Kimberly Choiniere, LMSW
A maladaptive pattern of substance use, leading to clinically
significant impairment or distress, as manifested by three or more
of the following, occurring at any time in the same 12-month
period :
1. Tolerance
2. Withdrawal
3. Larger amounts used over a longer period of use than intended
4. Inability to or persistent desire to cut down or control use
5. A great deal of time spent on obtaining, using or recovering
6. Important activities given up or reduced
7. Use despite problems caused or exacerbated by use
with or without physiological dependence
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Alcohol is the most widely used psychoactive drug in the world.
Alcoholism is the third leading cause of lifestyle-related death.
Approximately 51.5% of adults are current regular drinkers (CDC, 2011).
In 2008, 8.5% of adults in the U.S. met criteria for an alcohol use disorder (NESARC).
In 2008, more than 12 million Americans suffered from alcoholism and 40-50 million families
were affected (National Library of Medicine, NIAAA, NIH)
Approximately 80,000 deaths are attributable to excessive alcohol use each year in the U.S.
(CDC, 2013).
Alcohol use is in involved in 83% of homicides, 72% of child violence occurrences, 75% intimate
partner violence, more than 73% of felonies, and 64% of traffic deaths (CDC, NIAAA, and The
National Center on Addiction and Substance Abuse, 2008).
In 2010, alcohol-induced deaths, excluding accidents and homicides were 25,692 (CDC).
Economic cost of alcohol addiction was an estimated 223.5 billion dollars in 2006 (CDC).
Thirty to 80% of suicides are alcohol-related (Murphy, 1992).
Substance abuse is a condition influence by
biological, psychological, and social factors.
GenderAlcohol is more common in males, but there is a higher mortality and morbidity rate in females.
Memory and attention is more affected in females.
Age- Persons reporting first use of alcohol before the age of 15 are 5 times more likely to report
alcohol abuse then people who first used alcohol at age 21 or older. (SAMHSA 2004)
Genetic Heritage-alcohol is highly heritable at 40-60% in first degree relatives (Enoch, Goldman,
1999). Genetics determine vulnerability based on how substances affect an individual brain and
behavior (Washton, Zweben, 2008). A variety of genes increase susceptibility and variations in
effects on CNS. Genetic susceptibility has been extensively studied (for example, twin studies,
adoption studies, and pedigree studies). Temperament and childhood behavior problems play a
role in development of alcohol addiction.
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Socioeconomic status
Prevalence in certain peer groups and
subcultures
Religious prohibition against using
psychoactive substances
Family Environment, which includes social
learning as well as family systems model
The person using is not using [drugs] to have a
problem, they’re using drugs to find a solution”
(Vincent Felitti).
At heart, alcoholism feels like the accumulation of
dozens of…tiny fears and hungers and rages,
dozens of experiences and memories that collect
in the bottom of your soul, coalescing over many,
many, many drinks into a single liquid solution
(Carolyn Knap, Drinking: A Love Story, 1996).
Mental, emotional difficulties, cognitive and
behavioral problems increase risk of developing
alcohol abuse and dependence.
Alcohol is a potent reinforcer alleviating negative
affective states (Washton, Zweben, 2008).
Women with anxiety and mood disorders, as well as
males with drug abuse and antisocial personality
disorder are more prone to alcohol dependence
development.
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12 ounces of regular beer
5 ounces of wine
1.5 ounces of 80-proof distilled spirits
(whiskey, vodka)
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Dosage determines action on the body.
At low doses, alcohol acts as a disinhibitor
increasing euphoria.
At higher doses, alcohol can lead to sleep or
coma, and even death by respiratory distress.
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Alcohol is measured by the number of grams present
in 100 milliliters of blood expressed as a percentage.
Limited effects- 0.03%
Slowed reactions- 0.05%
Slurred speech and impaired motor coordination.10-.15%
Loss of consciousness- .30%
Death- 40%
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Alcohol is absorbed directly into the blood
stream from the gastrointestinal tract.
Alcohol is the only drug absorbed by every
cell in your body.
Alcohol affects all brain functions including
behavior, respiration, psychomotor,
coordination, sexuality.
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Immediate Effects: unintentional injury, including violence,
risky sexual behavior, miscarriage, stillbirth, and alcohol
poisoning
Long-Term Effects: Neurological (stroke, dementia,
neuropathy), cardiovascular (MI, cardiomyopathy, atrial
fibrillation, hypertension), cancer (mouth, esophagus,
liver, colon, breast), liver disease (alcoholic hepatitis,
cirrhosis, fatty liver, fibrosis), pancreatitis, gastritis,
immune system dysfunction (increased risk of TB and
pneumonia), malnutrition, brain cell damage, WernickeKorsakoff Syndrome
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Memory lapses after heavy drinking
Needing more alcohol to feel “drunk”
Alcohol withdrawal symptoms when you
haven’t had a drink for a while
Alcohol-related illnesses
May often drink alone, become violent, make
excuses for drinking, hide use, miss work,
continue despite negative consequences
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Experimental Use- few exposures which might be precipitated by curiosity
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Occasional/Irregular Use- modest amounts used infrequently
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Circumstantial Use- specific social situations
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Binge Use-large amounts over a short period of time (on average two hours) (most
common form of excessive consumption). Binge use is four or more drinks
consumed by females and five or more by males.
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Abuse- medicinal preoccupation
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Dependence- chronic use which may result in death
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Questions asked in a non-confrontational direct
manner- Why now?
Substance use quantity
Substance use frequency
Nature and extent of use
Assess for alcohol-related problems (medical,
behavioral, psychological)
Quantity-Frequency Methods
Drinking Self-Monitoring Logs (daily diary for
two weeks)
Prompted Daily Recall and Timeline Methods
(calendars, charts to collect information on
specific dates or days)
CAGE (Buchsbaum, Buchanan, Centor, Schnoll, & Lawton, 199;
Soderstrom, Smith, Kufera, Dischinger, Hebel, & McDuff, et al.,
1997)
Alcohol Use Disorders Identification Test (AUDIT) (WHO, 1997)
T-ACE (Sokol, Martier, & Ager, 1989) and TWEAK (Russell, Martier,
Sokol, Mudar, Bottoms, & Jacobson, et al., 1994)
CHARM (Sumnicht, 1991)
C: Cutting Down
A: Annoyance
G: Guilt
E: Eye Opener
(Buchsbaum, Buchanan, Centor, Schnoll, &
Lawton, 1991; Soderstrom, Smith, Kufera,
Dischinger, Hebel, & McDuff, et al., 1997)
1. Have you ever felt that you should cut down on
your drinking?
2. Have people annoyed you by criticizing your
drinking?
3. Have you ever felt bad or guilty about your
drinking?
4. Have you ever had a drink first thing in the
morning to steady your nerves or get rid of a
hangover?
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Brief Drinker Profile (Miller & Marlatt, 1984)
Structural Interview for DSM IV-TR (First, et al.,
2001)
Basic-Quantity Frequency Items (NIAAA, 1995)
Alcohol Dependence Scale (Skinner and Horn,
1984)
Drinker Inventory of Consequences (Miller,
Tonigan, and Longabaugh, 1995)
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Typical Pattern of Use
Episodic occasions of use
Time span of consumption, allowing
estimates of peak and typical BAL’S achieved
(Miller, Marlatt, 1984)
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Stage 1: Pre-contemplation (not ready with no intention to
change within the next six months)
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Stage 2: Contemplation (may be ready with the intention to
change within six months)
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Stage 3: Preparation (ready to change within 30 days)
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Stage 4: Action
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Stage 5: Maintenance (Prochaska & DiClemente, 1982)
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Usually within 24-48 hours after cessation
Mild symptoms include tremor, insomnia, sweating,
weakness, nausea, vomiting
Severe and potentially life-threatening delirium
tremens can occur if heavy drinker ceases use
abruptly without medications.
DTS can include extreme agitation, anxiety, profound
depression and lethargy, increasing mental
confusion, profuse sweating, elevated pulse rate, rise
in body temperature (Washton, Zweben, 2008).
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Naltrexone/ Depade/ReVia/Vivitrol
Acamprosate/Campral
Disulfram/Antabuse
Gabapentin/Neurontin in current study
(NIAAA, NIH, 2013)
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Substance abuse and dependence combined
into single substance use disorder
Specific to substance
Found within addictions and related disorders
Trauma is a stress that causes physical and
emotional harm from which you cannot remove
yourself (Larke Huang, Office of Behavioral Health
Care Equity, SAMHSA).
Trauma is a stress resulting from exposure to, or
witnessing of events that are severe and/or life
threatening (American Psychological Association).
The person has been exposed to a traumatic
event in which the person experienced ,
witnessed or were confronted with an event or
events that involved actual or threatened death
or serious injury, or a threat to the physical
integrity of self and others and the person’s
response involved intense fear, helplessness
and horror.
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The traumatic event is persistently reexperienced, in one or more
ways (examples include recurrent distressing dreams and
intrusive thoughts and recollections)
There is persistent avoidance of stimuli associated with the
trauma and numbing in three or more areas (examples include
detachment and markedly diminished interest in significant
activities)
Persistent symptoms of increased arousal in two or more areas
(examples include hypervigilance and difficulty falling asleep)
Duration is more than a month
The disturbance causes clinically significant distress, or
impairment in social, occupational, or other important areas of
functioning
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Natural Crises- tornadoes, earthquakes,
tsunamis
Manmade Disasters- war, genocide,
homicide, abuse, neglect, assault, witnessing
the abuse of others
Personal Loss-death, health trauma,
disability, accidents
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Ground Zero Study- 10 middle and high school
students
Exposures to trauma included proximity of
school to WTC, perceived fear, loss of loved one,
fear for loved ones safety
With three or more exposures, children were 19x
more likely to have increased use of alcohol and
drugs.
Identified correlations between severe childhood stress and various
addictions
Found that the effects of trauma are cumulative and identified
adverse experiences as abuse, neglect, divorce, death, domestic
violence, and/or having a mentally ill or addicted parent.
Boys in the sample with four or more adverse experiences were five
times more likely to become an alcoholic.
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Rate of physical abuse in alcoholics: 24% males
and 33% females
Rate of sexual abuse in alcoholics: 12% males
and 49% of females
Added long-term consequences are increased
rates of depression, anxiety, suicide, and
behavioral disorders
Traumatic events produce profound and
lasting changes in physiological arousal,
emotion, cognition and memory (Herman,
1992)
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Physical-increased blood flow, increased heart
rate, increase in adrenalin, fluctuations in blood
pressure
Affective-anxiety, numbness, fear, survivor’s
guilt
Cognitive- poor attention span, obsessive
thoughts, nightmares, flashbacks
Behavioral- sleep disturbances isolation, fatigue,
irritability, including substance abuse
Trauma victims attempt to control internal
states of hyperarousal, social withdrawal,
emotional pain and anger through the use of
substances (Van Der Kolk,1994).
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Increased rates of specific medical problems
seen in trauma survivors include
hypertension, chronic pain disorders, heart
disease, gastrointestinal disorders, HIV risk,
and mortality.
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MDD and dysthymia
Anxiety Disorders
Psychotic Disorders
Borderline and Antisocial Personality
Disorders
Dissociative Disorders
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Self-Administered Post-Traumatic Diagnosis
Scale (Coffey et al., 1998)
Impact of Events Scale-Revised
Davidson Traumatic Stress Scale
PTSD Checklist (Weathers, 1993)
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Checklist: 17-item self-report
screens, diagnoses, monitors symptoms
CAPS (Clinician Administered PTSD Scale):30item structured interview that addresses 17
symptoms and consists of a Life Events Checklist
(Blake, Weathers, Nagy, Kaloupek, Charney and
Kearne, 1995)
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SSRIS
SSNRIS
TCAS
MAOIS
Mood-stabilizing anticonvulsants
Atypical antipsychotics
Anti-adrenergic agents
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Seeking Safety (Najavits,1992)
Trauma Recovery and Empowerment Model
(TREM) (Harris, 1998)
Addiction and Trauma Recovery Integration
Model (ATRIUM) (Miller, 1994)
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Based on cognitive-behavioral and relational
theories
Addresses mind, body, spirit
12 weeks
Group setting
Peer or professionally facilitated
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Introduces a preschool subtype for PTSD for
children six years and younger
New specification includes a dissociative subtype
Removal of requirement that one needs to
experience fear, helpless, or horror in response
to a traumatic event
Avoidance symptoms will be separated into two
different clusters