Transcript Substance Abuse Assessment, Diagnosis, and Treatment - NASW-NC

Substance Abuse
Assessment,
Diagnosis, and
Treatment
Cheryl Corbin, MSW, LCSW, LCAS, CCS
• Drug abuse is a major public health
problem that impacts society on multiple
levels. Directly or indirectly, every
community is affected by drug abuse and
addiction, as is every family. Drugs take a
tremendous toll on our society at many
levels.
IMPACT
• Substance Abuse Costs Our Nation
More than $484 Billion per Year
Drug Abuse is COSTLY
Cost
• 88,000 people die from alcoholrelated causes annually
62,000 men
26,000 women
Reported in NIH (Nat’l Inst. on Alc Abuse & Prev) from: Centers for Disease Control and Prevention, Alcohol-related
disease impact
Death Rates
• 2014: Alcohol-impaired driving
fatalities accounted for 9,967 deaths
• 31% of overall driving fatalities
Nat’l Center for Statistics and Analysis, Nov 2015
Driving Fatalities
WHAT WE DO IS VERY
IMPORTANT
• Assessment  Diagnosis 
Treatment Plan  Treatment
•Assessment
Where do we Start?
• What do we look at/for?
• HOW do I ask the questions?
• Why do we ask these
questions?
Bio-Psycho-Social
BPS: Areas of Focus
• Who I am
• What I will be doing
• How long this will take
• What is the process
• Next steps
BPS-Introduction
• Strength(s)
• Need(s)
• Ability/Abilities
• Preference(s)
SNAP
• Physical Health
• Genetic Vulnerabilities
• Disability
• Drug effects
BPS-Biological
• Temperament (a person's nature, especially as it
permanently affects their behavior)
• IQ
• Self-esteem
• Coping skills
• Social Skills
• Mood issues
• Trauma
BPS-Psychological
• Peers/Peer Relationships
• Family circumstances
• Family Relationships
• School/Work
BPS-Social
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Appearance
Dress
Posture
Hygiene
Eye Contact
Orientation
Relational Behavior
Psychomotor activity
Speech
Mental Status
• Mood-the more sustained emotional makeup of the patient's
personality
• Affect- patient’s immediate expression of emotion
• Thought process-Coherent? Incoherent? Logical? Illogical?
• Thought content-Consistent w/ reality?
• Intellectual functioning
• Attention-Normal? Distracted?
• Concentration-use series 7s
• Judgment
Mental Status (cont’d)
• Insight
• Attitude- the emotional tone displayed toward the
examiner, other individuals, or their illness
• Memory: Short term (3-5 mins) LT:
• Effort
• Impulse control
• SI
• HI
Mental Status (cont’d)
• Interpretive Summary (Diagnostic
Summary or Clinical Interpretation)
• Treatment Recommendations
• Length of stay/treatment
• Prognosis
BPS
Diagnostic Impression
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Client is a (age )y/o male/female. presenting for treatment due to . Client’s drinking history
is as follows: first drink was at age __, the last drink was __. Client uses on average __times
per week in the amount of __. Client reports drug use is as follows:
There does not appear to be any unique challenges or problems that need to be addressed for
this individual.
The central themes that have been identified for this client are
SNAP is as follows:
Problem areas that will be addressed on the treatment plan are
This client does/does not have a co-occurring disorder.
Client describes childhood as ___ and family relationships as ___.
There is/is not a family h/o addiction. There is/is not a family history of mental health issues.
There is/is not SI. There is no homicidal ideation present for this client. This client’s
prognosis is ___. Level of care recommended for this client is ___.
Client’s diagnosis is:
Diagnostic code:
Estimated length of treatment:
Interpretive Summary
•DSM 5
Diagnosis
• Assessment  Diagnosis 
Treatment Plan  Treatment
Remember!
• 1. Used more than intended
• 2. Persistent desire or
unsuccessful efforts to control use
• 3. Great deal of time spent
obtaining, using or recovering
DSM 5 SUBSTANCE USE
DISORDER CRITERIA
• 4.
Craving, or strong desire or urge to
use
• 5. Failure to fulfill major role
obligations at work, school or home
• 6. Persistent or recurring social or
interpersonal problems cause or
exacerbated by use
• 7. Important social, occupational or
recreational activities given up or
reduced
• 8. Recurrent use in physically
hazardous situations
• 9. Continue use despite persistent or
recurring physical or psychological
problems
• 10. Tolerance - markedly increased
amounts required for intoxication or
desired effect, or markedly diminished
effect of the same amount used
• 11. Withdrawal symptoms developing
after cessation of use
• 1. Used more than intended
How do I phrase this?
• 2. Persistent desire or
unsuccessful efforts to control
use
How do I phrase this?
• 3. Great deal of time spent
obtaining, using or recovering
How do I phrase this?
• 4. Craving, or strong desire or
urge to use
How do I phrase this?
• 5. Failure to fulfill major role
obligations at work, school or
home
How do I phrase this?
• 6. Persistent or recurring
social or interpersonal
problems cause or exacerbated
by use
How do I phrase this?
• 7. Important social,
occupational or recreational
activities given up or reduced
How do I phrase this?
• 8. Recurrent use in physically
hazardous situations
How do I phrase this?
• 9. Continue use despite
persistent or recurring physical
or psychological problems
How do I phrase this?
• 10. Tolerance - markedly
increased amounts required for
intoxication or desired effect,
or markedly diminished effect
of the same amount used
How do I phrase this?
• 11. Withdrawal symptoms
developing after cessation of
use
How do I phrase this?
• Assessment  Diagnosis 
Treatment Plan  Treatment
Remember!
• Treatment and treatment planning is
“person-centered”
Tx Planning
#1: Date Identified:
Need
Goal
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Measurable
Objective
Intervention
.
Provider
Responsibility
Treatment Planning
Client
Initials
Target
Goal
Date
Date
Goal
Met
• I need to avoid getting into any more trouble because of
alcohol
• I need to stop using drugs
• I need to cut down on my drinking
• I want to feel better
• My relationship with my spouse isn't good; I want it to be
better
• I need to learn how to relax
• I need to deal with my feelings of anxiety
• I need to communicate better
Tx Planning: Need
• Client will achieve and maintain success at work
• Client will be better able to express thoughts and feelings to
others
• Client will maintain abstinence from…
• Client will provide drug-free urinalyses and alcohol-free
breathalyzer results
• Client will involve self with alcohol and drug free leisure
activities
• Client will manage stress with alcohol/drug-free coping skills
Tx Planning: Goals
• Client will identify 3 alternatives to alcohol consumption
• Client will identify and utilize 3 drug/alcohol-free coping
skills
• Client will attend 5 AA/NA meetings
• Client will report to work on time on a daily basis for 2
weeks
• Client will report involvement in 2 sober leisure/social
activities per week for one month
Tx Planning: Measurable
Objectives
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Psycho-education to increase knowledge
Individual tx to monitor mood
Ind tx to improve communication skills
Grp tx to improve peer interaction
Grp tx to improve communication skills
Grp tx to increase knowledge and understanding of addiction
and recovery
• Grp tx to address recovery issues
• CBT/MI/Psychodynamic/Pharmacotherapies
Tx Planning: Intervention
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Provide education to client
Provide ongoing support and positive feedback
Use CBT to identify and alter negative thought patterns
Use CBT to identify and alter
negative/unhealthy/destructive beliefs and belief patterns
• Use MI to assist and motivate client
• Use MI to assist client in the change process
• Monitor client mood, monitor client progress
Tx Planning: Provider
Responsibility
• Assessment  Diagnosis 
Treatment Plan  Treatment
Remember!
LOC
LOC
HOURS
INTENSITY
0.5
Early
Intervention
varies
Low intensity and brief treatment
1
Outpatient
Services
<9
Low to medium
2.1
IOP
Intensive
Outpatient
Services
9-19
Medium to high
2.5
Partial
Hospitalization
20 or
more per
week
Medium to high
3.1
Clinically
managed Low
Intensity
Residential
24/7
Medium to high
Clinically
Managed Low
Intensity
Residential
ASAM-Levels of Care
LOC
LOC
Hours
Intensity
3.3
Clinically Managed
Medium Intensity
Residential Services
24/7
High
3.5
Clinically Managed
High Intensity
Residential
24/7
High
3.7
Medically
Monitored Intensive
Inpt Services
24/7
High
4
Medically Managed
Intensive Inpatient
Services
24/7
High
ASAM Levels 3.3 to 4
Dimension 1
Acute Intoxication and/or Withdrawal Potential
Dimension 2
Biomedical Conditions and Complications
Dimension 3
Emotional, Behavioral, or Cognitive Conditions and
Complications
Dimension 4
Readiness to Change
Dimension 5
Relapse, Continued Use, or Continued Problem Potential
Dimension 6
Recovery / Living Environment
ASAM Dimensions
• No single treatment is appropriate for all individuals
• Treatment needs to be readily available
• Treatment must attend to multiple needs of the individual
(not just drug use)
• Multiple courses of TX may be required for success
• Remaining in TX for an adequate period of time is critical
for treatment effectiveness
NIDA’s Principles of
Treatment
• Drug addiction can be effectively treated
with behavior-based therapies and with
medications
• Addiction is a complex but treatable
disease that affects brain function and
behavior
NIDA
Treatment
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Seeking Safety
Dialectical Behavioral Therapy
Matrix Model
Minnesota Model (Hazelden Model)
Self-Help and Recovery Model
Living In Balance
Prime for Life / Prime Solutions
Dual Diagnosis
Treatment
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Motivational Interviewing
Cognitive Behavioral Therapy
CPT and PE for trauma
Relapse Prevention
Pharmacotherapies: Medication Assisted and
Pharmacological Interventions
Interventions
The Transtheoretical Model (TTM):
Stages of Change
Prochaska & DiClemente, 1983
Change Model
• The Transtheoretical Model (Prochaska & DiClemente, 1983;
Prochaska, DiClemente, & Norcross, 1992) is an integrative,
biopsychosocial model to conceptualize the process of
intentional behavior change. Whereas other models of
behavior change focus exclusively on certain dimensions of
change (e.g. theories focusing mainly on social or biological
influences), the TTM seeks to include and integrate key
constructs from other theories into a comprehensive theory of
change that can be applied to a variety of behaviors,
populations, and settings (e.g. treatment settings, prevention
and policy-making settings, etc.)—hence, the name
Transtheoretical
Overview of the Model
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Methadone
Buprenorphine
Suboxone
Naltrexone (Revia, Vivitrol: long acting)
Antabuse (Disulfiram)
Chantix
Acamprosate (Campral)
Pharmacotherapies
• Antabuse-causes a severe adverse reaction
• Naltrexone-Works by blocking in the brain the “high”
that is experienced when alcohol is consumed. By
blocking the pleasure the drinker receives, naltrexone
eventually reduces cravings
• Acamprosate-Reduces alcohol cravings and reduces the
physical distress and emotional discomfort people usually
experience when they quit drinking.
Meds for Cravings
• An opioid partial agonist
• Produces opioid effects such as euphoria or respiratory
depression
• These effects are weaker than those of full drugs such as
heroin and methadone
• Lower potential for misuse
• Diminish the effects of physical dependency to opioids
(withdrawal sx and cravings)
Buprenorphine
• Naloxone blocks or reverses the effects of opioid
medication, including extreme drowsiness, slowed
breathing, or loss of consciousness. An opioid is
sometimes called a narcotic. Naloxone is used to treat a
narcotic overdose in an emergency situation.
Naloxone
• Suboxone (buprenorphine and naloxone)
• Suboxone contains a combination of buprenorphine and
naloxone. Buprenorphine is an opioid medication.
Naloxone blocks the effects of opioid medication,
including pain relief or feelings of well-being that can
lead to opioid abuse.
Suboxone
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Agonists
Antagonists
Partial agonist/partial antagonist
Opiates and opioids
Terminology
The function of a neurotransmitter can be increased or
mimicked by drugs, medications, or other chemical agents
• Methadone
Agonists
• The function of a neurotransmitter can be decreased,
inhibited, or reversed by other agents
• Naloxone (Narcan) is an opioid antagonist
Antagonists
• Opiates are derived directly from the opium poppy by
departing and purifying the various chemicals in the
poppy. Morphine
• Opioids include all opiates but also include chemicals that
have been synthesized in some way (fentanyl).
• So heroin is an opioid but not an opiate. Morphine is an
opiate and also an opioid.
Opiates and Opioids
Neurotransmitter
General Function
Alcohol-Related
Function
Dopamine
Regulates motivation,
reinforcement, and fine
movement coordination
Mediates reinforcement
of alcohol consumption
Serotonin
Regulates bodily
rhythms, appetite, sexual
behavior, emotional
states, sleep, attention,
motivation
May influence alcohol
consumption, intoxication
and development of
tolerance; may contribute to
withdrawal sx and
reinforcement, may
modulate dopamine release
thereby increasing alcohol’s
rewarding effects
Neurotransmitters
Neurotransmitter
General Function
Alcohol-Related
Function
GABA (Gammaaminobutyric acid)
Serves as the primary
inhibitory
neurotransmitter in the
brain
May contribute to
intoxication and
sedation; inhibition of
GABA function
following drinking
cessation may contribute
to acute w/drawal sx
Glutamate
Serves as the major
excitatory
neurotransmitter in the
brain
May contribute to acute
w/drawal sx; inhibition
of glutamate function
following drinking
cessation may contribute
to intoxication and
sedation
Neurotransmitters
Neurotransmitter
General Function
Alcohol-Related
Function
Opiate Peptides
(including betaendorphin
Regulates various
functions as well as
produces morphine-like
effects, including pain
relief and mood
elevation
Contributes to
reinforcement of alcohol
consumption, possibly
through interaction with
dopamine
Neurotransmitters
Questions