Treating substance use disorders

“I recently spent five weeks in an inpatient rehabilitation center. Prior to returning to work I was advised to seek out an outpatient program. Coming to these groups has helped me understand my disease process as well as meeting others who were also struggling. My therapist was excellent in facilitating, as well as allowing me to be open and honest. This was a great experience.” Anonymous

What is a substance use disorder? 

“Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. According to the DSM-5, a diagnosis of substance use disorder is based on evidence of impaired control, social impairment, risky use, and pharmacological criteria.” (SAMHSA “Substance Use Disorders, online).

Life threatening, dangerous and/or conditions that impair healthy functioning are best treated as soon as symptoms appear or the condition is identified.  Unlike other chronic, life threatening conditions, attempts to self treat alcohol and drug use are usually attempted to avoid seeking professional help. Substance use disorder (SUD) treatment is similar to treatment for diabetes, heart disease, even cancer. One would not typically consider self treatment for these health conditions. Once suffering begins from most causes, one would seek out a professional specialist as soon as symptoms occur. This isn’t the case for SUD. Substance use is often not treated until the condition has progressed to a severe problem.

Though the legal age for drinking is 21 and 18 for cigarettes, using at those ages is not recommended. The human brain doesn’t fully develop until at least 25 years of age. The younger one uses any substance, the more likely lifetime problems will occur. The areas of the brain affected by regular substance use stops developing in many ways, causing developmental delays. Most addicts and alcoholics began using some substance during the teen aged years, even just cigarettes. The later a person begins using a substance, the fewer problems they tend to develop, especially if waiting until after 25 years of age.

How do I recognize a substance use disorder? 

Usually there are very early signs. Something as simple as smoking cigarettes, marijuana and/or experimenting with alcohol at an early age are often the first signs. Signs include, but are not limited to, getting into trouble, such as DWI, drug possession, testing positive on drug test at work at work, declining grades in school, suddenly becoming secretive and not getting along with family or friends. A single incident of these above is not indicative of a disorder, but are always cause for concern if alcohol or drugs are directly involved. “For healthy adults in general, drinking more than these single-day or weekly limits is considered “at-risk” or “heavy” drinking: Men: More than 4 drinks on any day or 14 per week. Women: More than 3 drinks on any day or 7 per week.” (NIAA online) Any use of prescription medication such as “benzos”, Klonopin, Valium, Xanax, Adderal, Concerta, Ritilan,  opiates or opioid medication that is not used as prescribed is indication of a problem, usually a serious problem.

Signs and Symptoms of Substance Abuse

Symptoms include memory loss, arguments, irritability, depression, or mood swings, use of alcohol to relax, to cheer up, to sleep, to deal with problems, or to feel “normal.” Other symptoms are headache, anxiety, insomnia, nausea, or other unpleasant feelings when one doesn’t drink or use a substance. Drinking alone, in the mornings, or in secret could be symptomatic of a severe disorder.

Signs include drinking/using more than planned or for a longer period than intended; spending less time on activities that used to be important or interesting; hanging out with peers who use or who get into trouble, hiding and/or lying about use, changes in appearance, requiring more of a substance to get the same effect. Having negative feelings when not using, including anxiety or nervousness, shakiness, unusual sweating, loss of appetite and headaches are signs of substance abuse.  Key signs are “continued use despite negative consequences” such as problems (on the job, in relationships, legal charges, health concerns), a person continues drinking and drugging.” A person who gets a DWI but continues drinking or is charged with drug possession, but continues to possess & use a drug are examples.

Almost no one gets into trouble for alcohol or drugs the first few times of use.  It is estimated, for example, that a DWI offender drives impaired about 75 times before being caught. People in possession of drugs or under age possession of alcohol typically participate in these behaviors on multiple occasions before it is noticed.

One has to pay attention to signs to recognize a substance use disorder in its early stages. The signs and symptoms, listed above, may be easily dismissed as caused by something other than substance use. If any of the above signs or symptoms occur, a person with no disorder would abstain to ensure the situations are not related to substance use. Continuing to drink or use when problems occur is a sure sign of a substance use disorder. We treat stage one cancer, early signs of high blood pressure, heart disease, diabetes, etc. as soon as symptoms arise. We wouldn’t wait to treat our diabetes until it has progressed to the point of amputating limbs. We wouldn’t wait until our cancer has reached stage 4 to begin treatment. However, in most cases, people do not seek services until substance use has reached the severe state. Like with all chronic disease, the earlier the condition is diagnosed and treated, the more likely a permanent recovery can occur.

What is substance use disorder treatment? 

Substance use treatment works best, as with other “dis-ease” if the “dis-ease” is interrupted early in its onset. Like cancer, early detection and proper treatment until completion is crucial. Proper treatment must begin with a comprehensive substance abuse assessment that includes a psychosocial interview, substance use history, family history, psychiatric history and an extensive drug screen processed by a laboratory. A “standardized test” is often used to support information gathered in the interview. The assessment must be completed by a clinician with proper credentials with a psychiatrist and Licensed Clinical Addictions Specialist available for consultation.

Upon completion of the comprehensive assessment a diagnosis a recommended level of care is determined according to the Addiction Society of Addictive Medicine (ASAM) criteria. If the assessment reveals no diagnosis, but the client has somehow gotten into trouble, a proven “best practice” education program is usually recommended. For mild disorders, a short outpatient or intensive outpatient program may be a start. For moderate to severe diagnoses, intensive out patient (IOP) is the most successful level of care, after need for detox or inpatient treatment is addressed. For the most severe disorders, detox and inpatient is necessary with “step down” to IOP and aftercare once the patient returns home.

Substance abuse treatment requires group counseling to be successful. Individual and family counseling are beneficial as a supplement to group counseling, but not as a replacement. Without group counseling, the client doesn’t learn the skills necessary to develop a long term recovery plan. Group counseling must be facilitate by a highly trained, licensed or certified counselor. If the counselor is not fully licensed or certified, ensure that the counselor has proper supervision by a psychiatrist, Licensed Clinical Addictions Specialist and Certified Clinical Supervisor. Programs that operate without the proper specialists to support the group counselor are questionable.

Group counseling should be “process” oriented to be successful. Process therapy includes building trust among the clients, peers and counselor. Process group therapy includes personal exploration, talking about what is affecting clients, helping clients give support and feedback to others as an experience of each members’ own healing.   Education, videos, manualized treatment works for clients with no diagnosis for whom education is sufficient. Education, videos, and manualized treatment do not offer the benefits of process group therapy for people with substance abuse disorders.   Qualified “process” group therapists know their group members well. They provide clients with the support they need each specific day, rather than relying strictly on a rigid lesson plan.

What causes people to seek out SUD treatment?

People with alcohol and drug abuse frequently don’t consider it an issue until long after symptoms have begun. The leading situation motivating people to choose to seek substance abuse treatment is a criminal or legal situation, problems at work or school. It might be possession of drugs, paraphernalia or DWI charge, testing positive at work, possession of drugs at school,  that motivates seeking a treatment center. Treatment that is “mandated” or “coerced” is proven to be as effective, and usually, more effective than voluntary treatment. It is erroneous to believe that treatment can’t help unless the person wants it. Most mandated clients initially do not want to be in treatment. However, after a few sessions, the majority of group members make significant progress. They become aware of problems caused by their use and lifestyle. Treatment participants clearly see the value and invest themselves in the treatment program if motivational techniques are used.

Before substance use progresses to severity requiring hospitalization or inpatient treatment, intensive outpatient (IOP) is usually the most successful level of care, especially when combined with aftercare outpatient followup. IOP costs less than 10% the cost of 30 days inpatient treatment. IOP to support inpatient treatment and continuing care upon returning home is usually necessary to help the patient remain abstinent long term. As in all chronic conditions, the earlier the intervention, the more likely a permanent recovery will take root. Would you knowingly wait until cancer or heart disease reaches late stages to receive treatment?

Will I be normal? How will it change me?

“Normal” tends to be different for each individual. Clients who work their treatment plan through to completion and develop positive recovery supports change their lives. Individuals develop a new normal for themselves, without the problems. They grow into a self that is unique, positive and works for them. How would the substance abuser’s life change with no more legal, family, work, school, social, financial, and emotional problems while at the same time becoming healthier, stable and happier? Since first entering the field in late 1987, it is this writer’s personal and professional experience that those who complete treatment, and engage an ongoing network of support, achieve far more than they could have ever imagined. As “they” say, don’t give up before the miracle happens.

Henry Tarkington, MSW, LCSW, LCAS, CCS

“I looked forward to coming to group every week and feel that I got a lot out of it. A lot of that had to do with the way the counselor ran group – not with a strong arm, but by guiding us always in the right direction. This allowed everyone to be comfortable and to feel less vulnerable about opening up. I think that I’ll remember the counselor’s kindness and encouragement for a long time – I know it has helped me this far.” Anonymous

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