Chapter 17 Handbook of Health Social Work, 2 nd Edition SUBSTANCE USE PROBLEMS IN HEALTH SOCIAL...

Chapter 17Handbook of Health Social Work, 2nd 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

TermsAddiction – 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.


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.


DSM-IV-TR Diagnostic Criteria for Substance AbuseA.A maladaptive pattern of substance use leading to clinically significant

impairment or distress, as manifested by one (or more) of the following occurring within a 12-month period:

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 persistent or recurrent social or

interpersonal problems caused or exacerbated by the effects 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, fourth edition, text revision, by American Psychiatric Association, 2000, Washington, DC: Author, pp.199.


DSM-IV-TR Diagnostic Criteria for Substance DependenceA maladaptive pattern of substance use leading to clinically significant impairment or distress, as

manifested by three (or more) of the following, occurring at any time in the same 12-month period.

1. 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.2. Withdrawal, as manifested by either of the following:a. The characteristic withdrawal syndrome for the substance.b. The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.3. The substance is often taken in larger amounts or over a longer period than was intended.4. There is a persistent desire or unsuccessful efforts to cut down or control substance use.5. A great deal of time is spent in activities necessary to obtain the substance, use the

substance, or recover from its effects.6. Important social, occupational, or recreational activities are given up or reduced because of

substance use.7. 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.

Source: Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, by American Psychiatric Association, 2000, Washington, DC: Author, p.197.


AlcoholJust over half of all Americans 12 years and older report current used of alcoholMore than 50% of American adults have a close family member who has met the diagnostic criteria for alcohol dependenceIn the United States and worldwide, it is one of the most widely used and dangerous drugsCNS depressantResearch suggests that genetics account for approximately 60% of alcohol vulnerability.


Alcohol EpidemiologyWhite American young adults aged 18-25 years reported the highest rates of problematic alcohol useAmerican Indian, Hispanic, and White American adolescents reported the highest levels of lifetime useHispanic adults aged 26-64 report the highest rate of bring drinkingYoung adults aged 18-25 years experience the highest rates of problem drinking

41% of this group reported binge drinking in the past month


Health Effects of AlcoholResearch suggests that alcohol is associated with 67% of partner assaults, 37% of rapes, 50% of homicides, and 40% of traffic fatalitiesThe average lifespan is decreased by 10-15 years for persons with alcohol dependenceChronic heavy drinking is a leading cause of cardiovascular illnesses, which are the leading cause of early mortality among those with alcohol dependenceMen with alcohol dependence are two time more likely than men without to die from atherosclerotic and degenerative heart diseaseWomen with alcohol dependence are four times more likely to die from the same disease than women who do not have alcohol dependence


Health Effects of AlcoholLiver disease is commonly associated with alcohol useAlcohol consumption may enhance acetaminophen liver toxicityAlcohol consumption is associated with greater severity of hepatitis CLong-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 liverAlcohol hepatitiscirrhosis


Health Effects of AlcoholPeople who have alcohol dependence are at increased risk for

cancers of the head, neck, esophagus, stomach, and lungHeavy alcohol use has a significant effect on the immune

system, which may result in infections such as pneumoniaHIV rates are higher among persons who abuse alcoholNeuropathy is associated with heavy alcohol useWernicke’s syndrome and Korsakoff’s psychosis are also

related to heavy useDrinking 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


TobaccoTobacco 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 efforts may be particularly relevant among people living with HIV, for whom smoking may negatively affect immune functioning over time and increase risk of infections of the respiratory tract

Tobacco can help with relaxation and concentrationWithdrawal symptoms, such as irritability, sleep disturbances,

craving, and cognitive deficits, can occur for a month or more following cessation


Tobacco Epidemiology2008 NSDUH estimated that 28.4% of the U.S. population 12

years and older were current users of tobacco productsAdolescents aged 12-17 years reported current use rates of

11.4%Boys were more likely than girls to report useAmerican Indian adolescents reported the highest rates of

tobacco useCurrent tobacco use rates peaked during young adulthoodMen used at greater rates than womenAmerican Indian and white American young adults reported

the highest rates of current use


Health Effects of TobaccoNIDA reports that tobacco use is the leading preventable

cause of disease, disability, and death in the United StatesApproximately 8.6 million Americans suffer 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


Health Effects of Tobacco Approximately 20% of pregnant women in the

U.S. smoke throughout their pregnanciesMaternal 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


CannabisMarijuana is the most commonly used illegal

drugUsers 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


Epidemiology of CannabisRates of cannabis use peaked for 18-25-year-

olds, with 16.5% reporting current useMale young adults reported higher current use

rates than female young adultsThe 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


Health Effects of CannabisLike 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 effects 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 suffer simultaneously from severe pain, nausea, and appetite loss

Although THC, the active ingredient in marijuana, is shown to have therapeutic effects, marijuana also delivers other toxic substances, including many found in tobacco smoke


CocaineCocaine is mostly sold as a white powder and can be snorted,

injected, or smoked Immediate effects 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 effects within 20 minutes Intravenous injection generally elicits effects in 30 seconds


Epidemiology of CocaineIn 2008, 14.7% of U.S. persons 12 years and older

reported that they had used cocaine during their lifetimesMen were more likely than women to report both lifetime

use and current useAmong adolescents 12-17 years old, girls reported

greater lifetime use than boysBoys 12-17 years old reported greater current use than

girlsCurrent cocaine use peaked among 21 year oldsAfrican Americans 26 years and older reported the

highest current use rate


Health Effects of CocaineCocaine’s health effects differ with the route of administrationSnorting may result in nosebleeds, lost sense of smell, and a persistently runny noseInjecting cocaine may result in allergic reactions and risk of contracting HIV and other blood-borne infections, including viral hepatitisSharing drug-related equipment for intranasal and inhalation use of cocaine may also increase the risk of contracting viral hepatitisCardiovascular and gastrointestinal illnesses are common, as are problems with the CNS and reproductive systemResearch 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.


Health Effects of CocaineCocaine abuse is associated with acute cardiovascular and cerebrovascular events, including heart attack and strokeStudies 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 uteroNIDA 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


HeroinHeroin can be smoked, snorted, injected under the skin, or injected into a veinUsers generally experience a pleasurable sensation followed by a period of drowsiness and mental cloudinessAlthough heroin has long been associated with marginalized groups of people, the 1990s saw its use spread to people from middle and upper-middle socioeconomic classesHeroin, derived from morphine, belongs to a class of substances known as opioids, which are used for relieving pain


Epidemiology of HeroinIn 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%


Health Effects of HeroinNIDA states that heroin is one of the most detrimental long-term

effects of heroin is addiction itselfRegular 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


Health Effects of Heroin Intranasal use may also increase the risk of viral hepatitisCollapsed 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


HallucinogensHallucinogens 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


Inhalants Inhalants are breathable chemical vapors found in many

common items and household substancesExamples include gasoline, paint, cleaning fluids, glue,

marking pens, lighter fluid, and lacquer thinnerThese substances are sniffed for the psychoactive effects 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


Epidemiology of InhalantsIn 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


Health Effects of InhalantsInhalants are extremely toxic and potentially lethalOver 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


PsychotherapeuticsPsychotherapeutic medication is the second most

commonly used illegal substance todayPsychotherapeutics 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


Epidemiology of PsychotherapeuticsAmong persons 12 years and older in the United

States, 20.8% reported lifetime useYoung 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


Health Effects of PsychotherapeuticsHealth 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


Health Effects of PsychotherapeuticsUsers 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


Health Effects of PsychotherapeuticsMethamphetamine is highly addictive, and it produces a

high of longer duration than that of cocaineIt 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


CNS DepressantsPrescribed to treat sleep and anxiety disordersInclude barbiturates and benzodiazepinesTolerance for these substances develops when they are

taken over timePhysical dependence, withdrawal, and addiction are all risksSleep 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


Prescription-type StimulantsInclude amphetamines like dextroamphetamine and Adderall

and methylphenidate as found in Ritalin and ConcertaUsers may experience euphoria, decreased appetite, and

heightened energy and attentionIrregular 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


MethamphetamineHighly addictiveProduces a high of longer duration than that of cocaineIt 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


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 eclecticismThis 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


USE PROBLEMS

Moral and Temperance PerspectivesEarly 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


USE PROBLEMS

Disease ModelsEarly in the 19th 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


USE PROBLEMS

Disease ModelsThese 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 effective as cognitive-behavioral and motivational enhancement therapy


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”

Efforts are made to use lapses and relapses as learning experiences that can inform future relapse-prevention strategies


USE PROBLEMS

Psychological ModelsAbstinence 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 relapseInterventions 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


USE PROBLEMS

Psychological ModelsNIDA 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


USE PROBLEMS

Motivational InterviewingMotivational interviewing model focuses on why people

change behavior rather than why they do notA 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


USE PROBLEMS

Motivational InterviewingThe 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 listeningThe social worker aims to assist the client with exploration of the

difference between the current situation and her future goalsSelf-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


USE PROBLEMS

Motivational InterviewingMotivational 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


USE PROBLEMS

Transtheoretical ModelPrecontemplation – 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


USE PROBLEMS

Transtheoretical ModelChange 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


USE PROBLEMS

Public Health-Harm Reduction ApproachHarm 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”


USE PROBLEMS

Public Health-Harm Reduction ApproachHarm 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


USE PROBLEMS

Additional Evidence-Based ApproachesBehavioral 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


USE PROBLEMS

Additional Evidence-Based ApproachesPromising 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


USE PROBLEMS

An Empathic, Invitational, and Supportive StanceThe 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 InformationFirst and foremost, gather information from the clients

themselvesGather information from involved family and friends and

other treatment providersFinally, gather information from existing

medical/treatment records, from biological tests such as toxicology screenings, and from other service providers

SCREENING

What Information to GatherSubstances being used, frequency of use, amount of useConsequences of useCircumstances in which one usesSocial workers may want to ask about substance use by close

family membersBecause 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 GatherRisk 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 GatherNIAAA 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 ConsumptionMore than 14 drinks per week or more than four drinks

on a given occasion by menMore than seven drinks per week or more than three

drinks on a given occasion by womenAny amount of alcohol consumption by pregnant

womenMore than seven drinks per week or more than three

drinks on any given occasion by older adultsAny alcohol consumption by children or adolescents

SCREENING

The following factors may suggest increased risk of substance use problems:

Mental health problemsPresence of infectious diseases such as HIV, hepatitis B

and C, and tuberculosisTrauma exposureInvolvement with peers who use drugs and alcoholHomelessness/housing instabilitySignificant familial conflict or instabilityVocational instabilityLegal problems

SCREENING

Established ToolsIt 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 CAGEOne of the most widely used short screening tools in the

substance abuse field. It consists of four questions about aspects of alcohol use:1. have you even felt that you should cut down on your

drinking?2. have people annoyed you by criticizing your drinking?3. have you ever felt bad or guilty about your drinking?4. 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: TICS1.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 ToolsMichigan Alcoholism Screening Test (MAST) is a 25-item

instrument designed to detect alcohol problemsShort MAST (SMAST) is 13 itemsBrief MAST (B-MAST) is 10 itemsDrug Abuse Screening Test (DAST) was designed to

identify problems related to the use of drugs other than alcohol

SCREENING

Brief InterventionBrief 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 offered

The client should guide the goal-setting processProviders offer 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 InterventionFollowing this screening clients receive information about the

status of their substance useIn 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 clientIt 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 InterventionThe provider gives advice to the client to change his behaviorThis 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 waysAttending to the way in which the suggestions are madeProviding 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 InterventionThe 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

SCREENING

Chapter 17 Handbook of Health Social Work, 2 nd Edition SUBSTANCE USE PROBLEMS IN HEALTH SOCIAL...

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