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Tuesday, March 2, 2021

Revolution

From Wikipedia, the free encyclopedia

In political science, a revolution (Latin: revolutio, "a turn around") is a fundamental and relatively sudden change in political power and political organization which occurs when the population revolts against the government, typically due to perceived oppression (political, social, economic) or political incompetence. In book V of the Politics, the Ancient Greek philosopher Aristotle (384–322 BC) described two types of political revolution:

  1. Complete change from one constitution to another
  2. Modification of an existing constitution.

Revolutions have occurred through human history and vary widely in terms of methods, duration and motivating ideology. Their results include major changes in culture, economy and socio-political institutions, usually in response to perceived overwhelming autocracy or plutocracy.

Scholarly debates about what does and does not constitute a revolution center on several issues. Early studies of revolutions primarily analyzed events in European history from a psychological perspective, but more modern examinations include global events and incorporate perspectives from several social sciences, including sociology and political science. Several generations of scholarly thought on revolutions have generated many competing theories and contributed much to the current understanding of this complex phenomenon.

Notable revolutions in recent centuries include the creation of the United States through the American Revolutionary War (1775–1783), the French Revolution (1789–1799), the Spanish American wars of independence (1808–1826), the European Revolutions of 1848, the Russian Revolution in 1917, the Chinese Revolution of the 1940s, the Cuban Revolution in 1959, the Iranian Revolution in 1979, and the European Revolutions of 1989.

Etymology

The word "revolucion" is known in French from the 13th century, and "revolution" in English by the late fourteenth century, with regard to the revolving motion of celestial bodies. "Revolution" in the sense of representing abrupt change in a social order is attested by at least 1450. Political usage of the term had been well established by 1688 in the description of the replacement of James II with William III. This incident was termed the "Glorious Revolution".

Types

A Watt steam engine in Madrid. The development of the steam engine propelled the Industrial Revolution in Britain and the world. The steam engine was created to pump water from coal mines, enabling them to be deepened beyond groundwater levels.

There are many different typologies of revolutions in social science and literature.

Alexis de Tocqueville differentiated between;

  • political revolutions, sudden and violent revolutions that seek not only to establish a new political system but to transform an entire society, and;
  • slow but sweeping transformations of the entire society that take several generations to bring about (such as changes in religion).

One of several different Marxist typologies divides revolutions into;

  • pre-capitalist
  • early bourgeois
  • bourgeois
  • bourgeois-democratic
  • early proletarian
  • socialist

Charles Tilly, a modern scholar of revolutions, differentiated between;

Mark Katz identified six forms of revolution;

  • rural revolution
  • urban revolution
  • Coup d'état, e.g. Egypt, 1952
  • revolution from above, e.g. Mao's Great leap forward of 1958
  • revolution from without, e.g. the allied invasions of Italy, 1944 and Germany, 1945.
  • revolution by osmosis, e.g. the gradual Islamization of several countries.

These categories are not mutually exclusive; the Russian revolution of 1917 began with the urban revolution to depose the Czar, followed by rural revolution, followed by the Bolshevik coup in November. Katz also cross-classified revolutions as follows;

  • Central; countries, usually Great powers, which play a leading role in a Revolutionary wave; e.g. the USSR, Nazi Germany, Iran since 1979.
  • Aspiring revolutions, which follow the Central revolution
  • subordinate or puppet revolutions
  • rival revolutions, e.g. communist Yugoslavia, and China after 1969

A further dimension to Katz's typology is that revolutions are either against (anti-monarchy, anti-dictatorial, anti-communist, anti-democratic) or for (pro-fascism, communism, nationalism etc.). In the latter cases, a transition period is often necessary to decide on the direction taken.

Other types of revolution, created for other typologies, include the social revolutions; proletarian or communist revolutions (inspired by the ideas of Marxism that aims to replace capitalism with Communism); failed or abortive revolutions (revolutions that fail to secure power after temporary victories or large-scale mobilization); or violent vs. nonviolent revolutions.

The term revolution has also been used to denote great changes outside the political sphere. Such revolutions are usually recognized as having transformed in society, culture, philosophy, and technology much more than political systems; they are often known as social revolutions. Some can be global, while others are limited to single countries. One of the classic examples of the usage of the word revolution in such context is the Industrial Revolution, Scientific Revolution or the Commercial Revolution. Note that such revolutions also fit the "slow revolution" definition of Tocqueville. A similar example is the Digital Revolution.

Political and socioeconomic revolutions

Perhaps most often, the word "revolution" is employed to denote a change in social and political institutions. Jeff Goodwin gives two definitions of a revolution. First, a broad one, including

any and all instances in which a state or a political regime is overthrown and thereby transformed by a popular movement in an irregular, extraconstitutional and/or violent fashion.

Second, a narrow one, in which

revolutions entail not only mass mobilization and regime change, but also more or less rapid and fundamental social, economic and/or cultural change, during or soon after the struggle for state power.

Jack Goldstone defines a revolution as

an effort to transform the political institutions and the justifications for political authority in society, accompanied by formal or informal mass mobilization and non-institutionalized actions that undermine authorities.

The storming of the Bastille, 14 July 1789 during the French Revolution.
 
Sun Yat-sen, leader of the Chinese Xinhai Revolution in 1911.
 
Khana Ratsadon, a group of military officers and civil officials, who staged the Siamese Revolution of 1932.

Political and socioeconomic revolutions have been studied in many social sciences, particularly sociology, political sciences and history. Among the leading scholars in that area have been or are Crane Brinton, Charles Brockett, Farideh Farhi, John Foran, John Mason Hart, Samuel Huntington, Jack Goldstone, Jeff Goodwin, Ted Roberts Gurr, Fred Halliday, Chalmers Johnson, Tim McDaniel, Barrington Moore, Jeffery Paige, Vilfredo Pareto, Terence Ranger, Eugen Rosenstock-Huessy, Theda Skocpol, James Scott, Eric Selbin, Charles Tilly, Ellen Kay Trimberger, Carlos Vistas, John Walton, Timothy Wickham-Crowley, and Eric Wolf.

Scholars of revolutions, like Jack Goldstone, differentiate four current 'generations' of scholarly research dealing with revolutions. The scholars of the first generation such as Gustave Le Bon, Charles A. Ellwood, or Pitirim Sorokin, were mainly descriptive in their approach, and their explanations of the phenomena of revolutions was usually related to social psychology, such as Le Bon's crowd psychology theory.

Second generation theorists sought to develop detailed theories of why and when revolutions arise, grounded in more complex social behavior theories. They can be divided into three major approaches: psychological, sociological and political.

The works of Ted Robert Gurr, Ivo K. Feierbrand, Rosalind L. Feierbrand, James A. Geschwender, David C. Schwartz, and Denton E. Morrison fall into the first category. They followed theories of cognitive psychology and frustration-aggression theory and saw the cause of revolution in the state of mind of the masses, and while they varied in their approach as to what exactly caused the people to revolt (e.g., modernization, recession, or discrimination), they agreed that the primary cause for revolution was the widespread frustration with socio-political situation.

The second group, composed of academics such as Chalmers Johnson, Neil Smelser, Bob Jessop, Mark Hart, Edward A. Tiryakian, and Mark Hagopian, followed in the footsteps of Talcott Parsons and the structural-functionalist theory in sociology; they saw society as a system in equilibrium between various resources, demands and subsystems (political, cultural, etc.). As in the psychological school, they differed in their definitions of what causes disequilibrium, but agreed that it is a state of a severe disequilibrium that is responsible for revolutions.

Finally, the third group, which included writers such as Charles Tilly, Samuel P. Huntington, Peter Ammann, and Arthur L. Stinchcombe followed the path of political sciences and looked at pluralist theory and interest group conflict theory. Those theories see events as outcomes of a power struggle between competing interest groups. In such a model, revolutions happen when two or more groups cannot come to terms within a normal decision making process traditional for a given political system, and simultaneously have enough resources to employ force in pursuing their goals.

The second generation theorists saw the development of the revolutions as a two-step process; first, some change results in the present situation being different from the past; second, the new situation creates an opportunity for a revolution to occur. In that situation, an event that in the past would not be sufficient to cause a revolution (e.g., a war, a riot, a bad harvest), now is sufficient; however, if authorities are aware of the danger, they can still prevent a revolution through reform or repression.

Many such early studies of revolutions tended to concentrate on four classic cases: famous and uncontroversial examples that fit virtually all definitions of revolutions, such as the Glorious Revolution (1688), the French Revolution (1789–1799), the Russian Revolution of 1917, and the Chinese Revolution (also known as the Chinese Civil War) (1927–1949). In his The Anatomy of Revolution, however, the Harvard historian Crane Brinton focused on the English Civil War, the American Revolution, the French Revolution, and the Russian Revolution.

In time, scholars began to analyze hundreds of other events as revolutions (see List of revolutions and rebellions), and differences in definitions and approaches gave rise to new definitions and explanations. The theories of the second generation have been criticized for their limited geographical scope, difficulty in empirical verification, as well as that while they may explain some particular revolutions, they did not explain why revolutions did not occur in other societies in very similar situations.

The criticism of the second generation led to the rise of a third generation of theories, with writers such as Theda Skocpol, Barrington Moore, Jeffrey Paige, and others expanding on the old Marxist class conflict approach, turning their attention to rural agrarian-state conflicts, state conflicts with autonomous elites, and the impact of interstate economic and military competition on domestic political change Particularly Skocpol's States and Social Revolutions became one of the most widely recognized works of the third generation; Skocpol defined revolution as "rapid, basic transformations of society's state and class structures [...] accompanied and in part carried through by class-based revolts from below", attributing revolutions to a conjunction of multiple conflicts involving state, elites and the lower classes.

The fall of the Berlin Wall and most of the events of the Autumn of Nations in Europe, 1989, were sudden and peaceful.

From the late 1980s, a new body of scholarly work began questioning the dominance of the third generation's theories. The old theories were also dealt a significant blow by new revolutionary events that could not be easily explained by them. The Iranian and Nicaraguan Revolutions of 1979, the 1986 People Power Revolution in the Philippines and the 1989 Autumn of Nations in Europe saw multi-class coalitions topple seemingly powerful regimes amidst popular demonstrations and mass strikes in nonviolent revolutions.

Defining revolutions as mostly European violent state versus people and class struggles conflicts was no longer sufficient. The study of revolutions thus evolved in three directions, firstly, some researchers were applying previous or updated structuralist theories of revolutions to events beyond the previously analyzed, mostly European conflicts. Secondly, scholars called for greater attention to conscious agency in the form of ideology and culture in shaping revolutionary mobilization and objectives. Third, analysts of both revolutions and social movements realized that those phenomena have much in common, and a new 'fourth generation' literature on contentious politics has developed that attempts to combine insights from the study of social movements and revolutions in hopes of understanding both phenomena.

Further, social science research on revolution, primarily work in political science, has begun to move beyond individual or comparative case studies towards large-N empirical studies assessing the causes and implications of revolution. Initial studies generally rely on the Polity Project’s data on democratization. Such analyses, like those by Enterline, Maoz, and Mansfield and Snyder, identify revolutions based on regime changes indicated by a change in the country’s score on Polity’s autocracy to democracy scale. More recently, scholars like Jeff Colgan have argued that Polity, which measures the degree of democratic or autocratic authority in a state's governing institutions based on the openness of executive recruitment, constraints on executive authority, and political competition, is inadequate because it measures democratization, not revolution, and fails to account for regimes which come to power by revolution but fail to change the structure of the state and society sufficiently to yield a notable difference in Polity score. Instead, Colgan offers a new data set on revolutionary leaders which identifies governments that "transform the existing social, political, and economic relationships of the state by overthrowing or rejecting the principal existing institutions of society." This most recent data set has been employed to make empirically-based contributions to the literature on revolution by identifying links between revolution and the likelihood of international disputes.

Revolutions have also been approached from anthropological perspectives. Drawing on Victor Turner’s writings on ritual and performance, Bjorn Thomassen has argued that revolutions can be understood as "liminal" moments: modern political revolutions very much resemble rituals and can therefore be studied within a process approach. This would imply not only a focus on political behavior "from below", but also to recognize moments where "high and low" are relativized, made irrelevant or subverted, and where the micro and macro levels fuse together in critical conjunctions.

Economist Douglass North argued that it is much easier for revolutionaries to alter formal political institutions such as laws and constitutions than to alter informal social conventions. According to North, inconsistencies between rapidly changing formal institutions and slow-changing informal ones can inhibit effective sociopolitical change. Because of this, the long-term effect of revolutionary political restructuring is often more moderate than the ostensible short-term effect.

While revolutions encompass events ranging from the relatively peaceful revolutions that overthrew communist regimes to the violent Islamic revolution in Afghanistan, they exclude coups d'état, civil wars, revolts, and rebellions that make no effort to transform institutions or the justification for authority (such as Józef Piłsudski's May Coup of 1926 or the American Civil War), as well as peaceful transitions to democracy through institutional arrangements such as plebiscites and free elections, as in Spain after the death of Francisco Franco.

Monday, March 1, 2021

Substance dependence

From Wikipedia, the free encyclopedia

Substance dependence
Other namesDrug dependence
SpecialtyPsychiatry

Substance dependence, also known as drug dependence, is an adaptive state that develops from repeated drug administration, and which results in withdrawal upon cessation of drug use. A drug addiction, a distinct concept from substance dependence, is defined as compulsive, out-of-control drug use, despite negative consequences. An addictive drug is a drug which is both rewarding and reinforcing. ΔFosB, a gene transcription factor, is now known to be a critical component and common factor in the development of virtually all forms of behavioral and drug addictions, but not dependence.

Within the framework of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), substance dependence is redefined as a drug addiction, and can be diagnosed without the occurrence of a withdrawal syndrome. It was described accordingly: "When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped. This, along with Substance Abuse are considered Substance Use Disorders." In the DSM-5 (released in 2013), substance abuse and substance dependence have been merged into the category of substance use disorders and they no longer exist as individual diagnoses.

Addiction and dependence glossary
  • addiction – a biopsychosocial disorder characterized by persistent use of drugs (including alcohol) despite substantial harm and adverse consequences
  • addictive drug – psychoactive substances that with repeated use are associated with significantly higher rates of substance use disorders, due in large part to the drug's effect on brain reward systems
  • dependence – an adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g., drug intake)
  • drug sensitization or reverse tolerance – the escalating effect of a drug resulting from repeated administration at a given dose
  • drug withdrawal – symptoms that occur upon cessation of repeated drug use
  • physical dependence – dependence that involves persistent physical–somatic withdrawal symptoms (e.g., fatigue and delirium tremens)
  • psychological dependence – dependence that involves emotional–motivational withdrawal symptoms (e.g., dysphoria and anhedonia)
  • reinforcing stimuli – stimuli that increase the probability of repeating behaviors paired with them
  • rewarding stimuli – stimuli that the brain interprets as intrinsically positive and desirable or as something to approach
  • sensitization – an amplified response to a stimulus resulting from repeated exposure to it
  • substance use disorder – a condition in which the use of substances leads to clinically and functionally significant impairment or distress
  • tolerance – the diminishing effect of a drug resulting from repeated administration at a given dose

Withdrawal

Withdrawal is the body's reaction to abstaining from a substance upon which a person has developed a dependence syndrome. When dependence has developed, cessation of substance-use produces an unpleasant state, which promotes continued drug use through negative reinforcement; i.e., the drug is used to escape or avoid re-entering the associated withdrawal state. The withdrawal state may include physical-somatic symptoms (physical dependence), emotional-motivational symptoms (psychological dependence), or both. Chemical and hormonal imbalances may arise if the substance is not re-introduced. Psychological stress may also result if the substance is not re-introduced.

Infants also suffer from substance withdrawal, known as neonatal abstinence syndrome (NAS), which can have severe and life-threatening effects. Addiction to drugs such as alcohol in expectant mothers not only causes NAS, but also an array of other issues which can continually affect the infant throughout his/her lifetime.

Risk factors

Dependence potential

The dependence potential of a drug varies from substance to substance, and from individual to individual. Dose, frequency, pharmacokinetics of a particular substance, route of administration, and time are critical factors for developing a drug dependence.

An article in The Lancet compared the harm and dependence liability of 20 drugs, using a scale from zero to three for physical dependence, psychological dependence, and pleasure to create a mean score for dependence. Selected results can be seen in the chart below.

Drug Mean Pleasure Psychological dependence Physical dependence
Heroin 3.00 3.0 3.0 3.0
Cocaine 2.39 3.0 2.8 1.3
Tobacco 2.21 2.3 2.6 1.8
Barbiturates 2.01 2.0 2.2 1.8
Alcohol 1.93 2.3 1.9 1.6
Benzodiazepines 2.23 1.7 2.1 2.8
Amphetamine 1.67 2.0 1.9 1.1
Cannabis 1.51 1.9 1.7 0.8
Ecstasy 1.13 1.5 1.2 0.7

Capture rates

Capture rates enumerate the percentage of users who reported that they had become dependent to their respective drug at some point.

Drug % of users
Cannabis 9%
Alcohol 15.4%
Cocaine 16.7%
Heroin 23.1%
Tobacco 31.9%

Biomolecular mechanisms

Psychological dependence

Two factors have been identified as playing pivotal roles in psychological dependence: the neuropeptide "corticotropin-releasing factor" (CRF) and the gene transcription factor "cAMP response element binding protein" (CREB). The nucleus accumbens (NAcc) is one brain structure that has been implicated in the psychological component of drug dependence. In the NAcc, CREB is activated by cyclic adenosine monophosphate (cAMP) immediately after a high and triggers changes in gene expression that affect proteins such as dynorphin; dynorphin peptides reduce dopamine release into the NAcc by temporarily inhibiting the reward pathway. A sustained activation of CREB thus forces a larger dose to be taken to reach the same effect. In addition, it leaves the user feeling generally depressed and dissatisfied, and unable to find pleasure in previously enjoyable activities, often leading to a return to the drug for another dose.

In addition to CREB, it is hypothesized that stress mechanisms play a role in dependence. Koob and Kreek have hypothesized that during drug use, CRF activates the hypothalamic–pituitary–adrenal axis (HPA axis) and other stress systems in the extended amygdala. This activation influences the dysregulated emotional state associated with psychological dependence. They found that as drug use escalates, so does the presence of CRF in human cerebrospinal fluid. In rat models, the separate use of CRF inhibitors and CRF receptor antagonists both decreased self-administration of the drug of study. Other studies in this review showed dysregulation of other neuropeptides that affect the HPA axis, including enkephalin which is an endogenous opioid peptide that regulates pain. It also appears that µ-opioid receptors, which enkephalin acts upon, is influential in the reward system and can regulate the expression of stress hormones.

Increased expression of AMPA receptors in nucleus accumbens MSNs is a potential mechanism of aversion produced by drug withdrawal.

Physical dependence

Upregulation of the cAMP signal transduction pathway in the locus coeruleus by CREB has been implicated as the mechanism responsible for certain aspects of opioid-induced physical dependence. The temporal course of withdrawal correlates with LC firing, and administration of α2 agonists into the locus coeruleus leads to a decrease in LC firing and norepinephrine release during withdrawal. A possible mechanism involves upregulation of NMDA receptors, which is supported by the attenuation of withdraw by NMDA receptor antagonists. Physical dependence on opioids has been observed to produce an elevation of extracellular glutamate, an increase in NMDA receptor subunits NR1 and NR2A, phosphorylated CaMKII, and c-fos. Expression of CaMKII and c-fos is attenuated by NMDA receptor antagonists, which is associated with blunted withdrawal in adult rats, but not neonatal rats While acute administration of opioids decreases AMPA receptor expression and depresses both NMDA and non-NMDA excitatory postsynaptic potentials in the NAC, withdrawal involves a lowered threshold for LTP and an increase in spontaneous firing in the NAc.

Diagnosis

DSM classification

"Substance dependence", as defined in the DSM-IV, can be diagnosed with physiological dependence, evidence of tolerance or withdrawal, or without physiological dependence. DSM-IV substance dependencies include:

Management

Addiction is a complex but treatable condition. It is characterized by compulsive drug craving, seeking, and use that persists even if the user is aware of severe adverse consequences. For some people, addiction becomes chronic, with periodic relapses even after long periods of abstinence. As a chronic, relapsing disease, addiction may require continued treatments to increase the intervals between relapses and diminish their intensity. While some with substance issues recover and lead fulfilling lives, others require ongoing additional support. The ultimate goal of addiction treatment is to enable an individual to manage their substance misuse; for some this may mean abstinence. Immediate goals are often to reduce substance abuse, improve the patient's ability to function, and minimize the medical and social complications of substance abuse and their addiction; this is called "harm reduction".

Treatments for addiction vary widely according to the types of drugs involved, amount of drugs used, duration of the drug addiction, medical complications and the social needs of the individual. Determining the best type of recovery program for an addicted person depends on a number of factors, including: personality, drugs of choice, concept of spirituality or religion, mental or physical illness, and local availability and affordability of programs.

Many different ideas circulate regarding what is considered a successful outcome in the recovery from addiction. Programs that emphasize controlled drinking exist for alcohol addiction. Opiate replacement therapy has been a medical standard of treatment for opioid addiction for many years.

Treatments and attitudes toward addiction vary widely among different countries. In the US and developing countries, the goal of commissioners of treatment for drug dependence is generally total abstinence from all drugs. Other countries, particularly in Europe, argue the aims of treatment for drug dependence are more complex, with treatment aims including reduction in use to the point that drug use no longer interferes with normal activities such as work and family commitments; shifting the addict away from more dangerous routes of drug administration such as injecting to safer routes such as oral administration; reduction in crime committed by drug addicts; and treatment of other comorbid conditions such as AIDS, hepatitis and mental health disorders. These kinds of outcomes can be achieved without eliminating drug use completely. Drug treatment programs in Europe often report more favorable outcomes than those in the US because the criteria for measuring success are functional rather than abstinence-based. The supporters of programs with total abstinence from drugs as a goal believe that enabling further drug use means prolonged drug use and risks an increase in addiction and complications from addiction.

Residential

Residential drug treatment can be broadly divided into two camps: 12-step programs and therapeutic communities. 12-step programs are a nonclinical support-group and spiritual-based approach to treating addiction. Therapy typically involves the use of cognitive-behavioral therapy, an approach that looks at the relationship between thoughts, feelings and behaviors, addressing the root cause of maladaptive behavior. Cognitive-behavioral therapy treats addiction as a behavior rather than a disease, and so is subsequently curable, or rather, unlearnable. Cognitive-behavioral therapy programs recognize that, for some individuals, controlled use is a more realistic possibility.

One of many recovery methods are 12-step recovery programs, with prominent examples including Alcoholics Anonymous, Narcotics Anonymous, Drug Addicts Anonymous and Pills Anonymous. They are commonly known and used for a variety of addictions for the individual addicted and the family of the individual. Substance-abuse rehabilitation (rehab) centers offer a residential treatment program for some of the more seriously addicted, in order to isolate the patient from drugs and interactions with other users and dealers. Outpatient clinics usually offer a combination of individual counseling and group counseling. Frequently, a physician or psychiatrist will prescribe medications in order to help patients cope with the side effects of their addiction. Medications can help immensely with anxiety and insomnia, can treat underlying mental disorders (cf. self-medication hypothesis, Khantzian 1997) such as depression, and can help reduce or eliminate withdrawal symptomology when withdrawing from physiologically addictive drugs. Some examples are using benzodiazepines for alcohol detoxification, which prevents delirium tremens and complications; using a slow taper of benzodiazepines or a taper of phenobarbital, sometimes including another antiepileptic agent such as gabapentin, pregabalin, or valproate, for withdrawal from barbiturates or benzodiazepines; using drugs such as baclofen to reduce cravings and propensity for relapse amongst addicts to any drug, especially effective in stimulant users, and alcoholics (in which it is nearly as effective as benzodiazepines in preventing complications); using clonidine, an alpha-agonist, and loperamide for opioid detoxification, for first-time users or those who wish to attempt an abstinence-based recovery (90% of opioid users relapse to active addiction within eight months or are multiple relapse patients); or replacing an opioid that is interfering with or destructive to a user's life, such as illicitly-obtained heroin, dilaudid, or oxycodone, with an opioid that can be administered legally, reduces or eliminates drug cravings, and does not produce a high, such as methadone or buprenorphineopioid replacement therapy – which is the gold standard for treatment of opioid dependence in developed countries, reducing the risk and cost to both user and society more effectively than any other treatment modality (for opioid dependence), and shows the best short-term and long-term gains for the user, with the greatest longevity, least risk of fatality, greatest quality of life, and lowest risk of relapse and legal issues including arrest and incarceration.

In a survey of treatment providers from three separate institutions, the National Association of Alcoholism and Drug Abuse Counselors, Rational Recovery Systems and the Society of Psychologists in Addictive Behaviors, measuring the treatment provider's responses on the "Spiritual Belief Scale" (a scale measuring belief in the four spiritual characteristics of AA identified by Ernest Kurtz); the scores were found to explain 41% of the variance in the treatment provider's responses on the "Addiction Belief Scale" (a scale measuring adherence to the disease model or the free-will model of addiction).

Behavioral programming

Behavioral programming is considered critical in helping those with addictions achieve abstinence. From the applied behavior analysis literature and the behavioral psychology literature, several evidence based intervention programs have emerged: (1) behavioral marital therapy; (2) community reinforcement approach; (3) cue exposure therapy; and (4) contingency management strategies. In addition, the same author suggests that social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious. Community reinforcement has both efficacy and effectiveness data. In addition, behavioral treatment such as community reinforcement and family training (CRAFT) have helped family members to get their loved ones into treatment. Motivational intervention has also shown to be an effective treatment for substance dependence.

Alternative therapies

Alternative therapies, such as acupuncture, are used by some practitioners to alleviate the symptoms of drug addiction. In 1997, the American Medical Association (AMA) adopted, as policy, the following statement after a report on a number of alternative therapies including acupuncture:

There is little evidence to confirm the safety or efficacy of most alternative therapies. Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious. Well-designed, stringently controlled research should be done to evaluate the efficacy of alternative therapies.

Treatment and issues

Medical professionals need to apply many techniques and approaches to help patients with substance related disorders. Using a psychodynamic approach is one of the techniques that psychologists use to solve addiction problems. In psychodynamic therapy, psychologists need to understand the conflicts and the needs of the addicted person, and also need to locate the defects of their ego and defense mechanisms. Using this approach alone has proven to be ineffective in solving addiction problems. Cognitive and behavioral techniques should be integrated with psychodynamic approaches to achieve effective treatment for substance related disorders. Cognitive treatment requires psychologists to think deeply about what is happening in the brain of an addicted person. Cognitive psychologists should zoom in to neural functions of the brain and understand that drugs have been manipulating the dopamine reward center of the brain. From this particular state of thinking, cognitive psychologists need to find ways to change the thought process of the addicted person.

Cognitive approach

There are two routes typically applied to a cognitive approach to substance abuse: tracking the thoughts that pull patients to addiction and tracking the thoughts that prevent them from relapsing. Behavioral techniques have the widest application in treating substance related disorders. Behavioral psychologists can use the techniques of "aversion therapy", based on the findings of Pavlov's classical conditioning. It uses the principle of pairing abused substances with unpleasant stimuli or conditions; for example, pairing pain, electrical shock, or nausea with alcohol consumption. The use of medications may also be used in this approach, such as using disulfiram to pair unpleasant effects with the thought of alcohol use. Psychologists tend to use an integration of all these approaches to produce reliable and effective treatment. With the advanced clinical use of medications, biological treatment is now considered to be one of the most efficient interventions that psychologists may use as treatment for those with substance dependence.

Medicinal approach

Another approach is to use medicines that interfere with the functions of the drugs in the brain. Similarly, one can also substitute the misused substance with a weaker, safer version to slowly taper the patient off of their dependence. Such is the case with Suboxone in the context of opioid dependence. These approaches are aimed at the process of detoxification. Medical professionals weigh the consequences of withdrawal symptoms against the risk of staying dependent on these substances. These withdrawal symptoms can be very difficult and painful times for patients. Most will have steps in place to handle severe withdrawal symptoms, either through behavioral therapy or other medications. Biological intervention should be combined with behavioral therapy approaches and other non-pharmacological techniques. Group therapies including anonymity, teamwork and sharing concerns of daily life among people who also suffer from substance dependence issues can have a great impact on outcomes. However, these programs proved to be more effective and influential on persons who did not reach levels of serious dependence.

History

The phenomenon of drug addiction has occurred to some degree throughout recorded history. Modern agricultural practices, improvements in access to drugs, advancements in biochemistry, and dramatic increases in the recommendation of drug usage by clinical practitioners have exacerbated the problem significantly in the 20th century. Improved means of active biological agent manufacture and the introduction of synthetic compounds, such as fentanyl and methamphetamine, are also factors contributing to drug addiction.

For the entirety of US history, drugs have been used by some members of the population. In the country's early years, most drug use by the settlers was of alcohol or tobacco.

The 19th century saw opium usage in the US become much more common and popular. Morphine was isolated in the early 19th century, and came to be prescribed commonly by doctors, both as a painkiller and as an intended cure for opium addiction. At the time, the prevailing medical opinion was that the addiction process occurred in the stomach, and thus it was hypothesized that patients would not become addicted to morphine if it was injected into them via a hypodermic needle, and it was further hypothesized that this might potentially be able to cure opium addiction. However, many people did become addicted to morphine. In particular, addiction to opium became widespread among soldiers fighting in the Civil War, who very often required painkillers and thus were very often prescribed morphine. Women were also very frequently prescribed opiates, and opiates were advertised as being able to relieve "female troubles".

Many soldiers in the Vietnam War were introduced to heroin and developed a dependency on the substance which survived even when they returned to the US. Technological advances in travel meant that this increased demand for heroin in the US could now be met. Furthermore, as technology advanced, more drugs were synthesized and discovered, opening up new avenues to substance dependency.

Society and culture

Demographics

Internationally, the U.S. and Eastern Europe contain the countries with the highest substance abuse disorder occurrence (5-6%). Africa, Asia, and the Middle East contain countries with the lowest worldwide occurrence (1-2%). Across the globe, those that tended to have a higher prevalence of substance dependence were in their twenties, unemployed, and men. The National Survey on Drug Use and Health (NSDUH) reports on substance dependence/abuse rates in various population demographics across the U.S. When surveying populations based on race and ethnicity in those ages 12 and older, it was observed that American Indian/Alaskan Natives were among the highest rates and Asians were among the lowest rates in comparison to other racial/ethnic groups.

Substance Use in Racial/Ethnic Groups
Race/Ethnicity Dependence/Abuse Rate
Asian 4.6%
Black 7.4%
White 8.4%
Hispanic 8.6%
Mixed race 10.9%
Native Hawaiian/

Pacific Islander

11.3%
American Indian/

Alaskan Native

14.9%

When surveying populations based on gender in those ages 12 and older, it was observed that males had a higher substance dependence rate than females. However, the difference in the rates are not apparent until after age 17.Drug and Alcohol Dependence reports that older adults abuse drugs including alcohol at a rate of 15-20%. It's estimated that 52 million Americans beyond 12 years old have abused a substance.

Substance Use in Different Genders w/ Respect to Age 
Age Male Female
12 and older 10.8% 5.8%
12-17 5.3% 5.2%
18 or older 11.4% 5.8%

Alcohol dependence or abuse rates were shown to have no correspondence with any person's education level when populations were surveyed in varying degrees of education from ages 26 and older. However, when it came to illicit drug use there was a correlation, in which those that graduated from college had the lowest rates. Furthermore, dependence rates were greater in unemployed populations ages 18 and older and in metropolitan-residing populations ages 12 and older.

Illicit Drug Dependence Demographics (Education, Employment, and Regional)
Education level Rates Employment status Rates Region Rates
high school 2.5% un-employed 15.2% large metropolitan 8.6%
no-degree, college 2.1% part-time 9.3% small metropolitan 8.4%
college graduate 0.9% full-time 9.5% non-metropolitan 6.6%

The National Opinion Research Center at the University of Chicago reported an analysis on disparities within admissions for substance abuse treatment in the Appalachian region, which comprises 13 states and 410 counties in the Eastern part of the U.S. While their findings for most demographic categories were similar to the national findings by NSDUH, they had different results for racial/ethnic groups which varied by sub-regions. Overall, Whites were the demographic with the largest admission rate (83%), while Alaskan Native, American Indian, Pacific Islander, and Asian populations had the lowest admissions (1.8%).

Legislation

Depending on the jurisdiction, addictive drugs may be legal, legal only as part of a government sponsored study, illegal to use for any purpose, illegal to sell, or even illegal to merely possess.

Most countries have legislation which brings various drugs and drug-like substances under the control of licensing systems. Typically this legislation covers any or all of the opiates, amphetamines, cannabinoids, cocaine, barbiturates, benzodiazepines, anesthetics, hallucinogenics, derivatives and a variety of more modern synthetic drugs. Unlicensed production, supply or possession is a criminal offence.

Usually, however, drug classification under such legislation is not related simply to addictiveness. The substances covered often have very different addictive properties. Some are highly prone to cause physical dependency, while others rarely cause any form of compulsive need whatsoever. Also, under legislation specifically about drugs, alcohol and nicotine are not usually included.

Although the legislation may be justifiable on moral or public health grounds, it can make addiction or dependency a much more serious issue for the individual: reliable supplies of a drug become difficult to secure, and the individual becomes vulnerable to both criminal abuse and legal punishment.

It is unclear whether laws against illegal drug use do anything to stem usage and dependency. In jurisdictions where addictive drugs are illegal, they are generally supplied by drug dealers, who are often involved with organized crime. Even though the cost of producing most illegal addictive substances is very low, their illegality combined with the addict's need permits the seller to command a premium price, often hundreds of times the production cost. As a result, addicts sometimes turn to crime to support their habit.

United States

In the United States, drug policy is primarily controlled by the federal government. The Department of Justice's Drug Enforcement Administration (DEA) enforces controlled substances laws and regulations. The Department of Health and Human Services' Food and Drug Administration (FDA) serve to protect and promote public health by controlling the manufacturing, marketing, and distribution of products, like medications.

The United States' approach to substance abuse has shifted over the last decade, and is continuing to change. The federal government was minimally involved in the 19th century. The federal government transitioned from using taxation of drugs in the early 20th century to criminalizing drug abuse with legislations and agencies like the Federal Bureau of Narcotics (FBN) mid-20th century in response to the nation's growing substance abuse issue. These strict punishments for drug offenses shined light on the fact that drug abuse was a multi-faceted problem. The President's Advisory Commission on Narcotics and Drug Abuse of 1963 addressed the need for a medical solution to drug abuse. However, drug abuse continued to be enforced by the federal government through agencies such as the DEA and further legislations such as The Controlled Substances Act (CSA), the Comprehensive Crime Control Act of 1984, and Anti-Drug Abuse Acts.

In the past decade, there have been growing efforts through state and local legislations to shift from criminalizing drug abuse to treating it as a health condition requiring medical intervention. 28 states currently allow for the establishment of needle exchanges. Florida, Iowa, Missouri and Arizona all introduced bills to allow for the establishment of needle exchanges in 2019. These bills have grown in popularity across party lines since needle exchanges were first introduced in Amsterdam in 1983. In addition, AB-186 Controlled substances: overdose prevention program was introduced to operate safe injection sites in the City and County of San Francisco. The bill was vetoed on September 30, 2018 by California Governor Jerry Brown. The legality of these sites are still in discussion, so there are no such sites in the United States yet. However, there is growing international evidence for successful safe injection facilities.

Euthanasia and the slippery slope

From Wikipedia, the free encyclopedia

Critics of euthanasia sometimes claim that legalizing any form of the practice will lead to a slippery slope effect, resulting eventually in non-voluntary or even involuntary euthanasia. The slippery slope argument has been present in the euthanasia debate since at least the 1930s.

Lawyer Eugene Volokh argued in his article The Mechanism of the Slippery Slope that judicial logic could eventually lead to a gradual break in the legal restrictions for euthanasia, while medical oncologist and palliative care specialist Jan Bernheim believes the law can provide safeguards against slippery-slope effects, saying that the grievances of euthanasia opponents are unfounded.

The slippery slope

As applied to the euthanasia debate, the slippery slope argument claims that the acceptance of certain practices, such as physician-assisted suicide or voluntary euthanasia, will invariably lead to the acceptance or practice of concepts which are currently deemed unacceptable, such as non-voluntary or involuntary euthanasia. Thus, it is argued, in order to prevent these undesirable practices from occurring, we need to resist taking the first step.

There are two basic forms which the argument may take, each of which involves different arguments for and against. The first of these, referred to as the logical version, argues that the acceptance of the initial act, A, logically entails the acceptance of B, where A is acceptable but B is an undesirable action. This version is further refined into two forms based on how A entails B. In the first, it is argued that there "is no relevant conceptual difference between A and B" – the premises that underlie the acceptance of A logically entail the acceptance of B. Within the euthanasia debate, van der Burg identifies one of Richard Sherlock's objections to Duff and Campbell as fitting this model. Duff and Campbell had presented an argument for the selective non-treatment of newborns suffering from serious defects. In responding to Duff and Campbell's stance, Sherlock argued that the premises which they employed in order to justify their position would be just as effective, if not more so, in justifying the non-treatment of older children: "In short, if there is any justification at all for what Duff and Campbell propose for newborns then there is better justification for a similar policy with respect to children at any age."

The second logical form of the slippery slope argument, referred to as the "arbitrary line" version, argues that the acceptance of A will lead to the acceptance of A1, as A1 is not significantly different from A. A1 will then lead to A2, A2 to A3, and eventually the process will lead to the unacceptable B. As Glover argues, this version of the argument does not say that there is no significant difference between A and B, but instead argues that it is impossible to justify accepting A while also denying B – drawing a line at any point between the two would be creating an arbitrary cut-off point that would be unjustifiable. Glover provides the example of infanticide (or non-voluntary euthanasia) and severely deformed children:

"If it is allowable at birth for children with some grave abnormality, what will we say about an equally grave abnormality that is only detectable at three months? And another that is only detectable at six months? And another that is detectable at birth only slightly less serious? And another that is slightly less serious than that one?"

— Jonathan Glover

The second primary form of the slippery slope argument is that of the "Empirical" or "Psychological" argument. The empirical version does not rely on a logical connection between A and B, but instead argues that an acceptance of A will, in time, lead to an acceptance of B. The process is not a logical necessity, but one which will be followed through a process of moral change. Enoch describes the application of this form of the argument thus:

"Once we allow voluntary euthanasia, she argues, we may (or will) fail to make the crucial distinction, and then we will make the morally unacceptable outcome of allowing involuntary euthanasia; or perhaps even though we may make the relevant distinction, we will not act accordingly for some reason (perhaps a political reason, or a reason that has to do with weakness of will, or some other reason)."

— David Enoch

Glover, however, notes that this line of argument requires good evidence that this direction will be followed, as not all boundaries are thus pushed.

More generally, it has been argued that in employing the slippery slope there can be an "implicit concession", as it starts from the assumption that the initial practice is acceptable – even though it will lead to unacceptable outcomes in the future. Nevertheless, van der Burg argues that this is not a useful concession, as the outcomes are intended to make it clear that the initial practice was not justifiable after all.

Response to the logical versions

Countering the first logical version of the slippery slope argument, it is argued that the different types of euthanasia are sufficiently distinct that it is not "logically inconsistent" to support one version while denying the others. It is possible to support, for example, voluntary euthanasia while denying non-voluntary euthanasia, just as it is possible to support both – the distinction comes not from a logical inconsistency, but a choice of principles, such that a focus on euthanasia as personal choice will support voluntary euthanasia but not non-voluntary euthanasia, while a focus on a person's "best interests" may allow for the support of both. From a more practical perspective, another option when faced with the logical version of the argument is to simply accept the consequences. This was the response by Duff and Campbell to Sherlock. Rather than arguing that their premises were flawed, they argued that Sherlock was correct: their criteria could also be applied to older children, and thus it should be applied, as it was "probably the most caring policy generally."

In responding to the "arbitrary line" version of the slippery slope argument, it is argued that the stance relies on the "paradox of the heap", and that it is possible to draw a line between the acceptable and unacceptable alternatives. Furthermore, in the case of euthanasia, it is possible to draw hard lines between different types of practices. For example, there is a clear distinction between voluntary and non-voluntary euthanasia, such that the arbitrary line approach cannot be applied.

The empirical argument

Glover argues that the empirical argument needs to be backed by evidence, as there are situations where we do not seem to push boundaries. Generally, two examples are discussed – Action T4, the Nazi euthanasia program in Germany between 1939 and 1941, and the Groningen Protocol in the Netherlands, which has allowed for non-voluntary euthanasia of severely deformed newborns.

Lewis notes that the focus has been on voluntary to non-voluntary euthanasia, rather than physician-assisted suicide to voluntary euthanasia, as there have been no instances of the latter: in jurisdictions where physician-assisted suicide have been legalised, there have been no moves to legalise voluntary euthanasia, while jurisdictions that have legalised voluntary euthanasia also allowed physician-assisted suicide at the same time.

Action T4

Hartheim Euthanasia Centre, where over 18,000 people were killed.

Leo Alexander, in examining the events of the Holocaust during the Nuremberg Trials, stated that the origins of the Nazi programs could be traced back to "small beginnings", and presented a slippery slope argument. Others have argued that Action T4 is not an example of the empirical slippery slope, as euthanasia was still a criminal act in Germany during that time, and there is "no record of the Nazi doctors either killing or assisting in the suicide of a patient who was suffering intolerably from a fatal illness".

Euthanasia historian Ian Dowbiggin linked the Nazis' Action T4 to the resistance in the West to involuntary euthanasia. He believes that the revulsion inspired by the Nazis led to some of the early advocates of euthanasia in all its forms in the U.S. and U.K. removing non-voluntary euthanasia from their proposed platforms.

The Groningen Protocol

Non-voluntary euthanasia is sometimes cited as one of the possible outcomes of the slippery slope argument, in which it is claimed that permitting voluntary euthanasia to occur will lead to the support and legalization of non-voluntary and involuntary euthanasia. Some studies of the Netherlands after the introduction of voluntary euthanasia state that there was no evidence to support this claim while other studies state otherwise.

A study from the Jakobovits Center for Medical Ethics in Israel argued that a form of non-voluntary euthanasia, the Groningen Protocol, has "potential to validate the slippery-slope argument against allowing euthanasia in selected populations". Anesthesiologist William Lanier says that the "ongoing evolution of euthanasia law in the Netherlands" is evidence that a slippery slope is "playing out in real time". Pediatrician Ola Didrik Saugstad says that while he approves of the withholding of treatment to cause the death of severely ill newborns where the prognosis is poor, he disagrees with the active killing of such newborns. Countering this view, professor of internal medicine Margaret Battin finds that there is a lack of evidence to support slippery slope arguments. Additionally, it is argued that the public nature of the Groningen Protocol decisions, and their evaluation by a prosecutor, prevent a "slippery slope" from occurring.

A 1999 study by Jochemsen and Keown from the Dutch Christian Lindeboom Institute published in the peer reviewed Journal of Medical Ethics, argued that euthanasia in the Netherlands is not well-controlled and that there is still a significant percentage of cases of euthanasia practiced illegally. Raanan Gillon, from the Imperial College School of Medicine, University of London commented in 1999 that "what is shown by the empirical findings is that restrictions on euthanasia that legal controls in the Netherlands were supposed to have implemented are being extensively ignored and from that point of view it is surely justifiable to conclude, as Jochemsen and Keown do conclude, that the practice of euthanasia in the Netherlands is in poor control". A similar conclusion was presented in 1997 by Herbert Hendin, who argued that the situation in The Netherlands demonstrated a slippery slope in practice, changing the attitudes of doctors over time and moving them from tightly regulated voluntary euthanasia for the terminally ill to the acceptance of euthanasia for people suffering from psychological distress, and from voluntary euthanasia to the acceptance of non-voluntary and potentially involuntary euthanasia.

An October 2007 study, published in the Journal of Medical Ethics, found that "rates of assisted dying in Oregon and in the Netherlands showed no evidence of heightened risk for the elderly, women, the uninsured (inapplicable in the Netherlands, where all are insured), people with low educational status, the poor, the physically disabled or chronically ill, minors, people with psychiatric illnesses including depression, or racial or ethnic minorities, compared with background populations. The only group with a heightened risk was people with AIDS."

A 2009 review study of euthanasia in the Netherlands concluded that no slippery slope effect has occurred, while another study of the same year found that abuse of the Dutch euthanasia system is rare. In 2010, a study found that there is no evidence that legalizing assisted suicide will lead us down the slippery slope to involuntary euthanasia.

Most critics rely predominantly on Dutch evidence of cases of "termination of life without an explicit request" as evidence for the slide from voluntary euthanasia to non-voluntary euthanasia. One commenter wrote that critics who rely on this slippery slope argument often omit two important elements, thereby using flawed logic. First, the argument is only effective against legalization if it is legalization which causes the slippery slope; and secondly, it is only effective if it is used comparatively, to show that the slope is more slippery in the Netherlands than it is in jurisdictions which have not legalized assisted suicide or euthanasia.  Since these questions have not been addressed by critics, little attention has been paid to available evidence on causation and comparability.

Research review studies

In the most recent review paper on euthanasia in the Netherlands, namely the 2009 paper entitled Two Decades of Research on Euthanasia from the Netherlands. What Have We Learnt and What Questions Remain? written by researchers from the Department of Public Health in the Netherlands, it was found that "public control and transparency of the practice of euthanasia is to a large extent possible" and that "[n]o slippery slope seems to have occurred". The researchers find that the legalization of euthanasia in the Netherlands did not result in a slippery slope for medical end-of-life practices because:

  1. The frequency of ending of life without explicit patient request did not increase over the studied years;
  2. There is no evidence for a higher frequency of euthanasia, compared with background populations, among:

In 2010, 4050 persons died from euthanasia or from assisted suicide on request. According to research done by the Vrije Universiteit (Amsterdam), University Medical Center Utrecht and Statistics Netherlands, and published in The Lancet, this is not more than before the introduction of the "Termination of Life on Request and Assisted Suicide (Review Procedures) Act" in 2002. Both in the Netherlands and in Belgium, the number of termination of life without explicit request for terminally ill patients, decreased after the introduction of the legislation about the termination of life. In effect, the legislation did not lead to more cases of euthanasia and assisted suicide on request.

Butane

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