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Substance Abuse

(9-10-14)

Sweet is the wine but sour’s the payment

Sean Gaffney & Seamus Cashman, Ed.s (1974, p. 30). Proverbs & Sayings of Ireland. New York: MJF Books.

A special issue of Alcohol Research & Health focused on “Women and Alcohol: An Update”: Vol. 26, 2002.

“Motivation or will can be damaged as a brain function, just as language or movement can be damaged by a stroke.”

(Harvard Mental Health Letter, “The addicted brain”, 2004, p. 4)

Screening for alcohol/drug abuse

  • I. Ask !
    • conditions conductive to valid self-report (adapted from Mayer, 1993, pp. 17-18):
      • client chemical free and not in withdrawal
      • absent or minimal external coercion
      • rapport and confidentiality established
      • client understands report will be checked
      • structured interview and tests used
      • client low on psychopathy
      • client shows compliance
    • Typical inquiry:
      • When was the last time you drank any alcohol? How much did you drink? What was the occasion before that? How much did you drink?
      • Has drinking ever caused you any problems at work?, in your marriage/relationships?, with friends?
      • Have you ever had a blackout? Have you ever attended AA? Have you ever gotten a DUI or had any other legal problems where alcohol was involved?
  • II. PDI-R Cardinal (screening) question:
    • “Has heavy drinking, or drinking, ever caused you any problems in your life?”
    • follows up with questions of duration
    • follows up with questions of functional effect
    • follows up with questions of specific criteria
  • III. CAGE Questionnaire for Alcoholism
    • 1. Have you ever tried to Cut down on your drinking?
    • 2. Are you Annoyed when people ask you about your drinking?
    • 3. Do you ever feel Guilty about your drinking?
    • 4. Do you ever take a morning Eye-opener?
    • Interpretation:
      • one point suggestive (explore)
      • two or three high index of suspicion
      • four may be diagnostic of alcoholism
      • Ewing, J.A. (1984). Detecting alcoholism. The CAGE Questionnaire. Journal of the American Medical Association, 252, 1905-1907
  • IV. RAPS Rapid Alcohol Problems Screen (Cherpitel, 1995)
    • During the last year have you had a feeling of guilt or remorse after drinking? REMORSE
    • During the last year has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? AMNESIA
    • During the last year have you failed to do what was normally expected of you because of drinking? PERFORM
    • Do you sometimes take a drink in the morning when you first get up? STARTER
    • During the last year have you lost friends or girlfriends or boyfriends because of drinking? LOST
    • RAPS4 (Cherpitel, 2000)
      • During the last year have you had a feeling of guilt or remorse after drinking? REMORSE
      • During the last year has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? AMNESIA
      • During the last year have you failed to do what was normally expected of you because of drinking? PERFORM
      • Do you sometimes take a drink in the morning when you first get up? STARTER
  • V. CRAFFT screen for adolescents (Knight, Sherritt, Shrier, 2000)
    • Table 1.   — CRAFFT Substance Abuse Screening Test for Adolescents
C—Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
R—Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
A—Do you ever use alcohol or drugs while you are by yourself, ALONE?
F—Do you ever FORGET things you did while using alcohol or drugs?
F—Does your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
T—Have you ever gotten into TROUBLE while you were using alcohol or drugs?
Two or more “yes” answers suggest a positive screen and that a more thorough assessment is needed.
From Knight JR, Sherritt L, Shrier LA, et al. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med 2002;156:607–14.

Future Directions

Langenbucher, Martin, Labouvie, Sanjuan, Bavly, & Pollock, (2000) present data and argue for the adoption of the Withdrawal-Gate Model in DSM-V, in which alcohol withdrawal is necessary and sufficient for the dependence diagnosis.

Evaluating Adolescents

Ross & Chappel (1998) discuss the difficulties in evaluating substance use problems in adolescents: “With adolescents, the key to detection is often subtle changes in the person’s usual functioning: academic performance; a different peer group; suspicious behavior (e.g., finding the person in odd places at odd times: bathroom, closet; wearing sunglasses or long-sleeve shirts, which is a change from previous behavior); newly occurring conduct problems; spending long periods away from home and avoiding parents upon return; small items of value or money missing from the home; and changes in energy levels; sleeping patterns, moods, and weight. More detailed guidelines for interviewing adolescents are provided by Banerjee et al.” (p. 820)

Banerjee, R. et al: Clinical evaluation. In Friedman L., et al (eds.): Source Book of Substance Abuse and Addiction. Baltimore, Williams & Wilkins, 1996

They suggest that underestimated or missed substance abuse in adolescents is a problem: “The binge nature of adolescent alcohol and other drug use combines with the absence of physical dependence and physiologic changes and with the reluctance of the adolescent to provide accurate information. Traumatic injury, involvement in accidents, or any drug overdose should always be red flags requiring an assessment for chemical dependence. (pp. 820-821)

Ross, S.M. & J.N. Chappel (1998). Substance use disorders: Difficulties in diagnosis. In D.A. Tomb (Ed.), The Psychiatric Clinics of North America, Vol 21, No 4, pp 803-833: Diagnostic Dilemmas, Part II. Philadelphia: W.B. Saunders Co.

Prevention Programs

“keepin it R.E.A.L.”–a prevention program for adolescents with empirical support

  • Refuse by verbalizing simple “no” statements
  • Explain by elaborating reasons for refusing
  • Avoid situations known to involve alcohol, tobacco, or other drugs
  • Leave the environment once substance use enters the picture

Williams, J.S. (2003). Multiculturalism at least as effective as cultural specificity in test of prevention program. NIDA Notes, 18, 8-10.

Hecht, M.L., et al. (in press). Cultural grounding in substance use prevention: An evaluation of the Drug Resistance Strategies intervention. Prevention Science, in press.

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