PSY1014: Drug and Alcohol Use and Abuse - Comprehensive Study Notes

Course and Resource Information

• Unit Name: PSY1014 Drug and Alcohol Use and Abuse

• Lecturer: Dr Michael T. Rowlands

• Lecture Date: $12/04/2024$

• Required Textbook: Hungerford, et al. Mental Health Care ($4^{th}$ edition), Chapter $10$: Substance Use Disorders.

Categories of Substances

• Substances are classified into three major categories based on their specific effect on the central nervous system (CNS) during intoxication:
      * Stimulants: These substances speed up the neurochemical activity in certain areas of the brain.
          * Examples: Amphetamine type substances, Cocaine, Caffeine, Nicotine, Ecstasy (i.e., MDMA).
      * Depressants: These substances slow down neurochemical activity.
          * Examples: Alcohol, Benzodiazepines, Inhalants, Opiates, Gamma hydroxybutyrate (GHB), Cannabis (including synthetic cannabinoids).
      * Hallucinogens: These substances alter the perception of the user.
          * Examples: LSD (acid), Ketamine, Magic Mushrooms, Cannabis, Datura, Tryptamines.

Effects and Motivations for Substance Use

• Stimulant Effects:
      * Induces a sense of euphoria and wellbeing.
      * Provides a boost in energy levels.
      * Promotes wakefulness and self-confidence.
      * Improves physical and cognitive performance.
      * Leads to reduced appetite.

• Depressant Effects:
      * Used primarily to socialise and relax.

• Hallucinogen Effects:
      * May affect all senses: visual, auditory, kinaesthetic, olfactory, or gustatory.
      * Alters the awareness of the passage of time.
      * Gating: The ability to dismiss extraneous stimuli is affected.
      * Users may report out-of-body experiences or dissociative states, such as depersonalisation.

• General Motivations for Use:
      * Experimentation.
      * Recreational use.
      * Situational factors.
      * Instrumental use.
      * To alleviate physical or emotional pain.

• Dependency Note: Not every individual who takes drugs becomes dependent. Dependency is contingent upon the specific drug, the person, and the environment.

Definitions and Clinical Progressions

• Substance Use: The use of any substance that does not lead to significant detrimental health effects.

• Substance Misuse and Substance Dependence: Relates to the continued use of a substance despite negative consequences, which often leads to various substance use disorders.

• Substance Use Disorder: Characterised as a change or alteration in brain chemistry. Symptoms and impacts may continue well beyond the period of detoxification or withdrawal.

• Substance Use Disorder/Addiction: Defined as a chronic, often relapsing brain disease that causes compulsive drug seeking and use despite harmful consequences to the individual and those around them.

• Progression Model: Occasional use $\rightarrow$ frequent and problematic use/misuse $\rightarrow$ dependent use, resulting in a disorder.

• The Brain and Self-Control: While initial drug use is usually voluntary, over time, brain changes challenge self-control and hamper the ability to resist intense impulses.

• Common Symptoms of Disorder/Addiction:
      * Tolerance.
      * Withdrawal.
      * Physical craving or dependence.
      * Psychological compulsions, obsessions, or dependence.

Theories and Biopsychosocial Factors Influencing Addiction

• The Incentive Sensitisation Theory of Addiction: Proposed by Robinson and Berridge ($1993$).

• Biological Factors:
      * Genetics.
      * Stage of development.
      * Gender.
      * Ethnicity.
      * Sensitivity to drugs.
      * Mental Illness.

• Personality Factors:
      * Sensation seeking.
      * Impulsivity.
      * Antisocial/Oppositional traits.
      * Anxiousness/Neuroticism.

• Academic Factors:
      * Low academic achievement.
      * Lower education levels.
      * Lower IQ.

• Social Factors:
      * Socioeconomic disadvantage.
      * Home and family environment.
      * Social and other stressors.
      * Immigration and acculturation.
      * Legal status and availability of drugs.
      * Social attitudes and perceptions.
      * Peer pressure (notably during adolescence).

• Psychological Factors:
      * Mental health disorders (e.g., Mood, Psychotic, or Eating Disorders).
      * Personality disorders (e.g., Borderline or avoidant personality).
      * Pre-existing medical conditions (e.g., chronic pain and pain management).

Health Promotion and the National Drug Strategy (NDS)

• Health promotion programs aim to change health behaviours at a population level (Thompson, $2015$).

• Australian Context: Strategies currently tackle community beliefs regarding health and illness.

• The National Drug Strategy (NDS): A cooperative venture between federal, state/territory governments, and the non-government sector.
      * Goal: To improve health, social, and economic outcomes for Australians by preventing harmful drug use uptake and reducing effects of licit and illicit drugs.
      * NDS $2017$–$2026$: Details national commitment to harm minimisation and provides indicators to monitor progress.
      * Perception Factor: When young people perceive drug use as harmful, the levels of use often reduce.

Harm Minimisation Pillars

• Harm minimisation is the overarching approach of the Australian health system (Allan, $2010$), in place since $1985$.

• This approach acknowledges that substance use will continue; the focus is to reduce harm for individuals and the community.

• The Three Pillars:
      1. Demand Reduction: Strategies to reduce the desire for and uptake of drugs.
      2. Supply Reduction: Strategies to control the production and distribution of drugs.
      3. Harm Reduction: Strategies to reduce the harm for those who continue to use drugs.

The Cycle of Change (Transtheoretical Model)

• Developed by Prochaska and DiClemente in the late $1970$s and early $1980$s ($1982$).

• Defines change as a process rather than a single event, involving cognitive and behavioural shifts.

• The Six Stages of Change:
      1. Precontemplation: Not considering change.
      2. Contemplation: Ambivalent about change.
      3. Determination or Preparation: Making a decision to change soon.
      4. Action: Observable behaviour change.
      5. Maintenance: The new behaviour requires less effort.
      6. Relapse and Recycling: Acknowledges the cyclical nature of change (DiClemente, $2003$).

• Termination: Potential end point where the old behaviour no longer presents a threat.

• Intervention Significance: People at different stages require different types of interventions to help them progress.

Stages of Treatment

• Mueser and colleagues ($2003$) detailed a four-stage treatment model to guide clinicians based on a person’s readiness to participate:
      1. Engagement:
          * A person may be enrolled but not yet engaged (often due to pressureจาก significant others).
          * Engagement occurs when the client feels the provider has something desirable to offer.
          * Pressure to cease use before engagement often leads to treatment dropout.
      2. Persuasion:
          * The person is prepared to listen to information.
          * Strategies include Motivational Interviewing (MI), psychoeducation, and group therapy.
      3. Active Treatment:
          * The person is prepared for change and begins making alterations.
          * Professionals should offer a range of strategies so the individual can assume control of the change.
      4. Relapse Prevention:
          * Assisting the person to expand recovery into a better quality of life.
          * Encouraging new risks and maintain vigilance to ensure progress is maintained over time.

Treatment Options and Methodologies

• Motivational Interviewing (MI):
      * Focuses on motivating the client to change destructive behaviour by weighing pros/cons against life goals.
      * Best for those ambivalent about change; assesses and enhances importance, willingness, and confidence.

• Cognitive Behavioural Therapy (CBT):
      * Addresses harmful thought patterns to regulate distressing emotions and behaviour.
      * Focuses on reducing/stopping illicit drug use and addresses related areas like employment, legal issues, and family relations.
      * Sessions occur $1$ or $2$ times per week with an emphasis on short-term goals.

• Contingency Management:
      * Voucher-Based Reinforcement (VBR): Used for opioid and stimulant abuse. Patients receive vouchers with monetary value (for food, movies, etc.) for every drug-free urine sample. Voucher values start low and increase with consecutive negative tests; a positive test resets the value to the initial low level.
      * Prize Incentives: Similar to VBR but uses chances to win cash prizes ($1$ to $100$ dollars) drawn from a bowl. Draws are gained for negative tests, attending counselling, or completing weekly goals. Resets to one draw upon any positive sample or unexcused absence.

• Pharmacotherapies + CBT: Combined approach often used for opiates and alcohol.

• Therapeutic Community: For complex cases; includes detachment from the drug context, psychosocial treatment, and vocational training.

• Special Considerations:
      * Polysubstance use requires flexible approaches.
      * Dual diagnosis (comorbid mental health issues) requires an integrated treatment system.