addictions module

UNDERSTANDING ADDICTION

Welcome to the module.

The module aims to provide the space for you to enhance your understanding of addiction, examine your own practice and reflect on your attitudes towards substance misuse. In considering the role of talking therapies with substance misuse, we will critically examine the paradigm shifts in policy and practice. We will review the modalities of harm-minimisation and health education and look at the efficacy of various treatments, considering shortfalls, generating debate about treatment reliability and innovation. In considering drug use and young people, we will look at the influencing culture of drug use in everyday life, and celebrity of rogue models.

Guided study activity 1

Health education - Consider the following questions (some of the chapter in the handout on 'Mutually Shared Destruction' should be of help, but you are encouraged to conduct some further research and reading of your own).

1) What do you think presents more of a health problem - HIV or Hepatitis?

2) Do you think clients at risk should be encouraged to have an HIV test?

3) What counselling skills are required for conducting health related counselling with at risk clients?

Guided study activity 2

Complete the MCQ (answers at the bottom of the page).

1 Laudanum is a concoction of: a) Alcohol & heroin b) Alcohol & morphine c) Alcohol & opium d) Alcohol & poesy

2 Kubla Khan was a poem written in an opiate haze by which drug using author: a) Samuel Taylor Coleridge b) Bram Stoker c) Robert Louis Stephenson d) Jean Cocteau

3 The Man with the Golden Arm was the first film to depict addiction after the relaxation of which code of censorship in 1951: a) The Waives Code b) The Hayes Code c) The Tales Code d) The Maize Code

4 There is evidence for a developmental causal pathway for addictive disorders based on what research: a) from randomised controlled trials (RCT) b) neurological research c) hereditary analysis d) single case study

5 Harm minimisation is not primarily concerned with which of the following: a) Crime reduction b) Reducing the spread of HIV c) Preventing more people using drugs d) Preventing drug associated fatalities

6 Since the harm minimisation became a central anchor for policy and treatment in the UK which one of the following statements is most accurate: a) Injecting drug users have been less likely to share b) Addicts have been more likely to enter into residential treatment c) More people have become addicted to drugs d) Needle exchange schemes have proved to be effective

7 In which country is there is some evidence that more liberal approaches to drug use can be effective when it comes to preventing drug related social related problems? Is it: a) Germany b) Belgium c) France d) Holland

8 The Drug Strategy Unit report 2005 estimates there are how many illicit substances misuers in the UK: a) 1,000,000 b) 3,000,000 c) 5,000,000 d) 10,000,000

9 In a randomised control clinical trial examining opiate withdrawal, Neuronal Electrical Therapy (NET) compared to methadone in terms of outcome of completed detoxification, was found to be: a) less effective b) more effective c) more expensive d) as effective

10 Which aspect of the programme at Thamkrabok most resembles the treatment philosophy of other successful programmes for addicts: a) the emphasis on peer support b) the use of meditation c) vomiting d) herbal tea

11 Clinical case work suggests which of the following statement is not true: a) drug users often have a fascination with death b) addiction is a consequence of a recreational use of drugs gone wrong c) drug misuse is a symptom of underlying problems d) drug use is a narcissistic disturbance

ANS: 1)b 2)a 3)b 4)d 5)c 6)c 7)d 8)b 9)d 10)a 11)b how did you do?

Guided study Activity 3

Obessive appetites - below is a link to an audio extract. Once you have listened to the extract consider the questions below here.

See you tube video

1. How does the anecdote resonate with your experiences of working with clients who have disordered appetites?

2. What do we understand of Mollie's emotional response to the client?

3. Think about one client who evoked a powerful response in you, where your capacity to maintain positive regard was challenged. Prepare a mini case narrative (like the one you have just heard) to bring to the Saturday PM workshop on addictive appetites.

Guided study 4

Case Presentation: prepare a mini case introduction where compulsion was a feature of client presentation. Your presentation should include i) background, where, when the client was seen, ii) key features of history, iii) any particular dilemmas or problems in relation to the case and the progress of therapy to date if current. You might want to use this case study in your essay.

HANDOUTS: please see reading pack.

Notes

Background

Levels of illicit drug use among young people in the UK are among the highest in the European Union (Hibbell et al., 2004). The rates of ‘ever cannabis use’ among respondents, aged 16 at time of interview in 2003, were 41 per cent for boys and 35 per cent for girls. The rates for use in the last 30 days were 23 per cent for boys and 16 per cent for girls. National surveys conducted among school pupils aged 11 to 15 in England found that the prevalence of taking any drugs was stable between 2001 and 2003 (Boreham and Blenkinsop, 2004). Prevalence of taking drugs in the last month was 12 per cent in 2003, while prevalence of taking drugs in the last year was 21 per cent, and the prevalence of having ever taken drugs was 30 per cent. Forty-two per cent of pupils had been offered drugs. The most commonly offered drug was cannabis (27%), followed by volatile substances (19%), poppers (12%), magic mushrooms (10%), crack (9%), cocaine (9%) and heroin (7%). Prevalence rates are strongly associated with age. At age 11, four per cent had taken drugs in the last month and eight per cent in the last year, compared with 23 per cent and 38 per cent of 15-year-olds respectively. In another series of school surveys from 1987-2005, Balding (2005) notes that over this time period young people (aged 11 to 15) are more likely to have been offered drugs (up to 53% of 14- to 15-year-olds in 2002) and have taken drugs (up to 33% of 14- to 15-year-olds in 1996). The surveys have also found that, as pupils get older, fewer think that cannabis is 'always unsafe'. On the other hand, in recent years young people have been less likely to know a drug user personally, or worry about drugs. Among the 16- to 24-year-old age group, the 2003/2004 British Crime Survey (Chivite-Matthews et al., 2005) indicates that around 2.8 million people in England and Wales have ever used any illicit drug and 0.5 million used a Class A drug in the last year.

REFERENCES:

Balding, J. (2005) Trends: Young People and Illegal Drugs. Attitudes to and experience of illegal drugs 1987–2004. Exeter: Schools Health Education Unit.

Chivite-Matthews, N., Richardson, A., O'Shea, J., Becker, J., Owen, N., Roe, S. and Condon, J. (2005) Drug Misuse Declared: Findings from the 2003/04 British Crime Survey England and Wales. London. Home Office Research Development and Statistics Directorate.

Boreham, R. and Blenkinsop, S. (2004) Drug use, smoking, and drinking among young people in England in 2003. London, The Stationery Office. (http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsStatistics/Publicatio

nsStatisticsArticle/fs/en?CONTENT_ID=4118153&chk=p9kEpR; accessed 08/02/2007). Hibell, B., Andersson, B., Bjarnason, T. et al. (2004) The ESPAD Report 2003. Alcohol

and other Drug use among students in 35 European Countries. Stockholm: The Swedish Council for Information on Alcohol and Other Drugs, The Pompidou group at the Council of Europe.

DUAL DIAGNOSIS

Although 'dual diagnosis' has become a clinically extant term, the literature about the aetiology of dual diagnosis has been fairly limited (Mueser et al, 1998). However, most people with dual diagnosis have been found to report their first mental disorder pre-dating their history of substance misuse (Kessler, 2004). This suggests that mental disorders, including those that have previously remitted, can be markers or causal risk factors for secondary substance use disorders. The phenomenon of primary mental disorder pre-dating substance misuse has leant impetus to the idea that substance misuse is sometimes a mechanism of self-medication for underlying psychiatric disorders. That is to say, an addict may use an illicit substance much in the same way that a patient may come to rely on prescribed anti-depressant medication in order to bring about long-term mood stabilisation. The 'self-medication' hypothesis emerged in the 1980s and has become clinically popular though there remains little consensus about clinically validity (Goswami et al, 2004). General models of aetiology in dual diagnosis coalesce around the idea that substance misuse is viewed either as the primary or secondary disorder though some models suggest substance misuse or mental disorder not in terms of precedent but rather as co-factors or bidirectional. Further clarification of aetiological factors, including the identification of subtypes of dual diagnosis, may have implications for developing more effective prevention efforts and treatment. It may be that depth psychology and psychoanalytic case analysis will be helpful in establishing clearer aetiological models to work from.

Rates of dual diagnosis seem to vary considerably. For instance in East Dorset, UK, Virgo et al (2001) found 12% of patients in addictions services and 12% of adult mental health patients in East Dorset were assessed to have a dual-diagnosis. Meanwhile Manning et al (2002) used a brief screening tool to detect problematic alcohol, drug use, psychosis and common mental health symptoms with two groups of patients in South London (50 substance misusers and 50 community mental health patients) dually diagnosing 92% of patients with a primary alcohol problem and 88% of those with a primary drug problem. 38% of the community mental health patients were also screened as meeting the criteria for dual diagnosis. In a psychiatric continuing care facility in a large Canadian city a cross-sectional survey with 207 successive outpatients found that nicotine, alcohol and cannabis were the most frequently abused substances (Margolese, 2004). Cocaine, heroin, hallucinogen, amphetamine, and inhalant use were rarely reported. Excluding nicotine, 45% of the patients met the criteria for substance misuse at some point during their lifetime (mainly alcohol and/or cannabis) while 14% were currently found to be misusing a substance. However, 69% of patients with a primary substance misuse diagnosis were found to be clinically depressed.

These different rates of dual diagnosis may point to geographical variations (urban, rural and national variations), although it is possible there are inconsistencies in screening tools that produce unlike results. The methodological inconsistencies in dual diagnosis studies have been highlighted by Todd et al (2004) in an extensive epidemiological case-control study with practitioners from generic mental health and substance misuse services (n = 2341) in Essex who were asked to assess dual diagnosis among their client group. The study highlighted that even pragmatic diagnostic criteria was subject to inter-relating time-frame variation (eg were problems still considered current) and there were basic core disagreements such as whether a personality disorder should be categorized as a 'mental health problem'. There were also disagreements about whether clients who were being treated primarily by Substance Misuse Services, but were also taking prescribed antidepressants, should necessarily be viewed as having a 'mental health problems' suggesting that the anti-depressant drugs were abused by some clients in the same way as illicit substances.

Among the adult mental patients alcohol and/or cannabis abuse seem to be the most common co-factor substances while among the patients with a primary substance misuse diagnosis, depression, social phobia and personality disorder are the commonest co-factors. For instance in a follow-up study with patients detoxified from alcohol, Ramsey et al (2004) found that during the first year 25% of the patients who remained abstinent from alcohol and drugs were diagnosed with a major depressive illness. And a cross-sectional survey of 615 current heroin users in Sydney found that 46% of the cohort met the diagnostic criteria for borderline personality disorder (BPD) and 71% for anti-social personality disorder (ASPD) (Darke, 2004). In another study gender differential in psychiatric and substance use comorbidity were assessed in 716 opioid abusers seeking methadone maintenance (Brooner et al, 1997). 47% of the men in the sample and 48% of the women were diagnosed with co-morbid disorders, the most common diagnoses being antisocial personality disorder (25.1%) and major depression (15.8%). It was noted that psychiatric comorbidity was associated with a more severe substance use disorder. Gender differentials were also examined in an Australian study of methadone maintenance patients (n=62) finding that 70% of males and 89% of females had a comorbid psychiatric illness (Callaly et al, 2001).

REFERENCES:

Brooner, RK; King, V L; Kidorf, M; Schmidt, C W Jr & Bigelow G E (1997) Psychiatric and substance use comorbidity among treatment-seeking opioid abusers. Archives of General Psychiatry. 54, 1: 71-80.

Callaly, T; Trauer, T; Munro, L & Whelan, G (2001) Prevalence of psychiatric disorder in a methadone maintenance population. Australian & New Zealand Journal of Psychiatry, 35, 5: 601-5

Darke, S; Williamson, A; Ross, J; Teesson, M & Lynskey, M (2004) Borderline personality disorder, antisocial personality disorder and risk-taking among heroin users: findings from the Australian Treatment Outcome Study (ATOS). Drug & Alcohol Dependence, 74, 1: 77-83

S, Goswami; S, K, Mattoo; D, Basu & G, Singh (2004) Substance-abusing schizophrenics: do they self-medicate? American Journal on Addictions 13, 2: 139-150

Kessler, R C (2004) The epidemiology of dual diagnosis. Biological Psychiatry, 56, 10: 730-7

V C, Manning; G, Strathdee; D, Best; F, Keaney; L, McGillray & J, Witton (2002) Dual diagnosis screening: preliminary findings on the comparison of 50 clients attending community mental health services and 50 clients attending community substance misuse services. Journal of Substance Use, 7, 4: 221-228

H C, Margolese; L, Malchy; J C, Negrete; R, Tempier & K, Gill (2004) Drug and alcohol use among patients with schizophrenia and related psychoses: levels and consequences. Schizophrenia Research 66, 2-3: 57-166.

K T, Mueser; R E, Drake & M A, Wallach (1998) Dual diagnosis: a review of etiological theories. Addictive Behaviors, 23, 6: 717-734

N, Virgo; G, Bennett, D; Higgins, L; Bennett & P, Thomas (2001) The prevalence and characteristics of co-occurring serious mental illness (SMI) and substance abuse or dependence in the patients of adult mental health and addictions services in eastern Dorset. Journal of Mental Health, 10 2: 175-188

Ramsey, S E; Kahler, C W; Read, J P; Stuart, G L & Brown, R A (2004) Discriminating between substance-induced and independent depressive episodes in alcohol dependent patients. Journal of Studies on Alcohol. 65, 5: 672-6

Todd, J; Green, G; Harrison, M; Ikuesan, BA; Self, C; Baldacchino, A & Sherwood, S (2004) Defining dual diagnosis of mental illness and substance misuse: some methodological issues. Journal of Psychiatric & Mental Health Nursing. 11, 1: 48-54.