Drug and Alcohol

Alcohol (drug class)

Alcohol Withdrawal Symptoms: Withdrawal can be fatal General Symptoms: headaches, nausea, tremors, anxiety, hallucinations, and seizures. In many cases, alcohol withdrawal requires medical treatment and hospital admissions. Medications may be used to treat physical symptoms while counseling and support groups help with controlling drinking behavior. 6-12 hours after ingestion: agitation, anxiety, headaches, shaking, nausea, and vomiting 12-24 hours after ingestion: disorientation, hand tremors, seizures 48 hours after ingestion: seizures, insomnia, high blood pressure, tactile/auditory/visual hallucinations, high fever, excessive sweating, delirium tremens Post-Acute Withdrawal Syndrome: irritability/emotional outbursts, anxiety, low energy, trouble sleeping, memory problems, dizziness, increased accidents, delayed reflexes

Hallucinogens (drug class)

LSD-distortion of time, mood swings, bad trips PCP-laced with THC or nicotine (may last several days) Ecstasy-MDMA (scientific name), Molly (slang term) DMT-dimethyltryptamine (drug that occurs naturally in many plants and animals, produces a brief but intense visual and auditory hallucinogenic experience) Withdrawal Symptoms: Psychological symptoms: panic, psychotic-breaks, mood swings, speech problems, rage, low impulse control Physical symptoms: tremors, seizures, stiffening muscles, elevated heart rate, increased blood pressure, increased breathing rate, fluctuations in blood pressure Usually outpatient, Because is a psychological addiction, various modes of behavioral therapies should be integrated into the treatment plan. Such as CBT/DBT

Stages of Change

Precontemplation - in denial about having a problem; not ready • Task: Increase awareness of risk of current behavior Contemplation - unsure; maybe I need to change but I don't know what to do • Task: Motivate and increase self-efficacy; evoke reasons for change Preparation - "Yes there is a problem and I'm going to change it' • Task: Negotiate a plan; assist in developing a change Action - I'm doing something to help my problem • Task: Implement a plan and follow-up Maintenance - I'm a pro; relapse prevention • Task: Reaffirm commitment; active problem-solving Relapse - assist in coping • Avoid demoralization

Lethality Assessment

-ALWAYS assess for lethality 1. Ideation (frequency, intensity, duration--in last 48 hours, past month, and worst ever) 2. Plan (Timing, Location, Lethality, Availability/Means, Preparatory Acts) 3. Intent: extent to which the person expects to carry out the plan and believes the plan/act to be lethal vs. self-injurious -studies show the highest rates of completed suicide related to depression/substance use -20% of people with gambling disorder have attempted suicide

LOC: Intensive Outpatient (Level 1)

-An organized non-residential treatment service in which the individual resides outside the facility. It provides structured psychotherapy and individual stability through increased periods of staff intervention. Services are provided according to a planned regimen consisting of regularly scheduled treatment sessions at least 3 days per week, for a total time between 5 and 10 hours per week. -Up to 10 hours/week (typically 3 groups a weekx 3 hours each), 1 individual session -•Cannot treat unstable medical/psychiatric conditions o Counseling and education Minimal to no risk of severe withdrawal Biomedical conditions are not severe enough to warrant inpatient, but if exist they may distract from recovery efforts Emotional/behavioral conditions do not obstruct participation; person is able to maintain stability between contacts Treatment acceptance/resistance: willing and cooperative; requires only monitoring and motivation rather than structure Relapse potential: needs support and counseling, difficulty postponing immediate gratification Recovery environment: not optimal, has support living environment or motivation to establish one; available supports willing to help facilitate recovery

Opiates (drug class)

-Heroin, fentanyl, morphine, vicodin (Hydrocodone), percocet (Oxycodone), codeine -Medication Assisted Treatment (Methadone/buprenorphine, subutex, vivitrol) Withdrawal Symptoms: Phase 1: aggression, headaches, irritation, muscle pain, sweating, stomach problems, insomnia, anxiety, loss of appetite, panic attacks Phase 2: stomach cramping, minor muscle aches, shivers, fatigue -medical detox-->inpatient rehab center -Unlike alcohol and sedative withdrawal, uncomplicated opioid withdrawal is not life-threatening. Rarely, severe gastrointestinal symptoms produced by opioid withdrawal, such as vomiting or diarrhea, can lead to dehydration or electrolyte imbalance. Most individuals can be treated with oral fluids, especially fluids containing electrolytes, and some might require intravenous therapies.

Club Drugs

-MDMA (Ecstasy) _Rohypnol-date rape drugs -GHB -Ketamine (dissociative) -Methamphetamine

Inhalants/Aerosols (drug class)

-Solvents: Glue, paint, kerosene, nail polish remover -Gases: Propane gas, cooking sprays -Nitrites-"whip its" (typical short lived euphoria, initial burst excitement) -Usually young aged users, euphoria Withdrawal Symptoms: hand tremors, irritability/agitation, rapid heartbeat, runny eyes/nose, nausea, vomiting, headaches, dizziness, insomnia, cravings, hallucinations, anxiety/depression, psychosis, mood changes, poor memory, difficulty concentrating, anger outbursts -Because of the profound damage inhalant use typically wreaks on someone's brain, health care workers are often advised to assume that chemical dependency and mental illness need to be addressed during inhalant withdrawal for long-term recovery to be successful.

Cannabis (drug class)

-THC -Joints & Blunts -Marijuana Withdrawal: Symptoms: irritability, difficulty sleeping, decreased appetite, restlessness, cravings, nausea, abdominal For most heavy marijuana users, withdrawal symptoms begin on the first day after quitting and peak within 48 to 72 hours. Symptoms generally last two to three weeks and dissipate over time. An outpatient program is best suited for those with milder forms of marijuana dependence, while inpatient programs are recommended for more severe addictions. A medically supervised detox is especially recommended for those who have co-occurring disorders, including addictions to other types of drugs and mental health conditions. In particular, addictions to other drugs such as benzodiazepines or alcohol can exacerbate the symptoms a person experiences during marijuana withdrawal.

Determining Level of Care

-Uses American Society of Addiction Medicine (ASAM) criteria 1.Acute Intoxication/Withdrawal: MUST BE ADDRESSED FIRST 2.Assessing Medical needs (types of drugs used-impact on body, co-existing medical problems): ex. cardiac/seizure issues, a lot of places won't take patients with high medical needs 3.Emotional/behavioral conditions (co-occurring disorder? mania? depression?) 4.Assessing Client Motivation (intrinsic/extrinsic), treatment acceptance (can scale this, a lot of issues mismatch between where therapist thinks client is and where they are) 5. Relapse potential (Emotional supports?) 6. Recovery Environment (How safe?) -Matching clients with types of services (Consider what will they agree to? What do they need?) Highest level dependent on what substance addicted to, benzos and alcohol (for a long time addiction highest level) Medically monitored-trems Detox first assess do they need a detox and environment in if surrounded by people also addicted want to detox (higher level recommended but not needed-ex opiod addiction have option to do their detox outpt with someone medically monitored) almost all forms detox can be done outpt (unless alcohol or benzos due to dangerous symptoms syptoms of withdrawal) Risk for suicide (mh+drug and a higher level of care) 2 reasons hosp mh or drug class/withdrawal Any detox in outpt therapy (ex not ready to give up need to assess readiness, in not ready harm reduction, ex MAT resources) Lethality screen/figuring out drug class (hosp or not?) if no higher level care needed, assess readiness for care (abstinence part of harm reduction, MAT-what client wants/what able to do) Buprenorphine higher level outpt care Halfway house probation (re-entry environment live in abstinence)

Steroids

-anabolic (increase growth of body tissues) -complications: reproductive system, kidney, liver, digestive system, cardiovascular, CNS -Withdrawal: weakness, fatigue, decreased appetite, weight loss, nausea, vomiting, diarrhea, abdominal pain Steroid use cannot be stopped abruptly; tapering the drug gives the adrenal glands time to return to their normal patterns of secretion. Physicians who treat steroid withdrawal include primary care physicians, endocrinologists, internal-medicine specialists, and others.

Barbituates

-end with tal or bital -Phenobarbital (for seizures) -Secobarbital (can treat trouble falling asleep or can also make patients sleepy before surgery or medical procedures) Withdrawal Symptoms: restlessness, agitation, insomnia, weakness, nausea, vomiting, anxiety, tremors/shaking, rapid heart rate, seizures, hallucinations, sleep disturbances, dangerously high fevers -Medical assistance is often recommended for barbiturate withdrawal to reduce the severity of withdrawal symptoms and prevent life-threatening consequences. The detox process can be completed in a hospital, inpatient rehab facility, or detox center. Outpatient detox may be an option for people with relatively mild barbiturate dependence. Users visit the center on certain days of the week to meet with a physician and receive a tapered dose.

Seeking Safety

-good approach to working with patients with PTSD/trauma -A directive approach that includes handouts, homework, and feedback -use common language -rehearse skills in sessions and model for the client -reevaluate goals and use commitments to facilitate progress -rather than focusing on the details of the traumatic event once a person has reached a stable environment is not as important as focusing on how the person got through the event -provide coping skills such as grounding, self-soothing, meeting basic ADL's, and cognitive affirmations -stay present focused -use of an integrated multi-model approach is best practice (ex EMDR, Exposure) -major tenet is to place the client in an environment of security for the person to recover

Amphetamines

-stimulant -Methamphetamine: Speed (10-20% pure, crystal meth, crank) -Ritalin, Adderall for ADHD, Adipex-diet pills Ephedrine (used to illicitly manufacture meth) -Withdrawal Symptoms: Symptoms: tremors, dizziness/blurry vision, oversleeping, excessive sweating, nausea and vomiting, difficulty breathing, fatigue, insomnia and restless sleep, muscle tension or aches, headaches -Moreover, ideally, patients should undergo a supervised detox by trained medical professionals to ensure the withdrawal process is safe, comfortable, and more likely to succeed.Inpatient (Residential) Rehab

Co-occurring disorders

-treat co-morbid conditions concurrently -Best practices/approaches (Multi-disciplinary Team approach, appropriate medications, access to treatment continued even with mild symptoms) -Comprehensive services/level of services -Treatment must be at least moderate intensity, initially 9-15 hours per week or even residential -treatment over longer period of time -Low intensity treatment is not effective

Benzodiazepines

-used to treat anxiety+panic attacks, insomnia, depression Valium, Librium, Xanax, Ativan, Klonipin, Restoril (insomnia), Rohypnol (Date Rape Drug) -can be addictive -potential for complicated withdrawal -withdrawal can be fatal -Withdrawal Symptoms: anxiety, panic, irritability, insomnia, sweating, headaches, muscle pain and stiffness, poor concentration, sensory distortions, heart palpitations, high blood pressure, agitation, tremors Stopping a benzo "cold turkey" without medical assistance is not recommended. Instead, medical detox is required for all benzodiazepine addictions. Medical detox generally involves tapering off the drugs with professional care and support.

Clinical Opiate Withdrawal Scale (COWS)

A clinician-administered instrument tool used to measure opiate withdrawal by measuring 11 common signs and symptoms. The tool determines the level of opiate withdrawal and also helps to determine the appropriate treatment.

LOC-Residential: Medically Monitored Short-Term Rehab (Level 3)

A residential facility that provides 24-hour professionally directed evaluation, care, and treatment for addicted individuals in acute distress, whose SUD symptomatology is demonstrated by moderate impairment of social, occupational, or school functioning. Rehabilitation is a treatment goal. (Clinically Managed Residential Detoxification (e.g., nonmedical or social detoxification setting). This level emphasizes peer and social support and is intended for patients whose intoxication and/or withdrawal is sufficient to warrant 24-hour support.?) Minimal to no risk of severe withdrawal Biomedical conditions: continued AOD use places individual in possible danger of serious damage to physical health Emotional/Behavioral conditions interfere with recovery; moderate risk of dangerous behaviors; impairment requires 24-hour setting; self-destructive behaviors related to intoxication Treatment acceptance: 24-hour intensive program needed to help individual understand consequences and severity of SUD Relapse potential: inability to establish recovery despite previous treatment in less intensive settings; unable to control use in face of available substances in environment Recovery environment: social elements unsupportive or highly stressful; coping skills inappropriate to conditions

LOC-Residential: Medically Monitored Long-Term Rehab (Level 3)

A residential facility that provides 24-hour professionally directed evaluation, care, and treatment for addicted individuals in chronic distress, whose SUD symptomatology is demonstrated by severe impairment of social, occupational, or school functioning. Habilitation is a treatment goal. Minimal to no risk of severe withdrawal Biomedical conditions: continued AOD places individual in danger of serious damage to physical health Emotional/behavioral conditions: disordered living skills, disordered social adaptation, disordered self-adaptiveness, disordered psychological status Treatment acceptance: 24-hour intensive program needed to help individual understand consequences and severity of SUD Relapse potential: inability to establish recovery despite previous treatment in less intensive settings; unable to control use in face of available substances in environment Recovery environment: social elements unsupportive or highly stressful; coping sills inappropriate to conditions; OR anti-social lifestyle

LOC-Residential: Medically Monitored Detox (Level 3)

A residential facility that provides a 24-hour professionally directed evaluation and detoxification of addicted individuals. (This level provides 24-hour medically supervised detoxification services.e.g., freestanding detoxification center) High risk of severe withdrawal, daily use with physical dependence but without psychiatric or medical disorder requiring medical management Biomedical conditions severely endangered by continued use, requires close medical monitoring but not intensive care Emotional/behavioral conditions interfere with recovery, moderate risk of dangerous behaviors, impairment requires 24-hour setting; self-destructive behavior related to intoxication Treatment acceptance/relapse potential/recovery environment: N/A

LOC: Halfway House (Level 2)

A treatment facility located in the community that is state licensed, regulated, and professionally staffed. Programs focus on developing self-sufficiency through counseling, employment and other services. Some of these programs staff medical and psychiatric personnel onsite to assist individuals with their medical and/or co-occurring needs. This is a live in/work out environment. -¾ house (Aren't always regulated by the state, self-pay boarding house for people in recovery essentially, A 3/4 house is a transitional living center that is very similar to a halfway house. Both are sober living homes designed to help you transition back into the rigors of your life. And both serve as shelters for people who have lost their home or have nowhere else to turn after finishing rehabilitation. However, the environment of a 3/4 house is considerably less structured and rigorously controlled than a halfway home.) -home-like environment • 3-6 months for those who are medically stable • Assistance around the clock • Teaches recovery skills, preventing relapse, improve emotional functioning Minimal to no risk of severe withdrawal Biomedical conditions do not interfere with treatment and do not require monitoring outside of this level; OR relapse would severely aggravate existing condition Emotional/behavioral conditions do not interfere with treatment and disorders are treated concurrently; at least one serious emotional/behavioral problem is present Treatment acceptance/resistance: Cooperates and accepts need for twenty-four-hour structured setting Relapse potential: unaware of relapse triggers, impulsivity, would likely relapse without a structured setting Recovery environment: lack of supportive persons in living environment; significant stressors; OR logistic barriers to treatment at less intensive LOC

LOC-Inpatient Hospitalization: Medically Managed Inpatient Residential (Level 4)

An inpatient health care facility that provides 24-hour medically directed evaluation, care, and treatment for addicted individuals with coexisting biomedical and/or psychiatric/behavioral conditions that require frequent medical management. Such a service needs to have 24-hour nursing care, 24-hour access to intensive and specialized medical care, and 24-hour access to physician care. Minimal to no risk of severe withdrawal Biomedical conditions: imminent risk of serious physical health problems requiring intensive medical management Emotional/Behavioral conditions: psychiatric complications of SUD; concurrent psychiatric illness; dangerous behaviors; mental confusion or other impairment of thought processes Treatment acceptance/relapse potential/recovery environment: N/A

LOC-Inpatient Hospitalization: Medically Managed Detoxification (Level 4)

An inpatient health care facility that provides a 24- hour medically directed evaluation and detoxification of individuals with a substance use disorder in an acute care setting (e.g., psychiatric hospital inpatient center). This level provides 24-hour care in an acute care inpatient settings. Risk of severe withdrawal, with co-occurring mental health or medial disorder requiring medical management; OR overdose requiring medical management; OR only available setting that meets individual's management needs Biomedical conditions: complications of SUD require daily medical management; OR medical problems requires diagnosis and treatment; OR recurrent seizures Emotional/behavioral complications of SUD require daily medical management; OR risk of dangerous behavior; OR substance use would have severe mental health consequences Treatment acceptance/relapse potential/recovery environment: N/A

LOC: Outpatient (Level 1)

An organized, non-residential treatment service providing psychotherapy in which the individual resides outside the facility. Services are usually provided in regularly scheduled treatment sessions for, 3 contact hours per week. -Up to 3 hours/week (individual counseling, aftercare groups) • • Ideal for people with jobs and strong support systems • Evaluation, treatment, and recovery follow-up Minimal to no risk of severe withdrawal Biomedical conditions are stable enough to permit participation Emotional/behavioral conditions are non-serious and transient; mental status allows full participation Treatment acceptance/resistance: willing and cooperative; requires only monitoring and motivation rather than structure Relapse potential: able to maintain abstinence with support and counseling Recovery environment: support living environment or environment in which stressors can be managed so that abstinence can be managed

Sedatives (drug class)

Benzodiazepines and Barbituates

Stimulants (drug class)

Cocaine and Amphetamines

DUDIT

DUDIT - the Drug Use Disorders Identification Test - was developed as a parallel instrument to the AUDIT (Alcohol Use Disorders Identification Test) for identification of individuals with drug-related problems. 11-item self-report Drug Use Disorders Identification Test (DUDIT)

LOC: Engagement/Early Intervention

Early intervention is an organized screening, and Psycho-educational service designed to help individuals identify and reduce risky substance use behaviors. For individuals at-risk of developing SUD but don't display any diagnostic criteria to be admitted to rehab Educate about negative repercussions of drug misuse Minimal to no risk of severe withdrawal No biomedical or emotional disturbances (or very stable) Treatment acceptance/resistance: willing to explore how current substance use may affect personal (medical/psych/social) goals Relapse potential: needs an understanding of current substance patterns; capable of continuing alcohol use at nonhazardous risk Recovery environment: individual's support system increases the risk of personal conflict about alcohol or drug use

Medication Management

Medication-Assisted Treatment (MAT): A therapeutic option that includes the use of prescribed medications to ameliorate the symptoms and/or cravings of SUD. Common MAT medications are methadone, buprenorphine and naltrexone. In order to maximize the effectiveness of these medications, it is recommended that they be used in combination with counseling interventions. -used in combination with counseling Opioid, alcohol, nicotine Normalize brain chemistry, block euphoric effects, relieve psychological cravings, normalize body functioning

Harm Reduction

Refers to policies, programs and practices that aim to reduce the harms associated with the use of psychoactive drugs. The defining features are the focus on the prevention of harm, rather than on the prevention of drug use itself, and the focus on people who continue to use drugs. Harm reduction approaches are sometimes offered as alternatives, not in place of the clinically recommended treatment, but as an effort to keep an individual safe while attempts are made to engage him or her in active treatment. Needle exchanges are an example of harm reduction. based on motivation o Looks at why drugs are a problem: are there ways we address problems without eliminating drug use? o Much of the harm associated with substance use is due to legal status/stigma o Examples: Needle Exchange (e.g. Prevention Point) Bad Date Lists Naloxone Distribution Designated Driver Methadone Maintenance Safe Injection Sites o Can still include abstinence as the goal, but does not impose an agenda o Assistance in management of drug use and health without requiring abstinence o Does not assume that drug users are powerless to control their behaviors Assumes that drug users themselves are the primary agents of reducing the harms of their drug use o Focus on the behavior that is potentially harmful to individual or society o Any reduction is a positive change

WAS

Scale for assessing and documenting alcohol withdrawal symptoms. Encompasses 10 areas—nausea and vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbancs, auditory disturbances, visual disturbances, headache or fullness in the head, and orientation and clouding of sensorium. Using this scale, assess the patient at least every 4 to 6 hours around the clock.

AUDIT

The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item screening tool developed by the World Health Organization (WHO) to assess alcohol consumption, drinking behaviors, and alcohol-related problems. Both a clinician-administered version (page 1) and a self-report version of the AUDIT (page 2) are provided.

LOC: Partial Hospitalization (Level 2)

The provision of psychiatric, psychological, or other therapies on a planned and regularly scheduled basis in which the individual resides outside the facility. Partial hospitalization is designed for those individuals who would benefit from more intensive services than are offered in outpatient treatment projects, but who do not require 24-hour residential care. This environment provides multi-modal and multi-disciplinary psychotherapy. Services consist of regularly scheduled treatment sessions at least 3 days per week, for a total time of at least 10 hours per week. -10 hrs/wk minimum Minimal to no risk of severe withdrawal Biomedical conditions are not severe enough to warrant 24-hour observation; relapse could severely exacerbate conditions Emotional/behavioral conditions: inability to maintain behavioral stability over 72-hour period; OR mild risk of dangerous behavior; OR history of dangerous behavior Treatment acceptance/resistance: structured milieu required due to denial or resistance, but not so severe as to require residential setting Relapse potential: likely to continue use without monitoring and intensive support; OR difficulty maintaining abstinence despite engagement in treatment Recovery environment: exposure to usual daily activities makes recovery unlikely; OR inappropriate support for recovery from significant others; OR estrangement from potential support in living environment

Suboxone (buprenorphine/naloxone)

This FDA-approved treatment for opiate addiction is available in 2- or 8- mg sublingual tablets. A partial antagonist at the mu opioid receptor and an antagonist at the kappa receptor, Suboxone® is an attractive treatment option for individuals as well as medical professionals because it is safer and has less potential for abuse than methadone.

Vivitrol (Naltrexone)

This injectable treatment for opioid or alcohol dependence can be administered once a month, as opposed to methadone, buprenorphine or oral naltrexone, which must be administered daily. Vivitrol® is not a controlled substance, and can be administered by any healthcare provider who is licensed to prescribe medications. Individuals must be abstinent from opioids for a minimum of 7-10 days before being administered Vivitrol®.

Motivational Interviewing

a collaborative conversational style for strengthening a person's own motivation and commitment to change Resolves ambivalence Partnership, Acceptance, Compassion, Evocation People change voluntarily when: • They are interested in their need for change • They think change is in their best interest • They organize a plan of action that they are committed to • They take steps necessary to make and sustain change Extrinsic vs. intrinsic motivation (necessary for long-term change) Key components: empathy, congruence, collaboration, self-efficacy Sandwich: MI sandwich in which a more structured standard assessment is sandwiched between two client-centered MI interventions. • Step 1: use OARS (Open Questions, Affirmation, Reflective Listening, and Summary Reflections), engaging, therapeutic alliance • Step 2: review objective assessment and collect information • Step 3: assist in readiness, continue OARS, elicit change

CBT

problem-focused, goal-oriented, challenging patients symptoms; help to identify self-defeating thoughts and behaviors which may often drive addiction Address harmful thought patterns Practice alternative ways of thinking Regulate distressing emotions Benefits: client and therapist work together, skill development o Medication management: used in combination with counseling Opioid, alcohol, nicotine Normalize brain chemistry, block euphoric effects, relieve psychological cravings, normalize body functioning - Know what would be a good fit for what person o E.g. someone in withdrawal needs more than 12-step or MI; someone cognitively-impaired wouldn't benefit from CBT