I have been asked to speak about abnormal consumer behaviors specifically from an addictions model. My comments will attempt to pull the four papers in this session together, but I also hope to present some information about commonalities across a wide spectrum of addictive behaviors, including such things as compulsive collecting and compulsive spending. One of the presenters this morning defined deviant behavior as "any behavior which differs from the normal standard". I submit that we would be hard pressed to defend this definition due to the difficulty in defining the term "normal". Many definitions of deviant behavior are very subjective and emotionally laden in nature, and often the term "deviant behavior" arises whenever someone else is doing something we ourselves don't like or approve of.
Later, however, these excuses and justifications become increasingly more global and nonspecific in nature. We estimated the presence of publication bias addicfion plotting addction funnel plots Wallace donovan model of addiction the network meta-analyses with a linear regression line [ 24 ]. We also treat process addictions Walalce as gambling, porn, and sex addiction. Functional neuroimaging studies in humans have shown that gambling Breiter et al,shopping Knutson et al,orgasm Komisaruk et al,playing video games Koepp et al, ; Hoeft Wallace donovan model of addiction al, and the sight of appetizing food Wang et al, a activate many of the same Sylvia boots ass regions i. This study has some limitations. Online resources II. The postulate that exercise serves as an ideal intervention for drug addiction has been widely recognized and used in human and animal rehabilitation.
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- Recently, there has been a dramatic rise in the adoption of alternative forms of peer support services to assist recovery from substance use disorders; however, often peer support has not been separated out as a formalized intervention component and rigorously empirically tested, making it difficult to determine its effects.
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Primary outcome measures were efficacy proportion of patients in abstinence, assessed by urinalysis and acceptability proportion of patients who dropped out due to any cause at the end of treatment, but we also measured the acute 12 weeks and long-term longest duration of study follow-up effects of the interventions and the longest duration of abstinence. Odds ratios ORs and standardised mean differences were estimated using pairwise and network meta-analysis with random effects.
The strength of evidence ranged from high to very low. Compared to TAU, contingency management CM plus community reinforcement approach was the only intervention that increased the number of abstinent patients at the end of treatment OR 2.
At the end of treatment, CM plus community reinforcement approach had the highest number of statistically significant results in head-to-head comparisons, being more efficacious than cognitive behavioural therapy CBT OR 2. CM plus community reinforcement approach was also associated with fewer dropouts than TAU, both at 12 weeks and the end of treatment OR 3. At the longest follow-up, community reinforcement approach was more effective than non-contingent rewards, supportive-expressive psychodynamic therapy, TAU, and step programme OR ranging between 2.
The main limitations of our study were the quality of included studies and the lack of blinding, which may have increased the risk of performance bias. However, our analyses were based on objective outcomes, which are less likely to be biased. PLoS Med 15 12 : e This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. All other authors have declared that no competing interests exist.
Drug use disorders are the 15th leading cause of disability-adjusted life years in high-income countries [ 1 ]. Cocaine and amphetamines are the most commonly abused stimulants in people aged 15—64 years, with an annual prevalence of misuse of 0. Patients addicted to stimulants experience a range of psychological and physical sequelae including psychosis and other mental illnesses, neurological disorders and cognitive deficits, cardiovascular dysfunctions, sexually transmitted diseases, and blood-borne viral infections such as HIV and hepatitis B and C [ 3 ], and are at increased risk of all-cause mortality [ 4 ].
Moreover, the social burden of stimulant abuse is worsened by its association with crime, violence, and sexual abuse [ 5 ]. In the absence of approved pharmacotherapies, several structured psychosocial and self-help approaches are available, such as contingency management CM a behavioural approach that consists in providing stimulant users with rewards upon drug-free urine samples , community reinforcement approach a multi-layered intervention involving functional analysis, coping-skills training, and social, familial, recreational, and vocational reinforcements , and step programme a set of guiding principles outlining a course of action for self-help recovery from addiction [ 8 ].
International guidelines are unclear on whether any specific intervention should be considered first [ 9 , 10 ]; for example, the National Institute for Health and Care Excellence NICE recommends CM alone, cognitive behavioural therapy CBT alone, or self-help groups based on step programme alone for the treatment of individuals with stimulant use disorders [ 8 ]. However, a recent systematic review showed that CM and CBT were well accepted and moderately efficacious at the end of treatment, but not at follow-up after treatment completion [ 11 ].
Previous pairwise meta-analyses relied on a limited number of studies with direct comparisons between different interventions [ 12 , 13 ]. From a clinical perspective, it is important to assess whether psychosocial interventions are effective and acceptable in both the short and long term, and also whether the combination of 2 approaches can produce a significant benefit.
We also screened international registers, hand-searched the reference lists of retrieved articles, and looked at key conference proceedings for the full search strategy, see S1 Text. When needed, we contacted the investigators and relevant trial authors to obtain information about unpublished or incomplete trials. All searches included non-English language literature. CBT, CM, community reinforcement approach, meditation-based therapies, non-contingent rewards, supportive-expressive psychodynamic therapy, step programme, and their combinations were all identified as structured psychosocial interventions.
We excluded studies on occasional users not actively seeking treatment and RCTs with study duration less than 4 weeks. We did not exclude studies on individuals with a comorbid substance use disorder including opioid, alcohol, or cannabis use or with a comorbid psychiatric disorder.
The same reviewers discussed any uncertainty regarding study eligibility and data extraction until consensus was reached; conflicts of opinion were resolved with another member of the review team AC. We considered as primary outcomes the efficacy and the acceptability of the interventions at the end of treatment [ 18 ]. Efficacy was measured as the proportion of individuals abstinent assessed by urinalysis , and acceptability as the proportion of individuals who dropped out from the study due to any cause.
As secondary outcomes, we also measured efficacy and acceptability at 12 weeks from the start of treatment and at the longest follow-up with follow-up starting at the end of treatment, independent of the duration of the intervention. If week data were not available, we used data ranging between 4 and 20 weeks giving preference to the time-point closest to 12 weeks.
Other secondary outcomes were the longest duration of abstinence measured both at 12 weeks and at the end of treatment. We incorporated indirect comparisons with direct comparisons using random-effects network meta-analyses within a frequentist framework using STATA network package , and results are presented with the network graphs package [ 20 ].
When dichotomous outcome data were missing, we assumed that patients who dropped out after randomisation had a negative outcome. Missing continuous outcome data were analysed on an endpoint basis, including only participants with a final assessment, as reported by the original study authors. We also calculated the number needed to treat NNT , which is the number of patients that need to be treated in order for 1 to benefit from the intervention compared with TAU.
We assessed incoherence between direct and indirect sources of evidence using local and global approaches. Coherence or consistency is an important assumption to check in network meta-analyses because it is the manifestation of transitivity in the data from a network of interventions: coherence exists when treatment effects from direct and indirect evidence are in agreement subject to the usual variation due to heterogeneity in the direct evidence [ 21 ].
Local incoherence was measured by using a loop-specific approach which identified inconsistent loops of evidence [ 22 ] and a side-splitting approach which separated evidence on a particular comparison into direct and indirect evidence [ 23 ].
Global incoherence was measured with the between-studies standard deviation SD heterogeneity parameter by using both a coherence and incoherence model and by measuring the chi-squared incoherence, with its P value. We estimated the presence of publication bias by plotting comparison-adjusted funnel plots for the network meta-analyses with a linear regression line [ 24 ]. We also estimated the ranking probabilities for all treatments, i.
To determine whether the results were affected by study characteristics, we performed subgroup network meta-analyses for abstinence and dropout at the end of treatment according to the following variables: year of publication, sex ratio, mean age group, intensity of the treatment, type of stimulant, risk of bias, opioid therapy, sample size, and comorbid alcohol misuse. Additionally, we performed sensitivity network meta-analyses for the primary outcomes by considering a only trials on individuals addicted to cocaine and no other stimulant and b only trials on individuals addicted to stimulants and on opioid substitution therapy.
From the initially identified 7, citations, we retrieved potentially eligible articles in full text Fig 1. We excluded 88 reports, but then included 4 additional studies 3 from trial registers and 1 from screening the references , resulting in 76 publications S3 Text describing 50 RCTs 6, participants , published between and Fig 2 ; Table 1 , comparing 12 psychosocial interventions or TAU listed and defined in S4 Text. Overall, 5, participants were randomly assigned to psychosocial treatments, and 1, to TAU.
Full clinical and demographic characteristics are reported in Table 1. The mean study sample size was participants, ranging between 19 and participants. The median duration of treatment was 12 weeks range 6— Dropout rates varied between A total of 37 studies were followed up after study completion, for a mean duration of About a third of the population was women About one-third of trials 18 of 50 enrolled participants on methadone maintenance.
The flowchart shows the records identified through database searching black boxes , the records screened blue boxes , the records excluded red boxes , and the studies included green boxes.
The figure plots the network of eligible direct comparisons for abstinence at the end of treatment 46 trials A and dropout due to any cause 43 studies B. The width of the lines is proportional to the number of trials comparing every pair of treatments, and the size of every node is proportional to the number of randomised participants. The numbers above each connection relate to the numbers of trials and the numbers below each connection relate to the number of patients for each direct comparison.
We present all the networks for specific outcomes in S2 Fig. Eight psychosocial interventions had at least 1 trial versus TAU, and all of them were directly compared with at least another psychosocial intervention. We obtained unpublished or supplementary information for 5 of the included studies [ 45 , 49 , 59 — 61 ]. The pairwise meta-analyses are presented in S4 Table , while data on heterogeneity are presented in S5 Table. The pairwise meta-analyses showed some statistically significant results in terms of abstinence and dropout.
The results of the network meta-analysis are presented in Fig 3. In terms of abstinence at the end of treatment, the combination of CM plus community reinforcement approach, the combination of CM plus CBT, and CM alone were superior to non-contingent rewards OR ranging between 2. Moreover, the combination of CM plus community reinforcement approach was also superior to the combination step programme plus non-contingent rewards and to CBT OR 4.
In terms of dropouts at the end of treatment, the combination of CM plus community reinforcement approach, community reinforcement approach alone, non-contingent rewards, CM alone, and CBT were better accepted than TAU OR ranging between 1.
Moreover, the combination of CM plus community reinforcement approach was better accepted than CBT, CM alone, CM plus CBT, community reinforcement approach plus non-contingent rewards, meditation-based therapies, non-contingent rewards, supportive-expressive psychodynamic therapy, step programme alone, and step programme plus non-contingent rewards OR ranging between 2.
Psychosocial treatments are reported in alphabetical order. Comparisons should be read from left to right. Abstinence and dropout estimates are located at the intersection between the column-defining and the row-defining treatment. For abstinence, ORs above 1 favour the column-defining treatment. For dropout, ORs above 1 favour the row-defining treatment. To obtain ORs for comparisons in the opposite direction, reciprocals should be taken.
Significant results are in bold and underlined. Fewer studies reported results for abstinence measured at 12 weeks of treatment S3 Fig and at the longest follow-up after treatment completion S4 Fig , but findings were in line with the outcome data at the end of treatment. Comparative abstinence and dropout at different time-points for each psychosocial intervention versus TAU are presented in Fig 4. Estimates are reported by ORs, where an OR above 1 favours the psychosocial intervention indicated on the left side over treatment as usual.
For each intervention, efficacy outcomes are reported in the blue-shaded area, while acceptability outcomes are reported in the pink-shaded area. OR, odds ratio. The common heterogeneity SD for the coherence model was 0. The global incoherence was not significant for all the outcomes considered S6 Table.
Tests of local incoherence did not show any inconsistent loops for abstinence and dropout at the end of treatment, although in some cases the ratio of the odds ratios RoR from direct and indirect evidence was large i.
We found only 1 inconsistent loop for abstinence measured at 12 weeks and no other inconsistent loops for the other outcomes considered at 12 weeks S7 Table ; S7 Fig. The test of incoherence from the side-splitting model did not show significant differences for abstinence at the end of treatment but found some differences between some comparisons for dropout at the end of treatment S8 Table.
The comparison-adjusted funnel plots of the network meta-analysis for abstinence and dropout at the end of treatment were not suggestive for significant publication bias S8 Fig.
We also performed subgroup analyses for abstinence and dropout at the end of treatment to study the effect of several potential moderator variables, the findings of which did not substantially differ from those of the primary analysis for most of the comparisons S10 Table. Predictivity intervals of mixed estimates are presented in S11 Table , while the overall limitations per comparison are presented in S12 and S13 Figs.
We found that 4 patients needed to be treated with CM plus community reinforcement approach to have 1 additional patient abstinent at the end of treatment compared toTAU NNT 4. Similarly, 3 patients needed to be treated with CM plus community reinforcement approach to have 1 fewer patient dropping out at the end of treatment compared to TAU NNT 3. For dropout at the end of treatment, the NNT ranged from 4. This network meta-analysis is based on 50 studies including 6, individuals randomly assigned to 12 different psychosocial interventions or TAU.
We found that CM alone or in combination with either community reinforcement approach or CBT had superior efficacy and acceptability compared to TAU at 12 weeks and at the end of treatment. This effect was not significantly influenced by clinical modifiers in the subgroup analyses and remained significant in the sensitivity analyses.
Moreover, CM in combination with community reinforcement approach and community reinforcement approach alone were more effective than TAU at the longest follow-up after treatment completion. Self-help groups following the step programme are also recommended [ 8 ].
Galanter M. Conclusion Peer support groups included in addiction treatment shows much promise; however, the limited data relevant to this topic diminish the ability to draw definitive conclusions. Dopaminergic neurons are inhibited, probably through the dorsal medial thalamus habenula , when expected rewards do not occur. To fully appreciate the recent arrival of the Biopsychosocial model, however, an examination of its parts is necessary. Including three studies previously mentioned, a total of articles were screened for eligibility. Recent work by Eslinger and colleuges has identified certain brain regions the amygdala, thalamus, and upper midbrain that were consistently activated by emotional stimulus with and without moral content.
Wallace donovan model of addiction. Table of contents
Embeds 0 No embeds. No notes for slide. Introduction to the BioPsychoSocial approach to Addiction 1. Be aware that there is no unified theory of addition, but that an integrated approach can help explain onset and maintenance of addictive behaviour. There are many different drugs that can be abused — legal and illegal. Never the less drug misuse remains a persistent issue worldwide 4.
All theories of addiction attempt to explain the processes that underpin the onset and maintenance of drug taking behaviors. DSM-IV definition 7. Addiction can be seen as a disease of the brain.
This approach suggest that the neural pathways of executive function become distorted and motivational processes become amplified as a consequence of the interaction between behaviours and their effects in the brain. That behavior is the ingestion of certain drugs. Robert West, What is addiction? Expert opinion 8. There are many chemical messengers in the brain, and of these Dopamine is the one most associated with addiction. All drugs of abuse increase dopamine in the brain systems associated with addiction.
Dopamine is the key to reward, acting as a precursor to the actual stimulus provided by the substance itself. Dopamine 9. The brain repeats pleasurable experiences and avoids pain, but automatic brain mechanisms do not think behaviour through to its conclusion, and do not learn from delayed negative outcomes. The brain is like a reckless infant, wanting what it wants right now.
Behaviour that produces right not pleasure is repeated, regardless of the long-term consequences. DuPont — The Selfish Brian, A neat description the brains specific areas of function with relation to addiction note the work was based on impulse control disorders, but has a clear analogue to addictions per se.
Additional structures that are important in this process include the hippocampus, which provides contextual memory relevant to motivational stimuli, and the hypothalamic and septal nuclei, which provide information relevant to primitive motivational behaviours such as sexual drives and nutrient ingestion. The nucleus accumbens NAcc also plays an important role.
The NAcc shell is proposed as important in modulating incentive salience, while the core is involved with the expression of learned behaviours in response to stimuli that predict motivationally relevant events experienced as pleasurable. Dopaminergic neurons are inhibited, probably through the dorsal medial thalamus habenula , when expected rewards do not occur.
Dopamine rewards logical and illogical expectations. What is the evidence? There is limited activation of the ventral striatum reward response in the addicted brain. The controls display much higher levels of activity — the differences are due to sensitisation This is particularly problematic in the case of heroin users released from long term prison sentences — most overdose deaths occur in the week following release What is the evidence?
Taken orally, it does not rapidly increase opioid- receptor activity, but does maintain enough activity to avoid withdrawal. Naltrexone is an opioid antagonist. It prevents heroin from binding to the receptor, but does not activate the receptor. Naloxone Narcan also works in this way, and can be used to address overdose by replacing the heroin. Fighting fire with fire — Pharmaceutical solutions to pharmaceutical problems What is the evidence? Has work on the biological basis for addiction contributed towards the development of effective interventions?
The utilisation of antagonists to reduce cravings and reverse overdose are good examples of this. We are more than our biology Although it is important to understand the brain mechanisms that underpin the onset and maintenance of additive behaviours, it is necessary to place these systems in the context of the individual and their surroundings.
Genetics and individual differences in brain architecture do not adequately explain why particular individuals initiate drug taking, develop addictions and then may or may not respond to a variety of interventions. Several psychological traits have been associated with addiction — impulsivity, depression, anxiety, reward sensitivity and learning capacity. Such characteristics are the product of biology, personality and circumstance. What are the risk factors for addiction?
Nature and Nurture Are some people born to be addicts? Do our thoughts control our behaviour or does our behaviour change the way we think? Could a combination of both heredity and environment make people the way they are? All of these questions are addressed by the various modalities of addiction theory.
The following slides provide a rapid summary of how different theoretical perspectives influence the understanding of, and treatment for, addiction. Moral Theory One of the earliest models of addiction. The moral theory denotes substance misuse as a vice or a sin. The theory implies that some individuals, through their own free will, make a conscious choice to become substance misusers. The Moral Brain.. Recent work by Eslinger and colleuges has identified certain brain regions the amygdala, thalamus, and upper midbrain that were consistently activated by emotional stimulus with and without moral content.
But some areas, including the orbital prefrontal cortex OFC , located just above the eye sockets, and the superior temporal sulcus, at the furrow between the frontal and temporal lobes, fired specifically in response to moral content alone. Learning Theory This theory contends that substance misuse is learned through the complex processes of behavioural acquisition and reinforcement. Many learning theories have evolved from simple classical and operant conditioning theories through to more complicated social learning theories that emphasize the interactions between personal dispositions and environmental situations.
We will briefly examine classical and operant conditioning. Classical Conditioning Pavlov Social Theory This theory hypothesizes that substance misuse develops and endures as a result of disruptive social forces such as unemployment, poverty, violence, family dysfunction, as well as gender and age inequities.
These forces are believed to act as social stressors and substance misuse is considered to be an adaptation to the resultant misery and unhappiness. Cognitive factors or processes such as anticipation, planning, expectancies, attributions, self-efficacy and decision-making were all shown to play a part in learning. Cognitive—behavioural therapy CBT is a product of social learning theory. Similar patterns of brain changes have been seen with CBT and with drug treatments, suggesting that psychotherapies and medications might work on the brain in parallel ways.
Behavioral and biological measures were conducted in addition to fidelity measures. Feasibility and acceptance data in the domains of patient interest, safety, and satisfaction were promising. In addition, mentees significantly reduced their alcohol and drug use from baseline to termination and the majority of mentors sustained abstinence. Fidelity measures indicated that mentors adhered to the delivery of treatment. Reported treatment effects occurred in reduction in the number of drinks per day period and number of days drank heavily per day period.
Beyond associated reductions in alcohol and drug use, services that have included peer support groups have been utilized to engage substance-using populations in treatment.
Often high recidivism substance-using patients have difficulty connecting to outpatient treatment, contributing to greater functioning disturbances. The primary outcome was post-discharge treatment attendance. MAP-engage that included peer support groups offered an alternative approach to address lack of attendance to outpatient treatment appointments post discharge that is relatively low in staff reliance.
Individuals who completed the program were significantly more likely to have received recovery support groups. Intervention for Seropositive Injectors—Research and Evaluation study, an RCT of a peer support intervention designed to assess the reduction in sexual and injecting-related risk behaviors, increased use of HIV care, and increased HIV medication adherence as primary outcomes, was discussed by Purcell et al.
The control condition was eight sessions of a video intervention. One out of the ten sessions was a peer volunteer activity during which participants went to a local service organization for 2—4 hours to observe, participate, and practice peer support skills. The topics from the group sessions included setting group rules and the power of peer mentoring, utilization of HIV primary care and adherence, and sex and drug risk behaviors.
Of the participants randomized, were assigned to the peer support condition and were assigned to the video discussion condition, totaling a sample of HIV injection drug users IDUs. Significant reductions were noted in both groups for reductions from baseline in injection and sexual transmission risk behaviors, but there were no significant differences between conditions. Participants in both conditions reported no change in medical care and adherence. Each intervention consisted of six sessions, 2 hours each twice a week.
For the peer-mentoring group intervention, participants received information regarding HCV and learned risk reduction skills. By the fifth session, training participants were involved in outreach and delivered information about reducing HCV transmission risk.
The control group watched a docudrama TV series about IDUs and participated in a facilitated group discussion focusing on family, education, self-respect, relationships, violence, parenting, and employment. Compared to the control group, participants in the peer support condition had significantly greater reductions in injection practices that could transmit HCV to other IDUs. Self-efficacy was significantly increased in the experimental condition, and post-intervention self-efficacy was a positive mediator between the intervention and distributive risk behaviors.
In the study previously discussed in the substance use section, Velasquez et al 71 also found a reduction in the number of days on which both heavy drinking and unprotected sex occurred among HIV-positive men who have sex with men. Craving has been associated with use of substances. One of the main objectives of this study was to assess program feasibility using a community-based participatory research approach.
Participants were 20 men on parole who were released from prison within the past 30 days, with only 13 completing the day peer mentor intervention. Marlow et al 78 measured step meeting participation using a item questionnaire that assessed participation in step programs, belief in the step framework, and investigated relationships with craving and negative affect. Questions assessing belief in step framework included: I am powerless over my drug and alcohol problem, I believe a higher power plays a role in my recovery, I am not alone with my drug and alcohol problem, I believe in the step faith and spirituality, and I am member of step.
Twelve-step meetings were attended by participants on an average of 17 days out of 30 days and participants contacted their sponsor on average ten times.
Pre- and posttest results on two abstinence subscales, negative affect and habitual craving, showed significant improvement, indicating an improved confidence level in the ability to abstain from substance use. Andreas et al 69 sought to examine Peers Reach Out Supporting Peers to Embrace Recovery PROSPER , a peer-driven recovery community that provides a number of peer-driven supports for members to be able to recover from drug use and criminality as they transition back into the community and to provide support to their family members and loved ones.
PROSPER provided a strategic mix of services, all planned, implemented, and delivered by peers including peer-run groups and group activities that take place in a light-hearted social environment away from traditional treatment settings. The result of this study suggests the importance of peer support among people who are reentering the community, which can promote positive outcomes such as reduced substance use and recidivism. Despite the recent surge in the adoption of peer support services within addiction treatment systems, there are relatively limited data rigorously evaluating outcomes.
Thus, we included studies of peer support groups that were delivered often in an array of other peer support treatments, which diminished our ability to disentangle the results. However, this review still provides a useful platform to begin to explore the inclusion of these peer support groups as a component of other peer services and associated benefits thus far to guide the field in the future researching of this area.
Although methodological limitations existed in studies that resulted from previous existing systematic reviews of peer support services, beneficial effects were noted. The previous reviews examined a range of peer support services. Drug abuse is inextricably linked with HIV due to heightened risk both of contracting HIV and of worsening its consequences, and HCV is one of the most common viral hepatitis infections transmitted through drug-using high-risk behaviors, making reduction of risk behaviors one of the priorities in substance abuse treatment at the National Institute on Drug Abuse.
Those who participated in treatments, including peer support groups, showed higher rates of abstinence than common in substance-abusing populations while also being more satisfied with the treatment. Beyond substance use, peer support groups offer unique advantages to engaging our historically difficult-to-engage populations.
Services that included peer support groups were found to be equally comparable to the additive of extensive DRT, and both were significantly better than standard treatment at increasing adherence to post-discharge substance abuse and medical and mental health outpatient appointments for high recidivism individuals with substance use disorders.
One study demonstrated a reduction in injection and sexually transmitted risk behaviors in both conditions, but there was no significant difference between the peer condition and the control condition, which was also an intervention. Thus, providing implications that these components ie, skill building and education of peer mentoring provided to HCV-injecting drug users can lead to safer practices of injection drug use and may contribute to reducing the risk in IDUs and the transmission of HCV to other IDUs.
Another study demonstrated significant reductions not only in risk behaviors but also in heavy drinking while accomplishing this. There were conflicting results from studies on whether or not quality-of-life improvements were associated with peer support groups being included in services. However, even given their widespread use, there are relatively limited empirical data relevant to this topic, which may diminish the ability to draw definitive conclusions, with resulting studies being ten.
Although this is similar in number to other reviews in related peer support topics, it is relatively low. We included only US studies due to not having access to other non-English search engines in addition to ruling out language barriers, but this also limits the data. Finally, some investigators note that self-selection into peer support groups and residential recovery homes is important in the process in treatment, 33 , 81 which then may confound outcomes and limit generalizability in RCTs for those select participants who may be solely interested in gains outside of participation such as participant payment.
More rigorous research is needed, including meta-analytic studies as more data surface in this area, to substantiate the results of the studies included in this review and further expand on this important line of research. National Center for Biotechnology Information , U. Journal List Subst Abuse Rehabil v. Subst Abuse Rehabil. Published online Sep Kathlene Tracy 1, 2 and Samantha P Wallace 3. Author information Copyright and License information Disclaimer.
This work is published and licensed by Dove Medical Press Limited. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.
This article has been cited by other articles in PMC. Conclusion Peer support groups included in addiction treatment shows much promise; however, the limited data relevant to this topic diminish the ability to draw definitive conclusions.
Keywords: behavioral treatment, mentorship, substance use, alcohol, drugs, recovery. Open in a separate window. Residential and sober living Since the s, a variety of residential options have emerged to help people with alcohol and drug addictions. Treatment and community settings Recently, there has been a dramatic rise in the adoption of alternative forms of peer support services within treatment and community settings to assist recovery from substance use disorders, because of the potential benefits offered to patients.
Existing systematic peer support reviews Bassuk et al 65 conducted a systematic review of the evidence on the effectiveness of peer support services for people in recovery from alcohol and drug addiction, which resulted in nine studies meeting the criteria for inclusion in the review.
Methods To effectively complete the review, the authors used a combination of searches on electronic scientific databases and screening results cross-checking the eligibility criteria to reduce the number of studies included in this article. Figure 1. Study identification and screening: Phase II The following keywords were used to identify all articles associated with several domains: substance use disorders, peer support or peer mentorship, and intervention.
Final selection Of the 16 records, ten articles were selected to be included in the article. Table 2 Included studies utilizing peer support groups. Engagement to treatment Beyond associated reductions in alcohol and drug use, services that have included peer support groups have been utilized to engage substance-using populations in treatment.
Secondary substance-related outcomes Craving has been associated with use of substances. Discussion Despite the recent surge in the adoption of peer support services within addiction treatment systems, there are relatively limited data rigorously evaluating outcomes. Footnotes Disclosure The authors report no conflicts of interest in this work. References 1. Azrin NH. Improvements in the community-reinforcement approach to alcoholism. Behav Res Ther.
Alcoholism treatment by disulfiram and community reinforcement therapy. J Behav Ther Exp Psychiatry. Cambridge: Cambridge University Press; A reinforcement-based therapeutic workplace for the treatment of drug abuse: six-month abstinence outcomes.
Exp Clin Psychopharmacol. Contingent reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow-up. J Consult Clin Psychol. The community-reinforcement approach. Alcohol Res Health. Effect of methadone dose contingencies on urinalysis test results of polydrug-abusing methadone-maintenance patients.
Drug Alcohol Depend. The community reinforcement approach with homeless alcohol-dependent individuals. A randomized trial of two methods for engaging treatment-refusing drug users through concerned significant others.
Engaging the unmotivated in treatment for alcohol problems: a comparison of three strategies for intervention through family members. J Subst Abuse. Measuring Peer Interaction in the Therapeutic Community. Homelessness and mental illness in a professional- and peer-led cocaine treatment clinic.
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Am J Drug Alcohol Abuse. The community reinforcement approach to the treatment of substance use disorders. Am J Addict. New York City: Guilford Press; A community-reinforcement approach to alcoholism. Peer Support in Mental Health and Addictions. A Background Paper. Wellington: Kites Trust; White WL. Peer-Based Addiction Recovery Support.
History, Theory, Practice, and Scientific Evaluation. Alcohol Alcohol. Bloomington: Author House; An historical and developmental analysis of social model programs. J Subst Abuse Treat.
Riessman F. Soc Work. Polcin DL, Borkman T. Recent Developments in Alcoholism. New York: Springer; Berkeley CA: University of California; Wright A. In: Shaw S, Borkman T, editors. What did we learn from our study on sober living houses and where do we go from here? J Psychoactive Drugs. The need for substance abuse aftercare: longitudinal analysis of Oxford House.
Addict Behav. Communal housing settings enhance substance abuse recovery. Am J Public Health. Humphreys K. Do enhanced friendship networks and active coping mediate the effect of self-help groups on substance abuse? Ann Behav Med. Predictors of participation in aftercare sessions and self-help groups following completion of intensive outpatient treatment for substance abuse.
J Stud Alcohol. Influence of outpatient treatment and step group involvement on one-year substance abuse treatment outcomes. Alcoholics Anonymous involvement and positive alcohol-related outcomes: cause, consequence, or just a correlate? A prospective 2-year study of 2, alcohol-dependent men. Psychiatric comorbidity, continuing care and mutual help as predictors of five-year remission from substance use disorders. Protective resources and long-term recovery from alcohol use disorders.
Alcoholics anonymous: what is currently known? Research on Alcoholics Anonymous: Opportunities and Alternatives. Ogborne AC. Assessing the effectiveness of alcoholics anonymous in the community: meeting the challenges. Trends in the treatment of alcohol problems in the US general population, through Affiliation with Alcoholics Anonymous after treatment: a study of its therapeutic effects and mechanisms of action.
Witbrodt J, Kaskutas LA. Does diagnosis matter? Differential effects of step participation and social networks on abstinence. Kaskutas LA. Alcoholics Anonymous effectiveness: faith meets science. J Addict Dis. Atheists, agnostics and Alcoholics Anonymous.
What causes addiction? Is it a disease? Is it a product of our environment? Is it a symptom of an underlying problem? No one theory has adequately explained the nature of addiction so, as a result, a number of treatment models have been created, each with different approaches.
As an addiction progresses, its impact extends to all aspects of functioning including health, relationships, career, and lifestyle. Treatment and prevention efforts have responded to this complexity by oversimplifying the origin and solution of addiction, and arguing with those who forward a competing theory. Historically, the disease model has been championed by physicians while learning theory and psychoanalysis supporters include psychologists: two groups of professionals not known for collaboration.
However, the good news is that collaboration in the field of addiction is on a general upswing. Evidence of this fresh approach to treatment is best exemplified by the rise of the Biopsychosocial model which attempts to unify competing addiction theories into an integrated conceptual framework.
The Biopsychosocial model recognizes that there are multiple pathways to addiction and that the significance of these individual pathways depends on the individual. Furthermore, the Biopsychosocial model was one of the first models to recognize the importance of treating the whole person, not just the addiction.
To fully appreciate the recent arrival of the Biopsychosocial model, however, an examination of its parts is necessary. These parts are discussed in the sections that follow. Margolis, Joan E. Typically, addiction treatment providers, regardless of the setting residential, outpatient, etc. The most common models are as follows:.
The disease model has been the dominant model of treatment in the United States since the s. In its purest form, the disease model contends that certain individuals have a distinct physical or psychological condition that renders them incapable of drinking or using drugs in moderation. In most treatment centers, the disease model has been blended with other models.
This has led to much confusion, even among clinicians and people in recovery. Another model with which the disease model has often been associated with, to its own detriment, is the moral model. The moral model emphasizes personal choice as the main reason why individuals become addicts.
Use of the moral model in treatment appears when clients fail to observe house rules or are struggling with coming to terms with their addiction.
Treatment centers that have failed to identify and weed out the practice of passing moral judgment of clients tend to kick clients out or treat clients as second-class citizens. A third model that the disease model is also confused with is a more recent arrival, the biological model. The biological model is the result of recent advances in genetic research, pharmacology and neuroscience.
This has led supporters of the biological model to suggest that addiction is, to varying degrees depending on the individual, a hereditary brain disorder that can be treated with medication. However, it is important to note that the disease model was established well before science was capable of brain scanning and DNA mapping.
One final model that is often confused with the disease model is the characterological model which asserts that there is an addictive personality and that addiction is a personality disorder. Individuals who manifest this personality defect show heightened character defense mechanisms such as denial. Journal of Studies on Alcohol , 55, The learning theory model focuses not so much on the internal workings of addiction such as physiology but, rather, on the thoughts cognitions and actions behaviors of individuals with addictions.
The learning theory model includes a behavioral modalities, b cognitive modalities, and c cognitive-behavioral modalities, which is an integration of behavioral and cognitive modalities.
However, recent developments in psychodynamic therapy have addressed these concerns and have developed several modalities that are now making vital contributions to the treatment of addictions. Zweben, pg. Zinberg Eds. George Vaillant.
Family theory also asserts that families, as a whole, tend to resist change which, in turn, can affect the progress of the individual. In contrast to the traditional theories, a model called the Biopsychosocial BPS model has been developed to explain the complex interaction between the biological, psychological, and social aspects of addiction.
Many clinicians and treatment providers particularly those in traditional addiction treatment use the same term to include a fourth factor, spirituality.
This information, Donovan hypothesized, would improve diagnosis and treatment. In their book, Theories on Alcoholism 5 , editors Chaudron and Wilkinson incorporated eleven theories on alcoholism into three sections based on the Biopsychosocial model:. However, these competing theories are rarely integrated into a therapeutic program. Currently, the Biopsychosocial model in addiction remains limited in its application to assessment and treatment planning.
Technical Assistance Publication Series Chapter 3. Assessment of Addictive Behaviors. D M Dononvan. J Wallace. Douglas Chaudron, D. Typically, addiction treatment providers develop their programs or approaches based on one of the addiction models detailed above. This approach of exclusively following techniques suggested by one particular addiction model, however, may not be in the best interest of the client since each client may benefit from techniques offered by other treatment models.
The Dynamics and Treatment of Alcoholism: Essential Papers is a collection of papers that traces our understanding of alcoholism. Papers were chosen based on their insight, readability, historical relevance, and clinical utility. Psychological Theories of Drinking and Alcoholism reviews established and emerging approaches that guide research into the psychological processes influences drinking and alcoholism. Kenneth E. Leonard, Howard T. Theory of Addiction presents a digest of major existing theories in one volume and develops a new synthetic theory of addiction, recognizing the diversity of the experience of addiction.
Robert West, Ainsley Hardy. Theories on Alcoholism C. Full text version available here. Treating Substance Abuse: Theory and Technique introduce the six most prominent psychosocial treatment approaches.
For each approach, includes basic theories and clinical strategies. Addiction Treatment: A Strengths Perspective covers the biological, psychological, and social aspects of alcoholism and other addictions.
Also discusses different emotions such as anger, loneliness, etc. John J. Edith Lisansky Gomberg. Jared C. Addiction is a Choice offers new approaches to understanding addiction and explains why current policies are ineffective by allowing people to feel blameless for the consequences of their choices.
Jeffrey A. Coming Clean: Overcoming Addiction Without Treatment examines stories of untreated addicts who have recovered from a lifestyle of substance abuse without professional help. A critical analysis of the disease model of addiction treatment.
Robert Granfield, William Cloud. Fighting Firewater Fictions: Moving Beyond the Disease Model of Alcoholism in First Nations is essential reading for anybody working in, or seeking to understand, aboriginal communities that are experiencing problems with alcoholism. Richard W. Heavy Drinking: The Myth of Alcoholism as a Disease argues that social and political responses to alcohol problems are neglected and research programs misdirected, because the disease model prevails so strongly.
A highly referenced text for opponents of the disease model. Herbert Fingarette. Contains interviews with people who have managed to stay sober. Anne M. William L. John Booth Davies.
Lance M. The Biopsychosocial Model: Application to the Addictions Field reviews the Biopsychosocial model and its historical roots in theory, specific applications to addictions, guiding principles, and research and clinical advantages. Evolution of the Biopsychosocial Model: Prospects and Challenges for Health Psychology identifies four areas that need to be addressed to ensure the continued evolution of the Biopsychosocial model.
Jerry Suls, Alex Rothman. Health Psychology, Vol. Addiction Disease Concept: Advocates and Critics February explores the typical argument between critics and advocates of the disease concept of addiction. White, Counselor Magazine. A Disease Concept for the 21st Century April considers the concept of the disease model and some proposals for an improved disease model.
Alcoholics Anonymous and the Disease Concept of Alcoholism suggests that the disease concept did not originate with Alcoholics Anonymous yet its members did have a large role in spreading and popularizing that understanding. Addiction as a Disease: Birth of a Concept explores the ways in which disease concepts of addiction emerged and co-existed alongside more popular perceptions of chronic intemperance. Also examined is the major role the concept played in 19th century addiction treatment.
The Rebirth of the Disease Concept of Alcoholism in the 20th Century traces the addiction-disease concept through the 20th century, depicting its hibernation, re-emergence, and commercialization. Addiction Disease Concept: Advocates and Critics February explores the typical arguments between critics and advocates of the disease concept of addiction.
Khantzian, Psychiatric Times, Vol. XVI, Issue 7. Spiritual Evocation June focuses on the integration of spiritual direction with the counseling style of motivational interviewing, which was designed specifically for working through ambivalence.