Summary of Addictions - Teesson et al. - 2nd edition

What is the origin of addiction? - Chapter 1

In every developed country people come into contact with alcohol. A minority of the population also comes into contact with other narcotics. Some people develop an addiction, others do not. Someone has an addiction when they have difficulty controlling substance use, when they are consuming large amounts at a time and/or when they continue to use the drug even though they know that this may cause problems (such as violence).

To feel the effect of narcotics time and time again, the person needs more and more of the substance in question: one becomes tolerant of the effect of the substance. Abrupt discontinuation of substance use leads to withdrawal symptoms. People with a substance problem have issues such as:

• A strong urge to consume the product.

• Difficulty controlling substance use.

• Problems regarding health, behavior and social relations caused by substance use.

What is a drug?

A drug is defined as a chemical agent that influences the biological functioning of humans and animals (food excluded). Psychotropic drugs act in the brain to influence mood, the thought process or behavior. Substance abuse is recognized as a disorder by the DSM-IV.

What are the effects of drugs?

Every type of drug has immediate and long-term effects. Some of these are shown in the table:

The biggest reason for using drugs is because they want to feel better.

What causes problems with substance abuse?

Researchers have different ideas about the cause of substance abuse: is it a chronic disease or is substance use more learned by the environment? Many former substance abusers see it as a chronic illness. The only way to recover would be through total abstinence.

Modern learning theories consider addiction as a result of constant substance abuse. This substance abuse is caused by a combination of genetic vulnerability and by their environment. When the person abuses drugs, the chance of addiction increases.

To give a good idea of ​​the cause of addiction, this term must first be defined. In the DSM (1994) dependency/addiction is defined as the tendency to take a drug which is not medically necessary. The drug must thereby lead to reduced health or reduced social functioning.

How to diagnose?

To classify psychological disorders, the DSM-IV is used worldwide. To diagnose substance abuse, the following criteria must be considered:

A. A maladaptive pattern of substance use that leads to clinically significant problems within twelve months. One or more of the following points must be addressed:

• Failure to perform important school, home or work activities.

• Repeated substance use in situations where physical damage can occur (for example when driving a car).

• Problems with the law through substance use.

• Use of substance continues to persist despite repeated social or interpersonal problems.

B. The symptoms must never have met the criteria for addiction for this type of product.

To diagnose substance dependency, the following criteria must be considered:

A. A maladaptive pattern of substance use that leads to clinically significant problems within twelve months. Three or more of the following points must be addressed:

• Tolerance (need increasing amounts of the product or experience a reduced effect with the same amount of product).

• Withdrawal.

• The product is taken in larger quantities or over a longer period of time than originally intended.

• A persistent desire or unsuccessful attempts to reduce substance abuse.

• A large amount of time spent on obtaining the drug, the use of the drug and the recovery of substance use.

• Important social, recreational and/or occupational activities are discarded as a result of substance use.

• The person knows that his or her physical or psychological problems are caused by the drug and continues to use the drug.

Note from summarizer: consult the DSM-V that has been issued for the current criteria for establishing substance abuse and substance dependency.

The substance use not only affects the individual, but also the people in his or her environment. The amount of substance use that is permitted depends on the culture. Many countries have drawn up guidelines for safe alcohol use.

What are the cultural factors and attitudes towards drugs?

There are huge cultural differences, especially in alcohol consumption: alcoholic may not be permitted in some countries, while in a country like France you are considered an outlier when you do not drink.

Who is susceptible to addiction? - Chapter 2

What is the US Epidemiology Catchment Area (ECA) study?

The ECA study was the first major epidemiological study (1991) on alcohol and drug problems in different communities. twenty thousand people in various American states were interviewed personally. A standardized interview which identified whether a mental disorder was present or absent was implemented to forty psychiatric diagnoses which contained substance dependency. A distinction was made between alcohol abuse and alcohol dependence. Disorders related to alcohol abuse were the second most common disorders. One in seven people reported alcohol problems at least once in life. Men reported this five times more often than women and the disorders were more common at a younger age. Heavy drinking led to problems rather than light drinking. People with alcohol-related problems also had to deal with another related diagnosis, such as drug abuse or schizophrenia, in almost half of the cases.

Alcohol dependency experienced an 'early onset' among eighty percent of the participants: the first symptoms were visible from their thirtieth year of life. There is a high remission rate, fifty percent of those who experienced this disorder did not experience any symptoms for at least a year. Most individuals who recovered from their alcohol dependence did so on their own and without professional guidance.

In addition to alcohol-related disorders, drug abuse and drug dependence were also looked at. Approximately one third of the participants had used at least one type of drug during the course of life. Cannabis was the most common form of drugs. Drug abuse or dependence can be determined in six percent of the population. Here, too, men had drug-related problems more often than women, and the problems were more common at a younger age. More than two thirds of people with a drug-related disorder also received a second diagnosis which was usually either alcohol-related disorders or an antisocial personality disorder.

There has been little research completed in regards to relapse in drug-related disorders. As with people with an alcohol-related disorder, people with a drug-related disorder also make little use of professional assistance to help their problems.

How about subsequent community surveys in developed countries?

After the ECA, there have been many more studies on alcohol and drug use. Prevalence comparisons are difficult to make because different methodologies and versions of the DSM have been used in the various studies. Yet comparable trends have been found.

America

Research supports the previously discussed results from the ECA study. Some important findings:

• Alcohol and drug dependence is often experienced with other psychiatric disorders.

• Most people with alcohol or drug-related problems do not seek professional help, although those with drug problems tend to seek help more often than those with alcohol problems. People with comorbid disorders looked for help more often.

• Nicotine dependence was associated with many other psychiatric disorders.

England and Europe

Similar results were also found here.

New Zealand

Similar results were found. After correction, the disorders related to substance use in the Maori were twice as high compared to the rest of the population.

Australia

Some additional research results:

• Disorders related to substance abuse were more common among people who live alone compared to people in a relationship.

• The prevalence of disorders related to substance abuse was higher among the unemployed.

• People born in English-speaking countries had drug-related disorders more often than people from non-English-speaking countries.

• The level of education or the living environment (countryside/city) did not influence the prevalence of disorders related to substance abuse.

• Tobacco dependence was related to affective or anxiety disorders.

The ECA study was the first major epidemiological study (1991) on alcohol and drug problems in different communities. twenty thousand people in various American states were interviewed personally. A standardized interview which identified whether a mental disorder was present or absent was implemented to forty psychiatric diagnoses which contained substance dependency. A distinction was made between alcohol abuse and alcohol dependence. Disorders related to alcohol abuse were the second most common disorders. One in seven people reported alcohol problems at least once in life. Men reported this five times more often than women and the disorders were more common at a younger age. Heavy drinking led to problems rather than light drinking. People with alcohol-related problems also had to deal with another related diagnosis, such as drug abuse or schizophrenia, in almost half of the cases.

What are the health consequences of substance abuse and dependence? - Chapter 3

What can be said about the relationship between substance abuse and negative health consequences?

The relationship between substance abuse and negative health consequences is not perfect. Not everybody who uses drugs experiences the same negative consequences and there are also people who never experience any negative health consequences. However, in general, a causal relationship (substance abuse leads to negative health effects) exists.

Tobacco leads to more deaths worldwide than alcohol and illegal drugs combined. The more developed the area, the larger the number of people who died because of tobacco or illegal drugs.

This is slightly different for alcohol since low levels of alcohol consumption can have positive effects on health. Developed countries with a low mortality rate have a relatively large number of alcohol deaths.

Alcohol and tobacco are both responsible for four percent of global diseases.

Can alcohol induce mortality and morbidity?

Alcohol has an influence on chronic health conditions. Here a review is discussed in which men and women are divided into light, medium or heavy alcohol consumers and their expected risk of developing different diseases per category. Here the relative risk is taken as the beginning: the risk of getting a disease compared to people who do not consume alcohol.

Some degree of alcohol consumption works preventively. For example, drinking 20 grams of alcohol per day provides good protection against coronary heart disease. Only when consuming 70 grams of alcohol or more is there a greater relative risk. Mind you, these types of figures apply to moderate drinking. They do not apply to people who regularly drink heavy alcohol.

In America, the consumption of alcohol contributes to the number of deaths caused by alcohol-related traffic accidents. To illustrate: in 2002, alcohol played a role in 41% of fatal traffic accidents.

Alcohol consumption is also related to crime, for example, in aggression towards others. However, research can not show a causal relationship. Factors such as personality, environment and social cues play a causal role.

Can tobacco cause mortality and morbidity?

According to the World Health Organisation, tobacco causes up to five million premature deaths worldwide (2000). There is a rising trend, especially in the developed countries. Tobacco use is even described as epidemic among young people. It is predicted that by 2020 about ten million people will die prematurely as a result of tobacco.

Tobacco use can lead to a variety of cancers including lung cancer, kidney cancer, bladder cancer and stomach cancer. Chronic Obstructive Pulmonary Disease is expected to account for about half of the tobacco-related premature deaths in 2020.

Smoking is not only dangerous for the smoker. Smoking during pregnancy leads to premature birth, a smaller child, reduced birth weight or stillborn children. Also, passive smoking increases the risk of various diseases such as lung cancer, breast cancer, and heart disease.

Can substance abuse result in mortality and morbidity?

People who abuse drugs have a thirteen times higher chance of premature death than their peers who do not take them. Four main causes of drug-related deaths are known:

• Overdose.

• HIV/aids caused by sharing needles.

• Suicide.

• Trauma.

The causal relationship between substance abuse and health has not been examined as clearly as with alcohol and tobacco. Substance abuse leads to fewer deaths than alcohol or tobacco, but the lost years are much larger. People who abuse drugs often have a very early death because drug use often takes place between the twentieth and fortieth years. By far most of the health problems due to drug use are found in men.

Cannabis

A cannabis overdose does not result in the death of the user. Nonetheless, there are also negative health consequences such as anxiety, dysphoria, and panic among new users and cognitive and psychomotor limitations during use which may lead to accidents when the user drives or uses machines. Chronic cannabis use often leads to dependence. Concerning health, chronic use of cannabis leads to, among other things, chronic bronchitis and a reduced respiratory system.

Amphetamines and cocaine

Both amphetamines and cocaine can cause death. Most people die from cardiovascular complications. With new users, even a small amount of cocaine can be fatal. Prolonged use can lead to, among other things, strokes and thrombosis in the coronary arteries. When amphetamines and cocaine are used simultaneously, the toxic effects are greatly increased. When these drugs are used in combination with other narcotics, this has additional negative consequences for the user's health. More than half of the regular users of amphetamines and cocaine are addicted.

Ecstasy

When only ecstasy is used, it is rarely fatal. More than 75% of the deceased ecstasy users also used other narcotics. In cases where the user only took ecstasy and died it is usually because of hyperthermia (uncontrolled rise in body temperature) or hyponatremia (sodium deficiency). In the long term, ecstasy use has an effect on neurocognitive functioning, especially on verbal and working memory.

Heroin

Heroin often leads to an overdose, which may or may not be fatal. Often there is simultaneous use of alcohol or benzodiazepines. Heroin and other drugs that are injected lead to more viruses in the blood such as HIV or hepatitis B or C. Despite the awareness of the possible effects of needle sharing, about one-fifth of users still use other's needles. Heroin addicts often suffer from psychological disorders such as depression, anxiety disorders, and antisocial personality disorders. Among the homeless, heroin users are overrepresented.

What is the controversy about the positive effects of alcohol and cannabis?

Research shows that alcohol consumption can have positive effects and that the use of cannabis can work therapeutically. People who drink only one to two glasses of alcohol per day have a reduced risk of death compared to total abstainers. When someone drinks heavily, however, the risk of death is seriously increased. The decreasing risk of death among moderate drinkers is mainly due to a reduced risk of heart disease.

Unfortunately, moderate alcohol consumption also leads to an increased risk of other diseases such as some forms of cancer. In addition, drinking alcohol and driving may lead to a significant risk increase in accidents that may lead to injury or death.

Recent research shows less positive effects on heart disease in moderate alcohol consumption compared to what was always assumed, due to the participant groups and exclusion criteria in these groups (i.e. people with poor health were excluded from participation). Another recent study shows that the positive effects of moderate drinking are alleviated in one go when a person occasionally drinks heavily.

Cannabis seems to be able to make a positive contribution to HIV or cancer-related exhaustion, pain that is not relieved during 'normal' treatment, neurological disorders such as Multiple Sclerosis, Tourette and nausea and vomiting due to chemotherapy, which is not alleviated through 'normal' treatments.

However, it is difficult to develop a good medicine based on cannabis because the plant contains a mixture of many different chemicals. In addition, there are also legal objections. However, research in America shows that the introduction of medicinal cannabis does not lead to increase in recreational use.

The relationship between substance abuse and negative health consequences is not perfect. Not everybody who uses drugs experiences the same negative consequences and there are also people who never experience any negative health consequences. However, in general, a causal relationship (substance abuse leads to negative health effects) exists.

Tobacco leads to more deaths worldwide than alcohol and illegal drugs combined. The more developed the area, the larger the number of people who died because of tobacco or illegal drugs.

This is slightly different for alcohol since low levels of alcohol consumption can have positive effects on health. Developed countries with a low mortality rate have a relatively large number of alcohol deaths.

Which theories exist about causes and preservation of addiction? - Chapter 4

What is the psychological basis of addiction?

In order to explain addiction, different theories adopt either a psychobiological or a psychosocial basis.

Neuroscientific theories

With neuroscientific equipment, it is becoming increasingly clear how the brain changes with regular drug use. It appears that regular drug use leads to permanent damage.

A hypothesis states that changes in the behavior of drug addicts are explained by changes in the various brain systems involved. The dopaminergic path towards the forebrain and the frontal cortex is mentioned. Changes in this path seem to play a central role in the development and maintenance of addictive behavior.

Drug administration leads indirectly to an increase in dopamine levels in the nucleus accumbens. Some drugs cause such an increase in dopamine, that the associated rewarding feeling is much greater than every day rewarding activities. The increase in dopamine levels due to drug use is seen as a sign of salience.

The dopamine reaction decreases with regular drug use because the neural path adapts to the effects the drug has. The number of neurons that responds to dopamine decreases, therefore, the daily rewarding activities have less of an effect. In case of withdrawal, this also explains the feeling of loss, depression and withdrawal.

In addition to the dopaminergic path, the opioid system also plays an important role in addiction. Opiates such as heroin act as agonists on the opioid receptors, and there is a rapid tolerance for regular use. The opioid receptors adapt quickly, so that increasingly larger amounts of drugs are needed to reach the desired state.

The opioid system also plays a role in the rewarding effects of other narcotics.

There are differences between the dopaminergic path and the opioid system in terms of addiction. The dopaminergic path focuses more on the stimulating and preparatory aspects of reward while the opioid system is more associated with the hedonic components of reward.

Research shows that there are changes in synaptic plasticity due to addiction: neuroadaptation. This takes place at the dopaminergic path and other parts of the limbic system. This has an influence on:

• Executive control.

• Cognitive possibilities.

• Memory.

• Learning.

• Habits.

• Homeostatic mechanisms.

A theory based on neuroadaptation states that neuroadaptation occurs through the direct effects of repeated drug use. This can be done in two ways:

1. Within-system adaptations.

2. Between-system adaptations.

Repeated drug use changes the chemistry in the brain so that it counteracts the effects of the drugs. When ending drug use, this leads to a disturbed homeostasis. Tolerance of the drug effects and withdrawal once one stops using drugs are explained through this chemical disturbance.

Originally, more attention was paid to the motivating effects of physical withdrawal.

The brain is restructured during adolescence. Up to about the 25th year of life, significant changes occur in the white and gray matter. Research has shown that heavy drinking can disrupt the normal development of late-developing areas of the brain. This can lead to reduced verbal and working memory.

Do genetic factors play a role in addictions?

Genetic theories try to explain who is more likely to become addicted. They assume that people differ in genetic vulnerability. Twin and adoptive studies show that vulnerability to drug addiction occurs in families; both genetic and environmental factors play a role. About forty to seventy percent can be attributed to the genes, depending on the types of drugs used.

Research shows that there is a common genetic vulnerability for disorders related to substance abuse.

Research into 'risk genes' has proven unsuccessful to date.

What are the psychological theories?

Behaviorism

The learning paradigms classical and operant conditioning are important in behavioral theories. Operant conditioning can explain addiction through the rewarding consequences of the drugs. There is instrumental behavior: the person uses the drugs because they are conducive to the rewarding consequences. Both positive reinforcement (the effects are rewarding) and negative reinforcement (withdrawal symptoms) can lead to addiction.

Classical conditioning forms the basis of the cue exposure theory. This theory states that cues are important in developing and maintaining addictive behavior. This can explain the strong tendency to use drugs after long periods of abstinence. There are two types of cues: exoreceptive cues that arise for drug use and interceptive cues that have more to do with the effect of drug use. One can respond autonomously, behaviorally or symbolically-expressively to these cues.

Social learning theory endorses the operant conditioning, which also includes the individual motives, inherited character traits, earlier learning, and current living conditions.

Cognitive theories

Different cognitive theories explain drug addiction. For example, it is argued that self-regulation is very important in the development of an addiction. Addictive behavior occurs when a person relies on drugs to maintain a physical and psychological balance.

Rational choice theories

Addicts have little control over drug use. This means that one continues to use drugs despite the desire to stop or that one uses larger quantities or uses drugs for longer than intended. According to rational choice theory, drug use or addiction is seen as the best choice for the person because of the circumstances. Drug use is, therefore, a rational choice. When drug addicts want to stop but this does not work, there seems to be an unreal choice. This is caused, for example, by human limited capacity to estimate future benefits. Another idea is that we attach more importance to the now rather than to the future, which makes it difficult to stop.

Personal theories

Some people have a greater chance of addiction because of an 'addicted personality'. Vulnerable personality factors could lead to later drug addiction. The Eysenck resource model states that drug use starts because drugs serve a specific purpose related to the personality of the user. Even if drug use leads to negative consequences, drug use is advantageous for these people. Eysenck came up with three personality dimensions (PEN model):

• Psychoticism.

• Extraversion.

• Neuroticism.

Are there any environmental factors?

Different aspects of a person's environment are associated with the risk of substance abuse and related disorders. The risk of drug use increases with:

• Genetic vulnerability.

• Drug use of the mother during pregnancy.

• Bad school performance.

• Behavioral and emotional problems early in childhood.

Strengthening takes place by:

• Reduced cognitive capacities.

• Bad parenting.

• Low Social-Economic Status.

• Impulse control disorders.

In addition, there are many more factors that can play a role. For example, anxiety or depression leads to a greater risk of using drugs at a young age. In addition, children of drug users have a greater chance of using drugs later on.

What are the synthetic theories about addiction?

Theories that address both the biological and the psychosocial explanations for drug addiction are called biopsychosocial or synthetic theories. Addicted behavior is derived from other problem behavior by the pathological involvement of a person in drug use, a strong urge to continue using drugs and reduced control over drug use.

The PRIME addiction theory states that the motivational system can become distorted by:

• Previous pathologies.

• Current abnormalities due to the addiction behavior.

• Pathological environment.

PRIME stands for Plans, Responses, Impulses, Motives and Evaluations. To treat addiction, the motivational system needs to be reformed.

In order to explain addiction, different theories adopt either a psychobiological or a psychosocial basis.

With neuroscientific equipment, it is becoming increasingly clear how the brain changes with regular drug use. It appears that regular drug use leads to permanent damage.

A hypothesis states that changes in the behavior of drug addicts are explained by changes in the various brain systems involved. The dopaminergic path towards the forebrain and the frontal cortex is mentioned. Changes in this path seem to play a central role in the development and maintenance of addictive behavior.

What are the effects of alcohol addiction on health? - Chapter 5

The effects of alcohol have been known for thousands of years. In 2004, two billion people worldwide drank alcohol according to the WHO. Nearly four percent of these users had an alcohol-related disorder. Not only the amount of alcohol consumed but the consumption patterns can have harmful effects. Because alcohol is consumed worldwide, related disorders are also diagnosed worldwide. Many people with a diagnosis also have comorbid problems such as anxiety disorders or depression.

Are there any preventative measures?

The number of heavy drinkers is high among adolescents. Prevention is therefore of great importance. The Preventure program is the first program to prevent alcohol and drug use during school age (Canada and England).

How to assess alcohol-related disorders?

Assessment is very important in intervention and treatment. The quantity and frequency of alcohol consumption must be determined. The goal is to determine why someone drinks so much and what comorbid problems there are in order to determine the intervention areas and to find a baseline against which progress or deterioration can be determined.

The assessment can take place in many ways: there can be a short screening or a deep assessment. Clinical research is often done, biological characteristics are tested and standardized questionnaires are used. The best known biological characteristic is serum gamma-glutamyltransferase (a liver enzyme).

A screening test for alcohol abuse in a medical setting is the AUDIT: the Alcohol Use Disorders Identification Test. It can be used on both adults and children. This test is particularly useful in lower-level harmful drinking.

To measure the degree of alcohol dependence, the SADQ (Severity of Alcohol Dependence Questionnaire) is often used. This measures the symptoms of physical dependence. To measure the psychological consequences of alcohol dependence, the SADDQ is used (Short Alcohol Dependence Data Questionnaire).

People who score high on self-efficiency are usually able to drink moderately. Physical well-being and cognitive dysfunctions are also important to measure.

People with an alcohol problem seeking treatment often have a comorbid drug-related or mental disorder. The presence of this must be measured, as this can disrupt or complicate the treatment process. Family problems can also affect the treatment process and must, therefore, be investigated.

What kind of interventions exist?

Common health interventions

The prevalence of alcohol abuse and addiction can be reduced by public health policies, such as increasing the price of alcohol or reducing its availability. Due to the shift in public focus to the negative consequences of casual alcohol use (for example, car accidents) rather than focusing on those with a serious alcohol problem, there has been a large reduction in alcohol consumption.

In Australia, educating people about the consequences of alcohol use has led to fewer related problems. According to research, the following preventive strategies seem to be effective in reducing excessive alcohol consumption:

• High taxes on alcohol.

• Not, or much less advertising with alcoholic products.

• More frequent testing for driving under the influence.

• Brief interventions by general practitioners.

• Control of drinking environments.

• Alcohol locks on vehicles.

• Guidelines for low-risk alcohol consumption.

• Health warnings on packaging.

Brief interventions

The first brief intervention was completed amongst stubborn smokers. Very brief interventions by general practitioners appeared to have a greater influence on the number of people who quit smoking than some interventions in the people who actively sought help.

Brief interventions have also had an effect on alcohol consumption: drinking was reduced for problem drinkers with a mild dependency. Components of brief intervention include:

• Information about safe drinking.

• Information about the negative health effects of alcohol.

• Suggestions about useful ways to reduce.

• Advice on self-monitoring of alcohol consumption.

Research shows that this method works especially well with men and that the length of the short intervention (five minutes to one hour) does not have much fo an impact. Research into interventions aimed towards students shows that highlighting the social norms of alcohol reduces alcohol abuse.

What is detoxification?

Detoxification is the removal of the substance from the body. The person is assisted in the recovery of the withdrawal symptoms. How intense the symptoms are depends, among other things, on the period of use. The detoxification can take place with or without medication. A drug that reduces withdrawal symptoms is gamma-hydroxy-butyric acid (GHB). Each person deals with withdrawal differently, for example, people who expect mild withdrawal symptoms can stay at home, while people with severe symptoms can be better admitted to a clinic.

Is the goal of treatment abstinence or moderation?

Research shows that people with a mild addiction can go for moderation while people with a heavy addiction should focus on total abstinence. There has been some controversy about moderation as a treatment because the AA has as a guideline that a former alcoholic should never drink again.

How do psychosocial interventions help?

Various psychosocial interventions have proved effective in the treatment of alcohol addiction.

Cognitive behavior therapy works from the principle that alcohol abuse is caused by negative life experiences. The treatment focuses on coping mechanisms in certain situations. This treatment method seems particularly effective in people who have not experienced a severe alcohol problem. The social skills training seems most effective.

Motivational enhancement therapy uses motivational strategies to utilize the person's own resources. The most important principles are:

• Determine personal interest and problems.

• Respond to the person in such a way that ambivalence disappears and motivation appears.

• Treatment focused on communication instead of learning on techniques.

• The focus is on intrinsic motivation to change.

• Change occurs because of the relevance with regard to the person's own values.

The purpose of family and marriage therapy is to involve important people in the recovery of the alcoholic. The contingency based community reinforcement involves family members who are close to the person in the treatment. Marriage therapy proved to be better than no therapy, but it is not better than individual therapy aimed at reducing addiction behavior.

A hypothesis states that exposure to alcohol cues while abstaining from alcohol should reduce desire and increase self-efficacy. This leads to more positive outcomes in the long term. Cautious research results suggest that this is a somewhat effective approach.

The oldest and most commonly used treatment method is the AA. They assume that alcohol abuse is a spiritual and medical illness. Unfortunately, little research has been completed into the impact of AA.

Research shows that the different treatment methods have an approximately comparable effect.

How are clients appointed to psychosocial treatment?

One of the largest studies of treatment outcomes was Project MATCH (1997). Research was done on cognitive behavioral therapy, motivational enhancement therapy and 12-step facilitation therapy (part of the AA). The three therapies did not lead to significantly different outcomes. No basis was found in regards to assigning a client to a particular theory based on their characteristics.

Stepped care

The most cost-effective treatment method seems to be that of stepped care. This approach consists of three steps:

1. One session of guidance focused on behavioral change.

2. Four sessions of 50 minutes of motivational enhancement therapy.

3. Referral to an alcohol treatment center.

Research shows that this intervention shows better results and is more cost-effective than brief intervention.

Are interventions over the telephone, internet or e-mail effective?

Web-based interventions for alcohol problems have high drop-out rates but prove themselves to be effective. E-therapy seems to be a very cost-effective solution.

What is pharmacotherapy?

There are different types of medications that can help people to abstain from alcohol and other substances such as disulfiram, however, the help that this medicine offers is limited and the risk factors and side effects must be taken into account. It seems particularly effective for well-motivated clients who also follow additional therapy.

Other medications that seem effective include naltrexone and topiramate. GHB seems more effective than most drugs and the side effects are also limited.

How should one treat complex clients?

People who participate in treatment for their alcohol addiction can experience comorbid problems. This leads to difficulties in therapy and poorer therapeutic outcomes.

Is there a stigma?

Most people with an alcohol problem do not seek professional help for it. In Australia, the number of people seeking help for depression is much higher. This is because effective interventions are available, the care services are well coordinated and there are public campaigns that focus on eliminating the stigma of depression.

What are the effects of alcohol on pregnancy?

More than twenty percent of women worldwide use alcohol during pregnancy even though it is known that this can lead to increased risks of developmental and cognitive problems in the child.

The effects of alcohol have been known for thousands of years. In 2004, two billion people worldwide drank alcohol according to the WHO. Nearly four percent of these users had an alcohol-related disorder. Not only the amount of alcohol consumed but the consumption patterns can have harmful effects. Because alcohol is consumed worldwide, related disorders are also diagnosed worldwide. Many people with a diagnosis also have comorbid problems such as anxiety disorders or depression.

What are the effects of a nicotine addiction on health? - Chapter 6

In addition to alcohol and caffeine, tobacco is widely used in the global population. The known diseases caused by this are constantly expanding. Smoking, after high blood pressure, is seen as the highest risk factor for death worldwide. Three times as many men as women die as a result of smoking. Almost three-quarters of smokers want to quit. There are many interventions that motivate people to stop.

How to assess tobacco addiction?

To assess tobacco addiction, one must look at their:

• Motivation to stop.

• Nicotine dependence.

• Smoking history (including attempts to stop in the past).

The degree of dependence is an indicator of the likelihood that someone will stop and won't start smoking again. The most common measurement method worldwide is the Fagerström Test for Nicotine Dependence. The monitoring of withdrawal symptoms is an important aspect of the intervention because these symptoms are predictive of relapse. The assessment should also focus on comorbid problems, including depression and anxiety disorders.

What types of intervention exist?

There is a guideline for smoking cessation:

1. Set a date (within one to two weeks) on which the client will stop.

2. Accompany the client in their attempt to stop:

3. Let the client tell others that he or she is going to stop;

4. Remove cigarettes from the client's environment;

5. Check out previous attempts to stop and determine what helped and what did not;

6. Pick up on everything that can interfere with the attempt to stop.

Abstinence must be seen as the goal of the attempt to stop. The client must be informed about the possible withdrawal symptoms. Active attention must be focused on triggers for relapse.

The interventions aimed to quit smoking can be classified as psychosocial, pharmacological and otherwise. Both psychosocial and pharmacological methods seem successful.

What kind of psychosocial interventions exist?

There are several ways to support a client in their pursuit to stop smoking. Even some short advice from the GP increases the chance that someone will want to quit smoking and also increases the chance that the person will remain abstinence a year later. The doctor's attitude to the difficulty that a person may experience in smoking cessation is of great importance to the success of the attempted cessation. Group interventions seem to be more effective than no intervention or interventions with minimal contact. Self-help materials work slightly better than no intervention. Self-help does not lead to a greater chance of success in combination with other forms of treatment.

What types of pharmacological interventions are there?

Nicotine replacement therapy seems to help with the withdrawal symptoms that smokers with a severe addiction have when they want to quit. The desire for nicotine is reduced and withdrawal symptoms are prevented. Nicotine is administered, for example, as a patch or nasal spray, which makes the effect weaker. All forms of this therapy are effective and increase the chance of quitting by 50-70%. Also antidepressants seem to help in stopping smoking, however, this does not apply to all antidepressants.

Nicotine receptor partial agonists show positive effects as helpful in stopping smoking. This appears to be a more cost-effective method than antidepressants.

Other medications (with little research into the effectiveness and side effects) are clonidine, nicobrevin, and nicotine vaccines.

Other therapies and interventions

Many other therapies such as acupuncture and feedback on biomarkers show some positive results but too little research has been done to draw clear conclusions.

Therapies such as hypnotherapy and biomedical risk assessments do not have positive effects according to research.

What populations exist with diseases related to smoking?

Some research has been done into the best ways for certain patient groups to quit. For example, people with COPD benefit greatly from nicotine replacement therapy linked to an intensive and long-term stopping program.

Interventions at work

Both individual counseling, group counseling, and pharmacological treatment have the same effects on the work floor as elsewhere.

Smoke reduction

The health benefits of reducing or stopping smoking are not very clear.

Reduction of tobacco damage

Snus is a tobacco product that does not produce smoke from Sweden and has ensured that the prevalence of smokers and smoking-related diseases has decreased. There is, however, controversy, since snus is not harmless to health either. However, there is hardly any difference in life expectancy between people who stop smoking and people who use snus.

In addition to alcohol and caffeine, tobacco is widely used in the global population. The known diseases caused by this are constantly expanding. Smoking, after high blood pressure, is seen as the highest risk factor for death worldwide. Three times as many men as women die as a result of smoking. Almost three-quarters of smokers want to quit. There are many interventions that motivate people to stop.

What are the effects of cannabis addiction on health? - Chapter 7

The drug that is most abused worldwide is cannabis. This drug comes from the cannabis sativa plant and has THC as a primary psychoactive ingredient. This leads to hallucinations. Marijuana is a mild drug from this plant, while hash has a stronger effect. The effect of smoking cannabis is direct, while cannabis processed in food has a slower but more unpredictable effect. Recently the medicinal effects of cannabis have been investigated, for example, in the reduction of nausea after chemotherapy because there are quite a few side effects cannabis use is usually not advised. Some countries have legalized medicinal cannabis.

How is cannabis addiction prevented?

Young people use cannabis on a large scale. The starting age is in the teenage years. Research shows that early use of cannabis can lead to later drug problems. Prevention programs can be roughly divided into skills-oriented, affect-oriented and knowledge-oriented.

How is one assessed for cannabis addiction?

Assessment of cannabis addiction consists of a structured clinical interview. It can also be useful to have insight into the self-efficacy of the client, which can be measured with the Situational Confidence Questionnaire (SCQ). The Cannabis Problems Questionnaire (CPQ) can help to monitor symptoms. To diagnose cannabis addiction, the DSM criteria must be met. Comorbid problems must also be assessed.

What interventions exist?

In many developed countries, more and more people are seeking help for cannabis addiction. The withdrawal symptoms, in particular, make it more difficult to stop taking the drug. Many people who seek treatment have comorbid problems. There are various psychological and pharmacological interventions for cannabis addiction.

What are the psychological interventions?

Psychological interventions consist of cognitive behavioral therapy or motivational enhancement therapy, both individually and in groups. The combinations of therapy in particular have promising results. Little is known about which specific intervention is better than another specific intervention. The treatment outcome is often reduced cannabis use and reduced dependency symptoms and problems instead of abstinence.

What type of pharmacological interventions are there?

Many pharmacotherapies have been evaluated in research but almost always in a laboratory setting with small sample sizes. The drug THC (oral administration) seems most promising in the reduction of withdrawal symptoms.

How to treat comorbidity?

When someone has a severe mental disorder such as schizophrenia, drug use can make the symptoms worse. In this type of patient group, it is very important to identify and treat drug use as quickly as possible. Sometimes the medication used in the treatment of a mental disorder can also have a positive effect on drug use.

The drug that is most abused worldwide is cannabis. This drug comes from the cannabis sativa plant and has THC as a primary psychoactive ingredient. This leads to hallucinations. Marijuana is a mild drug from this plant, while hash has a stronger effect. The effect of smoking cannabis is direct, while cannabis processed in food has a slower but more unpredictable effect. Recently the medicinal effects of cannabis have been investigated, for example, in the reduction of nausea after chemotherapy because there are quite a few side effects cannabis use is usually not advised. Some countries have legalized medicinal cannabis.

What are the effects of opioid addiction on health? - Chapter 8

Opioids are chemicals that bind to the opioid receptors. These receptors are normally activated by the body's own painkillers. Opioid agonists are drugs that activate opioid receptors. The activity of the central nervous system is thereby suppressed, resulting in effective pain relief. Drugs that block the action of opioid receptors are called opioid antagonists. Several opioid drugs can cause overdose even at low doses making them very dangerous. In addition, they are very addictive. These drugs are often injected, therefore, there is an increased risk of blood-related diseases such as hepatitis B and C and HIV. Addiction to opioid drugs is one of the most dangerous addictions for health. Of all annual global drug deaths, heroin is responsible for about 75%.

How is one assessed for opioid addiction?

There are various measuring instruments to measure the level of opioid addiction, examples are the Severity of Opiate Dependence Questionnaire and the Severity of Dependence Scale. Co-morbidity is also important for examining opioid dependency. There is often comorbidity with post-traumatic stress disorder and/or depression.

What sort of interventions are there?

Detoxification

Detoxification is not seen as a treatment for opioid addiction but as an important first step towards abstinence. Withdrawal symptoms are diverse and exist in the short and long term. Several factors play a role in whether or not to completely detoxify after opioid addiction. This includes, for example, the reasons for detoxifying that the individual has and the way in which the person detoxifies. In addition to the withdrawal symptoms, psychological and social problems often arise. Psychosocial contact and future treatments are therefore necessary. Different medications can help the detoxification process. These are, for example, the opioid methadone and buprenorphine.

It is very likely that people with an opioid addiction live in an environment that does not support the cessation of the addiction. This can make the treatment difficult. People who detoxify have a smaller chance of repalsing into their addiction than people who do not.

Drug-free treatment approaches

Drug-free treatment approaches include, for example, residential treatment in therapeutic communities, self-help groups and outpatient counseling. The first two do not involve another medication, the outpatient treatment can be used both with and without medication.

In residential treatment, the programs last for three to twelve months. Former users then live in a community of other former users and professionals. Group and individual therapy both take place. There is slight evidence that this type of treatment works somewhat better than other treatments and that one residential treatment works better than the other.

Both residential treatment and counseling programs show positive effects in reducing heroin use and offenses among clients who participate long enough to experience the positive effects (> 3 months).

Self-help groups often work with the 12 step program developed by the AA. They assume that drug addiction is a disease which has no possible cure, recovery can only take place if the client refrains from further drug use. In the case of self-help groups, insufficient research has been conducted to draw clear conclusions about the effectiveness.

Pharmacotherapy

Pharmacotherapies are often referred to as substitution theories as often heroin is replaced by another opioid. An example and frequently used means is methadone. Because of the effect, someone only has to take one dose orally (as opposed to heroin, where someone has to inject several times a day). Research shows that methadone is a suitable means to control opioid dependence. Methadone ensures that opioid drugs no longer cause a euphoric effect and it also ensures that no withdrawal symptoms occur.

Alternative maintenance treatments

The medicament buprenorphine acts both as an agonist and as an antagonist. This medicine needs to be taken less frequently as methadone. The risk of overdose is also lower. However, in large doses it is less effective than methadone. Methadone is therefore often used as the primary choice in most clinical settings.

Other medications are Levo-α-acetylmethadol (better effect than methadone but dangerous side effects), heroin injections (when other medications do not work), codeine (has potential but little researched has be done) and naltrexone (works on motivation and therefore has little promising long-term effects).

Opioids are chemicals that bind to the opioid receptors. These receptors are normally activated by the body's own painkillers. Opioid agonists are drugs that activate opioid receptors. The activity of the central nervous system is thereby suppressed, resulting in effective pain relief. Drugs that block the action of opioid receptors are called opioid antagonists. Several opioid drugs can cause overdose even at low doses making them very dangerous. In addition, they are very addictive. These drugs are often injected, therefore, there is an increased risk of blood-related diseases such as hepatitis B and C and HIV. Addiction to opioid drugs is one of the most dangerous addictions for health. Of all annual global drug deaths, heroin is responsible for about 75%.

How can addiction to psychostimulants such as cocaine, amphetamine, and ecstasy be treated? - Chapter 9

The most common psychostimulants are cocaine, methamphetamine and ecstasy. These drugs can be consumed in different ways: sniffing, swallowing, smoking or injecting. In particular, injection involves major risks as an overdose.

How to assess the client?

When assessing the client, one must look at drug use in the past: where, how and why. Different scales can be used to make a good assessment. Examples are the Readiness to Change Questionnaire and the Readiness Ruler. There are also measuring instruments that focus specifically on cocaine abuse, such as the Voris Cocaine Rating Scale.

Addiction to psychostimulants is often comorbid with other disorders such as depression and personality disorders. This should therefore be investigated prior to treatment.

What type of interventions exist?

Usually, the first step is detoxification: the client stops all drug use. Then there is a period of professional support for abstinence.

Detoxification

There are often few withdrawal symptoms. Medication is not recommended for dealing with the withdrawal symptoms of cocaine.

Pharmacotherapy

Depression is common in the use and withdrawal of psychostimulants. Some antidepressants are helpful in the withdrawal of psychostimulants such as cocaine and amphetamine. There is a lot of research still needed to be completed in the field of pharmacotherapy.

Psychological techniques

The psychological techniques have also not been studied much. The most important development focuses on dealing with unforeseen situations. There is little demand in treatments for ecstasy addiction.

When assessing the client, one must look at drug use in the past: where, how and why. Different scales can be used to make a good assessment. Examples are the Readiness to Change Questionnaire and the Readiness Ruler . There are also measuring instruments that focus specifically on cocaine abuse, such as the Voris Cocaine Rating Scale.

Addiction to psychostimulants is often comorbid with other disorders such as depression and personality disorders. This should therefore be investigated prior to treatment.

How can pharmacological treatments contribute to addiction care in the future? - Chapter 10

What factors play a role in the effectiveness of treatments?

Addiction occurs as a result of interacting factors that are by no means all known. Genetic and environmental factors can also make an important contribution to the occurrence of an addiction. Alcohol and tobacco contribute most to the global disease problems, not only in developed countries but also in developing countries. To determine the effectiveness of the treatment, motivational factors and individual preferences play a major role. More research is needed in the field of pharmacological treatments.

What may the advice be for the future?

In the future, a better understanding of the neurobiology of addiction can lead to better pharmacological treatments. Young people continue to consume alcohol and drugs, therefore, the request remains for effective treatment methods. It would be nice if pharmacological treatments could be applied in the public health approach.

Addiction occurs as a result of interacting factors that are by no means all known. Genetic and environmental factors can also make an important contribution to the occurrence of an addiction. Alcohol and tobacco contribute most to the global disease problems, not only in developed countries but also in developing countries. To determine the effectiveness of the treatment, motivational factors and individual preferences play a major role. More research is needed in the field of pharmacological treatments.