Addiction bad choices brain disease and bad environment
Addiction: bad choices, brain disease and bad environment Robert West University College London July 2013 1
Aims • To describe a more comprehensive model of behaviour for development of improved strategies to combat addiction West R. Models of Addiction. EMCDDA Insight Report, 2013 2
Outline 1. Defining addiction 2. An overview of models of addiction 3. A more comprehensive approach 3
The purpose of definitions • To include cases that should be included and exclude those that should not: i. e. to set the boundaries of a concept • To provide as concise a description of a concept as is necessary to help identify cases 4
Addiction as a brain disease Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in the individual pursuing reward and/or relief by substance use and other behaviours. The addiction is characterized by impairment in behavioural control, craving, inability to consistently abstain, and diminished recognition of significant problems with one’s behaviours and interpersonal relationships. Like other chronic diseases, addiction can involve cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. (American Society of Addiction Medicine) This considers addiction as a brain disease which implies that it requires treatment. It neglects environmental and social forces at play, the fact that it involves a continuum and that many individuals ‘recover’ without treatment. 5
Addiction as compulsive behaviour Addiction is a compulsive, uncontrollable dependence on a chemical substance, habit, or practice to such a degree that either the means of obtaining or ceasing use may cause severe emotional, mental, or physiologic reactions (Mosby’s Medical Dictionary 8 th ed) The use of the term ‘uncontrollable’ rules out cases where an individual is struggling successfully (for the time being at least) to control the behaviour 6
Addiction as choice Addiction involves strong preferences to engage in activities that have significant potential for harm because of the immediate pleasure, satisfaction or relief that they provide (e. g. Heyman) The focus on choice fails to take account of impulsive and compulsive nature of much addiction 7
Addiction as a context-sensitive disorder of motivation Addiction involves repeated powerful motivation to engage in a purposeful behaviour that has no survival value, acquired as a result of engaging in that behaviour, with significant potential for unintended harm. Brings in motivation, purpose, acquisition through engagement, and harm; makes no unnecessary assumptions 8
Seven things about addiction that need explaining 1. Most people who are exposed to the addictive substance/behaviour do not become addicted, but low impulse control and/or mood disturbance can increase vulnerability, as can adverse life circumstances 2. Even determined attempts to cease addictive behaviours have a low probability of success, but unaided recovery does occur 3. When ‘addicts’ attempt recovery, momentary risk of relapse is greatest in the first few days or weeks 4. Prevalence of a given addictive behaviour in populations is influenced by price and availability 5. Social norms substantially influence the chances of becoming addicted and recovery from addiction 6. Drugs that seek to reduce addictive urges can increase the chances of recovery but often do not 7. Behavioural interventions that seek to address addictive motivation and/or self-regulatory skills and capacity can increase the chances of recovery but often do not 9
Taxonomy of models of addiction 10
Automatic process theories 11
Reflective choice theories 12
Goal focused theories 13
Integrative theories 14
Process of change and biological theories 15
Population and group-level theories 16
A synthetic model (COM-B+PRIME) Aims to provide • a more comprehensive model of behaviour within which existing models can be understood and compared • a basis for improving existing models • a rational basis for the design of interventions to change behaviour 17
The COM-B model of behaviour Michie et al (2011) Implementation Science 18
The COM-B model of behaviour Physical and psychological capability: knowledge, skill, strength, stamina Michie et al (2011) Implementation Science 19
The COM-B model of behaviour Reflective and automatic motivation: plans, evaluations, desires and impulses Michie et al (2011) Implementation Science 20
The COM-B model of behaviour Physical and social opportunity: availability, prompts, reminders and cues Michie et al (2011) Implementation Science 21
PRIME Theory and the structure of human motivation 22
The rider and the donkey model of behaviour 23
Reflective Impulsive Action Affective Reflective Impulsive Action PRIME Theory and Dual Process Theories 24
PRIME Theory: 1 st law of motivation • At every moment we act in pursuit of our strongest motives (wants or needs) at that moment – Want: anticipated pleasure or satisfaction – Need: anticipated relief from, or avoidance of, mental or physical discomfort 25
PRIME Theory: 2 nd law of motivation • Evaluations (beliefs about what is good and bad) and plans (self-conscious intentions to do or not do things) can only control our actions if they create motives at the appropriate moments that are stronger than competing motives coming from other sources 26
PRIME Theory: 3 rd law of motivation • Self-control (acting in accordance with plans despite opposing motives) requires mental energy and depletes reserves of that energy 27
PRIME Theory: 4 th law of motivation • Our identities (thoughts, images and feelings about ourselves) can be a powerful source of motives – Labels: the categories we think we belong to – Attributes: the features we ascribe to ourselves – Personal rules: imperatives about what we do and do not do 28
PRIME Theory: 5 th law of motivation • Motives influence actions by creating impulses and inhibitions, which are also generated by habitual (learned) and instinctive (unlearned) associations; behaviour is controlled by the strongest momentary impulses and inhibitions 29
The battle over time between resolve and urge/impulse When the urge is stronger than resolve and the behaviour is available, a lapse will occur Urge/impulse Time Resolve Strength of urge 30
Stage of change model versus the SNAP model People move through ‘stages’ on the way to achieving lasting change Move people to the next stage with ‘stage-matched’ interventions’ ‘Personal rules’ govern behaviour, and transitions between these rules occur as a result of ‘tension and triggers’ Create motivational tension and triggers to ‘snap’ people into action and then 31 support to prevent them snapping back
Sources of urges/impulses Triggers Reminders Positive beliefs Want or need Urge/ impulse Acquired drive’ 32
Sources of resolve Reminders Personal abstinence rule Want or need to abstain Beliefs and feelings about the behaviour and abstinence Resolve to abstain Ability to inhibit impulses 33
Implications for measurement • Important to separate out: – prevalence of the behaviour precisely defined to match the nature of the problem – intensity of addiction through frequency and strength of the experience of motivation (means and SDs) – severity of addiction in terms of immediate harms • Develop composite measures involving multiple behaviours/substances • Measure motivation to change in terms of: – duty, desire and intention • Use COM-B+PRIME for a comprehensive assessment of the precise nature of the problem for individuals, groups or populations 34
Implications for intervention strategies • Broadens focus beyond just the individual or just the environment • Forces consideration of reflective, emotive and impulsive mechanisms • Provides a perspective that reveals the inappropriateness of debates about disease versus choice models • Provides a systematic system for designing intervention strategies for behaviour change 35
Behaviour Change Wheel Comms/marketing Using print, electronic, telephonic or broadcast media Education Increasing knowledge or understanding Persuasion Guidelines Incentivisation Fiscal Coercion Using communication to induce positive or negative Creating documents that recommend or mandate feelings or stimulate action practice. This includes all changes to service provision Creating expectation of reward Using the tax system to reduce or increase the financial Creating expectation of punishment or cost Regulation Training Establishing rules or principles of behaviour or practice Imparting skills Restriction Legislation Using rules that limit engagement in the target behaviour Making or changing laws or competing or supporting behaviour Environmental Changing the physical or social context Env/Soc Planning Designing and/or controlling the physical or social restructuring environment Modelling Providing an example for people to aspire to or imitate Service provision Delivering a service Michie S, M van Stratten, West R (2011) The Behaviour Change Wheel: A new method for Enablement Increasing means/reducing barriers to increase capability characterising and designing behaviour change or opportunity interventions. Implementation Science, 6, 42. 36
The example of comprehensive tobacco control • Educate the population about the harms of smoking, the benefits of stopping and best ways to stop • Use hard hitting campaigns and health professional advice to persuade smokers to try to stop and use the most effective ways of doing this • Where appropriate incentivise quitting • Use tax and social norms to reduce the attractiveness of smoking • Reduce ubiquity of smoking triggers and reminders • Use modelling in social marketing strategies • Provide behavioural and pharmacological support for quitting 37
Conclusions • A broad perspective on addiction is needed to mount effective countermeasures • The synthetic model (COM-B+PRIME) is an attempt to integrate existing models into a single coherent framework • When linked with the Behaviour Change Wheel it provides a basis for designing an intervention strategy that can be effective • However practicability, affordability and acceptability are also key factors that need to be considered 38
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