Basics of Addictions PDF

Ppt 1. BASICS OF ADDICTIONS Lecture 1: Basics of Addictions Learning-based models: - Classical conditioning = By Ivan Pavlov - involves associating a neural stimulus \[NS\] with unconditioned stimulus \[US\] that naturally and automatically triggers an unconditioned response \[UR\]...

Ppt 1. BASICS OF ADDICTIONS Lecture 1: Basics of Addictions Learning-based models: - Classical conditioning = By Ivan Pavlov - involves associating a neural stimulus \[NS\] with unconditioned stimulus \[US\] that naturally and automatically triggers an unconditioned response \[UR\] - E.g. food (unconditioned) causes a saliva response (conditioned) in dogs - Occurs when the ns is presented repeatedly in conjunction with the us to generate a ur - After continuous presentation of ns and us, the cs generates the ur alone Classical conditioning and addiction: - Stimuli associated with addiction may cause the onset of a 'pleasure' response triggered by use or other related responses - These stimuli can be internal (thoughts, emotions) or external (paraphernalia, contexts, places, people) Conditioned tolerance: - Where the body's response to a drug or substance becomes diminished over time due to repeated exposure in a specific environment or context (learned through conditioning) - E.g. if someone consistently takes a drug in a particular place, their body will prepare itself for the taking of drugs in theta environment - If they take it in a new place, the body may not be as prepared, potentially leading to stronger effects or overdose - This happens because the body learns to anticipate the drugs affects based on the cues in the environment where it is usually consumed Cravings: - An intense desire to consume a substance or engage in a behaviour, often driven by the brains reward system - In the context of addiction, cravings are linked to physical or psychological dependant on a substance - They often occur after a period of use in withdrawal, where the body or mind strongly desires the sub to alleviate dis or to experience pleasure Operant conditioning: - Where a behaviour is strengthened or weakened based on rewards/consequences associated with that behaviour - Experiencing reinforcers or punishments increase or decrease the likelihood of repeating the behaviour Operant conditioning and addiction: - Discriminative stimulus \[DS\] = stimuli present during conditioning that makes it possible to anticipate the circumstances in which the behaviour will be reinforced (e.g. invitation to a party where cocaine is known to occur) - Operant behaviour = addictive behave (using cocaine) - Consequence = positive/negative reinforcement/punishment (immediate pleasure/long-term health consequences) Positive reinforcement = when a behaviour is rewarded with a desirable stimulus to encourage it (e.g. fun, self-esteem) Positive punishment = adding an aversive stimulus to decrease likelihood of repeating an unwanted behaviour (e.g. intoxication, hangover, bad trip, family conflict) Negative reinforcement = when a behaviour is strengthened by removing an unpleasant stimulus (e.g. escape from problems, coping with withdrawal symptoms) Negative punishment = when a desirable stimulus is removed to decrease the likelihood of repeating the behaviour (e.g. deterioration of personal relationships, economic/health loss, social and community disconnection) Reinforcement in terms of nicotine - Non-habitual use only --\> on daily basis --\> nicotine addiction Reinforcement programmes: - Reason = based on number of times behaviour is performed - Interval = a function of the time period since last - Fixed = only for constant number of behaviours - Variable = variable number of behaviours Example: - Fixed = R: coffee machine -- I: monthly salary - Variable = R: slot machine -- I: surprise tests - Variable programmes are the most difficult to extinguish -- intermittent reinforcement is particularly powerful because it us more uncomfortable and maintains behaviour more consistently Bandura(1977): Social learning theory - Learning by observing models and the consequences experienced by them - SLT introduce the concept of cognitive processes to understand addictions - Anticipation, planning, expectations and attributed all contribute to addictive tendencies - Identification = learner identifies with model they are observing - Model status = status or authority of model can influence likelihood to emulate the behaviour - Attention to cognitive process = observer must pay attention and mentally the behaviour for learning to occur Decision-making models: Reflexive choice, cost benefit analysis: - Suggests that substance use can be a conscious decision, whether rational or biased - The person with drug addiction decides to use based on whether they see more benefits that harm (weigh up pros and cons) - This is in contrast to the external view, where they are perceived to experience more harm than good - It is the basis for educational and information programmes - People with addiction do not perceive the consequences despite, or they are perceived, but are worth the immediate reward Reinforcement pathology theory: - Based on behavioural economics models - Allows predicting sub use ad explaining why it is maintained despite negative consequence -- constraints and benefits are not the only determinants of addiction Two processes as determinants: 1. Reinforcement derived from drug use (demand) 2. Impulsive decision-making or delay discounting - Refers to the loss of value of a reinforcer over time - The preference for immediate reinforcers to these delayed in time but of higher value - In people with addiction, this discounting is even greater (e.g. short-term gratification vs long term health) Impulsive decision making: - Within addiction, this is associated with relapse - Compulsive consumption behaviour would be the result of excessive preference for immediately available reinforcers - Overevaluation of a product leading to short but intense reinforcement Cognitive bias: Attentional bias = when paying attention to stim in our environment, attentional bias makes it easier to pay attention to those stim that have produced positive reactions A person with addiction pays more attention to stim related to the addictive behaviour, increasing risk of relapse The hindsight bias = when a person with addiction remembers the positive aspects associated with the substance better than the negative ones Gateway theory: - Exposure to an addictive substance increases the likelihood to engage in the behaviour again - Increased exposure, greater accessibility, initial habituation to milder effects and behavioural similarities in methods of consumption (e.g. smoking, inhaling, injecting) all contribute to escalating drug use and addiction - E.g. smoking as a gateway drug to cannabis Combining these processes: - Automatic processes derived from learning based models are complementary to conscious processes - In any addictive process, there is a combination of compulsive (automated) and rational behaviours (cost-benefit analysis) with greater or lesser weight Self-medication hypothesis: - Individuals with psychological problems are more likely to consume addictive substances - This is usually as a coping mechanism - Addiction involves behaviours or sub abuse to address/cope with pre-existing needs (e.g. health, psychological, emotional­) - Addressing addiction usually involves understanding these underlying issues rather than focusing solely on the substance use itself Construction of identity: - Addiction can develop and persist partly due to how a person views themselves - Self-efficacy = one's belief in their ability to control their behaviour -- if someone doubles their ability to succeed, they may feel less motivated to try to overcome addiction Self-regulation theories: - Addiction involves failure to regulate behaviour due to weakened self-control - When self-control skills break down, immediate impulses and desires take over - This can be caused by ego-depletion = where a person's self-control resources are exhausted - Training in self-control improves recovery, but addiction is linked to broader difficulties in life regulation (e.g. work, leisure, finances) Theory of excessive appetites: - Combines multiple theories to explain addiction for behaviour that become central in a person's life - Addiction develops when the attachment intensifies and is motivated by high perceived rewards and low disadvantages As the behaviour escalates, natural, psychological and social dissuaders (e.g. hangovers) may limit it - Addiction leads to conflict and harm to social relationships may aid motivation to recover Importance of social control: - Most people engage in moderate consumption, but others are 'excessive' (as defined by social norms) Cognitive dissonance theory: - We generally seek coherence between our behaviours, thoughts and values - If we have a behaviour that throws this balance off, cognitive dissonance is generate and causes discomfort - To reduce this, the individual may modify the belief, change the behaviour, avoid thinking about it, or find a way to integrate the conflicting elements to create coherence Prochaska and DiClemente (1992): Transtheoretical Model of Change - Individuals are classified in one of the following based on their intention to change 1. Precontemplation = no recognition for need to change 2. Contemplation = thinking about change 3. Preparation = willingness to start change 4. Action = implementation of change 5. Maintenance = sustained change -- if not working correctly, can led to relapse Marlatt and Gordon (1984): Relapse prevention model - Designed to address relapse in the context of addiction and other problematic behaviours - Relapses are a result of a complex interplay of personal, environmental and situational factors - Discriminative stimuli are important in relapse (high-risk situations) **Abstinence violation effect:** - Refers to the attributional style of relapse that occurs in patients who are stopping using - Usually involves internal, stable and global attributional response - Also affective response of guilt and shame - Abstinence -- consumption -- internal, global and stable attributional process -- relapse - How individuals attribute a relapse and their emotional response to it can influence their ability to maintain recovery Lapse and relapse: - Lapse = an isolated episode - Relapse = more significant recurrence for a prolonged duration - It is important to accept that lapse/relapse is possible and analyse factors leading to this - Also to train coping skills in high-risk situations and decision making towards non-consumption - Also to train in coping and lifestyle strategies for abstinence Lecture 2: Brief history of addictions Ancient China: - Alcoholic beverages were consumed in China before 10000 BC Ancient Egypt: - Beer and wine were highly valued - Poppy was used for opioids with sedative effects e.g. to calm children) - Cannabis sativa was used for pain relief Greeks and romans: - Dionysus was god of the grape harvest, wine, feasting and revelry - Performance of rituals with wine in honour of god Medieval Europe: - Wine was consumed by noble classes, and it was considered healthy and a blessing from god Benjamin Rush (1746-1813): - A medical expert and suggested the first systematic description of the physiological damage caused by alcohol - Alterations to the liver, stomach, blood, nervous and muscular tissues - Chronic alcoholism is described as a progressive medical condition - His work gave impetus to the temperance movement Characteristics of the alcoholic: - Radical changes in personality - Affects the willpower - Suggested to be hereditary Treatment methods: - Sweating. Bloodletting, purgation, induced vomiting and fear responses - Used mercury to dehydrate through purging and vomiting -- these endangered patients - In 1810 he stressed the importance of developing specific institutions for alcoholics - His work gave impetus to the temperance movement Temperance movement (USA): - Religious and social movement aiming to reduce alcohol consumption and draw the nations attention to the adverse moral and social consequences of alcohol use - Early movement (1784-1861) = Marital abuse, family neglect, chronic unemployment linked to excessive alcohol use - Second wave (1872-1893) = After American civil war there were increased efforts to achieve abstinence - Early concept of addiction - Women's Christian temperance movement (1973) - Third wave (1893-1933) = Women's suffrage The dry law (Prohibition Act, Volstead Act): - 1851 Maine and other states put forward the Prohibition act The repeal (1933): Roosevelt - Great growth of the black market - Great depression 1929 Therapeutic use of psychoactive substances - Cocaine as anaesthetic and remedy for morphine addiction, sedation for surgery/toothache etc - Opiates used for pain to help with withdrawal symptoms - Cannabis used for migraines, sleep problems, general pain etc - Harrison Narcotics Act (1914) -- a law that regulated and taxed the production, importation and distribution of opiated and cocaine products The war on drugs: - Aims to reduce the demand for drugs by reducing the production, distribution and consumption of drugs - Began in the US, where it was first outlawed Inebriates' homes and asylums: - Institutions to treat people suffering from chronic alcoholism and other addictions - Inebriates' homes = Rehabilitation treatment with more of a social approach - Asylums = Medical and therapeutic treatment Physical treatments: - Eugenics and sterilisation aimed to put an end to the degeneration of alcoholics - Alcohol helps to cleanse society of its weak members - Naturalistic therapies (e.g. isolation) - Water sures hydrotherapy e.g. baths showers, dilution of alcohol - Pharmacological therapies (1860-1930) -- morphine and sedatives as treatment fir alcoholics - Electroconvulsive therapy (1934-1950s) and lobotomies Psychological treatments: Karl Abraham: - Alcoholism viewed as an unresolved oral dependency - Reflects symptoms of neurotic conflict, underlying psychosis and castration anxiety - Treatment = bringing unconscious motivations to the conscious level Freud: - Delayed psychosexual development, unconscious motivations, alcoholism as a disease - Treatment = to moderate drinking Aversive conditioning therapy: - Association of alcohol with aversive stimuli (e.g. worms and insects inti the drink, drink and vomiting - Results were relatively positive in motivated patients, however there were undesirable effects Therapeutic communities: - The soldiers suffered from war neurosis, and it was observed that patients gained a deeper understanding of their condition through active participation in interactions and discussions with the medical staff, rather than just using treatment Social theories of addiction: Sociocultural model: - Emphasises the complex and variable relationship between drugs, individuals and contexts - Societal definitions shape the meaning and significance of drug use, influencing perceptions of both the dug and their users - Ethnography = focuses on everyday experiences and social practices, analysing the discourse of individuals involved - It has shown how the positive/negative effects if different psychoactive substances cannot be separated from their cultural contexts - E.g. the use of psychoactive in tribal or traditional societies - Suggests society creates and enforces a lifestyle that isolates and stigmatizes people with deviant behaviour, often pushing them into alienating urban areas Behavioural economics model: - Costs = if an addictive substance in inexpensive, it is more likely to be consumed more frequently (bot just the price of the product but also social and health-related costs) - Influencing factors = risk perception, social norms, and the cultural environment that either encourages or discourages substance use - Accessibility = if the substance is easy to obtain, its consumption is likely to be more frequent and widespread (e.g. alcohol) Biological theories of addiction: - Psychoactive drug consumption alters brain functioning, leading to a chronic medical condition - Mechanisms of addiction = positive reinforcement, craving, impaired executive functions - Addiction as a brain disease = substances alter neural pathways involved The reward pathway: - The reward circuit (mesolimbic pathway) is the basic neurobiological substrate of learning and is linked to the experience of reinforcement - Dopamine is the neurotransmitter involved in the functioning of the reward circuit and is produced in the ventral tegmental area \[VTA\] when a natural/non-natural reinforcer is present DA is released from the VTA in the following structures: - Amygdala = assigns emotional significance to events experienced - Hippocampus = responsible for processing memory - Nucleus accumbens = responsible for indicating reinforcement is important - Prefrontal cortex = responsible for guiding attentional processes towards reinforcement Drugs and the reward pathway: - Brain produces large amounts of dopamine, and it's released into the reward circuit - Intense positive emotions are experienced, and the brain encodes the characteristics - This learning process leads the brain to perceive the reinforcer as rewarding and promotes repeated use - The brain becomes willing to overlook negative experiences Tolerance and abstinence: - If excessive dopamine is release, a euphoric and pleasurable effect is produced which the brain does not tolerate as a typical response - To prevent this, the postsynaptic neuron closes some dopaminergic receptors - Over time, the same amount of substance produces a diminished affect and a tolerance is built - Traditional reinforcers (e.g. chocolate, sex) lose their reinforcing capacity - Addiction leads to long lasting change in brain function -- scientists worry some brain areas may never fully recover from addiction Lecture 3: Criticisms of the 'brain disease' model: - They rely on studies that self-administer opioids in deprivation situations -- an enriched environment changes everything (e.g. in environments with positive stimuli (social companionship, toys, exercise) , rats tend to consume significantly less or no drugs at all) - Genetics is not very informative regarding addictions today\ neuroimaging studies have biases and do not show whether addiction is the cause or consequence of differences in brain structure and function or some combination of both - Viewing addiction as something inevitable can lead to learned helplessness - Many case studies are done on animals (e.g. rats) Risk and protective factors: - Resilience = the process of adapting well in the face of adversity, trauma, threats or even significant sources of stress \[APA, 2014\] - It is not a trait, but rather a set of processes - Early studies (e.g. Werner, 1995) concluded there were various protective factors associated with resilience, including individual and family factors Risk factor = those that increase the risk of probability of engaging in substance use/addictive behaviour/disorder - Macro situational factors (e.g. decrease in price) - Micro situational factors (e.g. night outs, neglectful parenting, victimization, peer pressure) - Individual (e.g. level of inclusivity, sensation seeking, high levels of impulsivity, high internalising and low externalising symptoms) Examples: - In relationships = parental maltreatment, child abuse, inadequate supervision - In communities = neighbourhood poverty and violence - In society = norms and laws favourable to substance use Protective factor = those that decrease the probability of engaging in substance use/addictive behaviour/disorder Examples: - Parental involvement - Availability of faith-based resources and after-school activities - Hate crime laws or policies limiting the availability of alcohol Responsibility according to different models: **Responsibility for addiction** **Responsibility for recovery** ----------------------- ------------------------------------------------------------------------------------------------- ---------------------------------------- Moral model Individual Individual Biological model Biological predisposition, drug brain Reversal of the alteration, medication Biopsychosocial model Multiple biological, social and psychological factors, importance of risk and predisposing fact individual Biopsychosocial model: - Biological, psychological and social factors equally contribute to sub abuse - It is the interaction of these that cause addiction - Addict can be developed without biochemical or neuropsychological alterations - Psychological and cultural differences explain varying effects of bio alterations - Psychological and social variables are crucial for recovery process What is addiction? - A compulsive behaviour of self-administration of a psychoactive substance or behaviour - Produces significant reinforcement, resulting from a learning process subject to operant and classical conditioning - These reinforcements have the ability to generate compulsive behaviour through neuroadaptive progresses or from intermittent reinforcement (e.g. gambling) - Addictive behaviour can have negative consequences and indirect effects on physical, psychological and social levels - The individual will exhibit significant desire/motivation or need to engage in that behaviour despite risks/harms - The intense desire is countered but opposing forces of self-regulation, leading to a perception of loss of control over the behaviour - Following repeated repetition of the behaviour homeostatic compensation and neurophysiological adaptation leads to a response of tolerance which gradually reduces the intensity of reinforcement - This can lead to larger consumption/engagement in the behaviour and potentially non-normative/abuse, resulting ins social conflict - The perception of loss of control and social conflict can lead to individual conflict regarding the appropriateness of the behaviour 1. Social construct = addiction is not an objective concept that can be defined uniformly -- its definition is subject to cultural, social and temporal circumstances 2. More than a choice = often individuals with addiction do not make a deliberate decision but instead are carried along by routines or circumstances 3. Balance of forces = it is a balance between the forces that promote a behaviour and those that oppose it 4. The situation = in most circumstances most activities are not addictive Psychoactive substance: - Various natural or synthetic compounds that act on the nervous system, causing alterations in the functions that regulate thoughts, emotions and behaviour The journey of substances in the body: 1. Drugs exert their effects on the brain and reach it through the circulatory system (absorption) 2. The effects of drugs depend on their concentration in the blood, which is determined by the route of administration 3. Depending on the route of administration (oral, inject, inhale etc), the concentration in the blood will vary and so will the effect 4. Once the drug enters the body, it is distributed throughout 5. Once the drug is distributed, it reaches the brain and produces its affects -- it accumulates in other tissues and organs that act as reservoirs (act to process and eliminate substances from the body) Metabolization: - As drugs are distributed, they undergo a series of change - Primarily in the liver, kidneys and intestines, they are metabolised and result in the formation of more/less/unchanged substance Excretion: - The elimination of drugs occurs mainly through the kidneys and urine, with small proportion also being excreted through sweat etc Routes of administration: - Oral = it enters the blood through the capillaries surrounding the small intestine and is distributed throughout the body (the slowest route) - Intravenous route = it enters directly into the blood and is the method that provides the greatest cost/benefit efficiency for the user - Snorted/nasal route = passes directly into the blood through the nasal membranes - Inhaled/smoked route = rapidly absorbed by the blood, allowing it to reach the brain within seconds Classification of drugs: - Original (natural vs synthetic - Criterion of danger (soft vs hard) - Criterion of legality (legal vs illegal) - Effects on CNS (depressants vs stimulants vs hallucinogens) Craving: - The uncontrollable desire to consume a drug - Can be triggered by ideas, memories, conditioned stimuli etc - This makes it very difficult for the user to control and promotes the search for the desired substance - The desire is only fulfilled through the consumption of the drug - The ultimate goal is to reduce the source of instigation - Cravings and consumption urges tend to be automatic and can become 'autonomous', continuing even when the person tries to supress them Intoxication: - The process by which the consumption of a substance exceeds the level of tolerance accepted by the body - Causes alterations in the level of consciousness, cognition, perception, behaviour etc Tolerance: - The process by which a person increases the amount of a substance consumed in order to maintain the rewarding effect initially obtained - Includes both the physical and psychological aspects - Variations in conditions and environment where the drug is consumed can reduce or eliminate this phenomenon, potentially leading to overdose Cross-tolerance: - Refers to the decreased effects of a particular drug as well as continued use of a different drug - When a person has developed tolerance to a drug, this extends to all drugs within the same pharmacological group or similar substances - The body's ability to develop tolerances to the effects of both substances due to their similarity in how they act on the CNS Reverse tolerance/sensitization: - When the body becomes more sensitive to the effects of a drug after repeated and prolonged use Withdrawal syndrome: - The set of signs and symptoms that appear when a substance is stopped or reduced - Acute = the organic and psychological symptoms experienced when consumption is abruptly stopped - Late = a set of dysregulations of the neurovegetative nervous system and basic psychological functions that persist for a long time after achieving abstinence (e.g. sleep problems, anxiety) - Conditioned = the emergence of symptoms typical of acute withdrawal syndrome without recent substance use (e.g. when visiting a street/friend they used to consume in/with) Detoxification: - The process by which a patient stops using and can remain abstinent without experiencing acute withdrawal syndrome - Detoxification treatments typically last between 7-14 days and does not pose significant risk to the patient - It should always be accompanied by specialised treatment for substance use and for relapse prevention Lecture 4: DSM-5 - ''addiction'' is not used as a diagnostic term in the official classification if disorders - ''substance use disorder'' is the official dsm-5 terminology Abuse: - A maladaptive pattern of substance abuse leading to clinically significant impairment or distress manifested by one or more for over 12 months 1. Recurrent substance use resulting in a failure to fulfil major role obligations (e.g. work, school, home) 2. Recurrent substance uses in situations where it is physically hazardous (e.g. driving a car) 3. Continues substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the orders if the substance Dependence: 1. Tolerance (a need for increased amounts of substance or diminished effects of the substance) 2. Withdrawal (characteristic withdrawal syndrome or the same/related substance taken to relieve or avoid withdrawal symptoms) 3. The substance is often taken in larger amounts or over longer periods of time than originally intended 4. There is persistence desire or unsuccessful efforts to cut down or control substance abuse 5. A great deal of time is spent in activities necessary to obtain the substance (e.g. visiting multiple doctors), using the substance (e.g. chain smoking), or recovering from its effects 6. Important social, occupational, or recreational activities are reduced due to substance use 7. The substance use is continued despite knowledge of having persistent physical or psychological problems as a consequence Substance-related disorders: - A problematic pattern of use of... leading to clinically significant impairment or distress, as manifested by at least two of the following occurring within a 12-month period - The categories if abuse and dependence have been consolidated into a single diagnosis called substance related disorders - Divided into two groups: substance use disorders and substance induced disorders +-----------------------------------+-----------------------------------+ | Specify if: | In early remission: none of the | | | criteria has been met for at | | | least 3 months but less than 12 | | | | | | In sustained remission: none of | | | the criteria has been met for 12 | | | month or more | +===================================+===================================+ | | In a controlled environment: used | | | when the individual is in an | | | environment with restricted | | | access to... | +-----------------------------------+-----------------------------------+ | Specify current activity: | Mild: presence of 2-3 symptoms | | | | | | Moderate: presence of 4-5 | | | symptoms | | | | | | Severe: presence of 6 or more | | | symptoms | +-----------------------------------+-----------------------------------+ Main differences between substance use disorders in DSM-IV-TR and DSM-5 +-----------------------------------+-----------------------------------+ | Consolidation of classifications | DSM-IV-TR: Presents two separate | | | categories: substance abuse and | | | substance dependence | | | | | | DSM-5: Combines these categories | | | into a single diagnosis | | | (substance use disorder) which | | | encompasses both | +===================================+===================================+ | Criteria | DSM-IV-TR: Specifies specific | | | criteria for abuse (4 criteria) | | | and dependence (7 criteria) | | | | | | DSM-5: Is based on a unified set | | | of 11 criteria that applies to | | | all | +-----------------------------------+-----------------------------------+ | Focus on the continuum | DSM-IV-TR: Tends to classify | | | disorders in a more categorical | | | manner | | | | | | DSM-5: Advocates for a more | | | continuous approach | +-----------------------------------+-----------------------------------+ | Elimination of the distinction of | | | dependence | | +-----------------------------------+-----------------------------------+ | Recognition of craving | | +-----------------------------------+-----------------------------------+ | Focus on functional impact | | +-----------------------------------+-----------------------------------+ None substance-related disorders: DSM-5 - Mental health conditions that involve behaviours or activities that can cause significant problems in a person's life, but do not involve the use of chemical substances such as drugs or alcohol - Often associated with addiction or compulsive behaviour - E.g. gaming disorder, binge eating disorder, sexual behaviour disorder, social media disorder Epidemiology: - Epidemiology = science that studies the distribution and determinants of diseases and other health related issues in populations - Drug epidemiology = essential for global health and requires appropriate attention, including training funding and support - Interventions must be adaptable, and evidence based to address changes in drug abuse patterns Conventional psychoactive drugs: - The most commonly consumed psychoactive substances are alcohol, caffeine, nicotine, cannabis, opioids, heroin, LSD etc - In 2015, 4.9% of global adult population abused alcohol, 22.5% used tobacco and 3.5% used cannabis - Alcohol, tobacco and caffeine are all commonly used despite negative effects on mental health and well-being Unconventional psychoactive substances: - The patterns of use and abuse of conventional psychoactive substances arew not well understood and often based on trial and error - It is crucial to have surveillance systems in place to track trends and prevent epidemics Drug-related mortality in spain, 2021: - 1,046 deaths were reported due to acute reactions to psychoactive substances Gender = 78% deceased were male Average age = 47.6 years with 74.8% being over 40 Criminal responsibility: - The material commission of an act is not sufficient to attribute a person the responsibility for a crime (imputable) - The ability to understand the injustice of the fact (cognitive ability) - The capacity to act in accordance to this understanding (volitional ability) Imputable: - Imputable or full accountability = maintains cognitive and volitional capacity at the time of the events to judge - Semi imputable/deceased accountability = at the time of the events that are judged, suffers a disorder deficiency or disturbance that interferes with - No imputable/ not = has voided cognitive or volitional capacity at the tune if the events to judge - The Imputable = a continuous variable Individuals exempt from criminal responsibility: - Those who are unable to understand the illegality of the act due to a mental anomaly at the time of crime - Individuals who commit criminal offence while in a state of complete intoxication - Those who have a severe impairment of conscious reality Mitigating circumstances include: - The causes above but when not all the necessary requirements for exemption of responsibility are met - Acting due to severe addiction - Acting under causes or stimuli so powerful they are in a state of frenzy, obsession etc - These do not completely eliminate responsibility, but can make consequences more severe Criteria for suspension of sentences: - The offender must be a first-time offender - The imposed penalty must not exceed 2 years - Civil liberties from the offence must be settled - Even if these are not met, judge can suspend custodial sentences of up to 5 years if it was committed due to substance dependence Suspension periods: - For custodial sentences up to 2 years = 2-5 years - Minor sentence = 3 months-1 year Conditions for suspension: - Prohibitions on approaching certain individuals or places - Part in programs for abstinence Remission of suspended sentences: - If the individual has not committed any new crimes and complied with rules, the judge will remit the sentence - Individual must demonstrate abstinence or ongoing treatment to qualify for remission Penitentiary legislation: - Allows for prison admin to refer inmates with substance use disorders to public or private community-based detoxification treat - Some follow up rules established - Time spend counts as serving the sentence - If they violate community treatment rules, they may be referred back to prison Ethical values: - Integrity - Transparency - Accountability - Community Basic principles: - Autonomy = recognize the right of others to choose and act according to their own desires or beliefs - Non-maleficence = obligation not to intentionally harm others - Beneficence = take positive steps to help others - Justice = equitable distribution of burdens and benefits - Fidelity = fulfil the responsibilities of trust in a relationship - Veracity = is the quality of being truthful and hones, promoting trust and transparency in relationships Ethical and legal guidelines: +-----------------------------------+-----------------------------------+ | Ethical: | Legal: | +===================================+===================================+ | - A set of professional | - Determined by the laws | | standards | | | | - Implemented if ethics are | | - A set of principles to guide | consistently violated | | profess behaviour | | | | - Often enforced through civil | | - It is often a matter of | or criminal penalties | | opinion and cultural context | | | | | | - Not always a legal concern | | +-----------------------------------+-----------------------------------+ Always maintain professional relationships: - Avoid dual relationships with clients (e.g. if a therapist is treating a family member or a close friend it can create conflicts of interest) - Avoid sexual relationships with clients - Avoid personal relationships with clients (e.g. a therapist should avoid becoming close friends with a client outside of therapy sessions) Confidentiality: - The clients' rights and limits of confidentiality should be explained at the beginning of the treatment - the relationship with any client should be private and confidential - client information should not be shared outside the treatment team - info should only be disclosed with the client or guardians' permission - must be maintained at all times, except when doing so could harm the client or others