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

2. 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

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

4. 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

5. 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.

6. 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

7. 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

8. 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

9. 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

10. Taxonomy of models of addiction

11. Automatic process theories

12. Reflective choice theories

13. Goal focused theories

14. Integrative theories

15. Process of change and biological theories

16. Population and group-level theories

17. 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

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

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

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

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

22. PRIME Theory and the structure of human motivation

23. The rider and the donkey model of behaviour

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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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’

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

33. 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

34. 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

35. 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

36. 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.

37. 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

38. 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