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The George Washington Un
Course Code
Counseling Substance Abusers

Counseling Substance Abusers Notes

December 3, 2019
Counseling Substance Abusers Fall 2019
Class 1
Chapter 1 Why Worry About Substance Abuse or Addiction?
Ongoing Issues
Substance use disorders (SUDs) are collectively still the most prevalent mental health
problem facing the US
The face of SUDs changes over time as popularity of specific substances rise and fall
Alcohol and nicotine are unique in their stability of popularity and legal status
Approximately 25% of patients seen by primary care physicians have an alcohol or drug
Excessive alcohol use was a factor in 50% of all deaths from acute traumatic injuries
(Baron, Garbely, & Boyd, 2009)
Approximately 25% of those individuals on Medicaid have a substance use disorder
Significant contributing Factors
Substance abuse is a factor in 50-75% of all psychiatric admissions
1/3 of those who commit suicide had alcohol disorders
Between 40
Adults with a substance use diroder were 2.7 times as likely to report having engaged in
the physical abuse of a child and 4.2 times as likely to report child neglect as non-using
control substance
Alcohol is a factor in 40-86% of all US homicides (Parrott & Giancola, 2006)
Illicit drug use in home increase a woman’s change of being murdered
The Scope of the Problem
Globally, about 200 million people (5% of world’s population) have abused illicit
substance at least once.
The world-wide illicit
Alcohol use in US
o Estimated 119 million drink at least once annually
o Between 8 to 16 million drinkers will become physically dependent on it
o 5.6 million abuse it on a regular basis
o 10% drink 60% of alcohol consumed
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o Top 30% drink 90% of alcohol consumed
o Majority with alcohol use disorder (AUD) are male
o Globally around 15.6 million people abuse or are addicted to heroin
o In the US, approximately 3 million have used heroin at some point
o There are 4 male users for every female user (Krambeer, von McKnelly,
Gabrielli, & Penick, 2001)
o Growing numbers are addicted to prescription narcotics
Class 2
Chapter 2- Drugs, the Body, and Brain
“I think one of the key things that both addicts and non-addicts must understand is
that this condition known as addiction (and related drug disorders) is an actual
biological illness. There are real differences in the brains of some people that rob
them of their ability to control their use of drugs or alcohol or compulsive behaviors
and then conspire against them once they enter recovery, creating an overpowering
need to resume using. It is important for them to know that they aren’t stupid or
crazy but that their brain functions and operates differently.”
- Darryl Inaba, Pharm.D., Addictions Recovery Center, Medford, OR
Substances (like marijuana) can be examined as
A. Molecule
B. Exotic Plant (biological, synthetic)
C. A source of financing for insurgencies
Drugs are usually classified by their effects
Uppers (CNS stimulants)
Amphetamine Congeners
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Designer Stimulants (bath salts)
Plant Stimulants (Khat)
Psychostimulants (phenylethlamines)
Side effect: insomnia, increased appetite
Downers (CNS depressants):
Opiates and opioids
o Benzodiazepines (klonopin, valium, alprazolam, Ativan)
o Sleep medications (ambian, lunesta)
Mixing substances are dangerous and can result in death
Effects: loss of inhabitation, relaxation (muscles), decreased coordination/sense of
pain, drowsiness, decreased heart rate
All Arounders (psychedelics)
o Ketamine
o Salvia
o Dxm
Other Drug Addictions:
Inhalants (deliriants)
Steroids and other sports drugs
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Psychiatric medications
Compulsive behaviors (gambling, eating, sex, videogames, shopping)
Effects: Produce an effect that is not dissimilar from cocaine
Historical Themes:
1. Cope with one’s environment
Harsh climates
o Coca often used in high altitude climates
o Alcohol to adjust to stressful situations
o Khat used in dessert environments
2. Susceptible brain chemistry
Brain structures and chemistry effect how we handle stress
3. Business and Government Involvement
What substances are popular, what substances are moved around the
What is accepted socially, what is legal or illegal
All countries now tax the sale of alcohol and cigarettes
Treatment and prevention is bigger issue
4. Refining and Synthesizing (manufacturing drugs)
8th century, methods of distilling alcohol
20th century synthesize drugs from chemicals
5. (New) Methods of Using
Pipes used to be used for tobacco and opium, then syringes were
Smokable cocaine
New methods for making butane hash oil
Ancient Cultures:
Centered around crops to support survival
Some considered medicine or food
Methods of use
Drinking marijuana
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Smoking opium
Chewing betel nut
Snorting cocaine
Injecting morphine
Inhaling alcohol
Volitizing cannabis extracts
o Butane hash oil?
Age of Discovery
European saw effects in other countries and popularized them and
government made profit off of them
Tobacco use
Preparation of theriac, the ancient cure all
Nitrous oxide parties
19th Century Refinement and Commercialization
Advancements in refinement of morphine in 1805, cocaine in 1859, and heroin in
1874 concentrated the psychoactive properties of the opium poppy and coca bush
which lead the way to their commercialization
Refinement: It takes 100 pounds of coca leaf to make 1 pound of cocaine
o The extraction process includes multiple steps as well as various toxic
chemicals including kerosene, gasoline, and acid
Morphine refined from opium
Opiates: directly from the opium poppy after refinement
o Opium, morphine, codeine
Opioids: Semisynthetic
o Heroin, hydrocodone, oxycontin
Opioids: Synthetic
o Fentanyl, methadone, Darvon, buprenorphine, Demerol
When synthetic and semisynthetic are mixed becomes more potent
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o Heroin-fentanyl combination that has resulted in many overdoses
Opioid Antagonists
o Naloxone (Narcan), naltrexone (Revia)
Revia: block euphoric effects and reduce cravings/withdrawal
(usually shot on a once a month basis)
The 20th Century and the Age of Regulation
Before there was a federal income tax system, the US government generated
significant revenue from the taxation of alcohol, opium, and tobacco
The Food and Drug Act (1906), The Smoking Opium Exclusion Act (1909), and
the Harrison Narcotic Act (1914) made cocaine and opiates illegal and this
fostered the growth of illegal drug sales
Put in place because effects did more harm than the revenue sales were worth
The Age of Regulation:
The next move by Congress was the prohibition of alcohol. Taxes on alcohol
supplied 50% of the US budget
Despite this the 18th amendment went into effect in 1920 making the
manufacture and distribution of alcohol a crime. Prohibition was repealed in
Although society looks back on Prohibition as a failure, it did have some
o Declines in cirrhosis of the liver and other alcohol related diseases as
well as admission to hospitals for alcohol related issues
o Dramatic declines in domestic violence and violent crime
The 1930s brought about the founding of Alcoholics Anonymous, The
Marijuana Tax Act (which was effectively a prohibition act and followed by
a massive propaganda campaign), and the synthesis of LSD by Dr. Albert
o Propaganda campaign was racially driven
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The 1960s were troubles years that included assassinations, race riots, and
the Vietnam War
o Young people were testing the authority of the government which
included the use of marijuana and LSD
The government pushed back with the Controlled Substances Act of 1970.
Followed by Nixon’s War on Drugs” campaign while expanding the
methadone maintenance program
o Caused mass incarceration of people of color across the country
The late 1970s and 1980s ushered in a new era of uppers. Smokable forms of
both cocaine and methamphetamine increased the intensity of the rush
(greater compulsive use patterns) and lowered the price
o Led to massive incarceration of people of color across the country
The 1990s became the decade of the brain as more neurotransmitters were
discovered and more imaging techniques were developed to understand the
relationships between psychoactive drugs, brain chemistry, and mental
o Connections between mental health, neurotransmitters, and drugs
The wars in Afghanistan and Iraq brought about thousands of cases of
physical trauma and PTSD for which veterans have been prescribed opiates
(prescription pain pills). The era of drug use has brought on another downer
o After Vietnam War heroin use spiked as well as during Civil War
The Body
Psychoactive drugs differ from other drugs because they can cross the blood-brain
barrier due to being similar to neurotransmitters
The Nervous System:
Divided into CNS and PNS
o CNS: brain and spinal cord
o PNS: somatic and autonomic
Somatic: voluntary and sensing stimuli
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Autonomic (unconscious): sympathetic (quick responses=
fight/flight, maintaining bodies homeostasis) and
parasympathetic (do not require immediate action, rest and
digest/feed and breed), sexual arousal, lacrimation,
urination/defecation, digestion
The various parts of the complete nervous system function together to
transmit, interpret, store, and respond to information from the internal
and external environments
Psychoactive drugs affect not only emotions and thoughts, but many
bodily functions as well, especially respiratory and cardiovascular
The Brain:
On the evolutionary scale, from a fish, turtle, and frog, to a rat, cat,
chimpanzee, and finally a human, the new brain has grown much larger
than the old brain, but the old brain tends to override it, particularly in
times of stress.
Only mammals have developed a new brain (cerebrum and cerebral
cortex) of any size. The brain of an adult human weighs about 3 lbs.
Old brain: regulating physical body functions, experiences basic emotions
and cravings, and imprinting survival memories
When someone uses a psychoactive drug, it is usually the old brain that
creates the memory. Substance use can get confused with survival
Routes of Administration:
Snorting and mucosal exposure
Sublingual is more like mucosal exposure
Injecting (quickest)
Orally (slowest way)
Contact or transdermal
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Blood circulation
Drug delivered to the brain by blood
The Liver:
Drug-laden blood enters the liver through the portal vein
Metabolites and drug-laden blood leave through the hepatic vein for the
The liver deactivates a portion of the drug with each pass through the
circulatory system
Nerves and CNS:
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Addiction memories in the brain are processed the same way as
Counseling Substance Abusers Fall 2019
Our new brain might have the conscious desire to remain drug free, but the old
brain can seek it out
Old brain can mistake cravings as a survival need
Subconscious memories play a role in euphoria and conscious memories play role in
the obsession
Subconscious memories are what maintain it
Willpower: our cortex (new brain) plays a role in decision making, reasoning, and
Dopamine: VTA is activated by survival activities
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Amygdala: linked to emotions
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Psychoactive Drug/Neurotransmitter Relationships
Neurotransmitters Directly Affected
GABA (gamma-amino butyric acid), met-
enkephalin, serotonin
GABA, glycine
Anandamide, arachidonylglycerol (2AG),
Noladin ether, acetylcholine, dynorphin
Endorphin, encephalin, dopamine
Acetylcholine, dopamine, serotonin
Epinephrine, endorphin, acetylcholine
Cocaine and Amphetamines
Dopamine, epinephrine, norepinephrine,
serotonin, acetylcholine
Serotonin, dopamine, epinephrine,
Dopamine, acetylcholine, alpha-
Counseling Substance Abusers Fall 2019
Counseling Substance Abusers Fall 2019
Counseling Substance Abusers Fall 2019
Opiod Effects vs. Withdrawal Symptoms
Withdrawal effects are often the opposite of the drug’s direct effects
Withdrawal Symptoms
Becomes dysphoria, depression, or craving
Becomes pain
Dryness of mouth
Becomes sweating, runny nose, tearing,
nausea, vomiting, and increased salivation
Becomes diarrhea
Slow pulse
Becomes rapid pulse
Low blood pressure
Becomes high blood pressure
Shallow breathing and suppressed
Become coughing and excessive yawning
Pinpoint pupils
Becomes dilated pupils
Becomes severe hyper-reflexes and muscle
Sedation and tranquility
Become anxiety, restlessness, and
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Categories for Substance
Dependence and Substance
Partial remission is included
Physiological Dependence as a
Caffeine is a substance related
Category for Substance Use Disorder only
Addition of symptom:
No more use of words such as ‘abuse’ and
Partial remission no longer included
(mild, moderate, severe specifiers are
used instead)
Physiological dependence specifier
Problems with law enforcement omitted.
Specific drugs addressed as individual
Caffeine use is no longer a disorder.
Gambling is included as sole behavioral
Counseling Substance Abusers Fall 2019
Class 3
Drug: Screening & Assessment
Important to gather full psychosocial history, including AODs when possible.
Ask open ended questions:
“How much (alcohol/cocaine/marijuana/etc.) do you use?”
“Do you use (alcohol/cocaine/marijuana/etc.)?”
Ask specifically about each psychoactive drug classification and tobacco.
Ask about quantity of use, frequency, setting, method of procurement,
administration route.
Additional Areas of Importance in Psychosocial Assessment for AOD:
Ask about family history of problems related to AOD.
o Genetic component, environmental component, trauma history,
Conduct risk assessment. Ask about SI/HI and history of abuse (sexual, physical,
o Some substances result in violence, impulsivity, hopelessness (plus ideation) can
increase SI or HI
o Abuse: substances can be used for numbing, history of PTSD/co-occurring
substance use, perpetrator could be an substance abuser, perpetrator could use
substance as a way to control, or a parent could give child substance as a way of
Review changes in social relationships/supports
o Could be influencers, sudden change in peer group (particularly with children
and adolescents),
Review legal history
o DUIs, charges involving impulsivity or ways to obtain substances (DV,
shoplifting, stealing, prostitution)
Review educational history (particularly with adolescents)
o Dropping out of school, poor grades, sudden drop in grades, truancy
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Review occupational and military history
o Military- having an injury (medications prescribed), PTSD, high levels of alcohol
use are normalized in military
o Inability to hold a job, lots of job changes, missing work
Review medical history
o Chronic pain diagnoses (Major injuries), frequent admittance to hospitals for
accidental injuries (can include DV)
Review connections between psychological and behavioral problems
o Eating disorders, PTSD, Bipolar disorder, ADHD, Schizophrenia
Common Self-Report Inventories:
Michigan Alcohol Screening Test (MAST)
25 item inventory of drinking habits
Easy to administer and score
Content of screening is obvious and consequently easy to have clients reporting false
o Mast: “Are you able to stop drinking when you want to?” “Has your spouse ever
complained about your drinking?”
Have you ever felt the need to Cut down on your drinking?
Have you ever felt Annoyed by someone criticizing your drinking?
Have you ever felt Guilty or bad about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or get rid of
a hangover (Eye-opener)?
o CAGE: Also obvious content and easy to under report. Further questioning needed
for any affirmative answers
o Even though both are transparent, not everybody will fall through the cracks and
those who indorse items are more motivated to seek treatment and follow
through with it
Alcohol Use Disorders Identification Test (AUDIT)
CCSC uses this during National Alcohol Screening Day.
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Can be self-report or part of a structured interview.
Includes questions about frequency of use and problems associated with use.
Demonstrated excellent detection of alcohol use disorders in clinical settings and
with various populations.
Problem-Oriented Screening Instrument for Teenagers (POSIT)
139-item screening developed by NIAAA for children ages 12 to 19.
Examines potential problems in a variety of areas including substance use, mental
and physical health, family and peer relations, and vocational/educational
AUDIT Practice
Select a celebrity persona to complete the AUDIT as
Pair up with a partner and score each other’s AUDIT personas
Decide which areas are crucial to discuss with your partner’s persona
Role play how you would follow up. What additional questions would you ask? What
would you suggest to your partner’s persona?
o 65+ metabolizes alcohol differently, so different recommendations. Excessive
drinking birth-25 is harmful because of physical development
o Gender differences: Bodies tendency to retain fluids, stomach enzymes (Men can
process more effectively), More muscle less fat, Men usually physically bigger
o Ethnicity: Native Americans, Inuits, Pacific Islanders at a higher risk. African
Americans at a lower risk because spirituality, community support
o Freshman, full time students, living on campus, involved in Greek life are at a
higher risk
o Have family member who is a problem drinker or in an alcoholic program
Addiction Severity Index (ASI)
Only to be used by trained professionals.
Arguably the most widely used assessment system in substance use treatment
Counseling Substance Abusers Fall 2019
Even if you do not plan to go into substance use treatment, it is good to have a basic
knowledge of the ASI.
A Note on Referrals:
Complications with referrals in this field.
Look for proper training, experience, accreditation, licensure or credentials, record
of complaints/sanctions.
Referring to a licensed/credentialed counselor/agency helps ensure that
competence is being monitored and ethical practices are in use.
Class 4
Models of Addiction
Models of Addictions:

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