Lecture 7 - Alcohol/Substance Use Disorders

Question 1

What does “substance use” cover?

Answer 1

Range of substances, both legal/illegal

Some terms interchangeable (use/misuse/abuse) or underlined (alcoholism/heavy drinker)

Definitions important (lifetime use/recent/current)

Question 2

What is DSM criteria for substance use disorder?

Answer 2

Not to do with freq/dose

Diagnosis reflects impact of current substance use on functioning in everyday life (harm being done)

Use can be problematic/harmful without dependence criteria met, particularly for people w/ mental health problems (who may have increased sensitivity)

Question 3

What are the physical consequences of drug use?

Answer 3

Direct: liver/heart & lung damage/increased cancer risk

Indirect: illness/injury/self-neglect/harm from risky behaviours

Question 4

What are the social/interpersonal consequences of drug use?

Answer 4

Conflict w/ others, exclusion/stigma, poor educational attainment, homelessness

Question 5

What are the mental health consequences of drug use?

Answer 5

Transient psychosis (eg. Cannabis nudged), depression/anxiety, people w/ established illness (more/worse symptoms, poorer functioning, relapses/hospitalisations, increased suicidality, aggression)

Increased rates of mental health problems due to substance use?

In 2019/20, 7027 hospital admissions w/ primary diagnosis of drug-related mental health/behavioural disorders

Question 6

What is the prevalence of drugs in the UK (2019-2020)

Answer 6

35% adults (16-59) taken drugs at some point, 9% in the last year

21% young adults aged 16-24 taken, drug use fell 1995-2013 but rising again now

Question 7

What is the prevalence of alcohol in the UK (2019-2020)

Answer 7

65% men/50% women drunk alcohol in past week, prevalence increases w/ age

38% of men and 19% of women aged 55-64 drinking ‘above safe limits’ (14 units +)

More people ‘never’ drinking increasing and binge drinking decreasing, particularly among young adults

Question 8

What groups are more likely to drink problematically/use illicit substances?

Answer 8

Young people (esp students), people w/ mental health problems, deprived areas

Question 9

What is relationship between substance use/mental health?

Answer 9

Highly comorbid (dually diagnosed)

eg. Drug diagnosis + bipoar disorder = 8.3%

Question 10

Should we intervene in substance use?

Answer 10

Multiple negative consequences (physical/psychological)

Less engagement w/ services, decreased medication + treatment adherence

NICE guidance – psychotherapeutic interventions should aim to stop/reduce use in people w/ mental health problems

Question 11

What is remission from disorder? (DSM-5)

Answer 11

At least 3 but less than 12 months w/out substance use disorder criteria (except craving)

Sustained remission = at least 12 months without criteria (except craving)

Question 12

What is abstinence?

Answer 12

Based on idea that there’s no “safe” amount of use, aim for complete cessation of use

Eg. Detoxification programmes, pharmacological interventions (naltrexone – reduced craving for alcohol/blocks opioids in brain, methadone – reduces withdrawal symptoms)

Success rates variable (dependent on motivation, coercion, not available for all drug types)

Question 13

What is harm reduction?

Answer 13

(enshrined in NICE guidelines for dual diagnosis)

Abstinence not necessary, reducing + stabilising substances use also desirable outcome

Reducing substance use will lead to improved outcomes

Question 14

What are the 5 main psychological interventions?

Answer 14

Motivation interventions (MI)

Cognitive Behavioural Therapy

Contingency management (CM)

Family (systemic) therapy (FT)

Psychoeducation (PE)

Therapy may involve combination of these (integrated therapy)

Question 15

What is psychological assessment?

Answer 15

Determines patterns/history/motives for use + positive/negative consequences + motivation to address problems

Seeks to understand role played by substances in life, identify factors maintaining substances use + obstacles to change/relapse risks

May take several session + involve significant others

Question 16

How should a substance use treatment plan be?

Answer 16

Be person centred (individual needs/preference accounted for)

Address problems/goals identified in assessment

Consider motivation to address substance use/obstacles to change

Identify treatment goals/target behaviours

Identify measurable outcomes

Question 17

What are the 6 stages of change?

Answer 17

Precontemplation: clients not thinking about changing substance abuse behaviour
Options: not address use, persuade client to change/challenge, enhance motivation to change

Contemplation: still using but begin to think about cutting back/quitting

Preparation: still using but intend to stop, planning for change

Action: begin make changes needed to carry out plan

Maintenance: sustain abstinence or maintain reduction

Relapse: return to earlier stage but hopefully gained insights

Question 18

What is Motivational Interviewing? (MI)

Answer 18

Person-centred counselling method for addressing common problem of ambivalence about change, collaborative conversation to strengthen motivation for/commitment to change

Seek to elicit/explore individual’s own arguments for change

View ambivalence as normal, resolving ambivalence is key to change

Responsibility for change w/ client

Accept client’s goal unlikely to be abstinence or even reduction

Emphasis on helping clients understand how substance use keeps them from achieving goals

Question 19

How does Motivational Interviewing work?

Answer 19

Reasons for change need to be stronger than reasons for staying same

Positive expectancies for effects of substance: “helps relax” “stops from feeling nervous” “rid of voices”

Aim of MI to enhance motivations to change, get client ready to make changes

Typical brief, standalone intervention or integrated with other (eg. CBT)

Question 20

What is psychoeducation?

Answer 20

Typically included in MI + other individual interventions

Provision of info about impact of substance use on mental health

Psychoeducation groups designed to educate clients about substance abuse/related behaviours + consequences, identify resources, counteract denial

Not sufficient as treatment on its own

Question 21

How does CBT work in alcohol/substance use disorders?

Answer 21

Identifies antecedents of drug use, focus on teaching user new/more effective skills for dealing w/ high-risk situations (eg. Negative emotional states/interpersonal conflict/social pressure/craving)

Aim to change learned behaviour by changing thinking patterns/beliefs/perceptions/assumptions

“I’m a failure” “I’m not strong enough to quit” etc.

Goes with relapse prevention

Question 22

How does family/systemic therapy work in alcohol/substance use disorders?

Answer 22

NICE guidelines state:

Family/carers should having opportunity to be involved in decisions about treatment/care, given info/support, offered family intervention, etc.

Large psychoeducation component

Teach communication skills + builds problem solving skills in family members, including client

Help family develop relapse prevention strategies (increase support, reduce burden)

Question 23

What is Contingency Management?

Answer 23

Behaviour modification (based on learning theory)

Incentivises/reinforces abstinence w/ aid of vouchers/privileges/prizes/financial incentives

Recommended by NICe for substance use interventions but evidence lacking for dual diagnosis