reward pathway)
  • THC concentration in available marijuana is greatly variable
  • Individual’s absorption of THC is greatly variable
  • Single joint may have between 5-150 mg of THC
  • 30-80% of THC is lost in combustion process and smoke that doesn’t get inhaled
  • Inhaled THC that reaches the bloodstream is as low as 5-24%
  • Acute effects vary widely depending on dose, setting, current state of the user, prior experience with the drug, and expectations
    • Mild or high euphoria
    • Increased talkativeness
    • Distortion in time
    • Enhancement of sensory experience
    • Introspective dreaminess
    • Lethargy and sleepiness
  • Cannabis intoxication can cause increased panic, anxiety, and paranoia
  • Impairs short-term memory
  • Mixed effects on tasks requiring attention, concentration, coordination, memory
  • Surprisingly small literature on problematic effects of cannabis use
  • History over the controversy regarding the addictive potential of cannabis
    • Tolerance?
    • Withdrawal?
    • Dependence?
  • Health effect concerns are primarily related to mode of delivery (smoking) rather than the psychoactive ingredient, THC
  • Appears to be increased risk for lung cancer
  • Demonstrated increased risk for chronic bronchitis
  • May be increased risk for heart disease
  • Little evidence of any permanent damage to the brain
  • Gateway to harder drugs?
  • Impaired social and occupational functioning?
  • Amotivational syndrome?
  • Causes psychoses?

March 06, 2012

• Substance/Drug Groups
  • Different systems of classifying drugs – all are imperfect
  • Some drugs don’t exactly fit into a category
  • Some drugs could be classified into more than one category
• Opium
  • History
    • Before the Harrison Act, Chinese immigrant workers brought in opium, but smoking it had a negative association with Chinese and didn’t catch on
    • It was implied that physician prescriptions were causing dependence
    • It was made illegal to have opioids that were not prescribed
    • The view of opioid users shifted from victims to criminals
    • Use among whites declined; use among lower class increased
    • The primary U.S. supply comes from southwest Asia, Colombia, and Mexico
    • Very few people use heroin
  • Abuse
    • Some drugs are made to deter abuse (ex. not water soluble pills) but this is less useful in preventing overdose
  • Pharmacology
    • Opioid antagonists block the actions of opioids, ex. naloxone, that reverses depressed respiration
    • The brain’s opioid receptors are responsible for pain perception and are there to receive endorphins (stress relief)
  • Benefits
    • Pain relief (pain is no longer bothersome) by reducing awareness/response to pain
    • Help treat intestinal disorders/infections by slowing down food-moving contractions
    • Cough suppression (antitussive)
  • Concerns
    • Tolerance: more is needed for same pain relief with prolonged use; context/environment of use also has an effect on level of tolerance
    • Physical: craving, yawning, nasal irritation, etc.
    • Not life-threatening, but extremely uncomfortable
    • Psychological dependence through positive and negative reinforcement
    • Acute toxicity: slowed respiration, dreaminess, nausea and vomiting
    • Chronic toxicity: none scientifically found; all associated are due to poor practice (ex. dirty needles)
  • Patterns
    • 3-4 injections per day
    • $30-$100 per day
    • Variable concentration; overdose-prone
    • Analgesic
    • Lack of hunger leads to malnutrition and poor health
    • “Maturing out” = gradually stopping use
  • Misconceptions
    • Heroin does not always cause full-body orgasms
    • Withdrawal symptoms are not always excrutiatingly painful, and more frequently resemble intestinal flu
    • First-time hooked his not true; dependence takes time; regularity is more influential than dosage
• Heroin
  • Overview
    • Processed from morphine which is a naturally occurring substance extracted from the seed pod of certain varieties of poppy plants
    • Typically sold as white or brownish powder or a black sticky substance known as “black tar heroin”
    • Most street heroin is cut/mixed with other substances, which affects its potency
    • Three times more potent as morphine (due to increased lipid solubility)
  • Routes into the Body
    • Intravenous: provides greatest intensity and most rapid onset of euphoria (7-8 seconds)
    • Intramuscular: relatively slow onset of euphoria (5-8 minutes)
    • Sniffed or smoked: peak effects are usually felt within 10-15 minutes
  • Mechanisms of Action
    • In the brain, it is converted to morphine, and binds with opioid receptors, blocking pain
    • Interacts with endorphins, producing pleasure/euphoria
  • Immediate Effects
    • Euphoria or rush, often accompanied by warm flushing of the skin, dry mouth, heavy feeling in limbs
    • Apathy
    • “Nodding” and drowsiness for several hours
    • Cardiac and respiratory functions slow
    • Mental functioning is clouded
  • Long-term Effects
    • Addiction (usually occurs over time)
    • Profound degree of tolerance and physical dependence
    • Withdrawal symptoms: may begin within a few hours; typically peak within 24-48 hours; subside in about a week
    • Restlessness and involuntary leg movements, muscle and bone pain, diarrhea, vomiting, cold flashes
    • Although withdrawal from heroin can be terrorizing, it’s not lethal; this contrasts alcohol withdrawal, which can be lethal
    • There are methods of helping someone in heroin withdrawal that makes the process more tolerable
    • Collapsed veins (intravenous injection), infectious diseases, bacterial infections, abscesses, infection of heart lining and valves, arthritis, lung complications
  • Toxicity
    • Triad of coma, pinpoint pupils, and depressed respiration strongly suggest poisoning
    • Naloxone, opiod antagonist, can reverse central nervous system effects of opioid intoxication and overdose
    • People can register to carry Naloxone to inject into a victim if needed to reverse the lethal effects of heroin overdose
    • This is a harm-reduction method – it reduces the harm associated with heroin use
  • Demographics
    • Has shifted to include more white middle-class persons, and adolescents / young adults
    • Why? Increased availability, decreased price, misconception that smoking or sniffing is less dangerous
• Cocaine
  • Overview
    • Source of cocaine is the coca leaf which has been ingested for thousands of years
    • The pure chemical is cocaine hydrochloride
    • Primary stimulant drug used in tonics and elixirs used in 1900s
  • History and Evolution
    • Cocaine used to be used as a local anesthesia; still sometimes used for nasal-region surgeries
    • Freud proposed use of cocaine as treatment for depression and morphine dependence
    • States passed regulations on cocaine because it was associated with the negativity of black people
    • Media transitioned from glorifying cocaine as a drug used by the rich, to vilifying it as causing violence
    • Cocaine laws put harsher and unproportional penalties on crack, which is more detrimental to black people
    • 1 kg. usually sells for $13,000-$25,000 and is 50-75% pure
    • Most production occurs in South America
    • Cocaine use has dropped significantly since the 1980s; the markets have shifted toward amphetamines
  • Two Forms
    • Hydrochloride salt: powdered form, can be dissolved in water, can be taken intravenously or intranasally
    • Freebase: has not been neutralized by an acid to make the hydrochloride salt, is smokable
    • Freebase is smokable and explosive; crack is smokable and stable
  • Crack Cocaine
    • Crack: a form of freebase cocaine that is processed from hydrochloride salt and is smokable, processed with ammonia or baking soda
    • Because it is smoked, the high is experienced in less than 10 seconds. Also, the high is of a greater intensity. Accounts for its highly addictive quality
  • Mechanism of Action
    • Interacts with dopamine in the reward pathway (the “go!” brain pathway)
    • Blocks the reabsorption (reuptake) of dopamine, resulting in high levels of dopamine stimulating the receiving neuron
    • High level of tolerance is developed
    • The memory of euphoria from cocaine use can trigger intense cravings, even after significant periods of abstinence
  • Short-Term Effects
    • Used intranasally, euphoric high can last for 15-30 minutes
    • Smoked, can last from 5-10 minutes
    • Depends on the person and the amount
    • Explains why people use a lot of this substance – because it doesn’t last a long time
    • Physical effects: constricted blood vessels and dilated pupils; increased temperature, heart rate, blood pressure
    • Immediate euphoric effects: hyperstimulation, mental alertness, reduced fatigue, helps with performance of mental and physical tasks; heightened awareness of sensations of sight, sound, and touch
    • Some toxicity may be caused by adulterants
  • Long-Term Effects
    • Highly addictive
    • Tolerance
    • Irritability, restlessness, paranoia
    • Auditory hallucinations
    • Cardiovascular effects: disturbance in heart rhythm and heart attacks
    • Respiratory effects: chest pain, respiratory failure
  • Maternal Cocaine Use
    • Prenatal exposure has resulted in premature delivery, low birth weight, and smaller head circumference
    • Epidemic of “crack babies” (babies born to women using crack during pregnancy) has not occurred as predicted
    • It does appear that there are subtle cognitive functioning deficits that occur in later years in children exposed prenatally
• Amphetamines
  • Overview
    • Can be used to induce sleeplessness and can be used to treat narcolepsy
    • Used by students, truck drivers doing long hauls, war soldiers to increase efficiency, and athletes to improve performance
    • Speed is amphetamine, sometimes mixed with heroin, providing a speedy effect
    • Whem amphetamine abuse rose, it was associated with drug-abusing hippies
    • Methamphetamine is made in meth labs and is a dangerous process involving extraction from household objects like cold medicine, Drano, or paint thinner
    • Crystal meth is the smokable form of methamphetamine
  • Pharmacology
    • Amphetamines have similar structures as neurotransmitters, allowing passage through blood-brain barrier and increased effect on central nervous system
    • Amphetamines stimulate release of neurotransmitters, rather than blocking reuptake
    • Half-life of amphetamines is 5-12 hours, complete elimination occurs in about two days
    • Amphetamine can be used as a relatively fast treatment for depression, appetite reduction for weight control/loss, treating ADHD by reducing activity level and increasing concentration (Ritalin)
    • Side effects of amphetamine treatment are stunted height and weight
  • Concerns
    • Acute toxicity: high doses may cause suspicion, paranoia, violence, and brain cell damage
    • Chronic toxicity: paranoid psychosis, schizoid personality, sleep deprivation; slow recovery back to normal (days, weeks)
    • Withdrawal from amphetamines is less physical; includes craving, lethargy, depressed mood
    • Use differing from prescriptions can cause a reinforcing effect

March 08, 2012: Psychotherapeutics

• Refers to substances that are typically prescribed for medical purposes
• Can classify these into three basic categories
  • Opioids: used to treat pain
  • Stimulants: used to treat attention deficit hyperactivity disorder
  • Central nervous system depressants: used to treat anxiety and sleep disorders
• How psychotherapeutics are misused
  • Unintentionally, by not following prescription directions, or taking in combination with other drugs (including alcohol)
  • Intentionally, by taking a drug for an effect that is not what the medical purpose is
• Why the relatively high use of psychotherapeutics?
  • Availability
  • Perception of safety
• Why should we be concerned?
  • Unintentional overdose deaths involving opioid pain relievers has quadrupled since 1999, and by 2007, outnumbered those deaths involving heroin and cocaine
• Prescription Opioids (Prescription Narcotics)
  • Overview
    • Morphine, codeine, oxycodone (OxyContin, Percodan, Percocet)
    • Used primarily for pain
    • Can also be used to treat diarrhea and coughs
    • OTC cough suppressants: in 2010, 6.6% of high school seniors took cough syrup to get high. At high doses, dextromethorphan – key ingredient found in cough syrup – can act like PCP or katamine, producing dissociative or out-of-body experiences
• Prescription Stimulants
  • Previously used to treat respiratory problems, obesity, and other ailments
  • Today, prescribed for only a few conditions (ADHD, narcolepsy) – Ritalin, Adderall
• Prescription CNS Depressants
  • Barbiturates: used to treat anxiety, tension, and sleep disorders – mephobarbital, pentobarbital sodium
  • Benzodiazepines: used to treat anxiety, acute stress reactions, and panic attacks – valium, librium, xanax

March 13, 2012: Review Session

• Four Broad Conceptual Frameworks for AOD (Ab)use
  • The perspectives provide a broad lens through which we can look at all the aspects of drug (ab)use – the host, user, and environment
  • Moral/Legal Perspective: substance use is a moral issue and the substance itself is evil
  • Medical/Pharmacological Perspective: substance use issues are like diseases
  • Psychosocial Perspective: the individual and the immediate environment are important
  • Sociocultural Perspective: what big things in the environment are going on that would affect drug use (larger structures, like poverty)
• Terminology
  • Continuum of problematic use, with one end being diagnosed disorders and the other end being use not meeting criteria for diagnostic disorders
  • Substance abuse disorder (less severe, one or more criteria, recurrent) vs. substance dependence disorder (more severe, three or more criteria)
  • Withdrawal: the opposite experience associated with intoxication that occurs when you stop taking a substance
  • Dependence: the state of needing the drug (physiological and psychological symptoms)
• Historical Perspectives
  • We have a tendency to glorify and vilify particular substances, swinging back and forth
  • Drugs take on some symbolic role and associate with a larger social issue; our responses to the social issue connects with our response to the drug
  • Often times, when we try to control a substance, there tends to be an increase in the potency of the substance
• History of Treatment/Intervention
  • Disease model / 12-step programs: requires a fundamental change in all aspects of one’s life
  • Cognitive-behavioral approaches: people lack basic skills to stop using and to avoid relapse
  • The above two approaches assume that people actually want to stop using the substance; the below helps people come to that decision
  • Motivational enhancement: increase a person’s motivation for change; move a person from contemplation (ambivalence) to preparation for change
  • Harm reduction: instead of reducing the substance using behavior, it reduces the harm associated with the behavior
• Tobacco
  • From a public health perspective, the most costly substance
  • More people die from pre-mature illnesses than alcohol, homicides, suicides, HIV, and a couple other things, combined
  • Tobacco is highly addictive and is extremely difficult to quit
  • Most treatments involve counseling, family involvement, and medication (such as a nicotine replacement)
• Alcohol
  • More related to crime and violence than any other substance
• Marijuana
  • We lack actual scientific evidence about the negative effects of marijuana
  • Most of the negative effects come from its mode of use, smoking
• Psychotherapeutics
  • Three general types
• Q&A
  • Do not need to know the formulation of different types of cocaine
  • Psychotherapeutics are considered illegal if they are used (particularly intentionally) in ways not as prescribed
  • Do not need to know many specifics about the nervous system, only as much as covered in lecture (no potassium/sodium-ion channels)

March 20, 2012: Information Gathering

• After Exam 1: What’s Next? The rest of the course is concerned with how we respond to the knowledge of substance use problems
• Definitions
  • Screening or Detection: identifying those person who are at high risk for having a problem
  • Diagnosis or Classification: confirmation of a substance abuse or dependence disorder
  • Assessment: comprehensive consideration of person’s substance use problems as they have affected multiple facets of his/her life
• Characteristics of Information Gathering
  • What kind of information is gathered?
  • What methods are used to gather information?
  • Who might gather information?
  • What are the reasons for gathering information?
• Concerns about Information Gathering
  • Defensiveness/resistance of the user or other person
  • Accuracy of method and tools
    • Sensitivity: ability of tool to avoid false negatives, accuracy in including all who have the problem
    • Specificity: ability of a tool to avoid false positives; accuracy in not including non-affected persons
• Screening
  • What information: substances used, amount and frequency of use, circumstances of use, problems associated with use
  • Method: interview/report of user/others, biological screen, records, established tools
  • Who: user, social service workers, educators, primary health care workers, clergy, pharmacists
  • Why: concerned/curious about own use, screen for potential problems, assess appropriate referral or level of intervention
• Screening Tools
  • CAGE
    • Four questions asked directly of the individual
      1. Have you ever felt you should Cut down on your drinking?
      2. Have people Annoyed you by criticizing your drinking?
      3. Have you ever felt bad or Guilty about your drinking?
      4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye opener)?
  • AUDIT
    • Developed by World Health Organization for use by primary health care workers
    • Ten items: 1-3 involve hazardous drinking, 4-6 concern alcohol dependence, 7-10 concern harmful alcohol use
• Diagnosis
  • Substance Abuse Disorder
    • Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following, occurring within a 12-month period:
    • Recurrent use resulting in failure to meet major role obligation (school, work, family, social)
    • Recurrent use in situations in which it is physically hazardous
    • Recurrent substance-related legal problems
    • Continued use in spite of social/interpersonal problems
  • Substance Dependence Disorder
    • Maladaptive pattern of use, leading to clinically significant impairment or distress, as manifested by three or more of the following:
    • Tolerance
    • Withdrawal
    • Substance taken in larger amounts or over longer time period than intended
    • Persistent desire / unsuccessful efforts to cut down or quit
    • Great deal of time spent in activities to obtain the substance, use the substance, or recover from its effects
    • Important social, occupational, or recreational activities are given up or reduced because of use
    • Continued use of substance despite knowledge of having a persistent/recurrent psychological or physical problem that is caused or exacerbated by the use
  • What: criteria named above
  • Method: structured interview
  • Who: professional trained to conduct the interview
  • Why: different reasons – shared understanding of the problem, qualification for services, insurance purposes, etc.
• Assessment
  • What?
    • Education, employment, military history
    • Medical, health history
    • Drinking, drug use history
    • Psychological, psychiatric history
    • Legal involvement
    • Family history
    • Relationships with close family/friends
    • Religion, spirituality
    • Why seeking help, circumstances of interview
  • Method: structured questionaire/interview; may be done over a period of time
  • Who: trained and qualified professional
  • Why: intervention referral and planning
  • Assessment: comprehensive consideration of person’s substance use problems as they have affected multiple facets of his/her life
  • Functional analysis: What role does substance use play in the individual’s life? What are hte positive consequences of using and the negative consequences associated with not using? In other words, why does the person use substances? (Advantage/Disadvantage & Cost-Benefit Matrix)
  • Motivation to Change Drug Using Behavior
    • Stages of Change
      1. Precontemplation
      2. Contemplation
      3. Preparation
      4. Action
      5. Maintenance
      6. Relapse
    • How do we know where a person is in the stages of change? Established tools; to some extent, we can assess motivation for change (and where a person might be in the stages) by looking at their cost-benefit analysis for drug-using behavior
  • Moving from Assessment to Treatment: we use the information gathered from the assessment – including the functional analysis and assessment of client’s motivation to change – to plan appropriate treatments

March 22, 2012

• Treatment System Components
  • Overview
    • Represent a continuum of care from early to late in the treatment process
    • Represent varying levels of treatment intensity
    • Represent different modalities of treatment
  • Detoxification Programs
    • Inpatient hospital detoxification
    • Inpatient, non-hospital detoxification
    • Outpatient detoxification
  • Intensive Treatment
    • Intensive inpatient care
    • Intensive outpatient care
    • Day treatment or partial hospitalization
  • Residential Programs
    • Theraputic communities
    • Halfway houses
    • Domicilaries
    • Missions
  • Outpatient Services (less intensive)
    • Intended for people who have moved to a place where they are confident that they are out of danger or risk for relapse
    • Individual counseling
    • Group treatment
    • Conjoint therapy
    • Family therapy
    • Multimodal approaches
    • Brief interventions
  • Pharmacotherapy: used throughout stages
  • Aftercare: finish intensive care, then meet for booster care
  • Maintenance: ongoing long-term service to maintain the change that they made
  • Education and Psychoeducation
    • Provide information to individuals about skills, what’s going on, resources
    • Give the individual an opportunity to practice new skills
  • Adjunctive Services
    • Services aimed not at the substance abuse directly, but other aspects of their lives that influence substance abuse
    • Example: housing, vocation
• Principles of Effective Drug Addiction Treatment
  1. Addiction is a complex but treatable disease that affects brain function and behavior
  2. No single treatment is appropriate for all individuals
  3. Treatment needs to be readily available
  4. Effective treatment attends to multiple needs of the individual, not just his/her drug use
  5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness; people who stay for three months tend to have positive outcomes
  6. Counseling (individual and/or group) and other behavioral therapies are critical components of effective treatment for addiction
  7. Medications are an important element of treatment for may patients, especially when combined with counseling and other behavioral therapies
  8. An individual’s treatment and services plan must be assessed continuously and modified as necessary to ensure that it meets his/her changing needs
  9. Many drug-addicted individuals also have other mental disorders. The lack of integration with drug and mental health treatment can cause problems; sometimes, drug treatment will make the individual get mental health treatment first, and mental health treatment will make the individual get drug treatment first
  10. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use
  11. Treatment does not need to be voluntary to be effective; mandated treatment can help turn a person around
  12. Drug use during treatment must be monitored continuously as lapses during treatment do occur
  13. Treatment programs should provide assessment for HIV/AIDS, hepatitis B & C, tuberculosis, and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection
  14. Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment; treatment sessions that may initially seen unsuccessful may have actually contributed to eventual success

Chapter 18: Treating Substance Abuse and Dependence

• Behavioral/Psychosocial Treatments
  • Used broadly for many types of substances
  • Defining treatment goals: what do you want to get out of treatment?
    • Abstinence: no drug use
    • Controlled/reduced use
  • Alcoholics Anonymous and Others: alcoholics are biologically different and don’t need to feel guilty about being al alcoholic, but must still be responsible for abstaining from alcohol; more effective for those who have made a personal choice to participate
  • Motivational enhancement therapy: motivates people away from denial and into a desire to change
    • Precontemplation: does not recognize a problem exists
    • Contemplation: problem might exist, considers changing
    • Preparation: decides and plans to change
    • Action: changes
    • Maintenance: keep the change
  • Contingency management: immediate rewards for clean urine samples, along with counseling
  • Cognitive-behavioral therapy: change behaviors that may lead to drug use
• Pharmacotherapies (Medication Treatments)
  • Detoxification and Maintenance Phase
    • Detoxification: immediate goal to relieve withdrawal
    • Maintenance: long-term to reduce relapse by using agonist/substitution, antagonist, and punishment therapy
  • Alcohol
    • Medication is important due to the serious nature of alcohol withdrawal
    • Benzodiazepines act as alcohol substitutes and decrease life-threatening symptoms to make the withdrawal process safer
    • Disulfiram (bad results when mixed with alcohol), naltrexone (blocks reinforcing effects), and acamprosate (normalize GABA and block glutamate increases) are used in the maintenance phase
  • Nicotine
    • Transdermal patch, gum, nasal spray, vapor inhaler, and lozenge all act as nicotine sources to replace smoking
    • Bupropion gradually decreases cigarette craving
    • Varenicline blocks the effects of nicotine
  • Opioids: reduce withdrawal symptoms, or make withdrawal occur during unconsciousness
  • Cocaine: no medications approved for treatment; modafinil shown to be effective
  • Cannabis: no medications approved for treatment; dronabinol shown to be effective
• Treatment: The Big Picture in the U.S.
  • Data suggests treatment should focus on outpatient interventions for alcohol, opioid, marijuana, and cocaine
• Is Treatment Effective?
  • Treatment is not a cure, and requires continued care throughout one’s lifetime
  • Reports show treatment is successful through reduced crime, increased employment, better health

March 27, 2012: Hallucinogens, Inhalants, and Performance-Enhancing Drugs

• Hallucinogens Overview
  • LSD
  • PCP
  • Ketamine
  • Psilocybin (from mushrooms)
  • Mescaline (from peyote cactus)
  • MDMA (ecstasy)
• LSD
  • Classic hallucinogen
  • Produced synthetically
  • Briefly used in psychotherapy prior to becoming illegal; the extent to which it is effective as an aid in exploring the mind is highly debatable
  • Adopted as a classic hippie drug in the 60s
  • Promoted by Timothy Leary as “mind expanding”
  • Today, it is more used for pleasure than self-enlightenment, so it is taken at smaller doses
• PCP
  • Developed as an analgesic – reduces perception of pain through inducing dissociative or trancelike state
  • Unpredictable psychoactive effects
  • Lower doses produce a sense of relaxation
  • Does not produce true hallucinations like LSD, but rather, distortion in body perception, euphoria
  • At large doses can induce a psychotic-like state
  • Despite popular lore, PCP does not directly induce violent behavior
• Inhalants
  • Volatile solvents
    • Paint, paint thinner, nail polish remover, correction fluid, glues, cements, dry cleaning fluid
  • Aerosol sprays, propellents, gases
    • Gasoline, lighter fluid, hair spray, spray paint, air canisters for filling balloons, aerosol propellents for whipping cream
  • Used primarily by children and adolescents
    • Cheap, common, and legally available substances
    • Produces a rapid, quick high similar to alcohol intoxication (initial stimulation/euphoria followed by drowsiness and lethargy
  • Because of rapid high, use is often repeated frequently over period of time
  • Short-term effects: confusion, delirium, nausea, vomiting
• Performance-Enhancing Drugs: Anabolic-Androgenic Steroids (AAS)
  • Synthetically produced variant of male sex hormone testosterone
    • Anabolic: muscle building
    • Androgenic: male sexual characteristics
  • Used legally to treat conditions related to hormone deficiency (growth)
  • Primary reasons for abuse
    • Enhance performance
    • Improve/change physical appearance
  • How are AASs used?
    • Cycling: steroids taken for period of weeks or months, stopped for short time, then started again
    • Stacking: use several different kinds at same time in order to maximize the effect
  • Effect of Brain
    • Different than most other drugs of abuse
    • Not immediately euphorigenic (does not increase dopamine activity)
    • Long-term use of AAS has impact on some of same brain pathways (dopamine, etc.) that are affected by other drugs of abuse
    • Can become reinforcing; can affect mood and behavior in significant ways
  • Health efects
    • Some reversible, other changes thought not to be reversible
    • Men: development of breasts, testicular shrinking, baldness, risk of prostate cancer, infertility
    • Women: growth of facial hair, deepened voice, enlarged clitoris, male-pattern baldness, cessation of menstrual cycle
    • Adolescents: potential for stunted growth due to premature skeletal maturation

March 29, 2012: Treatment – Disease Model and Self-Help Groups

• Disease Model and Self-Help (12-Step) Groups: these two models of treatment are often combined and used together
  • Some authors argue that they are very similar and complimentary
  • Some authors argue that they are often confused but are really quite distinct – both philosophically and pragmatically
• Disease Model
  • History going back to Benjamin Rush
  • Recognizes the disease of “alcoholism” as biopsychosocial (and spiritual)
  • Treatment and recovery focus on a fundamental shift or change in the individual’s life (across all domains)
  • 12-step facilitation model, or Minnesota model, is a natural outgrowth of the disease model
  • Treatment / theraputic change occurs via three modes of intervention: education, therapy, fellowship
• Self-Help (Mutual Help) Groups
  • 3 important dimensions along which mutual help groups vary
    • Fellowship / guided self-help
    • Spirituality
    • Goals
  • Fellowship Groups
    • Alcoholics Anonymous and other 12-step programs (Cocaine Anonymous, AI-Anon, etc.)
    • Secular Organization for Sobriety
    • Women for Sobriety: “an organization whose purpose is to help all women recover from problem drinking through the discovery of self, gained by sharing experiences, hopes, and encouragement with other women in similar circumstances”
    • All have abstinence as their goal
  • Guided Self-Help Groups
    • S.M.A.R.T. Recovery: “an abstinence-based, not-for-profit organization with a sensible self-help program for people having problems with drinking and using” – key areas of change are building motivation, coping with urges, problem solving, and lifestyle changes
    • Rational Recovery: “addictive voice recognition technique shows that the sole cause of addiction is the Addictive Voice – the thinking and feeling that supports your use of alcohol and other drugs; by learning to recognize your Addictive Voice, you can completely recover from substance addiction”
    • Moderation Management: supports moderation rather than abstinence by making progressive changes to lifestyle; aimed toward individuals who do not quickly return to pre-abstinence usage levels and can sustain moderate use
    • These groups are secular
    • S.M.A.R.T. and RR have abstinence as goal; MM has controlled drinking as goal
• Alcoholics Anonymous
  • Overview
    • Guided by the shared wisdom of experienced participants
    • Spiritually-based
    • Abstinence is the goal
    • 12 steps provide framework for the “work”
    • Steps 1-5: associated with initial phase of recovery
    • Steps 6-12: attitudes and behaviors acquired in steps 1-5 are renewed and reinforced
  • Twelve Steps
    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 understood him
    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. 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 personal inventory and when we were wrong promptly admitted it
    11. Sought through prayer adn 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
  • Rules of Etiquette
    • Anonymity
    • Confidentiality
    • Not interrupting
    • Respecting the right not to speak
    • Avoiding dual relationships
  • Meeting Format
    • Open or Closed
    • Open meetings can be attended by those who both have and have not accepted that they have a drinking problem
    • Types of meetings: speaker, discussion, step, specialty
    • Meetings usually last 1-1.5 hours
    • Speaker meetings: members and guest speakers share relatable stories of their addiction and recovery; this allows people to form connections, and reminds them of the past experiences they had with the consequences of addiction
    • Discussion meetings: participants select a topic and share opinions about it
    • Step meetings: focus on one of the 12 steps and discuss how members are working on accomplishing that step
    • Specialty meetings: meetings for men, women, gays, professionals, particular ethnicities, etc.
• “Circle of Recovery: Healing the Wounds of Drugs and Alcohol”
  • A group of African-American men came together to help each other through drug problems
  • They were better together than other people might be together because they shared a lot of background characteristics (gender, race)
  • Example of being emasculated: due to drug use, someone felt less manly because they were rejected/relieved of their duties in the military
  • Example of being dehumanized: a black man was asked why he was only half human because of his race; other Blacks felt shameful
• Joseph Nowinski’s “Self-Help Groups for Addiction” (1999)
  • People prefer to treat the consequences of substance abuse rather than reducing actual substance use
  • Turning to a self-help group is usually not an individual’s first resort
  • Alcoholics Anonymous evolved from the Oxford movement, and took a spiritual and psychological (rather than medical) approach to alcoholism
  • Following the success of AA, other 12-step programs emerged
  • Even though these might be self-help programs, AA emphasizes group helping (mutual help) and a calling to a higher power
  • AA emphasizes fellowship and spirituality; it is seen as a social movement
  • The steps of AA prompts people to accept they have a drinking problem and surrender (as a form of acceptance)
  • Secular fellowships are also non-profit and decentralized, but do not advocate a theistic belief
  • Participation in self-help groups can be used as treatment along with professional care
  • Someone can bond with a mutual help group by attendance, identification (find things in common with other members), and participation (through networking, sponsorship, rituals, and traditions)
  • Reports show that, out of AA members, 35% remained sober for 5+ years and another 34% remained sober for 1-5 years; a different survey indicated that 40% who remained with the fellowship for 1 year stayed sober for another year; 60% cease their involvement with AA in under one year

Tuesday, April 10, 2012: Cognitive-Behavioral Approaches to Treatment

• Learning Theory
  • Definition of Learning: relatively permanent change in behavior or behavioral ability of an individual that occurs as a result of experience
    • Behavioral viewpoint focuses on actual change in behavior
    • Cognitive perspective emphasizes the change in ability to exhibit the behavior
  • Classical Conditioning (Pavlov: bell, dog, and salivation)
    • Unconditioned stimulus (US) leads to unconditioned response (UR) without learning
    • If US is repeatedly presented after some neutral stimulus, the neutral stimulus alone is eventually sufficient to elicit the response
    • The neutral stimulus, now called the conditioned stimulus (CS), leads to the response, now called the conditioned response (CR)
    • Example: taking drugs with your cousin will cause the presence of your cousin to create a response to the drug – your cousin has become a trigger associated with drug use
  • Operant Conditioning (Skinner: rats and levers)
    • Behavior is controlled by its consequences
    • Consequences include:
    • Reinforcement: an event that increases the probability that the behavior preceding it will be repeated
    • Punishment: an event that decreases the probability that the behavior preceding it will be repeated
    • Reinforcement tends to work better than punishment, and it keeps good behavior going
    • Positive reinforcement: the reinforcing event involves the presentation of something rewarding
    • Negative reinforcement: the reinforcing event involves the removal of something aversive
  • Cognitive Learning (Bandura: violent behavior with Bobo doll)
    • Insight
    • Cognitive maps
    • Observational learning: behavior is acquired through observation and imitation
      1. Must pay attention to the behavior
      2. Must store the observation in memory
      3. Must remember and be motivated to do the behavior
      4. Behavior must be reinforced if it is expected to be repeated with regularity
• Cognitive-Behavioral Approaches Applied to Substance Use Problems
  • Cue Exposure
    • Assessment of cues or stimuli associated with conditioned craving – may identify a hierarchy of cues
    • Repeated exposure to the cues in a controlled setting such that the substance is not available
    • Physiological and subjective responses are assessed
  • Contingency Management: consequences
    • Involves setting up conditions such that desirable and/or undesirable events are contingent on specified behaviors (most often, nonuse or use of substances)
  • Observational learning
    • Most typically involves the teaching and practice of a variety of skills (coping, drug refusal, etc.) that will enhance the probability of either abstinence or moderate use
  • Advantages of Cognitive-Behavioral Approaches
    • Goals and strategies can be individualized, flexible, and specific
    • Accessible and understandable to the person receiving treatment; client awareness of cues, situations, reinforcers, etc. is central
    • Collaborative: the client has to bring in information from the outside
    • Accesses client/strengths…
  • Relapse Prevention
    • Concerned with maintenance of change after initial treatment
    • Two goals: prevent a lapse or initial return to substance use (transgression of one’s goal); successful management of lapse or relapse episodes
  • Successful Management of Relapse
    • Transform a “treatment failure” to an “error” or “temporary setback”
    • Not at all uses of a substance are termed a relapse, but rather, distinction is made between a lapse (or slip) and full-blown relapse
    • Provide valuable lessons for preventing future episodes
• Cognitive Behavioral Tools
  • Functional Analysis
    • Central and thorough assessment
    • What is the nature and determinants of substance use? Frequency, intensity; contextual conditions (social, environmental, emotional, cognitive, physical)
    • What skills and resources are lacking? Concurrent problems that are obstacles to abstinence
    • What skills and strengths does the individual have?
  • Behavioral Chaining around a lapse
    • Identify a recent lapse
    • Identify immediate conditions, events, cues, thoughts, emotions, etc. that surrounded that lapse
    • Move back in time and identify conditions just prior, and then prior again
    • Central idea: identify links between events, and break the link further back in the chain of events
  • Self-Monitoring Worksheets
    • Intensity of cravings
    • Situations – thoughts – feelings
• K.M. Carroll’s “Behavioral and cognitive behavioral treatments” (1999)
  • Assumptions for behavioral treatments: human behavior is learned and changed, the environment and context is important to consider and apply while learning, each client must be thoroughly assessed as a unique individual
  • Reciprocal determinism: there is an interdependence among cognitive, affective, and behavioral processes
  • There are many things that play a role in disorder development, such as genetics, comorbidity, personality, and environment
  • Conditioned responses can be extinguished by taking acts once associated with drug use and grouping them with neutral situations, and helping the victim understand the responses and find ways to deal with them
  • Cognitive change: changing maladaptive/wrong thoughts that contribute to continued use of a substance
  • Functional analysis: a comprehensive exploration of a patient that helps develop a future plan
    • What are the particular determinants of this person’s substance use? (Social, environmental, emotional, cognitive, physical)
    • What skills or resources does the individual lack, and what concurrent problems may be obstacles to becoming abstinent?
  • Behavioral approaches are strict, specific, and focused approaches, while cognitive behavioral treatments are broader
  • Therapy sessions are structured differently depending on the type of treatment; some styles may involve close monitoring, while others may have few meetings between the patient and physician
  • Contingency management approaches: positive incentives for abstinence that are better than the incentives acquired through drug use
  • Patients were found to be more successful in treatment if they had a significant other willing to take the treatment with them
  • Cue exposure approaches have shown moderate success; contingency management approaches have been shown to be effective in 40-60% of cases; coping-skills approaches have a high amount of empirical support
  • Strengths: flexible, acceptable to use in a wide range of situations, solid grounding, link science to treatment, well-defined goals and guidelines, build self-efficacy, strong level of empirical support
  • Weaknesses: lack of emphasis on isolating active ingredients (?), comparitive underutilization outside of academic settings, lack of emphasis on patient motivation, not much information about the patient response

Thursday, April 12, 2012: Stages of Change and Motivational Enhancement

• MISA Program at CPR in Chicago
  • Overview
    • Monday – Friday, 9 AM – 2:45 PM, located away from city
    • Community of 15-20 clients and 3-5 treatment team members
    • In a cottage with individual offices, large community room (for classes and lunch), outside patio for breaks, places to take walks
  • Daily Schedule
    • Treatment team meeting prior to arrival of clients
    • Brief community meeting
    • Class time
    • Break
    • Class time
    • Lunch
    • Class time
    • Community meeting
    • Clients depart
    • Team meeting wrap-up
  • Classes
    • Understanding our substance use
    • Drink/drug refusal skills
    • Problem-solving
    • Weekend review (behavioral chaining of success or lapse)
    • Social skills
    • Feelings and thoughts and substance use
  • Treatment Elements
    • Psychoeducation classes
    • Individual assessment, goal setting, and planning
    • Incentive program (points)
    • Level system
• Motivational Emhancement
  • Many related approaches/names
    • Stages of change theory
    • Motivational interviewing
    • Motivational enhancement therapy
    • Brief interventions (FRAMES)
    • Drinker’s check-up (DCU)
• Definition of Motivation
  • “Motivation is a state of readiness or eagerness to change, which may fluctuate from one situation to another” -Miller and Rollnick, 1991
  • Motivation is not something that someone has. Rather it is something that someone does.
  • We determine that a person is motivated, not based on what they say, but rather what they do
• Motivation and Change
  • We might say, “unless a client is motivated to change, (s)he is not going to change”
  • We also might say, “until a client wants to (is motivated to) change, there is nothing that I (a helper) can do”
• Measuring Motivation
  • Decisional balance: balancing the pros and cons, gains and losses
  • Stages of change (see below)
  • Motivational vectors: sample various dimensions of motivation for change (?)
  • Readiness ruler: ask client about his/her motivation for change on a numeric scale
• Stages of Change
  • Precontemplation: not considering change, often does not perceive a problem
  • Contemplation: seesaw ambivalently between change and remaining the same, weigh costs and benefits
  • Preparation/Determinationclear that change is needed, getting ready and considering what to do
  • Actiondecides which steps to take and initiates implementation
  • Maintenancesustaining change
  • Relapsedo not maintain change on the first try and cycle through stages again
• Key Concepts
  • Ambivalence
  • Resistance
  • Confrontation
  • Empathy
• Principles of Motivational Interviewing
  • Express empathy
    • Acceptance
    • Achieved through reflective listening
    • Brelieve and communicate that client’s perspective (ambivalence, reluctance to give up substance, etc.) is understandable, comprehensible, and valid
    • Emphasizing how unacceptable one’s current state is usually does not result in successful positive change
  • Develop discrepancy
    • Create and amplify, in client’s mind, a discrepancy between present behavior and broader goals
    • Consider concept of “cognitive dissonance”
    • Enhancing client awareness
    • Best if client (rather than therapist) discovers and articulates these discrepancies
  • Avoid argumentation
    • Client resistance is a sign to step back into empathic strategies rather than confront the client
    • Self-recognition of problem is critical
    • Arguing tends to get in the way of change, rather than facilitating it
  • Roll with resistance
    • We should expect “resistance”
    • Recognize that resistance is normal for any person who is ambivalent
    • Different than being passive
    • Take advantage of motivation and use it to your advantage
  • Support self-efficacy
    • Belief that the client can make a change; essential that both client and therapist believe this
• Brief Interventions
  • Evidence suggesting that very brief interventions (one session) can have a significant impact on client’s behavior
  • Only 5-15 min. of counseling can suppress heavy drinking
  • How does this jibe with one of the principles of effective treatment that treatment contact must be long enough (3 months) in order to be successful?
• FRAMES
  • Feedback: personalized feedback about individual status
    • Different from generic educational information
    • Good examples include laboratory test results, calendars with usage records, motivation scales, and feedback reports
    • Feedback is more effective when the client is ready to hear it
    • The manner in which the feedback is presented may cause the client to be more receptive to it
  • Responsibility: personal responsibility for change, freedom of choice
  • Advice: clear recommendation for the need for change
    • Advice must be concise and professional
    • Quick and generic advice may be harmful to the client’s momentum in discussion
  • Menu of options: a variety different options for change and treatment (rather than one solitary solution)
  • Empathy: reflective, warm, supportive, understanding, acknowledging practitioner style
  • Self-efficacy: a form of optimism, the client’s expectation that (s)he can change
• Drinker’s Check-Up (DCU)
  • Consists of an assessment followed by one counseling session
  • Evaluations have shown that DCU suppresses drinking behavior
• C.E. Yahne & W.R. Miller’s “Enhancing motivation for treatment and change” (1999)
  • The therapist with which an individual is working can significantly affect the success rate of the treatment
  • Client compliance affects treatment success – voluntary involvement is associated with better outcomes

Tuesday, April 17, 2012: Consideration of Culture – Race/Ethnicity

• Culture
  • Questions
    • What is it?
    • How do we talk and learn about it?
    • How is it related to AODA (or other issues)?
  • Definitions
    • Includes customs, beliefs, values, knowledge, and skills that guide a group’s behavior in a shared direction
    • Organized group of learned responses
    • Includes a unique world view shaped by environmental, historical, biological, and other forces that mark a people’s evolution
• Critical Questions for Human-Service Providers
  • How can we learn to be culturally competent providers of services and at the same time not stereotype a whole culture or race?
  • One solution is a conceptual framework offered by Amodeo and Jones (1997)
• Conceptual Framework – Culture and AODA
  • Culture-specific AOD dynamics
    • Using substances
    • Developing problems
    • Seeking help for problems
    • Experiencing a return to problems
    • Recovering from problems
  • Individual-specific AOD dynamics
    • Subgroup membership: ethnicity, class, age, gender, sexual orientation, rural/urban, religion, physical disability, etc.
    • Context of migration: voluntary/involuntary, refugee status, joining family members, seeking economic opportunity, etc.
    • Degree of acculturation: traditional, bicultural, fully acculturated, etc.
• Video
  • Portrays a bicultural treatment program for Native American youth in New Mexico
  • As you watch the video, keep in mind the video we watched earlier in the semester that depicted an adolescent treatment program at the Caron Foundation. What differences and similarities do you notice?
  • Keep in mind framework we just discussed: culture-specific and individual-specific AOD dynamics
• “Our Youth, Our Future”
  • Part of a reservation, had access to drugs as a group
  • The would get addicted and would think that that’s the end of the culture because everyone thought the whole tribe was revolved around drug use
  • Kids went to a reservation to learn about their culture, which gave them motivation to get clean

“Racial, Etnhic, and Cultural Issues” (Ch. 10) from Addiction Treatment: A Strengths Perspective

• Introduction
  • Historically, drug abuse problems have not been looked at in terms of differing cultures, and subjects have been white males
  • When cultural minorities were included in studies, they were referred to as the special population
  • In order to avoid stereotyping, other individual characteristics must be taken into consideration
  • Some minorities used drugs as a response to loss of culture and stress from immigration
  • This leads to the question of how clinicians can be sensitive to different cultures and different levels of acceptable behavior without stereotyping an entire group
• Asian Americans and Pacific Islanders
  • Prevalence Patterns
    • Rates of drug use and the number of people needing treatment is lower in Asians than in all other major etnhic groups
    • This might be caused by methodological issues (such as lumping Asians for a long time as “other” or just underestimating use), less accessible treatment options, and the belief that Asians lack the enzyme for alcohol metabolism which causes flushing and discomfort
  • Sociocultural Factors
    • Asians have the highest average annual salary, but they also have a large number of people under the poverty line
    • Many Asians cannot enter the mainstream because they do not have family members who are fluent in English
    • Along with wealth, there are other characteristics among Asians that are inconsistent across subcultures
    • Devotion, obligation, and duty to the family comes before individual needs
    • The initial response to mental health problems or substance use is ignorance, as long as it doesn’t hinder responsbilities; if it does, the individual is isolated
    • Seeking outside help is considered failure
  • Treatment Issues
    • It is beneficial to have unique and specialized treatment programs for the variety of different Asian subcultures
    • Asian treatment methods should be nonconfrontational
• Native Americans and Alaskan Natives
  • Prevalence Patterns
    • The myth and stereotype of Native Americans is that of seeing alcohol as irresistable
    • Natives have the highest rate of illicit drug use and the highest need of drug abuse treatment
    • Use tends to be more popular among youth than among adolescents
    • Natives have much higher rates of health-related drinking consequences
  • Sociocultural Factors
    • Socioeconomic factors may cause Natives to lose the ability to gain help and support for recovery
    • Loss of culture, such as being forced to give up Native culture and adapt a white culture, develops drug misuse
    • Civil rights and antipoverty movements have helped Natives turn their situation around by increasing education and businesses
• Spiritual and Cultural Values
  • Overview
    • Indians look more toward spirituality and ceremonies, while Westerners look more for theraputic treatment
  • Treatment Issues
    • Indians have reverted more to traditional treatment approaches
    • Studies have not proven or disproven these methods, but no one method works for everybody
    • Factors that contribute to treatment success are family involvement, counselors, long-term aftercare, and special care for females
    • Staff of culture-specific treatment programs should be of that culture so they are more sensitive to cultural differences
• Hispanics
  • Prevalence Patterns
    • Alcohol and illicit drug use problems and need for treatment varies greatly among various Hispanic groups, with Mexicans and Puerto Ricans at the highest rate and Carribeans, Central Americans, and Cubans at the lowest
    • Women drink less than men, and are more acculturated to drinking patterns
    • A severe consequence has been the spread of HIV and alcohol-related health problems and deaths
  • Socioeconomic Factors
    • Status has been improving, but Hispanics still have high levels of poverty and are the most undereducated
  • Cultural Factors
    • Tight family ties can be a protective factor against drugs, but also acts as a barrier for seeking help
    • Females are strongly discouraged from using drugs because of their importance in raising children
    • Males are less willing to admit they have drug problems because it goes against the macho image that is expected of men
    • Excessive amounts of stress might cause Hispanics to just accept problems rather than fixing them
  • Treatment Issues
    • It appears that Hispanics do not need culturally-specific treatment, but more research needs to be done
    • Treatment approaches take advantage of the close family ties and support
    • Treatment programs attract males by saying that receiving help to stay sober and support the family is the manly/macho thing to do
    • Latina females entering treatment usually have a lot of other life-related stressors, and have depression
• African Americans
  • Prevalence Patters
    • Overall, African Americans tend to have a higher rate of drug use and need for treatment
    • African American women have a higher rate of abstinence than those of other cultures
    • African Americans face higher risks of potential health problems and death (such as cirrhosis of the liver or car collisions) when using alcohol
    • A major consequence for drug use lately has been incarceration
  • Socioeconomic Factors
    • Povery rate has been declining but is still high, education has been increasing, and income has a high variability/distribution
    • Higher social class acts as a protective factor
    • Those living in poverty suffer from lots of related consequences, such as violence, lack of resources, racism, poor housing, etc.
  • Cultural Factors
    • Africans consider spirituality very important, and use it as a strong protective factor over hardships
    • Community and family support is important, and individual identity is formed through relationships
  • Treatment Issues
    • A big challenge for treatment is cultural bias and ignorance to the client’s needs
    • Pregnant mothers are afraid they will be separated from their children
• Model Ethnic-Centered Programs
  • Project Safe in Rockford, IL
  • Mixed-gender, African American-specific program in Waterloo, Iowa
• Summary and Conclusion
  • All addicts are not alike
  • Race, ethnicity, and cultural values are just as important as gender, education, socioeconomic status, etc.
  • Strengths-based approach adapts to the individual and collects personalized data

Thursday, April 19, 2012: Consideration of Culture – Gender/LGBT

• LGBT Issues Related to AODA (Overview)
  • Substance Use Rates
  • Similarities in Identity Development
  • Treatment
    • Together or Separate?
    • Gay Affirmative Practice
    • Issues Specific to Bisexual and Transgendered Persons
  • Resources
• LGBT Substance Use Rates
  • Difficult to assess
  • Some evidence that lesbians and gay men use at rates higher than in the general population
    • Fewer abstainers, more “heavy” drinkers, more persons with alcohol or drug problems
    • Newer studies have shown less disparity between gay/lesbian and general populations
• Similarities in Identity Development
  • Processes in identity development for LGBT persons and for persons who have substance dependence disorders (and may identify as an alcoholic or addict) are similar
  • Important difference: whereas substance dependence is understood to be an illness or disease, being LGBT is not an illness
• Aspects of Identity Development
  • Denial
  • Self-definition
  • Disclosure
  • Shame
  • Culture
  • Freedom
  • Loss
• Treatment – Separate or Together?
  • Yes: LGBT-specific treatment programs
    • Provides a safe place for persons to talk about all aspects of their lives
    • Have experience addressing the needs that substance use fills in the LGBT community
    • Can provide safe-sex education that is unique to LGBT persons
    • Understands the coming out process and its potential relationship to substance use
    • Understands the role of spirituality
  • No
    • Entering a specialized program results in disclosure and potential fear of discrimination
    • Separate programs may also reinforce homophobia and alienation from rest of society
    • Integrated treatment offers the richness and complexity of the “real world” and better prepares clients to enter back into it
    • Can be healing and effective for LGBT clients to receive social approval from non-LGBT persons
• Aspects of Gay-Affirmative Practices
  • Affirms a gay, lesbian, bisexual, or transgender identity as an equally positive human experience and expression to heterosexual and traditional male or female identity
  • Knowledge
    • Terminology
    • Impact of oppression
    • Policies that impact LGBT persons
    • Coming out and identity issues
    • Community resources
  • Terminology
    • Gay, lesbian, and bisexual refer to sexual orientation: emotional and sexual attraction to another
    • Sexual orientation is preferred over sexual preference (preference fuels the issue of whether it is a choice to be gay or straight)
    • Transgender refers to gender identity: challenges the assumption of identifying as either male or female according to biological sex; within this group, wide range of both biological sex and gender experience
  • Oppression
    • Both blatant (job, housing discrimination) and more subtle (vigilance/watchfulness required to know who to disclose to, care about public affection, etc.)
    • Recognition that these stressors can contribute to substance use
  • Attitudes
    • Honest self-examination and reflection for feelings/attitudes of heterosexism and homophobia
    • Minimize or exaggerate hte role of LGBT identity
    • View LGBT persons strictly in terms of their sexual behavior
    • Become uncomfortable talking about LGBT issues
  • Skills
    • Do not assume
    • Create a safe environment
    • “Treat” the substance use problem, not the client’s sexual orientation or gender identity
    • Examine substance use problem in context of client’s life as LGBT
    • Recognize interalized homophobia
    • In exploring social network, assess the extent to which client is out (to whom, level of support)
• Issues Specific to Bisexual and Transgender Individuals
  • Bisexual persons
    • Women have a higher chance of being bisexual than men
    • Lack of understanding/support from both heterosexual and homosexual communities
    • Experience of “betweenness”
    • Can be viewed as example of instability
  • Transgender persons
    • Use proper pronouns based on self-identity
    • Support use of legally prescribed hormones
    • Deal respectfully with pragmatic issues (residential room assignments, restrooms, etc.)
    • Find out the sexual identity of clients; do not assume they are gay
• Women and AODA Treatment
  • Shame
  • Parenting
  • Trauma/Violence
    • Recognize that women may use substances to self-medicate as way of coping with past and current traumas
    • In order to overcome substance use problems, trauma must be addressed – new ways of coping with aftermath of trauma must be developed
• Video: Dealing with Trauma – “Women Beat the Street – Getting Clean, Sober, and SAFE”
  • We did not get to watch this video, so it will not be on the exam
  • Developed for trauma survivors who have AODA issues
  • Pay attention to coping methods/skills that women develop to replace AOD use as a way of dealing with trauma symptoms

“Gender and Sexual Orientation Differences” (Ch. 11) from Addiction Treatment

• Introduction
  • Gays started getting more attention after they started being correlated with drug injections and the AIDS epidemic
  • There is no consensus as to whether gays should receive specialized treatment, and programs are being developed
• Gender Differences
  • All Women are Not Alike, and Neither are All Men
    • Gender, race, and class are more important in shaping drug use than the drug itself
    • Race and culture might act as a protective factor, but does not prevent addiction
  • Gender Differences in Prevalence
    • Surveys show that females use less drugs than males, but this discrepancy might be caused by poor methodology
    • Women have been seeking increasing amounts of help for gambling
    • Eating disorders are far more prevalent in females
    • Smoking rates for men have been dropping more quickly than for women; adolescent males and females are now equally likely to smoke
  • Sociocultural Gender Differences
    • Women felt more shameful of alcoholism and thought they would not be understood
    • Women are oppressed in the dominant culture
    • Invisibility: women are less likely to be encouraged to enter treatment; if they do enter treatment, they receive little support
    • Being a mom: women are less likely to enter treatment due to the obstacles created by having a child or being pregnant
    • Crime and punishment: women are prosecuted for using drugs while they are pregnant, and may have their children taken away
    • Jail and prison: rates of incarcerated females has risen, primarily for drug abuse
    • Violence: women are more likely to be victimized by violence due to media, ineffective laws, and little support
  • Psychological Differences by Gender
    • Women have lower self-esteem and higher rates of co-occurence of disorders (which leads to higher rates of PTSD)
    • Men are more responsive to nicotine’s rewarding effects, while women receive stronger effects; men generally use nicotine for relaxation while women use it for things like weight management
    • For women, gambling can act as a pain medication (“escape” gamblers, rather than “action” gamblers like men)
  • Biological Differences by Gender
    • When drinking, women are more likely to seek treatment sooner after recognizing drinking problems, be more physiological impaired, be intoxicated with less quantities of alcohol, and have a higher mortality rate
    • In both men and women, alcohol can cause loss of sexual interest or sexual incompetence
    • Smoking affects women’s reproductive systems
    • Different drugs have varying degrees of different effects on men and women
  • Treatment Implications
    • Treatment programs should address problems specific to women, accomodate women’s needs, empower women, and use female clinicians
    • Example: “A Woman’s Place” – reduction and sobriety is celebrated and they investigate the source of the success to continue it
    • Treatment for women should look at all aspects of their lives, rather than just the addiction
    • Critics argue abstinence-only produces discouraging results, as many people used alcohol after the treatment ended
• Substance Abuse Counseling and Sexual Orientation
  • Overview
    • Gay men are often falsely accused of choosing to be gay, molesting children, and being effeminate
  • Lesbians and Substance Misuse
    • Gays have been acknowleding the fact that substance abuse is becoming more prevalent in their community, but research cannot specifically say by how much
    • Tobacco and alcohol companies have targeted lesbians for advertising their products
    • High levels of drug use is caused by gay bars as a gathering place, other gays being role models, and receiving stress for being tagged as living an unaccepted lifestyle
    • There are many gay-specific treatment programs widely available
  • Gay Males and Substance Misuse
    • Gay men are more prone to being victimized by violence and committing suicide
    • Gay men are more likely than gay women to socialize and sexualize in groups; these settings are central to drug use
    • Gays tend to use alcohol as a social lubricant when initiating same-sex interactions
  • Treatment Issues
    • Gays may not want to join regular treatment groups due to current members’ homophobia
    • There should be openly gay people on the staff to make gays feel more welcome and comfortable
• Summary and Conclusion
  • Women are usually more disadvantaged than men, and require more support and assistance with other aspects of their lives in addition to treatment for their drug addiction
  • There is no clear research about the effectiveness of specialized treatment for women, but there is support for allowing the client to have a choice rather than being coerced
  • Gays need to be seen as individuals, in contrast to what they may experience outside as being ignored and dehumanized of their rights

Tuesday, April 24, 2012: Problematic Substance Use, Close Relationships, and Families

• Families
  • How are families understood in the process of addiction?
    • To blame?
    • Victims?
    • Possessing strength and resiliency?
    • Adaptive?
  • What roles do family members take on?
    • Enabler / codependent / family manager
    • Hero
    • Scapegoat
    • Lost child
    • Mascot
  • Key Processes/Rules
    • “Don’t talk, don’t trust, don’t feel”
    • “Walking on eggshells”
    • Maintain the status quo
    • Indirect communication patterns
• Video
  • Documentary that examines two programs: one for heroin-addicted parents and their children, and one aimed at prevention/intervention strategies in schools
  • Issues to Keep in Mind
    • How are families portrayed?
    • What roles are taken on by individuals?
    • What family rules/processes are followed (or not)?
    • Prevention/intervention strategies – where is the focus?
• Bill Moyers on Addiction: “Close to Home – The Next Generation”
  • T.J. has parents who are drug addicts
  • They are enrolled in a program called Focus on Families, which teaches T.J.’s parents parenting skills to increase the chances of their children not using drugs
  • They feel as if everything is working out fine, but they are placing T.J. at a higher risk of drug addiction
  • T.J. understands that drug use is bad, but the subliminal/indirect messages that he receives from his parents still makes him prone to drug use and addiction
  • T.J.’s parents are back on heroin, but are going back on a methadone treatment
  • T.J. has a strong opinion about drug use because he has been affected by it so negatively; he says he will never use heroin in his life, and even with alcohol, he says he will only use lightly
  • The intervention program reaches out to young people while they’re still young
  • Drug curriculum for young kids includes standard drug cirriculum, in addition to targeting emotions and real-life application on a personal level
  • TRUST is a program that intervenes in the lives of students most vulnerable to addiction and drug abuse
  • Those in danger of using tobacco are discouraged by having them realize they will be controlled by cigarettes and lose control of their lives
  • Kids are discouraged from using drugs by inviting former drug addicts to come speak to the students about their poor experiences with drugs
  • Counselor Robin has helped a guy named Joe overcome drug use, and has had a significant impact on his life; whenever Joe wants to use drugs, he goes to Robin

Thursday, May 1, 2012: Prevention and Policy

• Central Questions about Prevention
  • What are we trying to prevent?
  • Who are we targeting?
  • How will we know if our efforts have worked?
  • What are underlying assumptions of our prevention efforts?
• Public Health Model
  • Primary Prevention
    • Aimed primarily at young people
    • Concern about too much information
  • Secondary Prevention
    • Aimed at persons who have tried using a substance
    • Prevent further problematic use, or use of other substances
  • Tertiary Prevention
    • Relapse prevention
• Institute of Medicine’s “Continuum of Care”
  • Universal Prevention
    • Aimed at an entire population
  • Selective Prevention
    • Aimed at groups at risk
  • Indicated Prevention
    • Aimed at individuals (or groups) who have shown signs of developing problems
• Prevention Strategies
  • Public information and education
    • Heavily emphasized in the US, but relatively little evidence of effectiveness
    • Knowledge-attitudes-behavior model
    • Social influence model (inoculation theory)
  • Effective education programs
    • Research-based and theory driven
    • Developmentally appropriate information
    • Social resistance skills training
    • Presented in broader context of skills training, decision making, health education
    • Interactive teaching techniques
    • Include other components (family, etc.)
    • Culturally sensitive
    • Contain evaluation method
  • Service measures
    • Aimed at ameliorating or reversing problems from AOD use
    • Overlap with intervention/treatment – fall within the secondary/tertiary realm
    • Workplace initiatives (employee assistance programs)
    • DUI programs
  • Technological measures
    • Public Health Model: “modification in noxious agent or environment to affect the relationships between agent, host, and environment such that hte rate of the disorder is reduced”
    • “Lite” cigarettes and alcohol
    • E-cigarettes
    • Addiction of naloxene to OxyCotin to eliminate euphoric effect
    • Car ignition/breathalizer contingency
    • “Tipsy” taxi service
  • Legislative and regulatory measures
    • Schedule of controlled substances
    • Taxes
    • Public smoking bans
    • Advertising and media – both legislation and self-regulation
  • Economic measures
    • Pricing policies
    • Allocating tax revenues from sales of alcohol and tobacco for prevention programs
    • Cost-benefit and cost-effectiveness analyses
  • Other approaches
    • Peer
    • Family
    • Community

Tuesday, May 3, 2012: Montana Meth Project

• Self-Description
  • “Large-scale exercise in prevention, aimed at significantly reducing meth use in Montana”
  • Ongoing, research based, marketing campaign that realistically and graphically communicates the risks of methamphetamine
  • Community outreach
  • Policy initiatives
• Statistics
  • 52% of children in foster care are there due to meth. Cost: $12 million / year
  • 50% of adults in prison are there due to meth-related crime. Cost: $43 million / year
  • 20% of adults in treatment are there for meth addiction. Cost to the state: $10 million / year
• Approach
  • View methamphetamine as a consumer products marketing problem
  • Meth is a readily available, affordably priced consumer product
  • Distributed statewide through effective distribution channel
  • Many attributes are perceived as attractive, and little risk is perceived – “This is the root of the problem”
  • Goal is to arm Montana youth with facts so they can make a better informed decision
• Messaging Campaign
  • High-impact advertising that graphically communicates the risk of meth use
  • TV, radio, billboards, newspapers, Internet
  • Statewide targeting youths age 12-17
  • Reach 70-90% of the target audience three times per week
  • Also, produced “Montana Meth” documentary – shown in various venues throughout the state and nationwide on HBO
• Critical Review
  • Claims made by MMP – advertisements have caused
    • Dramatic shifts in perception of risks
    • More frequent parent-child communication
    • Greater social disapproval
    • Significant declines in meth use and associated crimes
  • MMP founder Tom Siebel testified before Senate Finance Committee Hearing: “the Meth Project results in Montana have been more significant than any drug prevention program in history”
  • Search of PsychInfo and Medline databases in April 2008 returned zero results – no peer reviewed literature
  • Methodological concerns: survey sample representative of Montana’s population? No
  • Concerns about claims: summary sections make claims that are not supported by data in appendices

Don Terry’s “User Friendly” (2003)

• Although providing clean needles to addicts isn’t ideal, it’s currently the best method that we have; the ideal solution is to make people quit, but it hasn’t been effective
• Addicts will always find a way to take drugs, so giving them clean needles allows them to be safe doing it
• The van provides all drug paraphanalia for safe usage except the drug itself
• CRA doesn’t require a one-to-one exchange of needles – you can drop off and leave with as many needles as needed
• Any positive change
• In one woman’s case, nothing stopped her drug use except time
• Drug users might stay clean for an extended period of time, but they can easily get back into the habit
• Research has clearly shown that needle exchange programs reduce HIV spread among intravenous users
• It is illegal to have syringes without a prescription, so the CRA must distribute them under a research exemption and must collect detailed data about people who use the program
• The people who run the program are often people who have suffered from drug use in the past
• The CRA trains people how to use Naloxone and distributes it with a prescription to save people from overdose

Tuesday, May 8, 2012: Course Review and Wrap-Up