WHO collaborative project on drug dependence treatment and HIV/AIDS
Workshop Beijing 29.-31.05.2006

 

Understanding

substance dependence

 

•             Uchtenhagen

Research Institute for Public Health and Addiction

Associated with Zurich University

 Overview

 

•             1. Describing addiction as a disease

 

•             2. Explaining addiction

 

•             3. Lessons from evaluating course and   interventions

 

•             4. Conclusions

 1.  Describing addiction as a disease

 

•             Descriptive diagnostics in ICD-10 and DSM-IV

 

•             The diagnostic criteria

 

•             A spectrum of subtypes ?

 

Diagnostic Criteria for Substance Dependence in ICD-10

1. Craving

2. Loss of control re timing and amount of use 

3. Withrawal syndrome following cessation of use

4. Increased tolerance for substance effects

5. Neglect of other interests and activities

6. Continued use in spite of negative consequences

 

3 of these 6 criteria must be met together during the last

12 months repeatedly or for at least one month

Specifiers for Substance Dependence in ICD-10

Status :

-            Actively dependent at present

-          Chronic use, episodic use

-             Abstinent at present

-          Early remission, partial remission, full remission

-             In substitution treatment

-             In aversive or antagonist treatment 

Substance :

-            Alcohol, opioids,cannabinoids, sedatives, cocaine, other stimulants,hallucinogens, tobacco, solvents, polydependence

2. Explaining addiction

 

•             Overviews of empirically based theories on etiology of addiction

 

•             Risk factors and protective factors for developing addiction

 

•             Is there a unified model of addiction ?

 

Konzept der Schutz- und Risikofaktoren

Some risk factors
on the population level

•      Social mobility disrupting functional networks (mass migration, urbanisation in slum areas with poverty, poor hygiene, high unemployment, lawlessness)

•      Major socio-cultural change (e.g. from socialist systems to market economies, changes in social value beliefs etc)

•      High availability of substances (vested interests) 

•      Special high risk constellations : high risk professions, multi-problem neighbourhood etc 

 

Some risk factors in the life cycle and on the individual level 

•      Adolescence, transition to adulthood, midlife, old age  (increased challenges for adaptation)

•      Learned helplessness, e.g. from child abuse, child neglect

•      Inability to cope with chronic situations of over-burdening or boredom 

•      Inability to cope with chronic unacceptable emotions (of guilt, shame, failure, loneliness etc)

•      Deficient emotional self control and sensation seeking

•      Increased risk from inadequate self esteem

Some protective factors 

 

•      Access to information and education

•      Access to social support and useful networks 

•      Adequate social  control  of behaviour (structural und personal)

•      Experience in managing emotional stress and crisis situations in life

•      Good „climate“ in school, family, workplace

•      Satisfactory perspectives for the future 

 

Is there a unified model of
explaining substance use ?

 

•      Environmental factors lead to increased levels of substance use   

•      Substance use is

–  Adaptive behaviour to socio-cultural norms (high availability, high acceptance, invested interests)

or

–  Self-manipulation to avoid chronic stress from a variable spectrum of stress-generating risk factors

 

 

Is there a unified model of
addiction etiology ?

•      Increased levels of substance use increase incidence and prevalence of dependence (in vulnerable individuals)

•      Transition from controlled use to addictive behaviour is a learning process on the basis of genetically determined disposition, personality factors and environmental stress leading to structural change in the brain

•      The learning process is potentially reversible  

 

 3. Lessons from evaluating course and interventions 

 

•             Lessons from „natural course“

 

•             Lessons from effective prevention

 

•             Lessons from effective treatment

 

 Summary statement

•             Substance dependence is understood as a chronic disease

•             A range of environmental and personal risk factors facilitate the transition from controlled use to dependent use 

•             Effective prevention and treatment are based on

–     reducing major risk factors on the population level

–     reinforcing protective factors in a learning process of individuals and societies