Addictive Behaviors PDF

Addictive Behaviours Week 1 - Why Do People Use Drugs? What are Drugs? A chemical substance that, when taken into the body, alters the structure or function of the body in some way 2 Key Points 1. There is no perfect definition 2. We often draw distinctions in ter...

Addictive Behaviours Week 1 - Why Do People Use Drugs? What are Drugs? A chemical substance that, when taken into the body, alters the structure or function of the body in some way 2 Key Points 1. There is no perfect definition 2. We often draw distinctions in terms of whether the substance in question has been intended to be used primarily as a way to induce physiological change Why do we use Drugs? To cope Peer pressure What are we taught about Drugs? They’re bad. “Just say no!” Drugs cause Addiction… Try it once, then you’re hooked Who uses Drugs? Criminals Bad people Different ethnic groups Celebs Drugs have many Benefits Mental illness Ex. Bob Marley, Albert Einstein, Steve Jobs (LSD → allowed them to be creative in their field) Bottom Line → Drugs offer relief from an unwanted condition Diseases/illness Pain Stress Boredom Theories Underlying Drug Use & Abuse 1. Tension “A physical, chemical, or emotional factor that causes bodily or mental tension and may be a factor in disease causation”  Aversive state Can cause fear, anxiety, conflict, frustration. Tension Reduction Theory “ I use drugs to calm down to help me think less…” Relief from tension & stress Homeostasis Assumptions of Tension Reduction Theory Alcohol/drugs reduce tension Individuals drink alcohol for its tension-reducing properties 2. Trauma Psychological damage as a result of distressing event Stress outside of one’s ability to cope Trauma & Substance Use 2 Major theories: 1. Trauma results in substance use 2. Substance use increases the chance of experiencing a traumatic event/developing PTSD Self-Medication Khantxian (1985): People use drugs to medicate for psychiatric disorders & painful emotions Alcohol & benzodiazepines → relaxation Cocaine & stimulants → antidepressant, improve focus in ADHD Cannabis → mood regulation in bipolar, schizophrenia Disease model 1957: American Medical Association called alcoholism a disease for 3 reasons 1. Alcoholism has a known cause 2. Symptoms get worse over time 3. Alcoholism has known outcomes Foundation of 12-step programs (AA) Genetic Model Development of addiction is a result of the influences of both genetic & environmental factors that contribute to risk over the lifetime Treatment would be individually tailored to each person & their unique genetics Testing the Genetic Model: Adoption Studies Sons of alcoholics are more likely to become alcoholics themselves Risk factor remain whether raised by biological or adopted parents (supports genetics) Twin Studies Identical twins (monozygotic or MZ) → genetically identical Fraternal twins (dizygotic or DZ) →no more genetically similar than non twin siblings Alcoholism concordance generally higher for MZ twins than DZ twins Personality Theory Cloninger (1987) three temperaments correlated with alcohol use: 1. Harm avoidant → cautious, apprehensice 2. Reward dependent → sensitive to social rewards, high dependence on social attachments & approval from others 3. Novelty seeking → impulsive, excitable, quick-tempered, fickle Personality Traits: Impulsivity & Disinhibition Sensation seeking Increased in children whose parents have alcohol use disorder Drug use involves risk - some people like that idea of risk taking Rebellion, rage, self-destructiveness, to feel “alive” Poor Self-Concept From within to the outside world Struggle to self-identify Reduced ability to prioritize, set & achieve goals, resolve conflicts Struggle with trust Not a requirement for development of addiction Mood & Affect Disorders Depression, Anxiety Self-medicate feelings Family Model Imbalance in parenting Marital troubles Modeling substance use behaviours Physical, sexual, emotional, violation/abuse Shame, abandonment, rejection Development Model: Adolescence Pressure Escape Availability Curiosity Emptiness Psychoanalytic Models Drugs as Power → getting “high” Drugs as Self-Destruction → positive & potent view of death Seduction & Sexuality → aphrodisiac Boredom Boredom is uncomfortable Meditation & mindfulness Social Learning Related to family model Addictive behaviours are learned habits Behaviour can be affected by individuals’ expectation of the use Sociocultural Models Factors that lead a society to have greeted rates of alcoholism ○ Degree to which the culture causes acute needs for adjustment of inner tensions in its members ○ The attitude towards drinking that the culture fosters ○ The degree to which the culture provides substitute means of satisfaction Feeling isolated from culture may conversely lead people to believe that rules don’t apply to them A few things to consider… Summary: Key Points People engage in drug use for many reasons No single model can fully predict why people engage in substance use (or develop addictive behaviours) ○ Some people have many risk factors & do not use drugs ○ Some people have few risk factors & do use drugs Genetics, environment, personality, psychology and experience all play a role in any individuals risk of developing an addiction ○ Not all of these risk factors are independent from one another Week 2 - Putting Drugs in Perspective Reading: The Drug Paradox Moral-Legal Perspective Perspective of law enforcement & criminal justice system Keep people & drugs away from each other Decrease availability Increase punishment A perfect system would mean complete deterrence Medical-Health Perspective Most commonly held by physicians & health care providers Treatment for physical effects of drug abuse, dependence & addiction Based on idea that people will want to be healthy Provides information that drugs are harmful to health Psychosocial Perspective Targeted at addressing the demand Prevent, intervene & treat problem use Early intervention for teens & youth Help for recovery Limitations → expensive Sociocultural Perspective Held by social agencies & institutions Adapt the environment for the individual Assumption → Use is a result of dissatisfaction with life/environment Broader, about creating communities and spaces rather than dealing with it individually Under-funded, less resources Stopping Drug Use from 2 Sides Demand Supply Prevention Incarnation Intervention Militarization Treatment Regulation Alcohol: The most dangerous drug? Major contributor to car accidents More Canadian visits to hospital for alcohol than heart attacks Over 100,000 admissions for alcohol poisoning, withdrawal, and others directly related to alcohol in 2021 ○ 263 per day ○ 10 Canadians die in hospital from conditions cause alcohol Leading cause of injury Pancreatitis, liver cirrhosis, diabetes, cardiovascular disease, some cancers Smoking 1965: 49% of Canadaians over 15 smoked Health-based intervention in the 1970s 2021: 11% of Canadians smoke Contributes to 17% of all deaths in Canada each year Responsible for over 85% of lung cancer cases Vaping Vaporizers & e-cigarettes for cannabis & nicotine Traditionally considered safer than smoking, but recent health scares are putting this into question (“vaping illness”)  Marketed to teens & young adults until recently, when Government of Canada banned promotion (July 2020) Cannabis No record of someone dying from an overdose Many medical uses with growing support ○ Epilepsy, anxiety, chronic pain, insomnia, nausea Can impair cognitive function Very little research into long-term risks Exacerbation of mental health problems in at-risk population ○ But heavy cannabis intoxication increases risk of fatal injury, especially if used while diving or when heavily mixing with other drugs Cannabis is getting stronger THC is increasing ○ 4% in 1995 → 12% in 2014 CBD is decreasing ○.28% in 2001 →.15% in 2014 The Ratio Matters: 1995 → 14:1 THC to CBD 2014 → 80:1 THC to CBD Controlled Drugs & Substances Act Established in 1996 - implements UN guidelines (among others) Lists drugs to be controlled Precursors to drugs Schedule I High abuse potential Lack of safety for use Requires prescription & sale in a regulated environment Illegal to manufacture, distribute or possess Codeine, phencyclidine (PCP), methamphetamine, amphetamines, ecstasy, MDMA Schedule II High abuse potential May lead to severe psychological physical dependence Synthetic cannabinoid receptor agonists Schedule III Moderate potential for abuse and/or physical or psychological dependence May pose additional risks for at-risk populations LSD, methylphenidate (Ritalin), psilocin, psilocybin (mushrooms), mescaline, methaqualone (quaaludes) Schedule IV Low abuse & risk potential Used for variety of medical purposes Barbiturates, benzodiazepines, anabolic steroids Unscheduled Sold without supervision of a medical professional Must include adequate labeling with instructions for safe use Individuals can make safe choices regarding their own use PAinkillers (Advil, Tylenol, Aspirin), stomach upset (Pepto Bismol, Tums), nasal sprays for congestion, antihistamines, etc. Nicotine, Alcohol, Cannabis (with regulations on sale & distribution) Offences Possession of schedule I, II, or III substance Seeking to obtain schedule I, II, III, IV substance Fines & prison time based on substance, amount, etc. Brief History of Drug Policy in Canada Before 1908 - Drugs unregulated in Canada 1911 - Opium & Drugs Act 1961 - Narcotic Control Act 1996 - Controlled Drugs & Substances Prohibition 1820s: Temperance movement formed 1850s - 1890s: individuals states start to enact prohibition laws 1919: 18th Amendment 1920s: rise of bootleggers, speakeasies 1933: 21st Amendment Prohibition of Cannabis 1923 - Cannabis prohibited in Canada 1936 - Reefer Madness (US) 1937 - Marijuana Tax Act in US 1960s Drug Culture LSD, mushrooms & cannabis to raise consciousness Exploration Sexual revolution Hippies labeled as rebelling against authority The War on Drugs Prohibition of drugs & military intervention Goal: stop illegal drug trade Racism & the US War on Drugs Black people are 3x more likely to be stopped by police than white people Black people are arrested for drug offences 2-11x the rate for white people Black offenders receive sentences that are 10% longer than white offenders Black Americans are 14% of drug users, but 56% of people in state prisons for drug offences Upon release: 17% of white job applicants get callback vs. 5% black job applicants Racism & the War on Drugs “The Nixon campaign in 1968, and the Nixon White House after that, had 2 enemies: the antiwar left & black people. You understand what I’m saying? We knew we couldn’t make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and black with heroin, and then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did.” Drug Cartels: Mexico In the last decade, up to 100,000 have died as a result of drug-related violence US is the largest market for illegal substances ○ 55 million users of illegal drugs, valued at $30-150 billion Viiolence is linked closely to access routes to the US TED talk on drug cartels Are we getting better? 2011: War on drugs declared a failure US National Prevention Strategy announced The Opioid Crisis in Canada 1 in 8 Canadians have a close friend or family member who has been dependent on or addicted to opiates 19,355 Canadians died from opioid overdose from Jan 2016 - Sep 2020 From 2012-17, opioid hospitalization rates increased by 27% 74% increase in opioid deaths in the 6 months of the Covid pandemic compared to the 6 months prior Legalization of Cannabis in Canada: Rationale #1 → Safety Combat the illegal market Prohibition doesn't stop people from using  People ended up with legal issues & criminal records for possessing The law is meant to reflect the current culture Prevent legal issues, allow for harm reduction Canadian Legalization of Recreational Cannabis 19+ can legally buy, use & grow recreational cannabis Sale in Ontario under OCS Many rules similar to alcohol consumption Legalization of Cannabis: Current Status Estimates that cannabis use has increased ○ End of 2020: 6.2 million (20%) of people over 15 used in previous 3 months ○ 7.9% Canadians age 15+ report daily or almost daily use Now legally available in many forms (edibles, drinks, oils, etc.) Growing social acceptance Ontario brought in $245 million in federal cannabis taxes in 2020-21, plus $170 million from OCS revenue ○ vs. - #31 million total in 2019-20 Drug Laws in Portugal 1933-1974: Under authoritarian rule 1980s: overdose deaths, crime, HIV & hepatitis were at levels much higher than the rest of Europe 2001: Decriminalized all drugs Policy has 3 pillars: ○ No such thing as soft or hard drugs. Only healthy or unhealthy relationships with drugs ○ Unhealthy relationships reflect frayed relationships with loved ones, the world around them, and themselves ○ Eradication of all drugs is impossible Drug Laws in Portugal (2) Cultural change: “junkies” → “people who use drugs” Decrease in HIV diagnosis ○ 104.2 → 4.2 cases/million from 2000-2015 Hepatitis C rates dropped Major reduction in drug overdoses Rate of death by drugs dropped to 3 per million (vs 17.3 EU average) Reduction in police workload Did Iceland stop teen drinking? Surveys: binge drinking was a big problem Participating in sport or organized groups was protective Government subsidized $650 per child per year to enroll them in hobbies  Parental involvements in kids’ lives: emotional support, monitoring Parent walks on Friday nights to enforce curfew “Neighbourhood effect” - supportive community benefits all kids, regardless of individual parental involvement Decriminalization pros & cons Minimizing harm Encourage responsible use Allow for regulation of production and sale drugs & alcohol Set boundaries - more easily identify problem use? Profits (taxes) from sales become public funds, instead of funding organized crime Increase awareness Increase easy access Makes drugs cheaper Makes use “acceptable” Advertising Legal drugs for adults only is impossible Summary: Key Points There are multiple perspectives that can be taken to address drug problems on large social scales Where there is demand for drugs, there will always be a supply A lot of drug policy has racist roots Be skeptical of firm, all-or-nothing moral stances on substance use Evidence-based approaches will be the most effective in minimizing harm Week 3 - Assessment of drug abuse, dependence, and addictions Reading: Fields Chapter 4: Assessment Use, Misuse, Abuse Use: taking medication as prescribed Misuse: use that is counter to prescription Abuse: taking drugs for desired side effects Behavioural Definition of Addiction 3 C's of addictive behaviours Compulsion Control Consequences 1. Compulsion Use “against will”, feeling of “having” to use Central to the disease model Obsessive relationship with the drug, preoccupation with using 2. Control Loss of control Inability to stop 3. Consequences Physical Psychological Sexual Social Financial Legal Diagnosing addiction: DSM 5 Diagnostic & Statistical Manual of Mental Disorders Substance use disorder (SUD) ○ List of 11 possible symptoms ○ 2-3 = mild, 4-5 = moderate, 6+ = severe Also includes a list of possible substance dependencies including: ○ Alcohol, opioids, cannabis amphetamine, sedatives (among others) DSM-5 Criteria for SUDs Impaired Control 1. Using for longer than intended, or in larger amounts 2. Wanting to reduce ise, but being unable to do so 3. Spending excessive time getting/usin/recovering from use 4. Intense cravings that make it difficult to focus on something else Social Impairment 5. Not managing responsibilities at work, home or school because of substance use 6. Continues use, even when causing problems in relationships 7. Giving up social, work or recreational activities because of substance use Risky Use 8. Using substances repeatedly, even when it puts you in danger 9. Continuing use even when it makes a physical or psychological problem worse (or if it causes a new health problem) Pharmacological Indicators 10. Needing more of the substance to get the desired effect (tolerance) 11. Development of withdrawal symptoms that are relieved when taking more of the substance The evolving diagnostic criteria for addiction “Substance dependence” and “substance abuse” combined under “addictions & related disorders) Assumed that abuse was “milder” than dependence  ○ Automatically lessened the perceived impact of problems resulting from abuse (ex. Neglecting major responsibilities at work or home) Other recent changes to diagnostic criteria Legal problems/trouble with the law dropped from diagnostic criteria Added craving as a diagnostic criterion ○ Studies of behaviour, pharmacology, genetic linked to experiencing craving ○ Debate: does craving add any diagnostic information (especially when considered with dependence) Quantity/frequency of consumption Should/could there be a biological test for diagnosing addiction? Biomarker: substance in the body that can be measured & potentially indicate disease or infection Drug metabolites: can be tested in blood, sweat, urine, saliva, hair, breath Genetics: variations in genes that process alcohol, nicotine & opioids have all been found in people with substance use disorders Brain imaging: structure & function of the brain (MRI, PET, etc.) Do behavioural addictions fall under the DSM5 definition? Gambling disorder is the only one included alongside substance use disorders ○ Internet gaming disorder was considered in DSM-V Evidence that it co-occurs with other substance use disorders Shares some symptoms, genetics and treatment options Tolerance Reduced reaction to a drug as a consequence of repeated use Reversible Physiological & psychological Dependence Physical Caused by tolerance Can happen with small doses, even small recreational amounts Grows with dose size, length of time engaged in regular use Psychological Emotional & motivational withdrawal Anxiety, anhedonia, dysphoria Motivation to avoid withdrawal symptoms Can happen with behaviours Withdrawal Set of symptoms that occur after stopping drug use abruptly Can occur after stopping prescription medication  Effect of dependence Can be fatal for some drugs Cold turkey Hair of the dog Post-Acute Withdrawal Symptoms (PAWS) Long-term withdrawal from alcohol, opiates and others Come & go over time, a few days each episode Signs can resemble mental illness Can be seen in newborns to addicted mothers Signs: impaired cognition, irritability, anhedonia, OCD, guilt, poor concentration, craving sensitivity to pain, poor coordination, lack of motivation, memory deficits, emotional dysregulation, sleep disturbances Common risk factors for developing addictions Family history Mental illness Some personality traits Experience with trauma Social factors Use from an early age Use of highly addictive substances Note: Anyone of any age, socioeconomic status, or gender can develop an addiction or substance use disorder Developing Addiction: Incentive Salience Brain develops positive association with the stimulus (drug or behaviour) and the feeling of reward Following repeated exposure, incentive salience develops Motivates people to keep taking the drug/performing the behviour Related directly to changes in the brain that may persist long after abstinence “Liking” vs. “wanting” Developing Addiction: Drive Theory Repeated drug use causes a druve (motivation) to seek a drug’s positive reinforcing effects ○ Drive reaches strong, irresistible levels that compel drug seeking & use Drive can come in the form of craving or withdrawal Drive builds until there is access to the drug Drive is reduced immediately following drug use The degree of strength of the reinforcer corresponds to the degree of drive experienced by the user Developing Addiction: Behavioural Stages of Addiction 1. Experimental 2. Social 3. Instrumental 4. Compulsive Denial “I can quit anytime I want” “He;s only drinking so much because he’s under a los of stress” It’s only my problem - I’m not hurting anyone” “She only drinks on weekends” “The doctor prescribed them all, it’s fine” “I don’t drink in the morning, I must be fine” “He’s not that bad, I know people that drink way more” “I only drink beer & wine, not the hard stuff” “She has a good job & always shows up, she must be fine” Some rationalizations for drug use Physical pain Relationship problems Death of a loved one “It’s Monday” Celebrations Vacations Boredom Sobriety “It’s Friday!” Some rationalizations for addiction/not seeking help “I’ve already ruined everything” “I don’t deserve to be happy & healthy” “I have it under control this time” “This is my life now” The “High Functioning Addict” Alcohol abuse Abuse can be hard to detect Slow downward spiral Alcohol abuse can look like… ○ Drinking to cope with your day ○ Being secretive about use ○ Underestimating effects on driving ability ○ A close relationship has expressed concern Alcoholism (alcohol use disorder) Most severe form of alcohol abuse Tolerance & withdrawal Alcoholics all abused alcohol at some point Not everyone who abuses alcohol becomes an alcoholic Alcohol abuse can turn into alcoholism without intervention/treatment University binge drinking 4-5 drinks within 2 hours (based on gender) Drinking prevalence in Canadia is 82% in those aged 18-24 35% report 5+ drinks in one sitting in the last 2 weeks Rates of college binge drinking as high as 40% once a month Those who drank within the past year report at least one of 24 harms from alcohol use ○ Physcial, academic, or dependence domains Alcohol poisoning University Alcoholism Common social activity Drinking to “get drunk” Blackouts, alcohol poisoning Development of tolerance Increased risk for alcohol use disorder Most people who use drugs do not develop an addiction With such high rates of substance abuse, why don’t more people end up as addicte to drugs & alcohol? People who use drugs can be intelligent, have good life skills, and can manage risks associated with drug use People who are vulnerable, however, have a higher risk of developing an addiction Constraint Theory Religious or moral reasons People they are close to disapprove Opportunities for use are decreased No friends that are sympathetic to drug use Dislike of drug effects or side effects Health problems/health care Concerned about legal risks Substance is not reaily available Substance is prohibitively expensive Why do people stop using? Stable intimate relationship Recovery from trauma Engagement in positive social activities Summary: Key Points Addiction is a progressive disorder with set criteria for diagnosis The line between controlled use and substance abuse is blurry ○ Social & cultural norms have a big influence We can identify problem substance use from a few angles Denial, rationalization and minimization can make it difficult to identify a substance use problem Most people who engage in substance use do not develop an addiction, but some factors increase the risk Week 4 - Drug-Specific Information Reading: Fisher & Harrison Chapter 2 Overview of last week Addiction is a progressive disorder with specific diagnostic criteria ○ The progression can be understood from a variety of theoretical perspectives It can be difficult to draw a clear line between safe/controlled use and substance abuse ○ These can be further influenced by social & cultural norms Denial & rationalization can complicate assessment Classification of psychoactive drugs Drugs Examples Narcotic analgesics Painkiller and designer drugs CNS depressants Sedative hypnotics, alcohol, tranquilizers, and barbiturates CNS stimulants Amphetamines, cocaine, nicotine, and caffeine Hallucinogens LSD, mescaline, psilocybin (mushrooms) Cannabis Sativa Cannabis and hashish Inhalants Volatile solvents, aerosol sprays, gasses Opioids Effects → Pain reliever, euphoria, cough suppressant, sedation Withdrawal → depression, nausea, aches, insomnia Natural: found in the poppy plant (extracted or refined) Semi-synthetic: created in a lab from a natural opiate ○ OxyContin, Dilaudid, Vicodin (with Tylenol/acetaminophen) Fully synthetic: made entirely in a lab Cannabis Intense thoughts & feelings Relaxation, giddiness Increased heart rate Frowsy Altered time/space perception Paranoia Increased appetite Dry mouth Charlotte Figi Young girl, lived in Colorado Rare form of epilepsy → 100s of seizures a week, frequently needed CPR Parents tried everything they could Got a cannabis plant very low THC, high CBD Made the CBD into an oil & ended up working for Charlotte Now it’s used for epilepsy MDMA Hallucinogen and stimulant Aka Molly, ecstasy Euphoria, empathy, positice mood, increased self-esteem Side effects → dry mouth, thirst, anxiety Withdrawal (“comedown”) → fatigue, anxiety, mood swings, panic, headaches, jaw aches Adulterant are a major concern Potential treatment for PTSD ○ Facilitates opening up in a clinical setting ○ Allows for manipulation of fear-related memories Serotonin Syndrome Overdose of serotonin (SSRI + MDMA or cocaine) High body temperature, sweating, agitation, anxiety Tremors, twitches, shivering Nausea, diarrhea, vomiting Hypomania, hallucination, confusion Seizures, coma (if severe) Can be fatal Hallucinogens (aka psychedelics) Mushrooms, LSD, mescaline/peyote Euphoria and dysphoria Tend to not be addicted to them; does not mean they are risk free Can have lasting effects on the brain → sensory distortion Stimulants Aka “uppers” - increase CNS activity Therapeutic doses generally used to treat ADHD Increases focus, elevates mood, arousal Decrease need for/ability to sleep (insomnia), decreased appetite Irritability, aggression, anxiety, hallucinations, depression Cocaine Blow, coke, crack, rock, snow Smoking is the most addictive Alert, energetic, euphoric or high 1880s → treatment for depression and addiction ADHD Inattention, hyperactivity impulsivity Number of children under 18 on psychostimulants has increased 5x from 1988 - 2010 ○ Increased rates of ADHD? “Big pharma?” Changing pressures & higher standards? Popularization on social media? Stimulant Abuse & Studying 2019-20: 11.9% of postsecondary students in Canada reported non-medical use of prescription stimulants in the previous year 18-22-year-olds in university more likely to use stimulants than those not in university Does not typically offer academic advantage when used non-medically Can lead to addiction Caffeine Most widely used psychoacitve drug, most common stimulant Works by inhibiting adenosine “No addictive potential” Yerkes-Dodson Law Relationship between stimulation & performance Optimal point of performance depends on task Healthy cognitive enhancement “Rest and reflect” - time without social media or your phone Eat a balanced diet Get plenty of rest Regular exercise Meditation, yoga Quality time with friends Drug Interactions Tolerance Cross-tolerance Reverse tolerance/sensitization Additive interactions ○ Effects are the sum of the 2 drugs ○ Ex. barbiturates + alcohol Synergistic interactions ○ Effects are greater than the sum of their parts ○ Ex. LSD + cannabis Antagonism ○ Combined effects of 2 drugs is less potent than individual effects of each Overdose reversal by Naloxone (Narcan) - Opioid Antagonist Rescue drug Routes of Administration Oral Inhalation Mucous membranes (dossolved in mouth, snorted) Skin (topical creams, transdermal patches) Rectal, vaginal Injection ○ Intravenous ○ Intramuscular ○ Subcutaneous Routes of Elimination Kidneys (urine) Lungs (breath) Bile (stomach/bowels) Skin (sweat) Hair, breast milk, saliva Set and Setting can influence effects and risks Factors that can alter the effect of drugs that are not related to the properties of the drug itself ○ Set: mindset-expectations, thoughts, moods (internal) ○ Setting: environment-social, physical (external) Resulting danger and effect is a result of the drug in question, the setting and the set