1.4: Special Considerations

Now that you have a sense of how to define addiction, along with a grasp of the role that drugs play in our society, it is time to turn our attention to additional issues. We call these special considerations because they are important to think about in the context of how addiction develops.

Addiction knows no boundaries. It doesn’t care about your gender, race, ethnicity, age, socioeconomic status, religion, or occupation. It can affect anyone at any point along the lifespan. However, a few populations have a special connection to or relationship with addiction.

This chapter examines drug use among older adults, as well as information on conditions that impact the development of addiction, such as co-occurring disorders, trauma, and chronic pain. The chapter concludes by discussing how behavioral addictions like compulsive gambling, shopping, or internet use fit into our definition.

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Substance Use in Older Adults

Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.
Updated 2020

The scope of substance use in older adults
While illicit drug use typically declines after young adulthood, nearly 1 million adults aged 65 and older live with a substance use disorder (SUD), as reported in 2018 data.¹ While the total number of SUD admissions to treatment facilities between 2000 and 2012 differed slightly, the proportion of admissions of older adults increased from 3.4% to 7.0% during this time.²

Are older adults impacted differently by alcohol and drugs?
Aging could possibly lead to social and physical changes that may increase vulnerability to substance misuse. Little is known about the effects of drugs and alcohol on the aging brain. However, older adults typically metabolize substances more slowly, and their brains can be more sensitive to drugs.³ One study suggests that people addicted to cocaine in their youth may have an accelerated age-related decline in temporal lobe gray matter and a smaller temporal lobe compared to control groups who do not use cocaine. This could make them more vulnerable to adverse consequences of cocaine use as they age.¹⁹

Older adults may be more likely to experience mood disorders, lung and heart problems, or memory issues. Drugs can worsen these conditions, exacerbating the negative health consequences of substance use. Additionally, the effects of some drugs—like impaired judgment, coordination, or reaction time—can result in accidents, such as falls and motor vehicle crashes. These sorts of injuries can pose a greater risk to health than in younger adults and coincide with a possible longer recovery time.

Prescription Medicines
Chronic health conditions tend to develop as part of aging, and older adults are often prescribed more medicines than other age groups, leading to a higher rate of exposure to potentially addictive medications. One study of 3,000 adults aged 57-85 showed common mixing of prescription medicines, nonprescription drugs, and dietary supplements. More than 80% of participants used at least one prescription medication daily, with nearly half using more than five medications or supplements,⁵ putting at least 1 in 25 people in this age group at risk for a major drug-drug interaction.⁵
Other risks could include accidental misuse of prescription drugs and possible worsening of existing mental health issues. For example, a 2019 study of patients over the age of 50 noted that more than 25% who misuse prescription opioids or benzodiazepines expressed suicidal ideation, compared to 2% who do not use them, underscoring the need for careful screening before prescribing these medications.⁶

Opioid Pain Medicines
Persistent pain may be more complicated in older adults experiencing other health conditions. Up to 80% of patients with advanced cancer report pain, as well as 77% of heart disease patients, and up to 40% of outpatients 65 and older. Between 4-9% of adults age 65 or older use prescription opioid medications for pain relief.⁷ From 1995 to 2010, opioids prescribed for older adults during regular office visits increased by a factor of nine.⁷
The U.S. population of adults 55 and older increased by about 6% between 2013-2015, yet the proportion of people in that age group seeking treatment for opioid use disorder increased nearly 54%.⁴ The proportion of older adults using heroin—an illicit opioid—more than doubled between 2013-2015,⁴ in part because some people misusing prescription opioids switch to this cheaper drug.⁴

Marijuana
Nine percent of adults aged 50-64 reported past year marijuana use in 2015-2016, compared to 7.1% in 2012-2013.10 The use of cannabis in the past year by adults 65 years and older increased sharply from 0.4% in 2006 and 2007 to 2.9% in 2015 and 2016.²²
Medical Marijuana
One U.S. study suggests that close to a quarter of marijuana users age 65 or older report that a doctor had recommended marijuana in the past year.10 Research suggests medical marijuana may relieve symptoms related to chronic pain, sleep hygiene, malnutrition, depression, or to help with side effects from cancer treatment.11 It is important to note that the marijuana plant has not been approved by the Food and Drug Administration (FDA) as a medicine. Therefore, the potential benefits of medical marijuana must be weighed against its risks, particularly for individuals who have other health conditions or take prescribed medications.¹¹
Risks of Marijuana Use
Regular marijuana use for medical or other reasons at any age has been linked to chronic respiratory conditions, depression, impaired memory, adverse cardiovascular functions, and altered judgment and motor skills.¹² Marijuana can interact with a number of prescription drugs and complicate already existing health issues and common physiological changes in older adults.

Nicotine
The Centers for Disease Control and Prevention (CDC) reports that in 2017, about 8 of every 100 adults aged 65 and older smoked cigarettes, increasing their risk for heart disease and cancer.²⁰ While this rate is lower than that for younger adults, research suggests that older people who smoke have increased risk of becoming frail, though smokers who have quit do not appear to be at higher risk.¹⁴ Although about 300,000 smoking-related deaths occur each year among people who are age 65 and older, the risk diminishes in older adults who quit smoking.¹³ A typical smoker who quits after age 65 could add two to three years to their life expectancy. Within a year of quitting, most former smokers reduce their risk of coronary heart disease by half.¹³

Nicotine Vaping
There has been little research on the effects of vaping nicotine (e-cigarettes) among older adults; however, certain risks exist in all age groups. Some research suggests that e-cigarettes might be less harmful than cigarettes when people who regularly smoke switch to vaping as a complete replacement. However, research on this is mixed, and the FDA has not approved e-cigarettes as a smoking cessation aid. There is also evidence that many people continue to use both delivery systems to inhale nicotine, which is a highly addictive drug.

Alcohol
Alcohol is the most used drug among older adults, with about 65% of people 65 and older reporting high-risk drinking, defined as exceeding daily guidelines at least weekly in the past year.16 Of particular concern, more than a tenth of adults age 65 and older currently binge drink,18 which is defined as drinking five or more drinks on the same occasion for men, and four or more drinks on the same occasion for women. In addition, research published in 2020 shows that increases in alcohol consumption in recent years have been greater for people aged 50 and older relative to younger age‐groups.²¹

Alcohol Use Disorder: Most admissions to substance use treatment centers in this age group relate to alcohol.² One study documented a 107% increase in alcohol use disorder among adults aged 65 years and older from 2001 to 2013.16 Alcohol use disorder can put older people at greater risk for a range of health problems, including diabetes, high blood pressure, congestive heart failure, liver and bone problems, memory issues and mood disorders.¹⁶

Risk Factors for Substance Use Disorders in Older Adults

Physical risk factors for substance use disorders in older adults can include: chronic pain; physical disabilities or reduced mobility; transitions in living or care situations; loss of loved ones; forced retirement or change in income; poor health status; chronic illness; and taking a lot of medicines and supplements. Psychiatric risk factors include: avoidance coping style; history of substance use disorders; previous or current mental illness; and feeling socially isolated.¹⁹

How are substance use disorders treated in older adults?
Many behavioral therapies and medications have been successful in treating substance use disorders in older adults. Little is known about the best models of care, but research shows that older patients have better results with longer durations of care.⁷ Ideal models include diagnosis and management of other chronic conditions, re-building support networks, improving access to medical services, improved case management, and staff training in evidence-based strategies for this age group.⁷
Providers may confuse SUD symptoms with those of other chronic health conditions or with natural, age-related changes. Research is needed to develop targeted SUD screening methods for older adults. Integrated models of care for those with coexisting medical and psychiatric conditions are also needed.² It is important to note that once in treatment, people can respond well to care.²

Key Takeaways

• While use of illicit drugs in older adults is much lower than among other adults, it is currently increasing.
• Older adults are often more susceptible to the effects of drugs, because as the body ages, it often cannot absorb and break down drugs and alcohol as easily as it once did.
• Older adults are more likely to unintentionally misuse medicines by forgetting to take their medicine, taking it too often, or taking the wrong amount.
• Some older adults may take substances to cope with big life changes such as retirement, grief and loss, declining health, or a change in living situation.
• Most admissions to substance use treatment centers in this age group are for alcohol.
• Many behavioral therapies and medications have been successful in treating substance use disorders, although medications are underutilized.
• It is never too late to quit using substances—quitting can improve quality of life and future health.
• More science is needed on the effects of substance use on the aging brain, as well as into effective models of care for older adults with substance use disorders.
• Providers may confuse symptoms of substance use with other symptoms of aging, which could include chronic health conditions or reactions to stressful, life-changing events. References:
1. Substance Abuse and Mental Health Services Administration. (2019). Results from the 2018 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/
2. Chatre S, Cook R, Mallik E et al. Trends in substance use admissions among older adults. BMC Health Services Research. 2017; 584(17). doi: https://doi.org/10.1186/s12913-017-2538-z
3. Colliver JD, Compton WM, Gfroerer JC, Condon T. Projecting drug use among aging baby boomers in 2020. Annals of Epidemiology. 2006; 16(4): 257–265.
4. Huhn AS, Strain EC, Tompkins DA, Dunn KE. A hidden aspect of the U.S. opioid crisis: Rise in first-time treatment admissions for older adults with opioid use disorder. Drug Alcohol Depend. 2018 Dec 1; 193: 142-147. doi: 10.1016/j.drugalcdep.2018
5. Qato DM, Alexander GC, Conti RM, Johnson M, Schumm P, Lindau ST. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA. 2008 Dec 24; 300(24): 2867-2878. doi: 10.1001/jama.2008.892
6. Schepis TS, Simoni-Wastila L, McCabe SE. Prescription opioid and benzodiazepine misuse is associated with suicidal ideation in older adults. Int J Geriatr Psychiatry. 2019; 34(1): 122-129. doi: 10.1002/gps.4999
7. Lehmann S, Fingerhood M. Substance-use disorders in later life, N Engl J Med. 2018 December 13; 379(24): 2351-2360. doi: 10.1056/NEJMra1805981
8. Galicia-Castillo, M. Opioids for persistent pain in older adults. Cleveland Clinic Journal of Medicine. 2016 June 6; 83(6). Retrieved from: mdedge-files-live.s3.us-east...lderAdults.pdf
9. Wu LT, Blazer DG. Illicit and nonmedical drug use among older adults: A review. Journal of Aging and Health. 2011; 23(3): 481–504. doi:10.1177/0898264310386224
10. Han BH, Palamar JJ. Marijuana use by middle-aged and older adults in the United States, 2015-2016. Drug Alcohol Depend. 2018; 191: 374-381. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/30197051
11. Abuhasira R, Ron A, Sikorin I, Noack V. Medical cannabis for older patients—Treatment protocol and initial results. Journal of Clinical Medicine. 2019; 8(11): 1819. https://doi.org/10.3390/jcm8111819
12. Volkow N, Baler R, Compton W, Weiss S. Adverse health effects of marijuana use. N Engl J Med. 2014 June 5; 370(23): 2219-2227. doi: 10.1056/NEJMra1402309
13. Centers for Disease Control and Prevention. Smoking and Older Adults. November 2008. https://www2c.cdc.gov/podcasts/media...ingSmoking.pdf. Accessed March 12, 2020.
14. Kojima G, Iliffe S, Jivraj S, Liljas A, Walters K. Does current smoking predict future frailty? The English longitudinal study of ageing. Age and Ageing. 2018 January; 47(1): 126-131. https://doi.org/10.1093/ageing/afx136
15. Older adults fact sheet. National Institute on Alcohol Abuse and Alcoholism. https://www.niaaa.nih.gov/alcohol-he...s/older-adults
16. Grant BF, Chou SP, Saha TD, et al. Prevalence of 12‐month alcohol use, high‐risk drinking, and DSM‐IV alcohol use disorder in the United States, 2001‐2002 to 2012‐2013: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiat. 2017; 74(9): 911‐923.
17. Kuerbis et al. Substance abuse among older adults. Clin Geriatr Med. 2014 Aug; 30(3): 629–654. doi:10.1016/j.cger.2014.04.008
Substance Use in Older Adults • July 2020 • Page 8
18. Han B, Moore A, Ferris R, Palamar J. Binge drinking among older adults in the United States, 2015-2017. Journal of the American Geriatrics Society. 2019 July 31; 67(10). doi.org/10.1111/jgs.16071
19. Bartzokis et al. Magnetic resonance imaging evidence of “silent” cerebrovascular toxicity in cocaine dependence. Biol Psychiatry. 1999; 45: 1203-1211.
20. Current cigarette smoking among adults in the United States fact sheet. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/data_sta...king/index.htm
21. White A, Castle I, Hingson R, Powell P. Using death certificates to explore changes in alcohol‐related mortality in the United States, 1999 to 2017. Alcoholism Clinical and Experimental Research. 2020 January 7; 44(1): 178-187. doi.org/10.1111/acer.14239
22. Han BH, Sherman S, Mauro PM, Martins SS, Rotenberg J, Palamar JJ.
Demographic trends among older cannabis users in the United States, 2006-2013.
Addiction. 2017; 112(3): 516-525. doi:10.1111/add.13670

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Part Two: Conditions that Impact the Development of Addiction

In 21st-century treatment centers, few clients are treated solely for a substance use disorder. In most cases, clients present with an extensive history that might involve mental health issues, trauma, attempts to manage chronic pain, or all of the above. It is critical for helping professionals, along with family members and friends, to understand the complex interaction of these problems.

We mentioned in Chapter 1 that addiction is a primary disorder, meaning that it requires its own treatment and is not simply a symptom of another problem. That said, addiction is rarely the only issue that someone is struggling with. Anxiety, depression, bipolar disorder, unresolved trauma, and severe pain are all commonly seen by helping professionals while treating addictive disorders.

The following interactive video explains the importance of treating co-occurring disorders in an integrated manner:

A link to an interactive elements can be found at the bottom of this page.

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SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach

The convergence of the trauma survivor’s perspective with research and clinical work has underscored the central role of traumatic experiences in the lives of people with mental and substance use conditions. The connection between trauma and these conditions offers a potential explanatory model for what has happened to individuals, both children and adults, who come to the attention of the behavioral health and other service systems.

People with traumatic experiences, however, do not show up only in behavioral health systems. Responses to these experiences often manifest in behaviors or conditions that result in involvement with the child welfare and the criminal and juvenile justice system or in difficulties in the education, employment, or primary care system. Recently, there has also been a focus on individuals in the military and increasing rates of post-traumatic stress disorder.

SAMHSA’s Definition of Trauma

Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.

The six key principles fundamental to a trauma-informed approach include:

1. Safety

Throughout the organization, staff and the people they serve, whether children or adults, feel physically and psychologically safe; the physical setting is safe and interpersonal interactions promote a sense of safety. Understanding safety as defined by those served is a high priority.

2. Trustworthiness and Transparency

Organizational operations and decisions are conducted with transparency with the goal of building and maintaining trust with clients and family members, among staff, and others involved in the organization.

3. Peer Support

Peer support and mutual self-help are key vehicles for establishing safety and hope, building trust, enhancing collaboration, and utilizing stories and lived experiences to promote recovery and healing. The term peers refers to individuals with lived experiences of trauma. In the case of children, these may be members of their family who have experienced traumatic events and are key caregivers in their recovery. Peers have also been referred to as trauma survivors.

4. Collaboration and Mutuality

Importance is placed on partnering and the leveling of power differences between staff and clients and among organizational staff from clerical and housekeeping personnel, to professional staff to administrators, demonstrating that healing happens in relationships and in the meaningful sharing of power and decision-making. The organization recognizes that everyone has a role to play in a trauma-informed approach. As one expert stated, “one does not have to be a therapist to be therapeutic.”

5. Empowerment, Voice and Choice

Throughout the organization and among the clients served, individuals’ strengths and experiences are recognized and built upon. The organization fosters a belief in the primacy of the people served; in resilience; and in the ability of individuals, organizations, and communities to heal and promote recovery from trauma. The organization understands that the experience of trauma may be a unifying aspect in the lives of those who run the organization, who provide the services, and/ or who come to the organization for assistance and support. As such, operations, workforce development, and services are organized to foster empowerment for staff and clients alike. Organizations understand the importance of power differentials and ways in which clients, historically, have been diminished in voice and choice and are often recipients of coercive treatment. Clients are supported in shared decision-making, choice, and goal setting to determine the plan of action they need to heal and move forward. They are supported in cultivating self-advocacy skills. Staff are facilitators of recovery rather than controllers of recovery. Staff are empowered to do their work as well as possible by adequate organizational support. This is a parallel process as staff need to feel safe, as much as people receiving services.

6. Cultural, Historical, and Gender Issues

The organization actively moves past cultural stereotypes and biases (based on race, ethnicity, sexual orientation, age, religion, gender-identity, geography, etc.); offers access to gender-responsive services; leverages the healing value of traditional cultural connections; incorporates policies, protocols, and processes that are responsive to the racial, ethnic and cultural needs of individuals served; and recognizes and addresses historical trauma.

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The Trauma-Addiction Connection

When a person fears for his/her safety, experiences intense pain, or witnesses a tragic or violent act, that person can be described as having experienced trauma. Levels of resiliency vary from person to person, so reactions to traumatic events are similarly varied. Although frightening experiences impact people at any age, adults will generally be more likely to manage through trauma than children will be. Further, some trauma is repeated or ongoing, such as that of child abuse or military combat. Other examples of traumatic events include car accidents, repeated bullying, street violence, sexual assault, domestic violence, growing up in an unstable home, natural disasters, or battling a life-threatening condition.

If trauma and the feelings associated with it are not resolved, serious long-term issues can develop. Post-traumatic stress disorder (PTSD) disrupts the lives of people who have experienced unresolved trauma by negatively impacting their relationships, emotions, physical body, thinking and behavior. PTSD sufferers may experience sleep disturbances, nightmares, anxiety and depression, flashbacks, dissociative episodes in which they feel disconnected from reality, excessive fears, self-injurious behaviors, impulsivity and addictive traits.

Researchers have been studying the connection between trauma and addiction in order to understand why so many drug and alcohol abusers have histories of traumatic experiences. Data from over 17,000 patients in Kaiser Permanente’s Adverse Childhood Experiences study indicate that a child who experiences four or more traumatic events is five times more likely to become an alcoholic, 60% more likely to become obese, and up to 46 times more likely to become an injection-drug user than the general population. Other studies have found similar connections between childhood trauma and addiction, and studies by the Veterans Administration have led to estimates that between 35-75% of veterans with PTSD abuse drugs and alcohol.

The reasons behind this common co-occurrence of addiction and trauma are complex. For one thing, some people struggling to manage the effects of trauma in their lives may turn to drugs and alcohol to self-medicate. Post-traumatic stress disorder symptoms like agitation, hypersensitivity to loud noises or sudden movements, depression, social withdrawal and insomnia may seem more manageable through the use of sedating or stimulating drugs depending on the symptom. However, addiction soon becomes yet another problem in the trauma survivor’s life. Before long, the “cure” no longer works, and it causes far more pain to an already suffering person.

Other possible reasons addiction and trauma are often found together include the theory that a substance abuser’s lifestyle puts him/her in harm’s way more often than that of a non-addicted person. Unsavory acquaintances, dangerous neighborhoods, impaired driving, and other aspects commonly associated with drug and alcohol abuse may indeed predispose substance abusers to being traumatized by crime, accidents, violence and abuse. There may also be a genetic component linking people prone toward PTSD and those with addictive tendencies, although no definitive conclusion has been made by research so far.

First Things First

Sometimes, years of self-medicating through drugs and alcohol have effectively dulled the memory of trauma, so the only problem seems to be substance abuse and addiction. A person who has suppressed or ignored traumatic experiences may work very hard to get and stay sober, only to find other addictive behaviors eventually replacing the drugs and alcohol. These might include compulsive overeating, gambling, sexual promiscuity or any other compulsion-driven behavior. Unfortunately, continuing to avoid resolution of trauma will almost guarantee ongoing suffering.

However, dealing with traumatic experiences is challenging work. Under the influence of drugs and alcohol, it is a nearly impossible task. That is why therapists always recommend working first on recovery from drug addiction and alcoholism. Then, when the trauma survivor is stronger and more clear-minded, s/he can begin working with a therapist in individual or group counseling to address the underlying problem of unresolved trauma. Specific treatment modalities have been developed for people suffering long-term effects after traumatic experiences, including trauma-focused therapies, PTSD Intervention, Body Psychotherapy which targets the physiological response to trauma, and medications for depression and anxiety.

Considering the frequent link between trauma and addiction, anyone working on recovery from substance abuse and addiction could benefit from an assessment by a skilled therapist, to determine if there are underlying issues that should be addressed and to devise an appropriate treatment plan. The best approach is always to work first on living a sober life, then on resolving past trauma and learning positive coping skills, thereby breaking the trauma-addiction connection and finding a better life all around.

Hackensack Meridian Carrier Clinic. (2019). Trauma and addiction. Retrieved from https://carrierclinic.org/2019/08/06...and-addiction/

For more information, visit carrierclinic.org

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The following video, produced by the Carrier Clinic, highlights the significant link between post-traumatic stress disorder and addiction.

A YouTube element has been excluded from this version of the text. You can view it online here: https://cod.pressbooks.pub/addiction/?p=44

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The following video examines the ways trauma and addiction are linked. The issue of trauma has become one of the most important concepts in the treatment of addiction.

A YouTube element has been excluded from this version of the text. You can view it online here: https://cod.pressbooks.pub/addiction/?p=44

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NAMI Guide to Dual Diagnosis

Dual Diagnosis

Dual diagnosis (also referred to as co-occurring disorders) is a term for when someone experiences a mental illness and a substance use disorder simultaneously. Either disorder—substance use or mental illness—can develop first. People experiencing a mental health condition may turn to alcohol or other drugs as a form of self-medication to improve the mental health symptoms they experience. However, research shows that alcohol and other drugs worsen the symptoms of mental illnesses. The professional fields of mental health and substance use recovery have different cultures, so finding integrated care can challenging.

How Common Is Dual Diagnosis?

According to a 2014 National Survey on Drug Use and Health, 7.9 million people in the U.S. experience both a mental disorder and substance use disorder simultaneously. More than half of those people—4.1 million to be exact—are men.

Symptoms

Because many combinations of dual diagnosis can occur, the symptoms vary widely. Mental health clinics are starting to use alcohol and drug screening tools to help identify people at risk for drug and alcohol abuse. Symptoms of substance use disorder may include:

• Withdrawal from friends and family
• Sudden changes in behavior
• Using substances under dangerous conditions
• Engaging in risky behaviors
• Loss of control over use of substances
• Developing a high tolerance and withdrawal symptoms
• Feeling like you need a drug to be able to function

Symptoms of a mental health condition can also vary greatly. Warning signs, such as extreme mood changes, confused thinking or problems concentrating, avoiding friends and social activities and thoughts of suicide, may be reason to seek help.

How Is Dual Diagnosis Treated?

The best treatment for dual diagnosis is integrated intervention, when a person receives care for both their diagnosed mental illness and substance abuse. The idea that “I cannot treat your depression because you are also drinking” is outdated—current thinking requires both issues be addressed.

You and your treatment provider should understand the ways each condition affects the other and how your treatment can be most effective. Treatment planning will not be the same for everyone, but here are the common methods used as part of the treatment plan:

Detoxification. The first major hurdle that people with dual diagnosis will have to pass is detoxification. Inpatient detoxification is generally more effective than outpatient for initial sobriety and safety. During inpatient detoxification, trained medical staff monitor a person 24/7 for up to seven days. The staff may administer tapering amounts of the substance or its medical alternative to wean a person off and lessen the effects of withdrawal.

Inpatient Rehabilitation. A person experiencing a mental illness and dangerous/dependent patterns of substance use may benefit from an inpatient rehabilitation center where they can receive medical and mental health care 24/7. These treatment centers provide therapy, support, medication and health services to treat the substance use disorder and its underlying causes.

Supportive Housing, like group homes or sober houses, are residential treatment centers that may help people who are newly sober or trying to avoid relapse. These centers provide some support and independence. Sober homes have been criticized for offering varying levels of quality care because licensed professionals do not typically run them. Do your research when selecting a treatment setting.

Psychotherapy is usually a large part of an effective dual diagnosis treatment plan. In particular, cognitive-behavioral therapy (CBT) helps people with dual diagnosis learn how to cope and change ineffective patterns of thinking, which may increase the risk of substance use.

Medications are useful for treating mental illnesses. Certain medications can also help people experiencing substance use disorders ease withdrawal symptoms during the detoxification process and promote recovery.

Self-Help and Support Groups. Dealing with a dual diagnosis can feel challenging and isolating. Support groups allow members to share frustrations, celebrate successes, find referrals for specialists, find the best community resources and swap recovery tips. They also provide a space for forming healthy friendships filled with encouragement to stay clean. Here are some groups NAMI likes:

• Double Trouble in Recovery is a 12-step fellowship for people managing both a mental illness and substance abuse.
• Alcoholics Anonymous and Narcotics Anonymous are 12-step groups for people recovering from alcohol or drug addiction. Be sure to find a group that understands the role of mental health treatment in recovery.
• Smart Recovery is a sobriety support group for people with a variety of addictions that is not based in faith.

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Chronic Pain Management

Excerpted from SAMHSA TIP 54: Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders

Chronic non-cancer pain (CNCP) is a major challenge for clinicians as well as for the patients who suffer from it. The complete elimination of pain is rarely obtainable for any substantial period. Therefore, patients and clinicians should discuss treatment goals that include reducing pain, maximizing function, and improving quality of life. The best outcomes can be achieved when chronic pain management addresses co-occurring mental disorders (e.g., depression, anxiety) and when it incorporates suitable nonpharmacologic and complementary therapies for symptom management.

Treatment recommendations:

• Treat chronic pain with non-opioid pain relievers as determined by pathophysiology
• Recommend or prescribe nonpharmacological therapies (e.g., cognitive–behavioral therapy, exercises to decrease pain and improve function)
• Treat comorbidities
• Assess treatment outcomes
• Initiate opioid therapy only if the potential benefits outweigh risk and only for as long as it is unequivocally beneficial to the patient
• Therapeutic exercise
• Physical therapy
• Cognitive–behavioral therapy
• Complementary and alternative medicine (CAM; e.g., chiropractic therapy, massage therapy, acupuncture, mind-body therapies, relaxation strategies)

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Part Three: Behavioral Addictions

As you may know, the Diagnostic and Statistical Manual (DSM) is the source of psychiatric diagnoses in the United States. Its updated publications are eagerly anticipated and scrutinized throughout the field of mental health because it holds such significant influence. The language we use to discuss mental health issues, whether or not an insurance company will pay for a certain treatment, and whether a condition is even considered a disorder, are all part of the impact felt by this book. While the diagnostic manual has been criticized (Dr. William Glasser, founder of Reality Therapy, once called it “the most destructive book to human relationships ever written”), it maintains its prominent role in modern American psychology.

Currently, the DSM recognizes only one other addiction besides substance use disorder, and that is gambling disorder. The characteristics of compulsive gambling are quite similar to those found in substance use disorder.

Although other behaviors have yet to receive the same recognition, it is clear that the negative patterns associated with them match our present understanding of addiction. These can include shopping, spending, sex, internet gaming, relationships, eating, and other related behaviors.

As you will see in this section’s video, Dr. Robert Lefever has identified three clusters of addictive behaviors, which he labels as follows:

The Hedonistic Cluster:

• Psychoactive substances such as alcohol, marijuana, heroin, cocaine, prescription pills, and methamphetamine
• Caffeine
• Nicotine
• Gambling
• Sex without regard for the other person

The Nurturement of Self Cluster:

• Food, especially those containing sugar and refined flour
• Bingeing/starving/purging/vomiting
• Shopping and spending
• Work
• Internet and computer use
• Exercise

The Relationship Cluster

• Use of other people (intimate partner or co-workers)
• Compulsive helping

Lefever notes that the outlets within each cluster are related in a way that makes it more likely that a person in recovery will relapse if he or she engages in any of the others in the same cluster. He also notes that people may have addictions in more than one cluster. This concept provides an excellent way of understanding the many faces of addiction. It also points toward the necessity of avoiding other behaviors within the same cluster.

A YouTube element has been excluded from this version of the text. You can view it online here: https://cod.pressbooks.pub/addiction/?p=44

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References

Hoffman, J. & Froemke, S. (Producers). (2007). Addiction (DVD).

Kuerbis, A., Sacco, P., Blazer, D. G., & Moore, A. A. (2014). Substance abuse among older adults. Clinics in geriatric medicine, 30(3), 629–654. https://doi.org/10.1016/j.cger.2014.04.008

National Alliance on Mental Illness. (2015). Dual Diagnosis.

NIDA. 2020, June 2. Principles of Adolescent Substance Use Disorder Treatment. Retrieved from https://www.drugabuse.gov/publicatio...rder-treatment on 2020, September 20.

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Chapter Quiz

A link to an interactive elements can be found at the bottom of this page.