Pills
by Shelley Steenrod, Ph.D., LICSW
Mariela is a 16-year-old Caucasian high school student. Prior to her prescription drug abuse, she had above average grades, positive family relationships, and a promising gymnastics career. A year ago, she found a prescription bottle of OxyContin in her family’s medicine cabinet and began to experiment with it, loving its relaxing and euphoric effect. Mariela’s mother, who uses the medication for chronic lower back pain, failed to notice missing pills for several months, at which point she began to lock the medication up.
Unfortunately, it did not take long for Mariela to figure out how to buy the pills at school, although it was very costly at $30 to $50 per Oxy. As Mariela’s dependence grew, her supplier suggested she crush it, to remove the time release coating, and snort it for a more powerful effect. Shortly thereafter, a more addicted Mariela became unable to afford the hefty street price of OxyContin and began to explore alternatives. Heroin, a comparable opiate, sells for only $5 a bag, and Mariela began to snort and then inject this more affordable drug.
Mariela is now in desperate straits. She uses heroin two to three times per day, alone, both for pleasure and to stave off withdrawal symptoms. She stopped attending gymnastic events several months ago, is failing all of her classes, lacks interest in school, and is forgetful. Her friend group has also shifted to other drug users. Mariela has tried to stop using on her own, but quickly returns to heroin or OxyContin as cravings arise or when “triggered” by stressful life events, school pressure, or friends. Mariela’s parents, unaware of the seriousness of the situation, realize that something is not right and turn to you, a social worker, for help.
Mariela’s story is far from unique. Prescription drug abuse, described by the National Institute on Drug Abuse (NIDA) as “the intentional use of a medication without a prescription; in a way other than as prescribed; or for the experience or feeling it causes” (National Institute on Drug Abuse, 2011), is a serious and growing problem in the United States. The National Survey on Drug Use and Health (NSDUH) reported that nearly 3% (or seven million) used prescription medications for non-medical purposes (Substance Abuse and Mental Health Services Administration, 2011).
Myths abound regarding the safety of prescription drugs. Many people believe they are safer than illicit drugs because they were originally prescribed by a doctor. In addition, pharmaceutical treatments of ADHD and chronic pain have flooded the United States, making prescription drugs widely available and increasing the perception that they are inherently safe.
People take prescription drugs for a wide range of reasons. Some take more of a drug than originally prescribed, desiring a more potent impact. Others take medicines, originally prescribed to family or friends, because their own medical symptoms are untreated (a scenario particularly true for individuals without insurance). The unique effect of each drug can also be a big motivator. For example, opioid prescription drugs offer powerful pain relief, in addition to feelings of euphoria and pleasure. Stimulant drugs, such as those prescribed for Attention Deficit Disorder, are often shared between college students for increased focus and energy.
However, prescription drug abuse is accompanied by significant health risks. Many prescription drugs are highly addictive and need to be managed by the prescribing physician to avoid the development of a tolerance or dependence. Alone, or in combination with other drugs and alcohol, illegal use of prescription drugs can also lead to overdose or death. Prescription drug abuse can also be a gateway to illegal street drugs. For example, Mariela switched from OxyContin to heroin, which is cheaper and more potent, but carries an increased risk for blood borne infections, such as HIV, Hepatitis C, and other communicable diseases.
Mariela is also taking risks with her brain. Magnetic resonance imaging (MRI) has firmly established that drug use can permanently change how the brain functions. Mood altering drugs activate the reward, or limbic, system, a crucial area responsible for motivation, reward, and behavior. Also called the pleasure center, this part of the brain makes us feel good when we engage in behaviors that are necessary for survival, such as eating, drinking, and sex. The reward pathway is also responsible for making sure we repeat the same behavior whenever possible by connecting to other areas in the brain that control memory and behavior.
When the limbic system is activated by mood altering drugs, the brain also interprets these chemicals as necessary for survival, thereby sending out increasingly dire cravings for more (and more) of the same. When a user finally succumbs to these intense cravings, the pathway is further reinforced for repeated drug use. Fortunately, research indicates that, over time, some brain function can be repaired, highlighting the importance of appropriate treatment for those with substance use disorders.
There are many important roles for social workers to fill in the identification and treatment of prescription drug addiction and other substance-related disorders. Social workers who work with youth can expect to see an increasing number of adolescents with prescription drug addictions. Because the Patient Protection and Affordable Care Act of 2010 encourages integration between behavioral health care (mental health and substance abuse services) and primary health care, social workers will be called upon to screen and assess adolescents for substance abuse and to provide generalist social work services including education, brokering, advocacy, and case management.
Screening
The CRAFFT (Knight, Serritt, Harris, & Chang, 2002; Center for Adolescent Substance Abuse Research, n.d.) is a standard screening instrument that quickly assesses for adolescent drug use. It is a face-to-face screen in which a clinician asks three “opening” questions: During the past 12 months, did you:
- Drink any alcohol?
- Smoke any marijuana or hashish?
- Use anything else to get high?
An adolescent who answers “yes” to any of these questions is then asked the following six questions:
C: Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
R: Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
A: Do you ever use alcohol or drugs while you are by yourself, or ALONE?
F: Do you ever FORGET things you did while using alcohol or drugs?
F: Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
T: Have you ever gotten into TROUBLE while you were using alcohol or drugs?
The CRAFFT is scored by awarding each affirmative answer one point. A score of zero indicates no risk for a substance related disorder. A score of one point indicates that the client could benefit from education about the risks of drug use and advice on cutting down, or eliminating use. A score of two or greater indicates the need for a more thorough assessment for substance abuse.
Mariela answered five out of six questions affirmatively, strongly indicating the need for further assessment. For example, she reported that she had driven a car while high, used drugs to relax, used drugs alone, forgotten things she had done while high, and been told by family and friends to cut down on her drug use.
Assessment
Substance abuse assessments are appropriate for youth with a “positive” screening result. Assessments allow for deeper examinations of the type, amount, method, and frequency of drug use along with a thorough analysis of the biopsychosocial consequences of such use.
Social workers use the information gleaned from an assessment to formulate a diagnosis and treatment plan. The recently released DSM-5 characterizes substance use disorders as “a cluster of cognitive, behavioral and psychological symptoms indicating that the individual continues using the substance despite significant substance-related problems” (American Psychological Association, 2013, p. 483). Each disorder is specified according to the substance used and may include: alcohol, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, stimulants, anxiolytics (anti-anxiety medications), and other substances.
It is important to note that the DSM-5 does not offer a specific category for prescription drug abuse. Instead, social workers should look to the category of drug that a client is using. For example, Mariela’s drug(s) of choice, first OxyContin and then heroin, are both opioids, so we examine her symptoms according to the 11 diagnostic criteria for Opioid Use Disorder (see DSM-5, Opioid Use Disorder). In Mariela’s case, she admits to: 1) taking larger amounts of opioids over time; 2) making several unsuccessful efforts to cut down; 3) spending a significant amount of time getting, using, and recovering from opioid use; 4) very strong cravings; 5) failure to meet her academic obligations; 6) regular use despite problems with friends and family; 7) giving up important activities (gymnastics); 8) using in dangerous situations; 9) a growing tolerance; and 10) the experience of withdrawal symptoms between episodes of use.
Mariela’s OxyContin and heroin use clearly indicate an opioid use disorder. Further, because she has nine of 11 symptoms, the DSM-5 specifies her disorder as severe.
Next, we look to the biopsychosocial consequences of Mariela’s drug use and other elements that are relevant to treatment planning. The American Society of Addiction Medicine (ASAM) recommends consideration of the following dimensions:
- Acute intoxication and/or withdrawal potential
- Biomedical conditions and complications
- Emotional, behavioral or cognitive conditions and complications (dangerousness/lethality, interference with addiction recovery efforts, social functioning, ability for self-care, course of illness)
- Readiness to change
- Relapse, continued use, or continued problem potential
- Recovery environment
The assessment reveals that Mariela is at moderate to severe risk of withdrawal as evidenced by intense cravings and increased tolerance. She is also sharing needles, putting her at risk of communicable, blood borne diseases, including HIV and Hepatitis C. Mariela does not have a history of mental health, behavioral, or cognitive problems. However, she is missing important developmental milestones of adolescence that will ultimately have an impact on her social functioning. The assessment further indicates that Mariela is highly unlikely to stop using drugs in her current environment. She is easily triggered for use, and her parents have been naïvely unaware of the extent of her drug use. She requires intensive motivating strategies and supervision to promote recovery.
Treatment Planning and Levels of Care
The ASAM criteria (Mee-Lee, 2013) also assist clinicians in matching client needs with the best level of care and appropriate treatment resources. To this end, the ASAM criteria describe and delineate the following eight levels of care:
- Early Intervention
- Outpatient Treatment
- Intensive Outpatient Treatment
- Partial Hospitalization
- Clinically Managed Low-Intensity Residential Treatment
- Clinically Managed Medium-Intensity Residential Treatment
- Medically Monitored High-Intensity Residential/Inpatient Treatment
- Medically Managed Intensive Inpatient Treatment (See Table 1.)
Table 1 Adolescent Prescription Drug Abuse
Descriptions of each level of care are beyond the scope of this article, but it is helpful to imagine the levels of care along a continuum, with early intervention as the least intensive and medically managed intensive inpatient treatment (hospital-based care) as the most intensive. Mariela’s status on each biopsychosocial dimension suggests that she initially needs Medically Monitored High-Intensity Residential/Inpatient Treatment to manage her withdrawal symptoms and biomedical needs, but can then likely “step-down” into a lower level of residential treatment to address her ambivalence toward change, likelihood of relapse, and need for a structured and motivational recovery environment.
In addition to screening, assessment and treatment planning, there are several additional social work roles that must be fulfilled to help Mariela and her family. These include educator, broker, advocate and case manager.
Educator
Mariela and her parents require basic information on addiction and recovery. The entire family will need to understand that addiction is a disease—not a personal failing—which requires life-long management. The first phase of treatment will address Mariela’s acute needs, and the second phase of treatment will address the chronicity of addiction.
Both Mariela and her parents will need help understanding that ongoing disease management will require significant lifestyle changes and treatment. An overview of 12-step and other support groups is also important.
Mariela and her family also need education on the treatment options that are available to them. Although the ASAM criteria, an industry standard for treatment and insurance providers, recommend residential care for Mariela, it is always important that clients and social workers collaborate in treatment planning. To this end, Mariela and her family may want to consider medically-assisted therapies in conjunction with other treatments. One such medication is Suboxone, a prescription drug that effectively eliminates cravings for opiates. Another medication, recently approved by the FDA, is Vivitrol. It is administered as a monthly injection to block the pleasurable effects of opiates, rendering their use meaningless.
Broker
Mariela may need help accessing appropriate treatment services, because adolescent substance abuse treatment is in short supply across the country. Identifying adolescent-centered services can be a difficult task, but it can be made easier by having a solid understanding of the public and private treatment resources in your particular region. Many states now have toll-free numbers and websites to point clinicians, clients, and families in the right direction. In addition, insurance companies generally contract with specific treatment providers for members of their specific plans.
Advocate
Social workers give voice to client needs when clients are unable to do so themselves. It may be essential to advocate for Mariela on several levels. For example, it may be essential to advocate with her insurance company to pay for the most appropriate treatment. It may also be important to advocate with treatment programs to make Mariela a priority, as they may be inundated with other clients with similar needs.
Case Manager
Mariela also has significant case management needs. Coordinated efforts between her primary care and substance use treatment providers are required, so she is tested for HIV and Hepatitis C and receives treatment specific to those results. Mariela also needs help re-engaging in high school. Recovery high schools have become more common over the last few years, and this may be a good choice to meet her academic needs in a drug-free environment, with regular support for sobriety.
Adolescent prescription drug abuse is a serious problem in the United States. Prescription drugs have become readily available to youth and appear safer than illegal drugs. As Mariela’s case illustrates, prescription drugs carry substantial risks and can lead to illicit drug use, especially in the transition from OxyContin to heroin. However, with appropriate services, prescription drug abuse is a treatable disease.
Mariela spent four days in a residential treatment program for medical withdrawal from heroin. She then spent six weeks in a second residential program that provided structure and supervision, one-on-one counseling, and motivational groups. At the same time, Mariela’s parents attended family psychoeducational meetings, support groups, and family therapy. When Mariela returned home, she enrolled in the recovery high school in her town, where she is back on track academically and attends 12-step groups. Mariela continues to see her original social worker, and they now work on recovery skills.
Visit the following websites for more information:
- http://www.asam.org/research-treatment/treatment
- http://www.ceasar-boston.org/CRAFFT/index.php
- http://www.drugabuse.gov/publications/topics-in-brief/prescription-drug-abuse
- http://www.ncbi.nlm.nih.gov/books/NBK64364/
- http://www.ncbi.nlm.nih.gov/books/NBK64350/
References
American Psychological Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA: American Psychological Association.
Center for Adolescent Substance Abuse Research. (n.d.). The CRAFFT screening tool. Retrieved May 15, 2014 from http://www.ceasar-boston.org/CRAFFT/index.php.
Knight, J. R., Sherritt, L., Harris, S. K., & Chang, G. (2002, June). Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatrics & Adolescent Medicine, 156:, 607–614.
Mee-Lee, D. (ed.). (2013). The ASAM criteria: Treatment criteria for addictive, substance-related, and co-occurring condition. Chevy Chase, MD: American Society of Addiction Medicine.
National Institute on Drug Abuse. (2011). Topics in brief: Prescription drug abuse. Retrieved June 06, 2014 from http://www.drugabuse.gov/publications/topics-in-brief/prescription-drug-abuse.
Substance Abuse and Mental Health Services Administration. (2011). Results from the 2010 national survey on drug use and health: Summary of national findings, NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration.
Dr. Shelley Steenrod is an associate professor of social work at Salem State University in Salem, Massachusetts, where she teaches substance abuse and other social work courses. She received her Master of Social Work from Boston University and her Ph.D. from the Heller School at Brandeis University. Dr. Steenrod’s research has focused on the use of standardized screening and assessment tools, patient placement criteria, and practice guidelines by substance abuse treatment professionals and organizations.