Alcohol and Substance Abuse

Medical & Psychosocial Aspects of Disability11/18/06

Substance Use StatisticsAccording to the 2005 National Household Survey on Drug Abuse, an estimated 19.7 million Americans aged 12 or older were current (past month) illicit drug users, meaning they had used an illicit drug during the month prior to the survey interview. This estimate represents 8.1 percent of the population aged 12 years old or older.

The overall rate of current illicit drug use among persons aged 12 or older in 2005 (8.1 percent) was similar to the rate in 2004 (7.9 percent), 2003 (8.2 percent), and 2002 (8.3 percent).

Marijuana was the most commonly used illicit drug (14.6 million past month users). In 2005, it was used by 74.2 percent of current illicit drug users. Among current illicit drug users, 54.5 percent used only marijuana, 19.6 percent used marijuana and another illicit drug, and the remaining 25.8 percent used only an illicit drug other than marijuana in the past month

Changes in use in past month ratio of persons 12 and over were noted for:

2002 2005Marijuana 6.2% to 6.0%Cocaine 0.9% to 1.0%Pain Relievers 2.6% to 2.6%Tranquilizers 0.8% to 0.7%

More Substance Use Stats

In 2005 an estimated 2.4 million (1%) Americans age 12 or older were current cocaine users and 682,000 (0.3%) were current (used at least once in past month) crack users1.1 million (0.4%) currently used hallucinogens 502,000 used Ecstasy 334,000 used

Oxycontin non-medically Current Heroin use was reported to be 136,000 (0.1%)

Demographics

Men are more likely to report drug use than women (10.3 vs. 5.7%)Rates and patterns of drug use vary by age, peaking among 18-20year oldsDrug use is correlated with education. Rate for H.S graduates is 8.6% vs. 5.0 percent for four year college graduates, even though college graduates were more likely to have tried drugs.

Substance use & race/ethnicity

In 2005, current substance use: White – 7.9% Black/African American – 9.5% Native American – 11.9% Native Hawaiian/Pacific Islander –

8.0% Asian – 3.1% Multi-racial – 12.6% Hispanic or Latino – 7.3%

Alcohol

In 2005, 51.8% of Americans age 12 or older report being current drinkers Over one fifth (22.7%) reported bingeing at least once in last 30 days6.6% reported heavy drinking

Alcohol

Age: highest prevalence of alcohol use is between 21 (69.4%) and 25 (67%). Rate gradually drops between 25 (63.7%) and 60 (50.8%).Men are slightly more likely to drink than women.likelihood of drinking alcohol increases with education, however, binge drinking and heavy drinking were least prevalent among college graduates

Employment

Unemployment is highly correlated with drug and alcohol use however,

8.2% of illicit drug users are full-time employed10.4% of drug users are part-time employedMost binge and heavy drinkers were employed in 2005. Among the 52.6 million adult binge drinkers, 42.1 million (80%) are full-time or part-time employees.12.5 million (80.8%) of the heavy drinkers are also employed.8.4% of full-time employed adults (18+) reported heavy use of alcohol versus 10.4% of unemployed adults (SAMHSA, 2005)

Substance abuse & work

Drug abuse problems in the workplace are estimated to cost employers $60 billion annually in violent crimes, fire accidents, health care costs, lost productivity, and accidents on the job (Backer, 1988; Stude, 1990). Substance abuse also is known to significantly compromise work performance resulting in high rates of absenteeism, accidents, time off for illness, and Workers’ Compensation claims (Cardoso et al., 1999).

Substance Abuse as a Disability

1990 Americans with Disabilities Act ADA statues and guidelines recognize

substance abuse as a disability People with a substance abuse problem are

protected at work, unless they are currently engaging in the illegal use of drugs.

A person with a coexisting disability can be legally discharged from a job if illegally abusing substances.

Substance Abuse as a Disability

Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. Substance USE Disorders

Abuse: Maladaptive pattern of substance use leading to a clinically significant impairment or distress as manifested by one or more of the following in a 12 month period:

Recurrent substance use resulting in a failure to fulfill a major role obligation at work, school or home

Recurrent substance use in situations in which it is physically hazardous

Recurrent substance-related legal problems Continued substance use despite having persistent or

recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

DSM-IV – Substance Use Disorders

Dependence is defined by the occurrence of withdrawal following the abrupt reduction of dosage of the drug or the administration of a drug antagoist. 3 or more of the following must occur within a 12 moth period:

Need for increased amounts of substance to achieve a desired effect (or markedly diminished effect with continued use of same amount)

Characteristic withdrawal syndrome for that substance or the same substance is taken to relieve or avoid withdrawal.

A substance is often taken in larger amounts for longer periods of time than was intended.

Persistent desire for a drug or unsuccessful efforts to cut down or control substance use.

A great deal of time is spent in activities to obtain a substance, use a substance or recover from its effects

Important social, occupational, or recreational activities are given up or reduced because of substance use

Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem.

Addiction is a brain disorder

Addiction is an independent disorder distinguished from drinking that is merely heavy, problematic, ill advised or socially unacceptable

Abuse - intentional overuse in cases of Abuse - intentional overuse in cases of celebration, anxiety, despair, self-celebration, anxiety, despair, self-medication, other mental health disorders medication, other mental health disorders or ignorance. Tends to decline with or ignorance. Tends to decline with consequences or adequate treatment of consequences or adequate treatment of other mental health disorder.other mental health disorder.

Functional Imaging

SPECT – single photon emission computed tomography

PET – positron emission tomography

fMRI – functional magnetic resonance imaging

Dopamine Pathways – Pleasure pathways

nucleusaccumbens

hippocampus

striatum

frontalcortex

substantianigra/VTA

cocaineheroinnicotineamphetaminesopiatesTHCPCPketamine

heroinalcoholbenzodiazepinsbarbiturates

alcohol

enzymesreceptorsresponses

malfunction MFB

Inherited genes oraltered expression

The explanation for why people respond differently!

Early exposure to drugs

abnormal proteins

Brain of the addicted is fundamentally different:

Gene expression (Liu, Nickolendko 1994; Daunais & McGinty 1995)

Glucose metabolism (Volkow, Gillespie, 1996)

Responsiveness to environmental cues (O’Brien, Childress, 1993; Kilgus & Pumariega, 1994)

What’s inherited???

TemperamentInitial sensitivity to rewarding or aversive qualities (like or dislike of the drug)ToleranceRates and routes of metabolismTaste preferencesResponse to memories related to use

Developing brain

Individuals who begin drinking before age 15 are 4 times more likely to develop alcohol dependence during their lifetimes than those who begin drinking at age 21. (Grant & Dawson 1997; Journal of Substance Abuse 9:103-110)

Earlier drinking more likely to result in alcohol dependence independent of family history (Grant, 1998)

Your Brain on DrugsYour Brain on Drugs

1-2 Min 3-4 5-6

6-7 7-8 8-9

9-10 10-20 20-30

YELLOW shows places in brain where cocaine goes (Striatum)

PET scan after cocaine PET scan after cocaine useuse

Alcohol 25 yrsAlcohol 25 yrs Cocaine 2 yrsCocaine 2 yrs Marijuana 12 Marijuana 12 yrsyrs

NormalNormal

SPECT

(blood flow)

Assessment and Diagnosis

Bio-psycho-social-spiritual Assessment DSM-IVR:Seven Criteria

Two dimensions- Obsession and Compulsion.

Job is last to go!Job is last to go!

AbuseAddiction

Usually self-limitedProgressive course

Likely to stop as consequences progress

Unable to stop because of consequences – loss of control

May have significant consequences

Significant consequences

Frequent character or personality pathology

No specific personality

Normal brain chemistryAbnormal brain chemistry

Bad judgment, poor morals, self will

Cravings, preoccupation

Key Concepts

Motivation: the probability that a person will enter into, continue and adhere to a specific change strategy.Resistance: the result of interacting with one’s environment- not a characteristic.Ambivalence: the heart of the problem, not pathological.

Other Substance Abuse Disorders

Substance Induced Disorders E.g.: Intoxication, delirium, dementia, mood

disorders, sleep disorders – all with the precondition that the disorder is a result of substance use

Polysubstance Related Disorders Refers to disorders resulting from the use of

at least 3 groups of substances over a 12 month period with no single substance as predominating.

Impact of Substance Abuse and Disability

Basic living skills homelessness, lack of income, repeated legal problems

Health Poor or deteriorating health often results from years of abuse &

neglect of health

Education Substance abuse can lead to significant deficits in academic

development and basic learning skills

Employment Early onset and lengthy periods of substance abuse often result in

difficulty in obtaining & retaining meaningful employment

Relationships Interpersonal & socialization skills may be poor because

relationships were often based on the acquisition and use of drugs. The ability to communicate outside of the drug community is frequently impaired.

Continuum of Use, Abuse & Dependency

ExperimentationRecreational/social useUseDependenceAddiction

Commonly Abused Substances

Drugs are psychoactive chemicals that bring about changes in biological, psychological, social and/or spiritual functioning. This includes legal drugs (e.g., alcohol, over the counter meds, tobacco, caffeine) and illegal drugs such as marijuana, heroin and cocaine. Stimulants: produce increased awareness, attention

or excitement levels followed by depressed levels: eg: cocaine, amphetamines

Depressants: produce the opposite effects – decreased tension levels followed by an increase in tension: eg: alcohol, heroin, barbiturates, and pain relief meds.

Substance Abuse and other Disabilities

Alcohol and Marijuana Use in a Community-Based Sample of Persons with SCI (Young, Rintala, Rossi, Hart, & Fuhrer, 1995)

Alcohol use = 59% No relationship to impairment, disability, handicap, medical

complications, health ratings, health maintenance behaviors, pain, depression, life satisfaction, perceived stress, or social support

Men more likely to drink History of alcohol abuse = 21%

No significant gender difference Alcohol abusers were more likely to rate overall health as worse, say

they didn’t get enough rest, more depressed and more stressed Not related to impairment, disability, handicap, medical complications

Marijuana use = 16% No gender difference Those who used marijuana were younger and younger at injury and had

lower educational level Users more depressed and stressed

Substance Abuse and other Disabilities

Heinemann (1986) cited studies reporting intoxication at the time of spinal cord injury to be as high as 68% and suggested that impaired judgment because of substance abuse is related to an increase in risk-taking behavior and injury. Alcohol and other drug use are also a major contributing factor to traumatic brain injuries, with an incidence of intoxication at injury of approximately 50% (Heinemann, 1993).Bogner et al (2001) found that approximately 80% of persons with TBIs from violence-related causes had a history of substance abuse. Substance abuse was considered to be a strong predictor of long-term rehabilitation outcomes including satisfaction with life and productivity.

Substance Abuse and other Disabilities

Alcohol and drug abuse also limit rehabilitation outcomes by contributing to functional limitations (Greer, 1986; Greer, Roberts, May, & Jenkins, 1988; NIDRR, 1990). Indirect and direct self-destructive behaviors associated with alcohol and drug abuse, such as refusal of essential treatment and other forms of self-neglect, may continue after the onset of disability and adversely affect the potential for rehabilitation (Ingraham et al., 1992).

Substance Abuse and other Disabilities

Early identification of persons with disabilities who abuse or are addicted to substances should minimize the incidence of secondary complications of disabilities, decrease the cost of rehabilitation, and improve rehabilitation outcomes. Heinemann (1986) indicated that rehabilitation health professionals including psychologists lack sophistication concerning the dual problems of substance abuse and disability. He argued that rehabilitation and health care professionals must be trained to recognize substance abuse problems and to intervene in a timely and effective manner.

Defense mechanisms

Denial I can stop using anytime I want

Projection The boss is on my back all the time. I think

I’m doing a great job. I just have a drink to calm my nerves. She’s making me sick!

Displacement My counselor makes me angry. She just

doesn’t get it that I’m trying. She’s on my back. She just wants to have a good client who does what she wants.

Theoretical Models of Substance Abuse

Moral model People who use substances and alcohol are weak –

places blame on the individual for the abuse and suggests that the person makes a conscious choice not to abuse substances

Spiritual model People who use substance and alcohol have lost

touch with a higher power and as a result have lost his or her way – return to a spiritual source will result in changing one’s abusive ways.

Disease model Substance abuse is illness – places importance on

biological factors.

Theoretical Models of Substance Abuse

Psychological Model Similar to disease model – focuses on maladaptation/poor

adustment at the emotional &/or cognitive level – substance abuse is seen as a compulsion

Social Model Based on the recognition of impact of negative life

experiences eg: societal attitudes, family relationships, finances, work pressures etc – maladaptive patterns of coping are possible causative agents for substance abuse

Bio-psycho-social model Sees substance abuse in a broad manner including biological,

psychological and social factors. The Bio-psycho-social-spiritual model adds the spiritual component. These are holistic models that place emphasis on all areas essential to personal well-being and integration.

Identification of Substance Abuse

Warning signs/symptoms Biological - loss of weight, liver disease, GI

conditions, loss of tooth enamel. Psychological - increase in anger, irritability,

lethargy, confusion Social – socializing with drug users, isolated from

non-using friends, lack of family relationships, loss of job, arrests

Spiritual – loss of values, denial of morality Medical detection – urinalysis can detect presence

of certain drug-related electrolytes and metabolites in the urine. Breathalyzer, hair samples

Identification of Substance Abuse

Screening through written materials CAGE: acronym for four questions asked

by the counselor to the individual – only used for ETOH screening)

MAST – Michigan Alcoholism Screening Test – only used for ETOH screening.

SASSI-2 SARDI Symptoms Checklist

Self-Reporting

CAGE

C- have you ever felt you ought to CUT down your drinking?A- have people ANNOYED you by criticizing your drinking?G- have you ever felt GUILTY about your drinking?E- have you ever had a drink first thing in the morning (EYE OPENER) to steady you nerves or get rid of a hangover.

Brief MAST Questions

Do you feel you are a normal drinkerDo friends or relatives think you are a normal drinkerHave you ever attended a meeting of AA?Have you ever lost friends or girlfriends/boyfriends because of drinking?Have you ever gotten into trouble at work because of drinking? Have you ever neglected your obligations, your family, or your work for 2 or more days in a row because you were drinking?

Have you ever had delirium tremens (DTs) severe shaking, heard voices, or seen things that weren’t there after heavy drinking?Have you ever gone to anyone for help about your drinking?Have you ever been hospitalized because of drinking?Have you ever been arrested for driving drunk?

Treatment

Medical detoxMethadone MaintenanceDrug-free Outpatient TreatmentChemical Dependency (28 days – Minnesota Model – Hazeldon type)Therapeutic CommunitiesSelf-help groups

Stages of Change: A model for understanding addictive behavior change

5 Stages: Precontemplation

Unawareness or denial of the problem Contemplation

Considering change Preparation

Increasing commitment and taking initial steps Action

The actual changing of behaviors Maintenance

Sustaining new behaviors

Spiral of changeFrom Prochaska, DiClemente & Norcross, 1992, p. 1104

Maintenance

ContemplationAction

Preparation

Termination

Precontemplation

Prochaska and DiClemente’s Wheel of Change

Relapse

10 Common Types of Change Processes

These are coping methods or strategies utilized by people when trying to implement change

Each change process is a category of coping activities which entails numerous techniques or interventions

Processes of Change

Cognitive-Affective Consciousness

raising Self-evaluation Dramatic relief Environmental re-

evaluation Social liberation

Behavioral Counter-

conditioning Stimulus control Reinforcement

management Helping

relationships Self liberation

Stages of Change Model

Clients can be categorized into different stages based on their readiness or motivation to change Interventions should be tailored accordingly

Not a linear process People can cycle through certain stages

before they master the behaviors they want to change

Predictors of Change

Self-efficacy Confidence in the ability to perform certain

tasks Usually lowest during precontemplation stage

and highest during maintenance

Decisional balance Evaluation of pros and cons pertaining to the

performance of specific tasks

Facilitate Change – Motivational Enhancement Therapy

Key Factors for Change for the Counselor:StyleStyleStyle

Miller & Rollnick (2002)

SOC Interventions

Interventions should be designed to build self-efficacy and positive decisional balance through specific coping strategies & skills training for movement through specific stages of changeSOC has been applied to many types of behavior changes: Smoking and other addictive behaviors Weight control Risky health behaviors Understanding change in general psychotherapy,

counseling and case management

Substance Abuse as a Disability recap

ChronicityDeficits in Basic FunctioningDenialEffects all elements of lifeExists on a continuumImpacts self-esteem, self-concept and self-imageNeeds an individualized rehabilitation programExacerbation and RemissionPerson-specific

Links

Substance Abuse & Mental Health Services Administration: http://www.samhsa.gov/ http://www.drugabusestatistics.samhsa.gov/

nsduh/2k5nsduh/2k5Results.pdf

National Institute on Drug Abuse: http://www.nida.nih.gov/National Institute on Alcohol Abuse and Alcoholism: http://www.niaaa.nih.gov/