1 Moving beyond ‘brain disease’ and ‘bad choice’ models of addiction University College London September 2012 Robert West

Aims To propose a more comprehensive model of behaviour than hitherto that can provide a basis for development and application of improved intervention strategies to combat addiction 2 West R. Models of Addiction. EMCDDA Insight Report

Outline 1.Defining addiction 2.An overview of models of addiction 3.A more comprehensive approach 3

The purpose of definitions To include cases that should be included and exclude those that should not: i.e. to set the boundaries of a concept To provide as concise a description of a concept as is necessary to help identify cases 4

Addiction as a brain disease Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in the individual pursuing reward and/or relief by substance use and other behaviours. The addiction is characterized by impairment in behavioural control, craving, inability to consistently abstain, and diminished recognition of significant problems with one’s behaviours and interpersonal relationships. Like other chronic diseases, addiction can involve cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. (American Society of Addiction Medicine) This considers addiction as a brain disease which implies that it requires treatment. It neglects environmental and social forces at play, the fact that it involves a continuum and that many individuals ‘recover’ without treatment. 5

Addiction as compulsive behaviour Addiction is a compulsive, uncontrollable dependence on a chemical substance, habit, or practice to such a degree that either the means of obtaining or ceasing use may cause severe emotional, mental, or physiologic reactions (Mosby’s Medical Dictionary 8 th ed) The use of the term ‘uncontrollable’ rules out cases where an individual is struggling successfully (for the time being at least) to control the behaviour 6

Addiction as choice Addiction involves strong preferences to engage in activities that have significant potential for harm because of the immediate pleasure, satisfaction or relief that they provide (e.g. Heyman) The focus on choice fails to take account of impulsive and compulsive nature of much addiction 7

Addiction as a context-sensitive disorder of motivation Addiction involves repeated powerful motivation to engage in a purposeful behaviour that has no survival value, acquired as a result of engaging in that behaviour, with significant potential for unintended harm. Brings in motivation, purpose, acquisition through engagement, and harm; makes no unnecessary assumptions 8

Seven things about addiction that need explaining 1.Most people who are exposed to the addictive substance/behaviour do not become addicted, but low impulse control and/or mood disturbance can increase vulnerability, as can adverse life circumstances 2.Even determined attempts to cease addictive behaviours have a low probability of success, but unaided recovery does occur 3.When ‘addicts’ attempt recovery, momentary risk of relapse is greatest in the first few days or weeks 4.Prevalence of a given addictive behaviour in populations is influenced by price and availability 5.Social norms substantially influence the chances of becoming addicted and recovery from addiction 6.Drugs that seek to reduce addictive urges can increase the chances of recovery but often do not 7.Behavioural interventions that seek to address addictive motivation and/or self-regulatory skills and capacity can increase the chances of recovery but often do not 9

Taxonomy of models of addiction 10

Automatic process theories 11

Reflective choice theories 12

Goal focused theories 13

Integrative theories 14

Process of change and biological theories 15

Population and group-level theories 16

A synthetic model (COM-B+PRIME) Aims to provide a more comprehensive model of behaviour within which existing models can be understood and compared a basis for improving existing models a rational basis for the design of interventions to change behaviour 17

The COM-B model of behaviour 18 Michie et al (2011) Implementation Science

The COM-B model of behaviour 19 Michie et al (2011) Implementation Science Physical and psychological capability: knowledge, skill, strength, stamina

The COM-B model of behaviour 20 Michie et al (2011) Implementation Science Reflective and automatic motivation: plans, evaluations, desires and impulses

The COM-B model of behaviour 21 Michie et al (2011) Implementation Science Physical and social opportunity: availability, prompts, reminders and cues

PRIME Theory and the structure of human motivation 22

The rider and the donkey model of behaviour 23

PRIME Theory and Dual Process Theories 24 Reflective Impulsive Action Reflective Impulsive Action Affective

25 PRIME Theory: 1 st law of motivation At every moment we act in pursuit of our strongest motives (wants or needs) at that moment –Want: anticipated pleasure or satisfaction –Need: anticipated relief from, or avoidance of, mental or physical discomfort

26 PRIME Theory: 2 nd law of motivation Evaluations (beliefs about what is good and bad) and plans (self-conscious intentions to do or not do things) can only control our actions if they create motives at the appropriate moments that are stronger than competing motives coming from other sources

27 PRIME Theory: 3 rd law of motivation Self-control (acting in accordance with plans despite opposing motives) requires mental energy and depletes reserves of that energy

28 PRIME Theory: 4 th law of motivation Our identities (thoughts, images and feelings and feelings about ourselves) can be a powerful source of motives –Labels: the categories we think we belong to –Attributes: the features we ascribe to ourselves –Personal rules: imperatives about what we do and do not do

29 PRIME Theory: 5 th law of motivation Motives influence actions by creating impulses and inhibitions, which are also generated by habitual (learned) and instinctive (unlearned) associations; behaviour is controlled by the strongest momentary impulses and inhibitions

30 The battle over time between resolve and urge/impulse Urge/impulse Time When the urge is stronger than resolve and the behaviour is available, a lapse will occur Resolve Strength of urge

31 Stage of change model versus the SNAP model Move people to the next stage with ‘stage-matched’ interventions’ Create motivational tension and triggers to ‘snap’ people into action and then support to prevent them snapping back People move through ‘stages’ on the way to achieving lasting change ‘Personal rules’ govern behaviour, and transitions between these rules occur as a result of ‘tension and triggers’

32 Sources of urges/impulses Urge/ impulse Positive beliefs Triggers Want or need Acquired drive’ Reminders

33 Sources of resolve Resolve to abstain Want or need to abstain Personal abstinence rule Ability to inhibit impulses Reminders Beliefs and feelings about the behaviour and abstinence

Implications for measurement Important to separate out: –prevalence of the behaviour precisely defined to match the nature of the problem –intensity of addiction through frequency and strength of the experience of motivation (means and SDs) –severity of addiction in terms of immediate harms Develop composite measures involving multiple behaviours/substances Measure motivation to change in terms of: –duty, desire and intention Use COM-B+PRIME for a comprehensive assessment of the precise nature of the problem for individuals, groups or populations 34

Implications for intervention strategies Broadens focus beyond just the individual or just the environment Forces consideration of reflective, emotive and impulsive mechanisms Provides a perspective that reveals the inappropriateness of debates about disease versus choice models Provides a systematic system for designing intervention strategies for behaviour change 35

36 Behaviour Change Wheel Michie S, M van Stratten, West R (2011) The Behaviour Change Wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6, 42. EducationIncreasing knowledge or understanding PersuasionUsing communication to induce positive or negative feelings or stimulate action IncentivisationCreating expectation of reward CoercionCreating expectation of punishment or cost TrainingImparting skills RestrictionUsing rules that limit engagement in the target behaviour or competing or supporting behaviour Environmental restructuring Changing the physical or social context ModellingProviding an example for people to aspire to or imitate EnablementIncreasing means/reducing barriers to increase capability or opportunity Comms/marketingUsing print, electronic, telephonic or broadcast media GuidelinesCreating documents that recommend or mandate practice. This includes all changes to service provision FiscalUsing the tax system to reduce or increase the financial cost RegulationEstablishing rules or principles of behaviour or practice LegislationMaking or changing laws Env/Soc PlanningDesigning and/or controlling the physical or social environment Service provisionDelivering a service

The example of comprehensive tobacco control Educate the population about the harms of smoking, the benefits of stopping and best ways to stop Use hard hitting campaigns and health professional advice to persuade smokers to try to stop and use the most effective ways of doing this Where appropriate incentivise quitting Use tax and social norms to reduce the attractiveness of smoking Reduce ubiquity of smoking triggers and reminders Use modelling in social marketing strategies Provide behavioural and pharmacological support for quitting 37

Conclusions A broad perspective on addiction is needed to mount effective countermeasures The synthetic model (COM-B+PRIME) is an attempt to integrate existing models into a single coherent framework When linked with the Behaviour Change Wheel it provides a basis for designing an intervention strategy that can be effective However practicability, affordability and acceptability are also key factors that need to be considered 38