Substance Use Problems E-Book

Mitch Earleywine

• Herausgeber: Hogrefe Publishing
• Kategorie: Fachliteratur
• Serie: Advances in Psychotherapy - Evidence-Based Practice
• Sprache: Englisch

Seitenzahl: 223

Veröffentlichungsjahr: 2018

Beschreibung

A fully updated new edition of the popular text that separates the facts from the myths about drug and substance use and provides practical, evidence-based guidance on dealing with them. The literature on diagnosis and treatment of drug and substance abuse is filled with successful, empirically based approaches, but also with controversy and hearsay. Health professionals in a range of settings are bound to meet clients with troubles related to drugs – and this text helps them separate the myths from the facts. It provides trainees and professionals with a handy, concise guide for helping problem drug users build enjoyable, multifaceted lives using approaches based on decades of research. Readers will improve their intuitions and clinical skills by adding an overarching understanding of drug use and the development of problems that translates into appropriate techniques for encouraging clients to change behavior themselves. This highly readable text explains not only what to do, but when and how to do it. Seasoned experts and those new to the field will welcome the chance to review the latest developments in guiding self-change for this intriguing, prevalent set of problems.

Leseprobe

Substance Use Problems

2nd edition

Mitch Earleywine

Psychology Department, Clinical Area, University at Albany, State University of New York, NY

About the Author

Mitch Earleywine, PhD, is Professor of Clinical Psychology at the University at Albany, State University of New York, where he teaches drugs and human behavior, substance abuse treatment, and clinical research methods. He has received over 20 teaching commendations, including the coveted General Education Teaching Award from the University of Southern California. His research funding has come from the National Institute on Alcohol Abuse and Alcoholism, the Alcoholic Beverage Medical Research Foundation, and the Marijuana Policy Project. He serves on the editorial boards of four psychology journals, reviews for over a dozen, and has more than 120 publications on drug use and abuse, including Understanding Marijuana (Oxford University Press, 2002). He served as Chair of the Board of Directors for the National Organization for the Reform of Marijuana Laws, and is a member of the Research Society on Alcoholism, the Association for the Advancement of Behavior Therapy, and the Drug Policy Alliance.

Advances in Psychotherapy – Evidence-Based Practice

Series Editor

Danny Wedding, PhD, MPH, School of Medicine, American University of Antigua, St. Georges, Antigua

Associate Editors

Larry Beutler, PhD, Professor, Palo Alto University / Pacific Graduate School of Psychology, Palo Alto, CA

Kenneth E. Freedland, PhD, Professor of Psychiatry and Psychology, Washington University School of Medicine, St. Louis, MO

Linda C. Sobell, PhD, ABPP, Professor, Center for Psychological Studies, Nova Southeastern University, Ft. Lauderdale, FL

David A. Wolfe, PhD, RBC Chair in Children’s Mental Health, Centre for Addiction and Mental Health, University of Toronto, ON

The basic objective of this series is to provide therapists with practical, evidence-based treatment guidance for the most common disorders seen in clinical practice – and to do so in a reader-friendly manner. Each book in the series is both a compact “how-to” reference on a particular disorder for use by professional clinicians in their daily work and an ideal educational resource for students as well as for practice-oriented continuing education.

The most important feature of the books is that they are practical and easy to use: All are structured similarly and all provide a compact and easy-to-follow guide to all aspects that are relevant in real-life practice. Tables, boxed clinical “pearls,” marginal notes, and summary boxes assist orientation, while checklists provide tools for use in daily practice.

Library of Congress Cataloging in Publication information for the print version of this bookis available via the Library of Congress Marc Database under the Library of Congress Control Number 2016933580

Library and Archives Canada Cataloguing in Publication

Earleywine, Mitch, author

Substance use problems / Mitch Earleywine (Psychology Department,

Clinical Area, University at Albany, State University of New York, NY). --

2nd edition.

(Advances in psychotherapy--evidence-based practice volume 15)

Includes bibliographical references.

Issued in print and electronic formats.

ISBN 978-0-88937-416-4 (paperback).--ISBN 978-1-61676-416-6 (pdf).--

ISBN 978-1-61334-416-3 (epub)

1. Drug abuse. 2. Drug abuse--Treatment. I. Title. II. Series: Advances

in psychotherapy--evidence-based practice ; v. 15

RC564.E25 2016

616.86’0651

C2016-901276-X

C2016-901277-8

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|v|Acknowledgments

My hearty thanks to Danny Wedding, Robert Dimbleby, and Linda Sobell for keeping me involved in this project. I thank my clinical supervisees who encouraged me to elaborate on these points. The graduate students who took the substance abuse treatment course in the last 26 years deserve congratulations for keeping me on top of this literature while encouraging me to explain it efficiently. The thousands (!) who took the infamous “Drug Class” kept me excited about these topics by letting me see this field through their eyes. My usual support team also gets unusual kudos: Robert Earleywine, the late Clark and Suzy Van Scoyk, David and Felice Gordis, Joe Earleywine (who critiqued sections with great candor and minimal ridicule), Jack Huntington, Paul Armentano, Allen St. Pierre, Keith Stroup, Rick Steves, and Domenico Scarlatti. My unbridled thanks to Nicholas Van Dam, who deserves an award for reading every word of this document and many that didn’t make it. His comments improved the book dramatically. Special thanks to Michelle Stiles, who turned my free associations into references. I also thank my new support team: The Musketeers (Brad Armour-Garb, Tony DeBlasi, and Larry Kranich), and Russ Belville also get my sincere gratitude. My unparalleled gratitude also goes to Joey Palamar for computing the alcohol statistics for Table 2.

My daughters, Dahlia and Maya, continue to teach me that no matter how much I may know about genetics and environment, I cannot explain all the variance in behavior. My wife, Elana, continues to show inexplicable support, including astounding clinical skill at dealing with frequent and severe bouts of DMS (drug manuscript syndrome). I dedicate this book to her with love.

But I think I owe the biggest debt to the clients who sat with me as we all crawled, walked, ran, and occasionally flew toward better lives.

Table of Contents

Acknowledgments

1 Description

1.1 Terminology

1.1.1 Diagnostic Terms

1.1.2 Common Drugs

1.1.3 Nonproblematic, Recreational Drug Use

1.1.4 Problematic Drug Use

1.2 Definitions

1.2.1 Substance-Related and Addictive Disorders

1.2.2 Codes From the DSM

1.2.3 Drug Problems

1.3 Epidemiology

1.3.1 World Statistics

1.3.2 Demographic Correlates

1.3.3 Recent Use

1.3.4 Problematic Use

1.4 Course and Prognosis

1.4.1 Chronicity

1.5 Differential Diagnosis

1.5.1 Deviant Arousal

1.5.2 Thought Disorder

1.6 Comorbidities

1.6.1 Impulse Control Disorders

1.6.2 Problem Gambling

1.6.3 Eating Disorders

1.6.4 Attention Deficit Disorders

1.6.5 Conduct Disorder

1.6.6 Personality Disorders

1.6.7 Mood Disorders

1.6.8 Anxiety Disorders

1.6.9 Suicide

1.7 Diagnostic Procedures and Documentation

2 The Biopsychosocial Model of Drug Problems

2.1 Interacting Components

2.2 Initiation

2.3 Regular Use

2.4 Problem Use

2.5 Treatment Outcomes

3 Diagnosis, Assessment, and Treatment Indications

3.1 Assessment Is Treatment

3.2 Timeline Followback (TLFB)

3.3 The Inventory of Drug Use Consequences (InDUC-2L)

3.4 Social Support

3.5 Treatment History

3.6 Brief Situational Confidence Questionnaire (BSCQ)

3.7 Motivation to Change

4 Treatment

4.1 Methods of Treatment

4.1.1 Empirically Supported Treatments (ESTs)

4.1.2 Harm Reduction, Drug Safety, and Abstinence

4.2 Efficacy and Prognosis

4.3 The Therapeutic Alliance as a Mechanism of Action

4.4 Variations and Combinations of Methods

4.4.1 The Spirit of Motivational Interviewing

4.4.2 Mutual-Help and Self-Help Groups

4.4.3 Mindfulness Meditation

4.4.4 Psychopharmacological Adjuncts to Treatment

4.5 Readiness to Change, Therapist Goals, and Problems in Carrying Out the Treatment

4.5.1 Interventions Tailored to Motivation

4.5.2 Readiness to Change and Motivation

4.5.3 Ambivalent About Change

4.5.4 Envisioning

4.5.5 Increased Readiness

4.5.6 Change Strategy

4.5.7 Avoiding Classically Conditioned Stimuli

4.5.8 Alternative Activities

4.5.9 Altering Beliefs

4.5.10 Generalizing Challenges to Maladaptive Cognitions

4.5.11 Implementing Change

4.5.12 Maintenance

4.5.13 Lapse and Relapse

4.5.14 Abstinence Violation

4.5.15 Apparently Irrelevant Decisions

4.5.16 High-Risk Situations

4.6 Multicultural Issues

5 Further Reading

6 References

7 Appendix: Tools and Resources

Inventory of Drug Use Consequences (InDUC-2L)

InDUC-2L Scoring Sheet

Brief Situational Confidence Questionnaire (BSCQ-8)

Shortened Inventory of Problems – Alcohol and Drugs (SIP-AD)

SIP-AD Scoring Sheet

|1|1Description

1.1 Terminology

This first section reviews diagnostic terms, epidemiology, prognosis, differential diagnosis, comorbidities, and diagnostic procedures for drug-related problems. A clear understanding of each of these topics will lay a foundation for efficient assessment and treatment.

1.1.1 Diagnostic Terms

Defining problem drug use can seem like a fool’s errand. Some people clearly have their lives altered by their use of psychoactive substances; others seem to use without troubles. The range of substances, intoxication experiences, and negative consequences is vast. Several terms appear to describe drug problems adequately, but many others are imprecise, ambiguous, or pejorative. The definition of problematic use reflects tacit assumptions about drugs and drug users. These assumptions can alter our interactions with clients in ways that may escape our awareness. Those who consider illicit drug use (or any illegal behavior) inherently wrong can find that their interactions with these clients differ dramatically from their interactions with other clients. The moral implications of using drugs change in different environments and different eras. Perhaps the best perspective for defining problem drug use requires understanding the goal of the definition. Ideally, identifying drug problems could serve as a step toward building a productive therapeutic relationship. Precise names for these problems can also aid communication within a treatment team. When everyone involved gives the same meaning to terms like addiction or substance use disorder, it is easier to avoid confusion.

Categories and Continua

Many used the term addict without a formal definition for years, which often led to misunderstandings. Dependence and abuse had specific meanings with acceptable discriminant validity, giving them the potential to improve communication, but subsequent research revealed that they seemed to stem from a single, underlying factor dubbed substance-related and addictive disorders. Recent work focuses on adapting substance-related and addictive disorders to provide a convenient way for clinicians and researchers to communicate. Nevertheless, two people with this diagnosis may not share a single symptom. A rigid focus on these diagnostic categories can also lead clinicians to miss a chance to prevent problems before they start. A client experiencing negative |2|consequences unrelated directly to the chosen symptoms might not qualify for a diagnosis, or at least not a severe one, but could still benefit from altering drug use. Thus, thinking about the impact of drugs on quality of life can prevent problems in a way that a premature focus on diagnoses might neglect.

Unfortunately, lay conceptions of diagnostic categories confuse both clients and the public. For example, some people define any use of an illegal drug as problematic, but busy clinicians rarely have time to split hairs over who does or does not qualify for a label. Perhaps the best approach to defining misuse relies on cataloging problems that stem from the drug. This approach may provide the most specific information for treatment. Many view drug problems categorically – either substance use interferes with someone’s life or it does not. Nevertheless, examining drug problems on a continuum has considerable utility and empirical support (Denson & Earleywine, 2006). One useful way to look at this range of troubles would place complete abstinence on one end of a continuum and serious troubles, including a diagnosis of severe substance use disorder, on the other. Unfortunately, the word abstinence has some odd connotations. People who do not use a drug might not be showing some effortful attempts to abstain. They might not show any interest. Non-use remains an awkward alternative but gets the meaning across. Nonproblematic use might fall near the abstinence end of the continuum, while troubles that might not qualify for a diagnosis might lie closer to the diagnosable disorder. Variation within substance use disorder is also acknowledged, from mild to severe, depending upon the number of symptoms. This continuous model might challenge those of us trained in the tradition of diagnosis or disease, but could also heighten awareness for the prevention of problems (see Figure 1). This continuous approach is also consistent with the reformulation of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013).

Figure 1 A continuum of drug use and problems.

|3|1.1.2 Common Drugs

Terms

Different psychoactive drugs can wax and wane in popularity, and it is challenging to keep up with trends in use and the rituals and slang associated with new drugs. Nevertheless, a little effort can go a long way in clinical work. Clients appreciate therapists who know their world. Professionals with some background information about common drugs can gain credibility in their clients’ eyes. Few therapists have time to become experts in every substance, but a general familiarity with commonly used drugs, the subjective effects that appear to motivate use, and common street names can prove helpful (see Table 1 for a focused list).

Table 1 Some Common Drugs, Reported Effects, and Street Names

Drug

Reported effects

Street names

Marijuana

Euphoria, laughter, hunger, sedation, aphrodisiac

Pot, grass, weed

Powder cocaine

Stimulation, confidence, improved focus, aphrodisiac

Coke, dust, powder, flakes, coca, snow

Crack cocaine

Extreme euphoria, stimulation, confidence

Crack, rock, sugar, bazooka, devil rocks

Heroin

Euphoria, sedation, analgesia

H, hard candy, dope, junk

Hallucinogens

Tangential thinking, perceptual aberrations, spiritual connection

Acid, X, candy, trips, ’shrooms

Inhalants

Laughter, analgesia, sedation

Rush, gas, huff, poppers

Pain relievers

Analgesia, euphoria, numbness

Oxy, Vics

Sedatives

Tranquility, relaxation

Reds, downers, downs

Stimulants

Increased arousal, improved focus

Uppers, ups, speed, crank, meth

Subjective Effects

Subjective effects vary with dosage, expectations, experience, and setting, so there are vast individual differences in response. An individualized approach is ideal, but general knowledge about substances can save clinicians time and effort. Drugs often produce certain effects as a result of straightforward physiological processes, and thus a few heuristics can apply across many drugs because we all share comparable nervous systems. Higher doses generally produce larger effects. For example, stimulants almost invariably increase heart rate, regardless of the user’s beliefs or situation. This effect increases as the amount of the drug increases. Other effects arise, at least in part, because users |4|believe these effects will occur. For example, those who believe that alcohol makes them more adept socially can feel more relaxed with others. Curiously, this social enhancement can arise even after drinking a placebo. In addition to expectations, a user’s previous experience with a drug can alter the drug’s impact. Those who have developed tolerance from prior use will experience a weaker effect from many drugs. By contrast, repeated exposure can make some individuals more sensitive to the negative consequences of drugs. For example, on the day after using MDMA, experienced users of the hallucinogen are more likely to report depressive symptoms than those who used the drug for the first time.

The intoxication experience also varies with setting. The same drug can have dramatically different effects in different circumstances. People who repeatedly use opiates in comparable settings can develop a conditioned tolerance to their effects, and the same dosage will fail to produce the euphoria or analgesia associated with earlier uses. This tolerance might not appear, however, when the drug is consumed in a different setting. Dramatic, sometimes lethal, sensitivity can return when individuals use the same drugs in the same amount but in a different environment. Setting can contribute to the subjective effects of a drug even independent of conditioning. Cannabis intoxication, for example, can feel relaxing in a group of friends but induce paranoia in a police station.

The subjective effects of drugs are difficult to describe but nearly all produce a reinforcing euphoria and relief from stress (Earleywine, 2005; see Table 1). Reactions to various drugs and the culture that often develops around them can be idiosyncratic. Clients often have their own slang, preferred effects, and other distinctions related to drugs. The street names of various drugs can change quickly in different eras and locations, too. Mental health professionals who let clients educate them about drugs often gain a great deal in little time. This information can prove useful for assessing drug use and for performing a functional analysis of the predictors and consequences of use. The most efficient way to learn about any drug is to ask clients about it directly.

Clinical Pearl: Recalling Quantities of Drugs Consumed

The recall of quantities, especially for some illicit drugs, can get complicated. Any unit of measurement that appeals to the client is usually best. Cannabis users have reported bowls, blunts, grams, joints, and even bong hits. Crack cocaine users often conceptualize quantity in terms of dollar amounts. Intranasal cocaine users frequently remember amounts in grams. Users of prescription drugs often recall the number of pills they took. Almost invariably, clients reach a certain day and claim that the amount was tremendously large but impossible to recall. Responses like, “I don’t know, but it was a lot,” can actually be a great place to start. Comparing that day to other days with large amounts often helps jog their memories. Mentioning an absurdly large amount can often help clients move toward a reasonable estimate. “Do you think you snorted 4 g?” can help clients overcome any embarrassment they might have about snorting 2 g. Questions like, “Was it more than on the 24th?” can help clients put the day’s use in perspective relative to other sessions of use. Throwing out a range of responses comparable to those reported from other days can also help. Questions like, “Do you think it was more than $700 worth?” or “Was it more than four pills?” can start a series |5|of questions moving higher and lower to get a good estimate of consumption. Precise estimates of quantity can prove particularly important as clients make progress toward recovery.

Many clients initially claim a specific, invariable pattern but later realize that their use ranges more than they thought. Those who say that they drink a six-pack and take four painkillers each night are often surprised when they walk through individual days and discover that, for example, weekdays they use markedly less and weekends they use considerably more than their average. This type of variation will actually prove useful when planning for high-risk situations later in treatment. This assessment also lays the groundwork for a functional analysis of the predictors, correlates, and consequences of use, as detailed in Section 4.

An important but untouted bonus of the Timeline Followback or any interview is its potential for the development of a good therapeutic relationship. The recall of each day’s use should focus as much as possible on different drugs and their amounts. However, it can be counterproductive to sacrifice rapport simply to get precise data. If a client recalls that a specific date marked a negative life event, express empathy and support before moving to the next date. Any client could lose heart when the pursuit of exact amounts grows too persistent. After revealing that a day marked the death of a parent or the initiation of a divorce, few would like the therapist’s first response to be, “And did you snort cocaine that day?” Acknowledging that these events must have been difficult can encourage a candid assessment of use and builds good connections between client and therapist.

1.1.3 Nonproblematic, Recreational Drug Use

Abstinence is easily defined as the complete absence of drug use. It makes an excellent anchor for the nonproblematic end of the drug use continuum. Fine distinctions moving from this end of the continuum to the problematic end, however, can generate heated debate. The idea that people can use drugs recreationally without negative consequences remains controversial despite the prevalence of controlled use of many psychoactive substances. The idea is worthy of our consideration, however, to prevent a premature or inappropriate focus on drug use when other problems might be more important for a specific client (Beck, Liese, & Najavits, 2005). For example, the modal consumer of alcohol drinks infrequently and rarely experiences so much as a hangover. The idea that people might use other drugs in a comparable way strikes some clinicians as odd. Many of us learned that certain drugs create inescapable biological changes that lead inexorably to problems. However, data do not always support this idea (Advokat, Comaty, & Julien, 2014), and important individual differences exist. Unfortunately, we have no way of knowing if any specific person will make the transition from initiation of use of a drug to problematic use. In addition, the use of illicit drugs invariably carries more risk because of their potential to create trouble with the law.

Lifetime and Recent Use

Table 2 lists the percentage of Americans who use various drugs. These epidemiological data show that many people have used an illicit drug at least once |6|in their lives, but relatively few have used one recently. Over 48% (more than 153 million) of Americans have used an illicit drug, but only about 9% (less than 30 million) have used one in the last month. These data support two intriguing ideas: First, it is obvious that not all drug use leads inexorably to continued use. Clients who mention use of an illicit drug might actually experience no negative consequences, and their therapy might not focus on drugs. Second, many clients with drug problems often emphasize that nearly everyone has tried illicit substances. Social psychology research on assumed similarity, the idea that others resemble ourselves, reveals that we all tend to guess that others behave as we do. Drug users are no exception. They are often surprised to learn that although many people have tried illicit drugs, few have used these drugs recently. Current users of illicit drugs are, in fact, in the minority.

Table 2 Drug Use (Aged 12 or Older) in the United States: Percentages

Lifetime

Past year

Past month

All illicit drugs

48.6

15.9

9.4

Marijuana

43.7

12.6

7.5

Alcohol

81.3

84.9

51.9

Cocaine

14.3

1.6

0.6

Heroin

1.8

0.3

0.1

Hallucinogens

15.1

1.7

0.5

Inhalants

8.0

0.6

0.2

Pain relievers

13.5

4.2

1.7

Sedatives

2.9

0.2

0.1

Stimulants

8.3

1.3

0.5

Note. aMarijuana is not illegal in some states in the US currently.

Adapted from “Results From the 2013 National Survey on Drug Use and Health: Summary of National Findings” by Substance Abuse and Mental Health Services Administration (SAMHSA), Department of Health and Human Services, 2014.

1.1.4 Problematic Drug Use

Separating safer drug use from problematic use depends upon our definitions of problems, and distinguishing between problem-free and troubled drug use can prove difficult. Clients who consider themselves problem-free users frequently fail to attribute negative life events to drugs. Thus, they often describe their troubles to clinicians but fail to mention their consumption of substances. The stigma commonly associated with the use of illicit drugs can also make clients reluctant to mention them spontaneously. Mental health professionals who are familiar with the numerous substance-related diagnoses and different |7|domains of drug problems invariably have a better chance of connecting drug use to negative life events. Although diagnostic systems differ, assessments of drug problems generally tap multiple domains. Most clients would like to build a life that includes a romantic partner, gratifying family relationships, close friends, satisfying work, financial stability, good health, delightful recreation, and a sense of personal development. Although the issue is often contentious, the popularity of 12-step approaches to problems has also led many clients and clinicians to reexamine the importance of a spiritual life and an appreciation for the divine. Drug use has the potential to interfere in all of these domains, making them appropriate targets for assessment. Most definitions of problems focus on at least some of these limitations to optimal functioning.

1.2 Definitions

The formal definitions for disordered drug use previously fell generally into categories of dependence and abuse (or harmful use). Clinicians applied the diagnoses reliably in many studies, but some of the nuances of symptoms were lost in the simple lists that often appeared in publication or questionnaires. For example, raters agreed quite well on diagnoses of abuse and dependence made from structured interviews (Ustün et al., 1997), but simplified questionnaires based on symptoms potentially created deviant estimates of the prevalence of these problems (Grant et al., 2007). Continued work suggested that the distinction between abuse and dependence might have been illusory, leading to a single, continuous diagnosis with a severity rating instead. Symptoms appear in the tables, with details below (American Psychiatric Association, 1994, 2013).

1.2.1 Substance-Related and Addictive Disorders

The DSM-5 (American Psychiatric Association, 2013) defines substance-related and addictive disorders to include intoxication, withdrawal, and substance use disorder. The substance use disorder requires at least two of 11 symptoms, with more symptoms suggesting more severity (see Table 3). Those who experience two to three symptoms receive the mild severity rating. Four to five symptoms lead to a diagnosis of moderate severity, with six or more qualifying for the severe category. These symptoms must create meaningful distress and occur within the same year. Each symptom reflects the idea that a person cannot function without the drug and makes maladaptive sacrifices to use it. Assessing these symptoms requires genuine clinical skill. Many clients associate drug use and related symptoms with stigma. A warm, nonjudgmental, empathic approach with questions that use straightforward, simple language will improve rapport and encourage candor (Beck et al., 2005). Frequent nods, smiles, and eye contact are essential, even when the clinician must take notes, as detailed in Section 3.

|8|Focus on Consequences