SUBSTANCE USE DISORDER

Substance use

The use of psychotropic substances, including medications, alcohol, or illegal drugs

Substance use disorder (SUD)

Disorder characterized by cognitive, behavioral, and physiologic symptoms; diagnosed by the DSM-5-TR

Addiction (ASAM definition)

A treatable, chronic medical disease, as described by the American Society of Addiction Medicine

U.S. drug overdose deaths in 2020

Over 92,000, a 30% increase from the previous year

Percentage of overdose deaths involving opioids

75%

Dependence

The person does not have adequate CONTROL over substance use and continues using despite clear EVIDENCE that it is HARMFUL

Symptoms of dependence

1) Taking larger amounts than intended

2) Unsuccessful attempts to control or reduce use

3) Tolerance for greater amounts over time

4) Social problems

5) Physical problems

Maladaptive behavior (without enough evidence for dependence)

Examples: driving while intoxicated; using the substance when it is clearly against your own best interest

Polysubstance abuse

Abuse of, or dependence on, more than one substance

Course of substance-related disorders

LIFE-LONG conditions; recurrence and relapse are common

True or False: The maladaptive behaviors of a person with a substance-related disorder are often enabled by people at home or work

TRUE

True or False: Substance abusers have a lower than average incidence of other medical and psychiatric problems

FALSE. They have a HIGHER than average incidence of other problems

U.S. adults with co-occurring disorders (2021 National Survey on Drug Use and Health)

9.2 million

Co-occurring disorder (dual diagnosis)

The simultaneous presence of a mental illness and a substance use disorder

Relationship between psychiatric illness and SUD

Psychiatric illness increases the likelihood of co-occurring SUD, and vice versa

Population particularly vulnerable to co-occurring SUD

Individuals with serious mental illness (SMI)

Settings where an OTA may encounter alcohol or substance abusers

1) Burn units

2) General medical services

3) Trauma units

4) Physical rehabilitation settings

5) Mental health settings

9 types of substances

1) Alcohol

2) Caffeine

3) Cannabis

4) Hallucinogens

5) Inhalants

6) Opioids

7) Sedatives

8) Stimulants

9) Tobacco

3 patterns of alcohol abuse

1) Regular daily drinking

2) Heavy weekend drinking

3) Periodic or episodic binge drinking

Marijuana

The most widely available illegal drug in the United States

Common uses of medical marijuana

1) Decrease pain

2) Anxiety

3) Muscle tension

4) Increase appetite and sleep

5) Reduce nausea and seizures

THC

Tetrahydrocannabinol, the chemical compound in marijuana

Most common ways to consume marijuana

Inhale, eat, ingest (dangerous in combination with other substances)

Commonly abused stimulants

1) Cocaine

2) Amphetamines

3) Methamphetamine

Ways cocaine can be used

Inhaled or injected

Crack

The smokable form of cocaine that produces a rapid high; the most addicting form of cocaine

Medical problems linked to crack

Heart failure, respiratory infections; exposed newborns can have serious birth defects

Opioid narcotics

1) Heroin

2) Morphine

3) Meperidine (Demerol)

Rate of addiction from illicit opioid use

About 50% of cases

Synthetic opioids

1) Oxycodone (Percocet)

2) Hydrocodone (Vicodin)

3) Fentanyl

What opioid abusers often turn to when they cannot get a prescription

Heroin

Other drugs listed with opioids

1) PCP (angel dust)

2) LSD

3) Amyl nitrite (poppers)

Medical disorders linked to opioid use

1) Heart problems

2) High risk of Hepatitis C

3) HIV

Naloxone

A drug that can reverse the effects of opioids

Childhood patterns that may lead to alcohol/substance abuse

1) Non-nurturing environment

2) Rejected as a child

3) Physically or sexually abused by drinker or ignored/smothered by nondrinker

4) Role reversal

5) Overprotected

PDS (Preferred Defensive Structure)

A characteristic set of defense mechanisms or strategies for achieving one's goals; substance users as a group tend to use a shared set

Denial

The first line of defense; lets the substance abuser ignore the disease, escape accountability, and avoid painful confrontation with the consequences of their actions

Projection

Transferring one's own feelings onto others; used to disguise unacceptable negative feelings

Rationalization

Giving reasons for drinking; helps the alcoholic distance himself from the compulsion by blaming someone else

Dichotomous thinking

Either-or / black-white reasoning, possibly from managing unpredictable childhood experiences; leads to wild behavior swings (overdependence/withdrawal, perfectionism/sloppy indifference)

Codependency

The unhealthy involvement of a non-substance abuser in controlling a substance abuser; most common in spouses and immediate family

Enabling

A codependent behavior that makes it easier for the substance abuser to continue to drink or use drugs

SBIRT

Screening, Brief Intervention, and Referral to Treatment; created at the University of Pittsburgh

Steps of SBIRT

Use a validated screening tool to assess risk; brief nonjudgmental discussion of risks after asking permission ("I am concerned about..."); refer to specialized treatment

ASAM's Six Dimensions of Multidimensional Assessment

1) Acute intoxication/withdrawal

2) Biomedical conditions

3) Emotional/behavioral/cognitive conditions

4) Readiness to change

5) Risk for relapse

6) Recovery/living environment

Three primary conceptual models of SUD

1) Psychological

2) Neurobiological

3) Sociological

Role of occupation in addiction recovery

Crucial in reshaping social lives, identities, habits, roles, and routines

Addiction-as-occupation

Concept emphasizing the need to restructure the individual's occupational life

Four dimensions assessed for occupational risk indicators

1) Doing

2) Being

3) Belonging

4) Becoming

Belonging dimension

The occupational science dimension that involves interpersonal connections; social connection is crucial for SUD recovery

How OT begins building positive social connections in SUD

By establishing a nurturing therapeutic relationship

Doing and Becoming dimensions in OT for SUD

Real-time application of skills in natural environments; skill mastery builds self-efficacy, confidence, and self-esteem

Evidence-based interventions for substance-related disorders

1) CBT

2) DBT

3) Assertive Community Treatment (ACT)

4) Therapeutic Communities (TCs)

5) Integrated Group Therapy (IGT)

4) Contingency Management (CM)

Where health promotion starts

Prevention

WHO's SAFER Initiative

Suggests cost-effective interventions to reduce alcohol-related harm

Service that gained prominence during COVID-19

Telehealth, including for psychiatric disorders

OT evaluation/intervention focus factors in SUD

Use of time (especially leisure); relapse prevention; cognitive/perceptual functions and skill development; daily living skills; valued occupational and social roles

Performance areas primarily affected by substance abuse

1) Leisure

2) Work

3) Social performance

Performance skills affected by substance abuse

1) Sensorimotor/perceptual

2) Cognition

3) Communication/interaction (psychosocial)

Performance patterns in substance abuse

Poor habits related to abuse replace healthy habits

Performance contexts in substance abuse

Consider the contexts where abuse takes place and how to strengthen the positive values of the person's sociocultural community

Overall treatment goal for SUD

Support a functional, recovery-oriented, abstinence-based lifestyle

Goal-setting rules in SUD treatment

Must have patient input; goals must be realistic or frustration, a sense of failure, and lower self-esteem will result

First phase of intervention

Patient EXTERNALIZES locus of control; directive, supportive counseling; may be in medical detox; OT normalizes/organizes daily routines and begins regaining cognitive and perceptual motor abilities

Second phase of intervention

Patient develops an INTERNAL locus of control; replaces unhealthy habits with healthy coping; cooperative social activities; stress management; behavioral/cognitive therapy; regular exercise

Third phase of intervention

Patient develops insight into the origin and consequences of addictive behavior; activities to increase self-awareness, self-concept, and self-esteem

Activities for social skills and self-expression

1) Expressive activities (art, clay, poetry, drama)

2) Assertiveness training

3) Stress management/relaxation

4) Rebuilding family relationships

Activities for daily living skills

1) Money management

2) Time management

3) Parenting skills

4) Nutrition/meal planning

5) Food preparation

6) Housekeeping

7) Community resources

General rule of relapse prevention

Avoid PEOPLE, PLACES, and THINGS associated with the abused substance; learn healthy substitutes for trigger situations; identify personal triggers

Feelings linked to relapse

Boredom and apathy

Perceptual/cognitive impairments after recovery

May disappear or diminish after a period of recovery and abstinence

Activity preference of newly sober alcoholics

Activities associated with ALCOHOL

Activity preference of alcoholics with longer recovery

Activities associated with SOBRIETY

Why some higher-functioning substance abusers succeeded in their careers

They were reliable, ambitious, and conscientious

Group treatment in chemical dependence

Very appropriate; creates belonging; decreases social isolation; builds interpersonal skills; practice reintegrating into social, family, and work settings

Alcoholics Anonymous (AA)

Founded in 1935; funded by voluntary member contributions; based on 12 steps; most successful program for maintaining sobriety

First 3 steps of AA

Admitting powerlessness over alcohol and promoting willingness to seek help from AA and other sources

Remaining 9 steps of AA

Understanding consequences of one's actions, mending social relations, maintaining a sober lifestyle, carrying the message of hope to other alcoholics

Al-Anon

Fellowship group for people affected by a loved one's drinking behavior

Narcotics Anonymous (NA)

Nonprofit fellowship of men and women for whom drugs had become a major problem

Celebrate Recovery

Christ-centered crisis response (recovery) program