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Addiction Trajectories

Based on these general orientations, this brief begins with a short presentation of the notion of trajectories and the methods used to describe them, then continues with a description of each of the phases of those trajectories, from initiation to rehabilitation, with emphasis on the transitions from one phase to the next and on potential outcomes of substance abuse trajectories. The notion of trajectory refers to the idea that persons with a given condition will develop through a series of phases, each of which has a certain number of attributes distinguishing it from the next.

These phases succeed each other in time, but are not necessarily linear: individuals may "skip" a phase, go back to a phase and get caught in loops. Etymologically speaking, however, the notion of phase refers to a crossing, a journey, and the idea is to go, in steps, from one state to the next. Addiction experts have also used the terms "career", "life cycle of addiction" and "natural history of addiction". The "path" most often studied in this field is as follows: consumption starts, then evolves towards substance abuse or dependence, followed by treatment, the expected effects of which are an end to or control of the abuse and an attenuation or disappearance of its harmful consequences.

Alksne, Lieberman and Brill identified three phases in the path to dependence: experimentation, periodical recreational use and compulsive use. Frykholm suggests three phases of disengagement: ambivalence impulsive attempts followed by relapses , treatment serious efforts to abstain and emancipation, when the individual definitely wants to be free of drugs and therapists. The question of addiction trajectories will be addressed here on the basis of these four phases followed by that of reintegration.

The work of Hser's team will serve as a departure point since those authors conducted a survey of the literature on each of the phases before reporting the findings of their own analyses and because they have systematically observed the differences between men and women.

The data were gathered from a retrospective longitudinal estimate structured interviews , and the study was conducted in the late s. For this reason, using this basic description, which provides the most widely validated data, we present more recent or more focused studies in order to reveal more contemporary observations or trends. However, it should be noted at the outset that these five phases merely refer to the trajectory most often studied.

This represents only one of the possible ways in which the phases can be linked since it reflects only one of the possible outcomes of each of the phases examined. For a fuller understanding of trajectories, it must be understood that a number of outcomes are possible for each phase, including cessation of consumption or avoiding the transition to abuse or dependence. As Frykholm notes: "The concept of a drug career does not imply that a drug abuser would have to go through all stages, but rather that he may give up drugs at any stage.

For example, after being introduced to a substance, some consumers will stop using it, while others will continue using without experiencing any problems, and a minority will be exposed to lethal consequences accident under the influence of drugs, suicide, infection with a terminal disease. Moderate drinkers, for example, are also likely to know or experience the problems associated with drinking. The purpose of primary and secondary prevention is to influence the course of the trajectory toward cessation or control of drinking and to avoid the transition to substance abuse.

A certain number of users will become abusers or dependants. Once dependence has started, treatment and rehabilitation are the outcomes most often studied. Spontaneous remission and death are also two possible outcomes. The purpose of the harm reduction approach Brisson and Riley, is to offset the negative consequences of excessive use.

Lastly, observers currently note growing interest in the future of rehabilitated addicts. Cessation, moderate use. Disease, trauma, death. Spontaneous remission.

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November Trajectories may also be viewed from the standpoint of transition from one substance to another. Various substances may be tried in succession, ranging from the more socially accepted or most accessible to those which present potentially higher risks of all kinds, including the risk of criminalization. For a review of studies on developments in substance use, see Vitaro, Carbonneau, Gosselin, Tremblay et al.

Thus there is the passage from alcohol and "recreational" substances cannabis, hashish, hallucinogenics to harder drugs cocaine and heroin. The reverse trajectory is also observed, the transition from one substance to another being the object of a voluntary effort rehabilitation or harm reduction or of a substitution mechanism replacing heroin, for example with cocaine or alcohol. Three methods may be used to study trajectories: prospective, retrospective and transversal.

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The prospective method consists in monitoring a cohort over a number of years and gathering data on it at regular intervals. Under this approach, the outcome of the phenomenon observed for each member of the cohort is not known. The retrospective method is used to examine a group of persons who have reached a given state or present a certain condition.

Risk & Protective Factors

It is based on recall. Under this approach, the finish line is known and the idea is to reconstitute the journey. Lastly, transversal studies consist in comparing groups of persons who are at various stages in a single problem. These three methods are mainly used in epidemiology and involve a quantitative approach. The qualitative approach is also used, particularly through interviews in which key informers are questioned retrospectively on various aspects of their addiction careers. Longitudinal studies and the developmental approach make it possible to begin studying trajectories in early childhood. Examined using the psychopathological approach, behavioural problems in childhood are a predictor of psychotropic substance abuse in adolescence and constitute predictive factors of addiction Vitaro, Carbonneau, Gosselin, Tremblay et al.

Socio-family factors and peer influence are also considered factors in early substance abuse and initiation. For both sexes, substance use is generally initiated by a man, who is himself a user or former user. However, this observation may be explained by the simple fact that the number of male users is greater than that of female users. The sole exception to this rule is that initiation to non-prescription medicine, which is more frequent among women, is also generally done by a woman.

However, among men, the initiator is most often a friend and, among women, a spouse. Women more often cite curiosity as a reason for first using a substance, or the need for relief in a period of crisis, whereas men more often refer to the "kick". For both men and women, peer influence is a significant factor. Women more often receive drugs as a gift than men. Most men and women first use cannabis, although some women begin their trajectory with prescription medication obtained by falsifying prescriptions or from a family member.

When they begin to use heroin, both men and women have already used and sold a number of drugs, although women have been less involved in criminal activities Hser, Anglin, McGlothin, It is thought that the use of soft drugs and drugs in general is very much linked to age. Use will peak in the early twenties, then decline and stop in the early thirties.

Thus only a minority of young people with drug experience will evolve into substance abuse or develop dependence. Prospective and transversal studies have also focused on predictive factors that distinguish between those who continue to use in moderation or give it up and those who evolve toward substance abuse behaviour Kandel and Raveis, Since politicians, clinical workers and researchers focus first of all on substance abusers, there is a tendency to dichotomize the outcome of this period between those who stop using and those who develop an abuse problem.

This conceals a third possibility, the extent of which is poorly known, that some may continue using without reaching a critical threshold or without getting into trouble with the law. This kind of controlled use is even observed in opiate users who develop control strategies linked to frequency of use no daily use , dose and administration method Blackwell, ; Strang, Heathcote and Watson, ; Zinberg, For both alcohol and drugs, it is considered that dependence starts more quickly in women than in men Wasilow-Miller and Erickson, ; Westermeyer and Boedicker, In the specific case of opiates, Anglin, Hser and McGlothlin report the finding that as much as twice as many women as men move on to daily use within a year.

More women live with a partner who is a daily user, but women drink and use cannabis less, are less often involved in the sale of drugs and less frequently arrested and imprisoned. The reasons for continuing or increasing substance use for women are a partner's habits and liking the effects of the drug. The latter reason is the first reason for men, followed by the influence of friends.

In the observed samples, which were generally recruited at treatment centres, the duration of the period of abuse and dependence in women seems shorter than for men as a result of the fact that they enter treatment sooner and that the older subjects began taking drugs later than men. Once again, women's substance abuse appears to be more influenced by the user's partner, who is also a user and on whom they depend for their support.

However, increasing numbers of women consume first because "they like it". Men and women use a variety of drugs, although men more often take a number of drugs together alcohol, cocaine and heroin. Women use more sedatives and prescription drugs than men, but fewer hallucinogenics and inhalants Hser, Anglin, Booth, Substance abuse paths, number of attempts to stop, relapses and periods of abstinence are similar between the two sexes.

Women may be less exposed to causes of involuntary cessation and thus may experience fewer periods of abstinence. A return to substance abuse after a period of abstinence is the result of both internal and external pressures: emotional problems anxiety, depression, anger , physical or psychological need, escape from personal problems or relief from pain and availability of drugs. In both sexes, abuse and dependence result in increased criminal activity, but that activity differs between men and women.

Prostitution is more frequent among women, the sale of drugs common to both men and women, although eventually more widespread among men Hser, Anglin and Booth, In the data gathered in the DATOS survey Grella and Joshi, and in Westermeyer and Boedicker , men were more in trouble with the law and more often had antisocial personalities. Women have more contact with the mental health system and more often suffer from depression and anxiety. They also develop physical health problems such as cardiovascular, gastrointestinal and liver diseases more quickly than men studies reported by Wasilow-Miller and Erickson, ; Westermeyer and Boedicker, , and their substance abuse problems expose them to more violence, high-risk sexual behaviour, sexually transmitted diseases, HIV infection, unwanted or early pregnancy, the birth of underweight babies or babies in withdrawal and abusive or negligent behaviour Wasilow-Miller and Erickson, The relative share of each of these ways of putting an end to dependence is hard to evaluate and their interaction virtually impossible to describe.

Spontaneous remission refers to the achievement of positive results in populations untreated by specialized organizations or recognized therapists.

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In this way, individuals manage to control their substance abuse alone or with the support of informal resources, friends, family members, natural helpers and volunteers Oppenheimer, Tobutt, Taylor and Andrew, ; Robins, Helzer and Davis, ; Stimson and Oppenheimer, ; Vaillant, Thus it appears that most individuals who solve their drinking problems do so without formal treatment.

This spontaneous remission is more common among women Copeland, In connection with spontaneous remission and natural history of recovery, reference is also made to the notions of maturing out and withdrawal Adler, ; Anglin, Brecht, Woodward and Bonett, ; Brecht and Anglin, ; Frykholm, ; Jorquez, All these authors have observed that, for addicts with a lengthy history of substance abuse, the main reason for wanting to stop is either being fed up with the street lifestyle or a physical inability to continue, or both.

Stimson and Oppenheimer suggest that some individuals become abstinent as a result of voluntary inner strength motivation , while others respond to circumstances or external pressures. A number of types of reasons are given for stopping substance abuse or altering substance abuse patterns, and these are often related to lifestyle as a whole. For example, "fatigue", the desire to change one's lifestyle, are often cited, in particular by women and long-term substance abusers.