Task 5

Question 1

screening

Answer 1

screening – designed to quickly identify risky patterns of substance use
assessment – establishes where on the continuum of substance use the patient falls: use, misuse, excessive use, or substance use disorder

Question 2

assessment

Answer 2

assessment – establishes where on the continuum of substance use the patient falls: use, misuse, excessive use, or substance use disorde

Question 3

Basic components of a substance use assessment include

Answer 3

Basic components of a substance use assessment include:
1. describing current and past patterns of substance use with an emphasis on characterizing use that may be excessive, harmful, or hazardous
2. diagnosing any substance-related disorder that may be present currently
3. documenting the effect of substance use on an individual’s mental and physical state

Question 4

Preparation for Substance use assessment

Answer 4

— Each interviewing setting has unique qualities and features that must be considered beforehand
— Clinicians should keep in mind that patients who are presenting for care in a non–addiction treatment setting may not be expecting complex and vigorous questions about substance use
— therefore, clinicians should describe to the patient, in clear terms, the purpose and intent of asking questions about substance use

— highest level of security and confidentiality in the interview room is fundamental to completing an accurate substance use assessment

— Electronic medical records and their use during the substance use assessment must be taken into consideration beforehand
— practice of typing and inputting information while inter-viewing (and thus making less eye contact) has drawn mixed reviews from clinicians and patients

— recognize the current physical and psychiatric state of the patient
— Patients who use substances will present in a wide variety of states, ranging from intoxication to withdrawal
— interview with an intoxicated patient should be limited to an assessment of the patient’s physical and psychiatric safety

Question 5

Preparation for Substance use assessment
(in general)

Answer 5

Review the Medical Record Beforehand
Check Prescription Drug Monitoring Program Database
Administer and Review Substance Use Screening Forms in Advance

Question 6

Interview Techniques

Answer 6

— patients may be experiencing shame, embarrassment, or guilt or simply be in denial or lack awareness or understanding of the severity of their illness

— interviewers should pay especially close attention to:
— verbal and nonverbal clues, such as not listening to questions
— minimizing use or consequences of use
— changing the subject
— discouraging inquiry by displaying irritation, anxiety, or other behaviors
— outright lying

— overcome barriers by:
— include asking open-ended questions
— control the pace of the interview, especially in regard to reviewing all substances
— summarize the patient’s history at end of session

Question 7

Structure of the Assessment

Answer 7

Substance Use History: Focus on Documenting Current Use

Ask About Non-Substance-Related Disorders (Behavioral Addictions)

Distinguish Substance Use from Substance Use Disorder

Substance use disorder treatment history

Psychiatric History

Medical History

Familial History

Social History

Question 8

Substance use disorder

Answer 8

Substance use disorder – defined globally as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by persistent or recurrent social or interpersonal problems caused by substance use

Question 9

Physical and Mental State examination

Answer 9

— Crucial because of the high frequency of overlapping conditions between medical and psychiatric disorders found in this population

Laboratory Testing
— useful laboratory data include urine toxicology, blood alcohol levels, and measures of substance metabolites or the biological effects of substance use
— e.g., biological markers of alcohol use

Question 10

Importance of Collateral Information

Answer 10

Importance of Collateral Information

 additional, objective information from sources other than the patient

— collateral information include family members, roommates, friends, employers, and other health care providers
— supply objective data and improve assessment, or they may advocate for a particular outcome and add to bias

Question 11

Strategies to Improve Clinical Skills in Conducting a Substance Use Assessment

Answer 11

Ú practical tips to increase their clinical knowledge and skills related to conducting a more efficient and thorough sub-stance use assessment

1. Attend the annual meeting of an addiction organization
2. Regularly review and refer to online addiction resources, which offer no-cost guides to screening, assessment, and enhancing clinical assessment skills
3. Access the Provider’s Clinical Support System, which is a online mentoring program that offers a national network of trained clinicians with expertise in addiction medicine and pain management
4. Visit local substance use disorder treatment programs to learn about available treatment options, effective treatment practices, and current trends in substance use

Question 12

Screening and brief intervention (SBI)

Answer 12

Screening and brief intervention (SBI) – a well-established clinical practice supported by evidence from controlled clinical trials

Purpose of Screening
— target of screening is any unhealthy substance use

Represents
1. a preventive intervention aimed at recurring behavioral risks
2. an initial step in the management of moderate to severe substance use disorders

“SBIRT” (SBI plus referral to treatment

Question 13

Unhealthy substance use

Answer 13

Unhealthy substance use – any use of alcohol or other drugs that increases the risk for or has been related to health consequences

— includes use of any illicit drugs or misuse of prescription or nonprescription drugs known to cause risk or harm, and amounts of alcohol known to increase the risk for health consequences
— also includes use with consequences that do not yet meet criteria for a disorder, as well as use leading to a substance use disorder

— aimed at detecting the entire spectrum of unhealthy use, from risky use to use with problems to a diagnosable disorder
— important because the majority of health consequences on a population level do not accrue to those with severe substance use disorders, but instead occur in people who are simply drinking too much, with no severe disorder

Question 14

tools for screening

Answer 14

CAGE questions
the Michigan Alcoholism Screening Test
— not sufficiently accurate for identifying the spectrum of unhealthy use

Laboratory testing
— not recommended for screening

combination of screening and testing (e.g., CAGE, laboratory testing) might be useful for assessment or monitoring

Question 15

Single-item screening questions (SSQs)

Answer 15

— administered quickly and easily
— validated in primary medical care settings

— Longer screening tools have
— Two disadvantages:
1. they cannot be memorized and used as easily in medical interviews in busy settings
2. they are more difficult to score
— BUT can provide more information about the severity of the risk identified

Question 16

Alcohol Use Disorders Identification Test—Consumption (AUDIT-C)

Answer 16

Alcohol Use Disorders Identification Test—Consumption (AUDIT-C)
— short screening version of the AUDIT with three alcohol consumption items
— is validated
— with optimal sensitivity and still reasonable specificity for unhealthy use

Question 17

Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)

Answer 17

Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)
— Long screening
— does not identify risky alcohol use amounts directly
— however, provides risk-level information that is useful for brief intervention

Two specific populations:
1. adolescents
2. pregnant women or women aiming to conceive

Ú for whom use of tailored screening tools is helpful, because for these patients, any use is unhealthy

Question 18

Assessment

Answer 18

Ú When a patient screens positive

Following three areas should be assessed:
1. drinking amounts, drug used, and frequency
2. substance use consequences, including substance use disorders
3. patient’s perception of his or her use and readiness to change

Ú Assessments, as an extension of screening, can also be considered part of the intervention when done in the context of a therapeutic relationship

Question 19

Assessment of Use

Answer 19

Assessment of Use
– quantity and frequency of alcohol use
– three questions:
1. On average, how many days per week do you drink alcohol?
2. On a typical day when you drink, how many drinks do you have?
3. What is the maximum number of drinks you had on any given occasion during the last month?

– drug use, the first item for each drug from the ASSIST
– or simply be asked what drugs he or she uses, how many days in the past month the patient used those drugs or any drugs, and how many times per day

Question 20

CAGE-AID

Answer 20

CAGE-AID – “or drug use” and “or used drugs”
– Questions:
– Have you ever felt that you ought to Cut down on your drinking or drug use?
– Have people Annoyed you by criticizing your drinking or drug use?
– Have you ever felt bad or Guilty about your drinking or drug use?
– Have you ever had a drink or used drugs first thing in the morning (Eye-opener) to steady your nerves, e.g., get rid of a hangover, or get the day started?

Question 21

CRAFFT – brief assessment to indicate to possible presence of a SUD

Answer 21

1. Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
2. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
3. Do you ever use alcohol or drugs while you are by yourself, or ALONE?
4. Do you ever FORGET thins you did while using alcohol or drugs?
5. Do your family and FRIENDS ever tell you that you should cut down on your drinking or drug use?
6. Have you ever gotten into TROUBLE while you were using alcohol or drugs?

2 or more “yes” answers indicate a higher likelihood of a disorder

Question 22

Assessment of the patient’s perception and readiness to change

Answer 22

Assessment of the patient’s perception and readiness to change
— Readiness to change lies on a continuum and can be assessed by using simple visual analogue scale-type questions
— E.g., “On a scale of 0 to 10, how ready are you to change your drinking?”

Question 23

Performing a brief intervention

Answer 23

— Brief intervention involves counseling to help the patient to abstain from or reduce substance use

— Brief interventions consist of feedback, advice, and goal setting
— Based on principles of motivational interviewing
— Goal of intervention depends on the level of severity of substance use and participant’s perception of the problem and readiness to change
— Best goal  abstinence

— Brief clinical interventions include:
— Clinical feedback about the patient’s risks and consequences of substance use
— Specific advice
— Goal setting

— The clinician has 2 initial concerns:
— Establish a trusting and preferably ongoing relationship that includes follow-up
— Determining how the brief intervention should be provided

Question 24

Abstinence Initiation

Answer 24

Abstinence Initiation – clients still use substances, focus on abstinence initiation as the first target

— Relapse prevention – requires abstinence for treatment entry, so that all their treatment is geared toward keeping the clients abstinent

Question 25

Relapse prevention

Answer 25

Relapse prevention – requires abstinence for treatment entry, so that all their treatment is geared toward keeping the clients abstinent

Question 26

coping skills training (CST)

Answer 26

— Common conceptualization  Client lacks important coping skills, including skills for handling:
— Internal states (mood, cravings, stress, etc.)
— Interpersonal situations (e.g., family conflicts)
— Employment situations

— Some of these states/ situations have developed learned associated with substance use  higher relapse risk for those situations

Question 27

Social learning theory

Answer 27

Social learning theory – identifying situations which trigger substance use (via operant/ respondent conditioning principles), cognitions that are elicited by these situations, and probable consequences

Question 28

Functional Analysis

Answer 28

Functional Analysis – using those aspects of social learning theory to analyze situations that pose a high risk for relapse

Question 29

Social learning principles

Answer 29

Social learning principles (also called Skills training)

guiding the intervention methods include:
— People learn through direct instruction
– Modeling of alternatives
– Learning to counter automatic thoughts/ beliefs with adaptive alternative thoughts
– Changing the environment to reduce triggering situations
– Increased contact with positive reinforcement for not using substances
– Changing social and/ or employment or living environment

Question 30

Aversive Conditioning Approaches

Answer 30

— Nausea based approaches – induction of nausea, then the client is exposed to or ingests the addictive substance
— Most common but modestly positive success
— For tobacco dependence  rapid smoking or rapid puffing procedures – nausea occurs from toxic levels of nicotine BUT only under medical supervision

— Electrical aversion – pairing electrical shocks with tasting the substance
— Less encouraging success

— Covert sensitization – imagining aversive scenes while drinking small amounts of alcohol
— Less encouraging success

Question 31

Cognitive Therapy

Answer 31

Cognitive Therapy
— Approach to modify both the core and drug-related beliefs and the automatic thoughts elicited by high-risk situations

Question 32

CBT appraoch

Answer 32

— To help the client learn new behaviors to replace the maladaptive ones
1. Start with analyzing the client’s personal situational
– antecedents of substance use
– thoughts and emotions that are triggered by these situations
– the core dysfunctional beliefs they have about themselves, other people, and the substance use
– and the patterns of behavior that the client uses in response to these beliefs

2. Through Socratic questioning and modelling, the therapist helps the client learn to develop alternative more adaptive thoughts to replace the maladaptive ones with

— Used to deal with situations that trigger drug use
— Also used to help person learn more effective ways to handle anger, depression, anxiety, and other emotions without using drugs
— Used as an aspect of CBT  not on its own

Question 33

Cognitive-Behavioral Skills Training

Answer 33

— Interpersonal skills for building better relationships
— Cognitive and behavioral emotion-coping skills for regulation moods more effectively
— Skills for coping sudden stressful events without using substances
— Coping with substance use cues without using

— Helps to increase clients’ sense of self-efficacy about handling situations without using substances
— Conducted in individual or group sessions  depends on client
— CST session topics are structured as skill-focused or situation-focused

Question 34

Cognitive-Behavioral Skills Training & alkohol dependnace

Answer 34

— Communication Skills Training – developing social skills designed to promote a lifestyle that encourages sobriety
— Cognitive-behavioral mood management training – designed to slow down the process of reacting to risky events
— Behavioral self-control training – teach moderation in alcohol consumption for problem drinkers who had not sought abstinence-oriented treatment

— CST has excellent support for use with alcohol and cocaine dependence

— Good support for marijuana dependence
— Persistent long after treatment has ended

Question 35

Contingency Management

Answer 35

Contingency Management
— Based on operant conditioning principles
— Patients who abstain from drugs are provided with financial incentives  immediate reinforcement
— Timing of reinforcement (immediately)
— Choosing an incentive that is personally valued by the target individual and is large enough to promote the targeted change
— Larger events generally produce more abstinence

abstinence during first 2 weeks of treatment predicts longer term abstinence 

most effective treatment approach for cocaine dependence, with efficacy also shown for opiate and marijuana dependence, particularly when combined with CST or community reinforcement that includes CST 

reducing value of voucher over time/ using fewer valuable incentives (e.g., lottery tickets) maintain abstinence while lowering the costs of the program

Question 36

long term results of Contingency Management

Answer 36

— Long-term efficacy  mixed results
— Concerns:
— High financial costs
— Differing results on whether people stay abstinent after finishing the program
— CM might undermine intrinsic motivation to change
— The success of CM could be affected by the findings of a recent fMRI study
— Sensitivity to monetary rewards was compromised in light of cocaine addiction

Question 37

Acceptance and Commitment Therapy

Answer 37

— Attempts to reduce, eliminate, or decrease the likelihood of negative thoughts and emotions (“Experiential avoidance”) may worsen potential outcome in the long term
— Focus on helping clients realize the breadth of their psychological difficulties and to overcome the cognitive and emotional barriers to stopping destructive drug use patterns

— 5 main treatment phases:
1. Creative Hopelessness – Making contact with the scope of the problem and the effort expended to solve it
2. Values Assessment – Exploration of the client’s personal values to direct and dignify the treatment
3. Control as the Problem – Identifying ineffective control strategies
4. Defusing Language – Making room for acceptance
5. Applied Willingness – Putting values into action.

Question 38

Cue-exposure with Response Prevention

Answer 38

— Designed to reduce respondent condition to stimuli that have been repeatedly associated with the drug in the past
— Repeated presentation of sight, sounds, and/or smells associated with drug use (“cues”) while the person is in a safe environment with no access to the drug  unreinforcement of drug

Question 39

Cue-exposure with Response Prevention mechanism

Answer 39

— 3 mechanisms by which cues are believed to pose a risk for relapse:
— by classical conditioned responses that elicit urge to use substance
— these reactions then interfere with a client’s ability to use coping skills effectively
— cues and internal responses to cues lead to operant behavior (substance use) that reinforce the behavior by reducing the aversive aspects of the response

Question 40

CET is believed to work through one or both of 2 mechanisms:

Answer 40

CET is believed to work through one or both of 2 mechanisms:

— Breaking the conditioned association between cues and substance use behavior  cues no longer elicit conditioned reactions
— Providing the opportunity to practice coping with urges to use so that urges will be less likely to disrupt the client’s ability to apply coping skills when in the presence of cues after treatment

Question 41

CET Implication s

Answer 41

— Exposure should occur long enough for responses to habituate within-session
— Wide variety of different cues should be used in exposure sessions
— Urge coping practices should occur early in exposure when elicited reactions are at a peak

Question 42

CET results

Answer 42

— CET has not been successful for opiate- or cocaine-dependent clients
— No effect after treatment ends for smokers
— Beneficial effect for people with alcohol use disorders

Question 43

Coping skills with best support

Answer 43

Coping skills with best support
— Telling themselves that they can wait out the urge and it will go down
— Thinking about the negative and positive consequences
— Imagining eating or drinking something else
— Imagining engaging in an alternative activity

Question 44

Virtual Reality

Answer 44

— Might be beneficial, as cues may trigger relapse or urges involve interpersonal or emotional situation
— But personal cues are far more effective
— Sets of photographs and VR programs are likely weaker methods

Question 45

Overview of the process of drug dependence treatment

Answer 45

Categories of treatment
1. Making contact with drug users
2. Detoxification
3. Drug substitution treatment
4. Use of Blocking or aversive drugs
5. Psychosocial treatment options

Question 46

Initial assessment

Answer 46

Initial assessment – interview designed to understand the nature of the drug problem(s) and associated harm
— Often there will be a medical examination and an assessment of psychological problems
— Good treatment program  identifies all areas where help is needed and designs a treatment plan that addresses each of these needs
— Assessment of these factors at beginning of treatment and at regular intervals during course of treatment

Question 47

Making contact with drug users

Answer 47

Making contact with drug users
— designed to provide factual info about drug use, assist in the safer use of drugs to minimize harms and facilitate access to the available treatment options
— can help people move to a higher stage of change (see above: “5 stages of change”)
— incl. peer outreach services, primary healthcare providers, social welfare workers, police, etc.

Question 48

Detoxification

Answer 48

Detoxification
— Focused on directly assisting a person cease drug taking
— E.g., prescribed medication to prevent relapse due to life threatening complications assoc. with the withdrawal symptoms
— Can help to attract the person into more comprehensive forms of treatment

— Blocking medication – stops the drug of dependence from having an effect
— Aversive medication – produces an unpleasant reaction when it is used in combination with drug but is safe when used by itself

Question 49

Drug substitution treatment

Answer 49

Drug substitution treatment
— Involves the medical and pharmacological treatment of drug dependence

— Prescription of drugs with a similar action to the drug of dependence but with lower degree of risk
— Not available for all drugs

— Will stabilize the physical condition of the user
— This helps the person to focus on other aspects of health and psychosocial functioning and to develop a new drug-free lifestyle and social network
— Often provided over long period of time and in combination with additional forms of treatment

— Removes the need for the individual to seek and use the harmful or illicit drug
— By providing the drug in a safer form, individual can focus on other areas of life
— Individual has the opportunity to separate from their drug-using peers

Question 50

Use of Blocking or aversive drugs

Answer 50

Use of Blocking or aversive drugs
— Use of blocking/ aversive agents to remove the positive reinforcement of drug use
— When in period of abstinence

Question 51

Psychosocial treatment options

Answer 51

Psychosocial treatment options
— Approaches incl. counselling, support groups, social and welfare support, and skills training
— Designed to address the psychological reasons for using drugs, support positive life changes, minimize the likelihood of relapse, and build skills to assist with the attempt to quit the drug and cope with other aspects of life

— Different reasons for treatment entry (voluntary basis, referral from GP, criminal court, etc.)

Question 52

key therapeutic issues arising from drug use and dependence:

Answer 52

— consequences of acute intoxication
— management of the physical withdrawal syndrome
— management of drug dependence
— withdrawal symptoms often have an effect opposite to that of the drug and can be life-threatening
— principles of cross-tolerance and the role of half-life on intensity and duration of the

Question 53

treatment alkohol

Answer 53

— Withdrawal symptoms can be life-threatening  require medical assistance
— Hydration, balancing of electrolyte abnormalities and dealing with the consequences of inadequate nutrition

— Benzodiazepines to alleviate withdrawal symptoms and to minimize likelihood of a seizure
— Gradually decreased over the course of a few weeks

— Antabuse is used to prevent relapse
— When taken and alcohol is taken  very unpleasant reactions
— For that first need to detoxify!

Question 54

treatment opiods

Answer 54

— Substitution of heroine with a longer acting opioid (e.g., methadone), or detoxification followed by the use of a blocking agent
— Withdrawal symptoms are not life threatening but very unpleasant
— Methadone does not produce euphoria, but will still alleviate withdrawal symptoms for 24 h

— Blocking agent  e.g., naltrexone, long-acting opioid antagonist
— Very important that the person has completely stopped using heroine  otherwise withdrawal symptoms might occur

Question 55

Psychosocial Interventions

Answer 55

Counselling
— Particular useful for people who need assistance to get some order back into their lives
— Counsellor builds trusting, non-judgmental relationship to help the person develop a sense of responsibility and self-confidence, and assist the person to develop their own solutions to their drug problem
— Individual or group basis
— Rarely sufficient by itself
— Vital addition to other treatment forms

Motivational Interviewing
— Involves specialized program designed to help people move through the stages of change
— Helps the person making decisions to change their drug use
— Exploring the consequences of drug use

Behaviorist approaches to treatment
— Major principle: drug-use is learned and can be “un-learned”
— One approach is to examine antecedent events for drug use and teach to avoid them or handle them without drug-use
— Alternatively, medication can be used to alter the reinforcing properties of the drug

— Contingency management – provides positive reinforcement contingent upon the person not taking the drug, abstinence is rewarded with vouchers

Question 56

Cognitive behavioral approaches

Answer 56

— CBT – recognize the triggers for craving or using drug, and to modify any dysfunctional cognitions underlying drug-using behavior
— Involves skills training and practice to deal with craving

— Relaxation training
— Teaching techniques to release stress and tension

— Drug refusal skills
— Teaching skills to refuse offers confidently

— Assertiveness skills
— Helps individual to express needs and emotions to others
— Role play is an essential part here

— Problem solving skills
— To help the individual deal with problems in everyday life
— Teaches people not to ignore problems or to let the pressure build up

— Cognitive restructuring
— Teaching individuals to identify and challenge the thoughts and feelings that may lead to drug use
— To help the person become aware of negative thinking and reframe it into something more positive

— Relapse prevention training
— Marlatt and Gordon – most relapse happens in high-risk situations
— People who are more optimistic and confident are less likely to follow the urge to use the drug
— Designed to reduce the impact of a failure by emphasizing the behavior change is not an all or nothing event
— Lifestyle factors (positive and negative) are examined and reasons for stopping drugs abuse are explores
— To help identify high-risk situations and providing skills to cope with them

Question 57

Peer support programs

Answer 57

— offer social support
— offered by people who have experienced drug problems themselves and may be assisted by medical or psychological staff

— Therapeutic communities – Principle  a structured, drug-free residential setting provides the best context to address the underlying causes of drug dependence
— Assist individuals to develop skills and attitudes to make positive changes
— Emphasize the acceptance of personal responsibility for decisions and actions
— Assign residents tasks of everyday living
— Drug users can leave usual environment and escape many high-risk situations

for example
— 12 Step Programs: Alcoholics Anonymous
— key steps to maintaining abstinence: admit one’s own powerlessness over the drug and develop a strong spiritual belief system
— opportunity to develop alternative social networks

Question 58

Primary Prevention

Answer 58

Primary Prevention
— designed to reach individuals before they have developed an addictive behavior
— target individuals who haven’t begun using alcohol and other drugs

— Goal:
— challenge individual/ environmental factors that promote unhealthy behavior

Question 59

Secondary Prevention

Answer 59

Secondary Prevention
— screening and detecting drug use and other addictive behaviors at an early stage
— in order to intervene before significant problems have developed

Question 60

Tertiary Prevention

Answer 60

Tertiary Prevention
— designed to prevent addictive behavior
— developing further and minimize the likelihood of serious medical and psychosocial consequences associated with drug

Question 61

Supply reduction efforts:

Answer 61

Supply reduction efforts:
— are based on the assumption that drug use and other addictive behaviors can be managed by controlling how easily can be obtained
— approach of drug law enforcement agencies

Question 62

Drug reduction efforts:

Answer 62

Drug reduction efforts:
— attempt to discourage individuals from using and abusing drugs or engaging in other unhealthy behaviors
— including prevention, education, and treatment strategies

Question 63

Types of primary prevention

Answer 63

Six general strategies:
1. Information dissemination approaches
2. Personal growth
3. Alternative approaches
4. Skills for resisting
5. Personal and social skills training
6. Public health approaches

Question 64

Information dissemination approaches

Answer 64

Information dissemination approaches
— aim to educate people of the harms assoc. with addictive behaviors
— may include messages designed to promote fear or moral behavior
— assumes that insufficient knowledge is cause of addictive behavior
— evidence suggests that this is not effective and may even lead to increase in addictive behavior

Question 65

Personal growth

Answer 65

Personal growth
— Incl. programs that are designed to promote self-esteem and develop social skills
— Focus on personal and social development
— No reliable effectiveness shown

Question 66

Alternative approaches

Answer 66

Alternative approaches
— Including providing activities in the community to reduce boredom and provide alternatives to addictive behavior
— No reliable effectiveness shown

Question 67

Skills for resisting

Answer 67

Skills for resisting
— Increase awareness of social influences and develop resistance skills
— Some effect on limiting drug use

Question 68

Personal and social skills training

Answer 68

Personal and social skills training
— Including programs that are designed to improve self-esteem without necessarily focusing on addictive behaviors
— Significant Effects on reducing harms associated with alcohol and drug use

Question 69

Public health approaches

Answer 69

Public health approaches
— Directed at general population
— Including legislative controls on the availability and price of drugs coupled with educational campaigns delivered through mass media
— Including fear arousal massages will not be effective in reducing the harms associated with addictive behavior

Question 70

Terror management theory

Answer 70

Terror management theory – focus on mortality-related risks may even lead to increase in that behavior if it’s important to a person’s self esteems

— To be effective campaigns that promote the adverse consequences of addictive behavior must also present info that can assist the person in changing their behavior

Question 71

Neurocognitive perspective on addiction:

Answer 71

— Behind capacity to resist craving and make adaptive decisions stands the reflective system (dependent on cognitive inhibitory control and delayed gratification)
— Reflexive processes – Automatic motivational and emotional responses to reward  yield faster approach action tendencies
— Impulsivity  subdivided into impulsive choice and impulsive action  both due to reward-seeking or poor inhibitory control
Ú compulsive substance seeking combined with a neglect of controlled decision-making in patients with AUDs are explained by deficits and perturbations within both reflective and reflexive systems

Question 72

Socio-environmental approach:

Answer 72

Socio-environmental approach:
— Implicates a number of social and environmental cues and certain individual sensitivity to them as involved not only in the very development of AUDs, but also processes of recovery and maintenance of abstinence
— Substance-related settings and social interactions  first trigger craving and ultimately relapse in even abstinent individuals (reward-pathway activation)

Question 73

Risks, challenges, and future directions of VR

Answer 73

Mind potential risks of VRs application:
— Cybersickness
— Superrealism, experience intensification, and information overload
— Depersonalization, derealization, and dysfunctional re-entry into the real world
— Unintended outcomes in vulnerable populations
— Misconceptions concerning the true benefits of VR exposure in vulnerable cohorts

Challenges:
— Questions of limited methodological quality
— Piecemeal evidence
— Potentially constricted reporting of negative outcomes
— General gaps in reporting

Question 74

Five stages of change:

Answer 74

1. Precontemplation stage – Individuals may not believe there is a problem with their behavior and may not see a need to change
2. Contemplation stage – As awareness of a problem increases, individuals may begin to weigh the pros and cons of engaging in a specific behavior, a state often described as “ambivalence”
3. Preparation stage – When a state of ambivalence is resolved in the direction of making a change, individuals may then begin to develop a change plan
4. Action stage – Individuals then embark on successive efforts to change the behavior
5. Maintenance stage – characterizes the ongoing efforts to keep momentum and reduce the likelihood of reengaging in previous behavioral patterns (e.g., relapse)

— model conceptualizes change as a nonlinear process
— characterized by a dynamic back and forth of motivational states as individuals move toward long-term shifts in their behavior
— unidirectional shift from being “unmotivated” to being “motivated”
— suggests that helping strategies should be sensitive to an individual’s position in the change process

Question 75

Agonists

Answer 75

Agonists
— E.g., methadone
— activate opioid receptors, thereby mimicking the action of the endogenous neurotransmitter

Question 76

Antagonists

Answer 76

Antagonists
— e.g., naltrexone, naloxone, Methadone
— occupy the opioid receptors, thereby blocking an agonist from exerting its effects

Question 77

Partial Agonists

Answer 77

Partial Agonists
— e.g., buprenorphine
— have agonists and antagonist action
— occupy the opioid receptors but produce only a partial response
— full effects of an opioid agonist will be partially blocked and can’t exceed those of the partial agonist
— can act as substitute without reaching a dangerous level of respiratory depression, as well as reducing euphoric effects

Question 78

Time course of opioid effect

Answer 78

Time course of opioid effect
— medication should have longer half-life and duration of action than the drug
— avoids the altering of “highs” and “lows” that occurs several times a day with short-acting drugs
— e.g., buprenorphine
— longer duration of effect when higher dose, due to higher levels of plasma
— but no difference in magnitude of opioid effect because it’s a partial agonist

Question 79

Buprenorphine

Answer 79

— described as an alternative substitute to methadone in maintenance and detoxification treatment
— produces less euphoria, sedation, positive reinforcement, and respiratory depression than full agonists  because k opioid receptor

— high affinity for opioid receptors
— prevents opioids from binding to receptors  attenuates their effects as “Blocker”

— as partial agonist it activates receptors less than full agonist
— resulting in relative drop in receptor activation and therefore a degree of “precipitated opioid withdrawal”
— prevented by starting treatment when patient is already in withdrawal

Question 80

Naloxone

Answer 80

— used as part of relapse prevention
— used once patient has completed detoxification

Question 81

Buprenorphine and naloxone combination

Answer 81

— alternative to Buprenorphine that exhibits less risk of diversion and abuse
— if taken intravenously, naloxone will precipitate withdrawal from opioids and block the effect of the buprenorphine

Question 82

Lofexidine and clonidine

Answer 82

— agonists at the α2-adrenergic auto-receptors
— used in opioid detoxification because they manage symptoms of withdrawal

Question 83

nicotine treatent options

Answer 83

Buproprion
Varenicline -agonist
Mecamylamine -antagonist

Question 84

alcohol effects many neurotransmitter

Answer 84

GABA
— chronic alcohol use leads to reduced GABA function
— as well as changes in specific receptor subunits that render it less sensitive to alcohol, resulting in tolerance

Glutamate
— major CNS excitatory neurotransmitter
— alcohol acts as antagonist at NMDA receptors
— alcohol withdrawal  over-activity of the NMDA system, leading to increased brain excitation

Question 85

Alcohol withdrawal

Answer 85

— exposes both reduction (tolerance) in GABA system and hyperactivity in the glutamate one
— changes result in excitation in the brain, which probably explains increased risk of seizures and neurotoxicity

Question 86

Alcohol possible treatments

Answer 86

Benzodiazepines
Acamprosate
Disulfiram
Naltrexone

Question 87

Canabis treatment

Answer 87

Rimonabant
— CB1 cannabinoid receptor antagonist
— Prescribed as an anti-obesity drug
— Potential role in treatment for cannabis abuse and dependence

Question 88

Naltrexone

Answer 88

— maintaining abstinence and reducing lapse and relapse
— opioid antagonist
— reduces pleasure associated with consuming alcohol

Question 89

Acamprosate

Answer 89

Acamprosate
— doubles rate of abstinence from alcohol compared to those without medication
— reduces the quantity and frequency of drinking in not achieving abstinence patients
— reduces craving and urge to drink

— enhances GABA-ergic function
— reduces the increase in glutamate function during withdrawal
— appears to antagonize NMDA receptors

Question 90

Disulfiram

Answer 90

Disulfiram
— relapse prevention
— inhibits aldehyde dehydrogenase (key enzyme involved in metabolism of alcohol)
— accumulation of aldehyde after drinking causes unpleasant effects, such as nausea and vomiting etc., when drinking alcohol
— also, increases DA levels acutely

Question 91

Benzodiazepines

Answer 91

Benzodiazepines
— most widely used for alcohol withdrawal
— act at the GABA-BDZ receptor complex to increase GABA function
— inhibits rates of delirium tremens and seizures

Question 92

only 10%–15% of individuals with a current SUD will come into contact with a treatment professional

Answer 92

— reasons include limited health care coverage, cost concerns, fear that doing so may impact employment, and stigma
— approximately 40% of individuals with a current SUD report not being ready to stop using ( problem becazse Motivation is a key construct in behavioral medicine and is a particularly salient issue in the treatment of SUDs)

Question 93

Five stages of change:

Answer 93

1. Precontemplation stage
2. Contemplation stage
3. Preparation stage
4. Action stage
5. Maintenance stage

— model conceptualizes change as a nonlinear process
— characterized by a dynamic back and forth of motivational states as individuals move toward long-term shifts in their behavior
— unidirectional shift from being “unmotivated” to being “motivated”
— suggests that helping strategies should be sensitive to an individual’s position in the change process

Question 94

Precontemplation stage

Answer 94

Precontemplation stage – Individuals may not believe there is a problem with their behavior and may not see a need to change

Question 95

Contemplation stage

Answer 95

Contemplation stage – As awareness of a problem increases, individuals may begin to weigh the pros and cons of engaging in a specific behavior, a state often described as “ambivalence”

Question 96

Preparation stage

Answer 96

Preparation stage – When a state of ambivalence is resolved in the direction of making a change, individuals may then begin to develop a change plan

Question 97

Action stage

Answer 97

Action stage – Individuals then embark on successive efforts to change the behavior

Question 98

Maintenance stage

Answer 98

Maintenance stage – characterizes the ongoing efforts to keep momentum and reduce the likelihood of re-engaging in previous behavioral patterns (e.g., relapse)

Question 99

the role of personal motivation Recently

Answer 99

Recently:
— motivational barriers to recovery have been viewed as coming not from the absence of pain but rather from the absence of hope, and empowering relationships developed during the treatment process are seen as important factors for enhancing motivation
— strategies to influence an individual’s motivation, particularly during the earlier stages of recovery have been developed and implemented

Question 100

the role of personal motivation — White (2014)

Answer 100

the baseline view was that recovery was not possible unless an individual was ready to change and that the motivation to change was derived from the pain of the person’s behavior, thus necessitating the need to “hit bottom”

— actions of loved ones, who could protect an individual from the painful consequences of his or her substance use and delay the need to change
— _therefore, teaching loved ones to refrain from rescuing (i.e., “enabling”) the individual was seen as an important way to accelerate the pace of change
— raising an individual from the “bottom” could be facilitated by a caring confrontation, although pain and threat remained the active ingredients for increasing motivation

Question 101

getting people to Seek Help

Answer 101

— use of certain clinician-guided, -planned, and -scripted family interventions shows demonstrated some efficacy in increasing treatment enrollment
— these types of interventions indicate that a significant proportion of family members do not go through with the intervention meeting, thereby reducing its overall clinical impact

Ú evidence indicates that the use of confrontation in individual, group, and family-focused interventions does not improve outcomes compared with other treatment strategies and may negatively affect treatment response and engagement

— certain counseling styles, such as those striving to convey accurate empathy and to minimize confrontational interactions, have been associated with significantly better treatment response

Question 102

MI framework

Answer 102

MI framework – goal is to rely most heavily on open-ended questions

— Open-ended questions cannot be answered with a simple “yes” or “no”
— designed to elicit from the client additional information, context, and room for further exploration of ambivalence

Affirmations
— with information from questions clinician highlights the client’s strengths, efforts, abilities, and what has been going well
— meant to linguistically reinforce desires or efforts to change that are consistent with the client’s goals

Reflections
— strategic efforts by the clinician to guess at the client’s meaning in a way that further focuses the conversation toward change
— can be either simple or complex

Summary statements
— Summary statements by the clinician allow further focusing of the session
— highlight the prospect of change

Question 103

The four processes of Motivational interviewing

Answer 103

Engaging: Building a Working Relationship

Focusing: Identifying a Specific Set of Changes to Address

Evoking: Inviting Clients to State Their Own Reasons for Change

Planning: Developing an Action Plan

Question 104

Engaging: Building a Working Relationship

Answer 104

— underpins any possibility of helping a client move toward change, because a collaborative, autonomy-reinforcing relationship helps clients build awareness of potential areas of change and open up about ways they may be contemplating changes
— precontemplation and contemplation stages can be particularly helped by a clinician’s engaging stance, which encourages openness, discussion of the issues surrounding their behaviors, and reasons for seeking a talk with the counselor

Question 105

Focusing: Identifying a Specific Set of Changes to Address

Answer 105

Focusing: Identifying a Specific Set of Changes to Address
— encompasses the clinician’s process of strategically narrowing the conversation and helping the client to target an area for potential movement

— align with the contemplation stage of change, because clients may require focused thought and discussion before being more actively ready to change
— may also align with earlier or later stages of change

— in precontemplation stage can benefit from conversations eliciting discussion of ways that particular behaviors are or are not serving their needs or values

— in the preparation or action stage can benefit from focused discussions on ways they might move toward the changes they have committed themselves to making

Question 106

Evoking

Answer 106

Evoking: Inviting Clients to State Their Own Reasons for Change
— clinician strategically “invites in” a client’s change talk and differentially responds to it
— tends to align with the preparation stage of change  stage in which most of the clinician’s directional effort occurs

Question 107

Planning: Developing an Action Plan

Answer 107

Planning: Developing an Action Plan
— clinician offers guidance, with the client’s permission, on how a plan might be put in place for making changes
— request for permission before providing advice ensures that the action stage of change aligns with the client’s own values
— can be used in action implementation

Question 108

Research on Motivational Interviewing

Answer 108

— MI is preferable to many other behavioral interventions because it requires relatively fewer sessions to demonstrate its effects
— MI is more effective than no treatment but comparable in efficacy to other psychosocial interventions
— BUT failed to find any long-term effect of MI on substance abuse outcomes