Addiction

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Addiction and how to get rid of it.

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Addiction : 

Addiction What is it? What causes it? What can we do about it?

FDA rules : 

FDA rules Pure Food and Drug Act, 1906: Labeling accuracy to eliminate adulteration An educational approach Cuforhedake Brane-Fude, labeled 30% alcohol Sherley Amendment, 1912: No “false and fraudulent” therapeutic claims on the label Harrison Narcotics Act, 1914: Trade controls and taxation (Dr. Hamilton Wright) Marijuana Tax Act (1937): Harry Anslinger Agriculture Department vs. Treasury Dept. Enforcement concerns merged under Department of Justice, 1968 DEA, 1973

The Controlled Substances Act, 1970 : 

The Controlled Substances Act, 1970 Schedule system: Based on abuse potential, medical usefulness, and risk of dependence Schedule I: Hi-no-hi. Heroin, marijuana, LSD Schedule II: Hi-yes-hi. Morphine, Marinol, cocaine, methamphetamine Schedule III: Moderate-yes-moderate. Amphetamine, barbiturates, PCP Schedule IV: Low-yes-less than III. Chloral hydrate Schedule V: Low-yes-less than IV. Cocaine mixtures

More recent legislation : 

More recent legislation The Orphan Drug Act, 1983 Analogue (Designer Drug) Act, 1986 Prescription Drug Marketing Act, 1987 Anti-Drug Abuse Act, 1988 (established ONDCP) aka Omnibus Drug Act Anabolic Steroids Control Act, 1990 http://www.druglibrary.org/schaffer/History/drug_law_timeline.htm

Expansion of FDA concerns : 

Expansion of FDA concerns Purity (1906) Safety (1938): The Food, Drug, and Cosmetics Act Toxicity assessment before marketing Instructions for use on the label Effectiveness (1962): Kefauver-Harris amendments Carter’s Little Liver Pills

Current FDA Approval Process : 

Current FDA Approval Process Safety: Pre-clinical testing of several dosages over relevant time periods on at least two species Carefully planned clinical trials with signed informed consent and annual reports Phase 1 clinical trials: Small doses on healthy volunteers: Pharmacokinetics and side effects Phase 2: Small sample of hospital patients Phase 3: Broader clinical trials on patients

Definition of addiction : 

Definition of addiction Textbook definition: A chronic, relapsing behavioral disorder. Pattern: Remissions and relapses Progression theories: Gateway progression Continuum of drug use “Maturing out”

Components/indicators of addiction : : 

Components/indicators of addiction : Tolerance Physiological dependence Psychological dependence (habituation) Craving

Substance features in addiction : 

Substance features in addiction Some substances are more likely to be associated with addiction than others, but there are many exceptions both ways Some substances are more likely to be self-administered by animals Heroin, cocaine, alcohol

Global explanations of drug addiction: Models : 

Global explanations of drug addiction: Models Moral model: Responsibility and guilt Physical dependence model Abstinence syndrome Negative reinforcement for continued drug-taking Environmentally cued craving and relapse (Wikler, 1980) Physical or psychological?

Positive reinforcement model : 

Positive reinforcement model Immediate reinforcement and discounting the future Progressive ratio research: CRF to FR schedules The breaking point Euphoria as a learned reinforcer: motive for relapse

Medical model : 

Medical model Disease as susceptibility (Jellinek, 1960) Disease as damage: Exposure model (Leshner, 1997) A useful counter to the moral model Problems: The model is psychiatric more than medical Drug usage falls on a continuum

Still more models : 

Still more models Incentive-sensitization Liking vs. wanting Opponent-process theory Craving as counteradaptation Lowering the hedonic set-point

Narrow-band explanations of addiction : 

Narrow-band explanations of addiction Biological: Dopamine hypothesis Personality Family causation Genetics Modeling/Social Learning Codependency and enabling ACOA Sociocultural influence A biopsychosocial model: DSM-IV

A Biopsychosocial approach : 

A Biopsychosocial approach A rapprochement: Factors in all models are considered. Positive reinforcement, Negative reinforcement, and self-medication Distinguishes between experimentation and later problem use Incorporates three factors: Social/interpersonal Cultural/attitudinal Intrapersonal

Content deleted to respect copyright : 

Content deleted to respect copyright

DSM-IV criteria for substance dependence : 

DSM-IV criteria for substance dependence At least three symptoms in 12 months: Tolerance Withdrawal Use beyond intention Inability to reduce usage Time-consuming Valued activities are abandoned or reduced Use continues despite problems

Slide 18: 

DSM-IV criteria for Substance Abuse One or more of the following, in 12 months Substance use repeatedly leads to failure to fulfill home, work, or school responsibilities Repeated substance use in physically hazardous situations Repeated legal problems from substance use Continued use despite resulting, repeated social or interpersonal problems Has not met the criteria for substance dependence for this substance class

1. Treatments for addiction : 

1. Treatments for addiction The decision Denial met by intervention or reality Cognitive changes (Prochaska, DiClemente & Norcross, 1992) Precontemplation: No problem! Contemplation: Maybe there’s a problem… Preparation Action Maintenance Cognitive therapy: Motivational interviewing

2. Treatment goals : 

2. Treatment goals Abstinence: The 12-step approach Controlled use Harm reduction Substitute addictions Methadone Gum-chewing Needle exchanges Water supply

3. Treatment stages : 

3. Treatment stages Detoxification (Detox) “Cold turkey” Gradual With pharmacological support Active treatment Relapse prevention

4. Treatment methods : 

4. Treatment methods Self-treatment (“spontaneous remission”) Perhaps 20% follow this route. Self-treatment often requires multiple attempts: Learning to quit. For 57%, quitting is the result of cost-benefits analysis. For 29%, the change is immediate.

More on self-treatment : 

More on self-treatment Sometimes because of “bottoming out” Positive life changes: marriage, childbearing, religious encounter Negative life changes: health problems, social or legal consequences of drug use, death of a friend

More treatment methods : 

More treatment methods Self-help groups like AA Twelve Steps Peer identification and support Sober social relationships Residential treatment Hospitalization The therapeutic community Milieu therapy Short-term residential programs Faith-based programs Salvation Army Teen Challenge

More treatments : 

More treatments Medication-assists Antagonist blockade Treat contributing conditions Substitution Antabuse Craving reduction Ibogaine Outpatient drug-free programs

Harm reduction approaches : 

Harm reduction approaches Provide substances, paraphernalia and injection rooms in ways that reduce crime and disease transmission Meet other needs of addicts Health care and nutrition Social support Employment or volunteer activities

Heroin maintenance therapy : 

Heroin maintenance therapy Switzerland:1,035 (237) chronic heroin addicts Required weekly psychotherapy Offered employment No unacceptable side effects for neighbors Reduced illegal use of heroin & cocaine, but not cannabis or alcohol

Old approaches with new promise : 

Old approaches with new promise Contingency contracting Access to methadone based on clean urine Financial contracting: smoking example Community reinforcement: Is this normalcy? Reward non-use Do not reward, even punish use Teach non-drug life choices Conjoint couples or family therapy Do faith-based programs use these methods?

Relapse prevention : 

Relapse prevention Risk of relapse is reduced by Frequent review of the decision Avoiding drug-related cues by moving and dumping drug-using friends Social connections with non-users Getting a job Learning substitute activities Developing structure for life

Harry J. Anslinger : 

Harry J. Anslinger Marijuana is smoked by… “musicians. And I’m not speaking about good musicians, but the jazz type.” -Commissioner of the U.S. Bureau of Narcotics, 1930-1962

The Australian approach : 

The Australian approach The Therapeutic Goods Administration (TGA) Drug Safety and Evaluation Branch Adverse Drugs Reaction Unit (ADRU) Manufacturers and suppliers (importers) are known as sponsors, and are responsible for both entry into the Australian Register of Therapeutic Goods and reporting of postmarketing adverse reactions to the ADRU. Only the ADRU reports must be based on Australian populations. Uses a partnership approach.

The TGA : 

The TGA Established by the Therapeutic Goods Act of 1989 A unit of the federal department of Health and Ageing. Covers assessment and monitoring activities Focuses on Quality, Safety, and Effectiveness Defines therapeutic goods Website: www.tga.gov.au/about/about.htm

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