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HEALTH AND WELLNESS 2/2013 WELLNESS AND ENVIRONMENT CHAPTER XV Katedra i Zakład Zdrowia Publicznego Uniwersytet Medyczny w Lublinie Chair and Department of Public Health Medical University of Lublin KRZYSZTOF WŁOCH, PIOTR KSIĄŻEK, EWA WARCHOŁ-SŁAWIŃSKA, BARTŁOMIEJ DROP Some Problems Of Addiction Wybrane Problemy Uzależnień People who have addiction have no control over their behavior. Addiction is not only restricted to using substances, such as drugs or tobacco, but also includes abstract things like gambling. Addiction refers to substance dependence or behavior. The paper will focus on drug addiction. Drug addiction: a drug addict has a compulsive need to use controlled substance in order to function normally. When such substances are unobtainable, the user suffers from substance withdrawal. WITHDRAWAL SYMPTOMS The patient has physical and emotion symptoms. The physical symptoms include headache, diarrhea, and insomnia. Some substance withdrawal may trigger violent behavior, seizures, and hallucination. The emotional symptoms include depression, loneliness, “frustration, anger, resentment and bitterness”. DEMOGRAPHICS There is no data to indicate which particular group is more susceptible to drug addiction. Drug addiction is across racial and ethnical boundaries. It is also across sexual and age boundaries. However, there is a strong indication that men are more prone to be drug addicts than women. Younger people are more likely to become addicts than the older people. HEALTH AND WELLNESS 2/2013 Wellness and environment CONSEQUENCES OF ADDICTION Addiction to drugs may also increase the tendency of high risk behaviors possibly due to the influence of the drug. An addict may do risky things such as driving fast, involving in unprotected sexual activities. Addiction to substances may also cause addicts to give up social relationships. The influence of addictive substances, such as drugs, may cause domestic abuse and lead to poor relationships with one’s family and loved ones. Drug addicts tend to conduct their addictive habits in secrecy. This may lead them to prefer solitude over companionship with others and not care about having relationships with family members or friends [1]. Addiction can lead to various financial issues due to the cost of the drugs as addictive substances can be very expensive. In the United States, a smoker who smokes 20 cigarettes per day will need to spend $330 per month to keep up his or her addiction. The costs of other substances, such as cocaine and heroin are even higher. Addiction to drugs may lead to law breaking behaviors. In order to maintain their substance addiction using high cost substances, an addict may conduct illegal activities, for example, stealing, robbery or murdering due to the financial burden that the substances have put them through. Furthermore, certain addictive drugs are illegal in certain countries, thus the usage of the drug would be considered illegal behavior. PERSONALITY People with certain personality traits, such as higher levels of curiosity, aggressiveness and lack of self-esteem, will be more likely to become a drug addict. The degree of curiosity one possesses may contribute to the individual becoming an addict. Some people are more curious than others. They will be more likely to experiment new things, such as drugs. This will increase the chance of them to experiment with highly addictive drugs and become addicted. Some personal traits like aggressiveness can lead to addiction. The drug satisfies their ego of being dominating over others. People who not have confidence in themselves and lack of self-esteem are more likely to turn to drugs in order to feel happy and secure [2]. PSYCHOLOGICAL FACTOR Mental illness. People who have psychological problems will have a higher risk to become the addict. The mental disorders include depression, attention-deficit disorder, obsessive compulsive disorder, and bipolar disorder. According to the survey conducted in 2002 by the National Survey on Drug Use and Health, 17.5 million adults were diagnosed with a serious mental disorder in the U.S.A. About 4 million of them have serious problems of addiction and mental disorders. 188 Krzysztof Włoch, Piotr Książek, Ewa Warchoł-Sławińska, Bartłomiej Drop Some problems of addiction Loneliness. Individuals that feel a lack of companionship in their lives may turn to fill this void in their life. They may also take the drugs in order to escape their lonely situation. Stress. In order to cope with the stress in life some people will resolve in using drugs to alleviate the level of the stress. In a neurological experiment, researchers found that monkeys who were under tremendous stress by being dominated by monkeys from the upper social ladder were more likely to self-medicate with cocaine. The scientist concluded that being in a stressful situation is an important contributing factor for a person to become the addict. SOCIOLOGICAL FACTOR Peer pressure can play a significant role forcing one to start taking drugs. The youth who tries to gain acceptance in a group, often will take drugs to become accepted in a social group. This is more common among the adolescent than other age groups as the young people desperately try to fit in and be accepted in a group. The type of family environment that one has experience can also influence the chance of an individual to start taking addictive substances. Young individuals from the family that takes drugs will be more likely to become a drug addict. Young people who not have a strong attachment to their family or siblings are at risk of becoming a drug addict. SOCIAL ENVIRONMENT Accessibility of drugs. Accessibility of drugs can certainly contribute to the problem of drug addiction. The typical example is Punjab, the city of India that is situated between India and Pakistan. Opium was legally consumed before India and Pakistan gained independence in 1947. Punjab is a gateway for smuggling opiates from Pakistan and Afghanistan. With the accessibility, drug usage is prevalent. Even schoolboys eat black bails of opium with tea before going to school. The majority of addicts are the young people between the ages of 15 and 35. Poverty, unemployment. A survey conducted on 600 drug addicts in rural and urban areas of Punjab found that the majority of the addicts are young people who are unemployed and poor. Rural versus urban. Most people assume that urban communities have a more serious problem with drug addiction because of high population and accessibility of drugs in the cities. However, in Canada, drug taking is less common in larger cities than in rural communities. The study published in the Canadian Journal of Psychiatry indicates the average substance use in Canada is approximately 11%, while in the rural area the rate of substance use can reach 14.02%. Isolation and limited programs contribute to the youth becoming drug addicts because of the lack of entertainments. 189 HEALTH AND WELLNESS 2/2013 Wellness and environment BIOLOGICAL FACTOR Genetics. Like alcohol abuse, some people with certain genetic components will be more susceptible to drugs. From much research it is found that people with certain genetic makeup will run a higher risk in becoming a drug addict. If certain genetic makeup influences the chance of getting addicted, the identical twins who have the same genomes will have higher concordance in displaying the same behavior, while the fraternal twin who do not have the same genomes will have less chance to display the same behavior. The study conducted in 1934 at the Medical College of Virginia on female twins found strong evidence to support this idea. The study showed that “the concordance for cocaine usage was 54% for identical twins and 42 % for fraternal twins”. Furthermore, the study indicated the “concordance for cocaine abuse was 47 percent for identical twins and 8 percent for fraternal twins; and for drug dependence, 35 percent for identical twins and zero for fraternal twins”. Age when drugs were first consumed. Because of the malleability of the youth’s brain, the young people are more likely to become addicted. This is supported by the data showing the higher percentage of addicts from their youthful time. Gender. The data showed that a higher percentage of people addicted to drugs are males. “According to Mayo Clinic, USA, males are twice as likely as females to have problems with drugs addiction” [2]. DELIVERY OF SERVICES IN THE HEALTH SERVICE SYSTEM PRIMARY CARE Screening and early intervention. Early detection and intervention increase the chance of recovery from the addiction. “It is estimated that two thirds of addicts see primary doctors every six months”. Thus primary doctors have an opportunity to recognize, diagnose the patients who suffer from drug addiction and intervene at an appropriate time. Treatments. In the primary care the goal is to get the addictive substance out the patient’s system. The regular procedure is to get it done “gradually by giving reduced dosages (tapering)”. In some cases a substitute drug is given. The primary care can either be inpatient or outpatient care depending upon what drug the patient is addicted to. Psychological therapy. Provide one-on-one therapy section with a psychiatrist or family sessions with a counselor. SECONDARY CARE In the primary care patients are under supervision all the time. In the secondary care facilities, patients are given more freedom. The goal of the secondary care is to help the addicts to reintegrate into “normal society in an assisted and safer manner”. Secondary care focuses on the psychological treatment. In the secondary program the newly recovering patients learn to deal with life issues such as “death of a loved one, disappointments, frustrations and boredom” in constructive ways. They learn to 190 Krzysztof Włoch, Piotr Książek, Ewa Warchoł-Sławińska, Bartłomiej Drop Some problems of addiction take part in charity works and rebuild their relationship with their friends and family [1]. Treatment for substance abuse is critical for many around the world. Often a formal intervention is necessary to convince the substance abuser to submit to any form of treatment. Behavioral interventions and medications exist that have helped many people reduce, or discontinue, their substance abuse. From the applied behavior analysis literature, behavioral psychology, and from randomized clinical trials, several evidenced based interventions have emerged: Behavioral marital therapy Behavioral marital therapy, sometimes called behavioral couple, or couples, therapy, has its origins in behaviorism and is a form of behavior therapy. The theory is rooted in social learning theory and behavior analysis. As a model, it is constantly being revised as new research presents. Motivational Interviewing - Express empathy. Empathy involves seeing the world through the client's eyes, thinking about things as the client thinks about them, feeling things as the client feels them, sharing in the client's experiences. Expression of empathy is critical to the MI approach. When clients feel that they are understood, they are more able to open up to their own experiences and share those experiences with others. Having clients share their experiences with you in depth allows you to assess when and where they need support, and what potential pitfalls may need focus on in the change planning process. In short, the counselor's accurate understanding of the client's experience facilitates change. - Develop discrepancy. This guides therapists to help clients appreciate the value of change by exploring the discrepancy between how clients want their lives to be vs. how they currently are (or between their deeply-held values and their day-to-day behavior). MI counselors work to develop this situation through helping clients examine the discrepancies between their current behavior and future goals. When clients perceive that their current behaviors do not tend to some important future goal, they become more motivated to make important life changes. Techniques used can include decisional balance sheets - Roll with resistance. - In MI, the counselor does not fight client resistance, but „rolls with it.” Statements demonstrating resistance are not challenged. Instead the counselor uses the client's „momentum” to further explore the client's views. Using this approach, resistance tends to be decreased rather than increased, as clients are not reinforced for becoming argumentative. MI encourages clients to develop their own solutions to the problems that they themselves have defined. In exploring client concerns, counselors may invite clients to examine new perspectives, but counselors do not impose new ways of thinking on clients. 191 HEALTH AND WELLNESS 2/2013 Wellness and environment - Rolling with resistance allows therapists to accept client reluctance to change as natural rather than pathological. Support self-efficacy. This guides therapists to explicitly embrace client autonomy (even when clients choose to not change) and help clients move toward change successfully and with confidence. As clients are held responsible for choosing and carrying out actions to change in the MI approach, counselors focus their efforts on helping the clients stay motivated, and supporting clients' sense of self-efficacy is a great way to do that. One source of hope for clients using the MI approach is that there is no „right way” to change, and if a given plan for change does not work, clients are only limited by their own creativity as to the number of other plans that might be tried. Community reinforcement approach. A comprehensive operant program built on a functional assessment of a client's drinking behavior and the use of positive reinforcement and contingency management for non-drinking. When combined with disulfiram community reinforcement showed remarkable effects. One component of the program that appears to be particularly strong is the nondrinking club. Applications of community reinforcement to public policy has become the recent focus of this approach. Exposure therapy. A technique in behavior therapy intended to treat anxiety disorders and involves the exposure to the feared object or context without any danger in order to overcome their anxiety. Procedurally it is similar to the fear extinction paradigm in rodent work. Numerous studies have demonstrated its effectiveness in the treatment of anxiety disorders such as PTSD and specific phobias [1, 2]. Contingency management. A type of treatment used in the mental health or substance abuse fields. Patients' behaviors are rewarded (or, less often, punished); generally, adherence to or failure to adhere to program rules and regulations or their treatment plan. As an approach to treatment, contingency management emerged from the behavior therapy and applied behavior analysis traditions in mental health. By most evaluations, contingency management procedures produce one of the largest effect sizes out of all mental health and educational interventions. Pharmacological therapy - A number of medications have been approved for the treatment of substance abuse. These include replacement therapies such as buprenorphine and methadone as well as antagonist medications like disulfiram and naltrexone in either short acting, or the newer long acting form. Several other medications, often ones originally used in other contexts, have also been shown to be effective including bupropion Modafinil and more. According to some nurse practitioners, stopping substance abuse can reduce the risk of dying early and also reduce some health risks like heart disease, lung disease, and strokes. 192 Krzysztof Włoch, Piotr Książek, Ewa Warchoł-Sławińska, Bartłomiej Drop Some problems of addiction In children and adolescents, cognitive behavioral therapy (CBT) and family therapy currently have the most research evidence for the treatment of substance abuse problems. These treatments can be administered in a variety of different formats, each of which has varying levels of research support Social skills are significantly impaired in people suffering from alcoholism due to the neurotoxic effects of alcohol on the brain, especially the prefrontal cortex area of the brain. It has been suggested that social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious, including managing the social environment. Rehabilitation using some of these treatment methods can be both institutional and in programs where the patients live at home and go to follow up-meetings connected with the therapy program. For substance abusers, the tertiary care in the form of rehabilitation is extremely important in the plan of letting the patients come back to normal life without the addiction. The final step to a complete recovery is through the tertiary care. The goal of the tertiary care is to turn an addict into a completely healthy person, physically and emotionally. Tertiary care encourages patients to “maintain their hobbies, interests which are conducive in bringing happiness to their life instead of using drugs. Get continuous support from local communities such as churches, charity groups. The tertiary care institutions help patients plan their education and career goals in order to help them reintegrate with the normal society. Hence live a happy and meaningful life without drugs [1, 2]. SPECIAL PROGRAMS Self-help groups. Self-help-groups allow people with the same problem to meet. In the process of discussion and sharing their feeling people are encouraged and motivated. These self-help-groups include “drug addiction anonymous” and “12 Steps”. “12 Steps” is a recovery program that helps patients remain motivated with spiritual assistance by trusting in God and admitting one’s mistake. SUBSTANCE ABUSE Substance abuse, by definition is a “patterned use of substance which can include drug, tobacco, or alcohol”. One can abuse drugs, alcohol, or tobacco and can be considered a substance abuser. Substance abuse is no good in any circumstances. People abuse substances such as alcohol, tobacco, and other drugs for varied and complicated reasons, but it is clear that our society pays a significant cost. The toll for this abuse can be seen in our hospitals and emergency departments both through direct damage to health by substance abuse and its link to physical trauma. Jails and prisons tally daily the strong connection between crime and drug dependence and abuse. Although the use of some drugs such as cocaine has declined in recent years, the use of other drugs such as heroin and “club drugs” has increased. It is all too common within most populations, especially in a lower economic class. Some of the people that you may see on the streets would probably be your typical user, but there are some drugs that are used by your everyday “girl or boy 193 HEALTH AND WELLNESS 2/2013 Wellness and environment next door” types. When it comes to helping individuals that abuse drugs, nurses can be the front line in aiding their care. Nurse can help these individuals with finding resources to help them, educate them about stopping the abuse of drugs, and how the government can help these individuals, as well. Nurses that are not familiar with individuals with substance abuse problems can be educated by laws, policies, what their role is in the care of these individuals, and by trying to get what the community itself provides, or what the state that they live in provides [1, 2]. Club drugs are favored over other recreational drugs, such as marijuana, lysergic acid diethylamide (LSD), methamphetamine, and opiates, because they are believed to enhance social interaction. They often are described as “entactogens”, giving a sense of physical closeness, empathy, and euphoria. MDMA is structurally similar to amphetamine and mescaline, which is a hallucinogen. However, it is not as stimulating or addictive as amphetamine, and is considered much less likely to cause psychosis than LSD and other potent hallucinogens. 2 GHB and Rohypnol are powerful sedative/hypnotic agents. Ketamine is a dissociative anesthetic that produces a dreamy tranquility and disinhibition in small doses. Unlike opiates, these sedatives encourage sociability and seldom cause nausea. There are many laws that encompass substance abuse addiction. When individuals become part of any governmental program to help them kick the habit, there are laws and policies that these individuals have to follow in order to be part of a drug rehabilitation program. Some addicted individuals are embarrassed of their problem, and when it comes to entering the program by law they must be tested to see what substances they come back positive on. Mandatory drug screens can be court appointed or be appointed by a drug rehab facility. However, mandatory screens are not only done once, they can be done periodically throughout the course of treatment, and even after treatment to make sure that, the individual does not use the substance. These screenings are mostly done by surprise without the individuals being notified. Law also protects substance abusers that enter into a rehab facility by this I mean all their information is held confidentially and only those working specifically with the individual are allowed to know their information [1]. Health education, promotion, and prevention are crucial for people with addiction. These people are weak and only know one way to solve their problems and that is by using substances. Often, a drug user has an underlying behavioral disorder or other mental illness, one that increases risk for substance abuse. Such disorders must be treated medically and through counseling along with treatment of the drug abuse. Substance abuse may start in childhood or adolescence. Abuse prevention efforts in schools and community settings now focus on school-age groups. In conclusion, substance abuse is something that is preventable. If we follow the primary, second and tertiary steps, the society as the whole can lower the substance abuse cases. Programs seek to increase communication between parents and their children, to teach resistance skills, and to provide information in order to correct children’s misperceptions about cigarettes, alcohol, and drugs and the consequences 194 Krzysztof Włoch, Piotr Książek, Ewa Warchoł-Sławińska, Bartłomiej Drop Some problems of addiction of their use. Most importantly, officials seek to develop, through education and the media, an environment of social disapproval from children’s peers and families [2]. WNIOSKI 1. Edukacja zdrowotna stanowi podstawę postępowania profilaktycznego w uzależnieniach. 2. Systemy wsparcia społecznego za podstawę III fazy profilaktyki w uzależnieniach. CONCLUSIONS 1. Health education constitutes the basis of prophylaxis approach in drug addiction. 2. Social support systems are the background in the tertiary care system in drug addiction. LITERATURE 1. Brunn K.: Alcohol consumption – from public health perspective, London 1974. 2. Glendening M., Laing W.: The politices of health care. ABPI, London, 1987. ABSTRACT The aim of the paper is the analysis of these data of ecological system which affect drug addiction. Their monitoring allows for functional and organizational reorganization of drug addiction treatment in the primary care system. STRESZCZENIE Celem pracy jest analiza tych danych systemu ekologicznego, które wpływają na nadużywanie narkotyków. Ich monitoring pozwala na organizację i funkcjonowanie systemu terapii w opiece pierwszorzędowej w ramach poz. Artykuł zawiera 22981 znaków ze spacjami 195