L5 Addiction

Addiction: Models, Policy & Treatment

Professor Celia Morgan
Email: Celia.morgan@exeter.ac.uk

What is 'Addiction'?

  • Key Questions Addressed:

    • What is addiction?

    • What causes it?

    • How do we prevent and treat it?

Learning Objectives

  1. Define addiction and understand why this is important.

  2. Discuss the leading theories in addiction science.

  3. Understand drug policy, the relative harms of drug addiction, prevalence, and cost to society.

  4. Assess the leading treatments for addiction and examine how they derive from the dominant theories and policy.

Definition of Addiction

  • Addiction Defined:

    • "A person is addicted to a specified behaviour if they have demonstrated repeated and continuing failures to refrain from or radically reduce the behaviour despite prior resolutions to do so, or if they would have demonstrated such failures under different personal or environmental circumstances" (Heather, 2017).

    • Significance: Defining addiction is crucial for determining how society approaches causation, prevention, and treatment.

Historical Context of Addiction

  • Ancient Practices:

    • Priests or shamans have ingested psychoactive plants for millennia to induce dissociative states.

    • Evidence indicates that beer was used as early as 5000 BC in Iran and Egypt.

    • The earliest reference to opium dates back to 3400 B.C., in Mesopotamia, where it was known to the Sumerians as Hul Gil, "the joy plant."

    • The mushroom Amanita muscaria (fly agaric) has been integral to religious rituals in Central Asia for at least 4000 years and is termed "entheogenic" (literally, from inside, god, create).

  • History of Alcohol Use in the UK:

    • Iron Age (400 BC): Beer found, used to purify water and provide hydration.

    • Middle Ages: One public house per 167 people, significantly higher than the current ratio of 1 per 1400; beer was more accessible than fresh drinking water.

    • Puritanical Influence: Decline in alcohol usage.

    • 18th Century: The introduction of gin led to the ‘great gin epidemic.’

    • Gin consumption surged from 527,000 gallons in 1685 to 11 million by 1750, leading to issues termed ‘gin madness.’

    • Beer and wine prices made them unaffordable for the poor; the crisis disproportionately affected lower socio-economic groups.

  • Cultural Impact of Gin:

    • A depiction (GRIPE PAWN BROKER) highlights the societal impact of gin, describing its effects on virtue and health, capturing a historical critique of addiction.

Drug Policies and the War on Drugs

  • Models of Addiction:

    • 17th Century Moral Model: Addicts viewed as weak-willed and deserving punishment; some countries still adhere to this model.

    • 20th Century Disease Model: Treating addiction as a medical issue; seen as a victimhood paradigm needing abstinence; belief that addiction is innate and irreversible. Example: incentive sensitization (Robinson & Berridge, 2000).

    • 1970s Onward: Behavioral reinforcement and social learning models proposed.

    • Biopsychosocial Model (Engel, 1977): Integration of biological, psychological, and social factors in understanding addiction formation and maintenance.

Prevalence of Substance and Alcohol Use Disorders

  • Lifetime Prevalence Rates (Combined):

    • 6.5% for alcohol use disorders.

    • 8.9% for illicit drug use disorders.

  • Addictive Potential Statistics:

    • Nicotine: 30-40% of users become dependent.

    • Alcohol: 20% of users become dependent.

    • Heroin: 20% of users become dependent.

    • Cocaine and cannabis: 10% of users become dependent.

    • Amphetamines: 10% of users become dependent.

  • Early Use Predictive of Future Problems: Early initiation of drug use is predictive of problematic use in adulthood.

Societal Costs of Addiction

  • U.S. Statistics:

    • 1 in 6 deaths attributed to alcohol and drug use.

  • U.K. Statistics:

    • 1 in 5 deaths attributed to cigarette use.

    • Death rate comparisons: 1 death every 2 days for heroin, 1 death every 20 minutes for alcohol, and 1 death every 4 minutes for cigarette use.

Misuse of Drugs Act (1971)

  • Key Points:

    • The Misuse of Drugs Act (MDA) establishes UK drug policy through criminal offences related to the possession, supply, and production of controlled drugs.

    • Aligns UK policy with the UN Single Convention on Drugs of 1961.

    • Implemented a drug classification system, categorizing substances as Class A, B, or C, which determines penalties based on classifications.

  • Statistics Related to MDA Compliance (1973-2018):

    • Cautions and prosecutions for drug offences and stops and searches data highlight trends over recent decades.

Drug-related Death and Control Statistics

  • Drug-related Deaths (1971-2020) in the UK:

    • Trends in drug-related deaths, highlighting the increasing mortality associated with drug use.

  • Trends in Drug Potency (2009-2019):

    • Variations in potency and market price of cannabis and cocaine across Europe.

The Harmful Effects of Various Drugs

  • Activity: Ranking and evaluating the harm of drugs based on their societal cost and health impacts, relevant to the Misuse of Drugs Act.

  • Public Perception vs. Scientific Consensus:

    • Data from Nutt et al. show discrepancies between public understanding and scientific evaluation of harm associated with various substances, including alcohol, cocaine, heroin, and cannabis.

Recent Drug Political Developments

  • Recent Updates on Ketamine:

    • Proposal to reclassify ketamine as a Class A substance due to a rise in illicit use and associated risks.

  • Historical Context:

    • 20+ years of drug reform in Portugal, demonstrating a model of decriminalization leading to reduced drug-related deaths and increased treatment requests.

Motivations and Treatments for Addiction

Complex Causes of Addiction

  • Stigmatization of Users:

    • The social stigma surrounding drug use results in users delaying seeking help, exacerbating health issues and mental health problems.

  • Personal Accounts of Stigma and Shame:

    • Accounts from users reflect the internalized stigma that prevents individuals from seeking necessary medical and psychological assistance.

Treatments for Addiction

  • Psychosocial Approaches:

    • Stigma-aware treatment recommendations that emphasize early intervention, addressing moral and social implications associated with drug use.

  • Evidence-based Policy Recommendations:

    • Discussion on the need for public understanding and specific services catered to ketamine use disorders to enable user access to help.

  • Cognitive Behavioral Therapy (CBT):

    • Addressing thinking biases and behavioral patterns of problematic users, encouraging proactive engagement in treatment by highlighting triggers, activities, and problem-solving skills.

  • Motivational Interviewing:

    • A collaborative approach aimed at enhancing a client’s motivation to change by exploring their values and goals through techniques like Open Questions, Affirmations, Reflective Listening, and Summarization (OARS).

  • Behavioral Treatment Models:

    • Incorporate methods such as reinforcement with vouchers for abstinence and the development of new associations to replace drug use behaviors.

Treatment Modalities

  • Cognitive Behavioral Therapy (CBT): Focuses on identifying thinking biases, triggers, and developing problem-solving skills to change behavioral patterns.

  • Motivational Interviewing (MI): A collaborative approach to enhance motivation via OARS:

    • O: Open Questions

    • A: Affirmations

    • R: Reflective Listening

    • S: Summarization

  • Behavioral Treatment: Uses voucher-based reinforcement for abstinence and replacement of drug-related associations.

  • Addressing Stigma: Social stigma causes users to delay seeking help. Effective policy must focus on reducing fear and increasing access to targeted services (e.g., specific services for Ketamine use disorders).

Final Recommendations

  • Summary of Recommendations:

    • Improve public and professional understanding of substance use disorders, create targeted services, and enable better access to help through reductions in stigma and fear in users.

Conclusion

  • Review of Learning Objectives:

  1. Definition and understanding of addiction.

  2. Discussion of leading addiction theories.

  3. Understanding drug policy and its societal impacts.

  4. Evaluation of treatments for addiction grounded in scientific theories and policy evaluation.

Example 10-Mark SAQs and Pointers based on Addiction Notes

Question 1: Compare and contrast the historical Moral Model of addiction with the 20th-century Disease Model.

Pointers (High 1st = 85\%; 2:1 = 65\% ; Pass = 45\%)

  • High 1st
    The response provides a sophisticated analysis of how the 17th-century Moral Model frames addiction as a failure of character or "weak will," justifying punishment and moral condemnation. This is sharply contrasted with the 20th-century Disease Model, which medicalizes the condition as an innate, irreversible biological state requiring abstinence. The answer demonstrates exceptional insight by noting the "victimhood paradigm" inherent in the disease model and linking it to specific neurobiological theories like incentive sensitization (Robinson & Berridge, 2000). It evaluates how these shifts in conceptualization fundamentally change societal responses from incarceration to medicalized care, while articulating the limitations of both in capturing the full human experience of addiction.

  • 2:1
    Provides a clear and accurate distinction between the two models. It identifies the Moral Model as viewing the individual as responsible and deserving of punishment, while the Disease Model treats addiction as a medical issue that is often considered permanent. It mentions the goal of abstinence within the disease model and provides a generally coherent argument about how these perspectives influence whether a person receives treatment or punishment.

  • Pass
    The response states that addiction used to be seen as a choice or a moral failing but is now often seen as a disease. It correctly identifies that the moral view leads to punishment and the disease view leads to doctors helping. The explanation is descriptive and lacks depth regarding the implications of either model on long-term recovery or specific theoretical examples.

Question 2: Discuss the discrepancy between the Misuse of Drugs Act (1971) drug classifications and scientific evidence regarding drug harms.

Pointers (High 1st = 85\%; 2:1 = 65\%; Pass = 45\%)

  • High 1st
    Demonstrates exceptional critical evaluation by contrasting the legal classification system (Classes A, B, and C) with empirical harm rankings. Using data from Nutt et al., the response highlights how legal substances like alcohol often present greater total harm to society and the individual than certain Class A or B drugs. It integrates specific statistics, such as death rates (e.g., 1 death every 20 minutes for alcohol vs. 1 every 2 days for heroin), to illustrate the limitations of current policy. It also contextualizes the MDA (1971) within global trends and mentions alternatives like the Portuguese decriminalization model as a way to reconcile policy with health outcomes.

  • 2:1
    Accurately explains the MDA (1971) system and its role in UK law. It mentions that scientific research (Nutt et al.) does not always align with these classifications and gives examples like alcohol or cannabis. It provides a balanced argument that policies are sometimes based on factors other than health risks, such as social or political concerns, though it may lack the specific statistical depth of a first-class response.

  • Pass
    The response notes that the UK has laws to group drugs into classes and that these determine how people are punished. It mentions that some legal drugs can be more dangerous than illegal ones but does not provide specific scientific citations or a clear evaluation of why this discrepancy exists.

Question 3: Explain the role of Motivational Interviewing (MI) in addiction treatment, specifically referencing the OARS framework.

Pointers (High 1st = 85\%; 2:1 = 65\%; Pass = 45\%)

  • High 1st
    Provides a precise and conceptually integrated account of MI as a collaborative, person-centered approach to enhance internal motivation. It correctly identifies and explains each component of the OARS framework: Open Questions, Affirmations, Reflective Listening, and Summarization. The response shows exceptional insight by linking MI to the Biopsychosocial Model, explaining how it addresses the psychological barriers of ambivalence and the social barriers of stigma. It argues that by exploring personal values and goals, MI reduces resistance in a way that traditional confrontational models do not.

  • 2:1
    Complete and accurate description of MI and the OARS framework. It explains how therapists use open questions and summaries to help patients want to change their behavior. It distinguishes MI from more structured behavioral treatments like CBT by focusing on the client's own motivation rather than just building skills. The response is coherent but remains largely descriptive of the framework.

  • Pass
    The response identifies MI as a treatment for motivation and correctly lists most of the OARS acronym. It explains that it involves talking to the patient to help them stop using drugs. It lacks precision in how these techniques actually function in a therapeutic setting and offers limited depth on the theory behind why MI is effective.

10-Mark SAQ Exemplars: High-Standard Responses

Question 1: Describe the historical shift in UK alcohol consumption from the Middle Ages to the 18th-century 'gin epidemic' and its societal implications.

Model Answer (High 1st Standard):
During the Middle Ages, beer was a primary source of hydration due to the contamination of fresh water, evidenced by a public house ratio of 1 per 167 people. The most significant shift occurred in the 18th century with the ‘great gin epidemic.’ Consumption increased from 527,000 gallons in 1685 to 11 million gallons by 1750, leading to the phenomenon of ‘gin madness.’ This surge was socio-economically driven: while beer and wine were priced for the elite, gin was highly affordable for the poor. Consequently, the crisis disproportionately impacted lower-income groups, highlighting how substance availability and pricing structures serve as social determinants of addiction. This period initiated a historical critique of drug harm that frames modern public health policy.

Question 2: Analyze the role of social stigma and shame as barriers to treatment engagement, referencing specific evidence-based policy recommendations.

Model Answer (High 1st Standard):
Social stigma acts as a critical barrier to recovery by fostering a cycle of internalized shame that prevents individuals from seeking early intervention. Users often report that the moral condemnation surrounding addiction leads to isolation and a delay in professional help-seeking until health crises occur. To mitigate this, policy recommendations must be ‘stigma-aware,’ focusing on:

  • Targeted Services: Creating specialized clinics (e.g., for ketamine use disorders) to reduce the ambiguity and fear associated with generalized addiction services.

  • Professional Education: Improving the understanding of substance use disorders among healthcare professionals to reduce prejudice.

  • Policy Reform: Shifting from punitive models toward public health frameworks that normalize treatment access. Integrating the Biopsychosocial Model helps bypass the 'character failure' narrative, encouraging users to engage with services before chronic issues develop.

Question 3: Discuss the addictive potential of various substances and the significance of early initiation in predicting lifetime substance use disorders.

Model Answer (High 1st Standard):
Addictive potential is measured by the percentage of users who develop dependence, known as the capture rate. Data indicates that nicotine has the highest potential at 30-40\%, followed by alcohol and heroin at 20\%. Conversely, cocaine, cannabis, and amphetamines exhibit lower capture rates of approximately 10\%. However, the pharmacological properties of a substance are significantly compounded by the age of first use. Early initiation—use during adolescence—is a powerful predictor of problematic addiction in adulthood. This vulnerability stems from the neurobiological impact of substances on the developing brain. High-standard interventions therefore prioritize delaying initial use through educational and social policies, as the statistical likelihood of long-term disorder increases exponentially with earlier onset.