EXAM PREP 2b03acca9553414b9413c9da86e2f079.pdf

EXAM PREP Completed Key Focus Basic characteristics of alcohol measures (what they measure and don’t measure) Use, Problems Expectancies AUDIT → hazordous use, dependence, harms SADQ → P...

EXAM PREP Completed Key Focus Basic characteristics of alcohol measures (what they measure and don’t measure) Use, Problems Expectancies AUDIT → hazordous use, dependence, harms SADQ → Physical withdrawal, Affective withdrawal, Withdrawal relief drinking, Alcohol consumption, Rapidity of reinstatement RAPI → DPI → AEQ → measures expectancies related to: Transforms experience, Enhances social/physical pleasure, Sexual experience and performance, Power and aggression, Social assertiveness, Reduces tension Basic characteristics/features of substance use disorders A chronically relapsing condition characterised by the compulsion to take one or more drugs with loss of control over drug intake and continued use despite negative consequence tolerance, withdrawal, salience, altered mood, cravings, conflict, relapse Criteria Criteria Description Category 1. Larger Takes substance use in larger amounts or over Impaired Control amounts or longer periods than originally intended longer periods Expresses a persistent desire to cut down or 2. Desire to cut regulate substance use but not managing to (may down report multiple unsuccessful efforts) 3. Time spent on Spending a great deal of time obtaining, using, and substance recovering from use of the substance Cravings to use the substance (an intense desire or urge for the drug that may occur at any time but 4. Cravings more likely when in an environment where the drug was previously obtained or used) EXAM PREP 1  Criteria Criteria Description Category 8. Physically Recurrent substance use in situations in which it is Risky Use hazardous use physically hazardous The individual may continue substance use despite knowledge of having a persistent or recurrent 9. Continued physical and psychological problem that is likely use despite caused or exacerbated by the substance (failure to problems abstain from the substance despite the difficulty it’s causing) Social 5. Role Failure to fulfill major role obligations at work, Impairment obligation failure school, or home because of substance use Continued substance use despite having persistent 6. Interpersonal or recurrent social or interpersonal problems problems caused by or exacerbated by the effects of a substance Giving up or reducing important social, 7. Reduced occupational, or recreational activities because of activities substance use (may withdraw from family activities and hobbies to use substances) Requiring a markedly increased dose of the substance to achieve the desired effect or a Pharmacological 10. Tolerance markedly reduced effect when the usual dose is consumed Withdrawal symptoms that can be relieved by 11. Withdrawal taking more of the substance Core tenets of MI, CBT, ACT, EMDR MI Empathy and underdstanding → validate expereinces highlighting discepancies → decisional balance not an argument → don’t confront resistance, work with it collaboration → work with the client encourage motivation → help find clients own motivations supportive communication → OARS, reflective listening Readiness → readiness ruler (importance and confidence) CBT EXAM PREP 2  Therapeutic Relationship Central to the process; build a strong, supportive alliance. Evidence-Based Enquiry Explore evidence for and against thoughts. Consider alternative explanations and usefulness of thoughts. Multi-Dimensional Approach Combines cognitive, behavioral, emotional, and physiological interventions. Structured and Goal-Oriented Task-focused, coping-focused, and outcome-focused strategies. Awareness and Understanding Increase awareness of internal processes and automatic thoughts. Behavioral Experiments Set up experiments to test thoughts and beliefs. Socratic Questioning Use open, non-confrontational questions to facilitate insight and alternative actions. Acceptance and Validation Accept and validate client's experiences and progress. Integration of Techniques Incorporate methods from various approaches (e.g., mindfulness, positive psychology, MI). Client Empowerment Emphasize self-help and problem-solving; clients become their own therapists. ACT Acceptance and Commitment: Embrace life experiences, including painful ones, without trying to eliminate them. Commit to actions that align with personal values, fostering a meaningful life. EXAM PREP 3  Psychological Flexibility: Stay present and aware, making choices based on values rather than being driven by momentary thoughts or emotions. Engage in behaviors that move you towards what is important to you. Mindfulness: Cultivate awareness of the present moment. Distinguish between the “thinking self” (the constant stream of thoughts) and the “observing self” (the part that is aware of thoughts and experiences). Cognitive Defusion: Reduce the impact of unhelpful thoughts by creating mental distance from them. Use techniques like naming thoughts, visualizing them in different contexts, and recognizing them as mere events in the mind. Values-Based Living: Identify and clarify what is truly important in life. Use values as a guide for making decisions and taking actions, ensuring that behavior is consistent with these values. Experiential Avoidance and Acceptance: Recognize and accept that pain and discomfort are part of life. Instead of avoiding negative experiences, accept them and commit to actions that are meaningful and aligned with values. Self-As-Context: Understand the concept of self as an ongoing process rather than a fixed entity. View thoughts and feelings as separate from the self, reducing the power of negative self-concepts. Committed Action: Take concrete steps towards living a valued life, despite any challenges or setbacks. Focus on consistent, values-driven behavior rather than temporary emotional states. Urge Surfing: EXAM PREP 4  Learn to ride out urges and cravings without acting on them. Observe urges as temporary and manageable, recognizing that they do not dictate behavior. Dealing with Dictator Thoughts: Identify and defuse from dominating negative thoughts that dictate behavior. Use mindfulness and acceptance to reduce the influence of these “dictator” thoughts. EMDR Memory Reprocessing: Focus on resolving trauma by reprocessing traumatic memories. All psychopathology is seen as a disorder of memories; resolving the memory resolves the symptoms. Components of Memory: Address multiple aspects of memory: images (or sensory experiences), thoughts, emotions, body sensations, and self-beliefs. 8 Phased Approach: History Taking: Understand the client's background and traumatic experiences. Preparation: Ensure the client is ready for EMDR, using techniques to manage after the session. Assessment: Identify and activate the traumatic memory. Desensitization: Reduce distress related to the traumatic memory. Installation: Reinforce positive beliefs to replace the negative ones. Body Scan: Check for any residual physical responses related to the memory. Closure: Ensure the client feels stable before ending the session. Reevaluation: Assess the impact of the previous session and any changes in symptoms. Bilateral Stimulation (BLS): Use eye movements or other forms of BLS (tapping, sounds) to facilitate reprocessing. EXAM PREP 5  BLS pairs with activated memory components to aid in adaptive processing and integration. Non-Talk Therapy: Useful for clients who find it difficult to talk about their trauma. The therapist does not need detailed information about the trauma. Adaptive Information Processing: Aim to help clients reprocess traumatic memories so they are stored adaptively. Shift from the memory feeling like it’s happening now to recognizing it as part of the past. Integration with Other Therapies: EMDR can be integrated with other therapeutic approaches like DBT, IFS, and somatic therapies, especially during preparation for clients with high levels of dissociation. Trauma Map: Recognize the interconnected nature of memories within a network rather than isolated incidents. Address how past traumatic experiences impact present and future triggers. Effects of different drugs physiologically Withdrawal Management Drug Physiological Actions Symptoms Strategies Enhances GABA-A, Thiamine inhibits NMDA supplementation, Tremors, seizures, receptors, affects sedatives (e.g., delirium tremens, Alcohol dopamine, serotonin, diazepam), supportive agitation, sweating, opioid, and care, assess risk nausea, vomiting noradrenaline factors, monitor systems progress Gradual tapering, Facilitate GABA Tremors, seizures, switch to long-acting action, release agitation, anxiety, benzodiazepine (e.g., Benzodiazepines inhibition of dopamine insomnia, muscle diazepam), regular in Nucleus stiffness monitoring, Accumbens psychological support Opioids Euphoria, drowsiness, Nausea, vomiting, Buprenorphine, gradual pain relief, sedation, cramps, diarrhea, dose reduction, EXAM PREP 6  Withdrawal Management Drug Physiological Actions Symptoms Strategies altered pain sweating, irritability, symptomatic perception anxiety, medications, restlessness psychological support Psychological support, CNS stimulant, Depression, fatigue, healthy diet, sleep increases alertness, insomnia, agitation, regulation, possible Amphetamines energy, endurance, lack of enjoyment, antidepressants, reduces hunger cravings diazepam for anxiety and sleep Anxiety, insomnia, Symptomatic treatment, Sedation, altered irritability, nausea, diazepam for severe Cannabis mood and perception poor concentration, cases, psychological headache, cravings support Cravings, irritability, Nicotine replacement Stimulant, increases anxiety, difficulty therapy (NRT), Tobacco heart rate, alertness, concentrating, behavioral therapy, and energy levels increased appetite support groups Alcohol Enhances GABA-A, inhibits NMDA receptors, affects multiple neurotransmitter systems causing sedation, euphoria, and craving. Withdrawal involves tremors, seizures, and delirium tremens, managed with thiamine, sedatives, and supportive care. Benzodiazepines Facilitate GABA action, leading to sedation and anxiolytic effects. Withdrawal symptoms include tremors, muscle stiffness, seizures, and anxiety, managed by gradual tapering and psychological support. Opioids Induce euphoria, drowsiness, and altered pain perception. Withdrawal is marked by nausea, cramps, sweating, and irritability, treated with buprenorphine and symptomatic medications. Amphetamines Act as CNS stimulants, increasing energy and alertness but can lead to psychosis and violent behavior. Withdrawal includes depression and fatigue, managed through psychological support and healthy routines. Cannabis EXAM PREP 7  Causes sedation and mood alterations. Withdrawal symptoms are generally mild and include anxiety, insomnia, and irritability, managed with symptomatic treatment and occasional use of diazepam. Tobacco Stimulates increased heart rate and energy levels. Withdrawal symptoms involve cravings, irritability, and anxiety, managed with nicotine replacement therapy (NRT) and behavioral therapy. Major types of pharmacotherapies and what they are used for 💊 Naltrexone: Opioid receptor antagonist used to reduce cravings and prevent relapse in alcohol and opioid dependence. 💊 Acamprosate: Modulates glutamate and GABA neurotransmission, used to maintain abstinence in alcohol dependence. 💊 Disulfiram: Inhibits aldehyde dehydrogenase, causing unpleasant reactions when alcohol is consumed, used to promote abstinence in alcohol dependence. 💊 Baclofen: GABA-B receptor agonist, used off-label for reducing cravings in alcohol dependence. 💊 Topiramate: Anticonvulsant that modulates glutamate and GABA, used off- label for alcohol and cocaine dependence. 💊 Buprenorphine: Partial opioid agonist, used to manage opioid withdrawal and reduce opioid use. 💊 Nicotine Replacement Therapy (NRT): Provides controlled doses of nicotine to reduce withdrawal symptoms and cravings in tobacco dependence. 💊 Antidepressants: Used to treat underlying or residual depression and anxiety associated with substance dependence. 💊 Antipsychotics: Used to manage psychotic symptoms and agitation in substance dependence, particularly in amphetamine and cannabis withdrawal. Stages of change The stages of change model describes a cyclical process that individuals undergo when attempting to modify addictive behaviors. These stages include pre-contemplation, contemplation, preparation, action, maintenance, and potential relapse. Understanding these stages helps in providing appropriate support and interventions tailored to each stage, ultimately aiming to achieve sustained behavior change and increased confidence in maintaining sobriety. 🔄 Pre-Contemplation: No intention of changing behavior; may involve denial or lack of awareness of the problem. EXAM PREP 8  💡 Contemplation: Recognition of the problem without commitment to action; can be prolonged as individuals weigh pros and cons. 📝 Preparation: Planning for change; involves gathering information and resources, though often inadequate preparation occurs. 🚀 Action: Active modification of behavior; implementing plans and strategies to change addictive behaviors. 🔧 Maintenance: Sustaining behavior change; involves ongoing efforts to maintain new behavior and prevent relapse. 🔄 Relapse: Possible at any stage; learning from relapses is crucial to improve future efforts and increase resilience against full relapse. Gambling 🛑 Problem gambling signs: Arguments with family, borrowing money, hiding gambling extent, and gambling to escape problems. 📋 DSM-V criteria: Requires four symptoms in a year, such as needing to gamble with more money, being irritable when cutting down, and chasing losses. 💰 Financial impacts: High losses, particularly in disadvantaged areas, leading to debts, illegal activities, and reduced earning capacity. 🧠 Mental health effects: Includes depression, anxiety, guilt, and high suicide attempt rates. ⚖️ Legal issues: Money laundering, tax evasion, and systematic breaches by gambling establishments. 🌐 Prevalence: Australians lose $22 billion annually, with the highest losses per capita worldwide. 🎰 EGMs: Easily accessible, high loss rates, and associated with other social problems. 📊 Assessment tools: Various scales for gambling urges, cognitions, motivations, and self-efficacy. 📈 Gambling triggers: Trauma, financial strain, underemployment, and social isolation. 📢 Marketing: Aggressive advertising and sponsorship in sports, promoting gambling as a social and patriotic activity. Queensland Responsible Code of Practice Major points from each of the core readings EXAM PREP 9  Intro to Addiction How do we define use, harmful use, dependence, addiction? Language and implicit bias careful of judgemental language → person centered vs Identity centred Negative character associations with terms like alcoholic, drug addict ect. TREATMENT PLAN Treatment plan is informed by: Diagnosis Formulation → working story - why they’re stuck Risk assessment → suicidality etc. evidence base → what works for this person and why? eg. in a legal situation Process issues → how your interaction with the client, dynamics. EXAM PREP 10  Substance Use Disorder/Dependence Disorder vs dependence → disorder has negative connotations A chronically relapsing condition characterised by the compulsion to take one or more drugs with loss of control over drug intake and continued use despite negative consequence Interferes with: Social ‼️ Major aspects of SUD functioning CRAVING Occupational LOSS OF CONTROL functioning SALIENCE Physical functioning Craving → trapped, like a tsunami is coming and you cant get away Unwanted wanting of something I want validate validate validate!! creates trust Focus on alcohol.. Briefly overview other commonly used drugs How many Australians use substances? We are all at risk of addictive behaviours Excluding caffeine, analgesics, prescribed drugs: No risky drinking, daily smoking or illicit drugs: 61% EXAM PREP 11  🍻 Alcohol any 🚬 Tobacco 💊 Illicit drugs 12% 15.6% (recent recently smoking users) 78% daily Mj 10.4%, 28% > 2 (24% Cocaine regularly 1991) 2.5%, or > 4 ecstasy sometimes 2.2%, Highest meth/amph age group 1.4%, —20s— injected often 0.3% binges Misuse of Daily use pharmas increases (excl over with age the counter) — 4.8% Trends Alcohol - almost everyone uses alcohol Upward trend of problematic use in 40s, 50s—cohort effect But 14-19 yr old drinking 5+ ≥ monthly falling since 2001 (39%à18%) Trends of teenage alcohol use over the last 20 years EXAM PREP 12  Tobacco - steep falls since 1940s—flattening out Adolescent smoking—falling since 2001 14-19 yrs ever 25%à 6%; daily 15%à 3% 40s: now highest group, but falling—22%à 17% Vaping Nicotine liquids illegal but prevalent 26.1% of 18-24 yearolds have ever vaped Less harmful than combustible tobacco but still not safe CDC 2020 – high rates of lung injury and can lead to lung injury-related death Lots of unknowns: Juices variable Don’t know what’s in them Some contents are harmless when ingested through the gut but could be dangerous heated and ingested via lungs Alcohol Harmful drinking → more than this increases risks of health issues drinking no more than 10 standard drinks a week and no more than 4 standard drinks on any one day Children under 18 years of age should not drink alcohol Women who are pregnant or breastfeeding “binge drinking” → heavy episodic drinking, not a very clear term. What is a standard drink? → when assessing alcohol problems assessing how many standard drinks + frequency Physical Effects of Alcohol Physical health consequences Headaches, Blackouts, hyperlipemia Paranoia, Forgetfulness, cirrhosis Impaired judgement, Accident and injury, Overdose, Death irritation/bleeding to stomach, oesophagus The liver breaks down 90% of alcohol consumed EXAM PREP 13  fatty cells, tissue scarring, duodenitis, gastritis, jaundice, hepatitis, pancreatitis irreversible cirrhosis cancers of the mouth, larynx, Increased risk of cancer in tongue, oesophagus, liver and throat and digestive organs lung Risk of diabetes and heart hypertension disease haemorrhagic stroke, Wernickes disease (vitamin B arrhythmia deficiency) cardiomyopathy Korsakoff’s psychosis Wernicke/Korsokoff’s Syndrome Caused by lack of Vitamin B 1 (thiamine) Two syndromes often occur together Amnesia Problems with comprehension Hallucinations Confabulation Diagnostic criteria ABCDE Addiction is characterised by: Inability to consistently Abstain; Impairment in Behavioural control; Craving; or increased “hunger” for drugs or rewarding experiences; Diminished recognition of significant problems with one’s behaviour and interpersonal relationships Dysfunctional Emotional response what’s their history of abstinence/relapses? → what happened, what changed etc quantity/frequency, reality vs standard drinks EXAM PREP 14  Abstinence (lack of) Behavioural control (impairment) Craving Diminished recognition of problems Emotional response (dysfunctional) The purpose of diagnosis Description of levels of psychopathology Communication between health professionals Guide Treatment Inform prognosis Guides Research Identifying capacity of someone to stand trial Cognitive or functional impairment Help client Old way of diagnosing DSM-IV-TR (2000) Substance Abuse Out of control behaviour Doesn’t meet criteria for dependence Social/occupational/recreational/legal problems Substance Dependence Withdrawal/tolerance Out of control use, inability to cease/cut down Use causes physical and or psychological problems and interferes with social/occupational functioning Features of Substance Use Disorder EXAM PREP 15  💊 Tolerance → same amount < effect Similar relapse rates Salience → importance between substances A maladaptive pattern of Altered mood substance use Craving Loss of function and loss of Withdrawal control Conflict / emotion Relapse DSM-5 – Substance Use Disorders 11 criteria including 7 previous dependence criteria, 3 previous abuse and 1 new criteria (craving) Impaired control (Criteria 1-4) Social Impairment (Criteria 5-7) 1. Takes substance use in larger 5. Failure to fulfil major role amounts or over longer period obligations at work, school, or than originally intended home because of substance use 2. Expresses a persistent desire to cut down or regulate substance 6. Continued substance use use but not managing to (may despite having persistent or report multiple unsuccessful recurrent social or efforts) interpersonal problems caused by or exacerbated by the 3. Spending a great deal of time effects of a substance obtaining, using and recovering from use of the substance 7. Giving up or reducing important social, occupational, or 4. Cravings to use the substance recreational activities because (an intense desire or urge for of substance use (may the drug that may occur at any withdraw from family activities time but more likely when in and hobbies in order to use environment where drug substances) previously obtained or used) Pharmacological (Criteria 10 and Risky Use (Criteria 8-9) 11) 8. Recurrent substance use in 10. Tolerance: requiring a markedly situations in which it is increased dose of the physically hazardous EXAM PREP 16  9. The individual may continue substance to achieve the substance use despite desired effect or a markedly knowledge of having a reduced effect when the usual persistent or recurrent physical dose is consumed and psychological problem that 11. Withdrawal symptoms that can is likely to have been caused or be relieved by taking more of exacerbated by the substance the substance (failure to abstain from the substance despite the difficulty it’s causing) Removed from Criteria → ongoing substance related legal problems Diagnosis → Key Points No distinction between use and dependence Includes Gambling Disorder Continuum of Substance Use Disorder Mild (2-3 symptoms), Moderate (4-5 symptoms), Severe (6+ symptoms) DSM 5 applies to separate drug classes → no polydrug use disorder Alcohol Cannabis Hallucinogens Inhalants Opioids Sedatives-Hypnotics Stimulants Tobacco Other (name it) Caffeine – not clear whether it is clinically significant – in Section 3 of DSM5 ‼️ Doesn’t specify amount of substance use Tolerance and withdrawal not necessary and sufficient EXAM PREP 17  Alcohol and drug policy Categorical vs. Dimensional Systems Withdrawal/Cravings Tobacco Nicotine Leading cause of preventable disease and death in Australia Only 11% of Australians now smoke daily (halved since 1991) Withdrawal → Pretty bad! Urges Irritated Problems concentrating Sleep disturbance Feeling hungry Anxious / sad / depressed Withdrawal peaks in 1 week and may last to 4 weeks Alcohol EXAM PREP 18  Withdrawal Usually peaks within 3 days of cessation Most settle within 7 days Return to normal within 2-4 weeks Common symptoms: Agitation, cravings, irritability/mood swings, restlessness, tremor-seizure, sweating, nausea/gastro symptoms, poor sleep/concentration, aches/pains, headache Cannabis Withdrawal Usually mild Cravings, anxiety, irritability, poor sleep, vivid dreams, difficulty concentrating Interventions Withdrawal Management usually focussed on managing anxiety/irritability/sleep Counselling support/Support Groups Prevention, early intervention, treatment Initial therapeutic focus A safe place for this person Ethical assurances EXAM PREP 19  Open-ended exploration of presenting issues Suicidality screening Validation Ambivalence and how it is manifesting Times where drug use has reduced or stopped … what was this like? Key sources of support in person’s life Commitment to come back Something to work on Creating a safe place So brave to come to therapy…. Recognise clients sense of vulnerability Most SUD clients are feeling unsafe to some degree SUD do not want any more finger wagging Don’t know what to expect, uncertain Feel ambivalent May have made big changes already… Treat every patient at every session the way that you would want to be treated Bring yourself into the room Realistic expectations for self and for client Suicide Risk Assessment EXAM PREP 20  frequency, type of problems experienced, situational use?, abstinence history - what worked what changed what triggered him back, timeline followback → calander sheet thing take them through a period of time Assessment and Formulation The cycle of addiction Triggers (anxiety etc.) → craving/wanting to reduce negative feelings → use → shame around use or behaviour during use → trying to stop using until triggered again Formulation Formulation → an account of what the problem(s) are, how they developed, and why they are continuing Formulation identifies targets for intervention → what mechanisms will lead to change e.g → changing positivive expectancies of use, addressing avoidant behaviours The five Ps Ideographically ties together: EXAM PREP 21  Presenting problem(s) Precipitating factors (often events or situations that led to help seeking) Predisposing factors (early experiences / traumas / traits) Perpetuating factors (theoretically informed reasons or mechanisms for why problems are continuing and/or not resolving) What cues them? Protective factors (resources that are eudemonic, or would be if they were present) What are the cycles? good assessment is founded on rapport → therapeutic alliance focus on aspirations, values and goals → what is really important to the client focus on strengths and drawing conclusions about positive expectancies Goal Setting should be client driven and behavioural SMART goals → Specific → eg. standard drink measurement Measurable Achievable Relevant → related to mechanisms of change Time-Bound assessment methods should capture: change mechanisms of change Importance of theory-driven assessment Why be theoretically driven? It gives you a direction → what you asses or what you do It improves efficiencies in information gathering You are in the field of behavioural science Science practitioner model Hypothesis making Data gathering EXAM PREP 22  Reflection and synthesis → graphing changes/data, shows trends/change etc. Evidence-based intervention Evaluate change Gives the client a sense of direction, and confidence that you have a plan Assessment – an opportunity to start using language of change Challenge – client buy in Theories of Drug Use The cognitive Triangle Thoughts → feelings → behaviour Automatic thoughts (from Albert Ellis) not always obvious to people → can be hard to identify Awfulising ”Its awful if others know about my drinking” “Its terrible if my team doesn’t respect me” Low-frustration tolerance ”I can’t cope with these urges” “I am powerless to do cope with this feeling of tension” EXAM PREP 23  Depreciation ” I am worthless” “Other people do not value me or what I do” “I am a loser if I do no get on top of this” Deeper thought processes → core beliefs about my relationship with substance use Unlovability My drug problems are a sign there is something wrong with me and my character I am a flawed person and therefore I am less than human Helplessness My troubles with alcohol are an indication that I am incompetent Vulnerability (I am likely to get hurt). Ineffective compared to other people (I am inferior, I can’t achieve like others) Worthlessness I am a bad immoral sinner I am toxic person Negative beliefs about the world Other people are dangerous and don’t care about me –I am alone *Can be difficult for people to face and often takes more time for people to feel safe enough to talk about, can bring up alot of emotions EXAM PREP 24  not about causation → models are more about linking internal and external factors that contribute to substance use Assessment Why is it important to do assessments? Accurate formulation Inform diagnosis Identifying goals Goals may not be the same as the presenting problems Sets language/agenda for change Measuring change Methods of assessment Interviews (self and others) Questionnaires (self and others) Blended/guided measures Qualitative versus quantitative methods Behavioural observation EXAM PREP 25  Biometric measures of drug use Choosing an assessment tool/method How is the information to be used? (diagnosis/assessment/screening/treatment/outcomes?) Over what time does the data need to be collected? How long will it take to administer the tool? What aspect of alcohol/drug use are you assessing? What training is needed to administer the tool? Is the measure valid and reliable? Questionnaires are accurate under certain conditions. Need a measure that will capture what you want to measure.. Need a measure that will provide a consistent ‘yard stick’ Psychometric cornerstones of assessment Reliability → Reliability of scales Test-retest reliability What might influence test-retest reliability of a measure of alcohol use? Intra-scale reliability Do the items that capture a certain construct all contribute in a similarly strong way? Reliability of interview Centrality of rapport Confidentiality/anonymity – clear expectations Limits of confidentiality – subpoena, child safety Being under the influence of alcohol/drugs Validity → Validity of scales: Are you measuring what you really want to measure? Convergent validity (correlation with an established measure of a construct that is very similar) EXAM PREP 26  Criterion validity (correlation with a known externally determined criterion (e.g., number of times in treatment, number of drink driving charges) The Interview Warmth, unconditional regard In real estate, its position, position, position…. In alcohol and drug treatment it is…____________, ______________, ______________ Awareness of the emotional state of the person Behaviour, affect, mood, physiological symptomatology Orientation/awareness Thought process Thought content – themes Thank the person for disclosures Set out and discuss issues around: Confidentiality Mandatory reporting Security of information Way information may be used Check for worries/concerns ‼️ Some bad starts Do you have a drug problem you want to talk about? What are your drug-related cognitions? What substances do you have a problem with? You have a drug problem – Let’s get down to tin tacks… You have a drug problem - I’m glad you’ve decided to do something about it. You’ve finally come to your senses – Now I want to find out how I can help you… Quantity/frequency measures Quantity/frequency questionnaires EXAM PREP 27  Usual number of standard drinks consumed per occasion and usual frequency of alcohol consumption in a given time period Multiple this out to get a total quantity consumed in a given time frame These measures usually give some definition of what a standard drink is. Can specify the time (e.g., in the last week, month, or 3 months) Useful Questionnaires useful questionnaires for 3 domains of alcohol use 1. Dependence/severity → how “bad” is the use 2. alcohol related problems → what problems does it cause 3. Alcohol expectancies → why do they use alcohol Alcohol Dependence AUDIT 10 Items measures hazardous alcohol use, dependence, harm Scores and treatment (tentative) 8-15: brief advice/education EXAM PREP 28  16-19 brief counselling and monitoring 20+ further diagnosis Severity of Alcohol Dependence Questionnaire 20 items, 5 scales with 4 items each (‘almost never’ to ‘nearly always’): Physical withdrawal Affective withdrawal Withdrawal relief drinking Alcohol consumption Rapidity of reinstatement Scores greater than 30 correlate with severe alcohol dependence Alcohol Problems Rutgers Alcohol Problems Index Screening tool for assessing alcohol problems Brief, easily administered tool for adolescence (10 minutes to complete) Unidimensional measure of alcohol problems Drinking Problems Index designed to measure alcohol-related problems 17 items Alcohol Expectancies DEP/AEQ measures expectancies related to following areas Transforms experience Enhances social/physical pleasure Sexual experience and performance Power and aggression Social assertiveness Reduces tension EXAM PREP 29  Pharmacological Treatment Substance Use disorder Characterised by tolerance → more needed for same effect over time, when wrong OD withdrawal → flipside of tolerance salience → importance of the substance compred to other motivatirs in life. what are you willing to give up to get the substance altered mood → make you feel good craving → hard to define. “unwanted wanting” conflict/emotion → loss of control, i want to cut down but i cant, i only wanted one but i had more. angst of resisting what you want. relapse → tendanciey for old dependent patterns of use to be reinstated after a period of abstinence. drug use differs between demographics high socioeconomic → cocaine low socioeconomic → meth, prescription abuse Relapse rates Relapse rates post treatment &/or withdrawal → Similar curves for different drugs Implies common underlying mechanism(s) Chronic Disease Model (McLellan et al JAMA 2000) EXAM PREP 30  Asthma, Hypertension, Type 2 Diabetes, Schizophrenia → similar conditions to SUD. needs medications and changes of lifestyle choices etc. can’t really be “cured”. environmental factors impact use and recovery Genetic predisposition (twin studies) Lack of definitive cure Similar results from treatment, ie 30-50% abstinence at 1 year Adherence (or concordance) lowest in lowest socio-economic groups / Dual Diagnosis / lack of supports Motivation / Control plays a major role in dependence Triangle of drugs / effects Drugs and effects classified into 3 types: 1. Depressentes/sedatives → relaxation, disinhibition, tranquility 2. stimulants → increased energy 3. Hallucinogens → heightened senses drugs can be placed within the triangles The war on drugs → paradox of prohibition harm minimisation vs harm maximisation Prohibition created distrust towards professionals from users. stigma, moral judgements EXAM PREP 31  Consultation For an effective alcohol and drug consultation → keeping people engaged Maintain a non-judgmental approach Ensure privacy and confidentiality Present information in a calm and reasoned manner Minimise distractions Avoid confrontation The therapeutic alliance is the most consistent predictor of outcome across different treatment modalities Drug use has a function for people, many young people in particular view it as the SOLUTION, not the problem. Value judgments Abuse → substance use Addiction → substance use disorder Drug → substance Junkie → substance user Withdrawal Management Withdrawal is the first step not the fix → the step to get them more stable for therapy etc. Withdrawal is not a definitive treatment Withdrawal is the first step in the overall management of a SUD Withdrawal is usually needed before admission to therapeutic communities or residential rehabilitation facilities Withdrawal states → relative decrease of the substance Drug decrease/absence > CNS rebound Reflects dependence / SUD → different for different substances Characteristic for each category of drug Withdrawal state mimics the opposite of drug effect Withdrawal management → The process by which a person ceases substance use while minimising withdrawal symptoms. (getting them off the EXAM PREP 32  drug safely) Effects of physiological neuro-adaptation Neuroadaptation → the brain's process of adjusting to a substance, leading to tolerance, dependence, and addiction through changes in neurotransmitter activity and brain structure. take the substance → adaptation happens Tolerance → need to drink or use a greater amount than before to get the desired effect (potency of drugs or alcohol seems less than before) Withdrawal Syndrome withdrawal symptoms occur on cessation or reduction in use symptoms are generally opposite to acute effects of the substance i.e. for CNS depressants: tremor, sweating, anxiety, agitation, depression, malaise, nausea, dizziness, headache relief of withdrawal symptoms by further drinking or drug use Pharmacokinetics → the rush faster onset related to speed of reaching the brain/crossing the blood brain barrier faster in/faster out = more addictive eg. the same BAL feels different on the way up on the way down drug delivery → smoked/injected vs. ingested EXAM PREP 33  Pharmacotherapy for dependence 3 paradigms 1. manage withdrawal 2. replacement of substance 3. maintain abstincence Agonists vs. Antagonists Agonists → mimic/replace drug action Antagonists → block the drug action BY SUBSTANCE Alcohol Actions of Alcohol Enhance GABA-A function acts to facilitate GABA action at the receptor Inhibit NMDA Glutamate function Neuropharmacology of alcohol: Receptor Type Effect GABA - sedation, anxiolytic, amnesia, ataxia benzodiazepine NMDA - glutamate sedation, amnesia, withdrawal mood altering, euphoria, positive reinforcement, dopamine craving serotonin impulsivity, craving, nausea EXAM PREP 34  opioid positive reinforcement, euphoria, craving noradrenaline activation, withdrawal Alcohol withdrawal Risk factors for withdrawal Age and gender related risks: syndrome: Males >80g / day level of consumption 10 -20 years duration of drinking Female >60g / day age 5-10 years co-existing medical Adolescents: uncommon, save disorders with dual / poly sedative use recent trauma or surgery Elderly: may be as little as 20g stimulating external daily environment Simple/Complicated/Delirium Tremens Syndrome Time of Onset Duration Symptoms tremor, tachycardia, sweating, agitation, Simple 6-48hrs 24hrs - 5days nausea, depressed mood, vomiting, anxiety, insomnia Complicated by gad mal and tonic- 4-48hrs usually single Fits clonic fits tremor, agitation, Delirium Tremens clouding of consciousness, (untreated has a 48hrs - 7days 3-12 days disorientation, fality rate of 15- hallucinations, paranoid 20%) delusions EXAM PREP 35  Alcohol withdrawal - principles of management Assess risk → who can be treated outside the hospital safely? severity of dependence previous withdrawals co-existing BZD dependence co-existing medical disorders ? Suitable for ambulatory withdrawal Monitor progress i.e. daily review Treat agitation / hyperactivity Liaise with other health workers involved in care case conferencing, care planning early engagement with an A&D counsellor Assess for suicidality thiamine IM (100mg) at least daily (Wernicke’s encephalopathy prophylaxis) Thiamine 100mg tds oral & multivitamins Use a sedative with anti-convulsant properties diazepam is preferred - titrate with withdrawal symptoms (alcohol withdrawal scale AWS) lots at the start then quickly ween so you’re not creating a new addiction Ensure that symptoms improve each day EXAM PREP 36  After withdrawal ? → something to do, someone to love, something to look forward to → finding a non-pharmacological substitute, compulsory supervision, new relationships, spiritual involvement changing social identity → self idetification ina group “i’m an addict” vs “im in recovery” acting outside the norms can create uncomfortavle feelings → increases likelihood of relapse Pharmacotherapy for alcohol dependence Naltrexone → opioid blocker Acamprosate → helps or doesn’t. less known about how it works. Disulfiram Baclofen Topiramate Antidepressants (for underlying or residual depression/anxiety) Alcohol-sensitising drugs Aldehyde dehydrogenase inhibitors (enzyme used in metabolising alcohol → stops the metabolising and turns it into a more toxic form that induces sickness) disulfiram (“Antabuse”) 200 - 500mg daily Very unpleasant flush reaction if alcohol is taken → too much of both mixed can kill you For: alcohol dependence accepts goal of abstinence need for external aid to abstinence high risk situations for drinking imminent Abstinence may be higher first 3-6 months when patients take these drugs (not supported by EBM) Best given under supervision with contingency management → can drink if you stop taking it Caution re inadvertent alcohol exposure EXAM PREP 37  Not subsidised on PBS (~$80/month) Indirectly: release of dopamine release of serotonin release of endorphins AA 1 yr abstinence 25-50% 10 year follow up showed 29% achieved 3 yrs abstinence 24% drank intermittently 49% continued high alcohol intake Benzodiazepines main “street” benzos diazapam → vallium temazepam → mormison nitrazepam → mogadon oxazepam → serepax alprazolam → xanax flunitrazepam → rohypnol Actions of Benzodiazepines GABAA agonists Facilitate the action of GABA Release inhibition of dopamine in Nucleus Accumbens Cross-tolerance with Alcohol Benzodiazepine Withdrawal Simple benzodiazepine withdrawal Somatic symptoms Psychological symptoms tremor, muscle twitching, anxiety, agitation, insomnia, fasciculation irritability EXAM PREP 38  aching and stiffness of depression muscles perceptual distortions (“cotton dizziness wool” feelings) headache, visual disturbance gastrointestinal symptoms Complicated benzodiazepine withdrawal Tonic-clonic seizures Delirium clouding of consciousness paranoid ideation/delusions visual and auditory hallucinations Elective weaning from long term benzodiazepines takes years to ween off long term users Do not stop abruptly Switch to long-acting drug in equivalent dose Generally use diazepam Balance slow withdrawal and rapid withdrawal (with more intense symptoms which resolve earlier) Stepwise dose reduction, 10-15%, weekly - fortnightly Some patients need intensive support Regular monitoring Risks with “street” drugs Variable strength increases risk of overdose May be ‘cut’ with toxic contaminants amphetamine used to be cut with strychnine Outbreaks of clostridia infection in Europe >50 deaths 2008 >1000 deaths in USA re heroin cut with fentanyl recent levamisole cut with cocaine in Australia - > deaths EXAM PREP 39  Contaminants may be poorly soluble i.e. talc / gel-caps Risk of contamination with pathogens Buprenorphine and mouth flora Synthetics ie THC >90% would prefer the real thing Harm reduction Replacement prescribing, Needle & Syringe programs, Safer sex HIV / Hep B / Hep C high risk due to sharing of needles and work in sex industry far more dangerous to health than opioids Crime Opioid and cocaine users ( mean $1000 / week habit) Injection risks Infections ie endocarditis infarctions & emboli ie vascular damage Stability more time for other things than drug acquisition overdose risk Opioids Initial effects of opioids Initially marked nausea / vomiting Rush – prickly itchy skin Drowsiness (the nod) Difficulty concentrating Euphoria (occasional anxiety) Altered pain threshold and perception (physical and emotional) Dry mouth, constipation, itching, sweating Pin point pupils, reduced respirations (reduces drive to breathe) Chronic opioid use Tolerance (may ‘tolerate’ 500mg morphine within 10 days → increases fast) EXAM PREP 40  Dysphoria, depression, irritability, hypochondria, increased pain sensitivity Growing problem in patients with persistent pain disorder (low back / headache / fibromyalgia) Still constipated and pupils pinned Opioid withdrawal usually unpleasant rather than dangerous but can be dangerous Onset of withdrawal reflects half life of opioid Short half life → (e.g. heroin) 6-12 hours, peak at 24-48 hrs Long half life → (e.g. methadone) 2-3 days, peak at 7 - 10 days, may continue weeks Drug seeking behaviour may occur within a few hours and is often the principal manifestation after 72 hours Early → dilated pupils, chills, sweating, Lacrimation (6-12 hours) Intermediate → rhinorrhoea (runny nose), piloerection (goosebumps) (18-24 hours) Full Withdrawal → increasing restlessness, vomiting, anxiety, irritability, diarrhoea, cramping Opioid withdrawal treatment Buprenorphine (Subutex / Suboxone) partial opioid agonist has transformed withdrawal (harder to overdose, doesn’t suppress breathing, withdrawal isn’t has bad) Provides general relief so other symptomatic medications for opioid withdrawal are not routinely required Unsupervised use of other sedative drugs in combination with buprenorphine can result in respiratory depression, coma and death safer than methodone Reduces heroin use in out-patient settings Long acting i.e. out-patient once daily dosing Duration of treatment: 4-8 days Daily dose regime: 8, 8, 6, 4, 2, 2 mg or similar Daily review EXAM PREP 41  Does carry risks → relapse + overdose, people don’t allow for tolerance → lose tolerance, go back old dose is lethal Amphetamines easy to stop hard to stay off → dopamine system Effects of Amphetamines CNS stimulant wakefulness alertness increased endurance increased energy reduced hunger sense of wellbeing toxicity psychosis, violent behaviour Actions of Amphetamines absorbed through nasal mucosa, orally, also IV methamphetamine can be smoked as “ice” 65% excreted in urine alkaline pH slows renal excretion active release of noradrenaline, dopamine, 5HT, also inhibits monoamine-oxidase dopamine responsible for majority of effects Methamphetamine withdrawal similar to cigarettes Withdrawal syndrome begins ~24 hours after the last use of methamphetamine. Feature of withdrawal (the “crash”) Dysphoria - depression Fatigue Inertia/psychomotor retardation EXAM PREP 42  General malaise Agitation Decrease in appetiteInsomnia and unpleasant dreams Craving for amphetamines Suicidal ideation may be prominent. Caution re risk Then ~weeks of fatigue, anxiety and lack of enjoyment. Management of psychostimulant withdrawal → sleep and food ? Antidepressants if depression persists (caution re serotonin toxicity) Diazepam for anxiety & sleep, no real evidence Mirtazapine (anti-depressant), Modafanil (used for narcolepsy, cf truck drivers…) trials unspectacular → some success Olanzapine (low dose) for paranoia Encourage healthy diet, diurnal routine Psychological support the major intervention for mood swings and potential suicidality Cannabis Use diazepam, + occasionally anti-psychotics Withdrawal Symptoms Anxiety / Irritability / agitation Insomnia Mood swings / tremor / nausea / anorexia Poor concentration / headache Perspiration / cravings Unlike alcohol withdrawal, THC rarely requires in-patient care Tobacco NRT → Maintenance Treatment → Alternatives to Withdrawal Opioids EXAM PREP 43  Replacement Therapies (Agonists) Methadone a synthetic opioid → used as a pharmacological replacement for heroin and other opioids. orally active long half-life (18-30 hours), and can be given under supervision as a once daily dose Cost to patient ~$35 per week (dispensing fee) Buprenorphine (Subutex, Suboxone, Buvidal & Sublocade) partial opioid agonist binds strongly to opioid receptors, often outcompeting other opioids → by displacing stronger opioids from the receptors, it can block their effects and reduce the risk of overdose about as effective as methadone in managing opioid dependence Suppresses self-administration of heroin by 70-90% long acting injections Antagonists naltrexone tablets or implants → in exceptional circumstances For those highly committed to abstinence → caution is needed Reduces craving in many Must be taken regularly (preferably daily, but >3 x week) Not a self-reinforcing medication - adherence a problem N/A re use opioids