Evidence-Based Treatments for Alcohol and Drug Abuse

A Practitioner's Guide to Theory, Methods, and Practice

Paul M. G. Emmelkamp, Ellen Vedel

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781135927165
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Evidence-Based Treatments for Alcohol and Drug Abuse encompasses the developments in the field over the last decade, blending theory, techniques and clinical flexibility.

Research in the past decade has shown that substance abuse and substance dependence are treatable. The field has witnessed the introduction of evidence-based psychological and specific pharmacological treatments. Unfortunately, many of the empirical supported therapies for addictions are still not widely applied by practitioners. The third volume in the Practical Clinical Guidebooks Series (PCG), Evidence-Based Treatments for Alcohol and Drug Abuse, defines the characteristics, classification, and prevalence of substance use disorders, and provides the clinician with practical guidelines applicable across a variety of treatment settings and patient groups.

Drawing on the recent research in the field, the authors provide the practicing clinician and student with an up-to-date understanding of the epidemiology, etiology, course and prognosis of substance abuse disorders that would be relevant to clinical practice. In addition to describing phenomenology and etiology, the book provides a comprehensive guide to the assessment and treatment of DSM-IV-TR substance abuse disorders (SUDs), including abuse and dependence of alcohol, stimulants, opiates, hallucinogens, cannabis/marijuana, sedative, and party drugs.

CHAPTER 1

Description of Substance Abuse and Dependence

PHENOMENOLOGY

The purpose of this chapter is to provide an overview and a synthesis of the information available on the clinical picture of substance-use disorders, the epidemiology of these disorders, comorbidity with other mental disorders, and current etiological models. Further, we will describe the course of these disorders and the detrimental consequences associated with chronic substance abuse. Finally, we will provide an overview of diagnostic measures that are relevant for clinical practice.

Research into substance-use disorders has increased enormously over the last decade, particularly in the field of brain chemistry. It would be impossible to explore all these issues within a single chapter. Rather than inundating our readers with a list of all the current controversies in the field, we have chosen to write a fair and balanced overview of the current state of research. This is intended to assist practitioners in understanding the problems of substance abusers and in diagnosing and planning treatment for their patients.

In recent years, the term addiction has been popularized to refer to any kind of compulsive behavior such as pathological gambling, sex addiction, Internet addiction, work addiction, and compulsive eating. Although some of the issues discussed here are also relevant to non-substance-abusing addictions, we limit our scope to substance abuse and substance dependence. moreover, since we target clinicians working in addiction centers and mental health centers, we will limit our discussion to those kinds of substance abuse and dependence that are primarily seen in these settings, such as the abuse of alcohol, opioids, cocaine, amphetamine, party drugs, and cannabis.

A Description of the Clinical Picture

In contrast to common perceptions, substance-use disorders are seen in people from all layers of society. Substance abuse is not restricted to the homeless, the poor, or the destitute. People from all walks of life can become addicted to substances, although certain substances are more likely to be (ab)used by the middle and upper classes (e.g., party drugs), while others are more likely to be popular among the lower classes of the society (e.g., heroin, crack cocaine). In the United States, 1.6 million people with full-time jobs are heavy alcohol and drug users (Substance Abuse and mental health Services Administration, 2004). likewise, there are many well-known citizens including film stars, pop stars, politicians, and Nobel Prize winners who have acknowledged that they had a substance-use disorder at some time.

Substance-Use Disorders: Abuse and Dependence

The system laid down in the fourth revised edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV-TR (American Psychiatric Association, 2000), distinguishes substance abuse from substance dependence and focuses on the maladaptive patterns of use leading to clinical significant impairment, and not on actual quantities and frequencies of use.

The DSM-IV-TR lists specific criteria that, if met, warrant the diagnosis of substance abuse (See table 1.1). It is striking that fulfillment of only one criterion is sufficient to warrant the diagnosis; extraordinarily, this means that a student who skips class several times because of a hangover meets the DSM-IV-TR criteria for such a diagnosis.

TABLE 1.1 DSM-IV-TR Criteria for Substance Abuse

A. 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 this 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. Symptoms do not fit the criteria for substance dependence for a particular class of substance.

TABLE 1.2 DSM-IV-TR Criteria for Substance Dependence

A. A 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 within a 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 (criteria sets for withdrawal are listed separately for specific substances). 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 effort to cut down or control substance use. 5. A great deal of time is spent in activities necessary to obtain the substance (for example, visiting multiple doctors or driving long distances), use the substance (for example, chain-smoking), 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 (for example, current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that a ulcer was made worse by alcohol consumption).

According to the DSM-IV-TR, an essential characteristic of substance dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues to use a particular substance despite significant substance-related problems. The formal criteria for substance dependence are listed in table 1.2.

Since only three endorsements are required, it is possible for a person to meet the current diagnostic criteria for substance dependence without having any physical symptoms of dependence (tolerance and/or withdrawal). however, continued heavy substance use is often associated with the development of tolerance and withdrawal. The intensity of response to a substance often diminishes as the same dose is administered repeatedly. As this tolerance develops, increasing doses are needed to produce the same desired effects. Substances that produce tolerance often produce, more or less synchronically, withdrawal as well. The withdrawal symptoms of the various substances vary greatly but usually include physical reactions such as nausea, sweating, palpitations, and cravings for the withdrawn substance. Consequently, many theoretical models have suggested that drug tolerance and withdrawal symptoms are both manifestations of a common underlying mechanism. The two effects both stem from the same general homeostatic system that underlies physiological adaptation.

Different substances are associated with various degrees of tolerance. Furthermore, not all drugs produce the physical dependence syndromes of tolerance and withdrawal. Individuals using alcohol and heroin as well as those who make heavy use of cocaine often develop substantial levels of tolerance. on the other hand, amphetamines and hallucinogens do not appear to produce such physiological dependence and withdrawal signs.

The severity of the dependence is an important factor in evaluating the disorder, as it can be important in determining the appropriate level of care. For example, in the case of heavy binge drinking and cocaine use three times per week, outpatient counseling may be sufficient. on the other hand, in the case of heavy daily alcohol use and the presence of high levels of tolerance and withdrawal symptoms, specialized treatment including medically supervised detoxification will be necessary.

The criteria for substance abuse described above are problematic in that the direction between substance-use disorders is one way. Someone who is defined as a substance abuser can go on to develop behavior that warrants the label substance dependence, which often happens. however, someone having been classified as substance dependent cannot ever again merely be classified as a substance abuser. Clearly, the disease model of substance abuse, which holds that a substance-dependent person cannot recover from dependency, influences this: once dependent, always dependent (Blume, 2004). however, epidemiological data indicate that many of those who at one point were classified as meeting the criteria for substance dependence in fact go back to what should only be classed as substance abuse. For example, users of alcohol can alternate periods of heavy drinking with periods of abstinence or controlled social drinking.

Individuals can become psychologically dependent on a substance without developing physiological dependence. Physical dependence is related to physical changes that allow tolerance to build up and cause withdrawal symptoms. In contrast, psychological dependence is related to the need to use substances for psychological needs—for example, relying on alcohol or drugs to cope with stress. In clinical practice, it is often difficult to distinguish between physical and psychological dependence, as in many patients these processes are interdependent.

Alcohol

In early theories on addiction, it was believed that once addicted to alcohol, individuals were unlikely to be able to control their drinking and were at great risk of dying from medical complications. These pessimistic views were based on evidence from alcoholics seen in clinical settings who were unable to stop drinking of their own accord. Drinking until severely intoxicated (loss-of-control drinking) is an important concept in the disease model of substance abuse. According to this disease model, the ingestion by alcoholics of even a small amount of alcohol triggers a physical demand for alcohol that overwhelms their ability to control subsequent drinking. This is expressed by the Alcoholics Anonymous slogan, “one drink, one drunk.” There are no epidemiological arguments to suggest that the loss-of-control drinking model is widely applicable. There is evidence that former heavy drinkers are quite able to become social drinkers or controlled drinkers (Vaillant, 1996). In other words, one single drink does not inevitably lead to loss-of-control drinking in former heavy drinkers. moreover, extensive epidemiological community studies have shown that many individuals who drink heavily do not develop alcohol dependence.

The effects of alcohol on alcohol nonabusers are directly associated with blood alcohol concentration (BAC) levels. mild euphoria is usually felt at levels of 30 mg/dl. At higher BAC levels, intoxicated individuals may experience “black-outs”—that is, an inability to remember what occurred during the drinking period. In general, the same intake in units of alcohol will result in a higher BAC level in females than in males. This is not only related to a difference in body weight, but is also primarily attributed to the female body being less effective in breaking down ethanol. even after relatively low doses of alcohol, withdrawal symptoms (such as a “hangover”) are common. In alcohol-dependent persons, seizures may occur during withdrawal of alcohol. Chronic alcohol consumption leads to adaptive changes in the brain, which presumably are related to the development of tolerance, withdrawal, and dependence and alcohol abuse can lead to substance-induced anxiety and depressive symptoms. These symptoms usually disappear within a few weeks after abstinence.

Two alcohol dependence subtypes have been defined in the literature, described as types A and B (Babor et al., 1992) and types 1 and 2 (Cloninger, Sigvardson, & Bohman, 1996), respectively. Although there are some differences between both typologies, there is evidence that overall, indeed two types of alcoholics can be distinguished. one type (type 1/type A) is characterized by later onset, less severe dependence, fewer childhood risk factors, and less psychiatric impairment. In contrast, familial alcoholism, early onset, greater severity of dependence, multiple childhood risk factors, and higher incidence of antisocial personality traits characterize the other type of alcoholics (type 2/type B). It is thought that the latter type may be more genetically determined than the former.

Another clinically important distinction is between continuous drinkers and those who drink excessive amounts of alcohol periodically. Some people regularly drink the same amount of alcohol each day while others are indulged in frequent periods of binge drinking alternated with moderate or even no alcohol use in between these periods.

Cannabis

The term cannabis refers to marijuana as well as hashish. marijuana is a combination of chopped-up dried flowering tops, leaves, and stems of the hemp plant, or Cannabis sativa. hashish is the brown or black resin from the flowering tops of the same plant, shaped into small rocks. Cannabis is usually smoked, and inhalation produces a state of relaxation and mild euphoria often accompanied by heightened perceptual acuity and intensified sensory inputs. These effects can last up to three hours after taking the drug. The active ingredient in cannabis is delta-9-tetrahydrocannabinol (THC). The effects of cannabis vary greatly depending on the dose and the quality of the drug as well as the users’ experience with cannabis and their expectancy about the effects of the drug. It is increasingly being acknowledged that cannabis it is not a safe recreational drug as it was once thought to be. A clinical perception that cannabis use is harmless may be based on lack of knowledge about recent developments in the potency of marijuana. Currently, cannabis contains much higher levels of THC compared to twenty years ago and data indicate a substantial increase in the potency (concentration) of THC in marijuana since the early 1990s (ElSohly et al., 2000). Smoking cannabis can increase the heart rate and has been associated with an increased risk of heart attack.

Although the DSM-IV-TR does not mention cannabis withdrawal, there is increasing evidence that it is associated with restlessness, irritability, anger, and sleep problems. Budney, Hughes, Moore, and Vandrey (2004) recently proposed diagnostic criteria for cannabis withdrawal syndrome. Ten percent of people who start using cannabis will develop dependence, and frequent use is associated with a higher risk of dependence. long-term use of cannabis damages short-term memory. The use of cannabis is sometimes associated with violence, but less frequently so than alcohol (Dawkins, 1997). Common street names for cannabis are grass, herb, skuck, and weed.

Opioids

Opiates are a subclass of opioids that are alkaloids extracted from opium. Besides heroin, commonly abused opiates include morphine and codeine. heroin use leads to immediate feelings of euphoria, a “rush,” accompanied by a warm flushing of the skin, dry mouth, and a heavy feeling in the user’s arms and legs. effects appear within 10 seconds when injected, but take slightly longer (10–15 minutes) to be felt when smoked or inhaled (snorted). Chronic heroin use produces tolerance and withdrawal symptoms. In multiple substance users, cocaine use is often related to continued use of heroin (see, e.g., Pérez, Trujols, Ribalta et al., 1997). Street names for heroin include smack, H, skag, and junk.

Cocaine

Cocaine is usually taken by inhalation though the nose (snorting) but can also be dissolved in water and injected. Cocaine produces euphoric effects after a few minutes, and this lasts from 15 to 30 minutes. Small amounts of cocaine make people energetic, and talkative, which explains why it sometimes is described as an “antidepressant” drug. larger amounts of cocaine intensify euphoria but can also induce anxiety, restlessness, bizarre aggressive behavior, and paranoia. The smokable form of cocaine is called crack cocaine, and gets its name from the crackling sound it makes when it’s smoked. Crack cocaine produces a more rapid and intense “high” lasting from 5 to 10 minutes, sometimes described as orgasmic. Following a period of intense euphoria an unpleasant period of restlessness, hyperarousal, and insomnia is accompanied with craving (high desire) for more cocaine and often leads to use of sedating agents such as alcohol, heroin, or sedatives or hypnotics to counteract these effects (Rounsaville, 2004).

Dependence takes longer to develop if cocaine is snorted, whereas if smoked or injected the drug can lead to dependence within months or even weeks. Some time ago, it was held that tolerance was not an aspect of cocaine abuse. It has become increasingly clear that tolerance and withdrawal, the latter typically characterized by symptoms of depression, fatigue, and disturbed sleep, are also associated with prolon...

Table of contents

• Front Cover
• Half Title
• PRACTICAL CLINICAL GUIDEBOOKS SERIES:
• Title Page
• Copyright
• Dedication
• Contents
• Perface
• Chapter 1: Description of Substance Abuse and Dependence
• Chapter 2: Clinical Interventions
• Chapter 3: Research Basis of Treatments
• Chapter 4:Clinical Cases
• Chapter 5: Complicating Factors
• Chapter 6: Maintenance and Follow-Up Strategies
• References
• Appendix
• Index