This document provides an overview of substance abuse and treatment. It discusses the definitions of use versus abuse and normal versus problematic substance use. It also outlines the challenges in treating substance abuse disorders, including co-occurring mental health and medical conditions. Finally, it summarizes the levels of substance abuse treatment based on the ASAM criteria and principles of treatment matching to provide the appropriate level and type of care.

1. Substance Abuse 101
Catherine McAlpine, Ph.D., LCSW-C
Manager, Behavioral Health and Crisis Services
401 Hungerford Drive, Rockville, MD 20850
Catherine.mcalpine@montgomerycountymd.gov

2. Workshop Objectives
• Understand what is “use” and “abuse” of alcohol
& other drugs
• Understand how substance use & co-occurring
disorders intersect with homelessness and other
social problems
• Learn the basics of “treatment matching” using
medical necessity criteria (ASAM)
• Gain basic knowledge of the County’s continuum
of care & how adults access treatment services

3. Historical Perspectives
• Early identification of alcoholism as an illness (B.
Rush)
• Incarceration, Insanity or Intervention?
• Criminalization – The Volstead Act, 18 Amendment to the U.S.
th
Constitution (1919, repealed 1933), The Controlled Substance Act of
1970
• Self help (1935) – when all else fails find a friend
• Medical Science challenges the Moral Model
• The Minnesotta Model
• Professionalization of Treatment
• Recovery Management

4. Challenges
• Binge Drinking
• Workplace – 70% are employed
• Aging Baby Boomers
• Co-occurring mental health & medical
• Abuse of Prescription Medications
• Pharmacotherapy
– Buprenorphrine
– Antagonists & Agonists

5. What’s Normal
• More than 60% of adults use alcohol on a
regular basis (lowest after age 65).
• Estimates are that 8-12% are problem
drinkers or alcoholic (over life span).
• Males 12-20 report binge alcohol use 21%
& overall 28.4% use in past 30 days
• Female 12-20 report binge alcohol use
16% & overall 27% use in past 30 days

6. When is use abuse?
• Relief seeking
• Impacts social network or employment
• Abuse – misuse, use other than as
directed, negative incident related to
intoxication or use (arrest)
• Dependence – loss of control, tolerance,
denial, and continued use despite
negative consequences

7. What is a Problem?
• World Health Organization
– Simple message: 4 for women, 5 for men
• Five Substances are 96% of admissions
– Alcohol 40%
– Opiates 18%
– Marijuana 16%
– Cocaine 14%
– Stimulants 9%

8. Signs of AOD Dependence
• Significant impairment or distress resulting from
use (role functioning, suicidal)
• Failure to fulfill roles at work, home or school
• Persistent use in physically hazardous situations
• Recurrent legal, financial , interpersonal or social
problems related to use
• Continued use despite life problems and/or
deterioration despite assistance & support
– Or …
• The person is not improving despite assistance

9. Is addiction a disease?
• Disease is defined as …
• (noun) 1. An abnormal condition of an organism
or part, especially as a consequence of infection,
inherent weakness, or environmental stress, that
impairs normal physiological functioning. 2. A
condition or tendency, as of society, regarded as
abnormal and pernicious. (American Heritage
Dictionary of the English Language, 1979)

10. Where Do We Begin?

11. Assessment
• Seven domains of a person’s functioning, similar
to biopsychosocial spheres
– Primary diagnosis of substance use/abuse
– Acuity of intoxication and/or withdrawal
– Emotional, behavioral & cognitive conditions
– Readiness to change
– Relapse, continued use or problem potential
– Recovery environment

12. What Is It? The Intersection of
Co-occurring Conditions
• Which came first?
• Which do you treat?
• How can you have an
impact on chronic
conditions?
• What about chronic pain
or pain management?
• Where do you begin so
you can set goals and
begin to work?

13. Signs and Symptoms
• Unclean, poor personal care, poor
physical and oral health.
• Tired, confused or seems spacey.
• Poor memory or poor historian on past
events.
• Losses things, arrives late and “forgets.”
• Multiple services with little or no progress.

14. Goals of Treatment
• Abstinence reduces morbidity & MH sx
• Increase employment, housing & social
connectedness
• Reduce criminal involvement
• Increase access to services & retention
• Improve client perception of + outcome
• Use evidence-based practices

15. ASAM Levels of Care
• .5 is early intervention or education
• Level I is outpatient (1-8 hour week)
• Level II is intensive outpatient (9+)
• Level III is residential with a variety of
service types: halfway house (3-9 months), long-term (6+
months), detox (1-5 days) & intermediate care (28 day)
• Level IV is acute care, hospital based

16. Quadrants & Levels of Care
Low/Low (misa) Low/High (miSD)
.5 Education Level II – IOP
Level I + 12 Step Level III
High/Low (MIsa) High/High (MISA)
.5 Education Level II – IOP
Level I + 12 Step Level III

17. Treatment Matching
• Match the “dose” of services to the illness
– Severity of impairment & ability to participate
– Least restrictive environment
– Prior treatment
– Social support
– Readiness to change
– Willingness to accept recommendation
– Plus medical & social necessity criteria
– Residency, age, gender, insurance etc.

18. What Works?
• Screening/Brief Intervention (SBRIT)
• Physician’s Office for Opioid Management
• Cognitive Behavioral Therapy
• Motivational Enhancement
• Relapse prevention – 12 Step, anxiety
management, social support & employment
• Integrated for Co-occurring
– Comprehensive Continuous Systems of Care
– Integrated Dual Disorders Treatment

19. Your Examples & Discussion

20. Respectful Understanding
• Good treatment begins with an empathic,
hopeful relationship, is strengths based
• Knowledgebase – you must have a factual
understanding of principles of addiction &
treatment, go to sites & self-help meetings
• Use of reflective listening & paraphrasing
• Accept that client will be dishonest
• Acceptance of chronic, relapsing disease
• Continue relationship thru non-compliance

21. Stages of Change:
A Trans-theoretical Model

22. Stages of Change
• Precontemplation - behavior not a problem, no change
• Contemplation - behavior is perhaps a problem, may
have a need to change, considering that change may
have benefits, no change yet
• Preparation - begins to plan for behavior change, further
consideration of benefits, no change yet
• Action - behavior change occurs, trying out new
behavior, integrating into daily life, change occurs
• Maintenance - behavior occurs regularly, some relapse
to prior behavior, relapse is then validated and reviewed,
new behavior resumes.
• Relapse – return to prior behavior, recognize failure

23. Vision Statement from
SAMHSA
• A Life in the Community
for Everyone.
• Prevention Works.
• Treatment is Effective.
• People Recover.

24. Recovery is …
• Grounded in resilience
• Supported by a foundation of hope
• An ongoing, dynamic, interactive process
• An interplay of a person’s strengths and
vulnerabilities
• A personal journey
• Continuous, even when symptoms recur

25. Characteristics
of Recovery
• Multiple Pathways
• Holistic Change Process
• Supported by Peers and Allies
• Is a Process of Stages: engagement,
recovery initiation and stabilization, recovery
maintenance and ongoing recovery
(adapted from Changing for Good (1994), Prochaska,
Norcross, and DiClemente. NY: Avon Books)

26. Social Forces Support Change
• Successful recovery often includes:
– connections to family
– stable sober housing
– employment
– follow-up on healthcare & nutrition
– extended course of treatment
The longer people participate in a treatment
regimen, the more likely they are to remain
abstinent and achieve a sustained
recovery. This has been verified via case
study and research data.

27. Local Resources
• Primary Adult Care (PAC)
• Access Team
• Crisis Center
• Jail-based services
• Avery Road Treatment Center
• Access to Recovery (ATR)
– Care Coordination
– Gap Services

28. Publicly Funded Programs
• Primary SUD • Primary Mental Health
– Avery Road Tx. Center – Threshold Services
– Avery Road Combined – St. Luke’s (have merged)
– Journeys for Women – Family Services, Inc.
– Bi-lingual Counseling – Crisis Center (crisis beds)
– Family Health Center – Fenton House
– KHI (Family Services) – Adventist Behavioral
– Outpatient Addiction & Health
Mental Health Services – Adult Behavioral Health
– Medication Assisted Tx. – Outpatient Addiction &
– Adventist Behavioral health Mental Health Services
– Journey to Self
Understanding