Ever since people first crushed and fermented grapes, the dark hand of alcoholism has been present. When the first games of chance and competition were born – so too was the addiction to gambling.
We can well imagine that abusing cannabis came, even as it was used for medicinal and religious purposes in the 3rd millennium BC.
And breathing in the toxic smoke from burning tobacco was a daily human habit, well before Christopher Columbus landed in the Americas in 1492 and brought it back to Europe.
But now, in our digital age, technology has accelerated our addictions.
And the stress and isolation brought to us by COVID-19 have pushed many to addictions they never thought they had.
Alcohol and cigarettes can be delivered to our doors from digital orders placed on mobile phones. The Dark Web and chemistry have conspired to create hazardous new psychoactive substances that pose as cannabis, available with a few keystrokes on a laptop. An Internet poker or roulette game can be found 24 hours a day, every day of the year. The Internet has sped us down the path of over-shopping, over-eating, and over-playing competitive games.
Ever adaptable and flexible, the Internet has even created new addictions – such as Internet pornography and anonymous sex “dating”.
If we are unlucky enough to fall down these digital “rabbit holes”, what are the results? Alice’s Wonderland? Or: failing health and finances; anxiety; depression; isolation, fractious and failing relationships, lost schooling and jobs; self-harm; and suicidal thoughts. “Jails, institutions and death” – as Alcoholics Anonymous warn us. A life without meaning, purpose or dignity.
But just as addictions have been accelerated by technology and new ones invented, technology has also enabled us to make recovery more convenient, available, cheaper, effective, and timely.
The longest journey for people suffering from addictions has been from the “bottle” to the therapy room. Any number of “barriers” stood in the way. Not enough time, not enough money, not enough knowledge of which therapist to see or what recovery involves.
But the biggest barrier of all to entering recovery was shame.
Now, therapy can be done on the Internet: information about therapists can be Googled; prices compared; social service agencies offering low-cost therapy or even free therapy can be found, and rich information and video testimonies on the recovery journey can be reviewed.
Best of all, Zoom therapy can be conducted with a therapist “once removed” from the personal space of the client by computer screens – and in the comfort of the client’s own living room or bedroom. Clients could even maintain much of their anonymity. In this safe space, shame may deign to take a back seat.
With digital recovery free from barriers, even if the sufferer is still reluctant to seek help, they may be more inclined to reflect on why they remain reluctant to get and receive help. If they do start to reflect honestly – they have started their first step on their recovery journey.
But more can be done with digital recovery.
I would submit that the next significant step in using the Internet to accelerate recovery is to bring the therapist to the clients where they are – on the sites that feed their addictions and perpetuate their suffering.
A therapist could join as a “player” in Animal Crossing, Fornite, a poker or roulette game. They can then engage suffering players in unthreatening and therapeutic conversations. Perhaps PornHub will produce an avatar “ambassador” – a therapist who guides users through a porn compulsiveness assessment? Perhaps the GrabEats avatar therapist will help customers with alcohol and calorie counts, consumption and portion control, alcohol use and dietary information – and motivational conversations to help customers build their resolve.
Engaging suffering people in their digital space opens a whole new avenue for the helping professional to guide someone towards a path of meaning and purpose.
Therapists may wish to think “Digital” – and harness the power of technology to enrich people’s lives – even if technology can also impoverish them.
What comes to mind when someone mentions alcohol? For many, alcohol is often associated with the temporary avoidance of daily struggles. Whether or not we have the habit to drink, it is a known fact that people may tend to have “blackouts” whenever they’re really drunk – and are unable to recall anything during these periods of time. As for young adults, perhaps it could also be attributed to their keen desire to look “cool” and to show off their high alcohol tolerance to their friends. However, alcohol can be addictive, and frequent heavy drinkers run the risk of becoming alcohol-dependent and hence developing alcohol use disorders. But what actions can we take if we find ourselves constantly wanting to submit to such an altered state of being, and seeing the appeal in losing control of ourselves as a form of escapism?
What is an Alcohol Use Disorder?
According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.;
DSM–5; American Psychiatric Association, 2013), an alcohol use disorder is essentially characterised by “a problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following, occurring within a 12-month period”:
Alcohol is often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
Craving, or a strong desire or urge to use alcohol.
Recurrent alcohol use resulting in a failure to fulfil major role obligations at work, school, or home.
Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
Recurrent alcohol use in situations where it is physically dangerous.
Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
In regards to the disorder’s severity, it is safe to say that an individual categorised under the ‘mild severity’ category would display two to three of the above symptoms, while those under ‘Moderate’ would display four to five. For persons who develop six or more of such symptoms, they would, unfortunately, be diagnosed to be severely alcohol-dependent.
In the development of alcohol abuse, we need to recognise that the physiological and psychological reward system in our brains are what contributes to the clouding of negative consequences and effects associated with alcohol dependence and addiction. In other words, the possibility for change is tough, and the learnt habit can be hard to kick. Positive and negative reinforcements play a major role, especially in the beginning stages of alcohol abuse. Positive reinforcement occurs when the chances of an individual performing an activity (in this case, drinking) is heightened due to his previous experience of feeling rewarded by the “high” he or she obtains when getting drunk. On the contrary, negative reinforcement occurs when the probability of alcohol-seeking behaviour increases upon allowing the drinker to avoid certain situations or negative stimuli. Therefore, it can be said that alcohol abuse is fuelled by the physiological and psychological reward system, thus increasing one’s motivation to consume more alcohol, though sometimes a little too much.
Alcohol addiction can be greatly detrimental to our lifestyles, as well as to our physical and mental health. Known to be a depressant, alcohol can have a significant impact on our brain’s activity. If you’re drinking unhealthy levels of alcohol in an attempt to manage other mental health conditions such as anxiety or depression, stop it immediately! Alcohol affects neurotransmitters in your brain, potentially worsening your pre-existing condition. As such, it is crucial that we help people with alcohol use disorders to move past their addiction to a more fulfilling lifestyle.
What forms of treatment can I consider?
Alcohol abuse can be treated with psychiatric or psychological intervention, sometimes a combination of both.
When it comes to psychiatric medications, psychiatrists may prescribe medications used primarily to treat alcohol withdrawal by targeting the GABA neurotransmitters in the brain, allowing the brain to restore its natural balance when the person abstains from alcohol. Another common medication prescribed mainly affects the individual’s alcohol metabolism. The drug increases the concentration of acetaldehyde, a product formed when alcohol is broken down. The buildup of this acetaldehyde induces undesirable effects such as vomiting, hence holding the person back from consuming large amounts of alcohol. However, despite these drugs being the commonly prescribed medications, it is extremely dangerous for one to source and consume them without first consulting a professional psychiatrist. Everyone’s case is different, and people may have differing medication needs.
Another form of treatment one can consider is Cognitive Behavioural Therapy (CBT). CBT is an effective method which focuses on helping one identify and uproot negative or irrational thoughts and/or behaviours. Being highly solution-focused, such forms of therapy can include trying to help these individuals to recognise situations in which they are inclined to drink, and how they can better repress themselves. As such, the main goal would be for these people to recognise their problematic behaviour, and subsequently cut down on and adhere to healthy alcohol consumption levels. Since the impact of alcohol abuse is usually not limited to the individual, family therapy may also be recommended at times, especially if the individual’s alcoholic behaviour causes others distress.
With economic growth and increased globalisation, alcohol consumption generally increases as it gets more affordable and popular as a drink for celebratory or social occasions, and even for stress-relief. This same trend has been observed in Singapore – where the per capita alcohol consumption in Singapore has nearly trebled from 2005 to 2015, and a study released in 2016 estimated the prevalence of binge drinking in Singapore to be 9.6 per cent of the population. Among young adults in the recent decade or so, the number of alcohol-related incidents including verbal abuse, physical abuse, domestic violence, as well as property damage and vandalism have also increased. According to the Institute of Mental Health, a nation-wide study in 2010 found that one in 19 of those aged 18 to 34 struggle with alcohol dependence, abuse and disorders. The study also highlighted that the chances of alcohol-use disorders in this age group were twice that of age groups above 35. In this article, we will thus explore why drinking is becoming more prevalent, and the types of alcohol-related harm that young adults are increasingly vulnerable to.
For sure, individuals don’t become an alcohol addict overnight – they usually start with binge drinking, which is the worrying trend among young adults. Binge drinking is defined as the heavy consumption of alcohol within a short span of time with the intention of being inebriated. Binge drinking can be classified under mainly two categories: extensive drinking on a single occasion, or continuous drinking over days or weeks. It isn’t a rare sight to see youths gathering on a Friday night or weekends to go clubbing – places where most drinks have high alcohol content. Even with the COVID19 pandemic at present, young adults can still be seen to gather in small groups to drink and socialise. As a matter of fact, more people have turned to drinking in order to cope with the COVID19 situation. On a global scale, studies have shown that alcohol sales and consumption has risen. As an example, according to a recent study conducted by the USA Nielsen Company, there has been a 240% increase in internet alcohol sales, including hard liquor. Needless to say, it is not surprising that more Singaporeans would pick up drinking in order to cope with their unpleasant emotions and distress as well.
Frequent binge drinking may lead to alcohol dependence or addiction, especially when these individuals start consuming larger amounts of alcohol in order to obtain the same “high”. So why are more young adults exposed to alcohol drinking? Firstly, Singapore’s progress and prosperity have brought about lifestyle changes of youths and young adults compared to their parents’ generation. The increasing independence and thrill-seeking behaviours of these younger people might also include experimenting with alcohol. Secondly, globalisation has undermined many of the traditional controls on alcohol, making it widely available and aggressively marketed and promoted throughout society.
People who begin drinking early in life run the risk of developing serious alcohol problems, including alcoholism, later in life. They also are at greater risk for a variety of adverse consequences and poor performance in school or at work.
Overall, alcohol-related harm doesn’t merely include alcohol poisoning or eventual liver failure. Rather, it can also refer to:
Other related long-term diseases due to chronic heavy drinking
Unintended sexual behaviours, including sexual assault
Accidents such as those caused by drunk-driving
Crime, including violent crimes and homicide
To reiterate, binge drinking can very well lead to alcoholism and it shouldn’t be taken too lightly. Identifying people at greatest risk can help stop problems before they develop. Young people are at greater risk of alcohol-related harm than adults. Excessive alcohol drinking as a teenager can greatly increase the risk of damage to the developing brain and also lead to problems with alcohol later in life. For those of you that find yourselves increasingly inclined to drink high amounts of alcohol, do consider taking proactive steps to reduce your intake. It may require strong willpower and determination initially, but things will be easier once you take the first step. Go for alcohol addiction treatment therapy or counselling, if it can give you the push you need to counter your drinking habits, or connect with like-minded people through peer support groups such as Alcoholics Anonymous. By curbing and reducing your alcohol consumption to safe levels, you will be doing both your physical and mental health a favour.
Dr. Barry L. Jackson, 2016, Drinking & Alcohol-Related Harm Among Young Adults, video recording, Mental Health Academy
Chodkiewicz J., Talarowska M., Miniszewska J., Nawrocka N. (2020) ‘Alcohol Consumption Reported during the COVID-19 Pandemic: The Initial Stage’, Int. J. Environ. Res. Public Health 2020, 17(13), 4677; https://doi.org/10.3390/ijerph17134677 (Accessed 22/08/2020)
Predictive algorithms, the creation of alternate realities in which we are unlimited by the constraints of the real world we live in – such methods are extensively practiced by the gaming industry to draw players in. Gaming is undeniably a popular and widely-adopted mode of de-stressing, but how much is too much?
In May 2019, the World Health Organisation officially recognised “gaming addiction” as a mental health condition. It is diagnosed when a person displays a gaming behaviour pattern that causes significant disruption to their daily life for a period of 12 months. Meanwhile, a study showed that Singaporeans aged 18 and above spend a weekly average of 7 hours and 26 minutes playing video games, and that approximately 10 percent of Singaporeans game for more than 20 hours per week. This ranks us as the highest in Asia, and third highest in the world, falling only behind Germany and the United States.
What leads these addicted individuals to their compulsive gaming behaviour? Besides the prevalence and ease of access to games on various gaming platforms, video games often act as a form of escapism for many players. As a shining proponent of the alluring, edge-cutting virtuality, games allow for players to throw themselves into a virtual landscape that is contrasted from their – comparatively – mundane everyday lives, and can serve as a distractor from real-life problems that they are unconfident or reluctant to face. Moreover, it can be easy to fall into the trap set by game creators. Game designers construct games in a way that applies principles of behavioural economics as well as psychological mechanisms to explore stages and levelling up processes that trigger the brain’s reward system. In-game statuses matter a lot to gamers – the higher the rank you possess, the more pride and self-esteem you hold, knowing that you can show it off to your friends or gaming counterparts. As a result, individuals are often inclined to continue striving to climb the virtual hierarchy.
Naturally, excessive gaming has its consequences. When an individual develops a gaming disorder, his lifestyles can be disrupted in more ways than one. What is also important to take note of, is that the harmful effects of gaming addiction is not only limited to the individual alone, but could also affect the people in his or her social circle. Some of these adverse effects can include:
Obsessive Behaviour Individuals who are addicted to video games are always anxious to get back to games and will often display irritable, bad-temper aggressive behaviour whenever they are separated from their games unwillingly.
Increased Social Isolation With extended periods of intense gaming, these individuals become more withdrawn and disconnected from family, friends and colleagues, causing them to drift away from their loved ones.
Other Mental Health Conditions Gaming addiction can eventually lead to other issues that include depression or anxiety disorders. Sometimes, depression may follow due to the prolonged social isolation.
Other Physical Health Conditions A gaming addiction can also have a number of physical effects. When one devotes an excessive amount of time to the gaming activity, this can lead to physical conditions such as the carpal tunnel syndrome, migraine, back-aches or eye-strain. Extreme addiction may cause gamers to skip meals and rest, or neglect their personal hygiene as they lose control of themselves and can’t resist the desire to play more and more.
Gaming addiction is a serious matter, and can be degenerative if not addressed in the early stages with the initial symptoms and signs. Habits, including unhealthy gaming habits, can be formed anytime between 1 to 3 months, and it will be significantly easier to curb such self-destructive behaviour the earlier we try to tackle it.
While we are concerned with the various health risks and conditions commonly associated with gaming addiction, we cannot deny that video games are also undoubtedly entertaining and can be a good way to de-stress. However, as the risk of gaming addiction increases with increasing time spent gaming, what we want to advocate is moderation, rather than complete avoidance. With that said, if you are someone who is battling gaming compulsion, try to keep the amount of time spent gaming under control by setting time limits for play and stick to them. If possible, try reducing your playtime gradually by setting a timer on your phone, or use softwares such as ‘Cold Turkey Blocker’ to help you do this by blocking access to websites or applications so that you can get offline when you need to.
Like other forms of addictions, don’t try to go cold turkey at one go. Stopping altogether may cause you to feel as though there is a huge void in your life, hence increasing the likelihood of a relapse instead.
According to the World Health Organisation, tobacco kills more than 8 million people worldwide each year, and is one of the biggest public health threats the world has ever faced. But contrary to popular belief that smokers are “uneducated regarding it’s harmful effects”, or are simply “not bothered to make an effort to quit”, studies have shown that 70% to 80% of smokers do hope to quit smoking. The only thing holding them back is that they can’t.
Nicotine is widely known to be a highly addictive substance. It is the chemical in tobacco that makes it hard to quit and nicotine withdrawal symptoms that smokers experience can be extremely unpleasant physically and mentally. Apart from the intense craving for nicotine, withdrawal symptoms may also include sweating, increased irritability, difficulty in concentrating, as well as difficulty in sleeping. However, nicotine dependence is causing the compulsion to smoke, it is other chemical substances that cause physical damage to the body. Chemicals such as tar can paralyse the hair-like structures in the lungs (also known as the cilia), contributing to diseases such as chronic bronchitis. Moreover, smokers are also vulnerable to the development of lung cancer. Cigarette smoke contains a cancer-causing substance, benzopyrene, which can attack and damage the p53 gene. When the tumour-suppressor gene is damaged, cancer cells have a higher chance of proliferating due to uncontrolled cell division, hence increasing the risk of tumour growth.
Ideally, quitting smoking and nicotine completely would be the best, but it’s proven to be tough for addicted cigarette smokers to stop all at once. As such, a harm reduction strategy would be switching to a less harmful nicotine alternative for smokers, and ideally would result in them ultimately quitting nicotine use altogether. This is all about lowering the health risks to individuals and wider society associated with tobacco smoking. Some of the more commonly known alternatives include electronic cigarettes and heated tobacco products (also known as heat-not-burn or HnB). Although these may not be accessible in Singapore, other countries have legalised these smoke-free nicotine products that generally deliver far lower levels of toxic compounds.
E-cigarettes are battery-operated electronic devices that mimic the act of regular smoking by heating a liquid to generate an aerosol, which is inhaled by users through the mouthpiece and exhaled as a visible vapour. Often, the usage of e-cigarettes is also known as “vaping”. Not to be confused with e-cigarettes, HnBs work in a different manner. In some way, HnBs are a hybrid of traditional cigarettes and e-cigarettes. In HnBs, the tobacco is heated to 350℃, compared to traditional cigarettes that combust and burn at a temperature of up to 900℃. On the other hand, e-cigarettes heat nicotine-containing liquid to approximately 250℃, causing it to be vapourised and then inhaled.
Although not risk-free, what makes e-cigarettes and HnBs a better option compared to conventional, combustible cigarettes? Cigarette smoke is pretty much the main cause of harm, with thousands of toxins released in high concentrations upon the combustion of tobacco. Unlike traditional cigarettes, its alternatives are smoke-free – this means that smoke-induced health effects are significantly reduced. When smokers make the switch to using e-cigarettes or HnBs, these devices also have the added advantage of replicating the ever so familiar hand-to-mouth ritual of smoking. However, it is crucial to note that both e-cigarettes and HnBs still contain nicotine, so while smoke-induced health effects are reduced, the effects of nicotine consumption is still prevalent, for as long as these products are used.
It must be acknowledged that many health professionals, tobacco-use control professionals and policy-makers who recommend the harm reduction alternatives have very good intentions. They advocate reduction in conventional cigarette smoking as a pragmatic way of reducing the devastating health effects associated with nicotine dependency. However, good intentions must always be supported by strong evidence.
This year, the Asia Pacific Behavioural and Addiction Medicine Conference (APBAM 2020) will be a socially distanced online conference. Focusing on “Tobacco Harm Reduction – Myths and Reality” for it’s first forum, the speakers will examine the use of new ways to overcome nicotine dependence, as well as the various policies that different countries have taken in their approaches and their effects on reducing the harms caused by cigarette smoking. Speakers will include Prof Alex Wodak (AUS), Dr. Jeremy Lim (SG), Dr. Takao Ohki (JP), Dr. Rusdi bin Abd Rashid (MY), Dr. Ben Cheung (HK), Dr. Munidasa Winslow (SG), Andrew da Roza (SG) & Dr Sivakumar Thurairajasingam. Do join us on 26th September 2020, we hope to see you there!
To non-smokers and those who have an occasional cigarette at a party or outside a bar, it is baffling why smokers just can’t simply quit. What’s the big deal?
If you think this, then the conclusion may be: “well they just don’t want to quit”; or “they are uneducated, and don’t know how much damage they’re doing to themselves and those around them”; “they have no conscience” or “they have no self-control”.
The problem with these conclusions is that the scientific evidence doesn’t support them.
70% to 80% of smokers want to quit – and many of them desperately want to quit – and most smokers fail.
A majority have tried to quit multiple times – and about 40% are still drawn to smoking -even after losing fingers and toes to gangrene, or lungs to cancer and COPD, as a result of smoking. Many suffer heart attacks, mouth, throat and colon cancer, or labour under serious diabetes problems; some even lose their close relationships with their families.
They wish that if only they could quit, their lives would be so much better – yet they continue to smoke.
So, there is more to the compulsion to smoking than meets the eye.
Perhaps kindness and compassion for smokers may be a more rational reaction – than dismissal, frustration, irritation, anger or contempt?
There are very good reasons why the chemicals in cigarette smoke are so compelling – and it’s to do with our brains and our bodies. It’s not a mystery.
Although nicotine in the smoke is a comparatively benign substance, and it doesn’t cause the damaging effects of the other harmful substances in the smoke – it is highly addictive. It is the nicotine that causes the addiction – but it is the tar and other substances that cause the damage.
In addition to nicotine, there is another substance, in smoke, that creates a potentially “pleasant” psychoactive effect. It is a monoamine oxidase inhibitor – which results in chemicals in the brain staying longer in the space between neurons and firing those neurons.
And the effect the smoker feels? Well, there can be numerous combinations of “positive” effects.
Those smokers who feel down, moody and unmotivated, may feel a pleasant “lift” or “boost”. Anxious, fearful and nervous smokers, may feel calmer, and more able to think straight. Smokers who are tired, sleepy or lethargic, may be able to focus, concentrate and pull themselves out of their procrastination.
Smoking helps some people become more energetic, have better reactions times and become more effective or efficient. Smoking enables people who are mentally tired with work or constant rumination, to feel like they are taking a break and “relaxing” from their thoughts. They can just let their minds gently wonder. They may even feel that after their “reverie” with a cigarette, they have managed to solve a problem that they have been grappling with.
Some people use smoking as a bonding experience. Ironically, all the community stigma that surrounds smokers makes some feel like a “band of brothers and sisters”, as they stand outside in smoking areas or in smoking rooms. It enables instant connection and the sense of “belonging”.
In short, the effects of smoking depend on how you are feeling in the moment.
Insidiously, mental illness and other addictions result in many becoming vulnerable to smoking – either to cope with: their illness; the difficult side effects of their medication; and the social stigma against mental illness addiction that so oppresses and shames them.
By way of examples, ADHD, schizophrenia, bipolar disorder, anxiety and major depressive disorders, and personality disorders, can all result in life-long suffering – that smoking may appear to “take the edge off”.
There is now persuasive research that some people are more genetically susceptible to being addicted to cigarette smoke. They may get more of a “buzz” from it, they may be more tolerant to its side effects, the effects may wear off faster, and they may feel the withdrawal effects (when not smoking) more keenly. They may have more trouble starting to quit – and staying quit.
There are many other vulnerability factors as well: adverse childhood events (which afflicts 2 out of every 3 Singaporeans); traumas; family and peer modelling; rebelliousness, isolation and loneliness, financial distress, problems in relationships and at work; and many more factors, may all conspire to lead smokers to smoke daily.
Once they smoke enough cigarettes for long enough – the brain changes, it becomes “hijacked” by the smoke.
Smokers experience brain changes as:
Tolerance – the need for more smoking, more often, to get the same effect;
Withdrawals – 45 minutes to two hours after smoking, they may feel the exact opposite of what they felt when they smoked – and therefore need a cigarette to feel “normal”;
Impulsiveness – in the moment (of smoking), they forget about the harms of tobacco and their resolves to quit, and habitually light up;
Smoking triggers – smoking cues are everywhere – and they trigger the urges and cravings – and once these build up, they become overwhelming;
Stress – their stress response slowly but inexorably ratchets upwards, daily – so that even things that used to be experienced as minor, now elicit strong and intolerable emotions. If health, relationships, jobs and self-image are all on the line because of smoking – the stress can be intense.
Luckily – there is a solution. Smokers now have access to psychotherapy, nicotine replacement therapy, quit smoking medication, and any number of other tools to help them on their quit journey. In other countries, new nicotine delivery technologies like e-cigarettes and heat-not-burn are being improved and refined – and they are much safer than smoking.