The Definitive Guide to Addiction Interventions

A Collective Strategy

Louise Stanger, Lee Weber

• Editore: Routledge
• Anno: 2018
• ISBN:
  9780429866609
• Edizione: 1
• Argomento: Psychologie
• Categoria: Sucht in der Psychologie

Written for a broad audience of medical and behavioral healthcare professionals, The Definitive Guide to Addiction Interventions: A Collective Strategy introduces clinicians to best practices in addiction interventions and bridges the gap between the theory and practice of successful intervention. Synthesizing decades of fieldwork, Louise Stanger explores the framework for successful invitations to change, what they look like in action, and how to adjust approach by population, and Lee Weber serves as editor. The authors summarize and compare intervention models in use today and explain the use of family mapping and individual portraiture as clinical tools. The text also teaches clinicians to troubleshoot common situations as they help move clients toward positive life decisions. Practical, ready-to-use clinical tools follow the text in downloadable worksheet form.

PART 1

Models of Intervention

1

AN UNDERSTANDING OF ADDICTION

The Brain Disorder of Addiction

In August 2011, the American Society of Addiction Medicine (ASAM) declared that addiction is:

A primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.¹

It was about time. There has been longstanding controversy over whether people diagnosed with addiction have choice over their behaviors or not. Two decades of advancements in neuroscience convinced ASAM that addiction needed to be redefined by what’s going on in the brain.

Research shows what we in the treatment industry saw manifest: the disease of addiction is centered in the brain. Many clinicians have observed that addiction is reflected in individuals pathologically pursing reward or relief by substance use or other behaviors. But now the science is catching up.

When ASAM officially noted the chemistry and biology behind addiction, a wave of relief could be felt among me and my colleagues. The moralizing, blaming, and stigma could now be addressed. Still, the ravages of addiction are gaining ground, not only in the United States. Addiction is a worldwide problem.²

Let’s take a look at some of the assumptions that this book is founded on. Having a grasp on what is happening around us can help us find the appropriate motivation to be better clinicians. Let’s take a look at some of the numbers. For additional background on the global pandemic of addiction, see our Chapter 1 eResource companion at: www.routledge.com/9781138618039. Further, you can access a checklist in Worksheet 1.1 (Quick Reference to Substance Use Disorders).

The Definition of Addiction

I hold with the ASAM definition of how addiction manifests:

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.¹

In other words, addiction reinforces itself.

As clinicians, we must have a clear understanding of how addiction is centered in the brain. Psychoactive substances affect neurotransmission and interactions within reward circuitry of the brain, leading to addictive behaviors that replace healthy behaviors. At the same time, memories of previous experiences trigger craving and renewal of addictive behaviors. Meanwhile, brain circuitry that governs impulse control and judgment is also altered in this disease, resulting in the dysfunctional pursuit of those same rewards.

The cycle of drug use goes like this:

Use a drug. Feel good. Use again. Feel good. Repeat until numb.

It is important to note here that the lexicon of addiction is evolving. A new and important distinction has been made in recent years for concise understanding. According to the National Institute on Drug Abuse (NIDA), the National Institutes of Health (NIH):

Continues to use the term “addiction” to describe compulsive drug seeking despite negative consequences. However, “addiction” is not considered a specific diagnosis in the fifth edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-5)—a diagnostic manual used by clinicians that contains descriptions and symptoms of all mental disorders classified by the American Psychiatric Association (APA).

In 2013, the APA updated the DSM, replacing the categories of substance abuse and substance dependence with a single category: substance use disorder. The symptoms associated with a substance use disorder fall into four major groupings: impaired control, social impairment, risky use, and pharmacological criteria (i.e. tolerance and withdrawal).³

Why is this distinction important? What are the diagnostic implications of no longer viewing substance abuse and substance dependence as two distinct, separate conditions?

The earlier DSM-IV division into two disorders was guided by the concept that “dependence syndrome” formed one dimension of substance problems, while social and interpersonal consequences of heavy use formed another. While related, DSM-IV placed dependence above abuse in a hierarchy; the separation made it impossible to diagnose abuse when dependence was present.⁴

So, what implications does this new definition have for clinicians? The change from categorizing substance abuse and dependence as separate issues into one new disorder does not affect clinicians dramatically. The DSM-5 aims to help clinicians more clearly diagnose and categorize addictions (substance use disorders). This mainly affects you if you are an individual clinician, particularly for reimbursements. In fact, I often view the DSM-5 as a billing tool used for insurance reimbursement; its categorization is applied for billing.

Therefore, clinicians may need to update intake questionnaires or billing systems accordingly. Additionally, you need to know the DSM-5 when in a clinical setting or while sitting down with a client or their family; DSM-5 criteria for addiction will guide the discussion and your case notes. Additionally, if you’re teaching, you want to share this definition with students.

This is not to understate the clinical relevance and incredible usefulness of diagnostic tools. The DSM-5 is absolutely critical for recognition and identification of addiction. The new combined condition – substance use disorder – allows clinicians to set the diagnostic threshold for the disorder at two or more criteria and classify the severity indicators of the condition as mild, moderate, or severe.

What are these new criteria for diagnosis of addiction? The new DSM-5 describes substance use disorder as a problematic pattern of use of an intoxicating substance leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:⁵

1. The substance is often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful effort to cut down or control use of the substance.

3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.

4. Craving, or a strong desire or urge to use the substance.

5. Recurrent use of the substance resulting in a failure to fulfill major role obligations at work, school, or home.

6. Continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use.

7. Important social, occupational, or recreational activities are given up or reduced because of use of the substance.

8. Recurrent use of the substance in situations in which it is physically hazardous.

9. Use of the substance 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.

10. 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) A markedly diminished effect with continued use of the same amount of the substance.

11. Withdrawal, as manifested by either of the following:

(a) The characteristic withdrawal syndrome for that substance (as specified in the DSM-5 for each substance).

(b) The substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.

Note: Current national surveys of drug use have not yet been modified to reflect the new DSM-5 criteria of substance use disorders, and therefore still report substance abuse and dependence separately.

Trauma and Addiction

Trauma can be broadly understood as a stress that causes physical or emotional harm from which you cannot remove yourself. Clinically, trauma is an overwhelming experience that cannot be integrated, and elicits animal defensive mechanisms and dysregulated arousal. However, not everyone reacts to similar traumatic situations in the same way; trauma is subjective, meaning what matters most is the individual’s internal beliefs and their innate sensitivity to stress. This is why people who witness the same event can have differing responses.

Trauma is both objective (something has happened) and subjective (this is how I feel about something).

Trauma is indigenous to experiences of substance abuse, mental health, and chronic pain. In fact, trauma leads to a cascade of biological changes and stress responses that are highly associated with post-traumatic stress disorder (PTSD), other mental illnesses, and substance use disorders.⁶ Some possible brain changes can include changes in limbic system functioning, hypothalamic–pituitary–adrenal axis activity changes with variable cortisol levels, and neurotransmitter-related dysregulation of arousal and endogenous opioid systems. In addition to biological changes triggered by trauma, people can also adapt harmful emotional and psychological patterns that lead to self-medication through the use of drugs and alcohol.

When does trauma arise? Trauma can stem from abuse or neglect, a frightening experience such as witnessing a murder, a car, boat, or airplane accident, during war, at school bullying and shootings, sudden life changes, not being told about something, or near-death experiences. Trauma also occurs in homes where a parent(s) used substances or when growing up in an environment where the expression of how one feels is not cultivated.

One of the most destructive forms of trauma is recurrent name-calling and humiliation, bullying, and embarrassment. The definition of trauma also includes responses to powerful one-time events, such as accidents, natural disasters, school shootings, public shootings, crimes, surgeries, deaths, and other violent events. It also includes responses to chronic or repetitive events, such as child abuse, neglect, combat, urban violence, concentration camps, battering relationships, and enduring deprivation.

The main point we’d like to make here is that the clinical tools outlined in this book will help you assess clients for possible trauma-related disorders. Given the prevalence of traumatic events in clients who present for substance abuse treatment, skills such as family mapping, retrospective biopsychosocial analysis, and po...