Discussion: Treatment of Substance Use Disorders

Of the substance disorders, alcohol-related disorders are the most prevalent even though only a small percentage of individuals actually receive help. Recidivism in the substance treatment world is also very high. As research into treatment has developed, more and more evidence shows that genes for alcohol-metabolizing enzymes can vary by genetic inheritance. Women have been identified as particularly vulnerable to the impacts of alcohol. Native Americans, Asians, and some Hispanic and Celtic cultures also have increased vulnerability to alcohol misuse.
Even with these developments, treatment continues to spark debate. For many years, the substance use field itself has disagreed with mental health experts as to what treatments are the most effective for substance use disorders and how to improve outcomes. The debate is often over medication-assisted treatment (MAT) versus abstinence-based treatment (ABT). Recently the American Psychiatric Association has issued guidelines to help clinicians consider integrated solutions for those suffering with these disorders. In this Discussion, you consider your treatment plan for an individual with a substance use disorder.
  
To prepare for our discussion, Please read “THE CASE OF XAVIER” and the materials for the week. Then assume that you are meeting with XAVIER as the social worker who recorded this case.
Then, by Wednesday night, Please post a 300- to 500-word response in which you address the following:

Provide the full DSM-5 diagnosis for Xavier Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may need clinical attention). Keep in mind a diagnosis covers the most recent 12 months.
Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis.
Describe the assessment(s) you would use to validate her diagnosis, clarify missing information, or track her progress.
Summarize how you would explain the diagnosis to Him.
Explain how you would engage him in treatment, identifying potential cultural considerations related to substance use.
Describe your initial recommendations for her treatment and explain why you would recommend MAT or ABT.
Identify specific resources to which you would refer her. Explain why you would recommend these resources based on his diagnosis and other identity characteristics (e.g., age, sex, gender, sexual orientation, class, ethnicity, religion, etc.).

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CASE OF XAVIER
INTAKE DATE: May 2018
DEMOGRAPHIC DATA:
This is a voluntary admission for this 32 year old Black male. This is Xavier’s first psychiatric hospitalization. Xavier has been married for 13 years and has been separated from his husband for the past three months. He has currently been living with his sister in Atlanta, GA., where his husband and son reside. Xavier has a two year degree in nursing. Xavier works as an RN. Religious affiliation is agnostic.
CHIEF COMPLAINT:
“I need to learn to deal with losing my husband and son.”
HISTORY OF ILLNESS:
This admission was precipitated by Xavier’s increased depression with passive suicidal ideation in the past three months prior to admission. He identifies a major stressor of his husband and son leaving him three months ago. Xavier has had a past history of alcohol binges and these binges are intensified when there is a need for coping mechanisms in times of stress. Xavier was starting vacation from work just prior to admission and recognized that if he did not come to the hospital for treatment of depression and alcoholism, he would expect to have a serious alcohol binge. Xavier reports that in the past three months since separating from his husband, he has experienced sad mood, fearfulness, and passive suicidal ideation. He denies a specific suicidal plan. Xavier’s husband reports that during these past three months prior to admission, Xavier made a verbal suicidal threat.
Xavier reports he has been increasingly withdrawn/non-communicative. His motivation has decreased, and he finds himself “sitting around and not interested in doing chores at home”. He reports decreased concentration at work and increased distractibility. Xavier has experienced increased irritability, decreased self-esteem, and feelings of guilt/self-blame. There is no change in appetite, but Xavier reports an intentional weight loss of 20 pounds in the last 5 months with dieting. Xavier states that for many years he doesn’t really sleep ever since he worked double shifts when requested. Xavier reports his normal sleep pattern for many years has been generally three hours of unbroken sleep. Xavier reports past history of euphoria, although his husband reports to intake worker having observed periods when Xavier’s mood is elevated; then in the next few hours, Xavier appears out of control with poor impulse control, increased arguing, temper tantrums and alleged shoving and pushing him and his son. After which Xavier feels tired and ends up sleeping more than average.  
Xavier denies suicidal ideation at the present time while on the evaluation unit.
Xavier reports a history of some alcohol binges in the past. He began drinking beer in 2003, after he turned 21 years old. Xavier reports that until two years prior to admission his pattern of drinking was to get drunk with his social group approximately twice per month. He denies a history of blackouts. He admits to the alcohol binges and heavy use of cocaine (snorting and freebasing on weekends) for a period of three months in 2015. Xavier has received a charge of driving while intoxicated in 03/2014 and had lost his driver’s license for six months. Since his marital breakup, Xavier reports using alcohol as a coping mechanism for stress (reporting that he will only drink on weekends now). 
PAST PSYCHIATRIC HISTORY:
Xavier was seen on an outpatient basis by Dr. S for a period of two months prior to admission. He was being seen for individual counseling because of the marital problems and depression. Dr. S recently referred Xavier for inpatient rehabilitation.
MEDICAL HISTORY:
In 2011, Xavier sustained a head injury when he hit his head on a coffee table. Xavier had a past history of fractured toes with pins being inserted in the third and fourth digits in his right foot after an accident in which he crushed his foot at work. Xavier denies a past history of seizures.
Xavier has had a weight loss of approximately 20 pounds secondary to dieting. Xavier is allergic to Codeine.
FAMILY MEDICAL AND PSYCHIATRIC HISTORY:
Father and grandfather have a history of cardiovascular disease.
PSYCHOSOCIAL AND DEVELOPMENTAL HISTORY:
Xavier reports that while growing up his parents maintained a satisfactory relationship. Father reportedly worked nights and slept during the day. Xavier did not have much contact with his father but now enjoys a close relationship with his father. He states he has always had his parents support.
During Xavier’s school years, he reports he was an underachiever in elementary school. He denies having had a history of discipline problems or hyperactivity. He states he did well in high school and earned grades of A’s and B’s. Xavier played football in HS. After completing high school, Xavier furthered his education and earned his license as a registered nurse. He states he graduated at the top of his class from nursing school.
Xavier has been married for 13 years and has recently been separated for the past three months. Xavier and his husband have one adopted son, age 4. Xavier states he feels invested as a parent and feels close to his son.
Leisure time activities Xavier has enjoyed in the past include playing softball, reading, playing poker, and watching football.  His husband has complained that he is doing less of that now since he is drinking more.  Xavier states he has several close friends.
CURRENT FAMILY ISSUES AND DYNAMICS:
Xavier’s husband reports that Xavier’s difficulties began to get worse a few months ago when he decided to move out of the house due to Xavier’s increasing erratic behavior. He moved into his parents’ house and Xavier is living with his sister. Husband states that Xavier has been suffering from mood swings where he is “very up” and feeling great, firm in his direction and then within the next few hours, he is often out of control, arguing, throwing temper tantrums, pushing and shoving, and becoming verbally abusive.
Husband states Xavier has been drinking for several years in the amount of a 12 pack of beer per day plus shots of hard liquor. Although Xavier reported he has been using cocaine on and off for about two years, husband states he does not think that Xavier is presently using cocaine. At one point, after threats from his husband, Xavier told him that he had gone to a clinic for outpatient rehabilitation, but he did not believe him.
Husband describes Xavier as “extremely depressed” now and says Xavier states, “life is over…I wish I was dead…don’t send my son over to visit because I don’t want him to find my dead body…everything I touch turns to garbage. Husband adds that Xavier suffers from poor self-esteem, lack of sleep, and an extremely boastful attitude. In terms of strengths, he is a good father, compassionate, creative, and can be an outstanding person.
Husband reports Xavier always had a bad relationship with his mother. Xavier is close to his father who is reported to have an alcohol problem and was allegedly loud and intimidating.
Xavier states he has financial problems now due to paying for counseling and child support.
MENTAL STATUS:
Xavier presents as a casually dressed male who appears his stated age of 32. Posture is relaxed. Facial expressions are appropriate to thought content. Motor activity is appropriate. Speech is clear and there are no speech impediments noted. Thoughts are logical and organized. There is no evidence of delusions or hallucinations. Xavier denies any hallucinations. Xavier admits to a recent history of passive suicidal ideation without a plan, but denies suicidal or homicidal ideation at the present time. Xavier admits to a history of decreased need for sleep but denies euphoric episodes. His husband has observed a history of notable mood swings. No manic-like symptoms are observed at the time of this examination.
On formal mental status examination, Xavier is found to be oriented to three spheres. Fund of knowledge is appropriate to educational level. Recent and remote memory appear intact. Xavier was able to calculate serial 7’s. In response to three wishes, Xavier replied “I wish that my marriage would work out, that my son would be happy, and that someone would give me a million dollars.”

 
Required Readings
Morrison, J. (2014). Diagnosis made easier (2nd ed.). New York, NY: Guilford Press.

Chapter 15, “Diagnosing Substance Misuse and Other Addictions” (pp. 238–250)
American Psychiatric Association. (2013q). Substance related and addictive disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm16
Gowin, J. L., Sloan, M. E., Stangl, B. L., Vatsalya, V., & Ramchandani, V. A. (2017). Vulnerability for alcohol use disorder and rate of alcohol consumption. American Journal of Psychiatry, 174(11), 1094–1101. doi:10.1176/appi.ajp.2017.16101180
Reus, V. I., Fochtmann, L. J., Bukstein, O., Eyler, A. E., Hilty, D. M., Horvitz-Lennon, M., … Hong, S.-H. (2018). The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. American Journal of Psychiatry, 175(1), 86–90. doi:10.1176/appi.ajp.2017.1750101
Stock, A.-K. (2017). Barking up the wrong tree: Why and how we may need to revise alcohol addiction therapy. Frontiers in Psychology, 8, 1–6. doi:10.3389/fpsyg.2017.00884
Optional Resources
Best, D., Beckwith, M., Haslam, C., Haslam, S. A., Jetten, J., Mawson, E., & Lubman, D. I. (2016). Overcoming alcohol and other drug addiction as a process of social identity transition: The social identity model of recovery (SIMOR). Addiction Research and Theory, 24(2), 111–123. doi:10.3109/16066359.2015.1075980
Hagman, B. T. (2017). Development and psychometric analysis of the Brief DSM-5 Alcohol Use Disorder Diagnostic Assessment: Towards effective diagnosis in college students. Psychology of Addictive Behaviors, 31(7), 797–806. doi:10.1037/adb0000320
Helm, P. (2016). Addictions as emotional illness: The testimonies of anonymous recovery groups. Alcoholism Treatment Quarterly, 34(1), 79–91. doi:10.1080/07347324.2016.1114314
Petrakis, I. L. (2017) The importance of identifying characteristics underlying the vulnerability to develop alcohol use disorder. American Journal of Psychiatry, 174(11), 1034–1035. doi:10.1176/appi.ajp.2017.17080915
Hom, M. A., Lim, I. C., Stanley, I. H., Chiurliza, B., Podlogar, M. C., Michaels, M. S., … Joiner, T. E., Jr. (2016). Insomnia brings soldiers into mental health treatment, predicts treatment engagement, and outperforms other suicide-related symptoms as a predictor of major depressive episodes. Journal of Psychiatric Research, 79, 108–115. doi:10.1016/j.jpsychires.2016.05.008

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