Substance Use and Addiction Theories
Substance Use and Addiction Theories
These analyses are based on real life scenarios that can be found and listened to using the links below – please listen to these before reading the blog commentary so as to familiarise yourself with the situations of each individual. Some of the various type of 'addiction theories' that are out there will be considered and applied – yet please bear in mind, this is theoretical and was me partly writing as an academic and not necessarily as someone that reflected what I saw or believed from the 'real world' and my own experience, although there was definitely relevance along with some 'real life' identification. This was my first assignment, now turned blog, as part of my Master's degree in 'Comparative Drug and Alcohol Studies and it opened my eyes to the fact that addiction is a term that is fraught with issues and applies in so many ways that it is pretty much impossible to define. But let me tell you – academics, scientists and researchers do love a good 'theory'! There is a whole world out there with a whole range of differences and unique reasons. Hence why, defining 'addiction' is almost impossible. If we think away from my academic writing however and look to the actual programme of Making Changes, I make it very clear that labels, such as addict or alcoholic are not what is important when it comes to recovery – they really do not matter. For now though, let's explore just some of the theories out there.
Real Life Case Studies
It is well known within the addiction-studies field that, "most cigarette, alcohol, and drug use begins during adolescence" and so it was perhaps inevitable that Emma, David and Max would start using drugs and/or alcohol during their teenage years, yet what will be highlighted in this blog is the different biological, psychological and sociological factors that played a role in their initial use. Following on from this, an analysis of their individual and continued drug using career paths will be explained, with a particular focus on the Brain Disease Model of Addiction and how it applies to Emma, who by virtue of her age, has the most detailed case.
Emma believed that she would always follow her alcoholic father's path and this type of parental influence can be, in part, explained by the theory of 'reasoned action'. Velleman suggests that, "by the time they start to drink alcohol, children already know a great deal, and have well developed attitudes, expectations and intentions about alcohol". Although there are many influences that contribute to this theory, such as culture, media and one's peers; the primary factor is the child's parent(s) and this process of socialisation highlights that through observational learning and imitation, children can model the same behaviours as their parents, notwithstanding any verbal language that might accompany those actions, simply put, "children often do what parents do, not what they say". Emma's initial use can therefore be explained, in part, by theories that fall under 'associative learning', which are mechanism's that operate outside of conscious awareness; Emma was likely developing these expectancies and attitudes towards drinking yet was unaware that she was doing so. Whilst this may be one explanation as to Emma's initial use of alcohol, it cannot be said that David and Max imitated their parents in such a way.
In David's case, it was his cousin who played a role in the initial use of heroin and it is suggested that Sutherland's principle of 'Differential Association' applies here. Additionally, the fact that David talks about the "family he never had" means that he may have been more susceptible to risk-associated behaviours than if the family he eluded to had actually been present. However; what society deems as 'risk-associated' behaviour appears to have moved away from an old-fashioned, traditional perspective, given that, "for many young people, taking drugs has become the norm" and those that do not take drugs will actually be in a minority group; "in one sense, they will be the deviants". Therefore, in the mind of David, as well as Emma and Max, it may not actually be a risk at all, instead it could be a rational choice, a point further supported by Higate,
"In our contemporary 'knowledge society', it is argued that risk is no longer about private fears of the random unknown. One important subtext of the risk discourse is that individuals…are understood to be naturally risk-averse and rational in the face of potential harm to their well-being. By making the right 'choice', and assimilating and acting on appropriate information, negotiating risk, it is suggested, becomes a process of calculation embedded into reflexive social practice."
Max's initial use is different still; using what he believes was an education on drug use from his Father he decided not to use "drugs of dependence", instead choosing cannabis. Max initially used cannabis as a way of coping with his Father's death and therefore it is proposed that he used cannabis as a way of 'self-medicating', albeit that there was still an exercise of consideration meaning that Max also carried out the role of 'rational actor'; he had good reasons for using cannabis in that it would act as a form of medication and therefore improve his well-being. Self-medication will be explored later in the blog as it also applies to Emma and David, yet further insight into the impact of Max's Father's death can perhaps be explained if we look to the 'Family Systems Theory'. This theory proposes that traumatic or premature deaths of family members can contribute to drug use as a functional replacement for those mourning that death, instead of it being resolved through an effective grieving process. Interestingly, Eisenstadt (1978) also suggests that, "…if the destructive elements and the depressive features of the experience of bereavement are neutralised, then a creative product or creatively integrated personality can result." The type of personality in question is one that desires fame, eminence and occupational excellence, all of which apply to Max and it is proposed that Max used cannabis to initially deal with and neutralise the grief of his Father's death, which, in turn, helped him to shape a foundation to build his career goals from. The theories outlined up to this point look to explain the initial use of all three case studies from a psychological and sociological perspective, yet there is also the biological aspect to consider in the form of genetics. There have been a number of research programmes in this area producing percentage-based predictions which suggest that, "addictions have a relatively high heritability, with estimates ranging from 39% to 72%" . In summary terms, it is safe to say that genetics can play a part, yet there are usually other psychological and socio-environmental factors that also need to be considered, such as those highlighted above. It is further suggested that genetics can also play a part in how an individual is affected following their initial use and that can determine how someone views their social and environmental surroundings with their biological and genetical make-up thus having a 'knock-on' effect on their future psychological and sociological nature after the initial use of drugs and/or alcohol;
"The strong heritability of alcoholism suggests the existence of inherited functional variants of genes that alter the metabolism of alcohol and variants of other genes that alter the neurobiologies of reward, executive cognitive function, anxiety/dysphoria, and neuronal plasticity".
With this in mind and by applying the suggestion to drugs as well as alcohol, Emma and David may have been more susceptible to the psychological triggers for continued drug use as a result of conditions like anxiety, which is something they both talk about significantly; this is an area that will be explored further when analysing 'problem' or 'addictive' use.
Problem and/or Addictive Use
As a starting point for this there will be a collective approach in how all three 'cope' with life itself and their capabilities in handling stress or anxiety, given that it plays such an influential role in their respective drug careers, particularly Emma and David.
As has been mentioned briefly above, Max initially used cannabis in the form of self-medication and it can be seen that this theory also applies to both Emma and David. Emma quite clearly uses alcohol and codeine as a way to self-medicate her inability to cope with being a parent, wife and employee and for David, heroin "blocks a lot of things that you don't want to deal with", whilst his regular cannabis use helped to "numb everything". As Gold and Coghlan (1976) explain, "some people are simply unable to cope with the conflicts and anxieties of normal life and turn to opioids as a means of reducing this anxiety" . West argues that this theory falls under a broader encapsulation known as the Rational Informed Stable Choice (RISC) model of behaviour and when this model is applied the person in question expects to receive benefits even if they come with adverse consequences, which are seen as worth accepting in order to obtain the benefit. An extreme application of this theory is described here,
"Under this view, it may be that the addict would prefer to live differently, but among the options that s/he sees as actually open to him or her this is judged to be the best on offer at the time. When we see the alcoholic sleeping on the street, living a life of degradation in a drink-fuelled haze with the likelihood of an early death, it is wrong to assume that s/he does so because s/he cannot stop drinking. This life may be preferable to his or her own life without alcohol".
Whilst Emma and David are not living on the streets, the principle of West's example does apply; alcohol and/or drugs, from their perspective, are their best option, albeit that neither of the options are appealing. They both, "intentionally use drugs to treat psychological symptoms from which they suffer"  and, "the drugs may not even make things better – they need only be judged to do so by the person concerned" and the rational choice, "does not have to be sensible or adaptive. It only has to result from a weighing up of the costs and benefits as the decision-maker sees them" . Additionally, whilst acute use of alcohol and/or drugs may relieve the anxiety and stress in the immediate moment, once that affect dissipates, it returns and may even be worse and so the cycle is repeated through habituation and to alleviate withdrawal symptoms.
In relation to Max's initial reasoning for the use of cannabis, it can be seen that he moves away from this as a result of dealing with the issue of the grief itself and so eradicating the need for cannabis as a method of self-medication. In addition to cannabis, Max also begins to use MDMA and proponents of the 'gateway theory' may well highlight the likelihood of this occurring; whilst this may be true, it is suggested that there is also rational choice as part of this, especially when viewed in the context of where and why it was taken. Max's use of MDMA has a strong, clear link to music and research into drug use within the dance music and club industry found that use of drugs in this particular way is understood to be normalised and governed by informal rules, "Here, the risks from drugs are countered through codes of acceptable versus excessive use within the context of shared sociality in the club space" . What general society may view as deviant behaviour therefore, is completely acceptable when carried out by those such as Max, in the environment and manner in which they do it; this latter observation can also be seen in what is known as 'conflict theory'. Max is also able to regulate his use to those times when he can afford it and when he is going to music events; this is very different from Emma; however, David has also shown examples of when he is able to cease using and this is sometimes referred to as the theory of 'spontaneous remission' which is part of the 'interactionist theory'.
Spontaneous remission can occur if users have, "a stable family network to refer to and with which one has never broken off relations". This perhaps explains why David is able to stop using from time to time; his 'social and personal capital' from a familial perspective is intact, yet it does not seem to be enough to keep him in remission for sustained periods and Scarscelli has also highlighted that,
"It is necessary to develop a coping strategy with the aim of confronting withdrawal symptoms and the craving to take the substance and redefining one's social relationships and lifestyle, if they were conditioned by the previous experience".
If we look to this research we can see that there needs to be a change to David's lifestyle and that any underlying issues, such as stress, need to be dealt with appropriately if he is able to spontaneously remiss for significant periods. Furthermore, it is suggested that he may be at risk of progressing from what is an arguably limited social functioning status to a more social deviant status if he continues to not work and remains at risk of criminal sanctions for the illegal use of heroin, which, if ever caught, may start to have a detrimental effect on the very things that maintain his current, albeit limited, social functioning status.
The unconscious expectancies that were highlighted earlier in relation to Emma as an adolescent can also be expanded on and applied here to David with a very similar type of theory called 'Cognitive Bias';
"Bias can occur not just because we believe things we want to believe but also in the very way in which our attention and memory operate. Cognitive Bias Theories…propose that addiction arises out of or is maintained by a tendency of the addict to pay greater attention to and selectively remember particular addiction-related information".
This highlights what can be a distorted view of what is actually happening; David creates a perspective of his circumstances that normalise and justify his actions, regardless of any negative consequences, furthermore,
"Defence mechanisms help to maintain the addiction through protecting the individual from full realisation of its harmful effects. Defence mechanisms that are characteristics of addiction include denial, paranoid projection, isolation of affect, rationalisation and intellectualisation" .
It is clear that so much depends on what the individual and society view as normal or deviant and this can make it difficult to say with certainty who is or is not addicted, yet it would appear that this principle does apply, to some extent, to David. It will now also be seen how 'functioning' in society has played a crucial role in Emma's alcohol and drug use career.
Emma's ability to deal with 'normal' life decreased; as seen with the transition from, "was not coping" to, "cannot cope anymore" and one of the causes may be found in the 'social position' she found herself in and the 'role theory' that emanated as a result of that. Knibbe et al. (1987) report that, "social positions in professional, relational, familial and parental domains involve specific obligations, during the performance of which drinking is mostly not allowed". It is their suggestion that the occupation of one or more of these social positions decreases the opportunity for drinking, yet this is certainly not the case for Emma, in actual fact it is these social positions that she is struggling with and that are a major cause of her alcohol and drug use. Furthermore, in and of itself, Emma's consumption may not be perceived as deviant by society, however, the fact she is doing it whilst being a mother, wife and at work is what labels it deviant, especially if Knibbe et al.'s 'role theory' is applied and so it is suggested that societies 'labeling theory' is perhaps more relevant here and that it is actually caused by the application of the 'role theory'.
As can be seen from all the evidence outlined above; there are a multitude of potential theories that can be applied to all three case studies and these theories tend to be aligned in some way to the principle of choice. A theory that explores the eradication of choice, the Brain Disease Model of Addiction (BDMA), will now be explored and applied where relevant.
'The Brain Disease Model of Addiction'
The BDMA can be summarised as,
"…the desensitization of reward circuits, which dampens the ability to feel pleasure and the motivation to pursue everyday activities; the increasing strength of conditioned responses and stress reactivity, which results in increased cravings for alcohol and other drugs and negative emotions when these cravings are not sated; and the weakening of the brain regions involved in executive functions such as decision making, inhibitory control, and self-regulation that leads to repeated relapse". 
It is important to point out that whilst the make-up of the BDMA is neurobiological, that it also incorporates psychological, environmental and sociological behaviours and considerations that also need to be taken into account so that the BDMA is correctly applied and not viewed in a narrow context.
This view has been supported by those such as Leshner who writes,
"As with many other brain diseases, addiction has embedded behavioural and social-context aspects that are important parts of the disorder itself…Addiction is not just a brain disease. It is a brain disease for which the social contexts in which it has both developed and is expressed are critically important".
The salient point that needs to be addressed before applying the BDMA is whether or not Emma, David and Max are indeed addicted to alcohol and/or drugs. In Emma's case it would seem that she is; Emma herself states that she is addicted and has relapsed from alcohol abstinence several times when attempting to stop. In David and Max's case, this would depend on who is judging whether or not they are addicted, and no-one can truly say, on the face of it therefore it may appear difficult to class them as addicted, at least to the level that Emma appears to be.
However, if Volkow and Koob are to be believed then the BDMA does apply to all three as there are different severity levels of addiction and this notion is outlined below,
"…in addiction, as is the case for any other medical condition, there is a severity dimension, and only a small percentage of those with a substance use disorder fall in the most severe category. However, we don't understand the argument of why this fact should negate the value of the disease model in addiction. It is basic research that is helping us understand this severity dimension and the mechanisms underlying the transition from mild to severe addiction that one day might enable us to develop interventions to revert those changes and/or to identify those who are at most risk when exposed to drugs to transition into a severe phenotype. In the meantime, research is already providing evidence that is guiding therapeutic interventions on the basis of the levels of severity". 
If this principle is applied it would appear that Emma falls into the small percentage of 'most severe' and that David and Max are at a severity level below Emma, perhaps 'mild addiction'. This is not so surprising given that Emma is 42 years of age and has had much more time for her addiction to develop and progress; for these reasons, Emma will be the primary focus for the application of the BDMA.
Whilst in residential treatment Emma escaped the anxiety she faced at home; she never knew there were such, "nice people out there" and having her own room, meals and other people to talk to meant that she, "didn't crave alcohol once". When listening to Emma it is quite clear to see that very quickly after returning to her home environment she was at risk of relapsing; Zinberg refers to this type of situation as the 'set' and the 'setting'. It appears that Emma's 'set' (personality) was firmly entrenched within her and is intertwined so tightly with her 'setting' (environment) that she automatically associated anxiety and self-medication through alcohol and codeine with it. Additionally, Higate points out that,
"The phrase 'head space' has been used to signal drug users' desire to achieve a 'controlled loss of control' in an increasingly stressful world. Here, it is argued that drugs can facilitate 'time-out' in bounded (regulated and unregulated) locations. In doing so, drugs can provide a brief reprieve or escape from the mundanity of paramount reality, the ritualised experiences of which may come to be linked with particular spaces and places" .
The issue for Emma was that she could never achieve a 'controlled loss of control'; it was simply a 'loss of control'; her brain was diseased to such an extent that to achieve 'head space' was impossible due to the overpowering nature of her craving, which, "is the central driving force for ongoing drug use, as well as for relapse following abstinence".
"These risk factors are further aggravated by protracted withdrawal symptoms resulting from drug induced neuroadaptation, but also by conditions such as psychiatric comorbidity, socioeconomic conditions and perceived drug availability".
It would seem that all of these factors applied in Emma's case; her stress levels and anxiety, family and work life, as well as the fact that alcohol and codeine were easily accessible. Similarities can be seen here from explanations above linked with the self-medication theory; the fundamental difference here is that proponents of the BDMA believe it is as a result of a diseased brain and not that of 'rational choice'. Furthermore, that the changes to Emma's brain, from a functional and decision-making perspective, have, "become deeply ingrained and cannot be immediately reversed through the simple termination of drug use (e.g. detoxification)" . This latter point goes some way to explaining why Emma has never remained abstinent until now and perhaps one of the most appropriate statements that applies to Emma's previously failed treatment comes from Leshner,
"If we understand addiction as a prototypical psychobiological illness, with critical biological, behavioural, and social-context components, our treatment strategies must include biological, behavioural, and social-context elements. Not only must the underlying brain disease be treated, but the behavioural and social cue components must also be addressed, just as they are with many other brain diseases…".
It is quite clear that Emma's treatments prior to her last one did not address these factors in the way that benefited Emma and her unique biological and psychological make-up as well as her sociological conditions post treatment. The key factor in Emma finally appearing to make some shift from a relapsing lifestyle to one that is more abstinent, at least for now, and solely in relation to alcohol; was the fact that the last treatment was specifically suited to her needs, in that it was a non-residential, post-withdrawal treatment programme. It can be taken from this piece of information that by embarking on treatment at home and with the support of her family that she broke the cycle of returning to the place she associated with stress, anxiety and the theories mentioned above that then apply and ultimately lead to relapse. Furthermore, the fact that the treatment was also for post-withdrawal meant that she was able, at least in some part, to deal with the triggers that would normally arise after treatment.
It is clearly evident that there are a vast number of complex theories that apply to Emma, David and Max's drug using career pathways, many of which have not even been discussed here. Upon consideration as to the usefulness of theoretical analysis, it is suggested that for David and Max, at this stage of their lives, such an analysis may not have been as crucial as it was for Emma, whose case highlighted the significance of applying the correct theories in order to achieve successful, post-withdrawal treatment.
Finally, whether one is a supporter of the BDMA or the model of 'choice', the fact is that in order to recover and abstain from severe addiction, all biological, psychological and sociological factors need to be part of a post-withdrawal treatment. Where an individual's addiction is not as severe, drug use theories still play a part in helping the individual, as well as society, understand their reasons for doing so and should the use ever get to the stage of 'problem' or 'addicted', that understanding, much like it did with Emma and as highlighted throughout this blog, could prove extremely useful in future prevention and treatment.
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