1. Substance Use Disorders: A Primer on Treatment
Kirk A. Weaver, Ph.D., LCPC, LCAC, MAC, NCC
Certified Clinical Mental Health Counselor
Director of Clinical Services
CKF Addiction Treatment

2. Addiction Defined, Part 1
Primary, chronic disease of
Brain reward
Motivation
Memory
Related circuitry

3. Addiction Defined, Part 2
Leading to dysfunction
Biological
Psychological
Spiritual
Social

4. Addiction Defined, Part 3
Resulting in
Inability to abstain
Impairment in behavioral control
Craving
Trouble in recognizing significance of behavior
Dysfunctional emotional response

5. Two Broad Categories of Addiction
Substance Use Disorders (SUD), or chemical addiction
Process or behavioral addiction

6. Examples
Substance
Process
Alcohol
Heroin
Tobacco
Gaming
Gambling
Food

7. Today’s focus is on substance addiction.

8. Addiction is a disease of the brain.

9. The addicted brain is damaged in three areas:
Positive motivation and “reward circuit” (basal ganglia)
Emotion modulation and “stress circuit” (extended amygdala)
Executive function and “deliberation circuit” (prefrontal cortex)

10. Damage to the prefrontal cortex means
Decreased ability in solving problems
Increased likelihood of making poor decisions
Higher probability of acting without thinking

11. People struggling with addiction
Lose their ability to manage their own behavior
Impaired autonomy

12. Is choice involved? Of course! But what starts as a choice
Can become a compulsion

13. One’s understanding of addiction is important
Lack of willpower?
Solution: more resolve
Lack of faith?
Solution: more spirituality
Lack of conscience?
Solution: more incarceration

14. If addiction is a disease, then treat it as such.

15. Everything changes. Perspective matters.

16. Even the language is different
“Traditional” Model
Disease Model
Addict
Relapse
Sobriety
Relapse Prevention
Person with Addiction
Flare-Up
Recovery
Recovery Management

17. As a disease, addiction must be managed
2000 issue of Journal of the American Medical Association
The following flare-up rates were compared for patients with
Hypertension (50-70%)
Asthma (50-70%)
Substance use disorders (40-60%)

18. Success rates for CKF are within that range.

19. An important difference between
ADDICTION
Inability to stop use
Failure to meet obligations
MAYBE tolerance and withdrawal
PHYSICAL DEPENDENCE
Tolerance
Withdrawal

20. Diagnostics Using the DSM-5
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

21. Substance-Related and Addictive Disorders
Substance Use Disorders
Substance-Induced Disorders
Substance Intoxication and Withdrawal
Substance/Medication-Induced Mental Disorders

22. Ten Categories of Substances
Alcohol
Caffeine
Cannabis
Hallucinogen
Inhalant
Opioid
Sedative/Hypnotic/Anxiolytic
Stimulant
Tobacco
Other (or Unknown)

23. DSM-5 Diagnostic Criteria Groups
Impaired Control (Criteria 1-4)
Social Impairment (Criteria 5-7)
Risky Use (Criteria 8-9)
Pharmacological (Criteria )

24. DSM-5 Diagnostic Criteria Severity
Mild: Presence of 2-3 symptoms
Moderate: Presence of 4-5 symptoms
Severe: Presence of 6 or more symptoms

25. So let’s talk about treatment.

26. What needs to be said here?
Money better spent on prevention
But people are suffering
Major assumption
People want relief from suffering

27. People use To get high/intoxicated To get symptom relief
E.g., from pain (emotional or physical)
Stress
To avoid withdrawal symptoms

28. So when you encounter a patient, you must
Determine context and severity of substance use
Examine medical, psychological, social history
Understand treatment history
Factor in your underlying assumptions
Remember our discussion in the first part of this presentation?

29. AND
Determine
Level Of
Patient
Motivation

30. Most providers in KS utilize a simple rubric
Transtheoretical Model of change (TTM)
Developed by Prochaska and Di Clemente et al. in 1977
Five-stage model of change based on
Specific stages
Identifiable processes between stages
Decisional balance
Self-efficacy

31. TTM Stages Precontemplation Contemplation Preparation Action
Maintenance

32. Treatment options depend on
Availability
Provider preferences
Patient choice (most important)

33. Four choices Medication-assisted treatment (MAT)
Other professional-partnered treatment
Community support treatment
Combination of any of the above

34. MAT Only available for alcohol, opioid, and nicotine use disorders
“Available” meaning approved by FDA
Alcohol (acamprosate, naltrexone, disulfiram, topiramate)
Opioids (naloxone, buprenorphine, naltrexone, methadone)
Lofexidine hydrochloride (non-opioid)

35. Commonly-Used Formulations, Part 1
Naltrexone extended-release (Vivitrol injection) for both alcohol and opioids
Methadone hydrochloride (Methadose, Dolophine) for opioids
Buprenorphine (Probuphine injection) for opioids
Buprenorphine/naloxone (Suboxone, Sublocade, Zubsolv, Cassipa, Bunavail) for opioids

36. Commonly-Used Formulations, Part 2
Acamprosate (Campral) for alcohol
Disulfiram (Antabuse) for alcohol
Naltrexone (including Vivitrol injections) for alcohol
Topiramate (Topamax) for alcohol

37. Commonly-Used Formulations, Part 3
Nicotine replacement therapies
Transdermal nicotine patch
Nicotine spray
Nicotine gum
Nicotine lozenges

38. Commonly-Used Formulations, Part 4
Bupropion hydrochloride (Zyban, Wellbutrin) for nicotine
Varenicline (Chantix) for nicotine

39. Notice how nicotine was included?
Part of a nationwide effort toward tobacco-free treatment facilities
CKF started in August 2018 with promising results

40. MAT means just that: Medication that is
Prescribed
Dispensed
Managed
Under supervision from a qualified med provider

41. Any MAT-related treatment
Should include
Behavioral health (BH) interventions
Provided by
Qualified BH practitioner(s)

42. BH Treatment for SUD Is not Is Ignoring presenting problem(s)
Dictating “the” solution
Focusing solely on deficits
Solving the issue
Non-directional
Providing symptom relief
Exploring options to heal
Promoting wellness
Teaching how to be creative
Joint alliance with a definite goal

43. Whatever the BH treatment approach,
The goal is disease management (remember our discussion?)
To manage the disease is to manage the self
People with impaired autonomy need help
The key is to develop a realistic, actionable recovery managment plan
In older parlance, a “relapse prevention” plan

44. What is a realistic goal?
Abstinence?
Harm reduction?

45. It depends.
On the patient
On the practitioner
On the context

46. Know your values
Know your practice location and its strengths/limitations
Know your referral sources

47. Once that goal is set A recovery management plan can be developed
Realistic
Actionable

48. Recovery Management Plan (RMP)
Similar to managing other chronic diseases
Requires thinking and planning
Involves others
Family
Friends
Specialists

49. Development of a good RMP
Self-awareness and reflection
Flare-ups (relapse) as a process vs. an event
Recognition requires willingness to learn

50. Elements of a good RMP (ADAPT)
Acknowledge early warning signs and triggers
Detail the worst possible scenario(s) and how to cope
Accept help from “emergency recovery team”
Play on strengths
Trend healthward

51. Working with persons in recovery
Social support (family and friends)
Community support groups (12-step, other)
Professional support

52. Community support groups
12-step groups
E.g., AA, NA, CA, SA, Celebrate Recovery, DRA
Alternative groups
E.g., SMART Recovery, Moderation Management, LifeRing

53. BH treatment can include
Recovery Coach
Case Manager
Medical professional (physician, nurse, etc.)
Licensed BH provider

54. BH treatment can include
Coaching
Case management
Didactic/psychoeducation
Counseling/therapy
Usually individual and group
Occasionally couples and/or family

55. Types of BH interventions
Evidence-based interventions are fashionable
Cf managed care
Almost any approach can be used when treating SUD
BUT the gold standards include
Motivational Interviewing (MI) and Motivational Enhancement Therapy (MET)
Cognitive-behavioral therapy (CBT)

56. Examples of Behavioral Treatments, Part 1
Mindfulness-based interventions
Rational-Emotive Therapy, cognitive-behavioral therapy
Acceptance and commitment therapy (ACT)
Exposure therapies (EMDR, aversion therapy)
Programs: T4C; Moral Reconation Therapy
Dialectical behavioral therapy (DBT) can apply as well

57. Examples of Behavioral Treatments, Part 2
Functional analytic psychotherapy (FAP)
Contingency Management/Motivational Incentives

58. Examples of Other BH Interventions
Community Reinforcement Approach (CRA)
Twelve-Step Facilitation (TSF)
Brief Eclectic Psychotherapy (BEP)

59. CKF offers many ways to help patients
Assessments (substance use, mental health, BIP)
Interventions (anger management, ADIS, Pathfinder)
Treatment (residential and outpatient SUD treatment; BIP)
Medication-Assisted Treatment (MAT) for alcohol and opioids

60. Thank you for coming!

61. Sources and Resources
American Association of Addiction Medicine (
CKF Addiction Treatment (
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
National Institute on Drug Abuse (
Pro-Change Behavior Systems (
Substance Abuse and Mental Health Services Administration (