Identification and Treatment of Substance Use Disorders: a Primer
1
Substance Use Disorders
Introduction to the Identification and Treatment
of Substance Use Disorders (SUDS)
B. Thomas Gray, Ph.D.
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12/29/03
Introduction to the Identification and Treatment
of Substance Use Disorders (SUDS)
B. Thomas Gray, Ph.D.
Substance Use Disorders (SUDs) are arguably the most common mental health problem in the United States. A large proportion of persons presenting for care in medical and mental health settings meet criteria for one or more SUDs, and it is inevitable that a psychologist engaged in clinical practice will encounter such individuals. It is therefore important to have a good working knowledge of the disorders and related problems. This article is intended to provide a general introduction to the SUDs and their treatment. It is impossible in this context to engage in a comprehensive review of all relevant areas, and this article alone is far from sufficient to allow the psychologist lacking background to become proficient in working with SUDs. For example, I do not address problematic use of nicotine or caffeine here. Because of the general nature of this discussion, specific references are not cited in the text; I have instead appended a rather lengthy bibliography, organized topically, for the use of those who wish to pursue further information. Internet addresses are also provided to resources such as Division 50 (Psychology of Addictions) of the American Psychological Association, the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, and other government outlets. Training opportunities are typically available on a regular basis in most areas, and the interested psychologist is encouraged to take advantage of as many as possible. My email address is provided here, as well, and I would be more than happy to assist anyone searching for further information and training.
Introduction
Epidemiology
Roughly one in ten people in the United States meet criteria for a SUD. A strong and compelling correlation has been repeatedly documented between substance use, particularly alcohol use, and a wide range of social and personal issues: violent crime, suicide, domestic violence, child abuse, and traffic accidents and fatalities. The economic cost of alcohol and other drug misuse runs into the tens of billions of dollars each year. Approximately 25% of children in the U.S. witness alcohol misuse in their families, and more than half of American adults have a close family member with serious alcohol problems.
One readily becomes inured to such statistics, yet the implications for psychologists are far reaching. A substantial proportion of the U.S. population clearly has problems relating to substance use, either through their own use, or that of a close relative. The frequency of SUDs is even higher among those who present for medical and and/or mental health care in a variety of settings. In many hospitals, for example, over half the emergency room visits are the direct or indirect result of alcohol and other drug use. Sixty percent or more of incarcerated individuals have direct or indirect connections with alcohol and/or other drug use. SUDs are also the most common disorder co-occurring with other mental health diagnoses. Available data suggest that 50% or more of patients diagnosed with Schizophrenia also have a concurrent alcohol or illicit drug use disorder (or both). One important conclusion that can be drawn is that the settings in which psychologists are frequently employed are precisely those where we find significant numbers of patients with SUDs. Consequently, whether a psychologist in clinical practice chooses to or not, she will almost inevitably be exposed to a substantial number of individuals who are abusing substances. Refusing to address SUDs means one of two things: the range of potential patients that can be seen by the clinician will either be dramatically reduced; or more likely, SUDs that exacerbate another mental health condition will be misdiagnosed or even overlooked, meaning the patient receives inadequate care.
Substances of Abuse
Drug Classification. Substances of abuse may be conveniently grouped into several different categories based on pharmacological similarities, as illustrated in Table I. Alcohol, for example, is grouped together with other minor tranquilizers and sedative-hypnotics, such as the benzodiazepines and barbiturates. This is because the effects of these various drugs on the individual are quite similar. In addition, the withdrawal syndrome that individuals experience after they become dependent on these substance is quite similar. This is why benzodiazepines are often effective in treating severe alcohol withdrawal.
Cannabis (marijuana and hashish) is a rather unique substance that is variously described in terms of sedative, stimulant, and even hallucinogenic properties. Different authorities classify cannabis in different ways, and for this reason, I have identified it as a separate category in Table I. A group of so-called Designer Drugs are also identified as a separate category. These are drugs that have been synthesized by illicit drug producers over the past 15 to 20 years, drugs that often have characteristics of more than one of the categories outlined in Table I. MDMA, commonly known as “ecstasy,” is one of these Designer Drugs that has gained considerable notoriety of late; it has properties of both amphetamines (psychostimulants) and hallucinogens.
A related substance deserving of mention is a combination of marijuana that is soaked in formaldehyde or a similar fluid used in embalming, with the latter usually classified as an inhalant. This product is often referred to on the street as “fry,” or “whack,” and greatly magnifies and alters the effects of the marijuana alone. The addition of the inhalant component seems likely to introduce the hazard of serious neuropsychological sequelaeRoute of Administration. An important question with many substances is the way in which it is taken. Alcohol, of course, is primarily used via a single route of administration – oral. Other drugs, however, may be taken in multiple ways. Cocaine and heroin, for example, may be used intranasally (“snorted”), injected subcutaneously (IM), injected intravenously (IV), or smoked. The differences in effect between the various routes of administration are quite significant. Perhaps most illustrative is that of cocaine. Prior to the later 1980s, clinicians generally did not believe that one could become seriously physically dependent on cocaine. In the mid-1980s, though, crack, the smokable form of cocaine, became widely available and quickly became extremely popular. Smoking cocaine delivers a notably more concentrated dose, and hence a much more powerful immediate effect, even than IV use of the drug. This made the drug considerably more physically and psychologically reinforcing, which was compounded by the fact that the more potent form also has a shorter duration of effect; thus, the behaviors involved in using crack had to be repeated more frequently, adding to the reinforcing properties. Given the substantial impact that route of administration can and does have with many substances, it is critically important for the clinician to inquire about this aspect of drug use during an interview early in the assessment process.
Diagnostic Issues.
DSM Categories. The current edition of the Diagnostic and Statistical Manual of Mental Disorders[1] (DSM) identifies numerous diagnoses related to substance use. By far the two most commonly diagnosed categories are abuse and dependence. Abuse of a substance is defined as continued use despite problems due to any of the following: abdication of primary role responsibilities (e.g., work, school, and/or family), legal entanglements, social and/or interpersonal difficulties caused by use, or use in hazardous situations such as driving. A diagnosis of dependence on a substance requires at least three of the following: physical tolerance; a distinct withdrawal syndrome[2]; use of more of the substance and/or for a longer period than intended (sometimes interpreted as loss of control over use); inability to reduce or stop use despite a desire to do so; an inordinate investment of time in using and/or recovering from the effects of use; important activities given up or reduced due to use; or continued use despite knowing that use is causing or exacerbating physical and/or mental problems. One may be diagnosed with either abuse or dependence of substances from most of the drug categories outlined in Table I, with dependence clearly being more problematic for the individual (and for those around him or her). Using three or more substances (excluding nicotine and caffeine) to the extent that criteria for Substance Dependence are met qualifies the individual for a diagnosis of Polysubstance Dependence.
Potential diagnostic confusion. Heavy and peavyHHHhhllalslHrolonged misuse of alcohol, of any of a variety of illicit drugs, of prescription drugs, or a combination thereof, will readily produce symptoms that will mimic those of virtually any other mental health disorder listed in the DSM. This can and often does make proper diagnosis quite challenging, particularly if assessment of substance use is not adequately conducted. Perhaps the clearest example is that of alcohol and depression. Alcohol is a central nervous system sedative, and consequently, anyone who drinks heavily for a protracted period of time will almost inevitably begin to show signs and symptoms of depression. Whether such an individual should be diagnosed with a depressive disorder concurrent with the alcohol use disorder along with a concurrent depressive disorder could be debated at some length. Regardless, it would be quite important in formulating an adequate treatment plan to recognize the possibility if not the likelihood that the depressive symptoms were secondary to alcohol misuse. If adequate history demonstrates the existence of a depressive disorder prior to the onset of problematic drinking, an independent diagnosis is clearly warranted. Once the patient has been able to maintain continuous abstinence from alcohol or other drugs for a period of at least a few weeks, the persistence depressive symptoms would similarly argue for an independent diagnosis.
Another clear example of the diagnostic confusion induced by use/abuse of substances is seen in the psychotic symptoms, auditory and visual hallucinations in particular, that are sometimes manifested by heavy psychostimulant abusers and by severely alcohol dependent individuals during acute withdrawal. The latter case is only rarely seen, and is potentially confusing because the typical hallucinations often do not appear until 24 to 36 hours following sudden cessation of alcohol use. It is essential for the clinician to be alert to such circumstances, and to accurately diagnose, however, because the situation is potentially emergent; as many as one in seven patients who reach such a point during withdrawal from alcohol dependence will die if untreated. The case of psychostimulants is more common. Persistent use of cocaine or amphetamine, particularly if smoked rather than taken intranasally or by injection, will almost inevitably produce auditory hallucinations, sometimes visual hallucinations, and occasionally tactile hallucinations; accompanying delusions are also often seen. These symptoms can easily be mistaken for a true thought disorder, when they are in fact secondary to misuse of psychostimulants.
Identification of SUDs
The above discussion has emphasized the importance of accurately identifying SUDs. A thorough clinical interview will typically be a fundamental source of information to provide the basis for accurate identification. Nevertheless, it is often useful to have available brief screening measures to aid in detection of SUDs, and as with most other disorders, paper-and-pencil forms of psychometrically sound tests are particularly efficient. A plethora of substance use screening instruments have been published over the years, especially within the last 15 to 20 years. These typically fall into two distinct categories, direct and indirect. Direct tests are those that inquire about various symptoms of substance abuse in a straightforward fashion. They consequently have high face validity, and are sometimes criticized for being readily subject to manipulation. Examples include the Michigan Alcoholism Screening Tests (MAST), the CAGE, the Alcohol Use Disorders Identification Test (AUDIT), and the Drug Abuse Screening Test (DAST). The other category is indirect tests, which are typically empirically derived from large question pools, and are purported to be useful in identifying substance abusers. Probably the best known example of an indirect test is the McAndrews Scale (MAC and MAC-R[3]) of the Minnesota Multiphasic Personality Inventory. A possible advantage of indirect tests is the claimed resistance to dissimulation.
Psychology has yet to see any reasonable test that correctly identifies all members of the target group and at the same time correctly excludes all non-members of the group. Obviously, this applies to substance abuse screening instruments, as well; all of the available tests are distinctly fallible. Nevertheless, some are more useful than others, and it is clear that direct tests have consistently yielded higher reliability estimates and greater actuarial accuracy than indirect tests. This holds true across a variety of different populations, including criminal justice groups (i.e., DWI samples). Figure 1 compares the MAST and the MAC/MAC-R on sensitivity (the percentage of those with a substance use disorder accurately identified by the tests) and specificity (the proportion of non-substance abusers accurately excluded by the test) for various samples. The predictive superiority of the direct test is clearly seen.
Manipulation of cutoff scores for any test will, of course, dramatically impact the actuarial outcome. A higher cutoff score will yield more false negatives (i.e., subjects who have SUDs but who are not identified as such by the test), and a lower cutoff score will yield more false positives (subjects who are identified by the test as having a SUD despite not meet criteria for one). In most clinical situations, the ideal approach is to use a lower cutoff, and then use a thorough interview to “weed out” the false positives. Such an approach is also very useful when more complex cases, such as those involving co-morbid substance use and other psychiatric disorders. Table 2 includes a number of questions or question categories that can be usefully added to a clinical interview format to provide a more complete picture of the patient’s substance use and potential problems relating to that.
Treatment
History
Before considering various treatment modalities, it is useful to briefly review the history of substance abuse treatment in the United States. Present day concerns regarding current levels of alcohol consumption in this country notwithstanding, it is interesting if not surprising to note that per capita alcohol consumption has declined rather substantially since Colonial days. Considerably higher levels of alcohol use were seen throughout the Nineteenth Century and into the early part of the Twentieth Century. By the mid-1800s, a powerful religious coalition that came to be known as the Temperance Movement was gaining cohesiveness, and with that, political influence. Segments of this group were strong supporters of the Pure Food and Drug Act of 1906, that required manufacturers to accurately label the contents of salable food and drug items; the Department of Agriculture was identified as the agency responsible for enforcement, and interestingly, the Coca Cola Company was one of the first targets. A second major piece of legislation backed by the Temperance Movement was the Harrison Act, passed in 1914. This act was focused on addictive drugs, and gave authority to the Treasury Department to strictly regulate these substances. The impact of the anti-drinking coalition culminated in 1919 when the 21st Amendment, also known as the Volstead Act, was ratified, ushering in the era of Prohibition.
In the 19th and early 20th centuries, several sources of treatment were available for persons with alcohol or other substance use problems. Especially prior to the Pure Food and Drug Act of 1906, a variety of patent medications were marketed as being useful treating problems related to use of several different substances, including especially alcohol and tobacco. One of the most successful of these was the so-called “Gold Cure,” which was actually a series of similar “programs” that at their core had “patients” regularly imbibe a mysterious elixir containing a “secret ingredient.” The latter was originally claimed to be gold, although it never was, and the claim was quickly dropped. Although several versions of this scheme appeared by the late 1800s, the original and most widespread enjoyed great popularity for some 20 years, until an increasingly skeptical public (and press) brought about its demise.
A number of private clinics, hospitals, and sanitaria offered services, usually residential or inpatient. Given that the superintendents and senior staffs of most of these facilities were psychiatrists, and that psychiatry at that time was in large part given over to psychodynamic psychotherapy, this was precisely the form of treatment that was most often provided. Meta-analytic studies of more recent applications of such approaches have generally shown psychodynamic treatment to be notably less effective than most other approaches. Probably the most common source of treatment for individuals with alcohol and/or other drug problems prior to Prohibition, however, was found in state hospitals and related public-funded institutions, such as “Inebriate Hospitals. “ Not surprisingly, given the predominance of psychiatric thinking in most of these facilities, some elements of psychodynamic thinking were also to be found in the care provided. The daily routine, for the most part, though, consisted of regular religious worship and work of some sort. The latter seems likely to have stemmed from the Judaeo-Christian homily regarding “idle hands.”