SUBSTANCE USE DISORDERS

Jacqueline Corcoran, Ph.D.

Virginia Commonwealth University

School of Social Work

DSM 5 changeAbuse and dependence subsumed into

use disorder

Severity: mild, medium, and severe

10 classesalcoholAmphetaminescannabiscocainehallucinogens inhalantsnicotineopiodsPCPsedatives/hypnotics/anxiolytics

Prevalence (lifetime, DSM-IV)

17.8% alcohol abuse and a 12.5% alcohol dependence

12-1.4% drug abuse.6% drug dependence

Other ratesAlcohol highest for American Indians, then bi-racial

personsLowest for Asian (enzyme breaks down alcohol)Males to females 5:1 for alcoholMen higher than women except for prescription drug

abuse of sedatives, hypnotics, or anti-anxiety drugs.

Co-morbidityAdolescents – 60%

Most commonly disruptive disorder, then depressionAdults -lifetime prevalence of 70% for at least 1

mental/emotional disorderMood disorderanxietypersonality disorders

Implication – when being seen for other disorders, inquire about substance use patterns

AssessmentOnset, progression, patterns, context, and frequency of use of all

substances Tolerance or withdrawal symptoms

Major life events Other disorders, including the relationship between the onset and

progression of the symptoms and substance use “Triggers” and context of use

Perceived advantages and disadvantages of use Motivations and goals for treatment

Number of times the individual has quit and the strategies that were used Impact of use disorders:

Financial and legal status Education and employment status

Condition of health (a physical examination may be warranted) Social support networks

Coping skills

Biologicalgenetic predisposition for alcohol problemsneurochemical irregularities implicated with substance

problems also same with mood, anxiety, impulsive, compulsive, personality disordersdopamine - activiating pleasure centers of limbic

portion of brain (alcohol, cocaine, hallucinogens)norephinephrine-panic response(increased heart rate,

respiration, and sweating) produced by cocaine and amphetamines

low levels of serontonin (satisfaction, contentment and well-being)

Psychological self-medicationcognitive distortions around substance-taking and

rationalization

Social low socioeconomic statusbut substance use also has consequences on

economicspeer involvementWomenGay and lesbian

Possible Goalsreducing or eliminating the substance use

Controlled drinking controversialreducing the physical harm associated with such use

harm reduction - working with clients to reduce the harmful consequences of the behavior, such as reducing the use of substances and encouraging the use of condoms and clean needles

improving psychological and social functioning (mending disrupted relationships, reducing impulsivity, building social and vocational skills, and maintaining employment)

relapse preventionFor adolescents, family focus

Alcoholics AnonymousAdvantages

Most common treatment approach

Little research on AA self-help groups

CBTTriggers and avoiding or coping with

Cognitive distortions around justifying use

Alternate reinforcers

Motivational Interviewing“a client-centered, directive method for enhancing intrinsic

motivation to change by exploring and resolving ambivalence”

Guiding principles:Listening and expressing empathy Developing discrepancies between problem behavior and

the client’s goals and values “Rolling” with resistance, which means avoiding power

struggles and instead making statements that help clients argue for change

Supporting self-efficacy, or the client’s sense of confidence that he or she can change

Developing a change plan

Family Involvementburden is imposed on families when a member has a substance use disorder.

Families can affect the abuser’s motivation and ability to comply with intervention

Types of family interventionAl-AnonJohnson Institute

30% go through with itCRAFT (community reinforcement as a family training

approach )Behavioral in nature: family member removes

drinking conditions, reinforces appropriate behavior, gives feedback of inappropriate behavior, and provides consequences if behavior exceeds agreed-upon limits

Family Intervention, cont.Behavioral couples therapy

main objective - to alter interactional patterns maintaining chemical abuse and to build a relationship that more effectively supports sobriety

communication skill-building, planning family activities, initiating caring behaviors, and expressing feelings

Family Intervention Adolescentsbrief strategic family therapy Functional family therapymultidimensional family therapymultisystemic therapy

Pharmacological Interventionsaversive medications, designed to deter client

drinkinganticraving medications, which purport to reduce

one’s desire to use substances

Aversivedisulfiram (Antabuse)Physicians reluctant to prescribe

AnticravingNaltrexone

an opioid receptor antagonist, a substance that blocks opioid receptors in the brain, so that the individual fails to experience positive effects from opiate (and alcohol use)

Acamprosate has been more recently approved by the FDA stabilize a chemical balance in the brain that is otherwise disrupted by

alcohol abuse, possibly by blocking glutamine receptors while activating gamma-aminobutyric acid.

for alcohol dependence, acamprosate was better at preventing a relapse, and naltrexone was better at preventing a “lapse” from becoming a relapse (that is, it prevented heavy drinking)

For heroin, substitution therapymethadone and buprenorphine (the latter can be

prescribed on an outpatient basis) goals being the prevention of withdrawal, the

elimination of cravings, and the blockage of euphoric effects obtained by illegal opiate use

CritiqueApplicability of criteria for adolescents and eldersPart of conduct disorder for adolescents