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Substance abuse
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Substance abuse involves a pathological use of a substance resulting in

• Functioning - Failing to fulfill important obligations, such as in repeatedly neglecting a child or

being absent from work.
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• Potentially hazardous behaviour - Putting oneself or others at repeated risk for physical injury,
for instance, by driving while intoxicated. p o
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• Having substance-related legal difficulties, such as being arrested for disorderly conduct.
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• Continued use of, despite a persistent social, psychological, occupational health problem.
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Substance Dependence - A person is said to be dependent on a substance when he or she has
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repeatedly self-administered it, resulting in tolerance, withdrawal, and compulsive behavior
(American Psychiatric Association, 2000). to
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Substance dependence can include physical dependence, when the body has adjusted to the
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substance and incorporates the use of that substance into the normal functioning of the body’s
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tissues.
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Physical dependence often involves
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• Tolerance, the process by which the body Dr.
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Simi Kapoor
adapts to the use of a substance, 2
requiring larger and larger doses of it to obtain the same effects, and eventually reaching a plateau.
Drugs with high tolerance potential may be dangerous because people who build up tolerance
need to take more of the drug to produce the effect they want and expect. If this amount is
progressively larger, any dangerous effects or side effects of the drug will become more of a
hazard. o r
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• Craving is a strong desire to engage in a behavior or consume a substance. It results from
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physical dependence and from a conditioning process: As the substance is paired with
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environmental cues, the presence of those cues triggers an intense desire for the substance.
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The Opponent Process Theory By Solomon discussed in chapter of Motivation describes this
process.
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• Dependence occurs when a drug becomes so incorporated into the functioning of the body’s
cells that it becomes necessary for “normal” functioning. If the drug is discontinued, the body’s
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dependence on that drug becomes apparent and withdrawal symptoms develop.
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• Withdrawal refers to the b e l
unpleasant symptoms, both physical and psychological, that
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people experience when they stop using a substance on which they have become dependent.
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Although the symptoms vary, they include anxiety, irritability, intense cravings for the
substance, nausea, headaches, tremors, and hallucinations. Withdrawal symptoms are the opposite
of the drug’s effects. Because alcohol produces mostly depressant effects, withdrawal from it
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produces symptoms of restlessness, irritability, and agitation. Usually the first symptom to appear
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is tremors, with hallucinations, disorientation, and possibly convulsions.
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• Psychological Dependence is a state in which individuals feel compelled to
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Kuse a substance
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for the effect it produces, without necessarily being physically dependent on it. Despite
knowing that the substance can impair psychological and physical i
S health, they rely heavily on
.
it—often to help them adjust to life and feel good—and spend much time obtaining and using
Dr 1998).
it. Dependence develops through repeated use (Cunningham,
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Users who become addicted usually becomespsychologically dependent on the substance first;
later they become physically dependentnas gtheir bodies develop a tolerance for it. Substances
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differ in the potential for producing o
psychological dependence: the potential is high for heroin and
beand lower for LSD (NCADI, 2000; Schuster & Kilbey, 1992).
cocaine, moderate for marijuana,
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Stages of Substance Use

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➢ Initiation and Maintenance - The Tension-Reduction Hypothesis (Cappell and Greeley
1987) suggests that individuals may develop a drink problem because alcohol reduces tension
and anxiety. Tension creates a heightened state of arousal and alcohol reduces this state, which
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perpetuates further drinking behaviour. It is not the actual effects of alcohol use that promote
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drinking but the expected effects (George and Marlatt 1983). Therefore, because a small
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continue with increased use. K a
amount of alcohol may have positive effects, people assume that these positive effects will

Curiosity m i
Peer pressure S i
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➢ Cessation - Prochaska and DiClemente (1984) adapted their stages-of-change model to
to
examine cessation of addictive behaviours. They argued that cessation involves a shift across
five basic stages:
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1) pre-contemplation: not ready to admit that he has a problem/not seriously considering
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quitting
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2) contemplation: starts realizing he has a problem but does not do anything about it/ having
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some thoughts about quitting
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 3) preparation: preparation of action items for quitting/seriously considering quitting
4) action: initial behaviour change i.e. reducing the consumption and ultimately ceasing
consumption
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5) maintenance: not consuming for a period of time/ maintaining behaviour change for a
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period of time.
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CESSATION PROCEDURES include: aversion therapies, contingency contracting,
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K cue
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exposure, self-management techniques and multi-perspective cessationmclinics:
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1 Aversion Therapies - aim to punish smoking and drinking.rather than rewarding it-
✓ electric shocks Dr
o vomiting whenever alcohol is consumed.
✓ administering a drug called Antabuse, which induces
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✓ rapid smoking technique/flooding - is a more
s successful form of aversion therapy (Danaher
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1977) and aims to make the actual process of smoking unpleasant. Smokers are required to sit
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in a closed room and take a puff o six seconds until it becomes so unpleasant they cannot
every
smoke any more. be
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✓ focused smoking, which involves smokers concentrating on all the negative experiences of
smoking
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✓ smoke-holding, which involves smokers holding smoke in their mouths for a period of time
and again thinking about the unpleasant sensations. Smoke-holding has been shown to be more
successful at promoting cessation than focused smoking and it does not have the side effects of
rapid smoking (Walker and Franzini 1985).
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2. Contingency Contracting Procedures – Substance abusers are asked to make a contract with
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either a therapist, a friend or partner and to establish a set of rewards/punishments, which are
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contingent on their substance abuse cessation. For example, money may be deposited with the
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therapist and only returned when they have stopped for a given period of time. They are therefore
rewarding abstinence.
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3. Cue Exposure Procedures - focus on the environmental
with substance abuse. Cue exposure techniques gradually
factors that have become associated
expose the individual to different cues
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and encourage them to develop coping strategies
o ntime and is opposite to cue avoidance procedures, which
extinguish the response to the cues over
encourage individuals not to goe tol
the places where they may feel the urge to smoke or drink.
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4. Self-management Procedures - Such procedures involve self-monitoring (keeping a record of
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own smoking/drinking behaviour), becoming aware of the causes of smoking/drinking and
becoming aware of the consequences of smoking/drinking.
5. Multi-perspective cessation clinics represent an integration of all the above clinical
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approaches. In addition, this multi-perspective approach often incorporates disease model-based
interventions such as nicotine replacement. po
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➢ Relapse - Marlatt and Gordon (1985) developed a relapse prevention model of addictions,
m
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which specifically examined the processes involved in successful and unsuccessful cessation
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attempts. They distinguished between a lapse, which entails a minor slip (e.g. a cigarette, a
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couple of drinks), and a relapse, which entails a return to former behaviour (e.g. smoking 20
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cigarettes, getting drunk).

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Relapse Process (Marlatt and Gordon, 1985)

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 Stages of Severity of Substance Use

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The criterion of Substance Use given below can help the therapist to report the severity level to
the recommending doctor.

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Factors Predisposing Substance Abuse

1. Genetic Predisposition
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Genetic factors along with environmental factors are significant contributors to addiction
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vulnerability. Genetic factors account for 40–60% of the risk factors. Knestler (1964)
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hypothesized that a gene or group of genes might contribute to predisposition to addiction in
several ways. Altered levels of a normal protein due to environmental factors could then change
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the structure or functioning of specific brain neurons during development. These altered brain
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neurons could change the susceptibility of an individual to an initial drug use experience.
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2. Environmental Exposure D
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A number of different environmental factors have been implicated as risk factors for addiction,
• an individual's exposure to the substance
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• lack of parental supervision and guidance,
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• the prevalence of peer substance use,
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• drug availability, b
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• Poverty/ broken homes
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3. Adverse Childhood Experiences (ACEs) - various forms of maltreatment and household
dysfunction experienced in childhood.
• stressful events such as physical, emotional, or sexual abuse,
• physical or emotional neglect, r
• witnessing violence in the household, o o
• a parent being incarcerated or suffering from a mental illness. a p
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As a result, the child's cognitive functioning or ability to cope with negative or disruptive
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particularly during adolescence. S i
emotions may be impaired. Over time, the child may adopt substance use as a coping mechanism,

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4. Age D
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There are two windows of vulnerability for alcohol use and abuse.
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• The first, when chemical dependence generally starts, is between the ages of 12 and 21
g
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(DuPont, 1988). Adolescence represents a period of unique vulnerability for developing an
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addiction. In adolescence, the incentive-rewards systems in the brain mature well before the
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cognitive control center. This consequentially grants the incentive-rewards systems a
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disproportionate amount of power in the behavioral decision-making process. Adolescents are
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increasingly likely to act on their impulses Dr.and engage in risky, potentially addicting behavior
Simi Kapoor 14
• before considering the consequences

Not only are adolescents more likely to initiate and maintain drug use, but once addicted they are
more resistant to treatment and more liable to relapse.
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• The other is in late middle age, in which problem drinking may act as a coping
K a method for
managing stress (Brennan & Moos, 1990). Late onset problem drinkers i are more likely to
m with people who have
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control their drinking on their own or be successfully treated, compared
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more long-term drinking problems (Moos, Brennan, & Moos, 1991).
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• Male menopause- feeling of not being young and strong Dranymore, adopting alcohol as a way of
regaining youth. to
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4. Comorbid Disorders o n
Individuals with comorbid mentale lhealth disorders such as depression, anxiety, attention-
deficit/hyperactivity disorderb(ADHD) or post-traumatic stress disorder are more likely to develop
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substance use disorders. tAlcoholism may represent untreated symptoms of depression, or
depression may actteas an impetus for drinking in an effort to improve mood. Accordingly, in some
Dr. Simi Kapoor 15
6. Psychological Factors-
• Self-Identity - The image of one’s self is a significant factor in initiation of use (Tombor et al.,
2015).
• Low self-esteem, o r
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• Dependency,
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• Feelings of powerlessness, i
• Social isolation im
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increase the tendency to imitate others’ behaviour abusers (Ennett & Bauman, 1993).
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• Feelings of being hassled, angry, or sad increaseo
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likelihood (Whalen, Jamner, Henker, &
Delfino, 2001; Wills, Sandy, & Yaeger, 2002).t
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Feelings of self-efficacy and good self-control skills help adolescents resist temptations (Wills et
al., 2010).
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Self-identity is also important for cessation. Identifying oneself as a substance abuser impedes the
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ability to stop, whereas t
identifying oneself as a quitter can promote it (Van den Putte, Yzer,
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Willemson, & detBruijn, 2009). Dr. Simi Kapoor 16
Sociocultural Factors

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SUBSTANCE PSYCHOLOGICAL EFFECTS
Alcohol distorted vision, hearing, and coordination
impaired judgment
altered perceptions/hallucinations and emotions
central nervous system damage
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memory loss – cannot remember events that occurred during the effect of alcohol, memory
p o
Drugs
impairment
violent, erratic, or paranoid behavior K a
hallucinations and "coke bugs"--a sensation of imaginary m i
insects crawling over the skin S i
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confusion, anxiety and depression, loss of interest in food
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"cocaine psychosis"--losing touch with reality, loss of interest in friends, family, a sense of distance

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and estrangement
Lose interest in sports, hobbies, and other activities
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use has been a contributing factor in a number of suicides.
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depression, anxiety, and paranoia
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violent behavior
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confusion, suspicion, and loss of control
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behavior similar to schizophrenic psychosis
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catatonic syndrome whereby the user becomes mute, lethargic, disoriented, and makes meaningless
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repetitive movements
Dr. Simi Kapoor 18
SUBSTANCE PSYCHOLOGICAL EFFECTS
Nicotine Nicotine alters levels of neuroregulators, including acetylcholine, norepinephrine,
dopamine, endogenous opioids, and vasopressin. Nicotine may be used by smokers
to engage these neuroregulators because they produce temporary improvements in
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performance or affect.
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causes a sudden surge in the endorphin levels, which lead to a heightened feeling of
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alertness. The euphoric feelings, coupled with the false perceptions about its ability
m i
to improve mental performance, are the root cause of nicotine addiction.
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Anxiety - tobacco lifts anxiety levels and increases vulnerability to mental
disorders, such as severe anxiety. r .
Depression. smoking aggravates depression
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Memory loss. increases risk of dementia and Alzheimer’s.
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severe damage of the brain - changing its structure and causing the death of healthy
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cells and neurons, resulting in mental decline.
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Changes in Psychological factors that Act as Warning Signs/Signals Of Substance Abuse for
a therapist to look out for:
• Unexplained changes in personality or attitude.
• Inflexibility, drama, dramatic mood swings o r
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• Increased irritability
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• Anger outburst i
• Emotional and Mental Withdrawal im
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• Increased inattentiveness r .
• Lack of motivation
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• Unexplained anxiousness or paranoia
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• Easily agitated, excitable and giddyn
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• Intervals of highs and lows –ehyperactivity to lethargy
• Increased feelings of t
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fear, paranoia and anxiety
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Behaviors Of A Substance Abuser
1. Using the substance in larger amounts, or for longer, than was intended.
2. Making efforts to reduce or stop use, but not being able to do so.
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3. Spending increased amounts of time getting, using, and/or recovering from using the substance.
p o
4. Having cravings or urges to use the substance. K a
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mor major life consequences
related to it. S i
5. Having some role failures (not adequately fulfilling life obligations)
.
Drsocial problems that have been caused
6. Continuing to use the substance despite relationship and
by it.
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7. Giving up important social, occupational sor recreational activities because of it.
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8. Having increased risk taking related to the substance, and/or using it in physically hazardous
situations be
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9. Continuing to use the substance even after gaining awareness that it is causing or exacerbating
Dr. Simi Kapoor 21
physical and psychological problems.

10. Tolerance: needing more of the substance to get the desired effect, or having a reduced effect
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with the same level of use. This is a physiological change that happens when we use substances
o
regularly over time
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11. Development of withdrawal symptoms, which can be relieved by taking more
something similar. m i
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Addictive behaviours are learned according to the following processes:

(1) Classical Conditioning – association of the substance with a positive feeling such as of
relaxation, with nicotine a euphoric feeling, with alcohol a feeling of calmness o r
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(2) Operant Conditioning - the probability of substance use will be increased by feelings of social
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acceptance, confidence and control (the positive reinforcer) and removal of withdrawal symptoms
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(the negative reinforcer).
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(3) Observational Learning/Modelling - by observing significant others carrying them out.
to
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(4) Cognitive Factors - Negative self-image, inability for problem solving behavior, lack of coping
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mechanisms and external attribution contribute to acquisition of addictive behavior.
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Factors such as positive self-image, ability for problem-solving behaviour, coping mechanisms
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and internal attributions also contribute to the cessation of an addictive behaviour.
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Factors That Can Lead to a Relapse (Witkiewitz & Marlatt, 2004)

• Low self-efficacy - Maintaining self-efficacy for staying abstinent is not always easy: people
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who quit a behavior and experience a lapse may lose their confidence in remaining abstinent
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and see their violation as a sign of a personal failure - the abstinence violation effect.
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• Negative emotions and poor coping - people often use substances to regulate K a
their emotional

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states, they tend to lack good coping skills to take the place of the substance when difficulties
i
arise. High craving The greater the craving, the more likely a relapse.
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• .
Expectation of reinforcement - People tend to relapse if they think that using the substance
Dr taste great and make me feel so
again would be rewarding, such as ‘‘Having a drink would
relaxed.’’
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• Low motivation - People at lower levelss of readiness to change when they try to quit are more
g
n readiness levels.
likely to relapse than people at higher
l o
• e users who quit, but lack constructive social support or have
Interpersonal issues - Substance
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social networks that promote substance use, are more likely to relapse than others who have

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strong, helpful support.
Dr. Simi Kapoor 24
MANAGEMENT TECHNIQUES

➢ The first phase of treatment is de- addiction program. Because the process of detoxification
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can produce severe symptoms and health problems, it is typically conducted in a carefully
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supervised and monitored medical setting. The typical program begins with a short-term,
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intensive inpatient treatment followed by a period of continuing treatment on an outpatient
basis. m i
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➢ Cognitive-Behavioral therapy – Learning coping techniquesSfor dealing with stress and
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relapse prevention skills enhance the prospects for long-term maintenance. Many CBT
programs begin with a self-monitoring phase. D
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s skills to help individuals resist social pressures
➢ Social Influence Approaches focus on training
g
to smoke. They include o n
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(1) discussions and films regarding how peers, family members, and the media influence
smoking; b
n t of specific refusal skills, such as saying, ‘‘No thank you, I don’t
(2) modeling and role-playing
smoke’’ te Dr. Simi Kapoor 25
➢ Life Skills Training approaches address general social, cognitive, and coping skills. Because
many teens who begin smoking seem to lack these skills, this approach focuses on improving
(1)personal skills, including critical thinking for making decisions, techniques for coping with
anxiety, and basic principles for changing their own behavior; and
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(2)general social skills, including methods for being assertive and making conversation (Botvin &
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Wills, 1985).
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(3) having each student decide his or her intention regarding whether to smoke and announce that
decision publicly to classmates (Flay et al., 1985). m i
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➢ Family therapy and Group Counselling - The advantage Dr of family counselling is that it eases
to
the patient’s transition back into his or her family.

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➢ Motivational enhancement procedures
o n are often included because the responsibility and the
capacity to change rely entirelylon the patient.
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➢ Some programs also n t
include medications for blocking the substance - brain interactions that
may contribute ttoeabuse. Dr. Simi Kapoor 26
➢ Relapse Prevention Techniques (Magill & Ray, 2009) – these techniques are essential.
Practicing coping skills or social skills for high risk-for-relapse situations is a mainstay of
relapse prevention interventions. In addition, the recognition that people often stop and restart
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an addictive behavior several times before they are successful has led to the development of
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techniques for managing relapses. Understanding that an occasional relapse is normal helps the
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patient realize that any given lapse does not signify failure. K a
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➢ Use Of Self-determination Theory - Because adolescents often begin use to boost their self-
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image with a sense of autonomy and control, self determination theory targets those same
.
cognitions, namely, autonomy and self-control; but from the opposite vantage point; that is,
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they target the behavior of cessation instead (Williams, McGregor, Sharp, Kouides, et al.,
2006). to
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➢ Awareness Of Long Term Benefits Of Cessation - Cessation can lead to short-term
g
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unpleasant withdrawal symptoms such as distractibility, nausea, headaches, constipation,
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drowsiness, fatigue, insomnia, anxiety, irritability, and hostility. Use is mood elevating and
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helps to keep anxiety, irritability, and hostility at bay. Smoking and use of drugs keeps weight
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down, a particularly significant factor for adolescent girls and adult women. However, they
t e Dr. Simi Kapoor 27
are unaware of the benefits of remaining abstinent over the long term, such as improved
psychological well-being, higher energy, better sleep, higher self-esteem, and a sense of mastery
(Piper, Kenford, Fiore, & Baker, 2012).

➢ Using an Internet program, such as Smoking Zine, to assist smoking prevention and o r
o
pself-
quitting
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interventions in schools (Norman et al., 2008). This program includes interactive
assessments with tailored feedback to prevent teens from starting to smoke,Kadvance the
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person’s readiness to change, and help smokers design a plan for quitting.
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Role of Therapists Dr
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Comprehensive, multifaceted rehabilitation programso offered by high-quality drug and alcohol
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rehab centers often include options for physical therapy, since the ultimate goal of addiction

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treatment is to help those with substance use disorders regain their good health in all its
dimensions.
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Physical therapists can createbcustomized recovery plans for patients in treatment for substance
use disorders, dependington the depth and nature of their maladies. Therapy will be offered as
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te at a pace that is reasonable and sustainable.
frequently as needed, Dr. Simi Kapoor 28