Assessment and Treatment of Addictive Behaviors Carl W. Lejuez, PhD

1. Assessment and Treatment of Addictive BehaviorsCarl W. Lejuez, PhD Lecture 3 Assessment of drugs, alcohol, and nicotine

2. Introduction to Substances

3. Definitions of Substance Use/Abuse/Dependence

4. Abuse • A maladaptive pattern of substance use, leading to a clinically significant impairment or distress, as manifested by one (or more) symptoms occurring at any time in the previous 12 months

5. Abuse: Symptom 1 • Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.

6. Abuse: Symptom 2 • Recurrent substance use in situations in which it is physically hazardous.

7. Abuse: Symptom 3 • Recurrent substance use-related legal problems.

8. Abuse: Symptom 4 • Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.

9. Abuse: Additional Criterion • The symptoms have never met the criteria for substance dependence for this class of substance.

10. Dependence • A maladaptive pattern of substance use, leading to a clinically significant impairment or distress, as manifested by three (or more) symptoms occurring at any time in the previous 12 months

11. Dependence: Symptom 1 • Tolerance as defined by either: • A need for markedly increased amounts of the substance to achieve intoxication or the desired effect • Markedly diminished effect with continued use of the same amount of the substance

12. Dependence: Symptom 2 • Withdrawal as manifested by either: • The characteristic withdrawal syndrome for the substance • The same or closely related substance is taken to relieve withdrawal symptoms

13. Dependence: Symptom 3 • The substance is often taken in larger amounts than intended

14. Dependence: Symptom 4 • There is a persistent desire or unsuccessful effort to cut down or control substance use

15. Dependence: Symptom 5 • A great deal of time is spent in activities necessary to: • Obtain the substance, • Use the substance, OR • Recover from its effects

16. Dependence: Symptom 6 • Important social, occupational, or recreational activities are given up or reduced because of substance use

17. Dependence: Symptom 7 • The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused by the substance

18. Developmental Considerations • Basic Theory and Support: • A number of researchers have suggested that occasional drug use may be best understood as a manifestation of developmentally appropriate experimentation.” • In a longitudinal study by Shelder and Block (1990), at age 18, relative to Experimenters, both Heavy Users and Abstainers appeared to be less psychologically healthy. • Evidence of suboptimal personality development and parenting were found at ages 7 and 11, thus predating any drug use.

19. Gateway Theory of Drug Use • Basic Features: • Sequencing implies that there is a fixed relationship between 2 substances, such that one substance is regularly initiated before the other. • Association implies that initiation of one substance increases the likelihood of initiation of the second substance. • Causation implies that use of the first substance actually causes use of the second substance (Causation is not supported by the gateway theory). • Strongest argument that can possible be made: “Use of a drug at a lower stage may be a necessary but not a sufficient condition for progressing to a higher stage” (Kandel, a gateway theory researcher).

20. Properties of drugs

21. Drug Use/Abuse/Dependence Assessment

22. Structured Clinical Interviews • Structured interviews in general tend to require clinical interviewers with specific training in the administration and scoring of the measures • Person conducting the interview needs to know what they’re looking for. • Needs to be familiar with DSM, and likely, with alcohol quantities, preferably with alcoholic or drinking populations.

23. Structured Clinical Interviews 2 • Clinical sensitivity is very important • High detail with respect to symptoms • generally viewed as confirmatory measures used to formulate a clinical diagnosis, rather than as screening measures. • Time of administration varies significantly, but most structured interviews take at least 15-20 minutes, and some several hours.

24. Structured Clinical Interview for DSM-IV (SCID-1) • SCID-1 (First, Spitzer, Gibbon, & Williams, 1997) is among the most widely used structured interviews for assessing psychological impairment & diagnosing other psychological disorders such as depression and anxiety. • Has modules for alcohol and other drugs, allowing assessment of substance use disorders in context of other psychological disorders.

25. SCID-1 Continued • Yields diagnosis of abuse or dependence • Allows for specifiers such as mild, moderate, or severe, as well as the stage of the disorder (i.e., current diagnosis, partial or full remission). • Requires extensive interviewer training • Can be time consuming and costly • Requires clinical judgement, which may affect diagnostic accuracy • Training takes several weeks, multiple observations and video tapes

26. Diagnostic Interview Schedule • DIS (Robbins, Cottler, & Keating, 1989) was developed to gather epidemiological data regarding the prevalence of SUDs • Also based on DSM • Easy to administer. Unlike SCID, DIS requires little clinical training. • Also does not require clinical judgement • Further, the DIS is available in both paper and pencil and computer-administered formats.

27. Addiction Severity Index • Comprehensive, structured clinical interview • Most commonly used comprehensive assessment specific to substance use • Gathers information about client functioning across a number of unique domains • including medical, employment, legal, family-social, psychiatric, and substance abuse. • Additionally, the ASI also assesses for emotional, physical, or sexual abuse. • Focus on SEVERITY of addiction and its consequences across multiple life domains • Not on formulating a diagnosis

28. Drug Abuse Screening Test • DAST • Self-report measure • Measures consequences of drug use

29. Timeline Followback (TLFB) • Widely used to obtain detailed picture of alcohol and other addictive behavior • Structured like a calendar • Broken down month by month • Using calendar, clients are asked to identify and note memorable occasions over the past thirty days to help prompt their recall of daily alcohol and other drug use behaviors over the past month.

30. Biological Assessment of Drug Use Utility: • Screening, assessment, and treatment outcome • Assessment of negative consequences of use (e.g, neurological functioning, liver functioning). Types: • Urine • Hair • Blood • Saliva • Sweat

31. Biological Assessment of Drug Use Urine Tests • Are the least expensive of the test methods (~$25-$50) • Can be done at home (for example by parents) • Detect use primarily within the past week (longer with regular use) • Can be affected by abstaining from use for a period of time before the test • Are often temperature tested to insure sample integrity Hair Tests • Are considered a relatively unintrusive method of drug testing • Are currently many times more expensive than urine tests (~$100-$150) • Detect substance use over a longer period • Do not usually detect use within the past week • Require a sample of hair about the diameter of a pencil and 1.5 inches long • They can not be done with a single hair • Are not significantly affected by brief periods of abstinence from drugs.

32. Biological Assessment of Drug Use Blood Tests • Are considered the most intrusive method of testing • Are the most expensive method of testing • Are the most accurate method of testing • Has a short detection time • Are the least common method of testing (due to cost and short detection time) Saliva Tests • Are considered a relatively unintrusive method of drug testing • Are still relatively uncommon • Are easy to administer Sweat (Patch) Tests • Are considered a relatively intrusive method of drug testing because they require the wearing of a patch for an extended period of time. • Are still relatively uncommon • Are controversial in terms of accuracy

33. Biological Assessment of Drug Use Which drugs are typically screened for in a urine test?The NIDA 5Expanded TestsAlso TestableMarijuana Barbituates HallucinogensCocaine Hydrocodone InhalentsAmphetamines Methaqualone Opiates BenzodiazepinesPCP Methadone Propoxyphene Ethanol MDMA

34. Biological Assessment of Drug Use DETECTION PERIODSThe following chart gives approximate detection periods for each substance by test type. The ranges depend on amount and frequency of use, metabolic rate, body mass, age, overall health, drug tolerance, and urine pH. SUBSTANCE URINE HAIR BLOOD Alcohol 6-24 hrs n/a unknownAmphetamine 1-4 days up to 90 days unknownBarbiturates 2-12 days unknown unknown Benzodiazepines 1-42 days unknown unknownCannabis (single use) 24-72 hrs up to 90 days 2-3 daysCannabis (habitual use) up to 12 wks up to 90 days 2 weeksCocaine 4-5 days up to 90 days 5 hoursCodeine/Morphine 2-4 days up to 90 days unknownHeroin 8 hrs up to 90 days unknownMethamphetamine 3-5 days up to 90 days 1-3 daysPCP 3-7 days up to 90 days 1-3 days

35. Biochemical Measurement of Smoking • Carbon Monoxide Monitoring • Carbon Monoxide (CO) from smoke measured in breath samples • Useful for measuring abstinence over previous 24 hours • Saliva Cotinine • Measured from saliva • Useful for measuring abstinence from 7 days to several months