Substance Use and Addictive Disorders

Description of Substance Use and Addictive Disorders

• The National Institute on Drug Abuse (NIDA) defines addiction as “…a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.”

Resource: NIDA drug addiction definition and overview:
http://www.drugabuse.gov/publications/media-guide/science-drug-abuse-addiction.

Prevalence

• The most recent available estimates suggest “22.5 million Americans aged 12 or older were current (past month) illicit drug users” (e.g., marijuana, cocaine, etc.) and approximately 58.3 million Americans age 12 or older participated in binge drinking (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012a).

Resource: SAMHSA 2011 National Survey on Drug Use Findings:
http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.pdf

Identification/Assessment Strategies

 Resource: National Institute on Alcohol Abuse and Alcoholism (NIAAA) list of substance use assessment instruments: http://pubs.niaaa.nih.gov/publications/AssessingAlcohol/quickref.htm

Substance Abuse Subtle Screening Inventory-3 (SASSI-3)
The Substance Abuse Subtle Screening Inventory-3 (SASSI-3) was designed to “...identify individuals with a high probability of having a substance dependence disorder, even if those individuals do not acknowledge substance misuse or symptoms associated with it.” (Miller, Roberts, Brooks, & Lazowski, 1997, p. 2). The SASSI was the most frequently used addictions assessment instrument by Master Ad- diction Counselors (MACs) and the addictions instrument that MACs believed should be most taught in counseling programs (Juhnke, Vacc, Curtis, Coll, & Paredes, 2003). The SASSI-3 has 10 scales. These scales report client identified substance abuse symptoms, potential defensiveness, random answering patterns, relative risk for legal problems resulting from their substance use (e.g., Driving Under the Influence), unrecognized problematic behaviors that are likely substance use related, and open acknowl- edgement of alcohol and other drug use (Balkin & Juhnke, 2013). The SASSI-3 can be administered by counselors who have a master’s degree in counseling and have been trained and supervised in the instru- ment’s use. The SASSI-3 is for clients 18 years and older with 3.2 or higher grade reading level. Adminis- tration and scoring time is approximately 15 minutes.

Resources: NIAAA SASSI-3 description, user qualifications, and ordering information: http://pubs.niaaa.nih.gov/publications/AssessingAlcohol/InstrumentPDFs/66_SASSI.pdf 
https://www.sassi.com/sassi-4-announcement/

Alcohol Use Inventory (AUI).
The Alcohol Use Inventory (AUI) is a 228 item instrument designed to assess a client’s alcohol involvement.  The AUI has 17 primary scales which are subdivided into four areas: (a) Drinking Benefits (i.e., drinking to: [1] improve sociability and mental functioning, [2] enhance mental alertness and creativity, [3] manage moods, and [4] cope with marital problems), (b) Drinking Styles (i.e., social, compulsive, sustained drinking), (c) Drinking Consequences, (i.e., social role maladaptation, delirium, hangover, and marital problems resulting from drinking), and (d) Concerns and Acknowledgments regarding alcohol (i.e., acknowledgment of the quantity of consumed alcohol, guilt associated with drinking, prior attempts to deal with drinking, readiness for help, and awareness of drinking problems) (Horn, Wanberg, & Foster, 1990). Six second-level scales are also provided: (a) Enhanced (those who consume alcohol to enhance their functioning), (b) Obsessed (persons who hide bottles, sneak drinks and drink prior to bed), (c) Disrupted 1 (those who report alcohol consumption caused by life disruptions  such as job loss), (d) Disrupted 2 (persons who experience uncontrolled life disruption as a result of their drinking and report symptomatology typically associated with heavy drinkers such as drinking shaving lotion), (e) clients who report anxiety, worry, guilt, shame related to drinking, and (f ) client who report “broad involvement with alcohol” (Horn et al., 1990, p.8). The AUI can be used with clients ages 16 years and older with a 6th grade or greater reading level. Administration time is 35-60 minutes.  This instrument can be used by master’s level counselors.

Resources: NIAAA AUI description, user qualifications, and ordering information: http://pubs.niaaa.nih.gov/publications/AssessingAlcohol/InstrumentPDFs/15_AUI.pdf  

Form 90 Drinking Assessment Interview (Form 90; NIAAA).
This face-to-face, assessment can be used as an initial substance use interview and provides information specific to the client’s alcohol consumption including total alcohol consumption, the number of drinks consumed per drinking day, percentage of abstinent days, and percentage of heavy drinking days (Del Boca & Brown, 1996). The Form 90 has good to excellent reliability (Tonigan, Miller, & Brown, 1997). It begins with 37 open-ended questions (NIAAA, 1996) related to four domains including: general demographics, living experiences, current medication use, and periods of abstinence. Clients review and plot their drinking behaviors, and analyze any personally atypical drinking patterns. Finally, clients complete a card- sort technique to identify their drugs of choice. Form 90 can be utilized by counselors with adult clients. Experienced interviewers administer the Form 90 to adults in 45 minutes.

Resource: Form 90:
http://casaa.unm.edu/inst/Form%2090%20AI.pdf

Intervention Strategies

Given the numbers of randomized substance use specific clinical studies, as well as substance use meta-analyses demonstrating addictions treatment efficacy, SAMHSA created SAMHSA’s National Registry of Evidence-based Programs and Practices (2012b). SAMHSA strongly encourages counselors to use evidenced-based practices (2012b). Summaries and links to three of the most thoroughly researched and efficacious substance use practices are described below.

Cognitive Behavioral Therapies (CBT)
Cognitive Behavioral Therapy (CBT) and related approaches are among interventions with the most support from meta-analytic studies examining the treatment of substance use disorders (Carroll, 2012; Magill & Ray, 2009; Martin & Rehm, 2012). A small and statistically significant effect size (g = 0.154, p< .005) was shown in a meta-analytic study of randomized controlled trails utilizing CBT with alcohol and drug users (Magill & Ray, 2009). According to Martin and Rehm (2012), three variations of CBT which received consistently strong support across studies for effectiveness at treating alcohol use included Community Reinforcement Approach, Social Skills Training, and Behavioral Self-Control Training. These three approaches focus on coping skills for environmental stressors and drinking behaviors. Magill and Ray (2009) determined that CBT interventions were most effective with marijuana users, with women, and that no differences were found between group or individual counseling formats. However, the length of time elapsed since treatment was negatively associated with effectiveness (Magill & Ray, 2009).  CBT approaches also have shown effectiveness at treating process addictions, such as internet addiction in adolescents (King, Delfabbro, Griffiths, & Gradisar, 2012) and gambling (Fortune & Goodie, 2012).

Resource: A version of Behavioral Self-Control Training, called Relapse Prevention Therapy, focuses on offering clients’ skills to cope with relapse: http://legacy.nreppadmin.net/ViewIntervention.aspx?id=97

Overview on CBT and substance use treatment: https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment/behavioral

Principles of Drug Addiction Treatment: A Research-Based  Guide (3rd Edition): https://www.drugabuse.gov/sites/default/files/podat_1.pdfgov/sites/default/files/podat_0.pdf

Motivational Interviewing (MI)
Motivational Interviewing (MI) has demonstrated significant utility with substance use and addictive disorders. Therefore, MI should be strongly considered as a potential counseling intervention of choice with persons presenting with such clinical concerns. Lundahl, Kunz, Brownell, Tollefson, and Burke (2010), Rubak, Sandbaek, Lauritzen, and Christensen (2005), and Vasilaki, Hosier, and Cox (2006) utilized meta-analysis to summarize Motivational Interviewing’s clinical efficacy with substance use, addictions, and other presenting concerns. Concomitantly, individual MI substance use and addictions- specific studies demonstrate MI’s clinical utility with substances such as alcohol, cannabis, cocaine, and tobacco (Baer, Kivlahan, Blume, McKnight, & Marlatt, 2001; Bernstein et al., 2005; Borrelli et al., 2005; Carroll et al., 2006; Marlatt et al., 1998; Monti et al., 1999; Senft, Polen, Freeborn, & Hollis, 1997).

Resource: SAMHSA Motivational Interviewing Overview:
http://www.integration.samhsa.gov/clinical-practice/motivational-interviewing

Couple and Family Therapy (CFT)
Existing literature is clear. Couples and Family Therapy (CFT) are “…consistently recognized among the most effective approaches for treating both adults and adolescents with drug problems” (Rowe, 2012, p.59). This is especially true for both adult and adolescent substance use (Carroll & Onken, 2005; CSAT, 2004; NIDA, 2006; Waldron, 1997; Waldron and Turner, 2008; Williams & Chang, 2000). In particu- lar, Brief Strategic Family Therapy and Multidimensional Family Therapy have proven themselves as highly effective change agents (Austin, MacGowan, & Wagner, 2005; Becker & Curry, 2008; Branningan, Schackman, Falco, & Millman, 2004; Coatsworth, Santisteban, McBride, & Szapocznik, 2001; Liddle, 2002; Liddle, Dakof, Henderson, & Rowe, 2011; Liddle, Dakof, Turner, Henderson, & Greenbaum, 2008; Liddle, Rowe, Dakof, Henderson, & Greenbaum, 2009; Liddle et al., 2006; Liddle et al., 2002; Santisteban, Suarez-Morales, Robbins, & Szapocznik, 2006; Szapocznik, Hervis, & Schawartz, 2003; Szapocznik & Williams, 2000; Vaughn & Howard, 2004; Waldron & Turner, 2008). Concomitantly, research by Carlson, Smith, Matto, & Eversman (2008), Fals-Stewart, Lam, & Kelley, (2009), and Gruber and Fleetwood (2004) remind counselors that family support is vitally important to maintaining substance use abstinence and couples and family therapy can provide such support.

Resource: Multidimensional Family Therapy use with adolescent cannabis users overview:
http://adaiclearinghouse.org/downloads/Multidimensional-Family-Therapy-for-Adolescent-Cannabis-Users-207.pdf

Brief Strategic Family Therapy Manual: http://archives.drugabuse.gov/pdf/Manual5.pdf

Fortune, E. E., & Goodie, A. S. (2012). Cognitive distortions as a component and treatment focus of pathological gambling:  A review. Psychology of Addictive Behaviors: Journal of the Society of Psychologists in Addictive Behaviors, 26(2), 298-310. doi: http://dx.doi.org/10.1037/a0026422

Gruber, K. J., & Fleetwood, T. W. (2004). In-home continuing care services for substance use affected families. Substance Use & Abuse, 39(9), 1379-1403.

Horn, J. L., Wanberg, K. W., & Foster, F. M. (1990). Guide to the Alcohol Use Inventory (AUI). Bloomington, MN: NCS Pearson.

Juhnke, G. A., Vacc, N. A., Curtis, R. C., Coll, K. M., & Paredes, D.M. (2003). Assessment instruments used by addictions counselors. Journal of Addictions & Offender Counseling. 23, 66-72.

King, D. L., Delfabbro, P. H., Griffiths, M. D., & Gradisar, M. (2012). Cognitive-behavioral approaches to outpatient treatment of internet addiction in children and adolescents. Journal of Clinical Psychology, 68(11), 1185-1195. doi: http://dx.doi.org/10.1002/jclp.21918

Liddle, H. A. (2002). Multidimensional family therapy for adolescent cannabis users, Cannabis Youth Treatment (CYT) Series (Vol. 5). Rockville, MD: Center for Substance Abuse Treatment (CSAT).

Liddle, H. A., Dakof, G. A., Henderson, C. E., & Rowe, C. L. (2011). Implementation outcomes of Multidimensional Family Therapy-Detention to Community (DTC)-A reintegration program for drug-using juvenile detainees. International Journal of Offender Therapy and Comparative Criminology, 55(4), 587-604.

Liddle, H., Dakof, G., Turner, R., Henderson, C., & Greenbaum, P. (2008). Treating adolescent drug abuse: A randomized trial comparing multidimensional family therapy and cognitive behavior therapy. Addiction, 103(10), 1660-1670.

Liddle, H. A., Rowe, C., Dakof, G. A., Henderson, C. E., & Greenbaum, P. (2009). Multidimensional Family Therapy for early adolescent substance abusers: Twelve month outcomes of a randomized controlled trial. Journal of Consulting and Clinical Psychology, 77(1), 12-25.

Liddle, H. A., Rowe, C., Gonzalez, A., Henderson, C., Dakof, G. A., & Greenbaum, P. (2006). Changing provider practices, program environment and improving outcomes by transporting Multidimensional Family Therapy to an adolescent drug treatment setting. The American Journal on Addictions, 15, 102-112.

Liddle, H. A., Rowe, C. L., Quille, T., Dakof, G., Mills, D. S., Sakran, E., et al. (2002). Transporting a research-based adolescent drug treatment into practice. Journal of Substance Abuse Treatment, 22, 1-13.

Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. (2010). A meta-analysis of Motivational Interviewing: Twenty-five years of empirical studies. Research on Social Work Practice, 20, 137-160.

Martin, G. W., & Rehm, J. (2012). The effectiveness of psychosocial modalities in the treatment of alcohol problems in adults: A review of the evidence. The Canadian Journal of Psychiatry/La Revue Canadienne De Psychiatrie, 57(6), 350-358.

Magill, M., & Ray, L. A. (2009). Cognitive-behavioral treatment with adult alcohol and illicit drug users: A meta-analysis of randomized controlled trials. Journal of Studies on Alcohol and Drugs, 70(4), 516-527.

Marlatt, G. A., Baer, J. S., Kivlahan, D. R., Dimeff, L. A., Larimer, M. E., Quigley, L. A., …Williams, E. (1998). Screening and brief intervention for high-risk college student drinkers: Results from a two-year follow-up assessment. Journal of Consulting and Clinical Psychology, 66(4), 604-615.