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From Screening to Healing: A Comprehensive Clinical Approach to Substance Use Disorders

Current image: The appropriate assessment of substance use disorders in treatment settings is necessary to guide diagnostic clarity, treatment planning, and risk management.

Substance use continues to be a widespread public health problem that significantly negatively affects both physical and mental health in almost all societies. Briefly defined as the repeated consumption of psychoactive substances such as alcohol, cannabis, opioids, and stimulants, substance use ranges from experimental or occasional use to substance use disorders (APA, 2022). It is essential to understand the frequency, type, and pattern of use in individuals who use substances, as these factors are known to be intertwined with broader psychological, social, and behavioral domains (Volkow et al., 2016).

The appropriate assessment of substance use disorders in treatment settings is necessary to guide diagnostic clarity, treatment planning, and risk management. The assessment of substance use disorders is conducted through the biopsychosocial model, narrative approaches, and various standardized tests. For example, the CAGE-AID (Cut down, Annoyed, Guilty, Eye-opener – Adapted to Include Drugs) screening tool, whose reliability has been repeatedly demonstrated, is widely used as an effective tool for identifying problematic substance use in both clinical and non-clinical populations (Brown and Rounds, 1995; Dhalla and Kopec, 2007). The inclusion of tools such as CAGE-AID and other approaches whose effectiveness has been demonstrated in assessment processes enables therapists to identify the client’s underlying maladaptive coping strategies, concurrent mental health problems, and potential barriers to therapeutic engagement.

As a result, a comprehensive understanding of substance use in the therapeutic context enables clients to gain mindful awareness of themselves and their environment, facilitating clinicians to design more targeted, empathic, and trauma-informed interventions and to select appropriate assessment tools for the client. Moreover, the knowledge gained in the current framework helps to build a strong approach to the therapeutic alliance, emphasizes the level of psychosocial support needed, and informs clinical decisions about safety, referral, and ongoing care coordination (SAMHSA, 2020). In light of these benefits, the current therapy sketch will elaborate on substance use disorders, include assessments of substance use disorders in a therapeutic context, and evaluate treatment modalities for substance use disorders.

What is Substance Use Disorder?

Substance use disorder, which has a highly complex structure, is defined as a chronic illness in which individuals compulsively seek and use drugs despite harmful consequences (SAMHSA, 2023). Individuals with substance use disorder focus intensely on using various substances (s), which impairs their ability to function in daily life (Torrise, 2024). The most common substances that individuals can develop addiction to are listed below:

  • Alcohol
  • Cannabis
  • PCP, LSD, and other hallucinogens
  • Inhalants, such as paint thinners and glue
  • Opioid pain killers, such as codeine and oxycodone, and heroin
  • Sedatives, hypnotics, and anxiolytics
  • Stimulants (including cocaine, amphetamine-type substances, and other stimulants)
  • Tobacco, nicotine

In addition to using the above substances regularly, there are many different symptoms of substance use disorder. While it is known that different substances can affect individuals in different ways, common signs and symptoms that can be observed in individuals with substance use disorder are as follows (APA, 2024):

  • Having a strong craving for drugs to the extent that it interferes with other thoughts
  • Trying to always have the drug in one’s possession
  • Taking larger amounts of drugs for longer than intended
  • Needing larger amounts of drugs over time to achieve the same effect
  • Continuing to take drugs even when on an unaffordable budget
  • Obtaining, using drugs, and Inability to fulfill daily obligations and work responsibilities due to drug use
  • Significant reduction in social or recreational activities
  • Doing things to get drugs that would not normally be done (e.g., stealing)
  • Engaging in risky activities while under the influence of drugs (e.g., driving)
  • Unsuccessful attempts to quit drugs
  • The appearance of withdrawal symptoms as soon as the drug is discontinued

As can be seen from the severity of the symptoms, substance use disorder is a disorder that significantly affects individuals’ lives in many dimensions. So much so that individuals may continue to use the substance even if they are aware that they may experience problems when exposed to the substance. This is because cessation of use can lead to withdrawal symptoms and the desire to return to intensive use, which is often experienced as anxiety (Torrise, 2024). Substance use disorder, which negatively affects the individual in many ways, can cause distorted thinking, behavior, and abnormal movements. In addition, brain imaging studies have shown that it causes changes in areas of the brain related to judgment, decision-making, learning, memory, and behavioral control (Torrise, 2024).

Why do individuals resort to substance use despite the many dimensions of harm? According to the National Institute on Drug Abuse, there are several underlying reasons (Torrise, 2024):

  • To feel good – pleasure and intoxication
  • To feel better – to reduce stress, distract from life’s problems, and feel lethargic
  • To do better – to improve performance or thinking
  • Curiosity, peer pressure, or experimentation

From another perspective, it is often questioned why some people become addicted while others do not. According to the Substance Abuse and Mental Health Services Administration (2023), the risk of addiction basically varies according to 3 different factors:

  1. Biology: Genetics accounts for almost half of an individual’s risk of addiction. Other critical factors, such as gender, ethnicity, and mental health, also play a significant role in the development of addiction.
  2. Environment: An individual’s social environment (family, friends, relatives, etc.), economic circumstances, peer pressure, experience of abuse, or exposure to drugs can significantly affect the risk of addiction.
  3. Development: During critical stages of life, such as adolescence, the risk of drug use increases. These are periods when individuals are more vulnerable, as areas of the adolescent brain that control decision-making and self-control continue to develop, increasing the likelihood of engaging in risky behaviors such as drug use.

Contrary to popular belief, addiction is not caused by a lack of willpower or moral principles. Substance use disorder is a serious disorder that changes the brain and makes it difficult to quit, even for those who want to. Sustained drug use leads to significant changes in the brain, making it difficult to resist intense demands. The changes in the brain can be permanent, which is why substance use disorder is known as a ‘’relapsing’’ disorder (SAMHSA, 2023). Although relapse rates are high in the context of substance use disorder, this does not mean that treatments are unsuccessful. As with other chronic diseases, addiction treatment should be continuous and tailored to the needs and circumstances of the individual (SAMHSA, 2023). The first step for the individual to enter the treatment process begins with the completion of appropriate assessments. Thanks to a well-structured treatment process in which tools with proven reliability and validity are integrated into the assessment stages, the individual can return to a healthy life. In the next section, it will be examined how the assessment processes, which constitute a critical basis for starting substance use disorder treatment, are handled in the therapy room.

How is Substance Use Disorder Assessed in the Therapy Room?

Clinicians use various methods to assess substance use disorders in clients during the therapeutic process. How the client is assessed is determined based on their history, current situation, and needs. The assessment process for substance use disorders consists of two important dimensions: Screening and Evaluation. In the first stage, a process called screening is used to determine whether the basic characteristics of substance dependence are present in the individual. Screening indicates the likelihood of the presence of a substance dependence problem. The purpose of screening is to identify as many potential and actual addicts as possible at the earliest stage in their history of use or addiction in order to provide appropriate intervention services (SAPAA, 2012). Assessment, on the other hand, is a comprehensive evaluation designed to definitively determine the presence or absence of a diagnosable substance use disorder. In other words, while individuals are screened to determine the possible presence of a substance-related problem, the assessment stage takes the process a step further by confirming the presence of a problem and recommending appropriate treatment methods (SAPAA, 2012). Each stage of assessments conducted in a therapeutic context has a multi-layered structure that focuses on the individual context and takes into account both objective and subjective data. These processes, which must be conducted by a trained professional, include structured and semi-structured interviews, biopsychosocial assessments, storytelling, and standardized tests. Information on some of the methods used in the assessment processes of substance use disorders in clinical settings is provided below:

Holistic Assessment Through the Biopsychosocial Model

When assessing substance use, clinicians can evaluate the client not only in terms of biological factors, but also within a framework that encompasses psychological dynamics and social environment. When biological factors (genetic predisposition, neurological effects), psychological processes (traumatic history, difficulties in regulating emotions), and social factors (family relationships, social expectations, economic conditions) are considered together, it is possible to understand more comprehensively why the client turned to substance use and why they continue this behavior. In other words, the biopsychosocial model of addiction provides a holistic and multifaceted conceptualization of the disorder (Giordano, 2021). According to Marlatt & Baer (1988), there are many factors that increase the risk of addiction, but all of them find their place in the biopsychosocial model of addiction. For example, individuals genetically predisposed to addiction have a higher risk of developing addiction at some point in their lives (Giordano, 2021). On the other hand, the Adverse Childhood Experiences (ACE) study found that more ACEs increase the likelihood of subsequent drug and alcohol use (Felitti et al., 1998). Furthermore, in some societies, alcohol and tobacco advertising is more targeted, and higher rates of substance use are observed in these societies, particularly among the poor (Primack et. al., 2007). In light of this information, it is clear how important it is to conduct a multidimensional assessment of the individual.

Narrative Assessment as a Window into Lived Experience

Every individual with a substance use disorder has a story within the same context. These stories are a reflection of the individual’s symptoms, needs, pain, and coping mechanisms. In the therapy room, the client sharing their life story in their own words deepens the therapist’s assessment (Norcross and Wampold, 2011). These narratives play a critical role in revealing the client’s internal resources, worldview, and motivation for change. Narrative-based assessment functions not only as an assessment tool but also as a healing space for the client (White and Epston, 1990).

Enhancing Clinical Insight with Standardized Tools

In substance use disorder assessment, standardized tests are important complementary tools that support the therapist’s clinical observations. These tests provide objective and measurable data about the client, helping to understand substance use levels, potential risks, and accompanying behavioral patterns in a more systematic way. Especially in the screening and preliminary assessment process, the findings obtained from these tools play a critical role in developing appropriate intervention plans.

Among the widely used standard tests developed specifically for the assessment of substance use disorders are scales such as CAGE-AID (CAGE Adapted to Include Drugs), AUDIT (Alcohol Use Disorders Identification Test), ASUS (Adult Substance Use Survey), and DAST (Drug Abuse Screening Test) (Levy et. al., 2023). One of these tests, CAGE-AID, is frequently preferred in clinical settings due to its short and easy-to-administer structure. To explain briefly:

The CAGE-AID tool is adapted from the CAGE alcohol assessment tool to include questions related to substance use. Its target audience consists of adults and adolescents. This assessment tool can be administered during a patient interview or through self-reporting. CAGE-AID is not used to diagnose substance use disorders; it is only used to indicate whether there is a problem (Brown et. al., 1998). The CAGE acronym represents the keywords in each question. The questions asked using the CAGE acronym are as follows:

  • Have you ever felt you should ‘’cut’’ down on your substance use?
  • Have people ‘’annoyed’’ you by criticizing your substance use?
  • Have you felt bad or ‘’guilty’’ about your substance use?
  • Have you ever used a substance first thing in the morning to steady your nerves or start the day (an ‘’eye’’ opener)?

A ‘’yes’’ answer to any of these questions by the client indicates a possible substance use disorder and indicates the need for further testing (Brown et al., 1998).

The information obtained during the assessment process serves not only to understand the current situation but also to develop an individualized, effective, and sustainable treatment plan. Treatment approaches shaped by assessment results play a critical role in both clinical effectiveness and long-term recovery. The next section will discuss various methods used in the treatment of substance use disorders.

What Are the Treatment Methods for Substance Use Disorders?

Various methods are used effectively in the treatment of substance use disorders. Since the first step in the treatment process is recognizing the problem, it is essential that the individual undergo appropriate assessments. This is because when the individual is unaware of their problematic substance use, the recovery process can be prolonged. While interventions by close friends and family members in the individual’s social environment often accelerate the treatment process, self-directed interventions are always welcomed and encouraged (Torrise, 2024).

Substance use disorders affect an individual’s life in multiple ways, so they usually require a multi-treatment approach. For many individuals, the simultaneous use of medication and individual or group therapy is considered the most effective method (Torrise, 2024). The ideal treatment approach for lasting recovery is one that addresses the individual’s specific circumstances and accompanying medical, psychiatric, and social issues. Medications used in the treatment of substance use disorders are used to control the individual’s cravings, alleviate withdrawal symptoms, and prevent relapses, while psychotherapy is used to help individuals better understand their behaviors and motivations, develop higher self-esteem, and cope with stress in a healthy way (Torrise, 2024). Individuals may require different treatment approaches at different times during the treatment process (APA, 2024).

In the context of substance use disorders, the various treatment approaches that will be tailored to the individual are as follows (NAMI, 2020):

Detoxification: Treatment for individuals with substance use disorders begins with detoxification, which is the biggest obstacle they must overcome. Inpatient treatment is generally considered to be much more effective than outpatient treatment for initial sobriety and safety. Individuals are monitored 24/7 by professionals, and the goal is to gradually reduce withdrawal symptoms.

Inpatient Rehabilitation: Individuals with substance addiction can benefit from inpatient rehabilitation centers, where they will receive 24/7 treatment services. Rehabilitation centers with a comprehensive approach offer individuals therapy, support, medication, and other health services.

Psychotherapy: Psychotherapy plays a crucial role in the treatment of substance use disorders. Individuals are taught how to cope with negative thought patterns that increase the risk of substance use, how to transform these into healthy thoughts, and much more through various approaches such as Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, and Family Therapy.

Medications: Medications that help alleviate withdrawal symptoms during the detoxification process are a major part of treatment.

Supportive Housing: Group homes or sober houses for newly sober individuals or those trying to avoid relapse are included in residential treatment centers.

Self-Help and Support Groups: Individuals can share their feelings, celebrate their successes, refer each other to professionals, and share tips for recovery through support groups. Furthermore, it provides a valuable space for forming healthy friendships that encourage sobriety.

If You or Someone You Know Is Struggling with Substance Use:

Help is always available!

  • For individuals in Chicago or across Illinois, you can contact the Illinois Helpline for Opioids and Other Substances at 1-833-234-63-43. This free and confidential service is available 24/7 and connects you with local treatment, recovery, and support resources. More information is available at https://helplineil.org/app/home. 
  • If you are located outside of Illinois, the Substance Abuse and Mental Health Services Administration (SAMHSA) offers national assistance. You can call 1-800- 662-HELP (4357) or visit https://www.samhsa.gov for support, treatment referrals, and information specific to your region. This is a free and confidential 24/7 service available in English and Spanish.

Takeaways:

  • Substance use disorder is defined as the recurrent consumption of psychoactive substances such as alcohol, marijuana, opioids, and stimulants.
  • Substance use disorders can cause individuals to have distorted thoughts, behaviors, abnormal movements, memory problems, and impaired decision-making processes.
  • The assessment process for substance use disorder consists of two important dimensions: screening and evaluation.
  • Substance use disorders are assessed through a variety of methods, including comprehensive biopsychosocial assessments, narrative approaches, and standardized tests.
  • For individuals with substance use disorders, the simultaneous application of medication and individual or group therapy is considered the most effective treatment method.

References

  1. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14, 245-258.
  2. Marlatt, G. A., & Baer, J. S. (1988). Addictive behaviors: Etiology and treatment. Annual Review of Psychology, 39, 223-252
  3. Primack, B. A., Bost, J. E., Land, S. R., & Fine, M. J. (2007). Volume of tobacco advertising in African American markets: Systematic review and meta-analysis. Public Health Reports, 122, 607-615.
  4. Levy S, Brogna M, Minegishi M, Subramaniam G, McCormack J, Kline M, et al. (1 May 2023). “Assessment of Screening Tools to Identify Substance Use Disorders Among Adolescents”. JAMA Network Open. 6 (5): e2314422. doi:10.1001/jamanetworkopen.2023.14422. ISSN 2574-3805. PMC 10203888. PMID 37213103. 
  5. Norcross, J. C., & Wampold, B. E. (2011). Evidence-Based Therapy Relationships: Research Conclusions and Clinical Practices. Psychotherapy, 48(1), 98–102. https://doi.org/10.1037/a0022161 
  6. White, M., & Epston, D. (1990). Narrative Means to Therapeutic Ends. New York: Norton. https://josefaruiztagle.cl/wp-content/uploads/2020/09/Michael-White-David-Epston-Narrative-Means-to-Therapeutic-Ends-W.-W.-Norton-Company-1990-1.pdf 
  7. Volkow ND, Koob GF, McLellan AT (January 2016). “Neurobiologic Advances from the Brain Disease Model of Addiction”. New England Journal of Medicine. 374 (4): 363–371. doi:10.1056/NEJMra1511480. PMC 6135257
  8. Brown, R. L., & Rounds, L. A. (1995). Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wisconsin medical journal, 94(3), 135-140. https://europepmc.org/article/med/7778330 
  9. Giordano, A. (2021, July 10). Addiction can occur regardless of a person’s character, virtue, or moral fiber. Psychology Today. https://www.psychologytoday.com/us/blog/understanding-addiction/202107/what-exactly-is-the-biopsychosocial-model-addiction 
  10. SAPAA (2012). Screening and Assessment. https://www.sapaa.com/mpage/wp_sa_screening 
  11. SAMHSA (2023). What is Substance Use Disorder? https://www.samhsa.gov/substance-use/what-is-sud 
  12. Torrise, B. (2024). What is a substance use disorder? https://www.psychiatry.org/patients-families/addiction-substance-use-disorders/what-is-a-substance-use-disorder 
  13. National Alliance on Mental Illness. (2024, April 30). Substance Use Disorders. National Alliance on Mental Illness (NAMI). https://www.nami.org/about-mental-illness/common-with-mental-illness/substance-use-disorders/ 
  14. Dhalla, S., & Kopec, J. A. (2007). The CAGE questionnaire for alcohol misuse: a review of reliability and validity studies. Clinical and Investigative Medicine, 30(1), 33-41.
  15. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Publishing.
  16. Substance Abuse and Mental Health Services Administration. (2020). TIP 42: Substance use disorder treatment for people with co-occurring disorders. U.S. Department of Health and Human Services. https://www.samhsa.gov/ 
  17. Brown RL, Leonard T, Saunders LA, Papasouliotis O. The prevalence and detection of substance use disorder among inpatients ages 18 to 49: an opportunity for prevention. Preventive Medicine. 1998;27:101-110. https://www.providerservices.iehp.org/content/dam/provider-services-rd/en/documents/providers/provider-resources/archive/amsc/2022/screening-tools/20220323%20-%20CAGE-AID-Questionnaire.pdf 
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