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Indira Gandhi National Open University Mental Health in
School of Social Sciences Special Areas

Addictions
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"Education is a liberating force, and in our

age it is also a democratising force, cutting
across the barriers of caste and class,
smoothing out inequalities imposed by birth
and other circumstances. "
-Indira Gandhi
 MPC-053
Mental Health in
Indira Gandhi Special Areas
National Open University
School of Social Sciences

Block

4
ADDICTIONS
UNIT 1
Alcoholism 5
UNIT 2
Substance Abuse and Addiction 39
UNIT 3
Tobacco Addiction 67
UNIT 4
Gambling, Internet and other Addictions 85
Expert Committee
Prof. Vimala Veeraraghavan (Chairperson) Prof. Ram Ghulam
Former Emeritus Professor Head, Dept. of Psychiatry
Discipline of Psychology M.G. [Link] College Indore, M.P.
IGNOU, New Delhi Superintendent -Mental Hospital Indore
Prof. T. B. Singh Prof. Dinesh Kataria
Professor, Clinical Psychology Dept. of Psychiatry
Institute of Behavioural Sciences Lady Hardinge Medical College
Gujrat Forensic Sciences University New Delhi
Gujrat
Prof. R. C. Jiloha
Prof. B. S. Chavan Head, Dept. of Psychiatry
Head, Dept. of Psychiatry G.B. Pant &Maulana Azad Medical College
Govt. Medical College, Chandigarh New Delhi
Prof. R. K. Chadda Prof. M. Thirunavukkarasu
Dept. of Psychiatry, AIIMS President, Indian Psychiatric Society
Ansari Nagar, New Delhi Head, Dept. of Psychiatry, SRM Medical
College Hospital & Research Center, Chennai
Dr. Rajeev Dogra
Clinical Psychologist Dr. Swati Patra
Dept. of Psychiatry, PGIMS (Programme Coordinator)
Rohtak Associate Professor
Discipline of Psychology
IGNOU, New Delhi

Programme Coordinator Course Coordinator

Dr. Swati Patra Dr. Swati Patra
Associate Professor Associate Professor
Discipline of Psychology Discipline of Psychology
SOSS, IGNOU, New Delhi SOSS, IGNOU, New Delhi

Course Writer
Units 1, 2 and 3 Prof. Dinesh Kataria
Deptt. of Psychiatry
Lady Hardinge Medical College
New Delhi
Unit 4 Dr. Manoj Kumar Sharma
Associate Professor
Department of Clinical Psychology
NIMHANS, Bangalore
Block Editors
Unit 1& 2 Prof. R. C. Jiloha
Head, Dept. of Psychiatry
G.B. Pant &Maulana Azad Medical College
New Delhi
&
Ms. Nitasha Borah
Lecturer
Goa Institute of Management, Goa

Unit 3 Dr. Pankaj Kumar

Assistant Professor
Department of Psychiatry
IHBAS, Dilshad Garden, Delhi

Unit 4 Prof. R.K. Chadda

Psychiatrist, Dept. of Psychiatry, AIIMS
Ansari Nagar, New Delhi

Material Production
Mr. Manjit Singh
Section Officer (Publication)
School of Social Sciences, IGNOU
November, 2014
© Indira Gandhi National Open University, 2014
ISBN-978-81-266-
All rights reserved. No part of this work may be reproduced in any form, by mimeograph or
any other means, without permission in writing from the Indira Gandhi National Open
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BLOCK 4 ADDICTIONS
Introduction
Block 4 of MPC 053 deals with Addictions. Society is changing rapidly. Technology is
advancing in leaps and bounds. The values of the society alongwith personal values are
declining. People are indulging in various activities for example, taking recourse to alcohol,
tobacco and gambling that may have a negative repurcussions on themselves as well as
their family. With the advent of internet age, more and more youngsters are becoming
addicted to it that has an adverse effect on their physical as well as mental health.
In this Block 4 of MPC 053, we will be focusing on various types of addictions, their
characteristic features and intervention strategies to deal with these.
Unit 1 is about “Alcoholism”. The prevalence of alcoholism is increasing and it is affecting
our human resource negatively. Here you will be learning about the consequences of
alcoholism, assessment of alcohol addiction and treatment of it.
Unit 2 describes “Substance Abuse and Addiction”. It deals with the use of various
drugs/substance by people. The use and misuse of drugs is affecting our adolescents,
adult and the elderly also. In this Unit, you will learn about the types of drugs, symptoms
in various types of substance intoxication, and the treatment and management of
substance abuse and addiction.
Unit 3 is on “Tobacco Addiction”. In this Unit you will understand about tobacco and
nicotine dependence and its health hazards. The Unit will also discuss the causes,
assessment, and treatment of tobacco dependence.
Unit 4 deals with “Gambling, Internet and Other Addictions”.You will learn about the
characteristic features of various behavioural addiction. Gambling and internet addiction,
being the most prevalent, it is important that we understand their causes and assessment
[Link] Unit will also describe various intervention methods for dealing with
behavioural addictions.
UNIT 1 ALCOHOLISM
Structure
1.0 Introduction
1.1 Objective
1.2 Addiction and Dependence
1.3 Classification of Dependence Syndrome
1.4 Dual Diagnosis of Alcohol Abuse and Dependence
1.5 Consequences of Alcohol Abuse and Dependence
1.6 Etiology of Alcohol Abuse and Dependence
1.7 Assessment of Alcohol Abuse and Dependence
1.8 Treatment of Alcohol Problems
1.8.1 Psychological Approaches
1.8.2 Pharmacotherapy
1.8.3 Preventing Relapse

1.9 Let Us Sum Up

1.10 Answers to Self Assessment Questions
1.11 Unit End Questions
1.12 Suggested Readings and References

1.0 INTRODUCTION
Alcohol is one of the oldest drugs known to man. It has been an important part of world
cuisines and a consistent feature on occasions ranging from celebrations to funerals
across cultures. Yet, there have always been those who have been unable to restrict
their use of alcohol and have suffered grievous consequences as a result. These persons
are often referred to as ‘alcoholics’ in lay terms. The concept of alcoholism is best
understood in the context of ‘addiction’. The term addiction usually conjures up images
of alcoholics and other drug addicts who manifest physical and/or psychological need
for chemical substances. Such individuals rely on substances to function or feel good
(psychological dependence). When their bodies reach a state of biological adjustment
to the chronic presence of a chemical substance (physical dependence), they require
increasing amounts to achieve the desired effect (tolerance). When denied access to
their chemical elixirs, their bodies experience adverse effects (withdrawal), typically the
opposite bodily effects as those sought. In this Unit, you will understand about the
diagnosis, consequences, etiology and treatment for alcoholism.

1.1 OBJECTIVES
After studying this Unit, you will be able to:
 differentiate between addiction and dependence;
 describe classification of dependence syndrome;
 explain dual diagnosis of alcohol use disorder; 5
Addictions  describe the consequences of alcohol misuse;
 explain the etiology related to alcohol abuse and dependence;
 understand the effects of alcohol withdrawal syndrome;
 know the screening for alcohol problem and tool for assessment of dependence;
and
 discuss the treatment and management of alcohol problem.

1.2 ADDICTION AND DEPENDENCE

Researchers and clinicians traditionally limit ‘addiction’ to alcohol and other drugs. Yet,
neuroadaptation, the technical term for the biological processes of tolerance and
withdrawal, also occurs when substance-free individuals become addicted to pathological
gambling, pornography, eating, overwork, shopping, and other compulsive excesses
(Coombs, 2004).
Recent scientific advances over the past decade indicate that addiction is a brain disease
that develops over time as a result of initially voluntary behaviour. “The majority of the
biomedical community now consider addiction, in its essence, to be a brain disease,”
said Alan Leschner (2001), former Director of the National Institute on Drug Abuse
(NIDA);”a condition caused by persistent changes in brain structure and
function.”
Addiction is, thus, a disease in and of itself, characterized by compulsion, loss of control,
and continued use in spite of adverse consequences (Coombs, 1997; Smith & Seymour,
2001).
The primary elements of addictive disease are three Cs:
1) Compulsive use:an irresistible impulse; repetitive ritualized acts and intrusive,
ego-dystonic (i.e., ego alien) thoughts e.g. the person cannot start the day without
a cigarette and/or a cup of coffee. Evening means a ritual martini, or two, or three.
In and of itself, however, compulsive use doesn’t automatically mean addiction.
2) Loss of Control: the inability to limit or resist inner urges; once begun it is very
difficult to quit, if not impossible, without outside help. This is the pivotal point in
addiction. The individual swears that there will be no more episodes, that he or
she will go to the party and have two beers. Instead, the person drinks until he or
she experiences a blackout and swears the next morning to never do it again; only
to repeat the behaviour the following night. The individual may be able to stop for
a period of time, or control use for a period of time, but will always return to
compulsive, out-of-control use.
3) Continued use despite adverse consequences: use of the substance continues
inspite of increasing problems that may include declining health, such as liver
impairment in the alcohol addict; embarrassment, humiliation, shame; or increasing
family, financial, and legal problems.
Substance dependence is the term which formally replaced ‘addiction’ in medical
terminology in 1964 when the World Health Organizations Expert Committee on Drug
Abuse proposed that the terms addiction and habituation be replaced with the term
dependence and distinguished between two types- psychological dependence and
physical dependence. Psychological dependence refers to “the experience of impaired
6 control over drug use” while physical dependence involves “the development of
tolerance and withdrawal symptoms upon cessation of use of the drug, as a consequence Alcoholism
of the body’s adaptation to the continued presence of a drug event” (UNIDCP, 1998).
Dependence conditions include Alcohol use disorders which often present as other
psychiatric syndromes. The Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV), and the International Classification of Diseases, Tenth Revision
(ICD-10) provide diagnostic criteria for the phenotypes “alcohol abuse” and “alcohol
dependence.” These two distinct categories have replaced the term “alcoholism,” which
was first discarded in DSM-III (National Institute on Alcohol Abuse and Alcoholism,
1995).
Alcohol consumption and alcohol dependence make a substantial contribution to the
current global burden of disease and account for 4.6% of all global disability-adjusted
life-years lost to illness (Rehm, Mathers & Popova, et al. 2009).
There are several alcohol dependence typologies. Two of the most popular ones along
with their phenotypic characteristics are (Jellinek, 1960):
alpha: representing a purely psychological continued dependence without loss of control
or inability to abstain
beta: physical complications without physical or psychological dependence
gamma: acquired tissue tolerance, adaptive cell metabolism, physical dependence and
loss of control
delta: shares the first three features of gamma,but inability to abstain replaces loss of
control
epsilon: dipsomania or periodic alcoholism
Cloninger et al.1981; Sigvardsson et al.1996 have distinguished between Type 1 and
Type 2 alcoholism:
Type 1 alcoholism
 Age of onset over 25 years
 No criminality or treatment for alcohol problems in the biological parents
 Loss of control (or psychological dependence)
 Guilt and fear about dependence
 Harm avoidance
 Reward dependence
Type 2 alcoholism
 Teenage age of onset (under 25 years)
 Alcohol abuse, criminality and treatment are extensive in the biological father
 Inability to abstain
 Aggressive behaviour
 Novelty-seeking personality traits

7
Addictions
1.3 CLASSIFICATION OF DEPENDENCE
SYNDROME
There is high agreement for the dependence syndrome construct across the two
diagnostic systems- Diagnostic and Statistical Manual- IV-TR (American Psychiatric
Association, 2000) and International Classification of Diseases-10(World Health
Organization, 1992). The ICD-10 includes a strong desire or sense of compulsion to
use substances, impaired capacity to control substance use, a physiological withdrawal
state with withdrawal relief and avoidance, tolerance, a preoccupation with substance
use andpersistent substance use despite clear evidence of harmful consequences. DSM-
IV TR includes tolerance,withdrawal, a persistent desire for or unsuccessful effort to
control substance use, substances taken in larger amounts or over longer periods than
intended, time spent in obtaining substances, reduction in obligations and activities and
continued use despite knowledge about harmful consequences. DSM-IV TR does not
include craving or compulsion to take substances but concedes that craving (a strong
subjective desire to use the substance) is likely to be experienced by most (if not all)
individuals with substance dependence.
Diagnostic guidelines for Dependence Syndrome in ICD-10 (WHO, 1992)
A definite diagnosis of dependence should usually be made only if three or more of the
following have been experienced or exhibited at some time during the previous year:
a) A strong desire or sense of compulsion to take the substance;
b) Difficulties in controlling substance-taking behaviour in terms of its onset,
termination, or levels of use;
c) A physiological withdrawal state when substance use has ceased or has been
reduced, as evidenced by the characteristic withdrawal syndrome for the substance;
or use of the same (or a closely related) substance with the intention of relieving or
avoiding withdrawal symptoms;
d) Evidence of tolerance, such that increased doses of the psychoactive substance
are required in order to achieve effect originally produced by lower;
e) Progressive neglect of alternative pleasures or interests because of psychoactive
substance use, increased amount of time necessary to obtain or take the substance
or to recover from its effects;
f) Persisting with substance use despite clear evidence of overtly harmful consequence,
such as harm to the liver through excessive drinking, depressive mood states
consequent to periods of heavy substance use or drug related impairment of
cognitive functioning; efforts should be made to determine that user was actually,
or could be expected to be, aware of the nature of extent of the harm.
The ICD-10 has opted for the newer concept of “Harmful Use” to define those individuals
who do not satisfy the definition of dependence syndrome and yet, do have problems
due to substance use. Harmful Use has been described as “a pattern of psychoactive
substance use that is causing damage to health, the diagnosis requiring that actual damage
should have been caused to the mental or physical health of the user.

8
 Alcoholism
1.4 DUAL DIAGNOSIS OF ALCOHOL ABUSE AND
DEPENDENCE
Drinking problems are complicated by a variety of concomitant problems. Of significance
is the comorbidity of alcohol use disorders with other psychiatric diagnoses. A high
percentage of those diagnosed with alcohol abuse or dependence also experience other
psychological problems, which may be antecedent to, concurrent with, or consequent
to their drinking. The most common Axis I disorders are other psychoactive substance
use disorders, depression, and anxiety disorders, occurring in up to 60% of males in
treatment. The most common Axis II disorder comorbid with alcoholism in males is
antisocial personality disorder, with rates ranging from 15 to 50%. Females more often
present with depressive disorders; 25 to 33% of women with alcoholism experience
depression prior to the onset of their alcoholism (Rosenthal &Westreich, 1999).
Bipolar affective disorder poses a particular risk of alcohol misuse, as does
schizophrenia, which is associated with patients being three times more likely to abuse
alcohol than those without it. In general, comorbidity leads to more frequent recurrence
of mental disorder, greater time spent in hospital and increased violence, homelessness
and family disintegration. Some important clinical issues to emerge from these findings
include that often substance use or misuse is not limited to one substance. Also, the
distinction as to whether a psychiatric disorder preceded or is the result of substance
use disorder can be difficult to make. It is important to recognise the role of early
childhood psychiatric disorder and the likelihood that this might predispose to substance
misuse in later life.
The terms comorbidity, dual diagnosis and coexisting/co-occurring substance
problems and psychological disorder are used [Link] may
present itself in a range of combinations and permutations, including the following:
i) Substance use – even one dose – may lead to psychological symptoms or psychiatric
syndromes.
ii) Harmful use may produce psychiatric symptoms.
iii) Dependence may produce psychological symptoms.
iv) Intoxication by a substance may produce psychological symptoms.
v) Withdrawal from substances may produce psychological symptoms.
vi) Substance use may exacerbate a preexisting psychiatric disorder.
vii) Psychological morbidity not amounting to a “disorder”may precipitate substance
use.
viii) Primary psychiatric disorder may lead to substance use disorder.
ix) Primary psychiatric disorder may precipitate substance use disorder, which may
in turn lead to psychiatric disorder.
Self Assessment Questions 1
1) Mention the primary elements of addictive disease.
.....................................................................................................................
.....................................................................................................................
9
Addictions .....................................................................................................................
.....................................................................................................................
2) Distinguish between Type 1 and Type 2 Alcoholism.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
3) Dual diagnosis is also known as co-morbidity. True False

1.5 CONSEQUENCES OF ALCOHOL ABUSE AND

DEPENDENCE
The physical complications of alcohol use are numerous. The health risks relate to the
pharmacological effects of alcohol, withdrawal, toxicity and deficiency syndromes as a
result of chronic abuse and from secondary effects such as domesticviolence and injury
resulting from drunk-driving offences. Psychological consequences of alcohol misuse
are also severe.
i) Effects on the central nervous system
Alcohol acts as a blocker of messages transmitted between nerve cells in the central
nervous system. There is no absolute threshold for blood alcohol concentrations below
which there is no impairment of complex psychomotor skills. At blood alcohol
concentrations (BAC) of 25 mg%, euphoria is apparent, lack of co-ordination occurs
at levels of 50 to 100 mg% and unsteadiness, ataxia, poor judgement and labile mood
are observed at 100 to 200 mg%. At 200 to 400 mg%, the drinker may be in a stage
1 anaesthetic state, with periods of amnesia. Intoxication can lead to death from coma
and respiratory depression at 400 to700 mg%. Acute intoxication with alcohol may
result in coma or death resulting from CNS depression, leading to respiratory depression
and cardiovascular collapse. Intoxicated patients are at an increased risk for other
traumatic and medical pathologies that may precipitate or be exacerbated by head
injury, infection or hypoglycaemia, which must be ruled out or appropriately treated.
The effects of raised alcohol levels are modified by age, sex and degree of alcohol
dependence; a high level of tolerance is indicated by high alcohol levels associated with
low levels of apparent impairment.
ii) Effects of alcohol withdrawal syndromes
These may be precipitated by a variety of circumstances,including lack of money to
purchase alcohol, acute illness or injury, nausea and vomiting or a decision to stop
drinking. Alcohol withdrawal syndromes(AWS) can be classified by severity into
mild,moderate or severe. In clinical practice,severity is often seen to present along a
continuum from mild tremor through to delirium and convulsions.

10
 Alcoholism
Table 1: Alcohol withdrawal severity
Mild alcohol withdrawal Occurs less than 24 hours after stopping or
decreasing alcohol intake. It may include
tremulousness, anxiety, nausea, vomiting,
sweating, hyperreflexia and minor autonomic
hyperactivity( sweating, tachycardia)
Moderate alcohol withdrawal An intermediate position along the continuum
with the hallmark of hallucinosis but an otherwise
clear sensorium
Severe alcohol withdrawal Occurs more than 24 hours and up to 5 days
after stopping agitation, hallucinations and
severe autonomic derangement. Seizures may
also be secondary to intoxication or trauma or
as a toxic effect of alcohol. It is characterized
by disorientation.
iii) Neurological nutritional deficiency syndromes
The initial presentation of nutritional deficiency in alcohol abusers may be of peripheral
neuropathy and cardiovascular disorder, for example, hypotensionor high-output cardiac
failure (e.g. beriberi) in combination with oral inflammation, and this is the result of
thiamine deficiency. Pellagra (niacin and protein deficiency) and scurvy (vitamin C
deficiency) are less common.
The most important presentation of nutritional deficiency is the Wernicke-Korsak off
syndrome(WKS), which is consequent on thiamine deficiency. Wernicke’s
encephalopathy (WE) and Korsakoff’s Psychosis (KP) are both part of this syndrome.
Alcoholic cerebellar degeneration presents as gross ataxia, and the pathology is that of
cell loss. It may respond to thiamine in the early stages. Central pontinemyelinolysis and
Marchiafava-Bignami syndrome are rare conditions, results from demyelination.
iv) Liver disease and gastrointestinal disorder
The spectrum of liver disease is not uniform but can be described under three main
headings: fatty liver, alcoholic hepatitis and cirrhosis. In reality, there is considerable
overlap in the clinical setting. Alcoholic fatty liver results from the inhibition of oxidation
of fatty acids combined with an increased in generation of triglycerides. The effects can
be reversed within a few weeks of abstinence from alcohol. Fatty liver is generally
asymptomatic and may in the early stages produce no changes in liver function tests
other than those related to the direct effect of the alcohol on liver function. It may,
however, present with right abdominal pain, nausea and vomiting, which resolve on
abstinence. Alcoholic hepatitis and cirrhosis result from chronic alcohol abuse. Alcoholic
hepatitis produces liver cell necrosis and inflammation. The clinical presentation is with
jaundice, pyrexia, right abdominal pain, ascites and possible encephalopathy. In patients
with poor liver function and a prothrombin time prolonged to a degree which precludes
liver biopsy, the prognosis is poor, with a third of patients dying in the acute episode.
Severe acute alcoholic hepatitis has a poor outcome with standard supportive
management. Cirrhosis involves a permanent loss of liver cells,which are replaced by
fibrosis with loss of the normal liver architecture. It may be asymptomatic or present
with gastrointestinal symptoms, ascites, encephalopathy and oesophagealvarices, which
may cause haemorrhage. Acute and chronic pancreatitis and gastritis and peptic ulcer
are other gastrointestinal consequences of alcohol abuse. 11
Addictions v) Cancer
Chronic alcohol consumption is a strong risk factor for cancer in the oral cavity, pharynx,
hypopharynx, larynx and oesophagus and is also a major aetiological factor in
hepatocarcinogenesis. Alcohol also increases the risk for cancer of the colorectum and
the breast.
vi) Cardiovascular disease
The effects of alcohol on the cardiovascular system are well documented and range
from the protective effects of light drinking for ischemeic stroke and coronary disease
through to the increased risk from heavy drinking for haemorragic stroke,
cardiomyopathy, hypertension and cardiac arythmias.
vii) Reproductive disorders
In premenopausal female alcoholics, there is an increase in the frequency of menstrual
disturbances, abortions and miscarriages and infertility. Regular consumption of alcohol
during pregnancy may affect the foetus. The abnormalities range from growth retardation
to foetal alcohol syndrome (FAS).Children with FAS have reduced body weight and
height, are hyperactive and have subnormal intelligence. Their faces may be recognized
by short palpebral fissures, short upturned noses, mid facial hypoplasia, low nasal bridge
and a thin upper lip.
Studies of male alcoholics have reported that alcohol consumption may affect
spermatogenesis and spermiogenesis and cause reduced sperm counts.
viii) Psychological and behavioural consequences
Alcohol abuse and dependence leads to maladaptive behaviours in the individual and
has negative effect on the interpersonal relationships. It hampers fulfilling the person’s
personal, family and social responsibilities. It also lowers the person’s self esteem and
confidence. Irritability, lack of motivation, depression, anxiety, aggressiveness
characterize the individual.
The effects of heavy drinking can be insidious and debilitating. It affects the immediate
family and the self in a negative way. Even though major medical conditions may not be
present, many people eat poorly when drinking, which results in nutritional deficits,
poor energy, or vague and diffuse physical discomfort. Long term effects of alcohol
abuse can have serious consequences. Mortality rates among persons of all ages are
elevated with alcohol dependence, and are higher among women than among men.

1.6 ETIOLOGY OF ALCOHOL ABUSE AND

DEPENDENCE
Genetic factors : Genetics appear to have a major role on how the brain responds to
and processes psychoactive substances (Smith & Seymour, 2001).
Familial transmission of alcohol consumption and dependence has been observed since
antiquity (Devor&Cloninger, 1989). Formal genetic studies of different populations
have revealed that genetic factors contribute an estimated 40–60% of the variance in
liability to alcohol dependence (Lynskey, Agarwal & Heath, 2010; Kendler, Chen,
Dick et al. 2012). Since family members share some of their genes as well as important
aspects of their environment, adoption and twin studies are conducted to distinguish
between environmental and genetic factors,. Family and twin studies reveal that parental
12 alcoholism is 6 times more likely and alcoholism is more common in twins, both mono
and dizygotic. Studies show that twin children living in foster homes tend to share abuse Alcoholism

or abstinence patterns similar to their biologic parents’ (Goodwin, 1976), and there is
evidence that if both biological parents are alcoholic, the child is about 400% more
likely to be alcoholic (Inaba & Cohen, 2000).
Longitudinal formal genetic studies have shown that the relative influence of genetic and
environmental risk factors on AD and alcohol-related phenotypes fluctuates over time
(Rose, Dick, Viken, et al. 2001; Dick., Pagan, Viken, et al. 2007; Kendler, Schmitt,
Aggen, et al. 2008). Research has revealed alternation between periods in which genetic
influences predominate and periods in which environmental influences are more
dominant. A detailed longitudinal study by Kendleret al. (2008) showed that
environmental influences on alcohol consumption were highest in adolescence. This
finding suggests that adolescence may be the optimal time point for educational
interventions.
Psychological Theories:A variety of theories relate to the use of alcohol to reduce
tension, increase feelings of power, and decrease the effects of psychological pain.
Psychodynamic Theories: Psychoanalytic approach view the alcoholic as an oral
dependent personality fixated at the oral stage of development. Lack of fulfillment of
the basic need for oral gratification leads the person to become dependent on alcohol.
This approach also advocates that some persons may use alcohol to help them deal
with self-punitive harsh superegos as a way of decreasing unconscious stress levels.
Wurmser (1984-85), for example, views the use of alcohol or drugs as an attempt to
escape from intense feelings of rage and fear arising from severe intra-psychic conflict
due to an overly harsh superego.
Behavioural Theories: Behavioural principles do go a long way toward explaining
the addictive processes, even though chemically dependent people have varying
personalities. For instance, positive reinforcement, something pleasurable happening
after a behaviour occurs that makes repeating a behaviour more likely, can happen
when people get high or when they feel relaxed and joyful while using substances. This
may not happen every time that a person uses. A reinforcement that doesn’t occur
regularly is often referred to as being on a variable or intermittent (random or
unpredictable) schedule. Behavioural researchers have determined that a variable
reinforcement schedule produces behaviour patterns more difficult to change than
behaviour patterns reinforced on a regular basis. This occurs because a person cannot
predict which use will be rewarded, so, just like gambling, a person keeps using in
hopes this will be the time he or she will hit the euphoric jackpot.
In the same way, using substances can be negatively reinforcing for a person. Negative
reinforcement occurs when an activity removes an aversive event or consequence,
therefore making it more likely that the behaviour will be repeated (just like positive
reinforcement). Sometimes this involves lifting a punishment and other times it might
involve removing nasty physical symptoms, such as drinking to beat a hangover or
using to avoid the chills. Negative reinforcement also can occur on a variable or intermittent
schedule, meaning that sometimes the use alleviates the nasty symptoms, but not always.
Addiction can develop as a result of these powerful behaviour patterns (desiring pleasure
and avoiding discomfort) reinforced in a random and unpredictable way. The compulsion
to use may arise as a conscious choice to seek highs and avoid lows, but eventually, the
behaviour takes on a life of its own as reinforcement becomes less predictable.

13
Addictions
Reinforcement Schedules and Using Substances
Continuous reinforcement means that it occurs regularly after every use, which
becomes less likely as tolerance develops.
Intermittent or variable reinforcement is more likely after tolerance develops, which
occurs in a random and unpredictable fashion that keeps the person coming back for
more.
Chemically dependent people likely are experiencing both intermittent positive
and negative reinforcement, since the substance sometimes makes them high, takes
away withdrawal, and self-medicates (but not always).
Self-medication also can be thought as negative reinforcement. The person may use the
substance to relieve aversive psychiatric or physical symptoms, such as depression,
anxiety, or chronic pain. More often than not, the substance use may actually make the
symptoms worsen over the long term. However, since using had been negatively
reinforced at times by relieving symptoms, the patient may continue the use of substances
to self-medicate, even if the substances make the symptoms worse.
In the typical classical conditioning paradigm, the development or “learning” of drinking
behaviour occurs through repeated pairings of: (1) a conditioned stimulus (CS), such as
a particular person and an unconditioned stimulus (US), such as a particular location or
time of day with (2) alcohol consumption. After repeated pairings, a conditioned response
(CR) develops where exposure to the CS or US results in the CR (drinking behaviour).
This model has been postulated to explain the initial development and maintenance of
craving and conditioned tolerance (both conditioned responses), for alcohol as well as
other drugs (Wikler, 1973; Siegel, 1983).
Social Learning Model : Social learning theories focus on cognitive constructs such
as expectancies, self-efficacy, and attributions to mediate the pathway from stimuli to
alcohol use as a response. Expectancies of the positive effects from using alcohol develop
as conditioned cognitions from repeated classical or operant pairings of alcohol use
with a positive experience (i.e., reinforcement). Self-efficacy refers to the expectation
by individuals that they can successfully perform a particular coping behaviour in certain
situations and that the behaviour will be reinforced. The Social Learning viewpoint
describes alcoholism as a result of a failure to cope. The self-efficacy for coping without
alcohol is low among alcoholic individuals, contributing to continued use and the eventual
development of dependence. Petraitis, Flay, and Miller (1995) have postulated a social
learning theory model of adolescent experimentation and the eventual problem use of
alcohol and other drugs.
Sociocultural Theories : Sociocultural theories are often based on observations of
social groups that have high and low rates of alcoholism. Theorists hypothesize that
ethnic groups such as Jews that introduce children to modest levels of drinking in a
family atmosphere and that eschew drunkenness have low rates of alcoholism.
Some other groups such as Irish men, with high rates of abstention but a tradition of
drinking to the point of drunkenness among drinkers, are thought to have high rates of
alcoholism. However, these theories often depend on stereotypes that are frequently
erroneous and there are several exceptions to these rules. For example, some theories
based on observations of the Irish and the French would have predicted high rates of
alcoholism among the Italians, although alcohol problems are not generally observed at
a high level in this group.
Childhood behaviour problems : Various studies indicate that childhood problem
14 behaviour and aspects of a child’s temperament may predict both behaviour problems
and problems with alcohol and substance abuse during adolescence and young Alcoholism
adulthood. An association between behavioural problems (i.e., conduct problems,
attention deficit disorder, and hyperactivity) occurring in childhood and adolescence
and consequent poor adult outcomes, including alcoholism, has been found in a variety
of samples, including child guidance clinic subjects (Robins, 1966), community samples
(Jones, 1968), and among adopted individuals at risk for alcoholism (Cadoret et al.,
1995).For many, these alcohol use disorders persist into young adult life and possibly
beyond (Rohde et al., 2001).
Temperament : While considerable research has shown that a predisposition to
alcoholism is partially due to genetic factors, several studies suggest that this genetic
susceptibility may be expressed, in part, through an individual’s temperament. Tarter
and Vanyukov (1994), for example, propose a temperament model of alcoholism risk
based on five temperament traits that increase an individual’s likelihood for developing
alcoholism.
These traits include behavioural activity level, sociability, attention span/persistence,
emotionality, and soothability. Genetics influence each of these five traits, and an
individual’s likelihood is increased or decreased by the deviation of each trait from the
population norm. Thus, individuals whose personality traits are closer to the population
norm are thought to have more control over their own behaviour, including substance
use. Individuals who have difficulties with behavioural and emotional regulation may be
more prone to developing alcoholism in relation to environmental influences and stressors,
including seeking environments conducive to alcohol and drug use. Indeed, each of
these traits, or trait clusters, that constitute a “difficult” temperament relate to an increased
risk for developing a problem with substance use and/or abuse (Ohannessian &
Hesselbrock, 1995; Tarter, Kabene, Escallier, Laird, & Jacob, 1990). It should be
noted, however, that prenatal, peri-natal, and neonatal circumstances can have profound
and persistent influences on temperament, as well (e.g., maternal stress and prenatal
exposure to stress hormones; medications delivered during pregnancy and/or delivery;
anoxia; hypoxia; birth trauma; child maltreatment; etc.).
Environmental risk factors : The pressures and influences of environment, particularly
home environment, neighbourhood and school environment have an impact on the use
of alcohol by the individual. The environmental influences can be positive or negative
and as varied as stress, love, violence, sexual abuse, nutrition, living conditions, family
relationships, health care, school quality, peer pressure and television that may lead to
alcohol abuse and dependence.
Environmental factors that play a part in the etiologyof drinking behaviour may be divided
into those factors that influence the availability of alcohol and those that render the
individual vulnerable to the use and abuse of alcohol. In a comparison of risk and
protective factors for adolescent substance use between the United States and Australia,
common risk and protective factors for the use of alcohol were identified as :
Risks
 Community norms favourable toward alcohol use
 Perceived availability of alcohol
 Poor family management
 Family history of substance use
 Parental attitudes favourable to alcohol use 15
Addictions  Favourable attitudes toward antisocial behaviour
 Favourable attitudes toward alcohol use
 Friends’ alcohol use
 Sensation seeking
 Antisocial behaviour
Family interaction : Positive parental attitudes to alcohol and drug use have a major
influence in shaping use in children. Where one or both parents abuse alcohol, families
manifest higher levels of conflict, disruption, economic difficulties, breakdown and
impaired mother-child attachment. In addition, problem drinking by parents may lead
to inconsistent and unpredictable parenting behaviours and contribute to poorer
monitoring of adolescent behaviour. A history of unfair, inconsistent and harsh discipline
by parents predicts both alcohol and depressive disorders.
Frequently, more than one member of the nuclear or extended family experiences a
substance dependency. This complicates the identification of specific influences that
family environment, child-rearing practices, or inter-parental interaction may play in the
development of alcoholism. Three general contemporary models of family influences
can be identified: a family disease model, a family systems model, and a behavioural
family approach (McCrady& Epstein, 1996; McCrady, Kahler, & Epstein, 1998).
The family disease model is based on an assumption that all family members suffer from
some degree of either alcoholism or codependency. Further, alcoholism and
codependency are interrelated in such a manner as to enable (perpetuate) the alcohol
problem. Although in this model the specific etiology is regarded as biological, alcoholism
is being maintained by the family disease (Sheehan & Owen, 1999).
In the family systems model, the etiology of alcoholism and substance abuse is focused
on the behaviour of family members around drinking, with particular attention paid to
the family of origin and the role of the spouse/partner (O’Farrell &Fals-Stewart, 1998;
Steinglass, Bennett, Wolin, & Reiss, 1987; Steinglass, Weiner, &Mendelson, 1971).
The model assumes that, over time, alcohol use stabilizes the family system and that the
family organizes their interactions and structure around alcohol use to achieve and
preserve system ‘homeostasis.’ In other words, the family maintains the alcohol problem
despite the associated problems because it is requires less effort than changing or because
it allows the family to avoid changing a more disturbing problem (e.g., sexual abuse).
The behavioural family approach focuses on the family members’ behaviours (especially
those of the spouse/partner), as both antecedents to and reinforcers of, alcohol or
substance use. These responses are thought to help develop and maintain the drinking
problem. Bennett and Wolin (1990) found that continuing interaction between adult
offspring and their alcoholic parents is associated with increased rates of alcoholism, at
least among the male offspring. On the other hand, certain family rituals, such as eating
dinner together or celebrating holidays together, may serve to protect offspring against
the development of alcoholism (cf. Bennet et al., 1987). It is important to note that
family member behaviour can influence the alcoholic individual to consider change, act
to change, maintain the change, or relapse to drinking (Walitzer, 1999).
Peer affiliation : Adolescents with alcohol- and drug-using friends are more likely to
use the same substances. Some adolescents may self-select into high risk groups because
of high levels of risk-taking and novelty-seeking [Link] often cite an
16 increased ability to socialize with friends, reducing tension and anxiety (especially in
mixed gender situations), reducing boredom, and/or getting high as reasons for their Alcoholism
alcohol and other substance use. Peer influences are consistently cited as risk factors
for initiating alcohol, tobacco, and other drug use among children and adolescents (cf.
Kandel & Yamaguhi, 1999; Wills, Vaccaro, & McNamara, 1992; Averna &
Hesselbrock, 2001). Peers influence adolescents’ values, behaviours, attitudes, and
choice of other friends. However, the closeness of the specific peer relationship is an
important determinant of the strength of peer influences on drinking behaviour. Alcohol
use by an adolescent’s best friend is more predictive of alcohol use and maintenance of
drinking behaviour than reports of use by other friends. Characteristics of peers may
also be relevant.
Employment : Certain occupations carry a higher risk of alcohol related problems.
These include being a publican, where there is easy access to alcohol, and in professions
such as law, where income and social pressure facilitate drinking . The level of stress in
a work environment may also contribute to risks for high alcohol intake. Unemployment
also has been suggested as a causative factor for heavy drinking.
Culture : Social and cultural factors associated with increased risk of alcohol problems
include permissive alcohol legislation such as lower age of legal drinking, greater
availability of alcohol and greater socioeconomic deprivation. The acceptance or
otherwise of drunken behaviour by societies shows great [Link] variations are
culture-bound, but there are historical examples of cultures in which changes in the
behaviours that are seen as acceptable have occurred over time.
It can be seen from the above discussion that alcohol use and abuse is best viewed
through the framework of a multifactorial biopsychosocial model, which acknowledges
the interplay of genetic, familial, physiological, psychological and social factors. Age,
role, sex, social group and peer pressure, the family, community and occupational
environment, as well as overall cultural values and controls on alcohol use, will act upon
drinking behaviour. The individual’s genetic makeup, personality, sense of control and
efficacy, degree of dependence, the presence of brain damage or psychiatric problems,
reaction to internal and external cues or stimuli, financial state and the values of a treatment
programme will all affect attempts to change drinking behaviour.
Self Assessment Questions 2
1) What is the most pertinent nutritional deficiency in alcohol abuse and dependence?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
2) Describe the features of Fetal Alcohol Syndrome.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
3) How does the family system model explain the etiology of alcoholism?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
17
Addictions
1.7 ASSESSMENT OF ALCOHOL ABUSE AND
DEPENDENCE
Assessment is not a one time phenomenon. This is carried out at various stages. Thus,
the stages of assessment include:
a) Preintervention: where the purpose of assessment is to define the problem, formulate
treatment, select an appropriate treatment from various modalities and motivate
clients for treatment.
b) Intervention: here assessment is done to monitor progress
c) Post intervention: assess maintenance and abstinence status.
Depending on the reasons for assessment and the settings in which the assessment is
being carried out (inpatient v/s outpatient), there can be various levels of assessment.
This can range from brief screening and basic assessment for diagnosis to specialized
assessment for taking clinical decision regarding treatment and re-assessment for
continuing care.

(Rao. Mohan &Lal, 2005)

The key to appropriate management is a thorough history, proper physical examination,

neuropsychiatric examination and relevant lab- investigation. Important aspects from
the alcohol use misuse perspective are as follows:
Phase 1 – Ask
i) Ask all patients about alcohol and other substance misuse, including prescribed
and over-the counter medications.
Clinical indicators for screening include:
 Patients who are pregnant or trying to conceive.
 Patients who are likely to drink heavily, such as smokers, adolescents, and
young adults.
 Patients who have health problems that might be alcohol induced, such as
cardiac arrhythmia, dyspepsia, liver disease, depression or anxiety, insomnia,
trauma.
 Patients have a chronic illness that isn’t responding to treatment as expected,
such as chronic pain, diabetes, gastrointestinal disorders, depression, heart
disease, hypertension.
ii) Differentiate between alcohol use, harmful use and dependence.
iii) Conceptualise assessment as ongoing and not necessarily “one-off” and record
the information.
iv) Recognise that the manner and style in which this is done can be a powerful
18 determinant of both the extent to which relevant information is elicited and
 engagement with the therapeutic process. It’s often best to ask about alcohol Alcoholism
consumption at the same time as other health behaviours such as smoking, diet,
and exercise. Some clinicians have found that prefacing the alcohol questions with
a non threatening opener such as “Do you enjoy a drink now and then?” can
encourage reserved patients to talk. In some situations, you may consider adding
the questions “How often do you buy alcohol?” and “How much do you buy?” to
help build an accurate estimate.
v) Be aware of, and sensitive to, the ambivalence alcohol-misusing patients may feel.
vi) Be nonjudgemental and act in a non-confrontational way.
Phase 2 – Assess
i) Assess the degree of dependence.
ii) Use the assessment process to educate patients about the effects of alcohol.
iii) Inform about withdrawal symptoms.
iv) Make some assessment of the level of motivation or “stage of change” at which
the patient may be.
Phase 3 – Advise
i) Continue the assessment within a brief 5- to 10-minute “motivational interviewing”
framework.
ii) Provide the patient with the opportunity to express anxieties and concerns.
iii) Offer personalised feedback about clinical findings, including physical examination
and biochemical and haematological tests.
iv) Discuss and outline the personal benefits and risks of continued drinking and safe
levels of drinking.
v) Provide self-help materials (e.g. manuals).
Phase 4 – Assist
i) Provide support and encouragement and instill positive expectations of success.
ii) Acknowledge that previous attempts may have engendered loss of confidence
and self-esteem.
iii) Suggest that if the goal is abstinence, a “quit date” is set, so the patient can plan
accordingly to rid of any alcohol in the house and safely (is it safe to stop drinking
abruptly or not?).Certain conditions warrant advice to abstain as opposed to cutting
down. These include when drinkers:
 are or may become pregnant
 are taking a contraindicated medication
 have a medical or psychiatric disorder caused by or exacerbated by drinking
 have an alcohol use disorder
If patients with alcohol use disorders are unwilling to commit to abstinence, they may
be willing to cut down on their drinking. This should be encouraged while noting that
abstinence, the safest strategy, has a greater chance of long-term success.
For heavy drinkers who don’t have an alcohol use disorder, use professional judgment
to determine whether cutting down or abstaining is more appropriate, based on factors
such as these:
 a family history of alcohol problems 19
Addictions  advanced age
 injuries related to drinking
 symptoms such as sleep disorders or sexual dysfunction
It may be useful to discuss different options, such as cutting down to recommended
limits or abstaining completely for perhaps a month or two, then reconsidering future
drinking. If cutting down is the initial strategy but the patient is unable to stay within
limits, recommend abstinence.
iv) Work through a range of alternative coping strategies, including the identification
of cues that might help distract the patient.
Phase 5 – Arrange
Be prepared to refer or organise admission to a specialist or appropriate unit if the
patient is,
 in severe withdrawal, including delirium tremens;
 experiencing unstable social circumstances;
 likely to develop serious withdrawal due from a severe degree of dependence or
a previous episode of severe withdrawal, including delirium tremens;
 severely dependent;
 has a severe comorbid physical illness;
 has comorbid mental illness, including suicidal ideation;
 using multiple substances;
 has a history of frequent relapse.
During all phases, close attention should be paid to the appropriateness of various
options for the particular individual – “tailor-made” where possible.
Various tools/scales are used to assess alcohol problems and determine their severity,
such as Alcohol Dependence Scale (ADS), AUDIT (Alcohol Use Disorder
IdentificationTest;Saunders et al., 1993), CAGE (Ewing, 1984), and Addiction Severity
Index (5th Edition): ASI (McLellan, Luborsky, Woody, & O’Brien, 1980; McLellan et
al., 1992).

1.8 TREATMENT OF ALCOHOL PROBLEMS

Alcohol abuse treatment occurs in a multitude of forms. It may be provided in outpatient
or inpatient settings, be publicly or privately funded, and may or may not involve the
administration of medication. The differences among the philosophies of, and the services
provided in various drug abuse treatment programs may be enormous.
A key therapist responsibility is to help a client find a treatment approach and treatment
setting that is effective for him or her, rather than slavishly adhering to a particular
treatment model or setting. A second and equally important therapist responsibility is to
enhance the client’s motivation to continue to try, even if the initial treatment setting is
not effective.
Treatment planning must be multidimensional to recognize that there is more than one
effective treatment for alcohol problems. Unlike certain disorders for which one treatment
approach has demonstrable superiority over others; in the alcohol field there are a
number of legitimate and empirically supported approaches to treatment. These
treatments are based in different conceptualizations of the etiology, course, treatment
20 goals, and length of treatment for alcohol problems.
 Table 2 : American Society of Addiction Medicine General Guidelines for Alcoholism
Selection of Treatment Settings
Level of Care Criteria
Level I. Outpatient treatment No serious risk for major withdrawal or
withdrawal seizures
No acute or chronic medical or
psychiatric problems that could
interferewith treatment
Some openness to change
Some ability to maintain change
Reasonable environmental support for
change
Level II. Intensive outpatient No serious risk for major withdrawal or
treatment withdrawal seizures
No acute or chronic medical or
psychiatric problems that could be
managed with intensive supervision
and
Some reluctance to change or
Limited ability to maintain change or
Limited environmental supports for
change
Level III. Medically monitored At least two:
intensive inpatient treatment Risk for withdrawal
Some level of acute or chronic medical
or psychiatric problems that could
be managed with intensive supervision
Reluctance to change
Limited ability to maintain change
Limited environmental supports for
change
Level IV. Medically managed Serious risk for major withdrawal or
intensive inpatient treatment withdrawal seizures or
Acute or chronic medical or psychiatric
problems that could interfere with
treatment

(Ray &Mondal, 2005)

1.8.1 Psychological Approaches

Among the treatments with the best empirical support are:
1) Brief Intervention: Brief intervention is designed to be conducted by health
professionals who do not specialize in addictions treatment. To identify the key
ingredients of brief intervention, six elements were proposed summarized by the
acronym FRAMES: feedback, responsibility, advice, menu of strategies, empathy,
and self-efficacy. It is generally restricted to four or fewer sessions, each session
lasting from a few minutes to 1 hour. It is most often used with adult and adolescent
patients who are not alcohol dependent, and its goal may be moderate drinking
rather than abstinence.
21
Addictions 2) Brief Strategic Family Therapy:For many individuals with substance abuse
disorders, interactions with their family of origin, as well as their current family, set
the patterns and dynamics for their problems with substances. Furthermore, family
member interactions with the substance abuser can either perpetuate and aggravate
the problem or substantially assist in resolving it. Family therapy is particularly
appropriate when the client exhibits signs that his substance abuse is strongly
influenced by family members’ behaviours or communications with them.
 Family involvement is often critical to success in treating many substance
abuse disorders—most obviously in cases where the family is part of the
problem.
 Focus on the expectation of change within the family (which may involve
multiple adjustments)
 Test new patterns of behaviour
 Teach how a family system works—how the family supports symptoms and
maintains needed roles
 Elicit the strengths of every family member
 Explore the meaning of the substance abuse disorder within the family
BSFT is based on three basic principles:
i) BSFT is a family systems approach.
ii) The patterns of interaction in the family influence the behaviour of each family
member.
iii) To plan interventions that carefully target and provide practical ways to change
those patterns of interaction.
In BSFT, whenever possible, preserving the family is desirable. While family
preservation is important, two goals must be set: to eliminate or reduce the
adolescent’s use of drugs and associated problem behaviours, known as “symptom
focus,” and to change the family interactions that are associated with the
adolescent’s drug abuse, known as “system focus.”BSFT can be implemented in
approximately 8 to 24 [Link] number of sessions needed depends on the
severity of the problem.
3) Cognitive Behavioural Interventions: Adapted from Marlatt and Gordon’s
Relapse Prevention treatment for problem drinking, CBT strategies are based on
the theory that learning processes play a role in the development of maladaptive
behavioural patterns. Individuals learn to identify and correct problematic
behaviours. CBT attempts to help patients recognize, avoid, and cope. That is,
RECOGNIZE the situations in which they are most likely to use alcohol, AVOID
these situations when appropriate, and COPE more effectively with a range of
problems and problematic behaviours associated with alcohol abuse.
CBT has two critical components:
 Functional analysis: For each instance of use during treatment, the therapist and
patient do a functional analysis, that is, they identify the patient’s thoughts, feelings,
and circumstances before and after the alcohol use. Early in treatment, the functional
analysis plays a critical role in helping the patient and therapist assess the
22
 determinants, or high-risk situations, that are likely to lead to alcohol use and Alcoholism
provides insights into some of the reasons the individual may be using alcohol
(e.g., to cope with interpersonal difficulties, to experience risk or euphoria not
otherwise available in the patient’s life). Later in treatment, functional analyses of
episodes of alcohol use may identify those situations or states in which the individual
still has difficulty coping.
 Skills training: CBT can be thought of as a highly individualized training program
that helps alcohol abusers unlearn old habits associated with abuse and learn or
relearn healthier skills and habits. By the time the level of substance use is severe
enough to warrant treatment, patients are likely to be using alcohol as their single
means of coping with a wide range of interpersonal and intrapersonal problems.
Because alcohol abusers typically come to treatment with a wide range of problems,
skills training in CBT is made as broad as possible. The first few sessions focus on
skills related to initial control of use (e.g., identification of high-risk situations,
coping with thoughts about use). Once these basic skills are mastered, training is
broadened to include a range of other problems with which the individual may
have difficulty coping (e.g., social isolation, unemployment). In addition, to
strengthen and broaden the individual’s range of coping styles, skills training focuses
on both intrapersonal (e.g., coping with craving) and interpersonal (e.g., refusing
offers of alcohol) skills. Patients are taught these skills as both specific strategies
(applicable in the here and now to control alcohol use) and general strategies that
can be applied to a variety of other problems. Thus, CBT is not only geared to
helping each patient reduce and eliminate substance use while in treatment, but
also to imparting skills that can benefit the patient long after treatment.
CBT has been offered in 12 to 16 sessions, usually over 12 weeks. An individual
format is preferred for CBT because it allows for better tailoring of treatment to
meet the needs of specific patients. However, a number of researchers and clinicians
have emphasized the unique benefits of delivering treatment to substance users in
the group format (e.g., universality, peer pressure).
4) Community Reinforcement Approach: CRA is an individual counseling approach
originally developed for alcoholism that includes a Job Club, Marital Counseling,
Social Skills/Relapse Prevention training and Disulfiram (Antabuse). Increasing
abstinence is the primary goal. To achieve and maintain abstinence, patients need
to make major lifestyle changes, particularly in four areas:
 Family relationships
 Recreational activities
 Social networks
 Vocation

High levels of satisfaction in an alcohol-free lifestyle are needed to compete with

the reinforcement derived from drug use and the drug-using lifestyle. Therefore,
increasing satisfaction in these areas is a major goal for reducing the probability of
continuing or resuming use. Patients are assessed at intake in each of these areas,
and individual treatment goals are developed by the therapist and patient together.
Specific types of counseling and skills training are provided on an as-needed basis,
depending on each patient’s lifestyle change goals and the skills needed to achieve
those goals. Therapists are expected to facilitate achievement of targeted goals
through extensive outreach whenever necessary.

23
Addictions 5) Contingency Management: Contingency Management involves systematically
reinforcing a client with a tangible good or service in exchange for a target behaviour,
that may be abstinence from alcohol or limited use of it.
6) Motivational Interviewing/ Enhancement: Motivational Enhancement Therapy
(MET) seeks to evoke from clients their own motivation for change and to
consolidate a personal decision and plan for change. The approach is largely client
centered, although planned and directed. As applied to alcohol abuse, MET seeks
to alter the harmful use of alcohol. Because each client sets his or her own goals,
no absolute goal is imposed through MET, although counselors may advise specific
goals such as complete abstinence. A broader range of life goals may be explored
as well.
MET comprises techniques whereby the counselor responds to client denial and
resistance by proposing thoughtful and detailed strategies that are designed to
increase client readiness to change (CSAT 1999; Miller and Rollnick 2002;
Prochaska and DiClemente 1984). The approach is based on the theory that
clients being treated for substance use disorders go through five stages of change:
precontemplation, contemplation, action, relapse, and maintenance. Client
resistance to treatment indicates that the counselor may be attempting to move the
client to the next stage too quickly.
MET is based on principles of cognitive and social psychology. The counselor
seeks to develop a discrepancy in the client’s perceptions between current behaviour
and significant personal goal; emphasis is placed on eliciting from clients self-
motivational statements of desire for and commitment to change. The working
assumption is that intrinsic motivation is a necessary and often sufficient factor in
instigating change. MET is typically conducted as individual counseling, though
family members may also be present and engaged. It is typically brief, limited to
two to four sessions that each last 1 hour. MET may be insufficiently directive for
clients who desire clear direction and advice.
7) Solution-Focused Brief Therapy: The Solution-Focused Model is a brief therapy
approach developed over the past 20 years at the Brief Family Therapy Center in
Milwaukee, WI. The approach was developed for low-income clients with serious
alcohol or other drug problems. Because the model stresses that the problem and
solution are not necessarily related, the type of drug is not seen as a critical factor
in determining differential treatment. Primarily, the model is designed to help clients
engage their own unique resources and strengths in solving the problems that bring
them into treatment. Goals are the entire focus of the solution-focused brief therapy
approach. The model uses a specialized interviewing procedure to negotiate
treatment goals whose qualities facilitate efficient and effective treatment. Goals
are the entire focus of this approach. The goals must be:
 Salient to the client rather than the therapist or treatment program.
 Small rather than large.
 Described in specific, concrete, and behavioural terms.
 Described in situational and contextual rather than global and psychological
terms.
 Stated in interactional and interpersonal rather than individual and intrapsychic
terms.
24
  Described as the start of something rather than the end of something. Alcoholism

 Described as the presence of something rather than the absence of something.

 Realistic and immediately achievable within the context of the client’s life.
The approach proposes that the solution(s) to the problems that a client brings
into treatment may have little or nothing to do with those problems. This is particularly
true in the treatment of problem drinking, where any of a variety of life experiences
or actions on the client’s part, which have little to do with his or her use of alcohol,
may result in a resolution of the problem. While the number of potential solutions
is limitless, one example is a problem drinker who stops using problematically
when he or she:
 Obtains employment.
 Ends or begins a relationship.
 Makes new friends.
 Relocates.
Treatment therefore need not make alcohol the primary focus to resolve the drinking
problem. Rather, the focus returns to helping the client achieve the personal goals
he or she sets.
8) Supportive-Expressive Therapy: Supportive-Expressive therapy (SE) is a
short-term psychodynamic treatment. Its goal is to help patients gain understanding
of conflictual relationship patterns. The main techniques include supportive
techniques to bolster the therapeutic alliance and interpretations to help patients
gain self-understanding. The therapy has two main components:
 Supportive techniques to help patients feel comfortable in discussing their
personal experiences.
 Expressive techniques to help patients identify and work through interpersonal
relationship issues.
Supportive-Expressive therapy (SE) also helps in alcohol dependence.
9) Twelve-Step Facilitation: TSF has been utilized in controlled outcome studies
with alcohol abusers and alcoholics and with persons who have concurrent alcohol-
cocaine abuse and dependency. It has been used with clients of diverse
socioeconomic, educational, and cultural backgrounds and a range of
maladjustment. It consists of a brief, structured, and manual-driven approach to
facilitating early recovery from alcohol abuse/alcoholism and other drug abuse/
addiction. TSF seeks to facilitate two general goals in individuals with alcohol or
other drug problems: acceptance (of the need for abstinence from alcohol or other
drug use) and surrender, or the willingness to participate actively in the 12-step
fellowships as a means of sustaining sobriety. These goals are in turn broken down
into a series of cognitive, emotional, relationship, behavioural, social, and spiritual
objectives.
The theoretical rationale is based in the 12 steps and 12 traditions of AA and
includes the need to accept that will power alone is not sufficient to achieve sustained
sobriety, that self centeredness must be replaced by surrender to the group
conscience, and that long-term recovery consists of a process of spiritual renewal.
25
Addictions The primary mechanism action is active participation and a willingness to accept a
higher power as the locus of change in one’s life. It is intended to be implemented
on an individual basis in 12 to 15 sessions and is based in behavioural, spiritual,
and cognitive principles that form the core of 12-step fellowships such as Alcoholics
Anonymous (AA) and Narcotics Anonymous (NA).
TSF was designed to be used in the context of short-term individual counseling
but has been adapted for use in a group format. One part of TSF (the conjoint
program) is specifically intended to be implemented through sessions with a significant
other (SO). It is suitable for problem drinkers and other drug users and for those
who are alcohol or other drug dependent.
10) Humanistic and Existential Therapies:Humanistic and existential
psychotherapies use a wide range of approaches to the planning and treatment of
substance abuse disorders. They are, however, united by an emphasis on
understanding human experience and a focus on the client rather than the symptom.
Humanistic and existential approaches share a belief that people have the capacity
for self awareness and choice. However, the two schools come to this belief through
different theories. Humanistic and existential therapeutic approaches may be
particularly appropriate for short-term substance abuse treatment because they
tend to facilitate therapeutic rapport, increase self-awareness, focus on potential
inner resources, and establish the client as the person responsible for recovery.
Thus, clients may bemore likely to see beyond the limitations of short-term treatment
and envision recovery as a lifelong process of working to reach their full potential.
Humanistic and existential approaches can be used at all stages of recovery in
creating a foundation of respect for clients and mutual acceptance of the significance
of their experiences. There are, however, some therapeutic moments that lend
themselves more readily to one or more specific approaches.
 Client-centered therapy can be used immediately to establish rapport and
to clarify issues throughout the session.
 Existential therapy may be used most effectively when a client has access to
emotional experiences or when obstacles must be overcome to facilitate a
client’s entry into or continuation of recovery (e.g., to get someone who
insists on remaining helpless to accept responsibility for her actions).
 Narrative therapy can be used to help the client conceptualize treatment as
an opportunity to assume authorship and begin a “new chapter” in life.
 Gestalt approaches can be used throughout therapy to facilitate a genuine
encounter with the therapist and the client’s own experience.
 Transpersonal therapy can enhance spiritual development by focusing on
the intangible aspects of human experience and awareness of unrealized
spiritual capacity.
Using a humanistic or existential therapy framework, the therapist can offer episodic
treatment, with a treatment plan that focuses on the client’s tasks and experiences
between sessions.
11) Group Therapy: Group psychotherapy is one of the most common modalities
for treatment of substance abuse disorders. Group therapy is defined as a meeting
of two or more people for a common therapeutic purpose or to achieve a common
26 goal. It differs from family therapy in that the therapist creates open- and closed-
 ended groups of people previously unknown to each other. Alcoholism

Group psychotherapy can be extremely beneficial to individuals with substance

abuse problems. It gives them the opportunity to see the progression of abuse and
dependency in themselves and others; it also provides an opportunity to experience
personal success and the success of other group members in an atmosphere of
support and [Link] are five models of group therapy that are effective for
substance abuse treatment:
 Psychoeducational Groups: designed to educate clients about substance abuse
and related behaviours and consequences. This type of group presents
structured, group-specific content, often taught by means of videotapes,
audiocassette, or lectures.
 Skills Development Groups: Skills development groups teach skills that help
clients maintain abstinence, such as
 Refusal skills
 Social skills
 Communication skills
 Anger management skills
 Parenting skills
 Money management skills
 Cognitive–Behavioural/Problem-Solving Groups: work to change learned
behaviour by changing thinking patterns, beliefs, and perceptions. The group
leader focuses on providing a structured environment within which group
members can examine the behaviours, thoughts, and beliefs that lead to their
maladaptive behaviour.
 Support Groups: bolster members’ efforts to develop and strengthen their
ability to manage their own thinking and emotions and to develop better
interpersonal skills as they recover from substance abuse.
 Interpersonal Process Groups: use psychodynamics, or knowledge of the
way people function psychologically, to promote change and healing. All
therapists using a “process-oriented group therapy” model continually monitor
three dynamics:
 The psychological functioning of each group member (intrapsychic
dynamics)
 The way people are relating to one another in the group setting
(interpersonal dynamics)
 How the group as a whole is functioning (group as-a-whole dynamics)
Multimodal Models of Treatment:
1) Minnesota Model: The Minnesota Model approach is typically characterized
by a thorough and ongoing assessment of all aspects of the client and of multimodal
therapeutic approaches. It may include group and individual therapy, family education
and support, and other methods.
27
Addictions A multidisciplinary team of professionals (e.g.,counselors, psychologists, nurses)
plan and assist in the treatment process for each client. The assumption is that
abstinence is the prerequisite. Treatment provides tools and a context for the client
to learn new ways of living without alcohol and other drugs. This type of treatment
can be employed on an inpatient or outpatient basis. The primary goal is lifetime
abstinence from alcohol and other mood-altering chemicals and improved quality
of life. This goal is achieved by applying the principles of the 12-step philosophy,
which include frequent meetings with other recovering people and changes in daily
behaviours.
The ultimate goal is personality change or change in basic thinking, feeling, and
acting in the world. This approach works by changing an addict’s beliefs about his
or her relationship to others and to self. This changed perspective occurs by
attending meetings, by self-reflection, and by learning new coping skills. Through
this process, the client’s understanding about himself or herself in relationship to
the self and to others is transformed.
Approximately 80 to 90 percent of the treatment occurs in groups; the remainder
is in individual sessions. The ideal treatment setting is residential, as this environment
most easily conveys dignity and respect for the individual and provides grounds
and physical space for solitude and reflection. This model can, however, be applied
in any setting.
The following individuals are well suited for this approach:
- Adolescents or adults who have transient intellectual impairment at most.
- People with average or better intellectual ability and at least sixth-grade reading
ability.
- Alcoholics or polydrug users.
- People who are dually diagnosed if the psychiatric disorder is stable or not
predominant in the clinical picture.
- People who have or develop at least moderate motivation and willingness to
change. (Although many come to treatment with some resistance, most will
be able to engage in the treatment process within 5 to 10 days. If they cannot,
they may be discharged.)
Those not suited for this approach include the converse of the above, as well as
individuals who are seeking methadone maintenance, those with poor reading
ability or memory impairment, and those not motivated to change.
2) Matrix Model:The Matrix IOP method was developed initially in the 1980s in
response to the growing numbers of individuals entering the treatment system with
cocaine or methamphetamine dependence as their primary substance use disorder.
Since then, it has also been adapted for treating the alcohol dependent population.
The Matrix Model is a comprehensive, multi-format program that covers six key
clinical areas:
 Individual/conjoint therapy
 Early recovery
 Relapse prevention
28
  Family education Alcoholism

 Social support
 Urine testing
It is an integrated therapeutic model incorporating:
 Cognitive behavioural
 Motivational enhancement
 Couples and family therapy
 Individual supportive/expressive psychotherapy and psychoeducation
 Twelve Step facilitation
 Group therapy and social support
The Matrix IOP approach provides a structured treatment experience for clients with
alcohol use disorders. Clients receive information, assistance in structuring a substance-
free lifestyle, and support to achieve and maintain abstinence from drugs and alcohol.
The program specifically addresses the issues relevant to clients who are dependent on
alcohol and their families.
For 16 weeks, clients attend several intensive outpatient treatment sessions per week.
This intensive phase of treatment incorporates various counseling and support sessions:
 Individual/Conjoint family sessions (3 sessions)
 Early Recovery Skills group sessions (8 sessions)
 Relapse Prevention group sessions (32 sessions)
 Family Education group sessions (12 sessions)
 Social Support group sessions (36 sessions)

1.8.2 Pharmacotherapy
Although it is imperative that pharmacological treatment is administered safely, it is
equally important to see it as one part of a phased treatment management process. In
other words, “prescribing” is nested within the overall treatment package,which includes
psychosocial components that have been negotiated, whether community or hospital
based. Pharmacological treatments are usually reserved for patients who have
dependence.
Which medication to use will depend on clinical judgment and patient preference. Each
has a different mechanism of action. Some patients may respond better to one type of
medication than another.
Three oral medications (naltrexone, acamprosate, and disulfiram) and one injectable
medication (extended-release injectable naltrexone) are approved for treating alcohol
dependence. They have been shown to help patients reduce drinking, avoid relapse to
heavy drinking, achieve and maintain abstinence, or gain a combination of these effects.
As is true in treating any chronic illness, addressing patient adherence systematically
will maximize the effectiveness of these [Link] has also been
found to be effective.
29
Addictions 1.8.3 Preventing Relapse
Addiction is a chronic disorder and the ultimate goal of long-term abstinence often
requires sustained and repeated treatment episodes. Nearly all addicted individuals
believe in the beginning that they can stop using drugs on their own, and most try to stop
without treatment. However, most of these attempts result in failure to achieve long-
term abstinence. Research shows that long-term drug use significantly changes brain
function and these changes persist long after the individual stops using drugs. These
drug-induced changes in brain function may have many behavioural consequences,
including the compulsion to use drugs despite adverse consequences—the defining
characteristic of addiction (Leshner, 1999).
The first 12 months of abstinence are especially difficult, and relapse is most common
during this time. If patients do relapse, recognize that they have a chronic disorder that
requires continuing care, just like asthma, hypertension, or diabetes. Recurrence of
symptoms is common and similar across each of these disorders, perhaps because they
require the patient to change health behaviours to maintain gains.
The most important principle is to stay engaged with the patient and to maintain optimism
about eventual improvement. Most people with alcohol dependence who continue to
work at recovery eventually achieve partial to full remission of symptoms, and often do
so without specialized behavioural treatment. For patients who struggle to abstain or
who relapse:
 If the patient is not taking medication for alcohol dependence, consider prescribing
one and following up with medication management
 Treat depression or anxiety disorders if they are present more than 2 to 4 weeks
after abstinence is established.
 Assess and address other possible triggers for struggle or relapse, including stressful
events, interpersonal conflict, insomnia, chronic pain, craving, or high-temptation
situations such as a wedding or convention.
 If the patient is not attending a mutual help group or is not receiving behavioural
therapy, consider recommending these support measures.
 Encourage those who have relapsed by noting that relapse is common and pointing
out the value of the recovery that was achieved.
 Provide follow-up care and advise patients to contact you if they are concerned
about relapse.
Psychological/ Psychotherapeutic Strategies
Several models have been proposed to conceptualize the maintenance or relapse
process, with associated treatments. The most prominent maintenance models include
Marlatt and Gordon’s (1985) relapse prevention (RP) model, the CENAPS® Model
of Relapse Prevention Therapy (CMRPT®) and the disease model, best exemplified
by the practices common to Alcoholics Anonymous.
RP Model (Marlatt& Gordon):The RP model is an extension of the functional-analytic
model and focuses on the interplay among environment, coping skills, and cognitive
and affective responses in maintaining successful change. In the RP model, relapse
occurs in response to a high risk situation for which the client either lacks or does not
apply effective coping skills. Low self-efficacy for coping with the situation may contribute
30
to the difficulties. If the client does not cope effectively, use of alcohol is likely. Following Alcoholism
initial drinking, Marlatt and Gordon suggested that a cognitive factor, the “abstinence
violation effect” (AVE), is activated. The AVE represents all-or-nothing thinking; after
drinking, the client makes a cognitive shift to viewing him- or herself as “drinking”;
therefore, he or she continues to drink. RP treatment focuses on several points of
intervention common to cognitive-behavioural treatment, such as identification of high-
risk situation and acquisition of coping skills, as well as cognitive restructuring to help
the client view a drinking episode as a “lapse” from which the client can learn and return
to abstinence rather than a “relapse” into previous drinking patterns.
RP also focuses on lifestyle changes to decrease the presence of high-risk situations,
and encourages development of a balance between pleasures and desires, and obligations
and responsibilities (a “want–should” balance) in the client’s life. In his more recent
work, Marlatt (Marlatt&Donovan, 2005; Witkiewitz&Marlatt, 2004) has described
relapse as “multidimensional and dynamic” (Marlatt&Donovan, 2005), and considers
the influence of longer-term risk factors such as family history and social supports, as
well as more proximal influences on relapse. He also suggests that there are reciprocal
interactions among cognitions, coping skills, affect and drinking.
The CENAPS® Model of Relapse Prevention Therapy (Terence Gorski):
CMRPT is a comprehensive method for preventing chemically dependent clients from
returning to alcohol and other drug use after initial treatment and for early intervention
should chemical use occur. It is a clinical procedure that integrates the disease model of
chemical addiction and abstinence-based counseling methods with recent advances in
cognitive, affective, behavioural, and social therapies. The method is designed to be
delivered across levels of care with a primary focus on outpatient delivery systems. The
CMRPT consists of five primary components:
1) Assessment.
2) Warning sign identification.
3) Warning sign management.
4) Recovery planning.
5) Relapse early intervention training.
Cognitive, affective, and behavioural therapy principles are targeted to accomplish the
specific goals of each CMRPT component. The CMRPT incorporates standard and
structured group and individual therapy sessions and psychoeducational (PE) programs
that focus primarily on these five primary goals. The treatment is holistic in nature and
involves clients in a structured program of recovery activities. Willingness to comply
with the recovery structure and actively participate within the structured sessions is a
major factor in accepting clients for treatment with this model.
This model is also similar to and has been heavily influenced by the Cognitive-Behavioural
Relapse Prevention Model developed by Marlatt and Gordon (George 1989; Marlatt
and Gordon 1985). The major difference is that the CMRPT integrates abstinence-
based treatment and has greater compatibility with 12-step programs than the Marlatt
and Gordon model.
Clients who do well with the CMRPT have average or above-average conceptual
skills and eighth grade or better reading and writing skills but no learning disabilities,
severe cognitive impairments, active impulse control disorders, or other diagnosis that
interferes with the ability to participate in a structured cognitive-behavioural therapy
program. In addition, they have been detoxified. 31
Addictions Pharmacological Strategies
Medicines like acamprosate, naltrexone and disulfiram are used; however, there are
conditions in which these should be used. Selective Serotonin Reuptake Inhibitors
(SSRIs) may also be considered under specified conditions.
Management of Dual Disorders
Dual disorders recovery counseling (DDRC) is an integrated approach to treatment of
patients with alcohol use disorders and comorbid psychiatric disorders. The DDRC
model, which integrates individual and group addiction counseling approaches with
psychiatric interventions, attempts to balance the focus of treatment so that both the
patient’s addiction and psychiatric issues are addressed.
The DDRC model is based on the assumption that there are several treatment phases
that patients may go through. These phases are rough guidelines delineating some typical
issues patients deal with and include:
Phase 1—Engagement and [Link] are persuaded, motivated, or
involuntarily committed to treatment. The main goal of this phase is to help stabilize the
acute symptoms of the psychiatric illness and/or the drug use disorder. Another important
goal is to motivate patients to continue in treatment once the acute crisis is stabilized or
the involuntary commitment expires.
Phase 2—Early [Link] phase involves learning to cope with desires to use
chemicals; avoiding or coping with people, places, and things that represent high-risk
addiction relapse factors; learning to cope with psychiatric symptoms; getting involved
in support groups, such as Alcoholics Anonymous (AA) getting the family involved (if
indicated); beginning to build structure into life; and identifying problems to work on in
recovery. This phase roughly involves the first 3 months following stabilization.
Phase 3—Middle [Link] this phase, patients continue working on issues from
the previous phase as needed. In addition, patients learn to develop or improve coping
skills to deal with intrapersonal and interpersonal issues. This phase also focuses on
helping patients cope with persistent symptoms of psychiatric illness; drug use lapses,
relapses, or setbacks; and crises related to the psychiatric disorder. Patients are usually
not tapered off medications until they have several months or longer of significant
improvement in psychiatric symptomology.
Phase 4—Late [Link] phase, also referred to as the “maintenance phase” of
recovery, involves continued work on issues addressed in the middle phase of recovery
and work on other clinical issues that emerge. Important intrapersonal or interpersonal
issues may be explored in greater depth during this phase for patients who have continued
abstinence and remained relatively free of major psychiatric symptoms. Many patients
with chronic or persistent forms of psychiatric illness (e.g., schizophrenia, bipolar disease,
recurrent major depression), or severe personality disorders such as borderline
personality disorder, often continue active involvement in treatment. Treatment during
this phase may involve maintenance pharmacotherapy, supportive DDRC counseling,
or some specific form of psychotherapy (e.g., interpersonal psychotherapy). Involvement
in support groups continues during this phase of recovery as well.
The DDRC approach can be adapted for virtually any type of addiction, mental health
disorder, or combination of dual disorders. However, it is best suited for mood, anxiety,
schizophrenic, personality, adjustment, and other addictive disorders, in combination
with alcohol or other drug addiction.
32
Clients with mental retardation, organic brain syndromes, head injuries, and more severe Alcoholism
forms of thought disorders are less suited for this counseling approach.
Self Assessment Questions 3
1) What are the stages of assessment of alcohol abuse and dependence?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
2) Mention the principles of Brief Strategic Family Therapy (BSFT).
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
3) What is psychoeducational group?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
4) Describe the treatment phases as per the Dual disorders recovery counseling
(DDRC) model.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

1.9 LET US SUM UP

The alcohol related disorders exact an immense toll on the mental and physical well-
being of many individuals. Consequently, they jeopardize the integrity of the family and
other social forces represented by the healthcare system, the law, and the economy.
Because of the prevalence of alcohol related disorders, and because they can
masquerade as diverse medical and other psychiatric disorders, their recognition and
initial treatment are relevant to all physicians, in particular, the mental health professional.
Alcohol -related disorders are heterogeneous in terms of the interactions between the
manifest psychopathology of the individual patient and the psychopharmacologic actions
of a given drug, within the relevant sociocultural context. This perspective is useful in
seeking an etiologic understanding of these disorders, conducting a clinical assessment,
planning for the initial treatment of the direct consequences of alcohol use and developing
and implementing a comprehensive treatment strategy for patients.
33
Addictions
1.10 ANSWERS TO SELF ASSESSMENT
QUESTIONS
Self Assessment Questions 1
1) The primary elements of addictive disease are, compulsive use, loss of control,
and continued use despite adverse consequences.
2) Type 1 alcoholism is characterized by:
 Age of onset over 25 years
 No criminality or treatment for alcohol problems in the biological parents
 Loss of control (or psychological dependence)
 Guilt and fear about dependence
 Harm avoidance
 Reward dependence
Type 2 alcoholism is characterized by:
 Teenage age of onset (under 25 years)
 Alcohol abuse, criminality and treatment are extensive in the biological father
 Inability to abstain
 Aggressive behaviour
 Novelty-seeking personality traits
3) True
Self Assessment Questions 2
1) The most pertinent nutritional deficiency in alcohol abuse and dependence is the
Wernicke-Korsakoff syndrome (WKS), which results from thiamine deficiency.
2) The features of Fetal Alcohol Syndrome (FAS) are as follows: children with FAS
have reduced body weight and height, are hyperactive and have subnormal
intelligence. Their faces may be recognized by short palpebral fissures, short
upturned noses, mid facial hypoplasia, low nasal bridge and a thin upper lip.
3) In the family systems model, the etiology of alcoholism is focused on the behaviour
of family members around drinking, with particular attention paid to the family of
origin and the role of the spouse/partner.
Self Assessment Questions 3
1) The stages of assessment are,
a) Pre intervention: where the purpose of assessment is to define the problem,
formulate treatment, select an appropriate treatment from various modalities
and motivate clients for treatment.
b) Intervention: here assessment is done to monitor progress
c) Post intervention: assess maintenance and abstinence status
34
2) BSFT is based on three basic principles: Alcoholism

i) That BSFT is a family systems approach.

ii) That the patterns of interaction in the family influence the behaviour of each
family member.
iii) To plan interventions that carefully target and provide practical ways to change
those patterns of interaction.
3) Psychoeducational Groups refer to groups designed to educate clients about
substance abuse and related behaviours and consequences. This type of group
presents structured, group-specific content, often taught by means of videotapes,
audiocassette, or lectures.
4) The treatment phases as per the Dual disorders recovery counseling (DDRC)
model are as follows: Engagement & stabilization, Early recovery, Middle recovery,
and Late recovery.

1.11 UNIT END QUESTIONS

1) Differentiate between addiction and dependence.
2) What are the clinical features of alcohol withdrawal syndromes?
3) Describe causes of alcohol dependence.
4) Discuss the consequences of alcohol abuse and dependence.
5) Explain alcoholism from behavioural theory perspective.
6) Discuss the various psychological approaches for the management of alcohol
dependence.
7) Explain humanistic and existential therapies for management of alcohol dependence.
8) Explain Matrix model of treatment of alcohol dependence.

1.12 SUGGESTED READINGS AND REFERENCES

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disorders (4th ed., text rev.). Washington, DC.
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American Society of Addiction Medicine (1996).Patient Placement Criteria for the
Treatment of Substance-related Disorders : Chevy Chase, Maryland.
Averna, S., & Hesselbrock, V. (2001). The relationship of perceived social support to
substance use in offspring of alcoholics. Addictive Behaviours, 26, 363-374.
Berglund, M., Thelander, S., &Jonsson, E. (2003). Treating Alcohol and Drug Abuse:
An Evidence Based [Link], Germany:Wiley-VCHVerlag.
Cloninger, C. R., Bohman, M. &Sigvardsson, S. (1981). Inheritance of alcohol abuse:
cross-fostering analysis of adopted [Link] General Psychiatry, 38, 861±868.
Coombs, R. H. (1997). Drug-impaired professionals. Cambridge, MA: Harvard
University Press.
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Addictions Coombs, R. (2004). Handbook of Addictive Disorders- A Practical Guide to Diagnosis
and Treatment. New Jersey. John Wiley & Sons. ISBN 0-471-23502-4
Crome, I. B. (1999). Substance misuse and psychiatric comorbidity: towards improved
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Currie, S. P., Clark, S., Hodgins, D. C., et al. (2004).Randomised controlled trial of
brief cognitive behavioural interventions for insomnia in recovering alcoholics. Addiction
99:1121 Sullivan, J. T., & K. Sykora, et al. (1989).
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36
Donovan, D.M. & Marlatt, G.A. (Eds.). (2005). Assessment of Addictive Behaviours
(2nd Ed.). New York: Guilford Press
Goodwin, D. W. (1976). Is alcoholism hereditary? New York: Oxford University Press.
Gorski, T. T. (2000). CENAPS model of relapse prevention therapy (CMRPT). In J.
J. Boren, L. S. Onken, & K. M. Carroll (Eds.), Approaches to drug abuse counseling
(pp. 21–34). Bethesda, MD: National Institute on Drug Abuse.
Inaba, D. S., & Cohen, W. E. (2000). Uppers, downers, all arounders (4th ed.).
Ashland, OR: CNS Publications.
Jellinek, E. M. (1960). The Disease Concept of Alcoholism, Hillhouse, (New Haven).
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influences on alcohol, caffeine, cannabis, and nicotine use from early adolescence to
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Kendler, S. K., Chen, Xiangning., Dick, D., Maes, H., Gillespie, N., Neale, C.M. &
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Schuckit MA (2005). Alcohol-related disorders. In: Sadock, BJ, Sadock VA, eds.
Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 8th ed. Vol. 1. Baltimore:
Lippincott Williams & Wilkins; 2005:1168
Leshner, A. (1999). Science-based views of drug addiction and its treatment. Journal
of the American Medical Association, 282(14), 1314–1316.
Lingford-Hughes, A. R., Welch, S., & Nutt, D. J. (2004). Evidence based guidelines
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Psychopharmacol18:293–335.
Lishman, W. (1987). Organic Psychiatry: The Psychological Consequences of Cerebral
Disorder. Oxford: BlackwellScientific.
Lishman,W. A. (1990). Alcohol and the [Link] J Psychiatry156:635–[Link]
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Lynskey, M. T., Agrawal, A., & Heath, A. C. (2010). Genetically informative research Alcoholism
on adolescent substance use:methods, findings, and challenges. Journal of the American
Academy of Child and Adolescent Psychiatry,49 (12), 1202-1214
Marlatt G.A. & Gordon J.R. (Eds.). (1985). Relapse prevention: Maintenance strategies
in the treatment of addictive behaviours. New York: Guilford Press.
McCrady, B. S., Kahler, C., & Epstein E. E. (1998). Families of alcoholics. In N. N.
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38
UNIT 2 SUBSTANCE ABUSE AND
ADDICTION
Structure
2.0 Introduction
2.1 Objectives
2.2 Substance Abuse Disorders
2.3 Illegal Drugs
2.3.1 Opiods
2.3.2 Depressants
2.3.3 Stimulants
2.3.4 Hallucinogens
2.3.5 Other Drugs

2.4 Assessment of the Drug User

2.5 Treatment and Management of Substance Abuse and Addictions
2.6 Let Us Sum Up
2.7 Answers to Self Assessment Questions
2.8 Unit End Questions
2.9 Suggested Readings and References

2.0 INTRODUCTION
Substance abuse and addictions results from the misuse of harmful or addictive substances
which include, alcohol, illegal or street drugs, prescription and over-the-counter
medicines, and volatile chemicals.
The resultant problems include both mental and physical illnesses, and family, housing,
employment, and legal difficulties. Treatment of substance abuse disorder is complex
and challenging as the reason for substance abuse and addiction is unique for each
abuser. Further, the family environment and situation of each abuser is unique. Treatment
and management of substance abuse need to take into account all these. Both
psychological and pharmacological interventions are used that may include detoxification
and substitute prescribing.
The use and misuse of drugs is increasing and affecting our children, youth, men and
women, and the elderly also. In this Unit, you will learn about the substance abuse
disorder, various drugs used, and the assessment and treatment of substance abuse.

2.1 OBJECTIVES
By the end of this Unit, you will be able to:
 explain the concept of substance abuse disorders;
 know the most commonly used illegal drugs;
 describe the signs and symptoms in the different types of substance intoxication
and withdrawal states; 39
Addictions  explain the assessment of a person with substance abuse disorders; and
 discuss the management and treatment of persons with substance abuse disorders.

2.2 SUBSTANCE ABUSE DISORDERS

A formal definition of substance abuse disorder, based on the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), is as follows:
Drug abuse is a maladaptive pattern of drug use leading to clinically significant impairment
or distress, as manifested by one or more of four symptoms or criteria in a 12-month
period.
 Recurrent drug use may result in a. failure to fulfill major role obligations at
work, school, or home. Repeated absences, tardiness, poor performance,
suspensions, or neglect of duties in major life domains suggests that use has crossed
over into abuse.
 Recurrent drug use in situations in which it is physically hazardous is a sign of
abuse. Operating machinery, driving a car, swimming, or walking in a dangerous
area while under the influence indicates drug abuse.
 Recurrent drug-related legal problems, such as arrests for disorderly conduct or
DUI [driving under the influence] arrests, are indicative of abuse.
 Recurrent use, despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of the drug, is indicative of abuse.
For example, getting into arguments or fights with others, passing out at others’
houses, or acting inappropriately in front of others (which is disapproved of) is
indicative of abuse.
In summary, drug use that leads to decrement in performance of major life roles,
dangerous action, legal problems, or social problems indicates a substance abuse
disorder.
Alternatively, a diagnosis of substance dependence, a more severe disorder, subsumes
a diagnosis of substance abuse. There are seven other criteria that, if met, constitute
substance dependence.
The criteria for substance dependence, provided by the DSM-IV-TR, include a
maladaptive pattern of drug use leading to clinically significant impairment or distress,
as manifested by three or more of the following seven symptoms occurring in the same
12-month period.
 Tolerance is experienced. Tolerance entails a need for markedly increased amounts
of a drug to achieve the desired drug effect or a markedly diminished effect with
continued use of the same amount of the drug.
 Withdrawal is experienced. Either a characteristic withdrawal syndrome occurs
when one terminates using the drug, or the same or a similar drug is taken to
relieve or avoid the syndrome.
 Larger amounts of the drug are taken over a longer period than was intended.
For example, an alcohol-dependent individual may intend to drink only two drinks
on a given evening but ends up having 15 drinks, or to “party” over the weekend
but the party lasts for 2 weeks until there is no more money for alcohol.
 There exists a persistent desire or unsuccessful effort to cut down or control
40 drug use. For example, a drug-dependent individual may decide to control his or
 her use but ends up abstaining on some evenings and using in excess on other Substance Abuse
and Addiction
evenings.
 A great deal of time is spent on activities needed to obtain the drug, use the
drug, or recover from its effects. For example, a person may travel long distances
or search all day to obtain cocaine, use the drug that night, and miss work the next
day to recover and catch some rest. In this scenario, 2 days were spent for 1 night
of “getting high.”
 Important social, occupational, or recreational activities are given up or
reduced because of drug use. For example, the drug abuser may be very high,
passed out, or hung over much of the time and thus may not spend time with family
and friends like he or she did before becoming dependent.
 Drug use continues despite knowledge of having a persistent or recurrent
physical or psychological problem that is likely to have been caused or worsened
by the drug. For example, someone who becomes paranoid after continued
methamphetamine use and is hospitalized but continues to use it after release from
the hospital exhibits this symptom.
Alternatively, the 10th revision of the International Statistical Classification of
Diseases and Related Health Problems (ICD-IO) provides eight classifications of
consequences from the use of a substance in its section on mental and behavioural
disorders due to psychoactive substance use (Chapter 5; F10-F19). The ICD-IO
definition focuses more on the mental or physical health complications and not social,
legal, or environmentally hazardous consequences of abuse, as does the DSM-IV-TR.
Let us know a few terms that we come across while discussing about substance abuse
and addiction.
a) Acute intoxication
The pattern of reversible physical and mental abnormalities caused by the direct effects
of the substance. These are specific and characteristic for each substance. Most
substances have both pleasurable and unpleasant acute effects; for some, the balance
of positive and negative effects is situation-, dose- and route-dependent.
b) At-risk use
A pattern of substance use where the person is at increased risk of harming their physical
or mental health. This is not a discrete point but shades into both normal consumption
and harmful use. At-risk use depends not only on absolute amounts taken but the situations
and associated behaviours.
c) Harmful use
The continuation of substance use despite evidence of damage to the user’s physical or
mental health or to their social, occupational, and familial well-being. This damage may
be denied or minimised by the individual concerned.
d) Withdrawal
Where there is physical dependence on a drug, abstinence will generally lead to features
of withdrawal. These are characteristic for each drug. Some drugs are not associated
with any withdrawals; some with mild symptoms only; and some with significant
withdrawal syndromes. Clinically significant withdrawals are recognised in dependence
on alcohol, opiates, nicotine, benzodiazepines, amphetamines, and cocaine. Symptoms
of withdrawal are often the opposite of the acute effects of the drug.
41
Addictions e) Complicated withdrawal
Withdrawals can be simple, as above or complicated by the development of seizures,
delirium, or psychotic features.
f) Substance-induced psychotic disorder
Illness characterised by hallucinations and/or delusions occurring as a direct result of
substance-induced neurotoxicity. Psychotic features may occur during intoxication and
withdrawal states, or develop on a background of harmful or dependent use. There
may be diagnostic confusion between these patients and those with primary psychotic
illness and comorbid substance misuse. Substance-induced illnesses will be associated
in time with episodes of substance misuse and may have atypical clinical features, (e.g.
late first presentation with psychosis, prominence of non-auditory hallucinations).
g) Cognitive impairment syndromes
Reversible cognitive deficits occur during intoxication. Persisting impairment (in some
cases amounting to dementia) caused by chronic substance use is recognised for
alcohol,volatile chemicals, benzodiazepines, and, debatably, cannabis. Cognitive
impairment is associated with heavy chronic harmful use/dependence and shows gradual
deterioration with continued use and either a halt in the rate of decline or gradual
improvement on abstinence.
h) Residual disorders
Several conditions exist (e.g. alcoholic hallucinosis,; persisting drug-induced psychosis;
LSD flashbacks, where there are continuing symptoms despite continuing abstinence
from the drug.
i) Exacerbation of pre-existing disorder
All other psychiatric illnesses, especially anxiety and panic disorders, mood disorders,
and psychotic illnesses may be associated with comorbid substance use. Although this
may result in exacerbation of the patient’s symptoms and a decline in treatment
effectiveness, it can be understood as a desire to self-medicate (e.g. alcohol taken as a
hypnotic in depressive illness) or escape unpleasant symptoms. Sometimes there is
debate about whether there is, for example, a primary mood disorder with secondary
alcohol use or vice versa. Careful examination of the time course of the illness may
reveal the answer. In any case, it is advisable to address substance misuse problems
first as this may produce secondary mood improvements and continuing substance
misuse will limit antidepressant treatment effectiveness.
j) The Dependence syndrome
Dependence includes both physical dependence (the physical adaptations to chronic,
regular use) and psychological dependence (the behavioural adaptations). In some drugs
(e.g. hallucinogens), no physical dependence features are seen.
This is a clinical syndrome describing the features of substance dependence. These
features form the core of both ICD-10 and DSM-IV descriptions of substance
dependence.
 Primacy of drug-seeking behaviour: The drug and the need to obtain it become
the most important things in the person’s life, taking priority over all other activities
and interests. Thus drug use becomes more important than retaining job or
relationships, remaining financially solvent, and in good physical health and may
diminish moral sense leading to criminal activity and fraud. If the person rates drug
use above health, then stern warnings about impending illness are likely to mean
42 little.
 Narrowing of the drug-taking repertoire: The user moves from a range of drugs to Substance Abuse
and Addiction
a single drug taken in preference to all others. The setting of drug use, the route of
use, and the individuals with whom the drug is taken may also become stereotyped.
 Increased tolerance to the effects of the drug: The user finds that more of the drug
must be taken to achieve the same effects. They may also attempt to combat
increasing tolerance by choosing a more rapidly acting route of administration,
(e.g. IV rather than smoked), or by choosing a more rapidly acting form, (e.g.
freebase cocaine rather than cocaine hydrochloride). In advanced dependence
there may be a sudden loss of previous tolerance; the mechanism for this is unknown.
Clinically, tolerance is exhibited by individuals who are able to display no or few
signs of intoxication while at a blood level in which intoxication would be evident in
a non-dependent individual.
 Loss of control of consumption: A subjective sense of inability to restrict further
consumption once the drug is taken.
 Signs of withdrawal on attempted abstinence :A withdrawal syndrome,
characteristic for each drug, may develop. This may be only regularly experienced
in the mornings because at all other times the blood level is kept above the required
level.
 Drug taking to avoid development of withdrawal symptoms: The user learns to
anticipate and avoid withdrawals, (e.g. having the drug available on waking).
 Continued drug use despite negative consequences :The user persists in drug use
even when threatened with significant losses as a direct consequence of continued
use, (e.g. marital break-up, prison term, loss of job).
 Rapid reinstatement of previous pattern of drug use after abstinence:
Characteristically, when the user relapses to drug use after a period of abstinence,
they are at risk of a return to the dependent pattern in a much shorter period than
the time initially taken to reach dependent use.
Concept of Addiction
Addiction is a disease characterised by compulsion, loss of control, and continued use
in spite of adverse consequences (Coombs, 1997; Smith & Seymour, 2001). The
primary elements of addictive disease are three Cs:
1) Compulsive use: an irresistible impulse; repetitive ritualized acts and intrusive,
ego-dystonic (i.e., ego alien) thoughts e.g. the person cannot start the day without
a cigarette and/or a cup of coffee. Evening means a ritual martini, or two, or three.
In and of itself, however, compulsive use doesn’t automatically mean addiction.
2) Loss of control: the inability to limit or resist inner urges; once begun it is very
difficult to quit, if not impossible, without outside help. This is the pivotal point in
addiction. The individual swears that there will be no more episodes, that he or
she will go to the party and have two beers. Instead, the person drinks until he or
she experiences a blackout and swears the next morning to never do it again; only
to repeat the behaviour the following night. The individual may be able to stop for
a period of time, or control use for a period of time, but will always return to
compulsive, out-of-control use.
3) Continued use despite adverse consequences: use of the substance continues
inspite of increasing problems that may include declining health, such as liver
impairment in the alcohol addict; embarrassment, humiliation, shame; or increasing
family, financial, and legal problems. 43
Addictions Drug addiction refers to a situation where drug procurement and administration appear
to govern the individual’s behaviour, and where the drug seems to dominate the
individual’s motivational hierarchy. Jaffe (1975) has described addiction as “a behavioural
pattern of compulsive drug use, characterized by overwhelming involvement with the
use of a drug, the securing of its supply, and a high tendency to relapse after withdrawal
(abstinence).” This definition follows the general lexical usage of the term and is consistent
with the word’s etymology (Bozarth 1987).
Drug addiction is defined behaviourally. It carries no connotations regarding the drug’s
potential adverse effects, the social acceptability of drug usage, or the physiological
consequences of chronic drug administration (Jaffe 1975). This latter point is especially
important because some investigators have mistakenly used the term addiction to
describe the development of physical dependence (see Bozarth 1987a, 1989; Jaffe
1975). Although drug addiction frequently has adverse medical consequences, it is
usually associated with strong social disapproval, and it is sometimes accompanied by
the development of physical dependence, these factors do not define addiction nor are
they invariably associated with it. Drug addiction is an extreme case of compulsive drug
use associated with strong motivational effects of the drug.

Substance dependence is the term which formally replaced ‘addiction’ in medical

terminology in 1964 when the World Health Organizations Expert Committee on Drug
Abuse proposed that the terms addiction and habituation be replaced with the term
dependence and distinguished between two types- psychological dependence and
physical dependence. Psychological dependence refers to “the experience of impaired
control over drug use” while physical dependence involves “the development of
tolerance and withdrawal symptoms upon cessation of use of the drug, as a consequence
of the body’s adaptation to the continued presence of a drug event” (UNIDCP, 1998).
Researchers and clinicians traditionally limit ‘addiction’ to alcohol and other drugs. Yet,
neuroadaptation, the technical term for the biological processes of tolerance and
withdrawal, also occurs when substance-free individuals become addicted to pathological
gambling, pornography, eating, overwork, shopping, and other compulsive excesses.
Acquisition and Maintenance Phases of Addiction
Drug addiction is frequently divided into two phases—acquisition and maintenance.
This conceptual partition acknowledges that different factors may be involved in these
two phases and that different degrees of drug-taking behaviour are associated with
these phases. The progression from the acquisition phase to the maintenance phase of
addiction is not a quantal change, but rather it represents a shift in the importance of
various factors that control the individual’s behaviour along with an increase in the
motivational strength of the drug-taking behaviour.
 Prior to the first experience with a drug, the direct rewarding effects of drug
administration are largely irrelevant in governing the individual’s behaviour,
44
  except of course in that expectancies are developed from social interactions Substance Abuse
and Addiction
(e.g., media exposure, conversations with experienced users).
 Initiation of drug-taking behaviour is governed by intrapersonal and sociological
variables such as curiosity about the drug’s effects or peer pressure to try the
drug.
 After initial exposure to the drug, pharmacological variables are relevant and
will influence subsequent drug-taking behaviour.
 Intrapersonal and sociological factors are probably still important in
determining continued drug use, but they are less significant as the potent
rewarding effects are repeatedly experienced.
 At some point there is a shift in control from intrapersonal/sociological to
pharmacological factors in governing drug-taking behaviour. This is
concomitant with a marked increase in the motivational strength of the drug
and with a progression from casual to compulsive drug use and ultimately to
drug addiction. This may occur very rapidly for some drugs such as heroin or
free-base cocaine and much more slowly for other drugs such as alcohol.

The division of addiction into two separate phases does not presume that different
mechanisms are involved in each phase. Rather, the demarcation acknowledges the
possibility of different mechanisms but more importantly emphasizes differences in the
motivational strength between the acquisition and maintenance of addictive behaviour.
The same psychobiological process underlies both phases but additional variables are
important in the acquisition of addiction. These other variables lose much of their influence
as the addiction fully develops and as it becomes increasingly under control of basic
pharmacological mechanisms.
45
Addictions
Self Assessment Questions 1
1) What is tolerance of drugs?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
2) What is harmful use of substances?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
3) Drug addiction is frequently divided into two phases such as _________ and
___________.

2.3 ILLEGAL DRUGS

A study of 300 street child laborers in slums of Surat in 1993 (Bansal & Banerjee)
showed that 135 (45%) used substances. The substances used were smoking tobacco,
followed by chewable tobacco, snuff, cannabis and opioids. Injecting drug use (Tripathi
& Lal, 1999) is also becoming apparent among street children as are inhalants (Praharaj,
Kumar, Verma & Arora, 2008).
There are serious sexually transmitted disease risks, including HIV that women partners
and drug users face (Murthy, 2008; Kumar & Sharma, 2008).
The Global Youth Tobacco Survey (Sinha et al.) in 2006 showed that 3.8% of students
smoke and 11.9% currently used smokeless tobacco.
There are as many patterns of drug use as drug user and individual patient assessment
is mandatory; nonetheless a number of patterns of use of illegal drugs can be recognised:
 Experimental use:Use of drug in order to explore effects. Common among young
and heavily driven by drug availability and drug use among peers. Very common
for softer drugs, (e.g. cannabis, volatile chemicals), rarer for more hard drugs,
(e.g. heroin).
 Situational use : Drug use limited to certain situations, (e.g. parties, raves). Mainly
drugs with stimulant/hallucinogenic properties.
 Recreational use : Regular but non-dependent use. May be limited in time by
period of life (e.g. ending at the end of university life) or may progress to dependent
use.
 Polydruguse: Non-dependent use of variety of drugs. One drug may be taken to
potentiate the effects of another or to manage unpleasant after effects of drug use.
Risks can be additive or multiplicative.
 Dependent use:Use of a drug for which a dependence syndrome has developed.
Continued use may be motivated more by the desire to avoid withdrawals than by
positive drug effects which may have diminished due to the development of tolerance.
Tendency is for the use of the dependent drug to predominate, with other drugs
being taken only if the primary drug is unavailable.
 Dual diagnosis use:Drug users who also suffer from a major mental illness. An
important group for therapeutic intervention.
46
Categories of drugs of abuse Substance Abuse
and Addiction
 Opiates e.g., heroin, dihydrocodeine, methadone, codeine, buprenorphine,
pethidine.
 Depressants e.g., benzodiazepines, barbiturates, alcohol, GHB.
 Stimulants e.g., amphetamine, cocaine, MDMA.
 Hallucinogens e.g., LSD, PCP, mushrooms, ketamine.
 Others e.g., cannabis, volatile substances, anabolic steroids.
Table 1 : COMMONLY ABUSED DRUGS

Substances: Category and Commercial and Street How Administered Intoxication Effects /
Name Names Potential Health
Consequences
CANNABINOIDS euphoria, slowed thinking
and reaction time, confusion,
Hashish boom, chronic, gangster, I/swallowed, smoked impaired balance and
hash, hash oil, hemp coordination / cough,
frequent respiratory
infections; impaired memory
blunt, dope, ganja, grass, and learning; increased heart
Marijuana herb, joints, Mary Jane, pot, I/swallowed, smoked rate, anxiety, panic attacks;
reefer, sinsemilla, skunk, tolerance
weed
DEPRESSANTS reduced anxiety; feeling of
well-being; lowered
inhibitions; slowed pulse and
breathing; lowered blood
pressure; poor concentration /
fatigue; confusion;
impaired coordination,
memory, judgment

sedation, drowsiness /
Barbiturates Amytal, Nembutal, Seconal, injected, swallowed depression, unusual
Phenobarbital: barbs, reds, excitement,
red birds, phennies, tooies, fever, irritability, poor
yellows judgment, slurred speech,
dizziness,
Ativan, Halcion, Librium,
Valium, Xanax: candy,
benzodiazepines (other than injected, swallowed sedation, drowsiness /
downers, sleeping pills,
flunitrazepam) dizziness
tranks
visual and gastrointestinal
flunitrazepam Rohypnol: forget-me pill, disturbances, urinary
Mexican Valium, R2, Roche, swallowed, snorted retention,
roofies, roofinol, rope, memory loss for the time
rophies under the drug’s effects

drowsiness, nausea /
GHB
vomiting, headache, loss of
gamma-hydroxybutyrate: G, swallowed consciousness,
Georgia home boy, grievous
loss of reflexes, seizures,
bodily harm, liquid ecstasy
coma, death

euphoria / depression, poor

methaqualone reflexes, slurred speech, coma
Quaalude, Sopor, Parest:
ludes, mandrex, quad, quay injected, swallowed
47
Addictions

DISSOCIATIVE increased heart rate and blood

ANESTHETICS pressure, impaired motor
function / memory
loss; numbness; nausea /
vomiting

Ketalar SV: cat Valiums, K, injected, snorted, smoked at high doses, delirium,
ketamine Special K, vitamin K depression, respiratory
depression and arrest
PCP and analogs phencyclidine: angel dust,
boat, hog, love boat, peace possible decrease in blood
injected, swallowed, smoked pressure and heart rate,panic,
pill
aggression, violence/ loss of
appetite, depression
HALLUCINOGENS altered states of perception
and feeling; nausea;
persisting perception
disorder (flashbacks)

increased body temperature,

LSD lysergic acid diethylamide: swallowed, absorbed through heart rate, blood
acid, blotter, boomers, cubes, mouth tissues pressure; loss of appetite,
microdot, yellow sunshines sleeplessness, numbness,
weakness, tremors

Mescaline buttons, cactus, mesc, peyote

persistent mental disorders
swallowed, smoked
psilocybin magic mushroom, purple
passion, shrooms nervousness, paranoia
swallowed
OPIODS & MORPHINE pain relief, euphoria,
DERIVATIVES drowsiness / nausea,
constipation, confusion,
sedation,respiratory
depression and arrest,
tolerance, addiction,
unconsciousness,coma, death

Codeine
Empirin with Codeine, Injected, swallowed less analgesia, sedation, and
Fiorinal with Codeine, respiratory depression than
Robitussin A-C, Tylenol with morphine
Codeine: Captain Cody,
Cody, schoolboy; (with
glutethimide) doors & fours,
loads, pancakes and syrup

fentanyl Actiq, Duragesic, Sublimaze:

Apache, China girl, China injected, smoked, snorted
white, dance fever, friend,
goodfella, jackpot, murder 8,
Heroin TNT, Tango and Cash
staggering gait

48
Heroin
staggering gait Substance Abuse
injected, smoked, snorted
Morphine diacetylmorphine: brown and Addiction
sugar, dope, H, horse, junk,
skag, skunk, smack, white
horse

Opium Roxanol, Duramorph: M,

Miss Emma, monkey, white injected, swallowed, smoked
stuff

Oxycodone HCL laudanum, paregoric: big O,

black stuff, block, gum, hop
swallowed, smoked
hydrocodonebitartrate,
OxyContin: Oxy, O.C., killer
swallowed, snorted, injected
acetaminophen
Vicodin: vike, Watson-387
swallowed

STIMULANTS increased heart rate, blood

pressure, metabolism;
feelings of exhilaration,
energy, increased mental
alertness / rapid or irregular
heart beat; reduced
appetite, weight loss, heart
failure, nervousness,
insomnia

rapid breathing / tremor, loss

Amphetamine Biphetamine, Dexedrine: injected, swallowed, of coordination;
bennies, black beauties, smoked,truck drivers, uppers irritability, anxiousness,
crosses, hearts, LA snorted restlessness, delirium, panic,
turnaround, speed, truck paranoia, impulsive
drivers, uppers behavior, aggressiveness,
tolerance, addiction,
psychosis

increased temperature / chest

Cocaine hydrochloride: blow,
Cocaine injected, smoked, snorted pain, respiratory failure,
bump, C, candy, Charlie,
nausea,abdominal pain,
coke, crack, flake, rock,
strokes, seizures, headaches,
snow, toot
malnutrition, panic attacks

MDMA (methyl Adam, clarity, ecstasy, Eve, swallowed mild hallucinogenic effects,
enedioxymethamphetamine) lover’s speed, peace, STP, X, increased tactile sensitivity,
XTC empathic feelings/ impaired
memory and learning,
hyperthermia, cardiac
toxicity, renalfailure, liver
toxicity

Methamphetamine aggression, violence,

Desoxyn: chalk, crank, injected, swallowed, smoked, psychotic behavior /
crystal, fire, glass, go fast, snorted memoryloss, cardiac and
ice, meth, speed neurological damage;
impaired memory and
learning,
tolerance
Methylphenidate (safe and injected, swallowed, snorted
effective for treatment of Ritalin: JIF, MPH, R-ball, additional effects attributable
ADHD) Skippy, the smart drug, to tobacco exposure: adverse
vitamin R pregnancy outcomes; chronic
lung disease, cardiovascular
disease, stroke
nicotine smoked, snorted, taken in
cigarettes, cigars, smokeless cancer; tolerance
tobacco, snuff, spit tobacco, snuff and spit tobacco
bidis, chew

49
Addictions

OTHER COMPOUNDS

Anabolic steroids Anadrol, Oxandrin, Injected, swallowed, applied no intoxication effects /

Durabolin, Depo- to skin hypertension, blood clotting
Testosterone, Equipoise: and cholesterol changes,
roids, juice liver cysts and cancer, kidney
cancer, hostility and
aggression, acne; in
adolescents, premature
stoppage of growth; in males,
prostate cancer, reduced
sperm production, shrunken
testicles, breast enlargement;
in females,
menstrualirregularities,
development of beard and
other masculine
characteristics
inhaled
Inhalants stimulation, loss of inhibition;
Solvents (paint thinners,
headache; nausea or
gasoline, glues), gases
vomiting; slurred speech,
(butane, propane, aerosol
loss of motor coordination;
propellants, nitrous oxide),
wheezing / unconsciousness,
nitrites (isoamyl, isobutyl,
cramps, weight loss,
cyclohexyl): laughing gas,
muscle weakness, depression,
poppers, snappers,whippets
memory impairment, damage
to cardiovascularand nervous
systems, sudden death

2.3.1 Opiates
The opiates are a group of chemicals derived from the opium poppy
(papaversomniferum); synthetic compounds with similar properties are called opioids.
They have potent analgesic properties and as such have wide legitimate uses in medicine.
They are widely abused for their euphoriant and anxiolytic properties. Heroin is the
most frequently abused opiate.

2.3.2 Depressants
Drugs of this group produce their effects by generalised or specific cortical depression.
They include the benzodiazepines, alcohol, and the barbiturates. They can be taken for
their pleasurable anxiolytic and relaxant properties alone, or as a way of counteracting
unpleasant side-effects of other drugs of abuse.

2.3.3 Stimulants
These drugs potentiate neuro-transmission and increase cortical excitability producing
effects of increased alertness and endurance, diminished need for sleep, and a subjective
sense of well-being. They include cocaine (and crack cocaine), amphetamines, 3,4,
methylenedioxymethamphetamine (MDMA or ecstasy), and caffeine.

2.3.4 Hallucinogens
Hallucinogens (or psychedelics) are a heterogeneous group of natural and synthetic
substances which produce altered sensory and perceptual experiences. They include:
lysergic acid diethylamide (LSD), phenylcyclidine (PCP), magic mushrooms, ketamine,
mescaline, 2,5-di-methoxy 4-methylamphetamine (DOM), and dimethyltriptamine
50 (DMT).
2.3.5 Other Drugs Substance Abuse
and Addiction
a) Cannabis
This is the most commonly used illegal drug, with only a small minority of its users ever
using another illegal drug. It has been used for centuries as a pleasurable mind-altering
substance and as a medication for a wide variety of ailments. Clinical trials are underway
to clarify its role in the treatment of chronic pain. Its illegal use is of interest to psychiatrists
because of its association with other drugs of abuse (as a gateway drug) and because
of its exacerbating effect on chronic psychotic illnesses.
Cannabis is produced from the dried leaves, flowers, stems, and seeds of the weed
Cannabis Sativa. It may be distributed as herbal material (grass or marijuana), as a
resin (hash), or as cannabis oil. Cannabis may be smoked in cigarettes, alone, or mixed
with tobacco; the resin form may be eaten directly or incorporated into foodstuffs (e.g.
cakes).
Usage pattern is very variable, from infrequent situational use to daily heavy use; the
latter at highest risk of harmful effects and most likely to take other drugs.
The effects of intoxication are apparent within minutes if the drug is smoked, peaking in
30 minutes and lasting 2-5 hours. The effects of orally consumed cannabis are slower
to begin and more prolonged. The immediate effects include mild euphoria ,a sense of
enhanced well-being, subjective sense of enhanced sensation, relaxation, altered time
sense, and increased appetite. Physically there is mild tachycardia and variable dysarthria
and ataxia.
Acute harmful effects include mild paranoia, panic attacks, and accidents associated
with delayed reaction time. Cannabis is normally smoked with tobacco, therefore all of
the health risks associated with tobacco will also apply. The tendency of cannabis
smokers to inhale deeply and to retain the smoke in the lungs for as long as possible will
exacerbate this risk. Chronic harmful effects include dysthymia, anxiety/depressive
illnesses, the disputed amotivational syndrome (possibly representing a combination of
chronic intoxication in a heavy user and a long half-life). The drug is not usually associated
with physical dependency but there is a mild but characteristic withdrawal syndrome in
the previously heavy regular user who stops suddenly, consisting of insomnia, anxiety,
and irritability. Cannabis use can precipitate an episode of or relapse of schizophrenia.
In addition, in regular users it is associated with dose-related paranoid ideation and
other psychotic features.
b) Volatile substances
Simple hydrocarbons such as acetone, toluene, xylene, and butane have intoxicant
properties. These chemicals are found in a variety of common products including glue,
solvents, lighter fuel, paint stripper, fire extinguishers, aerosols, paints, petrol, typewriter
correcting fluid, and nail varnish remover. They are rapidly absorbed when deeply
inhaled or by sniffing propellant gases or aerosols. They cause non-specific increased
permeability of nerve cell membranes and produce euphoriant effects, disinhibition,
slurred speech and blurred vision, and visual misperceptions.
Acute harmful effects include local irritation, headache, cardiac arrhythmias, acute
suffocation by bag or laryngeal oedema, unconsciousness, and sudden death. Chronic
harmful effects include liver and kidney damage, memory/concentration impairment,
and probable long-term cognitive impairment. There is a withdrawal syndrome similar
to alcohol in very heavy regular users.
51
Addictions c) Anabolic steroids
These prescription-only medicines (e.g. nandrolone and stanozolol) have limited legitimate
uses in the treatment of aplastic anaemia and osteoporosis. They can be abused by
athletes and body builders seeking competitive advantage or, more rarely, for their
euphoriant effects alone. They produce increased muscle mass and strength, with
increased training time and reduced recovery time as well as euphoriant effects and a
sense of increased energy levels.
Use of anabolic steroids is associated with physical health problems including
hypertension, hypogonadism, gynaecomastia, amenorrhoea, liver damage, impotence,
and male pattern baldness; and with mental health problems including acute emotional
instability.

2.4 ASSESSMENT OF THE DRUG USER

In most cases an assessment of a patient’s history of drug use will form part of a routine
psychiatric interview. In addition, all doctors should consider the possibility of, and be
prepared to ask about, comorbid drug misuse when interviewing patients for other
reasons. The more detailed assessment described here is appropriate for patients in
whom drug use is the primary focus of clinical concern and who are being assessed for
entry into a treatment programme. The detailed assessment of a patient with drug use
problems will usually be carried out over more than one consultation. There are only a
few circumstances (such as an opiate-dependent patient presenting as an acute medical
emergency), where treatment should be considered before full assessment. History
should cover the following topics:
a) Background information
Name, address, next of kin, GP, names of other professionals involved (e.g. social
worker, probation officer).
b) Reasons for consultation now
Why has the drug user presented now, (e.g. pressure from family, pending conviction,
had enough, increasing difficulty injecting)?. What does the user seek from the program?
In females, is there a possibility of pregnancy?
c) Current drug use
Enquire about each drug taken over the previous 4 weeks. Describe the frequency of
use (e.g. daily, most days, at weekends); and the number of times taken each day.
Record the amount taken and the route. Ask the user about episodes of withdrawal.
Include alcohol, tobacco, and cannabis. If there is IV use, inquire about needle or other
equipment sharing.
d) Lifetime drug use
Record the age at first use of drugs and the changing pattern of drug use until the most
recent consultation. Enquire about periods of abstinence or stability and the reasons for
this (e.g. prison, relationship, treatment programme).
e) Complications of drug use
Overdoses deliberate or accidental. History of cellulitis, abscesses, or phlebitis. Hepatitis
B and C and HIV status if known.
52
f) Previous treatment episodes Substance Abuse
and Addiction
Timing, locus, and type of previous drug treatment. How did the treatment attempt
end? Was the treatment helpful?
g) Medical and psychiatric history
All episodes of medical or psychiatric inpatient care. Contact with hospital specialists.
Current health problems. Relationship with GP.
h) Family history
Are there other family members with drug or alcohol problems? Family history of medical
or psychiatric problems.
i) Social history
Current accommodation. How stable is this accommodation? Sexual orientation and
number of sexual partners. Enquire about safe sex precautions. Describe the user’s
relationship: sexual, personal, and family. Note how many of these individuals currently
use drugs.
j) Forensic history
Previous or pending [Link] of imprisonment. Enquire about continuing
criminal activity to support drug use (remind the patient about confidentiality).
k) Patient’s aims in seeking treatment
What is the patient’s attitude to drug use? What treatment options do they favour?
l) Mental status examination (MSE)
Observe for history or objective signs of depressed mood or suicidal thoughts or plans.
Inquire directly about generalised anxiety and panic attacks (a benzodiazepine user
may be self medicating a neurotic condition). Inquire directly about paranoid ideas and
hallucinatory experiences and the directness or otherwise of their relationship with drug
use.
m) Physical examination
General condition. Weight. Condition of teeth. Signs of IV use (examine particularly
arms for signs of phlebitis, abscess, or old scarring). Examine for enlarged liver. Signs
of withdrawals on assessment.
n) Urine screening
This is essential. Several specimens should be taken over several weeks. Repeated
absence of evidence of a drug on screening make its dependent use unlikely.
Occasionally, testing errors do occur so do not take action (e.g. stopping maintenance
prescription) on the basis of the results of a single sample.
o) Blood testing
FBC, LFT, discuss with patient the need for HIV and Hepatitis screening.
Standardised assessment and screening tools: Such tools can be a useful means of
gathering data by providing an objective (reliable and valid) view of the client’s difficulties
and current life situation (Ries, 1995; Winters, 1999). Furthermore, when conducted
appropriately the process of standardised assessment can be a source of rapport building.

53
Addictions Summary of available screening and assessment measures

54
 Substance Abuse
and Addiction

Self Assessment Questions 2

1) What information is collected as part of History during assessment of the drug
abuser?
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2) What are Hallucinogens?
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3) What are the categories of drugs of abuse?
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2.5 TREATMENT AND MANAGEMENT OF

SUBSTANCE ABUSE AND ADDICTIONS
The longer-term goal of treatment will be eventual abstinence from drugs, but this may
not be an achievable short-or medium-term goal in an individual case. Immediate
treatment aims are therefore: to reduce drug related mortality and morbidity; to reduce 55
Addictions community infection rates; to reduce criminal activity, including the need for drug users
to sell to others to finance their own habit; to optimise the patient’s physical and mental
health; and to stabilise where appropriate on an alternative substitute drug. The following
things can be kept in mind.
i) Make diagnosis
Confirm drug use (history, signs of withdrawals, urine testing). Assess presence and
extent of dependence. Assess severity of current problems and risk of future
complications. Explore social, relationship, and medical problems. Assess stage of change
and motivation. What are the short-term and medium-term aims of treatment?Consider
need for emergency treatment
Where there is evidence of psychotic illness or severe depressive illness the patient may
require inpatient assessment.
ii) Engage in service
Treatment of drug misuse cannot be carried out through one off interventions. Patients
should be engaged in the service by empathic and non-judgemental interviewing,
availability of the service close to the point of need, and ability of the service to respond
to change in a previously ambivalent patient. Substitute prescribing will be a strong
motivator for engagement in some patients but should always also have a role in helping
the patient achieve some worthwhile change.
iii) Decide treatment goals and methods
After assessment and diagnosis the doctor should discuss with the patient their thoughts
about treatment options given the patient’s drug history and local treatment availability.
The doctor may have strong feelings about the appropriateness of a certain treatment
but this will not be successful unless the patient agrees. Plans may include:
 Return to dependent use as previously Where individuals present in withdrawals,
without other medical surgical or psychiatric reasons for admission, and where
there is no history of complicated withdrawal, and where there has been no previous
involvement in treatment services, it is inappropriate to prescribe. The individual
should not receive replacement medication. They should be offered the opportunity
to attend for further assessment.
 Counselling and support for non-dependent drug use particularly episodic use this
may be the appropriate course. Give drug information and harm-reduction advice,
possibly coupled with referral to a community resource.
 Detoxification: Where there is drug dependence and the patient wishes abstinence,
then a plan for detox is considered. This may be community-based, with
psychological support, symptomatic medication, or reducing substitute medication,
or as an inpatient. Consideration should be given to support after detox. How is
abstinence to be maintained?
– Supported detox without prescription Some individuals can withdraw from
drugs of dependence without use of a prescription. This may occur particularly
where other changes in a person’s life (e.g. change of area, break from
dependent partner) facilitate abstinence. Unsupported detox without any
medical help is frequently reported by users.
– Supported detox with symptomatic medication. Here, in addition to the
56 support mentioned above, the individual is prescribed other, non-replacement
 drugs to ameliorate withdrawal symptoms (e.g. lofexidine in opiate Substance Abuse
and Addiction
withdrawal).
– Conversion to substitute drug with aim of detox Here the aim is to convert
the individual’s drug use from street-bought to prescribed, Then, from a period
of stability, attempt supervised reduction in dose, aiming towards abstinence.
 Conversion to substitute drug with aim of maintenance. Here the aim again is to
convert from street to prescribed drugs, with stabilisation via maintenance
prescribing in the medium term. In a dependent user who does not feel that they
can move to abstinence in the short term, maintenance prescribing to suitably
selected patients is useful and associated with overall health benefits.
iv) Address other needs
The drug treatment service should consider part of its role as being a gateway to other
services which the drug user may require but be reluctant or unable to approach
independently. Patients with social, financial, or physical health needs should have these
explored and the need for referral considered. Do not make such referrals without the
knowledge and agreement of the patient. Review psychiatric symptoms which have
been attributed to drug use to assess their resolution. Consider in-house or specialist
psychiatric treatment of residual anxiety/ depressive symptoms.
Principles in the management of Substance Abuse and Addictions
Addiction is a brain disease. While the path to drug addiction begins with the act of
taking drugs, over time a person’s ability to choose not to do so becomes compromised,
and seeking and consuming the drug becomes compulsive. This behaviour results largely
from the effects of prolonged drug exposure on brain functioning. Addiction affects
multiple brain circuits, including those involved in reward and motivation, learning and
memory, and inhibitory control over behaviour. Some individuals are more vulnerable
than others to becoming addicted, depending on genetic makeup, age of exposure to
drugs, other environmental influences, and the interplay of all these factors.
Addiction is often more than just compulsive drug taking—it can also produce far-
reaching consequences. For example, drug abuse and addiction increase a person’s
risk for a variety of other mental and physical illnesses related to a drug-abusing lifestyle
or the toxic effects of the drugs themselves. Additionally, a wide range of dysfunctional
behaviours can result from drug abuse and interfere with normal functioning in the family,
the workplace, and the broader community. Because drug abuse and addiction have so
many dimensions and disrupt so many aspects of an individual’s life, treatment is not
simple. Effective treatment programs typically incorporate many components, each
directed to a particular aspect of the illness and its [Link] treatment
must help the individual stop using drugs, maintain a drug-free lifestyle, and achieve
productive functioning in the family, at work, and in society.
Thus, treatment planning must be multidimensional and recognize that there is more
than one effective treatment for substance dependence. However, there are certain
basic treatment principles that apply across modalities.
Principles of EffectiveTreatment
Scientific research in the west since the mid-1970s shows that treatment can help patients
addicted to drugs stop using, avoid relapse, and successfully recover their lives. Based
on this research, key principles have emerged that should form the basis of any effective
treatment programs: 57
Addictions  Addiction is a complex but treatable disease that affects brain function
and behaviour:Drugs of abuse alter the brain’s structure and function, resulting in
changes that persist long after drug use has ceased. This may explain why drug
abusers are at risk for relapse even after long periods of abstinence and despite
the potentially devastating consequences.
 No single treatment is appropriate for everyone: Matching treatment
settings,interventions, and services to an individual’s particular problems and needs
is critical to his or her ultimate success in returning to productive functioning in the
family, workplace, and society.
 Treatment needs to be readily available: Because drug-addicted individuals
may be uncertain about entering treatment, taking advantage of available services
the moment people are ready for treatment is critical. Potential patients can be lost
if treatment is not immediately available or readily accessible. As with other chronic
diseases, the earlier treatment is offered in the disease process, the greater the
likelihood of positive outcomes.
 Effective treatment attends to multiple needs of the individual,not just his
or her drug abuse: To be effective, treatment must address the individual’s drug
abuse and any associated medical, psychological, social, vocational,and legal
problems. It is also important that treatment be appropriate to the individual’s age,
gender, ethnicity, and culture.
 Remaining in treatment for an adequate period of time is critical: The
appropriate duration for an individual depends on the type and degree of his or
her problems and needs. Research indicates that most addicted individuals need
at least 3 months in treatment to significantly reduce or stop their drug use and that
the best outcomes occur with longer durations of treatment. Recovery from drug
addiction is a long term process and frequently requires multiple episodes of
treatment. As with other chronic illnesses, relapses to drug abuse can occur and
should signal a need for treatment to be reinstated or adjusted.
 Counseling—individual and/orgroup—and other behavioural therapies are
the most commonly used forms of drug abuse treatment: Behavioural
therapies vary in their focus and may involve addressing a patient’s motivation to
change, providing incentives for abstinence, building skills to resist drug use,
replacing drug-using activities with constructive and rewarding activities, improving
problem solving skills, and facilitating better interpersonal relationships. Also,
participation in group therapy and other peer support programs during and following
treatment can help maintain abstinence.
 Medications are an important element of treatment for many patients,
especially when combined with counseling and other behavioural therapies:
For example, methadone and buprenorphine are effective in helping individuals
addicted to heroin or other opioids stabilize their lives and reduce their illicit drug
use. Naltrexoneis also an effective medication for some opioid-addicted individuals
and some patients with alcohol dependence.
 An individual’s treatment and services plan must be assessed continually
and modified as necessary to ensure that it meets his or her changing
needs: A patient may require varying combinations of services and treatment
components during the course of treatment and recovery. In addition to counseling
or psychotherapy, a patient may require medication, medical services, family
therapy, parenting instruction, vocational rehabilitation, and/or social and legal
services. For many patients, a continuing care approach provides the best results,
58
 with the treatment intensity varying according to a person’s changing needs. Substance Abuse
and Addiction
 Many drug-addicted individuals also have other mental disorders: Because
drug abuse and addiction—both of which are mental disorders—often co-occur
with other mental illnesses, patients presenting with one condition should be
assessed for the other(s). And when these problems co-occur, treatment should
address both (or all), including the use of medications as appropriate.
 Medically assisted detoxification is only the first stage of addiction
treatment and by itself does little to change long-term drug abuse: Although
medically assisted detoxification can safely manage the acute physical symptoms
of withdrawal and, for some, can pave the way for effective long-term addiction
treatment, detoxification alone is rarely sufficient to help addicted individuals achieve
long-term abstinence. Thus, patients should be encouraged to continue drug
treatment following detoxification.
 Treatment does not need to be voluntary to be effective: Sanctions or
enticements from family, employment settings, and/or the criminal justice system
can significantly increase treatment entry, retention rates, and the ultimate success
of drug treatment interventions.
 Drug use during treatment must be monitored continuously, as lapses during
treatment do occur: Knowing their drug use is being monitored can be a powerful
incentive for patients and can help them withstand urges to use drugs. Monitoring
also provides an early indication of a return to drug use, signaling a possible need
to adjust an individual’s treatment plan to better meet his or her needs.
 Treatment programs should assess patients for the presence of HIV/AIDS,
hepatitis B and C, tuberculosis, and other infectious diseases as well as
provide targeted risk reduction counseling to help patients modify or
change behaviours that place them at risk of contracting or spreading
infectious diseases: Typically, drug abuse treatment addresses some of the drug-
related behaviours that put people at risk of infectious diseases. Targeted counseling
specifically focused on reducing infectious disease risk can help patients further
reduce or avoid substance-related and other high-risk behaviours. Counseling
can also help to manage their illness.
You can refer to Table 2 of Section 1.8 in the Unit 1 regarding chosing an
appropriate treatement setting.
Comprehensive Drug Abuse Treatment

59
Addictions Optimum care will involve engaging the patients with the service, exploring and
encouraging motivation to change, and suggesting harm reduction strategies. It should
always be a comprehensive t reatment plan addressing the various needs of the individual
and involving the family and the community.
Medical Detoxification
A process whereby individuals are systematically withdrawn from addicting drugs in an
inpatient or outpatient setting, typically under the care of a physician. Detoxification is
sometimes called a distinct treatment modality but is more appropriately considered a
precursor of treatment, because it is designed to treat the acute physiological effects of
stopping drug use. Medications are available for detoxification from opiates, nicotine,
benzodiazepines, alcohol, barbiturates, and other sedatives. In some cases, particularly
for the last three types of drugs, detoxification may be a medical necessity, and untreated
withdrawal may be medically dangerous or even fatal. Detoxication is not designed to
address the psychological, social, and behavioural problems associated with addiction
and therefore does not typically produce lasting behavioural changes necessary for
recovery. Detoxification is most useful when it incorporates formal processes of
assessment and referral to subsequent drug addiction treatment.
Scientifically based psychological approaches to drug addiction treatment
Relapse Prevention: A cognitive behavioural therapy, it was developed for the treatment
of problem drinking and adapted later for cocaine addicts. Cognitive-behavioural
strategies are based on the theory that learning processes play a critical role in the
development of maladaptive behavioural patterns. Individuals learn to identify and correct
problematic behaviours. Relapse prevention encompasses several cognitive-behavioural
strategies that facilitate abstinence as well as provide help for people who experience
relapse. The relapse prevention approach to the treatment of cocaine addiction consists
of a collection of strategies intended to enhance self-control. Specific techniques include
exploring the positive and negative consequences of continued use, self-monitoring to
recognize drug cravings early on and to identify high-risk situations for use, and developing
strategies for coping with and avoiding high-risk situations and the desire to use. A
central element of this treatment is anticipating the problems patients are likely to meet
and helping them develop effective coping strategies. Research indicates that the skills
individuals learn through relapse prevention therapy remain after the completion of
treatment. In one study, most people receiving this cognitive-behavioural approach
maintained the gains they made in treatment throughout the year following treatment.
Cognitive Behaviour Therapy: Suitable for Alcohol, Marijuana, Cocaine,
Methamphetamine, Nicotine abuse and dependence. Cognitive-behavioural therapy
was developed as a method to prevent relapse when treating problem drinking, and
later was adapted for cocaine-addicted individuals. Cognitive-behavioural strategies
are based on the theory that learning processes play a critical role in the development of
maladaptive behavioural patterns. Individuals learn to identify and correct problematic
behaviours by applying a range of different skills that can be used to stop drug abuse
and to address a range of other problems that often co-occur with it. Cognitive-
behavioural therapy generally consists of a collection of strategies intended to enhance
self-control. Specific techniques include exploring the positive and negative consequences
of continued use, self-monitoring to recognize drug cravings early on and to identify
high risk situations for use, and developing strategies for coping with and avoiding high-
risk situations and the desire to use. A central element of this treatment is anticipating
likely problems and helping patients develop effective coping strategies.
60
Supportive-Expressive Psychotherapy: It is a time-limited, focused psychotherapy Substance Abuse
and Addiction
that has been adapted for heroin- and cocaine-addicted individuals. The therapy has
two main components:
 Supportive techniques to help patients feel comfortable in discussing their personal
experiences.
 Expressive techniques to help patients identify and work through interpersonal
relationship [Link] attention is paid to the role of drugs in relation to problem
feelings and behaviours, and how problems may be solved without recourse to
drugs.
Individualized Drug Counseling: Focuses directly on reducing or stopping the addict’s
illicit drug use. It also addresses related areas of impaired functioning such as employment
status, illegal activity, family/social relations, as well as the content and structure of the
patient’s recovery program. Through its emphasis on short-term behavioural goals,
individualized drug counseling helps the patient develop coping strategies and tools for
abstaining from drug use and then maintaining abstinence. The addiction counselor
encourages 12-step participation and makes referrals for needed supplemental medical,
psychiatric, employment, and other services. Individuals are encouraged to attend
sessions one or two times per week. In a study that compared opiate addicts receiving
only methadone to those receiving methadone coupled with counseling, individuals who
received only methadone showed minimal improvement in reducing opiate use. The
addition of counseling produced significantly more improvement. The addition of onsite
medical/psychiatric, employment, and family services further improved outcomes.
In another study with cocaine addicts, individualized drug counseling, together with
group drug counseling, was quite effective in reducing cocaine use. Thus, it appears
that this approach has great utility with both heroin and cocaine addicts in outpatient
treatment.
Motivational EnhancementTherapy: A client-centered counseling approach for
initiating behaviour change by helping clients to resolve ambivalence about engaging in
treatment and stopping drug use. This approach employs strategies to evoke rapid and
internally motivated change in the client, rather than guiding the client stepwise through
the recovery process.
This therapy consists of an initial assessment battery session, followed by two to four
individual treatment sessions with a therapist. The first treatment session focuses on
providing feedback generated from the initial assessment battery to stimulate discussion
regarding personal substance use and to elicit self-motivational statements. Motivational
interviewing principles are used to strengthen motivation and build a plan for change.
Coping strategies for high-risk situations are suggested and discussed with the client. In
subsequent sessions, the therapist monitors change, reviews cessation strategies being
used, and continues to encourage commitment to change or sustained abstinence. Clients
are sometimes encouraged to bring a significant other to sessions. This approach has
been used successfully with alcoholics, nicotine and marijuana-dependent individuals.
Behavioural Therapy forAdolescents: Incorporates the principle that unwanted
behaviour can be changed by clear demonstration of the desired behaviour and consistent
reward of incremental steps toward achieving it. Therapeutic activities include fulfilling
specific assignments, rehearsing desired behaviours, and recording and reviewing
progress, with praise and privileges given for meeting assigned goals. Urine samples
are collected regularly to monitor drug use. The therapy aims to equip the patient to
gain three types of control: 61
Addictions Stimulus Control helps patients avoid situations associated with drug use and learn to
spend more time in activities incompatible with drug use.
Urge Control helps patients recognize and change thoughts, feelings, and plans that
lead to drug use.
Social Control involves family members and other people important in helping patients
avoid drugs. A parent or significant other attends treatment sessions when possible and
assists with therapy assignments and reinforcing desired behaviour.
Multidimensional Family Therapy (MDFT): For adolescents, it is an outpatient
family –based drug abuse treatment. MDFT views adolescent drug use in terms of a
network of influences (that is, individual, family, peer, community) and suggests that
reducing unwanted behaviour and increasing desirable behaviour occur in multiple ways
in different [Link] includes individual and family sessions held in the clinic, in
the home, or with family members at the family court, school, or other community
locations. During individual sessions, the therapist and adolescent work on important
developmental tasks, such as developing decision making, negotiation, and problem-
solving [Link] acquire skills in communicating their thoughts and feelings to
deal better with life stressors, and vocational skills. Parallel sessions are held with family
members. Parents examine their particular parenting style, learning to distinguish influence
from control and to have a positive and developmentally appropriate influence on their
child.
Multisystemic Therapy (MST): Addresses the factors associated with serious
antisocial behaviour in children and adolescents who abuse [Link] factors include
characteristics of the adolescent (for example, favorable attitudes toward drug use),
the family (poor discipline, family conflict, parental drug abuse), peers (positive attitudes
toward drug use), school (dropout, poor performance), and neighborhood (criminal
subculture). By participating in intense treatment in natural environments (homes, schools,
and neighborhood settings) most youths and families complete a full course of treatment.
MST significantly reduces adolescent drug use during treatment and for at least 6 months
after treatment. Reduced numbers of incarcerations and out-of-home placements of
juveniles offset the cost of providing this intensive service and maintaining the clinicians’
low caseloads.
12 Step Facilitation Therapy: Used for the treatment of Alcohol, Stimulants, Opiate
dependence and abuse,Twelve-step facilitation therapy is an active engagement strategy
designed to increase the likelihood of a substance abuser becoming affiliated with and
actively involved in12 step self-help groups and, thus, promote abstinence.
Three key aspects predominate: acceptance, which includes the realization that drug
addiction is a chronic, progressive disease over which one has no control, that life has
become unmanageable because of drugs, that willpower alone is insufficient to overcome
the problem, and that abstinence is the only alternative; surrender, which involves giving
oneself over to a higher power, accepting the fellowship and support structure of other
recovering addicted individuals, and following the recovery activities laid out by the 12
step program; and active involvement in 12 step meetings and related activities. While
the efficacy of 12 step programs (and 12 step facilitation) in treating alcohol dependence
has been established, the research on other abused drugs is more preliminary but
promising for helping drug abusers sustain recovery.
Community ReinforcementApproach (CRA) Plus Vouchers: This is an intensive
24-week outpatient therapy for treatment of cocaine and alcohol addiction. The treatment
62 goals are twofold:
 To achieve cocaine abstinence long enough for patients to learn new life skills that Substance Abuse
and Addiction
will help sustain abstinence.
 To reduce alcohol consumption for patients whose drinking is associated with
cocaine use.
Patients attend one or two individual counseling sessions per week, where they focus
on improving family relations, learning a variety of skills to minimize drug use, receiving
vocational counseling, and developing new recreational activities and social networks.
Those who also abuse alcohol receive clinic-monitored disulfiram (Antabuse) therapy.
Patients submit urine samples two or three times each week and receive vouchers for
cocaine-negative samples.
The value of the vouchers increases with consecutive clean samples. Patients may
exchange vouchers for retail goods that are consistent with a cocaine-free lifestyle. This
approach facilitates patients’ engagement in treatment and systematically aids them in
gaining substantial periods of cocaine abstinence.
Voucher-Based Reinforcement Therapy In Methadone MaintenanceTreatment:
Helps patients achieve and maintain abstinence from illegal drugs by providing them
with a voucher each time they provide a drug-free urine [Link] voucher has
monetary value and can be exchanged for goods and services consistent with the goals
of treatment. Initially, the voucher values are low, but their value increases with the
number of consecutive drug-free urine specimens the individual provides. Cocaine- or
heroin positive urine specimens reset the value of the vouchers to the initial low value.
The contingency of escalating incentives is designed specifically to reinforce periods of
sustained drug abstinence. Studies show that patients receiving vouchers for drug free
urine samples achieved significantly more weeks of abstinence and significantly more
weeks of sustained abstinence than patients who were given vouchers independent of
urine analysis results.
The Matrix Model: The model provides a framework for engaging stimulant abusers
in treatment and helping them achieve abstinence. Patients learn about issues critical to
addiction and relapse, receive direction and support from a trained therapist, become
familiar with self-help programs, and are monitored for drug use by urine [Link]
program includes education for family members affected by the [Link] therapist
functions simultaneously as teacher and coach, fostering a positive, encouraging
relationship with the patient and using that relationship to reinforce positive behaviour
change. Therapists are trained to conduct treatment sessions in a way that promotes
the patient’s self-esteem,dignity, and self-worth. A positive relationship between patient
and therapist is a critical element for patient [Link] materials draw heavily
on other tested treatment approaches. Thus, this approach includes elements pertaining
to the areas of relapse prevention, family and group therapies, drug education, and self-
help participation. Detailed treatment manuals contain work sheets for individual sessions;
other components include family educational groups, early recovery skills groups, relapse
prevention groups, conjoint sessions, urine tests, 12-step programs, relapse analysis,
and social support groups.
Psychological approaches
Substance misusers vary in their suitability for psychological treatments, and it may be
more or less appropriate in individual cases due to age, cognitive ability or dysfunction,
education, willingness and capability or capacity to view problems as psychological.
However, psychological treatments are pivotal to treatment effectiveness, even when
63
Addictions pharmacological treatments are administered. Standardisation of approaches and
outcome measures is complex. Treatment philosophies, environments and settings may
differ greatly (e.g. primary care, accident and emergency, prisons). Additional resources
for treatment (e.g. support by other agencies such as housing, education, probation)
may vary. Some groups may be discriminated against across a variety of services,
because of general stigmas around substance misuse, poorly trained staff, and lack of
resources or due to old age, female sex or ethnic minority status.
Stages of change
A model for understanding motivation and action towards change in harmful patterns of
drug use proposed by Prochaska and DiClemente is helpfuld in the treatment of
substance abuse. Motivation is regarded as a prerequisite for and a precursor to action
towards abstinence or more controlled drug use.
 Pre-contemplation. The user does not recognise that problem use exists, although
this may be increasingly obvious to those around them.
 Contemplation. The user may accept that there is a problem and begins to look at
both the positive and negative aspects of continued drug use.
 Decision. The point at which the user decides on whether to continue drug use or
attempt change.
 Action. The point of motivation, where the user attempts change. A variety of
routes exist by which change may be attempted, which may or may not include
medical services.
 Maintenance. A stage of maintaining gains made and attempting to improve those
areas of life harmed by drug use.
 Relapse. A return to previous behaviour but with the possibility of gaining useful
strategies to extend the maintenance period on the user’s next attempt.

Self Assessment Questions 3

1) Mention the types of control behaviour therapy aims at.
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2) What is detoxification?
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3) How does cognitive behavioural therapy help in substance abuse?
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64
 Substance Abuse
2.6 LET US SUM UP and Addiction

Taking of substance starts from using it to various degrees of use, resulting in misuse,
abuse, harmful use, addiction and dependence. A variety of factors – biological,
psychological and social – interact, and result in substance abuse and dependence.
Consequences of substance use cuts across various aspects such as physical
consequences, psychological, social, economic, familial and legal consequences. The
treatment and management of substance abuse should follow a comprehensive approach.

2.7 ANSWERS TO SELF ASSESSMENT

QUESTIONS
Self Assessment Questions 1
1) Tolerance refers to a need for markedly increased amounts of a drug to achieve
the desired drug effect or a markedly diminished effect with continued use of the
same amount of the drug.
2) Harmful use of substances refers to the continuation of substance use despite
evidence of damage to the user’s physical or mental health or to their social,
occupational, and familial well-being.
3) acquisition and maintenance
Self Assessment Questions 2
1) Following information is collected as part of History during assessment of the drug
abuser:
Background information, reasons for consultation now, current drug use, previous
treatment, medical, psychiatric, forensic, family and social history, mental status
examination, and physical examination.
2) Hallucinogens (or psychedelics) are a heterogeneous group of natural and synthetic
substances which produce altered sensory and perceptual experiences.
3) The categories of drugs of abuse are Opiates, Stimulants, Depressants,
Hallucinogens, and Others such as cannabis etc.
Self Assessment Questions 3
1) Behaviour therapy aims at three types of control: stimulus, urge and social control.
2) Detoxification refers to a process whereby individuals are systematically withdrawn
from addictive drugs in an inpatient or outpatient setting, typically under the care
of a physician.
3) Cognitive behavioural therapy aims at enhancing self-control, self-monitoring to
recognize drug cravings early on and to identify high risk situations for use, and
developing strategies for coping with and avoiding high-risk situations and the
desire to use.

2.8 UNIT END QUESTIONS

1) Differentiate between substance abuse and substance dependence.
2) Explain the concept of drug addiction. 65
Addictions 3) Describe the Matrix model.
4) Describe the psychological approaches to drug addiction treatment.
5) What are the principles of effective treatment?

2.9 REFERENCES
Farrell M, Howes S, Taylor C, Lewis G, Jenkins R, Bebbington P, Jarvis M, Brugha T,
Gill B, Meltzer H. (2003). Substance misuse and psychiatric comorbidity: An overview
of the OPCS National Psychiatric Morbidity Survey. International Review Psychiatry.
15:43.
Hubbard RL, Craddock SG, Anderson J. (2003). Overview of 5-year follow-up
outcomes in the Drug Abuse Treatment Outcome Studies (DATOS). J Subst Abuse
Treat. 25:125.
Humphreys K. (2004). Circles of Recovery: Self-Help Organizations for Addictions.
Cambridge, UK: Cambridge University Press.
Jaffe JH. (2009). Substance-related disorders: introduction and overview. In: Sadock
BJ, Sadock VA, eds. Kaplan &Sadock’s Comprehensive Textbook of Psychiatry.7th
ed. Vol. 1. Baltimore: Lippincott Williams & Wilkins.
Jaffe JH, Anthony JC. (2005). Substance-related disorders: introduction and overview.
In: Sadock BJ, Sadock VA, eds. Kaplan &Sadock’s Comprehensive Textbook of
Psychiatry.8th ed. Vol. 1. Baltimore: Lippincott Williams & Wilkins.
Jarvis TJ, Tebbutt J, Mattick RP, Shand F, Heather N. (2005). Treatment Approaches
for Alcohol and Drug Dependence: An Introductory Guide. 2nd ed. Hoboken: John
Wiley & Sons Inc.
Johnston LD, O’Malley PM, Bachman JG. (2003). Monitoring the Future National
Results on Drug Use: Overview of Key Findings, 2002. (NIH Publ. No. 03-5374).
Bethesda, MD: National Institute on Drug Abuse.
Kendler KS, Jacobson KC, Prescott CA, Neale MC. (2003). Specificity of genetic
and environmental risk factors for use and abuse/dependence of cannabis, cocaine,
hallucinogens, sedatives, stimulants, and opiates in male twins. Am J Psychiatry. 160:687.
McNiel DE, Binder RL, Robinson JC. (2005). Incarceration associated with
homelessness, mental disorder, and co-occurring substance abuse. Psychiatric Services.
56:840’ 846.
Pagnin D, de Queiroz V, Saggese EG. (2005). Predictors of attrition from day treatment
of adolescents with substance-related disorders. Addict Behav. 30:1065-1069.
Somers JM, Goldner EM, Waraich P, Hsu L. (2004). Prevalence studies of substance-
related disorders: A systematic review of the literature. Can J Psychiatry. 49.
Suelves JM. (2005). Preparing professionals to treat substance-related disorders.
PsychCRITIQUES. 50.
Weisner C, Matzger H, Kaskutas LA. (2003). How important is treatment? One-year
outcomes of treated and untreated alcohol-dependent individuals. Addiction. 98:901.

66
UNIT 3 TOBACCO ADDICTION
Structure
3.0 Introduction
3.1 Objectives
3.2 Tobacco and Nicotine Dependence
3.3 Epidemiological Trends of Tobacco Use
3.4 Indian Tobacco Products
3.5 Causes of Tobacco Dependence
3.6 Health Hazards associated withTobacco Use
3.6.1 Physical Morbidity Associated with Tobacco Use
3.6.2 Psychiatric Morbidity Associated with Tobacco Use

3.7 Nicotine Withdrawal Syndrome

3.8 Assessment of Tobacco Dependence
3.9 Treatment of Tobacco Dependence
3.9.1 Nonpharmacological Management
3.9.2 Pharmacological Management
3.9.3 Non-nicotine Pharmacological Treatment

3.10 Let Us Sum Up

3.11 Answers to Self Assessment Questions
3.12 Unit End Questions
3.13 References

3.0 INTRODUCTION
Tobacco is one of the most highly addictive and most extensively used drugs around the
world. Cigarette smoking is perhaps the most common form of nicotine use in the
world. and certainly the most lethal in the long run. Even though it is considered as a
significant risk factor in many health problems such as lung diseases, cancer and
cardiovascular diseases, it is highly common throughout the world. The risk for non
smoking people is also high as second hand smoke causes serious health consequences
for [Link] scientific literature clearly establishes the actions of nicotine within the
central nervous system that lead to the development of dependence, and withdrawal
symptoms. Other factors that contribute considerably to nicotine’s highly addictive
potential include the efficient drug delivery system of the cigarette, its high level of
availability, the small number of legal and social consequences of tobacco use, and the
sophisticated marketing and advertising methods used by tobacco companies. The
past three decade has seen considerable progress in understanding the neurochemical
basis of nicotine’s effects and in the development of effective behavioural and
pharmacological interventions to promote cessation. In this Unit you will learn about
the causes, health hazards and treatment of tobacco dependence.

67
Addictions
3.1 OBJECTIVES
After studying this Unit, you will be able to,
 explain tobacco and nicotine dependence;
 know the Indian tobacco products;
 explain the causes of tobacco and nicotine dependence;
 describe the health hazards of tobacco use;
 know the nicotine withdrawal syndrome;
 describe the assessment of tobacco dependence; and
 discuss the management of tobacco dependence.

3.2 TOBACCO AND NICOTINE DEPENDENCE

Tobacco is a plant product obtained from ‘Solaneace’ family in the plant kingdom.
‘Nicotianatobaccum’ is the main source of tobacco in northern India. There are nearly
3000 chemicals in tobacco smoke and 4000 in smokeless tobacco.
Let us distinguish between a few terms we come across while discussing any substance
abuse. These are intoxication, harmful use, abuse, addiction, dependence and withdrawal.
The term intoxication is used for a reversible nondependent experience with a substance
that produces impairment. Harmful use is similar to abuse, but it usually applies to drugs
prescribed by physicians that are not used [Link] dependence, also
referred to as habituation, is characterized by a continuous or intermittent craving for
the substance to avoid a dysphoric state.
Drug addiction and drug dependence are often used [Link] current
nosology, “addiction” word is only used for behaviour addictions and for other substances,
‘’dependence’’ term is [Link] usually refers to repetitive pattern of a behaviour
or substance use irrespective of its harmful consequences. Whereas drug depndence
usually refers to a syndrome characterised by physiological, cognitive,
somatic,psychological set of symptoms associated with use of a particular substance .
It is associated with craving, tolerance, withdrawal and use despite harmful consequences
of the same.
Brain researchers have found a pleasure centre in the brain, which becomes activated
when good (i.e. likable) things like food, sex, music comes our way. Nicotine is the
main active chemical in tobacco responsible for addiction, which stimulates the same
pleasure centre and therefore is felt by the user as a highly satisfying and rewarding
experience, resulting in repeated use. Nicotine generally causes heightened alertness
and improved functioning in continuous repetitive tasks. Users also report relaxation
and decrease in fatigue with smoking and; irritability, restlessness, anger and frustration
with difficulty in concentration and sleep while trying to leave.
From tobacco smoke, nicotine is absorbed through lung and in smokeless tobacco, it
passes through mucosal membrane of mouth and nose or [Link] of absorption is
enhanced in an alkaline environment and reduced in an acidic environment. Because of
the large surface area of the lungs, the mildly acidic smoke of cigarettes is absorbed
almost immediately and completely on inhalation, giving rise to high concentration arterial
nicotine boli which reach the brain in less than 10 seconds. Nicotine has a distributional
68 half-life of about 15 minutes and a terminal half-life in blood of about 2 hours. About 70
to 80 per cent of nicotine is metabolized to cotinine, which has a half-life of around 16 Tobacco Addiction
hours. This means that blood levels decline overnight to non-smoking levels, and regular
cigarettes are required over the course of the day to maintain elevated blood nicotine
concentrations. Repeated inhalation of tobacco generates boli of nicotine delivered into
the brain, superimposed on a relatively stable level of plasma nicotine maintained by the
smoker throughout the smoking day.

3.3 EPIDEMIOLOGICAL TRENDS OF TOBACCO

USE
Tobacco is the commonest substance of use in India, is legally and socially sanctioned
and used in a wide variety of ways including smoking, chewing, applying to gums,
sucking and gargling.
Global Adult Tobacco Survey (GATS) India (2010) data revealed that more than one
out of three adults in India (35 per cent) used tobacco in some form or the other.
Among them, 21 per cent of adults used only smokeless tobacco, 9 per cent only
smoked and 5 per cent smoked as well as used smokeless tobacco. Overall tobacco
use is much higher among Indian males at 48 percent but is also a serious concern
among females among whom prevalence is 20 per cent.
In India, khaini or tobacco-lime mixture (12 per cent) is the most commonly used
smokeless tobacco product, followed by gutkha (a mixture of tobacco, lime and areca
nut) (8 per cent), betel quid with tobacco (6 per cent) and tobacco dentifrice (5 per
cent). Bidi (9 per cent) is most commonly used smoking product, followed by cigarette
(6 per cent) and hukkah (1 per cent).
The WHO, the US Centers for Disease Control and Prevention, and the Canadian
Public Health Association developed the Global Tobacco Surveillance System (GTSS)
to assist the WHO member states in establishing such a method. The Global Health
Professions Student Survey (GHPSS) is one of the components of GTSS. All countries
conducting the GHPSS use a common survey methodology, similar field procedures
for data collection, and similar data management and processing [Link] GHPSS
is a school-based survey of third-year students pursuing advanced degrees in dentistry,
medicine, nursing, and pharmacy. The GHPSS uses a core questionnaire that includes
questions on demographics, prevalence of tobacco use, knowledge and attitudes about
tobacco use, exposure to secondhand smoke (SHS), desire of smokers to stop smoking,
perception of the health professional’s role in patient counseling, and training received
in counseling patients on smoking-cessation techniques
As per the Global Health Professions Student Survey (GHPSS), India (2009), 6.5 per
cent third year dental students smoked cigarettes and 8.6 per cent used other tobacco
products. Among medical students, 13.4 per cent third year medical students smoked
cigarettes and 11.6 per cent used other tobacco products. Global Youth Tobacco
Survey(GYTS) India, 2009 revealed that 14.6 per cent of 13-15 years school going
children in India used tobacco products out of which 4.4 per cent smoked cigarettes
and 12.5 per cent used other forms of tobacco. These figures are alarming because
these professional students will themselves lead the war against tobacco and because
earlier initiation increases chances of long term dependence.

3.4 INDIAN TOBACCO PRODUCTS

 Tobacco use in smoking form: Bidi, cigarette, hookah, chillum and chiroot are the
few common modes of smoking tobacco in India. Cigar smoking is limited to 69
Addictions certain limited social groups. Bidi is an unprocessed form of tobacco wrapped in
a tendu leaf and tied with a string. Bidi smoking stick is specific to India although
it is being exported and raising alarm bells in other countries as well. It is about 6
times more common than cigarette smoking (Taylor et al 2001). Although bidi
contains about 1/4 the amount of tobacco compared to a cigarette, it delivers a
comparable amount of tar and nicotine. A bidi is thus no less dangerous than a
cigarette.
 Smokeless Tobacco: In India, tobacco is used in smokeless manners in a wide
variety of ways with multitude products such as betel quid, mixture of tobacco,
lime areca nut, tobacco with lime, mishri, mawa,gutkha and many others.

3.5 CAUSES OF TOBACCO DEPENDENCE

There is no simple answer to the question - “why people use tobacco ?” There are
some biological factors as well as factors in the environment which interact together to
give rise to tobacco dependence. Initiation of smoking is subject to a number of
influences: environmental, behavioural, and personal factors all play a part. Environmental
influences include parental smoking (approximately doubling the likelihood of a child
starting to smoke), and smoking by siblings and friends. Tobacco advertising and
promotions effectively target young people with images of smoking as trendy, sporty,
and successful. Young people from deprived backgrounds where smoking is the norm
are more likely to become smokers.
Availability, social sanction and peer pressure are important factors that promote initiation
and continuation of use of tobacco, leading to tobacco [Link] smoking
is linked with poor school performance, truancy, low aspirations for future success, and
early school leaving or drop-out. Smoking in adolescents is frequently associated with
other problem behaviours including alcohol and other drug use and other risk taking or
rebellious behaviours, as well as with low self-esteem, anxiety, and depression. School-
based interventions to reduce smoking by teenagers have shown some initial success,
but longer term follow-up has found that these effects dissipate leading researchers to
advocate approaches involving the creation of a wider social environment supportive
of non-smoking.
Stressful living circumstances also lead to high rates of smoking in the unemployed, lone
parents, people who are divorced or separated, the homeless, heavy drinkers, drug
users, and prisoners.
Self Assessment Questions 1
1. Differentiate between addiction and dependence.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
2. Mention the ways in which tobacco is used.
.....................................................................................................................
.....................................................................................................................
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 Tobacco Addiction
.....................................................................................................................
.....................................................................................................................
3. What is smokeless tobacco?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

3.6 HEALTH HAZARDS ASSOCIATED WITH

TOBACCO USE
3.6.1 Physical Morbidity Asssociated with Tobacco Use
Use of tobacco leads to premature deaths. Smoking causes deaths from cancer, the
great bulk of deaths from chronic respiratory disease, and is a major contributor to
circulatory diseases. Smoking is recognized to cause 80 per cent or more of all lung
cancers. In addition it is responsible for most cancers of the upper respiratory tract (lip,
tongue, mouth, pharynx, and larynx) and for a smaller fraction of cancers of the bladder,
pancreas, oesophagus, and kidney. Among both men and women, deaths from
cardiovascular disease (ischaemic heart disease, aortic aneurysm, and stroke) outnumber
those from all other causes, including lung cancer.
Tobacco use in any form has marked effects upon the soft tissues of the oral cavity.
Tobacco use is associated with oral precancerous lesions such as leucoplakia and
erythroplakia. Leucoplakia is the most common precancerous lesion associated with
smoking and/or chewing tobacco. Oral submucous fibrosis (OSMF) is emerging as a
new epidemic, especially among the youth. In this disease, fibrous bands develop in the
mouth, mucosa looses its elasticity and the ability to open the mouth reduces progressively.
In extreme cases, victims may be only able to open their mouths enough to pass through
a drinking straw. This disease does not regress, has no known cure and has a very high
potential for cancer development. The dramatic increase in OSMF among young people
in India has been attributed to chewing gutka and paan masala.
“Tobacco use has an adverse effect on the sexual and reproductive health of both men
and women. Men who smoke have a lower sperm count and poorer sperm quality than
non-smokers. The effects of maternal tobacco use (smoked and smokeless) during
pregnancy include decreased foetal growth, spontaneous abortions, foetal deaths,
pregnancy complications including those that predispose to preterm delivery and long
term effects on the surviving children. Exposure to second-hand smoke during pregnancy
has been associated with lower infant birth weight.”
([Link]
As well as being the single largest cause of preventable premature death, cigarette
smoking is a cause of a number of disabling but generally non-fatal conditions. These
include cronic obstructive pulomonary disease, peripheral vascular disease, cataracts,
Crohn’s disease, gastric and duodenal ulcers, hip fracture in elderly people, and
periodontitis, the major cause of tooth loss in adults. Passive smoking also causes a
significant burden of disease in non-smokers, especially infants and children.
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Addictions Health Consequences Associated with Tobacco Use
1) Respiratory diseases: chronic obstructive pulomary disease, pneumonia, bronchitis
2) Oral lesions: leucoplakia,erythroplakia, oral submucosalfibrosis,oral cancer
3) Cancerous lesios: carcinoma involving bladder, cervix, oesophagus, stomach,
kidney, larynx, lung, pharynx
4) Heart & blood vessel disease: coronary heart disease, peripheral vascular disease
5) Sexual dysfunction: erectile dysfunction, infertility, decrease sperm counts
The World Health Organization (WHO) has estimated that approximately 5.4 million
people died worldwide from tobacco-related illnesses in 2006 and says that “unless
urgent action is taken, tobacco’s annual death toll will rise to more than eight million” by
the year 2030, with over 80% of those deaths occurring in low-income countries.

3.6.2 Psychiatric Morbidity Asssociated with Tobacco Use

obacco use is higher among persons with mental illness than general population.. Among
severe mental illnesses, approximately 50 per cent of all psychiatric outpatients, 70 per
cent of outpatients with bipolar I disorder, almost 90 per cent of outpatients with
schizophrenia, and 70 per cent of substance use disorder patients smoke. Moreover,
data from UK (Meltzer [Link]. 1995) conducted in general population suggested that
persons with neurotic disorders e.g. depression, phobia, obsessive compulsive disorder
are twice as likely to smoke as compared to general population and are less successful
in their attempts to quit smoking than other persons.
It is not fully clear, why do people with mental health problems smoke more, few
possible explanations are discussed. There might be common aetiologies to both smoking
and mental illness. There is also evidence to suggest that nicotine may be a form of self
medication. Nicotine may help ameliorate symptoms of attention deficit hyperactivity
disorder, depressive symptoms and negative symptoms of schizophrenia.
([Link]/niceMedia/documents/smoking_mentalhealth.pdf).
Tobacco has serious impact on physical and mental health of [Link], a holistic
health approach for these patients should address tobacco dependence management
in addition to management of primary mental disorder.

3.7 NICOTINE WITHDRAWAL SYNDROME

DSM-V Syndromal Description
Nicotine Dependence
A pattern of nicotine use, leading to clinically significant impairment or distress as
manifested by at least three of seven criteria occurring at sometime during a 12 month
period.
1) Tolerance
a) Absence of nausea, dizziness and other characteristic symptoms despite using
substantial amounts.
b) A diminished effect with continued use of the same amount of nicotine.
2) Withdrawal
72
 a) Presence of characteristic withdrawal syndrome or Tobacco Addiction

b) The use of substance or related substances to relieve or avoid withdrawal

symptoms.
3) Use of nicotine in large amounts or over a longer period than was intended.
4) Persistent desire or unsuccessful efforts to cut down or control nicotine use.
5) A great deal of time spent in activities necessary to obtain the substance, in use of
the substance or in recovery from its effects.
6) Important social, occupational or recreational activities given up or reduced because
of substance use.
7) Continued use despite having a persistent or recurrent physical or psychosocial
problem that it is likely to have been caused or exacerbated by nicotine use.
Nicotine Withdrawal
1) Daily use of nicotine for at least several weeks.
2) Abrupt cessation of nicotine use or reduction in the amount of nicotine used,
followed within 24 hours by 4 or more of following signs
 Irritability, frustration or anger
 Anxiety
 Difficulty in concentrating.
 Increased Appetite
 Restlessness
 Depressed mood
 Insomnia
3) The symptoms in criteria above causes clinically significant distress or impairment
in social, occupational or other important areas of functioning.
4) The symptoms are not due to a general medical condition and are not better
accounted by any other mental disorder.
Self Assessment Questions 2
1) What are the physical health hazards associated with the use of tobacco?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
2) Describe the signs of nicotine withdrawal.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
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Addictions
3.8 ASSESSMENT OF TOBACCO DEPENDENCE
Assessment can be carried out by various means. These are Clinical examination and
interview, Instruments or Questionnaires, and Objective methods. Let us know about
each of these.
A) Clinical: Here, assessment is carried out by eliciting information as well as carrying
out a detailed examination of the patient in following domains:
i) History
ii) Physical examination
iii) Mental status examination
The relevant information can be gathered from patient as well as the care giver including.
 Frequency of use
 type(s) of tobacco product being used
 duration of use
 route of intake
 complications (physical, social, familial, occupational)
 attempts to leave the drug (abstinence)
 reasons for relapse
B) Instruments / Questionnaires: This provides a more structured way of
assessment. For assesment of dependence in tobacco users, there are simple tools/
questionnaires which can be applied easily and in a very short period of time by
any person. Some of them are mentioned below:
i) CAGE Questionnaire:
This simple tool is very useful for screening person with any addictive distorders and
can be applied in very short span of time. It is suitable for use in community settings. It
has four components which is framed into questions with answer in “Yes” or “No”.
a) Cut Down
b) Annoyed
c) Guilt
d) Eye Opener
Two or more of “Yes” response will qualify a person for tobacco dependence and need
for treatment (See in Box)
CAGE Questionnaire
A) Have you ever felt a need to cut down or control your smoking, but have difficulty
doing so?
B) Do you ever get annoyed or angry with people who criticize your smoking or tell
you that you ought to quit?
74
 Tobacco Addiction
C) Have you ever felt guilty about your smoking or about you did while smoking?
D) Do you ever smoke within half an hour of waking up (eye opener)?
ii) The Fagerstrom test for Nicotine dependence is another standard instrument used
as a screening test to assess the severity of nicotine dependence. There are scales
for both smoking and smokeless tobacco. Based on the score, the level of addiction
can be low (score less than 4), medium (score 4-6) or high (score more than 6).
C) Objective methods such as measurements of the concentration of nicotine or its
metabo-lite, cotinine, in blood, urine, or saliva is often used in research as an
objective index of dependence because it provides an accurate measureof the
quantity of nicotine consumed, which itself is a marker of dependence. Carbon
monoxide concentration of expired air is a measure of smoke intake over preceding
hours; it is not as accurate an intake measure as nicotine based measures, but it is
much less expensive and gives immediate feedback to the smoker.

Diagnosis ICD 10 of World Health Organization (WHO) and DSM V of American

Psychiatric Association (APA) have independently proposed a cluster of factors to
make a uniform diagnosis of tobacco use disorders.
Dependence: It requires presence of 3 of following in past 1 year:

75
Addictions
3.9 TREATMENT OF TOBACCO DEPENDENCE
Tobacco dependence is a chronic condition that often requires repeated interventions.
Because effective tobacco dependence treatments are available, every patient who
uses tobacco should be offered at least one of these treatments. Tobacco dependence
treatments are both clinically effective and cost effective in relation to other medical and
disease prevention interventions.

3.9.1 Non Pharmacological Management

A variety of behaviour therapies, ranging in complexity from simple advice offered by a
physician or other health care providers so much more extensive therapy offered by
counselors, have been shown to be effective for tobacco [Link] persons can be
helped to identify high risk situations, avoid them and manage withdrawal. Self help tips
help patients to overcome and manage the use of tobacco.
Variuos approaches/ methods are described below
Brief Intervention (DGHS, 2011) – This consists of advice to stop using tobacco,
given to all tobacco users, usually during the course of a routine consultation or interaction.
Explain clients following benefits of leaving nicotine.
Begin this way- From the moment you quit smoking, it only takes 20 minutes for your
body to start undergoing beneficial changes.
 20 Minutes:Blood pressure drops to normal; pulse rate drops to normal;
temperature of hands and feet increases to normal.
 Within 8 Hours:Carbon-monoxide level in blood drops to normal; oxygen level in
blood becomes normal.
 Within 24 Hours to 48 hours:Chance of heart attack decreases. nerve endings
start regenerating; ability to smell and taste begins to improve.
 Within 72 hours:Bronchial tubes relax, making breathing easier.
 Within 2 Weeks to 3 Months: Circulation improves, lung function increases up to
30%
 Within 6 Months:Coughing, sinus congestion, fatigue and shortness of breath
decrease. The lungs function better, as congestion reduces, so does the chance of
infection.
 Within 1 Year: Risk of coronary heart disease decreases to half that of a smoker.
 Within 10 Years: Risk of dying from lung cancer is reduced to half.
 Within 15 Years: Risk of dying from a heart attack is equal to a person who never
smoked
Behavioural Support – This involves support, other than medications, aimed at helping
people stop their tobacco use. It can include all cessation assistance that imparts
knowledge about tobacco use and quitting, provides support and teaches skills and
strategies for changing behaviour.
Basic knowledge, certain competencies and skills are required to provide effective
counseling for tobacco cessation.
76
Strategies For Tobacco Cessation - The 5 “A”S and 5 “R”S Tobacco Addiction

The Five A’s (Ask, Advise, Assess, Assist and Arrange) and
Five R’s (Relevance, Risk, Rewards, Repetitions, Roadblocks) is a five to fifteen minute
research based counseling approach that has proven global success.
The Five A’s Approach
STEP 1: ASK
tobacco-use status be queried and documented at every visit.
STEP 2: ADVISE
A clear strong personalized message should be given to all tobacco users to quit”. It is
important to tell the tobacco user about the benefits of quitting.
STEP 3: ASSESS
Assess two things
i) Level of dependence
ii) Readiness for change: Determine willingness to make a quit attempt and offer help
as per the stages of change in which client is.
a) Not ready (Pre contemplation)
These tobacco users are not seriously considering quitting in the near future. They only
see the positive aspects of tobacco and do not like to acknowledge the disadvantages.
Encourage such a person to think about his/her tobacco use and make an offer of help.
Offer them written information on the harms of tobacco use and benefits of quitting.
b) Unsure (Contemplation)
These tobacco users are seriously considering quitting in the near future. This group is
particularly amenable to brief motivational interviewing. Talk to them about the relevant
health effects of tobacco use and barriers to cessation.
c) Ready (Preparation)
These tobacco users are planning and ready to quit and have usually made a 24-hour
quit attempt in the past year. This group is motivated to quit soon and is the group most
likely to attemptto quit in the near future._
d) Action
These are former tobacco users who have quit in the last 6 months. This is when the
risk of relapse is highest with about 75% of relapses occurring in this stage, within the
first week. This is aperiod where support and strategies to prevent relapse are important.
If relapse occurs, it is important that this should not be seen as failure, but considered a
learning experience and as part of quitting process.
e) Maintenance
These are tobacco users who quit for more than 6 months. The non-tobacco use
behaviour is established and the threat of tobacco use gradually diminishes. The chances
of relapse diminish over time.

77
Addictions STEP 4 : ASSIST
The following strategies are suggested to assist tobacco users in motivational stage:

STEP 5: ARRANGE
Arrange or schedule a follow-up. Follow up contact should occur soon after the quit
date, preferably during the first week. A second follow up contact is recommended
within the first month. Follow up visits after advice to quit have been shown to increase
the likelihood to successful long term [Link] the follow up, quitters have
some common withdrawal problems and a solution should be suggested accordingly.
PERSONS WHO ARE NOT WILLING TO QUIT TOBACCO
THE 5 “R”s APPROACH
For tobacco users who are not ready to make a quit attempt, provide a brief intervention
designed to promote the motivation to quit and information about harmful effect of
tobacco. The tobacco user may have fears and concerns about quitting, or may be
demoralized because of previous unsuccessful attempts and relapse. This group may
respond to a motivational intervention build around the 5 “R”s; i.e. Relevance, Risk,
Rewards, Roadblocks and Repetition. It is designed to educate, reassure and motivate
the client to quit tobacco use.

78
 Tobacco Addiction

Algorithm of stepwise management of tobacco cessation (three tier approach)

It was developed as a part of WHO tobacco cessation programme and currently is
also being used in the community settings and has been found to be of great clinical use.
Algorithm promotes individualisation of treatment as per severity of tobacco dependence.
If low level of dependence, then start with self help tips and followed by behavioural
interventions and if it fails then only pharmacological management to be considered.
However, if dependence is of higher level then directly patient can be started with
pharmacological management along with behavioural interventions.

Step 3 Intensive treatment programme

Step 2 Brief intervention

Step 1 Self help tips

assess level of dependence mild dependence moderate dependence severe dependence

3.9.2 Pharmacological Management

Pharmacological effects of nicotine play a crucial role in tobacco addiction, and
pharmacotherapy has to address this component of tobacco dependence. A
pharmacological treatment for smoking cessation should both block the positive
reinforcing effects of nicotine and prevent or reduce the development of withdrawal
symptoms.
Nicotine Replacement Therapy(NRT)
Nicotine replacement therapy (NRT) acts in several ways; it relieves craving and
withdrawal symptoms, which are relieved with relatively low blood nicotine levels, and
causes positive reinforcement for arousal and stress relieving. . Nicotine replacement
products are available in a number of forms, including gum, transdermal patch, nasal
spray, lozenge, and inhaler. The various forms of nicotine replacement therapy differ in
79
Addictions terms of route of administration and speed of absorption, as well as in the extent to
which they offer a situational response to craving and a behavioural ritual to replace the
rituals of cigarette smoking. None gives the high concentration arterial bolus of nicotine
characteristic of cigarette smoking, and the overall dose of nicotine they provide is
typically only one-third to one-half of that from cigarettes. This, coupled with the absence
of toxic tar and gas phase components of cigarette smoke, gives them a reassuring
safety profile.
Gum is available in 2 mg and 4 mg (per piece) doses. For those smoking <25 cigarettes
per day, the 2-mg dose is recommended; for >25 per day, the 4-mg dose is
recommended. Gum should be used for up to 12 weeks, no more than 24 pieces per
day. Dosage should be tailored to the individual patient. NRT should be used cautiously
in cardiovascular patients, common adverse effects are soreness and jaw-ache.
The efficacy of nicotine replacement therapy appears to be largely independent of other
elements of [Link] absolute success rates are higher with more intensive
behavioural support, the effect of nicotine replacement therapy in doubling the chance
of quitting is found in brief interventions and over-the-counter.

3.10 NON-NICOTINE PHARMACOLOGICAL

TREATMENTS
1) Bupropion, an atypical antidepressant with some noradrenergic and dopaminergic
activity, became the first non-nicotine medicine licensed for smoking cessation in
the United States, Canada, and Mexico. The mechanism of action appears not to
be related to the drug’s antidepressant effect but rather to pathways common to
addiction. Clinical trials, among non-depressed smokers, have shown clear
advantage over placebo, and there is evidence that bupropion and the nicotine
skin patch have additive effects in enhancing outcomes.
2) Varenicline a new drug has sown promising results in patients with nicotine
dependence. It is more effective than 24-hour NRT and bupropion . Like NRT
and bupropion, varenicline significantly reduces nicotine withdrawal symptoms,
and there is also evidence it makes smoking less rewarding so may help prevent
‘slips’ develop into full relapse.
3) Clonidine is one of the medication that is effective but having too many side
effects and not in use.
Combination Therapy
Combined behavioural and pharmacological therapies appear to be the best approach
for treating tobacco dependence. Because these therapies operate by different
mechanisms, complementary and potentially additive effects may be expected. Nicotine
Replacement Therapies (NRT) combined with supportive counseling are the most widely
used and intensively reached treatment method. Although self help strategies alone
marginally affect quit rates, individual and combined pharmacotherapies and counseling
either alone or in combination can significantly increase cessation.
Self Assessment Questions 3
1) What are the methods of assessment of tobacco dependence?
.....................................................................................................................

80
 Tobacco Addiction
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
2) Mention the components of the CAGE questionnaire.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
3) What are the five A’s?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
4) The 5 “R”s are Relevance, __________, Rewards, ____________________
and Repetition.
.....................................................................................................................
.....................................................................................................................
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.....................................................................................................................

3.11 LET US SUM UP

Tobacco dependence or addiction has a huge cost on our population in terms of reduced
manpower, decreased productivity, impaired relationships and mortality. Significant
progress has been made in understanding the relationships among nicotine’s behavioural,
subjective, physiologic, and neuroregulatory effects. Moreover, this type of scientific
research on nicotine dependence has led to improved techniques for reducing tobacco
use. Guideline researches conclude that first-line medications, including bupropion and
nicotine replacement therapies, should be used in conjunction with behaviourally based
counseling to produce optimal outcomes in smoking cessation. Despite the development
of new medications and their increasing availability over the counter, treatment challenges
remain.

3.12 ANSWERS TO SELF ASSESSMENT

QUESTIONS
Self Assessment Questions 1
1) Addiction usually refers to repetitive pattern of a behaviour or substance use
irrespective of its harmful consequences. Whereas drug depndence usually refers
to a syndrome characterised by physiological, cognitive, somatic,psychological
set of symptoms associated with use of a particular substance . It is associated 81
Addictions with craving, tolerance, withdrawal and use despite harmful consequences of the
same.
2) Tobacco is used in a wide variety of ways such as smoking, chewing, applying to
gums, sucking and gargling.
3) Tobacco is used in smokeless manners in a wide variety of ways with multitude
products such as betel quid, mixture of tobacco, lime areca nut, tobacco with
lime, mishri, mawa, gutkha and many others.
Self Assessment Questions 2
1) The physical health hazards associated with the use of tobacco are Respiratory
diseases: chronic obstructive pulomary disease, pneumonia, bronchitis, Oral lesions:
leucoplakia,erythroplakia, Oral submucosalfibrosis,oral cancer, Cancerous lesions:
carcinoma involving bladder, cervix, oesophagus, stomach, kidney, larynx, lung,
pharynx, Heart & blood vessel disease: coronary heart disease, peripheral vascular
disease; and Sexual dysfunction: erectile dysfunction, infertility, decrease sperm
counts.
2) Following are the signs of nicotine withdrawal:
i) Irritability, frustration or anger
ii) Anxiety
iii) Difficulty in concentrating
iv) Increased Appetite
v) Restlessness
vi) Depressed mood
vii) Insomnia
Self Assessment Questions 3
1) The methods of assessment of tobacco dependence are Clinical examination and
interview, Instruments or Questionnaires, and Objective methods.
2) The components of the CAGE questionnaire are, Cut Down, Annoyed, Guilt, and
Eye Opener.
3) The Five A’s are Ask, Advise, Assess, Assist and Arrange.
4) Risk, Roadblocks.

3.12 UNIT END QUESTIONS

1) Discuss the causes of tobacco dependence.
2) Describe the various assessment methods of tobacco dependence.
3) Explain the non-pharmacological management of tobacco dependence.
4) How will you assist tobacco users in the motivational stage?
5) Discuss pharmacological management of tobacco dependence.

82
 Tobacco Addiction
3.14 REFERENCES
Altman, D.G., Levine, D.W., Coeytaux, R., Slade, J., and Jaffe, R. (1996). Tobacco
promotion and susceptibility to tobacco use among adolescents aged 12 through 17
years in a nationally representative sample. American Journal of Public Health, 86,
1590–3.
Bajaj P (2004) The Extent, Pattern andTrends of Drug Abuse in India:
[Link] Delhi. United Nations Officeon Drugs and Crimes & Ministry of
SocialJustice and Empowerment, Government ofIndia.
Collishaw, N.E. and Lopez, A.D. (1996). The tobacco epidemic: a public health
emergency. World Health Organization (WHO) Tobacco Alert. WHO, Geneva
DGHS (Directorate General of Health Services), (2011). Tobacco dependence treatment
guidelines. National Tobacco Control Programme, , Ministry of Health & Family Welfare
Government of India.
Global Health Professions Student Survey (GHPSS), India, 2009, (http://
[Link]/LinkFiles/GHPS_India_2009_Dental.pdf and http://
[Link]/LinkFiles/GHPS_India_2009_medical.pdf Accessed 12 May,
2014).
Global adult tobacco survey fact sheet India 2009-10, Ministry of Health and Family
Welfare, Government of India 2010.
The Global Tobacco Surveillance System Collaborating Group. (2005). The global
tobacco surveillance system (GTSS): purpose, production and potential. J Sch Health
75:15-24.
Global Youth Tobacco Survey (GYTS) Country Factsheets, India (by year of completion
and state). Centers for Disease Control and Prevention, [Link] from URL:
[Link] (GYTS/factsheets/pdf_files/
india)(accessed on 30 September2004).
Glynn, T.J., Greenwald, P., Mills, S.M., and Manley, M.W. (1993). Youth tobacco use
in the United States—problem, progress, goals, and potential solutions. Preventive
Medicine, 22, 568–75.
Gross, J. and Stitzer, M.L. (1989). Nicotine replacement: 10-week effects on tobacco
withdrawal symptoms. Psychopharmacology, 98, 334–41.
Heatherton TF, Kozlowski LT, FreckerRC,Fagerström KO. (1991). The Fagerström
Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire.
Br JAddict 86:1119-27
Hurt, R.D., Sachs, D.P.L., Glover, E.D., et al.(1997). A comparison of sustained-
release bupropion and placebo for smoking [Link] England Journal of Medicine,
337, 1195–202.
Jorenby, D.E., Leischow, S.J., Nides, M.A., et al. (1999). A controlled trial of sustained-
release bupropion, a nicotine patch, or both for smoking [Link] England Journal
of Medicine, 340, 685–91.
Meltzer, H., Gill, B., Pettigrew, M., and Hinds, K. (1995).The prevalence of psychiatric
morbidity among adults living in private [Link] Surveys of Psychiatric
Morbidity in [Link] Majesty’s Stationery Office, London.
83
Addictions Peto, R., Lopez, A.D., Boreham, J., Thun, M., Heath, C., and Doll, R. (1996). Mortality
from smoking worldwide. British Medical Bulletin, 52, 12–21.
Rani M, Bonu S, Jha P, Nguyen SN,Jamjoum L.(2003) Tobacco use in India:prevalence
and predictors of smoking and chewing in a national cross sectional house-hold survey.
Tobacco Control. 2003Dec;12(4):e4. Available at: [Link]
full/12/4/e4. Accessed on 14 May 2005.
Russell, M.A.H., Stapleton, J.A., Feyerabend, C., et al. (1993). Targeting heavy smokers
in general practice: randomised controlled trial of transdermal nicotine patches. British
Medical Journal,306, 1308–12.
Sutherland, G., Russell, M.A.H., Stapleton, J., Feyerabend, C., and Ferno, O. (1992).
Nasal nicotine spray: a rapid nicotine delivery system. Psychopharmacology, 108, 512–
18.
Tobacco Free Initiative (TFI), World Health Organization (WHO). Facts and Figures
About Tobacco, Jun. 2007.
World Health [Link] Report on the Global Tobacco Epidemic, 2008.
The MPOWER Package. WHO.
[Link]/niceMedia/documents/smoking_mentalhealth.pdf.

84
UNIT 4 GAMBLING, INTERNET AND
OTHER ADDICTIONS
Structure
4.1 Introduction
4.2 Objectives
4.3 Characteristic Features of Behavioural Addiction
4.4 Types of Behavioural Addiction
4.5 Epidemiology
4.6 Factors Causing Behavioural Addictions
4.7 Assessment of Behavioural Addiction
4.8 Interventions for Behaviour Addiction
4.9 Let Us Sum Up
4.10 Unit End Questions
4.11 Answers to Self Assessment Questions
4.12 References
4.13 Suggested Readings

4.1 INTRODUCTION
Behavioural addiction is a new emerging concept. Newly emerging knowledge about
the human brain suggests that the reward system operates not only in response to
chemical stimulation, but also to the experiential behaviour. Thus the human beings are
also liable to develop addiction to certain behaviours as well as daily activities. Such
behaviours may include shopping, exercise, sex, gambling, internet and many more.
The World Health Organization discourages the use of term addiction and has
substituted it with dependence. Dependence refers to repeated use of a psychoactive
substance or substances, to the extent that the user (referred to as an addict) is
periodically or chronically intoxicated, shows a compulsion to take the preferred
substance (or substances), has great difficulty in voluntarily ceasing or modifying substance
use, and exhibits determination to obtain psychoactive substances by almost any means.
Typically, tolerance is prominent and a withdrawal syndrome frequently occurs when
substance use is interrupted. The life of the addict may be dominated by substance use
to the virtual exclusion of all other activities and responsibilities. A person may develop
dependence to a wide variety of psychoactive substances like alcohol, barbiturates,
opioids, cannabis, benzodiazepines, stimulants, and so on. The topic has been discussed
in Unit 2 in detail. In line with drug dependence, behavioural addiction, also called
process addiction or “non-substance-related addiction”may be defined as a repeated
tendency by an individual to engage in some specific activity, despite harmful
consequences, as deemed by the user himself to his individual health, mental state, or
social life. It includes usages of internet, mobile, social networking sites, pornography,
gambling etc. The rationale for the existence of this category is that compulsive behaviours
85
Addictions follow the same clinical pattern, and may even derive from the same neural network as
compulsive substance use.
In this Unit, you will learn about the behavioural addictions such as gambling, internet
etc.

4.2 OBJECTIVES
After studying this Unit, you will be able to:
 describe the characteristic features of behavioural addiction;
 describe types of behavioural addictions;
 know the important characteristics of gambling and internet addictions;
 know the prevalence of various behavioural addictions;
 discuss the factors causing behavioural addictions; and
 know the intervention strategies for dealing with behaviour addictions.

4.3 CHARACTERISTIC FEATURES OF

BEHAVIOURAL ADDICTION
Essential feature of behavioural addiction is the failure to resist an impulse, drive, or
temptation to perform an act that is harmful to the person or to others. Characteristic
features of the behavioural addictions are described as below:
 Salience – Salience occurs when a particular activity becomes the most important
activity in a person’s life and dominates thinking (preoccupations), feelings
(cravings), and behaviour (deterioration of socialized behaviour).
 Mood modification – Behaviour modifies the mood and provides pleasure, comfort
and may be relaxing.
 Tolerance –Increasing the use or engagement in a particular activity is required to
achieve the same effect
 Withdrawal symptoms –Experiencing unpleasant feeling states and/or physical
sympoms subsequent to discontinuation
 Conflict – Behaviour may lead to conflicts between the users and those around
them (interpersonal conflict), conflicts with other activities (job, social life, hobbies
and interests) or within the individual themselves (intrapsychic conflict)
 Relapse –There is a tendency for repeated reversions to earlier patterns of the
particular activity after a period of abstinence.
Salient features of the behavioural addictions may be described by 4 Cs as follows:
Craving: User often thinks about the particular activity (e.g., internet), while s/he is
engaged in other activities.
Control: Addicted users feel difficulty in controlling/ stopping the use/ engagement in
the particular activity.
Compulsion: Person keeps himself/ herself engaged in the particular activity though
86 there are other things to do.
Consequences: Person experiences problems in academic, interpersonal, and Gambling, Internet
and other Addictions
occupational area, and suffers psychological distress due to excessive engagement in
the particular activity.
Behavioural addiction has certain similarities to substance addiction, as depicted in
Table 1.
Table 1. Similarities between Substance Dependence and Behavioural Addiction

Category Substance Dependence Behavioral addiction

Craving Yes Yes
Tolerance/loss of Yes, increased amount to Yes, loss of control
control achieve the same effects
Withdrawals Physical and psychological Psychological :
restlessness/irritability
on discontinuation or on
being asked to stop
Consequences Dysfunctions in physical Dysfunction in
and psychosocial areas psychosocial areas

Thus symptoms common to behaviour addictions includes mood swings, gaining feeling
of euphoria from the activity, compulsive need to act out the behaviour, obsessive thinking
about and planning the behaviour and allowing the behaviour to take precedence over
work, health, and family.
Self Assessment Questions 1
1. What is behavioural addiction?
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.....................................................................................................................
2. What are the 4 C’s of behavioural addiction?
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4.4 TYPES OF BEHAVIOURAL ADDICTION

Different types of behavioural addictions include gambling, internet addiction, cellphone
addiction, eating addiction, shopping addiction, exercise addiction, sex addiction, work
addiction, etc. Out of these, only gambling disorder finds a place in DSM-5 and ICD
10. DSM-5 has included internet gaming disorder as a condition needing further study.
Important characteristics of these behavioural addictions are briefly discussed as below.
Gambling disorder or problem gambling
Problem gambling refers to an urge to gamble despite harmful negative consequences
or a desire to stop. It can be defined as placing something of value at risk with the belief
of gaining something.
87
Addictions It can occur on different levels and goes through different phases. Level of gambling
are: Level 0 person who did not gamble; Level 1 refers to social or recreational gambling
and does not leads to any significant problem; Level 2 referred as at- risk gambling or
problem gambling; Level 3 associated with significant psychosocial dysfunctions. It
meets the DSMIV-TR criteria of pathological gambling (Hollander 2008).
The different phases of gambling are as follow:
Winning Phase: The individual uses gambling as a way to get excitement or to manage
the stressor. The person wins lots of game during this phase or makes money by winning.
Losing Phase: The person remains preoccupied with gambling or to bet more to reduce
the loss.
Desperation phase:The person start experiencing health and relationship problems as
well as hopelessness & desperation due to gambling. H/she keeps fantasizing about the
winning and indulges in crimes to support the gambling.
Hopeless phase: The person starts entertaining the depressive ideas about future, his or
her abilities to overcome the current problems and leads to psychological problems.
Thus pathological gambling is characterized by persistent and recurrent problematic
gambling behaviour leading to clinically significant impairment or distress. The person
has a pathological need to gamble with increasing amounts of money in order to achieve
the desired [Link] disorder has been included in DSM-5 under non
substance related disorders.
Attempts to reduce or stop gambling lead to irritability or restlessness. The person
might have made multiple unsuccessful attempts to control, cut back or stop the
behaviour. There is a preoccupation with gambling, persistent thoughts of reliving past
gambling experiences, planning the next venture, and thinking of ways to get money
with which to gamble. The person often gambles, whenever distressed. After losing
money in gambling, the person returns another day to chase one’s losses. Lying to
conceal the extent of involvement in gambling is common. The behaviour may affect
adversely different aspects of life like education, employment or relationships. The person
often relies on others to provide money to relieve desperate financial situation caused
by gambling.
Internet Addiction or Internet Gaming Disorder
In the last two decades, internet has rapidly become a way of life. One of its effects has
been excessive use of internet to the extent of neglect of all other interests and
responsibilities. One may become addicted to internet. Though internet addiction is not
recognized as a formal psychiatric disorder, recently, the American Psychiatric
Association has included internet gaming disorder as condition needing further studyin
the 5th edition of its Diagnostic and Statistical Manual of Mental Disorders, 5th edition
(DSM-5), before it is recognized as a disorder. It is important to mention here that
internet gaming has gradually become a booming market.
DSM -5 has defined internet gaming disorder as persistent and recurrent use of internet
to engage in games, often with other players, leading to clinically significant impairment
or distress. Important characteristic of the disorder include preoccupation with internet
games with previous gaming activity or anticipating playing the next game. This is distinct
from internet gambling which comes under gambling disorder. The person gets withdrawal
symptoms in form of anxiety, irritability or sadness, when internet gaming is not available.
88 Tolerance is often present with a need to spend increasing amounts of time in internet
gaming. Unsuccessful attempts at controlling the activity may be present. The person Gambling, Internet
and other Addictions
loses interests in the hobbies and entertainment activities enjoyed earlier. Use of internet
continues despite knowledge of associated psychosocial problems. The person may
deceive his/her family members, therapists and others regarding the amount of internet
gaming. The activity is indulged in to escape or relieve a negative mood. The behaviour
has often resulted in relationship problems and affected education or career adversely.
DSM-5 does not include use of internet activities in business or profession, recreation
or sexual internet sites as indicative of internet gaming disorder.
Thus internet addiction can be described as a maladaptive pattern of internet use,
characterised by psychological dependence, withdrawal symptoms when off-line for
prolonged periods, loss of control, compulsive behaviour, and clinically significant
impairment of normal social interactions or distress.
The criterion proposed for internet addiction disorder are as follows (Young 1999):
1) Preoccupation: a strong desire for the internet
2) Withdrawal: discontinuation leads to dysphoric mood, anxiety, irritability
3) Tolerance: marked increase in usages to achieve satisfaction
4) Difficult to control: persistent desire and/or unsuccessful attempts to control
5) Disregard of harmful consequences: continued excessive use despite harmful
consequences
6) Social communications and interests are lost: loss of interests and previous
hobbies
7) Alleviation of negative emotions: uses as a way of coping
8) Hiding from friends and relatives: deception of actual costs/time to maintain
habit
Cell Phone addiction
Mobile or cell phone addiction has also attracted the attention of behaviour scientists,
though it is not recognized as a formal disorder. Excessive use is likely to be associated
with a loss of sense of time or a neglect of basic drives. A person apparently addicted
to cell phone use may report feelings of anger, tension and/or depression on not being
able to use it, especially when the phone or network is inaccessible. Tolerance to the
use may be seen including the need for new and better cell instrument, more software
or more hours of use. Other negative repercussions include lying, arguments, poor
achievement, social isolation and fatigue.
Important characteristics of cellphone addiction include excessive use, manifested in
both high economic cost and in numerous calls and messages; problems, especially
with parents, associated with excessive use of mobile phones; interference with other
school or personal activities; a gradual increase in use to obtain the same level of
satisfaction as well as the need to replace functioning devices with new models; and
emotional alterations when the use of the phone is impeded.
Shopping Addiction/ Compulsive Buying
Shopping addiction is characterised by excessive spending behaviour which is poorly
controlled, markedly distressful, time-consuming, and results in familial, social, vocational,
and/or financial difficulties. 89
Addictions Compulsive buying was included as an impulse control disorder in DSM-III-R, but
was excluded from DSM-IV and DSM-5. The behaviour is characterized by
maladaptive buying or shopping impulses or behaviour, as indicated by frequent
preoccupation with buying or impulses to buy that is experienced as irresistible, intrusive,
and/or senseless and frequent buying of more than can be afforded. The buying
preoccupations, impulses, or behaviours cause marked distress. The behaviour does
not occur exclusively during periods of hypomania or mania.
Eating Addiction
Eating disorders and eating pathology are characterized by maladaptive attitudes,
behaviours, and intrapsychic experiences around eating, weight, and body image that
cause significant distress or impairment. According to DSM-IV TR, eating disorders
fall into three primary categories - anorexia nervosa, bulimia nervosa and eating disorder
not otherwise specified.
Exercising or Obligatory Exercise or AnorexiaAthletica
It refers to a compulsion for exercise, with guilt and anxiety if the person doesn’t work
out. Hausenblas and Downs (2000 a) identify exercise addiction based on the following
criteria that are modifications of the DSM-IV TR criteria for substance dependence:
 Tolerance: increasing the amount of exercise in order to feel the desired effect,
be it “a buzz” or sense of accomplishment;
 Withdrawal: in the absence of exercise the person experiences negative effects
such as anxiety, irritability, restlessness, and sleep problems;
 Lack of control: unsuccessful attempts to reduce exercise level or cease exercising
for a certain period of time;
 Intention effects: unable to stick to one’s intended routine as evidenced by
exceeding the amount of time devoted to exercise or consistently going beyond
the intended amount;
 Time: a great deal of time is spent preparing for, engaging in, and recovering from
exercise;
 Reduction in other activities: as a direct result of exercise, social, occupational,
and/or recreational activities occur less often or are stopped;
 Continuance: continuing to exercise despite knowing that this activity is creating
or exacerbating physical, psychological, and/or interpersonal problems.
Work Addiction
It refers to working excessively hard and the existence of a strong, irresistible inner
drive (McMillan, O’Driscoll, & Burke, 2003). The most widely empirically studied
approach to workaholism assumes three underlying dimensions; the so-called workaholic
triad consisting of work involvement (work involvement is a generalized attitude of
psychological environment with work, i.e., being highly committed to work and devoting
a good deal of time to it); drive (drive is the inner pressure to work which is maintained
by internal fulfillment rather than external pressure, i.e., feeling compelled to work because
of inner pressures); and work enjoyment (work enjoyment is the level of pleasure
derived from work, i.e., experiencing work to be pleasant and fulfilling).
Diagnosis:
According to Porter (1996), like alcoholism, workaholism is an addiction which is
90 characterised by
1) Excess work behaviour implying the neglect of family, personal relationships and Gambling, Internet
and other Addictions
other responsibilities;
2) Distorted self-concept (that is, striving through work for better feelings of self);
3) Rigidity in thinking (that is, perfectionist about work details, non-delegation of
tasks);
4) Physical withdrawal into work and anxiety if away from work;
5) Progressive nature (that is, needs increasingly to work more to boost self-esteem
and block other feelings)
6) Denial (that is, uses workplace affirmations to offset objections from others).
Sex Addiction
Sexual addictions include arousal addictions that stimulate and thrill; satiation
addictionsthat ease tension and discomfort; and fantasy addictions that escape
mundane reality.
Sexual addicts progress through a four-step addiction cycle, which intensifies each time
it is repeated.
Preoccupation stage: In stage one, the preoccupation stage; the sexual addict’s mind
is completely consumed with thoughts about sex. An obsessive search for sexual
stimulation is created by this mental state that the addict is in.
Ritualization stage: The second stage, ritualization, is the sex addict’s routine or routines
that lead up to the sexual behaviour. The preoccupation of the addict is intensified
during this stage, which adds arousal and excitement.
Compulsive sexual behaviour: During the third stage, compulsive sexual behaviour,
the addict participates in the actual sexual behaviour, which he or she is unable to
control or stop. Compulsive sexual behaviour is the end goal of preoccupation and
ritualization.
Despair: In the final stage, despair, the addict experiences a feeling of utter hopelessness
because of his or her behaviour and the powerlessness that he or she has over this
behaviour. In order to numb the pain that the addict feels after going through this cycle,
the addict begins to engage in the preoccupation stage again, which starts the addiction
cycle over again (Carnes, 2001).
Case Vignette: A 17 year old boy has excessive use of mobile, internet and
laptop for three and a half years. Initially the family was not much concerned
about it and thought it as a part of growing up. The boy was watching You
Tube for hours, seeing gadgets, new launches about computer hardwares,
FaceBook and playing internet games. He started spending 8-10 hours on
device (control). He would finish his work to save time for the above
activities(craving).At one time he developed dry eyes because excessive
watching of You Tube on his small mobile phone screen. Because of his habit
of excessive internet use he started doing badly in studies. He became very
irritable and started losing his appetite. Teachers started complaining about
his lack of interest in class. His friends also complained about his lack of
energy (consequences). He started using it even if he is in company of relatives,
friend or while watching TV(compulsion).

91
Addictions
4.5 EPIDEMIOLOGY
Symptoms of internet gaming disorder and internet addiction can be observed with
similar frequency in both men and women (Akman& Mishra, 2010). Male youth are
over represented in a lot of behavioural addictions, particularly problem gambling (Vitaro
et al, 2001). Gambling is more common in older females (McCormack et al., 2003) or
those who have disabilities, or too much idle time (McNeilly& Burke, 2000; Southwell
et al., 2008). However, they are less likely to encounter practical difficulties as a result
of their gambling such as arrests, indebtedness, family problems etc. (Petry, 2002). It is
hard to establish the extent of sex addiction although estimates range from 3-6% of the
population (Carnes, 1999).
Prevalence of internet gaming disorder is unclear because of varying criteria used by
different investigators. Higher rates have been reported from Asian countries and in
male adolescents 12-20 years of age. There are a large number of reports from Asian
countries, especially China and South Korea, but fewer from Europe and North America.
Point prevalence in adolescents has been reported upto 8.4% in males and 4.5% in
females.
Lifetime prevalence of gambling has been reported to be 0.4-1.0% rates are 0.6% in
males and 0.25 in females. Lifetime prevalence in African-Americans is reported to be
higher than the White population in USA.
Indian scenario: In India, other than lottery, legal gambling is limited to betting on
horse racing. Even though the exact statistics are not known, there is potential for
newer behavioural addiction. As of 2010, there were 52 million active users of internet:
the usage has gone up from 9.3hrs/week to 15.7hrs/week and around 4% browse
through mobiles (Sinha,2010). Five percent of the youthin the age group 18-25 years
have addictive use of social networking sites and 24% have problematic usage of internet
(Menon& Sharma 2013; Barathkar & Sharma 2011).
A study by the Indian Council of Medical research (Sharma, Benegal, Rao & Thennarasu
2013) on 2755 subjects in age group of 18 to 65 years from low to higher socioeconomic
status (interviewed using door to door survey methodology) from an urban locality in
Bangalore revealed that addictive use was present in 1.3% (2% males & 0.6% females)
for internet; 4.1 % (5% males & 3.1% females) for mobile phones; 3.5% for social
networking sites; 4%(male-3.2% & female-4.8%) for shopping; 0.2% for sex/online
pornography,and 1.2% (offline & online) had gambling addiction. Statistically significant
differences were observed in relation to family status for internet and Facebook
addictions. It was more among singles,unmarried and lesser in joint families. The number
of years of marriage had a negative correlation with shopping, sex, mobile, internet and
Facebook addiction. Physical(eye strain)/Psychological distress (decrease sleep,
irritability and restlessness)were present in 6.8% subjects with mobile phone users, in
4.2 % with internet use and in 3%of those with social networking sites.
Addictive use of video game/ Facebook is reported in 7% of the subjects in age group
of 13-17. It was also associated with psychological distress as well as unawareness to
handle the online sexual content. This leads to dysfunctions in area of academic, social
life and losing out recreational activities. Parent shown lack of awareness about teenagers
online behaviours (Sharma&Shyam 2014).

92
 Gambling, Internet
Self Assessment Questions 2 and other Addictions

1) What is pathological gambling?

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2) Describe briefly important features of internet gaming disorder?
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4.6 FACTORS CAUSING BEHAVIOURAL

ADDICTIONS
Let us now see the various factors responsible for causing behavioural addictions.
 Substance dependence: One of the strongest correlates of problem gambling,
and of other process addictions like sex addiction, is substance abuse (Bourget et
al., 2003). People who abuse substances (especially those who use heroin,
methadone or cocaine) are 4 to 10 times more likely than the general population
to have a gambling problem (Ledgerwood & Downey, 2002). Most commonly
the substance abuse predates the process addiction, but sometimes the process
addiction begins first, or both concerns arise simultaneously (Kausch, 2003).
 Other behavioural addictions: Some theorists believe that tolerance for one
kind of behavioural addiction breeds increased tolerance for other kinds, i.e.,
cross-tolerance (Carnes et al., 2005). Problem gambling, for example, frequently
occurs alongwith other process addictions, particularly an involvement with risky
sexual practices. Process addictions go together, substitute for one another and
reinforce one another (Vitaro et al., 2001).
 Poor impulse control (“impulsivity” or “impulsiveness”) and risk-taking:
Poor impulse control has been linked to abuse of most substances as well as most
of the process addictions. By giving comparatively free rein to their urges, people
who are impulsive may expose themselves to multiple risks, including substance
abuse, unsafe sexual practices and problem [Link] particular risky
behaviours can become so interchangeable that some theorists prefer to think in
terms of a “problem behaviour syndrome” rather than focusing on a particular
behaviour in isolation (Barnes et al., 2005). Such a concept seems especially apt
with regard to youth.
 Childhood neglect, trauma, physical or sexual abuse: Grossly pathological
incidents or ongoing conditions in childhood are linked to commensurately negative
outcomes later in life, including problem gambling (Moore & Jadlos, 2002).
 Psychiatric issues: Process addictions such as problem gambling tend to coexist
93
Addictions with other psychiatric disorders like depression, personality disorders and
substance use disorders (Petry, 2005).
 Social deprivation (poverty, marginalization): Social and economic
marginalization mayincrease the risk of behavioural addictions.
 Age and gender: Males are overrepresented in a number of problem behaviours,
particularly problem gambling and substance abuse. Youth who experience problem
gambling typically begin gambling quite early in life (Pagani et al., 2009). The
older adults who experience problem gambling are more likely to be females who
lack a life partner,have too much idle time, and have disabilities (McNeilly &
Burke, 2000). However, they are less likely to encounter practical difficulties as a
result of their gambling (arrests, indebtedness, family problems, etc.).
Case vignette
A 16 year old boy who dropped out of school sought treatment for irritability,
anger outbursts and sleep [Link] case evaluation, it was found
that the boy was involved in excessive use of internet/You Tube and gaming
for the last three years. However, irritability, anger outburst and sleep
disturbance preceded the excessive use of internet/You Tube and gaming.
He had also initiated the use of alcohol and cigarette in company of friends.
This would increase, whenever he was restrained or advised not to use
internet/ You Tube and gaming. His personality was characterized by low
frustration tolerance and oppositional behaviour. Significant family
disturbance was present secondary to his excessive use of internet/ you tube
and gaming.

4.7 ASSESSMENTOF BEHAVIOURAL ADDICTION

Assessment includes three important steps:
1) Take a detailed history
2) Assess for associated psychiatric illnesses, substance use and risk factors
3) Assess motivation for treatment
One should look specifically into the following issues (Littman-Sharp, 2004):
 Precipitating factors
 Current level of functioning
 Relationships and work situation
 Legal situation, especially if there is history of gambling
 Physical and mental health, both history and current problems
 Past treatment
 Crisis issues (particularly potential for harm to self or others)
 Motivation level and treatment goals
One can inquire along the following lines.
 On what days do you typically get connected to the internet? What time of the day
94 do you usually sign in to the internet?
 How long do you usually stay connected in a typical login? Gambling, Internet
and other Addictions
 Where do you usually use the computer?
 What functions of the internet/social networking sites are you using?
 How many hours on average do you allocate for each function in a week?
 Can you list the functions you use from the most important one to the least important
one?
 What aspects of each function do you like the most?
 What do you think your problem exactly is, how do you interpret it?
 What are the effects of social networking sites on your living environments?
 What made you decide to take treatment now? (at his/her own will, directed by
his/her relatives, changed social roles, coincidence)
 How long can you keep away from getting connected to the social networking
sites when you feel the desire/urge to get connected to it?
 How long you can tolerate boredom?
 How did your social networking sites start and continue? (may have started after
a loss).
 What are the factors affecting the continuity of your usage of social networking
sites? (alcohol, substance use, presence of others).
One needs to find out whether the users are dependent on a specific function of the
internet, because constant and frequent use of a particular function may trigger internet
addiction. This also helps in planning suitable interventions (is it a specific internet addiction
or a general one?).
The following case vignette describes the details one needs to elicit while assessing a
client with internet addiction.
Case Vignette
A 19 year old male, educated up to 12th standard, presented with complaints of
increased use of social networking sites for the last four years. Further history revealed
normal developmental milestones, average academic record and absence of high
risk behaviours. There was an increasing use of video games for the last four years.
He was spending 6-7 hours per day on video games and neglecting his academics.
Initially, he would use internet at home on mobile phone or computer and later in the
internet cafes, when his parents starting objecting. He also started stealing and lying
to support his habit. The enjoyment rewards earned on winning a game, using free
time and fighting boredom were the maintaining factors for the behaviour.
There are various questionnaires and scales that can be used to assess the behavioural
addictions. These are,
Readiness to change Questionnaire(Rollinck 1992).
Internet addiction test: It is a 20 /7item questionnaire based on 5-point Likert scale
to assess addiction to internet (Young, 1995; Widyanto, McMurran, 2004).
The Lie-Bet Tool: It is two items questions tool, used to rule pathological gambling
behaviours (Johnson et al 1988).
95
Addictions Sex addiction screening test: It is designed to indicate the presence of sex addiction
(Carnes, 1992).
Eating Addiction test: The EAT-26 can be used in a non-clinical as well as a clinical
setting not specifically focused on eating disorders (Garner et al 1982).
Work Addiction Test: It is a 25 items self report questionnaire based on work habit
description which measures five functional indicators of work addiction: compulsive
tendencies, control, impaired communication, inability to delegate and self worth. It is
rated on 4 point Likert scale (Robinson, 1999).
Facebook Intensity Questionnaire: It measures Facebook usage beyond simple
measures of frequency and duration, incorporating emotional connectedness to the site
and its integration into individuals’ daily activities (Ellison 2007).
Self Assessment Questions 3
1. What are common psychiatric comorbidities with behavioural addiction?
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2. Write the important steps in the assessment of behavioural addiction.
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4.8 INTERVENTIONS FOR BEHAVIOUR

ADDICTIONS
Interventions include psychoeducation, psychotherapeutic interventions and motivation
enhancement, cognitive therapy, behaviour therapy and family oriented therapy.
Psychoeducation
The person needs to be educated about the nature of problem, giving information about
maintaining factors and negative consequences resulting from it. Self –help material in
form of pamphlets can also be given.
Psychotherapeutic intervention
Psychotherapeutic intervention includes two approaches: total abstinence or controlled
use. Given the internet’s numerous advantages and positive uses in day-to-day life, it is
impractical to try the total abstinence model (as in treatment of substance use disorders),
even in those who are addicted to the internet. The guiding principle should primarily be
‘moderate and controlled use’. In the abstinence model, the individual abstains from a
particular internet application (e.g. using chat rooms or playing games) and uses other
applications in moderation. This model of abstinence is recommended for those who
have tried and failed to limit their use of a particular application .The intervention starts
with collecting information about the initiating factor as well as the maintaining factors.
96
Motivational enhancement therapy Gambling, Internet
and other Addictions
The subjects are often not much motivated for treatment and motivation needs to be
enhanced. Motivational enhancement therapy (MET) is a systematic intervention
approach for evoking change in internet addicts. It is based on principles of motivational
psychology and is designed to produce rapid, internally motivated change. This treatment
strategy does not attempt to guide and train the client, step by step, through recovery,
but instead employs motivational strategies to mobilize the client’s own change resources.
Motivational interviewing is assisted by motivational balance exercise. To help a person
make the decision of change it would be a useful exercise to encourage him/her to
consider the advantages and disadvantages of changing and continuing use of internet.
This will help him/her understand the need for change after weighing the costs and
benefits. To facilitate change from using to not using the internet, one has to tip the
balance so that the positives of quitting outweigh the negatives of continuing internet
use. This could, in turn, enhance the person’s commitment to change.
Healthy use does not happen in one step – people progress through five stages on the
way to successful change:
 Pre contemplation: Not thinking about healthy use in the foreseeable future
 Contemplation: Thinking about changing but not ready to change
 Preparation: Committed to and getting ready to change
 Action: healthy use of technology
 Maintenance: maintaining healthy use.
Movement through the stages occurs as people utilize distinct (virtually universal)
processes of change. Progress through the early stages is dependent on particular shifts
in the person’s decisional balance, i.e., how they see the pros and cons of quitting.
Initiating and maintaining healthy use requires a sufficient sense of confidence – self-
efficacy – in one’s ability to actually carry out the actions required to change. People
change as they progress through five stages. Helping people change their addictive
behaviour involves changing their excessive use of internet/other behavioural addiction
as well as enhancing their motivation to maintain them.
Patients unwilling to make a quit attempt during a visit may lack information about the
harmful effects of information technology/behavioural addiction. They may have fears
or concerns about control use. Such patients may respond to a motivational intervention
that provides the clinician an opportunity to educate, reassure, and motivate such as the
motivational intervention built around “5 R’s”: relevance, risks, rewards, roadblocks,
and repetition.
Relevance: Encourage the patient to indicate why quitting is personally relevant. One
should be as specific as possible. Motivational information has the greatest impact if it
is relevant to a patient’s disease status or risk, family or social situation (e.g., decrease
communication), health concerns, age, gender, and other important patient characteristics
(e.g., personal barriers to develop control use).
Risks: Ask the patient to identify potential negative consequences of excessive use of
information technology addiction/indulgence in other behaviours (gambling, shopping,
etc,).
Rewards: The clinician should ask the patient to identify potential benefits of controlled
use of information technology/ change in engagement of other behaviours (gambling,
97
Addictions sex, shopping etc). The clinician may suggest and highlight the benefits that seem most
relevant to the patient.
Roadblocks: The clinician should ask the patient to identify barriers or impediments to
control use and note elements of treatment (problem solving, pharmacotherapy) that
could address barriers.
Repetition: The motivational intervention should be repeated every time an unmotivated
users visits the clinic setting.
Brief Intervention
Brief intervention essentially can be used with many types of behaviour problems. It
takes only 5-15 minutes. Steps of brief intervention can be described as 5 A’s:
Ask – about information technology use/other addictions and their pattern
Advice – Advise to quit. Give a clear, strong, and personalized message
Assess – Assess for commitment and barriers to change
Assist – the client committed to change. Reinforce commitment to change. Help make
a plan and develop strategies to manage triggers. Foresee possible weaknesses in plan
and guide for developing and refining plans.
Cognitive behaviour Therapy
Cognitive behaviour therapy works on the principle that the addiction is formed once a
person feels that he/she does not have any social and family support, thereby developing
the so-called maladaptive cognitions and behaviours (which are the mental evaluations
or screeners of interpretation) about themselves and the world.
It includes two components: functional analysis and skill training. Functional analysis
includes triggers/reason for use (e.g boredom) that lead to a subject’s maladaptive
behaviours and the immediate beneficial consequences (e.g., feeling good) that maintained
the maladaptive behaviours as well as the structured assessment on internet addiction
test. Skills training include development of coping style and dealing with various triggers.
The internet user generally believes that the virtual world treats them ([Link] more
pleasure) well in comparison to real world. It manifests in form of all-or-nothing
maladaptive cognitions such as “I am respected more in the virtual world”, “I always
have to restrain myself or obey my parents/brother in the real world whereas in virtual
world I can do anything”. These types of beliefs can be challenged in a therapeutic
settings by dysfunctional method of fulfilling the unfulfilled need using virtual field as well
as by imparting the skill training to develop alternative pleasurable activities in the real
world. It can be done by helping the client to shift from the virtual world to reality. By
understanding one’s virtual social link/world and the needs it fulfilled, it can provide
insights and facilitate the process of enriching the real lives and reduce their indulgence
in the virtual world.
Excessive internet users use avoidant coping/less problem solving styles. Clients can be
helped to develop coping strategy based on their strengths and resources, which will
help them to expand their offline [Link] clients should be counseled to work on
developing alternative pleasurable activities or redevelop their old hobbies.
Family Oriented therapies

98 Family based interventions have also been found useful (Doug 2012). Family members
like parents or the spouse can be included in treatment. Objective is to enhance the Gambling, Internet
and other Addictions
understanding of negative consequences of excessive internet use/engagement in other
behaviours, strengthen the coping skills and increase prosocial peer behaviours and
enhancing parenting practices.
Individual sessions with adolescent focus on facilitating the engaging in treatment and
enhancing motivation for alternative behaviours in coping with high risk situations.
Individual sessions with parents focus on enhancing the healthy use of internet, increasing
the parenting practices, observing the child internet use and other behaviours, explaining
the rationale for developing healthy use of technology and setting rule in relation to
internet use.
The joint session can focus on parental commitment to the adolescent as well as
developing a positive parent-child relationship. It is an essential prerequisite for effective
parental monitoring of child internet use.
Implications
Bearing in mind the co morbidity of the disorder with other psychiatric illnesses especially
depression, anxiety disorders and sometimes even severe mental illnesses, a detailed
psychiatric evaluation is necessary. Specific therapy for the behavioural addictions should
only be started subsequently. Parents need to be watchful of their wards, since onset is
often during adolescence. There is a need to understand the prevalence /pattern/
longitudinal work to address the development of theses addiction in Indian context &
related burden associated with it. It will also help to use standardized tool to assess
these addictions and help in developing the specific intervention modules.
Self Assessment Questions 4
1) What is psychoeducation?
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2) What is motivational enhancement therapy?
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3) Write the two components included in cognitive behaviour therapy?
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99
Addictions
4.9 LET US SUM UP
With the newer advances in the field of technology, the young generation becomes
hooked onto the internet and cell phone, and develops addiction to these. In response
to this recent developments include opening of internet deaddiction centres/ clinics in
major cities such as in Bangalore and Delhi for dealing with this new generation disorder.
In this Unit, you learned about various types of behavioural addictions, their assessment
and intervention strategies. One’s own personality and motivational factors and one’s
environmental factors play a crucial role in the causation and consequently, in the
intervention of the behavioural addictions.

4.10 UNIT END QUESTIONS

1) What are different types of behavioural addictions?
2) How do we assess a person with internet gaming disorder?
3) What are the psychological causes of behavioural addiction?
4) What are risk factors for behavioural addictions?
5) Discuss the brief intervention method for gambling disorder.
6) Discuss principles of management of behavioural addictions.
7) How would you conduct motivation enhancement in a person with behavioural
addiction?

4.11 ANSWERS TO SELF ASSESSMENT

QUESTIONS
Self Assessment Questions 1
1) Behavioural addiction, also called process addiction or “non-substance-related
addiction” refers to repeated tendency by an individual to engage in some specific
activity, despite harmful consequences, as deemed by the user himself to his
individual health, mental state, or social life.
2) The 4 C’s of behavioural addiction are Craving, Control, Compulsion and
Consequences.
Self Assessment Questions 2
1) Pathological gambling is characterized by persistent and recurrent problematic
gambling behaviour leading to clinically significant impairment or distress. The person
has a pathological need to gamble with increasing amounts of money in order to
achieve the desired excitement.
2) Internet gaming disorder refers to persistent and recurrent use of internet to engage
in games, often with other players, leading to clinically significant impairment or
distress. Important characteristic of the disorder include preoccupation with internet
games with previous gaming activity or anticipating playing the next game.
Self Assessment Questions 3
1) Psychiatric comorbidities with behavioural addiction are depression, personality
disorders and substance use disorders.
100
2) The important steps in the assessment of behavioural addiction include: Gambling, Internet
and other Addictions
 Take a detailed history
 Assess for associated psychiatric illnesses, substance use and risk factors
 Assess motivation for treatment
Self Assessment Questions 4
1) Psychoeducation refers to providing information to the client about the nature of
problem, giving information about maintaining factors and negative consequences
resulting from it.
2) Motivational enhancement therapy (MET) is a systematic intervention approach
based on principles of motivational psychology and is designed to produce rapid,
internally motivated change. This treatment strategy does not attempt to guide and
train the client, step by step, through recovery, but instead employs motivational
strategies to mobilize the client’s own change resources.
3) The two components included in cognitive behaviour therapy are: functional analysis
and skill training.

4.12 REFERENCES
Akman, I., & Mishra, A. (2010). Gender, age, and income differences in Internet usage
among employees in [Link] in Human Behaviour, 26, 482-490.
Barnes GM, Welte JW, Hoffman JH, Dintcheff BA. Shared predictors of youthful
gambling, subst ance use, and delinquency. Psychology of Addictive
Behaviours.2005;19(2):165–174
Bourget, D., Ward, H. & Gagne, P. (2003).Characteristics of 75 gambling-related
suicides in [Link] and the Law (CPA Bulletin), December, 17–21.
Carnes, PJ (1992). Don’t call it love: When the diagnosis is sexual addiction. New
York, NY: Bantam Books.
Doug Hun Han, sun Mu Kim, youngSik Lee and Perry F Renshaw (2012). The effect
of family therapy on the changes in the severity of on-line game play and brai activity in
adolescents with on-line game [Link] Research neuroimagng,
2002(2);126031
Ellison, N. B., Steinfield, C., Lampe, C. (2007). The benefits of Facebook ‘‘friends:’’
Social capital and college students’ use of online social network [Link] of
Computer-Mediated Communication, 12, 1143-1168.
Garner, David M.; Olmstead, Marion; Polivy, Janet (Spring 1983). “Development and
validation of a multidimensional eating disorder inventory for anorexia nervosa and
bulimia”.International Journal of Eating Disorders2 (2), 15–34.
Hausenblas, H. A., & Symons Downs, D. (2000a).A review of exercise dependence.
Psychology of Sport and Exercise, 3,89-123
Johnson, E.E., Hamer, R, Nora, R.M., Tan, B, Eistenstein, N &Englehart, C (1988)The
Lie/bet questionnaire for screening pathological gamblers. Psychological Reports,80,
83-88
101
Addictions Kausch, O. (2003). Patterns of substance abuse among treatment-seeking pathological
[Link] of Substance Abuse Treatment , 25, 263 – 270.
Ledgerwood, D. M., & Downey, K. K. (2002). Relationship between problem gambling
and substance use in a methadone maintenance population. Addictive Behaviours, 27,
483-491.
Littman-Sharp, N. (2004). Introduction to the treatment of problem [Link] S.
Harrison & V. Carver (Eds.), Alcohol and Drug Problems: A Practical Guide for
Counsellors(pp. 675–707). Toronto: Centre for Addiction and Mental Health.
McMillan, L.H.W., O’Driscoll, M.P., & Burke, R.J., (2003) Workaholism: A review
of theory, research and new directions. In C.L. Cooper & I.T. Robertson (eds)
International Review of Industrial and Organizational Psychology. New York: John Wiley.
Pp. 167-190.
McNeilly, D. & Burke, W. (2000). Late life gambling: The attitudes and behaviours of
older adults. Journal of Gambling Studies, 16, 393–415.
Menon Indu S., Sharma, Manoj Kumar, Chandra; Prabha S; &Thennarasu K. (2014)
Social Networking Sites: An Adjunctive Treatment Modality for Psychological Problems,
Indian Journal of Psychological Medicine,36(3),260-63
Moore, T. & Jadlos, T. (2002). The etiology of pathological gambling: A study to
enhance understanding of causal pathways as a step towards improving prevention and
treatment.
Pagani, L. S., Derevensky, J. L., and Japel, C. (2009). Predicting gambling behaviour
in sixth grade from kindergarten impulsivity: a tale of developmental continuity. Arch.
Pediatr. Adolesc. Med. 163, 238–243
Petry, N. (2002).A comparison of young, middle-aged, and older adult treatment-
seeking pathological [Link] Gerontologist, 42, 92–99.
Petry, N. M., Stintson, F. S. & Grant, B. F. (2005) Comorbidity of DSM-IV pathological
gambling and psychiatric disorders: results from the National Epidemiologic Survey on
Alcohol and Related Conditions. Journal of Clinical Psychiatry, 66, 564–574
Porter, G. (1996). Organizational impact of workaholism: Suggestions for researching
the negative outcomes of excessive work. Journal of Occupational Health Psychology,
1, 70–84.
Robinson Bryan E. (1999) The work addiction test:Development of a tentative measure
of workaholism. Perceptual and Motor Skills: Vol 88, pp. 199-210.
Sharma MK; Benegal, V; Girish N &Thennarasu; K (2013). Behavioural addiction in
the community: an [Link] ICMR funded [Link] DHHS. Reducing
tobacco use: a report of the Surgeon General 2000. Available from: [Link]/
tobacco/sgr_tobacco_use.htm
Sinha (2010). Internet in India, acsessed on Ist August2011: [Link]
internet-usage-in-india-market-statistics-297
Vitaro, F., Brendgen, M., Ladouceur, R. & Tremblay, R. (2001). Gambling, delinquency,
and drug use during adolescence: Mutual influences and common risk factors. Journal
of Gambling Studies, 17, 171–190.

102 Widyanto, L &McMurran, M (2004). The Psychometric Properties of Internet Addiction

test. Cyber Psychology and Behaviour 7, 443-450. Gambling, Internet
and other Addictions
Young, K. S. (1996). Internet addiction: the emergence of a new clinical disorder.
Cyberpsychology and Behaviour, 3, 237-244.
Young, K. S. (1999). Internet addiction: symptoms, evaluation and treatment. In:
VandeCreek, L. and Jackson, T. (eds.) Innovations in Clinical Practice: A Source Book.
Florida: Professional Resource Press, 19-31.

4.13 SUGGESTED READINGS

 Akman, I., & Mishra, A. (2010). Gender, age, and income differences in Internet
usage among employees in organizations. Computers in Human Behaviour, 26,
482-490.
 American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders Fifth Edition Text Revision (DSM-5) American Psychiatric Association;
Washington, DC: 2013.
 Grant JE, Schreiber LRN, Odlaug BL (2013). Phenomenology and Treatment of
Behavioural Addictions. Canadian Journal of Psychiatry; 58(5):252–259
 Kuss DJ (2013). Internet gaming addiction: current perspectives. Psychology
Research and Behaviour Management. 6: 125-137.
 Leeman RE, Potenza MN (2013) A targeted review of the neurobiology and
genetics of behavioural addictions: an emerging area of [Link] Journal
of Psychiatry; 58(5): 260–273.
 Murali, V. and George, S. (2007). Lost online: an overview of Internet addiction.
Advances in Psychiatric Treatment, 13, 24–30.
 Michelle,B&Sharma,MK (2012) Problematic internet use and Mental health
problems. Asian Journal of Psychiatry,5(3),279-80

103
 MPC 053

MENTAL HEALTH IN SPECIAL AREAS

IBLOCK 1: MENTAL HEALTH IN SPECIAL POPULATION

Unit 1: Child and adolescent mental health

Unit 2: Old age and mental health

Unit 3: Women and mental health

Unit 4: Marriage and mental health

I BLOCK 2: SPECIFIC ISSUES ON MENTAL HEALTH

Unit 1: Deliberate self harm and suicide

Unit 2: Problems related to school

Unit 3: Problems related to sex

Unit 4: Problems related to work area

I BLOCK 3: DEVELOPMENTAL DISORDERS

Unit 1: Mental Retardation

Unit 2: Specific learning disabilities (Reading, Writing, Maths)

Unit 3: Other learning disabilities (Cerebral palsy, Multiple disabilities)

Unit 4: Assessment and certification

Unit 5: Rehabilitation

I BLOCK 4: ADDI~TIONS

Unit 1: Alcoholism

Unit 2: Substance abuse and addiction

Unit 3: Tobacco addiction

Unit 4: Gambling, internet and other addictions

SOSS-IGNOUlP.O. 3T/November, 2014

ISBN: 978-81-266-6839-7