From "chance" of drug use to "negligence" of risk behaviors

EDITORIAL

From "chance" of drug use to "negligence" of risk behaviors

Felix Kessler

Psiquiatra, Vice-diretor, Centro de Pesquisa em Álcool e Drogas, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil

Correspondence

I recently came across an interesting book that deals with the subject of chance. It is called "The Drunkard's Walk".¹ According to the author, physicist Leonard Mlodinow, the expression symbolizes the trajectory followed by molecules that float and collide at random in space and corresponds to a metaphor for the way in which events occur in the lives of human beings, from choosing a career, meeting a spouse through to the simplest everyday events. Despite the pejorative nature of the term, the association encouraged me to trace certain parallels with studies published recently in scientific journals about the psychiatric and neurobiological aspects of taking psychoactive substances (PS) and engaging in risk behaviors (RB).

Countless random - but not causeless - events occur during life and, of these, taking drugs is one that may prove to be less gratifying than initially imagined. Chronic exposure can lead to a series of physical, psychological and social consequences, and acute intoxication considerably increases the incidence of RB, such as unprotected sexual relations and violent behavior.² When they try PS, users ignore or are unable to assess the countless variables which, together with chance, can lead people to put themselves at risk or to become addicts.

Some authors³ still argue about the existence of voluntary control of drug taking and associated behaviors, which take the debate into the sphere of ethics and morals and to prejudiced conclusions about users. Opinions such as, "he takes drugs because he wants to" increase this impression of free will. The fact that people seek out something that is harmful to them (drugs) and repeatedly expose themselves to situations that cause harm tends to provoke anger and repulsion around them, or negative countertransferential feelings in their therapists, especially during the repeated relapses as treatment progresses. There are people who question whether there is a self-destructive element to these attitudes. However, this is not the direction in which science has been taking us. Current studies approach the problem as adaptive behavior that is linked with cerebral dysfunctions.^4,5

The hypotheses to explain the phenomenon of PS use and RB are highly complex. As when evaluating the majority of human behaviors, the experiences and subjectivity of each individual person and their physical and psychiatric constitution should be taken into account in order to avoid reductionisms and generalizations.

Risk behaviors have been conceptualized in many different ways, but currently the majority of definitions suggest that they are based on the idea of an opportunity of obtaining some type of attractive reward at a given time, despite a chance of loss, danger or damage. Since the results are unpredictable, the likelihood that they will be negative increases. It is like driving at night, under the influence of alcohol, at 80 miles an hour, in order to arrive earlier or simply to experience greater emotion or pleasure. However, if there is a defect in the road surface there may not be enough time or reaction speed to take evasive action. Or perhaps there will be. Either way, a simple event, a chance event, may seal the fate of a person engaged in RB. Some might say, vulgarly, that this person is "giving bad luck a chance".

So what leads a person to make this type of choice and to put their own life at risk repeatedly? Do we not learn very early on that one of the primary objectives of animals is to guarantee their own survival? At first sight this behavior would appear to be "carelessness" that swims against the tide of continuation of the species.⁶

However, our understanding of the way in which people process decision-making is being altered and improved by the integration of information from subjects such as mathematics, psychology, behavioral economics and modern neuroscience. In general, people think they are in full awareness of the facts, able to rationally analyze situations and make a correct decision, failing to take into account individual neurobiological difficulties and possible environmental influences. It was found that, when people are confronted with uncertainty and randomness, their judgment may be faulty and the consequences harmful or even fatal. This is because of the large number of encephalic structures involved in processes such as a) forming preferences between choices, b) selecting and carrying out actions and c) experience (memory) and evaluation of the results.⁷ When certain regions of the cerebral reward system (which directs people towards more intense and more immediate gratification) encounter powerful stimulants like drugs it becomes necessary to apply brakes, which may not always work properly. The cortical frontal areas of the brain are more related to controlling behavior and executive functions, which include abstract thinking, planning, motivation, attention to tasks and inhibition of impulses.⁸ People with prefrontal deficits, whether caused by drug abuse or not, also have reduced self control and worse risk perception.⁹

The decision to take drugs is aggravated if it is made during adolescence, which is a phase when thinking tends to be omnipotent, denying or devaluing potential risks and the influence of chance in what may happen. This is why taking drugs itself has been considered an RB. The younger person is the greater the tendency to be curious and exploratory, in detriment to assessing consequences properly. It is also known that, depending on the culture in which a person lives, during experimentation or a short period of frequent use, expectations of the results and belief about the effects tend to be positive.¹⁰ Ernst & Paulus⁷ came to the conclusion that RB in adolescents are the fruit of intense maturation of the ventral striatum (the reward system) when compared with the amygdala (which is associated with the avoidance system) and the prefrontal cortex (the regulatory system). These regions tend to remain immature beyond 20 years of age. Therefore, the age at which drugs are first taken may play an important role in the development of an addictive disorder, i.e. the later that experimentation occurs, the lower the risk of problems due to PS use.¹¹

A series of studies in the literature have also explored other aspects of personality associated with risk behaviors. Currently, the sensation seeking, impulsivity and novelty seeking are receiving the greatest attention. Sensation seeking is considered to be a personality trait characterized by a desire for intense and pleasurable stimuli, often observed in conjunction with increased susceptibility to boredom.¹² These traits generally exhibit prominent genetic elements, which have been demonstrated in animal models, and there is a tendency to attenuation with age. They can be assessed using scales (for example, the Barratt Impulsiveness Scale) or tests (for example, the Iowa Gambling Test, the Delay Discounting Test and the Risky Gains Procedure) in which people with these characteristics tend to choose superficially seductive gains, with immediate advantages, but which are not in their interests over the long term or involve greater risk, in common with substance addicts and pathological gamblers.¹³ Individuals with certain psychiatric disorders often exhibit these traits, including those with antisocial personality disorders, affective disorders and attention deficit hyperactivity disorder.¹⁴

The relationship between risk behavior and sensation seeking has been known since the 1970s and is well-documented.¹³ The interaction with impulsivity is more complex. The definition of impulsivity itself has an intimate relationship with risk or harm: "A predisposition to rapid and unplanned reactions to internal or external stimuli without taking the negative consequences of these reactions into account or assessing them incorrectly".¹⁵ Very often, impulsive individuals do have a rational notion of the consequences, but are unable to exert inhibitory control over their impulses and apply this knowledge at the moment of making a decision. It is very common for patients to describe how an intense desire to use a substance (craving) made them change their decision (to quit) at the last moment. Nowadays impulsivity is considered a marker of vulnerability to the development of disorders associated with PS use, but can also be triggered or increased by chronic exposure.¹⁶

The cognitive-motivational theory proposes a relationship between decision making and the basic systems of motivation, memory and attention for each personality trait, by which people with the impulsivity/novelty seeking trait have heightened emotional responses to rewards and frustration, while the harm avoidance trait is associated with more active inhibitory systems.¹⁷

If we wish to understand RB better we can review findings from studies of specific populations,¹⁸ such as the one published in this edition of the Revista de Psiquiatria do Rio Grande do Sul about heroin users. We can also imagine examples, such as the middle-class 15-year old who is offered marijuana by those of his peers that he most admires. He has no academic problems, but says he feels a lack of attention from his parents who, according to him, work too hard. He says he is going through a difficult phase (almost synonymous with adolescence) because he feels shy and ugly and can't "make out" with girls. What are the chances that he will drink alcohol at a party? What the chances that he will accept a ride from an intoxicated friend? What are his chances of suffering a severe or fatal accident? What the chances that he will become addicted to marijuana?

The answers depend on yet more questions. In addition to the personality traits already mentioned, we cannot ignore other factors that are considered to increase risk: extension of family conflict, other stressors, psychiatric comorbidities, genetic predisposition to addiction,¹⁵ the type of marijuana he is offered (its dependence generating potential), the number of times (opportunities) that his peers offer him drugs and the importance the drug has within the peer group, among others. Once more, the random combination of these aspects can increase or reduce his chances.

In the case of alcohol, the probability of use and dependence in Brazil is not small, because of the power of the pro-alcohol culture and the difficulties implementing public policies that are already well-established in other countries, such as restricting alcohol advertising, controlling sale to minors, testing drivers with breathalyzers and increases taxation on some drinks.²⁰

I would therefore like to finish by emphasizing that the consumption of PS, whether licit or illicit, has been influenced by society's carelessness, which goes back decades, of these external factors that contribute to exacerbating the problem. I decided to put quotation marks around the word "chance" in certain parts of this editorial in order to stress the fact that these risk behaviors are no longer controlled by the laws of Nature or of Physics alone, but also by human laws, which can and should be changed.

In Brazil, the battles against smoking that have already been won are an example in favor of preventing alcohol abuse and dependence and experimentation with marijuana and cocaine/crack through education, by offering opportunities for gratification that compete with drugs and even using repressive strategies. In parallel, it is necessary to develop and employ evidence-based therapeutic approaches to treating these disorders and preventing the RB associated with them. If not, we will continue to witness these "chance events" and "accidents" with ever greater frequency.

REFERENCES

References

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Publication Dates

• Publication in this collection
  24 May 2010
• Date of issue
  Dec 2009