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					Addiction Models:




 Dr. Ronald Y.L. Chen
  Specialist in Psychiatry
Common Reactions from Health
Care Providers
   Difficult to understand
       Change rapidly
       Polydrug abuse
       No formal training
   Addicts are difficult patients
   Not treatable
   Not profitable
   No source of referral/networking
New Perspectives
   Fascinating neuroscience research
   Interplay of biological and psychosocial
    factors
   Challenge in clinical practice
   Multi-disciplinary approach
   New medications:
       e.g. buprenorphine; naltrexone (opioids
        dependence)
Perspective of drug abuse


                            Brain/Mind




      Body                               Social
Moral Model (1)
   Infringement of societal rules
   Punishable crime
   Sinful act
   Responsible for his/her own action
   Longest standing view
Moral Model (2)
   Causes:
       Spiritual deficit
       Conscious choice
   Treatment:
       Spiritual Guidance
       Moral Persuasion
       Imprisonment/Social Consequences
Characterological Model (1)
   Character problem
   “Addictive personality”
   Traits include:
       Impulsivity
       Sensation seeking
       low self-esteem
       Inability to cope with stressors
       Egocentricity
       Manipulative
       Need for control and power, while feeling
        impotent and powerless
Characterological Model (2)
       Treatment:
        Psychotherapy
        Identification and modification of self-
         esteem, interpersonal skills, impulse
         control, improved boundary setting
Learning Model
   Classical conditioning
   Operant conditioning
   Social learning
Classical Conditioning (1)
   Ian Pavlov
   A stimulus elicits a certain response
       Unconditioned Stimulus (US)
       Unconditioned Response (UR)
       Conditioned Stimulus (CS)
       Conditioned Response (CR)
Classical Conditioning (2)
   US (food) elicits UR (salivation)
    naturally
    Classical Conditioning (3)
   The neutral stimulus was paired with the US
    for a number of times
Classical Conditioning (4)
   CS (food dish) alone produces CR
    (salivation)
Classical Conditioning in Addiction

   Physiological arousal during drug intake
    or addictive behaviour becomes
    conditioned to the specific situation
   Interaction with operant conditioning
    processes
Operant Conditioning
   A response is emitted to obtain an
    outcome
      Behaviors operate on the environment to

      produce consequences
   Controlled by its consequences
   Reinforcement (positive or negative) and
    punishment
Operant Conditioning in
Addiction
   Positive reinforcements:
       Excitement
       Self-esteem and status
       Monetary gains
       Social rewards….etc
   Negative reinforcements:
       Escape from problems in life
       Reduction of aversive stress and emotional
        states….etc
Social Learning
   Individuals learn how to behave through a
    process of modeling and reinforcement
   Assimilate and mirror behaviors by observing
    the actions of others and the consequences
    of their actions
       E.g. successful high-status role models
   Emphasized the role of cognition in learning
       Memory based; cognitive organisation
   Learn which behaviour gain desired
    reinforcement
    Cognitive Model
   Dysfunctional cognitions and perceptions
    as factors contributing to development
    and maintenance of addictive behaviour
   Addicts have more irrational beliefs, and
    cognitive biases, distortions and errors
   These help to maintain addictive
    behaviors despite harmful effects
Existential Model (1)
   Focus on beliefs, attitudes, and values of
    addicts
      Beliefs about oneself and about the role of

       substance/behaviour in one's life
      Benefits greater than cost

   Addicts use substance/behaviour to deal with
    specific problems they believe they have
      e.g. lack of confidence in social-sexual

       dealings
Existential Model (2)
   Fulfills essential intrapsychic,
    interpersonal, and environmental needs
   Views about oneself in regard to the
    addictive problem are crucial for
    treatment
   If the client and therapist see the
    problem differently, e.g. viewing it as a
    disease or not, treatment will generally
    not succeed
Expectancy Model
   Observation & exposure to behaviours
    creates set of beliefs about that behaviour
   Outcome expectancies are one set of
    beliefs
   e.g. sugar water but told that it was an
    emetic, 80% of subjects in one study
    responded by vomiting
   Positive & Negative outcome expectancies
       Determine level & pattern of addictive
        behaviour
Social Model
   Disruptive social forces as social stressors
       unemployment, poverty, violence,
       family dysfunction, gender and age inequities
   Addiction is considered to be an adaptation to
    the resultant misery and unhappiness
   Treatment
       environmental modification
            Reduce social stressors
            Availability of substance
       Improve social functioning of addicts
            Job & social skill training
Biological/Disease Model
   Unique, irreversible, and progressive disease
   Underlying biological disturbances
   Out of addicts own control
   Not sinful but sick
   Causal Factors
       Genetic factors
       Constitutional disease/dysfunction
       Biological effects of substances
   Treatment
       Identification and confrontation of the condition
       Lifelong abstinence
Intermission (10 mins)
Dopamine System (多巴安)
 The nucleus
 accumbens is
 activated when
 a monetary, chocolate,
 sexual, luxury, or
 other reward is
 anticipated




 The medial prefrontal
 cortex is activated when
 a reward is received




Richard L. Peterson, 2004
Biopsychosocial Model
   Origins are complex, variable and multifactoral
   Interaction between biological, psychological
    and sociocultural factors
   combinations, interactions and the weightings
    of specific factors are different for different
    individuals
   accommodates diversity and respects
    individual differences
   selectively accommodate and respect a broad
    range of other theories of addiction and
    program approaches
Biopsychosocial Model:
Advantages
   focuses attention on the diversity of client
    needs
   client-centered clinical practices
   provides a broad and flexible framework
    for conceptualizing the nature of the
    problem
   provision of a range of program options
   consistent with current addiction research
Factors Associated with Persistent
Drug Use

   Neurobiology:
       genetic risk, drug effects on brain functioning
   Psychological factors:
       classical & operant conditioning,
        psychopathology
   Social factors:
       peers, stress, drug a/v, drug using life-style
       Adverse effects from addiction: family, job,
        social
Types of Addiction
   Drug, alcohol, chemical
   Behavioural addiction
       Gambling
       Internet
       Shopping
       Sex
       Work
       Exercise
       …etc.
   Experimentation of gateway drugs
   Use of drugs with greater dependence
    liability
   Irregular Use, Abuse, Dependence
    Substance Abuse (DSM IV)
   A maladaptive pattern of substance use leading to
    clinically significant impairment or distress, as
    manifested by one (or more) of the following, occurring
    within a 12-month period:
       Recurrent substance use resulting in a failure to fulfill
        major role obligations at work, school, or home
       Recurrent substance use in situations in which it is
        physically hazardous
       Recurrent substance-related legal problems
       Continued substance use despite having persistent or
        recurrent social or interpersonal problems caused or
        exacerbated by the effects of the substance
   The symptoms have never met the criteria for
    Substance Dependence
Dependence
Once a person hits the dependents phase,
there’s not much voluntary action any
more. Addiction becomes more like a
chronic disease with relapse and
remission.

O’Brien CP. A Physician Approach to Treating Addiction.
Hospital Practice, April 1997
    Substance Dependence (DSM IV)
   A maladaptive pattern of substance use, leading to
    clinically significant impairment or distress, as
    manifested by three (or more) of the following,
    occurring at any time in the same 12-month period:
       Tolerance
            A need for markedly increased amounts of the substance to
             achieve intoxication or desired effect
            Markedly diminished effect with continued use of the same
             amount of the substance
       Withdrawal
            The characteristic withdrawal syndrome for the substance
            The substance is taken to relieve or avoid withdrawal symptoms
    Substance Dependence (DSM IV)
    cont.
   The substance is often taken in larger amounts or over a
    longer period than was intended
   There is a persistent desire or unsuccessful efforts to cut
    down or control substance use
   A great deal of time is spent in activities necessary to obtain
    the substance, use the substance, or recover from its effects
   Important social, occupational, or recreational activities are
    given up or reduced because of substance use
   The substance use is continued despite knowledge of having
    a persistent or recurrent physical or psychological problem
    that is likely to have been caused or exacerbated by the
    substance
    Dependence Central Features
   A strong desire or sense of compulsion to take the
    substance / perform the addictive behaviour
   Difficulty controlling substance taking / addictive
    behaviour
   Physiological withdrawal state
   Evidence of tolerance
   Neglect of alternative pleasure or activities
   Persisting with substance use / addictive behaviour
    despite evidence of harmful consequences
   Narrowing personal repertoire to substance use /
    addictive behaviour
Comprehensive Assessment
   Biopsychosocial approach
   Identify client’s health & social needs
   Help clients to think about why they
    use the substance and what they
    should change
   Identify mutually agreed treatment
    goals
Assessment process (1):
   Why has the client presented now?
     legal problem, health or social
      reasons
     what do they see as a problem?

   How has the client presented?
     arranged appointment

     emergency

     accompanied by others
Assessment process (2)
   How does the client appear?
       unkempt
       drowsy, elated, restless
       poor concentration
       inconsistent history
   Any indications of drug use?
       needle marks
       pupils dilated, constricted
       tremor, weight loss
       skin lesion, abscess
Assessment Process (3)
   Drug history:
       initiation of drug use
       patterns of drug use (combination, replacement
        etc.)
       when did drug taking become a problem
       withdrawal symptoms (may mimic other illnesses)
       period of abstinence
       level of control
       current drug use (route, frequency, dose, setting,
        source)
Assessment Process (4)
   Previous treatment:
       in-patient
       out-patient
       Specialists
       Rehabilitation
       why relapse
   Risk taking behaviour:
       unsafe setting e.g. share syringe or other
        equipment
       unsafe sex
       aware of HIV, hepatitis B&C etc.
    Assessment Process (5)
   Assessment of physical health:
     any medical problem
     any drug related medical problems
      e.g. abscess, cellulites, thrombosis,
      septicaemia, bacterial endocarditis,
      convulsion, TB, hepatitis, HIV
    Assessment Process (6)
   Assessment of psychological health
      dependence syndrome

      withdrawal syndrome

      personality disorder

      suicidal/violent behaviour

      mood disorder

      drug induced psychosis

      drug induced cognitive impairment
    Assessment Process (7)
   Assessment of social situation:
     Legal

     Financial

     Employment

     Accommodation

     Personal relationships: partner,
      family, children, friends
Physical Examination (1):
   General
       self-neglect, undue drowsiness, high arousal,
        signs of withdrawal, fever, height/weight
   Skin
       abscess, injecting sites, venous ulcers, anaemia,
        parasites, jaundice, palmar erythema, spider
        telangiectasia, rashes, self-mutilation
   Chest
       chest infections, cardiac murmurs, wheeze
Physical Examination (2)
   Abdomen
       hepatomegaly, splenomegaly, groin
        sinuses, pregnancy
   Musculo-skeletal system
       arthralgia, muscular & bone pain can be
        manifestation of withdrawal syndrome, but
        can also be other medical illnesses e.g.
        prodromal phases of hepatitis
       septic arthritis, infective osteomyelitis,
        rhabdomyolysis
Physical Examination (3)
   Central nervous system
       convulsion esp. withdrawal from alcohol &
        benzodiazepines
       cerebral abscesses
       peripheral neuropathy e.g. chronic alcohol
        abusers or inhalation of organic solvents
       cerebral toxoplasmosis, cryptococal
        meningitis, cerebral lymphoma in HIV
Investigation
   urine for toxicology screening
   full blood count (Hb, MCV)
   liver function (liver enzymes, hepatitis
    antibodies or carrier status)
   consider counseling and screening for
    HIV
   STD screen
   pregnancy test if amenorrhoea
     Urine Screen
   Purpose
      to confirm the client is using the drugs and which one

      for medical-legal protection

      to help reduce street diversion

      to encourage honesty

   When to do urine screen
      when a client first presents as useful baseline and for
       future comparison
      to confirm use before starting a substitute
       prescription
      before restarting treatment after a break

      at random throughout treatment period

				
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posted:10/15/2011
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