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From the Publisher“This volume on drug problems is excellent…powerful and compelling…” (PsycCRITIQUES, 8th February 2005)
"...a lot of useful information..." (Addiction, June 2006)
"...a lot of useful information..." (Addiction, June 2006)
TRUTH OR FICTION
After reading this chapter, you should be able to answer the following questions:
1. People can recover from drug problems on their own. True of False?
2. Drug problems always get worse over time. True of False?
3. Adolescents drug problems are essentially the same as adult drug problems. True of False?
4. Relapse is a sign that treatment did not work. True or False?
5. Scaring drug users is a highly effective way to motivate change. True or False?
6. Virtual reality may be used in the treatment centers of the future. True or False?
7. Cravings are always biological in nature. True of False?
Answers on p. 47.
Not too many issues in the United States can elicit as many emotions as discussing drug-related problems. It seems that almost everyone in American society has an opinion about drug use, drug policy, and drug treatment. This is likely the result of how drug use in this country has touched so many of us in personal ways. Many people know of someone who has (or has had) a drug problem: a family member, a friend, or a friend of a friend. Drug problems also affect those who have been victimized by drug-related accidents or crime, and many others who care for those harmed by substance abuse. Drug problems can affect all ofus by contributing to higher health care and insurance costs, and through higher tax burdens to support services. The abuse of drugs constitutes a major health problem in the United States, with widespread consequences that affect us all in some form or fashion.
Unfortunately, since drug problems have created strong opinions in this country, many opinions are slow to change even when they are inconsistent with the most recent scientific research. As a result, there is a wide array of new research that remains unknown by people who develop drug policies, who treat people with drug problems, and who may know or live with a person who has problems with drugs. Every day we learn more about what we should be doing to help people with drug problems, but unfortunately it takes time for the latest research to trickle down to the people who would benefit from this knowledge.
Partly at fault are scientists, who may find it difficult to talk about the research in ways that are understandable to nonscientists, or who have difficulties communicating the relevance of the research findings for treatment or for policymaking decisions. Partly at fault are policymakers, who often make important decisions for reasons that are more political than scientific. And finally, partly at fault are clinicians, who are suspicious of science or uncomfortable with new techniques, or who may be overly burdened by heavy clinical loads that limit their ability to stay current with the latest in research. Because of these problems in communicating new research findings and translating them into new policies and treatments that will help people with drug problems, progress toward reducing drug problems in the United States has been unnecessarily slowed. It is hoped that this book will be able to bridge this gap by bringing new information about treating drug problems to a wide variety of Americans, particularly those clinicians in the trenches who deserve to know.
Prevalence of Drug Abuse
Epidemiological research suggests that probably 10 to 20% of the population of the United States may have problems related to substance use, with approximately 5% of the population having problems with drugs other than alcohol (Substance Abuse and Mental Health Services Administration [SAMHSA], 2003). The most widely abused substances in the United States are alcohol, tobacco, and marijuana, but the typical pattern is for a person to abuse more than one substance at a time. An example might be that a person may smoke both cigarettes and marijuana, or may use both cocaine and heroin.
Tables 1.1 and 1.2 show the extent to which U.S. citizens report illegal drug use. As can be seen from the Table 1.1, many Americans have used drugs at least once, with marijuana being the most commonly reported substance used either during one's lifetime or during the past year. Perhaps surprisingly, prescribed pain medications are the second most commonly reported drug used by Americans within the last month. The abuse of prescribed drugs is often poorly recognized and does not get the same press as the abuse of street drugs like heroin or cocaine, but it represents a serious health threat to many Americans. Table 1.2 illustrates that men are more likely to use drugs than women, and that there may be some differences across racial and ethnic groups in drug use patterns, which will be discussed in greater detail later in this chapter. Tables 1.1 and 1.2 suggest that drug misuse and experimentation are not uncommon behaviors. Furthermore, a comparison of the lifetime usage numbers to the statistics presented earlier about drug abuse problems indicates that drug misuse does not always mean a drug problem.
Problems related to substance misuse cost Americans around $140 billion in 1998 (Office of National Drug Control Policy [ONDCP], 2001). Drug problems have been linked to a variety of health problems, including accidental deaths, suicides, homicides, hepatitis and other liver diseases, heart and kidney diseases, cancers, and HIV. Many of these health problems are among the top 10 causes of death in the United States for different age and ethnic groups. For instance, liver diseases associated with substance abuse were the 10th leading cause of death for adults aged 25-34 in the year 2000 (mostly caused by alcohol use, but some caused by drug-related hepatitis), the 6th leading cause of death for adults aged 35-44, the 4th leading cause of death among adults aged 45-54, and the 7th leading cause of death for adults aged 55-64. Infection with HIV, which is highly associated with drug usage, was the 10th leading cause of death in 2000 for adults aged 15-24, 6th for those aged 25-34, 5th for those aged 35-44, and 8th for those aged 45-54. In addition, the top five killers in the United States for all age groups during 2000 (heart disease, cancer, strokes, chronic obstructive pulmonary disease, and unintentional injuries) all have been found to have some direct or indirect association with substance abuse (National Center for Injury Prevention and Control [NCIPC], 2003). Finally, drug problems have been identified as a cause of traumatic brain and spinal cord injuries, cognitive impairment, hypertension, malnutrition, severe burns, and drownings.
What Exactly Is a Drug Problem?
There are many different ways to define having a drug problem, but ultimately it is up to the individual to decide whether she or he has one. Historically, two different angles have been used to define a drug problem. The first looks at how many drugs the person consumes and when, or at what some researchers and therapists call consumption rates and patterns. The advantage to considering consumption rates and patterns is that heavy drug use often can lead to health-threatening and other negative consequences for the person using the drugs. However, consumption rates and patterns can be misleading in some instances because of differences in body size, gender differences, and other between-person differences. Because of this, the second angle of defining a drug problem, which has to do with examining the consequences of drug use, is also quite useful to consider.
Not surprisingly, consumption and consequences have been found by scientists to be related. However, the relationship is not always as strong as one would think. Some people who use just a very little amount of a drug can have significant difficulties; alternatively, some people can use a substantial amount of drugs with relatively few consequences. Because of these wide variations between individuals, it is a good idea to consider both consumption and consequences when determining whether a person has a drug problem. The next section of this chapter discusses key factors that researchers and clinicians look at when determining whether a diagnosis of a drug problem is appropriate.
The Three C's
Drug problems are often typified by what has been called the three C's (compulsive use, loss of control, and continued use despite adverse consequences). Although some people who have drug problems experience all of the C's, there are many who do not. However, a person with a drug problem will likely have experienced at least one of them, so assessing for them is quite useful when evaluating for a drug problem. The three C's are described in detail in the following sections.
First, drug problems often are linked to what is called compulsive drug use. Compulsive use of drugs generally means that a person uses drugs automatically and habitually without thinking about the consequences of the behavior. Three important aspects related to compulsive drug use include reinforcement for substance use, cravings for the substance, and habit. To begin with, compulsive use of drugs is reinforced because the early stages of drug use reward the person either by stimulating the pleasure centers of the brain (e.g., the nucleus accumbens) or by taking away withdrawal or psychiatric symptoms, pain, or negative emotional states. Reinforcement is quite potent, making it likely that the person will use the drug again.
However, as the person increasingly uses the substances, tolerance develops. The euphoria of drug use may diminish or become more unpredictable, with highs or symptom relief occurring less frequently over time. The person may find that the pleasurable rewards come only intermittently. Many behavioral researchers, beginning with B. F. Skinner, have studied the powerful effects of intermittent or variable reinforcement in maintaining a particular behavior. Variable reinforcement, which means that the reinforcement happens randomly and becomes unpredictable to the person engaging in the behavior, contributes to keeping a person hooked on a behavior (reinforcement is discussed in greater detail later in this chapter).
Second, compulsive users of drugs often report they experience cravings for the substances that they prefer. Cravings have been described to me as gripping urges to use substances that will sometimes seem to come "out of the blue." Cravings seem to have both physical and psychological components. Physical cravings seem to occur as a direct result of withdrawal symptoms. When the drug is not being administered after a period of continuous use, the body experiences neurochemical imbalance; aversive symptoms, ranging from shakes to seizures, can occur. Cravings may be the result of the person's interpreting bodily signals that trigger the desire to ingest the substance in order to avoid physical withdrawal symptoms.
In addition, chronic or heavy drug abuse can sometimes alter a person's physiology, so that a chronic neurochemical imbalance may result. Such an imbalance can contribute to chronic symptoms of anxiety or depression. It is unclear whether these imbalances can be completely reversed over time with abstinence, but we do know that these symptoms and the underlying neurochemical changes that contribute to them may continue for months or even years after the drug was last used. Former clients of mine have told me about experiencing what they thought were physical cravings - some after months of abstinence - that in reality were being cued by their symptoms of anxiety or depression. The good news is that newer pharmacological agents can be very helpful in moderating physical withdrawal symptoms, and in reducing or alleviating depression and anxiety that can trigger a craving for drugs.
The other kind of craving a person may experience is psychological. Psychological cravings are triggered by the context of the drug experience rather than by the drugs themselves, and the user often misinterprets these cravings as a desire for drugs when what they actually want is a drug-related experience. A very common psychological craving occurs when a person misses experiences associated with using situations, such as socialization or recreational activities. The person will initially believe that the craving is physical but when you investigate further using behavioral analysis (explained in greater detail in Chapter 4), the craving is not physical at all, but related to missing an experience associated with using substances. The use of drugs has been paired so closely to an experience of socialization that the craving may be misattributed to needing the drug when in reality the person is craving an experience given up to avoid drug-using situations. Even though psychological cravings are not physiologically triggered, they can be extremely powerful experiences and often place a person at high risk for relapse (discussed later in this chapter and in Chapter 7). Treatment for psychological cravings focuses on exposure to emotional triggers, and changing behavioral responses and beliefs related to expectancies about substance use (see discussions about therapies in Chapter 5).
Psychological cravings also can be linked to a user's expectancies, or beliefs about what substance use will do for him or her. Positive expectancies about substance use can be related to what is termed euphoric recall of substance use experiences, which simply means that a person remembers the good times of using while perhaps forgetting or minimizing the memory of bad times. Positive expectancies often glamorize the drug use experiences by selectively remembering the pleasant using experiences while ignoring the not-so-good experiences. Expectancies will be discussed in greater detail later in this chapter.
Third, compulsive drug use also is related to habit. Habitual behavior is deeply ingrained in our memory processes and often leads to automatic responses without a moment of pause for the person to consider the actions before they occur. Habitual memory is part of implicit memory, which is the type of memory related to automatic behaviors such as driving a car or riding a bike. Can you imagine unlearning how to drive a car? But in a sense, that is exactly what a person who has abused drugs must do in order to break a compulsive behavior that may have lasted for many years. Behavioral scientists often will say that "the best prediction of behavior in the future is what has been done in the past," and with good reason, since habits, bad or good, are very difficult to change.
Habitual behavior tends to operate on autopilot, too. An example of how the automatic processes of habitual memory operate would be an instance in which you are cleaning house on autopilot, and then you stop for a moment and have no memory of having dusted the table even though it looks clean. Habitual behavior often means acting without thinking, so that you often have no awareness of what you are doing at a particular moment (or why). The same is true for compulsive drug use, when a person may use a drug without even being aware of what he or she is doing. Habit can place the person in a high-risk situation before he or she even knows it.
Loss of Control
Loss of control also is typical among people who abuse drugs, and some drug users will describe their habits as being out of control. Loss of control has been described as an inability to predict when or how many drugs will be consumed. Some drug users describe loss of control as powerlessness, meaning that the desire for substances controls their behavior.
Excerpted from Treating Drug Problems by Arthur W. Blume Excerpted by permission.
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Chapter 1: Drug Problems: An Overview.
Chapter 2: Recognizing a Drug Problem.
Chapter 3: Utilizing Optimal Professional Resources.
Chapter 4: Developing an Effective Treatment Plan.
Chapter 5: Recovery Tools, Programs, and Theories.
Chapter 6: Continuing Care.
Chapter 7: Posttreatment Recovery Management.
Chapter 8: New Beginnings: Moving Beyond Addictions.