Substance Abuse: A Social Worker’s Guide

1. Substance Abuse: A Social Worker’s Guide Presented by Tiffany Egan, LMSW

2. FACE OF ADDICTS

3. Substance Abuse- A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12‐month period: • Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance‐related absences, suspensions, or expulsions from school; neglect of children or household • Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) • Recurrent substance‐related legal problems (e.g., arrests for substance‐related disorderly conduct) • Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequence of intoxication, physical fights) • The symptoms have never met the criteria for Substance Dependence for this class of substance. DSM-IV–TR

4. Substance Dependence - A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12‐month period (emphasis ours): • Tolerance, as defined by either of the following: • A need for markedly increased amounts of the substance to achieve intoxication or desired effect or Markedly diminished effect with continued use of the same amount of the substance • Withdrawal, as manifested by either of the following: • The characteristic withdrawal syndrome for the substance or The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms • The substance is often taken in larger amounts or over a longer period than was intended • There is a persistent desire or unsuccessful efforts to cut down or control substance use • A great deal of time is spent on activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain‐smoking), or recover from its effects • Important social, occupational, or recreational activities are given up or reduced because of substance use • The substance use is continued despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine‐induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption) DSM-IV–TR

5. Combines the DSM-IV categories of substance abuse and substance dependence into a single disorder measured on a continuum from mild to severe • Each specific substance (other than caffeine) is addressed as a separate use disorder (e.g., alcohol use disorder, stimulant use disorder, etc.), • Cannabis Withdrawal , Caffeine Withdrawal and Tobacco Use Disorder are new disorders • Caffeine Withdrawal was in DSM-IV Appendix B “for further study” • DSM-5 does not separate abuse and dependence but criteria is provided for Substance Use Disorder • Drug craving or a strong desire or urge to use a substance added • Problems with law enforcement eliminated • The chapter also includes gambling disorder as the sole condition in a new category on behavioral addictions • No Apparent Category for Individuals with Co-Occurring Mental Illness and Substance Abuse DSM V – SUBSTANCE-RELATED AND ADDICTIVE DISORDERS

6. Which category of substances was added as a substance related disorder? QUESTION

7. The substance-related disorders are divided into two groups: • Substance-Induced Disorder • Substance-Use Disorder • Criteria is provided for substance use disorder, accompanied by criteria for intoxication, withdrawal, substance/medication-induced disorders, and unspecified substance-induced disorders, where relevant. DSM V

8. Substance – Induced Disorder • It includes… • Intoxication • Withdrawal • Other substance/medication-induced mental disorders • (e.g., substance-induced psychotic disorder, substance-induced depressive • disorder). • Criterion for substance intoxication are included within the substance-specific sections • Does not apply to tobacco DSM V

9. Substance-Use Disorder:includes a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems. • The diagnosis of a substance use disorder is based on a pathological pattern of behaviors related to use of the substance. • The more neutral term substance use disorder is used to describe the wide range of the disorder, from a mild form to a severe state of chronically relapsing, compulsive drug taking. • Some clinicians will choose to use the word addiction to describe more extreme presentations, but the word is omitted from the official DSM-5 • Applied to all 10 classes of drugs (except caffeine) DSM V

10. The substance-related disorders encompasses 10 separate classes of drugs: • Alcohol • Caffeine • Cannabis • Hallucinogens • separate categories for phencyclidine [or similarly acting rylcyclohexylamines] and other hallucinogens] • Examples: LSD, Mushrooms, Ecstasy • Inhalants • solvents, aerosols, gases, and nitrites • Opioids • heroin, morphine, oxycontin • Sedatives, Hypnotics, and Anxiolytics • Stimulants • amphetamine-type substances, cocaine, and other stimulants • Tobacco • Other or unknown substances DSM V – Drug Classes

11. Alcohol Related Disorders Alcohol Use Disorder Alcohol Intoxication Alcohol Withdrawal Other Alcohol-Induced Disorders Unspecified Alcohol-Related Disorder Caffeine-Related Disorders Caffeine Intoxication Caffeine Withdrawal Other Caffeine-Induced Disorders Unspecified Caffeine-Related Disorder Cannabis-Related Disorders Cannabis Use Disorder Cannabis Intoxication Cannabis Withdrawal Other Cannabis-Induced Disorders Unspecified Cannabis-Related Disorder DSM V – Drug Classes

12. Hallucinogen-Related Disorders Phencyclidine Use Disorder Other Hallucinogen Use Disorder Phencyclidine Intoxication Hallucinogen Persisting Perception Disorder Other Phencyclidine-Induced Disorders Other Hallucinogen-Induced Disorders Unspecified Phencyclidine-Related Disorder Unspecified Hallucinogen-Related Disorder Inhalant-Related Disorders Inhalant Use Disorder Inhalant Intoxication Unspecified Inhalant Related Disorder Opioid-Related Disorders Opioid Use Disorder Opioid Intoxication Opioid Withdrawal Other Opioid-Induced Disorders Unspecified Opioid-Related Disorder DSM V – Drug Classes

13. Sedative-, Hypnotic-, or Anxiolytic-Related Disorders Sedative, Hypnotic, or Anxiolytic Use Disorder Sedative, Hypnotic, or Anxiolytic Intoxication Sedative, Hypnotic, or Anxiolytic Withdrawal Other Sedative-, Hypnotic-, or Anxiolytic-Related Disorder Stimulant-Related Disorders Stimulant Use Disorder Stimulant Intoxication Stimulant Withdrawal Other Stimulant-Induced Disorders Unspecified Stimulant-Related Disorder DSM V – Drug Classes

14. FAMOUS ADDICT

15. Among individuals who have used cannabis regularly during some period of their lifetime, up to one-third report having experienced cannabis withdrawal (i.e. irritability, anger or aggression ; nervousness or anxiety ; sleep difficulty ; decreased appetite ; restlessness ; depressed mood)(physical symptoms; abdominal pain, shakiness/tremors, sweating, fever, chills, or headache) - American Psychiatric Association, 2013 STATISTIC

16. How many drug classes are there for substance related disorders according to DSM V? QUESTION

17. Severity Scale DSM-5: • The severity of each Substance Use Disorder is based on: • - 0-1 criteria: No diagnosis • - 2-3 criteria: Mild Substance Use Disorder • - 4-5 criteria: Moderate Substance Use Disorder • - 6 or more criteria: Severe Substance Use Disorder1 • Criteria: • Taking the substance in larger amounts or for longer than the you meant to • Wanting to cut down or stop using the substance but not managing to • Spending a lot of time getting, using, or recovering from use of the substance • Cravings and urges to use the substance • Not managing to do what you should at work, home or school, because of substance use • Continuing to use, even when it causes problems in relationships • Giving up important social, occupational or recreational activities because of substance use • Using substances again and again, even when it puts the you in danger • Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance • Needing more of the substance to get the effect you want (tolerance) • Development of withdrawal symptoms, which can be relieved by taking more of the substance. DSM V – Severity Scale

18. Criterion A criteria can be considered to fit within overall groups of impaired control, social impairment, risky use, and pharmacological criteria. Impaired control over substance use is the first criteria grouping (Criteria 1-4). • Impaired Control: The individual may take the substance in larger amounts or over a longer period than was originally intended (Criterion 1 - #s 1-4) • Social Impairment: The individual may express a persistent desire to cut down or regulate substance use and may report multiple unsuccessful efforts to decrease or discontinue use (Criterion 2 - #s 5-7). • Risky Use: The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects (Criterion 3 - #s 8-9). • Pharmacological: Craving (Criterion 4 - #s 10-11) : an intense desire or urge for the drug that may occur at any time but more likely when in an environment where the drug previously was obtained/used. • Craving has also been shown to involve classical conditioning and is associated with activation of specific reward structures in the brain. • Craving is queried by asking if there has ever been a time when they had such strong urges to take the drug that they could not think of anything else. • Current craving is often used as a treatment outcome measure because it may be a signal of impending relapse. DSM V

19. For Substance Use Disorders… • Specify criteria • Specify if: • Early remission: at least 3 months, but less than 12 months without substance use disorder criteria (except craving) • Sustained remission: at least 12 months without criteria (except craving) • Specify if: • In a Controlled Environment. This additional specifier is used if the individual is in an environment where access to alcohol and controlled substances is restricted. • Examples of these environments are closely supervised and substance-free jails, therapeutic communities, and locked hospital units • On Maintenance Therapy. Taking prescribed agonist medications (i.e. methadone, buprenorphine, oral naltrexone, & no other criteria met) DSM V

20. People with drug problems might act differently than they used to. They might: • Spend a lot of time alone • Lose interest in their favorite things • Get messy—for instance, not bathe, change clothes, or brush their teeth • Be really tired and sad • Be very energetic, talk fast, or say things that don't make sense • Be nervous or cranky (in a bad mood) • Quickly change between feeling bad and feeling good • Sleep at strange hours • Miss important appointments • Have problems at work • Eat a lot more or a lot less than usual People with an addiction usually can't stop taking the drug on their own. They want and need more. They might try to stop taking the drug and then feel really sick. Then they take the drug again to stop feeling sick. They keep using the drug even though it's causing terrible family, health, or legal problems. They need help to stop using drugs. Signs of Abuse & Addiction

21. FAMOUS ADDICT

22. Cocaine indicators have decreased over time, but the DEA Field Divisions report availability is higher than in the past. STATISTIC

23. What are some signs of abuse/addiction? QUESTION

24. CAGE AID Substance Abuse Screening Tool • DAST – Drug Abuse Screening Test ; DAST 10 • The NIDA (National Institute on Drugs Abuse) Quick Screen • Simple Screening Instrument for Substance Abuse Self-Administered Form • Addiction Severity Index (ASI) • SASSI • Audit C (for alcohol) • CAGE (for alcohol) Screening & Assessment Tools

25. Substance abuse and behavioral disorder counselors typically do the following: • Assess and evaluate clients’ mental and physical health, addiction or problem behavior, and readiness to treatment • Help clients develop treatment goals and plans • Review and recommend treatment options with clients and their families • Help clients develop skills and behaviors necessary to recover from their addiction or modify their behavior • Work with clients to identify behaviors or situations that interfere with their recovery • Teach families about addiction or behavior disorders and help them develop strategies to cope with those problems • Refer clients to other resources and services, such as job placement services and support groups • Conduct outreach programs to help people identify the signs of addiction and other destructive behavior, as well as steps to take to avoid such behavior Social Work Role

26. These standards were developed to broadly define the scope of services that social workers shall provide to clients with substance use disorders, that clients & their families should expect, and that program administrators should support. • Ethics & Values • Qualifications • Assessment • Intervention • Decision Making & Practice Evaluation • Record Keeping • Workload Management • Professional Development • Cultural Competence • Interdisciplinary Leadership & Collaboration • Advocacy • Collaboration NASW Social Work Standards

27. 2 1 3 5 4 7 8 6 FAMOUS ADDICTS Name that Star! 9

28. Alprazolam was the primary benzodiazepine that was misused, based on treatment admission and toxicology laboratory data. STATISTIC

29. What is the common name for alprazolam and what does it treat? QUESTION

30. The National Institute on Drug Abuse (NIDA) created a list of guiding principles that characterize the most effective treatments. The principles include the following: 1. No single treatment approach is appropriate for all individuals. 2. Treatment needs to be readily available. Effective treatment attends to the multiple needs of the individual, not just his or her substance use. 4. An individual’s treatment plan needs to be assessed continually and modified as necessary. 5. Remaining in treatment for an adequate time is critical for effectiveness. 6. Counseling and other behavioral therapies are critical components of effective substance abuse treatment. 7. Medications are an important element of treatment for many people, especially when combined with behavioral therapies. 8. Substance-abusing individuals with coexisting medical disorders should have the disorders treated in an integrated way. 9. Medical detoxification is only the first stage of substance abuse treatment and by itself does little to change long-term drug and alcohol use. 10. Treatment does not need to be voluntary to be effective. 11. Possible substance use during treatment must be monitored continuously. 12. Treatment programs should provide assessment for HIV, hepatitis B, hepatitis C, tuberculosis, and other infections and provide counseling to help people change their risk for infection. Treatment

31. Motivational Enhancement Therapy • Cognitive behavioral therapy • Twelve-Step Facilitation • Structured family and couples therapy • Community reinforcement therapy • Contingency Management • Pharmacological therapies (According to NIDA and the National Institute on Alcohol Abuse and Alcoholism) Evidence Based Treatments

32. Motivational Enhancement Therapyis a program based on the principles and practices of motivational interviewing, an approach to helping people make behavior change that is based on a client-centered, goal-oriented way of increasing a person’s intrinsic motivation to change, capitalizing on his or her readiness. • Motivational Interviewing (MI) is a client‐centered, directive method for enhancing intrinsic motivation to change (by exploring and resolving ambivalence) that has proven effective in helping clients clarify goals and commit to change. MI has been modified to meet the special circumstances of clients with COD, with promising results from initial studies to improve client engagement in treatment. • Cognitive behavioralapproaches help people recognize, avoid, and cope with situations in which they are likely to use substances by using awareness raising and skill-building activities. Evidence Based Treatments

33. Twelve-Step Facilitation is a structured, individualized approach to introducing a person to a Twelve-Step program that typically helps the person have a better understanding of his or her role in therapy and what is expected. Structured family and couples therapysuch as Multidimensional Family Therapy, addresses a variety of influences on the substance-abusing patterns of the person and includes family members in the therapy sessions so as to treat people within their natural social environment. Community reinforcement therapyis an approach of connecting a person who has substance abuse problems with a range of services within his or her community. Evidence Based Treatments

34. Contingency management, also known as motivational incentives, is an approach that uses positive reinforcement (e.g., special rewards such as gift certificates) to increase positive behaviors (e.g., not using substances for a specified period of time). • Contingency Management (CM) maintains that the form or frequency of behavior can be altered through the introduction of a planned and organized system of positive and negative consequences. It should be noted that many counselors and programs employ CM principles informally by rewarding or praising particular behaviors and accomplishments. Similarly, CM principles are applied formally (but not necessarily identified as such) whenever the attainment of a level or privilege is contingent on meeting certain behavioral criteria. Demonstration of the efficacy of CM principles for clients with COD is still needed. • Pharmacological therapiesinclude the use of medications like naltrexone (Rivia, Dapade, Vivitrol), disulfiram (Antabuse), methadone, and buprenorphine (Suboxone, Subutex, Zubsolv) to help stabilize a person’s life during treatment. Evidence Based Treatments

35. Brief Interventions/Therapies • Client Engagement • Johnson Model Intervention • Resistance in Treatment • Stages of Change Model Other Interventions

36. FACE OF ADDICTS

37. In 2010, 8.9% percent of persons 12 years of age and over had any illicit drug use in the past month STATISTIC

38. Name two evidence based treatment models for working with addiction? QUESTION

39. SAMHSA's 2002 report to Congress defines co-occurring disorders as: • Individuals who have at least one mental disorder as well as an alcohol or drug use disorder. While these disorders may interact differently in any one person (e.g., an episode of depression may trigger a relapse into alcohol abuse, or cocaine use may exacerbate schizophrenic symptoms), at least one disorder of each type can be diagnosed independently of the other. • refers to an individual having co-existing mental health and substance use disorders. Co-Occurring Disorders

40. Some of the most common psychiatric disorders seen in patients with co-occurring addiction issues include: • schizophrenia • bipolar disorder • borderline personality disorder • major depression • anxiety and mood disorders • post traumatic stress disorder • pathological gambling • sexual and eating disorders • conduct disorders • attention deficit disorder Co-Occurring Disorders

41. Whatever the relationship between mental health problems and problematic substance use, the research shows that their co-existence is likely to worsen a range of outcomes for service users. These include: •• Increased rates of violence. •• Increased rates of suicide. •• Higher levels of mental health symptoms. •• Increased relapses, numbers of hospitalizations and time spent in hospital. •• Poorer general health, including increased rates of hepatitis C and HIV. •• Higher rates of offending and incarceration. •• Unstable housing and homelessness. •• Loss of family supports. •• Financial problems. •• Financial costs to treatment services. Co-Occurring Disorders

42. The 12-Step Assessment Process (by SAMHSA) • 1. Engage the client • 2. Upon receipt of appropriate client authorization(s), identify and contact collaterals (family, friends, other treatment providers) to gather additional information • 3. Screen for and detect COD • 4. Determine severity of mental and substance use disorders • 5. Determine appropriate care setting (e.g., inpatient, outpatient, day-treatment) • 6. Determine diagnoses • 7. Determine disability and functional impairment • 8. Identify strengths and supports • 9. Identify cultural and linguistic needs and supports • 10. Identify additional problem areas to address (e.g., physical health, housing, vocational, educational, social, spiritual, cognitive, etc.) • 11. Determine readiness for change • 12. Plan treatment Social Work Assessment

43. Motivational Interviewing (MI) • Contingency Management (CM) • Cognitive‐Behavioral Therapy (CBT) is a general therapeutic approach that seeks to modify negative or self‐defeating thoughts and behaviors, and is aimed at achieving change in both. CBT uses the client's cognitive distortions as the basis for prescribing activities to promote change. Distortions in thinking are likely to be more severe with people with COD who are, by definition, in need of increased coping skills. CBT has proven useful in developing these coping skills in a variety of clients with COD. • Relapse Prevention (RP) has proven to be a particularly useful substance abuse treatment strategy and it appears adaptable to clients with COD. The goal of RP is to develop the client's ability to recognize cues and to intervene in the relapse process, so lapses occur less frequently and with less severity. RP endeavors to anticipate likely problems, and then helps clients to apply various tactics for avoiding lapses to substance use. Indeed, one form of RP treatment, Relapse Prevention Therapy, has been specifically adapted to provide integrated treatment of COD, with promising results from some initial studies. Co-Occurring Disorders Evidence Based Treatments 8

44. Integrated Dual Disorders Treatment Co-Occurring Disorders Evidence Based Treatments 8

45. FACE OF ADDICTS

46. Over 8.9 million persons have co-occurring disorders; that is they have both a mental and substance use disorder. • Only 7.4 percent of individuals receive treatment for both conditions with 55.8 percent receiving no treatment at all. STATISTIC

47. Name 2 common co-occurring disorders Co-Occurring Disorders

48. Susan presents to you asking for help for her heroin addiction. She has been using drugs off and on for 4 years (from pills to heroin) and is currently using about $60/day by IV drug use. Susan does not have stable housing and lives with her boyfriend sometimes. Susan has one child (age 4) who is with her mother due to CPS involvement (open case). Susan also feels some anxiety and sadness, but has never been diagnosed. She has many physical withdrawals when she does not use (sweating, cramps, nausea). Susan relies on the bus for transportation and her boyfriend will give her money sometimes. How do we help her? Treatment Plan EXAMPLE

49. Problems • The problems must be specific, not vague. A problem is a brief clinical statement of a condition of the patient that needs treatment. • Long Term Goals • A goal is a brief clinical statement of the condition you expect to change in the patient or in the patient’s family. Goals usually are abstract statements that you cannot actually see happen. • Short Term Objectives • An objective is a specific skill that the patient must acquire to achieve a goal. The objective is what you really set out to accomplish in treatment. It is a concrete behavior. Objectives must be measurable. • Therapeutic Interventions • Interventions are what you (as the clinician) do to help the patient complete the objective. Interventions also are measurable and objective. There should be at least one intervention for every objective. • Diagnostic Suggestions Treatment Plan Components

50. Susan presents to you asking for help for her heroin addiction. She has been using drugs off and on for 4 years (from pills to heroin) and is currently using about $60/day by IV drug use. Susan does not have stable housing and lives with her boyfriend sometimes. Susan has one child (age 4) who is with her mother due to CPS involvement (open case). Susan also feels some anxiety and sadness, but has never been diagnosed. She has many physical withdrawals when she does not use (sweating, cramps, nausea). Susan relies on the bus for transportation and her boyfriend will give her money sometimes. How do we help her? LIST PROBLEMS Treatment Plan EXAMPLE