Chapter 7 and Lecture 6: Substance use and abuse

Primary prevention programs and campaigns: Who is targeted

• Promote healthy behaviors in younger people, and also parents of those ppl

• Major groups: Sugar consumption, cigs, alcohol

CDC’s Anti-smoking campaign (2012)

• Effective if give ppl information of support, and what’s the immediate health outcome (if doesn’t include these, the message won’t be effective at all)

• Impact of these ads were much more effective than they thought (more calls to toll-free quit line and website visits)

• But results are mixed: 2 largest US tobacco companies reported no impact on 2012 earnings

CDC’s final report (based on surveys) and criticisms

• Vast majority recalled seeing at least on of these ads once, quit smoking, quit smoking immediately, or quit permanently

• Criticisms:

  • Correlational, not causational

  • Measured intension to change, but not if they actually quit (there’s no longitudinal study)

Most successful anti-smoking ads (based on experimental)

Emotionally evocative and contain personalized stories

• Make ppl intend to quit

• There’s still no longitudinal study on this

• In addition to health agencies and medical professionals, the mass media, news outlets, and the internet play an important role in disseminating health-related information

Name methods for changing health behaviours

Providing info (educational appeals—general or tailored—-personal): How info is delivered affects effectiveness (persuasion + behavior change)

Message framing

• Gain-based, loss-based

• Fear appeals: Message framing that assumes instilling fear (and high level of anxiety) will lead to change. lasts short-term

Educational appeals (RECHECK CUZ UNSURE)

Assuming that providing general correct information (vs. tailored content) → motivate ppl to improve a health behaviour if they have the knowledge.

• Esp effective in societies that ALREADY have good education abt how these behaviors are harmful (social contex)

Effective message for educational appeals

• Social context

• Colour & vividness of ads

• The receiver’s education level (higher)

• Expertise, likeability, and relatability of messenger.

• Avoiding jargon & stats

• Short, strong arguments at start & end

• Placement of strong arguments.

• In some cases, Presentation of both sides.

• Clear conclusions

• Avoidance of extremes (like extreme conclusions)

Message Framing

Refers to whether the information emphasizes the benefits (gain-framed) OR costs (loss-framed) associated with a behaviour or decision. (doesn’t have to be both at the same time)

• No sig diff between effects for gain-framed vs loss-framed

Gain-framed messages

focus on experiencing desirable consequences and/or avoiding negative ones.

Work best for motivating behaviours that serve to prevent or recover from illness or injury (e.g., using condoms, performing physical therapy)

Ex. “If you exercise, you will become more fit (gains) and less likely to develop heart disease (avoidance of negative outcome)”

Loss-framed messages

focus on experiencing undesirable consequences and/or avoiding positive ones.

• E.g., “If you do not get your blood pressure checked, you could get a stroke without knowing the risk before”

• Work best for behaviours that: 

  • Occur less frequently 

  • To detect a health problem early (e.g., drinking and driving, getting a mammogram)

  • When outcome of bahavior is uncertain (ex. vaccines in general)

Vaccine for COVID and type of message framing

Gain-based and loss-based work good equally

Fear appeals

Message framing that assumes instilling fear (and high level of anxiety) will lead to change. Effects tend to be transient (lasts short-term)

Fear appeals message is More persuasive if

• Emphasize clear consequences

• Include personal testimonial

• Provide specific detailed instructions 

• Boost self-efficacy before urging them to change

Too much fear can also be problematic

• Avoidance! (even in some avoidance, ppl still have info processing, we can see long-term effects)

• Too extreme/Unrealistic (ppl don’t take it seriously)

• Depends on if the person intends to change

Behavioral methods

focus on helping people manage the antecedents (cues) & consequences of a behaviour (reinforcement)

Cognitive methods

focus on changing people’s thought processes (teach self-management)

CBT

Evidence-based psychotherapeutic intervention that promotes self-observation and self-monitoring to increase awareness and control of negative thoughts and harmful behaviours.

Goal of CBT

• Regulation of thoughts, attitudes, beliefs, emotions, and behaviours through personal coping strategies (to be able to do this unsupervised)

• Self-management: Clients can eventually apply these methods themselves

CBT: Applied to Alcohol Misuse

• Identify unhelpful/unrealistic thoughts and beliefs that contribute to the problem behaviour

  • “I can’t relax without my alcohol.”

  • “My friends find me boring when I’m sober.”

• Identify triggers (internal/external) that cause you to drink

  • Negative experiences (personal conflict),

  • Specific social situations (culture that drinks after work like Japan), 

  • Or locations, etc. (live close to liquor store)

• Engage in more realistic and helpful thoughts

  • “I know I can’t stop drinking once I start.”

  • “Lots of people have fun without alcohol.”

Why maintaining health behav changes can be diff (lapses and relapses)

Lapse: a minor slip that should be expected, which does not indicate failure (e.g. a person who quits smoking has a cig)

Relapse: Falling back to one’s original patt of undesirable behavior; very common when ppl try to change long-term habits (e.g. eating and smoking behavs)

Adstinence-violation effect

when a person committed to total abstinence experiences a lapse, views it as a total personal failure → lead to a full relapse

• Need to tell ppl that lapse is normal!

• This effect could prevent ppl from trying again

Relapse prevention method is a self-management program in which clients

1.  Learn to identify high-risk situations by generating a list of conditions that lead to lapses.

2. Acquire coping skills through training that will enable the person to deal with high-risk situations and avoid lapses.

3. Practice coping skills in high-risk situations under a therapist’s supervision

Motivational interviewing

A one-on-one counselling style designed to help indv explore and resolve their ambivalence in changing a behav

• Originally developed for counselling of alcoholics

• Work best for alcohol reduction

• Semi-directive, client-centered approach to counselling/therapy.

• Adopts a transtheoretical model (stages of change) combined with CBT

(Motivational interviewing) 2 key features of transtheoretical model combined with CBT

• Decisional Balance: Clients list pros and cons of changing behaviour; then discuss.

• Personalized Feedback: Clients receive information on their pattern of problem behaviour, comparisons with norms, and risks of behaviour (usually second visit)

Social engineering

In addition to changing the individual, we can also change the social environment in order to better support healthy behaviours

• Nutritional guidelines

• Seatbelt laws, road safety

• School vaccination programs

• Smoking prohibitions

Example of motivational interviewing: Brief Alcohol Screening and Intervention for College Students (BASICS)

A harm reduction approach.

Designed to help students make better alcohol-use decisions based on a clear understanding of the risks associated with problem drinking.

Program is only 2 brief interviews/sessions

1. Assessing risk of problem behaviours, obtaining commitment to monitor drinking between interviews.

2. Providing personalized feedback, including comparison to norms, risks, and advice on how to drink safely.

Strategies include: Slowing down, spacing drinks; Different types of drinks; Drink for quality vs. quantity; Enjoy mild effects of alcohol.

Studies on BASICS show…

• Reduce their alcohol consumption (drink less rather than don’t drink): Less number of days drunk

• Experience fewer negative consequences (like hangovers, blackouts, or risky behavior).

• Highly effective (compared to control group) in maintaining these improvements over time

Is mass media effective when promoting health?

Most effective when combined w other methods and targeted at ppl ALREADY motivated to change

Tailored advice and promoting health

Designing advice specifically for an individual (e.g., based on their age or smoking history) is more successful than general educational appeals

Social engineering

In addition to changing the individual, we can also change the social environment in order to better support healthy behaviours.

Challenge: Often faces public resistance (seen as limiting freedom)

Examples (don’t memorize):

• Nutritional guidelines

• Seatbelt laws, road safety

• School vaccination programs

• Smoking prohibitions

• Taxation of alcohol to increase cost

• Restricting alcohol to adults

• Eliminating trans fats in foods

• Vaccine mandate / passports

Regulation/Prohibition of Drugs and consequences

A traditional approach to preventing substance use/misuse is to regulate, prohibit, and/or criminalize addictive or harmful substances.

4 types of drugs

• Stimulants: (e.g., amphetamines, caffeine, cocaine) Increase physiological/psychological arousal.

• Depressants: (e.g., alcohol, benzodiazepines/Valium) Decrease arousal and induce relaxation.

• Hallucinogens (Psychedelics): (e.g., marijuana, LSD) Produce perceptual distortions.

• Narcotics (Opiates): (e.g., morphine, heroin) Relieve pain and produce a euphoric feeling

Initiation of most drug use (in adolescence vs adulthood)

• Most drug use starts in adolescence: Ex. smoking, drinking, weed

• What drugs mosttly likely to start in adulthood: Tranquilizers and painkillers (like OxyContin)

Polysubstance use

Many ppl use more than one substance (e.g. Tobacco, alcohol, weed). Heavy users of less serious drugs are more likely to progress to using more serious drugs

Factors for use and abuse of drugs

• Similar to smoking: Peer model/pressure, low self-control, high sensation-seeking

• Rebellious, impulsive, accepting illegal behavior, less socially conforming

• Marginalized groups (lgbt teens), use drugs and polysubstance use, often a way to cope w severe stressors and toxic envi

Long-term drug use risks

• Drugs taken during pregnancy harm the fetus, and the babies are likely to be born addicted!

• Stimulants: Raise HR & BP → heart attack/stroke

• Marijuana: Lung damage (like cigs)

• Opioid: Overdose death, Fentanyl and Naloxone

Decriminalization

Decriminalization does not typically increase the use of drugs

Does not impact crime rates

Harm reduction approach

Aims to reduce the harm of substance/drug use; and to treat people who use drugs with respect and dignity rather than criminalizing them

(ex. BASICS, Vancouver’s Downtown East Side — DTES)

• To reduce/remove the effects of social stigma.

• To better motivate them to be healthy and contributing members of society

• Less likely to use substances in a safer way

• More likely to seek out rehabilitation

Prevention focus of harm reduction approach

Prevention should begin early, program must address when and why the person start use

3 approaches to deal w drug use

1. Public Policy and Legal Approaches:

   • Taxation (of tobacco and alcohol is effective)

   • Restrictions: Prohibiting underage purchase/consumption and restricting ads.

   • Drug Laws: Main approach has been outlawing possession, but evidence suggests that decriminalization of marijuana does not increase its use

2. Health Promotion and Education: (Implemented by professionals): life skill training — social, cognitive, coping skills. Ex. cope w anxiety)

3. Family Involvement: (Implemented by professionals)

Vancouver’s Downtown East Side (DTES), 1997: Public health emergency declared…

• Overdose deaths

• Spike in rates of HIV / Hepatitis C

Then solution for DTES → INSITE supervised drug consumption site, 2003: Goal

• Reduce public injecting of drugs

• More safer use of substance

• Reduce overdose death

Peer-reviewed Benefits of this INSITE

• Reduction in public injecting and syringe sharing

• Increases use of detox services and addiction treatment/sign

• Decreased overdosed deaths

• Decreased new cases of HIV infection

In 2008, it was revealed that the RCMP published false data which claimed adverse effects of Insite

• There is an extensive body of Canadian and international peer-reviewed research reporting the benefits of supervised injection sites

• The RCMP commissioned... reports to provide an alternative analysis of existing SIF research... These reports did not meet conventional academic standards.”

• → ppl see harm reduction site as harmful

Harm Reduction Today: Numerous safe consumption sites have opened around Canada.

In 2020, BC became the first and only jurisdiction globally to launch a large-scale province-wide safer supply policy.

• Allows individuals with opioid use disorder at high risk of overdose to receive pharmaceutical-grade opioids. 

  • (Overdosed deaths are cuz on the streets opioids are mixed w other stronger ones like fentanyl)

  • COVID increased overdose deaths, illegal drugs, distribution

• Some provinces are testing decriminalization of illicit substances

Some provinces in Canada are testing decriminalization of illicit substances

• Reduction of fine of drugs (heroin, fent, cocaine)

• Increased in hospitalization could be a sign that ppl trust more in healthcare (results unclear)

• No negative impacts on crime rates

• In 2023, BC decriminalized possession of some illicit substances

• Stigma is asso w negative outcomes

• BC has the highest Exposure to illegal (unregulated) drug supply

Addiction

a state of psychological and/or physical dependence on the use of drugs or other substances, such as alcohol, or on activities or behaviours, such as gambling

Psychological dependence

a state in which individuals feel compelled to use a substance or engage in a behaviour for the effect it produces. 

Craving: a strong desire for the substance, is a key motivational state

Physical dependence

exists when the body has adjusted to a substance and incorporated it into the “normal” functioning of the body’s tissues.

• Affects neurotransmitter, but over time, your body normalized it → withdrawal makes it hard for you to quit

Addiction pathway

Psychologically dependent first → physically dependent

• Heroin (narcotics) and cocaine (stimulant) have high potential for psychological dependence, marijuana is moderate, and LSD is lower

DSM-5-TR and Addiction: diagnosis that’s possible in substance Use disorder (alcohol, cannabis)

• Substance toxicity (accumulate toxic things in body)

• Withdrawal

Criticism of this on Substance disorders (and addiction) on DSM

• Even drug toxicity levels are diff among drugs: Caffeine vs opioid toxicity is totally diff level but it falls under same category 

• Not recognized in DSM: Gambling disorder, it’s in Behavioral addiction instead (other examples, addiction in porn, shopping, phone, sugar)

• Sex addiction is in diff category on DSM

Short-Term Effects of Alcohol

Mostly psychological

• Reduced coordination

• Diminished cognitive ability

• Judgment, decision-making

• Aggression / Emotionality

• Accidents

Long-Term Effects of Alcohol

Mostly biological

• Liver damage

• Cardiovascular disease

• Various types of cancer!

• Depression

• Alcohol Use Disorder

• Impaired immune function

• High BP, brain damage, Cancer

Why alcohol use is a complicated case of health-compromising behavior (Negatively impact physical/mental health)

Normalized or even encouraged

Alcohol use disorder

Problematic pattern of alcohol use → significant impairment or distress as seen by at least 2 of the following list, occurring within a 12-month period

Tolerance and withdrawal are the keys in any addiction disorder

Severity of alcohol use disorder on DSM

1-3 criteria: Mild disorder

4-5 criteria: Moderate disorder

>6: Severe disorder

Substance-Related Cues

• Internal and environmental stimuli (e.g., the sight/smell of smoke or beer) become associated with the substance's effect through classical conditioning.

• These cues can elicit attention and craving.

• Incentive-sensitization theory

Incentive-sensitization theory

dopamine increases when see cues, make them highly desirable and noticeable → motivates the person to use drugs

Expectancies and substance

• Ideas about the outcomes of behavior, learned from personal experience and observation, influence substance use.

• Positive Expectancies (e.g., that drinking is "fun" or "sociable") are acquired early, often from watching models like family or celebrities.

• Negative expectancies → influence the decision to stop using a substance.

Substance users and personality

• Impulsive, high risk-taking, sensation-seeking

• Low self-regulation

• History of adverse childhood, depression, anxiety

Heredity influences addiction:  twin studies for both smoking and alcohol problem

• Age-Related Influence: Social factors are more important during teen, and genetic factors more imp in adulthood.

• Counteracting Risk: High parental monitoring can counteract a child's high genetic risk.

• Epigenetics: Environmental factors can alter the operation of genes involved in substance use

Factors for alcohol use and abuse

• Expectancies: The chief reason for starting is social and cultural factors, particularly positive expectancies of heightened sociability and reduced tension.

• Drink for positive reinforcement (taste, laugh) vs negative reinforcement (suppressing stress or negative thoughts)

• Heavy drinkers: feel more stimulated when drinking, high stress, or have a trauma.

• Genetics: Heredity plays a much stronger role when abuse begins before age 25. Gene patterns can also create a tolerance to alcohol, or in some cases, protect against heavy drinking (e.g., by producing facial flushing)

Drinking status in Canada

Most are Light frequent and infrequent drinkers > former drinkers and abstainers > heavy frequent and infrequent drinkers.

Canada is at top 3 most drinkers (Australia > brazil > Canada > others > muslim countries)

Binge/heavy drinking

5 or more drinks on a single occasion at least once in a 30-day period

• 19% of Canadians 12+ y/o. But 40% among European 15-16 y/o

• 17% in NA become abuser at some point

• Alcohol abuse in NA most likely to develop between 18 and 24 y/o

Alcohol intervention

• 12-step programs and AA: Mentor/mentor. May be comparable to other treatments, and effectiveness inconsistent

• CBT: Small but sig treatment effect in experiments

• Motivational interviewing: Consistent and sig effects in large majority of studies; better than traditional counselling (or CBT)

Individuals who have developed dependence continue use largely to prevent…

the intense, unpleasant symptoms of withdrawal (e.g., delirium tremens in alcohol addiction)

Intrapersonal High Risk Situations for relapse

• Negative emotional states (e.g., anger, depression, boredom).

• Positive emotional states (e.g., celebrations).

• Exposure to alcohol-related cues

• Non-specific cravings

Interpersonal High Risk Situations for relapse

• Situations involving other people, especially interpersonal conflict.

• Social pressure, both direct and indirect.

• Exposure to settings and situations that are cues (e.g., passing bar)

Stages to prevent relapse

• Identify high-risk situation where lapses are most likely

• Adopt Competent and coping skills

• Practice effective coping skills in high-risk situation

Which is best between long-term abstinence (no drink at all) vs moderation (controlled drinking)?

Controlled moderation drinking works better than abstinence for

• Less severe drinking problem

• Better social support

• Younger ppl

• Short history of alcohol misuse (moderation is unrealistic for long-term drinkers, so abstinence is better)

• Have not experienced severe withdrawal

Previous studies about mild-moderate drinkers

Mild-moderate drinkers have lower risks of (protective against) Coronary heart disease than abstainers and severe drinkers! (BUT THIS WAS NOT CONTROLLED – flaw)

Concern from newer studies about mild-moderate drinkers

• Many abstainers abstain cuz of illness and/or medication

• This might complicate things cuz if these ppl are included for comparison, it could be their underlying illness that’s leading to CHD, not their abstinence

• When this error was controlled, no sig diff between abstainers and moderate drinkers in developing CHD

Smoking trends

• Highest rates in Europe

• >80% of smokers live in developing countries

• In Canada: Smoking peaked in the mid-1960s → dropped steadily. Young adults (20–24) smoke the most. E-cigarettes/vaping are a growing public health concern

• Few ppl become regular smokers after early 20s, habit often starts in grade 8

• More smoking: Lower education, income, job rank, also Indigenous ppl

Factors for starting and regular use

• Start more if: See smoking as low risk, have family/friends who smoke, low self-esteem, thrill-seeking

• Reinforcement: Pleasure from smoking → negative reinforcement (coping with stress or negative emotions by smoking more) → maintain the habit.

• Biology: Mom smoking during pregnancy → function of the insula (control the desire to smoke) routes to sustained smoking

Smoking and health risk

• Lung cancer (deadliest in NA)

• Cardiovascular Disease (CHD and Stroke): Due to atherosc

• Chronic obstructive pulmonary disease (also impairs immune function → nore frequent respiratory infections)

• Vaping increase risk of heart attack and coronary artery disease