Addiction

What is it?
What causes it?
What can we do
about it?
 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
 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
 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/Hi
story/
drug_law_timeline.htm
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
 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
 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 :
 Tolerance
 Physiological dependence

 Psychological dependence (habituation)

 Craving
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
 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
 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
 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
 Incentive-sensitization
 Liking vs. wanting
 Opponent-process theory
 Craving as counteradaptation
 Lowering the hedonic set-point
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 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
 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
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
 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
 Abstinence: The 12-step approach
 Controlled use
 Harm reduction
 Substitute addictions
 Methadone
 Gum-chewing
 Needle exchanges
 Water supply
3. Treatment stages
 Detoxification (Detox)
 “Cold turkey”
 Gradual

 With pharmacological support

 Active treatment
 Relapse prevention
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
 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
 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
 Medication-assists
 Antagonist blockade
 Treat contributing conditions

 Substitution

 Antabuse

 Craving reduction

• Ibogaine
 Outpatient drug-free programs
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
 Switzerland:1,035
(237) chronic heroin Illicit heroin use
addicts
80
 Required weekly 70 Res.
psychotherapy 60 drug-
50 free
 Offered employment 40 Meth.
 No unacceptable side 30 maint
20
effects for neighbors 10 Heroin
 Reduced illegal use of 0 maint.
heroin & cocaine, but
Some

None
Daily

not cannabis or
alcohol
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
 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
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 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
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