This write up should be useful for anyone who comes into contact with people that use excessive amount of drugs, alcohol, or show addictive behaviours. Firstly, we will go through what addictive behaviours have in common, whether they rely on the use of drugs, or some other form of behaviour. We will then go through what happens in the brain when we use different drugs. After this we will discuss how continued drug use changes the brain, and our decision making. It is important to get a strong grounding in the biological basis of addiction so you can understand why specific treatments work. There is no one size fits all treatment for addiction, and people usually benefit from a combination of interventionS and support services. So in the final part we will step through the recovery pathway to show which treatment options are suitable in what phase of treatment.
There are several terms that we use alongside each other to, for example, describe alcohol use. Addiction, dependence, abuse, alcohol use disorder. The general public may use any of these, but they mean slightly different things to professionals. We will use the term addiction to describe compulsive use of drugs and alcohol. But of course it can describe behavioural addiction like gambling, game playing, and eating disorders as well.
Addiction is a disease that is characterized by several of the following. The need for more and more drugs to get the same effect, tolerance, hunger for drugs or rewarding experiences, craving, the inability to control the frequency and amount of use, loss of control, an excessive amount of time spent on drug use at the expense of other activities, continued use, even after clear problems arrive, and withdrawal symptoms or cessation of use. This shows that the addiction involves more than using a lot of drugs. The lack of control over the use is very prominent. Drugs change the way we perceive the world, how we make decisions, and in fact, reliance on a drug may create a biased view of what is important. They actually alter the brain itself. The body will start to expect a drug and adapt to the continued presence. Several of the biological signs of addiction, such as tolerance and withdrawal symptoms, are the result of this adaptation. Why can’t people just stop using? The effects of continued drug use on the brain result in drug-taking becoming a compulsive behaviour. Trying to stop using druga requires a high level of motivation and a change of behaviour that’s difficult to maintain. Relapse is common in people who try to quit, and addiction is similar to other chronic diseases in that respect. Why do only some people develop an addiction? Whether an addiction develops depends on the person, the drug, and the environment. We see that continued drug use increases impulsivity, increases compulsive behaviour, and reduces the capacity to plan. This, unfortunately, decreases the chance that you will make rational decisions around drug use, and may curb your use.
This is where the bio-psycho-social model comes in. So as you can see, there are three factors to examine -- biological, psychological, and social. Let’s starts with the biological. We all differ in how we experience drug effects, how bad the side effects are, and how we respond to when we stop cold turkey. Some people can, for example, stop using cigarettes after prolonged use, but most will experience withdrawal symptoms and cravings. Genes and neurobiological factors explain some of these differences, but there are many other important factors. Next, let’s look at social factors. These factors influence community, environment, connectedness, accessibility to drugs, and the likely acceptance of drug use. Important factors are, for example, social support, or social pressure, family background, and relationships. Other important social issues include income, job security, and the effects of poverty. The third group is psychological factors. These are things like coping skills, attitudes and perceptions which influence how likely you are to react to drug effects, and decide to start or continue drug use. We know, for example, that people who are thrill seekers are much more likely to try drugs. People with poor social skills or mental health issues are likely to use drugs to try to overcome or cope with difficulties they experience in daily life. The biological, psychological, and social factors interact, and it’s the combination of factors that results in a risk profile for an individual. All these factors work in both directions. They can reduce the risk of drug use, as well as increase the risk that a person will get into trouble with drug use. To summarize, addiction is a chronic disease. Using alcohol and other drugs doesn’t always result in addiction. Addiction is characterized by compulsive drug use. A complex interaction of biological, psychological, and social factors influences our chances to develop addiction.
I’ll show the different classes of drugs of abuse, identify which drugs are the most widely used in the world, and look at what kind of effect they have and why. We briefly look at how drugs affect the brain by disrupting normal neurotransmission and how the long-term exposure to drugs changes neurotransmission. We can group them as opioids, such as heroin and morphine, stimulants, such as methamphetamine, cocaine, MDMA or ecstasy, nicotine, and caffeine, cannabis, sedatives, such as alcohol, benzodiazepines, GHB or fantasy, hallucinogens, such as LSD and ketamine, and hazards, such as inhalants, solvents, and petrol. The top five in most countries are alcohol, nicotine, cannabis, stimulants, and opioids.
Drugs excite, relax, distort our sense of reality, or have a combination of these effects. Drugs cause an effect by affecting normal neurotransmission or a range of neuro chemicals in the brain, neurotransmitters. The way drugs are taken affects the time of onset of effects, but also the addictive potential. Most drugs of abuse cause an activation of the dopamine system in the brain. This is involved in the compulsive use of drugs. With repeated drug use, the magnitude of the effects reduces. We call this tolerance. People may keep chasing the initial rush, but they need more and more to experience it. Repeated drug use changes several neuro-chemical systems in the brain and body. It takes time to normalise when drug use has stopped, and some take a very long time to function normally again.
When a person has been using high levels of alcohol for an extended period of time, the brain adapts. It adapts to counter the continuing depressant effect of alcohol, but when you suddenly stop using alcohol, the brain can show hyper excitability. In some cases this can lead to a medical emergency. This is why it is important to assess the extent of someone’s use and dependence, and be mindful of unintended withdrawal, for example, during hospital admission or presence. To choose a suitable treatment we need to understand what has changed and how we can support recovery. We need to understand which withdrawal symptoms to expect, and how to support a client when they experience craving. So let’s starts with the first question. Why do we use drugs in the first place? People use drugs because they are looking for specific, immediate effects. They want to relax, get energy, or are looking for mind-altering effects. An additional effect of nearly all drugs of abuse is that they either directly or indirectly stimulate the mesolimbic dopamine system, which causes reinforcement of that behaviour. The shorter the time between the action and the effect, the stronger the link between the action and the feeling. The stronger the link, the more likely that you will do the same action again.
Drug use begins by choice. There are many risk and protective factors that influence that choice. For some people, drug use will remain controlled and at low levels, while for other people use will increase until a level is reached that could be called abuse or misuse. For various reasons individuals may increase or decrease their drug use and move up and down the left arm of the pathway shown in the graphic. If drug use is frequent for a sustained period of time, dependence may develop. Dependence occurs when the body becomes adapted to drug use. Dependence also involves drug use becoming a compulsive behaviour. People differ in the rate of recovery from dependence. People also vary in the type of intervention needed, and these needs are likely to change in the course of recovery.
The intoxicating effects of drugs, the effects that drug users are seeking, occur immediately. The negative effects -- hangovers, fights, overdoses, heart attacks, cancer -- occur later and might not happen at all. This makes it easy for people who use drugs to ignore the negative aspects of their drug use. Screening and brief interventions are about identifying drug use, helping drug users to gain insight into the consequences of their drug use, and to motivate them to take action to change their behaviour. For people who are not yet dependent, the aim of screening and brief intervention is to encourage them to reduce their drug use themselves.
There are many variations on the pathway to recovery and many different expectations of recovery. For some people, recovery means sustained abstinence from drug use. But this can seem an impossible goal to someone who is dependent, and focusing only on abstinence devalues other achievements. We define recovery as individuals achieving the highest level of autonomy of which they are capable. Recovery is not a linear process. It Is based on continual growth and improved functioning. People who are dependent may need a combination, or sequence of interventions to address both psychosocial and physiological dimensions of dependence.
Brief intervention should be personalised and offered in a supportive, non-judgmental manner. Guide the person with information, but don’t tell them what to do. The aim is to develop insight to motivate the person to take action for themselves. Clinical experience and research has shown that effective brief intervention shares some consistent features. These have been summarised using the acronym, FRAMES, which stands for Feedback, Responsibility, Advice, Menu of Options, Empathy, and Self-efficacy.
Shabir Ahmad is a UPSC aspirant from Raiyar Doodhpathri.
Disclaimer: The views and opinions expressed in this article are the personal opinions of the author. The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.