Drugs and Alcohol: A First Year Overview PDF

# Drugs and Alcohol Professor Celia Morgan ## Introduction - Who am I? - Why am I interested in addiction? ## Learning Objectives - How big a problem is drug and alcohol use? - What is addiction? - What causes addiction? - How do we treat it? ## Essential Tasks - Attend/watch lecture - Read *Int...

# Drugs and Alcohol Professor Celia Morgan ## Introduction - Who am I? - Why am I interested in addiction? ## Learning Objectives - How big a problem is drug and alcohol use? - What is addiction? - What causes addiction? - How do we treat it? ## Essential Tasks - Attend/watch lecture - Read *Into the Realms of Hungry Ghosts (Part 3: Chapters 11-16)* ## Optional Tasks - Readings in folders on ELE - Own reading around the topic, news to recent papers ## Prevalence - **Which of the following drugs have you tried?** - Alcohol - 180 - Cannabis - 67 - Cocaine - 15 - MDMA - 12 - Ketamine - 15 - Magic Mushrooms/Psilocybin - 13 - Heroin - 3 - Tobacco - 88 - Drinking alcohol is normative in the UK; around 8% smoke tobacco. - **Number of past-year users in millions (2017)** - Cannabis - 188 - Opioids - 53 (29 opiates) - Amphetamines & prescription stimulants - 29 - Ecstasy - 21 - Cocaine - 18 - United Nations World Drug Report, 2024: Almost 292 million, or 1 in 18, people used a drug in 2022, 20 per cent more than a decade earlier. ## Harm - **Please rank these drugs in the order of how harmful they are:** - 1st - Heroin - 2nd - Cocaine - 3rd - Ketamine - 4th - MDMA - 5th - Magic Mushrooms / Psilocybin - 6th - Alcohol - 7th - Tobacco - 8th - Cannabis - **WHICH DRUGS ARE MOST HARMFUL?** - **What the public think** - Heroin - 97% - Cocaine - 97% - Ecstasy - 90% - LSD - 60% - Tobacco - 88% - Mushrooms - 63% - Cannabis - 70% - Alcohol - 72% - **What science says** (Overall harm score (100=maximum)) - Heroin - 97 - Cocaine - 55 - Ecstasy - 54 - LSD - 20 - Tobacco - 72 - Mushrooms - 20 - Cannabis - 63 - Alcohol - 0 - *Researchers led by Prof. David Nutt asked experts to rank drugs on 16 criteria of harm to the user and to wider society* - The cost of **Alcohol** to society - £11 billion - alcohol-related crime - £7 billion - lost productivity through unemployment and sickness - £3.5 billion - cost to NHS - **Total** - £21 billion - **Over 6 million people in England smoke.** - Smoking is the single largest cause of preventable ill health and premature death. - 17% of all deaths in people aged 35+ - £11bn - The annual cost of smoking to society in England - £2.6bn - Direct costs to the NHS - £760m - Costs to social care - **Illegal drug use costs in the UK** - ~300 000 opiate and crack users in UK - Estimated to have cost the UK £11 billion per year - Only £30 million of that to drug treatment and prevention - £2.6 billion legal costs for prosecuting drug offences ## Addiction - **What is addiction?** - "A state in which an organism engages in compulsive behaviour" - "Behaviour was once rewarding or pleasurable" - "Loss of control in limiting intake" - **177 responses**: A word cloud depicting commonly cited words to describe addiction. - **DSM-5 Criteria for Substance Use Disorder**: A table depicting severity and criteria for diagnosing addiction, see below. | Criterion | Severity | |-----|-----| | Use in larger amounts or for longer periods of time than intended | 0-1: No diagnosis | | Unsuccessful efforts to cut down or quit | 2-3: Mild SUD | | Excessive time spent using the drug | 4-5: Moderate SUD | | Intense desire/urge for drug (craving) | 6 or more: Severe SUD | | Failure to fulfill major obligations | | | Continued use despite social/interpersonal problems | | | Activities/hobbies reduced given use | | | Recurrent use in physically hazardous situations | | | Recurrent use despite physical or psychological problem caused by or worsened by use | | | Tolerance | | | Withdrawal | | ## Alcohol Withdrawal - An illustration depicting common symptoms during alcohol withdrawal. - Day 1: Hangover symptoms - Day 2: Night sweats - Day 3: Shaking - Day 4: Paranoia - Day 5: Relief - Day 6: Brain fog - Day 7: Cravings - Day 8: Better sleep ## Causes of Addiction - **What causes addiction?** - **Why do people use drugs and alcohol?** - **229 responses**: A word cloud depicting commonly cited reasons for drug and alcohol use. See below. - To avoid reality, Disassociating, adverse life events, Feel good, Boring, Gratification, Numb pain, To avoid, Feel good, Escape from reality, Coping mechanism, Socialising, Culture, Relax, Relax, Experience, To avoid, Get loose, Intrigue, Stress, Trauma, Boredom, To avoid, Peer pressure, Culture, Addiction, Enjoyable, Peer pressure, Good time, Pain, Confort, Adventure, Fun, Pleasure, Escape, To cope, Relieve the pain, To cope, Conformity, To fit in, Release, Curiosity, Dopamine, Happiness, To fit in, Banter, To escape from reality, Social inclusion, Social anxiety, Relaxes inhibitions, To escape, To cope, Why not, Social pressure, Only source of happy, Mental illness, Escape reality, Alleviate stress, To cope, Social inclusion, Mental health issues, Relieve the pain, Dissociation, Pressure, To escape, Socialising, Good time, Relaxation, Enjoyment, Mood intensifier, Mental health issues, Social occasions. <start_of_image>- **Why do people become addicted to drugs?** - **167 responses**: A word cloud depicting commonly cited reasons for becoming addicted to drugs. - No control, Increasing dosage, To feel numb, Depend on for well-being, Mental illness, Other mental disorders, Feel better, Love them, Friends, Drug properties, Loss of control, Opportunity, Weak mind, Loneliness, Social influences, Cultural norms, A need, Feels Good, Economic, Habit, Dependant, Normalized, Traume, Habitual banter, Genes, Increased tolerance, Genetics, Dependence, Over-dependence, To stop, To feel better, Chase the high, Dependent, To feel numb, Predisposition, Take to much, Cope, Addiction, Escapism, To stop withdrawl, Lack of control, Weaknes, Lack of support, Chemicals, Comfort, Stress, Tolerance, Accident, Like the feeling, Too fun, Fragile heart, Society, Peer pressure, Addictive gene, They try it for fun, Adaptation, Avoid withdrawl, Lack of purpose, Crave the dopamine high, They feel cool, Biology, Chasing a high, Too boring, Biological lecturer, Mental health issues, Positive experience, To satisfy cravings, Need to escape, Craving - Instant reward, Genetic predisposition, No Control, Increasing dosage, To feel numb, Depend on for well-being, Mental illness, Other mental disorders, Feel better, Love them, Friends, Drug properties, Loss of control, Opportunity, Weak mind, Loneliness, Social influences, Cultural norms, A need, Feels Good, Economic, Habit, Dependant, Normalized. ## Vulnerability - Biological/Genetic - Environmental/Social - Interaction - **Genetic Risk of Alcoholism** - Identical twins (MZ) 54% concordance - Fraternal twins (DZ) 28% - Even when raised in different environments - 4 x higher risk for adoptee children when natural parents had alcohol problem - An illustration depicting the function of alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH), and the role of ALDH2 in the risk of alcoholism. - “ALDH2 Gene codes for ALDH. Genetics can be protective against alcoholism (OR 0.25 Li et al. 2012, Human Genetics)” - An illustration of a mother smoking, a father drinking, and a child between them, attempting to illustrate the interaction of genes and the environment. - “Genes interact with our environment: Availability - Social Learning” ## The Social Environment and Addiction - **Did you know?** An illustration of a child, in a sad position, with text indicating "There is a stronger link between childhood trauma and addiction, then there is between obesity and diabetes. Two thirds of addicts report being abused as children. That means that the war on drugs is a war on traumatized people that just need help." - **Leza et al. 2021 ACES and SUD** - “Early Adversity has Lasting Impacts” - An illustration showing how early adversity can impact mental and physical health and lead to risky behavior and reduced opportunities, see below. | | | |-----|-----| | **Adverse Childhood Experiences** | | | **More than 4 ACEs** | 5 x use drugs, 11 x inject drugs, 7 x have alcohol use disorder (see Leza et al., 2021)| | | | | **Traumatic Brain Injury** | Depression, Anxiety, Suicide, PTSD | | **Fractures** | | | **Burns** | | | **Unintended Pregnancy** | Maternal Health | | **Pregnancy Complications** | | | **Fetal Death** | | | **Injury** | Mental Health | | **Maternal Health in Pregnancy** | | | **Infectious Disease** | | | **HIV** | | | **STDS** | | | **Chronic Disease** | Cancer, Diabetes | | **Risky Behaviors** | Alcohol & Drug Abuse, Unsafe Sex | | **Opportunities** | Education, Occupation, Income | | - An illustration depicting reduced striatal D2 receptor density in addiction. - “Reduced striatal D2 receptor density in addiction” - An illustration of a brain, with images highlighting different areas and colors to illustrate regions associated with pleasurable and displeasure experiences. - “D2 receptors can predict initial response to stimulant drugs [Volkow et al (1999)]” - An illustration of monkeys in individual and social housing conditions, and a graph depicting the level of D2 receptor density. - "Environment changed D2 receptor density in dominant but not subordinate monkeys" - "D2 receptor changes interact with social environment *Morgan et al (2002). Monkeys ind. housed 1.5 years, then groups of 4. Subordinate= social stress*" - A graph illustrating cocaine use in dominant and subordinate monkeys. - “What happened when they gave these socially housed monkeys access to cocaine?” - The dominant monkeys used **more** - 8 - The subordinate monkeys used **more** - 74 - They both used the **same amount** - 4 - A graph showing the amount of cocaine reinforcement and intake in monkeys that were individually housed or socially housed. - "Same cocaine use when individually housed, subordinate (in black) much higher cocaine use when socially housed" - An illustration depicting a rat park in a standard housing with text indicating that it is “Figure 2 – Standard Rat Housing”, and two more illustrations “Figure 6a - "Aerial View" of Rat Park, North Wing” and “Figure 6b - Naptime and Recess”, plus a graph illustrating morphine consumption in caged and socialized rats. - “Rat Park: Alexander 1981” - “Fig 7 – Some Experimental Results” - **Also happens in humans...** - Crack cocaine users in hospital for a number of weeks were given the opportunity to earn $950. They were given the choice between either immediate gratification with pharmaceutical grade crack, or delayed gratification with money. Those that were given small rewards chose the crack, while those that were given large rewards chose the money. - “Crack cocaine users in hospital for a number of weeks, chance to earn $950. Make choices between **pharmaceutical grade crack (immediate)** or **money (delayed)**, small rewards chose crack, large rewards money (Hart, 2000).” - When US soldiers were deployed to Vietnam, approximately 20% developed heroin addiction, however, on their return to the US, they dropped back down to their pre-deployment levels of addiction. - “Lack of other rewards mean addicts choose drugs - Vietnam War 20% heroin addiction but on return dropped back down to pre deployment levels” ## Treatment - **Questions/Break** - 12 questions - 3 upvotes - **What are the treatments for addiction?** - **Common addiction treatments** - **Medication** - Benzodiazepines e.g. alcohol - Methadone e.g. heroin - Drugs that block or change effects of substances e.g. naltrexone, disulfiram, buproprion - Semaglutide - **Motivational Interviewing** - A diagram depicting the four components of Motivational Interviewing - Acceptance - Compassion - Partnership - Evocation - "Motivational Interviewing (Rollnick & Miller, 1995): The spirit of MI" - **OARS** - **Open Questions** - to explore concerns, promote collaboration, and understand the client's perspective - **Affirmations** - to support strengths, convey respect - **Reflective Listening** - to explore deeper, convey understanding, deflect discord, elicit change talk. - **Summarize** - to organize discussion, clarify motivation, provide contrast, focus the session and highlight change talk. - "Key Skills in Motivational Interviewing" - "Key skills for motivational interviewing" - **Motivational Enhancement Therapy**: A diagram depicting the six components of Motivational Enhancement Therapy. See below. | | | |-----|-----| | **Measure** | Your clients' motivation to change using the behavioural change rulers. | | **Assess** | Your clients' readiness to change using the transtheoretical model | | **Strengthen** | Your clients' importance to change by aligning with their values, beliefs, and goals | | **Transform** | Your communication skills, encouraging your clients to present the arguments for change rather than against | | **Explore** | Your clients' ambivalence and resolve it using the decisional balance tool | | **Reframe** | Your clients' resistance in this constructive way that encourages conversation and reinforces change talk | - **Contingency Management** - **“Not why the addiction, but why the pain.” - Gabor Maté** - **Cognitive Behavioural Therapy** - Recognising thinking biases, underlying beliefs - Coping with cravings - Identifying high risk situations and triggers - Problem solving skills - Activity scheduling, goal setting - **Treatments that work on building healthy connection:** - 12 step programmes like Alcoholics Anonymous - "So the opposite of addiction is not sobriety. It is human connection." - Johann Hari - **The Twelve Steps:** - We admitted we were powerless over alcohol—that our lives had become unmanageable. - Came to believe that a Power greater than ourselves could restore us to sanity. - Made a decision to turn our will and our lives over to the care of God as we understood Him. - Made a searching and fearless moral inventory of ourselves. - Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. - Were entirely ready to have God remove all these defects of character. - Humbly asked Him to remove our shortcomings. - Made a list of all persons we had harmed, and became willing to make amends to them all. - Made direct amends to such people wherever possible, except when to do so would injure them or others. - Continued to take personal inventory,and when we were wrong, promptly admitted it. - Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. - 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. - **Are alcoholism treatments effective? The Project MATCH data** - “Project MATCH was the largest and most expensive alcoholism treatment trial ever conducted. The results were disappointing. There were essentially no patient-treatment matches, and three very different treatment groups produced nearly identical outcomes. These results were interpreted post hoc as evidence that all three treatments were quite effective. We re-analyzed the data in order to estimate effectiveness in relation to quantity of treatment." - “But in the largest study of **MI, CBT** and **12 step** no differences and limited treatment effects“ - **Relapse is very common** - "Quitting smoking is easy. I’ve done it hundreds of times.” - Mark Twain - **“The ketamine blew my mind': can psychedelics cure addiction and depression?”** - ““The ketamine blew my mind” https://www.theguardian.com/lifeandstyle/2021/mar/13/it-blew-my-mind-can-psychedelic-drugs-cure-addiction-depression" - **Any questions?** - 12 questions - 3 upvotes