Addiction - Session 3
Literatuur:
3.1 Diagnostics and assessment
o Galanter, M., Kleber, H. D., & Brady, K. T. (Eds.). (2015). Textbook of substance
abuse treatment. Arlington: American Psychiatric Publishing. Chapter 6 Assessment
of the patient
o Galanter, M., Kleber, H. D., & Brady, K. T. (Eds.). (2015). Textbook of substance
abuse treatment. Arlington: American Psychiatric Publishing. Chapter 7 Screening
and brief intervention
3.2 Psychological interventions
o Galanter, M., Kleber, H. D., & Brady, K. T. (Eds.). (2015). Textbook of substance abuse
treatment. Arlington: American Psychiatric Publishing. Chapter 26 Motivational
Enhancement
o Galanter, M., Kleber, H. D., & Brady, K. T. (Eds.). (2015). Textbook of substance abuse
treatment. Arlington: American Psychiatric Publishing. Chapter 27 Motivational
Enhancement
o Moss, A. C., & Dyer, K. R. (2010). Psychology of Addictive Behaviour. New York:
Palgrave MacMillan. Chapter 6 Treatment options for addictive behaviours
o Moss, A. C., & Dyer, K. R. (2010). Psychology of Addictive Behaviour. New York:
Palgrave MacMillan. Chapter 7 Primary prevention options for addictive behaviours
o Pearson, F. S., Prendergast, M. L., Podus, D., Vazan, P., Greenwell, L., & Hamilton, Z.
(2012). Meta-analyses of seven of the National Institute on Drug Abuse's principles of
drug addiction treatment. Journal of Substance Abuse Treatment, 43(1), 1–11.
doi:10.1016/j.jsat.2011.10.005
- 3.3 Pharmacological treatment
o Watson, B., & Lingford-Hughes, A. (2007). Pharmacological treatment of addiction.
Psychiatry, 6(7), 309–312. doi:10.1016/j.mppsy.2007.04.008
Galanter, M., Kleber, H. D., & Brady, K. T. (Eds.). (2015). Textbook of substance abuse
treatment. Arlington: American Psychiatric Publishing. Chapter 6 Assessment of the patient
Introduction:
- Factors influencing identification, assessment and diagnosis substance-related disorder: clinical
setting, style of interviewing, attitude of the clinician, patient characteristics
- Goals in assessing patients with SUD:
o Identify the presence of a substance-related disorder, as well as signs of harmful or
hazardous use, so that prevention and early intervention may take place
o Make an accurate diagnosis and relating this to any other co-occuring medical or
psychiatric disorders
o Identify barriers to treatment as well as strengths and supports
o Assess and enhance the patients motivation to change
o Formulate and help to initiate appropriate evidence based interventions and treatments
Eliciting the substance abuse history
- Interviewing style:
, o Patients often don’t discuss their substance use openly with physicians because of their
feelings of shame, discomfort, fear, distrust, and hopelessness
o Obstacles to obtaining an accurate history include the patient’s defences, such as denial,
minimization, rationalization, projection, and externalization
o Open-ended questions may circumvent these obstacles and help the clinician understand
how the patient defines the problem, which can set the direction for the rest of the
interview
In an honest, respectful, matter of fact manner, non-judgemental
Avoid Why questions, state first that other people have experienced it too, this
reduces shame.
Avoid using labels, look at the pattern ‘It would help me to understand the pattern
of your cocaine use’
o Use a respectful, genuine, empathic, and supportive style
- Patient characteristics:
o Age, gender, partner, or marital status, legal and employment status, culture, and ethnicity
Women might be more prone to men to explain that mood or anxiety is the
problem
Cultural norms may differ regarding the quantity or frequency of substance use
and may affect the social acceptability and the patient’s description of his or her
use
o Level of insight into as well as personal explanation for the nature of the problem
o Psychiatric or medical comorbidity
o Stage in the course of illness
o Current phase of use
Intoxication: unlikely to elicit a valid history
Requesting detoxification/ having acute withdrawal symptoms: medical need for
detoxification and preventing withdrawal complications. Asses symptoms as it
could be dangerous (alcohol, sedatives, hypnotics, anxiolytics)
Full Remission: Find out what supports the patient has used to maintain
abstinence and recovery, to examine how any other illnesses may be affecting the
patient’s recovery, and to ascertain what types of treatments or interventions may
help support he ongoing recovery
o Stage of readiness for change
Pre-contemplative: Need for more probing
Strategies:
establish a pattern of use and that then elicit advantages and
disadvantages of such use.
Calendar method.
Patterns of usage: type, quantity, frequency, time of day for each day of
past week/month. Compare last month to previous 6 months usage.
During developmental periods (e.g. childhood), important life events,
o Reserve time at the end of the interview to summarize what the clinician has heard about
the history, any diagnostic implications the clinician is considering, treatment options and
possibly recommendations
Ask if patient wants to add any information; risks or vulnerabilities
Diagnosing substance related disorders:
- Substance-Related Disorders:
o Substance dependent and substance abuse have been replaced with Substance use
disorder
o Described as a problematic pattern of substance use leading to clinically significant
impairment or distress, as manifested by at least two symptoms occurring in a 12 month
period
Mild: 2-3 symptoms
Moderate 4-5
, Severe >6
o Specify the disorder if in early remission (3-12 month no criteria) or sustained remission
(>12 month), and if on maintenance therapy (opioid or tobacco only, medication) or in
controlled environment
- Substance intoxication and substance withdrawal:
o Substance intoxication: occurs after recent use of substance and causes clinically
significant problematic behavioural or psychological changes that developed during or
shortly after substance use
o Substance withdrawal: reduction or cessation of substance use that has been heavy or
prolonged and symptoms characteristic of withdrawal from a particular substance are
experienced.
o Knowledge of syndromes characteristics of each category is important in eliciting an
accurate history and clinical status
Content of the Interview:
- History of Substance Related Disorder:
o It is important to ask the patient about all categories of substances and not only about the
primary ones. Categories:
Central nervous system depressant: alcohol, sedative-hypnotics including
barbiturate and benzodiazepines
Stimulants: Amphetamines, cocaine
Cannabis: marijuana, Hashish, Synthetic cannabinoids (spice)
Hallucinogens: phencyclidine, Lysergic acid diethylamide (LSD), Mescaline,
Psilocybin (mushrooms
Opiates: Heroin, morphine, codeine, oxycodone, methadone, buprenorphine,
fentanyl
Nicotine: cigarettes, chewing tobacco, snuff
Inhalants: paint thinner, gasoline, glue, cleaning fluids
Designer Drugs: MDMA/ecstasy, Ketamine/ special K, GHB, Bath salts
Caffeine: coffee, tea, soft drinks, chocolate, energy drinks, medications
o Address following areas:
age at first substance use: framework for the history and guides the interviewer’s
subsequent questions. Has diagnostic and prognostic implications
frequency of substance use, amount of substance taken during an episode of use,
and route of administration for the substance: help understand the progression of
substance use over time
consequences associated with substance use
treatment history: understanding which treatments have or have not worked
previously
periods of abstinence, relapses:
- Psychiatric history:
o Psychiatric problems are comorbid with substance use disorder, yet they each worsen the
prognosis for the other disorder. Integrated treatment is most effective.
o Substance-induce mental disorder: when the full criteria for a mental disorder occur during
or within 1 month of an intoxication with or withdrawal from a substance that is capable of
causing the mental disorder.
Specify if onset during intoxication or onset during incontinuation/withdrawal
- Medical History:
o Important to look at medical history and current problems as they require treatment
regardless of their relationship to substance use, and patients with substance-related
disorders often neglect their health and routine medical care and are at risk for a number
of co-occurring medical disorders.
o For each medical condition, the interviewer needs to determine whether it can be caused
by the substance use disorder
Literatuur:
3.1 Diagnostics and assessment
o Galanter, M., Kleber, H. D., & Brady, K. T. (Eds.). (2015). Textbook of substance
abuse treatment. Arlington: American Psychiatric Publishing. Chapter 6 Assessment
of the patient
o Galanter, M., Kleber, H. D., & Brady, K. T. (Eds.). (2015). Textbook of substance
abuse treatment. Arlington: American Psychiatric Publishing. Chapter 7 Screening
and brief intervention
3.2 Psychological interventions
o Galanter, M., Kleber, H. D., & Brady, K. T. (Eds.). (2015). Textbook of substance abuse
treatment. Arlington: American Psychiatric Publishing. Chapter 26 Motivational
Enhancement
o Galanter, M., Kleber, H. D., & Brady, K. T. (Eds.). (2015). Textbook of substance abuse
treatment. Arlington: American Psychiatric Publishing. Chapter 27 Motivational
Enhancement
o Moss, A. C., & Dyer, K. R. (2010). Psychology of Addictive Behaviour. New York:
Palgrave MacMillan. Chapter 6 Treatment options for addictive behaviours
o Moss, A. C., & Dyer, K. R. (2010). Psychology of Addictive Behaviour. New York:
Palgrave MacMillan. Chapter 7 Primary prevention options for addictive behaviours
o Pearson, F. S., Prendergast, M. L., Podus, D., Vazan, P., Greenwell, L., & Hamilton, Z.
(2012). Meta-analyses of seven of the National Institute on Drug Abuse's principles of
drug addiction treatment. Journal of Substance Abuse Treatment, 43(1), 1–11.
doi:10.1016/j.jsat.2011.10.005
- 3.3 Pharmacological treatment
o Watson, B., & Lingford-Hughes, A. (2007). Pharmacological treatment of addiction.
Psychiatry, 6(7), 309–312. doi:10.1016/j.mppsy.2007.04.008
Galanter, M., Kleber, H. D., & Brady, K. T. (Eds.). (2015). Textbook of substance abuse
treatment. Arlington: American Psychiatric Publishing. Chapter 6 Assessment of the patient
Introduction:
- Factors influencing identification, assessment and diagnosis substance-related disorder: clinical
setting, style of interviewing, attitude of the clinician, patient characteristics
- Goals in assessing patients with SUD:
o Identify the presence of a substance-related disorder, as well as signs of harmful or
hazardous use, so that prevention and early intervention may take place
o Make an accurate diagnosis and relating this to any other co-occuring medical or
psychiatric disorders
o Identify barriers to treatment as well as strengths and supports
o Assess and enhance the patients motivation to change
o Formulate and help to initiate appropriate evidence based interventions and treatments
Eliciting the substance abuse history
- Interviewing style:
, o Patients often don’t discuss their substance use openly with physicians because of their
feelings of shame, discomfort, fear, distrust, and hopelessness
o Obstacles to obtaining an accurate history include the patient’s defences, such as denial,
minimization, rationalization, projection, and externalization
o Open-ended questions may circumvent these obstacles and help the clinician understand
how the patient defines the problem, which can set the direction for the rest of the
interview
In an honest, respectful, matter of fact manner, non-judgemental
Avoid Why questions, state first that other people have experienced it too, this
reduces shame.
Avoid using labels, look at the pattern ‘It would help me to understand the pattern
of your cocaine use’
o Use a respectful, genuine, empathic, and supportive style
- Patient characteristics:
o Age, gender, partner, or marital status, legal and employment status, culture, and ethnicity
Women might be more prone to men to explain that mood or anxiety is the
problem
Cultural norms may differ regarding the quantity or frequency of substance use
and may affect the social acceptability and the patient’s description of his or her
use
o Level of insight into as well as personal explanation for the nature of the problem
o Psychiatric or medical comorbidity
o Stage in the course of illness
o Current phase of use
Intoxication: unlikely to elicit a valid history
Requesting detoxification/ having acute withdrawal symptoms: medical need for
detoxification and preventing withdrawal complications. Asses symptoms as it
could be dangerous (alcohol, sedatives, hypnotics, anxiolytics)
Full Remission: Find out what supports the patient has used to maintain
abstinence and recovery, to examine how any other illnesses may be affecting the
patient’s recovery, and to ascertain what types of treatments or interventions may
help support he ongoing recovery
o Stage of readiness for change
Pre-contemplative: Need for more probing
Strategies:
establish a pattern of use and that then elicit advantages and
disadvantages of such use.
Calendar method.
Patterns of usage: type, quantity, frequency, time of day for each day of
past week/month. Compare last month to previous 6 months usage.
During developmental periods (e.g. childhood), important life events,
o Reserve time at the end of the interview to summarize what the clinician has heard about
the history, any diagnostic implications the clinician is considering, treatment options and
possibly recommendations
Ask if patient wants to add any information; risks or vulnerabilities
Diagnosing substance related disorders:
- Substance-Related Disorders:
o Substance dependent and substance abuse have been replaced with Substance use
disorder
o Described as a problematic pattern of substance use leading to clinically significant
impairment or distress, as manifested by at least two symptoms occurring in a 12 month
period
Mild: 2-3 symptoms
Moderate 4-5
, Severe >6
o Specify the disorder if in early remission (3-12 month no criteria) or sustained remission
(>12 month), and if on maintenance therapy (opioid or tobacco only, medication) or in
controlled environment
- Substance intoxication and substance withdrawal:
o Substance intoxication: occurs after recent use of substance and causes clinically
significant problematic behavioural or psychological changes that developed during or
shortly after substance use
o Substance withdrawal: reduction or cessation of substance use that has been heavy or
prolonged and symptoms characteristic of withdrawal from a particular substance are
experienced.
o Knowledge of syndromes characteristics of each category is important in eliciting an
accurate history and clinical status
Content of the Interview:
- History of Substance Related Disorder:
o It is important to ask the patient about all categories of substances and not only about the
primary ones. Categories:
Central nervous system depressant: alcohol, sedative-hypnotics including
barbiturate and benzodiazepines
Stimulants: Amphetamines, cocaine
Cannabis: marijuana, Hashish, Synthetic cannabinoids (spice)
Hallucinogens: phencyclidine, Lysergic acid diethylamide (LSD), Mescaline,
Psilocybin (mushrooms
Opiates: Heroin, morphine, codeine, oxycodone, methadone, buprenorphine,
fentanyl
Nicotine: cigarettes, chewing tobacco, snuff
Inhalants: paint thinner, gasoline, glue, cleaning fluids
Designer Drugs: MDMA/ecstasy, Ketamine/ special K, GHB, Bath salts
Caffeine: coffee, tea, soft drinks, chocolate, energy drinks, medications
o Address following areas:
age at first substance use: framework for the history and guides the interviewer’s
subsequent questions. Has diagnostic and prognostic implications
frequency of substance use, amount of substance taken during an episode of use,
and route of administration for the substance: help understand the progression of
substance use over time
consequences associated with substance use
treatment history: understanding which treatments have or have not worked
previously
periods of abstinence, relapses:
- Psychiatric history:
o Psychiatric problems are comorbid with substance use disorder, yet they each worsen the
prognosis for the other disorder. Integrated treatment is most effective.
o Substance-induce mental disorder: when the full criteria for a mental disorder occur during
or within 1 month of an intoxication with or withdrawal from a substance that is capable of
causing the mental disorder.
Specify if onset during intoxication or onset during incontinuation/withdrawal
- Medical History:
o Important to look at medical history and current problems as they require treatment
regardless of their relationship to substance use, and patients with substance-related
disorders often neglect their health and routine medical care and are at risk for a number
of co-occurring medical disorders.
o For each medical condition, the interviewer needs to determine whether it can be caused
by the substance use disorder
