Substance use disorders with a focus on alcohol and the DSM 5, risk and protective influences, assessment and goal-formulation, and treatment.

1. SUBSTANCE USE
DISORDERS
Jacqueline Corcoran, Ph.D.
Virginia Commonwealth University
School of Social Work

2. DSM 5 change
Abuse and dependence subsumed into
use disorder
Severity: mild, medium, and severe

3. 10 classes
 alcohol
 Amphetamines
 cannabis
 cocaine
 hallucinogens
 inhalants
 nicotine
 opiods
 PCP
 sedatives/hypnotics/anxiolytics

4. Prevalence (lifetime, DSM-IV)
17.8% alcohol abuse and a
12.5% alcohol dependence
12-1.4% drug abuse
.6% drug dependence

5. Other rates
 Alcohol highest for American Indians, then bi-racial
persons
 Lowest for Asian (enzyme breaks down alcohol)
 Males to females 5:1 for alcohol
 Men higher than women except for prescription drug
abuse of sedatives, hypnotics, or anti-anxiety drugs.

6. Co-morbidity
 Adolescents – 60%
 Most commonly disruptive disorder, then depression
 Adults -lifetime prevalence of 70% for at least 1
mental/emotional disorder
 Mood disorder
 anxiety
 personality disorders
 Implication – when being seen for other disorders, inquire
about substance use patterns

7. Assessment
Onset, progression, patterns, context, and frequency of use of all
substances
Tolerance or withdrawal symptoms
Major life events
Other disorders, including the relationship between the onset and
progression of the symptoms and substance use
“Triggers” and context of use
Perceived advantages and disadvantages of use
Motivations and goals for treatment
Number of times the individual has quit and the strategies that were used
Impact of use disorders:
Financial and legal status
Education and employment status
Condition of health (a physical examination may be warranted)

8. Biological
 genetic predisposition for alcohol problems
 neurochemical irregularities implicated with substance
problems also same with mood, anxiety, impulsive,
compulsive, personality disorders
 dopamine - activiating pleasure centers of limbic
portion of brain (alcohol, cocaine, hallucinogens)
 norephinephrine-panic response(increased heart rate,
respiration, and sweating) produced by cocaine and
amphetamines
 low levels of serontonin (satisfaction, contentment and
well-being)

9. Psychological
 self-medication
 cognitive distortions around substance-taking and
rationalization

10. Social
 low socioeconomic status
 but substance use also has consequences on
economics
 peer involvement
 Women
 Gay and lesbian

11. Possible Goals
reducing or eliminating the substance use
Controlled drinking controversial
reducing the physical harm associated with such use
harm reduction - working with clients to reduce the harmful consequences
of the behavior, such as reducing the use of substances and encouraging
the use of condoms and clean needles
improving psychological and social functioning (mending
disrupted relationships, reducing impulsivity, building social
and vocational skills, and maintaining employment)
relapse prevention
For adolescents, family focus

12. Alcoholics Anonymous
Advantages
Most common treatment approach
Little research on AA self-help groups

13. CBT
Triggers and avoiding or coping with
Cognitive distortions around justifying use
Alternate reinforcers

14. Motivational Interviewing
“a client-centered, directive method for enhancing intrinsic
motivation to change by exploring and resolving
ambivalence”
Guiding principles:
 Listening and expressing empathy
 Developing discrepancies between problem behavior and
the client’s goals and values
 “Rolling” with resistance, which means avoiding power
struggles and instead making statements that help
clients argue for change
 Supporting self-efficacy, or the client’s sense of
confidence that he or she can change
 Developing a change plan

15. Family Involvement
burden is imposed on families
when a member has a substance
use disorder.
Families can affect the abuser’s
motivation and ability to comply
with intervention

16. Types of family intervention
 Al-Anon
 Johnson Institute
 30% go through with it
 CRAFT (community reinforcement as a family training
approach )
 Behavioral in nature: family member removes
drinking conditions, reinforces appropriate behavior,
gives feedback of inappropriate behavior, and
provides consequences if behavior exceeds agreed-upon
limits

17. Family Intervention, cont.
 Behavioral couples therapy
 main objective - to alter interactional patterns maintaining
chemical abuse and to build a relationship that more effectively
supports sobriety
 communication skill-building, planning family activities,
initiating caring behaviors, and expressing feelings

18. Family Intervention Adolescents
 brief strategic family therapy
Functional family therapy
multidimensional family therapy
multisystemic therapy

19. Pharmacological
Interventions
 aversive medications, designed to deter client
drinking
 anticraving medications, which purport to reduce
one’s desire to use substances

20. Aversive
 disulfiram (Antabuse)
 Physicians reluctant to prescribe

21. Anticraving
 Naltrexone
 an opioid receptor antagonist, a substance that blocks opioid receptors in
the brain, so that the individual fails to experience positive effects from
opiate (and alcohol use)
 Acamprosate
 has been more recently approved by the FDA
 stabilize a chemical balance in the brain that is otherwise disrupted by
alcohol abuse, possibly by blocking glutamine receptors while activating
gamma-aminobutyric acid.
 for alcohol dependence, acamprosate was better at preventing a relapse,
and naltrexone was better at preventing a “lapse” from becoming a
relapse (that is, it prevented heavy drinking)

22. For heroin, substitution
therapy
 methadone and buprenorphine (the latter can be
prescribed on an outpatient basis)
 goals being the prevention of withdrawal, the
elimination of cravings, and the blockage of euphoric
effects obtained by illegal opiate use

23. Critique
 Applicability of criteria for adolescents and elders
 Part of conduct disorder for adolescents