Table of Contents

Chapter 1: Understanding Addiction..................................................................................................1

Overview..................................................................................................................................... 1
The Continuum of Alcohol and Other Drug Use........................................................................ 2
Reinforcers within the Cycle of Addiction ............................................................................. 4
Theories of Causation ............................................................................................................. 6
The Stages of Change ................................................................................................................. 7
Drugs of Abuse ......................................................................................................................... 10
Withdrawal from Drugs of Abuse......................................................................................... 14
What Is Recovery?.................................................................................................................... 15
Stuck Points in Recovery ...................................................................................................... 18
References................................................................................................................................. 19
Optional Resources for Further Reading/Use ....................................................................... 19
Chapter 2: Screening, Intake and Orientation ................................................................................21
Overview................................................................................................................................... 21
Screening................................................................................................................................... 22
Screening Interviews and Instruments .................................................................................. 23
Chemical Testing .................................................................................................................. 24
Assessment................................................................................................................................ 26
Purpose and Definition of Assessment ................................................................................. 26
Information Gathering .......................................................................................................... 27
Data Analysis ........................................................................................................................ 30
Treatment Plan Development ............................................................................................... 30
Criteria for Substance Dependence Diagnosis and Placement ................................................. 31
Diagnostic and Statistical Manual of Mental Disorders, IV-TR........................................... 31
International Classification of Diseases (ICD) ..................................................................... 32
American Society of Addiction Medicine (ASAM), Patient Placement Criteria, 2R .......... 33
Matching Clients with Appropriate Treatment ..................................................................... 33
Risk Assessment ....................................................................................................................... 34
Risk Assessment for Violence .............................................................................................. 34
Risk Assessment for Suicide................................................................................................. 35
Screening and Assessment for Co-Occurring Disorders ...................................................... 36
Engaging the Client in Treatment ............................................................................................. 38
Goals of the Initial Interview ................................................................................................ 38
The Interview Climate .......................................................................................................... 39
Building the Helping Relationship........................................................................................ 39
Communication Techniques ............................................................................................. 40
Building Motivation for Treatment....................................................................................... 41
Overview to Intake and Orientation.......................................................................................... 43
The Intake Process ................................................................................................................ 43
Orientation to Treatment....................................................................................................... 44
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Summary ................................................................................................................................... 45
References................................................................................................................................. 46
Chapter 3: Treatment Theories, Principles and Practices.............................................................49
Evolving Models of Treatment ................................................................................................. 49
Contributions of the 12-Step Approach .................................................................................... 51
Current Perspectives on Addiction Treatment.......................................................................... 51
Changes in the Addiction Treatment Field ........................................................................... 52
Conceptualizing Client Motivation and Change....................................................................... 54
Evidence-based Treatment Practices/Clinical Practice Guidelines .......................................... 55
Special Treatment Considerations: Co-Occurring Disorders ................................................... 58
Special Treatment Considerations: Co-Occurring Disorders ................................................... 59
Mental Health Disorders ....................................................................................................... 59
HIV/AIDS ............................................................................................................................. 60
Physical and Cognitive Disabilities ...................................................................................... 60
Types of Treatment Programs................................................................................................... 61
Detoxification ....................................................................................................................... 62
Outpatient Treatment ............................................................................................................ 63
Residential Treatment ........................................................................................................... 64
Self-Help Groups .................................................................................................................. 64
Medication-Assisted Treatment ................................................................................................ 65
Understanding Relapse ............................................................................................................. 67
Relapse Prevention................................................................................................................ 69
Principles and Procedures of Relapse Prevention................................................................. 70
Client-Counselor Relationship.................................................................................................. 71
Therapeutic Alliance............................................................................................................. 72
Behaviors to Avoid ............................................................................................................... 72
Counseling Skills .................................................................................................................. 73
Helping Traits ................................................................................................................... 73
Active Listening................................................................................................................ 74
Understanding Normal Human Behavior.............................................................................. 75
Emotional Development ....................................................................................................... 75
Developmental Tasks............................................................................................................ 75
Defense Mechanisms ............................................................................................................ 76
Healthy Personality............................................................................................................... 77
Individual Counseling............................................................................................................... 78
Group Counseling ..................................................................................................................... 78
How Is Group Work Different From Individual Counseling?.............................................. 78
Group Counseling Theory..................................................................................................... 79
Stages of Group Development .......................................................................................... 79
Communication in Groups: Content and Interactive Process ........................................... 80
The Counselor as Group Leader ........................................................................................... 81
Stages of Group Treatment ................................................................................................... 81
Groups Commonly Used in Substance Abuse Treatment..................................................... 82

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Educational Groups............................................................................................................... 82
Group Leadership, Concepts, and Techniques ..................................................................... 83
Group Goals and Principles .................................................................................................. 83
Family Counseling .................................................................................................................... 84
Crisis Prevention and Intervention............................................................................................ 86
Defining a Crisis ................................................................................................................... 86
Crisis Prevention and Intervention Models........................................................................... 87
Crisis Prevention................................................................................................................... 87
Verbal De-Escalation ........................................................................................................ 88
Steps in Crisis Intervention....................................................................................................... 91
References................................................................................................................................. 93
Optional Resources for Further Reading/Use ....................................................................... 96
Chapter 4: Case Management and Referral ...................................................................................97
Overview................................................................................................................................... 97
Definition of Case Management ............................................................................................... 98
Functions of Case Management................................................................................................ 99
Case Management Principles.................................................................................................. 101
Strengths-Based Case Management........................................................................................ 103
The Role of Case Manager ..................................................................................................... 103
Service Planning ................................................................................................................. 105
Planning, Goal-setting, and Implementation ...................................................................... 105
Linking, Monitoring and Advocacy........................................................................................ 107
Advantages and Disadvantages of Case Management........................................................ 108
Making It All Work ................................................................................................................ 108
Working Principles of Service Coordination.......................................................................... 111
Making Referrals .................................................................................................................... 112
Summary ................................................................................................................................. 113
References............................................................................................................................... 114
Optional Resources for Further Reading/Use ..................................................................... 116
Chapter 5 Documentation..............................................................................................................117
Overview................................................................................................................................. 117
Role of Documentation ........................................................................................................... 117
Access to Documentation ....................................................................................................... 118
Sharing Information within an Agency............................................................................... 118
Client Access ...................................................................................................................... 119
External Parties ................................................................................................................... 119
Records Retention and Storage............................................................................................... 119
Regulations That Apply to Client Records ............................................................................. 119
Single State Authority (SSA) for Substance Abuse............................................................ 120
Accreditation Bodies........................................................................................................... 120
Third Party Payers............................................................................................................... 120
Provider Agencies............................................................................................................... 120

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Types of Documentation......................................................................................................... 120

Intervention Documentation ............................................................................................... 121
Treatment Documentation .................................................................................................. 121
Screening............................................................................................................................. 122
Comprehensive Assessment................................................................................................ 123
Treatment Plans .................................................................................................................. 124
Progress Notes .................................................................................................................... 126
Discharge Summary............................................................................................................ 127
Elements of a Discharge Plan ......................................................................................... 127
Documentation Skills.............................................................................................................. 128
Some Technical Considerations.......................................................................................... 129
References............................................................................................................................... 130
Chapter 6: Professional and Ethical Responsibility.....................................................................131
Overview................................................................................................................................. 131
Professional Ethics.................................................................................................................. 131
Codes of Ethics ................................................................................................................... 132
Foundations of Ethics ......................................................................................................... 133
Ethical and Moral Decision Making ................................................................................... 133
Guidelines for Ethical Conduct........................................................................................... 135
Confidentiality ........................................................................................................................ 136
Ethical Issues in Confidentiality ............................................................................................. 140
Honoring Diverse Values.................................................................................................... 143
Supervision and Consultation ................................................................................................. 144
Definition of Clinical Supervision ...................................................................................... 144
Models of Supervision ........................................................................................................ 145
Critical Issues in Supervision.............................................................................................. 146
Role of Clinical Supervision in Evidence-Based Practice.................................................. 146
Applicable Laws and Regulations .......................................................................................... 147
The Baker Act ..................................................................................................................... 147
Criteria for Involuntary Placement ................................................................................. 148
The Marchman Act ............................................................................................................. 148
Confidentiality and HIV/AIDS ............................................................................................... 149
Confidentiality of Test Results ........................................................................................... 149
Client Rights ........................................................................................................................... 150
Responding to Individual Differences .................................................................................... 152
Characteristics of Culture ................................................................................................... 153
Major Cultures in the U.S. .................................................................................................. 153
Cultural Competence .......................................................................................................... 155
Evidence of Cultural Competence ...................................................................................... 156
Specific Cultural Groups..................................................................................................... 156
Summary ................................................................................................................................. 157
References............................................................................................................................... 158
Optional Resources for Further Reading/Use ..................................................................... 160

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Chapter 7 Criminal Justice Services ............................................................................................161

Overview................................................................................................................................. 161
The Drug Abuse and Crime Connection................................................................................. 162
Treatment in Criminal Justice Settings ................................................................................... 163
Choosing Candidates for Treatment ................................................................................... 163
The Treatment Service Continuum for Criminal Justice .................................................... 164
Treatment Approaches ........................................................................................................ 165
Recovery Support................................................................................................................ 166
Criminal Law .......................................................................................................................... 167
Classification of Crimes...................................................................................................... 167
Drug Offenses ..................................................................................................................... 168
Juvenile Offenses ................................................................................................................ 168
Drug Courts............................................................................................................................. 169
Core Elements of Drug Courts............................................................................................ 169
Drug Court Program Characteristics................................................................................... 170
Special Populations................................................................................................................. 170
Cultural Minorities.............................................................................................................. 171
Women................................................................................................................................ 171
Juvenile Offenders .............................................................................................................. 172
Treatment Approaches in Specific Correctional Settings....................................................... 172
Pretrial and Diversion Settings ........................................................................................... 173
Jails ..................................................................................................................................... 173
Prisons................................................................................................................................. 173
Community Supervision ..................................................................................................... 174
Levels of Sanctions ................................................................................................................. 174
Juvenile Detention and Commitment Services ....................................................................... 176
Commitment Programs ....................................................................................................... 176
Confidentiality Regulations .................................................................................................... 176
Disclosures without Consent............................................................................................... 177
Disclosures by Court Order ................................................................................................ 178
Summary ................................................................................................................................. 178
References............................................................................................................................... 179
Optional Resources for Further Reading/Use ..................................................................... 180
Chapter 8 - Prevention ......................................................................................................................181
Overview................................................................................................................................. 181
Prevention as a Process of Facilitating Change ...................................................................... 182
Identifying the Target Behavior in Prevention ................................................................... 182
Risk and Protective Factors .................................................................................................... 183
Domains for Risk and Protective Factors ........................................................................... 184
Developmental Assets............................................................................................................. 186
Levels of Prevention Populations ........................................................................................... 187
The Strategic Prevention Framework ..................................................................................... 187
Strategic Prevention Framework Key Principles............................................................. 189
CSAPs Prevention Strategies................................................................................................. 190
Science and Prevention ........................................................................................................... 193
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Logic Models .......................................................................................................................... 194

Adapting Prevention Programs and Activities........................................................................ 196
Adapting for Learning Style ............................................................................................... 196
Adapting for Cultural and Linguistic Relevance ................................................................ 197
Community Coalitions ............................................................................................................ 198
Parents/Families and Prevention............................................................................................. 198
Summary ................................................................................................................................. 200
References............................................................................................................................... 201
Resources for Further Reading/Use .................................................................................... 201
Appendix
1. Florida Entry Level Addiction Professional Role Delineation Study
2. NIDA Drug Chart
3. Florida Clients Rights
4. HIV Confidentiality Summary
5. Marchman Act Summary (Chapter 397, Florida Statutes)

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Chapter 1: Understanding Addiction

Overview
In order to understand and treat substance abuse we need to have some understanding of the
meaning of addiction. Addiction is defined as a chronic disorder precipitated by a combination
of genetic, biological/pharmacological and social factors. It is characterized by compulsive, at
times uncontrollable, drug craving, seeking, and use that persist even in the face of extremely
negative consequences. Drug seeking becomes compulsive, in large part as a result of the effects
of prolonged drug use on brain functioning and, thus, on behavior. For many people, drug
addiction becomes chronic, with relapses possible even after long periods of abstinence.
Dependence is usually accompanied by tolerance and withdrawal and is generally associated
with a wide range of social, legal, psychiatric, and medical problems. Tolerance occurs when
certain drugs are taken repeatedly and the person no longer responds to the drug in the way that
person initially responded. Stated another way, it takes a higher dose of the drug to achieve the
same level of response achieved initially. So for example, in the case of heroin or morphine,
tolerance develops rapidly to the analgesic effects of the drug.
As a consequence of its compulsive nature involving the loss of control over alcohol and other
drug use, addiction is typically a chronically relapsing disorder (IOM, 1990, 1995). Although
individuals who are dependent on a substance can often complete detoxification and achieve
temporary abstinence, they find it very difficult to sustain that condition and avoid relapse over
time. Most persons who achieve sustained remission do so only after a number of cycles of
detoxification and relapse.
The following are key components of addiction/dependence:
1. Compulsion: Compulsion means loss of control or loss of choice. The person feels
compelled to use. Compulsive behavior has a driven quality, as though one is pulled along
by forces out of one's control. Simply making a rational decision to not use is often not
adequate to facilitate stopping a compulsive behavior. Compulsive use is often evident in a
user's unsuccessful attempts to control or regulate use of a substance.
2. Continued use despite adverse consequences: Addiction involves continuing to use even
though one knows it is causing problems. Substance abuse adversely affects relationships,
job functioning, health, finances and the capacity to manage one's life on all levels. The
activity of using assumes priority over other needs, including personal and financial security,
comfort, relationships, health and employment.
3. Craving: Craving often occurs daily or, is experienced with regular binges. The user
experiences intense psychological preoccupation with getting or using the substance. Craving
is marked by dysphoria (an emotional state marked by anxiety, depression, and restlessness).
With the exception of recalling the euphoria of the substance, craving feels very bad.
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4. Denial: Denial involves a true distortion of perception caused by craving. The user, under the
intense pressure of acute craving, is temporarily blinded to the risks and consequences of
using.

The Continuum of Alcohol and Other Drug Use

Currently, clinicians recognize that substance abuse disorders exist along a continuum from risky
or problematic use through varying types of abuse to dependence that meets diagnostic criteria.
Moreover, progression toward increasing severity is not automatic. Many individuals never
progress beyond risky consumption, and others cycle back and forth through periods of
abstinence, excessive use, and dependence. Recovery from substance dependence is seen as a
multidimensional process that differs among people and changes over time within the same
person.
At one end of the continuum, individuals are relatively "disease-free" but engaging in
maladaptive behaviors over which they have some control. These individuals may repetitively
use alcohol and/or other drugs, and over time they may abuse these substances. They choose to
live a certain lifestyle in which their maladaptive behavior may or may not result in other disease
states associated with use (e.g., cirrhosis of the liver). If these individuals stop this negative
cycle they can, perhaps on their own, learn alternative coping mechanisms and self-efficacy.
Individuals at the other end of the continuum, however, seemingly have no control over their use.
Some individuals appear to lose control the first time they use drugs. For these individuals drug
use is like a toggle switch that is either on or off. For them, total abstention is the only
alternative because they have no control processes once the switch is turned on. They may use
until they die unless someone else can turn their switch off and keep it off. There is no logic to
this behavior, and no choice. Users of this type will often ruin their own lives and the lives of
those around them in their drive to use their drugs of choice. It seems that as one moves toward
a more "at-risk" end of the continuum there is less and less control over substance use.
It is unclear what causes the difference in loss of control among those at different points of the
continuum. Researchers do not understand the process very well. They do know that other
factors may exacerbate the process, including biologically based differences in metabolic
processes, different levels of susceptibility to the reinforcing effects of drugs, personality
disorders or depression, and an inability to tolerate frustration or emotional discomfort. Some
processes are under individual control, but many are not, and it does appear that the less control
the individual has over these types of processes, the more likely he or she is to fall into substance
abuse.
During the early stages of substance abuse, the alcoholic or drug abuser experiences increasing
tolerance and use. In the later stages of abuse, life becomes centered on obtaining, using, and
recovering from drug use. Loss of control, ethical deterioration, and noticeable withdrawal
symptoms ensue. It is unclear, however, whether such a progression is inevitable.
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There are four different and distinct categories or stages of addiction, they are: Use, Misuse,
Abuse and Dependency/Addiction. These are defined in the following way:

Use Is the use of drugs or alcohol in a socially accepted or medically sanctioned

manner to modify or control mood or state of mind.
Misuse Is the taking of a drug or alcohol in damaging quantities or in quantities
other than the prescribed dosage, or the use of an illegal drug.
Abuse Is typified by the continued use of alcohol or other drugs in spite of negative
consequences.
Dependency/Addiction Is characterized by the repeated, compulsive seeking or use
of a substance despite adverse social, psychological and/or physical consequences. A
wide range of substances, both legal and illegal, can be abused addictively.

In each stage a series of behaviors or symptoms are prevalent:

Stage 1: Use

The user learns he/she can produce a good feeling by using substances.
The individual uses at parties, under peer pressure, or on weekends.
He/she finds it easy to get drunk or high, due to a lack of tolerance for the substance.
The user learns that substances provide euphoria every time; he/she trusts the effects.
The user controls the use; i.e., regulates quantity to control the mood swing; regulates
frequency of use.
No adverse behavioral effects may be detected; the substance has not yet interfered with
lifestyle.
The user feels good (euphoria), with few consequences.

Stage 2: Misuse

The user, having learned that substances produce good feelings, starts to actively seek
those feelings by planned use of drugs/alcohol.
Planned use involves buying substances.
Tolerance begins to be developed (i.e., the user needs more of the drug to get the same
effect as before).
Use may still be controlled and the effect is anticipated.
Individual uses substance at appropriate times and places; e.g., not at work, not early in
the morning, etc.
Individual develops self-imposed rules about use; e.g., "I won't drink before 5:00 p.m.,"
"I won't drink around my family," etc.
Individual may suffer some slight problems, such as hangovers.

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Stage 3: Abuse

The individual becomes preoccupied with the mood swing.

The individual experiences a cost increase due to high tolerance.
There is an increase in frequency of substance use.
Solitary use occurs.
Loss of control occurs; i.e., getting drunk when not expecting to, using more than
planned, breaking self-imposed rules, inability to predict outcome of use.
Lifestyle begins to change. Individual rearranges life so he/she can continue to use.
Blackouts occur more frequently. ("Blackouts" are memory lapses that occur when the
user is awake and appears to be engaged in normal activity; later, however, the person is
unable to remember what has been said or done.)
The individual uses to cope with feelings, such as anger, guilt, fear, or anxiety.
The individual may be sneaky about getting, using, and hiding substance.
The individual may be irritable, or may become angry easily.
Rationalization and projection occur more frequently. ("Rationalization" is a person's
attempt to explain his/her behavior in order to avoid responsibility. "Projection" is
attributing one's problems to another person.)
The individual violates his/her value system, which contributes to emotional distress.
The individual experiences many consequences, such as deterioration of relationships,
problems at work, financial difficulties, etc.
Denial grows. ("Denial" is a person's way of coping with a painful situation by refusing
to accept it or believe it. By denying the existence of a problem, a person doesn't have to
deal with it or assume any responsibility for it.)
The individual gives up important activities.
Self-esteem decreases.
The individual's physical appearance deteriorates.

Stage 4: Chronic Dependence/Addiction

Individual uses substance to feel normal (physical dependency) and avoid pain (physical
or emotional), rather than for achieving euphoria.
Blackouts are longer and more frequent.
The desire to use the substance becomes most important.
The individual experiences complete loss of control; e.g., arrests, theft, prostitution, etc.
The individual experiences physical problems.
The individual experiences paranoid thinking and fear of insanity.
The individual feels very alone; isolated.
The individual feels a loss of desire to live; may have suicidal thoughts, attempts (CSAT,
1994, TAP 11).

Reinforcers within the Cycle of Addiction

Many factors influence a persons initial alcohol and/or drug use. Personality characteristics,
peer pressure, and psychological stress can all contribute to the early stage of alcohol and drug
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abuse. These factors are less important as drug use continues and the person repeatedly
experiences the potent pharmacological effects of the drug. This chemical action, which
stimulates certain brain systems, produces the addiction, while other psychological and social
factors become less and less important in influencing the individuals behavior. When the
pharmacological action of a drug dominates the individuals behavior and the normal
psychological and social control of behavior is no longer effective, the addiction is fully
developed. This self-perceived "loss of control" is a common feature of drug addiction and
reflects the biological nature of the problem. Addiction, therefore, is typically described in terms
of biological, psychological and social processes.
Psychological aspects: Individuals sometimes choose to use substances in order to enhance the
perceived rewards of other experiences. When used for these reasons, the substance begins to
fulfill multiple functions for the user such as serving to enhance sex, enhance social situations,
boost the user's sense of self-worth, alleviate stress and tension and relieve painful feelings.
As the substance user becomes increasingly dependent upon the drug or alcohol to fulfill unmet
needs and compensate for deficits in coping skills, their capacity to manage life's problems
diminishes. The repertoire of coping skills which one develops and utilizes to manage stress and
regulate self-esteem often atrophy as drug and alcohol use substitute for internal and
interpersonal resources. The individual often becomes locked into a cycle of avoidance. He or
she alleviates stress by using, medicates against painful feelings by using and deals with social
anxiety by using.
As one increasingly relies upon the substance, one becomes
less adept at coping. Confidence in managing one's moods
and regulating self-esteem are lost.
Biological aspects: Alcohol and other drugs significantly
affect the reward/pleasure centers in the brain's mesolimbic
system, which plays a large part in experiencing pleasure in
whatever people find rewarding, things such as chocolate,
sex or a job well done. Addiction alters the pathways in the
brain's pleasure centers, stealing the brain's normal ability to
experience pleasure. For example, when a person ingests an
addictive drug, the brain is flooded with a neurotransmitter
called dopamine which is strongly related to the experience
of pleasure. Normally, when people experience something
pleasurable, the brain releases more dopamine. The current
thinking is that the problem with chronic use of addictive drugs is that flooding the brain with
dopamine causes it to begin to generate less of its own in an effort to maintain some kind of
chemical balance. Thus, the chronic user of addictive drugs loses his/her ability to experience
pleasure from the normal life experiences creating the dependency on the drug to experience
pleasure. Ultimately, it can become a ceaseless craving for the drug.

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Injury caused by insensitivity in pleasure centers causes the user to feel the opposite of the drug
euphoria. Sobriety starts to feel the opposite of the euphoric drug-induced state. Sobriety starts
to become associated with dysphoria and discomfort, and the drug-induced state can be
perceived as the normal, balanced place to be.
Co-occurring mental health and substance use disorders and addiction are another important
biological consideration. If a person suffers from depression or anxiety, they may use substances
to medicate uncomfortable feelings. For the persons with co-occurring disorders, receiving
psychiatric treatment with medication often helps stabilize one's baseline mood, which in turn
facilitates recovery or sobriety.
Social aspects: Due to the social networks woven between users, substances often become a
crucial part of one's identity and social fabric. A culture, sense of ritualized bonding and
belonging develop around the substance and its users. The substance serves as a social lubricant,
dissolving inhibitions, social discomfort and tension.
By understanding the biological, social and psychological factors that create powerful
reinforcements of the addictive cycle, we can appreciate the immense challenge involved in
breaking the cycle of addiction. Recovery means withstanding physiological and psychological
discomfort, learning new skills and finding other sources of pleasure and self-worth.

Theories of Causation
The mechanism of addiction has been investigated by many researchers and various models
related to substance addiction in humans have been presented. Several explanations (or
"models") have been presented to explain the
causation of addiction:
Dr. E.M. Jellinek is recognized as the premier

researcher in the field of alcoholism, and was

The moral model states that addictions are the
strongly influential as a proponent of alcoholism
result of human weakness, and are defects of
as a disease. He even went on to typify drinkers
character. Those who advance this model do
into four classes, with the two most severe
not accept that there is any biological basis for
classes being alcoholics. His writings and
addiction. They often have scant sympathy
descriptions did more for the acceptance of the
for people with serious addictions, believing
disease concept of alcoholism and of A.A. as a
respectable therapeutic modality than any other
either that a person with greater moral
medical force of the time. Most every person in
strength could have the force of will to break
A.A.-based recovery centers in this country
an addiction, or that the addict demonstrated a
great moral failure in the first place by starting encounters the "Jellinek Curve," which describes
the progression of the disease.
the addiction. Elements of the moral model,
especially a focus on individual choices, have
found enduring roles in other approaches to the treatment of dependencies.

The disease model holds that addiction is an illness, and comes about as a result of the
impairment of healthy neurochemical or behavioral processes. While there is some dispute

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among clinicians as to the reliability of this model, it is widely employed in therapeutic

settings. This popular model of addiction is credited to E.M. Jellinek who presented a
comprehensive disease model of alcoholism in 1960. The World Health Organization
acknowledged alcoholism as a serious medical problem in 1951, and the American Medical
Association declared alcoholism as a treatable illness in 1956. Following Jellinek's work, the
American Psychiatric Association began to use the term disease to describe alcoholism in
1965, and the American Medical Association followed in 1966. As with many concepts and
theoretical models in the addiction field, the disease concept was originally applied to
alcoholism and has been generalized to addiction to other drugs as well. The "disease of
addiction" is viewed as a primary disease. That is, it exists in and of itself and is not
secondary to some other condition.

The genetic model posits a genetic predisposition to certain behaviors. It is frequently noted
that certain addictions "run in the family," and while researchers continue to explore the
extent of genetic influence, there is strong evidence that genetic predisposition is often a
factor in dependency. Researchers have had difficulty assessing differences, however,
between social causes of dependency learned in family settings and genetic factors related to
heredity.

The cultural model recognizes that the influence of culture is a strong determinant of
whether or not individuals fall prey to certain addictions. For example, alcoholism is rare
among Saudi Arabians, where obtaining alcohol is difficult and using alcohol is prohibited.

The blended model attempts to consider elements of all other models in developing a
therapeutic approach to dependency. It holds that the mechanism of dependency is different
for different individuals, and that each case must be considered on its own merits.

The Stages of Change

Recent evidence suggests that there are definite stages people go through when dealing with the
cessation of an addiction. This seems to be the case with both people who eliminate addictions
on their own and those who seek the assistance from professionals. It has long been known that
addictions, by their very nature, are hard to break and many attempts at cessation result in
failure.
The transtheoretical stages-of-change model (Prochaska and DiClemente, 1984) emerged from
an examination of 18 psychological and behavioral theories about how change occurs, including
components that make up the bio-psychosocial framework for understanding addiction. The five
stages of change are precontemplation, contemplation, preparation, action, and maintenance.
These stages can be conceptualized as a cycle through which clients move back and forth. The
stages are not viewed as linear, such that clients enter into one stage and then directly progress to
the next. Framing clients' treatment within the stages of change can help the clinician better
understand clients' treatment progress (CSAT, 1999, TIP 35).
This model also takes into account that for most people with substance abuse problems,
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recurrence of substance use is the rule, not the exception. After a return to substance use, clients
usually revert to an earlier change stage--not always to maintenance or action, but many times to
some level of contemplation. In this model, recurrence is not equivalent to failure and does not
mean that a client has abandoned a commitment to change.

The stages of change are (CSAT, 1999):

Precontemplation - Not yet acknowledging that there is a problem behavior that

needs to be changed.
Contemplation - Acknowledging that there is a problem but not yet ready or sure
of wanting to make a change.
Preparation - Getting ready to change.
Action - Changing behavior.
Maintenance - Maintaining the behavior change or Relapse (Returning to older
behaviors and abandoning the new changes).

Stage One: Precontemplation

During the precontemplation stage, substance-using persons are not considering change and do
not intend to change behaviors in the foreseeable future. They may be partly or completely
unaware that a problem exists, that they have to make changes and that they may need help in
this endeavor. Alternatively, they may be unwilling or too discouraged to change their behavior.
Individuals in this stage usually have not experienced adverse consequences or crises because of
their substance use and often are not convinced that their pattern of use is problematic or even
risky.
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Stage Two: Contemplation

As these individuals become aware that a problem exists, they begin to perceive that there may
be cause for concern and reasons to change. Typically, they are ambivalent, simultaneously
seeing reasons to change and reasons not to change. Individuals in this stage are still using
substances, but they are considering the possibility of stopping or cutting back in the near future.
At this point, they may seek relevant information, reevaluate their substance use behavior, or
seek help to support the possibility of changing behavior. They typically weigh the positive and
negative aspects of making a change. It is not uncommon for individuals to remain in this stage
for extended periods, often for years, vacillating between wanting and not wanting to change.
Stage Three: Preparation
The decisional balance tips in favor of change when an individual perceives that the envisioned
advantages of change and adverse consequences of substance use outweigh any positive features
of continuing use at the same level and maintaining the status quo. An individual enters the
preparation stage, during which commitment is strengthened. Preparation entails more specific
planning for change, such as making choices about whether treatment is needed and, if so, what
kind. Preparation also entails an examination of one's perceived capabilities--or self-efficacy-for change. Individuals in the preparation stage are still using substances, but typically they
intend to stop using very soon. They may have already attempted to reduce or stop use on their
own or may be experimenting now with ways to quit or cut back. They begin to set goals for
themselves and make commitments to stop using, even telling close associates or significant
others about their plans.
Stage Four: Action
Individuals in the action stage choose a strategy for change and begin to pursue it. At this stage,
clients are actively modifying their habits and environment. They are making drastic lifestyle
changes and may be faced with particularly challenging situations and the physiological effects
of withdrawal. Clients may begin to reevaluate their own self-image as they move from
excessive or hazardous use to nonuse or safe use. For many, the action stage can last from 3 to 6
months following termination or reduction of substance use. For some, it is a honeymoon period
before they face more daunting and longstanding challenges.
Stage Five: Maintenance (or Relapse)
During the maintenance stage, efforts are made to sustain the gains achieved during the action
stage. Maintenance is the stage at which people work to sustain sobriety and prevent recurrence.
Extra precautions may be necessary to keep from reverting to problematic behaviors. Individuals
learn how to detect and guard against dangerous situations and other triggers that may cause
them to use substances again. In most cases, individuals attempting long-term behavior change
do return to use at least once and revert to an earlier stage. Recurrence of symptoms can be
viewed as part of the learning process. Knowledge about the personal cues or dangerous
situations that contribute to recurrence is useful information for future change attempts.
Maintenance requires prolonged behavioral change--by remaining abstinent or moderating
consumption to acceptable, targeted levels--and continued vigilance for a minimum of 6 months
to several years, depending on the target behavior.

Certification Exam Study Guide

Florida Certification Board

Drugs of Abuse
People abuse drugs that are both illegal substances and drugs that can be obtained legally
through prescriptions. Over the last few years the abuse of drugs obtained through prescriptions
or stolen from pharmacies has become a serious problem. There are six main types of drugs that
are considered mind-altering. The following descriptions of these drug classifications provide
very brief summaries. See Appendix A for selected fact sheets that contain detailed information
about some of the most common drugs of abuse.
Stimulants
Stimulants are used to relieve tiredness and increase alertness. Nicotine, from tobacco, is a
stimulant. Cocaine and amphetamines are much stronger types of stimulants. People who use
stimulants develop tolerance, which means that they must take larger and larger amounts of the
drug to get the same effects. The more drugs the person takes, the higher the chance is that they
will become addicted. The most common stimulants are cocaine, crack cocaine, amphetamines,
methamphetamine, nicotine, and caffeine.
Possible effects: Increased heart and respiratory rates, elevated blood pressure, dilated pupils
and decreased appetite; high doses may cause rapid or irregular heartbeat, loss of
coordination, collapse; may cause perspiration, blurred vision, dizziness, a feeling of
restlessness, anxiety, delusions
Symptoms of Overdose: Agitation, increase in body temperature, hallucinations, convulsions,
and possible death
Withdrawal Syndrome: Apathy, long periods of sleep, irritability, depression, and
disorientation
Narcotics/Opioids
The term "narcotic," derived from the Greek word for stupor, originally referred to a variety of
substances that dulled the senses and relieved pain. Today, the term is used in a number of ways.
Some individuals define narcotics as those substances that bind at opiate receptors while others
refer to any illicit substance as a narcotic. In a legal context, narcotic refers to opium, opium
derivatives, and their semi-synthetic substitutes. Narcotics are used in medicine to relieve pain.
They dull the senses, and can cause sleepiness. They are very addictive with continued use. The
most common narcotics are opium, morphine, heroin, codeine fentanyl, oxycontin,
destromethorphan, methadone, buprenorphine, and naloxone.
Possible effects: Euphoria, drowsiness, respiratory depression, and constricted (pin-point)
pupils
Symptoms of Overdose: Slow, shallow breathing, clammy skin, convulsions, coma, possible
death
Withdrawal Syndrome: Early symptoms include watery eyes, runny nose, yawning, and
sweating. Restlessness, irritability, loss of appetite, nausea, tremors, and drug craving appear
10

Certification Exam Study Guide

Florida Certification Board