What role does and/or can “spirituality” play in recovery? (Please be specific). Can spirituality interfere w/ treatment? How? What role does the 12-step program play in a spiritual approach to recovery? (How do you think it works?)
Sixth Edition
Substance Use Counseling
Theory and Practice
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Sixth Edition
Substance Use Counseling
Theory and Practice
Patricia W. Stevens
Retired Professor of Counselor Education and Supervision
Transitions Family Counseling, Louisville, CO
Robert L. Smith
Professor & Department Chair
Counseling and Educational Psychology
Texas A&M University, Corpus Christi, TX
330 Hudson Street, NY, NY 10013
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Library of Congress Cataloging-in-Publication Data
Names: Stevens, Patricia W. | Smith, Robert L. (Robert Leonard)
Title: Substance use counseling : theory and practice / Patricia Stevens,
adjunct faculty, practitioner, and consultant, Boulder, CO, Robert L. Smith,
professor & department chair, Counseling & Educational Psychology,
Texas A&M University, Corpus Christi, TX.
Description: Sixth edition. | Boston : Pearson, [2018] | Includes
bibliographical references and index.
Identifiers: LCCN 2016054858 | ISBN 9780134055930 | ISBN 0134055934
Subjects: LCSH: Substance abuse—Treatment. | Substance
abuse—Patients—Counseling of.
Classification: LCC RC564 .S765 2018 | DDC 362.29/186—dc23 LC record available at
https://lccn.loc.gov/2016054858
1 17
ISBN 10: 0-13-405593-4
ISBN 13: 978-0-13-405593-0
This book is for all the dedicated students and practitioners who strive to make
a difference in the lives of their clients and in the quality of life for all. May they
continue to find this text to be helpful for them in their personal journey and in
their professional career.
—Patricia Stevens
This text is dedicated to the many brave individuals and family members
experiencing problems and challenges related to addictions, and to the many
professionals devoted to working and conducting research in the field of
addictions.
—Robert Smith
About the Authors
Dr. Patricia W. Stevens is a retired Counselor Educator currently in clinical private practice in
Louisville, CO. She trains student counselors through online teaching. Dr. Stevens also consults
with universities in program development and accreditation (CACREP, NCATE/CAEP).
Dr. Stevens is a member of ACA, AAMFT, and served on the CACREP board for eight
years. She has held multiple leadership positions in ACA and its divisions, including President
of the IAMFC, Board-Member-at-Large of AACD, and Co-Chair of the Professional Standards
Committee. Dr. Stevens has also served on several editorial boards of ACA and its divisions.
Though retired, she continues to be active in the profession and her clinical work.
Through the years she has delivered more than 70 presentations at the local, state, regional,
national, and international levels in the areas of substance abuse, gender implications in counseling, challenges of aging, and ethical/ legal issues in counseling. In the counseling field, she
has published more than 50 articles, chapters, and books. Dr. Stevens has prepared and taught
more than 26 different courses in the counseling curriculum.
Dr. Stevens is a Fulbright Scholar and works with the Red Cross as a Mental Health
Disaster Relief volunteer. She volunteers at her local Red Cross and her local senior center.
Robert L. Smith, Ph.D., FPPR, is Professor & Chair of the Counseling and Educational Psychology
Department, as well as the Doctoral Program Coordinator at Texas A&M University–Corpus Christi.
He completed his Ph.D. at the University of Michigan. As a licensed psychologist, he has worked
as a private practitioner in addition to serving as the chair of three counselor education programs.
He is the author of several books and more than 80 professional articles. He serves as the Executive
Director and co-founder of the International Association of Marriage and Family Counselors. He is
also the founder of the National Credentialing Academy for Family Therapists. His research interests
include the efficacy of treatment modalities in individual psychotherapy, family therapy, and substance abuse counseling. He is a Diplomate-Fellow in Psychopharmacology with the International
College of Prescribing Psychologists and consultant with the Substance Abuse Program in the U. S.
Navy. Dr. Smith as an international lecturer is currently involved in the development and implementation of graduate programs in counseling and psychology in Latin America.
vi
About the Contributors
Dr. Robert Dobmeier is an associate professor and Coordinator of the Mental Health Counseling
Program at the College of Brockport. Dr. Dobmeier has prior work experience as a mental health
counselor, supervisor, and director. He has worked for several Office of Mental Health and Office of
Alcoholism and Substance Abuse Services licensed agencies in western New York. Dr. Dobmeier
is a Licensed Mental Health Counselor and is a member of the New York Mental Health Counseling
Association, and former Co-President of the New York Association of Counselor Education and
Supervision. He has advocated for recognition of diagnosis in the scope of practice for mental
health counselors in New York State. As President of the Association for Adult Development and
Aging, and Chair of their Public Policy and Legislation Committee, he has advocated for Medicare
reimbursement for the services of professional counselors. He is also a member of the American
Counseling Association, Association for Counselor Education and Supervision, and Association
for Spiritual, Ethical, and Religious Values in Counseling. Dr. Dobmeier is a founding member
of ACA-NY. He is also a member of the Greater Rochester Chapter of NYMHCA and the North
Atlantic Regional Association for Counselor Education and Supervision. Dr. Dobmeier is a member of Chi Sigma Iota and of Nu Chapter. Among the courses Dr. Dobmeier enjoys teaching are
several mental health courses, most recently Leadership and Advocacy, Research and Program
Evaluation, Measurement and Evaluation, and Spirituality in Counseling.
Dr. Claudette Brown-Smythe is a graduate of Syracuse University, where she completed a doctor
of philosophy degree in counseling and counselor education, and a dual masters’ degree in rehabilitation and community counseling. Prior to that, she attended the University of the West Indies
in Jamaica, where she completed her Bachelor of Science and Master’s of Social Work with an
emphasis in group and community development. In Jamaica, she worked as a school counselor
and later as a college professor training and supervising school counselors. As a social worker,
she worked in rural and inner-city communities in Jamaica, educating and doing advocacy around
issues of child abuse and child poverty, and later worked on these same issues with the aged in
the Caribbean. Dr. Brown-Smythe has worked in various fields in counseling: school counseling,
college counseling, and mental health and rehabilitation counseling. With more than 15 years of
experience in training and supervision, her current employment is at The College at Brockport State
University of New York as a Visiting Assistant Professor in the counselor education department
and coordinator of the certificate in advanced studies. She is a Certified Rehabilitation Counselor
(CRC), a Nationally Certified Counselor, (NCC), and an Accredited Clinical Supervisor (ACS).
Her professional and research interests include addressing diversity issues in counseling and supervision; exploring loss and grief in counseling; supervision in counseling; spirituality, wellness, and
well-being; counseling older adults; and training paraprofessionals as mental health and rehabilitation facilitators. Dr. Brown-Smythe is a recipient of the NBCC inaugural Minority Fellowship.
Linda L. Chamberlain, Psy.D., is a licensed psychologist and Coordinator of the Center for
Addiction and Substance Abuse (CASA) at the Counseling Center for Human Development,
the University of South Florida in Tampa, Florida. She has worked in the addictions field since
1980 as both a clinician and educator with a focus on individual and family recovery from substance abuse and the treatment of problem gambling. Dr. Chamberlain coauthored a book on
the treatment of problem gambling entitled Best Possible Odds and has written numerous articles and contributed to several books on the dynamics and treatment of addictions and family
vii
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About the Contributors
therapy. Dr. Chamberlain has presented workshops and counselor training through the American
Counseling Association and the American Psychological Association, and has been an invited
speaker at local, national, and international conferences on addictions.
Ashby Dodge is a licensed clinical social worker with a private practice in New York City that
focuses on couples/family therapy, young professionals, LGBTQ issues, sexual assault survivors,
and substance abuse. Ashby is currently Clinical Director at The Trevor Project, the nation’s
leading organization providing crisis intervention and suicide prevention services to LGBTQ
youth, ages 13 to 24. Ashby’s clinical style is largely strengths-based, helping people find positive and practical solutions to any number of life stressors and problematic relationships.
Dr. Kristina DePue is an Assistant Professor at the University of Florida (UF). She received her
doctoral degree in Counselor Education from the University of Central Florida. Before attending UCF, Dr. DePue graduated from Vanderbilt University for both her master’s and bachelor’s degrees. Helping individuals struggling with addiction has been a personal mission of
Dr. DePue’s for more than 11 years. She has worked in many roles in treatment settings and
was part of Vanderbilt’s initiation of the Collegiate Recovery Community (CRC). Dr. DePue’s
research is focused on substance use in the collegiate population, specifically focusing on
student-athletes and mild traumatic brain injury (mTBI), diagnosis, and self-harm. Additional
research endeavors involve the trajectory of addiction and recovery, highlighting the relationship between the bottoming-out experience, the turning point, and early recovery. Dr. DePue
serves on the editorial boards for the Journal of Addictions and Offender Counseling and for the
Annual Review of Best Practices in Addictions and Offender Counseling. Dr. DePue is actively
involved in both the American Counseling Association (ACA) and the International Association
of Addiction and Offender Counselors (IAAOC) and has served as the IAAOC Collegiate
Addiction Committee Chair for the past two years. She is also on the Board of Directors for UF’s
CRC. Currently, Dr. DePue is working on funding projects that focus on mTBI and substance
use in college athletes, statistical modeling of addiction trajectories, examining the effectiveness
of CRCs nationwide, and using technology to assist in harm reduction for college drinkers.
Leigh Falls Holman, Ph.D., LPC-MHSP-S, RPTS, NCC, AMHCA Diplomate and CMHC in
Substance Abuse and Co-Occurring Disorders, Trauma Counseling, and Child and Adolescent
Counseling, teaches at The University of Memphis. She served as President of the International
Association of Addiction and Offender Counselors from 2015 to 2016 and was previously recognized by IAAOC as an Outstanding Counseling Professional in 2013 for her contributions to
the profession. Dr. Holman has published and presented at professional conferences on addiction
and offender topics and has been a clinician for 20 years.
Melanie M. Iarussi is an assistant professor in the Counselor Education Programs at Auburn
University. She earned her Ph.D. in Counselor Education and Supervision from Kent State
University. Her clinical background is in substance abuse counseling, college counseling, and
private practice. She is a Licensed Professional Counselor and a Certified Substance Abuse
Counselor. She is also a member of the Motivational Interviewing Network of Trainers. Melanie’s
research interests include counselor training in substance use and addiction counseling, college
student substance use and recovery, and applications of motivational interviewing.
Davina A. Moss-King, Ph.D., CRC, NCC, CASAC has been a substance abuse counselor
for 25 years. Dr. Moss-King is a Certified Rehabilitation Counselor and a National Certified
About the Contributors
Counselor, as well as a Credentialed Alcohol and Substance Abuse counselor in New York
state. Dr. Moss-King received her doctorate in Counselor Education with honors in 2005 from
the State University of New York at Buffalo. Her world-acclaimed dissertation “Unresolved
Grief and Loss Issues Related to Substance Abuse” was published as a book, Unresolved Grief
and Loss Issues Related to Heroin Recovery, in 2009. Dr. Moss-King’s research interest is opioid disorders and neonatal abstinence syndrome, which has evolved to writing an internationally accredited online course, “Opioid Dependence during Pregnancy” (2015), along with an
article entitled “Neonatal Abstinence Syndrome—the Negative Effects on Our Future” (2015).
Dr. Moss-King is an adjunct professor at Canisius College’s Counselor Education and Human
Services Department, Buffalo, NY. Dr. Moss-King is the founder and president of Positive
Direction and Associates, Inc., a consulting company that provides educational seminars focusing on opioid use disorders, women’s health, and rebuilding families. Dr. Moss-King is a
member of the American Psychological Association and the National Association of Neonatal
Therapists.
Summer M. Reiner is an Associate Professor in the Department of Counselor Education, The
College at Brockport, State University of New York in Brockport, NY. She served as president of the Association for Adult Development and Aging (AADA), North Atlantic Region
Association for Counselor Education and Supervision (NARACES), and the American
Counseling Association of New York (ACA-NY). She served as chair of the American
Counseling Association North Atlantic Region (ACA-NAR). Dr. Reiner was most recently
elected president of the Association for Counselor Education and Supervision (ACES) and to
the American Counseling Association Governing Council. She is a National Certified Counselor
(NCC), an Approved Clinical Supervisor (ACS), a licensed mental health counselor (LMHC–
NY), and a permanently certified school counselor in New York. She teaches courses in career,
school counseling, practicum, internship, and human development and provides clinical supervision to students.
Dr. Reiner has authored journal articles on spirituality issues, school counseling issues,
and professional counselor identity. In 2010, she received a research grant from the Council for
Accreditation of Counseling and Related Educational Programs (CACREP). The research grant
resulted in a publication on Professional Counselor Identity and was recognized as one of the top
cited articles in the Journal of Counseling and Development during 2013. She also has a book
chapter in a process addictions text on work addiction.
Dr. Daniel T. Sciarra is Professor of Counselor Education and Director of Counseling programs at Hofstra University. Fluently bilingual in Spanish, he maintains a clinical practice
with Latino children, adolescents, and families through the Child Guidance Center of Southern
Connecticut. In addition to numerous articles and book chapters on the subject of multicultural counseling, Dr. Sciarra is the author of three books, Multiculturalism in Counseling
(Peacock, 1999), School Counseling: Foundations and Contemporary Issues (Brooks/Cole,
2004), and Children and Adolescents with Emotional and Behavioral Disorders (Allyn &
Bacon, 2010). His fourth book, Teaching Difficult Students: Interventions That Work, will
be released in July of 2016. A former bilingual school counselor with the New York City
Board of Education, Dr. Sciarra holds a doctorate in Counseling Psychology from Fordham
University, a master’s degree in counseling from Boston College, and a bachelor’s degree in
English education from Fairfield University. He is a licensed psychologist, licensed mental
health counselor (LMHC), and a national certified counselor (NCC). His research interests
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About the Contributors
include multicultural counseling, racial identity development, and the role of the school
counselor in the promotion of academic achievement and educational attainment among
students of color.
Dr. Genevieve Weber is an associate professor in the Department of Counseling and Mental
Health Professions, School of Health and Human Services at Hofstra University. She is a
Licensed Mental Health Counselor in the state of New York, with a specialization in Substance
Abuse Counseling. Dr. Weber teaches a variety of courses related to the training of professional
counselors, including group counseling, multicultural counseling, counseling the LGBTQ client,
psychopathology, and psychopharmacology and treatment planning. She has more than 10 years
of experience working in community agencies, where she provides counseling to diverse clients
with both substance abuse and mental health concerns. Dr. Weber is a Senior Research Associate
with Rankin and Associates Consulting, where she works with institutions to maximize equity
through assessment, planning, and implementation of campus climate intervention strategies. In
her research and professional presentations, Dr. Weber focuses on the impact of homophobia
and heterosexism on the lives of LGBTQ people.
Preface
Welcome to the sixth edition of our book. The authors are both proud and delighted to bring you
this new edition in a new format with significantly updated and new content. This edition is different in many ways. It has been significantly updated to reflect the changes in the DSM-5
related to the criteria for assessment and diagnosis of substance use disorders. These changes
required a complete revision of all terminology within the book to coordinate with the new diagnostic criteria. This edition also addresses the changing face of substance use in our country—
from the different demographics of substance users to the substances themselves and how they
are used. New effective treatment assessments, methods, and settings are included to assure the
student’s knowledge of current practice in the field.
There are drugs available and regularly used today that were not even known when we
wrote the first edition of this book, and the field of substance use counseling has shifted in
response to these changes. Now there are designer drugs—synthetic drugs. Marijuana has been
legalized in some states for both medical and recreational use. Synthesized marijuana is now
being produced, and it is lethal. Prescription drug use among adolescents has skyrocketed. Meth
production is at a pandemic level. Administration of a drug to another person without their consent is becoming more common. In this book, new information has been added and updated
information and research references have been included to address these facts. With the addition
of gambling as an addiction in the DSM-5 and the prevalence of other dysfunctional behaviors in
today’s society, the authors felt it was necessary to educate students and clinicians on these
behaviors so a chapter has been included on behavioral addictions. New chapter cases in each
chapter provide the student with additional critical thinking exercises related to that chapter
topic. At the end of Chapters 1 through 13, MyCounselingLab activities allow students to see
key concepts demonstrated through video clips, practice what they learn, test their understanding, and receive feedback to guide their learning and ensure that they master key learning outcomes and professional standards.
In the first edition we stated that our goal was to develop a text that was helpful for the
general clinician as well as for students in beginning substance use courses, and this goal remains
the same. The book is intended to be an adjunct to, not a replacement for, counseling theory and
techniques, public policy, and school-specific books and coursework. The text provides you with
information specific to the substance use field that must then be integrated with your other counseling knowledge.
As we originally intended, the book is designed to take the reader/student through the
process of working with substance use clients and/or behavioral addiction clients from client recognition of need for treatment (in whatever way that is recognized by the client)
through the recovery process and beyond. Chapters build on each other as they take you
through the process, but each can be used independently for resources or information.
Although it is impossible to show you skill sets with a real person, the authors have developed book case studies that are used across the chapters (and therefore represent the process
of a client). These case studies provide practical application of the information in each chapter. In addition, each chapter has a case study that specifically addresses the information in
that chapter.
We hope that you find the text enjoyable, informative, and a practical read. If so, we have
met our goal.
xi
xii
Preface
New to This Edition
This new edition has been thoroughly revised. Specific changes include, but are not limited to:
• a new chapter on behavioral addictions
• updated use and cost of use statistics in Chapter 1
• new information in Chapter 2 on ethical issues concerning the Patient Protection and
Affordable Care Act and the Health Insurance Portability Accountability Act
• added Integrated Approach as a new theoretical model in Chapter 4
• revised Chapter 6 with new assessment and diagnostic information and information on the
Mental Health and Substance Abuse Parity Act and the Affordable Care Act on substance
use treatment
• in Chapter 7, the Addiction Society of America diagnostic and treatment criteria and new
pharmacotherapy information
• in Chapter 9, re-inclusion of Claudia Black’s concept of family roles
• in Chapter 11, substantial changes to the LGBTQ section and new section on counseling
military and immigrants with substance use issues
• in Chapter 12, a new section on the socioeconomic impact of substance use
• new terminology to match the DSM-5 criteria for assessment and diagnosis
• ethical codes updated to the latest revision
• updated research references and statistics
Also Available with MyCounselingLab®
This title is also available with MyCounselingLab, an online homework, tutorial, and assessment
program designed to work with the text to engage students and improve results. Within its structured environment, students see key concepts demonstrated through video clips, practice what
they learn, test their understanding, and receive feedback to guide their learning and ensure they
master key learning outcomes.
• Learning Outcomes and Standards measure student results. MyCounselingLab organizes
all assignments around essential learning outcomes and the professional counseling
standards.
• Video- and Case-Based Assignments develop decision-making skills. Students watch
videos of actual client-therapist sessions or high-quality role-play scenarios featuring
expert counselors. They are then guided in their analysis of the videos through a series
of short-answer questions. These exercises help students develop the techniques and
decision-making skills they need to be effective counselors before they are in a critical
situation with a real client.
• Licensure Quizzes help students prepare for certification. Automatically graded, multiplechoice Licensure Quizzes help students prepare for their certification examinations, master
foundational course content, and improve their performance in the course.
• Video Library offers a wealth of observation opportunities. The Video Library provides
more than 400 video clips of actual client-therapist sessions and high quality role-plays in
a database organized by topic and searchable by keyword.
• MyCounselingLab includes the Pearson eText version of the book, which integrates
MyCounselingLab.
Preface
Acknowledgments
We wish to thank, first and foremost, the professors who choose this text and the students who
purchase the book, some of whom have let us know how valuable the book has been for them.
We appreciate the time and energy the reviewers invested in the reviews for this edition. Their
insightful comments assist us in publishing a better text.
Thanks to Kevin Davis for his continued belief in this book. Anne McAlpine has been our
go-to person for all manner of issues. She has been accessible and knowledgeable each time we
have asked. Thanks, Annie! Pam Bennett, our Project Manager, has been exceptionally patient
throughout this process. She has kept us on schedule during some chaotic times. We all thank her
for her time and energy.
We wish to thank our contributors. They have all worked diligently to provide a state-ofthe-art textbook for training students and clinicians. This edition provided new challenges that
they all met with kindness, patience, and professionalism. New contributors have added knowledge and skills to the text and a new perspective that aligns with the changing field. We also
wish to thank the reviewers for this edition, who provided us with valuable input for revising this
edition: Jeff Blancett, University of Memphis & Victory University; Victor J. Manzon, Western
Michigan University; and Martin L. Michelson, University of Illinois at Springfield.
And, again and again, we are grateful to our family and friends who continue to be supportive each time we revise this text.
xiii
Brief Contents
Chapter 1
Introduction to Substance Use Disorder Counseling
Chapter 2
Ethical and Legal Issues in Substance Use Disorder Counseling
Chapter 3
The Major Substances of Use and Their Effect on the Brain and Body
Chapter 4
Etiology of Substance Abuse: Why People Use
Chapter 5
Assessment and Diagnosis
Chapter 6
Treatment Planning and Treatment Settings
Chapter 7
Individual Treatment
Chapter 8
Group Counseling for Substance Use Disorders
Chapter 9
Family Counseling with Individuals Diagnosed with Substance Use
Disorder 208
1
26
91
112
143
166
Chapter 10 Retaining Sobriety: Relapse Prevention Strategies
185
228
Chapter 11 Working with Special Populations: Treatment Issues and
Characteristics 251
Chapter 12 Working with Diverse Cultures: Exploring Sociocultural Influences and
Realities in Substance Use Disorder Treatment and Prevention 283
Chapter 13 Prevention
308
Chapter 14 Behavioral Addictions/Non–Substance-Related Disorders: An
Overview 332
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49
Contents
Chapter 1 Introduction to Substance Use Disorder
Counseling 1
Societal Costs of Substance Use Disorders
Productivity 7
Substance-Related Diseases 8
Hepatitis 8
HIV/AIDS 9
5
A (Very) Short History of Substance Use 10
Alcohol 10
Cocaine 12
Morphine, Heroin: The Opioids 13
Marijuana 15
Amphetamines 16
Hallucinogens 17
Tobacco 17
The Importance of Terminology in Substance Use Disorder
Counseling 18
The Profession in the 21st Century 20
An Overview of this Text 20
Conclusion
25
Chapter 2 Ethical and Legal Issues in Substance Use
Disorder Counseling 26
Education and Training of Mental Health Professionals Working with
Substance Use Disorder 26
Ethics 30
Confidentiality 32
Code of Federal Regulations 42, Part 2 33
Health Insurance Portability and Accountability Act of 1996
(HIPAA) 35
Patient Protection and Affordable Care Act 36
Confidentiality in Group Counseling or 12-Step Groups 37
Confidentiality of Minors 37
Ethical Conflicts Specific to Substance Use Disorder Counselors 41
Dual Relationships 41
Clients and Criminal Activity 42
xv
xvi
Contents
Conflicting Laws 42
Ethical Code Conflicts
Ethical Decision Making
Conclusion
43
43
47
Chapter 3 The Major Substances of Use and Their Effect on
the Brain and Body 49
The Brain 50
Neuroscience Research 50
The Structure of the Brain 50
Psychoactive Substances and the Brain 55
Controlled Substances Schedules 56
Depressants 56
Alcohol 57
Benzodiazepines: Prescription and Over-the-Counter Medications
Barbiturates 63
GHB (Identified as a Club Drug) 64
Opiates 65
Stimulants 67
Cocaine 68
Amphetamines 71
Tobacco 73
Caffeine 74
Cannabis 75
Cannabicycohexanol/Spice (K2) 79
Hallucinogens 81
Lysergic Acid Diethylamide (LSD; Identified as a Club Drug) 82
Phencyclidine (PCP; Identified as a Club Drug) 82
Ketamine (Identified as a Club Drug) 83
A Further Look at Club Drugs 84
MDMA (Ecstasy) 85
Volatile Substances or Inhalants 86
Anabolic-Androgenic Steroids 87
Conclusion
89
Chapter 4 Etiology of Substance Abuse: Why People Use
Understanding Theory 91
Overview of Substance Use Disorder Theories 92
Moral Theory 92
Aspects of Use Addressed by the Moral Theory 92
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61
Contents
Disease/Medical Theory 93
The Neurobiology of Substance Use Disorders 95
A Look at Brain Function Reward 95
Genetic Theory 97
Aspects of Use Addressed by Genetic Theories 99
Behavioral Theories 101
Aspects of Use Addressed by the Behavioral Theory 101
Sociocultural Theories 104
Aspects of Use Addressed by Sociocultural Theories 105
An Integrated Approach: Substance Use Disorders in the 21st
Century 108
Conclusion
110
Chapter 5 Assessment and Diagnosis
112
Issues in Assessment 112
The Diagnostic Interview 114
DSM-5 Diagnosis 115
DSM-5 Criteria for Substance Use Disorders 116
Behavioral Characteristics 117
Phase 1: The Prodromal Phase 118
Phase 2: The Crucial Phase 119
Phase 3: The Chronic Phase 120
Assessing the Behavioral Symptoms of Use 121
Social Characteristics 121
Family Characteristics 123
Assessing the Social and Family-Related Symptoms 124
Screening and Assessment Instruments 125
The Michigan Alcoholism Screening Test (MAST) 126
The Drug Abuse Screening Test (DAST-20) 126
The CAGE Questionnaire 127
Tolerance, Worried, Eye-Opener, Amnesia, K/Cut-down (TWEAK) 128
The Alcohol Use Disorders Identification Test (AUDIT) 128
The Substance Abuse Subtle Screening Inventory
(SASSI-3 and SASSI-A2) 129
The Addiction Severity Index (ASI) 129
Problem Oriented Screening Instrument for Teenagers (POSIT) 130
Screening, Brief Intervention, and Referral to Treatment (SBIRT) 130
The Millon Clinical Multiaxial Inventory (MCMI-II) and Minnesota
Multiphasic Personality Inventory (MMPI-2) 131
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xviii Contents
ASAM Criteria for Patient Placement
Diagnosis 133
Differential Diagnosis 133
Dual Diagnosis 134
Conclusion
132
138
Chapter 6 Treatment Planning and Treatment Settings
What Is Treatment Planning? 143
How to Develop a Treatment Plan
What Is a Treatment Setting? 147
Types of Treatment Settings 150
143
144
Medical Detoxification and Stabilization 150
Dual-Diagnosis Inpatient Hospitalization 151
Partial Hospitalization Programs 153
Temporary Recovery or Halfway Homes 154
Intensive Outpatient Programs 154
Special Issues Impacting Treatment Planning 155
Federal Legislative Changes and Implications for Treatment 155
External Reviewers: Health Care Accreditation Organizations
and Managed Care 156
Conclusion
159
Chapter 7 Individual Treatment
166
Beginning Individual Treatment 166
Intervention 168
Direct Impact Individual Therapy 170
The Therapeutic Alliance 170
Motivational Interviewing 170
The Method of Motivational Interviewing 171
The Spirit of Motivational Interviewing 171
Change Talk 172
Motivational Enhancement Therapy 173
Cognitive–Behavioral Therapy 174
Eye Movement Desensitization and Reprocessing Therapy
The Mindfulness Technique 175
Pharmacotherapy 176
Medication During and After Treatment 176
Beyond Discontinuation of Use 177
Coping Skills Training/Life Skills Training 177
174
Contents
Vocational Readiness 179
Harm Reduction 180
Harm Reduction from the Therapist’s Perspective 180
Apply Motivational Interviewing 181
Applying EMDR 181
Coping Skills 182
Vocational Readiness 182
Applying Harm Reduction 182
Applying Suboxone Treatment/Self-Help Group 182
Conclusion
183
Chapter 8 Group Counseling for Substance Use
Disorders 185
Types of Groups 186
Therapeutic Factors in Group Counseling for Substance Use
Disorders 186
Matching Clients to Appropriate Group Counseling 188
Matching Readiness to Change 189
Matching Culturally Relevant Treatment 191
The Group Leader 192
Stages of Group Development 193
Specific Methods for Group Counseling for Substance Use
Disorders 197
Twelve Step Facilitation Counseling Groups 197
Cognitive Behavior Therapy and Skill Building 198
Motivational Interviewing 199
An Example: Cannabis Youth Treatment: Integrating MI
and CBT 200
Family and Couples Group Counseling 201
Group Treatment in the Continuum of Care 201
Group Treatment Efficacy 203
Conclusion
206
Chapter 9 Family Counseling with Individuals Diagnosed with
Substance Use Disorder 208
Defining Family 210
General Systems Concepts 210
Homeostasis 211
Feedback Loops 211
Hierarchy, Roles, Rules, Subsystems, and Boundaries
212
xix
xx
Contents
Wholeness 214
Change 214
Values 214
Systems and Addictive Families 215
The Marital Dyad and Substance Use Disorder 215
The Family and Substance Use 217
Children in the Substance Use Family 219
Children’s Roles in SUD Families 220
Treatment with Substance Disordered Families 221
Programs Using Family Therapy 223
How Successful Is Family Therapy in SUD Treatment?
Conclusion
224
226
Chapter 10 Retaining Sobriety: Relapse Prevention Strategies
Determinants of Relapse 229
Environmental 230
Behavioral 230
Cognitive 231
Affective 231
Interpersonal Determinants 232
Summary 232
Models of Relapse Planning and Management 233
The Disease Model 233
Developmental Models 234
A Cognitive–Behavioral/Social Learning Model 236
Harm Reduction 239
Evidence-Based Practices toward Relapse 239
Self-Help Recovery Organizations: Adjuncts to Professional
Intervention 240
Alcoholics Anonymous Model 240
Spirituality as a Resource 243
AA-Associated 12-Step Programs 244
Moderation Management (MM) 244
Rational Recovery 245
Secular Organizations for Sobriety/Save Our Selves (SOS) 245
Women for Sobriety (WFS) 246
Self-Help for Dually Diagnosed Persons 246
A Well-Rounded Life with Hope 247
Conclusion
249
228
Contents
Chapter 11 Working with Special Populations: Treatment Issues
and Characteristics 251
Children and Adolescents 251
Risk Factors 254
Prevention and Intervention 255
Women 257
Risk Factors 258
Prevention and Intervention 259
The LGBTQ Community 260
LGBTQ Identity Development 261
Risk Factors 263
Prevention and Intervention 263
People with Disabilities 266
Risk Factors 268
Prevention and Intervention 268
Immigrants 270
Risk and Protective Factors 271
Barriers to Treatment 272
Older People 273
Risk Factors 273
Prevention and Intervention 274
Homelessness 276
Risk Factors 276
Treatment 278
The Military 278
Risk Factors 279
Prevention and Treatment 280
Conclusion
281
Chapter 12 Working with Diverse Cultures: Exploring
Sociocultural Influences and Realities in Substance
Use Disorder Treatment and Prevention 283
American Indians and Alaskan Natives
Cultural Values 285
Risk Factors 287
Barriers to Treatment 287
Prevention and Intervention 288
Asian Americans 289
Cultural Values 290
284
xxi
xxii
Contents
Risk Factors 291
Prevention and Intervention 293
African Americans 294
Risk Factors 295
Cultural Values 296
Barriers to Treatment 296
Prevention and Intervention 297
Hispanics 298
Cultural Values 299
Barriers to Treatment 301
Prevention and Intervention 302
Socioeconomic Status (SES) and Substance Use Disorders
SES and Substance Use Disorder Outcomes 303
The Indirect Effects of SES 304
Conclusion
Chapter 13 Prevention
302
306
308
The Need for Prevention 311
Emotional Impact 311
Social Impact 312
Medical Impact 313
Financial Impact 313
History of Substance Use Prevention 313
Conceptualizing Prevention 319
Public Health 319
Models and Theories of Public Health 320
Developing Prevention Strategies 325
Conclusion
330
Chapter 14 Behavioral Addictions/Non–Substance-Related
Disorders: An Overview 332
A Definition of Behavioral Addiction 333
A Word of Caution 334
General Criteria for Behavioral Addictions
Cognitive Changes 334
Emotional Changes 335
Gambling Disorder (GD) 335
Diagnosis and Assessment 336
Treatment Options 337
Summary 337
334
Contents xxiii
Sex Addiction 338
Diagnosis and Assessment 339
Treatment 340
Summary 341
Exercise Addiction 341
Diagnosis and Assessment 342
Treatment 342
Summary 343
Compulsive Buying Disorder (CBD)
Diagnosis and Assessment 344
Treatment 345
Summary 345
Internet Addiction Disorder (IAD)
Assessment and Diagnosis 346
Treatment 346
Summary 347
Conclusion
Appendix
349
References
359
Name Index
404
Subject Index
419
347
343
345
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CHAPTER
1
Introduction to Substance Use
Disorder Counseling
Patricia Stevens, Ph.D.
A
lcohol, tobacco, marijuana, prescription drugs, illegal drugs—all are used daily by
many in our world today, sometimes with dire consequences. Drugs are used for celebrations, for mourning, for religious rituals, for pain relief, for stress relief, and recreationally. We hear about them daily on the radio, on television, and on the Internet. On the
Internet, we can find information about what each drug’s composition is as well as how to make
many of them ourselves.
Children are beginning to experiment and use at an earlier age, and many of our elders are
using a variety of substances, both prescribed and not. Young and old, people use drugs to forget,
to feel better (physically and mentally) or not feel at all, to be friendly, to disinhibit, and because
of peer pressure. Tobacco, alcohol, and marijuana (in some states) are legal drugs used with
social sanction and are easily available. Even if you individually do not use a drug (and this
includes alcohol and tobacco), you probably have a user in your family or friend group, or know
someone who uses drugs inappropriately.
Consequences of the use of legalized substances (for purposes of this discussion I
include alcohol, tobacco, marijuana, and prescription drugs) and illegal substances continue to
be disturbing. Many do not understand the far-reaching effects of use. Statistically, for each
person who misuses a substance, four or five other people are somehow personally or professionally affected by this use—from minimally to severely—and societal costs reach into the
multiple millions. For example, “the average cost for 1 full year of methadone maintenance
treatment is approximately $4,700 per patient, whereas 1 full year of imprisonment costs
approximately $24,000 per person, usually paid from tax funds” (National Institute on Drug
Abuse [NIDA], 2012).
Until the mid-1990s, the tobacco industry denied that there were any physical consequences
or addiction from tobacco use even as people were dying from lung cancer. A $145 billion
verdict in a 2000 class action suit led by Dr. Howard A. Engle, a Miami Beach pediatrician
who smoked and who eventually died of chronic obstructive pulmonary disease, led the way
to multiple suits against the tobacco companies; they tried to settle, paying out $10 billion
per year in perpetuity. They also placed in the public domain more than 35 million pages
of internal documents on the effects of smoking, which included lung cancer and
addiction. In 2014, a Florida woman was awarded $23.6 billion in a suit against
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Chapter 1 • Introduction to Substance Use Disorder Counseling
R. J. Reynolds Tobacco Company that was filed in 1996, when her husband died at age 36
(Sifferlin, 2014). And while smoking has decreased in the past 10 years, “in 2013, young
adults aged 18 to 25 had the highest rate of current use of a tobacco product (37.0 percent),
followed by adults aged 26 or older (25.7 percent), then by youths aged 12 to 17 (7.8 percent). Young adults also had the highest rates of current use of the specific tobacco products. Among young adults, the rates of past month use in 2013 were 30.6 percent for
cigarettes, 10.0 percent for cigars, 5.8 percent for smokeless tobacco, and 2.2 percent for
pipe tobacco” (Substance Abuse and Mental Health Services Administration [SAMHSA],
2014, p. 47).
Other statistics that speak to the use of tobacco and its relationship to other drug use
include:
• In 2013, the prevalence of current use of a tobacco product was 40.1% for American
Indians or Alaska Natives, 31.2% for persons reporting two or more races, 27.7% for
Whites, 27.1% for Blacks, 25.8% for Native Hawaiians or Other Pacific Islanders, 18.8%
for Hispanics, and 10.1% for Asians
• Among adults aged 18 or older, current cigarette use in 2013 was reported by 33.6% of
those who had not completed high school, 27.7% of high school graduates with no further
education, 25.5% of persons with some college but no degree, and 11.2% of college
graduates.
• The annual average rate of past-month cigarette use in 2012 and 2013 among women aged
15 to 44 who were pregnant was 15.4%.
• In 2013, past-month alcohol use was reported by 65.2% of current cigarette smokers
compared with 48.7% of those who did not use cigarettes in the past month.
• Among persons aged 12 or older, 24.1% of past-month cigarette smokers reported
current use of an illicit drug compared with 5.4% of persons who were not current cigarette smokers.
Alcohol, which has been legal in the United States since the 1933 repeal of Prohibition,
has multiple consequences—including but not limited to financial loss of work production,
increased medical costs for use-related issues, increased intimate partner violence and incest,
increased accidents (in all domains), and higher individual risks for a multitude of physical
diseases. (SAMHSA, 2014)
According to the SAMHSA 2013 National Survey on Drug Use and Health (SAMHSA,
2014):
• Slightly more than half (52.2%) of Americans aged 12 or older reported being current
drinkers of alcohol in the 2013 survey, which was similar to the rate in 2012 (52.1%). This
translates to an estimated 136.9 million current drinkers in 2013.
• The rate of current alcohol use among youths aged 12 to 17 was 11.6% in 2013.
• An estimated 8.7 million underage persons (aged 12 to 20) were current drinkers in 2013,
including 5.4 million binge drinkers and 1.4 million heavy drinkers. In 2013, an estimated
10.9% of persons aged 12 or older had driven under the influence of alcohol at least once
in the past year.
• 1.4 million received treatment for the use of alcohol but not illicit drugs.
Chapter 1 • Introduction to Substance Use Disorder Counseling
• In 2013, 2.5 million persons aged 12 or older reported receiving treatment for alcohol
use during their most recent treatment in the past year, 845,000 persons received
treatment for marijuana use, and 746,000 persons received treatment for pain relievers
(pp. 89, 90, 104).
Further, someone dies in an alcohol-related automobile crash every 51 minutes in
the United States (National Highway Traffic Safety Administration, 2013); the annual cost of
alcohol-related crashes is $59 billion (Blincoe, Miller, Zaloshnja, & Lawrence, 2010). In 2006,
the World Health organization reported that 55% of people involved in intimate partner violence
(IPV) believed that their partner/perpetrator had been drinking alcohol before the incident.
Although research continues to be complicated on this issue, alcohol use appears to be correlated
with IPV, if not cause and effect. Diseases whose risk factors rise with the use of alcohol include
human immunodeficiency virus (HIV), hepatitis, and other infectious diseases; cardiovascular
complications; respiratory, gastrointestinal, and musculoskeletal effects; kidney and liver
damage; neurological and mental health issues; hormonal issues; cancer; and pre- and postnatal
complications.
The legalization of marijuana is a recent phenomenon, and studies to document what, if
any, effect legalization might have on individual use are in process. SAMHSA’s 2013 survey
still categorizes marijuana as an illicit drug, as it is on the federal level. Statistics on 2013
use show:
In 2013, marijuana was the most commonly used illicit drug, with 19.8 million current (pastmonth) users. It was used by 80.6% of current illicit drug users
• In 2013, there were 2.4 million persons aged 12 or older who had used marijuana for
the first time within the past 12 months; this averages to about 6,600 new users each
day. The 2013 estimate was similar to the estimates in 2008 through 2012 (ranging
from 2.2 million to 2.6 million), but was higher than the estimates from 2002 through
2007 (ranging from 2.0 million to 2.2 million).
• In 2013, among persons aged 12 or older, an estimated 1.4 million first-time past-year
marijuana users had initiated use before the age of 18. This estimate was similar to the
corresponding estimate in 2012. The estimated 1.4 million persons in 2013 who initiated use before the age of 18 represented the majority (56.6%) of the 2.4 million recent
marijuana initiates.
In 2012, concentrations of tetrahydrocannabinol (THC), the active ingredient in marijuana, averaged close to 15%, compared to around 4% in the 1980s. This higher concentration creates problems for new and regular users since many times they are not aware of what the concentration
may be in each batch.
Marijuana affects the brain areas that influence pleasure, memory, thinking, concentration,
sensory and time perception, and coordinated movement. A large long-term study (Meier et al.,
2012) showed that people who began smoking marijuana heavily in their teens had a significant
decline in their neuropsychological functioning well into adulthood.
Marijuana smoke is an irritant to the lungs causing the same problems that tobacco users
experience such as daily cough and phlegm production, more frequent acute chest illness, and a
heightened risk of lung infections. Marijuana also raises heart rate by 20-100% shortly after
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Chapter 1 • Introduction to Substance Use Disorder Counseling
smoking; this effect can last up to 3 hours. NIDA (2014a) reports on a study that estimated that
marijuana users have a 4.8-fold increase in the risk of heart attack in the first hour after smoking
the drug.
NIDA (2014a) further reported that chronic marijuana use has been linked to mental
illness. High doses of marijuana can produce a temporary psychotic reaction in some users and
may worsen the course of illness in patients with schizophrenia. Associations have also been
found between marijuana use and other mental health problems, such as depression, anxiety,
suicidal thoughts among adolescents, and personality disturbances, including a lack of motivation
to engage in typically rewarding activities.
The use of prescription drugs for medical misuse or nonmedical purposes is a growing
problem, particularly among our youth and elderly populations. For purposes of this discussion we will include the nonmedical use of prescription-type pain relievers, tranquilizers,
stimulants, and sedatives. The National Survey of Drug Use and Health reports combine the
four prescription-type drug groups into a category referred to as “psychotherapeutics.”
(SAMHSA, 2014).
These include, but are not limited to:
Opioids
• Fentanyl (Duragesic)
• Hydrocodone (Vicodin)
• Oxycodone (OxyContin)
• Oxymorphone (Opana)
• Propoxyphene (Darvon)
• Hydromorphone (Dilaudid)
• Meperidine (Demerol)
• Diphenoxylate (Lomotil)
Central nervous system depressants
• Pentobarbital sodium (Nembutal)
• Diazepam (Valium)
• Alprazolam (Xanax)
Stimulants
• Dextroamphetamine (Dexedrine)
• Methylphenidate (Ritalin and Concerta)
• Amphetamines (Adderall)
The following statistics on persons aged 12 and older provide a sense of the scope of the
problem:
• 4.5 million were using nonmedical pain relievers in 2013 (492,000 were using
OxyContin).
• 1.7 million were using nonmedical tranquilizers.
• 1.4 million were using nonmedical stimulants (NIDA, 2014a).
Substance use among the elderly is relatively common but often is undetected or ignored
by health and social workers. Psychosocial and health factors related to the aging process are the
major contributors to alcoholism and other drug abuse. Although there is much less research
Chapter 1 • Introduction to Substance Use Disorder Counseling
regarding elderly prescription nonmedical use or misuse, Medicare’s drug program, known
as Part D, now covers about 38 million elderly and disabled people and pays for more than one
in four prescriptions dispensed in this country.
In 2012, the most recent year for which data is available, Medicare covered nearly
27 million prescriptions for powerful narcotic painkillers and stimulants with the highest
potential for abuse (Centers for Medicare & Medicaid Services, 2015). Prescription drug
abuse is present in 12% to 15% of elderly individuals who seek medical attention. Of the
current population, 83% of older adults, people age 60 and over, take prescription drugs.
Older adult women take an average of five prescription drugs at a time, for longer periods of
time, than men. And studies show that half of those drugs are potentially addictive substances, such as sedatives, making older women more susceptible to potential abuse issues
(Basca, 2008).
Psychoactive medications with abuse potential are used by at least 1 in 4 older adults,
and such use is likely to grow as the population ages. It is estimated that up to 11% of older
women misuse prescription drugs and that nonmedical use of prescription drugs among all
adults aged 50 years or older will increase to 2.7 million by the year 2020 (Simoni-Wastil &
Yang, 2006).
Culbertson and Ziska (2008) discuss the lack of screening instrument validity for the
elderly populations, even though the elderly use 25% of all prescription drugs. “The prevalence
of abuse may be as high as 11% with female gender, social isolation, depression, and history of
substance abuse increasing risk” (p. 22).
Much of the foregoing data was collected by the Substance Abuse and Mental Health
Services Administration, which is part of the Department of Health and Human Services, one of
the premier research organizations in the world. Some data was collected by other national associations and by peer-reviewed published articles. And yet, we still must ask questions about
research in the field, due to the very nature of the field. For example, how many of the “current
users” meet the criteria for substance use disorder [SUD](American Psychiatric Association,
2013)? How many of them are recreational users? How do we objectively define recreational
use? How many of them are physiologically or psychologically attached to the drug? Does this
difference in definition lead to problems when comparing data collected? Does self-report affect
data collection? Another problem is an outgrowth of the first: the question of how to collect data.
Not only do definitions differ, but also substance use may lend itself to isolation and minimization of the facts about the problem.
These issues leave us without a clear idea of the actual number of recreational users and
those with more serious problems. In the United States we have waged a “war on drugs” for over
a century. In spite of the billions of dollars spent on these efforts in everything from media campaigns to criminal enforcement in an effort to eliminate drug use, virtually every drug that has
ever been discovered is available to substance users in the United States, no matter their age or
location (Doweiko, 2013).
Societal Costs of Substance use Disorders
The impact of use on the quality of life of the individual user and of family, neighbors, and
friends cannot be estimated. What we can estimate is the objective costs to society, to the work
force, and to medical care. When these economic valuation studies endeavor to incorporate such
quality-of-life impacts and costs, the resulting cost, though estimates, are typically several times
greater than the objective criteria costs (See Figure 1.1).
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Chapter 1 • Introduction to Substance Use Disorder Counseling
Budget Authority in Millions of Dollars.
International
$1,590.7
6%
Treatment
$10,267.8
39%
Interdiction
$3,805.0
14%
Domestic Law
Enforcement
$9,367.0
36%
Prevention
$1,306.2
5%
FIGURE 1.1
Cost of Substance Use in Law enforcement.
Surgeon General’s, Report, 2004: ONDCP, 2004: Harvard 2000 NIDA
Source: “National Drug Control Budget: FY 2016 Funding Highlights” (Washington, DC: Executive Office of the President,
Office of National Drug Control Policy), February 2015, Table 3, p. 18.
http://www.whitehouse.gov///sites/default/files/ondcp/press-releases/ond
Estimated Economic Cost to Society Due to Substance Abuse and Addiction:
Illegal drugs:
Alcohol:
Tobacco:
$181 billion/year
$185 billion/year
$193 billion/year
Total:
$559 billion/year
The total costs of drug abuse and addiction due to use of tobacco, alcohol and illegal drugs are estimated
at $524 billion a year. Illicit drug use alone accounts for $181 billion in health care, productivity loss, crime,
incarceration and drug enforcement.
FIGURE 1.2 Estimated Economic Cost of Substance Abuse and Addiction to Society.
For fiscal year (FY) 2016, a total of $27.6 billion was requested by the president to support
2015 National Drug Control Strategy efforts to reduce drug use and its consequences in the
United States. This represents an increase of more than $1.2 billion (4.7%) over the enacted
FY 2015 level of $26.3 billion (National Drug Control Budget, 2015, p. 2). This budget provides
funds for public treatment facilities, prevention, and so forth.
The estimated total cost of drug use in the United States is $559,000,000,000 (559 billion)
(NIDA, 2014c), as shown in Figure 1.2.
The National Drug Intelligence Center includes more modalities in their health cost and
estimates. These include the following (reported in thousands of dollars): speciality treatment
costs ($3,723,338), hospital and emergency department costs for nonhomicide cases ($5,684,248),
Chapter 1 • Introduction to Substance Use Disorder Counseling
7
Table 1.1 Admissions to Publicly Licensed Treatment Facilities, by Primary Substance, CY2007-CY2011
2007
2008
2009
2010
2011
Cacaine
250,761
230,568
186,994
152,404
143,827
Heroin
261,951
280,692
285,983
264,277
278,481
Marijuana
307,053
347,755
362,335
346,268
333,578
Methamphetamine
145,936
127,137
116,793
115,022
110,471
Non-Heroin
Opiates/Synthetic*
98,909
122,633
143,404
163,444
186,986
Source: Treatment Episode Data Set (TEDS) 2004 – 2014. Published by Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2016.
*These drugs include codeine, hydrocodone, hydromorphone, meperidine, morphine, opium, oxycodone, pentazocine, propoxyphene, tramadol,
and any other drug with morphine-like effects. Non presecription use of methadone is not included.
Note: Tennessee included heroin admissions in the “other opiates” category through June 2009. In this report, Tennessee’s 2009 heroin
admissions are still included in the other opiates category since there is less than a full year of disaggregated heroin data.
Table 1.2 Estimated Number of Emergency Department Visits Involving Illicit Drugs, CY2007-CY2011
2007
2008
2009
2010
2011
Cocaine
553,535
482,188
422,902
488,101
505,224
Heroin
188,162
200,666
213,118
224,706
258,482
Marijuana
308,407
374,177
376,468
460,943
455,636
Methamphetamine
67,954
66,308
64,117
94,929
102,961
MDMA
12,751
17,888
22,847
21,836
22,498
CPD Painkillers
94,448
124,020
146,377
179,787
170,939
Source: Substance Abuse & Mental Health Services Administration (SAMHSA). Published by Substance Abuse & Mental Health Services
Administration (SAMHSA).
hospital and emergency department costs for homicide cases ($12,938), insurance administration
costs ($544), and other health costs ($1,995,164). These subtotal $11,416,232” (p. 3). Tables 1.1
and 1.2 break down some of these costs further.
Productivity
“Productivity includes seven components [costs reported in thousands]: labor participation costs
($49,237,777), specialty treatment costs for services provided at the state level ($2,828,207), specialty
treatment costs for services provided at the federal level ($44,830), hospitalization costs ($287,260),
incarceration costs ($48,121,949), premature mortality costs (no homicide: $16,005,008), and premature mortality costs (homicide: $3,778,973). These subtotal $120,304,004” (National Drug Intelligence
Center, 2011, p. ix) (See Figure 1.3).
In addition to those just listed, multitudes of other costs are associated with SUD. These
include the losses to society from premature deaths and fetal alcohol syndrome; social welfare
administration costs, and property losses from substance-related motor vehicle crashes; and costs
of related diseases (hepatitis C, HIV/acquired immunodeficiency syndrome [AIDS], cirrhosis of
the liver, lung cancer, etc.).
8
Chapter 1 • Introduction to Substance Use Disorder Counseling
Cost of SA for crime, health costs, and loss of productivity
$120,304,004
$61,376,694
$11,416,232
Crime
Health
Productivity
FIGURE 1.3 Cost of Substance Use for Crime, Health Costs, and Loss of Productivity.
Substance-Related Diseases
Although, as mentioned earlier, there are many diseases that may be considered related to
substance use, there are three that should be highlighted here.
Hepatitis
Although hepatitis takes multiple forms, we will discuss only two here. Both hepatitis B (HBV)
and hepatitis C (HCV) are liver-damaging viruses that are spread through exposure to contaminated blood and body fluids. Hepatitis B is the most common cause of liver disease in the world.
HBV is blood-borne and can be transmitted through any sharing of blood. HBV is also found in
the semen of infected males, and transmission through sexual contact is likely.
In 2012, a total of 44 states submitted 40,599 reports of chronic hepatitis B to the Centers
for Disease Control and Prevention (CDC). The CDC also received 2,895 case reports of acute
hepatitis B during 2012. Of these acute cases, 42% did not include a response (i.e., a “yes” or
“no” response to questions about risk behaviors and exposures) to enable assessment of risk
behaviors or exposures. Of the 1,690 case reports that had risk behavior/exposure information:
60.6% (n = 1,024) indicated no risk behaviors/exposures for hepatitis B.
39.4% (n = 666) indicated at least one risk behavior/exposure for hepatitis B during
the 6 weeks to 6 months prior to illness onset (injections, multiple sex partners, household
with known HBV individuals) (CDC, 2012)
Hepatitis C (HCV), the most common blood-borne infection in the United States, is a viral
disease that destroys liver cells. There are approximately 3.2 million U.S. residents affected by
HCV. Mortality from HCV exceeds mortality from HIV/AIDS in the U.S. (CDC, 2012).
In 2012, a total of 145,762 reports of chronic hepatitis C infection were submitted to the CDC
by 44 states. In addition, there were 1,778 reported cases of acute HCV—a 75% increase
Chapter 1 • Introduction to Substance Use Disorder Counseling
c ompared with the number of cases reported in 2010. This number represents an estimated 21,870
total acute cases. Some say that the numbers infected are higher than those for HIV/AIDS.
HCV is mostly transmitted through the sharing of needles, and sexual transmission is low.
The largest increase of cases was among persons aged 0-19 years. Further, of the acute cases
reported with responses to risk behavior questions (63%), 65% indicated at least one risk behavior/
exposure in the 2 weeks to 6 months prior to illness onset. Of those who reported risk information,
513 (75%) indicated injection drug use risk and 86 (13%) indicated recent surgery (CDC, 2012).
People with newly acquired HCV are either asymptomatic or have a mild clinical illness.
They may exhibit such symptoms as jaundice, abdominal pain, loss of appetite, nausea, and diarrhea. However, most infected people exhibit mild or no symptoms. HCV RNA can, however, be
detected in blood within 1 to 3 weeks after exposure.
About 85% of people with acute hepatitis C develop a chronic infection. Chronic hepatitis
is an insidious disease whose barely discernible symptoms can mask progressive injury to liver
cells over two to four decades. (CDC, 2012). Chronic hepatitis C, as well as excessive alcohol
consumption, often leads to cirrhosis of the liver and liver cancer. Liver cancer is the tenth most
common cancer and the fifth most common cause of cancer death among men, and the ninth
most common cause of cancer death among women. (American Cancer Society, 2015)
Since the publication of the fifth edition of this book, amazing progress has been made in
the treatment and cure of HCV. There are now several antiviral drugs on the market that cure the
disease. As well, there are multiple other drugs in clinical trials and in process. This breakthrough will save millions of lives in the coming years.
HIV/AIDS
An estimated 35 million people were living with HIV or AIDS worldwide in 2011, with 2.1 million
new cases in 2012. In the United States, about 1.2 million people were living with HIV at the end
of 2011, the most recent year for which this information was available. Of those people, about
14% do not know they are infected. An estimated 1.5 million people died from AIDS-related
illnesses in 2013, and an estimated 39 million people with AIDS have died worldwide since the
epidemic began. (CDC, 2012).
Six common transmission categories are male-to-male sexual contact (MSM), injection
drug use (IDU), male-to-male sexual contact and injection drug use (MSM+IDU), heterosexual
contact, mother-to-child (perinatal) transmission, and other (including blood transfusions and
unknown cause). The highest rate of infection remains male-to-male sexual contact, but injection
drug use is second.
African Americans are most affected by HIV. In 2010, African Americans made up only
12% of the U.S. population, but had 44% of all new HIV infections. Additionally, Hispanics/
Latinos are also strongly affected. They make up 17% of the U.S. population, but had 21% of all
new HIV infections. In 2010, MSM had 63% of all new HIV infections, even though they made
up only around 2% of the population. Individuals infected through heterosexual sex made up
25% of all new HIV infections in 2010.
HIV especially affects young people, aged 13 to 24. They comprised 16% of the U.S. population, but accounted for 26% of all new HIV infections in 2010. Not all young people are equally
at risk, however. Young MSM, for example, accounted for 72% of all new infections in people
aged 13 to 24, and young, African American MSM are even more severely affected (CDC, 2012).
We would be remiss not to discuss these major diseases along with the other secondary
costs of the primary use of substances. At best this information is frightening; in reality, it is
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Chapter 1 • Introduction to Substance Use Disorder Counseling
t errifying. The cost of SUD and diseases related to SUD, in addition to the monetary and societal
costs, is, in many cases, a human life. Many times the life of a person using substances ends in
pain and suffering, alone in an unimaginable place.
It is imperative that all counselors have the knowledge to make connections about substance use with their clients’ problems—and to remember the frequency with which SUD occurs.
It is not unusual for clients to “forget” to let the counselor know about their use, yet this is often
the root of the problem they are presenting. And with substance use may come disease information that is relevant to treatment.
Ethical codes and law now give us direction in handling cases of infectious diseases with
clients. Read and understand your responsibility to your client, their partners, and yourself.
Without thorough knowledge and understanding of the complete context of the client’s life, you
cannot serve the client ethically or effectively.
A (Very) Short History of Substance use
Ever wonder how long humans have been using mind-altering drugs? Did they even realize they
were mind altering before we had the technology to ascertain the brain and physiological
changes, or did it just feel good? What were they using? Where did they find it?
Well, humankind has used mind- or mood-altering drugs at least since the beginning of
recorded history and probably before prehistoric times. Over the centuries, drugs have been used
medicinally, religiously, and socially. In tribal societies, mind-altering drugs were commonly
used in healing practices and religious ceremonies. Alcohol consumption was recorded as early
as the Paleolithic times of the Stone Age culture with the discovery that drinking the juice of
fermented berries created a pleasant feeling. Alcohol, cocaine, marijuana, opium, and tobacco
have all been used for medical purposes through the years.
An overview of the historical perspective of humankind’s use of substances for both analgesic and mind-altering purposes and the multidimensional functions that drugs have played
throughout history may provide a context for understanding today’s substance use issues and
ensuing ramifications. History may also provide some rationale for the treatment methods used
with substance users over the past 50 years.
A perusal of some of the early legends that relate to the discovery of substances as well as
the development of other drugs may add a perspective to the current view of drug use in our
Western society. A complete history would be impossible to provide here, so we endeavor to
provide you with the most entertaining and educational historical summary.
Alcohol
It has been documented that early cave dwellers drank the juices of mashed berries that had been
exposed to airborne yeast. The discovery of late Stone Age beer jugs established the fact that
intentionally fermented beverages existed at least as early as the Neolithic period (ca. 10,000 bce).
When they found that the juice produced pleasant feelings and reduced discomfort, they began to
intentionally produce an alcoholic drink.
Beer was the major beverage among the Babylonians, and as early as 2700 bce they worshipped
a wine goddess and other wine deities. Oral tradition recorded in the Old Testament (Genesis 9:20)
asserts that Noah planted a vineyard on Mount Ararat in what is now eastern Turkey. (In fact, Noah
was perhaps the first recorded inebriate!) Egyptian records give testimony to beer production. They
believed that the god Osiris, who was worshipped throughout the entire country, invented beer, a
beverage that was considered a necessity of life and was brewed in the home on a regular basis.
Chapter 1 • Introduction to Substance Use Disorder Counseling
Homer’s Iliad and Odyssey both discuss drinking wine, and Egypt and Rome had gods or goddesses of wine. The first alcoholic beverage to obtain widespread popularity in what is now Greece
was mead, a fermented beverage made from honey and water. However, by 1700 bce, wine making
was commonplace, and during the next thousand years, wine drinking assumed the same function so
commonly found around the world: It was incorporated into religious rituals, became important in
hospitality, was used for medicinal purposes, and became an integral part of daily meals. As a beverage, it was drunk in many ways: warm and chilled, pure and mixed with water, plain and spiced.
A 4,000-year-old Persian legend tells the story of the discovery of wine. A king had vats of
grapes stored, some of which developed a sour liquid at the bottom. The king labeled these vats as
poison but kept them for future use. One lady of the court was prone to severe headaches that no
one could remedy. Her pain was so severe that she decided to kill herself. She knew of the poisoned grape juice, went to the storage area, and drank the poison. Needless to say, the lady didn’t
die but in fact found relief. Over the next few days, she continued to drink the “poison” and only
later confessed to the king that she had been in the vats. In the 10th century, an Arabian physician,
Phazes, who was looking to release the “spirit of the wine,” discovered the process of distillation.
By the Middle Ages, alcohol was used in ceremonies for births, deaths, marriages, treaty
signings, diplomatic exchanges, and religious celebrations. Monasteries offered wine to weary
travelers who stopped for rest and safety. In Europe, it was known as the “water of life” and
considered the basic medicine for all human ailments. Water pollution is far from new; to the
contrary, supplies have generally been either unhealthful or questionable at best. Ancient writers
rarely wrote about water, except as a warning. Travelers crossing what is now the Democratic
Republic of the Congo in 1648 reported having to drink water that resembled horse’s urine. In
the late 18th century, most Parisians drank water from a very muddy and often chemically polluted Seine. Certainly we can see why wine was the beverage of choice during this time period.
In addition to being used in rituals and for its convivial effect, alcohol was one of the few
chemicals consistently available for physicians to use to induce sleep and reduce pain. Alcohol
has been used as an antiseptic, an anesthetic, and in combinations of salves and tonics. As early
as 1000 ce, Italian winegrowers were distilling wine for medicinal purposes.
When European settlers brought alcoholic beverages in the form of wine, rum, and beer to
the Americas, native cultures were already producing homegrown alcoholic beverages.
The Mayflower’s log reports, “We could not take time for further search or consideration, our victuals having been much spent, especially our bere.” Spanish missionaries brought g rapevines, and
the Dutch opened the first distillery in 1640. American settlers tested the strength of their brews by
saturating gunpowder with alcohol. If it ignited, it was too strong; if it sputtered, too weak.
In 1760, President Adams wrote in his diary that taverns were
becoming the eternal haunt of loose, disorderly people . . . . These houses are becoming the nurseries of our legislators. An artful man, who has neither sense nor sentiments, may, by gaining a
little sway among the rabble of the town, multiply taverns and dram shops and thereby secure the
votes of taverner and retailer and of all; and the multiplication of taverns will make many, who
may be induced to flip and rum, to vote for any man whatever. (Cherrington, 1920, p. 37)
Then in 1790 federal law provided that each soldier receive one-fourth pint of brandy,
rum, or whiskey per week. In the Civil War, army regulations prohibited the purchase of alcohol
by enlisted men, and soldiers who violated the rule were punished, but men on both sides found
ways around it. Members of a Mississippi company got a half-gallon of whiskey past the camp
guards by concealing it in a hollowed-out watermelon; they then buried the melon beneath the
floor of their tent and drank from it with a long straw. If they could not buy liquor, they made it.
One Union recipe called for bark juice, tar water, turpentine, brown sugar, lamp oil, and alcohol.
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World War I, which took place primarily in Europe between 1914 and 1918, saw foot s oldiers
as well as commanders imbibing. With the advent of Prohibition (1920–1933), when the U.S.
Constitution outlawed the manufacture, transport, and sale of alcoholic beverages, many returning
soldiers were none too happy. The Eighteenth Amendment prohibited the sale of alcoholic beverages,
but the federal Volstead Act, which became law during the Prohibition era, enforced the amendment.
During Prohibition, alcohol continued to be made and used (sometimes called bathtub gin
because it was made in bathtubs). Data for the era shows that alcohol consumption may have
actually increased during Prohibition, instead of decreasing as the moral entrepreneurs had hoped.
“Per capita consumption of alcohol increased during Prohibition, according to the federal
Wickersham Commission. More specifically, it increased over 500% between 1921 and 1929,
according to a study published by Columbia University Press. It’s important to point out that per
capita consumption dropped dramatically between 1910 and the imposition of Prohibition in
1920. So Prohibition reversed a downward trend in alcohol consumption” (Hanson, n.d.).
Groups such as the Anti-Saloon League believed drinking alcohol was amoral, deviant,
and counter to Christianity. As one of the most effective groups to lobby for Prohibition, the
Women’s Christian Temperance Union (WCTU) was founded in 1874 in the United States. The
WCTU began as a group of housewives in Ohio concerned about their husbands drinking away
household income. They blamed alcohol for a majority of societal problems and considered the
lack of willpower to resist as the individual drinker’s problem. The WCTU grew in membership
from 22,800 in 1881 to a reported 344,892 in 1921.
After 13 years, Prohibition was repealed, alcohol became legal again, and its legal use
continues today. To date, alcohol is the only mind-altering substance to have been fully legalized
by Federal and State governments after a period of prohibition. In fact, the Eighteenth Amendment
to the Constitution remains the only one to have been repealed.
It is of interest to note the remarks of the founding director of the National Institute on
Alcohol Abuse and Alcoholism (NIAAA): “Alcohol has existed longer than all human memory.
It has outlived generations, nations, epochs and ages. It is a part of us, and that is fortunate
indeed. For although alcohol will always be the master of some, for most of us it will continue to
be the servant of man” (Chafetz, 1965, p. 223).
This (very) brief history provides context for the use of alcoholic beverages throughout time
as well as the complexity of opinions about their worth. Is it the “demon” or the “servant of man”?
Cocaine
Like alcohol, coca has been around for thousands of years. South American Indians have used
cocaine as it occurs in the leaves of Erythroxylum coca for at least 5,000 years. In traditional Indian
cultures, Mama Coca was considered a benevolent deity. She was regarded as a sacred goddess who
could bless humans with her power. Before the coca harvest, the harvester would have sexual intercourse with a woman to ensure that Mama Coca would be in a favorable mood. Typically, a mixture
of coca and saliva was rubbed onto the male organ to prolong erotic ecstasy for both partners.
Traditionally, the leaves have been chewed for social, mystical, medicinal, and religious purposes. Coca has even been used to provide a measure of time and distance. Native travelers sometimes
described a journey in terms of the number of mouthfuls of coca typically chewed in making the trip.
The active ingredient in cocaine was not isolated until 1860 by Albert Neiman. Cocaine
was then added to wine and tonics in the mid-19th century as well as to snuff, and advertised as
a cure for asthma and hay fever. Sigmund Freud experimented with cocaine as a cure for depression and digestive disorders, hysteria, and syphilis. He also recommended cocaine to alleviate
Chapter 1 • Introduction to Substance Use Disorder Counseling
withdrawal from alcohol and morphine addiction. He and his friends experimented with every
method of introducing cocaine into the body. Freud himself used cocaine daily for a considerable
period of time. In fact, in 1884, he published a hymn of praise to cocaine entitled Uber Coca
(Public Broadcasting System, n.d.).
During this time, the mid- to late-1800s, the medical profession was blissfully ignorant of
the addictive qualities of cocaine. So, not surprisingly, by the late 1800s, more than half the scientific and medical community had developed healthy “coke” habits. As more was learned about
cocaine’s addictive properties, these individuals discontinued their own use and also stopped
prescribing it to patients to alleviate all types of medical problems.
An American named John Stith Pemberton developed his own version of a European drink that
included extract of coca leaves and kola nuts. He advertised this product as an “intellectual beverage”
or “brain tonic.” This product, later known as Coca-Cola, contained about 60 milligrams of cocaine
in an 8-ounce serving. It was only a moderate hit, and after the cocaine and alcohol ingredients were
banned in Atlanta, GA, Pemberton sold the company to Asa Griggs Candler for a paltry $2,300.
In the 20th century, cocaine grew in popularity as it decreased in cost. However, as people
began to see the rise of violence among abusers of the drug in the lower socioeconomic stratum
and a rise in the awareness of cocaine’s harmful physical effects, anti-cocaine legislation began.
The first federal legislation regarding cocaine was the 1906 Pure Food and Drug Act that required
manufacturers to precisely label product contents. In 1914, the U.S. Congress passed the Harrison
Narcotics Act, which imposed taxes on products containing cocaine. Soon, drug enforcement
officials transformed the law to prohibit all recreational use of cocaine. By the 1930s, synthetic
amphetamines were available and began to take the place of the now-illegal cocaine. By the
early 1980s, the use of freebase cocaine became popular again among those searching for the
“highest” high. Freebase is a form of cocaine produced when the user takes cocaine hydrochloride and mixes liquid with baking soda or ammonia to remove the hydrochloric acid and then
dissolves the resultant alkaloidal cocaine in a solvent, such as ether, and heats it to evaporate the
liquid. The result is pure, smokable cocaine. The conversion process in freebasing was dangerous and time-consuming and was not suitable for mass production. The danger and volatility of
the process led to drug dealers developing a more potent, less volatile form of cocaine: crack.
In the conversion process for crack, the drug is similarly cooked down to a smokable substance, but the risky process of removing the impurities and hydrochloric acid is taken out. Thus, all
that is required is baking soda, water, and a heat source, often a home oven. As this process allowed
people essentially to get more bang from their buck by delivering the drug more efficiently, cocaine
became available to the lower socioeconomic stratum. This development gave rise to the “crack
epidemic,” and American society was drastically affected by the increase in availability.
Morphine, Heroin: The Opioids
Opium is a derivative of the poppy plant, and early humans learned that by splitting the top of the
Papaver somniferum (poppy) plant, they could extract a thick resin. Later it was discovered that
the dried resin could be swallowed to control pain. By the Neolithic Age, there is evidence that
the plant was being cultivated for this purpose (Doweiko, 2013).
As long ago as 3400 bce, the opium poppy was cultivated in lower Mesopotamia.
The Sumerians refer to it as Hul Gil, the “joy plant.” In 460 bce, Hippocrates, “the father of medicine,” dismissed the magical attributes of opium but acknowledged its usefulness as a narcotic and
styptic in treating internal diseases, diseases of women, and epidemics. In 129–199 ce, there were
reports of opium cakes being sold in the streets of Rome. Ships chartered by Queen Elizabeth I in
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1601 were instructed to purchase the finest Indian opium and transport it back to England. In 1729,
China found it necessary to outlaw opium smoking because of the increasing number of opium
addicts. The Chinese railroad workers brought opium smoking to the United States, and by the
beginning of the 19th century, opium dens were common throughout the nation.
Friedrich Sertürner of Paderborn, Germany, made a startling discovery in 1806. He found
the active ingredient of opium by dissolving it in acid and then neutralizing it with ammonia. The
result: alkaloids—“principium somniferum,” or morphine. Physicians believe that opium had
finally been perfected and tamed. Morphine was lauded as “God’s own medicine” for its reliability, long-lasting effects, and safety. Morphine was freely used in the Civil War and in other wars
for pain as well as for dysentery. The resulting addiction was known as “soldier’s disease.”
When Dr. Alexander Wood of Edinburgh in 1843 discovered a new technique of administering morphine, injection with a syringe, he also found that the effects of morphine on his
patients were instantaneous and three times more potent. C. R. Alder Wright originally synthesized a new drug in 1874 by adding two acetyl groups to the molecule morphine. In 1895,
Heinrich Dreser, who worked for the Bayer Company in Elberfeld, Germany, found that this
drug did not produce the common morphine side effects. Bayer began production of diacetylmorphine and coined the name “heroin.”
From 1895 until 1914, opium, morphine, and heroin were available without a prescription.
Tonics and elixirs were available throughout the 19th century at most drugstores and were consumed mostly by women. In pharmacological studies, heroin proved to be more effective than
morphine or codeine. The Bayer Company started the production of heroin in 1898 on a commercial scale. The first clinical results were so promising that heroin was considered a wonder
drug. Indeed, heroin was more effective than codeine in respiratory diseases. It turned out, however, that repeated administration of heroin resulted in the development of tolerance, and the
patients soon became heroin addicts. In the early 1910s, morphine addicts “discovered” the
euphonizing properties of heroin, and this effect was enhanced by intravenous administration
with the hypodermic syringe. Heroin abuse began to spread quickly.
However, on December 17, 1914, the Harrison Narcotics Act, which aimed to curb drug
abuse (especially of cocaine, as discussed earlier, but also of heroin) and addiction, was passed.
It required doctors, pharmacists, and others who prescribed narcotics to register and pay a tax.
This one law created a significant change in the use and availability of opioids.
During the 1930s and ’40s, heroin was associated with the jazz cultural identity, then in the
’50s with the Beatnik generation and in the ‘60s with the hippie movement. During the Viet Nam
war, there was a 10% to 15% addiction rate among soldiers (Public Broadcasting System, n.d.)
With improvements in the quality of street heroin in the ’80s and ’90s, it became possible to
snort or smoke heroin as well as inject the drug. Currently, heroin appears to be increasing in
use, particularly among youth (see SAMHSA, 2014).
Heroin, illegally available on the street, is usually diluted to a purity of only 2% to 5%
but purity can differ widely. It is usually mixed with baking soda, quinine, milk sugar, or other
substances. The unwitting injection of relatively pure heroin is a major cause of heroin overdose,
the main symptoms of which are extreme respiratory depression, deepening into coma and then
into death. Aside from this danger, heroin addicts are prone to hepatitis and other infections
owing to their use of dirty or contaminated syringes. Scarring of the surfaces of the arms or legs
is another common injury, because of repeated needle injections and subsequent inflammations
of the surface veins.
Another drug, oxycodone, is a semisynthetic opioid agonist derived from thebaine, a
constituent of opium. Oxycodone tests positive as an opiate in available field-test kits.
Chapter 1 • Introduction to Substance Use Disorder Counseling
Pharmacology of oxycodone is essentially similar to that of morphine in all respects, including
its abuse and dependence liabilities. Pharmacological effects include analgesia, euphoria, feelings of relaxation, respiratory depression, constipation, papillary constriction, and cough suppression. Oxycodone abuse has been a continuing problem in the United States since the early
1960s. It is administered orally, rectally, nasally, or by IV injection. Considered a controlled
prescription drug (CPD), oxycodone is one of the most abused drugs in the United States today
(see SAMHSA, 2014).
Marijuana
Marijuana (or cannabis) has been used recreationally and medicinally for centuries. The earliest
account of its use is in China in 2737 bce. In Egypt, in the 20th century BCE, cannabis was used
to treat sore eyes. From the 10th century bce up to 1945 (and even rarely to the present time),
cannabis has been used in India to treat a wide variety of human maladies. In ancient Greece,
cannabis was used as a remedy for earache, edema, and inflammation.
In colonial times, hemp, the plant from which marijuana is derived, was an important crop.
Our forefathers used it to produce paper, clothing, and rope. It was so important in those early
days of America that Virginia introduced legislation in 1762 that exacted penalties on farms that
did not produce it. In 1793 the invention of the cotton gin made the separation of cotton fiber
from the hull easier and far less expensive than it had been previously. Hemp, however, remained
a cash crop until well after the Civil War because of its availability and the ease with which it
could be made into clothing. Eventually, the price dropped until it was no longer profitable, and
many hemp growers switched to tobacco.
In 1850, the United States Pharmacopeia (USP) recognized marijuana (hemp) for its
medicinal value. It was used to treat lack of appetite, gout, migraines, pain, hysteria, depression,
rheumatism, and many other illnesses. Nothing is mentioned about the “high” that marijuana is
famous for in the early reports on the herb, but that omission seems appropriate in contexts
where its medicinal aspect is stressed. Dosage problems due to different plant strengths kept it
from being continued as a “legitimate” drug, and it has been removed from the USP, but adherents still point to marijuana’s medicinal value as a major point for legalization.
The continued primary interest in this drug has been for its euphoric effects. In November
1883, “A Hashish-House in New York” by H. H. Kane, was published in Harper’s Monthly. He
carefully describes the wonders of the hashish (a cannabis derivative) house and writes a vivid
description of his trip to “Hashishdom.” He enjoys the experience but is grateful for the sights
and sounds of the “normal” world upon exiting the house of dreams. In mid-19th century Europe,
members of the French romantic literary movement used cannabis extensively. Through their
writings, American writers became aware of the euphoric effects attributed to the drug.
With the beginning of Prohibition, individual use of marijuana increased in the 1920s as a
substitute for alcohol. After Prohibition, its use declined until the 1960s, when it gained significant popularity along with LSD and “speed.” It has been used as an analgesic, a hypnotic, an
anticonvulsant, and recently an antinausea drug for individuals undergoing chemotherapy for
cancer. Advocates of marijuana for medicinal use cite it as a treatment for asthma, depression,
drug withdrawal, epilepsy in children, glaucoma, and nausea, and as an antibiotic.
On October 27, 1970, the Comprehensive Drug Abuse Prevention and Control Act was
passed. Part II of this act is the Controlled Substance Act (CSA), which defines a scheduling
system for drugs. This schedule places most of the known hallucinogens (LSD, psilocybin,
psilocin, mescaline, peyote, cannabis) in Schedule I. Despite all the years of conflict about
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whether marijuana was medicinal or not and the history of its medicinal use, in 1988 administrative law judge Francis Young of the Drug Enforcement Administration (DEA) found after thorough hearings that marijuana has clearly established medical use and should be reclassified, as a
prescriptive drug (DEA, 1988).
Twenty-three states and Washington, DC, have now legalized marijuana for medicinal use,
and four states have legalized the drug for recreational use. Even in these states, the controversy
continues about the value of the drug as a viable medication for certain conditions, as well as the
financial implications of legalization and the abuse of that legalization. The state of Colorado currently has four lawsuits pending to repeal the recreational and medicinal use of marijuana.
Amphetamines
Amphetamines were discovered in 1887 and used in World War II by U.S., British, German, and
Japanese soldiers for energy, alertness, and stamina. In the late 1920s, they were seriously investigated as a cure or treatment for a variety of illnesses and maladies, including epilepsy, schizophrenia, alcoholism, opiate addiction, migraine, head injuries, and radiation sickness.
Amphetamines were also prescribed to treat depression, induce weight loss, and heighten
capacity for work. Misuse increased in the 1930s with the sale of Benzedrine over the counter. In
the 1950s came the beginning of injection use, with capsules broken open and their contents
injected into the body with a syringe to heighten the effect of the drug. By the early 1960s,
“mainlining” was a major problem in America. In 1962, San Francisco pharmacies were selling
injectable amphetamines, and law enforcement began to close these shops. This drew national
attention and led to the beginning of the home-based “speed labs.”
Methamphetamine (meth), more potent and easy to make, was discovered in Japan in
1919. The crystalline powder was soluble in water, making it a perfect candidate for injection. In
Japan, intravenous methamphetamine abuse reached epidemic proportions immediately after
World War II, when supplies stored for military use became available to the public. In the United
States in the 1950s, legally manufactured tablets of both dextroamphetamine (Dexedrine) and
methamphetamine (Methedrine or meth) became readily available. College students, truck
drivers, and athletes regularly used these drugs to energize and to prolong awake time.
Meth is produced as pills, powders, or chunky crystals called ice. The crystal form, nicknamed crystal meth, is a popular drug, especially with young adults who frequently go to dance
clubs and parties. Swallowed or snorted (also called bumping), methamphetamines give the user
an intense high. Injections create a quick but strong, intense high, called a rush or a flash.
Methamphetamines, like regular amphetamines, also take away appetite.
Meth labs are now a major problem across the country—in every type of neighborhood,
rich and poor. Meth labs turn up in houses, barns, apartments, trailers, campers, cabins, and motel
rooms—even the backs of pickups. The equipment for a meth lab can be small enough to fit in a
duffel bag, a cardboard box, or the trunk of a car. It is important to be alert about the possibility
of a lab near your home, as the fumes from the product are lethal (Weisheit & White, 2010).
One of the newer hallucinogens, Ecstasy, or Molly (an abbreviation for “Molecule” and
generally refers to a “purified” form of Ecstasy), is also classified as an amphetamine. Ecstasy is
referred to as the chemical MDMA (methylenedioxymethamphetamine). MDMA was first synthesized in 1912. The Merck Company patented it in 1914 Germany after Merck stumbled across
MDMA when trying to synthesize another drug. MDMA was an unplanned by-product of this
synthesis. It may have been tested by Merck and also by the U.S. government over the next years
to treat a variety of symptoms. However, it was never found to be effective.
Chapter 1 • Introduction to Substance Use Disorder Counseling
As a street drug, Ecstasy was originally most popular with the White population but now
has a broader range of ethnic users. These drugs are used to enhance the user’s feeling of wellbeing while providing more energy/arousal. However, MDMA users may experience symptoms
such as muscle tension, involuntary teeth clenching, nausea, blurred vision, faintness, and chills
or sweating, especially with multiple doses.
At high doses, MDMA can interfere with the body’s ability to regulate temperature.
On rare but unpredictable occasions, this can lead to a sharp increase in body temperature
(hyperthermia), which can result in liver, kidney, or cardiovascular system failure or even death
(NIDA, 2014d).
Essentially Molly and Ecstasy have two types of action: a psychogenic effect, plus an
amphetamine or “speed”-like effect. Molly is more potent than Ecstasy, hence increasing the
psychedelic and amphetamine-like component. Molly may be “cut” or mixed with pure amphetamine or methamphetamine since there is no quality control on the manufacture of these illegal
drugs. The amphetamine component of Molly can be very potent.
All amphetamines are addictive. They are considered Schedule II drugs (use potentially
leading to severe psychological or physical dependence); except for Ecstasy and Molly, which
are Schedule I drugs, the most dangerous drugs of all the drug schedules, with potentially severe
psychological or physical dependence) (Drug Enforcement Administration, 2014).
Hallucinogens
Hallucinogens have been around for about 3,500 years. Central American Indian cultures used
hallucinogenic mushrooms in their religious ceremonies. When the New World was discovered,
Spanish priests, in an effort to “civilize” the Indians, tried to eliminate the use of the “sacred
mushrooms.” This continued until the American Indian Religious Freedom Act in 1978, and its
amendment in 1994, provided Native Americans with the right to use peyote in religious services.
In 1938, the active ingredient that caused hallucinations was isolated for the first time by a
Swiss chemist, Albert Hofmann. He was studying a particular fungus in bread that appeared to
create hallucinations. The substance he synthesized during this research was LSD (lysergic acid
diethylamide). Between 1950 and the mid-1970s, LSD was well researched by the U.S. government in the hope that it could be used to understand the psychotic mind and to view the subconscious. It was called “the truth drug.” LSD has been used in the treatment of alcoholism,
depression, epilepsy, cancer, and schizophrenia. Before the early 1960s, the drug had limited
availability, but as researchers, clinical practitioners, research participants, and physicians used
the drug and shared it with friends, it became more popular. Because LSD was easy and inexpensive to make (at that time, the formula could be purchased from the U.S. Patent Office for
50 cents), a black market began to emerge.
Hallucinogens were a primary drug in the 1960s. Dr. Timothy Leary, a Harvard professor and icon of the 1960s counterculture of music, made the term “turn on, tune in and drop
out” popular. Then the “Summer of Love” in 1967 in San Francisco firmly linked LSD to this
movement.
After losing popularity in the 1970s and ’80s, LSD began to resurface in the 1990s with the
rave culture but has since seemed to decline in use.
Tobacco
It is believed that tobacco was growing in the Americas around 6000 bce. As early as 1 bce,
Indians in the New World were using tobacco for medicinal and religious purposes.
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In 1492, natives in the New World offered Columbus dried tobacco as a gift. Sailors
c arried tobacco back to Europe, where it began to be cultivated. In the 16th century, it was
believed that tobacco could cure many illnesses, and in the 1600s, it was used as money. By
1632, in the Americas, it was illegal to smoke tobacco in public in Massachusetts. Smoking
became quite popular in Europe and Asia, but it faced harsh opposition from the church and
government. Public smoking was punishable by death in Germany, China, and Turkey and by
castration in Russia. Despite this early response, people continued to smoke and eventually were
at least moderately accepted into society.
The first tobacco company in the United States, P. Lorillard, was founded in 1760 in New York
City and remains open today. With the Industrial Age came the invention of machinery to make the
cigarette a smaller, less expensive, neater way to smoke, making the price affordable to almost
everyone. Laws were passed that allowed the decrease in price, and after 1910, public health officials
began to campaign against chewing tobacco and for smoking tobacco. Smokers also realized that,
unlike cigars, cigarette smoke could be inhaled, entering the lungs and the bloodstream, creating a
more intense feeling. World War I brought a dramatic increase in smoking and in World War II,
cigarettes were included in soldiers’ rations. In the 1940s and ’50s, smoking was seen as sophisticated.
Nicotine is one of the most addictive drugs. In the mid-19th century, when the pure form
of nicotine was extracted, it was deemed a poison. A few hours of smoking are all that is needed
for tolerance to begin to develop. The body immediately begins to adapt to protect itself from the
toxins found in tobacco. As this process begins, it creates a rapid physiological development that
requires smoking again to return to a normal feeling.
By the mid-1950s, however, research began to show the negative effect of tobacco. The
highly addictive nature of nicotine was acknowledged as a health hazard by the Surgeon General
of the United States in his 1964 report on tobacco. In his report, the Surgeon General outlined the
various problems that could be related to, or caused by, smoking…
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