case study on substance abuse

Module 9: Substance-Related and Addictive Disorders

Case studies: substance-abuse disorders, learning objectives.

• Identify substance abuse disorders in case studies

Case Study: Benny

The following story comes from Benny, a 28-year-old living in the Metro Detroit area, USA. Read through the interview as he recounts his experiences dealing with addiction and recovery.

Q : How long have you been in recovery?

Benny : I have been in recovery for nine years. My sobriety date is April 21, 2010.

Q: What can you tell us about the last months/years of your drinking before you gave up?

Benny : To sum it up, it was a living hell. Every day I would wake up and promise myself I would not drink that day and by the evening I was intoxicated once again. I was a hardcore drug user and excessively taking ADHD medication such as Adderall, Vyvance, and Ritalin. I would abuse pills throughout the day and take sedatives at night, whether it was alcohol or a benzodiazepine. During the last month of my drinking, I was detached from reality, friends, and family, but also myself. I was isolated in my dark, cold, dorm room and suffered from extreme paranoia for weeks. I gave up going to school and the only person I was in contact with was my drug dealer.

Q : What was the final straw that led you to get sober?

Benny : I had been to drug rehab before and always relapsed afterwards. There were many situations that I can consider the final straw that led me to sobriety. However, the most notable was on an overcast, chilly October day. I was on an Adderall bender. I didn’t rest or sleep for five days. One morning I took a handful of Adderall in an effort to take the pain of addiction away. I knew it wouldn’t, but I was seeking any sort of relief. The damage this dosage caused to my brain led to a drug-induced psychosis. I was having small hallucinations here and there from the chemicals and a lack of sleep, but this time was different. I was in my own reality and my heart was racing. I had an awful reaction. The hallucinations got so real and my heart rate was beyond thumping. That day I ended up in the psych ward with very little recollection of how I ended up there. I had never been so afraid in my life. I could have died and that was enough for me to want to change.

Q : How was it for you in the early days? What was most difficult?

Benny : I had a different experience than most do in early sobriety. I was stuck in a drug-induced psychosis for the first four months of sobriety. My life was consumed by Alcoholics Anonymous meetings every day and sometimes two a day. I found guidance, friendship, and strength through these meetings. To say early sobriety was fun and easy would be a lie. However, I did learn it was possible to live a life without the use of drugs and alcohol. I also learned how to have fun once again. The most difficult part about early sobriety was dealing with my emotions. Since I started using drugs and alcohol that is what I used to deal with my emotions. If I was happy I used, if I was sad I used, if I was anxious I used, and if I couldn’t handle a situation I used. Now that the drinking and drugs were out of my life, I had to find new ways to cope with my emotions. It was also very hard leaving my old friends in the past.

Q : What reaction did you get from family and friends when you started getting sober?

Benny : My family and close friends were very supportive of me while getting sober. Everyone close to me knew I had a problem and were more than grateful when I started recovery. At first they were very skeptical because of my history of relapsing after treatment. But once they realized I was serious this time around, I received nothing but loving support from everyone close to me. My mother was especially helpful as she stopped enabling my behavior and sought help through Alcoholics Anonymous. I have amazing relationships with everyone close to me in my life today.

Q : Have you ever experienced a relapse?

Benny : I experienced many relapses before actually surrendering. I was constantly in trouble as a teenager and tried quitting many times on my own. This always resulted in me going back to the drugs or alcohol. My first experience with trying to become sober, I was 15 years old. I failed and did not get sober until I was 19. Each time I relapsed my addiction got worse and worse. Each time I gave away my sobriety, the alcohol refunded my misery.

Q : How long did it take for things to start to calm down for you emotionally and physically?

Benny : Getting over the physical pain was less of a challenge. It only lasted a few weeks. The emotional pain took a long time to heal from. It wasn’t until at least six months into my sobriety that my emotions calmed down. I was so used to being numb all the time that when I was confronted by my emotions, I often freaked out and didn’t know how to handle it. However, after working through the 12 steps of AA, I quickly learned how to deal with my emotions without the aid of drugs or alcohol.

Q : How hard was it getting used to socializing sober?

Benny : It was very hard in the beginning. I had very low self-esteem and had an extremely hard time looking anyone in the eyes. But after practice, building up my self-esteem and going to AA meetings, I quickly learned how to socialize. I have always been a social person, so after building some confidence I had no issue at all. I went back to school right after I left drug rehab and got a degree in communications. Upon taking many communication classes, I became very comfortable socializing in any situation.

Q : Was there anything surprising that you learned about yourself when you stopped drinking?

Benny : There are surprises all the time. At first it was simple things, such as the ability to make people smile. Simple gifts in life such as cracking a joke to make someone laugh when they are having a bad day. I was surprised at the fact that people actually liked me when I wasn’t intoxicated. I used to think people only liked being around me because I was the life of the party or someone they could go to and score drugs from. But after gaining experience in sobriety, I learned that people actually enjoyed my company and I wasn’t the “prick” I thought I was. The most surprising thing I learned about myself is that I can do anything as long as I am sober and I have sufficient reason to do it.

Q : How did your life change?

Benny : I could write a book to fully answer this question. My life is 100 times different than it was nine years ago. I went from being a lonely drug addict with virtually no goals, no aspirations, no friends, and no family to a productive member of society. When I was using drugs, I honestly didn’t think I would make it past the age of 21. Now, I am 28, working a dream job sharing my experience to inspire others, and constantly growing. Nine years ago I was a hopeless, miserable human being. Now, I consider myself an inspiration to others who are struggling with addiction.

Q : What are the main benefits that emerged for you from getting sober?

Benny : There are so many benefits of being sober. The most important one is the fact that no matter what happens, I am experiencing everything with a clear mind. I live every day to the fullest and understand that every day I am sober is a miracle. The benefits of sobriety are endless. People respect me today and can count on me today. I grew up in sobriety and learned a level of maturity that I would have never experienced while using. I don’t have to rely on anyone or anything to make me happy. One of the greatest benefits from sobriety is that I no longer live in fear.

Case Study: Lorrie

Figure 1. Lorrie.

Lorrie Wiley grew up in a neighborhood on the west side of Baltimore, surrounded by family and friends struggling with drug issues. She started using marijuana and “popping pills” at the age of 13, and within the following decade, someone introduced her to cocaine and heroin. She lived with family and occasional boyfriends, and as she puts it, “I had no real home or belongings of my own.”

Before the age of 30, she was trying to survive as a heroin addict. She roamed from job to job, using whatever money she made to buy drugs. She occasionally tried support groups, but they did not work for her. By the time she was in her mid-forties, she was severely depressed and felt trapped and hopeless. “I was really tired.” About that time, she fell in love with a man who also struggled with drugs.

They both knew they needed help, but weren’t sure what to do. Her boyfriend was a military veteran so he courageously sought help with the VA. It was a stroke of luck that then connected Lorrie to friends who showed her an ad in the city paper, highlighting a research study at the National Institute of Drug Abuse (NIDA), part of the National Institutes of Health (NIH.) Lorrie made the call, visited the treatment intake center adjacent to the Johns Hopkins Bayview Medical Center, and qualified for the study.

“On the first day, they gave me some medication. I went home and did what addicts do—I tried to find a bag of heroin. I took it, but felt no effect.” The medication had stopped her from feeling it. “I thought—well that was a waste of money.” Lorrie says she has never taken another drug since. Drug treatment, of course is not quite that simple, but for Lorrie, the medication helped her resist drugs during a nine-month treatment cycle that included weekly counseling as well as small cash incentives for clean urine samples.

To help with heroin cravings, every day Lorrie was given the medication buprenorphine in addition to a new drug. The experimental part of the study was to test if a medication called clonidine, sometimes prescribed to help withdrawal symptoms, would also help prevent stress-induced relapse. Half of the patients received daily buprenorphine plus daily clonidine, and half received daily buprenorphine plus a daily placebo. To this day, Lorrie does not know which one she received, but she is deeply grateful that her involvement in the study worked for her.

The study results? Clonidine worked as the NIDA investigators had hoped.

“Before I was clean, I was so uncertain of myself and I was always depressed about things. Now I am confident in life, I speak my opinion, and I am productive. I cry tears of joy, not tears of sadness,” she says. Lorrie is now eight years drug free. And her boyfriend? His treatment at the VA was also effective, and they are now married. “I now feel joy at little things, like spending time with my husband or my niece, or I look around and see that I have my own apartment, my own car, even my own pots and pans. Sounds silly, but I never thought that would be possible. I feel so happy and so blessed, thanks to the wonderful research team at NIDA.”

• Liquor store. Authored by : Fletcher6. Located at : https://commons.wikimedia.org/wiki/File:The_Bunghole_Liquor_Store.jpg . License : CC BY-SA: Attribution-ShareAlike
• Benny Story. Provided by : Living Sober. Located at : https://livingsober.org.nz/sober-story-benny/ . License : CC BY: Attribution
• One patientu2019s story: NIDA clinical trials bring a new life to a woman struggling with opioid addiction. Provided by : NIH. Located at : https://www.drugabuse.gov/drug-topics/treatment/one-patients-story-nida-clinical-trials-bring-new-life-to-woman-struggling-opioid-addiction . License : Public Domain: No Known Copyright

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Co-occurring Mental Health and Substance Use Disorders: Guiding Principles and Recovery Strategies in Integrated Care (Part 1)

Individuals with co-occurring mental health and substance use disorders (CODs) have complex treatment needs. Historically, these issues were treated separately, as competing discreet needs. Barriers in access to integrated care for substance related and mental health disorders prevented many individuals from finding relief from their COD. The structures in place that prevented integrated care were many. Public and private funding, research, and public policy all created troughs between disciplines of care. Researchers and practitioners have noted how the separation of mental health and substance abuse treatment has created additional barriers and obstacles for clients with CODs: Parallel treatment results in fragmentation of services, non-adherence to interventions, dropout, and service extrusion, because treatment programs remain rigidly focused on single disorders and individuals with dual disorders are unable to negotiate the separate systems and to make sense of disparate messages regarding treatment and recovery (Osher, Drake, 1996; Drake, Mueser, Brunette, and McHugo. 2004).

Mental health services and treatment structures for substance related disorders were on divergent paths and many professionals considered one another with skepticism. Today, some, but not all, of those barriers have been eliminated.

According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) 2011 National Survey on Drug Use and Health, Mental Health Findings, more than 8 million adults in the United States have CODs. Only 6.9% of individuals receive treatment for both conditions and 56.6% receive no treatment at all (SAMHSA, 2012).

This is the first of two practice briefs that will explore eight principles of integrated care for CODs (Mueser et al., 2003). This brief will examine the first four of the following principles:

• Principle 1: Integration of mental health and substance use services
• Principle 2: Access to comprehensive assessment of substance use and mental health concerns
• Principle 3: Comprehensive variety of services offered to clients
• Principle 4: An assertive approach to care/service delivery
• Principle 5: Using a harm reduction approach to care
• Principle 6: Motivation-based and stage wise interventions
• Principle 7: Long-term perspective of care
• Principle 8: Providing multiple psychotherapeutic modalities

After a brief review of each principle, an illustrative case study will be provided and suggestions for implementing each of the principles in a client session will be offered (SAMHSA, 2009a; 2009b).

Principle 1: Integration of Mental Health and Substance Use Services

Multidisciplinary teams provide integrated services and relevant care that is client centered and longitudinal in nature. Agency policies and practices recognize the relapse potential with CODs and do not penalize clients for exhibiting symptoms of their mental health or substance related disorders. Team members may include the client and their family members or supportive persons, practitioners who are trained in substance abuse and mental health counseling, and a combination of physicians, nurses, case managers, or providers of ancillary rehabilitation services (therapy, vocational, housing, etc.) such as social workers, psychologists, psychiatrists, marriage and family therapists and peer support specialists. Based on their respective areas of expertise, team members collaborate to deliver integrated services relevant to the client’s specific circumstances, assist in making progress toward goals, and adjust services over time to meet individuals’ evolving needs (Mueser, Drake, & Noordsy, 2013). The team members consistently and regularly communicate with the client to discuss progress towards goals, and they work together to meet the individual treatment needs of each client.

Penny, 43, experienced her first depressive episode in her mid teens. During her first treatment for substance use (marijuana and alcohol) at age 17, Penny was diagnosed with attention deficit hyperactivity disorder (ADHD). However, over the next few years, she became increasingly edgy and irritable with intermittent periods of euphoria, accelerated energy and impulsive behaviors followed by periods of despair. She had repeated hospitalizations and concurrent and sequential contact with both mental health and substance abuse treatment systems over the years. Penny was labeled with a variety of diagnoses, including bipolar disorder, ADHD, major depression, anxiety disorder, borderline personality disorder, and chemical dependence.

Penny’s multi-disciplinary team consisted of her primary practitioner who held LADC/LPCC dual licenses, a primary care physician, a psychiatrist, a family therapist, a peer recovery support specialist, and a vocational specialist. Penny participated in individual therapy as well as recovery skills groups with her primary practitioner. Her primary care physician monitored Penny’s physical concerns including her diabetes and hypothyroid disorder. Penny’s psychiatrist prescribed and monitored Penny’s mood-stabilizing medications and provided case consultation to Penny’s team. The family therapist provided ongoing support to Penny and her boyfriend Don, and helped Penny and her team decide if and when to begin reparations in her relationship with her children. In addition, the family therapist provided feedback to the team about how Penny’s relationships impacted her recovery status and overall stability. The vocational specialist acted as a resource for Penny once she expressed a desire to return to work, helped Penny and her team identify resources for employment, and acted as liaison with Penny’s employer. The peer recovery support specialist helped Penny identify recovery support groups and helped Penny and her team identify barriers and resources to overcome those barriers to recovery success.

Principle 2: Access to Comprehensive Assessment of Substance Use and Mental Health Concerns

Integrated care recognizes that CODs and the resulting consequences of those conditions are commonplace. Therefore, practice protocols that standardize comprehensive biopsychosocial assessments are essential to identifying major mental illnesses and substance use. A comprehensive assessment includes screening, and when needed, further examination of substance use and mental health concerns. Practitioners utilize information collected from the comprehensive assessment to provide recommendations for treatment —such as the role one condition has on the efficacy of particular treatment strategies for the other condition(s). Screening tools for substance related disorders can include the CAGE-AID (Brown & Rounds, 1995), the Michigan Alcohol Screening Test (MAST) (Selzer, 1971), the Drug and Alcohol Screen Test (DAST) or the Alcohol Use Disorders Identification Test (AUDIT) (Saunders et al., 1993). For mental health concerns the Global Appraisal of Individual Needs-Short Screener (GAIN-SS) (Dennis, Chan, & Funk, 2006), or Brief Symptom Inventory (BSI) (Derogatis & Melisaratos, 1983) may be used.

When feasible, the practitioner gathers information from the client’s family and other professional resources who might have relevant information regarding symptom severity, substance use, and role functioning. Information gathered during the initial assessment can assist in a collaborative goal setting process. Ongoing assessment is critical in the treatment of co-occurring disorders and involves evaluation of changes in circumstances, substance use, stability and symptom expression, and goal attainment. Conducting a comprehensive integrated assessment helps define areas that can be addressed in treatment and identify specific treatment recommendations (Mueser et al., 2013). The context of the comprehensive assessment should occur within a recovery-oriented perspective. Progress toward recovery is individualized as described in the following definition: A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential (SAMHSA, CMHS, 2011).

Penny and her primary practitioner completed a comprehensive biopsychosocial assessment that included questions about distressing mental health symptoms as well as substance use patterns and periods of abstinence/remission. During her early 20s Penny entered college to become a nurse. Soon after beginning school, her anxiety increased. She experienced racing thoughts, extreme irritability, interruptions in sleep and a pronounced overconfidence followed by periods of despair and an inability to get out of bed. Penny returned to using alcohol and marijuana and eventually discontinued her education.

In her early 30s, Penny completed substance abuse treatment and was abstinent from alcohol and marijuana. She also participated in individual therapy and was prescribed lithium. She experienced a period of relative stability and returned to school. However, Penny disliked the side effects of her medication and felt she was stable enough to discontinue taking the lithium. She sought care from a physician for her anxiety and was placed on the benzodiazepine Xanax.

Penny currently lives with Don, her boyfriend of 8 years. Due to chronic conflict in their relationship, she is in danger of becoming homeless. Don has a construction business and manages to make a solid living. They both smoke marijuana most evenings as a way to wind down from the day. Don occasionally uses cocaine and in very rare situations Penny has joined him. She has been abstinent from alcohol since receiving a DWI 9 months ago. Penny has been estranged from her two adult children, Linda, 24, and Jeff, 22, for 6 months and 3 years, respectively. Her parents are deceased.

Penny’s practitioner was able to collect information from Penny’s boyfriend, her children, previous therapists, agencies and hospitals with whom she has had contact. During the assessment the practitioner discovered information about periods of increased mental illness symptoms while Penny was abstinent from substances, and a return to substance use in correlation with mental illness symptoms. The comprehensive assessment provided initial information about Penny’s current mental illness symptoms and substance use and was used to determine treatment priorities and programs that align with Penny’s needs.

Principle 3: Comprehensive Variety of Services Offered to Clients

Clients are provided with comprehensive integrated services that are cohesive, relevant and responsive to their identified needs and goals (Bipolar Disorder, n.d.). Practitioners coordinate with one another and collaborate with the client to prioritize treatment needs in a manner that does not overwhelm the client. A multidisciplinary team provides support for a broad range of issues relevant to the client population served by the agency. This includes culturally relevant information about community support systems and an array of mental health or substance related resources available to clients and their support persons.

Comprehensive services that are relevant to persons with CODs often include but are not limited to: medication assisted therapy, cognitive behavioral therapy (CBT), family therapy, life skills/ psychosocial rehabilitation, psychoeducation, and supported employment. Medication assisted therapy helps control distressing symptoms of many health and mental health dis-orders and is helpful for mood stabilization. Medication is also used in the treatment of substance use disorders to inhibit substance use, reduce cravings, reduce withdrawal symptoms, and as replacement therapy. CBT helps people with CODs learn to change harmful or negative thought patterns and behaviors.

Family therapy enhances coping strategies and focuses on improving communication and problem solving amongst family members and significant others. Life skills/rehabilitation provides clients with new information and opportunities to practice skills such as sleep hygiene practices, self-care, stress reduction and management, and medication maintenance. Psychoeducation provides information about the interacting dynamics of CODs and treatment (e.g., recognition of early signs of relapse so they can seek support before a full-blown episode occurs.) Supported employment provides opportunities for the client to contribute meaningfully in a work environment. A vocational specialist is part of the treatment team and works as a liaison with employers, client and the rest of the treatment team to support the client in the work environment. A case manager/navigator assists the client and their support persons in access-ing resources necessary to their recovery. These relationships are longitudinal in nature and supportive rather than therapeutic.

Penny and her treatment team agreed that she would benefit from mood stabilizing medication for her mental health disorder as well as cognitive behavioral therapy to help her develop coping strategies to help regulate and stabilize symptoms such as feelings of despair, racing thoughts, and behavioral dysregulation. Penny and Don recently began family counseling to explore the role and impact of substance use on their relationship, to develop communication skills and to identify strategies to help Don support Penny in her recovery from COD. Penny expressed interest in mending the relationship with her children in the future. If they are reunited, Penny identified a goal of attending family therapy with her children to improve communication and explore the impact of her COD on her relationship with them. Penny also identified a desire to return to work and will be making an appointment to discuss her work goals with the supported employment specialist.

Penny participates in a skills group to assist her in managing the symptoms of her CODs such as emotional and behavioral regulation, self care, sleep hygiene, and to manage triggers related to her substance use.

Principle 4: An Assertive Approach to Care/Service Delivery

Assertive outreach involves reaching out to individuals who are at risk or in crisis and their concerned persons, by providing support and engaging them in the change process. Sometimes this occurs by engaging the individual who seeks care for a substance use issue and providing services that stabilize a COD. An assertive approach is time unlimited and occurs in a variety of situations, including a client’s own community setting (Bond, 1991; Bond, McGrew, & Fekete, 1995). Assertive outreach includes meeting the client in community locations and providing practical assistance in daily living needs. These strategies increase or decrease in intensity depending on the client’s day-to-day living needs such as housing, transportation, money management, or seeking employment. This approach also provides opportunities to explore and address how substance use interferes with goal attainment.

Assertive outreach by Penny’s multidisciplinary team included meeting with a vocational specialist to assist Penny in looking for a job. Penny’s primary practitioner met with Penny weekly in Penny’s home and discussed progress towards her goals. Although Penny had not declared she wanted to stop using or cut down this provided Penny’s practitioner with an opportunity to introduce discrepancy by exploring how substance use interfered with taking steps toward Penny’s goals and practicing or using coping skills. Penny and her primary practitioner examined how Penny’s use impeded her ability to follow through with completing job applications and job interviews as steps toward finding steady, meaningful work.

This brief examined four of the eight principles of COD treatment. The first four principles underscore the importance of the integration of COD services and access to comprehensive assessment and care using assertive outreach and a client centered approach. The next brief will explore the latter four COD principles and implementation strategies. The final COD principles emphasize a long-term care model using a harm-reduction approach, motivation-based stage-wise treatment interventions and multiple treatment modalities (Mueser et al., 2003). The principles in both briefs place the client and their support persons, front and center as active participants, guides, resources and experts in their own recovery. Unpacking the principles of integrated treatment for CODs provides opportunities for practitioners to utilize multiple strategies to engage clients in treatment as discussed in this practice brief.

As you consider the practice of integrated care, examine your agency and your own clinical practice. Consider how you might try new strategies in an effort to implement the principles of COD treatment. We invite practitioners to engage in a dialogue surround-ing the strategies implemented in sessions to engage COD clients. Please consider the following and email us to describe successful COD strategies and challenges utilizing the principles of COD treatment.

• What strategies have you tried using one of the above principles that worked particularly well?
• What challenges have you encountered?
• Please provide suggestions for additional strategies you found helpful.

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New research and insights into substance use disorder.

Addictions to alcohol, illicit drugs and other substances remain a serious threat: According to the National Center for Health Statistics, part of the Centers for Disease Control and Prevention, from April 2020 to April 2021, nearly 92,000 people in the U.S. fatally overdosed on drugs — the single highest reported death toll during a 12-month period. The National Center for Drug Abuse Statistics has deemed the situation “a public health emergency.” All groups ages 15 and older experienced a rise in these grim statistics, intensified by the use of fentanyl.

Currently, substance use disorder affects more than 20 million Americans ages 12 and over. These numbers are troubling, says Johns Hopkins neuroscientist and addiction researcher Andrew Huhn , “but with a multifaceted approach, people with substance use disorders can recover.”

Drawing from his background in neuroscience and behavioral pharmacology, Huhn identifies risk factors for relapse and medication strategies — bolstered by supervised withdrawal and counseling — to improve treatment outcomes. “My research focuses on understanding the human experience of substance use disorder,” he says, noting that medications for opioid overdose, withdrawal and addiction “are safe, effective and continue to save lives.”

Now, thanks to a recent collaboration with Ashley Addiction Treatment, a residential treatment center in Havre de Grace, Maryland, Huhn, Kelly Dunn and colleagues are combining efforts to identify patients likely to benefit from supervised withdrawal or opioid maintenance therapy. The goal is to expand treatment options to improve health care for people with the condition. “Relapse remains common, but a subset of patients have done well,” says Dunn.

Concurrently, Huhn, Dunn and colleagues are building a research database based on the Trac9 program, which charts patients’ progress in real-time through technology, such as a tablet or phone — as well as alerting clinicians to a relapse and the need for intervention. They are also using wearable devices to monitor sleep and cardiovascular outcomes, and a smart phone application to track each time a patient notes having successfully ignored a craving for alcohol or a drug. Much of this research takes place at Behavioral Pharmacology Research Unit , located on the Johns Hopkins Bayview Medical Center campus.

Their published work includes studies showing a greater need for treatment of older adults with alcohol and opioid use disorders. Two additional studies have garnered national attention, both on how fentanyl use affects the treatment of opioid use disorder . Much of the illicit opioid supply in the U.S. is mixed with fentanyl, leading to a recent surge in fentanyl-related overdose deaths.

Yet another study showed promise in the use of a sleep medication to improve opioid withdrawal outcomes. Researchers in Huhn’s lab continue to glean insights from neuroimaging, ambulatory monitoring in real time, and repeated measures of behaviors.

Greg Hobelmann , the CEO of Ashley, who trained at Johns Hopkins and is a part-time faculty member, chairs an elective at the Ashley facility in addictions psychiatry. He, along with Eric Strain and Huhn are building infrastructure that includes intake data on every patient, as well as outcomes data when people complete the Ashley program — and for the year that follows. Biospecimens will also be included in the project, for studies in areas such as genetics.

“The biggest and most exciting thing is being able to create predictive models of relapse risk and then create strategies to improve those outcomes,” says Huhn. Jimmy Potash , director of the Johns Hopkins Department of Psychiatry and Behavioral Sciences couldn’t agree more. “This will be a powerful platform for discovery of better approaches to treating addiction,” he says. “I’m eager to see it — and our relationship with Ashley Addiction — move forward.”

Despite enduring challenges in addictions psychiatry, Huhn is hopeful. “We have the ability to continue collecting data and to test hypotheses,” he says. “It’s the kind of stuff we hope will turn into a game-changer, similar to what has happened in cancer and heart disease treatments. We build research into the treatment and let that guide our approach to care.”

Learn about a web-based education intervention to reduce opioid overdose, Low-Cost Intervention Reduces Risk of Opioid Overdose.

Related Reading

Johns hopkins bayview’s center for addiction and pregnancy supports new mothers and their babies in the fight against substance use disorders.

Center offers judgment-free care, helping moms and newborns

• Open access
• Published: 25 May 2017

Intensive Case Management for Addiction to promote engagement with care of people with severe mental and substance use disorders: an observational study

• Stéphane Morandi 1 ,
• Benedetta Silva 1 ,
• Philippe Golay 1 &
• Charles Bonsack 1  

Substance Abuse Treatment, Prevention, and Policy volume  12 , Article number:  26 ( 2017 ) Cite this article

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Co-occurring severe mental and substance use disorders are associated with physical, psychological and social complications such as homelessness and unemployment. People with severe mental and substance use disorders are difficult to engage with care. The lack of treatment worsens their health and social conditions and increases treatment costs, as emergency department visits arise. Case management has proved to be effective in promoting engagement with care of people with severe mental and substance use disorders. However, this impact seemed mainly related to the case management model. The Intensive Case Management for Addiction (ICMA) aimed to improve engagement with care of people with severe mental and substance use disorders, insufficiently engaged with standard treatment. This innovative multidisciplinary mobile team programme combined Assertive Community Treatment and Critical Time Intervention methodologies. The aim of the study was to observe the impact of ICMA upon service use, treatment adherence and quality of support networks. Participants’ psychosocial and mental functioning, and substance use were also assessed throughout the intervention.

The study was observational. Eligible participants were all the people entering the programme during the first year of implementation (April 2014–April 2015). Data were collected through structured questionnaires and medical charts. Assessments were conducted at baseline and at 12 months follow-up or at the end of the programme if completed earlier. McNemar-Bowker’s Test, General Linear Model repeated-measures analysis of variance and non-parametric Wilcoxon Signed Rank tests were used for the analysis.

A total of 30 participants took part in the study. Results showed a significant reduction in the number of participants visiting the general emergency department compared to baseline. A significantly decreased number of psychiatric emergency department visits was also registered. Moreover, at follow-up participants improved significantly their treatment adherence, clinical status, social functioning, and substance intake and frequency of use.

Conclusions

These promising results highlight the efficacy of the ICMA. The intervention improved engagement with care and the psychosocial situation of people with severe mental and substance use disorders, with consequent direct impact on their substance misuse.

Only a minority of people with co-occurring severe mental and substance use disorders seek help and are treated for their problems [ 1 , 2 , 3 ]. On a personal level, important identified barriers to treatment are symptoms, lack of awareness of being in need of help, stigma or social problems such as homelessness or insufficient financial resources. On a structural level, the service location and organisation or the unavailability of addiction specialists have been recognised as care access limitations [ 4 , 5 ]. Absence of care can lead to health and social complications and contributes to higher costs of public services as emergency department visits arise [ 6 ]. Different models of case management have proved to be effective in promoting engagement with care of people with substance use disorders in a variety of settings [ 7 , 8 , 9 ]. Case management also showed to reduce substance misuse among homeless people with severe mental illness [ 10 ]. However, the impact of these interventions seemed to be mainly determined by the case management reference model [ 11 ]. Assertive community treatment (ACT) improved housing stability and was cost-effective for homeless people with severe mental and substance use disorders, reducing inpatient and emergency department visits. Critical Time Intervention (CTI) showed promise for housing support, psychiatric symptoms and substance use in this population.

In 2001, an Intensive Case Management (ICM) programme for people with severe mental disorders (in French Suivi Intensif dans le milieu -SIM), was developed and tested in Lausanne, Switzerland, an urban area of 265′000 inhabitants [ 12 ]. The intervention combined the Assertive Community Treatment (ACT) [ 13 , 14 ] and the Critical Time Intervention [ 15 ] methodologies. As in the ACT model, case managers and psychiatrists provided home visits when needed. A caseload limited to a maximum of 20 clients per full-time professional allowed case managers to spend more time with each person and to intensify the follow-up during crisis periods. The multidisciplinarity of the team granted an approach that was not exclusively focused on the illness. Each professional could discuss and provide specific help on a wider range of issues, such as housing or income. These specificities of ACT are key elements that contribute to clients’ satisfaction and promote their engagement with care [ 16 ]. The ICM programme in Lausanne differed from ACT in three aspects. First, because of a lack of resources, the team was only available between 8 a.m. and 6 p.m. During nights and weekends, clients could be referred to the local psychiatric emergency department (ED). Second, situations were regularly discussed among team members, but each client was followed by a specific case manager and by the psychiatrist when no other doctor was involved in the situation. Third, the team members only delivered services that other professionals could not provide, such as intensive home visits or practical help for time consuming administrative procedures. This led to a closer collaboration with other members of the health and social network and made discharge towards other services easier. The ICM programme borrowed also elements from the critical time intervention model (CTI) [ 15 ]: 1. The intervention was time-limited to critical or transitional periods; 2. It aimed to engage clients with other services through a smooth process; 3. During the programme, it offered a psychological as well as a practical help adapted to client’s needs; 4. Client’s resources and limitations were assessed in vivo and practical solutions proposed.

In Lausanne, the ICM intervention has proved to be effective in promoting engagement with care of people with severe mental illness and improving both their clinical and social functioning [ 17 ]. These results were in line with international studies on ICM for severe mental disorders that have shown to reduce hospitalisations, increase participants retention in care and improve their social functioning [ 18 ]. Based on the ICM model, in 2014 a pilot project of Intensive Case Management for Addiction (ICMA) (in French Suivi Intensif dans le milieu pour les problèmes d’addiction - SIMA) was developed and implemented in the same area. The programme was tested with a group of hard-to-reach people with severe mental and substance use disorders, who have difficulties to engage with addiction or psychiatric services. This paper presents findings from the ICMA observational study.

Aims of the study

The main aim of the study was to test whether ICMA improved engagement with care of people with severe mental and substance use disorders. Specifically, expected primary outcomes were: decreased rates of unplanned service use and involuntary hospitalisations, improved level of treatment adherence and enhanced quality of primary (relatives) and secondary (caregivers) support networks. The secondary objective was to evaluate the programme impact on participants’ well-being through the measure of their social conditions (housing, legal status and criminal records), clinical status, social functioning, and alcohol and other illicit drug use.

The ICMA programme was addressed to people with severe mental and substance use disorders hard-to-reach or refusing traditional addiction or psychiatric treatment. ICMA participants repeatedly failed to attend outpatient appointments and/or were involuntarily hospitalised with no ambulatory care options after discharge. Eligible study participants were every consecutive person entering the programme during the first year of implementation between April 2014 and April 2015. Inclusion criteria for the programme were: to be aged between 18 and 65 years and to live in the urban area of Lausanne, Switzerland. Exclusion criterion for the programme was the participant’s ability to collaborate with an addiction treatment or the psychiatric services. Data were collected through structured questionnaires and medical charts. Assessments were conducted at baseline (T0) and at 12 months follow-up or at the end of the programme if completed earlier (T1).

During the first year of implementation, 30 participants entered the programme and were eligible for the study (Table 1 ). They were mainly male (73%), single (63%) and with an average age of 39 years. Half were Caucasian (50%) while 30% were mixed-race. Only 33% were native of Switzerland. Ninety-seven percent were unemployed, although 37% had achieved a secondary or higher education degree. The primary diagnosis was mental and behavioural disorder due to psychoactive substance use (57%), especially alcohol (59%), followed by schizophrenia, schizotypal and delusional disorders (20%), affective disorder (13%) and personality disorder (10%). Eighty-three percent of the participants were hospitalized at least once in their life, the average age of first admission was 31 years and 57% had at least one involuntary hospitalization. More detailed socio-demographic and clinical characteristics of the participants were published elsewhere [ 2 ].

Intervention description

Two full-time case managers, one nurse and one social worker, and a 20% psychiatrist were recruited for the project. Participants were addressed to ICMA programme by their relatives, or by their health or social professionals. Programme admission and objectives were discussed during multidisciplinary team meetings. When needed, contacts were made with other professionals already involved in the situation. If inclusion criteria were met, the situation was assigned to a case manager. The referring relative or professional had to be present during the first contact with the participant in order to share their concerns and to explain why the intervention was requested. If the participant disagreed with the concerns of the referring relative or professional, they were encouraged to express their own expectations and needs. The intervention was then focused on the participant’s agenda. Most of the time, participants identified a social problem, such as finding a home or a source of income, as their main concern. This allowed the case managers or the psychiatrist to provide a practical support and to develop the therapeutic relationship. This practical help also gave the opportunity to follow the participant during their daily activities and to assess their resources and limitations in vivo. Based on these observations, the participant’s support network and the recovery plan were progressively developed.

The programme was completed when another addiction treatment or psychiatric service was permanently in charge of the participant. The decision to end the ICMA was always taken by the case manager in accordance with the participants and the other care providers. The intervention could also end if participants moved out of the catchment area, if they were lost to follow-up, if they refused to go on with the programme or in case of death.

Socio-demographic characteristics, diagnoses and clinical history data were collected at baseline through structured questionnaires and medical charts. Primary and secondary outcomes measures were assessed at baseline (T0) and at 12 months follow-up or at the end of the programme if completed earlier (T1).

Primary outcomes

The primary outcome measures focused on service use, treatment adherence and quality of primary (relatives) and secondary (caregivers) support networks. Service use data before and during programme were provided by medical charts. Namely, the researchers assessed whether or not participants had been hospitalized (voluntary and/or involuntary) in a psychiatric or addiction treatment unit or had been admitted in the general or psychiatric ED at least once during the reference period. The frequency of readmission and contact with the ED, and the number of inpatient days were also recorded.

Treatment adherence was assessed by case managers on the basis of two items rating appointment and medication adherence on a visual-analogic scale ranging from 0 (no adherence) to 100 (total adherence). Two other treatment adherence items assessing psychotropic medication compliance and appointment attendance were incorporated in the Health of the Nation Outcome Scale (HoNOS) [ 19 ], which is routinely assessed by clinicians at the institutional level. The HoNOS evaluates mental and social functioning through 12 observer-rated items, quoted on a Likert – type scale from 0 (no problems during the reporting period) to 4 (severe to very severe problem during the reporting period). The French HoNOS has been shown to have moderate internal consistency, excellent test-retest reliability and good inter-rater reliability [ 20 ]. The predictive validity of HoNOS has always been modest and the French version is no exception. However it has been shown to be suitable for use at the item level for discriminating clinically meaningful clusters of patients [ 21 ].

The quality of primary and secondary support networks was evaluated by case managers through the Support Network Scale [ 22 ], with anchors ranging between 1) adequate and helpful, and 2) inadequate (gathering the answers: exhausted and overwhelmed, inactive and unstable, inadequate and incompetent, absent and nonexistent).

Secondary outcomes

Secondary outcome measures combined data on participants’ housing conditions (stable housing vs. homeless), legal status (legal guardianship, involuntary hospitalization and/or penal measures underway), criminal records (number of participants with at least one crime, infraction and/or victimisation occurred during the previous 12 months), psychosocial and mental functioning, and alcohol and other illicit drug use in the previous 30 days.

To assess participants’ psychosocial and mental functioning several validated and widely used scales were deployed. The 12 observer-rated items of the HoNOS [ 19 ] were assessed. Item-level scores rather than composite scores were used in the analysis [ 21 ]. The Crisis Triage Rating Scale (CTRS) assess participants’ dangerousness, ability to cooperate and support system on the basis of three Likert – type subscales ranging from 0 (no problems during the reporting period) to 4 (severe to very severe problem during the reporting period) [ 23 , 24 ]. The subscales Ability to cooperate and Support system were also analysed as primary outcome measures of treatment adherence and quality of primary and secondary support networks. The CTRS has been validated in English, showing good reliability and validity [ 23 , 24 ]. The French version has been shown to be sensible to change in assertive community treatment settings [ 17 ].

The Global Assessment of Functioning Scale (GAF) rates the participants’ social, occupational and psychological functioning on a numeric scale from 1 to 100 [ 25 ]. The Clinical Global Impression – Severity scale (CGI-S) evaluates illness severity at the time of assessment on a 7-point scale quoting from 1 (normal) to 7 (among the most extremely ill) [ 26 ]. The GAF (which is the DSM-IV fifth axis) and CGI-S are clinical global impression scales for which inter-rater reliability has been shown to be satisfactory to excellent [ 27 , 28 ].

Alcohol and other illicit drug use in the previous 30 days were self-reported. A structured questionnaire was administered by case managers to assess whether or not participants had been using alcohol and/or other illicit drug at least once during the last month. Namely, the case managers aimed at assessing the alcohol and other illicit drug use frequency, the average number of alcohol units consumed per drinking day and if the participants had been part at least one time of a heavy alcohol use episode (> than 10 alcohol units).

Statistical analysis

Primary and secondary dichotomous outcomes were analysed using McNemar-Bowker’s exact test. General Linear Model repeated-measures analysis of variance was performed for continuous and ordinal variables. Highly skewed continuous and ordinal variables were analysed using non-parametric Wilcoxon Signed Rank tests.

Baseline data were compared with 12 months follow-up measures or with final assessment if the programme was completed earlier.

In order to verify whether longer engagement in the programme impacted outcomes at T1, the relationship between programme duration and the outcomes’ variations (T0 vs. T1) was tested using Spearman’s rank correlation coefficient. These analyses revealed no impact of the programme duration on the outcomes.

Services use data, before and during programme, were compared over the same time span (i.e.: 6 months before vs. 6 months during programme; 8 months vs. 8 months; etc.) based on each individual programme length, but no longer than the 12 months evaluation point.

Assuming a sample size of 30 and interest in moderate sized effects (i.e., Cohen’s d ≥ 0.5; described as observable and noticeable to the eye of the beholder) and using a conservative estimate of the correlation between time 1 and time 2 measurements, 72% power for the comparison of pre- and post-measurements could be achieved adjusting for the use of the Wilcoxon test. Assuming even a reasonable correlation between the first and the second measurements ( r  = 0.7), the power becomes 90.8% which could be considered as more than adequate. Deviations from normality would further increase power.

All statistical tests were two-tailed and significance level was set at .05. Statistical analyses were performed with the IBM SPSS statistical package version 23.

Out of 30 participants enrolled at the baseline, 17 were still undergoing the programme after 12 months while 13 had completed it. At the end of ICMA intervention, 2 participants were transferred to other services of the Department of psychiatry, 2 to the alcohology service, 2 to private psychiatrists, 3 to other psychosocial services and 3 were not referred to any service (one improved sufficiently, one moved and the last one refused to be referred to another service). One 50 years old participant died during the programme. The cause of the death was undetermined. The mean programme duration was 10.00 ± 2.83 months. During the first year of implementation, each participant had on average 1.25 contacts per week with the case manager (1.07 h per week).

No significant influence of the programme duration on the primary outcomes’ variations was found.

Longitudinal analysis comparing service use over the same time span before and during programme (Table 2 ) showed a significant decreased rate of general ED contacts (73% to 50%; p  = .039). The decrease in the number of contacts with the psychiatric ED (Wilcoxon z = −1.997; p  = .046; r  = −.36) was also significant, with on average 0.60 ± 1.22 (Mdn = 0.0; IQR = 1) contacts before starting the programme and 0.20 ± 0.55 (Mdn = 0.0; IQR = 0) during the following period. No significant differences were found for the number of voluntary and involuntary psychiatric hospitalisations, the number of general ED visits and the number of total inpatient days. The decreased rate of involuntary hospitalizations (33% to 13%) did not reach statistical significance.

Participants’ treatment adherence improved significantly during the programme (Table 3 ). At T1, participants scored significantly better on medication adherence (F(1,23) = 15.754, p  = .001, ƞ p 2  = .407) and appointment adherence (F(1,29) = 9.604, p  = .004, ƞ p 2  = .249). Besides, the severity scores on the two additional HoNOS-based items testing participants’ appointment attendance (F(1,27) = 12.911,  p  = .001, ƞ p 2  = .323) and psychotropic medication compliance (F(1,23) = 10.827,  p  = .003, ƞ p 2  = .320) decreased significantly. The enhanced participants’ compliance was also confirmed by the reduced score achieved at T1 on the CTRS Ability to Cooperate subscale (F(1,28) =16.605, p  < .001, ƞ p 2  = .372).

Finally, the support network quality improved significantly. Sixty-seven percent of the participants’ primary (relatives) and secondary (professionals) networks were described by case managers as “adequate and helpful” at T1 versus only 10% at baseline ( p  < .001). A significant improvement was also achieved on the CTRS Support System subscale (F(1,27) = 12.680, p  = .001, ƞ p 2  = .320).

Secondary outcomes are reported in Table 3 . No significant influence of the programme duration on the secondary outcomes’ variations was found.

Participants’ psychosocial and mental functioning improved significantly during the programme. The item-level HoNOS analysis showed significant ameliorations at T1. After 12 months (or at the end of the programme if completed earlier), participants decreased their severity scores on eight items out of 12: Non-accidental self-injury (F(1,28) = 4.589, p  = .041, ƞ p 2  = .141), Problem drinking or drug-taking (F(1,28) = 24.852,  p  < .001, ƞ p 2 =.470), Cognitive problems (F(1,28)=7.965,  p  = .009, ƞ p 2  = .221), Problems with depressed mood (F(1,27) = 27.842, p  < .001, ƞ p 2  = .508), Problems with relationships (F(1,28) = 18.453, p  < .001, ƞ p 2  = .397), Problems with activities of daily living (F(1,28) = 7.451, p  = .011, ƞ p 2  = .210), Problems with living conditions (F(1,28) =10.684, p  = .003, ƞ p 2  = .276), Problems with occupation and activities (F(1,28) = 20.786, p  < .001, ƞ p 2  = .426). While only 5 of these results remained significant after correction for multiple comparison (Problem drinking or drug-taking; Problems with depressed mood; Problems with relationships; Problems with living conditions; Problems with occupation and activities), the total number of significant differences was well above what could be expected by chance (12 × 0.05 = 0.6 comparison with p -values of .05 or lower).

A significant positive change was also registered on the CTRS Dangerousness Subscale (F(1,28) = 31.832, p  < .001, ƞ p 2  = .532). These results were further confirmed by the GAF and the CGI-S. Participants’ global functioning improved significantly during the programme (F(1,28) =24.207, p  < .001, ƞ p 2  = .464) while CGI-S scores decreased significantly (F(1,28)=11.290, p =.002, ƞ p 2  = .287).

Analysis showed no significant changes concerning participants’ housing conditions and legal status. Nevertheless, only 7% of the participants were still homeless at T1 compared to the 24% at T0. The decreased trend of victimisations (35% to 6%) of participants between the 12 months before and after the beginning of the programme was not significant.

Self-reported alcohol and other illicit drug use results are reported in Table 4 . Comparing T0 and T1, no significant differences were found concerning the number of alcohol consumers during the previous 30 days. Nevertheless, the average number of alcohol units consumed per drinking day decreased significantly, from 12.26 ± 11.61 at the baseline to 5.48 ± 8.53 at T1 (F(1,26) = 8.246, p  = .008, ƞ p 2  = .241). Similar results were found for the rate of heavy drinkers: while 71% of the participants had been part at least once of a heavy alcohol use episode (> than 10 alcohol units) at T0, only 32% reported a similar episode at T1 ( p  = .001). A significant result was also found at T1 for the frequency of alcohol use (Wilcoxon z = −2.721, p  = .007).

The rate of other illicit drug use decreased significantly, from 69% at baseline to 45% at T1 ( p  = .016). Furthermore, the frequency of use at T1 was significantly reduced compared to the baseline (Wilcoxon z = −3.064, p  = .002).

Throughout the intervention, ICMA significantly reduced the number of participants visiting the general ED and the number of psychiatric ED visits. Moreover, at follow-up participants showed significant improvements in their treatment adherence, clinical status, social functioning and the rates and frequency of alcohol and other illicit drug use. These findings were in line with previous studies on the effectiveness of ICM in population with severe mental and substance use disorders [ 18 , 29 ]. From the local authorities’ point of view, they justified the high costs of the programme due to the small caseload, the high intensity of the intervention and the very specific target population. However, the long term programme cost-effectiveness should be assessed in the future.

The ICMA intervention was able to overcome barriers to care access on both the personal and the structural level. On the personal level, immediate practical help focused on participant’s needs allowed this latter to build a strong relationship with the care provider avoiding distrust and suspicion. The experience of a positive therapeutic relationship erased the memory of bad previous experiences with care services such as coercion, and overcame the addiction behaviours. On the provider’s level, mobility, proactivity, commitment and availability of care offered the opportunity to answer participants’ demands. Finally, on the system’s level, the intervention mobilized the network, eased the care coordination and allowed the development of new therapeutic options.

Emergency Department use, hospitalisation, coercion, support network quality

Appointment attendance and medication compliance increased during the intervention. Participants’ improved treatment adherence significantly reduced the rate of admission to the general ED and the number of psychiatric ED visits. However, no significant impact was found on the number of people admitted to the psychiatric hospital. This could be explained by the heterogeneity of the sample. Before the intervention, some participants were regularly hospitalised or had had long inpatient stays. In these situations, the ICMA allowed a prompt discharge and return into the community. Other participants had had no contact with care services for long periods before the enrolment. Therefore, once in the programme, their highly decayed health status required immediate inpatient care. The small sample size did not allow subgroup analysis that could have had possibly show differences between “heavy service users” and participants who avoided care before entering the programme as highlighted by previous studies [ 30 , 31 ]. If the rate and the number of psychiatric admissions did not decrease, the use of compulsion seemed positively, but not significantly, reduced.

The quality of the support network was greatly improved by the ICMA intervention. An important part of the case managers’ and the psychiatrist’s work was dedicated to develop and enhance the collaboration with other social and health services as well as participants’ relatives, and to improve care coordination. On a system level, regular appointments with other services’ management staff were organised. Moreover, case managers weekly attended other services team meetings. On a clinical level, regular contacts with each member of the network were constantly fostered.

Clinical and social outcomes and substance use

Most clinical and social outcomes improved during the intervention. If the social functioning improvements can easily be explained by the fact that case managers and the psychiatrist provided practical help and supported the participants during social procedures, their clinical evolution needs to be further discussed. Clinical improvements may be explained by three factors. First, the introduction of medications or a better compliance to the current treatment as well as to the psychotherapeutic interventions may have positively impacted the participants’ mental health state. Secondly, ICMA may have broken the vicious circle in which this population is often trapped. In fact, severe substance use disorders are associated with social dropout and inappropriate medical care. In these conditions, participants’ needs are misunderstood. Help is often provided only during crisis periods and mainly through compulsion (involuntary admission or guardianship) [ 32 , 33 ]. The use of coercion can lead to increased anxiety, loss of self-esteem and mood disorders, with a consequent intensification of alcohol and other illicit drug consumption [ 34 ]. Focusing more attentively on participants’ primary needs, ICMA offered them a new perspective on their situation. The rapid changes in the participants’ social context may have enhanced their sense of empowerment and self-confidence and given them hope, reducing the rate and frequency of alcohol and other illicit drug use. Conversely, the reduction of substance intake may have decreased cognitive problems and mood disorders, reduced behavioural problems such as self-injury, eased participants’ relations with others and prevented physical complications. This may have positively influenced the number of ED visits.

While in need for further experimentation on a larger sample, the intervention seemed to positively influence the rates of homelessness and victimisation in this highly vulnerable population during the follow-up period. This former finding confirmed the positive impact of ACT and CTI in improving housing stability and reducing the rate of homelessness among people with severe mental and substance use disorders [ 11 ]. The latter finding pointed at the ICMA as an excellent approach to reduce victimisation among this highly vulnerable population which gathers several risk factors such as severe mental and substance use disorders, homelessness, and absence of contact with psychiatric services [ 35 , 36 ].

Strengths and limitations

Regarding the strengths, this was a prospective exploratory study. Despite the difficult-to-engage target population, none of the participants refused to take part in the research project.

Two main methodological limitations were the absence of a control group and the modest sample size. The intervention was tested on a local level in Lausanne, an urban area of 265′000 inhabitants in the French-speaking part of Switzerland. Generalizability of the results may thus be restricted. Besides, some measures were self-reported while others were rated by the case managers.

Despite the limited scale of this observational project, the results are promising, highlighting the efficacy of ICMA methodology to improve engagement with care and the psychosocial situation of this hard-to-reach population, with consequent direct impact on substance problems. Further research is needed to confirm the programme effectiveness. However, the high-risk profile of these participants and the dangers related to the lack of an adapted care could represent an ethical and actual obstacle to the assessment of this issue in a randomised controlled trial setting.

The ICMA does not replace other addiction treatment services. Its aim is to locate and design an alternative way to promote participants’ engagement with standard care and to offer people with severe mental and substance use disorders new opportunities, a better control on their lives and an improved well-being.

Abbreviations

Emergency Department

• Intensive Case Management

Intensive Case Management for Addiction

Green-Hennessy S. Factors associated with receipt of behavioral health services among persons with substance dependence. Psychiatr Serv. 2002;53:1592–8.

Article   PubMed   Google Scholar  

Morandi S, Silva B, Monnat M, Bonsack C. Assertive community treatment: promoting engagement with care of people suffering severe addiction. Revue Médiale Suisse. 2016;12:1149–53.

Google Scholar  

Tucker JA, Vuchinich RE, Rippens PD. A factor analytic study of influences on patterns of help-seeking among treated and untreated alcohol dependent persons. J Subst Abus Treat. 2004;26:237–42.

Article   Google Scholar  

Cucciare MA, Timko C. Bridging the gap between medical settings and specialty addiction treatment. Addiction. 2015;110:1417–9.

Priester MA, Browne T, Iachini A, Clone S, DeHart D, Seay KD. Treatment Access Barriers and Disparities Among Individuals with Co-Occurring Mental Health and Substance Use Disorders: An Integrative Literature Review. J Subst Abus Treat. 2016;61:47–59.

van Draanen J, Corneau S, Henderson T, Quastel A, Griller R, Stergiopoulos V. Reducing Service and Substance Use Among Frequent Service Users: A Brief Report From the Toronto Community Addictions Team. Subst Use Misuse. 2013;48:532–8.

Drummond C, Gilburt H, Burns T, Copello A, Crawford M, Day E, et al. Assertive Community Treatment For People With Alcohol Dependence: A Pilot Randomized Controlled Trial. Alcohol and Alcoholism. 2017;52:234–41.

Morgenstern J, Blanchard KA, McCrady BS, McVeigh KH, Morgan TJ, Pandina RJ. Effectiveness of intensive case management for substance-dependent women receiving temporary assistance for needy families. Am J Public Health. 2006;96:2016–23.

Article   PubMed   PubMed Central   Google Scholar  

Rapp RC, Van den Noortgate W, Broekaert E, Vanderplasschen W. The Efficacy of Case Management With Persons Who Have Substance Abuse Problems: A Three-Level Meta-Analysis of Outcomes. J Consult Clin Psychol. 2014;82:605–18.

Hwang SW, Burns T. Health interventions for people who are homeless. Lancet. 2014;384:1541–7.

de Vet R, van Luijtelaar MJA, Brilleslijper-Kater SN, Vanderplasschen W, Beijersbergen MD, Wolf J. Effectiveness of Case Management for Homeless Persons: A Systematic Review. Am J Public Health. 2013;103:E13–26.

Conus P, Bonsack C, Gommeret E, Philippoz R. Le Soutien psychiatrique Intensif dans le Milieu (SIM) à Lausanne : un projet pilote. Revue Medicale de la Suisse Romande. 2001;121:475–81.

CAS   PubMed   Google Scholar  

Burns T, Catty J, Wright C. Deconstructing home-based care for mental illness: can one identify the effective ingredients? Acta Psychiatr Scand. 2006;113:33–5.

Burns T, Firn M. Assertive Outreach in Mental Health: A Manual for Practitioners. Oxford: Oxford University Press; 2002.

Herman DB. Transitional Support for Adults With Severe Mental Illness: Critical Time Intervention and Its Roots in Assertive Community Treatment. Res Soc Work Pract. 2014;24:556–63.

Priebe S, Watts J, Chase M, Matanov A. Processes of disengagement and engagement in assertive outreach patients: qualitative study. Br J Psychiatry. 2005;187:438–43.

Bonsack C, Adam L, Haefliger T, Besson J, Conus P. Difficult-to-engage patients: A specific target for time-limited assertive outreach in a Swiss setting. Can J Psychiatry-Revue Canadienne De Psychiatrie. 2005;50:845–50.

Dieterich M, Irving CB, Bergman H, Khokhar MA, Park B, Marshall M. Intensive case management for severe mental illness. Cochrane Database Syst Rev. 2017;1:Cd007906.

Wing J, Curtis RH, Beevor A. Health of the Nation Outcome Scales (HoNOS) - Glossary for HoNOS score sheet. Br J Psychiatry. 1999;174:432–4.

Article   CAS   PubMed   Google Scholar  

Lauzon S, Corbière M, Bonin JP, Bonsack C, Lesage AD, Ricard N. Validation de la version française du Health of the Nation Outcome Scales (HoNOS-F). Can J Psychiat. 2001;46:841–6.

CAS   Google Scholar  

Golay P, Basterrechea L, Conus P, Bonsack C. Internal and Predictive Validity of the French Health of the Nation Outcome Scales: Need for Future Directions. PLoS ONE. 2016. doi: 10.1371/journal.pone.0160360 .

Guay J, Laval CJd, Normand-Laramée Cdr. Principes et stratégies d'implantation de l'approche-milieu. Centre de réadaptation Normand-Laramée; 2000.

Bengelsdorf H, Levy LE, Emerson RL, Barile FA. A Crisis Triage Rating Scale Brief Dispositional Assessment of Patients at Risk for Hospitalization. J Nerv Ment Dis. 1984;172:424–30.

Turner PM, Turner TJ. Validation of the crisis triage rating scale for psychiatric emergencies. Can J Psychiatr. 1991;36:651–4.

Article   CAS   Google Scholar  

Goldman HH, Skodol AE, Lave TR. Revising axis V for DSM-IV: a review of measures of social functioning. Am J Psychiatry. 1992;149:1148–56.

Guy W. ECDEU assessment manual for psychopharmacology. Rockville, Md.: U.S. Dept. of Health, Education, and Welfare, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute of Mental Health, Psychopharmacology Research Branch, Division of Extramural Research Programs; 1976.

Boyer P. Echelle d’evaluation globale du fonctionnement. In: Guelfi JD, editor. L'évaluation clinique standardisée en psychiatrie Volume 1. Paris: Edition Médicales Pierre Fabre; 1993. p. 87–92.

Morandi S, Golay P, Lambert M, Schimmelmann BG, McGorry PD, Cotton SM, et al. Community Treatment Order: Identifying the need for more evidence based justification of its use in first episode psychosis patients. Schizophrenia Research. (In press).

Vanderplasschen W, Wolf J, Rapp RC, Broekaert E. Effectiveness of different models of case management for substance-abusing populations. J Psychoactive Drugs. 2007;39:81–95.

Burns T, Catty J, Dash M, Roberts C, Lockwood A, Marshall M. Use of intensive case management to reduce time in hospital in people with severe mental illness: systematic review and meta-regression. Br Med J. 2007;335:336–40.

Clausen H, Landheim A, Odden S, Benth JS, Heiervang KS, Stuen HK, et al. Hospitalization of high and low inpatient service users before and after enrollment into Assertive Community Treatment teams: a naturalistic observational study. Int J Ment Heal Syst. 2016;10

Hall W, Farrell M, Carter A. Compulsory treatment of addiction in the patient's best interests: More rigorous evaluations are essential. Drug Alcohol Rev. 2014;33:268–71.

McCormack RP, Williams AR, Goldfrank LR, Caplan AL, Ross S, Rotrosen J. Commitment to assessment and treatment: comprehensive care for patients gravely disabled by alcohol use disorders. Lancet. 2013;382:995–7.

Quello SB, Brady KT, Sonne SC. Mood Disorders and Substance Use Disorder: A Complex Comorbidity. Sci Pract Perspect. 2005;3:13–21.

Latalova K, Kamaradova D, Prasko J. Violent victimization of adult patients with severe mental illness: a systematic review. Neuropsychiatr Dis Treat. 2014;10:1925–39.

Maniglio R. Severe mental illness and criminal victimization: a systematic review. Acta Psychiatr Scand. 2009;119:180–91.

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Acknowledgement

We wish to thank the case managers for their work and we also express our gratitude to all clients for their participation.

This work was supported by the Public Health Service of Canton Vaud. The funding body didn’t have any role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Availability of data and materials

The datasets generated and analysed during the current study are not publicly available because public archiving of data was not explicitly authorized by the ethic committee. Nevertheless anonymous data are available from the corresponding author on reasonable request.

Authors’ contributions

SM contributed to the conception and design of the study. SM and BS contributed to the acquisition of the data. BS and PG undertook the data analysis. SM and BS contributed to the interpretation of the data and drafted the manuscript. PG and CB were involved in the critical revision of the manuscript. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

The study was approved by the Swiss Ethics Committee on research involving human of Lausanne (08 September 2014; N. 316/14). No explicit consent was required since data were collected as part of a routine outcome monitoring procedure. However, participants were informed about the research and the possibility of being excluded if they wished so. All participants agreed to take part in the study.

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Morandi, S., Silva, B., Golay, P. et al. Intensive Case Management for Addiction to promote engagement with care of people with severe mental and substance use disorders: an observational study. Subst Abuse Treat Prev Policy 12 , 26 (2017). https://doi.org/10.1186/s13011-017-0111-8

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DOI : https://doi.org/10.1186/s13011-017-0111-8

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Using Motivational Interviewing to Treat Adolescents and Young Adults with Substance Use Disorders

A case study of hazelden betty ford in plymouth.

Young people receiving treatment for substance use disorders (SUDs) present a unique clinical challenge. Though premature dropout from treatment happens with adults, as many as 50% of teens and young adults with substance use disorders do not complete treatment. In addition, many who do complete treatment do not fully engage with the treatment process (Gogel et al., 2011). Treatment engagement involves more than just being physically present; it involves actively taking part in all aspects of the treatment process and becoming emotionally invested in those processes as well as in peers attending the same services (Szapocznik et al., 2003; Wise et al., 2001). Another factor that may complicate treatment engagement is the fact that many adolescents enter treatment because of external pressures (such as parental insistence) and, as a result, may have low motivation to engage (Battjes et al., 2003). Because both retention and active engagement in treatment are associated with positive outcomes and recovery from substance use disorders (Williams and Chang, 2000; Moos & Moos, 2003; McWhirter, 2008), organizations offering treatment services to youth should focus on approaches that promote engagement and enhance the patient's intrinsic motivation and commitment to change.

The Hazelden Betty Ford Foundation has a facility in Plymouth, Minnesota , that focuses on providing substance abuse treatment to adolescents and young adults. In a recent interview with me, Dr. Joseph Lee, medical director of the Youth Continuum, stressed the importance of empathy in working with adolescent and young adult patients. A key piece of that work involves recognizing that empathy differs from identification. Empathy is the ability to imagine and accurately understand the feelings of another person and respond in a helpful way, and people with strong empathy can do this while maintaining a sense of being separate from that person (Buckman et al., 2011; Amsel, 2015). Identification, on the other hand, can be expressed as either relating to someone else so much that you lose a sense of yourself, or as identifying someone as so similar to yourself that you feel they must do and experience their situation as you do or did.

"We needed to take an honest look at how we were viewing and working with our patients," said Dr. Lee.

"This clinical introspection was especially critical as we began to treat more patients awash in the opioid epidemic . These kids are even more likely to drop out than other kids, and for them, the risk of going back out and using drugs can be fatal." The realization that empathic rapport is critical to helping the patient get better, combined with too many patients leaving treatment prematurely, particularly those with a high degree of clinical severity, prompted Lee and other clinical leaders to improve clinical practice at the therapist level.

"These kids are even more likely to drop out than other kids, and for them, the risk of going back out and using drugs can be fatal."

The Hazelden Betty Ford Foundation had therefore identified an opportunity to strengthen their empathy in working with patients, along with addressing the urgent needs to keep young patients in treatment, increase their engagement in the treatment process and increase their motivation to change. The next step in the process was to decide on a therapeutic approach to meet these objectives. As applied to patients with substance use disorders, motivational interviewing (MI) is a brief psychotherapy aimed at increasing the patient's motivation and ability to change his/her addictive behaviors (Miller, Zweben, DiClemente, & Rychtarik, 1992). It focuses heavily on therapists bringing empathy to the therapeutic process with clients. Figure 1 lists the five elements of the approach, as outlined by Miller et al. (1992). The first element is expressing empathy for the client, which can be done in a number of ways. Empathic communication signals dignity and respect for the client and helps prevent the development of a superior/inferior relationship where the therapist is telling the client what he or she should be feeling. Empathic communication involves reflective listening, communicating an acceptance of where the client is and supporting them in the process of change (Miller & Rollnick, 1991). In addition to its strong focus on empathy, MI was chosen by Plymouth staff because it is an evidence-based practice in treating substance use disorders, with several studies indicating its effectiveness for adolescent and young adult populations (Barnett et al., 2012; Brown et al., 2015).

"Once we identified that we needed to start doing MI in a more formalized, consistent way across our clinicians, we needed to map out and implement a plan for doing it," Dr. Lee observed.

As one might imagine, this plan was fairly complex. Though all staff in patient-facing roles received training, the implementation of Motivational Interviewing was heavily concentrated on two roles: alcohol/drug addiction counselors and addiction technicians. Addiction counselors are a core part of the residential program. They administer assessments, participate in treatment planning and engage in therapy with the patient around his or her unique needs and challenges. The addiction technicians help support the patient, including easing their transition between the medical services unit and the residential treatment unit, helping them get to appointments on time and filling in for other non-clinical aspects of treatment, such as conducting meditation exercises.

Systematic training of staff in these two roles was a vital first step in implementing Motivational Interviewing with patients. Several tactics were used as part of training, including the use of an Motivational Interviewing text, required attendance at several two-day workshops and in-person training by both external MINT-certified specialists and several Plymouth staff well-versed in Motivational Interviewing methods, including Dr. Lee; Travis Vanderbilt, an LADC counselor; and David Wells, a PhD-level psychologist in the mental health clinic. Once counselors and technicians were trained, Lee and other Plymouth Motivational Interviewing experts set up a process to measure how counselors conducted therapy sessions with patients. The process involves periodically taping therapy sessions and auditing them for elements of Motivational Interviewing. The conclusions of these audits are then shared with each counselor in regular supervision meetings with his/ her manager. "The results of the audits and feedback on the clinician's use of Motivational Interviewing are a vital part of the process and happens on an ongoing basis," says Dr. Lee. "But we focus on making these conversations collegial and constructive as opposed to punitive…the idea is to model Motivational Interviewing even in the practitioner/supervisor discussions."

Successful implementation of Motivational Interviewing with Plymouth staff took several months, as is typically the case with clinical programs addressing behavioral health issues. By the middle of 2016, Motivational Interviewing was fully implemented and used consistently with all residential patients. Figure 2 shows atypical discharge rates for patients as a function of when they were discharged from the Plymouth residential program. These rates represent the percentage of patients who left treatment prematurely for various reasons (against staff advice, against medical advice, or occasionally at staff request). Over the last several quarters, the percentage of atypical discharges has been trending downward in a pattern consistent with the timeframe of motivational interviewing implementation. Only 9.9% of patients discharged in Q1 of 2017 left treatment prematurely, as opposed to 13.28% of patients in Q3 of 2015 (a 25% decrease). Though several other factors may have impacted these rates for example, an increase over time in the use of Suboxone for patients with opioid use issues the results are encouraging.

Qualitative feedback from staff members at Plymouth also suggests a positive impact of Motivational Interviewing on both staff and patients. Staff members described it as a "very person centered" approach, in part because it allows the clinician to effectively build rapport through empowerment rather than directives. Young patients are very receptive to the approach because they feel they are being worked with in a collaborative way, not talked down to or ordered to do certain things. Several staff members reported being able to help emotionally distressed patients change their mind about leaving treatment. In a couple of cases, the patient had left the facility, but the counselor was able to convince them to come back. Plymouth staff members directly attributed these outcomes to their use of Motivational Interviewing. "Motivational Interviewing is helping our patients because it reduces many of the impulsive decisions and encourages them to think through their actions before doing them," said one staff member. "It also helps them process through emotions they are not used to experiencing before making important decisions." Several counselors also reported that the therapeutic alliance formed with their patients has been strengthened through the use of Motivational Interviewing, which is quite important given the role of the alliance in predicting positive outcomes after treatment (Connors et al., 1997; Cook et al., 2015).

Behavioral health provider organizations wanting to implement evidence-based clinical practices in a highly accurate, reliable way can do so through an implementation science approach. At its core, implementation science involves the use of research and measurement to ensure that practices are implemented correctly within clinical settings (Proctor et al., 2009). The first step of the approach is to identify a practice that has a strong evidence base, meaning that it has been studied in a scientific manner and found to produce positive outcomes across studies. The second step involves mapping out how to deliver the clinical practice based on the organization's current structure, staffing models, clinical workflows and other processes related to care delivery. A key part of the second step is the training of staff directly administering the program or practice. Hazelden Betty Ford in Plymouth has completed these steps with regard to implementing motivational interviewing with residential patients. Clinical leaders and other staff will focus on subsequent steps over the coming months. This work will focus on evolving and standardizing the processes for measuring how effective each counselor is at implementing Motivational Interviewing with patients. Most importantly, counselors and supervisors will make sure that these assessments are used to continuously improve Motivational Interviewing practice.

"Motivational Interviewing is helping our patients because it reduces many of the impulsive decisions and encourages them to think through their actions before doing them."

This final step, though critical, is often overlooked by organizations implementing new clinical practices. It is one thing to implement something and occasionally measure how things are going. It is another thing to use what is learned and apply it back to care delivery on a continuous, long-term basis. As more behavioral health service providers use this model to bring evidence-based practices to patients, we can expect patient engagement and outcomes to improve.

Case Study October 2017.  Download the  Adolescent Motivational Interviewing case study .

Acknowledgements

Dr. joseph lee, medical director of the youth continuum.

Joseph Lee, MD, has extensive experience in addiction treatment for youth and families from across the country and abroad, providing him an unparalleled perspective on emerging drug trends, co-occurring mental health conditions and the ever-changing culture of addiction. A triple board certified physician, Lee completed his medical degree at the University of Oklahoma, his adult psychiatry residency at Duke University Hospital and his fellowship in child and adolescent psychiatry at John Hopkins Hospital. He is a diplomat of the American Board of Addiction Medicine and is a member of the American Academy of Child and Adolescent Psychiatry's Substance Abuse Committee. He is also the author of  Recovering My Kid: Parenting Young Adults in Treatment and Beyond , which provides a candid, helpful guide for parents in times of crisis.

• Amsel, B. (2015). Losing myself in your feelings: Empathy and identification. www.goodtherapy.org/blog/losing-my-self-inyour- feelings-empathy-and-identification-0925154 Barnett, E., Sussman, S., Smith, C., Rohrbach, L. A., & Spruijt-Metz, D. (2012). Motivational interviewing for adolescent substance use: A review of the literature. Addictive Behaviors, 37, 1325-1334.
• Battjes, R. J., Gordon, M.S., O'Grady, K. E., Kinlock, T. W., & Carsell, M. A. (2003). Factors that predict adolescent motivation for substance abuse treatment. Journal of Substance Abuse Treatment, 24, 221-32.
• Brown, R. A., Abrantes, A. M., Minami, H., Prince, M. A., Bloom, E. L., Apodaca, T. R. et al. (2015). Motivational interviewing to reduce substance use in adolescents with psychiatric comorbidity. Journal of Substance Abuse Treatment, 59, 20-29.
• Buckman, R., Tulsky, J. A., & Rodin, G. (2011). Empathic responses in clinical practice: Intuition or tuition? Canadian Medical Association Journal, 183, 569-571. doi:10.1503/ cmaj.090113
• Connors, G. J., Carroll, K. M., DiClemente, C. C., Longabaugh, R., & Donovan, D. M. (1997). The therapeutic alliance and its relationship to treatment participation and outcome. Journal of Consulting Clinical Psychology, 65, 588-598.
• Cook, S., Heather, N., & McCambridge, J. (2015). The role of the working alliance in treatment for alcohol problems. Psychology of Addictive Behaviors, 29, 371-381.
• Gogel, L. P., Cavaleri, M. A., Gardin, J. G. II & Wisdom, J. P. (2011). Retention and ongoing participation in residential substance abuse treatment: Perspectives from adolescents, parents and staff on the treatment process. Journal of Behavioral Health Services & Research, 38, 488-496.
• Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (37-69). New York, NY: Oxford University Press.
• McWhirter, P. T. (2008). Enhancing adolescent substance abuse treatment engagement. Journal of Psychoactive Drugs, 40, 173-182.
• Miller, W. R., and Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.
• Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational enhancement therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. National Institute on Alcohol Abuse and Alcoholism; Rockville, MD: NIAAA Project MATCH Monograph Series Volume 2, DHHS Publication No. (ADM) 92-1894.
• Moos, R. H., & Moos, B. S. (2003). Long-term influence of duration and intensity of treatment on previously untreated individuals with alcohol use disorders. Addiction, 98, 325-338.
• Proctor, E. K., Landsverk, J., Aarons, G., Chambers, D., Glisson, C., & Mittman, B. (2009). Implementation research in mental health services: An emerging science with conceptual, methodological, and training challenges. Administration and Policy in Mental Health, 36, 24-34. doi:10.1007/s10488-008-0197-4
• Szapocznik, J., Perez-Vidal, A., & Brickman, A. L., et al. (1988). Engaging adolescent drug abusers and their families in treatment: A strategic structural systems approach. Journal of Consulting and Clinical Psychology, 56(4), 552-557.
• Williams, R. J. & Chang, S. Y. (2000). A comprehensive and comparative review of adolescent substance abuse treatment outcome. Clinical Psychology: Science and Practice, 7, 138-166.
• Wise, B. K., Cuffe, S. P., & Fischer, T. (2001). Dual diagnosis and successful participation of adolescents in substance abuse treatment. Journal of Substance Abuse Treatment, 21, 161-165.

Harnessing science, love and the wisdom of lived experience, we are a force of healing and hope ​​​​​​​for individuals, families and communities affected by substance use and mental health conditions.

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Introduction to Social Work: An Advocacy-Based Profession

Student resources, case studies.

Case Study for Chapter 10: Substance Use and Addiction

Jennifer’s brother Emmett resorted to drugs and alcohol to drown his sorrow after their dad left their mother. The local inner city high school had its share of dealers and Emmett’s will power was nil. While weed (cannabis, marijuana, pot) was Emmett’s initial drug of choice, his substance use later led him to having a heroin addiction. Now out of the closet as a gay man, Emmett also was introduced to the club/party drugs of ecstasy and crystal meth. It breaks Jennifer’s and her mom’s heart to watch Emmett maintain his addiction despite some brief stints in drug rehab and attendance at local AA meetings. Emmett’s sponsor uses tough love—a mix of encouragement and challenge—to help Emmett stay on his path to and through recovery.

1) What local, state, and national policy and practice resources exist for social workers who work with people who abuse substances?

2) With the help of a social worker, how might family members intervene to help Emmett recover and maintain his sobriety? How might they benefit personally from social work services as well?

3) How much stigma encircles people who succumb to substance abuse or addiction?  

4) What specific challenges might need to be addressed in treatment in order for Emmett to truly achieve a high functioning level?

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Substance Use Disorders Among US Adult Cancer Survivors

• 1 New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts
• 2 Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
• 3 Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
• Comment & Response Substance Use Disorders Among Cancer Survivors Alain Braillon, MD, PhD JAMA Oncology

Question   What is the cancer type–specific prevalence of substance use disorder (SUD) among adult US cancer survivors?

Findings   In this cross-sectional study of 6101 adult cancer survivors who responded to the National Survey on Drug Use and Health for 2015 through 2020, the overall prevalence of active SUD (within the past 12 months) was approximately 4%, with higher prevalence in some subpopulations, including survivors of head and neck cancer (approximately 9%) and esophageal and gastric cancer (approximately 9%). Alcohol use disorder was the most common SUD.

Meaning   Findings of this study highlight subpopulations of adult cancer survivors who may benefit from efforts to integrate cancer and addiction care.

Importance   Some individuals are predisposed to cancer based on their substance use history, and others may use substances to manage cancer-related symptoms. Yet the intersection of substance use disorder (SUD) and cancer is understudied. Because SUD may affect and be affected by cancer care, it is important to identify cancer populations with a high prevalence of SUD, with the goal of guiding attention and resources toward groups and settings where interventions may be needed.

Objective   To describe the cancer type–specific prevalence of SUD among adult cancer survivors.

Design, Setting, and Participants   This cross-sectional study used data from the annually administered National Survey on Drug Use and Health (NSDUH) for 2015 through 2020 to identify adults with a history of solid tumor cancer. Substance use disorder was defined as meeting at least 1 of 4 Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria for abuse or at least 3 of 6 criteria for dependence.

Main Outcomes and Measures   Per NSDUH guidelines, we made adjustments to analysis weights by dividing weights provided in the pooled NSDUH data sets by the number of years of combined data (eg, 6 for 2015-2020). The weighted prevalence and corresponding SEs (both expressed as percentages) of active SUD (ie, within the past 12 months) were calculated for respondents with any lifetime history of cancer and, in secondary analyses, respondents diagnosed with cancer within 12 months prior to taking the survey. Data were analyzed from July 2022 to June 2023.

Results   This study included data from 6101 adult cancer survivors (56.91% were aged 65 years or older and 61.63% were female). Among lifetime cancer survivors, the prevalence of active SUD was 3.83% (SE, 0.32%). Substance use disorder was most prevalent in survivors of head and neck cancer (including mouth, tongue, lip, throat, and pharyngeal cancers; 9.36% [SE, 2.47%]), esophageal and gastric cancer (9.42% [SE, 5.51%]), cervical cancer (6.24% [SE, 1.41%]), and melanoma (6.20% [SE, 1.34%]). Alcohol use disorder was the most common SUD (2.78% [SE, 0.26%]) overall and in survivors of head and neck cancer, cervical cancer, and melanoma. In survivors of esophageal and gastric cancers, cannabis use disorder was the most prevalent SUD (9.42% [SE, 5.51%]). Among respondents diagnosed with cancer in the past 12 months, the overall prevalence of active SUD was similar to that in the lifetime cancer survivor cohort (3.81% [SE, 0.74%]). However, active SUD prevalence was higher in head and neck (18.73% [SE, 10.56%]) and cervical cancer survivors (15.70% [SE, 5.35%]). The distribution of specific SUDs was different compared with that in the lifetime cancer survivor cohort. For example, in recently diagnosed head and neck cancer survivors, sedative use disorder was the most common SUD (9.81% [SE, 9.17%]).

Conclusions and Relevance   Findings of this study suggest that SUD prevalence is higher among survivors of certain types of cancer; this information could be used to identify cancer survivors who may benefit from integrated cancer and SUD care. Future efforts to understand and address the needs of adult cancer survivors with comorbid SUD should prioritize cancer populations in which SUD prevalence is high.

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Jones KF , Osazuwa-Peters OL , Des Marais A , Merlin JS , Check DK. Substance Use Disorders Among US Adult Cancer Survivors. JAMA Oncol. 2024;10(3):384–389. doi:10.1001/jamaoncol.2023.5785

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Teen Cocaine Addiction Case Study: Chloe's Story

This case study of drug addiction can affect anyone – it doesn’t discriminate on the basis of age, gender or background. At Serenity Addiction Centres, our drug detox clinic is open to everyone, and our friendly and welcoming approach is changing the way rehab clinics are helping clients recover from addiction.

We’ve asked former Serenity client, Chloe, to share her experience of drug rehab with Serenity Addiction Centre’s assistance.

Chloe’s Addiction

If you met Chloe today, you would never know about her past. This born and bred London girl is 20 years old, and a flourishing law student with a bright future in the City.

A few years ago though, it seemed as if this straight A student was about to throw away her life, thanks to a  class A drug addiction .

Chloe had a great childhood. By her own admission, school was a breeze for her, with strong academic achievement and social skills making her as successful on the playground as she was in the classroom.

Age 7, Chloe started at a boarding school, and loved having friends around her all the time. With no parents about, Chloe and her friends found themselves invited to house parties. As soon as I could convince people they we 18, they moved on to London’s nightclubs.

It was here where Chloe first came across drugs, and it was a slippery slope to cocaine addiction. She explains: “At 15, I was taking poppers, graduated to MDMA at 16, and then I tried cocaine at our year 13 parties. I got separated from my friends, and found them taking cocaine in a back room. I didn’t want to be left out, so I tried it.” 

Chloe scored straight As in her A levels, and accepted a place at Kings College London to study law. She was introduced to new people, and it seemed that cocaine was available at every place they went. Parties, clubs, and even her new friends were all good sources of a line of cocaine. As a self confessed wild child by this point, Chloe didn’t want to miss out.

The demands of a law degree were high, but so was Chloe’s desire for more cocaine.

Going out almost every night to snort coke, she started to wonder if she was becoming an addict. She spent every penny of the generous allowance from her parents. Chloe spent every penny available on credit cards, and even took on a £2000 bank loan to support her habit.

Chloe estimated that at one point, her addiction had saddled her with more than £13,000 of debt.

Coming out of Addiction Denial

Chloe’s light bulb moment finally came when her best friend, who she shared a flat with, sat her down and asked why they were drifting apart.

Chloe realised that cocaine had become more important to her than her friends, family, and studies. It had to stop. Chloe found the details for Serenity Addiction Centres, and called the same day to ask for help with her addiction.

One thing Chloe particularly appreciated about Serenity Addiction Centres was the flexible approach of the counsellors . They got to know Chloe, listening to her worries, and working out a non-residential rehab plan for her. This allowed her to continue with her studies.

Chloe’s treatment was organised at a clinic not far from her university, allowing her to keep her studies on track, and keeping her life as normal as possible.

Chloe says: “Talking about how I was using cocaine, along with contributing problems from earlier in my life, were a massive help. I didn’t want to be known just as a party girl”.

“If I’d not found Serenity Addiction Centres, there would probably have been a long wait for NHS treatment. Serenity Addiction Centres got the right treatment. Everything was organised with privacy and discretion. I only shared what was happening with my flatmate.”

This level of discretion was really helpful, and the rapid results of her treatment meant that after just three months Chloe felt able to tell her parents what had been happening. 

Life after rehab

It’s amazing that Chloe has now had nearly a year where not taken cocaine, and faced her debts by working part time to repay what she owes. Even better, thanks to Serenity’s fast intervention. Chloe is on course for a 2:1 in her law degree.

If you’re ready to detox? Serenity Addiction Centre’s addiction support team are here to help you find the rehab programme which works for you. Serenity can help you beat your addiction. Gaining control over drugs, allowing you to move on and take back control of your life.

This Drug Addiction Case Study is here so others may identify. Contact us today , and begin your detox journey with Serenity Addiction Centres.

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