Symptoms

Substance abuse criteria

Substance abuse is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one (or more) of the following, occurring within a 12-month period:

• recurrent substance use resulting in a failure to fulfill major role obligations at work, school or home (such as repeated absences or poor work performance related to substance use; substance-related absences, suspensions or expulsions from school; or neglect of children or household)
• recurrent substance use in situations in which it is physically hazardous (such as driving a car or operating a machine when impaired by substance use)
• recurrent substance-related legal problems (such as being arrested for substance-related disorderly conduct)
• continued substance use despite having persistent or recurrent social or interpersonal problems caused or made worse by the effects of the substance (for example, arguments with a spouse about the consequences of intoxication or physical fights).

Substance dependence criteria

Addiction (called substance dependence by the American Psychiatric Association) is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring any time in the same 12-month period:

• tolerance, as defined by either:
  • a need for markedly increased amounts of the substance to achieve intoxication or the desired effect, or
  • markedly diminished effect with continued use of the same amount of the substance.
• withdrawal, as manifested by either:
  • the characteristic withdrawal syndrome for the substance, or
  • the same (or closely related) substance being taken to relieve or avoid withdrawal symptoms.
• taking the substance in larger amounts or over a longer period than intended
• having a persistent desire or making unsuccessful efforts to cut down or control substance use
• spending a great deal of time in activities necessary to obtain the substance, use the substance or recover from its effects
• giving up or reducing important social, occupational or recreational activities because of substance use
• continuing substance use despite knowing about a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., continuing to use cocaine despite having cocaine-induced depression or continuing to drink despite knowing that an ulcer was made worse by alcohol consumption).

Screening and Assessment

Level I Screening Tools:

• CAGE
• CRAFFT
• index of suspicion (e.g., social difficulties,legal issues, self-harm, violence, non-compliance with healthy activities)

• ask a few straightforward questions (e.g., Has a relative, friend, doctor or other health care practitioner been concerned about your drinking or other drug use or suggested cutting down?)

Level II Screening Tools:

• Dartmouth Assessment of Lifestyle Instrument (DALI)
• Michigan Alcoholism Screening Test (MAST)
• Drug Abuse Screening Test (DAST)
• Alcohol Use Disorders Identification Test (AUDIT)
• South Oaks Gambling Screener (SOGS)

Assessment of substance use problems

Various factors can make it difficult to assess the existence or severity of substance use problems:

• Clients often do not admit having a substance use problem and may go to great lengths to conceal their substance use.
• Primary care practitioners may lack the awareness or confidence to ask about these issues.
• Primary care practitioners may have a negative view of substance use problems or treatment outcomes.
• Cultural views and developmental challenges may interfere with assessment

Whichever assessment technique is used, Canadian best practices for concurrent disorders (Health Canada, 2002) require primary care practitioners to take various steps. In order of priority, focus on:

• engagement and alliance-building
• assessing the severity of presenting symptoms
• crisis intervention and crisis management
• stabilization
• diagnostic efforts within multiple-contact, longitudinal treatment

When trying to get an idea of the severity of the substance use problem, keep the following in mind:

• Adopt a high index of suspicion—the amount/frequency of substance use may be underreported due to cognitive issues, stigma or fear of potential consequences.
• Take an integrated longitudinal history.

​Every comprehensive assessment should target specific areas, for example:

• drug use—assess types, doses (amounts), cost, frequency, duration, mode of use, effects of drug, complications (physical, social, psychological), last use and presence of withdrawal symptoms.
• alcohol use—assess number of units, frequency and duration of use, last use, withdrawal symptoms and complications.

Treatment

Health Canada (2002) has developed treatment guidelines based on best practice principles:

• Provide integrated assessment and treatment for clients with concurrent issues.
• Use person-centred care.
• Focus on harm reduction.
• Keep treatment flexible and ensure it is a good match for the client:
• • Consider the least intensive or least intrusive treatment.
  • Offer a menu of diverse choices.
• Use a systems approach (involve family, peers, community, schools, service providers, spiritual and cultural centres).
• Involve the family and significant adults in the client's life.
• Use stages of change.
• Use motivational enhancement.
• Provide a continuum of care.
• Provide ongoing care.

To provide integrated assessment and treatment, primary care practitioners often need to work with other resources in the community. For example, primary care practitioners may need to work with case managers if clients' substance use problems have impaired their ability to manage on their own. In fact, case management may be the most important aspect of helping clients deal with substance use problems.

Integrated assessment and treatment should:

• be comprehensive
• be assertive
• reduce negative consequences of substance use
• have a long-term perspective
• be motivation-based
• include multiple psychotherapeutic models
• include cultural competency
• go beyond "acute treatment" medication management and symptom reduction
• take a broad psychosocial approach to encourage long-term positive outcomes in such areas as housing, income, employment and social support.

Abstinence versus harm reduction

A common treatment approach for substance use problems is 12-step programs. They can exist as part of the continuum of care under a harm reduction approach; however, many 12-step programs do not advocate harm reduction.

Traditionally, 12-step programs place a strong focus on abstinence and spirituality. They consider addiction as a disease characterized by denial, and the counsellor's goal is to break down denial. Clients must accept the label of "alcoholic," "addict" or "being sick." The counsellor expects the client to be unmotivated and opposed to change. Therefore, the counsellor has to point the client toward abstinence, using directive—and sometimes aggressive and confrontational—methods.

Treatment Options: 12 Step Program

Medication

Medications for substance use problems are typically used to:

• treat intoxication or withdrawal states (e.g., benzodiazepines for alcohol withdrawal)
• decrease the reinforcing effects of the abused substance
• discourage the use of the abused substances (e.g., naltrexone for alcohol)
• act as an agonist substitution (e.g., methadone).

Prescribing Medication

The following guidelines are based on Health Canada's (2002) best practice principles for treating and prescribing medications to address mental health:

• Ensure the medication being prescribed is not known to have a high interaction risk with any substances clients might be taking (i.e., buproprion should not be prescribed for a client who binge drinks or has a head injury, as it might create a higher risk of seizures). Check with a pharmacist as well.
• Ensure clients understand the goals of treatment (i.e., informed consent). The concept that clients must stop their substance use before starting a medication has been shown to be without merit. Many people on medications use alcohol, marijuana, nicotine, benzodiazepines and narcotics. Explain the risks, what is being targeted and the pros and cons of trying or not trying medication. Remember that it should be clients who decide whether or not to take the medication, just like with any other form of therapy.
• Start low and go slow. Often, the substance use has existed for a long time, so there is no merit to rushing in with high doses of medication that may increase the risk of adverse effects.
• Explain to clients that they may feel worse before they feel better. Medications often take time to start working, and often work only once the right dose is titrated. There may also be some drug interactions.
• Ensure an adequate length of trial. If a medication usually takes four to six weeks to be effective once the right dose is reached, clients cannot know if it would have worked if they stop medication prematurely. In addition, stopping early has exposed clients to potential side-effects without benefit.

 Barriers to Treatment

Stigma is one of the most significant barriers to treatment. Negative stereotypes are associated with every aspect of problematic substance use. The stigma extends to the client, the treatment and the health care practitioner, and is reflected in terms such as "substance abuse" and "addiction."

In addition to stigma, other barriers to treatment include:

• lack of properly trained primary care practitioners
• lack of program resources and approaches
• lack of client engagement in treatment because substance use affects cognition, mood,interpersonal factors and insight
• poor fit with and poor co-ordination of existing resources.