Addiction Treatment: Theory and Practice

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Sandra Rasmussen

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    Dedication

    In memory of Slim H.

    Preface

    This book is a comprehensive text that provides a foundation for addiction practice by health and human service professionals. It is broad in scope and inclusive in content. It builds upon generic concepts and skills of caring and helping. The text is divided into five parts comprising 20 chapters. Each chapter begins with a list of objectives and a chapter outline and ends with a summary, a checklist of skills related to the chapter topic, some suggested areas for further study, and references. Each also includes a challenge to practitioners to affirm and advance addiction treatment in this new century, a concept I call addiction practice 2000. Throughout, the text emphasizes the knowledge considered essential for general addiction practice. An appendix containing examples of treatment tools and other resources for clients and clinicians completes the book.

    Part I: Addiction

    Addiction jeopardizes the health and well-being of individuals, families, and communities. Chapter 1 defines addiction, depicts the many faces of addiction, asserts that treatment works, and describes effective prevention programs. Addiction practice terms and concepts are also defined. Chapter 2 examines the origins, characteristics, adequacy, and relevance of conventional, contemporary, and comprehensive theories and models of addiction. Addiction practitioners use theories and models of addiction to ground and guide their practice. Chapter 3 reviews substances of abuse, including central nervous system depressants, central nervous system stimulants, opioids, and hallucinogens. It describes use and abuse of marijuana, inhalants, anabolic steroids, designer drugs, and herbs. Because addiction includes both chemical and nonchemical addictive disorders, Chapter 4 discusses pathological gambling, compulsive shopping, sex and love addiction, eating disorders, and other addictive behaviors. Chapter 5 describes the multidisciplinary group of health professionals, paraprofessionals, volunteers, and recovering people who work in addiction treatment.

    Part II: Addiction Treatment

    Treatment works! Chapter 6 compares and contrasts different treatment methodologies, describing the client and clinician roles associated with each treatment approach. Chapter 7 discusses short-term, intermediate, and long-term client goals. Treatment goals reflect desired client change. Chapter 8 addresses the concepts of addiction severity and treatment intensity. It describes the Addiction Severity Index (ASI) and the American Society of Addiction Medicine Patient Placement Criteria for the Treatment of Substance-Related Disorders 2 (ASAM PPC-2). Clinicians use addiction severity to determine treatment intensity. They place clients in appropriate levels of care and specify the number, type, and frequency of interventions and services.

    Part III: Treatment Process

    Addiction treatment is a collaborative process between clinicians and client, a process of assessment, diagnosis, treatment planning, intervention, and evaluation. Chapter 9 explains assessment—how clinicians and client collect and organize data about the substance abuse or addictive behavior, the client, and the environment. Chapter 10 describes diagnosis—how clinicians and client validate, cluster, and interpret assessment data to denote or name the client's problem. This chapter includes DSM-IV diagnoses for substance-related disorders and other addictive disorders. Chapter 11 discusses treatment planning—the way clinicians and client establish and prioritize treatment goals, specify objectives or expected outcomes, select interventions, and designate services. Treatment plans reflect level of care and intervention dose. Chapter 12 reviews intervention—the actions clinicians and client use to reach outcomes, achieve treatment goals, meet client needs and ultimately resolve client problems. Intervention with individual clients includes medical management, nursing, counseling, medication, spiritual care, social services, and psychological services. Many interventions utilize groups, the family, and the community. Chapter 13 examines evaluation—the way clinicians, client, and providers evaluate client treatment and the treatment program. Total Quality Management (TQM) is the continuous monitoring and evaluation of the treatment program to improve both process and outcome.

    Part IV: Client Diversity and Treatment Matching

    Clients differ in age, ethnocultural characteristics, gender, and sexual orientation. Effective treatment respects and reflects client diversity. Chapter 14 highlights addiction across the lifespan from perinatal addiction to prescription drug abuse by older adults. Treatment needs of addicted infants, adolescents, and older adults are examined. Chapter 15 discusses multiculturalism and addiction. It challenges clinicians to develop treatment initiatives for clients with diverse ethnocultural characteristics. In Chapter 16 clinicians confront the many dilemmas posed by women and addiction, especially the great disparity between treatment needs and access to effective services. Chapter 17 urges clinicians to develop sensitive treatment for gay, lesbian, bisexual, and transgender clients and to accept the challenge for prevention and early intervention with gay and lesbian youth.

    Part V: Treatment Collaboration for Coexisting Medical, Psychological, and Social Problems

    Medical, psychological, and social problems that coexist with addictive disorders increase addiction severity and confound treatment. Chapter 18 reviews alcohol-related medical problems, adverse medical effects of drug abuse, HIV/AIDS, pain, and physical disabilities. Chapter 19 notes the prevalence of dual disorders. Clients with dual disorders experience more severe and chronic medical and social problems. They relapse with alcohol and other drugs more frequently, decompensate psychiatrically more often, have more crises, and progress more slowly in treatment. Barriers to treatment are legion! Chapter 20 shows how social problems such as unemployment, poverty or excess, home-lessness, unsafe neighborhoods, and legal problems contribute to the development of addictive disorders, influence treatment planning, and impact recovery. The book concludes with a challenge to addiction practitioners to affirm and advance addiction practice 2000.

    Acknowledgments

    In Memoirs of Childhood and Youth, Albert Schweitzer avows: “Sometimes our light goes out but is blown again into flame by an encounter with another human being. Each of us owes the deepest thanks to those who have rekindled this inner light.” Addiction Treatment reflects the expectations and encouragement of colleagues and clients, students and sponsors, friends and family, the fellowship, and Sage Publications.

    Colleagues include nurses, counselors, social workers, physicians, psychologists, educators, and administrators from The NORCAP Center of Southwood Community Hospital, Brown University Center for Alcohol and Addiction Studies, and AdCare Hospital and Recovery Services. Clients like “steady Eddie,” Serine M. and her family, Michelle R., and Tom F. showed me that recovery is a journey, not a destination. Hundreds of students challenged me, especially those concentrating in addiction studies or conducting research with special addiction populations. The lives, and in some cases deaths, of Ella, Charlotte, Ann, Eileen, and Judy taught me the meaning of survival, beauty, genuineness, courage, and fidelity.

    Thanks to my special friends Barbara and Francis who were always there. Appreciation to my family who reminded me, that even though I am a busy nurse, counselor, and teacher, I am first and foremost a caring mother and loving grandmother. And finally, abiding gratitude to the fellowship of recovering men and women who willingly shared “their experience, strength, and hope.”

    Special thanks to Francis D. Doucette, Ph.D., J.D., who edited the draft manuscript with rigor and red pen. Sincere appreciation to the staff of the Office of Publishing Services of Rhode Island College and the many editors and assistants from Sage who expedited publication.

  • Appendix: Exhibits

    Exhibit A: Treatment Costs for Mental Health and Substance Abuse Problems

    The majority of treatment costs for mental health and substance abuse problems are paid for by federal, state, and local governments. According to a study by the Substance Abuse and Mental Health Services Administration (SAMHSA), more than $79 billion was spent on treatment for mental health and substance abuse problems in 1996. Of this total, $66.7 billion was spent on the treatment of mental illness, $5 billion on the treatment of alcohol abuse, and $7.6 billion on the treatment of other drug abuse. Government funding (including Medicare, Medicaid, and other federal, state, and local government programs) paid for the majority of all three types of treatment. Treatment for other drug abuse had the highest proportion of government funding (66%), and treatment for mental illness had the lowest (53%).

    In 1996, treatment costs for mental illness, alcohol, and other drug abuse, by payer, were as follows:

    • Mental illness ($66.7 billion) Private, 47% Government, 53%
    • Alcohol abuse (includes patients with primary alcohol problems) ($5.0 billion) Private, 43% Government, 58%
    • Other drug abuse (includes patients with primary drug disorders and patients with combined drug and alcohol disorders) ($7.6 billion) Private, 34% Government, 66%

    Government in the above list includes Medicaid, Medicare, and other local, state, and federal government sources. Private includes private insurance, out-of-pocket expenses, and other private sources.

    SOURCE: Based on CSAT by Fax, December 16, 1998. Adapted by the Center for Substance Abuse Research from Tami Mark et al., National Expenditures for Mental Health, Alcohol and Other Drug Abuse Treatment, 1996, September 1998. Prepared by the MEDSTAT Group for the Substance Abuse and Mental Health Services Administration. Copies of the report are available on-line at http://www.health.org/mhaod/spending/htm.
    Exhibit B: Definition of Alcoholism

    The Joint Committee to Study the Definition and Criteria Diagnosis of Alcoholism of the National Council on Alcoholism and Drug Dependence (NCADD) and the American Society of Addiction Medicine (ASAM) have developed a definition of alcoholism. The following statement was prepared by the NCADD.

    Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by continuous or periodic: impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial.

    • Primary refers to the nature of alcoholism as a disease entity in addition to and separate from other pathophysiologic states which may be associated with it. Primary suggests that alcoholism, as an addiction, is not a symptom of an underlying disease state.
    • Disease means an involuntary disability. It represents the sum of the abnormal phenomena displayed by a group of individuals. These phenomena are associated with a specified common set of characteristics by which these individuals differ from the norm, and which places them at a disadvantage.
    • Often progressive and fatal means that the disease persists over time and that physical, emotional, and social changes are often cumulative and may progress as drinking continues. Alcoholism causes premature death through overdose, organic complications involving the brain, liver, heart, and many other organs, and by contributing to suicide, homicide, motor vehicle crashes, and other traumatic events.
    • Impaired control means the inability to limit alcohol use or to consistently limit on any drinking occasion the duration of the episode, the quantity consumed, and/or the behavioral consequences of drinking.
    • Preoccupation in association with alcohol use indicates excessive, focused attention given to the drug alcohol, its effects, and/or its use. The relative value thus assigned to alcohol by the individual often leads to a diversion of energies away from important life concerns.
    • Adverse consequences are alcohol-related problems or impairments in such areas as: physical health (e.g. alcohol withdrawal syndromes, liver disease, gastritis, anemia, neurological disorders); psychological functioning (e.g. impairments in cognition, changes in mood and behavior); interpersonal functioning (e.g. marital problems and child abuse, impaired social relationships); occupational functioning (e.g. scholastic or job problems); legal, financial, or spiritual problems.
    • Denial is used here not only in the psychoanalytic sense of a single psychological defense mechanism disavowing the significance of events, but more broadly to include a range of psychological maneuvers designed to reduce awareness of the fact that alcohol use is the cause of an individual's problems rather than a solution to those problems. Denial becomes an integral part of the disease and a major obstacle to recovery.

    For more information about alcoholism as a disease, call the Council's 24-Hour Information & Referral Helpline. We have general pamphlets on alcoholism and articles which discuss the advances science is making in identifying the biological and environmental elements which seem to play a role in the development of alcoholism. Call 1-800-622-2255 or 1-800-475-4673.

    Exhibit C: Do You Have a Gambling Problem?

    Gamblers Anonymous offers the following 20 questions to individuals who are questioning whether they might have a gambling problem. According to G.A., “Most compulsive gamblers will answer yes to at least seven of these questions.”

    • Did you ever lose time from work or school due to gambling?
    • Has gambling ever made your home life unhappy?
    • Did gambling affect your reputation?
    • Have you ever felt remorse after gambling?
    • Did you ever gamble to get money with which to pay debts or otherwise solve financial difficulties?
    • Did gambling cause a decrease in your ambition or efficiency?
    • After losing did you feel you must return as soon as possible and win back your losses?
    • After a win did you have a strong urge to return and win more?
    • Did you often gamble until your last dollar was gone?
    • Did you ever borrow to finance your gambling?
    • Have you ever sold anything to finance gambling?
    • Were you reluctant to use “gambling money” for normal expenditures?
    • Did gambling make you careless of the welfare of yourself or your family?
    • Did you ever gamble longer than you had planned?
    • Have you ever gambled to escape worry or trouble?
    • Have you ever committed, or considered committing, an illegal act to finance gambling?
    • Did gambling cause you to have difficulty in sleeping?
    • Do arguments, disappointments, or frustrations create within you an urge to gamble?
    • Did you ever have an urge to celebrate any good fortune by a few hours of gambling?
    • Have you ever considered self-destruction as a result of your gambling?
    Exhibit D: Substance Abuse by Nurses

    Nurses who abuse alcohol and other drugs jeopardize public safety, stigmatize the nursing profession, and diminish their own personal health and well-being. Loss of control in the work setting, overwhelming personal demands, and access to addictive substances increase the risk of substance abuse by nurses. A public health agent-host-environment model can help us to address this serious problem.

    Environment. Increasingly, job security for nurses is fraught with uncertainty. Layoffs inevitably follow mergers, and some nurses find themselves competing with colleagues and applying for the same positions they have held for years. Because reimbursement determines services and patient census dictates staffing, many nurses hold several part-time or per diem positions, usually without benefits. Job satisfaction from direct patient care has disappeared for many nurses, who instead find themselves lost in paperwork. Despite higher patient acuity, an increasing number of unlicensed personnel care for patients.

    Work stress increases the risk of substance abuse by nurses; thus reducing that work stress decreases the likelihood that nurses will abuse drugs. Organized nursing must work tirelessly to promote working conditions that assure greater job security and increase job satisfaction.

    Host. Nurses exemplify the Type “E” personality: “everything for everybody.” Personal responsibilities for most working nurses are legion. Nurses work fulltime or more. They are parents, sometimes single parents. Or they may juggle the challenges of a two-career family. Often they assume responsibility for aging parents. In their spare time, nurses continue their own educations and advance their careers.

    Nurses may self-medicate with alcohol or other drugs to manage personal stress. When nurses relinquish their “super-person” syndrome and develop a “self-care” lifestyle, they can manage personal stress more effectively and without chemicals.

    Agent. Access to drugs, be it free beer at a fraternity party or medications in a patient's kitchen cupboard, invites use. Nurses are among the very few health professionals who administer medications to patients. In the “old days” of stock drugs, it was fairly easy for nurses to self-diagnose and self-medicate. Today, nurses find ways to hide their drug use with the unit dose system until chart audits, patient and family complaints, or impaired nursing practice prompt an investigation. We can truly recognize the “insanity of addiction” when nurses divert drugs, knowing it is only a matter of time before a computerized medication system identifies a pattern of “excessive administration of controlled substances” by particular nurses.

    Because nurses will continue to administer medications, access to drugs remains a risk factor. All nurses need to understand substance abuse and that substance abuse by nurses is a very serious personal, professional, and public safety problem. Schools of nursing curricula, as well as continuing education hours for all nurses who renew their licenses, must include substance abuse education for nurses.

    When nurses abuse alcohol or other drugs, early intervention, intensive treatment, and extensive rehabilitation are required to protect the public and help the impaired nurses. The Massachusetts Board of Registration in Nursing recognizes the seriousness of this problem. To protect public safety and help impaired nurses, the board offers the Substance Abuse Rehabilitation Program for nurses who meet admission criteria.

    SOURCE: Adapted from Sandra Rasmussen, “Substance Abuse by Nurses,” to appear in Nursing Board News (Massachusetts Board of Registration in Nursing).
    Exhibit E: Code of Ethics of the American Academy of Health Care Providers in the Addictive Disorders

    Since Hippocrates wrote his oath more than 2000 years ago, health care providers have sought to establish standards for ethical and competent medical and psychological treatment. The American Academy itself was created to establish such a standard in the field of addiction treatment, which it succeeded doing with the creation of the Certified Addiction Specialist (C.A.S.) credential. The C.A.S. credential reflects the highest and most comprehensive standard in the field today, a standard that is based both on the acquisition and demonstration of a body of knowledge in the area of addiction treatment and on the adherence to the strict ethical standards set forth below.

    The Academy's membership is comprised of clinicians from a variety of disciplines and treatment modalities who include nurses, doctors, psychologists, psychiatrists, social workers, forensic counselors and counselors, unified in their commitment to providing the highest quality of health care to individuals suffering from addiction. Our diverse membership is also unified in their recognition of the ethical standards and considerations that are specific to this field.

    This code is meant to provide only a very general outline of the principles for those health care providers specifically treating the addictions and is in no way exhaustive of the ethical responsibilities of our membership. Since our members come from a variety of disciplines and may carry multiple credentials, the principles set forth here should not be viewed as in any way supervening or abrogating other ethical codes that our members might be bound to. On the contrary, the Academy's code is meant to supplement or complement other standards, both legal and ethical, while setting forth a code of conduct that addresses the issues that are unique to working with individuals with addictions. This code is also meant to serve notice to the public as to the standards of health care and treatment that they can expect from Academy members.

    Academy members are bound by the Academy's ethical code and will be held to the letter and spirit of this code. The membership of those violating this code will be subject to inquiry and review, and the credential could be suspended or revoked.

    It is important to note that addiction treatment has historically been an area in which professional standards have been inconsistent; this code is meant to set forth a crucial, consistent, ethical standard.

    Principles of Conduct
    I. Competence

    Academy members recognize both the strengths and limitations of their ability to treat addictions. They continually seek to stay abreast of innovations in the understanding and treatment of addiction. They also only treat addictions that they are knowledgeable about and capable of treating. As a corollary to this, they only offer treatment services which are within their realm of competence (competence which is determined on the basis of their education, clinical supervision, and experience).

    II. Maintenance of Competence

    Because of the continual changes in the field of addiction treatment, Academy members strive to maintain the awareness of research findings and changes in treatment techniques and approaches that is necessary to maintain their competence in the field.

    III. Nondiscrimination

    In their work in the addictions, members of the Academy do not discriminate against their clients or co-workers on the basis of race, gender, religion, sexual orientation, age, disability, ethnicity, socioeconomic status, or national origin. They also do not unfairly discriminate on the basis of addiction or the medical complications of the addiction. While alcoholism and drug addiction are recognized by the federal government to be disabilities and individuals suffering from such addictions are protected from discrimination under the Federal Rehabilitation Act, Academy members do not restrict their nondiscrimination practices to these individuals but extend them to all people suffering from addiction, recognizing that all such addictions are debilitating.

    • Academy members are knowledgeable about the unique or special issues that face the individuals that they are treating both on the basis of their individual situations and on the basis of the addiction from which they suffer.
    • Academy members are able to recognize instances in which individual differences between themselves and their client affect their ability to provide the highest quality health care. In such cases, Academy members either take the necessary steps to be come competent in these areas or they make referrals to agencies or individuals who can best address their client's needs.
    • Academy members recognize those personal issues and conflicts that might affect their ability to provide their clients with the best possible health care. In such instances, they will refer the patient to someone better able to deal with him/her or will refrain from treating the patient until the Academy member has adequately resolved these issues.
    • Academy members recognize that there are individuals who suffer from multiple addictions. In such cases, Academy members will only treat the addictions that they are competent to treat. With regard to the other addictions, they will either take the steps necessary to become competent in these areas or will make referrals to agencies or individuals who can best address them.
    • Academy members recognize that many clients suffering from addiction, suffer from other mental disorders as well. Academy members treat only the problems that they are competent to treat. In complicated cases, cases in which several disorders must be treated simultaneously, Academy members will seek the requisite support and consultation and, if this is not available, will refer the client to the appropriate agency or clinician.
    • Academy members recognize that many clients seeking treatment for addiction may also suffer from medical complications and/or viral infections e.g., HIV, TB or hepatitis that eventuate from their addiction. If they are not competent to work with such clients, they will either take the necessary steps to become competent, or will consult with others and make referrals to the agencies or individuals who can best address the client's needs.
    IV. Harassment

    Academy members do not engage in any type of harassment, sexual or otherwise, in the work place.

    • The Academy considers sexual harassment to be any activity that demands or creates a hostile environment for an individual through sexual behavior or language. This includes unwelcome or unwanted advances of a sexual nature, verbal and non-verbal behavior of a sexual nature that would be deemed inappropriate by a reasonable person, and soliciting sex within the context of one's professional responsibilities.
    • Academy members do not engage in any other forms of harassment in the work place. This includes activities that involve the exploitation, denigration of others or that, otherwise, create a hostile work environment for others.
    V. Conflicts of Interest

    Because of the potential legal conflicts inherent in treating addiction, Academy members are familiar with the laws concerning their responsibilities and are able to anticipate those responsibilities that might potentially conflict with their role as health care provider. In cases in which the conflicts might be too great, the Academy member does his/her best to avoid such dual-roles.

    VI. Confidentiality

    Because of the popular stigmatization of addiction and of the legal implications that it often has, Academy members take the patient-client confidentiality agreement very seriously and take considerable precautions to ensure it. Because of the potential limitations on confidentiality (as suggested in Principle V), Academy members are careful to apprise their clients of the limits of confidentiality.

    VII. Clients Receiving Services Elsewhere

    Individuals being treated for an addiction often receive health services from other sites. In considering whether to treat such individuals, Academy members consult these other services and determine whether the client is best served in this manner. Academy members also anticipate and attempt to resolve potential conflicts that might arise from this arrangement.

    VIII. Making Referrals

    In making referrals, Academy members consider the best possible placement for their clients. Such referrals are always based on the best interests of the client and never on the financial interests of the clinician. Academy members attempt to familiarize themselves with a particular treatment site before making a referal to that site.

    IX. Assessment Tools

    Because definitions of addiction have changed radically in the past several years, Academy members are careful to use up-to-date assessment tools, tools that are compatible with contemporary theories of addiction, when diagnosing addiction.

    X. Relapse

    Since relapse is a critical part of addiction, Academy members are familiar with the facts concerning relapse and include relapse prevention as part of their treatment approach.

    XI. Impaired Professionals

    As a corollary to Principle I, but one worth mentioning in its own right, Academy members who develop their own addiction-related difficulties will refrain from providing treatment until such time as they have adequately addressed and resolved these difficulties and are again able to provide competent treatment.

    SOURCE: Reprinted by permission of the American Academy of Health Care Providers in the Addictive Disorders.
    Exhibit F: Organizations, Associations, and Other Resources Related to Addiction Treatment
    Government Web Sites

    Center for Substance Abuse Prevention http://www.samhsa.gov

    Center for Substance Abuse Treatment http://www.samhsa.gov

    Drug Enforcement Administration http://www.usdoj.gov/dea

    Indian Health Service http://www.tucson.ihs.gov

    National Institute of Mental Health http://www.nimh.nih.gov

    National Institute on Alcohol Abuse and Alcoholism http://www.niaaa.nih.gov

    National Institute on Drug Abuse http://www.nida.nih.gov

    National Institutes of Health http://www.nih.gov

    National Library of Medicine http://www.nlm.nih.gov

    Office of Minority Health Resource Center http://www.omhrc.gov

    Office of National Drug Control Policy http://www.whitehousedrugpolicy.gov

    Substance Abuse and Mental Health Services Administration http://www.samhsa.gov

    U.S. Department of Health and Human Services http://www.os.dhhs.gov

    Addiction and Related Organizations

    American Anorexia/Bulimia Association Regeant Hospital 425 East 61st Street, 6th Floor New York, NY 10021 phone: (212) 575–6200

    American Medical Association, Office of Alcohol and Other Drug Abuse 515 North State Street Chicago, IL 60610 phone: (312) 464–4202

    American Methadone Treatment Association 217 Broadway, Suite 304 New York, NY 10007 phone: (212) 566–5555

    American Society of Addiction Medicine 4601 North Park Avenue, Suite 101 Chevy Chase, MD 20815 phone: (301) 656–3920

    Association of Halfway House Alcoholism Programs of North America Rural Route 2, Box 415 Kerhonkson, NY 12446 phone: (914) 626–1684

    Entertainment Industries Council 500 South Buena Vista Street Burbank, CA 91521 phone: (818) 560–4231

    Faith Partners Against Substance Abuse 1406 Ethridge Avenue Austin, TX 78703 phone: (512) 476–2896

    International Community Corrections Association 3903 Gresham Place Alexandria, VA 22305 phone: (703) 836–0279

    International Council on Alcohol and Addiction Case postale 189

    1001 Lausanne Switzerland phone: 011 41 21 320 9865

    Mothers Against Drunk Driving 511 East John Carpenter Freeway, Suite 700 Irving, TX 75062-8187 on-line: http://www.madd.org

    National Association for Children of Alcoholics 11426 Rockville Pike, Suite 100 Rockville, MD 20852 phone: (888) 554–2627; (301) 468–0985 on-line: http://www.health.org/nacoa

    National Association of Anorexia Nervosa and Associated Disorders P.O. Box 7 Highland Park, IL 60035 phone: (708) 433–4632

    National Coalition for the Homeless 1012 14th Street NW Washington, DC 20036 phone: (202) 387–5000

    National Council on Alcoholism and Drug Dependence 1511 K Street NW, Suite 433 Washington, DC 20005 phone: (202) 737–8122 on-line: http://www.ncadd.org

    National Council on Compulsive Gambling 444 West 56th Street, Room 3207S New York, NY 10019 phone: (202) 765–3833

    National Organization on Fetal Alcohol Syndrome 1815 H Street NW, Suite 750 Washington, DC, 20006 phone: (202) 785–4585 on-line: http://www.nofas.org

    Partnership for a Drug-Free America 405 Lexington Avenue, 16th Floor New York, NY 10174 phone: (212) 922–1560 on-line: http://www.drugfreeamerica.org

    Partnership for Recovery

    601 13th Street NW, Suite 410 South

    Washington, DC 20503

    phone: (202) 737–0100

    Students Against Destructive Decisions

    P.O. Box 800

    Marlboro, MA 01752

    phone: (800) 787–5777

    on-line: http://www.saddonline.com

    Therapeutic Communities of America

    1611 Connecticut Avenue NW, Suite 4-B

    Washington, DC 20009

    phone: (202) 296–3503

    Professional Associations

    American Academy of Health Care Providers in the Addictive Disorders

    767C Concord Avenue

    Cambridge, MA 02138

    phone: (617) 661–6248

    American Bar Association, Standing Committee on Substance Abuse

    740 15th Street NW

    Washington, DC 20005

    phone: (202) 662–1785

    American Counseling Association

    5999 Stevenson Avenue

    Alexandria, VA 22304

    phone: (703) 823–9800

    American Psychiatric Association

    1400 K Street NW

    Washington, DC 20002

    phone: (202) 682–6326

    American Psychological Association

    750 First Street NE

    Washington, DC, 20002

    phone: (202) 336–5857

    American Public Health Association

    14405 Briarwood Terrace

    Rockville, MD 20853

    phone: (301) 460–4185

    Employee Assistance Professionals Association

    2101 Wilson Boulevard, Suite 500

    Arlington, VA 22201

    phone: (703) 522–6272

    on-line: http://www.eap.association.com

    International Certification and Reciprocity Consortium

    120 First Flight Lane

    Morrisville, NC 27560

    phone: (919) 572–6823

    National Association of Addiction Treatment Providers

    501 Randolph Drive

    Litz, PA 17543

    phone: (717) 581–1901

    National Association of Alcoholism and Drug Abuse Counselors

    1911 North Fort Meyer Drive, Suite 900

    Arlington, VA 22209

    phone: (800) 548–0487

    on-line: http://www.naadac.org

    National Association of Social Workers

    750 First Street NE, Suite 700

    Washington, DC 20002

    phone: (202) 408–8600

    National Association of State Alcohol and Drug Abuse Directors

    808 17th Street NW, Suite 410

    Washington, DC 20006

    phone: (202) 293–0090

    on-line: http://www.nasadad.org

    National Nurses Society on Addiction

    4101 Lake Boone Trail, Suite 201

    Raleigh, NC 27607

    phone: (919) 783–5871

    on-line: http://www.nnsa.org

    Educational Resources

    Hazelden Publishing and Education

    P.O. Box 176

    Center City, MN 55012

    phone : (800) 328–9000

    on-line: http://www.hazelden.org

    Johnson Institute

    7205 Ohmn Lane

    Minneapolis, MN 55439

    phone: (800) 231–5165

    on-line: http://www.johnsoninstitute.com

    National Clearinghouse for Alcohol and Drug Information

    P.O. Box 2345

    Rockville, MD 20847

    phone: (800) 729–6686

    on-line: http://www.health.org

    National Women's Resource Center

    515 King Street, Suite 410

    Alexandria, VA 22314

    phone: (800) 354–8824

    on-line: http://www.nwrc.org

    Substance Abuse Librarians and Information Specialists

    P.O. Box 9513

    Berkeley, CA 94709–0513

    phone: (510) 642–5208

    on-line: http://www.salis.org

    Research Institutions

    Betty Ford Center

    3900 Bob Hope Drive

    Rancho Mirage, CA 92270

    phone: (800) 854–9211; (760) 773–4100

    on-line: http://www.bettyfordcenter.com

    Center for Alcohol and Addiction Studies

    Brown University

    Box G-BH

    Providence, RI 02912

    phone: (401) 444–1818

    on-line: http://www.caas.brown.edu

    Center for Science in the Public Interest

    1875 Connecticut Avenue NW, Suite 300

    Washington, DC 20009

    phone: (202) 332–9110

    on-line: http://www.cspinet.org

    Christopher D. Smithers Foundation

    P.O. Box 67

    Mill Neck, NY 11765

    phone: (516) 676–0067

    on-line: http://aaw.com/smithers

    Harvard Medical School, Division of Addictions

    220 Longwood Avenue

    Goldenson Building 231, Room 523

    Boston, MA 02115

    phone: (617) 432–0058

    on-line: http://www.hms.harvard.edu/doa

    Hazelden Foundation

    P.O. Box 11

    Center City, MN 55012

    phone: (612) 257–4010

    on-line: http://www.hazelden.org

    Johnson Institute Foundation

    2909 Wayzata Boulevard

    Minneapolis, MN 55405

    phone: (612) 374–9100

    National Association for Responsible Gaming

    P.O. Box 25366

    Kansas City, MO 64119

    phone: (816) 453–9964

    on-line: http://www.ncrg.org

    National Center on Addiction and Substance Abuse at Columbia University

    152 West 57th Street

    New York, NY 10019

    (212) 841–5200

    on-line: http://www.casacolumbia.org

    Robert Wood Johnson Foundation

    Route 1 and College Road East

    P.O. Box 2316

    Princeton, NJ 08543

    phone: (609) 452–8701

    on-line: http://www.rwjf.org

    Rutgers University Center of Alcohol Studies

    Smithers Hall, Busch Campus

    Piscataway, NJ 08855

    phone: (732) 445–4442

    on-line: http://www.rci.rutgers.edu

    Multicultural Resources

    Latino Council on Alcohol and Tobacco

    1015 15th Street NW, Suite 409

    Washington, DC 20005

    phone: (202) 371–1186

    National Asian Pacific American Families Against Substance Abuse

    300 West Cesar Chavez Avenue, Suite B

    Los Angeles, CA 90012

    phone: (213) 625–5795

    National Black Alcoholism Council

    1101 14th Street NW, Suite 802

    Washington, DC 20005

    phone: (202) 296–2696

    National Coalition of Hispanic Health and Service Organizations

    1501 16th Street NW

    Washington, DC 20036

    phone: (202) 387–5000

    on-line: http://www.cossmho.org

    Self-Help Organizations

    Adult Children of Alcoholics

    World Service Organization

    P.O. Box 3216

    Torrance, CA 90510

    phone: (310) 534–1815

    Al-Anon/Alateen Family Group Headquarters

    1600 Corporate Landing Parkway

    Virginia Beach, VA 23454

    phone: (757) 563–1600

    on-line: http://www.al-anon.alateen.org

    Alcoholics Anonymous

    General Service Office

    475 Riverside Drive

    New York, NY 10115

    phone: (212) 870–3400

    on-line: http://www.aa.org

    Anorexia and Bulimia Support, Inc.

    432 West Onondaga Street

    Syracuse, NY 13202

    phone: (315) 474–7011

    Cocaine Anonymous

    World Service Organization

    P.O. Box 2000

    Los Angeles, CA 90049

    phone: (310) 559–5833

    on-line: http://www.ca.org

    Gam-Anon International Service Office, Inc.

    P.O. Box 157

    Whitestone, NY 11357

    phone: (718) 352–1671

    Gamblers Anonymous

    World Service Office

    P.O. Box 17173

    Los Angeles, CA 90017

    phone: (213) 386–8789

    on-line: http://www.gamblersanonymous.org

    Jewish Alcoholics, Chemically Dependent Persons and Significant Others

    426 West 58th Street

    New York, NY 10019

    phone: (212) 397–4197

    on-line: http://www.jacsnet.org

    Nar-Anon Family Group Headquarters, Inc.

    P.O. Box 2562

    Palos Verdes, CA 90274

    phone: (310) 547–5800

    Narcotics Anonymous

    World Service Office

    P.O. Box 9999

    Van Nuys, CA 91409

    phone: (818) 773–9999

    on-line: http://www.wsoinc.com

    National Self-Help Clearinghouse

    25 West 43rd Street, Room 620

    New York, NY 10036

    phone: (212) 354–8525

    on-line: http://www.selfhelpweb.org

    Recovery Network

    1411 Fifth Street, Suite 200

    Santa Monica, CA 90401

    phone: (310) 393–3979

    on-line: http://www.recoverynetwork.com

    Sex and Love Addicts Anonymous

    Fellowship-Wide Services, Inc.

    P.O. Box 199, New Town Branch

    Boston, MA 02258

    phone: (617) 332–1845

    Women for Sobriety

    P.O. Box 618

    Quakertown, PA 18951

    phone: (215) 536–8026

    on-line: http://www.mediapulse.com/wfs

    Exhibit G: Alcoholics Anonymous: How it Works and Twelve Steps

    Rarely have we seen a person fall who has thoroughly followed our path. Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way. They are naturally incapable of grasping and developing a manner of living which demands rigorous honesty. Their chances are less than average. There are those, too, who suffer from grave emotional and mental disorders, but many of them do recover if they have the capacity to be honest.

    Our stories disclose in a general way what we used to be like, what happened, and what we are like now. If you have decided you want what we have and are willing to go to any length to get it—then you are ready to take certain steps.

    At some of these we balked. We thought we could find an easier, softer way. But we could not. With all the earnestness at our command, we beg of you to be fearless and thorough from the very start. Some of us have tried to hold on to our old ideas and the result was nil until we let go absolutely.

    Remember that we deal with alcohol—cunning, baffling, powerful! Without help it is too much for us. But there is One who has all power—that One is God. May you find Him now!

    Half measures availed us nothing. We stood at the turning point. We asked His protection and care with complete abandon.

    Here are the steps we took, which are suggested as a program of recovery.

    • We admitted we were powerless over alcohol—that our lives had become unmanageable.
    • Came to believe that a Power greater than ourselves could restore us to sanity.
    • Made a decision to turn our will and our lives over to the care of God as we understood Him.
    • Made a searching and fearless moral inventory of ourselves.
    • Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
    • Were entirely ready to have God remove all these defects of character.
    • Humbly asked Him to remove our shortcomings.
    • Made a list of all persons we had harmed, and became willing to make amends to them all.
    • Made direct amends to such people wherever possible, except when to do so would injure them or others.
    • Continued to take personal inventory and when we were wrong promptly admitted it.
    • Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
    • Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

    Many of us exclaimed, “What an order! I can't go through with it.” Do not be discouraged. No one among us has been able to maintain anything like perfect adherence to these principles. We are not saints. The point is that we are willing to grow along spiritual lines. The principles we have set down are guides to progress. We claim spiritual progress rather than spiritual perfection.

    Our description of the alcoholic, the chapter to the agnostic, and our personal adventures before and after make clear three pertinent ideas:

    • That we were alcoholic and could not manage our own lives.
    • That probably no human power could have relieved our alcoholism.
    • That God could and would if He were sought.
    NOTE: The Twelve Steps of Alcoholics Anonymous and “How It Works” (excerpted from Chapter 5 of the book Alcoholics Anonymous) are reprinted with the permission of Alcoholics Anonymous World Services, Inc. (A.A.W.S.). Permission to reprint and adapt the Twelve Steps does not mean that Alcoholics Anonymous is affiliated with any program discussed in this volume. A.A. is a program of recovery from alcoholism only—use of the Steps, or an adapted version of the Steps, in connection with programs and activities which are patterned after A. A., but which address other problems, or use in any other non-A.A. context, does not imply otherwise.
    Exhibit H: Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)

    Exhibit I: Clinical Institute Narcotic Assessment (CINA)

    Exhibit J: AUDIT (Alcohol Use Disorder Identification Test)

    AUDIT is a brief structured interview, developed by the World Health Organization, that can be incorporated into a medical history. It contains questions about recent alcohol consumption, dependence symptoms, and alcohol-related problems.

    Begin the AUDIT by saying, “Now I am going to ask you some questions about your use of alcoholic beverages during the past year.” Explain what is meant by alcoholic beverages: beer, wine, liquor (vodka, whiskey, brandy, etc.).

    Record the score for each question in the brackets on the right side of the question.

    • How often do you have a drink containing alcohol?

    • How many drinks containing alcohol do you have on a typical day when you are drinking?

    • How often do you have six or more drinks on one occasion?

    • How often during the last year have you found that you were unable to stop drinking once you had started?

    • How often during the last year have you failed to do what was normally expected from you because of drinking?

    • How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

    • How often during the last year have you had a feeling of guilt or remorse after drinking?

    • How often during the last year have you been unable to remember what happened the night before because you had been drinking?

    • Have you or has someone else been injured as the result of your drinking?

    • How often has a relative, friend, or a doctor or other health worker expressed concern about your drinking or suggested you cut down?

    Record the total of the specific items.[ ]

    A score of 8 or greater may indicate the need for a more in-depth assessment.

    Exhibit K: Example of a Client Health History and Physical Exam

    Exhibit L: Sample Genogram Forms

    Exhibit M: Example of an Admissions/Intake Assessment Form

    Exhibit N: Example of a Treatment Outcome Follow-Up Questionnaire

    Exhibit O: Example of a Program Outcome Service Satisfaction Questionnaire (Rehabilitation Version)

    Exhibit P: Key Components of a Drug Court Program

    Although drug court programs vary based on community needs and resources, the National Association of Drug Court Professionals (NADCP) brought together a group of drug court practitioners and other experts from across the country to develop an outline of what they believe to be the key components. The committee included representatives from courts, prosecution, public defense, treatment, pretrial services, case management, probation, court administration, and academia and others with drug court experience. The following 10 components:

    • Drug courts integrate alcohol and other drug treatment services with justice system case processing.
    • Using a nonadversarial approach, prosecution and defense counsel promote public safety while protecting participants’ due process rights.
    • Eligible participants are identified early and promptly placed in the drug court program.
    • Drug courts provide access to a continuum of alcohol, drug, and other related treatment and rehabilitation services.
    • Abstinence is monitored by frequent alcohol and other drug testing.
    • A coordinated strategy governs drug court responses to participants’ compliance.
    • Ongoing judicial interaction with each drug court participant is essential.
    • Monitoring and evaluation measure the achievement of program goals and gauge effectiveness.
    • Continuing interdisciplinary education promotes effective drug court planning, implementation, and operations.
    • Forgoing partnerships among drug courts, public agencies, and community-based organizations generates local support and enhances drug court effectiveness.
    Source: Defining Drug Courts: The Key Components. Drug Courts Program Office, Office of Justice Programs, January 1997

    About the Author

    Sandra Rasmussen, Ph.D., R.N., L.M.H.C., C.A.S., teaches psychiatric/mental health nursing at Rhode Island College. She has also taught for more than 10 years in the Graduate Program in Counseling Psychology at Cambridge College, where she coordinates the Addiction Studies Program. In addition, she is a faculty mentor in the Professional Psychology Doctoral Program for Walden University. She currently works as an addiction clinician for AdCare Hospital; she provides clinical supervision for AdCare Recovery Services corrections treatment staff. She is a member of the board of directors of the Massachusetts Council on Compulsive Gambling and serves on the Substance Abuse Rehabilitation Evaluation Committee of the Massachusetts Board of Registration in Nursing. She facilitates a weekly addiction support group for nurses and other health professionals.

    Dr. Rasmussen was previously Director of Counseling, then Executive Director, of the NORCAP Center for Addictions of Southwood Community Hospital. NORCAP provided multiple levels of treatment via a network of inpatient and outpatient facilities throughout southeastern Massachusetts. She was also engaged by Brown University Center for Alcohol and Addiction Studies as a collaborating investigator with Project MATCH. She served as site coordinator for the GAMMA Project. In her current research, she is investigating the relationship between developmental tasks and treatment outcome with young adult clients.

    Dr. Rasmussen received her Ph.D. in clinical psychology and public practice from Harvard University. She holds graduate degrees in child development and nursing management and an undergraduate degree in nursing. She is a registered nurse, licensed mental health counselor, and certified addiction specialist.


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