Transcript Handbook of Health Social Work, 2 nd Edition

SUBSTANCE USE
PROBLEMS IN HEALTH
SOCIAL WORK
Chapter 17
Handbook of
Health Social
Work, 2 nd
Edition
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
 Chapter Objectives:
 Define terms and diagnostic categories used to describe substance
use problems.
 Identify the prevalence of substance use and problems across
sociodemographic groups.
 Present information about the psychoactive and health effects of
substances that are commonly used.
 Provide an overview of practice and research regarding prominent
approaches to assist people experiencing substance use problems.
 Provide general information to guide screening for substance use
problems and brief intervention to address these problems in
healthcare settings.
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Terms
 Addiction – commonly implies a severe level of problematic
substance use that involves dependence and continued pursuit
and use of substances in the midst of negative consequences.
 Substance – refers to both legal and illegal psychoactive
substances that affect the central nervous system (CNS) when
consumed. Users experience pleasure or diminished pain through
the alteration of mood, cognition, perception, memory, or
consciousness.
 Drug – most often used to refer to illegal “street” psychoactive
substances and prescribed medications used illegally.
 Binge drinking – consumption of alcohol that elevates the blood
alcohol concentration (BAC) to .08 gram percent and higher.
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Terms
 Intoxication – a reversible state caused by the recent use of a
substance that is typically characterized by a substance specific constellation of physiological, behavioral, and
cognitive-emotional changes.
 Withdrawal – describes substance-specific behavioral,
physiological, and cognitive -emotional changes that result
from stopping or reducing substance use, particularly when
use has been significant and long term.
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
DSM-IV-TR Diagnostic Criteria for Substance A buse
A .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 1 2 -month period:
1 . Recurrent substance use resulting in a failure to fulfill major role
obligations at work , school, or home.
2. Recurrent substance use in situations in which it is physically
hazardous.
3. Recurrent substance -related legal problems.
4. Continued substance use despite having per sistent or recurrent social
or interpersonal problems caused or exacerbated by the ef fects of the
substance.
B. The symptoms have never met the criteria for Substance Dependence
for this class of substance.
From Diagnostic and Statistical Manual of Mental Disorders, four th
edition, text revision, by American Psychiatric Association, 2000,
Washington, DC: Author, pp.199.
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
D S M - I V -T R D i a g n o s t ic C r i te r i a f o r S u b s t a nc e D e p en d en c e
A m a l a d a p t i ve p a t te r n o f s u b s t a n c e u s e l e a d i n g to c l i n i ca l l y s i g n i fi ca n t i m p a i r me n t o r
d i s t r e s s , a s m a n i fe s te d b y t h r e e ( o r m o r e ) o f t h e f o l l ow in g , o c c ur r i n g a t a ny t i m e i n t h e
s a m e 1 2 - m o n t h p e r i o d.
1 . To l e r a n c e, a s d e f i n e d b y e i t h e r o f t h e f o l l ow in g :
a . A n e e d f o r m a r ke d l y i n c r e a s e d a m o u n t s o f t h e s u b s t a n c e to a c h i eve i n tox i c a t io n o r d e s i r e d
ef fect.
b . M a r ke d l y d i m i ni s h e d e f f e c t w i t h c o n t i n ue d u s e o f t h e s a m e a m o un t o f t h e s u b s t a nc e .
2 . W i t h d r awa l , a s m a n i fe s te d b y e i t h e r o f t h e f o l l ow i n g :
a . T h e c h a r a c te r is t i c w i t h d r awa l s y n d r o m e f o r t h e s u b s t a nc e .
b . T h e s a m e ( o r a c l o s e l y r e l a te d ) s u b s t a n c e i s t a ke n to r e l i eve o r av o i d w i t h d r awal
s y m p to ms .
3 . T h e s u b s t a nc e i s o f te n t a ke n i n l a r g e r a m o un t s o r o v e r a l o n g e r p e r i o d t h a n w a s
i n te n d e d .
4 . T h e r e i s a p e r s i s te n t d e s i r e o r u n s u c c e s s f ul e f f o r t s to c u t d o w n o r c o n t ro l s u b s t a nc e
use.
5 . A g r e a t d e a l o f t i m e i s s p e n t i n a c t i v i t i e s n e c e s s a r y to o b t ai n t h e s u b s t a n c e , u s e t h e
s u b s t a n c e , o r r e c ov e r f r o m i t s e f f e c t s .
6 . I m p o r t a n t s o c i a l , o c c up a t io n a l , o r r e c r ea t i o n a l a c t i v i t i e s a r e g i v e n u p o r r e d uc e d
because of substance use.
7. T h e s u b s t a nc e u s e i s c o n t i n ue d d e s p i te k n o w l e d g e o f h av i n g a p e r s i s te n t o r
r e c u r r e n t p hy s i c a l o r p s yc h o l o g ic al p r o b l e m t h a t i s l i ke l y to h av e b e e n c a u s e d o r
ex a c e r b a te d b y t h e s u b s t a nc e .
S o u r c e : D i a g n o s t ic a n d S t a t i s t ic a l M a n u a l o f M e n t a l D i s o r d e r s , f o u r t h e d i t i o n , tex t r ev i s i o n , by
A m e r i c a n P s yc h i a t r i c A s s o c i a t i o n , 2 0 0 0 , Wa s h i n g to n , D C : Au t h o r, p .1 97.
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Alcohol
Just over half of all Americans 12 years and older report
current used of alcohol
More than 50% of American adults have a close family member
who has met the diagnostic criteria for alcohol dependence
In the United States and worldwide, it is one of the most widely
used and dangerous drugs
CNS depressant
Research suggests that genetics account for approximately
60% of alcohol vulnerability.
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Alcohol Epidemiology
White American young adults aged 18 -25 years reported the
highest rates of problematic alcohol use
American Indian, Hispanic, and White American adolescents
reported the highest levels of lifetime use
Hispanic adults aged 26 -64 report the highest rate of bring
drinking
Young adults aged 18-25 years experience the highest rates of
problem drinking
41% of this group reported binge drinking in the past month
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Health Ef fects of Alcohol
Research suggests that alcohol is associated with 67% of
partner assaults, 37% of rapes, 50% of homicides, and 40% of
traf fic fatalities
The average lifespan is decreased by 10 -15 years for persons
with alcohol dependence
Chronic heavy drinking is a leading cause of cardiovascular
illnesses, which are the leading cause of early mortality among
those with alcohol dependence
Men with alcohol dependence are two time more likely than
men without to die from atherosclerotic and degenerative heart
disease
Women with alcohol dependence are four times more likely to
die from the same disease than women who do not have alcohol
dependence
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Health Ef fects of Alcohol
Liver disease is commonly associated with alcohol use
Alcohol consumption may enhance acetaminophen liver toxicity
Alcohol consumption is associated with greater severity of
hepatitis C
Long-term moderate to heavy alcohol use is associated with
changes in the liver that are described in three phases, together
known ass alcoholic liver disease:
Fatty liver
Alcohol hepatitis
cirrhosis
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Health Ef fects of Alcohol
 People who have alcohol dependence are at increased risk for
cancers of the head, neck, esophagus, stomach, and lung
 Heavy alcohol use has a significant ef fect on the immune
system, which may result in infections such as pneumonia
 HIV rates are higher among persons who abuse alcohol
 Neuropathy is associated with heavy alcohol use
 Wernicke’s syndrome and Korsakoff’s psychosis are also
related to heavy use
 Drinking alcohol during pregnancy increases the risk for
spontaneous abortion, low birth weight, small brain volume,
heart defects, varying levels of mental retardation, and facial
abnormalities
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Tobacco
 Tobacco kills more than 430,000 U.S. citizens each year -more
than alcohol, cocaine, heroin, homicide, suicide, car
accidents, fire, and AIDS combined
 Smoking cessation is positively associated with increased
abstinence from illegal drug use 12 months after completing
substance use treatment
 Smoking cessation ef forts may be particularly relevant among
people living with HIV, for whom smoking may negatively
af fect immune functioning over time and increase risk of
infections of the respiratory tract
 Tobacco can help with relaxation and concentration
 Withdrawal symptoms, such as irritability, sleep disturbances,
craving, and cognitive deficits, can occur for a month or more
following cessation
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Tobacco Epidemiology
 2008 NSDUH estimated that 28.4% of the U.S. population 12
years and older were current users of tobacco products
 Adolescents aged 12-17 years reported current use rates of
11 .4%
 Boys were more likely than girls to report use
 American Indian adolescents reported the highest rates of
tobacco use
 Current tobacco use rates peaked during young adulthood
 Men used at greater rates than women
 American Indian and white American young adults reported
the highest rates of current use
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Health Ef fects of Tobacco
 NIDA reports that tobacco use is the leading preventable
cause of disease, disability, and death in the United States
 Approximately 8.6 million Americans suf fer from at least one
serious illness caused by smoking, and annual estimates
indicate that smoking is responsible for economic losses of
$75 billion is excess medical costs
 Cigarette use is strongly associated with lung cancer, heart
disease, and chronic obstructive pulmonary disease
 Smokers are at increased risk for stroke and peripheral
vascular disease, and many cancers of the mouth, throat,
larynx, and esophagus are related to cigarette use
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Health Effects of Tobacco
Approximately 20% of pregnant women in the
U.S. smoke throughout their pregnancies
Maternal smoking is associated with
abruption of the placenta, low birth weight,
premature delivery, and increased risk of
sudden infant death syndrome
In the U.S., cigarette smoking remains the
single largest preventable cause of adverse
pregnancy outcomes
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Cannabis
 Marijuana is the most commonly used illegal drug
 Users may experience mild euphoria, relaxation,
and enhancement or distortion of perceptual
experiences
 Intoxication often involves impairment in attention
and short-term memory
 Lethargy and sleepiness occur as the effects wear
off
 Addiction can occur as a result of long-term use in
some people
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Epidemiology of Cannabis
 Rates of cannabis use peaked for 18-25-yearolds, with 16.5% reporting current use
 Male young adults reported higher current use
rates than female young adults
 The gender difference continued among persons
26 years and older, with 5.8% of men and 2.8%
of women reporting current use
 Persons identifying as two or more races or as
American Indian reported the highest rates of
current use
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Health Ef fects of Cannabis
 Like tobacco, marijuana is frequently smoked and appears to
pose similar health risks, such as increased rates of
respiratory problems and cancer
 Research examining marijuana use during pregnancy has
produced mixed findings
 Increasing attention is being given to the positive or
medicinal ef fects or marijuana use
 Evidence is strongest for alleviating pain, nausea, and
appetite loss such that “for patients such as those with AIDS
or who are undergoing chemotherapy, and who suf fer
simultaneously from severe pain, nausea, and appetite loss
 Although THC, the active ingredient in marijuana, is shown to
have therapeutic ef fects, marijuana also delivers other toxic
substances, including many found in tobacco smoke
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Cocaine
 Cocaine is mostly sold as a white powder and can be snorted,
injected, or smoked
 Immediate ef fects include mental alertness; increased energy;
euphoria; and increased heart rate, blood pressure, and body
temperature
 With high duration time and doses of stimulants, individuals may
experience stimulant delirium, which can include symptoms of
disorientation, confusion, anxiety, and fear
 In episodes of high doses, individuals may also experience
symptoms of psychosis and paranoia and behavioral compulsions
 Crack cocaine, if smoked, results in a rapid and intense high within
a matter of seconds
 Snorting powder cocaine generally elicits ef fects within 20 minutes
 Intravenous injection generally elicits ef fects in 30 seconds
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Epidemiology of Cocaine
 In 2008, 14.7% of U.S. persons 12 years and older
reported that they had used cocaine during their
lifetimes
 Men were more likely than women to report both lifetime
use and current use
 Among adolescents 12-17 years old, girls reported
greater lifetime use than boys
 Boys 12-17 years old reported greater current use than
girls
 Current cocaine use peaked among 21 year olds
 African Americans 26 years and older reported the
highest current use rate
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Health Effects of Cocaine
Cocaine’s health effects differ with the route of administration
Snorting may result in nosebleeds, lost sense of smell, and a
persistently runny nose
Injecting cocaine may result in allergic reactions and risk of
contracting HIV and other blood-borne infections, including viral
hepatitis
Sharing drug-related equipment for intranasal and inhalation use of
cocaine may also increase the risk of contracting viral hepatitis
Cardiovascular and gastrointestinal illnesses are common, as are
problems with the CNS and reproductive system
Research suggests that cocaine is particularly dangerous when used
in combination with alcohol-the body transforms cocaine and alcohol
into a substance that is more toxic than either drug alone.
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Health Effects of Cocaine
Cocaine abuse is associated with acute cardiovascular
and cerebrovascular events, including heart attack and
stroke
Studies have documented that babies born to women who
use cocaine during pregnancy are prematurely delivered,
have low birth weight and have smaller head
circumferences than babies not exposed to cocaine in
utero
NIDA asserts that predictions about “crack babies”
suffering profound irreversible damage has proven to be a
“gross exaggeration” because more of these children have
been able to recover from earlier deficits
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Heroin
Heroin can be smoked, snorted, injected under the skin,
or injected into a vein
Users generally experience a pleasurable sensation
followed by a period of drowsiness and mental cloudiness
Although heroin has long been associated with
marginalized groups of people, the 1990s saw its use
spread to people from middle and upper-middle
socioeconomic classes
Heroin, derived from morphine, belongs to a class of
substances known as opioids, which are used for relieving
pain
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Epidemiology of Heroin
In 2008, 1.5% of persons in the United States
12 years and older reported that they had
used heroin in their lifetime
Lifetime use rates were highest for those 26
years and older
Young adults 18-25 years old reported a
lifetime heroin use rate of 1.4%
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Health Effects of Heroin
 NIDA states that heroin is one of the most detrimental long -term
effects of heroin is addiction itself
 Regular users experience tolerance, need to administer higher
doses to get the desired effects, and develop physical
dependence
 If heroin is not readministered, painful physiological withdrawal
symptoms may occur for up to a week
 Symptoms of withdrawal include restlessness, muscle and bone
pain, insomnia, gastrointestinal disturbance, involuntary leg
movements, and cold flashes
 Overdose leading to death is possible and is a significant risk for
street users who do not know the purity level of the heroin they
have
 For heroin injectors there is the risk of acquiring blood -borne
viruses such and HIV and hepatitis C
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Health Ef fects of Heroin
 Intranasal use may also increase the risk of viral hepatitis
 Collapsed veins, liver disease, abscesses, infection of the
heart lining and valves, and pulmonary complications are
possible outcomes of long -term heroin use
 Studies indicate that infants born to women with heroin
dependence are more frequently premature, tend to have low
birth weight, and often experience a range of perinatal
complications and abnormalities
 Maternal heroin use is also associated with miscarriage and a
greater risk of SIDS
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Hallucinogens
 Hallucinogens comprise a broad group of over 100 different
substances that share the capacity to affect a variety of sensory
distortions and hallucinations
 Historically, select hallucinogens have been used among some
groups as part of religions and spiritual rituals
 With the exception of ecstasy, hallucinogens pose few known
health risks
 The use of LSD has been associated with enduring psychoses,
but it is unclear the extent to which LSD is causal
 During the acute hallucinogenic state there is the risk of
accidental injury or death -particularly true with PCP
 Taken in high dosages, MDMA is associated with hyperthermia
and can lead to cardiovascular, kidney, and liver failure
 Neurotoxicity has been demonstrated in animals, and though
studies have not definitively shown the same results in humans,
clinical reports have documented toxic effects and fatality
associated with ecstasy use
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Inhalants
 Inhalants are breathable chemical vapors found in many
common items and household substances
 Examples include gasoline, paint, cleaning fluids, glue,
marking pens, lighter fluid, and lacquer thinner
 These substances are snif fed for the psychoactive ef fects
 Intoxication generally resembles that of alcohol and may
include stimulation and euphoria, followed by disinhibition,
agitation, and lightheadedness
 With increased volume of vapor inhalation, anesthesia and
unconsciousness can result
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Epidemiology of Inhalants
 In 2008, an estimated 1.1% of American youth aged
12-17 years reported current inhalant use, and 9.3%
reported lifetime use
 Lifetime use rates were higher for girls than for boys
 Among all adolescents, 14 year olds were the most
likely to report inhalant se in the past month
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Health Effects of Inhalants
 Inhalants are extremely toxic and potentially lethal
 Over 700 deaths, mostly of teens and preteens, were
reported to the National Inhalant Prevention
Coalition between 1996 and 2001
 Negative health effects include damage to the brain,
lungs, kidneys, and liver
 Inhalant use has been associated with sudden death,
known as sudden sniffing death syndrome
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Health Effects of Inhalants
 Inhalants are extremely toxic and potentially lethal
 Over 700 deaths, mostly of teens and preteens, were
reported to the National Inhalant Prevention
Coalition between 1996 and 2001
 Negative health effects include damage to the brain,
lungs, kidneys, and liver
 Inhalant use has been associated with sudden death,
known as sudden sniffing death syndrome
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Psychotherapeutics
 Psychotherapeutic medication is the second most
commonly used illegal substance today
 Psychotherapeutics include the nonmedical use of
prescription-type pain relievers, tranquilizers, stimulants,
and sedatives
 They comprise numerous kinds of substances that are
obtained either with a prescription or illegally
 Classes of these substances most commonly abused
include opioids, CNS depressants, and stimulants
 Opioid users, depending on the dose administered, often
experience euphoria followed by a significant decrease in
tension and anxiety
 CNS depressants provide a calming and sedating function
 Stimulants cause an increase in alertness, attention, and
energy along with a feeling of euphoria
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Epidemiology of Psychotherapeutics
 Among persons 12 years and older in the United
States, 20.8% reported lifetime use
 Young adults 18-25 years old, when compared with
other age groups, reported the highest lifetime use
rate
 Youth identifying as two or more races or as
American Indian reported the highest rates of use
 During young adulthood, White Americans joined
American Indians and persons identifying as two or
more races to report the highest rates of current use
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Health Effects of Psychotherapeutics
 Health consequences of psychotherapeutics varied widely
because the substances themselves have such wide variation
in chemical and psychoactive properties
 Long-term use of opioids can result in tolerance, physical
dependence, and addiction
 If use is abruptly stopped or reduced, withdrawal symptoms
such as restlessness, insomnia, irritability, diarrhea, nausea,
and cold flashes may occur
 CNS depressants, prescribed to treat sleep and anxiety
disorders, can produce tolerance, physical dependence,
withdrawal, and addiction
 Sleep disorder medications can also be associated with
problematic use
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Health Effects of Psychotherapeutics
 Users of prescription-type stimulants may experience
euphoria, decreased appetite, and heightened energy and
attention
 Irregular heartbeat, high body temperature, and
cardiovascular failures or seizures are associated with
high dosages of stimulants
 Combining stimulants with decongestants may result in
dangerous elevations in blood pressure or heart
arrhythmias; combining them with antidepressants may
heighten the stimulant’s effect
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Health Effects of Psychotherapeutics
 Methamphetamine is highly addictive, and it produces a
high of longer duration than that of cocaine
 It can cause of variety of serious health effects including
rapid heart rate, increased blood pressure, hyperthermia,
and over time, changes in brain functioning, significant
weight loss, dental problems, psychosis, and various
problems related to mood and behavior
 Methamphetamine overdose can lead to convulsions and,
without proper medical attention, can be fatal
 Research suggests that use during pregnancy may lead to
prenatal complications, premature delivery, and heath
and brain problems for the baby
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
CNS Depressants
 Prescribed to treat sleep and anxiety disorders
 Include barbiturates and benzodiazepines
 Tolerance for these substances develops when they are taken
over time
 Physical dependence, withdrawal, and addiction are all risks
 Sleep disorder medications such as zolpidem, eszopiclone,
and zalepon are also CNS depressants, but seem to be
associated with reduced risk of problematic use
 If used in combination with alcohol, pain medications, some
cold and allergy medications, or other substances that make
one drowsy, CNS depressants can slow one’s breathing and
heart rate-possibly leading to death
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Prescription-type Stimulants
 Include amphetamines like dextroamphetamine and Adderall
and methylphenidate as found in Ritalin and Concerta
 Users may experience euphoria, decreased appetite, and
heightened energy and attention
 Irregular heartbeat, high body temperature, and cardiovascular
failures or seizures are associated with high dosages of
stimulants
 Combining stimulants with decongestants may result in
dangerous elevations in the blood pressure or heart
arrhythmias
 Combining them with antidepressants may heighten the
stimulant’s effects
SUBSTANCE USE PROBLEMS IN HEALTH
SOCIAL WORK
Methamphetamine
 Highly addictive
 Produces a high of longer duration than that of cocaine
 It can cause a variety of serious health effects including
rapid heart rate, increased blood pressure, hyperthermia,
and over time, changes in brain functioning, significant
weight loss, dental problems, psychosis, and various
problems related to mood and behavior
 Overdoses can lead to hyperthermia and convulsion and
without proper medical attention, can be fatal
 Research suggest that use during pregnancy may lead to
prenatal complications, premature delivery, and heart and
brain problems for the baby
PROMINENT APPROACHES TO CONCEPTUALIZE
AND ADDRESS SUBSTANCE USE PROBLEMS
 Conceptual models that explain the development of
substance use problems tend to articulate and advocate
for specific interventions and desired outcomes
 Substance use problems as the result of a complex illness
that requires God’s power for healing vs. substance use as
the result of learning processes
 Commitment to a particular intervention may be shaped
by evaluation of available evidence, personal preferences,
one’s own treatment and recovery experiences, and
affiliations based on training and association
PROMINENT APPROACHES TO CONCEPTUALIZE
AND ADDRESS SUBSTANCE USE PROBLEMS
Systematic of informed eclecticism
 This process involves systematically considering available
evidence to guide intervention, with preference for
approaches that are evidence-based, comprised of clearly
described strategies and techniques, consistent with
social work ethics, within the social worker’s
competencies, and culturally competent
PROMINENT APPROACHES TO CONCEPTUALIZE
AND ADDRESS SUBSTANCE USE PROBLEMS
Moral and Temperance Perspectives
 Early models conceptualized problematic substance use as a
moral issue, reflecting moral weakness, sin, and volitional
disregard for social norms of behavior
 The temperance movement emerged in the United States in
the late 1800s and advocated for the judicious moderate use
of alcohol, based on its potential for harmful consequences
 This conceptualization would suggest that limiting access to
alcohol by making it more costly or less available and
encouraging moderation and abstinence would be useful
interventions
 The moral perspective informs interventions that focus on
punishment through social and legal consequences for
substance use
PROMINENT APPROACHES TO CONCEPTUALIZE
AND ADDRESS SUBSTANCE USE PROBLEMS
Disease Models
 Early in the 19 th century, Benjamin Rush, a physician in the
United States, proposed a disease framework for
understanding alcohol use problems
 In 1935 AA began and contributed to disseminating the
conceptualization of alcoholism as a disease rather than a
moral failing
 The model reflects the perspective that alcohol is “an
obsession of the mind and an allergy of the body”
 The conceptualization reflects recognition of the psychological
and biological components of the disease perspective
 The conceptualization of problematic substance use as a
persistent medical condition has continued to evolve with
recognition that it is influence by biological, environmental,
behavioral, and genetic components
PROMINENT APPROACHES TO CONCEPTUALIZE
AND ADDRESS SUBSTANCE USE PROBLEMS
Disease Models
 These conceptualizations recognize that complex, intersecting
factors influence the onset and course of substance use problems
and, as with other chronic health conditions, require multifaceted
intervention strategies
 Furthermore, as with other chronic health conditions, long -term
treatment is require to address addiction as “a chronic, relapsing
illness”
 Although risk for relapse often dominates common understanding
of addiction, rates of relapse with addiction are comparable to
relapse rates associated with type 1 diabetes
 AA and other 12-step approaches are among the most prominent to
emerge from disease conceptualization of substance use disorders
 Findings of Project MATCH, a large clinical trial of alcohol
treatment, suggests that 12 -step facilitation conducted by a
therapist is as ef fective as cognitive -behavioral and motivational
enhancement therapy
PROMINENT APPROACHES TO CONCEPTUALIZE
AND ADDRESS SUBSTANCE USE PROBLEMS
Psychological Models
 In Relapse Prevention, “addictive behaviors are viewed as
overlearned habits that can be analyzed and modified in the same
manner as other habits”
 The analyses of these habits involves the examination of factors
that contribute to maintaining the behavior, such as antecedents in
the situation or environment, expectations about the outcome of
substance use, and previous experiential learning about the
substance
 The analysis also include examination of consequences of the
behavior with particular attention to the social context and
interpersonal components associated with substance using behavior
 In this model, “a single slip” is not seen “as an indication of total
failure”
 Ef forts are made to use lapses and relapses as learning experiences
that can inform future relapse -prevention strategies
PROMINENT APPROACHES TO CONCEPTUALIZE
AND ADDRESS SUBSTANCE USE PROBLEMS
Psychological Models
 Abstinence violation effect is a phrase used to describe the
cognitive and affective responses a person may experience
when he is committed to absolute abstinence but then
engages in substance use
 Such experiences may increase the person’s risk for relapse
 Interventions based on Relapse Prevention’s conceptualization
focus on assisting clients with identifying situations that may
increase their risk of relapse, strengthening their ability to
cope with or modify such situations, addressing expectations
regarding anticipates outcomes of substance use,
strengthening self-efficacy, reducing the intensity of the
abstinence violation effect through cognitive interventions,
and fostering learning from lapses and relapses
PROMINENT APPROACHES TO CONCEPTUALIZE
AND ADDRESS SUBSTANCE USE PROBLEMS
Psychological Models
 NIDA notes the effectiveness of cognitive -behavioral
treatment with people experiencing problematic use of
alcohol, nicotine, marijuana, cocaine, and
methamphetamine and highlights that people often
experience sustained retention of skills in the year
following treatment
 Positive findings of several studies suggest that this
approach can help increase the period of abstinence,
reduce the severity of relapse, and have comparable
effectiveness with a12-step approach with both alcohol
and other drug use
PROMINENT APPROACHES TO CONCEPTUALIZE
AND ADDRESS SUBSTANCE USE PROBLEMS
Motivational Interviewing
 Motivational interviewing model focuses on why people
change behavior rather than why they do not
 A spirit of collaboration aims to create an egalitarian
partnership rather than a context of confrontation and
argument between the social worker and the client
 The aim is “to create a positive interpersonal atmosphere
that is conducive but not coercive to change
 Rather than resuming that the client lacks awareness,
information, or competence and then attempting to
impart them to the client, the worker engaged aims to
evoke from the client her perspectives, interests, and
sources of motivation
PROMINENT APPROACHES TO CONCEPTUALIZE
AND ADDRESS SUBSTANCE USE PROBLEMS
Motivational Interviewing
 The presumption of evocation is that change is facilitated by
eliciting intrinsic motivation regarding what is most meaningful to
the client and her aims
 Motivational interviewing recognizes that the client has a choice
regarding accepting assistance and that ultimately she will be
responsible for making a behavior chance
 “when motivational interviewing is done properly, it is the client
rather than the counselor who presents the arguments for change”
 Emphasis on reflective listening
 The social worker aims to assist the client with exploration of the
dif ference between the current situation and her future goals
 Self-efficacy is supported by two main elements: the social worker’s
belief that change is possible and the recognition that ultimately
the client will be responsible for the change
PROMINENT APPROACHES TO CONCEPTUALIZE
AND ADDRESS SUBSTANCE USE PROBLEMS
Motivational Interviewing
 Motivational interviewing involved fewer sessions than usual
treatment, which suggests that motivational interviewing may
require less cost and time to achieve gains
 The effects of motivational interviewing were not shown to
differ by gender or problem severity in the meta -analyses
 Findings of Project MATCH indicate that MET is as effective as
CBT and 12-step facilitation; however, given the brevity of the
MET intervention, it is deemed a more cost -effective
intervention
 In its recent review of effective treatments, NIDA indicates
that MET’s effectiveness appears to differ by drug used, with
greater effectiveness for alcohol and marijuana, and to be
particularly useful in enhancing treatment engagement rather
than altering drug use
PROMINENT APPROACHES TO CONCEPTUALIZE
AND ADDRESS SUBSTANCE USE PROBLEMS
Transtheoretical Model
 Precontemplation – no intention of changing behavior in the
foreseeable future. Many people are unaware or underaware of their
problems during this stage
 Contemplation – awareness that a problem exists and serious
consideration about overcoming it but no commitment to take
action at this time. Contemplators typically experience ambivalence
and often weight the “pros and cons of the problem and the
solution to the problem”
 Preparation – intention to take action in the next month;
unsuccessful in taking action during the past year
 Action – modification of behavior, experiences, or environment to
overcome problems. This stage involves successful alteration of the
addictive behavior for a period of 1 day to 6 months
 Maintenance – prevention of relapse and consolidation of gains
attained during action
PROMINENT APPROACHES TO CONCEPTUALIZE
AND ADDRESS SUBSTANCE USE PROBLEMS
Transtheoretical Model
 Change can begin before a person has identified that she has
a problem and proceeds with increased recognition of a
problematic behavior to considerations about how change
might be approached to engaging in behavior change and
finally making a sustained behavior change
 Relapse is “the rule rather than the exception with addictions”
 Relapse is viewed as an opportunity for learning rather than as
a failure
 Important to match the intervention strategy to the client’s
state of change
 There may be a lack of distinction between each of the
discrete stages and that there is limited clarity regarding the
relationship between readiness for change and the stages
 Review suggests that there is a lack of evidence to suggest
that people more through stages in a stepwise fashion
PROMINENT APPROACHES TO CONCEPTUALIZE
AND ADDRESS SUBSTANCE USE PROBLEMS
Public Health-Harm Reduction Approach
 Harm reduction is sometimes seen as “at odds” with abstinence
oriented traditional approaches
 “improvement rather than cure” is “the only realistic expectation for
the treatment of addiction”
 The approach recognizes that many clients are not ready to pursue
abstinence at the time they come into contact with treatment
systems
 Harm reduction is a method of engaging clients as they are
 It recognizes that the person who is currently using substances has
strengths, and it draws on these to empower the client to reduce
harms in his life and to achieve goals that are important to him
 Harm reduction values positive changes in clients’ lives, including
those that may not focus on their substance use
 Harm reduction “does not attempt to minimize or ignore the real
and tragic harm and danger associated with licit and illicit drug
use”
PROMINENT APPROACHES TO CONCEPTUALIZE
AND ADDRESS SUBSTANCE USE PROBLEMS
Public Health-Harm Reduction Approach
 Harm reduction strategies that aim to reduce harmful
effects of drug use include direct practice or treatment
interventions, environmental modifications or public
health approaches, and public policy and advocacy
initiatives
 The authors conclude that “there is substantial evidence
that syringe exchange programs are effective in
preventing HIV risk behavior and HIV seroconversion
among IDUs
PROMINENT APPROACHES TO CONCEPTUALIZE
AND ADDRESS SUBSTANCE USE PROBLEMS
Additional Evidence-Based Approaches
 Behavioral strategies that incorporate vouchers or incentives
to support abstinence from cocaine, alcohol, stimulants,
opioids, marijuana, and nicotine
 The Matrix model, which incorporates relapse prevention,
group therapy, self-help, education about drugs, and family
therapy to assist people the reduction of stimulant and other
drug use
 Multisystemic treatment, multidimensional family therapy, and
brief strategic family therapy
 Family oriented interventions with adults experiencing
substance use problems
 Mental illness frequently co-occurs with substance use
problems, affecting an estimated 50-75% of people with
substance use disorders
PROMINENT APPROACHES TO CONCEPTUALIZE
AND ADDRESS SUBSTANCE USE PROBLEMS
Additional Evidence-Based Approaches
 Promising approaches to assist people with co -occurring
substance use and mental health concerns include
motivational interview, contingency management, cognitive
behavioral treatment, relapse preventions, assertive
community treatment, intensive case management, and the
modified therapeutic community model
 A growing body of evidence supports the use of trauma specific treatments to address co -occurring trauma and
substance use
 Interventions may vary according to focus, location, intensity,
identity of the helping system, client system, and public or
private funding sources
SCREENING
An Empathic, Invitational, and Supportive Stance
 The clinician must be empathic and recognize that it is
often embarrassing and difficult for clients to talk about
their substance use
 It is important that clinicians have an appreciation for
how difficult it can be to change substance -using behavior
 The clinician needs to be able to discriminate between the
person and his or her substance-using behavior
 Clinicians need to convey a sense of respect for the
person, acknowledging her inherent dignity, value, and
worth
 Clinicians should be careful not to dismiss or overlook the
problematic substance-using behavior
SCREENING
Sources of Information
 First and foremost, gather information from the clients
themselves
 Gather information from involved family and friends and
other treatment providers
 Finally, gather information from existing
medical/treatment records, from biological tests such as
toxicology screenings, and from other service providers
SCREENING
What Information to Gather
 Substances being used, frequency of use, amount of use
 Consequences of use
 Circumstances in which one uses
 Social workers may want to ask about substance use by close
family members
 Because it may be particularly difficult for clients to respond
honestly about using illicit substances, it is generally helpful
to begin with inquiring about alcohol use and then to discuss
other drug use
 CSAT Consensus Panel suggests that persons who are high risk
for illicit drug use be asked about alcohol and other drug use
together
 Questions regarding other drug use may be less stigmatizing
when paired with questions regarding alcohol use
SCREENING
What Information to Gather
 Risk factors for other drug use include psychiatric illness,
genetic predisposition, peers who use alcohol and other drugs,
familial conflict, and HIV positive status
 NIAAA recommends simply beginning by asking “do you
sometimes drink beer, wine, or other alcoholic beverages?”
 Regardless of what the report about drinking alcohol,
adolescents should be asked about use of other drugs,
particularly marijuana
 Women who are pregnant or who have experienced a major life
transition should be asked about prescription drug use and
over-the-counter sleep aids
 Finally, all older adults should be asked about over -the-counter
and prescription drug use
SCREENING
What Information to Gather
 NIAAA recommends that positive answers to “do you sometimes
drink beer, wine, or other alcoholic beverages?” should be followed
with a question about frequency and amount
 such questions can begin with “how many times in the year have
you have five or more drinks in a day (for men) of four drinks in a
day (for women)
 If the person reports one or more days of heavy drinking, the next
questions should include, “on average, how many days a week do
you drink?” and “on a typical drinking day, how many drinks do you
have”?”
 “what is the maximum number of drinks you consumed on any given
occasion during the past month?”
 With information about the frequency and amount of alcohol use,
the social worker is able to determine if the client’s alcohol
consumption is within a safe range or is potentially problematic
SCREENING
At-risk Consumption
 More than 14 drinks per week or more than four drinks on
a given occasion by men
 More than seven drinks per week or more than three
drinks on a given occasion by women
 Any amount of alcohol consumption by pregnant women
 More than seven drinks per week or more than three
drinks on any given occasion by older adults
 Any alcohol consumption by children or adolescents
SCREENING
The following factors may suggest increased risk of
substance use problems:
 Mental health problems
 Presence of infectious diseases such as HIV, hepatitis B
and C, and tuberculosis
 Trauma exposure
 Involvement with peers who use drugs and alcohol
 Homelessness/housing instability
 Significant familial conflict or instability
 Vocational instability
 Legal problems
SCREENING
Established Tools
 It is essential that these tools demonstrate accuracy in
their screening ability as reflected by the measure’s
sensitivity and specificity
 Sensitivity refers to the measure’s ability to identify all
persons with the designated problem
 Specificity refers to the instrument’s ability not to include
people who do not have the designated problem
SCREENING
Established Tools: The CAGE
 One of the most widely used short screening tools in the
substance abuse field. It consists of four questions about
aspects of alcohol use:
1.
2.
3.
4.
have you even felt that you should cut down on your drinking?
have people annoyed you by criticizing your drinking?
have you ever felt bad or guilty about your drinking?
have you even had a drink first thing in the morning to steady
your nerves or get ride of a hangover?
 A positive answer to two or more questions in considered
clinically significant
SCREENING
Established Tools: TICS
1. In the last year, have you ever drank or used drugs more
than you meant to?
2. Have you felt you wanted or needed to cut down on your
drinking or drug use in the last year?

A positive response to either question is likely to accurately
identify the presence of a current substance use disorder
amount 80% of adults
SCREENING
Established Tools: Additional Tools
 Michigan Alcoholism Screening Test (MAST) is a 25 -item
instrument designed to detect alcohol problems
 Short MAST (SMAST) is 13 items
 Brief MAST (B-MAST) is 10 items
 Drug Abuse Screening Test (DAST) was designed to
identify problems related to the use of drugs other than
alcohol
SCREENING
Brief Intervention
 Brief interventions are defined as “those practices that aim to
investigate a potential problem and motivate an individual to begin
to do something about his substance abuse, either by natural,
client-directed mean or by seeking additional treatment”
 The general goal of all brief interventions is based on a philosophy
of harm reduction
 Goals specific to individuals depend on their aims, the
characteristics of their use, their readiness for change, and the
setting in which the intervention is of fered
 The client should guide the goal -setting process
 Providers of fer feedback to clients to inform them about the risks
associated with their substance use; however, this feedback process
should be interactive, with incremental provision of information and
elicitation of the client’s responses to it
SCREENING
Brief Intervention
 Following this screening clients receive information about the
status of their substance use
 In addition to education clients about their general status,
health social workers should also provide clients with
information regarding the health interactions and
consequences of their substance use
 Responsibility for change is placed with the client
 It is important for the client to know that while the
professional is concerned and interested in his welfare,
ultimately it is the decision and responsibility of the client to
make changes in his substance use behavior
 Care must be taken so that the client does not feel alone in
trying to change or blamed for his problems
 Social workers should recognize the the step is about self determination and empowerment
SCREENING
Brief Intervention
 The provider gives advice to the client to change his behavior
 This advice will vary depending on the client and can range
from suggesting a change in substance use behavior to
providing relevant information about substance use
 Key element of giving advice in a way that is consistent with
motivational interviewing include asking permission from the
client to provide the advice
 Providing information in culturally relevant ways
 Attending to the way in which the suggestions are made
 Providing the client with information about the options and
discussing his perspectives about them are central elements
of assisting the client with making an informed decision about
how he would like to proceed
SCREENING
Brief Intervention
 The social worker should use an empathetic stance that
conveys respect, caring, warmth, and reflective listening
 Socials workers should seek to enhance clients’ sense of
self-efficacy
 Conveying hope, optimism, and recognition of clients’
strengths are meaningful ways in which to achieve this
goal