By David Clark, Wired In
 
Leading  addiction  scientists  met  in  New  Mexico,  USA,  in  2004  at  a  “think-tank” conference  to  share  research  findings  in  their  respective  areas  and  discuss  possible implications for treatment and prevention interventions.

This conference resulted in a seminal book,  “Rethinking Substance Abuse: What  the Science Show, and What We Should Do about It” which I will consider in this and a following article.  

The participants  in  this meeting believe  that whilst scientific  research has  revealed a great  deal  about  the  nature  of  substance  use  problems  and  how  they  can  be prevented and treated, very little of this science has found its way into practice. 

Moreover,  they  point  out  that  following  drastic  cuts  in  financial  support  for  already starved  treatment  and  prevention  efforts,  the  existing  US  intervention  system  is  in dire straits.  

Major gaps exist between what research has actually shown to be effective and what is  actually  practiced  in  treatment  settings. 

Services  continue  to  be  marginalised, stigmatised  and  isolated  from  the  rest  of  the  health  care  system. 

Consumers  have very  little  reliable  information  to  use  in  finding  and  selecting  services,  and  judging their effectiveness. 

Given these problems, the book editors pointed out that it is, “not difficult to imagine starting  over  from  scratch  to  envision  a  more  compassionate,  effective  and  cost-efficient intervention system.” 

They  draw  together  the  wealth  of  scientific  understanding  from  the  range  of  topic areas considered to produce a set of ten cross-cutting principles, and then reflect on their implications with ten recommendations for interventions.  

I  will  outline  these  important  Principles  and  Recommendations  developed  by  this group  of  American  scientists  and  clinicians,  allowing  you  to mull  over  how  relevant they are to reducing the suffering related to substance use problems in your country.      

Principle 1. Substance use is chosen behaviour

Substance  use  is  a  behaviour,  chosen  from  among  behavioural  options.  It  is influenced by the same principles of learning and motivation that shape other forms of human behaviour.  

Even  when  substance  use  becomes  self-perpetuating  it  is  not  unique,  as  it  shares common  characteristics  with  other  compulsive  behaviours  such  as  pathological gambling and overeating.

The willful-choice  aspect  of  drug  use  is  sometimes  underplayed  or  denied  (e.g.  the disease model), in part due to efforts to inspire compassionate care rather than harsh and moralistic treatment of people with a substance use problem.

This has resulted in conflicting pubic opinions of whether problematic use (addiction) to drugs and alcohol is, or is not, a matter of personal choice. 

The  science  of  recovery  from  substance  use  problems  gives  intentional  change  a prominent role. The scientists note, “Most people who recover from drug problems do so on their own, without formal treatment. The stages and processes of such “natural” change are  indistinguishable  from  those  that occur with  treatment, and are common across  the  spectrum  of  problem  severity. 

In  this  sense,  effective  interventions facilitate and perhaps speed natural change processes.”  Evidence  also  suggests  that  change  often  involves  a  kind  of  “click”,  a  decision, commitment, or turnabout. This is reflected in popular concepts such as “hitting rock bottom”  and  experiencing  a  transformational  turning  point. 

Personal  commitment appears to be a final common pathway towards change. 

The authors sum up by saying that there is “every reason to treat the individual drug user  as  an  active  participant,  a  responsible  choosing  agent,  and  a  collaborator  in … treatment  interventions.  Furthermore,  there  are  myriad  opportunities  in  society  to trigger and promote self-change”. 

2. Substance use problems emerge gradually and occur along a continuum of severity

No  one  sets  out  to  become  addicted  to  drugs.  The  process  is  gradual,  starting with experimental use, moving on to more frequent use, and so on.  

There  is  no  signpost  saying  that  someone  has  become  addicted  to,  or  dependent upon, drugs or alcohol. Addiction emerges as someone’s life becomes more and more centered on drugs or alcohol.

The diagnostic criteria for dependence and addiction are arbitrary cutoff points along a gradual continuum.   Society  needs  to  be  able  to  address  problems  with  a  wide  range  of  severity. Interventions which are useful at one  level of severity may be unhelpful or counter-productive  at  another  level  of  the  continuum. 

In  general,  it  is  easier  to  change behavior in the earlier stages of substance use related problems.

3. Once  well-established,  substance  use  problems  tend  to  be  come  self-perpetuating

One  characteristic  of  addictive  behaviors  is  that  they  become  “self-organizing”  and robust. Once established, they can become particularly resistant to ordinary forces of persuasion, punishment and self-control.

Addressing one aspect of this self-organising system is often ineffective.  There  a  variety  of  routes  into  problematic  substance  use.  It  is  important  to understand for each individual what is maintaining their pattern of substance use, and what components need to be addressed in order to produce stable behavioral change.  

One  consistent  theme  is  that  an  initial  period  of  abstinence  can  be  helpful  in destabilising dependent substance use. 

4. Motivation is central to prevention and intervention 

There is abundant evidence indicating that motivational factors (in their broad sense) are central to our understanding of substance use, and also in preventing and treating substance use problems.   Motivational  factors are  involved  in patterns of  change. 

If people who have  stopped substance use on  their own, without  formal  treatment, are  later asked how and why they did so, they will often refer to a choice or a decision point.  

Life  events  can  instigate  a  change  in  problem  substance  use.  Reduced  use  or abstinence can be  triggered by relatively brief  interventions,  the  impact of which are thought to reflect the clients’ motivation and commitment to change. 

The  transtheoretical  model  of  change  posits  a  sequence  of  stages  through  which people  pass,  starting  with  increased  concern  or  motivation  to  change,  decisional consideration, commitment, planning, taking action, and maintaining this change.  

“The decision or commitment to change appears to represent a final common pathway through which change  is  instigated. Often, once personal commitment has emerged, the individual may require little additional help towards making change.” 

Taking action also predicts change. Better outcomes occur when a person stays longer in treatment, attends more fellowship meetings, adheres to treatment advice, or takes their  medication.  It  appears  that  actively  doing  something  toward  change  may  be more  important  than  the  particular  actions  that  are  taken. 

The  traditional  wisdom that, ”It works if you work it” appears to be true of many routes to change.   Motivation  for change  is malleable, and can  respond  to even brief  interventions. The idea  that  there  is  nothing  that  one  can  do  until  the  person  “hits  bottom”  is  simply wrong.  

Positive  reinforcement,  unilateral  intervention  through  family  members,  and  brief motivational  counselling  and  advice,  have  all  been  shown  to  instigate  change  in seemingly  unmotivated  people.  It  is  not  necessary  to  wait  until  the  person  has developed a serious substance use problem before trying to help. 

5. Drug and alcohol use responds to reinforcement

Preferred  substances  are  powerful  reinforcers,  chosen  from  a  range  of  options. However, even dependent substance use is highly responsive to immediate contingent non-drug reinforcement.  

Since  stopping  substance use eliminates one  source of positive  reinforcement,  long-term change typically involves finding alternative reinforcers – “in essence, developing a rewarding life that does not rely on drug [and alcohol] use.”

One complexity is that drug use tends to be associated with a foreshortening of time perspective, so  that  longer-term delayed  rewards are discounted  in value  relative  to the immediate effects of the substance.  

6. Substance use problems do not occur in isolation, but as part of behaviour clusters

Amongst adolescents, drug use often represents one part of a much  larger cluster of problems,  including  poor  school  performance,  precocious  sexuality, mood  problems and antisocial behaviour. Drug problems in adults are often linked to a variety of other health, social, employment and criminal justice issues.  

Interventions  that  target  a  broader  range  of  life  functions  are  more  successful  in resolving drug and alcohol problems. Drug use occurs in the context of life problems, and abstinence is often well down on a client’s list of priorities.   If recovery  is promoted by having a more generally rewarding  life  that does not rely on  drug  use  for  reinforcement,  then  we  must  not  focus  solely  on  drug  use  in treatment programs.       

7.  There  are  identifiable  and  modifiable  risk  and  protective  factors  for problem substance use

There  are  risk  and  protective  factors  that  affect  the  initiation,  progression  and maintenance of drug use. This means that we can identify subgroups who are likely to be at higher risk for substance use problems.  Hereditary  factors  contribute  to  risk  for alcohol problems, and evidence  is mounting for a role of genetic predisposition in problematic drug use. 

People  with  more  access  to  non-drug  positive  reinforcement,  stimulating environments,  and  stress-buffering  resources  are  at  lower  risk.  Having  close,  high quality  relationships  with  people  who  are  not  involved  in  substance  use  is  one protective factor. Social and other coping skills that increase access to other forms of reinforcement and modulate stress are also protective.  

Substances are often used as a response to stress, but also tend to exacerbate stress in the long run. Escapist reasons for substance use and avoidant styles of coping are both associated with increased risk of substance use problems.  

8. Drug problems occur within a family context

Problematic  use  of  drugs  and  alcohol  by  parents  is  a  risk  factor  for  young  persons’ drug  use,  and  is  also  linked  to  a  variety  of  family  problems  and more  general  risk factors.   Parents with drug and alcohol problems are less likely to provide the kind of parenting that  reduces  their  child’s  risk. 

For  example,  children  of  parents with  substance  use problems  are  less  likely  to  develop  self-regulation  skills,  particularly  if  parenting  is disrupted before the age of six, a critical age for learning self-control.  

This  is particularly  true  for children who have other developmental  risk  factors, such as a difficult temperament or attention-deficit hyperactivity syndrome.   

The likelihood of domestic violence and child abuse is greatly increased when parents have drug and/or alcohol problems.  Conversely,  family environments  can be protective against  future  substance misuse. Factors that decrease first use of substances, decrease risk of future problematic use. 

Parental disapproval of drug use  is protective. An optimal parent style  is one that  is, “consistent,  supportive,  and  authoritative  (moderately  structured  and  midway between  the  extremes  of  permissive-negative  and  neglectful  and  authoritarian-punitive)”. 

Parental monitoring of  children’s whereabouts, activities and  friends  is a particularly important  factor.  A  family  involvement  in  religion  or  other  conventional  activities  is also  a  strong  protective  factor.  In  adolescence,  these  family  factors  counterbalance the influence of peers. 

Children who are particularly susceptible to adverse peer influence include those who are  “extroverted,  present-  (not  future-)  focused,  have  low  self-  esteem  and  low grades, use avoidant coping styles, spend more time away from home (e.g., part-time work), and tend to be followers”. 

Effective  interventions  with  families  have  tended  to  concentrate  on  two  factors. Firstly,  strengthening  family  skills  for  positive  communication  and  monitoring. Secondly,  building  family  reciprocity  in  exchanging  and  sharing  positive reinforcement.     

9. Substance use problems are affected by a larger social context

An individual’s larger social context influences the risk, severity and length of time of substance use problems.   Environments  in which  drugs  are more  readily  available  promote  use. On  the  other hand, the availability of other reinforcers and activities is protective against substance use problems.  

Social modelling can promote or deter use. Cultures in which abstinence is the norm, and  in which drug use  is stigmatised, have  lower  rates of drug use and drug-related problems.  On the other hand, criminal sanctions for use are relatively ineffective in suppressing drug use, particularly once it is an established pattern.  Norms  about  substance  use  play  an  important  role. 

Clear  norms  and modelling  of moderation influence drinking rates.   However,  some  people  misperceive  behavioural  norms.  Young  people  who overestimate  the  percentage  of  peers who  smoke  or  drink  are more  likely to do so themselves, and start to engage in these activities at a younger age.

Communicating the  actual  behavioural  norms  for  a  group  (norm  correction)  can  have  a  deterrent effect on use.  The  normative  social meaning  of  substance  use, which  often  has  symbolic  value,  is also  important. 

When  psychoactive  drugs  become  marketable  commodities, advertising  tends  to  normalise  use  and  to  associate  it with  attractive  and  symbolic outcomes. 

10. Relationship matters

There  is  something  therapeutic  about  certain  relationships. 

For  example,  it matters who is delivering a treatment for substance use problems.   Research  has  shown  that  the  clients  of  randomly  assigned  counsellors  often  differ widely in outcomes even if they are receiving the same manual-guided treatment.  

The  clients  of  counsellors  who  are  higher  in  warmth  and  accurate  empathy  show greater  improvements  in  substance  use  problems.  As  early  as  the  second  session, clients’  ratings  of  their  working  relationship  with  the  counsellor  are  predictive  of treatment outcome.  

Motivation  for  change  seems  to  emerge  in  the  relationship  between  client  and counsellor, even in relatively brief periods of counselling.  

Some  counsellors  have  consistently  worse  outcomes  than  their  colleagues.  A confrontational style that puts clients on the defensive is counter-therapeutic.   

The American addiction experts indicated that these ten principles suggest, “particular directions  in designing programs,  systems, and  social policy  to  reduce drug use and associated suffering, societal harms and costs.”

We consider their ten broad recommendations for addressing substance use problems in society in my following article.     

Recommended reading:   “Rethinking Substance Abuse: What the Science Show, and What We Should Do about It” edited by William R. Miller and Kathleen M. Carroll, Guilford Press, 2006
 
DC 17/05/09
 
Source: Wired In