Transcript Slide 1

Understanding Substance Use
Richard Fisher, LCSW
Connecticut Department of Mental Health and Addiction Services
Classes of Substances DSM-5
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Alcohol
Caffeine
Cannabis
Hallucinogens
Inhalants
Opioids
Sedatives, Hypnotics, Anxiolytics
Stimulants (amphetamines/cocaine/others)
Tobacco
Others
DSM - 5
Substance Use Disorders:
(mild, moderate, severe)
Substance Induced Disorders
(intoxication, withdrawal, delirium,
psychosis, sexual dysfunction, anxiety,
depression, sleep and more)
Why Do People Use Substances
Social (to be sociable)
Enhancement (to get high)
Coping (escape)
Conformity (to fit in)
Avoid Withdrawal
Why Addiction?
Natural
rewards such
as food and
sex kindle a
network of
brain areas
collectively
called the
reward circuitry
It gets us to do more
of the kinds of things
that keep us alive
and lead to our
having more
offspring: foodseeking and
ingestion, hunting
and hoarding,
selecting a mate and
actually mating.
Addictive drugs
mimic natural
rewards such as
food and sex by
kindling the same
network of brain
areas collectively
called the reward
circuitry
Addictive drugs fire up the reward
circuitry in a way that natural
rewards can’t — by, in a sense,
pressing a heavy thumb down on
the scale of pleasure.
Over time, the desire for the drug
becomes more important than the
pleasure the addict gets from it. By
the time the thrill is gone, longlasting changes may have occurred
within key regions of the brain.
Addiction was once defined in
terms of physical symptoms of
withdrawal
It’s now seen as changes in brain
circuits, or combinations of neurons
Over time, these subcellular changes alter the
strength of connections in the circuit, essentially
hardwiring the yen for drugs that is reignited not by
the drugs and also by environmental cues —
people, places, things and situations associated
with past drug use
-Cocaine and
amphetamines prolong the
effect of dopamine on its
target neurons.
-Heroin inhibits other
neurons that inhibit these
dopamine neurons. (In the
logic circuitry that is the
brain, a double negative
roughly equals a positive.)
Multicausal Model
• Conceptualizes chemical dependency
based on interaction of three factors, “the
agent, the host, the environment”
– The Agent is the substance
– The Host is the substance dependent person
– The Environment consists of the social,
cultural, political, and economic variables
ENVIRONMENT
AGENT
HOST
25
20
15
10
Marijuana
Heroin
Cocaine
Alcohol
5
0
Percentage of People That Try Substance that Develop Dependence
Factors in the Development
Problematic Substance Use
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Genetics
Upbringing
Psychiatric/Neurological Issues
Cultural Issues
Trauma/Abuse
Age of First Use
Friends/Social Pressures
Availability
Clinical Versus Community
Populations
1. Higher personal vulnerability (e.g., family
history, lower age of onset)
2. Higher severity (acuity & chronicity)
3. Higher rates of co-morbidity
4. Greater personal and environmental
obstacles to recovery
5. Lower recovery capital (personal assets /
family and social supports)
Substance Abuse over the
Lifespan
General Population
Schizophrenia
Bipolar
Major Depression
Severe Major Depression
OCD
Phobia
Panic Disorder
17%
47%
56%
27%
47%
33%
23%
36%
Prevalence of COD among Men
and Women Entering Addiction
Treatment (CT)
60
50
40
Men
Women
30
20
10
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Any
Depression
Anxiety
PTSD
Clinical Research
AOD problems
• Transient and chronic forms
• Most people with AOD problems do not
seek help from mutual aid societies or
professional treatment
• Transient disorders: Natural recovery and
brief intervention
Substance Misuse
•Episode(s) of
overdoing it
(It may only take
one time to result
in serious
repercussions)
•Experimentation
Most AOD problems resolve
themselves naturally or through brief
intervention
• Aging out
• Resolution of crisis (divorce, grief, layoff
etc.)
Addiction as a Chronic Illness
Addiction
A primary, chronic, neurobiologic
disease characterized by impaired
control over drug use or
compulsive use, continued use
despite harm, and craving
Risk Factors for Addiction
Genetics—Forty to sixty percent of a person’s
vulnerability to addiction may be genetic.
Mental illness —A person may attempt to
relieve depression or anxiety with substances.
Environmental factors —Examples include
poverty, poor parental support, living in a
community with high drug availability, and
using substances at an early age.
High Relapse Rates
• Of those who relapse following treatment, 80%
do so within 90 days of discharge (Hubbard et
al, 2003)
• The majority of people completing treatment
resume use within the year following treatment
(Wilborne&Miller, 2002)
• 25-35% of clients who compete treatment will be
re-admitted to treatment within one year, 50%
within 2-5 years (Hubbard et al,
1989;Simpson&Broom,2002)
Stable Recovery
• Most people treated for SUDs who
achieve a year of stable recovery do so
after multiple treatment episodes over the
span of years (Anglin et al, 1997; Dennis
et al, 2002)
• Risk of relapse drops to below 15% after
4-5 years of stable recovery (Jin et al,
1998)
There are many
roads to recovery
Moderation Based
• Lower problem severity
• Greater Recovery Capital
• Often problems developed during transition
from adolescence to adulthood
• Often moderate use after successful resolution
of crisis (grief, divorce, layoff etc.)
Abstinence-Based
• Guided mainstream addiction treatment in
US
• Nicotine and Caffeine historically excepted
12 Step
Developmental/Lifestyle Change
Medical Necessity
Religious (conversion/affiliation)
Political (drugs as tool of
oppression)
Abstinence Goal vs. Getting a Life
Worth Living
Harm Reduction
Medication Assisted Treatment
• Methadone
• Suboxone
• Others for alcohol
Psychosocial Treatments
many falls when learning, of limited
effectiveness alone
Moderate to Severe
Disorders
Psychosocial + Environmental
Supports (Recovery Supports)
Housing
Employment
On-going Recovery
Monitoring
Education
Basic Needs
Psychosocial, Environmental +
Medication
Reducing Craving
Acamprocate (Campral)
Naltrexone (Revia,
Depade, Vivtrol)
Aversive
Disulfiram
(Antabuse)
Opioid Replacement
Psychiatric Medications
Methadone,
Buprenorphine
(Suboxone)
Contexts for Recovery
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Solo or Natural Recovery
Treatment Assisted Recovery
Peer-Assisted
Faith Based Recovery
Secular Recovery
Styles of Recovery
• Acultural: not involved with others in
recovery or recovery community
• Bicultural: involved with others in recovery
and also people without addiction/recovery
background
• Culture of Recovery: mostly functions in
culture of recovery
Screening
Use of CAGE or Audit or
other screening tool
Assumptive questioning
yields more accurate
responses
How much do you drink?
Vs Do you drink?
When was the last time
you used marijuana?
(cocaine, non-prescribed
pills etc) Vs Do you use
drugs?
Open Ended questions
Closed
• Would you like to get
clean?
• How many bags of
heroin do you do a
day?
• Would it be hard to
stop using?
Open
• How do you feel
about your cocaine
use?
• Tell me about your
drinking
• Describe how you use
on an average day?
Support Self-Efficacy
“How do you think you have been hurt by
cocaine use?
“What are your concerns about what might
happen if things go on the way they are?”
“When you are ready to stop drinking, do you
see any advantages?”
Eliciting Self-Motivation
On a scale of 0 to 10, how important is it for
you to…
Get clean and sober?
Answer: “About a 4”
You say….????
Eliciting Change
What might work for you if
you did decide to…
•Stop drinking
•Stop smoking crack
cocaine
•Look into a 12-Step Group
Being Effective vs. Being Right
• Relationship is your most important tool
(you: empathy)
• How does client understand the problem,
the causes and possible solutions (you:
Do you think that will work?)
What Does Not Work
Lecturing
Confrontation
Shaming
Moralizing
Threatening
Brief Intervention
• Share concerns about health
• Educate about safe consumption (consider
health issues)
• Educate about health risks
• Ask about adverse effects on family, work
etc.
• How much of a problem do they think it is?
• Access readiness to change
Maintenance
Action
Preparation
Contemplation
Precontemplation
Interventions
• "Based on what we've been discussing, would you be
willing to change your drinking habits (or drug use)?"
• "Can we set a specific date to reduce your alcohol use?
Could you cut back, beginning this week?"
• "Since you agree to cut back on your drinking, you may
find that this booklet offers some helpful advice about
how to go about it."
• "Would you be willing to see a counselor to discuss your
drug use further? Think of this referral as comparable to
sending you to a cardiologist for a heart problem."
Patient Minimizes or Refuses
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Diary of use
Try to cut down
Use of collateral sources (family)
What would work for you should you
decide to stop or cut down?
• Use of biological markers (breathayzer or
urine toxicology)
• Revisit next visit
Referral
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Detoxification
Intensive Out-patient
Methadone/Suboxone (Opioids)
Out-patient Counseling
Residential programs
Sober Housing
12-Step
Connecticut Community for Addiction Recovery
Commitments
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Physicians Emergency Certificate (PEC)
Police Evaluation Request
Psychologists Emergency Evaluation Certificate
LCSW/APRN Emergency Certificate (only in
certain prescribed programs, i.e. mobile crisis)
• Substance Use Disorder Commitment (to in-pt
treatment through probate court supported by
MD within previous 2 days)
• Police Protective Custody to treatment facility
Confidentiality
•42 CFR Part 2
•HIPPA
Info Line: 2-1-1 or 1-800-203-1234
http://www.infoline.org/referweb/
DMHAS
www.ct.gov/dmhas
Assist Screening
http://www.who.int/substance_abuse/publications/media_assist/en/
http://whqlibdoc.who.int/publications/2010/9789241599382_eng.pdf
Resources
•Rethinking Drinking (booklet,
online) http://rethinkingdrinking.niaaa.nih.gov/
• Tips for Cutting Down on Your Drinking
http://pubs.niaaa.nih.gov/publications/Tips/tips.pdf
• Harmful Interactions: Mixing Alcohol with Medications
http://pubs.niaaa.nih.gov/publications/Medicine/Harmful_Int
eractions.pdf