Challenging Dogma - Fall 2009

Wednesday, December 16, 2009

Drug Addiction and the Transtheoretical Model - Sheela Nimishakavi

By far one of the most biologically irrational aspects of human behavior, drug addiction has debilitated the lives of many people. While the fundamental mechanisms of addiction are well understood, an effective program to stop addiction has yet to be determined. The complex processes underlying drug addiction treatment have typically been broken down into stages using the transtheoretical model (TTM). The TTM defines five stages through which individuals progress, beginning with pre-contemplation and culminating in termination of the addictive behavior.
During pre-contemplation, the addicted individual has no interest in changing their behavior. At some point, a sense of concern toward their addictive behavior can tip them into the contemplation phase during which the individual thinks about drug cessation. This phase is characterized by a conscious weighing of risks against benefits. For example, weighing the adverse effects of withdrawal symptoms against the benefits of a healthier lifestyle. When this balance gets tipped towards a decision to quit, the individual enters the preparation stage, which involves planning for cessation. Preparation is followed by action, or implementing those plans created in the previous stage. Once this action has been engrained into the individual’s normal behavior, they are said to have entered the maintenance stage. Maintenance, then, is the final stage in the transition from addiction to recovery, ultimately leading to the end of this progression (DiClemente, 2004).
Since its inception, the TTM has formed the basis for drug addiction intervention programs, often praised for its rational representation of human motivation and intention leading to action and ultimately termination of the addictive behavior. The initial focus on motivation takes into account all of the individual’s personal reasons wanting to change their addictive behavior. When these personal factors result in an enhanced motivation, the intention to change eventually becomes action. Furthermore, although the model does not allow for an individual to skip stages in the progression, it does account for relapses and reverting to previous stages. In fact, it is fairly common for drug users to relapse several times before successfully terminating the addictive behavior (DiClemente 109). It is important to note, however, that once an individual crosses the contemplation stage, they can never revert back to the pre-contemplation stage.
With an understanding of the individual’s motivational factors and intention to change, stage-specific intervention programs could then be created. For instance, DiClemente et al. discusses how targeted self-help information can be given to smokers to aid cessation (108). Taking into account an individual’s specific stage different information should be helpful, theoretically, to lead to the next stage in the progression (108). Take, for example, an individual in the contemplation stage. Information on the advantages of cessation could tip the balance between risks and benefits and thus encourage the individual to enter the preparation stage. Moreover, group level interventions have also been created out of the TTM. After a clinical evaluation to determine the individuals’ stages, those in the same stage are grouped together and participate in stage-specific activities together (113).
For all of its advantages, the TTM does have serious flaws that ultimately undermine its use as a drug addiction intervention model. Among these, three stand out as integral to the model’s failure to accurately describe and address the needs of the recovering drug addict. Critics of the TTM assert that the distinctions between the stages are based on arbitrary values. In addition, the model does not take into account social aspects of drug abuse, which researchers contend plays a large role in drug addiction. Lastly, some say stages should not be used at all in forming interventions but rather context.
Arbitrary Stages
Progression from one stage to the next in the TTM differs across behaviors, but all involve a set number of days. For example, in the case of smoking cessation, the pre-contemplation phase occurs when a smoker has not thought about quitting for at least six months. The individual moves from the pre-contemplation to the contemplation phase when he or she has been thinking about stopping for between thirty one days and six months or if they have not attempted to stop for twenty four hours in the last year (West, 1036). The list continues on through maintenance without any explanation for these seemingly arbitrary values.
A paper by Stephen Sutton points out that with arbitrary staging values, different time periods would put individuals in different stages. Thus, the particular stage of an individual often times depends on which variation of the TTM was used (176). This has important implications in terms of creating an intervention for drug use. If the intervention were tailored to the individual based on which stage they were categorized into, a different variation of the TTM would place the individual into a different stage. Therefore, the intervention targeted toward that person would necessarily change. With a subjective categorization of patients into stages, it can be asserted that the intervention would also be arbitrary. Thus, interventions based on this progression of stages are not truly tailored toward the individual and cannot be effective.
Social Factors
The TTM is largely an individual-based model. It deals with the individual’s motivations for behavior change and their personal behavior change goals. Moreover, the five stages do not mention any social influences or environmental factors as having an affect on stage progression but rather focus on intrapersonal thought. Given the social nature of substance abuse, and the substantial role that environmental factors play in drug addiction, an intervention that does not take these issues into consideration cannot properly address the problem.
Research from Anderson et al. explores how social factors such as family and interpersonal relationships are implicated in substance use treatment outcomes. They found that individuals with peers who did not use were able to abstain after rehabilitative treatment (43). Having a social network of peers who did not use drugs increased the odds of abstaining by four times (45). On the other hand, peers that did use were detrimental to post-treatment outcomes, reducing the odds of abstaining by three-fold (45). The findings from this study indicate that environmental and social factors have a clear relationship to drug addiction treatment outcomes and further suggest that a successful intervention program that prevents relapse should account for these factors (45).
Concurring with the Anderson et al. study, Silberg et al. found that environmental factors, specifically peer influence, had a significant effect on drug addiction. Data from Silberg et al. indicate that the social factors affecting initial use of drugs are not the same as those affecting heavy substance abuse and addiction (665). Thus, in forming drug addiction intervention programs, these differing consequences need to be accounted for. Initial substance use was found to be due to varying factors, however the persistence of drug abuse was primarily due to environmental factors such as peer influence or family use (671).
Considering that external factors play such a large role in initiating drug use and the persistence of drug use, a successful intervention program must necessarily include a stipulation for social factors. Moreover, whether drug abuse treatment occurs in a rehabilitative institution or at a treatment facility near the individual’s home, the addict must face these social and environmental factors again. If the intervention does not take these factors into consideration, the individual could relapse. Moreover, evidence from several studies indicate that family based counseling and outpatient addiction treatment programs have better treatment outcomes than individual-based interventions.
In a study by O’Farrell et al. substance abuse patients living with family members were randomly assigned to either behavioral family counseling (BFC) or individual based treatment (IBT) (2). At baseline, no significant differences existed between individuals in each treatment group besides the treatment assignment. In terms of the treatment regimen, all major factors were the same between the two groups, except in the BFC group the family member attended sessions with the patient and participated in activities with them (2). Three months post treatment, the results indicate that individuals in the BFC treatment group had a significantly greater number of abstinent days than the IBT group (4). The results of this study strongly support the contention that individual based interventions such as those based on the TTM do not work.
Another study by Friedmann et al. focused on outpatient drug treatment and measured outcome success in terms of percent substance abuse relapse in drug-involved parolees. The study was based on the well-known fact that many drug-involved offenders abstain from using while they are in prison. However, upon release and being back in the social environment in which parolees were before incarceration, about 24% of offenders will return to prison for a parole violation involving substance use (228). Thus, Friedmann et al. studied whether integrating an outpatient drug treatment program into parole would improve the percent of time abstinent. Such a program allows parolees to learn mechanisms to cope with drug relapse prevention while simultaneously facing external factors that influence substance use (230). As compared to the control group, the parole group with outpatient drug treatment was more likely to meet with their parole officer and abstain from substance use (232).
The findings from these studies provide compelling evidence that discredits the TTM as an effective model for drug addiction interventions on the basis that accounting for social and environmental factors is essential to abstinence. Peers have an enormous influence on drug use and thus a model for intervention should include a provision for the affects of peers on individual behavior.
An important corollary to social and environmental factors and drug interventions is context, or situations in which the self-efficacy of the individual is reduced. As indicated by the TTM, self-efficacy is vital to progressing from the contemplation stage to preparation and later action. In terms of drug addiction, situations associated with drug use can cause intense cravings, or a “hot” state. The self-efficacy of individuals during these “hot” states is dramatically reduced as compared to “cold” states, or periods when the individual does not crave the drug.
Recent research from Nordgren et al. indicates that bodily states have profound influences on the self-efficacy and intention of drug users to quit. They assert that bodily states provide feedback information about the condition of the body and control behavior to satiate visceral needs (722). Moreover, individuals tend to overestimate their self-efficacy during “cold” states when their visceral needs are fulfilled, and underestimate the effect of “hot” states on behavior (722). In their study, smokers were separated into two groups- a satiated group and a craving group. To create a condition of satiety, subjects were asked to smoke fifteen minutes before completing a survey asking questions about their cigarette craving, self efficacy to quit, and their intentions of quitting. Subjects in the craving condition group were asked to refrain from smoking for two hours, watched a video in which two individuals discuss how much they enjoy cigarette smoking, and held an unlit cigarette in their mouth. They were then asked to complete the same questionnaire (723). The results of this study indicate, as predicted, a much lower rating of self efficacy and intention to quit in the “hot” state group, and a much higher rating of self-efficacy and intentions to quit in the “cold” state, satiated group (724).
Adding to this data, a 2007 study by Nordgren and colleagues delves into the effects of “hot” states on impulsive behavior. They tested their theory that individuals in “hot” states are more accepting of impulsive behaviors by examining the subjects’ reactions to a video of a man eating four cheeseburgers in three minutes. One group was in a “cold” state while watching this video and the other was in a hungry, “hot” state (76). Again, as expected, those in the “hot” state were more accepting of this impulsive behavior (78).
The Nordgren et al. studies demonstrate the overpowering effect of visceral “hot” states on human behavior. This information in mind, it becomes clear why the TTM cannot be used to develop a successful intervention for drug addiction. The stages of the TTM occur while individuals are in the “cold” state, self-efficacy is high, and thus the intention to quit seems tangible. The TTM assumes that intention to quit remains constant from day to day and does not consider the dynamic nature of “hot” states.
On its surface the TTM appears as a logical model for drug addiction behavior and cessation. The studies mentioned, however, clearly discredit this model on multiple grounds specifically because of its arbitrary stages, lack of social and environmental factors, and failure to account for changing context. Failure to address these aspects creates a rift between the drug treatment plan and the real world and thus minimizes or even negates outcome success. It follows, then, that a successful intervention for drug addiction treatment should consider these factors.
Proposal: Visceral State Monitoring Model (VSMM)
The visceral state monitoring model is a drug addiction intervention program based on closely following the changes in bodily stage during treatment. The goal of such monitoring is to determine in which contexts an individual’s visceral functions are elevated (e.g. blood pressure, heart rate) and they are likely to experience extreme drug cravings. Furthermore, if it is known which contexts result in a “hot” visceral state, those can be avoided in the future, or the individual can learn how to cope with them without relapsing. For example, if a man walks by the corner where he used to buy cocaine from his dealer, his heart rate would change indicating that he was experiencing a craving.
The intervention involves three aspects, each directly opposing a factor of the TTM. The first is that individuals will receive drug treatment and counseling at a center near their home. Secondly, treatment will be incorporated into daily living. Lastly, a portable heart rate monitor will track changes in visceral state.
Drug Treatment
The drug treatment protocol for the VSMM will be based on what would be best for the patient and the specific drug they are addicted to. The treatment will not be set in stages, however, like the TTM. Rather, the intervention will use the approach Anderson et al. used in their study, which is a questionnaire. Patients will periodically be asked to fill out a questionnaire on their current level of drug craving, how many times they craved the drug that week, and where or in what situations their most intense cravings occurred (43). Furthermore, patients will be inquired about whether they relapsed, and if so, whether they relapsed following a situation in which they had an intense craving for the drug. In this way, patients are not categorized into groups based on arbitrary dates. Their stage, and thus treatment protocol, is based on their physiological craving for the drug.
This is a more efficient and reliable method for designing a drug intervention program, as compared to the TTM, because the stages are not arbitrary. The self-reported levels of craving will determine the type of medication and counseling the patient will need in order to further reduce the frequency of drug cravings. Thus, the patient could technically be in a particular stage and receiving a particular type of treatment for a long time or a very short time as there is no set number of days. This is a more effective method of approaching drug treatment specifically because the intervention is not based on the passage of time between stages, as it is with the TTM. Rather, the intervention protocol goes hand in hand with the individual’s physical craving for the drug.
Furthermore, actual drug treatment and counseling will occur in the primary care setting. A study from Kahan et al. indicates that patients who receive addiction treatment as a part of their primary care have greater outcomes as compared to those who attend counseling sessions (e.g. Alcoholics Anonymous) (1109.e2). Furthermore, this study found that by incorporating drug treatment into primary care, physicians were able to maintain long-term follow up, which is crucial for drug addiction treatment success (1109.e4)
Incorporation into Daily Life
Research from O’Farrell et al. and Friedmann et al. indicate that intervention programs that occur while the individual is incorporated into society have much greater outcomes. The individual needs to learn how to adjust to life without the substance and if he or she learns how to do so in an environment that they will not be living in, they may relapse. Quitting could seem easier when the individual is isolated from the troubles of every day life. However, in order to successfully quit, the drug addict must learn how to deal with these issues and not use the drug. Furthermore, the Anderson et al. study indicates the profound influence that peers and social networks can have on drug abuse. Recovering addicts need to learn how to see their peers and not partake in substance abuse. Thus, the best way to accomplish this is to intertwine daily life with treatment.
The VSMM accomplishes this in two ways. First off, actual drug treatment and counseling will occur in a primary care setting at a clinic close to the recovering addict. This is a key factor, as many addicts will not keep up with their treatment if they have to travel far to obtain it. Furthermore, the VSMM would incorporate aspects of the behavioral family counseling program discussed in the O’Farrell et al. study. That study indicated that when addicts who lived with family members other than their spouse attended counseling sessions with them, the outcomes were more successful than if the same programs were completed alone (4). Therefore, the VSMM would have a family counseling session as part of the treatment program. In this way the model accounts for the fact that peers play a large role in drug addiction and in recovery. As a part of the drug treatment program, the family members will know what the protocol entails and what they can do to help.
Visceral Monitoring
An important issue with drug addiction treatment is that the patient does not know when he or she will get an intense craving. While the individual could avoid areas that would likely cause an intense craving, such as places where they would use, a random memory could put the individual in a “hot” state. When in such a state unexpectedly, the individual would be more likely to succumb to the craving and relapse. Thus, it is critical to know where the individual has these cravings and what situations can put them in a “hot” state.
Furthermore, being in a “hot” state might not manifest itself externally and the individual would not realize that they were in that state. Thus, a mechanism would be required that would monitor bodily reactions to situations. The VSMM accomplishes this with the use of a portable heart rate monitor networked with a computer at the drug treatment clinic. When the patient’s heart rate increases, the computer will record this data. As there are many situations that can increase an individual’s heart rate, as part of the treatment at the clinic, either a physician or counselor would need to ask the individual what situations arose in order to determine whether the individual was actually in a “hot” state and craving the drug.
With this information, the intervention could then be tailored in such a way as to encourage the individual to avoid such situations. For example, if a woman’s heart rate increases due to being in a “hot” state every time she walks by the local high school, as part of the intervention she could be advised to take another route. Some situations that put individual’s in a “hot” state are unavoidable and thus another aspect of the treatment would be to teach the individual how to deal with the situation and not make the impulsive decision to use. This aspect of the VSMM accounts for the fact that even highly motivated individuals who intend to quit could relapse. Thus intention and motivation are not static ideas. These can change drastically from day to day and in certain contexts.
Recent research clearly indicates that the problem of drug addiction is multifaceted. All of these factors must be taken into consideration in order to develop an effective intervention. This idea becomes clear when looking at the model most used to develop drug interventions, the TTM. This model does not take social factors or context into account and assigns arbitrary stages to individuals to develop personalized interventions. The VSMM intends to make up for the TTM where it lacks by incorporating aspects of the individual’s social environment and peers into the treatment program. The treatment is very personalized, but occurs in the individual’s real social environment. Furthermore, the progress of the individual is judged on the frequency of drug cravings, rather than the individual’s beliefs as in the TTM. The VSMM provides a method for providing long-term care and follow up on drug addiction patients and allows them to continue living their lives as well as obtain treatment at the same time. All in all, based on the research presented here, the VSMM is a more effective method of drug addiction treatment.

Works Cited

1. Anderson, Kristen G. Ramo, Danielle E. Schulte, Marya T. Cummins, Kevin. Brown, Sandra A. “Substance use treatment outcomes for youth: Integrating personal and environmental predictors.” Drug and Alcohol Dependence 2007, 88: 42-48.
2. DiClemente, Carlo C. Schlundt, Debra. Gemmel, Leigh. “Readiness and stages of change in addiction treatment.” The American Journal on Addictions. 2004, 13: 103-119.
3. Friedmann, Peter D. Rhodes, Anne G. Taxman, Faye S. “Collaborative behavioral management integration and intensification of parole and outpatient addiction treatment services in the Step’n Out Study.” Journal of Experimental Criminology 2009, 5: 227-243.
4. Kahan, Meldon. Wilson, Lynn. Midmer, Deana. Ordean, Alice. Lim, HeeYung. “Short-term outcomes in patients attending a primary care-based addiction share program.” Canadian Family Physician 2009, 55: 1108-1109,e1-5.
5. Nordgren, Loran F. Pligt, Joop van der. Harreveld, Frenk van. “Evaluating eve: Visceral states influence the evaluation of impulsive behavior.” Journal of Personality and Social Psychology 2007, 93: 75-84.
6. Nordgren, Loran F. Pligt, Joop van der. Harreveld, Frenk van. “The instability of health cognitions: visceral states influence self-efficacy and related health beliefs.” Health Psychology. 2008, 27: 722-727.
7. O’Farrell, Timothy J. Murphy, Marie. Alter, Jane. Fals-Stewart, William. “Behavioral family counseling for substance abuse: A treatment development pilot study.” Addictive Behaviors 2009, 35: 1-6.
8. Silberg, Judy. Rutter, Michael. D’Onofrio, Brian. Eaves, Lindon. “Genetic and environmental risk factors in adolescent substance use.” Journal of Child Psychology and Psychiatry. 2003, 44: 664-676.
9. Sutton, Stephen. “Back to the Drawing Board? A review of applications of the transtheoretical model to substance abuse.” Addiction 2001, 96: 175-186.
10. West, Robert. “Time for a change: putting the Transtheoretical (stages of change) Model to rest.” Addiction 2005, 100: 1036-1039.



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