Slide 1: Time for thought...

• What are your values about substance abuse?  Do you think the criteria for diagnosis are too strict and exclude people who should be included?
• Are they too broad and vague, overdiagnosing "normal" behavior and pathologizing substance use?

Slide 2: Substance abuse: A problem with huge costs

• Costs Americans billions of dollars each year
• Kills 500,000 annually
• Implicated in a variety of serious social problems and crimes

Slide 3: Substance abuse: A problem with a cultural context

• Average consumption of alcohol in U.S. has decreased within recent years.
• Membership of AA doubled within the '80s, from 2% of Americans in 1979, to more than 5% in 1990 (Men: 8%, Women: 3%)
• Alcohol consumption is about 1/3 of what it was in early 1800s (Rorabaugh, 1991)
• Use of illicit drugs has dropped from 13.7% in 1979 to 5.8% in 1994 (U.S. Dept. of Health & Human Services, 1995)

Slide 4: Substance abuse (APA, 1994)

(A) A maladaptive pattern of substance use leading to clinically   significant impairment or distress (1+ in
      12 mo. period) & symptoms have never met criteria for Substance Dependence for this class of substance:
            (1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home;
            (2) recurrent substance use in situations in which it is physically hazardous;
            (3) recurrent substance-related legal problems;
            (4) continued substance use despite having persistent or recurrent social or interpersonal problems caused
                  or exacerbated by the effects of the substance.
(B) The symptoms have never met the criteria for Substance Dependence for this substance.
                                                                                                                p. 578

Slide 5: Substance dependence (APA, 1994)

A maladaptive pattern of substance use, leading to clinically significant impairment or distress (3+ in 12 mo. period):
            (1) tolerance (1+):
                    (a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect; or
                    (b) markedly diminished effect with continued use of the same amount of the substance;
            (2) withdrawal (1+):
                    (a) characteristic withdrawal syndrome for the substance; or
                    (b) same (or closely related) substance is taken to relieve or avoid withdrawal symptoms;
            (3) larger amounts of substance taken or longer period than intended;
            (4) persistent desire or unsuccessful efforts to cut down or control substance;
            (5) great deal of time is spent in activities necessary to obtain substance, use substance, or recover
                  from its effects;
            (6) important social, occupational, or recreational activities are given up or reduced because of substance use;
            (7) substance use is continued despite knowledge of having a persistent or recurrent physical or psychological
                  problem that is likely to have been caused or exacerbated by the substance.
                                                                                                                   p. 578

Slide 6: Problems with substance abuse work

• Addictiveness does not correlate well with our culture’s reactions towards a drug.
• Other things (internet, chocolate, sex) can meet the DSM definition of addiction
• Regier et al. (1990) suggests that more than 50% of people abusing substances have a second disorder
• Self-medicating?
• What are the effects of the drug & of the other disorder?

Slide 7: Questions to assess drinking behavior

• How do you feel when alcohol is not available? uncomfortable?  relieved?
• How does your drinking change when you're under stress?  fighting with people important to you?  depressed?
• How has your drinking changed since you first started drinking?  Are you in more of a hurry to get your first drink than you used to be?
• What feelings do you have about your drinking?  Do you sometimes feel guilty or out of control?  Do you make rules about what and when to drink?
• How do other people react to your drinking?  Do they see it as a problem?  talk about your drinking?
• How do you react to other people's opinions about your drinking?  Do you try to avoid certain people while drinking?  Do you try to hide your drinking?  Do you often regret things you did or said while drinking?
• How does your drinking affect other parts of your life?  your memory?  your work?  driving?  relationships?
Modified from Harvard Mental Health Letter, 8/96

Slide 8: Questions to ask a client's friends and relatives about alcohol use

• Of friends and relatives:
• What kinds of feelings do you have about this person's drinking?  Are you ever worried or embarrassed?
• How does she/he view her/his drinking?  as a problem?  normal?  Does she/he often promise to quit?
• How do you interact with others around the drinking?  Do you lie to conceal it?  Do you try to justify it?
• Has she/he ever had problems stemming from her/his alcohol use?  legal problems?  driven drunk?
• How are others reacting towards her/his drinking?  Do others talk about it?  How?
• How does she/he behave after a drunken episode?
Modified from Harvard Mental Health Letter, 8/96

Slide 10: Time for thought...

Pay attention to the factors that encourage people to use substances on college campuses (or don’t discourage use).  What, if anything, would you do about these?

Slide 11: Causes of substance abuse: Biological vulnerability

• Among men, both twin & adoption studies suggest genetic basis of alcoholism, contradictory evidence for women.
• Due to cultural limits on women’s drinking???
• Higher proportion of alcoholics have the DRD2 gene (Alcoholics: 67%, Non-alcoholics: 20%)
• Ability to metabolize alcohol.  Without aldrehyde dehydrogenase become ill.
• Absent in 30-50% of Asians, contributing to low rates of alcohol use in this population
• Vulnerability does not mean inevitability.
• Drug must be available.
• Person must choose to use the drug.
• Not everyone who uses drug and is vulnerable will become dependent.

Slide 12: One person’s story...

And that’s the thing: while addictive tendencies may very well be genetic, becoming an actual drug addict happens over time…The more barriers there are -- be they the cops or the hassle or the fear of dying -- the less likely you are to get addicted.
                                                                                                 Van Deventer, 2001, p. 14

Slide 13: Causes of substance abuse: Learning

• Positive reinforcement -- Use to get positive consequences
• Negative reinforcement -- Use to cope with unpleasant aspects of life.
• Only 12% of VN vets still using 3 years after returning to US
• Adolescents reporting  being lonely, crying, or tense were more likely to use drugs as a way of coping with feelings (Chassin et al, 1993)
• Cocaine addicts with ADHD:  When attention was improved with Ritalin, cocaine use dropped (Khantzian et al., 1984)
• Opponent-process theory -- With time, motivation for taking drug moves from search for pleasant aspects (A) to avoidance of aversive aspects (B)

Slide 14: Causes of substance abuse: Cognitive

• Use depends on our expectancies about substance
• If believe you're getting a drug (whether or not you are) and expect to be less inhibited, you are (Cooper et al., 1992)
• Survey of 7th & 8th graders of expectations about drugs and their use of them: Those expecting positive consequences are more likely to begin using them in the subsequent year.
• “Urges” to use drug predict relapse.

Slide 15: Causes of substance abuse: Cultural

• What are expectations for normal use within culture?
• Children of parents who use substances are more likely to use.
• Exposure to substance use?
• Normalization of substance use?
• Monitored less and likely to develop friends who use (Chassin et al., 1993)
• Conflicting messages about drug use

Slide 16: Can you abuse a prescribed drug?

• Interviewer: You met Elvis Presley.  How would you describe him?
• Richard Nixon: Some say, because he used drugs, he could not be an example to young people, but they overlook the fact that he never used illegal drugs, only drugs prescribed by his doctor.
From the videotape archives at the Richard Nixon Library,
Quoted in Delia Ephron (1995)

Slide 17:
My dear friend,
I had not intended to discuss this controversial subject at this particular time.  However, I want you to know that I do not shun a controversy.  On the contrary, I will take a stand on any issue at any time regardless of how fraught with controversy it may be.  You have asked me how I feel about whiskey.  Here is how I stand on the issue.
If, when you say whiskey, you mean the Devil’s brew; the poison scourge; the bloody monster that defiles innocence, dethrones reason, destroys the home, creates misery, poverty, fear; literally takes the bread from the mouths of little children; if you mean the evil drink that topples the Christian man and woman from the pinnacles of righteous, gracious living into the bottomless pit of degradation and despair, shame and helplessness and hopelessness; then certainly, I am against it with all of my power.
But, if when you say whiskey, you mean the oil of conversation, the philosophic wine, the ale that is assumed when great fellows get together, that puts a song in their hearts and laughter on their lips, and the warm glow of contentment in their eyes; if you mean Christmas cheer; if you mean that stimulating drink that puts the spring in the old gentlemen’s step on a frosty morning; if you mean the drink that enables the man to magnify his joy and his happiness and to forget, if only for a little while, life’s great tragedies and heartbreaks and sorrows; if you mean that drink, the sale of which pours into our Treasury untold millions of dollars which are used to provide tender care for little crippled children, our blind, our deaf, our pitiful aged and infirm; to build highways, hospitals, and schools; then certainly, I am in favor of it.  This is my stand, and I will not compromise.
Your congressman.
Congressman Billy Matthews in Marlatt, Larimer, Baer & Quigley, 1993, p. 462

Slide 18:
I began smoking (in Boy Scouts!) at age 11.  By the time I was a college freshman freed from the restrictions of school and home, my smoking had increased to a pack a day.  The seminal Surgeon General's Report Smoking and health was issued that year (1964), but I didn't notice.  The warnings that began appearing on cigarette packs a couple of years later were also easy to ignore, since I had grown up knowing that smoking was unhealthy.  As a graduate student and young professor I often smoked while leading class discussions, as had some of my favorite teachers.  That ended in 1980, when an undergraduate student, no doubt empowered by the anti-smoking movement, asked me to stop because smoke bothered him.  A few years later there were hardly any social situations left in which it was acceptable to smoke.  Even my home was no longer a refuge, since my children were pestering me to quit.  And so I did.  Now my status as a former smoker puts me in company with fully half of all who have ever smoked regularly and are alive today.  For many of us the deteriorating social environment for smoking made it easier to quit.
(Cook, 1993, p. 1750)

Slide 19: Twelve Steps of Alcoholics Anonymous

1. We admit we are powerless over alcohol -- that our lives had become unmanageable.
 2. We come to believe that a power greater than ourselves could restore us to sanity.
 3. We make a decision to turn our will and our lives over to God as we understand God.
 4. We made a searching and fearless moral inventory of ourselves.
 5. We admit to God, ourselves, and to another human being the exact nature of our wrongs.
 6. We are entirely ready to have God remove all these defects of character.
 7. We humbly ask God to remove our shortcomings.
 8. We made a list of all persons we had harmed, and became willing to make amends to them all.
 9. We made amends to all persons we had harmed whenever possible, except when to do so would injure
     them or others.
10. We continue to take personal inventory and, when we are wrong, promptly admit it.
11. Sought through prayer and meditation to improve our conscious contact with God, as we understand
      God, praying only for knowledge of God's will for us and the power to carry that out.
12. Having had a personal awakening as the result of these steps, we try to carry this message to alcoholics
       and to practice these principles in all our affairs.