Section 7.3 Substance Abuse and Addictive Behaviour

Revision notes 7.3

Section 7.3 Substance abuse and addictive behaviour

Learning outcomes

Explain factors related to the development of substance abuse or addictive behaviour.
Examine prevention strategies and treatments for substance abuse and addictive behaviour.

What is substance abuse?

A substance is anything an individual ingests to alter their cognition (thought processes), behaviour or affective state (mood). This broad definition allows substances such as coffee or food to be seen as potentially addictive substances. Substance abuse can be defined as: the overindulgence or dependence on a drugor other chemical leading to effects which are detrimental to the individual’s physical and mental health, or the welfare of others (Nutt et al., 2007). There is a social paradigm to substance abuse as a person is said to be addicted when the behaviour leads to a significant impairment of their ability to meet their obligations in employment, relationships or the community.

Alcoholism

Alcoholism can be defined as a disabling addictive disordercharacterized by a compulsive need for alcohol that leads to negative effects on the drinker’s physical, emotional and social health. As with other drug addictions, alcoholism is seen by Western medical establishments as a treatable disease. It is characterized by an incremental physiological tolerance for the drug. This leads to an uncontrolled increase in consumption that has severe consequences for the alcoholic and the people around them. Alcoholism leads to mental, social and physical dysfunctions including:

brain shrinkage
liver disease and strokes
tremors, sleep disruption and amnesia
anti-social, aggressive and irrational behaviour
depression, anxiety, hallucinations and ultimately death.

Physiological factors

Recent research into biological predispositions for alcoholism has usually focused on identifying an addictive gene. The research suggests the following.

Alcoholism does run in families and is particularly prevalent within male bloodlines. According to the US Centers for Disease Control, about 17% of men and 8% of women in the USA become alcoholics at some point in their lives.
Addiction is linked to risk-taking behaviour, low inhibition, resistance to punishment and a tendency to favour short-term over long-term rewards. This may explain why it is more prevalent in men than women.
Overstreet (2000) argues that despite different life experiences, twin brothers show remarkable consistency in alcohol preference.
According to Prescott et al. (2005), genetic contributions to alcoholism in males of white, Northern European descent are well established.
Cross (2004) cites Enoch who speculates that genetic predisposition manifests itself in different ways in different racial and cultural groups. For example, a certain genotype may lead to an anxious personality: Europeans who have this type of personality may drink to relieve anxiety as is the norm in this culture; native Americans who have the same type of personality may be more sensitive to the effects of alcoholism and so be protected.
Cross (2004) also cites Lingford–Hughes use of brain-imaging techniques to examine the number of GABA receptors in the brains of alcoholics compared to non-alcoholics. GABA is thought to be involved in calming the body; fewer GABA receptors would suggest a greater susceptibility to anxiety and therefore an increased likelihood for alcohol consumption in certain cultural groups.

It should be noted that genetic predisposition does not determine behavioural destiny – biological architecture does not automatically mean an individual will become an alcoholic.

Cognitive and sociocultural factors

Social learning theory assumes behaviour is the result of reinforcement, punishment or observational learning. In the West, alcohol advertising is widespread. Alcohol use and to some extent, misuse, is normalized.

Saffer and Dave (2003) found heavy advertising by the alcohol industry in the USA has such considerable influence on adolescents that its removal would lower underage drinking. Their analysis suggests that eliminating alcohol advertising in a local setting could reduce monthly drinking by adolescents from about 25% to about 21%, and binge drinking from 12% to around 7%.

Snyder et al. (2006) found youths who saw more alcohol advertisements drank more on average. They also found young people in markets with more alcohol advertisements showed increased drinking levels into their late 20s whereas drinking reached a plateau in the early 20s for young people in markets with fewer advertisements.

Dring and Hope (2001) studied the impact of alcohol advertising in Ireland and found the following.

Alcohol advertisements were identified as their favourites by the majority of teenagers surveyed.
Most of the teenagers believed the majority of the alcohol advertisements were targeted at young people. The teenagers interpreted alcohol advertisements as suggesting that alcohol is a gateway to social and sexual success. This is contrary to the code governing alcohol advertising. They also thought the advertisements suggested that alcohol has mood altering and therapeutic properties (cited in the Institute of Alcohol Studies fact sheet).

There is widespread official acceptance that advertising influences alcohol consumption.

In the UK, the Advertising Standards Authority (ASA) has strict guidelines for the advertising of alcohol.

Advertisers are not allowed to promote alcohol to under-18s and this includes any context, medium or content which the ASA thinks might appeal to under-18s (e.g. text messages).
No medium can be used to promote alcohol if more than 25% of its regular audience is under 18. This refers to children’s networks, some magazines and teen shows on the TV.
In adverts promoting alcohol, none of the models should look under 25. They also cannot be seen acting a way that could be termed ‘adolescent’. People who are younger may be seen onscreen during family celebrations – but not in a way that suggests they have consumed alcohol.
Adverts cannot reflect the culture of people who are under 18 in a way that would promote drinking. For example, pop stars that appeal to children cannot be used to sell alcohol, even to an adult audience.

(Cited from KidsAndAdvertising (2010)).

However despite these policies, the data suggests young people are still influenced by alcohol advertising. The question is whether this leads to alcoholism. There is recognition that alcohol advertising and the normalization of alcohol consumption has pernicious effects. The World Health Organization’s European Charter on Alcohol states: ‘All children and adolescents have the right to grow up in an environment protected from the negative consequences of alcohol consumption and, to the extent possible, from the promotion of alcoholic beverages.’ As part of a strategy for alcohol action, the charter suggests that each Member State should ‘implement strict controls, recognizing existing limitations or bans in some countries, on direct and indirect advertising of alcoholic beverages and ensure that no form of advertising is specifically addressed to young people, for instance, through the linking of alcohol to sports.’ The charter has been signed by all the member states of the EU, including the UK (studies cited from Institute of Alcohol Studies, UK).

Prevention strategies and treatments for substance abuse and addictive behaviour

An alcoholic has to be clearly defined as being addicted to alcohol, not addicted to the effects of alcohol, because this will affect treatment. There is a high probability some users will be cross-using alcohol with other sedatives as part of their need to self-medicate. Failure to investigate a user’s full drug repertoire could cause serious harm if addictions are not uncovered and treated properly. For example: Many alcoholics cross use with benzodiazepine, a drug with very similar effects to alcohol. Benzodiazepine addiction can lead to cravings for and consumption of alcohol and, if not managed properly, it can lead to serious health problems (Poulos, 2004).

The following section deals with users who are only addicted to alcohol – however dual addictions should always be considered by healthcare professionals.

Alcoholics Anonymous

The key historical contribution of Alcoholics Anonymous (AA) is the assertion that alcoholics were in a state of insanity and not in a state of sin. This new medical paradigm paved the way for alcoholism to be treated as a diseaseand not as a personal or moral failing.

AA is centred around ‘the twelve steps and twelve traditions’. The twelve steps are guidelines for self-improvement (Alcoholics Anonymous, 2001). They can be altered to suit different personal, cultural and religious needs – although there is a heavy emphasis on spirituality and a surrendering of free will, first to the power of the addiction and secondly to the power of a sponsor and a notion of God. According to VandenBos (2007) they can be summarized:

an acceptance that one cannot control one’s addiction or compulsion
a recognition of a greater power as a source of strength
a need to examine past errors in one’s history with the help of a supportive sponsor (experienced member)
an attempt to make amends for these errors
an attempt to commit to a new life with a new code of behaviour
a commitment to helping others who suffer from the same addictions or compulsions.

The key assumptions of powerlessness and the need to adopt a higher power on the road to recovery can be seen as controversial. If adopted professionally, it may mean an individual finding strength and support in a more experienced and former addict.

Evaluation

Positives

AA is free, voluntary and community based.
There is no doubt it helps many people manage and sometimes overcome a debilitating addiction.
It offers friendly, community-based social and emotional support in a well-meaning atmosphere by former addicts. This is inherently difficult to quantify.

Negatives

Like any self-help programme, AA depends on will power and long-term commitment to succeed. AA offers a framework for self-improvement but is not a cure. Criticisms should be seen in this context.

It is difficult to quantify the effectiveness of AA. Any research group will be self-selecting because people chose to attend AA and any comparison between AA attendees and non-AA alcoholics is inherently flawed.
The use of non-healthcare professionals has led to abuse (e.g. ‘thirteenth stepping’– male members can sometimes prey on vulnerable female members). AA has responded to these criticisms with clear guidelines suggesting men be sponsored by men, and women be sponsored by women – except in the case of homosexual individuals who can be sponsored by the opposite sex.
AA is an organization which believes in paying help forward, passing on expertise to others who need it. Healthcare professionals are not a key part of this paradigm.
Gaston et al. (2005) note the reliance on the notion of spiritualism – this isn’t suitable for all cultural groups.
Honeymar (1997) notes how AA has many religious undertones which may infringe on an individual’s cultural and personal identity.
There is the lack of subtlety in the meeting format and this may deter some people from seeking help.
Not all AA attendees are full-blown alcoholics but they will be forced to see themselves as such in the context of the meetings. Cutting out alcohol completely is not an appropriate lifestyle choice for many, nor is it fully needed in all instances.

Drug treatment

Disulfiram is often considered the most effective drug for dealing with alcoholism; it creates an intense sensitivity in the user to the effects of alcohol. Disulfiram blocks the enzyme acetaldehyde dehydrogenase from converting alcohol into the relatively harmless acetic acid. Alcohol is instead stored in the body as acetaldehyde and this is widely believed to be the cause of hangovers. Therefore, the effect of disulfiram is to cause an instant and intense ‘hangover’ in anyone who drinks alcohol while taking the drug. Symptoms include shortness of breath, nausea, vomiting, throbbing headache, visual disturbance, mental confusion, postural fainting, and circulatory collapse.

Naltrexone has the effect of reducing the cravings for alcohol while the alcoholic consumes alcohol. In other words, the presence of naltrexone in the blood acts as negative reinforcer for alcohol consumption. This approach is known as the Sinclair method and is an example of pharmacological extinction.

Evaluation

Positives

Sinclair (2001) found 27% of naltrexone patients had no relapses to heavy drinking throughout 32 weeks, compared with only 3% of placebo patients. Sinclair argues that this clearly demonstrates the efficacy of naltrexone as long as it is used in conjunction with coping skills therapy.
The data showed a detoxification period is not required and targeted medication taken only when craving occurs is effective in maintaining the reduction in heavy drinking. This is a highly appropriate real-world drug for those alcoholics who experience highly pleasurable effects from drinking.

Negatives

Taking naltrexone before drinking will have to occur for the rest of the patient’s life, otherwise the endorphin conditioning – the positive association with alcohol – will re-establish itself. Therefore, freedom from naltrexone would only result from complete abstinence from alcohol.
Drug treatments offer an effective way for alcoholics to control their corrosive habits but they are most effective if used in conjunction with a therapy and are supported by motivation and a desire to control the behaviour on the part of the alcoholic.
Drug treatments do not tackle the negative thought processes which may lead some people to drink, nor do they tackle the underlying social issues which may have caused the alcoholic to seek self-medication in alcohol consumption.

Biopsychosocial treatment (BPS)

This represents an eclectic approach to treatment. The approach assumes biological,psychological and social factors play a significant role in alcoholism and therefore they should be represented in treatment. Separating the illness into constituent elements allows the clinician to distinguish between volition (e.g. personal need, desires, motivation) and biological deterministic elements (e.g. genetic predisposition and brain chemistry) which can often remove responsibility from the paradigm of understanding a person’s illness.

Case formulation and the perspectives model

Tavakoli (2009) suggests treatments should take place under the notion of a case formulation. This means historical data, medical examination, and a variety of studies are used to reach an impression, diagnosis, and treatment plan tailored for an individual patient, rather than a broad approach to an illness that ignores personal details. The very act of listening to patients is a therapeutic practice in itself and can offer some relief from whatever symptoms or grief are ailing them. Any interest the clinician shows in learning the life stories of patients promotes a deeper appreciation for their innate temperaments and behavioural choices.