✅ L7 - Alcohol and Substance use Disorders

Question 1

What is meant by substance use? What is the DSM-5 criteria for substance use disorder?

Answer 1

1. “Substance use” covers a range of substances, both legal and not.
2. How is drug use operationalised?
   - Lifetime use (ever)
   - Recent (last year/month/week?)
   - Current use: quantity? frequency?
3. DSM-5 diagnosis criteria focuses on impact of current substance use on functioning in everyday life (harm)
   - Substance use can be problematic/harmful without dependence criteria being met
   - Particularly for people with mental health problems (may have increased sensitivity to a substance’s effects)
   - Divided to mild/moderate/severe SUD based on number of criteria met: high/frequent usage, withdrawal symptoms, poor/impair functioning due to substance use

Question 2

What is the consequence of use on the individual’s social relationship, physical and mental health?

Answer 2

1. Physical Health
   - Direct: Liver, heart & lung damage, increased cancer risk => UK recommended max alcohol limits based on cancer risks (esp breast cancer, directly in-line with alcohol consumption)
   - Indirect: illness, self-neglect, harm from risky behaviours (hepatitis, HIV, overdose)
2. Social & Interpersonal:
   - Conflict with others
   - Exclusion/stigma
   - Poor educational attainment
   - Homelessness
3. Mental health:
   - Psychosis (cannabis-induced)
   - Depression & Anxiety (e.g. alcohol)
   - Worsen established MH illness (e.g. psychosis): more/worsen symptoms, poorer functioning, more relapses and hospitalisations, increased suicidal & aggression
   - Substance use and mental health problems are highly comorbid => “dually diagnosed”.
   - Comorbidity rates of lifetime prevalence of SUD: especially high for schizophrenia (47%) and bipolar disorder (56%)

Question 3

Statistics on the prevalence of drug usage and alcohol consumption in the UK?
(Don’t need to rmb by heart, just know the trend (and why increase, what groups are vulnerable?)

Answer 3

1. Drug usages:
   - 35% of adults (16-59) had taken drugs at some point during their lifetime.
   - Drug use increase mostly due to increased use of class A drugs in 16-24-yrs-old (MDMA/ecstasy and powdered cocaine)
   => Drug-related hospital admissions are five times more likely in the most deprived areas.
2. Alcohol consumptions:
   - Prevalence increases with age (up to 75)
   - 38% of men and 19% of women aged 55-64 drinking ‘above safe limits’ (14 units +)
   - ‘Never drink’ increasing & ‘binge-drinking’ decreasing in young ppl
   => Variation in prevalence: Some groups likely to drink problematically than others (e.g. students; people with mental health problems)

Question 4

Should we intervene with substance usage, and what is the DSM-5 criteria for remission?

Answer 4

1. Why should we intervene?
   - Multiple negative consequences (physical, psychological)
   - Less engagement and adherence to MH treatment
   - NICE: interventions should aim to stop/reduce use in people with mental health problems.
2. DSM-5 Remission criteria:
   - Early remission is defined as between 3-12 months without SUD criteria (except craving)
   - Sustained remission is defined as at least 12 months without SUD criteria (except craving).

Question 5

Should we aim for abstinence of substance use?

Answer 5

1. Idea: no “safe” amount of use
2. Example of interventions:
   - Detoxification programmes (opioid treatment programmes)
   - Pharmacological interventions: (e.g. naltrexone – reduces craving, methadone – reduces withdrawal)
3. Success rates variable:
   - Highly dependent on motivation to change (sometimes mandatory)
   - Pharmacological aids not available for all drug types (e.g. cannabis, amphetamine)
4. Alternative answer - harm reduction:
   - Abstinence is not necessary - reducing and stabilising substance use also a desirable outcome
   - Reducing substance use -> improved health-related outcomes

Question 6

What are the main psychological interventions:

Answer 6

1. Motivational interventions (MI) – motivational interviewing
2. Cognitive Behavioural Therapy (CBT)
3. Contingency management (CM)
4. Family (systemic) therapy (FT)
5. Psychoeducation (PE)

=> Therapy may involve a combination of these e.g. MI + CBT + FT + PE (“integrated therapy”)

Question 7

How to carry out psychological assessment in clients with substance use?

Answer 7

1. Determines:
   - Patterns of use (what substances; when used; where; how much?)
   - History of use; previous treatment
   - Motives for use
   - Consequences of use (negative & positive)
   - Motivation to address problems
2. Seeks:
   - Understand substance use’s role in client’s life
   - Identify factors maintaining substance use
   - Obstacles to change/relapse risks

=> May take several sessions and involve significant others (e.g. family members)

Question 8

What should a treatment plan for clients with substance disorder consider?

Answer 8

1. Be person centred: take individual’s needs and preferences into account
2. Address problems and goals identified during assessment
3. Consider client’s motivation to address substance use and obstacles to change
4. Identify treatment goals, target behaviours, treatment outcomes
   => Accounting the stages of change and target treatment accordingly

Question 9

What are the six stages of change (Prochaska & DiClemente)?

Answer 9

1. Precontemplation: not thinking about changing, not thinking substance use a problem
2. Contemplation: still use substances, but start thinking to cut back or quit.
3. Preparation: still using, but intend to stop, start planning
4. Action: choose a strategy for discontinuing substance use
5. Maintenance: work to abstain or reduce usage and prevent relapse.
6. Relapse: many may relapse and return to an earlier stage, but gained new insights into problems

Question 10

Describe what is meant by motivational interviewing (MI), and how it works?

Answer 10

1. What is MI?
   - A person-centred counselling to address ambivalence about change.
   - Aim of MI: enhance motivation to change through a shared conversation
   - Explore individuals’ argument for change
   - Brief, either stand-alone intervention or integrated with another (e.g. CBT)
2. How it works?
   - Use during pre-contemplation stage
   - Key to change: resolving ambivalence (mixed feelings)
   - Accepts that client’s goal unlikely to be abstinence (or even reduction)
3. Emphasis: understanding how substance use prevent clients from achieving goals
   => Reasons for change need to be stronger than reasons for staying the same

Question 11

Describe Psychoeducation (PE), CBT, and Family Therapy (FT) for substance use disorder?

Answer 11

Psychoeducation:
1. Typically included in MI and other interventions
2. Designed to educate about substance use + related behaviours & consequences, identify resources to change, counteract denial
=> Effective but not sufficient as a standalone treatment
___
CBT:
1. Identifies high-risk situations of drug use
- Teaching effective skills to deal with high-risk situations
- Examples: negative emotional states, interpersonal conflict, and social pressure and craving.
2. Aims to change learned behaviours by changing thinking patterns, beliefs, and assumptions.
___
Family therapy (FT):
1. NICE states that family & carers should be…
- Involve in deciding treatment and care
- Offered family intervention
- Given support at local support groups and organisation
2. How it works?
- Large psychoeducation component
- Teaches communication and problem-solving skills for clients + family
- Helps family develop relapse-prevention strategies => increase support; reduce burden + conflict

Question 12

Describe contingency management (CM) for substance use disorder?

Answer 12

1. Reinforces abstinence or reduce substance use with reward (e.g. vouchers, privileges, or financial incentives)
2. Behavioural modification based on Skinner’s learning theory
3. NICE recommended but lacking evidence for dual diagnosis