徐静蕾奶奶的星星:substance use disorders

Understanding the nature and dynamics of substanceuse disorders (SUDs) can help child protective services (CPS) caseworkers inscreening for SUDs, making informed decisions, and developing appropriate caseplans for families experiencing this problem.

The Continuum of Alcohol and Drug Use

Substance use, like many human behaviors, occursalong a broad continuum from no use to extremely heavy use. The likelihood ofan individual experiencing problems stemming from substance use typicallyincreases as the rate of use increases. The continuum for the use of substancesincludes substance use, substance abuse, and substance dependence or addiction.

Substance use is the consumption of low or infrequent doses ofalcohol or drugs, such that damaging consequences are rare or minor. Inreference to alcohol, this means drinking in a way that does not impairfunctioning or lead to negative consequences, such as violence. In reference toprescription drugs, use involves taking medications as prescribed by aphysician. Regarding over-the-counter medications, use is defined as taking thesubstance as recommended for alleviating symptoms. Some people who choose touse substances may use them periodically, never use them to an extreme, ornever experience life consequences because of their use.

Substance abuse is a pattern of substance use that leads tosignificant impairment or distress, reflected by one or more of the following:

• Failure to fulfill major role obligations at work, school, or home (e.g., substance-related absences from work, suspension from school, neglect of a child's need for regular meals)

• Continued use in spite of physical hazards (e.g., driving under the influence)

• Trouble with the law (e.g., arrests for substance related disorderly conduct)

• Interpersonal or social problems.⁹

Additionally, use of a medication in a mannerdifferent from how it is prescribed or recommended and use of an intravenousdrug that is not medically required are considered substance abuse.

Individuals may abuse one or more substances for acertain period of time and then modify their behaviors because of internal orexternal pressures. Abuse is characterized by periodic events of abusive use ofsubstances, which may be accompanied by life consequences directly related toits use. With proper intervention, an individual with substance abuse problemscan avert progression to addiction. At this level of progression, the abusersoften are not aware, or if they are, they may not be honest with themselvesthat the negative consequences they experience are linked to their substanceuse. With proper intervention, these individuals are able to choose to limit orto cease substance use because of the recognition of the connection between useand consequences. Other people, however, may continue abusing substances untilthey become addicted.

Substancedependence or addiction isthe progressive need for alcohol or drugs that results from the use of thatsubstance. This need creates both psychological and physical changes that makeit difficult for the users to control when they will use the substance or howmuch they will use. Psychological dependence occurs when a user needs thesubstance to feel normal or to engage in typical daily activities. Physicaldependence occurs when the body adapts to the substance and needs increasingamounts to ward off the effects of withdrawal and to maintain physiologicalfunctioning. Dependence can result in:

• The continued use of a substance despite negative consequences. The individual continues drug or alcohol use despite incidents, such as accidents, arrests, or a lack of money to pay for food because it was spent on drugs.

• An increase in tolerance to the substance. The individual requires more of the alcohol or drug to obtain the same effect.

• Withdrawal symptoms. The individual needs to consume the substance in order not to experience unpleasant withdrawal effects, such as uncontrollable shaking and tremors or intense nausea.

• Behavioral changes. The individual who is dependent:

• Uses more than intended

• Spends a majority of the time either obtaining, using, or withdrawing from the use of the substance

• Cannot stop using until the substance is gone or the individual passes out.

Criteria for diagnosing substance dependence andsubstance abuse as an SUD have been defined in theDiagnostic andStatistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), the American PsychiatricAssociation's classification index for mental disorders. (See Appendix D, Diagnostic andStatistical Manual of Mental Disorders Criteria, for moreinformation on this topic.)

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Appropriate and Inappropriate Uses of Substances

Certain substances, when used appropriately, havehelpful and even lifesaving uses. Many individuals use various drugs to helpovercome physical and psychological problems. Drugs can alleviate cold and flusymptoms, make it easier to sleep, reduce physical or emotional pain, and helpovercome feelings of anxiety, panic, or depression. Some of these drugs requirea prescription from a doctor to be obtained legally, while others areconsidered safe enough to be sold over the counter to the public. Althoughthese drugs have many health benefits, many also can be used in a higherquantity or in combination with other substances to produce either a"high" or a numbing effect. Combining these drugs with alcohol orother drugs can intensify their effects and increase risks to the user and tothose around the user. Individuals who abuse prescription medication sometimesresort to forging prescriptions, to visiting several doctors who will prescribethe same drug without asking questions ("doctor shopping"), or tobuying stolen drugs. Exhibit 2-1 provides key statistics for commonly abusedsubstances.

Other substances may not have medicinal qualitiesbut can affect users psychologically and physically or lower inhibitions andimpair judgment if misused. For instance, some individuals drink alcohol atsocial gatherings to feel more comfortable talking and relating to others.Being of legal age and drinking alcohol is a commonly accepted practice in theUnited States. Of course, alcohol often can be misused and can negativelyaffect events ranging from traffic safety to the ability to care adequately forchildren.

With respect to child protection, substance usebecomes problematic when it contributes to the harm of children. This can bedifficult for CPS caseworkers to identify because the distinction between"normal" alcohol use and problematic use may be blurred and subjectto interpretation. (See Chapter 4, In-homeExamination, Screening, and Assessment of Substance Use Disorders,for more information about identifying SUDs.)

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Characteristics of Addiction

Knowing the characteristics of addiction can helpinform effective intervention and practice with individuals suffering fromSUDs. Characteristics include:

• Progressive Nature. A central feature of addiction is a progressive use of a substance, whether alcohol, prescription medications, or illegal drugs. The physical, emotional, and social problems that arise from addiction typically continue to worsen unless the SUDs are treated successfully. If left untreated, addiction can cause premature death through overdose; through organic complications involving the brain, liver, heart, and many other organs; and by contributing to motor vehicle crashes, homicide, suicide, and other traumatic events.

• Denial and Concealment. Addiction can be difficult to identify, even for individuals experiencing it. People who are addicted to a substance often engage in elaborate strategies to conceal the amount being consumed and the degree to which the substance is affecting their lives. Another dimension of addiction is that individuals who suffer from it often do not perceive that their pattern of drinking or drug use creates or contributes to their problems. Additionally, the use of substances may affect their memory or perception of events or of what they have said or done. This lack of recognition commonly is identified as denial.

• Chronic Disease. The National Institute on Drug Abuse has defined addiction as a chronic disease, like heart disease, hypertension, and diabetes. Studies have shown alcohol and drug abuse treatment is about as effective as treatments required for these other chronic diseases. Lifetime management of chronic diseases in all cases requires individuals to change their habits and activities and to take precautions that prevent them from relapsing or worsening their condition.

• Lapses and Relapses. Lapses and relapses are common features of addiction. A lapse is a period of substance use after the individual has been clean and sober for some length of time. A relapse is not only using the substance again, but also returning to the problem behaviors associated with it.¹²

Addiction is difficult to deal with; manyindividuals lapse or relapse one or more times before being able to remainabstinent. If lapses or relapses occur, they do not necessarily mean thattreatment has failed. They can point the way toward needed improvements in howthose individuals are approaching recovery. Most individuals who have lapsed orrelapsed can identify, prior to the lapse or relapse, certain situations,thoughts, or behaviors that contributed to the use of the substance.

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Why Some People Become Addicted

Many theories and explanations have been proposedto describe the reasons why some individuals become addicted to substances andothers do not. Research on the causes of addiction is not conclusive, andmultiple factors may contribute to it. Early explanations for addictionincluded moral weakness, insanity, demonic possession, and character pathology.¹³ Theseexplanations, combined with the problematic behaviors that sometimes accompanyaddiction, have created a serious stigma. Recent research, however, indicatesthat substance addiction is a brain disease that changes its structure andfunctioning, which in turn affects an individual's behaviors. Although theinitial use of a substance may be voluntary, a person's ability to controlfuture use may be seriously impaired by changes in the brain caused by prioruse.¹⁴

Some research, including adoption and twinsstudies, has demonstrated a biological and genetic predisposition to addiction,with scientists estimating that genetic factors account for 40–60 percent of anindividual's risk of addiction.¹⁵ Thesestudies suggest that an individual's genes play a role in vulnerability toaddiction. For example, one study found that children whose parents areaddicted to drugs or alcohol are three times more likely to develop an SUDlater in life than children whose parents are not addicted.¹⁶ Otherresearch emphasizes a social factor to explain that addictions appear to"run in the family." These studies suggest that children who grow upin families with SUDs may model their adult behavior on what they have seen andknown in their familial experience.¹⁷ Riskfor addiction can also be affected by gender, ethnicity, developmental stage,and social environment.¹⁸ Inother words, both nature and nurture contribute to a person's vulnerability orresistance to substance abuse.

Many self-help groups, such as 12-step programs,consider addiction a progressive illness that is physical, spiritual, andemotional in nature. They believe that individuals who are addicted must admitthat they are powerless over the substance; that is, they are unable to resolvethe problem on their own and must seek help outside themselves.¹⁹

Addiction

People who are addicted to drugs are from all walks of life. Many suffer from poor mental or physical health, occupational, or social problems, which make their addictive disorders much more difficult to treat. Even if there are few associated problems, the severity of addiction itself ranges widely among people.

Isn't drug addiction a voluntary behavior? A person may start taking drugs voluntarily, but as times passes and drug use continues, something happens that makes a person go from being a voluntary drug user to a compulsive drug user. This happens because the continued use of addictive drugs changes the brain. These changes can be dramatic or subtle, but often, without treatment, they result in compulsive or even uncontrollable drug use.

How is addiction similar to a disease? Drug addiction is a brain disease. Every type of drug abuse has its own mechanism for changing how the brain functions. Regardless of which drug a person is addicted to, many of the effects on the brain are similar. These may include modifications in the molecules and cells that make up the brain, changes in memory processes and thinking, transformation of moods, and sometimes changes in motor skills, such as walking and talking. These changes can have a significant influence on all aspects of a person's behavior and can cause the individual to do almost anything to obtain the drug.

Why can't drug addicts quit on their own? In the beginning, almost all addicted individuals believe that they can stop using drugs on their own, and most try to stop without treatment. However, most of these attempts fail to achieve long-term abstinence. Research has shown that long-term drug use results in significant changes in brain function that persist long after the individual has stopped using drugs. These drug-induced changes in brain function can have many behavioral consequences, including the compulsion to use drugs despite adverse consequences—one of the defining characteristics of addiction.

Understanding that addiction has such an important biological component may help explain the difficulty in achieving and maintaining abstinence without treatment. Psychological stress from work or family problems, social cues (e.g., meeting individuals from one's drug-using past), or the environment (e.g., encountering streets, objects, or even smells associated with drug use) can interact with biological factors to hinder sustained abstinence and to make relapse more likely. Research studies indicate, however, that even the most severely addicted individuals can participate actively in treatment and that active participation is essential to good outcomes.²⁰

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Negative Consequences of Substance Use Disorders

Negative consequences from alcohol and drug use,abuse, and dependence generally fall into three categories: loss of behavioralcontrol, psychophysical withdrawal, and role maladaptation.

Loss ofbehavioral control happenswhen individuals do things they normally would not do because their inhibitionsand reasoning abilities are impaired. Loss of behavioral control can includepassing out, having a blackout (i.e., short-term memory loss), behavingviolently, leaving children unsupervised or in a potentially unsafe situation,and neglecting children's basic needs.

Psychophysicalwithdrawal occurswhen individuals experience physical symptoms that result from withdrawing fromusing a substance. Indicators of psychophysical withdrawal include becomingnauseated or vomiting; feeling feverish, hot, sweaty, agitated, or nervous; andexperiencing significant changes in eating or sleeping patterns. In advancedcases, withdrawal may include experiencing, seeing, or hearing things that arenot there, such as having the sensation of bugs crawling on the skin or havingseizures or convulsions. Physical withdrawal, particularly from alcohol andheroin, can be life threatening.

Rolemaladaptation occurswhen individuals cannot conform to what are generally considered their expectedroles (e.g., parent, breadwinner). For parents, this can mean difficulties incaring properly for their children (e.g., prioritizing a need for drugs over achild's needs for food and clothing). Other examples of role maladaptation dueto SUDs include relationship problems, failure to keep a job, difficultiespaying the bills, and criminal activity.

Problems in one area will not necessarily indicateor predict problems in other areas. Someone who experiences regular hangoversfrom drinking (defined as anxiety, agitation, nausea, and headaches) canexperience these symptoms without experiencing a significant loss of behavioralcontrol or role maladaptation. Others struggling with addiction, however, maysuffer from all three consequences.

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Co-Occuring Issues

CPS caseworkers must place SUDs into context withthe other problems that families may face. In general, these families have morenumerous and complex issues to address than those who are not abusing oraddicted to alcohol and drugs. Similarly, child abuse and neglect seldom occurin a vacuum; these families often are experiencing several layers of problems.For both SUDs and child maltreatment, common co-occurring issues include mentaland physical illnesses, domestic violence and other trauma, economicdifficulties or poverty, housing instability, or dangerous neighborhoods andcrime.²¹ Allof these challenges can constitute barriers to successful participation in SUDtreatment and, when addressed, can improve an individual's chances of attaininglong-term abstinence. The following sections describe some of the most commonco-occurring issues experienced by families affected by child maltreatment andSUDs. The goal is to increase caseworker awareness of the variety of symptomsand factors, particularly those most likely to affect assessment and decisionsregarding services for families and children involved in CPS cases.

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Mental Illness

SUDS have a strong association with mentalillness. In 2007, an estimated 24.3 million adults aged 18 or older had aserious mental illness.²² (Havinga serious mental illness is defined as having a diagnosable mental, behavioral,or emotional disorder during the past year that met the DSM-IV criteria.)Adults with a serious mental illness are much more likely to have used illicitdrugs within the past year than those adults without a serious mental illness(28.0 percent versus 12.2 percent).²³

It is not clear why there is a high correlationbetween SUDs and mental illness. Three ways in which they may relate to oneanother are:

• The disorders may occur independently of each other.

• The mental health disorder may place an individual at greater risk for SUDs.

• Alcohol or drug intoxication or withdrawal may result in temporary mental health disorders, such as paranoia or depression.²⁴

It is common for either the SUD or the mentalhealth issue to go undiagnosed. In addition, not all mental health problemsaffecting a parent necessarily will appear severe or profound. As a result,when one issue is identified, it is important to screen for the other. Whenboth are identified, current accepted practice is to treat both disorderssimultaneously, especially with individuals who have serious mental illnesses.

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Physical Health Problems

SUDs can cause or worsen physical health problems.For example:

• Alcohol abuse can cause numerous physical problems related to the function of the liver, heart, digestive system, and nervous system.

• Marijuana use is associated with ailments ranging from a burning or stinging sensation in the mouth or throat, to respiratory problems, to an increased likelihood of cancer in the throat and lungs.

• Individuals who inject drugs, such as heroin or methamphetamine, put themselves at risk of contracting infectious diseases, such as HIV/ AIDS and hepatitis C, through the sharing of syringes and other injection paraphernalia.

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Domestic Violence and Other Forms of Trauma

Trauma can take the form of a physical injury or apainful or disturbing experience that can have lasting effects. It can resultfrom exposure to a variety of events ranging from natural disasters to violentcrimes. The consequences of trauma can be significant, affecting the victim onbiological, psychological, social, and spiritual levels.

Individuals who have experienced a traumatic eventsometimes turn to drugs or alcohol in an effort to deal with the resultingemotional pain, anxiety, fear, or guilt. If the pattern becomes wellestablished, it may indicate that the person has an SUD. SUDs, particularly ifthey are active over a period of time, increase the likelihood of furtherexposure to accidental and intentional acts that may result in additionaltrauma. In addition, individuals who have not experienced a traumatic event,but have an SUD, have an increased likelihood of exposure to events that maythen result in trauma, such as being assaulted.

Studies have shown that a high percentage of womentreated for SUDs also have significant histories of trauma.²⁵ Womenwho abuse substances are more likely to experience accidents and acts of violence,including assaults, automobile accidents, intimate partner violence, sexualabuse and assault, homicide, and suicide.²⁶

Alcohol commonly is cited as a causal factor andprecursor to adult domestic violence. Research studies indicate thatapproximately 25 to 50 percent of domestic violence incidents involve alcoholand that nearly one-half of all abusers entering batterer intervention programsabuse alcohol.²⁷ Despitethe evidence that many batterers and victims abuse alcohol, there is noempirical evidence that substance use disorder directly causes domestic violence.However, SUDs increase the severity and frequency of the batterers' violenceand interfere with domestic violence interventions.²⁸ Theyalso contribute to the increased severity of injuries among victims.²⁹

Post-traumatic Stress Disorder

Women who abuse substances sometimes cite continued substance use as a perceived aid in controlling symptoms of post-traumatic stress disorder (PTSD).³⁰ PTSD is a psychiatric disorder that can occur following the experience or the witnessing of life-affecting events, such as military combat, violent or sexual assaults, or natural disasters. People who suffer from PTSD often relive the experience through nightmares and flashbacks, have difficulty sleeping, and feel detached or estranged. PTSD also is associated with impairment of the ability to function in social or family life, including employment instability, marital problems and divorce, family discord, and difficulties in parenting. Research has indicated that women with PTSD are twice as likely to abuse or to be dependent on alcohol and are four times as likely to abuse or to be dependent on drugs.³¹ When compared to other traumas, sexual abuse and physical abuse have been found to be associated with the highest rates of PTSD.³²

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Poverty

SUDs cross all socioeconomic lines, but studiesshow that there is a relationship between poverty and substance abuse.³³ Peopleliving in poverty sometimes turn to substances for relief from the anxiety andthe stress associated with economic insecurity. Of course, spending money onalcohol or drugs often only contributes to economic problems. Dealing illegaldrugs is viewed by some as a source of income and a means of escaping poverty.Unfortunately, some individuals suffering from economic hardship feel that theyhave little to lose if they get involved in drugs, no matter what the effectsare on themselves or their families.

Parents who are distracted by their financialproblems may have less energy and attention for parenting. In some homes, thepsychological distress of poverty may be directed toward the children. Researchhas indicated a strong association between child maltreatment, particularlyneglect, and poverty.³⁴ CPScase plans invariably need to address issues related to poverty and establishservice plans for families.

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Homelessness

In some cases, extreme poverty and other factorsmay lead to homelessness. Homeless people typically experience severaloverlapping challenges, including SUDs, mental illnesses, and a variety ofphysical health problems. Parents with children account for approximately 11percent of the homeless population, and this number appears to be growing.³⁵

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Crime

Crime has a strong association with drug use. Inthe most recent study of its kind, more than three out of every four State,Federal, or local jail inmates previously were involved seriously with drugs oralcohol in some way (e.g., convicted of a drug- or alcohol-related crime, usedillicit substances regularly, were under the influence of alcohol or drugs whenthey committed crime).³⁶ Anotherstudy found that adults who were arrested for a serious offense were much morelikely to have used an illicit drug in the prior year (60.1 percent) than thosewho were not arrested (13.6 percent).³⁷ Inaddition, many individuals in prisons and jails experience multiple,overlapping problems. For instance, research indicates that among inmates witha serious mental disorder, 72 percent have a co-ccurring SUD.³⁸ Itoften is challenging for these individuals to obtain appropriate serviceseither in prison or upon their release.

Because women are generally the primary caretakersof their children, the increase in the number of incarcerated women over thepast decade is particularly relevant to CPS caseworkers. The Bureau of JusticeStatistics reports that the female prison population increased from 44,000 in1990 to more than 111,000 in 2006.³⁹ One-thirdof incarcerated women have been convicted of drug offenses, and approximately65 percent of women in prison report having used drugs regularly.⁴⁰ Additionally,75 percent of incarcerated women are mothers, and two-thirds have minorchildren, who often are placed outside the home while their mothers areincarcerated.⁴¹

In response to problems arising from low-level,nonviolent drug offenses, many States and localities have establishedalternative, less putative programs, such as drug courts, to rehabilitateoffenders. (For more information on drug courts, see Chapter 8, Putting ItTogether: Making the Systems Work for Families.)