Treating Substance Use Disorders

Sample Conceptualization & Treatment Plan

The sample conceptualization and treatment plan is based on the following video about Kevin. Please note that the video is provided for the purpose of creating the sample conceptualization. It is not intended to be an educational/instructive video.

Conceptualization and Treatment Plan

Click here to download a .pdf of the sample treatment plan.

Playback problems? This video is available on YouTube at youtu.be/7T5CUL2A_t0

Humanistic Approaches to Treating Substance Use

Carl Rogers is a key figure in the humanistic counseling movement, and many of Rogers' ideas including the importance of warmth, genuineness, empathy, and positive regard for clients are now foundational in counseling.

Motivational Interviewing

Motivational interviewing is a widely used, well researched, humanistic counseling approach that is particularly useful for changing clients' substance use.

Playback problems? This video is available on YouTube at youtu.be/2yvuem-QYCo

The following demonstration shows a social worker using motivational interviewing to support a client in seeking professional treatment for her alcohol use.

Playback problems? This video is available on YouTube at youtu.be/67I6g1I7Zao

The state of Oregon published a brief handout describing a skills based approach to motivational interviewing. Check it out here.

Humanistic Substance Use Treatment Exploration Questions

1. Briefly summarize the motivational interviewing process.
2. How might you use motivational interviewing in your future work with clients?

Harm Reduction

Substance use disorders are difficult to treat, and conceptual frameworks rooted in criminal justice and moral frameworks have been largely unsuccessful at treating substance use disorders and minimizing harm associated with substance use. If we took a group of 100 people with substance use disorders and followed them for 17 years, somewhere between 1/2 and 1/3 would be in remission (Fleury, et al., 2016). In other words, somewhere between 50 and 66 of those 100 people would still use substances. Harm reduction programs are based on data indicating that a majority of people with substance use disorders will not stop using substances, so there is a need to minimize negative consequences associated with substance use including HIV, Hepatitis C, and overdoses. Thus, harm reduction is congruent with public health and, to some extent, the disease model of conceptualizing.

Harm reduction focuses on preventing consequences from substance use, rather than abstinence. While there are many positive consequences associated with harm reduction, such as reduced HIV/AIDS transmission, there is evidence that mental health professionals may not embrace harm reduction because of their personal biases. To learn more about how personal bias can impact treatment decisions, read Davis and Hawk (2015). Additionally, members of the general public may also have difficulty setting aside their biases and life experiences, so that they can conceptualize the benefits of a harm reduction approach. Further, historic racial and ethnic tensions may come into play, for example when a community is trying to decide where to locate harm reduction clinics.

...many countries, (notably in Europe) quickly embraced harm reduction and the idea of treating drug use as a public health problem, while the US cut funding for treatment and prevention and moved instead toward enhanced criminalization, further entrenching long-standing, disproportionally race-based negative outcomes...

(Eversman, 2015, p. 189)

While there is no universal definition for Harm Reduction, the Harm Reduction Coalition describes harm reduction as a "...set of practical strategies and ideas aimed at reducing negative consequences associated with drug use..." as well as "...a movement for social justice built on a belief in, and a respect for, the rights of people who use drugs". The Harm Reduction Coalition suggests that programs incorporate the following Principles of Harm Reduction:

• Accepts, for better and or worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.
• Understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence, and acknowledges that some ways of using drugs are clearly safer than others.
• Establishes quality of individual and community life and well-being - not necessarily cessation of all drug use - as the criteria for successful interventions and policies.
• Calls for the non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing attendant harm.
• Ensures that drug users and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them.
• Affirms drugs users themselves as the primary agents of reducing the harms of their drug use, and seeks to empower users to share information and support each other in strategies which meet their actual conditions of use.
• Recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities affect both people’s vulnerability to and capacity for effectively dealing with drug-related harm.
• Does not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use.

Harm Reduction Coalition

Harm reduction is a complex process that can be counter-intuitive, particularly for people who are used to conceptualizing substance use using a moral or a criminal justice framework. For example, researchers exploring the effects of the Silk Road, a marketplace that enabled people to easily purchase a wide range of illicit substances, which would then be shipped directly to their homes, found that:

Although it was typical among this sample for use to increase upon access to Silk Road, it was clear that for some participants, the capacity to more easily satiate desires for drugs necessitated new practices of self-control...[participant one] P1 explained that..."this whole summer, I've had such abundance. I really have no desire to take anything anymore". For P1 Silk Road was a trigger for his drug use to increase dramatically, peak then decline rapidly... Similarly, P15 related the "ease of making an occasional order on SR as a treat" to his "decreased desire to do hard drugs"...

(Barratt, Lenton, Maddox, & Allen, 2016, p. 53)

...it is generally accepted that increased availability of drugs is associated with increased prevalence of use and subsequent harm. Our study... indicates that there is a more complex story to tell about how changes in drug availability affect drug use and harm trajectories.

...there was evidence that consistently high availability reduced the need for purchasing larger quantities of drugs... This reduction in hoarding behaviours helped some respondents to moderate their use and feel more in control of purchases made online... There was also evidence that the desire for drugs can become satiated after the honeymoon period triggered by the saturation availability of a previously scarce drug. For some, high availability may assist them in maintaining a controlled drug use pattern resulting in reduced harm, whereas for others, high availability facilitated intense use and subsequent harm.

These findings suggest that the mere availability of cryptomarkets for illicit drug transactions does not determine an increased use or increased harm.

(Baratt et al., p. 55)

Two versions of the Silk Road have been shut down, however, the Silk Road 3.0 continues to operate. The Silk Road has been estimated to conduct over one billion dollars of business per year. Check out the Online Markets Unit to learn more about Silk Road and other online drug markets.

The Harm Reduction Coalition provides information on and resources for harm reduction programs in addition to working directly with governments and agencies to implement harm reduction programs. If you are interested in best practices for harm reduction programs, check out some of their resources, like their Guide to Developing and Managing Syringe Access Programs.

The Grand Rapids Red Project provides resources including trainings, syringe access programs, HIV prevention and case management, and peer counseling.

Harm reduction Exploration Questions

1. What are some of the risks and ethical considerations for counselors using a harm reduction approach with clients?
2. How might a counselor integrate a harm reduction approach when treating a client whose substance use is interfering with their daily life?
3. What harm reduction resources, such as free needle clinics, are available in your community?

Medical Approaches

As we learned in the Physiology Unit, using substances alters the brain's neurochemistry. Researchers are developing medical treatments, including medications and vaccines, to reduce cravings are relapses. The following interview with Dr. Thomas Kosten describes how vaccines can play a role in treating substance use disorders.

Playback problems? This video is available on YouTube at youtu.be/soYFdU67TCA

Prescription Treatments for Substance Use Disorders

While counselors do not prescribe medications, it is important that they have awareness regarding how prescription medications can interact with mental health concerns. There are multiple prescriptions that a physician or psychiatrist may prescribe to a client to ease cravings or withdrawal symptoms. Some resources for learning about prescriptions include:

• The Prescribers' Digital Reference (PDR)
• Medline Plus
• The National Institutes for Health Drug Information Portal

Some prescription medications that are used to treat clients with substance use disorders include:

• Disulfiram (Antabuse)
  • Used with clients who are motivated to cease using alcohol. Taking alcohol in conjunction with, or for up to 14 days after, Disulfiram produces severe side effects including vomiting, headaches, chest pain, and difficulty breathing.
• Suboxone
  • used to treat opioid cravings and as a maintenance treatment for people who are addicted to opioids. Suboxone contains an opioid agonist (buprenorphine) combined with an opioid antagonist (naloxone).
• Naloxone (Narcan)
  • An opioid antagonist that can be used to reverse opioid overdoses. Naloxone blocks opioids' effects, so it can result in a person with an opioid use disorder immediately experiencing withdrawal symptoms. Naloxone is approved for use in infants and neonates who are experiencing opioid overdoses.
  • The United States Surgeon General has issued guidance regarding the importance of expanding access to Naloxone, as doing so could save many lives. The Surgeon General's statement is available here.
• Naltrexone (Vivitrol & ReVia)
  • Naltrexone is an opioid antagonist that is used for managing opioid withdrawals and reducing cravings for alcohol.
• Methadone hydrochloride
  • Methadone is an opioid agonist that is prescribed as a maintenance treatment for clients with opioid use disorders.

Residential Treatment Programs

This section is coming soon.

Abstinence vs Moderation

This section is coming soon.

Smokefree.gov (self-help)

In response to the health concerns associated with tobacco use, the United States federal government launched smokefree.gov, so that people can access strategies, resources, information, and support as they cease using tobacco. Services offered through the website include articles on the health risks associated with smoking, quizzes, a savings calculator, a craving journal, apps to set a quite date, and phone and text support. Visitors have the option of signing up to receive between three and five text messages per day for six to eight weeks

As you review the resources on smokefree.gov, consider the theories that were used to develop the resources. For example, encouraging people to manage nicotine cravings by choosing to spend free time in smoke free venues is a behavioral suggestion. Calling a counselor is probably more interpersonal or humanistic. Articles on the benefits associated with quitting smoking are psychoeducational.

Tobacco Hotlines

877-44U-QUIT (877-448-7848)
The National Cancer Institute's trained counselors provide information and support for quitting in English and Spanish. Call Monday through Friday 9:00 a.m. to 9:00 p.m. Eastern Time.
800-QUIT-NOW (800-784-8669)
All states have quitlines with counselors who are trained specifically to help smokers quit. Call this number to connect directly to your state's quitline. Hours of operation and services vary from state to state.
(smokfree.gov)

Smokefree.gov Exploration Questions

1. What theories seem to be most influential in creating the smokefree.gov website?
2. How might a counselor use the resources on the smokefree.gov website when working with a client who is attempting to stop using nicotine?

12 Step Programs

12-step models have been used to treat substance use disorders for many decades. Examples of 12- step programs include AA, NA, and Al-Anon. Al-Anon uses a 12-step program to support friends and family members of people who use substances. Alateen is similar to An-Anon, however, their services are targeted toward children and teens.

The 12-steps are:

1. We admitted we were powerless over alcohol-that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and become willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message back to alcoholics, and to practice these principals in all our affairs.

(Alcoholics Anonymous World Services, Inc., 2012)

Alcoholics Anonymous

Alcoholics Anonymous (AA) is a well known alcohol treatment provider. However, data regarding the effectiveness of AA is scarce, which is understandable given that anonymity is a defining feature.

Narcotics Anonymous

Narcotics Anonymous (NA)

We offer recovery from the effects of addiction through working a twelve-step program, including regular attendance at group meetings. The group atmosphere provides help from peers and offers an ongoing support network for addicts who wish to pursue and maintain a drug-free lifestyle. Our name, Narcotics Anonymous, is not meant to imply a focus on any particular drug; NA's approach makes no distinction between drugs including alcohol. Membership is free, and we have no affiliation with any organizations outside of NA including governments, religions, law enforcement groups, or medical and psychiatric associations. Through all of our service efforts and our cooperation with others seeking to help addicts, we strive to reach a day when every addict in the world has an opportunity to experience our message of recovery in his or her own language and culture.

Information About NA

12 Step Program Exploration Questions

Review the AA, NA, and Al-Anon websites before responding to the exploration questions.

1. What resources are available on these websites?
2. What type of client might be more likely to benefit from attending 12 step meetings?
3. How can 12 step meetings be used in conjunction with other approaches to treating substance use?
4. What ACA ethics codes might a counselor consider before deciding if it is appropriate to attend a 12 step meeting with a client?
5. Bonus: Locate and attend a local 12 step meeting. Call ahead to see if you can attend as an observer.