Transcript Assessing and Diagnosing Substance Abuse Disorders

Brittany Baker, LMSW

The rate of any current substance use disorder was only slightly
greater than that estimated for independent mood disorders,
9.35%, representing 19.4 million US adults.
 Arch Gen Psychiatry. 2004;61(8):807-816

It is estimated that 9 percent of children in this country (6 million)
live with at least one parent who abuses alcohol or other drugs
 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2003).

Studies indicate that between one-third and two-thirds of child
maltreatment cases involve substance use to some degree
 (HHS, 1999).

According to the legislature, in 2009, the economic costs of
alcohol and drub abuse was worth discussion.
 $254.7 billion annually with $97.7 billion due to drug abuse


Short answer, yes.
Longer answer, according to a report by the
Substance Abuse and Mental Health Services
Administration (SAMHSA) the following was
true in 2013 for teens aged 12-17:
▪ On an average day,
▪ 881,684 smoked cigarettes
▪ 646,707 smoked marijuana
▪ 457,672 drank alcohol

In recent decades the perceived risk of harm to
self has declined, resulting in higher usage.
 The consequences?
▪ Higher Death Rates.
▪ 18% of drivers ages 16-20, drive under the influence.
▪ According to the Youth Risk Behavior Surveillance System conducted
by CDC, unintentional injuries, such as MVAs cause 29% of deaths in
adolescents, %0% of these deaths were alcohol related.
▪ Higher STD Contraction Rates.
▪ Higher drug usage has been linked to higher percentage of STD
contraction. This is because adolescents are more apt to be impulsive
during use and have multiple sex partners.
▪ Higher Juvenile Delinquency Rates.
▪ currently approximately 52% of males in the juvenile system are
linked to drug or alcohol use.

Many adolescents who are considered to be
using drugs are likely to suffer from other
medical, mental health, or environmental
stressors:




Depression, Anxiety, Eating Disorders
Parent-Child Conflict, Social Incompetency
Loss and Grief
Academic Failure
 Social Workers are trained to look at the entire picture of a case,
this is why we are better than LPCs and LCDCs. 

What are you assessing
 Introducing substances
▪ What is it?
▪ Why is it used?
▪ What does current use look like?

Process of Assessing
 What are they reporting
 What are they not reporting
 What is observable

What do they report?
 Name of Substance (street or clinical, past and/or







current use)
When started
How frequent
At what amount per use
For how long at current rate
Last use
Attempts at sobriety
Longest sobriety


What may NOT be reported by patient
Family History
 Hereditary factor

Get family reports
 Some patients will underreport.
▪ This is for numerous reasons (i.e guilt, shame, avoidance of
prosecution)
▪ One Australian study found number one factor of underreporting to be
full time employment, most likely fear of termination
▪ However, remain cautious because family member may not
understand situation in its entity.

Medical conditions
 Liver disease, heart conditions

Use your Senses/Intuition
 Appearance, smell


Alcohol
Found in:
 Beer, Wine, Liquor

Why people intake:
 Increased sociability, self esteem, euphoria
 Cope with mood disorders i.e. depression

Signs of current use:
 Flushed face, slurred speech, unsteady gait,
distinct smell

Cannabis
 preparation of the Cannabis plant for either
recreational or medicinal purposes.

Common Names
 hashish, weed, pot, marajuana

Why people intake:
 Lower anxiety, euphoria

Signs of current use:
 Impaired cognition, slower reaction time, reddened
eyes, distinct smell, inappropriate affect/laughing


Opioids
Common Names:
 Heroin, morphine, vicodin, hydrocodone,
oxycotin, narco, codeine

Why People Intake:
 Decreased perception or reaction to pain

Signs of current use:
 Constricted pupils, unbalanced gait, slurred
speech, difficulty staying awake

Benzodiazepines
 Decreases excitability of neurons, resulting in
lower communication and a “relaxed” feeling

Common Names:
 “Downers”, Xanax, also BARS, Ativan, Klonopin,
Valium,

Why Intake:
 Decrease anxiety, agitation, insomnia

Signs of current use:
 Similar to those of opioid abuse

Stimulants
 Amphetamines, Methamphetamines, Cocaine

Street Names:
 ADHD meds, meth, dust, crack, coke

Why Intake:
 Increase concentration, energy, weight loss

Signs of current use:
 Dilated pupils, restlessness, increase heart rate,
insomnia, high anxiety, possible paranoia,
extreme weight loss quickly, open pores on face.

New and Upcoming Drugs

K-2
▪ A synthetic form of marijuana known to cause long-term psychosis

Bath Salts
▪ A group of designer drugs, crushed, resembling Epson salt, but
chemically resembling cocaine or amphetamine.

Krokodil
▪ A synthetic form of opiate similar to heroin, and MUCH cheaper,
hence its rise in use. ($150 vs $6)
 DSM-IV has specified substance “abuse” and
“dependence” with the ability for the clinician to
specify the substance type and notate the state of
remission, if applicable.
 DSM-V has removed these terms and replaced it
with substance “use”, allowing the clinician to
specify the severity of the use.
▪ The purpose of this appears to be to help minimize the stigma
related to “abusing” or “misusing” substances and being an
“addict” because of physical dependence.
▪ This prompts the discussion as to how addiction is seen by society
and treated in psychiatry.

In order to be diagnosed with Substance Use Disorder the patient must meet at least 2 of the 11
criteria for the diagnosis. the criteria are very similar to those outlined in DSM-IV for abuse and
dependence combined. A patient meeting 2-3 if the criteria indicates mild substance use disorder,
meeting 4-5 criteria indicates moderate, and 6-7 indicates severe (APA, 2013).

Diagnostic Criteria












Continuing to use opioids despite negative personal consequences
Repeatedly unable to carry out major obligations at work, school, or home due to opioid use
Recurrent use of opioids in physically hazardous situations
Continued use despite persistent or recurring social or interpersonal problems caused or made worse by
opioid use
Tolerance as defined by either a need for markedly increased amounts to achieve intoxication or desired
effect or markedly diminished effect with continued use of the same amount
Withdrawal manifesting as either characteristic syndrome or the substance is used to avoid withdrawal
Using greater amounts or using over a longer time period than intended
Persistent desire or unsuccessful efforts to cut down or control opioid use
Spending a lot of time obtaining, using, or recovering from using opioids
Stopping or reducing important social, occupational, or recreational activities due to opioid use
Consistant use of opioids despite acknowledgment of persistent or recurrent physical or psychological
difficulties from using opioids
Craving or a strong desire to use opioids (*Note - This is a new criterion added since the DSM-IV-TR)

Many substances are known to lead to
“substance induced” mental health states
 i.e. K-2 is well known to create “substance
induced psychosis”.
▪ After initial sobriety is achieved, sometimes psychosis does not
revert. This is because K-2 appears to actively change the
physiological cells of the brain in some.
 i.e. some stimulants can push a diagnosed Bipolar
person into a “state” of mania.
▪ This person may remain in state of mania and require medication
management to recenter

Initially, the adolescent may require
detoxification due to dependence on the
drug.
 Some drug dependencies may require inpatient
treatment during initial detox due to withdrawal
symptoms.
▪ Shakiness, vomiting, dizziness, racing heart beat, higher
blood pressure, possibility of seizures.
▪ There are medications that can aid with symptoms of withdrawal
 ETOH: Librium, Valium*
 Opiate: Catapres (Clonodine)*, Robaxin

CBT/Behavior Modification
 Most program and treatment modalities
incorporate a foundation of CBT/BM.
▪ Identifying reason for use/consequences of use
 The “cue” for use; i.e. paraphilia
 The results of use; i.e. DUI, probation
▪ Changing the behavior
▪ Seeing positive results
▪ Changing the thought process
▪ Motivational Intervention, Contingency Management,
and Relapse Prevention are running themes of most
studies.


12-Step
“Minnesota Model”
▪ Adaptation of the 12 step program leading to the
baseline of 28 days for rehab. This is the current length
of stay seen as sufficient by most insurance companies.

Family Systems/Therapy
▪ Old Style Paradigm
▪ Second Paradigm
▪ Third Paradigm *added the importance of peer group to treatment

Treatment is seen as most effective when
monotherapeutic models are combined:
 Adolescent brains are not as matured as adults
and require creative manipulation of skills to be
successful.
 Individualized treatment and accountability are
key.
 Kids have to “buy in” to what you are teaching.

Important Program Characteristics for Success:
 Skills Development
▪ General Life Skills
 Staffing
▪ Recovering “users”
 Peer Monitoring
▪ Social Learning/Accountability
 Conflict Resolution
▪ Linked to social skills
 Family Involvement
▪ Support
 Community Involvement
▪ Options

Seven Challenges
 Listed and supported as an evidenced-based treatment from
SAMSHA this incororates the following elements:
▪ We decided to open up and talk honestly about ourselves and about alcohol and
other drugs.
▪ We looked at what we liked about alcohol and other drugs, and why we were
using them
▪ We looked at our use of alcohol or other drugs to see if it has caused harm or
could cause harm.
▪ We looked at our responsibility and the responsibility of others for our
problems.
▪ We thought about where we seemed to be headed, where we wanted to go,
and what we wanted to accomplish.
▪ We made thoughtful decisions about our lives and about our use of alcohol and
other drugs.
▪ We followed through on our decisions about our lives and drug use. If we saw
problems, we went back to earlier challenges and mastered them

Cannabis Youth Treatment (CYT)
 Motivational/CBT Enhancement
 Family Support Network
 Community Reinforcement
 Skills Enhancement
▪ Problem Solving, Anger Management, Communication,
Planning, Cravings, Relapse Prevention

Diversion Models/Drug Courts for Adolescents
▪
▪
▪
▪
▪
▪
▪

Intensive Community Supervision
Day/Evening Treatment
Tracking/Monitoring
Mentor Tutoring
Work Apprenticeship
Restitution
Community Service/Volunteer Work
Medication Management
 While mainly used in adults, some medications can be
used to help management relapse prevention:
▪ ETOH: Antabuse, Campral
▪ Opiates: Suboxone, Methadone

Bridget F. Grant, PhD, PhD; Frederick S. Stinson, PhD; Deborah A. Dawson, PhD; S. Patricia
Chou, PhD; Mary C. Dufour, MD, MPH; Wilson Compton, MD; Roger P. Pickering, MS;
Kenneth Kaplan, BS. Prevalence and Co-occurrence of Substance Use Disorders and
Independent Mood and Anxiety Disorders Results From the National Epidemiologic Survey
on Alcohol and Related Conditions. Arch Gen Psychiatry; 61(8):807-816

Child Welfare Information Gateway. 2009. Parental substance use and the child welfare
system. Bulletins for Professionals.

Hanson, R. F., Self-Brown, S., Fricker-Elhai, A. E., Kilpatrick, D. G., Saunders, B. E., &
Resnick, H. S. (2006). The relations between family environment and violence exposure
among youth: Findings from the National Survey of Adolescents. Child Maltreatment 11(1),
3-15.

McGregor, Kiah and Makkai, Toni. Self-reported Drug Use: How Prevalent is Underreporting? Australian Institute of Criminology. Issues and Trends of Criminology. June 2003.
No.260

State legislature. 2009. The council of state governments resolution supporting state
legislative mental health caucuses.

Substance Abuse and Mental Health Services Administration. (2003). Children living with
substance-abusing or substance-dependent parents. (National Household Survey on Drug
Abuse). Rockville, MD: Office of Applied Studies. Retrieved January 28, 2008, from
www.oas.samhsa.gov/2k3/children/children.htm

Treatment Centers.NET. July 2012. Signs and symptoms of drug abuse.
http://www.treatment-centers.net/signs-and-symptoms.html.
McHugh, Katharyn. 2011. “Cognitive-Behavioral Therapy for Substance Use Disorders”
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2897895/


CYT.http://www.uclaisap.org/dmhcod/assets/Transition%20Age%20Youth/Resources/Adol
escent%20Brief%20Treatment%20Manual%20Order%20Form.pdf

http://sevenchallenges.com

Substance use by adolescents on an average day is alarming

SAMHSAhttp://www.samhsa.gov/newsroom/advisories/1308285320.aspx