Reducing Substance Use and Abuse PDF

CHAPTER 7 REDUCING SUBSTANCE USE AND ABUSE CHAPTER OUTLINE I. Substance Abuse A. Section Introduction 1. Term “addicted” used to refer to excessive use of alcohol and drugs a. then - common knowledge that these substances had psychoactive...

CHAPTER 7 REDUCING SUBSTANCE USE AND ABUSE CHAPTER OUTLINE I. Substance Abuse A. Section Introduction 1. Term “addicted” used to refer to excessive use of alcohol and drugs a. then - common knowledge that these substances had psychoactive effects on mood, cognition or behavior b. now – recognize that other substances also have psychoactive qualities and other behaviors are referred to as “addictive” B. Addiction and Dependence 1. Definition of addiction a. condition produced by repeated consumption of a natural or synthetic substance in which the person has become physically and psychologically dependent on the substance 2. Physical dependence a. the body has adjusted to the substance and requires it for normal functioning i. tolerance – process through which body increasingly adapts to substance and larger doses of the substance required to produce the same effect ii. withdrawal – unpleasant physical and psychological symptoms experienced when a substance is discontinued or markedly reduced once person has become dependent b. substances differ in the extent to which they produce dependence 3. Psychological dependence a. definition = compulsion to use a substance for its pleasant effect without necessarily being physically dependent on it b. despite knowing that substance impairs psychological and physical health, people may come to rely heavily on it and spend good deal of time obtaining and using it c. dependence develops through repeated use d. persons not dependent on substance experience less tolerance and withdrawal e. absence of substance may result in craving – motivational state involving strong desire to use substance f. addicted persons tend to become psychologically dependent before they become physically dependent. g. substances differ in the extent to which they produce psychological dependence 221  4. diagnosing substance dependence and abuse a. depends on extent and impact of clear and ongoing use b. abuse = when dependence has produced at least one of the following problems: i. failure to fulfill important obligations ii. putting self or others at risk for injury iii. having substance-related legal difficulties c. classification of psychiatric disorders now includes pathological use of tobacco, alcohol, and drug C. Processes Leading to Dependence 1. Section introduction a. section covers factors associated with substance use and abuse i. apply to all addictive substances ii. are described in main theories of substance dependence iii. have been shown to have role in developing and maintaining dependence 2. Reinforcement a. definition = process through which consequence strengthens behavior upon which it is contingent b. types of reinforcement i. positive reinforcement 1) event or item person finds to be pleasant or wants added after behavior has occurred a) example: “buzz”/elation after smoking ii. negative reinforcement 2) reducing or removing aversive circumstance after behavior has occurred a) example: reduction of stress after smoking c. other information on relationship of reinforcement to substance use/abuse i. both positive and negative reinforcement occur very soon after use of substance ii. dependence and abuse occur partly because users rely on substance to regulate cognitive and emotional states 3. Avoiding withdrawal a. because withdrawal is unpleasant, people want to avoid it i. if person has experienced withdrawal, continue using substance because they want to avoid it ii. example: delirium tremens b. each substance has its own set of withdrawal symptoms 4. Substance-related cues a. people associate substance use with internal/environmental stimuli that are regularly present during its use b. association occurs through classical conditioning i. several responses may be present, but critical one is craving 222  c. evidence for role of cues to substance dependence i. learning cues enables body to anticipate and compensate for substance’s effect ii. incentive-sensitization theory proposes that dopamine enhances salience of stimuli associated with substance use so they become powerful in directing behavior iii. impact of cues 1) grab substance user’s attention 2) arouse anticipation of reward gained from substance 3) compel person to get more substance and use it 5. Expectancies a. definition = ideas about the outcomes of behavior developed either through own experience or from watching experiences of others b. example related to alcohol use i. drinking alcohol often incorporated in “fun” activities ii. children observe adults drinking and having “fun” iii. before ever having a drink for themselves, children have associated drinking with a positive outcome iv. teens see drinking as “sociable” and “grown up” – 2 things they want to be c. outcomes and expectancies can be either positive or negative 6. Personality and Emotional Factors a. Individuals who abuse substances tend to be impulsive, high in risk- taking or sensation-seeking, and low in self-regulation b. Adults with childhood trauma history (e.g., abuse or neglect) who are very depressed or anxious are at risk for substance abuse. 7. Genetics a. evidence of genetic influence on smoking i. twin studies find odds of cigarette smoking and dependence on tobacco more similar for identical twins ii. genetic markers have been identified for smoking b. evidence of genetic influence on drinking i. twin, adoption and animal studies have found genetic influence for developing alcohol problems ii. genetic marker has been found for this too c. genetic markers for smoking and alcohol use are different II. Smoking Tobacco A. Section Introduction 1. History a. early explorers found native populations using tobacco and took it to Europe in the 1500's for use in medicinal purposes b. mass-production began in early 1900's and popularity grew rapidly 2. Smoking trends a. today, 36% of men and 8% of women worldwide smoke 223  b. in US, peak of popularity was in the 1960's with 51% males and 34% females smoking i. impact of Surgeon General's report in 1964 on dangers of smoking 1) prior to report most people didn’t know about dangers 2) since report, numbers of smokers have declined to current rate of 18% of adults in the US. 3) teen smokers has dropped to 8.5% 3. Cigarette manufacturers still profit from increased price of cigarettes and international sales a. although smoking has declined in industrialized countries, it has increased in developing countries such as in Asia and Africa B. Who Smokes and How Much? 1. Section introduction a. there are 5 times more nonsmokers than smokers in the US 2. Age and gender differences in smoking a. few Americans begin smoking regularly before age 12 b. patterns in development of smoker i. many people start out as infrequent smoker, trying out the habit on a less-than-daily pattern; some will progress to a daily pattern up to half-pack a day ii. pattern starts in eighth grade involving more teens in later grades iii. teens who don’t plan on completing college are at higher risk of progressing to heavy smoking iv. percentages of smokers level off in adulthood and declines after 40 years of age v. many adults are former smokers c. gender differences in smoking i. Worldwide, 80% of smokers are men ii. Gender gap has narrowed in the US ii. cigarette advertising targeting one gender or the other has contributed to gender shifts in smoking rates d. important observation - smoking prevalence can be altered 3. Sociocultural differences in smoking a. Over 80% of world's smokers live in developing countries b. in the US, smoking prevalence differs across ethnic groups i. high school seniors: majority are White ii. early adults: for men and women, majority are White iii. after 45 years: for men, majority are Black c. patterns across social classes i. percentage of smokers declines with increase in education, income, and job prestige 224 C. Why People Smoke 1. Section introduction a. initial experience of smoking is usually unpleasant b. many teens know that smoking is unhealthy but try it again anyway 2. Starting to smoke a. modeling and peer pressure influence smoking in teenage years i. modeling from parents and friends 1) teens usually smoke first cigarette in company of and receive encouragement from peers ii. media models such a having a favorite movie star who smokes also influences teens b. personal characteristics related to smoking i. being rebellious or a risk-taker ii. low self-esteem and concern about body weight iii. believing that smoking can enhance their image, making them look mature, glamorous, and exciting c. In the US, girls and Whites are more influenced by smoking by peers or family members 3. Becoming a regular smoker a. Speed at which the habit develop is important because the faster it does, the more likely the person will smoke heavily, become dependent, and have trouble quitting b. psychosocial factors that influence starting also influence continuing to smoke c. factors related to continuing to smoke in teens include i. at least 1 parent who smokes ii. perception that parents are unconcerned or encourage smoking iii. having siblings/friends who smoke iv. rebellious, thrill-seekers, low in school motivation v. receptiveness to tobacco advertisements vi. peer pressure to smoke vii. positive attitudes about smoking viii. did not believe smoking would harm their health ix. believing they could quit smoking if they wanted d. other related findings i. having family or friends who smoke reduces beliefs that smoking is harmful ii. teens usually smoke and smoke more in the company of others who smoke iii. teens who smoke receive more offers for cigarettes from friends e. impact of reinforcement on smoking i. taste of cigarette reported as positive reinforcement 1) research shows that changing taste of cigarette to make it less pleasant reduces smoking in some smokers 225  ii. some smokers report smoking cigarettes reduces stress 1) smokers with greater stress smoke more 2) smokers report less anxiety and more ability to express opinions during stressful situations when allowed to smoke a) however, findings suggest they don’t actually perform better or feel more relaxed than nonsmokers 3) smoking may reduce stress temporarily but increase it in the long run f. biological factors sustain smoking i. nicotine passes from smoking mother to baby during pregnancy and making child more susceptible to addictive effects of nicotine ii. genetics have been linked to likelihood of becoming a smoker, how easily/strongly become physically dependent on tobacco and how easy/difficult it is to quit smoking iii. insula, an area of the brain, controls desire to smoke 1) when damaged, people lose desire to smoke 4. The role of nicotine a. physical dependency is due to substances in cigarette smoke i. carbon monoxide - reduces oxygen-carrying capacity of blood ii. tars - don't affect desire to smoke iii. nicotine - arouses the body and is the addictive chemical in cigarette smoke 1) effects of nicotine include release of chemicals in central and sympathetic nervous systems that result in arousal, increased alertness, heart rate and blood pressure a) contributes to the positive and negative reinforcement of smoking b. nicotine regulation model i. smokers smoke to regulate the amount of nicotine in the body and avoid withdrawal symptoms. 1) evidence: ultralow tar cigarette smokers smoke more cigarettes ii. model doesn't explain why ex-smokers still crave cigarettes or people who smoke but don't get addicted c. a complete explanation of the development and maintenance of smoking involves the interplay between biological, psychological, and social factors 226 D. Smoking and Health 1. Section introduction a. annual deaths related to smoking i. 6 million deaths worldwide related to smoking annually b. health impact of smoking i. smoking reduces life expectancy by several years ii. smoking increases risk of illness 1) more smoked, greater the odds of developing lung cancer 2) if reduce smoking to less than one pack per day, odds will reduce to that of nonsmoker within 15 years iii. smoking and nicotine impair immune function 2. Cancer a. studies linking smoking with cancer i. statistics showed nonsmokers live longer than smokers ii. laboratory studies using animals exposed to cigarette tar linked tobacco tars and other byproducts of tobacco smoke to cancer b. prospective studies link smoking to cancers of the lung, mouth, pharynx, esophagus, bladder, pancreas and kidney c. lung cancer prevalence rates paralleled smoking prevalence i. additional support from this type of research comes from increase of lung cancer in women as their smoking rates increased and decrease in prevalence in men as their smoking has decreased d. effect of smoking on lungs i. smoke causes irritation in cells below surface of the lung and destroys the protective cilia ii. lung cancer originates in bronchial tubes due to continual contact of carcinogens with bronchial lining 3. Cardiovascular Disease a. prevalence of CHD i. leading cause of death worldwide ii. in US, 28% of deaths due to CH; claims as many lives as cancer, diabetes, and Alzheimer’s combined iii. 1 in 4 of Americans who die from CHD are under 65 year old b. smoking and risks for CHD i. smokers are much more likely to develop CHD than non- smokers ii. more a person smokes, greater the likelihood iii. having greater stress plus smoking heightens risk for CHD iv. smokers tend to have lifestyles that include other risk factors for CHD (such as physical inactivity) 227  c. how nicotine and carbon monoxide contribute to cardiovascular functioning i. nicotine - constricts blood vessels, increases heart rate, cardiac output, and blood pressure ii. carbon monoxide - reduction of oxygen to the heart may cause damage and lead to atherosclerosis d. smoking is linked to greater levels of serum cholesterol and size of plaques on artery walls e. quitting smoking reduces cholesterol levels within 2 months and risk of heart attack or stroke within a few years 4. Other illnesses a. smoking is linked to development of chronic obstructive pulmonary disease i. includes emphysema and chronic bronchitis with permanently decreased airflow on exhalation ii. 80% of CLRD cases in the US are related to smoking iii. CLRD incapacitates its victims by reducing their mobility and life functioning; accounts for 6% of deaths worldwide b. smoking is also linked to acute respiratory infections i. children of smokers more likely to develop pneumonia ii. smokers more likely to develop common cold due to immune system impairment III. Alcohol Use and Abuse A. Section Introduction 1. Alcoholic beverages were commonly consumed in ancient cultures 2. Puritans in colonial America enforced laws against drunkenness 3. Temperance movement led to Prohibition 4. Repeal of Prohibition was followed by increased use of alcohol and softening attitudes about alcohol B. Who Drinks, and How Much? 1. Age, gender, and alcohol use a. drinking is influenced by age and gender i. females experience more intoxication than males do from same amount of alcohol 1) less blood volume 2) metabolize alcohol less quickly b. drinking often begins in adolescence i. 68% of high school seniors have tried alcohol ii. males report more drinking than do females and this difference continues into adult life iii. Most young and middle-aged adults drink but prevalence declines in older adults 228 2. Sociocultural differences in using alcohol a. alcohol use varies widely across cultures i. in US, per capita consumption is 2.3 gallons of ethanol 1) alcohol use across countries is differentiated into those countries that integrate alcohol use into daily life v. those countries that restrict its use a) daily drinking occurs more in “integrating” countries whereas intoxication occurs more in “restricting” countries ii. in US ,more white Americans drink than other race/ethnic groups iii. drinking on a daily basis is higher for White Americans, Native and Hispanic Americans than for Black and Asian Americans 1) drinking rates in Native Americans are moderating 3. Problem drinking a. in US, 64% of adults drink at least occasionally i. most are light-to-moderate drinkers ii. many drink heavily but don’t necessarily meet definition of substance abuse b. patterns of drinking i. binge drinking = drinking 5 or more drinks on single occasion at least once during 30-day period 1) 9% of adolescents, 38% of 18- to 34-year olds, 19% of those over 35 drink heavily 2) binge drinking is a problem on college campuses 3) most who develop problems with drinking do so within 5 years of starting to drink ii. heavy use drinking = binge drinking 5 or more times in a month 1) next step toward alcohol abuse a) 17% of adults in US become alcohol abusers b) rates of alcohol abuse among women nearing those among men iii. problem drinkers = drinking heavily on a regular basis and who suffer social and occupational impairments from it 1) characteristics include getting drunk frequently, drinking alone or during the day, driving while drunk 2) alcohol abuse more common among men 3) abuse likely to develop between ages of 18 to 25 in both sexes iv. alcoholics = people who abuse alcohol, are physically dependent on it, have a high tolerance for it, have blackout periods or substantial memory loss and experience delirium tremens when they stop drinking 229  c. images of alcoholic v. real "typical" alcoholic or problem drinker i. stereotypic image: scruffy looking, unemployed male derelict with no family or friends ii. demographics of actual alcoholics: married, living with family, employed, increasingly women 1) although those in lower social classes are at greater risk for abusing, more problem drinkers are in higher classes and hold high-status jobs 2) problem drinking increases in adolescence, increases sharply in early adulthood, and declines in ages thereafter iii. alcohol abuse is major social problem that affects large numbers of people from all segments of societies around the world C. Why People Use and Abuse Alcohol 1. Chief reasons for starting are social and cultural factors a. children and adolescents acquire expectancies about the positive effects of alcohol from watching others enjoy themselves while drinking i. the more TV ads for alcohol seen by teens, the more likely they are to drink in the future 2. Developmental aspects a. same factors that initiated drinking intensify to maintain it b. for adolescents and young adults i. role of peers increases 1) for teens, drinking occurs with peers at parties or in car a) teens who don’t plan to complete college drink more b) persons who start drinking in early adolescences more likely to become problem drinkers in adult life 2) for late adolescents and early adults, drinking occurs almost always with friends or at bars ii. why social aspects of drinking is important 1) modeling has an influence on drinking rates 2) social atmosphere creates a subjective norm that drinking is appropriate and desirable 3. Role of reinforcement and substance-related cues a. positive reinforcement occurs when person likes the taste or feeling they get or perceives it facilitates business or social functioning i. increases expectancy of desirable consequences when considering drinking in the future b. negative reinforcement occurs when alcohol is used to reduce stress or negative feelings i. although tension is reduced initially, as more alcohol is consumed, anxiety or depression actually worsens 230  4. Other psychosocial factors that differentiate problem drinkers from those who do not abuse alcohol a. perceive fewer negative consequences for drinking b. experience higher levels of stress c. live in an environment that encourages drinking d. have experienced major trauma e. having family members who drink heavily f. strong reaction to substance-related cues 5. Developmental and biological factors related to problem drinking a. heredity plays stronger role when abuse begins before age 25 b. family history of alcoholism is related to more tolerance to alcohol c. having a specific gene pattern is linked experiencing stronger cravings for alcohol after a drink d. those with high genetic risk for dependence find alcohol more rewarding each time they drink e. some genetic patterns seem to protect against alcohol abuse 6. Genetics combine with psychosocial processes in the development of problem drinking D. Drinking and Health 1. Health hazards associated with drinking a. how drinking could hurt others i. drinking during pregnancy could result in fetal alcohol syndrome or impaired learning ability even at lower alcohol consumption 1) best advice is to not drink at all during pregnancy ii. increased risk of accidents 1) drunk driving is associated with over 10,000 traffic deaths each year b. judging degree of impairment from drinking i. drinking impairs cognitive, perceptual, and motor performance for several hours after consumption ii. problems with assessing levels of impairment 1) misconceptions about the effects of alcohol a) thinking the effects of alcohol will disappear once one starts a task that requires attention b) underestimating the impact of later drinks in a series c) believing that beer and wine have different effect than hard liquor 2) “super-sizing” drinks but still counting it as 1 drink c. how drinking could hurt the drinker i. development of diseases such as cirrhosis of the liver, some forms of cancer, high blood pressure, and heart and brain damage as a result of long term drinking 231  2. Potential benefits of drinking in moderation a. lower morbidity and mortality rates have been associated with light or moderate drinking, esp. for wine i. improves blood cholesterol levels ii. reduces cardiovascular and endocrine reactions IV. Drug Use and Abuse A. Section Introduction 1. Definition a. drug = psychoactive substances other than nicotine and alcohol that can cause physical or psychological dependence 2. Brief history a. use of drugs have long history i. use of marijuana in China in 27 centuries B.C. ii. in US, addiction to narcotics in patent medicines in 19th century 1) laws against use of narcotics began in early 1900s 3. See “highlight” box regarding types and effects of drugs a. stimulants = chemicals that produce physiological and psychological arousal b. depressants = chemicals that decrease arousal and increase relaxation c. hallucinogens = chemicals that produce perceptual distortions d. narcotics = sedatives that relieve pain B. Who Uses Drugs and Why? 1. Age, gender, and sociocultural differences in drug use a. developmental trends in drug use i. use tends to begin in adolescence, except for tranquilizers, barbiturates, and painkillers which tends to occur in adulthood through prescriptions ii. high use drug in adolescence is marijuana with over 45% of teens using before graduating from high school 1) teen use of other drugs occurs later with lower prevalence a) 5% try cocaine before high school graduation iii. use of drugs fluctuates over time and has been decreasing 1) use influenced by teens’ beliefs in harmfulness of drugs, not drug availability b. gender patterns in drug use i. males use drugs more than females 1) use pattern increases from ages 12 to 25 years old and then declines c. patterns based on year in school and race/ethnicity i. use increases with grade in school ii. use is lower in seniors who plan to attend college iii. use is higher in White students followed by Hispanic and then 232  Black students d. polysubstance abuse is likely in some users i. likelihood of moving from less serious drugs to more serious drugs depends on how heavily earlier drug was used ii. smoking cigarettes and using alcohol linked to using other drugs later 2. Why adolescents use drugs a. factors determining initial and early stages of use i. availability of drug and social learning 1) seeing peers/important adults model use and attitudes about drugs influences use 2) use of marijuana is more influenced by peers who are likely to introduce teen to drug b. after starting, continued use is influenced by whether person liked the experience. i. reinforcing effect of anxiety/tension reduction is noted ii. drug-related cues associated with drug elicit effect of drug and compel further use iii. social pressure and encouragement also maintain and increase drug use c. factors linked to progression to drug abuse i. personality traits linked to drug abuse include rebelliousness, impulsivity, sensation seeking, low social conformity, low commitment to religious beliefs, and acceptance of illegal behavior C. Drug Use and Health 1. Health effects of drug use not as well documented as those of drinking or cigarette smoking a. drug use still less prevalent than drinking and smoking b. users often unwilling to reveal their drug use to researchers due to illegal nature of behavior 2. Known health effects a. babies born to addicted mothers may also be addicted b. millions of teens/young adults drive under the influence of drugs – increased risk of accidents c. use of marijuana linked to lung damage similar to that of smoking cigarettes d. use of (crack) cocaine is linked to cardiovascular and neurological problems as well as poor general health V. Reducing Substance Use and Abuse A. Preventing Substance Use 1. Section introduction a. focus of prevention programs is helping people avoid beginning to use specific substances to begin with 233  b. factors that need to be considered i. when do people tend to start 1) use often begins in junior high school and increases sharply in high school a) prevention programs need to be focused during those times ii. why do people start 1) need to focus on psychosocial factors that encourage use c. addressing substance use in college i. prevalence of substance use is higher among high school students to later join fraternities and sororities in college ii. frequency of binge drinking is higher in Greek system than elsewhere on campus iii. prevention programs need to be directed toward all students but esp. toward those in Greek system d. substance focus of programs i. historically prevention programs have focused on use of a particular substance only ii. now programs focus on use of all three substances 1) areas of focus include public policy & legal issues, health promotion & education, and family involvement 2. Public policy and legal approaches a. governments attempt to reduce per-capita consumption of substances by creating barriers to buying and using them i. strategies for reducing use of tobacco 1) increasing price through taxation 2) restricting advertisement and purchase of cigarettes ii. strategies for reducing use of alcohol 1) increasing price through taxation 2) prohibiting underage purchase or consumption 3) limiting number of purchase outlets has not been effective iii. strategies for reducing use of drugs 1) making possession, sale, and consumption illegal 3. Health promotion and education a. historically fear-arousing warnings have been used i. approach doesn’t consider prior social experiences and current psychosocial forces that influence use ii. knowing that a substance is harmful isn’t sufficient to prevent use iii. problems with approach points out need to know why teen use the substance b. psychosocial influences i. research has identified that social influences and associated 234  social skills, rather than knowledge of long-range health consequences, affect teen substance use 1) these factors have been incorporated into school- based programs c. examples of smoking prevention efforts i. social influence approaches 1) teach skills for resisting social pressures to smoke 2) techniques included a) discussion/films on how others influence smoking b) modeling/role-playing refusal skills c) requiring public disclosure of intention to smoke ii. life skills training approaches 1) address general social, cognitive, and coping skills 2) focus on increasing a) personal skills including critical thinking and coping b) general social skills such as assertiveness and conversation making iii. programs also involve follow-up assessments of self-report and biochemical analyses d. success of approaches i. evidence suggests that children who have gone through these programs are less likely to begin smoking and fewer are likely to start smoking over the next 15 years e. ways to improve future programs i. programs should be long enough to have an impact, be administered correctly/fully, and have “booster” sessions ii. programs need to start before 5th grade and focus on attitudes about smokers iii. need to get parents involved and, if they smoke, influence them to quit while child is young f. extension of smoking prevention efforts to other substances i. results indicate that similar programs are effective in preventing/reducing drinking and marijuana use 4. Family involvement approaches a. programs focus on getting parents more actively involved in supervision of their children b. research evidence as to why this focus is important i. children without supervision are 4 times more likely to use ii. children less likely to use if know their parents would disapprove and/or punish them for doing so iii. parents of teens who use often don’t know about it c. programs include weekly session designed to teach parenting skills to 235  help children delay or reduce using i. skills include 1) how to monitor behavior and use appropriate discipline 2) teach ways to resist peer pressure 3) how to reduce family conflict B. Quitting a Substance without Therapy 1. Section introduction a. in most societies, substance use has been viewed as deviant behavior i. nonusers resent substance use ii. users feel guilty about offending others and recognize that use is unhealthy/irrational b. at same time, users often think they are as healthy as nonusers and aren’t concerned about potential health problems i. few users (26%) seek therapy to quit 2. Stopping smoking on one’s own a. motivation to quit i. primary motivation for quitting is concern for health ii. small percentage of people who start smoking have actually quit within 20 years from starting b. effectiveness of attempts to quit on own i. over 60% who attempt to quit eventually succeed and remain abstinent over 7 years ii. heavy smokers have much more difficulty quitting and report more difficulty with withdrawal symptoms iii. results suggest that most people can quit smoking on their own c. factors that influence success in quit effort i. have made the decision they are ready to quit ii. feel confident they can succeed iii. smoke less than pack a day iv. experience less stress v. have less nicotine dependence and less craving and withdrawal symptoms vi. highly motivated vii. willing to try again even if fail in current attempt d. methods used in community-wide stop-smoking contest i. majority try quitting cold turkey ii. use oral substitutes iii. most “go it alone” although some use support buddy iv. most used cognitive strategies v. some used reward or punishment strategies e. invalid beliefs often prevent success in quitting i. switching to “light” cigarettes under belief they reduce health risks ii. pointing that some smokers they know lived to old age 3. Stopping alcohol and drug use on one’s own 236  a. little is known on quitting alcohol and drug use on own b. estimates that approximately 21% of drinkers quit on own based on changes observed in research control groups c. factors that influence successful quitting these substances on own i. higher self-esteem ii. few past experiences with intoxication iii. social networks with members who drink less iv. social support from spouse v. changed pros/cons of drinking 4. Early intervention a. early intervention efforts try to identify people at risk for substance abuse and then provide them with information to reduce risk b. efforts are successful for light drinkers but not heavy drinkers i. also providing information for persons at risk for problem drinking is effective in reducing risk c. successful programs have occurred with high-risk drinkers in college, medical, and worksite settings i. employee assistance programs are helpful but employees with addictions don’t tend to seek help 1) EAPs don’t identify problem until it is usually severe 2) workers are concerned about employer finding out about problem 3) program may help to reduce workplace stress that influences substance use C. Treatment Methods to Stop Substance Use and Abuse 1. Section introduction a. users who seek treatment are typically psychologically and physically dependent on substance, which reduces chances of success 2. Psychosocial methods for stopping substance abuse a. use stages of change model to address desire and readiness for change i. although most who seek treatment want to change, others have been coerced to enter treatment by family, employer or law ii. critical transition period for change involves move from contemplation to preparation/action stages of model 1) ways to encourage transition a) giving clear advice on why and how to change b) removing barriers to change c) introducing external consequences d) offering helping and showing helping attitude b. implement methods based on motivational interviewing to bolster person’s self-efficacy c. provide positive reinforcement for stopping or reducing use i. programs that incorporate have been shown to be more 237  effective in reducing use or supporting abstinence than those that don’t d. might use aversion strategies i. examples 1) satiation = doubling/tripling smoking rates 2) use of emetics = medications that produce nausea when targeted substance is used ii. use of these methods have been linked to greater abstinence at followup e. address substance-related cues i. to extinguish impact of cues, therapists have repeatedly exposed person to cues without allowing them to use substance f. reduce negative reinforcement i. teach stress management to reduce negative reinforcement of substance use 1) progressive muscle relaxation 2) meditation 3) cognitive restructuring g. incorporate cognitive-behavioral methods 3. Highlight box (pg. 193) a. box reviews process of detoxification b. should treatment be residential or out-patient? c. should goal of treatment be abstinence or controlled substance use? 4. Clinical methods and issues box (pg. 195) a. box covers behavioral methods to control environmental conditions sustaining undesirable behaviors i. self-monitoring = recording information about problem behavior ii. stimulus control = eliminating substances/cues for substance or behavior in environment iii. response substitution = replacing problem behavior with different behavior iv. behavioral contracting = spelling out conditions and consequences regarding problem behavior in writing 5. Self-help groups a. use of Alcoholics Anonymous for problem drinking i. thousands of chapters around the world for alcoholics and their families b. AA philosophy i. once an alcoholic, remain an alcoholic throughout life ii. taking even one drink can precipitate a drinking binge – abstinence is the program goal iii. Twelve Steps are based on spiritual awakening, public confession, and contrition iv. need to attend meetings on regular basis 1) promotes franks discussions 238  2) develop friendships with ex-drinkers 3) receive encouragement and knowledge from others who have quit c. effectiveness of AA i. originally no good evidence of treatment effectiveness due to anonymity and lack of systematic information keeping ii. recent evidence of effectiveness 1) interventions conducted by professional therapists finds AA as effective as other methods 2) longer and more frequently person uses AA, less binge drinking and better social functioning iii. AA probably not effective for people who don’t believe in God b. discusses principal of self-management 6. Chemical methods for treating substance abuse a. chemical treatments used in smoking interventions i. nicotine replacement therapy = reduces cravings and withdrawal symptoms ii. bupropion hydrochloride and varenicline = antidepressant medication b. chemical treatments used in alcohol abuse treatment i. disulfiram (Antabuse) = emetic used to produce nausea if person drinks ii. naltrexone = blocks “high” feeling c. chemical treatments used in narcotic addiction treatment i. methadone = has physiological effects similar to opiates but doesn’t produce euphoria and prevents euphoria if person does use opiates; used in methadone maintenance program ii. buprenophine = also blocks euphoria effect of opiates 7. Multidimensional programs a. use of psychosocial or chemical methods by themselves are not as effective as combining methods into multidimensional approach i. combined effectiveness has been demonstrated for each substance group b. other features to consider in designing multidimensional programs i. use biochemical analyses to verify self-report at beginning of program ii. brief daily phone calls improves client performance on certain aspects of interventions (such as recording progress) iii. involving family/significant others improves outcome iv. having physician actively involved in program improves success D. Dealing With the Relapse Problem 1. Section introduction a. preventing backsliding or relapse is a major problem in treatment programs 239 2. The relapse problem a. likelihood of relapse is highest in first few weeks/months of program b. rates of relapse range from 50% to 80% c. relapse is a problem in treatment for all 3 substance groups 3. Why people relapse a. withdrawal symptoms contribute strongly to relapse i. users need to know that cravings and symptoms will diminish within a short period of time b. satisfaction with results of having quit also contribute to likelihood of relapse c. other factors contributing to relapse (see Table 7.4, pg 197) i. low self-efficacy ii. negative emotions such as anxiety or frustration iii. high craving iv. expectation that using substance again will be reinforcing v. low motivation vi. lack of constructive social support d. relapse factors related to smoking i. reduced perception of health risks for smoking following a relapse 1) means person has moved to lower stage of change and will need support to move back to action stage ii. weight gain during quit attempt 1) ex-smoker has increased caloric intake 2) metabolism has declined 3) person will need to control diet, exercise more, or use nicotine patch to control metabolism 4. Can relapses be prevented? a. 5 approaches to reducing occurrence of relapse i. relapse prevention method 1) method based on view that relapse occurs through cognitive events of abstinence violation effect 2) therapist-supervised self-management program involving a) identification of high-risk situation b) development of specific behaviors and thought patterns to help in high-risk situations c) practicing effective coping skills in high-risk situations ii. interventions can provide rewards for abstinence and counseling for the first year or more after treatment iii. clients can continue using a chemical method after treatment ends (e.g., methadone) iv. relaxation methods, such as mindfulness meditation, can reduce negative emotions 240 v. clients can be helped to develop social networks that provide constructive support 241