Substance-Related and Addictive Disorders
What should we consider when dealing with substance use issues with children/teens?
* Informed consent * Mandated reporting * Substance Use = symptom, rather than primary issue * Ex. LGBTQ+ Youth are at increased risk for substance use due to family rejection, bullying, etc. Must treat primary issue while also ensuring safety
Considerations for Substance Use Amongst Diverse Groups
* Religious practices (Drinking wine at temple/mass (Catholicism & Judaism)) * Veterans and military (Alcohol for bonding or self-medicating) * Adolescents (Exploration & peer pressure) * Geographic locations... (Specific State Laws)
List Some Risk Factors for Substance Use
* Trauma * Discrimination * Ethnic background... * Age... * Sex/gender & sexual identity... * Higher amongst men * Higher rates amongst LGBTQ+ population 20-30 percent of gay and transgender people meet the criteria for substance use disorder compared to just 9 percent of the hetero/cis population (SAMHSA)
13 Principles of Effective Substance Use Treatment (APA)
1) Addiction is a complex, but treatable, disease that affects brain function and behavior. 2) No single treatment is appropriate for everyone. 3) Treatment needs to be readily available. 4) Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5) Remaining in treatment for an adequate period of time is critical. 6) Counseling— individual and/or group —and other behavioral therapies are the most commonly used forms of drug abuse treatment. 7) Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. 8) An individual's treatment and services plan must be assessed continually and modified as necessary to ensure it meets his or her changing needs. 9) Many drug-addicted individuals also have other mental disorders. 10) Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. 11) Treatment does not need to be voluntary to be effective. 12) Drug use during treatment must be monitored continuously, as lapses during treatment do occur. 13) Treatment programs should assess patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, as well as provide targeted risk-reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases.
What are the hallmark features of substance use disorders?
1. Cluster of cognitive, behavioral, and physiological symptoms 2. Use of substance(s) despite significant use-related problems 3. Change in brain chemistry/circuits/functioning as result of use (effects persist after detoxification)
List 5 questions to answer when engaging in the diagnostic process for a substance use disorder:
1. Is this person currently using or have they recently used substances? 2. What is the type of substance involved? 3. Is it a substance use disorder? Intoxication? Or withdrawal? 4. Do they meet the full criteria? *Consideration of Unspecified *Other vs. Unspecified in DSM *Still want to give rationale for Unspecified 5. What is the severity: mild, moderate, or severe?
What % or all driving fatalities is alcohol use responsible for?
31%
How potent is Fentanyl?
50x more potent than heroin and 100x more potent than morphine
Prevalence of Alcohol Use Disorder 2022 National Survey
86.3% of people ages 18 or older reported that they drank alcohol at some point in their life. 70.1% reported alcohol use in the past year 55.9% reported alcohol use in the past month 5.7% of U.S. adults have met criteria for a diagnosis of Alcohol Use Disorder Among youths aged 12 - 17, it is estimated that 1.8% have Alcohol Use Disorder
Describe a "________ use disorder"
A problematic pattern of substance uses over a period of time that causes distress and/or impairment
Describe a "Other ________ -induced disorder"
A temporary disorder that is developed in the context of severe intoxication and/or withdrawal * Ex. _______ -induced bipolar disorder
What is the most important tool when assessing for a substance use disorder?
A trusting therapeutic relationship!
List some inappropriate terms/language to use around substance use disorders:
Abuse Drunk Addict Junkie Druggie Tweaking
What is the third leading cause of preventable deaths in the United States?
Alcohol Use
What should you first assess for when treating substance use disorders?
Assess need for detoxification (does patient drink to avoid withdrawal symptoms?) Important to know: certain substances can lead to death due to withdrawals (e.g., benzodiazepines, such as Xanax and Valium, alcohol, and opioids more rarely)
Considerations for Differential Diagnosis
Be clear about informed consent to develop rapport & trust Gather a thorough history Review previous documentation Complete collateral interviews (if possible) Check in regularly about substance use
What treatment or method has had the least amount of success with smoking cessation?
Cold Turkey
How is the behavior pattern of substance use disorders described?
Criteria is grouped for substance use disorders into 4 categories
According to the Drug Enforcement Administration, "______________ is the most prevalent and the most significant synthetic opioid threat to the United States" (2021).
Fentanyl
List some examples of Opioids:
Heroin (illegal) Fentanyl, methadone, pethidine, tramadol and carfentanil (synthetic) Oxycodone (OxyContin®) (pain reliver legal by prescription) Hydrocodone (Vicodin®) (pain reliver legal by prescription) Codeine (pain reliver legal by prescription) Morphine (pain reliver legal by prescription)
Describe Group 1 of the behavior patterns for substance use disorders:
Impaired control over substance use: Taking larger amounts or over a longer period of time than was intended
What addiction should be considered that is not yet in the DSM?
Internet Gaming Disorder (IGD) (In ICD-11)
What are some of the drugs used in Psychedelic Assisted Therapy?
LSD MDMA Ketamine Psilocybin Ibogaine
Describe characteristics of Gambling Disorder
Need to gamble with increasing amounts to achieve desired excitement Restless or irritable when trying to cut down or stop gambling Repeated unsuccessful efforts to control, cut back on, or stop gambling Frequent thoughts about gambling (reliving past gambling or planning future gambling) Gambling when feeling distressed After losing money gambling, often returning to get even Lying to hide gambling activity Risking or losing a close relationship, a job, or a school or job opportunity because of gambling Relying on others to help with money problems caused by gambling
What are some medications used for smoking cessation?
Nicotine Replacement Treatments (NRTs) Nicotine gum Nicotine patch Inhaler, nasal spray etc. Bupropion SR (Wellbutrin or Buspar) Antidepressant - mechanism in use for nicotine dependence unclear: reduction of pleasurable effect?
The _______________ crisis was declared a nationwide Public Health Emergency on Oct. 27, 2017
Opiod
What are Opioids?
Opioids are natural or synthetic (made in laboratories to mimic the properties of natural opioids) chemicals that interact with opioid receptors on the nerve cells in the body and brain to reduce feelings of pain. Opioids reduce the perception of pain, but can also cause drowsiness, mental confusion, euphoria, nausea and constipation. At high doses, they can depress respiration.
Describe Group 4 of the behavior patterns for substance use disorders:
Pharmacological criteria: Craving, desire, or urge to use substance Tolerance
List the suggested/possible symptoms of Internet Gaming Disorder:
Preoccupation with gaming Withdrawal symptoms when gaming is taken away or not possible Tolerance, the need to spend more time gaming to satisfy the urge Inability to reduce playing, unsuccessful attempts to quit gaming Giving up other activities, loss of interest in previously enjoyed activities due to gaming Continuing to game despite problems Deceiving family members or others about the amount of time spent on gaming The use of gaming to relieve negative moods, such as guilt or hopelessness Risk, having jeopardized or lost a job or relationship due to gaming
Tobacco Use Disorder
Prevalence of Smoking Centers for Disease Control and Prevention: 2021 National Health Interview Survey: • 14% of U.S. adults smoke cigarettes; 75% of these smoke daily. • Cigarette smoking kills approximately 480,000 Americans each year. • Estimated cost for direct medical care is about $170 billion. • Estimated cost for lost productivity is about $156 billion. • Rates of smoking higher for divorced/separated/widowed than those for married or single. • Rates of smoking highest for American Indian/Alaska Native; lowest for Asian. • Prevalence rates decline with increasing education (GED 36%, graduate degree 4.1%) and higher household income
General Treatment Considerations
Referral for Medical Evaluation Elevated risk for danger to self or others Dual diagnosis Interaction between substance abuse and other mental disorders What will you treat? Does the client need a referral for substance abuse treatment before their depression is treated? Coordination and consultation must then occur Our scope of competence in the substance use field- Not an interventionist
Describe a "________ withdrawal disorder"
Reversible substance-specific syndrome due cessation of substance
Describe a "________ intoxication disorder"
Reversible substance-specific syndrome due to recent ingestion of substance
Describe Group 3 of the behavior patterns for substance use disorders:
Risky use (physical & legal): Use in situations that are hazardous Continued use despite knowledge of problems
Describe Group 2 of the behavior patterns for substance use disorders:
Social impairment (relationships & employment): A great deal of time is spent trying to obtain the substance Recurrent use resulting in failure to fulfill major roles, social/interpersonal problems Activities are reduced
What word would you use in place of Addict?
Speak of the "Addiction"
DSM-5-TR Diagnostic Criteria of Intoxication
Specific diagnostic criteria vary by substance Development of reversible syndrome due to recent ingestion (ex. headache, seizures, altered mental status, and visual loss) Behavioral or psychological changes *Rule out general medical condition
DSM-5-TR Diagnostic Criteria of Withdrawal
Specific diagnostic criteria vary by substance Development of syndrome due to cessation or reduction Distress or impairment in functioning *Rule out general medical condition
How do we decide between the different severity levels for substance use disorders?
Two or three symptoms indicate a mild substance use disorder; four or five symptoms indicate a moderate substance use disorder, and six or more symptoms indicate a severe substance use disorder. A severe SUD is also known as having an addiction.
What does multicomponent CBT look like and what is it used to treat?
Tx for smoking cessation (25 - 33% abstinence at 12 months follow-up) Can be done with individuals or groups Phase One: Preparation - motivation and commitment. Set a "Quit Day", self-monitor smoking behavior Phase Two: Quitting - self-management and nicotine fading. Gradual reduction in blood levels by switching to lower nicotine content products, cutting down Phase Three: Maintenance - relapse prevention
What would you say in place of substance abuse?
Use
Describe "Unspecified _______ -related disorder."
When full criteria are not met for the other alcohol disorders
What are the different types of diagnoses in each substance category
_________ use disorder _________ intoxication _________ withdrawal Other _________ -induced disorders Unspecified _________ -related disorder
Do we typically give a diagnosis of intoxication/withdrawal? Why or Why not? What should we give?
it is a temporary diagnosis We diagnose them one session with intoxication, they are sober or not going through withdrawal the next time, we would expire the intoxication/withdrawal diagnosis Therefore, a substance use disorder, which encompasses addiction, intoxication, and withdrawal, is more encapsulating and is better to use
What are some common medical complications that result from alcohol use?
liver disease, pancreatitis, anemia, upper gastrointestinal bleeding, nerve damage, and impotence
According to data collected by Centers for Disease Control and Prevention, __________________ use accounts for approximately 80% of all illicit drug use by adults as well as adolescents in the United States.
marijuana
Describe the trans theoretical Model of Change (Prochaska & DiClemente)
pre-contemplation contemplation preparation action maintenance relapse
List the Specific Substances/Non-Substances outline for addiction considerations in DSM-5-TR
• Alcohol • Caffeine • Cannabis • Hallucinogens • Inhalants • Opioids (heroine, morphine, and pain meds) • Sedatives, Hypnotics, or Anxiolytics (Ex. benzodiazepines, Barbiturates) • Stimulants (amphetamine, cocaine, ADHD meds) • Tobacco • Other (or Unknown) • Non-Substance-Related (Gambling)
