Early Intervention: Identifying And Engaging Individuals At Risk For Substance Misuse And Substance Use Disorders
Early intervention services can be provided in a variety of settings to people who have problematic use or mild substance use disorders. These services are usually provided when an individual presents for another medical condition or social service need and is not seeking treatment for a substance use disorder. The goals of early intervention are to reduce the harms associated with substance misuse, to reduce risk behaviors before they lead to injury, to improve health and social function, and to prevent progression to a disorder and subsequent need for specialty substances use disorder services., Early intervention consists of providing information about substance use risks, normal or safe levels of use, and strategies to quit or cut down on use and use-related risk behaviors, and facilitating patient initiation and engagement in treatment when needed. Early intervention services may be considered the bridge between prevention and treatment services. For individuals with more serious substance misuse, intervention in these settings can serve as a mechanism to engage them into treatment.
Strategies To Reduce Harm
Strategies to reduce the harms associated with substance use have been developed as a way to engage people in treatment and to address the needs of those who are not yet ready to participate in treatment. Harm reduction programs provide public health-oriented, evidence-based, and cost-effective services to prevent and reduce substance use-related risks among those actively using substances, and substantial evidence supports their effectiveness., These programs work with populations who may not be ready to stop substance use â offering individuals strategies to reduce risks while still using substances. Strategies include outreach and education programs, needle/syringe exchange programs, overdose prevention education, and access to naloxone to reverse potentially lethal opioid overdose., These strategies are designed to reduce substance misuse and its negative consequences for the users and those around them, such as transmission of HIV and other infectious diseases. They also seek to help individuals engage in treatment to reduce, manage, and stop their substance use when appropriate.
Outreach and Education
Needle/Syringe Exchange Programs
Naloxone is an opioid antagonist medication approved by the FDA to reverse opioid overdose in injectable and nasal spray forms. It works by displacing opioids from receptors in the brain, thereby blocking their effects on breathing and heart rate.
Sedative Hypnotic Or Anxiolytic Use Disorder
Sedative-hypnotic and anxiolytic drugs slow down brain activity. These drugs include benzodiazepines such as Xanax and barbiturates such as phenobarbital. Quaaludes are another type of anxiolytic drug.
People with sedative hypnotic or anxiolytic use disorders misuse these drugs and experience withdrawal symptoms.
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Categories Of Substance Use Disorder Symptoms
The American Psychiatric Association , the health professionals behind the DSM-5, recognizes four categories of substance use disorder criteria.
The four categories are:
What Is The Dsm
The DSM-5 is the reference guide psychiatrists and other mental health professionals use to diagnose a variety of mental illnesses.1
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders provides the most up-to-date published information on mental disorders and diagnostic criteria. It also includes information on how racism and discrimination impact mental disorders.
The DSM-5 now categorizes substance use disorder into a single continuum. There are no longer two separate definitions for substance abuse and substance dependence.
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What Are Substance Use Disorders
The DSM-5-TR recognizes substance-related disorders resulting from the use of 10 separate classes of drugs:
While some major groupings of psychoactive substances are specifically identified, the use of other or unknown substances can also form the basis of a substance-related or addictive disorder.
The activation of the brains reward system is central to problems arising from drug use. The rewarding feeling people experience due to taking drugs may be so profound that they neglect other normal activities in favor of taking the drug.
The pharmacological mechanisms for each class of drug are different. But the activation of the reward system is similar across substances in producing feelings of pleasure or euphoria, which is often referred to as a high.
The DSM-5-TR recognizes that people are not all automatically or equally vulnerable to developing substance-related disorders. Some people have lower levels of self-control that predispose them to develop problems if exposed to drugs.
The Impact Of Dsm Classification Changes On The Prevalence Of Alcohol Use Disorder And Diagnostic Orphans In Lebanese College Youth: Implications For Epidemiological Research Health Practice And Policy
Affiliation Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
Roles Data curation, Formal analysis, Project administration, Writing original draft, Writing review & editing
Affiliation Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Rima A. Afifi
Roles Investigation, Writing original draft, Writing review & editing
Affiliations Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa City, Iowa, United States of America, Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
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Addiction Treatment In Massachusetts
Behavioral therapy can help people recover from many different substance disorders, such as alcohol use disorder, opioid use disorder, and cannabis use disorder.
At Northeast Addictions Treatment Center, we offer evidence-based therapy in our many different outpatient options that can get you or your loved one on the path to recovery.
Reach out to one of our drug specialists to learn more about our rehab facility in Quincy, Massachusetts.
Components Of Early Intervention
One structured approach to delivering early intervention to people showing signs of substance misuse and/or early signs of a substance use disorder is through screening and brief intervention .
Research has shown that several methods of SBI are effective in decreasing âat-riskâ substance use and that they work for a variety of populations and in a variety of health care settings., As mentioned earlier, this research has demonstrated positive effects for reducing alcohol use , the research with SBI among those with other substance use disorders has shown mixed results.-
In addition, research shows that SBI can be cost-effective. For example, a randomized study compared SBI to screening alone for alcohol and drug use disorders among patients covered by Medicaid in eight emergency medicine clinics in the State of Washington. A year later, investigators compared total Medicaid expenditures between the two groups and found that the costs per member, per month for the SBI group were $185 to $192 lower than the costs for the screening-only group. This added up to a savings of more than $2,200 per patient in one year.
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Electronic Clinical And Recovery Support Tools
Several studies have examined the application of technology-assisted tools to RSS. In general, Web- and telephone-based recovery support tools focus on providing remote support to individuals following substance use disorder treatment. Examples of e-recovery support tools include: A-CHESS, a smartphone application that provides monitoring, information, communication, and support services to patients, including ways for individuals and counselors to stay in contact and MORE, a Web-based recovery support program that delivers assessments, clinical content, and access to recovery coaching support online. Preliminary evidence shows that technology-assisted recovery support approaches may be effective in helping individuals to maintain their recovery.,, In 2014, a study found that participants receiving ongoing counseling services through Web-based videoconferencing technology experienced comparable rates of decreased drug use and program attendance as did individuals receiving in-person care.
Presentation On Theme: Dsm 5 Substance
1 DSM 5 Substance-Related and Addictive DisordersMichael Ryan, LCSW, CASACOctober 2013
2 Use of the ManualThe primary purpose of the DSM-5 is to assist trained clinicians in the diagnosis of their patients mental disorders as part of a case formulation assessment that leads to a fully informed treatment plan for each individual.
3 The symptoms contained in the respective diagnostic criteria sets do not constitute comprehensive definitions of underlying disorders, which encompass cognitive, emotional, behavioral, and physiological processes that are far more complex than can be described in these brief summaries. Rather, they are intended to summarize characteristics syndromes of signs and symptoms that point to an underlying disorder.
4 Substance-Related and Addictive DisordersIn the fifth addition of the Diagnostic and Statistical manual of Mental Disorders , the revised chapter of Substance-Related and Addictive Disorders includes substantive changes to the disorders grouped plus changes to the criteria of certain conditions.
5 Substance Use DisordersThe DSM-5 Substance-Related Disorders Work Group has proposed eliminating two categories in the current DSM-IV.Substance use disorder in the DSM-5 combines the DSM-IV categories of substance abuse and substance dependence into a single disorder measured on a continuum from mild to severe.
25 ICD-10-CMCodes Alcohol 305.00 Mild 303.90 Moderate Severe Cannabis Mild Moderate Severe
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What Is Substance Use Disorder
A substance use disorder is characterized as a pattern of negative symptoms resulting from continued substance abuse.
Some people are more predisposed to developing substance issues compared to others. Factors such as genetics, family history, home environment, and more can play major factors.
Some of the most common substances of abuse are:
All of the substances above can provide a slew of desired effects, activating the brains reward system with pleasurable feelings.
As the brain becomes accustomed to a vast amount of dopamine from drug use, substance dependence may form. This can lead to health problems as well as legal problems.
What Should The Diagnostic Threshold Be
The studies in Table 2 and others demonstrate that the substance use disorders criteria represent a dimensional condition with no natural threshold. However, a binary diagnostic decision is often needed. To avoid a marked perturbation in prevalence without justification, the work group sought a threshold for DSM-5 substance use disorders that would yield the best agreement with the prevalence of DSM-IV substance abuse and dependence disorders combined. To determine this threshold, data from general population and clinical samples were used to compute prevalences and agreement between DSM-5 substance use disorders and DSM-IV dependence or abuse, examining thresholds of two or more to four or more DSM-5 criteria . As shown, prevalence was very similar, and agreement appeared maximized with the threshold of two or more criteria, so it was selected. Another recent large independently conducted study further supported this threshold .
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Should Cannabis Caffeine Inhalant And Ecstasy Withdrawal Disorders Be Added
Cannabis withdrawal was not included in DSM-IV because of a lack of evidence. Since then, the reliability and validity of cannabis withdrawal has been demonstrated in preclinical, clinical, and epidemiological studies . The syndrome has a transient course after cessation of cannabis use and pharmacological specificity . Cannabis withdrawal is reported by up to one-third of regular users in the general population and by 50%95% of heavy users in treatment or research studies . The clinical significance of cannabis withdrawal is demonstrated by use of cannabis or other substances to relieve it, its association with difficulty quitting , and worse treatment outcomes associated with greater withdrawal severity . In addition, in latent variable modeling , adding withdrawal to other substance use disorders criteria for cannabis improves model fit.
While some support exists for adding withdrawal syndromes for inhalants and Ecstasy , the literature and expert consultation suggest that evidence remains insufficient to include these in DSM-5, but further study is warranted.
Severity Levels Of Substance Use Disorders
Similar to other mental health disorders, the DSM-5-TR lists three levels of substance use disorders.
The number of criteria the patient relates to, along with the family history of drug abuse and current health, determines a patients SUD severity.
What level a patient falls into can help doctors decide which addiction treatment programs are recommended for recovery.
The sooner a patient receives treatment, the less likely a SUD can develop into deeper issues.
The three levels of SUD severity are:
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Diagnosing Substance Abuse Disorders
Substance use disorders should be evaluated by a psychiatrist, psychologist, or licensed counselor specializing in drug and alcohol addictions. A health professional may utilize blood or urine tests to assess current drug use. However, it is important to note that there is not a lab test that can establish dependence or addiction.
To diagnose a substance use disorder, a healthcare practitioner will evaluate the individual by completing a physical exam and taking a medical history. They will also ask questions about current and past substance use, including its frequency, amount, and duration.
Present Status And Future Directions
Since 2007, the Substance-Related Disorders Work Group addressed many issues. The members conducted and published analyses, and they formulated new criteria and presented them widely for input. The DSM-5 Task Force requested a reduction in the number of disorders wherever possible, and the work group accomplished this.
Implementing the 11 DSM-5 substance use disorders criteria in research and clinical assessment should be easier than implementing the 11 DSM-IV criteria for substance abuse and dependence, since now only one disorder is involved instead of two hierarchical disorders. A checklist can aid in covering all criteria. Eventually, reducing the number of criteria to diagnose substance use disorders will further aid implementation, which future studies should address.
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Should Any Criteria Be Added
If new criteria increase diagnostic accuracy, the set will be improved by their addition. The work group considered two criteria for possible addition: craving and consumption.
Support for craving as a substance use disorder criterion comes indirectly from behavioral , imaging, pharmacology , and genetics studies . Some believe that craving and its reduction is central to diagnosis and treatment , although not all agree . Craving is included in the dependence criteria in ICD-10, so adding craving to DSM-5 would increase consistency between the nosologies.
The work group considered adding quantity or frequency of consumption as a criterion. A putative criterion of five or more drinks per occasion for men and four or more drinks for women fit well with other criteria in the U.S. general population , as did at least weekly cannabis use and daily cigarette use . However, issues included worsening of model fit , unclear utility among cannabis users , and lack of a uniform cross-national alcohol indicator . Quantifying other illicit drug consumption patterns is even more difficult.
Substance Use Research And The Dsm
In 1980, the DSM-III introduced the categories of âabuseâ and âdependence,â requiring pathological patterns of use or negative consequences of use for a diagnosis of abuse and tolerance or withdrawal for a diagnosis of dependence . Dependence was considered a âmore severe form of Substance Use Disorder than Substance Abuseâ . In 1987, revisions to the DSM provided that abuse consisted of hazardous use or continued use despite negative consequences plus never having met criteria for dependence, the latter being a new hierarchical diagnostic rule. The diagnosis of dependence in the third edition, revised , required meeting at least three of an expanded list of nine criteria. By 1994, the criteria in the fourth edition had expanded to the now familiar one criterion of four for diagnosing abuse and three of seven for diagnosing dependence. These criteria are illustrated in .
DSM-IV vs. DSM-5 Criteria for Substance Disorder Diagnoses
In 2007, the DSM-5 Substance-Related Disorders Work Group was established. A central question for the Work Group was whether to keep abuse and dependence as separate disorders. The Work Group examined studies involving more than 200,000 subjects. In multiple studies, the dependence criteria were found to be valid and reliable, but the abuse criteria produced equivocal or weak results., Often, abuse was diagnosed by a single criterion, usually hazardous use. One option considered by the Work Group was simply to discard the abuse category.
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Potential Legislative Approaches To The Current Science
With concepts of addiction and dependence falling out of use in the DSM , there may be a variety of measures that states can take to reform their substance use diversion statutes. One would be to rely on legal definitions of dependence and addiction that are untethered from the DSM or other clinical nomenclature, as some states’ statutes already seem to do. This, of course, has the disadvantage of putting forensic assessments at odds with the evolving science and future clinical practice.
Another approach would be to require individual clinical assessments of substance use disorders, using some significant threshold identified in law. This is the approach taken thus far by Connecticut, as described above. The critical element in this method is determining what factors should define the threshold, one that meets the needs of public policy, satisfies legal imperatives, and comports with clinical forensic practice.
A third approach would be to require individual clinical assessments to determine the presence of any substance use disorder and allow courts to divert defendants so diagnosed at the courts’ discretion. This approach harmonizes with the DSM-5 objective to identify patients who might benefit from interventions at milder severity levels, but it may leave courts with insufficient guidance for the exercise of discretion.
Severity Of Substance Use Disorders
The DSM-5-TR allows clinicians to specify how severe or how much of a problem the substance use disorder is, depending on how many symptoms are identified.
- Mild: Two or three symptoms indicate a mild substance use disorder.
- Moderate: Four or five symptoms indicate a moderate substance use disorder.
- Severe: Six or more symptoms indicate a severe substance use disorder.
Clinicians can also add in early remission, in sustained remission, on maintenance therapy for certain substances, and in a controlled environment. These further describe the current state of the substance use disorder.
Understanding the severity of a substance use disorder can help doctors and therapists better determine which treatments to recommend. Choosing the appropriate level of care may improve a person’s chances of recovery.
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