LMSW: Substance Use

Substance use disorder

A problematic pattern of using alcohol or another substance that results in impairment in daily life or noticeable distress

a person with this disorder will often continue to use the substance despite consequences

The person must have at least two of the following for a given substance within the same 12-month period

1. Taking the substance in larger amounts or for longer than the you meant to

2. Wanting to cut down or stop using the substance but not managing to

3. spending a lot of time getting, using, or recovering from use of the substance

4. cravings and urges to use the substance

5. not managing to do what you should work, home, or school because of substance use

6. continuing to use, even when it causes problems in relationships

7. giving up important social, occupational, or recreational activities because of substance use

8. using substances again and again, even when it puts you in danger

9. continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance

10. Needing more of the substance to get the effect you want (tolerance)

11. Development of withdrawal symptoms, which can be relieved by taking more of the substance

Substance intoxication

The development of a reversible, substance-specific syndrome as a result of the recent ingestion of a substance; must include maladaptive behavior or psychological changes and specific signs of the substance’s effects on the nervous system

Substance withdrawal

A substance-specific maladaptive behavioral change with physiological and cognitive correlates, due to cessation or reduction of heavy or prolonged substance use

Signs of Intoxication

inappropriate sexual or aggressive behaviors; impaired judgment; slurred speech; emotional lability; incoordination; unsteady gait; involuntary; rhythmic movement of the eyes; impaired attention or memory; stupor; coma

Signs of withdrawal

Sweating; tachycardia; hand tremor; insomnia; nausea or vomiting; transient illusions or hallucinations; anxiety; psychomotor agitation; gran mal seizures; delirium tremens (DT’S)

Wernicke- Encephalopathy and Wernicke-Korsakoff syndrome

are different conditions that often occur together. Both are due to brain damage caused by a lack of vitamin B1 (thiamine)

Wernicke-Korsakoff syndrome

is a chronic memory disorder caused by severe deficiency of thiamine (vitamin B-1). The individual may attempt to compensate for memory loss by fabricating memories. It can cause hallucinations and can also lead to personality changes. The prognosis for Wernicke-Korsakoff syndrome is generally poo

Wernicke-Encephalopathy

is an acute, life threatening (but reversible) condition that requires emergency treatment. It results from severe acute deficiency of thiamin. Individuals may experience confusion, loss of muscle coordination (leg tremors), and vision changes (abnormal eye movements, double vision, eyelid drooping). The prognosis is good if treated accordingly.

Amphetamines/Cocaine

Signs of Intoxication: euphoria; anxiety; hyperactivity; grandiosity; confusion; anger; paranoia; auditory hallucinations; tachycardia; elevated or lowered blood pressure; dilated pupils; perspiration or chills; nausea or vomiting; weight loss; psychomotor agitation; muscular weakness; confusion; seizures.

Signs of Withdrawal: dysphoric mood; fatigue; vivid and unpleasant dreams; insomnia or hypersomnia; increased appetite; psychomotor agitation or retardation.

Caffeine

Signs of Intoxication: restlessness; nervousness; excitement; insomnia; flushed face; diuresis; gastrointestinal disturbance; muscle twitches; rambling flow of thought and speech; tachycardia or arrhythmia; periods of inexhaustibility; psychomotor agitation.

Signs of Withdrawal: headache (most common); changes in mood (such as depression and anxiety); difficulty concentrating; fatigue; increased appetite.

Cannabis

Signs of Intoxication: impaired motor coordination; euphoria; anxiety; sensation of slowed time; impaired judgment; social withdrawal; conjunctival injection (redness of the eyes); increased appetite; dry mouth; tachycardia.

Signs of Withdrawal: irritability; anger or aggression; nervousness or anxiety; sleep difficulty (insomnia); decreased appetite or weight loss; restlessness; depressed mood; stomach pain; shakiness/tremors; sweating; fever, chills, and/or headache.

Hallucinogens

Signs of Intoxication: perceptual changes; anxiety; depression; ideas of reference; paranoid ideation; pupillary dilation; tachycardia; sweating; palpitations; blurred vision; tremors; incoordination.

Hallucinogen Persisting Perception Disorder (Flashbacks): Following the cessation of use, the reexperiencing of one or more of the perceptual symptoms that were experienced while intoxicated with the hallucinogen; this reexperiencing causes significant distress or impairment in social, occupation, or other important area of functioning.

Opioids

Signs of Intoxication: initial euphoria followed by apathy or dysphoria; pupillary constriction; drowsiness or coma; slurred speech; impairment in attention and memory.

Signs of Withdrawal: dysphoric mood; nausea or vomiting; muscle aches; lacrimation or rhinorrhea (runny eyes & nose); pupillary dilation; diarrhea; yawning; fever; insomnia.

Substance Use vs. Substance Induced Disorder:

Substance induced disorders are disorders that are caused by taking (or ceasing taking) drugs or alcohol. A substance use disorder, on the other hand, means that the primary area of concern is the use of a substance; it isn't causing another disorder to occur. ● So a substance induced mood disorder could look like depression that starts after a person begins heavy abuse of alcohol on a regular basis. The depression is induced (caused) by the substance use.

Other Important Facts/Considerations

12 Step Programs (AA, NA, etc.) are almost always part of addiction treatment and are based on a disease model (the idea that alcoholism is a disease that cannot be cured but only controlled).

The Alcoholic Family

Dependent

enabler

hero

scapegoat

lost child

mascot

Dependent

The alcoholic family member

enabler

often the spouse; the person who does everything to get the dependent to stop drinking expect what might actually work ( confrontation or leaving the relationship

hero

the family member who is aware of what is going on and tries to assume responsibility for the family by being successful (often the oldest child)

Lost child

the member who quietly withdraws from the family system (often the 3rd child)

Mascot

the member who “plays the clown in order to relieve family tension or their own pain (often the youngest child

Remisions

The following specifiers are used only after NO criteria for Substance Use Disorder except cravings have been met for at least 3 months. (These specifiers do not apply if the person is on agonist therapy [e.g., methadone] or in a controlled environment, [e.g., locked hospital unit].) ● Early Full Remission: None of the criteria for Substance Use Disorder except cravings are met for at least 3 months but less than 12 months. ● Sustained Full Remission: None of the criteria for Substance Use Disorder except cravings have been met for at least a 12-month period (or longer).

Screening Tool

The CAGE questionnaire is a quick screening tool used to assess for alcohol problems specifically. This screener helps determine whether a person drinks in excess and may benefit from alcohol treatment. The CAGE questionnaire asks the following questions: 1. Have you ever felt you needed to Cut down on your drinking? 2. Have people Annoyed you by criticizing your drinking? 3. Have you ever felt Guilty about drinking? 4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover? *Two or more "yes" responses indicate the individual may have a problem with alcohol and necessitates further assessment

Medication Interventions: for alcohol

Naltrexone, Disulfiram (Antabuse), and Acamprosate are the most common drugs used. ● Naltrexone is what we see come up most commonly on the exam (it blocks the euphoric effects and feelings of intoxication). ● Disulfiram (Antabuse) works by creating an unpleasant reaction to alcohol. Use of disulfiram requires medical supervision. ● Acamprosate can reduce the desire to drink alcohol by stabilizing chemical signaling in the brain that could otherwise be disrupted during withdrawal from alcohol.

Medication Interventions: for opioids

Methadone, Naltrexone, and Buprenorphine can be used. ● Methadone is most often used. It works by reducing cravings and withdrawal and blunts or blocks the effects of opioids. ● Naltrexone can also be used for opioid use disorder. While it's used in pill form for alcohol, for opioid use disorder it's available as an extended-release injectable. Like its use with alcohol use disorder, it blocks the euphoric effects and feelings of intoxication. ● Buprenorphine: suppresses and reduces cravings for opioids

Motivational Interviewing

is a treatment model that focuses on resolving ambivalence and using the person’s own values and concerns to elicit change (rather than imposing or “coercing” a person to change behavior). It helps individuals move from a place of indecision regarding making change to a place of motivation towards making change and meeting their goals. While it can be used for a number of presenting problems, it is a common treatment approach for individuals engaging in substance abuse.

The stages of change in Motivational Interviewing are as follows:

1. Pre-contemplation: In this stage, the client is not yet thinking about change.

2. Contemplation: During this stage, the client is thinking about and talking about change. They are considering whether or not to work towards change.

3. Preparation: The client is actively planning out steps to take in order to make change happen during this stage.

4. Action: During this stage, the client is taking positive steps to put the plan from the previous stage into practice.

5. Maintenance: During this stage, the client is maintaining the change that has been made.

● Some models add an additional stage for ‘relapse’. This is to acknowledge that relapse often occurs and can be viewed as another step in the process as opposed to a failure in the treatment process.

Harm Reduction

is an intervention that aims to reduce the negative effects of alcohol and drug use. It acknowledges that despite prevention and abstinence efforts, some clients will continue to engage in alcohol and drug use. Harm reduction includes things like:

● limiting the number of days you drink per week ● limiting the number of drinks you consume in one sitting

● having a designated driver

● utilizing needle exchange sites

● utilizing injection sites

Contingency Management

is a type of behavioral therapy that uses incentives to help clients abstain from drugs and alcohol. Clients are encouraged to engage in sobriety and engage in behaviors supporting sobriety. As goals are achieved and behaviors are modified (for example, a clean drug test, participation in groups, good attendance to treatment, etc.), clients receive rewards.