Addiction: bad choices, brain disease and bad environment Robert West University College London July 2013

West R. Models of Addiction. Aims To describe a more comprehensive model of behaviour for development of improved strategies to combat addiction West R. Models of Addiction. EMCDDA Insight Report, 2013

Outline Defining addiction An overview of models of addiction A more comprehensive approach

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

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.

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 8th 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  

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

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

Seven things about addiction that need explaining 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 Even determined attempts to cease addictive behaviours have a low probability of success, but unaided recovery does occur When ‘addicts’ attempt recovery, momentary risk of relapse is greatest in the first few days or weeks Prevalence of a given addictive behaviour in populations is influenced by price and availability Social norms substantially influence the chances of becoming addicted and recovery from addiction Drugs that seek to reduce addictive urges can increase the chances of recovery but often do not 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

Taxonomy of models of addiction

Automatic process theories

Reflective choice theories

Goal focused theories

Integrative theories

Process of change and biological theories

Population and group-level theories

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

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

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

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

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

PRIME Theory and the structure of human motivation

The rider and the donkey model of behaviour

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

PRIME Theory: 1st 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

PRIME Theory: 2nd 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

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

PRIME Theory: 4th 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

PRIME Theory: 5th 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

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

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

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

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

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

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

Behaviour Change Wheel Education Increasing knowledge or understanding Persuasion Using communication to induce positive or negative feelings or stimulate action Incentivisation Creating expectation of reward Coercion Creating expectation of punishment or cost Training Imparting skills Restriction Using rules that limit engagement in the target behaviour or competing or supporting behaviour Environmental restructuring Changing the physical or social context Modelling Providing an example for people to aspire to or imitate Enablement Increasing means/reducing barriers to increase capability or opportunity Comms/marketing Using print, electronic, telephonic or broadcast media Guidelines Creating documents that recommend or mandate practice. This includes all changes to service provision Fiscal Using the tax system to reduce or increase the financial cost Regulation Establishing rules or principles of behaviour or practice Legislation Making or changing laws Env/Soc Planning Designing and/or controlling the physical or social environment Service provision Delivering a service 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.

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

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