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Evidence Based Practices for Mental Health Professionals

By Jim Messina, Ph.D., CCMHC, NCC, DCMHS


Chapter 14 Substance Use Disorders

LEARNING OBJECTIVES FOR

SUBSTANCE USE DISORDERS

After reading this section you will learn the answers to the following questions:

  1. What are the ICD-10-CM Codes for Substance Use Disorders?
  2. What are the clinical descriptors for Substance Use Disorders?
  3. What are the common prescription and non-prescription used and abused in Substance Use Disorders?
  4. What are the common symptoms for Substance Use Disorders?
  5. What are some common mental health comorbidities of Substance Use Disorders?
  6. What are the common populations which are treated for Substance Use Disorders?
  7. What are the common treatment settings for Substance Use Disorders?
  8. What are the Evidence Based Practices for treating Substance Use Disorders?
  9. What area the common psychopharmacological treatments for Substance Use Disorders?
  10. What are some common manuals, guideline books and client workbooks for treating Substance Use Disorders?
  11. What are some good references you can use to learn more in-depth information about Substance Use Disorders?

 A Note from Drugs

 

"I destroy homes, tear families... apart - take your children, and that's just the start.

I'm more costly than diamonds, more costly than gold - the sorrow I bring is a sight to behold.

And if you need me, remember I'm easily found.

I live all around you, in schools and in town.

I live with the rich, I live with the poor, I live down the street, and maybe next door.

My power is awesome - try me you'll see.

But if you do, you may never break free.

Just try me once and I might let you go, but try me twice, and I'll own your soul.

When I possess you, you'll steal and you'll lie.

You'll do what you have to just to get high.

The crimes you'll commit, for my narcotic charms, will be worth the pleasure you'll feel in your arms.

You'll lie to your mother; you'll steal from your dad.

When you see their tears, you should feel sad.

But you'll forget your morals and how you were raised.

I'll be your conscience; I'll teach you my ways.

I take kids from parents, and parents from kids, I turn people from God, and separate from friends.

I'll take everything from you, your looks and your pride, I'll be with you always, right by your side.

You'll give up everything - your family, your home, your friends, your money, then you'll be alone.

I'll take and I'll take, till you have nothing more to give.

When I'm finished with you you'll be lucky to live.

If you try me be warned this is no game.

If given the chance, I'll drive you insane.

I'll ravish your body; I'll control your mind.

I'll own you completely; your soul will be mine.

The nightmares I'll give you while lying in bed.

The voices you'll hear from inside your head.

The sweats, the shakes, the visions you'll see.

I want you to know, these are all gifts from me.

But then it's too late, and you'll know in your heart, that you are mine, and we shall not part.

You'll regret that you tried me, they always do.

But you came to me, not I to you.

You knew this would happen.

Many times you were told, but you challenged my power, and chose to be bold.

You could have said no, and just walked away.

If you could live that day over, now what would you say?

I'll be your master; you will be my slave.

I'll even go with you, when you go to your grave.

Now that you have met me, what will you do?

Will you try me or not?

It’s all up to you.

I can bring you more misery than words can tell.

Come take my hand, let me lead you to hell."

Signed

DRUGS

ICD-10-CM Codes for Substance Use Disorders in DSM-5

Caffeine-Related Disorders

F15.929 Caffeine Intoxication

F15.33 Caffeine Withdrawal

F15.99 Unspecified Caffeine-Related Disorder

Cannabis Related Disorders

F12.10 Cannabis Use Disorder Mild

F12.20 Cannabis Use Disorder Moderate

F12.20 Cannabis Use Disorder Severe

F12.129 Cannabis Intoxication Without perceptual disturbance with use disorder Mild

F10.229 Cannabis Intoxication Without perceptual disturbance with use disorder Moderate or Severe

F10.929 Cannabis Intoxication Without perceptual disturbance without use disorder

F12.122 Cannabis Intoxication With perceptual disturbance with use disorder Mild

F10.222 Cannabis Intoxication With perceptual disturbance with use disorder Moderate or severe

F10.922 Cannabis Intoxication With perceptual disturbance without use disorder

F12.288 Cannabis Withdrawal

F12.99 Unspecified Cannabis-Related Disorders

Hallucinogen Related Disorders

F16.10 Phencyclidine Use Disorder Mild

F16.20 Phencyclidine Use Disorder Moderate

F16.20 Phencyclidine Use Disorder Severe

F16.10 Other Hallucinogen Use Disorder Mild

F16.20 Other Hallucinogen Use Disorder Moderate

F16.20 Other Hallucinogen Use Disorder Severe

F16.129 Phencyclidine Intoxication With use disorder Mild

F16.229 Phencyclidine Intoxication With use disorder Moderate or severe

F16.929 Phencyclidine Intoxication Without use disorder

F16.129 Other Hallucinogen Intoxication With use disorder Mild

F16.229 Other Hallucinogen Intoxication With use disorder Moderate or severe

F16.929 Other Hallucinogen Intoxication Without use disorder

F16.983 Hallucinogen Persisting Perception Disorder

F16.99 Unspecified Phencyclidine-Related Disorder

F16.99 Unspecified Hallucinogen-Related Disorder

Inhalant-Related Disorders

F18.10 Inhalant Use Disorder Mild

F18.20 Inhalant Use Disorder Moderate

F18.20 Inhalant Use Disorder Severe

F18.129 Inhalant Intoxication With use disorder Mild

F18.229 Inhalant Intoxication With use disorder Moderate or severe

F18.929 Inhalant Intoxication Without use disorder

F18.99 Unspecified Inhalant-Related Disorders

Opioid-Related Disorders

F11.10 Opioid Use Disorder Mild

F11.20 Opioid Use Disorder Moderate

F11.20 Opioid Use Disorder Severe

F11.129 Opioid Intoxication Without perceptual disturbance with use disorder Mild

F11.229 Opioid Intoxication Without perceptual disturbance With use disorder Moderate or severe

F11.929 Opioid Intoxication Without perceptual disturbance Without use disorder

F11.122 Opioid Intoxication With perceptual disturbance with use disorder Mild

F11.222 Opioid Intoxication With perceptual disturbance With use disorder Moderate or severe

F11.922 Opioid Intoxication With perceptual disturbance Without use disorder

F11.23 Opioid Withdrawal

F11.99 Unspecified Opioid -Related Disorders

Sedative-, Hypnotic-, or Anxiolytic-Related Disorders

F13.10 Sedative, Hypnotic, or Anxiolytic Use Disorder Mild

F13.20 Sedative, Hypnotic, or Anxiolytic Use Disorder Moderate

F13.20 Sedative, Hypnotic, or Anxiolytic Use Disorder Severe

F13.129 Sedative, Hypnotic, or Anxiolytic Intoxication with use disorder Mild

F13.229 Sedative, Hypnotic, or Anxiolytic Intoxication with use disorder Moderate or severe

F13.929 Sedative, Hypnotic, or Anxiolytic Intoxication without use disorder

F13.239 Sedative, Hypnotic, or Anxiolytic Withdrawal Without perceptual disturbance

F13.222 Sedative, Hypnotic, or Anxiolytic Withdrawal With perceptual disturbance

F13.99 Unspecified Sedative-, Hypnotic-, or Anxiolytic- Related Disorder

Stimulant-Related Disorder

F15.10 Amphetamine-Type Substance Use Disorder Mild

F15.20 Amphetamine-Type Substance Use Disorder Moderate

F15.20 Amphetamine-Type Substance Use Disorder Severe

F15.10 Cocaine Use Disorder Mild

F15.20 Cocaine Use Disorder Moderate

F15.20 Cocaine Use Disorder Severe

F15.10 Other or unspecified stimulant Use Disorder Mild

F15.20 Other or unspecified stimulant Use Disorder Moderate

F15.20) Other or unspecified stimulant Use Disorder Severe

F15.129 Amphetamine or other stimulant Intoxication Without perceptual disturbance with use disorder Mild

F15.229 Amphetamine or other stimulant Intoxication Without perceptual disturbance With use disorder Moderate or severe

F15.929 Amphetamine or other stimulant Intoxication Without perceptual disturbance Without use disorder

F14.129 Cocaine Intoxication Without perceptual disturbance with use disorder Mild

F14.229 Cocaine Intoxication Without perceptual disturbance With use disorder Moderate or severe

F14.929 Cocaine Intoxication Without perceptual disturbance Without use disorder

F15.122 Amphetamine or other stimulant Intoxication With perceptual disturbance with use disorder Mild

F15.222 Amphetamine or other stimulant Intoxication With perceptual disturbance With use disorder Moderate or severe

F15.922 Amphetamine or other stimulant Intoxication With perceptual disturbance Without use disorder

F14.122 Cocaine Intoxication With perceptual disturbance with use disorder Mild

F14.222 Cocaine Intoxication With perceptual disturbance With use disorder Moderate or severe

F15.922 Cocaine Intoxication With perceptual disturbance Without use disorder

F15.23 Amphetamine or other Substance Withdrawal

F14.23 Cocaine Withdrawal

F15.99 Unspecified Amphetamine or other Substance-Related Disorders

F14.99 Unspecified Cocaine-Related Disorders

Tobacco-Related Disorders

Z72.0 Tobacco Use Disorder Mild

F17.200 Tobacco Use Disorder Moderate

F17.200) Tobacco Use Disorder Moderate

F17.203) Tobacco Withdrawal

F17.209) Unspecified Tobacco-Related Disorder

Other (or unknown) Substance-Related Disorders

F19.10) Other (or unknown) Substance Use Disorder Mild

F19.20 Other (or unknown) Substance Use Disorder Moderate

F19.20 Other (or unknown) Substance Use Disorder Severe

F19.129 Other (or unknown) Substance Intoxication With use disorder Mild

F19.229 Other (or unknown) Substance Intoxication With use disorder Moderate or severe

F19.929 Other (or unknown) Substance Intoxication Without use disorder

F19.239 Other (or unknown) Substance

F19.99 Unspecified Other (or unknown) Substance -Related Disorder

Non-Substance-Related Disorders

F63.0 Gambling Disorder

 

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.) (DSM-5). Washington, DC: Author.

Gordy: Substance Use Disorder


Gordy is a 20 year old college student in the local community college which he has been attending for the past three years. He just entered the fall semester and said he needed to get some help to get through school this semester when he call to make this appointment. His real name is Gordy and all his buddies call him “Flash” because when he is on cocaine he is like a flash of lightening with all the energy in the world. 


He says that when he comes down he then gets on the stimulants available to him through his friends who have been faking ADHD with their doctors. He says that he has been trying to get off cocaine and stimulants and he fears that he is becoming addicted to both. He says that every time he tries to go off a week or two of both of them, something happens and he gets right back into use of them deeper and more intensely. 


He says that the reason he is still in the community college is that he has not been able to complete many of his courses due to having withdraw due the need to take time off to recover from the withdrawal symptoms he has when he stops his drug use. He wants to graduate from community college and go on to become an engineer and he knows that he will never accomplish this goal if he keeps on being hooked on both cocaine and stimulants. 


He says he has never gone for help before and the reason he has come in is that his college advisor told him he would be withdrawn from the college completely if he does not succeed in getting passing grades in the four courses which he enrolled in this semester. 


You tell Gordy you will work with him as long as he does the following:

  1. First you need to stop using cocaine and stimulannts from this point forward and you need to admit to yourself you have a severe substance abuse problem.
  2. You will immediately get yourself to a 12 Step Program be it AA or NA in our community and go to at least 90 meetings in 90 days.
  3. At the AA or NA meetings you will meet people like yourself and after 30 days going to these meetings you will select a sponsor whom you will give permission for us to meet together to discuss your progress in the 12 Step Program in your effort to recover from substance abuse
  4. I will work with you weekly over this time educating you substance abuse and the impact it has on your body, mental health, intellectual functioning and the relationships you have in your family and peer group and what are the healthy steps needed to become sober and abstain from substance use in the future.


Before Gordy comes in for his next session you give him his first homework assignment and explain that it you will be using well researched and proven behavioral and cognitive behavioral therapy techniques to help him strengthen his resolve to give up his drug use and acquire a normal health existence.

In 2010, Dupont declared that prescription drug use is an epidemic. He went on to say that nonmedical use of prescribed controlled substances will mean that a major overhaul of the medical, legal and public health process will have happen (Dupont, 2010). He cautioned, however, that preventing illegal, non-medical use of prescription drugs must be balanced so as not to become an obstacle for physcians who are appropriately using drugs for legitimate medical reasons (Dupont, 2010).

Clasifications and Names of Prescription Drugs Abused

Classification

Medication Generic Names (Commercial Names)

Opiod Analgesics (Opioides):

Morphine

Morphine, long-acting (Avinza, Kadian)

HYDROmorphone (Dilaudid)

OXYcodone (Oxecta)

OXYcodone, long-acting (OxyContin)

HYDROcododone (Vicodin, Lortab)

OXYmorphone (Opana)

OXYmorphone, long-acting (Opana ER)

Codeine

Fentanyl

Methadone

Sedatives: Barbiturates

Methohexital (Brevital) and Thiopental (Pentothal)

Amobarbital (Amytal), Pentobarbital (Nembutal), Secobarbital (Seconal), Butalbital (Fioricet, Fiorinal)

Phenobarbital (Luminal)

Sedatives: Non-Barbiturates

Benzodiazepines, Carbamates-Meprobamate (Miltown)

Chloral Derivatives - Chloral hydrate (Noctec)

Ethchlorvynol (Placidyl)

Piperidines - Glutethimide (Doriden) and Methyprylon (Noludar)

Quinazolinone - Methaqualone (Quaalude)

Imidazopyridine - Zolpidem (Ambien), zaleplon (Sonata), eszopiclone (Lunesta) and Alpidem

Antihistamines (over-the-counter sleep aids) Diphenhydramine and doxylamine

GHB- Gamma-hydroxybutyrate

Hypnotics: Benzodiazepines:

Diazepam (Valium, Diastat; Diastat AcuDial

Midazolam (Versed)

Anxiolytics: Anti-anxiety Meds:

Alprazolam (Xanax, Niravam, Xanax XR)

Lorazepam (Ativan)

Chlordiazepoxide (Librium)

Clonazepam (Klonopin)

Clorazepate (Tranxene SD; Tranxene T-Tab)

Diazepam (Valium, Diastat; Diastat AcuDial)

Midazolam (Versed)

Oxazepam (Serax)

Stimulants:

Ritalin

Metadate

Concerta

Dexedrine

Adderall

Focalin

Research in 2007 found that 48% of persons with schizophrenia and 56% of persons with bipolar disorder had comorbid substance use disoders (Biegel, Kola and Ronis, 2007; Palomo, Archer, Kostrezeqa and Beninger, 2007). Individuals with comorbid mental health and substance abuse disorders were more likely to experience multiple relapses, many hospitalization and/or incarcerations and homelessness. They were most likely to engage in risky behaviors, violence and jeopardize their health (Biegel, Kola and Ronis, 2007).  A study of opiod dependent users, found that opioid using women were more likely to chose amphetamines, methamphetamines and phencylclidine (PCP); whereas, opioid using men more likely to use and abuse methadone and marijuana. This reinforced the understanding that many drug abusers will abuse more than one drug (Beck et al., 2011).


The drive to utilize Evidence Based Practices in the substance use disorder treatment field is an attempt to reduce costs while increasing treatment effectiveness (Steenrod, 2009), even though at times, national, state and local public and private agencies involved in promoting EBPs cannot substantially and universally implement treatment as desired (Best, Day, Morgan, Oza, Copello and Gossop, 2009). An example is that with the American Indian and Alaskan Native population, researchers were unwilling to fully use EBPs with them. They feared that positive results would appear as data manipulation concerning these minorities. They feared clinicians in the field would not use EBPs if they felt the data was favorably skewed with them for these populations. This would result in weaker treatment services available at these sites, since the clinicians would not use these biased EBPs (Larios, Wright, Jernstrom, Lebron and Sorenson, 2011).


In their research, Glasneer-Edwards et al. (2010) found that close to 50% of their national sample of individusl with substance abuse disorders met criteria for co-morbidity of Depressive Disorders, Anxiety Disorders and Antisocial Personality Disorder (2010, p. 12). Hides, Samet and Lubman (2010) conducted a meta-analysis into Cognitive Behavior Therapy (CBT) and found that CBT along with antidepressant medications were effective in treating substance use disorder with co-morbid depressive disorder.


Cognitive Behavior Therapy (CBT) is psychotherapy based on principles of learned behaviors which become conditioned. The clinician works with clients to turn these thoughts and behaviors around so as to reduce and hopefully stop substance abuse through learning new coping skills and implementing relapse prevention strategies (Lee and Rawson, 2008). In 2013, Naar-King, Earnshaw and Breckon proposed using CBT to address maintaining behavior change within a system which utilized Motivational Interviewing (MI) (2013).


Motivational Interviewing (MI) has the goal of enhancing intrinsic motivation to make the necessary changes to changes one’s unwanted or illicit behaviors and it involves a counselor using specific statements and questions to help the client identify and own his/her own rationale for wanting to change (Craig, 2012).  Craig (2012) describes the two step MI process in which counselors and clients collaborate in shared decision making. First, a counselor listens to the clients and follows up on more upbeat topics they said, making clients think about the topics in their own lives. Next, clients become more motivated to make positive change which hopefully lessens chances of recidivism, or the act of repeating an undesirable behavior after the client has either experienced negative consequences of that behavior, or has been treated or trained to extinguish that behavior.  


Clinicians have recognized Contingency Management as an Evidenced Based Practice in treating substance abuse disorders by encouraging clients to remain drug free through external reinforcement (Roll, 2007). In involves such things as giving attendance certificates for group participation; court sanctions for non-participation in programming; and vouchers or chances for in house lottery prizes for drug free screenings (Roll, 2007).


Clinicians have used supportive-expressive psychodynamically oriented psychotherapy, which emphasizes developing and maintaining a therapeutic alliance between therapist and clients, as one component along with CBT and 12 Step groups with cocaine dependent clients (Crits-Christoph et al., 2008).


There are a variety of family systems approaches which clinicians have bundled into Multidimensional Family Therapy. This therapy engages the family, especially with the target client who typically is an adolescent, to help develop a supportive environment to prevent relapse and improve the family’s functioning (Waldron and Turner, 2008).


Unfortunately, the efforts at substance abuse prevention have not always attained their desired goals (Valente, Chou and Pentz, 2007) and clinicians spend a great deal of energy and time designing and crafting appropriate prevention and treatment programs for substance use disorders in communities with little to no measurable decrease in incidence of these disorders (Bobor, Stenius and Romelsjo, 2008).


Treatment modalities research that address substance use disorders include:

1) Cognitive behavior therapy (CBT) (Ducharme, Knudsen and Roman, 2006; McMurran, 2007; Lee and Rawson, 2008; Liddle, Dakof, Turner, Henderson and Greenbaum, 2008; Litt, Kaddon, Kabola-Cormier and Petry, 2008; Riley, Rieckmann and McCarty, 2008; Waldron and Turner, 2008; Magill and Ray, 2009; Hides, Samet and Lubman, 2010; Kiluk, Nich, Babuscio and Carroll, 2010; Ogel and Coskun, 2011; Black, Woodworth, Tremblay and Carpenter, 2012; Cooper, 2012; Riley, Srikanth, Choi and McCarty, 2012; Kuerbis and Sacco, 2013; Naar-King, Earnshaw and Breckon, 2013; van Dam, Ehring, Vedel and Emmelkamp, 2013; Van Emmerik-van Oortmerssen, Vedel, Koeter, de Bruijn, Dekker, van den Brink and Schoevers, 2013).

2) Motivational Interviewing (MI) (Amodeo, Ellis and Samet, 2006; Riley, Rieckmann and McCarty, 2008; Craig, 2012;    Riley, Srikanth, Choi and McCarty, 2012; Kuerbis and Sacco, 2013; Naar-King, Earnshaw and Breckon, 2013).

3) Contingency Management (CM) (Roll, 2007; Sigmon, 2007; Lee and Rawson, 2008; Litt, Kaddon, Kabola-Cormier and Petry, 2008; Killeen, McRae-Clark, Waldrop, Upadhyaya and Brady, 2012; Petry, Alessi and Rash, 2013).

4) Supportive-expressive (SE) psychotherapy (Crits-Christoph et al., 2008).

5) Multisystemic (family) Therapy (MST) (Vaugh and Howard, 2004; Austin, Macgowan and Wagner, 2005; Liddle, Dakof, Turner, Henderson and Greenbaum, 2008; Waldron and Turner, 2008; Hogue and Liddle, 2009; Spas, Ramsey, Palva and Stein, 2012).

6) Pharmacotherapy only (Acharyya and Zhang, 2003; Keen and Oliver, 2004; Ducharme, Knudsen and Roman, 2006; van den Brink and Haasen, 2006; ADIS International, 2007; Palomo, Archer, Kostrezeqa and Beninger, 2007; Sigmon, 2007; Kuerbis and Sacco, 2013).

7) 12 Step Programming: (Donovan and Wells, 2007; Kelly and Myers, 2007; Gossop, Stewart, and Marsden, 2008; Stewart, 2009; Zafiridisand Lainas, 2012).

8) Computer and Technology Supported Treatments (Kay-Lambkin, Baker, Lewin and Carr, 2009; Kiluk, Nich, Babuscio and Carroll, 2010; Klein and Anker, 2013).


The following are settings that researchers have studied for drug abuse treatment:

1) Outpatient drug-free (OPDF) (Acharyya and Zhang, 2003; Ducharme, Knudsen and Roman, 2006).

2) Outpatient methodone (opiod antagonist) maintenance treatment (OPMMT) (Acharyya and Zhang, 2003; Ducharme, Knudsen and Roman, 2006; van den Brink and Haasen, 2006; Donovan and Wells, 2007).

3) Short-term inpatient (STI) (Acharyya and Zhang, 2003; Womack, Compton, Dennis, McCormick, Fraser, Horton, Spitznagel and Cottler, 2004).

4) Long-term residential (LTR): (Acharyya and Zhang, 2003; McMurran, 2007; McNeese-Smith et al., 2007; Gossop, Stewart, and Marsden, 2008).

Assignment for Gordy after his first session

Behavioral Chains in Recovery

What are behavioral chains?

Behavioral chains are:

  1. A series of specific behavior traits resulting in a final behavior in need of attention, remediation, or change before a recovered lifestyle can be achieved or regained.
  2. Steps leading to a behavior targeted for change or relapse work.
  3. The series of stimuli/response reactions, ultimately leading to a problem behavior or relapse event.
  4. Specific behavior traits that make up and are the causal agents of a problem behavior pattern when linked together.
  5. Linked behavior traits with some degree of predictability as to the ultimate consequence or outcome.
  6. The result of linking emotional cues or triggers and respondent behaviors into a series of events that contribute to the exacerbation of problem behavior patterns or relapse of this pattern

 

What are some characteristics of behavioral chains?

  1. If the chain of behavior patterns is broken at any point, it probably will not progress to the final behavior.
  2. The earlier the break in the link, the easier it is to undo the chain.
  3. Behavior chains often go unidentified prior to the occurrence of the final link in the chain.
  4. Behavior chains are self‑propelling; they have a momentum of their own to go on and on.
  5. The chains can be diagramed, but one must begin with the last link and trace backward to each preceding behavior or emotional cue or trigger.
  6. Behavior chains can be broken into habitual patterns that give insight into chain‑breaking strategies and alternative behavior traits which help to prevent future relapse.

 

What are some examples of behavioral chains?


Example 1: You have decided to participate in the “Great Smoke Out'' day sponsored by the American Cancer Society. You arrive at work.

  • Craving for a cigarette begins.
  • You take the money out with which to purchase a pack.
  • Guilt feelings over craving a cigarette begin.
  • Anxious if you don't have enough money to get cigarettes.
  • Nervous until “break” time.
  • Craving increases.
  • Get up from desk anxious to get to lobby.
  • Excited about this decision.
  • Put money into cigarette machine.
  • Open pack of cigarettes.
  • Enjoy the smell of a new pack.
  • Anticipation of pleasure waiting to be experienced.
  • Nervous that a co‑worker will catch you lighting up.
  • Walk into bathroom; enter a stall.
  • Put cigarette in mouth.
  • Pull out lighter and ignite flame.
  • Touch flame to cigarette and take a deep drag on cigarette.
  • Continue smoking cigarette to completion.
  • Guilt feelings begin over having given in to the urge to smoke.
  • Craving for another cigarette begins.

 

Example 2: The Pizza Binge

  • You have had a horrible day at work and are feeling pressured by your boss to either increase daily quota of work or face a poor performance evaluation.
  • You leave work in distress, upset over not having been assertive, not standing up for your rights with the boss.
  • In the heavy commuter traffic, you feel upset over course of the day.
  • Driver in the car next to you cuts in front of you, making you shout and gesture to him.
  • You pass several pizza shops and think of a big, deep‑dish pizza with all the trimmings.
  • You honk horn loudly at driver in front of you who has slowed down the pace of traffic.
  • Angry at self for losing temper.
  • See billboard with a deep‑dish pizza advertised.
  • You feel the seat belt pressing in on your stomach and you think more about food.
  • Depressed over your boss's inability to show appreciation for your good work.
  • Annoyed at the slow pace of traffic.
  • Getting hungry and tasting the pizza as you pass the twelfth pizza shop.
  • Finally you pull into a pizza shop parking lot.
  • You call home to say you will be late, that you have more work to do at the office.
  • Check your wallet to see if you have enough money for a pizza.
  • Angry at self for allowing work, boss, and traffic to upset you.
  • Get into pizza shop and stand at “take out'' counter.
  • Feel exhilarated when it is your turn to order.
  • Order a large, deep‑dish pizza with all the works.
  • Mentally review the day's events as you wait your 25 minutes.
  • Get angry again over your boss's rudeness and lack of caring.
  • Feel depressed as you review the route your life has taken: overworked, underappreciated, and taxed by a forty‑five minute commute twice a day.
  • Feeling sorry for self for the hard knocks life has dealt you.
  • Your name is called; you feel excited over your rewarding of yourself; you deserve it!
  • Pay for pizza and carry it to your car.
  • Open pizza box and become intoxicated by the aroma.
  • You eat one piece.
  • You take a deep breath, feeling rewarded and at peace.
  • You continue to eat piece after piece and relish each flavor.
  • You force yourself to eat the last three pieces, then the crust.
  • You feel stuffed, embarrassed: What have you done! Why did you eat the whole thing?
  • Guilty and depressed, you dispose of all evidence of the pizza.
  • You drive home feeling hopeless, trapped. Why did you lie about doing work at the office when you were going to binge on Pizza? Why did you binge? You hate yourself.

 

How can you control a behavioral chain?

In order to control a behavioral chain, the links need to be identified and broken. You can work at:

  1. Interpreting events in your life differently so that they are less likely to have the power to lead you to exercise habitual problem behavior or relapse to old behaviors.
  2. Using rational thinking about what is happening in your life eliminates the "shoulds'' and "musts'' from your thinking about how others should treat you and how you should treat others.
  3. Substituting positive affirmations and positive self‑talk when you are being bombarded with emotional cues or irrational thoughts about yourself, events, or others.
  4. Taking responsibility for your own actions, not blaming other persons or events for making you fall into the behavior chain.
  5. Substituting alternative, healthy behavior, for those behavior traits that lead to the problem behavior or relapse event.
  6. Substituting required activities for antecedent behavior in a chain, such as doing office work, paying bills, cleaning the house, opening the mail, paying attention to defensive driving techniques, etc.
  7. Substituting enjoyable activities for antecedent behaviors in a chain such as enjoying a hobby, listening to music, exercising, calling an understanding friend, writing a letter, going to a movie, reading for pleasure.
  8. Substituting positive behavior in a chain for a behavior known to lead to habitual problems or relapse events.
  9. Reinforcing positive behavior traits and ignoring negative behavior patterns, or substituting new behavior traits for negative behavior patterns or relapse events.
  10. Recognizing the behavior that habitually leads to predictable, negative‑consequence behavior chains or relapse events.

 

What beliefs block you from recognizing the behavioral chains in your problem behavior patterns?

I never know why I do the things I do. It's beyond me.

There is no sense in looking at the causes of my behavior. What's important is to treat the symptoms.

I've always done it this way. I will never change.

What difference does it make what behavior preceded my problem behavior? All I know is I have a problem I can't seem to shake.

It takes too much time to work on analyzing the chain of events leading to my problem behavior.

So, what difference will it make to identify antecedent behaviors or events when they are out of my control anyway?

I'm compulsive; that's all I need to know to explain why I act the way I do.

I'm so embarrassed by the way I act; I'd hate to tell anybody else about it.

I am a loser and there is no helping me.

If it weren't for ________ (spouse, parent, child, boss, job, problem of the day), these things would never happen.

 

Identify the behavioral chains in your life

In your personal journal prior to your next counseling session, take five separate problem behavior traits or relapse events from the past month and create a behavioral chain on each. Remember to list events, persons, emotional cues, reactions, feelings, thoughts and behavior traits that led to the final problem behavior or relapse event. Once you have completed the five chains, respond to the following 4 review items:

  1. In reviewing the behavioral chains of these five problem behaviors or relapse events, I recognize that my problem behavior is usually linked with the following antecedent behaviors: (Make a list for each problem. Note similarities.)
  2. I could substitute the following activities if similar chains should occur in the future:
  3. The following emotions often lead me to my problem behavior or relapse event:
  4. I need to take the following actions so I can recognize when I'm in the midst of a behavioral chain leading to one of my problem behavior patterns or relapse events:


After completing this assignment I am committing to work on not allowing myself to relapse back into use of the substances I have been abusing.

Signed                                                                Date:


Adapted from: Section 3, Chapter 11: Behavioral Chains Use in Recovery in: Messina, J.J. (2013). Self-Esteem Seekers Anonymous-The SEA’s Program of Recovery, retrieved at www.coping.us

Populations served by Drug Use Disorder treatment programs include:

1) Adolescent/College age (Vaugh and Howard, 2004; Austin, Macgowan and Wagner, 2005; Jowers, Bradshaw and Gately, 2007; Harris, Baker, Kimball, and Shumway, 2007; Kelly and Myers, 2007; Liddle, Dakof, Turner, Henderson and Greenbaum, 2008; Riley, Rieckmann and McCarty, 2008; Waldron and Turner, 2008; Hogue and Liddle, 2009; McDevitt-Murphy, Murphy, Monahan, Flood and Weathers, 2010; Ogel and Coskun, 2011; Esposito-Smythers, Spirito, Kahler, Hunt and Monti, 2011; Black, Woodworth, Tremblay and Carpenter, 2012; Curry et al., 2012; Fauziah, Nen, Nur Saadah and Sarnon, 2012; Killeen, McRae-Clark, Waldrop, Upadhyaya and Brady, 2012; Riley, Srikanth, Choi and McCarty, 2012; Spas, Ramsey, Palva and Stein, 2012).

2) Adults (McMurran, 2007; McNeese-Smith et al., 2007; Lee and Rawson, 2008; Litt, Kaddon, Kabola-Cormier and Petry, 2008; Magill and Ray, 2009; Stewart, 2009; Hides, Samet and Lubman, 2010; Kiluk, Nich, Babuscio and Carroll, 2010; van Dam, Ehring, Vedel and Emmelkamp, 2013; Van Emmerik-van Oortmerssen, Vedel, Koeter, de Bruijn, Dekker, van den Brink and Schoevers, 2013).

3) Older adults (Cooper, 2012; Salmon and Forester, 2012; Kuerbis and Sacco, 2013).


Researched comorbidities with Drug Use Disorders include:

1) Alcohol use Disorder (Back, Sonne, Killeen, Dansky and Brady, 2003; Magill and Ray, 2009)

2) Depression (Womack, Compton, Dennis, McCormick, Fraser, Horton, Spitznagel and Cottler, 2004; Kay-Lambkin, Baker, Lewin and Carr, 2009; Hides, Samet and Lubman, 2010; McDevitt-Murphy, Murphy, Monahan, Flood and Weathers, 2010; Esposito-Smythers, Spirito, Kahler, Hunt and Monti, 2011; Curry et al., 2012; Salmon and Forester, 2012; Petry, Alessi and Rash, 2013).

3) Bipolar Disorder (Petry, Alessi and Rash, 2013)

4) Anxiety Disorder (McDevitt-Murphy, Murphy, Monahan, Flood and Weathers, 2010; Petry, Alessi and Rash, 2013).

5) PTSD (Back, Sonne, Killeen, Dansky and Brady, 2003; McDevitt-Murphy, Murphy, Monahan, Flood and Weathers, 2010; Black, Woodworth, Tremblay and Carpenter, 2012; van Dam, Ehring, Vedel and Emmelkamp, 2013).

6) Schizophrenia (Palomo, Archer, Kostrezeqa and Beninger, 2007; Petry, Alessi and Rash, 2013).

7) Conduct Disorder (Spas, Ramsey, Palva and Stein, 2012)

8) Adult ADHD (Van Emmerik-van Oortmerssen, Vedel, Koeter, de Bruijn, Dekker, van den Brink and Schoevers, 2013).

Medications Used to Treat Substance use Disorders

Classification

Drug Name (Generic Name)

Methadone (Synthetic Opiod) (Opiod Antagonist)

Dolophine (Methadone)

Symoron (Methadone)

Methadose (Methadone)

Physeptone (Methadone)

Heptadon (Methadone)

Diamorphine Hydrochloride (Opiod Antagonist)

Diamorphine (Diamorphine Hydrochloride)

Diacetylmorphine (Diamorphine Hydrochloride)

Buprenophine (Opiod Antagonist)

Buprenophine Hydrochloride

Naloxone (Opiod Antagonist)

Narcan (Naloxone)

Nalone (Naloxone)

Nacanti (Naloxone)

Buprenophine and Naloxone (Combined) (Opiod Antagonist)

Suboxone (Buprenophine and Naloxone)

Zubslov (Buprenophine and Naloxone)

Anticonvulsants (treat opiod and cocaine abuse or cocaine and alcohol abuse)

Topamax (Topiramate)

Gabitril (Tiagabine)

Disulfram (treat opiod and cocaine abuse)

Antabuse (Disulfiram)

Atypical Antipsychotics (treat cocaine and alcohol abuse)

Risperdal (Risperdone)
Zyprexa (Olanzapine) 

Seroquel (Quetiapine fumarate)

Geodon (Ziprasidone) 
Abilify (Aripiprazole)   

Invega (Paliperidone palmitrate) 

Clozaril (Clozapine)

The use of methadone has the best researched evidence for treating opiod use disorders (Keen and Oliver, 2004; Ducharme, Knudsen and Roman, 2006). Other opiod antagonists that clinicians recognize as effective treatments to sustain abstinence from opiods are: buprenophine, naloxene and diamorphine hydrochloride (van den Brink and Haasen, 2006). AIDIAS (2007) published a listing of medications which were effective in comorbid use and abuse of substances and include: baclofen, anticonvulsants and atypical antipsychotics.

Handouts for Gordy to better explain the elements involved in his treatment

  1. TEA System
  2. ALERT System
  3. ANGER System
  4. LET GO System
  5. CHILD System
  6. RELAPSE System

All available online at: www. coping.us at: http://coping.us/seastoolsforrecovery.html

Treatment Workbook For Addictive Problems


Arkowitz, H., Westra, H.A., Miller, W.R. and Rollnick, S. (2008). Motivational interviewing in the treatment of psychological problems. New York: The Guilford Press.

 

Ciarrocchi, J.W. (2001). Counseling problem gamblers: A self-regulation manual for individual and family therapy. San Diego, CA: Academic Press.

 

Cleveland, H.H., Harris, K.S. and Wiebe, R.P. (2010). Substance abuse recovery in college-community supported abstinence. New York: Springer.

 

Coombs, R.H. (2004). Handbook of addictive disorders: A practical guide to diagnosis and treatment. Hoboken, NJ: John Wiley & Sons, Inc.

 

Coombs, R.H. and Howatt, W.A. (2005). The addiction counselor’s desk reference. Hoboken, NJ: John Wiley & Sons, Inc.

 

Daley, D.C. and Marlatt, G.A. (2006). Overcoming your alcohol or drug problem, Effective recovery strategies, workbook, second edition. New York: Oxford University Press.

 

Finley, J.R. and Lenz, B.S. (2009). Addiction treatment homework planner, fourth edition. Hoboken, NJ: John Wiley & Sons, Inc.

 

Ladouceur, R. and Lachance, S. (2007). Overcoming your pathological gambling, therapist guide. New York: Oxford University Press.

 

Leukefeld, C.G., Gullotta, T.P. and Stanton-Tindall, M. (2009). Adolescent substance abuse: Evidenced based approaches to prevention and treatment. New York: Springer.

 

Marlatt, G.A. and Donavan, D.M. (2005). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors, second edition. New York: The Guilford Press.

 

Messina, J.J. (2013). Tools for coping series: (1) Self-esteem seekers anonymous-The SEA’s program manual; (2) Laying the foundation: Personality traits of low self-esteem; (3) Tools for handling loss; (4) Tools for personal growth; (5) Tools for relationships; (6) Tools for communications; (7) Tools for anger work-out; (8) Tools for handling control issue; (9) Growing down:Tools for healing the inner child; (11) Tools for a balanced lifestyle, retrieved at www.coping.us

 

Miller, P.M. (2009). Evidence-base addiction treatment. Burlington, MA: Elsevier, Inc.

 

Miller, W.R. and Rollnick, S. (2002). Motivational interviewing: Preparing people for change. New York: The Guilford Press.

 

Perkinson, R.R. and Jongsma, A.E. (2009). The addiction treatment planner, fourth edition. Hoboken, NJ: John Wiley & Sons, Inc.

 

Rosengren, D.B. (2009). Building motivational interviewing skills: A practitioner workbook. New York: The Guilford Press.

 

Ross, D., Kincaid, H., Spurrett, D. and Collins, P. (2010). What is addiction? Cambridge, MA: The MIT Press.

 

Shah, J.Y. and Gardner, W.L. (2008). Handbook of motivation science. New York: The Guilford Press

 

Springer, D.W. and Rubin, A. (2009). Substance abuse treatment for youth and adults: Clinicians guide to evidence-based practice. Hoboken, NJ: John Wiley & Sons, Inc.

References for Substance Use Disorders


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ADIS International (2007). Few pharmacotherapies appear effective in the treatment of dual

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Amodeo, M., Ellis, M.A. and Samet, J.H. (2006). Introducing evidence-based practices into

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Gossop, M., Stewart, D. and Marsden, J. (2008). Attendance at narcotics anonymous and

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Harris, K.S., Baker, A.K., Kimball, T.G. and Shumway, S.T. (2007). Achieving systems-based

sustained recovery: A comprehensive model for collegiate recovery communities. Journal of Groups in Addiction and Recovery, 2, 2-4. doi: 10.1080/15560350802080951 

 

Hides, L., Samet, S. and Lubman, D.I. (2010). Cognitive behaviour therapy (CBT) for the

treatment of co-occurring depression and substance use: Current evidence and directions for future research. Drug and Alcohol Review, 29(5), 508-517. DOI: 10.1111/j.1465-3362.2010.00207.x

 

Hogue, A. and Liddle, H.A. (2009). Family-based treatment for adolescent substance abuse:

Controlled trials and new horizons in services research. Journal of Family Therapy, 31, 126-154.

 

Howard, M.O., Perron, B.E., Vaughn, M.G., Bender, K.A. and Garland, E. (2010). Inhalent use,

inhalant-use disorders and antisoical social behavior: Findings from the national epidemiological survey on alcohol and related conditions (NESARC). Journal of Studies on Alcohol and Drugs, 71(2), 201-209.

 

Jowers, K.L., Bradshaw, C.P. and Gately, S. (2007). Taking school-based substance abuse

prevention to scale: District wide implementation of keep a clear mind. Journal of Alcohol and Drug Education, 51(3), 73-91.

 

Kay-Lambkin, F.J., Baker, A.L., Lewin, T.J. and Carr, V.J. (2009). Computer-based

psychological treatment for comorbid depression and problematic alcohol and/or cannabis use: A randomized controlled trial of clinical efficacy. Addiction, 104(3), 178-188. doi:10.1111/j.1360-0443.2008.02444.x

 

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brief review of the evidence base. Drugs: Education, Prevention and Policy, 11,(2), 149-156. DOI: 10.1080/0968763031000075906

 

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narcotics anonymous: Review, implications and future directions. Journal of Psychoactive Drugs, 39(3), 259-269.

 

Killeen, T.K., McRae-Clark, A.L., Waldrop, A.E., Upadhyaya, H. and Brady, K.T. (2012).

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Kuerbis, A. and Sacco, P. (2013). A review of existing treatments for substance abuse among the

elderly and recommendations for future directions. Substance Abuse: Research and Treatment, 7. 13-37. doi: 10.4137/SART.S7865

 

Larios, S.E., Wright, S., Jernstrom, A., Lebron, D. and Sorenson, J.L. (2011). Evidence-based

practices, attitudes, and beliefs in substance abuse treatment programs serving American Indians and Alaska natives: A qualitative study. Journal of Psychoactive Drugs, 43(4), 355-359. DOI: 10.1080/02791072.2011.629159

 

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Magill, M. and Ray, L.A. (2009). Cognitive-behavioral treatment with adult alcohol and illicit

drug users: A meta-analysis of randomize controlled trial. Journal of Studies on Alcohol and Drugs, 70(4), 516-527.

 

McDevitt-Murphy, M.E., Murphy, J.G., Monahan, C.J., Flood, A.M. and Weathers, F.W. (2010).

Unique patterns of substance misuse associated with PTSD, depression and social phobia. Journal of Dual Diagnosis, 6, 94-110. DOI: 10.1080/15504261003701445

 

McMurran, M. (2007). What works in substance misuse treatment for offenders? Criminal

Behaviour and Mental Health, 17, 225-233. doi: 10.1002/cbm.662 

 

McNeese-Smith, D., Nyamathi, A., Longshore, D., Wickman, M., Robertson, S., Obert, J.,

McCann, M., Wells, K. and Wenzel, S.L. (2007). Process and outcomes of substance abuse treatment between two programs for clients insured under managed care. American Journal of Drug and Alcohol Abuse, 33(3), 439-446. doi: 10.1080/00952990701315186 

 

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evidence suggests lack of effectiveness or harm. International Journal of Mental Health and Addiction6(4), 568-576. doi: 10.1007/s11469-008-9146-4 

 

Naar-King, S., Earnshaw, P. and Breckon, J. (2013). Toward a universal maintenance

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Petry, N.M., Alessi, S.M. and Rash, C.J. (2013). Contingency management treatments decrease

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Riley, K.J., Rieckmann, T. and McCarty, D. (2008). Implementation of met/cbt 5 for

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Riley, K.J., Srikanth, P., Choi, D. and McCarty, D. (2012). Treatment length and outcomes

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Roll, J. M. (2007). Contingency management: An evidence-based component of

methamphetamine use disorder treatment.  Addiction, 102(1), 114-120. 

 

Salmon, J.M. and Forester, B. (2012). Substance abuse and co-occurring psychiatric disorders in

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van Dam, D., Ehring, T., Vedel, E. and Emmelkamp, P.M.G. (2013). Trauma-focused treatment

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van den Brink, W. and Haasen, C. (2006). Evidenced-based treatment of opioid-dependent

patients. The Canadian Journal of Psychiatry, 51(10), 635-646. 

 

Van Emmerik-van Oortmerssen, K., Vedel, E., Koeter, M.W., de Bruijn, K., Dekker, J.J.M., van

den Brink, W. and Schoevers, R.A. (2013). Invetigating the efficacy of integrated

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Waldron, H.B. and Turner, C.W. (2008). Evidence-based psychosocial treatments for adolescent

substance abuse. Journal of Clinical Child and Adolescent Psychology, 37(1), 238-261. doi: 10.1080/15374410701820133c 

 

Womack, S., Compton, W.M., Dennis, M., McCormick, S., Fraser, J., Horton, J.C., Spitznagel,

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WHERE DO I GO FROM HERE?

CONCERNING SUBSTANCE USE DISORDERS

Now that you have read this section, in “My Mental Health Professional Practitioner Journal” record your answers and reactions to the following questions:

  1. How will this information help me as a Mental Health Professional?
  2. How interested am I in implementing Evidence Based Practices concerning Substance Use Disorders in my clinical practice?
  3. Why is it important that I learn more about Substance Use Disorders?
  4. What more do I need to know about this Substance Use Disorders?
  5. Where can I go to obtain more information about Substance Use Disorders and their mental health comorbidities?
  6. Where can I go to obtain the journal articles, manuals, workbooks or guidebooks on Substance Use Disorders?