An Introduction to
Substance Use Disorders
Tejasi Bilgi, LMFT
Co-occurring Disorders
The coexistence of both a mental health and a substance use
disorder is referred to as co-occurring disorders.
• According to SAMHSA’s 2014 National Survey on Drug Use and Health
(NSDUH) approximately 7.9 million adults in the United States had cooccurring disorders in 2014.
• People with mental health disorders are more likely than people
without mental health disorders to experience an alcohol or substance
use disorder.
• In many cases, people receive treatment for one disorder while the
other disorder remains untreated.
Future is INTEGRATED CARE
DSM 5 Definition of Substance Use Disorders
“A substance use disorder describes a problematic pattern
of using alcohol or another substance that results in
impairment in daily life or noticeable distress.”
According to the DSM-5, a diagnosis of substance use
disorder is based on evidence of impaired control,
social impairment, risky use, and pharmacological
criteria.
Diagnostic Criteria for SUD:
Must display 2 of 11 symptoms within 12-months:
• Consuming more alcohol or other substance than originally planned
• Worrying about stopping or consistently failed efforts to control one’s use.
• Spending a large amount of time using drugs/alcohol, or doing whatever is
needed to obtain them
• Failure to “fulfill major role obligations” due to use such as at home, work,
or school.
• “Craving” the substance (alcohol or drug)
Diagnostic Criteria for SUD:
• Continued use despite health consequences and worsening of health/
mental health.
• Continued use despite effects on relationships with others
• Repeated use of the substance in a dangerous situations (
• Giving up or reducing activities in a person’s life because of the
drug/alcohol use
• Building up a tolerance to the alcohol or drug.
• Experiencing withdrawal symptoms after stopping use.
What is drug addiction?
• Drug addiction is a chronic disease characterized by compulsive,
or uncontrollable, drug seeking and use despite harmful
consequences and changes in the brain, which can be long
lasting.
• These changes in the brain can lead to the harmful behaviors
seen in people who use drugs.
• Drug addiction is also a relapsing disease. Relapse is the return
to drug use after an attempt to stop.
Addiction - a practical definition:
The 3 “C’s”
Control - there are repeated attempts to cut back or
control use, with episodes or loss of control in between.
 Compulsion - a person experiences a sense that they
must use. Can be due to tolerance, withdrawal or
psychological need.
 Consequences - substance use is continued despite
significant negative consequences.

Why Do People Use Drugs?
Forget problems
 Get high
 Lose or gain weight
 Relax, energize
 Go to sleep, stay awake
 Boredom, depression
 Gain confidence
 Be cool, socialize, friends
 Experience altered states

Why Do People Use Drugs?
cont’d
Symbol of rebellion
 Sex
 Sports
 Religious ritual
 Have fun, excitement
 Reduce anxiety
 Experiment
 Avoid withdrawal if dependant
 Reduce pain (i.e. physical, emotional, etc.)

Recognizing Addiction
• Being secretive or
evasive.
• Lying frequently.
• Mood swings.
• Major changes in sleep or
energy levels.
• Fluctuations in weight.
• Attitude and appearance
changes.
• Loss of interest in things
previously enjoyed.
• Failing to meet
obligations.
• Loss of memory.
• Stealing.
Why are some people at
higher risk for SUDs/
addiction?
“Just because you are prone to addiction doesn’t mean
you’re going to become addicted. It just means you’ve
got to be careful.” --Dr. Glen Hanson
So how do drugs/ alcohol
work?
STIMULANTS
•Cocaine
•Methamphetamine
•Amphetamines
•Ritalin
•Cylert
•Tobacco
INHALANTS
•Glues
•Paint thinner
•Gasoline
•Laughing gas
•Aerosol sprays
CANNABINOIDS
DEPRESSANTS
•Hashish
•Marijuana
• “Ear wax”
•Brownies / edibles
•Barbiturates
•Benzodiazepines
•Flunitrazepam
•GHB (Gammahydroxybutyrate)
•Methaqualone
•Alcohol
•Tranquillisers
•Sleeping pills
•Ketamine
•“Roofies”
OPIOIDS AND
MORPHINE
DERIVATIVES
•Codeine
•Fentanyl and
fentanyl analogs
•Heroin
•Morphine
•Opium
•Oxycodone HCL
•Hydrocodone
bitartrate,
acetaminophen
ANABOLIC
STEROIDS
•Anadrol
•Oxandrin
•Durabolin
•Stanozol
•Dianabol
HALLUCINOGENS
PRESCRIPTION
DRUGS
•LSD (lysergic acid
diethylamide)
•Mescaline
•Psilocybin
•Magic Mushrooms
•Ecstasy
•MDMA /Molly
•Opiods: Codeine,
Oxycodone,
Morphine
•Central nervous
system
depressants:
barbiturates,
benzodiazepines
•Stimulants:
dextroamphetamin
e, methylphenidate
4 Degrees of Drug Use
1) Experimentation
2) Social use
3) Binge drinking
4) Substance use and addiction
The Standard Drink:
In the United States, one
"standard" drink contains
roughly 14 grams of pure
alcohol, which is found in:
12 ounces of regular beer, which
is usually about 5% alcohol
5 ounces of wine, which is
typically about 12% alcohol
1.5 ounces of distilled spirits,
which is about 40% alcohol
Drinking Guidelines
• Men: No more than 4 drinks on any day and 14 drinks per week
• Women: No more than 3 drinks on any day and 7 drinks per week
• Men and Women >65: No more than 3 drinks
on any day and 7 drinks per week
Beer
12 oz
Wine
5 oz
Fortified Wine
3.5 oz
Liquor
1.5 oz
THE PROCESS
OF
RECOVERY
Model of Change
Stages of Recovery
Early Recovery: Getting Clean
• Concrete changes in daily living
• Adequate sleep, diet, exercise
• Staying away from those who are using
• Building support; education
Stages of Recovery
Middle Recovery: Stabilization
• Able to turn energies to family, work, relationships,
friendships
• Support, life skills, relaxation, stress management
• Less focus on using
Stages of Recovery
Late Recovery: Maintenance
• Insight into early trauma
• Healing, repairing self-esteem
Aspects of Recovery:
• Recognition
• Cessation
• Education
• Support
• Counselling
• Relapse Prevention
• Dealing with Underlying Issues
Relapse
Definition:
• Relapse: Return to previous behaviors
Relapse Factors
Common Triggers of Relapse
Individual
• Unpleasant feelings
• Unpleasant physical states
• Positive emotional states
• Testing personal control
• Urges, cravings
Relapse Factors
Common Triggers of Relapse (cont.)
Interpersonal
• Enhancing good feelings
• Social Pressure
• Conflict with others
Personal Relapse Factors
• People – former ‘using’ friends (i.e. dealers, partiers,
etc.)
• Places – former ‘using’ settings (i.e. pubs, crackhouses, etc.)
• Things – former ‘using’ objects / paraphernalia (i.e.
pipes, etc.)
Personal Relapse Factors
• Times – former ‘using’ rituals (i.e. beer after work, etc.)
• Activities – previously associated with substance use (i.e.
pool, darts, etc.)
• Emotional states – emotions previously associated with
substance use (i.e. anger, etc.)
• Events – events formerly associated with substance use
(i.e. concerts, etc.)
Processing a Relapse
A relapse is not inevitable but it is a common experience in the
recovery process. It can be an opportunity to learn:
• What was the trigger(s)?
• What was the high risk situations?
• What will one do differently in the future?
• How did the person manage to stop drinking / using drugs?
•How was this lapse / relapse different from the last one?
•In what ways is the person stronger / wiser?
What does the person know now that they
did not know before?
SBIRT/ CRAFFT
What is SBIRT?
• Screening to identify patients at-risk for developing
substance use disorders.
• Brief Intervention to raise awareness of risks, elicit
internal motivation for change, and help set healthy
goals.
• Referral to Treatment to facilitate access to
specialized services and coordinate care between
systems for patients with highest risk.
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Video: Anti-SBIRT
Video: Effective SBIRT
SBIRT Work Flow
Screening
No Use
Low Risk
Reinforce
healthy
choices
CRAFFT Score 1 or >
Moderate Risk
High Risk
Brief Intervention
1-4 sessions
Brief Intervention AND
Referral to Treatment
Follow-up
Brief Screen (Pre-Screen)
During the past 12 months, did you:
1. Drink any alcohol (more than a few sips)?
2. Smoke any marijuana or hashish?
3. Use anything else to get high?
If any “YES” ask full CRAFFT questions
If all “NO” just ask CAR question
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Another Brief Screen (S2BI)
In the past year how many times have you used…
1.
2.
3.
4.
5.
6.
7.
8.
Tobacco products
Alcohol
Marijuana
Illegal drugs (such as cocaine or Ecstasy)
Prescription drugs not prescribed for you (such as pain medication or
Adderall)
OTC medications (such as cough medicine) for non-medical reasons
Inhalants (such as nitrous oxide)
Herbs or synthetic drugs (such as salvia, K2 or bath salts)
If any “YES” ask full CRAFFT questions
If all “NO” just ask CAR question
No history of use History past year use History monthly use
History daily use
No Risk
Severe Risk
Mild Risk
Moderate Risk
Levy et al. JAMA Pediatr. 2014
Full Screen: CRAFFT
1. Have you ever ridden in a car driven by someone (including yourself)
who was “high” or had been using alcohol or drugs?
2. Do you ever use alcohol or drugs to relax, feel better about yourself, or
fit in?
3. Do you ever use alcohol or drugs while you are by yourself, or alone?
4. Do you ever forget things you did while using alcohol or drugs?
5. Do your family or friends ever tell you that you should cut down on your
drinking or drug use?
6. Have you ever gotten into trouble while you were using alcohol or
drugs?
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CRAFFT Scoring
Low Risk
Moderate Risk
High Risk
Abstinence
CRAFFT Score 1
CRAFFT Score 2+
If 1+ provide brief intervention
If 2+ also consider referral to treatment.
Source: American Academy of Pediatrics, 2011
CRAFFT IS IN AWARDS
Optional: