Chemical Dependence

&
Addiction
Marla K. Ruhana, LMSW
Wayne State University

Diagnostic categories
The terms addiction, alcoholism,
dependence are often used interchangeably.
However addiction & alcoholism are not in the DSM
nomenclature.

DSMs 2 diagnostic categories:

Substance Abuse or Substance Dependence

Substance Abuse criteria (DSM-IV, 1994)

Recurrent use leading to failure to fulfill major
obligations (e.g. work, school, family).
Recurrent use in situations that are physically
hazardous (e.g. driving, operating machinery).
Recurrent substance-related legal problems.
Recurrent social or interpersonal problems.
Within a 12-month period.

Abuse vs. Dependence

Substance Dependence criteria (DSM-IV, 1994)
With or without physical dependence
(Must have 3 or more over a 12 month period)
1. Increased Tolerance (physical dependence)
Decreased tolerance with advanced alcohol dependence

2. Withdrawal (physical dependence)

3. Loss of control**** (the hallmark of addiction??)
Longer periods of time than intended.
Larger amounts than intended.
4. Unsuccessful attempts to stop or cut down
5. Preoccupation with using
6. Giving up important activities
7. Continued use despite adverse consequences

General population rates

Lifetime prevalence = 15%
Yearly prevalence = 5%

Does alcohol abuse lead to

dependence?
The available evidence suggests No.
In a study of 1,300 men and women who
met the criteria for alcohol abuse, only 3%
met the criteria for dependence in a 5 year
follow up (Schuckit et al. 2001)

Effectiveness of SA Treatments
How effective is treatment?
Only 10% to 15% of SA clients are initially ready to deal with
the problem.
Programs have 20% to 40% success rates.
Most people go through multiple treatments before
experiencing success.

How do we measure success?

Abstinence?
Harm reduction?
Should abstinence be the sole objective of how we deal with
the drug problem?

Working with alcohol & drug

problems

Screening

Is there a problem? ASK: How much? How often? For how

long?

Assessment (bio-psycho-social)
Level of severity; available resources; clients strengths.

Assess motivation & readiness to change

Stage of readiness

Determine if co-morbidity or other related factors

Level of care
Education? OP? IOP? Residential/Inpatient? Detox?

Psychoeducation
Short/long term impact of alcohol/drugs; dynamics of
addiction; gender/age differences.

Treatment - CBT

Standard Drink Measure

At risk drinking by gender & age

[These standards may vary slightly according to the study]
Per occasion

Per week

Populatio
n

Moderat
e

Men

2 drinks

3-4
drinks

>4
drinks

14 drinks

>14
drinks

Women

1 drink

2-3
drinks

>3
drinks

7 drinks

>7 drinks

Older
Adult
> 65 yrs

1 drink

2 drinks

2-3
drinks

7 drinks

>7 drinks

Low risk High risk Moderate

At risk

Information compiled from NIAAA guidelines for at risk drinking (1995); U. S. Dept. of
Agriculture and Dept. of Health & Human Services, NIAAA Alcohol Alert #62, July 20
American Society of Addiction Medicine, ASAM, 1994.

Key Concepts:
Tolerance:

Physical tolerance
Behavioral tolerance
Cross tolerance
Tolerance reversal

Withdrawal
Immediate physical or
psychological symptoms
Nausea, vomiting, muscle
cramps, aches, tremors,
hallucinations, seizures,
depression, anxiety, etc.
Short lasting (days, weeks)

Dependence

Post-Acute Withdrawal (PAW)

Less physical, symptoms/More
psychological symptoms

Blood Alcohol Content

(BAC)
Legal limit in Michigan
= 0.08%

Blackouts

Mood swings, irritability,

depression, anxiety, loss of
energy, poor sleep, decreased
concentration, loss of
enthusiasm, anhedonia.
Longer lasting (months, years)

UNIVERSAL SCREENING WIDENS THE NET

ABSTAINERS &
MILD DRINKERS
(70%)

MODERATE
(20%)
at risk drinkers

SEVERE
(5-10%)

Specialized Treatment
Brief Intervention
Primary Prevention

Drinking Episodes Defined

(NIAAA Advisory Council Task Force)

A drinking binge is a pattern of drinking that

brings blood alcohol concentrations (BAC) to
0.08 or above.
Typical adult males: 5 or more drinks in about 2
hours.
Typical adult females: 4 or more.
For some individuals, the number of drinks
needed to reach binge level BAC is lower.

Special vulnerable groups

Women in general & pregnant women in particular
Metabolism
Fetal alcohol syndrome

Persons with family history of alcohol/drug

dependence
Genetics and dependence

Teens
Most addictions start during adolescence
Brain development and impulsive behavior

Persons with mental illness

Self-medicating
Exacerbation of symptoms

Older adults
Slowed metabolism

Women & Alcohol: Background Issues

Alcohol use problems are significant among
women, despite the greater frequency of use
among men

Frequent,

heavy
drinking in women:
7 or more drinks in
one week, or
3 or more drinks on
one occasion

Women & Alcohol: Background Issues

(cont.)
2.7 to 4.5 million women over age 12 in U.S. are alcohol
abusers or alcoholics (Blumenthal, 1998; Straussner & Attia, 2002)
Trauma and substance abuse in women:
Strong link between trauma and AOD use among women.
30%-59% of women with SUD have PTSD (Najavitz et al., 1998)

Less alcohol required for intoxication

Differences in amounts of alcohol dehydrogenase,
enzyme, (ADH) contribute to different metabolic and
absorption rates than males.
Women progress to dependence more quickly and
experience more physical effects with fewer years of use.

Genetic Basis of Alcoholism

Alcohol dependence is a complex disorder

Many pathways lead to the development

of alcohol dependence

Many genes are likely involved in the

development of alcohol dependence

Children of alcoholic parents have 4xs

greater chance of developing
alcoholism than other children

40% -60% of the variance of risk may be

genetic

Concordance rates between identical

twins = 54%

Concordance rates between fraternal

twins = 28%

2002 Microsoft Corporation.

Etiology: Primary and Secondary

Factors
Primary factors contributing to alcoholism
Genetic (about 40-60% for alcoholism)
Substance induced (changes brain functioning/pathways)

Secondary factors contributing to alcoholism

Environment (helps create drug abuse)

The tendency to alcoholism is inherited (3-4 times

greater)
Genetics predestiny.
Genetics = increased vulnerability to alcohol dependence.

Polygenetic (not driven by a single gene)

Therefore, not every child in the same family has the
same risk to develop alcoholism.

Neurobiology and Addiction

Addiction is a brain disease

expressed in the form of
compulsive behaviors
Alan Lesner, M.D. (former director of NIDA)

Neurobiology and Addiction

Research focus: How people become addicted
Focus on limbic system or pleasure pathway
Medial forebrain bundle
Nucleus accumbens
Rich in dopamine receptors
Dopamine = pleasure neurotransmitter
Drug use floods the brain with dopamine
Such overflow leads the neurons to shut down receptors
Brain of addicts = diminished dopamine receptors
Decreased dopamine levels Loss of pleasure and joy

The brain on cocaine

Epidemiology of Comorbidity
Alcohol use disorders
are common
Psychiatric disorders are
common
Co-occurrence of
alcohol and psychiatric
disorders is common.
In such cases both
disorders should be
treated
simultaneously.

Epidemiology of Comorbidity
(cont.)
Odds ratio of alcohol/
drug disorders is 2.7
times more if any
mental disorder exists
This is 10-20 times
greater than expected
for schizophrenia,
mania, antisocial
personality disorder

Epidemiology of Comorbidity -

(OR) = Odds

Ratio
Individuals w/alcohol dependence
Psychiatric
disorder

Men

Women

OR

OR

Anxiety

35.8

2.2**

60.7

3.1

Mood

28.1

3.2**

53.5

4.4**

Drug depend.

29.5

9.8**

34.7

15.8**

Antisoc pers.

16.9

8.3**

7.8

17.0**

Persons with ADHD at risk of early onset alcohol dependence (5.81 odds ratio), with
**Odds ratio sig. different from 1 at .05, 2-tail test (Kessler et al., 1997)
17%-45% having alcohol use disorders.
Trauma: 25%-30% of people exposed to severe trauma and 5% to 10% of those exposed
to moderate trauma will develop a SA problem. Higher comorbidity among male
Veterans and women civilians.

Screening & Assessment

Screening

ASK!! Re: quantity and frequency

Do you drink alcohol?
On an average how many days a week do you drink?
When you drink, how many drinks do you have average?
Maximum # of drinks consumed on any one occasion past
month

Biopsychosocial approach
Multiple sources
Client, significant others, history, instrument data
Popular instruments: MAST, DAST, CAGE, AUDIT, TWEAK

Motivation & readiness to change

Does client admit a problem?
Is he/she ready to take action to deal with the problem?
If not, then what do we do?

Public Domain Instruments for

Alcohol & Drug Assessment
MAST Michigan Alcoholism Screening Test
AUDIT Alcohol Use Disorder Identification Test
CAGE Cut Down, Annoyed, Guilty, Eye Opener
TWEAK (for women):
Tolerance, Worried, Eye
Opener,
Annoyed, K/Cut Down
CRAFFT (for teens):
DAST Drug Abuse Screening Test

Ethical Issues
Confidentiality

Inform client of rights

Release of information
Limits of confidentiality: Inform client before treatment begins
Mandatory reporting: What should be reported?
May discourage clients from seeking treatment

Informed consent
Obtain consent. Is client competent to provide consent?
Minors?
Incapacitated patients?

Coercion? If you do not abide by treatment then

Explain options and alternatives to the suggested
intervention/treatment

Ethical Issues:
The duty to care
Policies for discontinuation of treatment
Abstinence vs. harm reduction
Continued relapses, motivation etc..

Respecting client self-determination

Who has the right to select the treatment goal

Respect for cultural differences
Providing choices & options
Abstinence vs. controlled drinking

Credentialing mechanisms
Education (e.g. MSW, licensure)
Specialization certification (e.g. CAADC, etc.)

CBT Treatment of Substance

Abuse

CBT treatment of substance abuse occurs at two levels:

Cognitive
Identify and reframe thoughts that lead to alcohol/drug use.
Behavioral
Identify and address skills deficits.

Effective treatment of substance abuse tend to be

multimodal
Multimodal approaches combine strategies from
various theoretical models such as:

Cognitive strategies
Behavioral strategies
Affective strategies
Insight-oriented strategies
Experiential strategies
Spiritual strategies
Art-based strategies

CBT Treatment of Substance

Abuse
Cognitive strategies:
Assess clients level of confidence (or lack of) about
ability to change
Identify beliefs that facilitate alcohol/drug use (Beck et al.,
1993):
Permission-giving
Ex. I deserved to have a drink I have worked hard.
Anticipatory
Ex. It is going to be great meeting my friends Friday
night and having a few beers.
Relief-oriented
Ex. If I have a drink it will help me calm down.

CBT Treatment
Cognitive strategies:
Identify strategies to challenge & reframe beliefs
Advantages vs. disadvantages inventory
Advantages

Disadvantage
s

Alcohol/Drug
Use
Sobriety

Self-statements to reinforce benefits of sobriety

Self-statement to dampen thoughts of using
Coping cards: 3 x 5 index cards.
Cognitive modeling self-instruction

CBT Treatment of Substance

Abuse
Functional Analysis;
Identifies triggers or antecedents (i.e.,
cognitive, behavioral, affective, situational,
relational, somatic).
Helps client connect the triggers with the
behavior and its consequences:
Trigger
Consequences
Anticipate and plan

Action

CBT Treatment

(cont.)

Behavioral Strategies
Skills building to maintain sobriety
Refusal skills, assertiveness, communication, anger
management, boundaries setting, parenting

Exposure (imaginal)
Behavioral log
Track daily use of alcohol/drugs: how much, when, where, with
whom.

Activity log
Tracking daily activities
Identifying gaps of idle time that may prove to be triggers to
use.

Relaxation skills
Imagery, breathing, meditation

In session role-play and reverse role-play

Behavioral experiments
Test out new behaviors; evaluate hypotheses

The A-B-C-D-E Model

(Ellis, 2003)

Activating
event

Beliefs
about the
event

Consequence
s (Emotional
&
Behavioral)

Disputation
of Beliefs
(B)

New
emotions
and
behaviors

The A-B-C-D-E Model

(Ellis, 2003)

Activating
event

Beliefs
about the
event

Consequences
(Emotional &
Behavioral)

Disputation
of Beliefs (B)

New
emotions and
behaviors

Saturday
night sitting
alone at home.
I was (2)
feeling bored
and lonely.
Thought of
calling friends
but (3) they
will probably
think Im a
loser. Who else
would be alone
on a Saturday
night? (4) Ill go
out and get
high.

I cant stand
it to be alone
on a Saturday
night. Only
losers are
alone on
Saturday
nights. I am
a loser. If I
go out and
get high I will
feel
better.***

Emotions:

I am on
probation, next
arrest will
result in jailtime and cost
thousands of
dollars.
Although
drinking makes
feel good
initially it
really creates
more problems
for me. I can
stand some
discomfort.
I need to plan
my Saturday
nights because
they are a high
risk for me.

Plan my
Saturday
nights earlier.

(1)

Anxious
(80/100).
Edgy, restless.
Depressed
(50/100).
Behaviors:
Went out and
got drunk.
Drove back
home drunk at
2 AM risking
possible arrest
while already
on probation.
Next day felt
defeated.

Identify
activities (i.e.
go to a movie,
read a book,
contact friends
earlier in the
week, visit my
brother)
Feels more
empowered as
he is aware of
alternative
behaviors.

Other Treatment Issues

Spirituality
Religious, not religious, agnostic, atheist.
Connect with others, family, community, purpose &
meaning.

Lifestyle change
Change people, places, and things that promote using.

Balanced lifestyle
Health, recreation, relationships, spirituality, work.

Relapse prevention
Strategies to avoid relapse; identify and plan for high
risk situations; relapse could be a learning experience.

Aftercare
Booster sessions, support groups (AA, NA, SMART
Recovery, Rational Recovery).