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Addiction Basics


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An overview of the history and basic concepts of addiction treatment in the United States.

Published in: Health & Medicine

Addiction Basics

  1. 1. Introduction to Addiction Basics: …What the Non-Specialist Needs to Know By Elizabeth Kotkin, MA, LMFT, Clinical Standards Coordinator Department of Alcohol and Drug Services Santa Clara County
  2. 2. National Treatment Trends: o 3.5 million people age 12 or older received substance abuse treatment in 2002 o 54% were for alcohol o 46% were for drugs o 70% men o 30% women o Over 50% were white, 26% African-American, 7.7% Hispanic, 2.2% Native Americans, and less than .06% Asian/Pacific-Islanders.
  3. 3. o Of those admitted for drug treatment, 38% were for treatment of primary cocaine use, 25.5% for heroin use and 19.1% for marijuana National Treatment Trends:
  4. 4. Current Drug Trends In USA: • Marijuana: Estimated 14.6 million users in 2002, one third of whom used 20 or more days during the last month. • Hallucinogens: 1.2 million users estimated in 2002, including 676,000 users of Ecstasy • Stimulants: Estimated 2 million users of cocaine in 2002, 567,000 of whom used crack ….Methamphetamines show increased use in Bay Area • Heroin: Estimated 166,000 users, many under the age of 25 in 2002 • Prescription Drug Abuse: Estimated 6.2 million took prescription drugs non- medically in 2002: • 4.4 million use pain relievers • 1.8 million use tranquilizers • 1.2 million use stimulants • 0.4 million use sedatives
  5. 5. Alcohol Trends In The USA • Alcohol: a CNS depressant which accounts for 85% of the drug addiction problem in the USA • 10% of those who drink consume 50% of the alcohol used in this country. The majority of those who do drink currently, do so less than once per week. • 1996 overall per capita alcohol consumption in USA was 2.35 gallons of pure alcohol per person per year • 120 million Americans 12 or older reported being current drinkers of alcohol in 2002. • 54 billion (22.9 %) were binge drinkers and 15.9 million (6.7%) were heavy drinkers • Prevalence of current alcohol use is increasing in 2002: • 2 % at age 12 • 6.5% at age 13 • 13.4 % at age 14, • 19.9 % at age 15, • 29 % at age 16 • 26.2% at age 17 • 70.9 % at age 21 (peak rate)
  6. 6. Monitoring the Future Statistics: 2004 • 50,000 students in the 8th, 10th and 12th grade were surveyed. • Any illicit drug use in the prior 12 months continued to decline in 2004. This trend has been consistent since 1996 for 8th graders (23.6% in 1996 to 15.2% in 2004) • Marijuana is by far the most widely reported drug used of the illicit drugs, but it also declined some in 2004 • There was a resurgence of inhalant use in all grades reported, but it was particularly a problem for 8th graders • The reported alcohol use by American teens is mixed in 2004. There was an overall drop in all grades since 2002. But for 12th graders, alcohol use tended towards an increase. • Any reported use of alcohol for the past 12 months in 2004: 36.7% for 8th graders, 58.2% for 10th graders and 70.6% of 12th graders.
  7. 7. US HISTORY: Alcohol Colonial period: o Before contact with Europeans, Native Americans had little experience with alcohol o Europeans brought alcohol to the Americas, and it pervaded every aspect of colonial life o Alcohol =“good creature of god” o “Rough justice”
  8. 8. US HISTORY: Alcohol New Nation: 1790: Quaker Reform Movement: first jail in Philadelphia Benjamin Rush (1746-1813) Physician-General of the Continental Army and signer of the Declaration of Independence Disease concept and abstinence the cure Method: religious conversion and medical intervention 1810: Establishment of “Sober Houses”
  9. 9. Early 19th century (1790-1830): o Highest period of alcohol consumption in US history o 1792: 2,579 distilleries --per capita consumption: 2.5 gallons o 1810: 14,191 distilleries --per capita consumption: 4.5 gallons o 1830: all time USA high-- per capita consumption of 7.1 gallons US HISTORY: Alcohol
  10. 10. Effect of Alcohol on Families
  11. 11. US HISTORY: Alcohol 1825-1850: o Temperance Movement: a Women’s Movement influenced by Rush and led by Carrie Nation o Public perception of alcohol shifted to “demon rum”
  12. 12. Demon Rum
  13. 13. US HISTORY: Alcohol 1850-1900: o 1841: Dorothea Dix (1802-87) reform movement to create mental hospitals o Institutionalization for the treatment of alcoholics becomes popular o 1870: American Association for the Cure of Inebriates began with six institutions o By 1902: there were more than 100 addiction centers in USA
  14. 14. US HISTORY: Drugs Colonial period: o Enthusiastic advocacy of “therapeutic potential” of opium by medical profession o 1770- 1914:“Dover's powder”: most widely used opium compound
  15. 15. US HISTORY: Drugs 19th Century: o Between 60%-80% of opiate users were women o Drug use widely accepted for both sexes. o Opiates prescribed for “female problems” (painful menstruation) and “neurasthenia”
  16. 16. 19th Century Injection Kit
  17. 17. o Cocaine: used for neurasthenia, “wasting disease” and as a cure for opiate addiction (Freud) o Chloral Hydrate: Sedative-hypnotic (laughing gas) used for neurasthenia o Cannabis: widely prescribed between 1840-1900 for asthma, bronchitis, “women’s diseases” like headaches and neurasthenia Popular 19th Century Drugs
  18. 18. End of 19th — beginning of 20th Century: o 1885-1917:, opiate use widespread -seemed uncontrollable o Increased advertising, over-prescription, mass production and opium-bearing patent medicines o Change in doctors’ attitudes: understanding of habituation and the chemical actions of these drugs in the body Criminalization of Addiction:
  19. 19. Shift in Public Perception Elizabeth Barrett Browning
  20. 20. Opium Wars, 19th Century
  21. 21. o 1909: US convenes Shanghai Opium Conference-results in international focus on lack of drug regulation internally in US. o 1906: the Pure Food and Drug Act (accurate labeling of ingredients ) led to decrease in use of patent medicines, o Harrison Narcotic Act (1914) restricts the rights of doctors to prescribe opiates. Legal Remedies Enacted:
  22. 22. “Opium-Smoking New York” Harper’s Weekly, 1881
  23. 23. o Anti-drug legislation promoted to public to counter perceived social and economic “threats” of minorities, primarily Asians and Blacks (and later, Mexicans in the case of marijuana) Racist Stereotypes : o 19th Century view of opiate dependency as a “misfortune” shifts to fear of the “dope fiend”
  24. 24. o Prohibition of alcohol in the 20’s (alcohol prohibition repealed in 1933, drug prohibition is not). o 1937: Marijuana tax act in effect makes it illegal More Legal Remedies Enacted:
  25. 25. Anti-Marijuana Propaganda
  26. 26. Definitions According to Gold and Miller (1994), recent research indicates that drugs are addictive because they “reinforce drug-taking behavior…addiction arises because prolonged use of the drug alters the basic neurochemistry of the brain, leading to physiological and psychological changes…(which) in turn result in continued and accelerating use of the drug.” The American Psychiatric Association’s DSM-IV (APA, 1994) now reflects this updated research-based definition of addictive disorder, with core concepts including: (1) Compulsion (2) Loss of control (3) Continued use despite negative consequences
  27. 27. Drugs Of Abuse: Common Terms • Intoxication: reversible, substance-specific syndrome • Short-acting vs. long-acting drugs: Drugs that have quick onset are more reinforcing and more likely to be abused • Drug “half-life”: The time it takes for a drug to become pharmacologically inactive • Cross-tolerance: Development of tolerance to one drug within a class of drugs leads to tolerance to other drugs within that same class of drugs • Tolerance: Need to increase dosage to achieve the same effect
  28. 28. The Faces of Addiction
  29. 29. • Dimension 6: Recovery Environment ASAM Dimensions • Dimension 5: Relapse/Continued Use Potential • Dimension 4: Readiness to Change • Dimension 3: Emotional, Behavioral or Cognitive Conditions and Complications • Dimension 2: Biomedical Conditions and Complications • Dimension 1: Acute Intoxication and/or Withdrawal
  30. 30. Motivational Interviewing “Motivation can be understood not as something one has but rather as something one does. It involves recognizing a problem, searching for a way to change and then beginning and sticking with that change strategy” Miller (1995) o Motivational Interviewing is a way to minimize resistance, resolve ambivalence and induce change. o Readiness levels are accepted starting points for treatment rather than reasons for elimination from treatment services.
  31. 31. Motivation: The Old Way
  32. 32. o Motivation is key to change and it is constantly in flux o Motivation is influenced by social interaction, namely the counselor’s style o At all stages of change, ambivalence is seen as normal and not pathological o Confrontation is a goal, not a therapeutic technique CONCEPTUALIZING MOTIVATIONAL INTERVIEWING
  33. 33. Client Resistance Involves feelings-actions-behaviors of an interpersonal nature where there is a lack of collaboration
  34. 34. Stages Of Change • Precontemplation stage • Contemplation stage • Preparation stage • Action stage • Maintenance • Relapse
  35. 35. “There is a myth…that more is always better. More education, more intense treatment, more confrontation will necessarily produce more change. Nowhere is this less true than with precontemplators. More intensity will often produce fewer results with this group. So it is particularly important to use careful motivational strategies, rather than mount high-intensity programs…We cannot make precontemplators change, but we can help motivate them to move to contemplation.” DiClemente, (1991)
  36. 36. Stage 1: Precontemplation • The client does not consider change. Seeks treatment due to outside pressures such as family, job, etc., or due to legal and/or medical concerns
  37. 37. Motivational Interviewing Tasks Building Readiness • A) Raise doubt about client’s belief that AOD use is harmless • B) Increase the client’s perception of risks and problems with current behaviors
  38. 38. Clinical Interventions • A) Establish rapport and trust and explore what brought client into treatment • B) Summarize: link the information together, especially focusing on the client’s ambivalence. Educate about possible links to AOD use
  39. 39. “Contemplation is often a very paradoxical stage of change… Ambivalence is the archenemy of commitment and a prime reason for chronic contemplation. Helping the client to work through the ambivalence, to anticipate barriers, to decrease the desirability of the problem behavior and to gain some increased sense of self-efficacy to cope with this specific problem are all stage-appropriate strategies.” DiClemente, (1991)
  40. 40. Stage 2: Contemplation o The client is highly ambivalent about change. The client both considers change and rejects it. The client will seesaw between reasons for concern and justifications for continued AOD use
  41. 41. Ambivalence • A state of mind in which a person has coexisting but conflicting feelings, thoughts, and actions about something • The “I do but I don’t” dilemma
  42. 42. Motivational Interviewing Tasks: Increasing Commitment • A) Tip the decisional balance and strengthen self-efficacy • B) Evoke from the client reasons to change and risks of not changing
  43. 43. Clinical Interventions • A) Show interest in how AOD use affects all areas of the client’s life • B) Reframe resentment: validate the client’s observations, but offer a new interpretation of the data
  44. 44. Stage 3: Preparation • The client is committed to and planning to make a change in the near future but is still considering what to do • Goal: Help client to get ready to make a change • Elements of Change:…Ready….Willing….Able
  45. 45. Strategies For Preparation Stage • Clarify goals & strategies • Menu of options • Offer advice • Negotiate change plan • Identify barriers • Get social support • Treatment expectations • Publicize change plans
  46. 46. Stage 4: Action • Client has decided to make a change • Client has verbalized or demonstrated a firm commitment to change • Efforts to modify behavior and/or environment are being taken • Client demonstrates motivation and effort to achieve real change • Client is involved in, and committed to, the change process • Client is willing to follow suggested strategies and activities to change
  47. 47. Maintenance and Relapse