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Treatment of Chemical Dependency

Module Five Lecture In this module we begin looking at the process of treatment for drug abuse and dependency. In your book, treatment approaches regarding alcohol abuse and alcohol dependency was addressed to some degree in the chapter on alcohol. Much of the historic treatment models are based upon treatment for alcoholism. Chapter 17 in your book also looks at substance abuse treatment via Prevention. There are three levels of prevention: primary (no development of a problem and use of education to try and prevent a problem from developing); secondary (evidence of use and possible misuse and intervention to try and prevent a serious problem from developing); and tertiary (the person needs treatment for a more severe problem with their use of substances). Chapter 18 in your book addresses the concept of the Harm Reduction model which looks at helping a person who is misusing substances to make a change that is short of complete abstinence of the drug. For example, a person might be motivated to start drinking less as opposed to not drinking at all. The idea is that any change that is healthier is a positive step. In the next chapter we will look at methadone maintenance as a treatment for heroin dependency. Methadone maintenance would be an example of harm reduction as the person is still using an opiate drug (methadone) as a replacement for heroin in order to live a less chaotic lifestyle. Throughout the next modules in discussions about other psychoactive drugs, reference will be made to the more generic treatment models, and how they need to be modified based upon the drug the person may be dependent upon.

Before treatment can begin, a thorough assessment must take place. In this class just an overview of the assessment process will be covered. In taking the Assessment, Case Planning, and Management class, students go through the assessment process in more detail. A good substance abuse evaluation or assessment is composed of at least five components: Having the client complete a screening instrument such as a (M)ichigan (A)lcoholism (S)creen (T)est; and/or

(S)ubtance (A)buse (S)ubtle (S)creening (I)nventory; or one of many other pencil and paper “tests.” These tests are used to not diagnose, but to begin identifying problem use with chemicals. Along with completion of a screening instrument, a good assessment will include a clinical interview where the counselor can ask a series of questions to begin developing an understanding of the client in terms of her or his drinking/drugging pattern, past drinking/drugging pattern, current family history, family of origin history, current lifestyle including structure of day, sleep or eating difficulty, hobbies and interests, and a mental status examination to screen for possible psychiatric issues such as depression, anxiety, and/or psychosis. Again, it is in the Assessment, Case Planning, and Management class where the clinical interview is discussed in greater detail. A good assessment will also include referring the client to a doctor for a complete physical to see if damage has been done to the body, and a psychological evaluation to screen for possible psychiatric problems. It is becoming more common in seeing clients who have a co-occurring mental illness such as Bipolar Disorder, Post Traumatic Stress Disorder, or a psychotic disorder along with their chemical dependency. This is more commonly known as dual-diagnosis and requires treating both disorders together to increase chances for successful recovery from both disorders. If possible, it’s also helpful to interview the person’s significant other, whoever that might be, to get a sense of what they have observed about this person’s use of chemicals, as often the client him or herself is not the best reporter of his or her use of substances.

This thorough assessment leads to a diagnostic impression regarding the person’s use of chemicals. The tool that is used is the DSM-V. As of the first of January, 2014, agencies need to refer to the DSM-V for diagnosis. The DSM-V diagnosis has changed from Substance Dependence or Abuse as categorized in the DSM-IV-TR to Substance Use Disorder and the degree of a problem is rated on a continuum mild, moderate, or severe. As was true with the DSM-IV, the same criteria are used for each drug. The more criteria the person meets, the greater the severity of a problem he or she has with the substance. Here are the criteria:

Substance-Use Disorder A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period: 1. 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) 2. 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) 3. 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 consequences of intoxication, physical fights) 4. tolerance, as defined by either of the following: a. a need for markedly increased amounts of the substance to achieve intoxication or desired effect b. markedly diminished effect with continued use of the same amount of the substance (Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.) 5. withdrawal, as manifested by either of the following: a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances) b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms (Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta- blockers.)

6. the substance is often taken in larger amounts or over a longer period than was intended 7. there is a persistent desire or unsuccessful efforts to cut down or control substance use 8. a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects 9. important social, occupational, or recreational activities are given up or reduced because of substance use 10. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance 11. Craving or a strong desire or urge to use a specific substance. Severity specifiers: Moderate: 2-3 criteria positive Severe: 4 or more criteria positive

Specify if: With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present)

Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 4 nor 5 is present) Course specifiers (see DSM-V for definitions): Early Full Remission

Early Partial Remission Sustained Full Remission Sustained Partial Remission On Agonist Therapy In a Controlled Environment

There is a another possibility. Sometimes people use poor judgement with their use of chemicals, like trying to drive after having too much to drink, but that in itself does not necessarily mean they fit the criteria for Substance Abuse Disorder. This type of situation is better known as an incident. There is no indication of a major alcohol or drug problem. In terms of treatment, prevention is in order. Educating the individual about alcohol and other drugs, and the problems that can ensue with abuse of the substances. Typically there is no or little counseling involved and probably no referral to a 12-Step program like Alcoholics Anonymous or Narcotics Anonymous.

If the person has a diagnosis of mild to moderate Substance Use Disorder, they have developed a pattern of maladaptive use of the chemical and are beginning to suffer consequences as a result. This individual needs the same information that the person who is involved in an incident, however, there will be counseling as to how the person can relate to the information she or he is learning. Often these individuals will be asked to remain abstinent during their time in treatment. Part of this is seeing if they can indeed, remain alcohol or drug free. If not, this is more evidence that their problem with substances has become more severe. There is debate as to whether these individuals should be mandated to attend 12-Step support groups like AA or NA. For one thing, they may not have a desire to quit their use and as a result, take away from those who are using meetings seriously in their attempt to remain sober. Others

would point out that by listening to testimonies of people who have lost everything in relationship to their alcohol or other drug use can be eye-openers to those who may progress to that point if they do not change their behavior.

One of the outcomes of a thorough assessment besides a diagnostic impression, are treatment recommendations. The clinician consults with others to determine the best probable course of action in order to help the alcohol or drug abusing individual. This would probably involve determination of level of care; a continuum of care moving from a least restrictive treatment environment, to the most restrictive treatment environment, at all times keeping in mind being able to meet the client’s needs. The least restrictive environment would be outpatient counseling, meeting with the client one or two individual sessions in combination with group counseling. With this kind of arrangement the person can still go to work and be with his or her family in the evening. This level of care would be recommended more for mild to moderate Substance Use Disorder, although in some situations, more severe use might be addressed on this level of care, especially if the program is what is called an IOP or Intensive Outpatient Program, where the individual may go in to the treatment facility everyday for an hour or two.

There are times, however, when the therapeutic or treatment environment needs to be even more intensive and restrictive. This is where residential treatment or inpatient treatment becomes important. Working with the person 24 hours a day, seven days a week for a period of 30 days to a year in length. Part of this is determined by the severity of the substance abuse, the need to have the person removed from his or her living situation in order to maintain abstinence, the healthy support system the person may or may not have in place, whether they may also be suicidal, and if they need a break from their family, or if their family needs a break from them. Then there is a level of care in between outpatient and residential known as partial care. An example of partial care would be a day treatment program where the person goes for treatment during the day, but then returns home at night.

Of course, one of the deciding factors in deciding upon what level of care to recommend, are dollars. Does the person have money to pay for a more expensive residential stay? If she or he can’t pay out of pocket, do they have health insurance, and if they do, does it pay for substance abuse treatment in a residential setting. Unfortunately in today’s managed care world, the person has a limited amount of time, if any time, his or her insurance will pay for treatment, and in many states, including Nebraska, there may be long waiting lists to get into state funded facilities, or sliding fee scale facilities allowing people to pay what they can.

Finally, what is involved in terms of treatment if the person has a diagnosis of Substance Use Disorder-Severe. Again, the person may or may not be treated in a residential setting. In any case, however, the person needs to go through a safe detoxification, or removal of the drug from the body. As discussed in the module on alcohol, withdrawal can be fatal if not medically managed. During the detoxification process the person is introduced to the treatment process. After detox the person begins his or her treatment. Most treatment facilities have historically used the medical model and 12-Step Model, based upon Alcoholics Anonymous, as their primary treatment approach, although the 12Step Model is not the only approach that is used. In the Treatment Issues class, a number of treatment models or methodologies are studied including, but not limited to, the 12-Step approach.

The medical model, which gained favor in the 1950's, got the medical community involved in the person’s treatment. The American Medical Association defined alcoholism as a disease that should be seen in the same light as any other biological disease such as heart disease or diabetes. That there was no “cure” for alcoholism, but if the person quit drinking, he or she could successfully recover knowing that they could never take another drink without sliding back to where they were before; and if left untreated would ultimately lead to death. In defining it as a disease, it was seen to develop in stages as other diseases and had a biological or genetic cause. The AMA was

heavily influenced by AA in its approach and strongly suggested that doctors in treating their patients recommend regular attendance at AA meetings. All of this occurred without any proof that alcoholism indeed was a disease process, but it did help to reduce the stigma associated with alcoholism in terms of the person being weak willed or immoral. Scientists continue to look for ways to medically treat alcoholism and other drug dependencies, especially in the area of medication. Trying to find a medicine that could be administered to the person to help ease withdrawal and eliminate craving for the drug. On a number of levels they’ve been successful with”medicines” like methadone and naltrexone for opiate and alcohol dependency.

Alcoholics Anonymous was started in the 1930's by two men, Bill Wilson, and Dr. Bob Smith in Akron, Ohio. Both were recovering alcoholics who began to support each other in their recovery, and then began to reach out to other alcoholics. Bill Wilson had had a spiritual conversion that set off his quest for sobriety. This lead to the 12-Steps which are sometimes known as the therapeutic component of AA. In your book you’ll find the 12-Steps, which when followed will not only help the alcoholic, or drug dependent individual stay sober, but also change his or her life. The focus of the 12-Steps is to admit one is powerless over the chemical and that his or her life has become unmanageable, and to turn her or his life over to a “Higher Power.” It is with the direction of the Higher Power and the support of his or her fellow alcoholics that the person is able to maintain his or her sobriety. Other steps deal with taking a moral inventory, admitting to self, another person, and the Higher Power the exact nature of one’s character defects, asking the Higher Power to remove these defects, to atone to others for misdeeds committed during the time the person was drinking or using, and to maintain these steps on a daily basis. Ultimately, the last step is to take the message to other struggling chemically dependent people. The 12-Step meetings become the cornerstone of sobriety, where sharing takes place about struggles and triumphs in completion of the steps and with everyday life. Members are encouraged to find a sponsor, someone they can rely on for support to help keep them sober when tempted to drink or use

again. Members also become familiar with the “big book.” The actual name of the book in Alcoholics Anonymous, but seldom is it called by that title. Many meetings center around readings from the “big book,” with the first part of the book an introduction to the philosophy of AA and 12-Steps. The rest of the book consists of testimonies of those who have been helped by AA.

Many treatment facilities incorporate the 12-Step model in their treatment approach where the individual can learn about 12-Steps and begin to work on them. The clients also become acquainted with going to meetings, and finding a sponsor. Then as part of aftercare, continuing their meetings and working through the steps.

One model of treatment for chemical dependency is the Terrence Gorski’s Developmental Model of Recovery. This model is often used in conjunction with the 12-Step meetings as an adjunct to treatment. Even though this model has been around for awhile now, it still seems contemporary when looking at the Stage of Change Model and Motivation Enhancement Model. According to Gorski, recovery takes place in stages, thus the clinician needs to know where the client is in order to provide the most effective care. Initially most people come into a treatment facility thinking they do not have an issue with their use of chemicals. Sometimes we deem this kind of thinking as denial. This stage of recovery is known as Transition. The goal of the counselor at this point is to address the denial in order to help the client face the obvious in order to begin recovery. Denial may be defined a number of different ways, but knowing it is a defense mechanism the person is using to protect their essence of being as it’s frightening to think one’s behavior might be out of control, and to protect their dependency upon the drug. It should not be taken personally, as the person is not “lying” to others, but lying to self. (D)on’t (E)ven k(N)ow (I) (A)m (L)ying. Denial can take many forms from absolutely refusing to accept the possibility of chemical dependency or even a problem with use of a chemical, to minimizing (maybe a couple of drinks now and then) to rationalizing and blaming others for the situation (You’d have one now and then if you were married to my wife/husband). Denial can be dealt with in a number of ways,

from confrontation in educating the person as to the facts of chemical dependency and how those facts relate to that individual, to family education and interventions where concerned others voice their feelings about the person’s use of chemicals and how that use if affecting them personally, with the hope the person will go into treatment. Another way to approach denial with a client is to make sure all homework assignments are in writing, things are harder to deny when they are written down. For example, Step One homework where the client is to write down a certain number of times how their use of chemicals has hurt them or someone else. It’s hoped the person will begin to contemplate and weigh the advantages and disadvantages of admitting his or her use is problematic, and then accepting help.

In hopefully making a self-diagnosis, the person then moves into the Stabilization stage. As a result of giving up the denial, many feelings can begin to overwhelm the individual, everything from shame to fear and anger. It’s at this time she or he needs lots of emotional support from the counselor and other treatment staff to support from family, friends, and formal support groups like AA. With these stages there is no set time frame as to how long each stage lasts, as it’s very individual. And there is not a firm line where one stage ends and the other begins. This leads then into the Working stage. This is the stage where the hard work of learning new coping mechanisms to deal with life are learned. In AA a distinction is made between being sober and being dry. Not drinking or using is being dry, but actually changing one’s whole life without the use of the chemical is sobriety. This means learning how to manage stress, how to manage feelings, how to structure one’s day, learning how to communicate with others in healthy ways, learning how to have fun, and finding a purpose or meaning in one’s life absent the substance, to live life on life's terms...