____________________________________ Substance Use Disorders: Assessment and Treatment, 2nd Edition
trauma and SUD and dialectical behavioral therapy for those with characteristics of borderline personality disorder and SUD. Today, as never before, treatment for abuse of alcohol and opioids may be assisted by pharmacologic therapies that reduce craving and decrease the incidence of relapse. Within the total population of individuals with SUDs, there are groups that require special attention. Women experience a more rapid onset of serious symptoms of SUD, are more likely to have experienced developmental trauma, and are more likely to have a comorbid psychiatric disorder than men. They benefit most from programs that are gender specific. Adolescents do not have the same capacity for decision making, planning, and impulse control as adults. These factors have to be taken into account, and treatment needs to be geared toward the development of these capacities. Older adults are metabolically different from younger adults and experience lower tolerance when using substances. Also, older adults may have multiple chronic conditions for which they are taking a variety of medications and adding other substances to the mix can create a lethal cocktail. Additionally, older adults may be reluctant to discuss their use of substances other than those prescribed or even their misuse of prescribed substances. Consequently, clinicians need to approach older adults with special empathy and regard. Individuals who are lesbian, gay, bisexual, or transgender (LGBT) may be more prone to sub- stance use problems because of the prejudice they experience from society as a whole. Although this prejudice appears to be lessening, it is still a significant stressor. These populations have special needs and concerns that should be incorporated into treatment for a SUD. In a perfect world, all providers of SUD treatment would have specialized programs for LGBT individuals. Unfortunately, research indicates that even provid- ers that say they have specific programs for this group do not actually do anything different for LGBT individuals than they do for straight individuals. Individuals with physical challenges require appropriate accommodations in SUDs treatment, and providers have an obligation to provide such accommodations. Veterans may have problems with PTSD or TBI as well as SUD. As in any other comorbid condition, integrated care is essential to address the disorders simultaneously. It is also important for clinicians to recognize that many veterans also have some difficulty reintegrating into civilian life. The best support in reintegration may come from another veteran who has successfully made the adjustment. Finally, individuals who have chronic benign pain conditions as well as a SUD require special care. Clinicians need to work closely with other profes- sionals to ensure that the least dangerous effective treatment is being used and to carefully monitor the use of opioids if they are being used. As a final word, it is important that clinicians understand that this course is just an introduction into the clinical reality of SUDs. It is not possible in the time and space available to do more than touch on some significant points. Much more remains to be learned. Practitioners are asked to please make use of the resources indicated at the end of this course and
CONCLUSION Substance use disorders and general abuse of substances are significant public health problems worldwide. In the United States alone, it is estimated that 21.5 million people aged 12 and over suffer from a substance use disorder (SUD). Although alcohol is by far the most abused drug, the problem also encompasses dependence and abuse of a whole range of other substances: marijuana; various sedatives and tranquil- izers; stimulant drugs such as cocaine, amphetamine, and methamphetamine; narcotic analgesics, both natural and synthetic; a whole range of designer drugs; and hallucinogenic substances. The abuse of substances can ultimately lead to an array of human misery for individuals, families, and society as a whole. Such suffering most often includes physical, social, legal, and occupational problems. All drugs that are implicated in dependence have the ability to alter significantly the func- tion of the brain. Most specifically, they stimulate activity in the reward circuitry, in many instances more powerfully than natural rewards such as food, water, and sex. Long-term use of such substances alters the brain in ways that lead to craving for the substance, compulsive use, and significant and even life-threatening discomfort when the substance is not avail- able. Although there are different theories about the causes of addiction, recent evidence emphasizes the role played by early developmental trauma, neglect, and inconsistent nurtur- ance in laying the groundwork for subsequent problems with substance use for many individuals. Perhaps partly because of these underlying problems, many individuals with a SUD also have comorbid psychiatric disorders. Although SUD is an extremely debilitating disorder, it is also a treatable disorder. The process begins with identification of a possible problem with substances through screening, followed by a thorough assessment of the nature of the problem and any other disorders that may complicate recovery, initial treatment using a competent treatment approach, and finally a lifelong process of continuing recovery. Just as with any chronic illness, recovery from a SUD may be punctuated with relapses into disordered patterns of behavior. These relapses are best seen as part of the long-term evolution of recovery rather than as failures. In recent years, a good deal of scientific effort has gone into identifying treatment approaches that are especially effec- tive. These “evidence-based” treatments have been tested under controlled conditions and have proven their worth. Among these approaches are motivational interviewing, cognitive- behavioral therapy, contingency management, and 12-step facilitation. These treatment approaches may be delivered in residential/inpatient treatment programs, intensive outpatient programs, or outpatient treatment programs. They lend them- selves to both individual and group modalities. Given the fre- quent history of developmental trauma experienced by people with SUD, treatment programs should strive to be truly trauma informed. In addition, there is evidence-based treatment for special groups, including Seeking Safety for individuals with
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