Addiction and Drug Abuse
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Introduction

The abuse of alcohol and drugs from a psychological perspective comes under the heading of externalising disorders. This category essentially encompasses the tendency of an individual to act out their problems. Other externalising disorders include:
  • Conduct disorders
  • Anti-social personality
This is opposed to the internalising disorders, such as depression and anxiety.

Addiction

Anything that causes the release of dopamine in the brain can become addictive.
 
Stages of Change
There a psychological model known as the stages of change model, which can be a useful tool in understanding alcohol addiction. It can also be applied to any type of addiction. It shows 5 phases of the addiction, which can then also be applied to abstinence. E.g.:
  • Pre-contemplation – the patient is not yet thinking about drinking
  • Contemplation – the patient is thinking about drinking
  • Preparation – the patient is preparing to drink – e.g. goes and buys alcohol
  • Action – the patient drinks
  • Maintenance – the patient continues in this pattern of behaviour
  • Pre-contemplation 2– the patient is not thinking about stopping drinking
  • Contemplation 2 – the patient is thinking about stopping drinking
  • Preparation 2– the patient is making plans to stop drinking
  • Action 2– the patient tries to stop drinking
  • Maintenance 2– the patient is able to continue without drinking
  • Pre-contemplation 3 – the patient is not yet thinking about drink again
  • Contemplation 3 – the patient is thinking about drinking again
  • Etc, etc
 
By working out what phase the patient might be in, we are then able to target our treatment for them. For example, a patient in Maintenance 1, is very unlikely to stop drinking if you simple say ‘It would be good for your health if you stopping drinking.’, whereas a patient in contemplation 2 would probably respond well to some encouragement and asking them about any plans they have made to alter their behaviour.
However – there are still measures you can take whatever phase the patient is in. You can help ‘push’ the patient along to the next state if you use the right techniques. These techniques are known as motivational interviewing. You should encourage / empower the patient to think for themselves, and not try to guide them through the process! For example, if you wanted to encourage a patient in the maintenance or pre-contemplation phases you could ask questions like:
  • What’s good about drink?
  • What’s bad about drinking?
    • The patient might say something about health issues, so you could respond with: ‘ah your health is bad?’

The idea is to get the patient to think about their life from a different perspective. If you try to push them along the path, you will encounter resistance, and the harder you push, the more resistance you will likely encounter!
Don’t tell the patient they have a problem, just allow them to talk about issues. If they say something that you think is a problem, but to them may not appear a problem, just reflect this back at the patient.

There is also the possibility to leave the cycle, and have a ‘full recovery’ between the maintenance and pre-contemplative stages.

The 12-step approach

This includes the famous Alcoholics anonymous groups, but a similar approach is used in other groups, and for other addictions. In this approach, individuals are encouraged to surrender themselves to a higher power (i.e. God). Patients do not need to be specifically religious, just to have a belief in a higher power. By having the feeling of giving up their choice, many people find it much easier to now give up their addictive substance. Although this approach is not for everyone, it is still very successful.
Generally the 12-steps are recommended to supplement medical and other treatments – e.g. as a follow up treatment after detox. The 12-steps are only really useful for somebody with dependence and not just a heavy drinker.
The original 12 steps are as follows, but they are often slightly adapted to fir different cultural norms:
  1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
  2. Came to believe that a Power greater than ourselves could restore us to sanity.
  3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
  4. Made a searching and fearless moral inventory of ourselves.
  5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
  6. Were entirely ready to have God remove all these defects of character.
  7. Humbly asked Him to remove our shortcomings.
  8. Made a list of all persons we had harmed, and became willing to make amends to them all.
  9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
  10. Continued to take personal inventory and when we were wrong promptly admitted it.
  11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His Will for us and the power to carry that out.
  12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

Alcohol

Alcohol use disorders are considered in their own seperate article.

Drugs

Taking a Drug history

This will generally be similar to taking a drinking history, however, you need to ask about each individual substance. You should ask:
  • Quantity used
  • Frequency used
  • Pattern of usage
  • Age of onset of taking drugs
  • When was the most recent use?
  • Method of administration
  • Money spent on drugs each week
    • Illegal activity (e.g. stealing to get money)
  • Risky behaviours
  • Tolerance
  • Dependence
    • Physical harm
    • Psychological harm
    • Social problems
  • Motivation to quit
    • Desire to change
    • Need to change
    • Ability to change
    • Reasons to change
    • Ambivalence – does the patient not really know whether they want to stop taking or not? If they are in rehab, do they really believe they will not use when they leave.
  • Physical problems
    • Cellulitis (from injecting)
    • Hepatitis
    • Aneurysms
    • Abscesses
    • Infection
    • Other drug related medical issues (particularly accidental injury)
  • Trigger factors to use drugs
  • Understanding and insight
 
Clinical features of drug use
Opiates – pinpoint pupils, low BP, venepuncture marks.
Benzodiazepines – disinhibited or gives the impression of intoxicated, but is not drunk
Psychostimulants – rapid speech, large pupils, agitation, restlessness, high BP.
Features of Withdrawal
Opiates – dilated pupils, high BP, sweaty, runny nose (rhinorrhea), cramps
  • Note how these may appear similar to psychostimulant use!
Benzodiazepines – hypersensitivity, hyper-reflexia, depersonalisation
Psychostimulants – agitation, restlessness
Heroin
  • Cold/shivery
  • Flu-like symptoms
  • Body pain
  • Cannot kill you! – unlike alcohol – even though patients will say it is an awful experience, the addiction is psychological and not physical.
 

Quick Overview of Types of drugs

Cannabis – THC
  • Resin – dried crumbled – weak
  • Leaf – hash – grass – weak>>strong
  • Oil – strongest form
  • Classed as a hallucinogen – but is not very strong, and people rarely have full hallucinations
  • Heavy regular use leads to anxiety and depression
  • Occasional use gives you very slightly increased chances of the above
  • Probably causes schizophrenia
  • In people with a psychological disorder it is likely to make it worse
  • You can get addicted to cannabis!
  • Any drug that causes addiction must release dopamine. – cannabis does cause the release of dopamine
Opiates
  • Start of with smoking
  • Then subcutaneous – ‘skin popping’ – all up the arm – looks like train stations
  • Finally inject
  • Very addictive – got to have it or they feel really bad.
  • Medically – it is one of the least harmful. But injecting isn’t very good for you.
  • Strongly associated with depression – but could just be social effects
  • Respiratory depression – can be reversed with naloxone

Cocaine
  • Stimulant – causes a pure release of dopamine into the brain!
  • If you take it, then whatever you do gives you a big reward – makes people repetitive
  • Crack releases al your dopamine straight away – cocaine is not quite as strong
    • Made by cooking cocaine with acid and lemon juice. Extremely addictive
  • Lasts about an hour – then you want more
  • It is used medically as a local anaesthetic. It numbs the area and reduces the blood supply to the area.
  • Cardiotoxic – very dangerous!
Amphetamine (speed)
  • Stimulant
  • Excess energy
  • Elation
  • Very similar to cocaine
  • Amphetamine can be injected
Crystal meth
  • Like the ‘crack’ version of amphetamine
  • Really easy to make
 
MDMA
  • Stimulant
  • Also causes serotonin release – so makes you feel very happy, and close to other socially
  • Very high tolerance effect – so people have to use more
  • Commonly cut with other stuff – so not very good quality
  • Its a relatively safe drug – about 50 deaths on pure ecstasy in the UK
  • Causes a big mood drop about 4 days after you take it
  • Lots of clones of it floating around on the market – which have not yet been made illegal – dubious legality

LSD
  • Man-made
  • Not addictive – no dopamine
  • Hallucinogenic
  • Gives you highs for 12 hours
Benzodiazepines
  • People use them like alcohol to relax
  • Use them to come off other drugs
  • Can go into coma with high dose – or if you combine with alcohol
Magic Mushrooms
  • Naturally occurring
  • Hallucinogenic, and also release serotonin, so cause euphoria
Ketamine
  • Anaesthetic
  • Dissociative – it makes them dissociated from reality
  • Use it to come down off other drugs – dissociates them from the effects of coming off the drug
  • Not addictive
  • Oversedation can occur
Dual-diagnosis
  • This is where a patient has an alcohol/drug problem AND another psychological diagnosis

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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) currently works as a GP Registrar and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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