Substance Use and Abuse

Definitions

• Substance: Prescribed and over-the-counter medicines and legal and illegal drugs (e.g., alcohol, marijuana, and prescription drugs).
• Substance abuse: When a person uses a substance inappropriately.
• Intoxication: Changes in behavior, thinking, or perception that occur as the result of consuming a substance.
• Increased tolerance: When a person needs to consume larger amounts of a substance to achieve the same effect.
• Dependence: When the body becomes dependent on (or addicted to) a substance.
• Withdrawal: Symptoms (mild to life-threatening) that can occur when a substance-dependent person stops using the substance.

Some symptoms of withdrawal can be life-threatening and indicate that the situation is serious and requires a medical intervention. Follow your clinic policies and procedures in this situation.

Serious withdrawal symptoms can include:

• Loss of consciousness.
• Changes in responsiveness of pupils.
• Increased anxiety.
• Hallucinations.
• Temperature greater than 100.4F.
• Increased or decreased blood pressure and heart rate.
• Insomnia.
• Abdominal pain.
• Upper and lower gastrointestinal bleeding.

Five categories of substances are described in this section: stimulants, depressants, hallucinogens, inhalants, and designer drugs. Under each category, specific drugs are listed and described along with signs of intoxication, side effects, and withdrawal symptoms. For more details on the types of drugs in each category, including symptoms of and consequences related to their use, refer to the most current version of the DSM.

Stimulants

Stimulants (or “uppers”) temporarily increase (or stimulate) different aspects of physical and mental functioning.

Stimulant drugs include:

• Cocaine, an illegal stimulant substance that is usually sniffed, smoked, or injected.
• Methamphetamine, an illegal stimulant substance that is sniffed, smoked, or injected.
• Caffeine, a legal stimulant substance found in coffee, tea, energy drinks, chocolate, and some over-the-counter medications.
• Nicotine, an age-restricted legal stimulant substance found in cigarettes and chewing tobacco.
• Prescribed medication, stimulant substances typically prescribed for ADHD, weight loss, and sleep disorders.

The effects of stimulant intoxication vary depending on the person and the substance.

Some common effects of stimulant intoxication include:

• Increased alertness, attention, and energy.
• Increased blood pressure, heart rate, and breathing.
• Increased feelings of anxiety, restlessness, and aggression.
• Increased feelings of hostility, paranoia, and even psychotic symptoms.
• Decreased appetite or thirst.

Long-term and inappropriate use of stimulants can lead to tolerance, addiction, dependence, withdrawal, and health problems.

• Improper stimulant use can result in an elevated body temperature, irregular heartbeat, heart failure, and seizures.
• Withdrawal from cocaine, methamphetamine, and some prescription drugs can include intense cravings for the substance, decreased energy, and paranoid thinking.
• Caffeine withdrawal symptoms include headache, irritability, and fatigue.
• Nicotine, when smoked or chewed as tobacco, carries serious health risks related to cancer, heart disease, and respiratory problems.

Depressants

Depressants, or “downers,” temporarily decrease (depress) the activity and function of the Central Nervous System.

Depressants drugs include:

• Alcohol, an age-restricted legal and socially used drinkable depressant substance.
• Opioid-based medications, legal (if properly prescribed and taken) pain medications that are also highly addictive depressant substances (e.g., Oxycontin, Vicodin, Percocet) .
• Heroin, an illegal, highly addictive opioid substance made from morphine and typically smoked or injected.
• Sedative-hypnotic medications, legal (if properly prescribed and taken) medications typically prescribed to treat the symptoms of anxiety, panic, and sleep problems.
• Other depressants, such as vanilla extract, antifreeze (which can be deadly), Pine Sol, cold medicine, rubbing alcohol (which is poisonous), and mouthwash. These are sometimes drunk for their depressant qualities.

The effects of depressant intoxication vary depending on the person and the substance.

Some common effects of depressant intoxication include:

• Slowed brain function.
• Slowed pulse and breathing.
• Lowered blood pressure.
• Poor concentration.
• Confusion.
• Fatigue.
• Dizziness.
• Slurred speech.
• Sluggishness.
• Visual disturbances.
• Dilated pupils.
• Disorientation.
• Lack of coordination.

Long-term and inappropriate use of depressant substances can lead to tolerance, addiction, dependence, withdrawal, and health problems.

• The risk of overdose is high and withdrawal can be life threatening. Follow your clinic policies and procedures if a client seems to be experiencing withdrawal from a depressant drug.
• Mixing depressant drugs is a common cause of overdose. For example, if a client mixes alcohol with a prescribed pain medication, the risk of overdose increases. This is because depressant drugs slow down the functions of the Central Nervous System (CNS). Important functions of the CNS include respiration and heart rate. When either (or both) of these functions is slowed down too much, death is possible.
• Some symptoms of depressant withdrawal include insomnia, weakness, nausea, severe agitation, high body temperature, delirium, hallucinations, and convulsions.
• Depressants can lead to chronic fatigue, depression, breathing difficulties, sexual problems, sleep disorders, high blood pressure, weigh gain, and diabetes.

Hallucinogens

Hallucinogens are substances that interfere with the brain and Central Nervous System, altering a person’s perception of reality.

Hallucinogenic drugs include:

• Marijuana, a substance derived from the cannabis leaf that is age-restricted legal in some places and illegal in others. Marijuana is a hallucinogenic in high doses and a depressant in low doses. Marijuana can be prescribed to treat symptoms of some medical conditions. Although marijuana is typically smoked, it can also come in edible form (e.g., brownies, cookies, butter) or vaporized. Street names for marijuana include weed, pot, herb, bud, dope, reefer, grass, chronic, Mary Jane, and skunk.
• Psilocybin, an illegal psychedelic drug found in hundreds of mushroom species. Some indigenous tribes have a history of consuming hallucinogenic mushrooms for spiritual or ritual purposes. Street names for psilocybin include magic mushrooms, boomers, and fungus.
• MDMA, an illegal substance with both stimulant and psychedelic properties. MDMA typically produces feelings of euphoria among users. Street names for MDMA include ecstasy and Molly.
• LSD, an illegal psychedelic substance that can cause hallucinations, delusions, and distortion in time and reality. LSD can be extremely potent with long-lasting effects when taken in high doses. Effects can last 8-10 hours. Street names for LSD include Acid, blotter, doses, dots, and trips.
• PCP, an illegal psychedelic substance that can cause feelings of detachment from surroundings, hallucinations, delusions, mania, and delirium. High doses can be fatal. Street names for PCP include Angel Dust, Embalming Fluid, and Rocket Fuel.

The effects of hallucinogen intoxication vary depending on the person and the substance.

Some common effects of hallucinogen intoxication include:

• Intense emotions (e.g., happiness, sadness, fear).
• Feeling detached from one’s environment and oneself.
• Distortions in time and perception.
• Hallucinations (e.g., seeing, hearing, smelling, tasting, or feeling things that are not real).

Long-term and/or inappropriate use of some hallucinogenic substances can lead to persistent anxiety or depression. Rare but serious side effects can include heart failure (MDMA) and flashbacks (LSD).

Inhalants

Inhalants are substances (or fumes) found in household items that are sniffed (or “huffed”) to cause an immediate high.

Inhalants include:

• Aerosol sprays.
• Cleaning fluids.
• Glue.
• Paint.
• Paint thinner.
• Gasoline.
• Propane.
• Nail polish remover.
• Correction fluid.
• Marker pens.
• Nitrous Oxide (“whippets”).

The effects of inhalant intoxication vary depending on the person and the substance.

Some common effects include:

• Rapid high that resembles alcohol intoxication.
• Dilated blood vessels.
• Increased heart rate.
• Dizziness.
• Drowsiness.
• Slurred speech.
• Depressed reflexes.
• Muscle weakness.
• Stupor.
• Euphoria.
• Giddiness.
• Decreased coordination.

Inhalant use can cause immediate and irreversible brain damage and death. Long-term inhalant use can cause a number of health problems, including damage to the brain, lungs, heart, liver, and kidneys.

Designer drugs

Designer drugs include artificial substances developed to mimic the effects of other illegal substances such as stimulants, psychedelics, and depressants.

Designer drug examples include:

• Spice and K2, substances made of plant material and laced with artificial cannabinoids or THC (the psychoactive ingredients found in marijuana).
• Bath Salts, substances made of salt-like material and laced with substances intend to mimic amphetamines (stimulants).

The effects of designer drug intoxication vary depending on the person and the substance. Designer drugs are made of artificial substances that are changed all the time. When the substance changes, the effects of the substance change.

Some common effects include:

• Agitation.
• Extreme nervousness.
• Panic attacks.
• Exaggerated fear.
• Paranoia.
• Rapid heartbeat.
• Elevated blood pressure.
• Hallucinations.
• Tremors.
• Seizures.

Long-term effects of designer drugs use are not well understood. Some documented serious side effects include psychotic symptoms that last for days, suicidal ideation and completion, and harm to others.

Substance use and abuse is a problem across the lifespan. Substance use problems often co-occur with other behavioral health problems. For example, substances are often used to numb the feelings that come along with Posttraumatic Stress Disorder ( PTSD ).

Substance abuse is related to many health and social problems. Prevention of substance abuse is important. Consider making educational materials available to clients in the clinic and around the community. Resources are available for free from the Substance Abuse and Mental Health Service Administration (SAMHSA). The ASAM criteria can also be helpful when assessing and intervening with substance use.

SAMHSA produced an adaptable Screening, Brief Intervention, and Referral for Treatment (SBIRT) Model that is used to inform the following guidelines. The SBIRT model is considered a best practice for client care.

Screening for Substance Abuse

Screen your clients for substance abuse following your clinic’s procedures. SAMSHA recommends screening for substance use/abuse starting as young as eight years old and continuing regular screening throughout the lifespan. Screening young people for substance abuse supports early intervention and prevention of problems later in life. Screening routinely at clinic visits can make the topic of substance use easier to talk about during sensitive periods of development, like adolescence, pregnancy, and older adulthood. If a client screens positive for substance use, assess the level of risk and work with your supervisor and clinical team to identify the most appropriate type of intervention.

Assessing Level of Risk

Assess your client’s level of risk. Consider the screening results and additional risk factors for substance abuse. Clients are considered “at risk” for substance abuse if they screen positive to your screening questions. The level of risk may increase if other risk factors are in place. Depending on the level of risk, choose a brief intervention. For clients who are currently abusing substances or are substance dependent, consider a referral for additional treatment.

Choosing Brief Interventions

Brief interventions are delivered when a client screens positive for substance abuse. The goal of a brief intervention is to motivate healthy behavior change and prevent potential harm from substance abuse. For example, if a client is abusing alcohol but is not ready to reduce or stop using alcohol, a brief intervention might include a plan for the client to only drink indoors to prevent the negative consequences of winter weather exposure. Fitting brief interventions to the client’s stage of change can increase the success of the intervention.

Referring to Treatment

Substance abuse treatment can improve the health of clients who are abusing substances or are substance-dependent. Know the available resources in the community and make appropriate referrals to treatment.

Stages of Change

Research has identified six stages of change. Each stage of change is listed here along with a “primary task” that can help guide the brief intervention. Assess your client’s stage of change before intervening.

Pre-contemplation

• Definition: The client is not yet considering a change, is unwilling to change, or is unable to change.
• Primary task: Raising awareness.

Contemplation

• Definition: The client is aware of the need to change but is uncertain or ambivalent about the change.
• Primary task: Resolving uncertainty or ambivalence and helping the client to choose change.

Determination/Preparation

• Definition: The client is committed to change and planning how to change.
• Primary task: Identifying appropriate change strategies.

Action

• Definition: The client is taking steps toward change, but is not yet stabilized in the change.
• Primary task: Supporting change strategies and helping the client reduce the risk of relapse.

Maintenance

• Definition: The client has achieved goals and is working to maintain the change.
• Primary task: Developing new skills to maintain recovery.

Recurrence/Relapse

• Definition: The client has “slipped” and used the substance again.
• Primary task: Coping with the consequences and determining what to do next.

Provider Tips

• People do not always move from one stage to the next. Sometimes clients skip stages, both forward and backward.
• Recurrence/relapse is common and part of the change process.
• Shaming clients for their substance use and/or trying to scare them about their substance abuse can be counterproductive.
• Maintain a non-judgmental, supportive stance.
• Use active listening skills, like reflection and open-ended questions, to understand how best to help your client.
• Affirm your client’s efforts to make healthy changes.
• Respect your client’s autonomy.

What does recovery from substance abuse look like?

In many cases, recovery from substance abuse involves abstinence from the substance, but not always. Sometimes the goal is to reduce the harm associated with the substance use. Usually, the client is in charge of the goal (i.e., abstinence or harm reduction); however, sometimes there are legal or other matters that require abstinence as a goal. In these cases, additional treatment may be necessary to help the client obtain and maintain abstinence.

Child and Youth Substance Use

Substance use can influence brain development. The younger a person is when he begins using substances, the more likely his use will develop into a problem as an adult.

Experimenting with substances can lead to use. Use can lead to abuse and abuse can lead to dependence. Substance dependence can lead to decreased mental, social, and physical functioning.

Peer pressure influences young people in powerful ways, so screening youth for substance use can help identify and treat a substance abuse problem early. Follow your organizational policies regarding what age you should begin screening youth. If a youth screens positive for substance use, assess the level of risk. Based on the level of risk, the individual may need a substance use assessment and related treatment plan.

Elder Substance Use

As our bodies change over time, the ability to process substances can also change. Older adults often have a lower tolerance for alcohol and are prescribed more medications on average; this increases the risk of dangerous interactions between the alcohol and medicine.

Screen adults and elders for substance use regularly. If a client screens positive for substance use, assess the level of risk. Based on the level of risk, consider recommending a substance abuse assessment and a treatment plan that includes a level of treatment appropriate to the level of need.

Referral information, including reports from medical providers, school staff, clinicians, or other sources regarding the client's wellbeing.

Releases of Information ( ROIs ) that are current or updated before getting information about the client from other sources.

Client history related to sensory functioning, development, and psychological history.

Treatment Plan, including a history of the presenting problem and recommended course of treatment. Review the DSM-5 for criteria on Substance Abuse and Dependence.

Signs and symptoms of specific substances are summarized in the Introduction section of this chapter. In this section, general signs of substance abuse are summarized.

Risk factors increase the likelihood of negative outcomes resulting from substance abuse. Protective factors decrease the likelihood of negative outcomes resulting from substance abuse. Some risk and protective factors are fixed, meaning they do not change over time. Other risk and protective factors are variable, meaning they may change over time. All factors should be considered when developing treatment plans.

Personality changes

• Poor judgment (e.g., skipping school, missing work, driving drunk)
• Careless behavior (e.g., disregarding safety)
• Spending less time being happy or more time being gloomy or angry
• Lack of interest in normal activities
• Changes in levels of energy, appetite, or need for sleep
• Not seeming to care about much
• Appearing unkempt or disheveled
• Unreliable or unpredictable
• Engaging in risky behaviors
• Negative attitude toward family or community

Changes in emotions and mood

• Low self-esteem or negative self-talk
• Changes in mood, including depression or mania
• Frequent or rapid mood changes
• Lack of interest in normal activities

Problems in the family/home environment

• Withdrawn or isolated from family, friends, community
• Secretive behaviors related to substance use
• Initiating frequent arguments and physical outbursts or aggression
• Knowingly breaking family or community rules

Social concerns

• Living in a community with high rates of use
• Easy access to the substance
• Avoiding long-time friends or preferring to be with others who are using substances
• Changes in dress and behavior
• Trouble with the legal system

Health concerns

• Dental problems related to substance use
• Scratches, skin lesions, or evidence of skin-picking
• Rash around the nose and mouth
• Lasting cough or runny nose
• Symptoms of physical withdrawal after periods of non-use

School- or work-related concerns

• Frequent absences or tardiness
• A significant drop in grades or work performance
• Disruptive behavior
• New or increased problems with discipline
• Loss of interest in school or work

Individual characteristics that increase risk

• Aggressive behavior
• Lack of self-control
• Difficult temperament
• Impulsivity
• Low self-esteem/self-worth

Family dynamics that increase risk (especially for minors)

• A lack of attachment with primary caregivers
• Adverse childhood experiences, including neglect and abuse
• Ineffective parenting
• Substance abuse in the family

Factors outside the family that increase risk

• Lacking social skills
• Academic or work failure
• Associating with friends who use/abuse substances

Global protective factors

• Healthy, strong bond with family, community, and culture
• Parental involvement in the minor’s life
• Clear limits and expectations for youth
• Community engagement
• Religion and spirituality

History of substance use

• Have you ever taken, huffed, sniffed, or smoked something to:
  • Make you feel better or different?
  • Help you feel more awake or alert?
  • Help you sleep?
  • Make you stop experiencing certain memories or feelings?
• If the client answered yes to any of the questions above, ask the following questions.
  • What substance did you use and how did you use it?
  • When was the last time you used it?
  • How often have you used it?
  • How did it make you feel?
  • Do you use it by yourself or with others?
  • Have you ever used any other substance?
  • Have you ever used different substances as the same time?
  • Have you ever heard or seen things that you realized were caused by the substance?
  • Have you ever tried to stop using and found it hard to do so?
  • Has a family member or friend told you that you needed to quit using the substance?

Motivation for changing behaviors

• How do you usually spend your day?
• Are there things that you do not do now but would like to?
  • If the answer is yes, ask for more details.
• Do you play any sports?
  • If the answer is yes, ask for more details.
• Do you think you have a problem with using?
• Would you like to stop using?
• What do you think might help you stop using?
• Do you participate in any school or cultural activities?
• How do you think things would go if you stopped using?
• Would your family or primary caregiver be supportive?
• Who else would support your effort to stop using?

Routinely review: BHA/P Services and Common Interventions for how to prepare for and conduct interventions during appointments and for information on the levels of service available throughout Alaska.

Specifically, you may consider exploring the client's motivation to change their substance use habits. Many clients are mandated for substance use treatment and will attend sessions, but may not be motivated to change their patterns of substance use. Motivational Interviewing is an evidence-based approach to help the client identify benefits of reduced use. Any time a client identifies how these behavior changes look or potential benefits of new behaviors, it is called " change talk." Reinforcing and promoting a client's change talk is a key factor in supporting meaningful changes to their patterns of substance use. This will help you and the client identify unique and individual goals for treatment.

You can help the client develop skills related to mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness (see BHA/P Services and Common Interventions ). Many THOs also use the Seeking Safety model for patients that experience substance use problems or have a history of trauma.

There are many levels of treatment for substance abuse disorders. Consult with your supervisor to determine if your organization has a standard model of treatment used for clients who experience problems related to their substance use and develop a treatment plan with an appropriate level of treatment.

Below are some recommendations for brief interventions based on your client’s stage of change.

Precontemplation stage of change

• The primary task is to raise awareness.
• Provide factual information about the substance use/abuse.
• Discuss what gives the person’s life meaning (e.g., values).
• Explore how the substance use/abuse aligns (or does not align) with these values.

Contemplation stage of change

• The primary task is to resolve ambivalence and help the person choose healthy behavior change.
• Explore how important the change is to the person.
• Explore how confident the person feels in making the change.
• Explore pros and cons of the behavior change.

Determination/Preparation stage of change

• The primary task is to help identify appropriate change strategies.
• Offer a “menu” of change options, such as spending time with sober friends, joining an AA group, or getting consultation for medication to assist recovery.
• Identify barriers that might get in the way of the change efforts.
• Encourage the person to make these plans known to friends and family.

Action stage of change

• The primary task is to implement change strategies and prevent relapse.
• Support a realistic view of change and reinforce small steps.
• Identify situations that trigger use and develop coping strategies.
• Engage social support.

Maintenance stage of change

• The primary task is to develop new skills to maintain recovery.
• Help identify alternative activities that do not include substance use.
• Maintain supportive contact with the person.
• Set short- and long-term goals for recovery.

Recurrence/Relapse stage of change

• The primary task is to cope with consequences and decide what’s next.
• Help the person see the recurrence/relapse as a learning experience.
• Explore what led to the recurrence/relapse.
• Explain the stages of change and help the person get back on track.

Be sure you are familiar with the information in: Mandatory Reporting and Duty to Warn and Documentation and Billing. Report instances of the following, consistent with your organization's policies and procedures:

• Child abuse or neglect.
• Suicidal thoughts or plans.
• Intentions to cause harm or injury to the self or others.

Stimulants
Substance (Drug)	Physical Dependence	Psychological Dependence	Withdrawal Syndrome
Cocaine	Possible	Moderate to high	Depression; lack of Interest; increased sleep; easily annoyed or angry; not connecting to the here and now
Amphetamines and methamphetamine	Possible	Moderate to high	Same as above
Ritalin	Possible	Moderate to high	Same as above
Caffeine	Yes	Possible	Easily annoyed or angry; headaches
Nicotine	Yes	Yes	Easily annoyed or angry

Depressants
Substance (Drug)	Physical Dependence	Psychological Dependence	Withdrawal Syndrome
Opium	High	Moderate to high	Runny nose; watery eyes; loss of appetite; nausea; feelings of panic; chills and sweats; shaking; cramps
Morphine	High	Moderate	Same as above
Codeine	Moderate	Moderate	Same as above
Heroin	High	High	Same as above
Methadone and other narcotics	High	Moderate	Same as above
Chloral hydrate	Moderate	Moderate	Unable to sleep; anxiety; shaking; loss of reality; seizures; possible death
Barbiturates	Moderate to high	Moderate to high	Same as above
Methaqualone	High	High	Same as above
Benzodiazepines	Low to moderate	Moderate to high	Same as above
Alcohol	Usually moderate; can become high with long-term use	Moderate to high	Same as above

Hallucinogens and Inhalants
Substance (Drug)	Physical Dependence	Psychological Dependence	Withdrawal Syndrome
Amphetamine-like variations, club drugs (DOM, STP, MDA, MDMA, Ecstasy, MMDA, TMA)	Unknown	Unknown	None reported. Dehydration and heart arrhythmia may be issues while using.
Phencyclidine (PCP)	Low	High	None reported. Self-harm is a concern while using
Psilocybin	None	Low	None reported
Mescaline	None	Low	None reported
Peyote	None	Low	None reported
LSD	None	Low	None reported. Self-harm and suicides are concerns while using. (exaggerated physical strength, aggression?)
Marijuana	Low	Moderate	Over activity; problems sleeping
THC or Marinol	Low	Moderate	Same as above
Hashish	Low	Moderate	Same as above
Inhalants	None	Moderate to high	Depression; easily annoyed or angry; prolonged sleep; not caring; not connecting to the here and now. Sudden death events and suicides are a high risk with inhalant abuse.