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Help Me! Full Assessment of a Case Study Client Name: Roberta Assessment Date: February 4, 2024 Substance Use History Drug First Use: Yes or No Pattern of use over time? Frequency of use in past month? Date/Amount of most recent use? Prescribed Muscle relaxants, and pain medication. (Opioids) Yes There is a pattern of use overtime. The frequency of use within the past month is undisclosed. The amount of use is undisclosed. It is assumed that Roberta used within the past 24 hours as she has disclosed obtaining medication from her peers. Diagnostic Criteria Checklist Criteria Yes No Criteria Yes No Was the substance taken in larger amounts or over a longer period of time than intended? X Were important social, occupational, or recreational activities given up or reduced because of substance use? X Is there a persistent desire or unsuccessful efforts to cut down or control substance us? X Has the substance been used recurrently in physically hazardous situations? X Was a great deal of time spent in activities necessary to obtain or use the substance, or recover from the substance? X Has use continued despite knowing of having a persistent or recurrent physical or psychological problem that is caused or exacerbated by substance use? X 1

Criteria Yes No Criteria Yes No Have they continued to use the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the substance use? X Has recurrent use of the substance resulted in a failure to fulfill major role obligations at work, school, or home? X Is tolerance present? X Is withdrawal present? X Is there a craving or strong desire or urge to use the substance? X DSM-5-TR Diagnosis: Severe Opioid Use Disorder DSM-5-TR Diagnostic Code: 304.00 (F11.20) Assessment Analysis 2

Basis of Diagnosis Roberta, a 16-year-old high school student, exhibits over six indicators outlined in the diagnostic checklist for opioid use disorder, suggesting a basis for diagnosis. She discloses a significant leg injury in October, for which she received prescribed pain medication and muscle relaxers. During the interview, Roberta displays restlessness, indicative of early withdrawal symptoms from opioids, implying recent usage within the past 24 hours (Jacques, 2020). Roberta mentions her inability to participate in the school swim team without pain medication due to persistent pain. Despite being unable to obtain a prescription, she resorts to purchasing pain medication from peers, resulting in academic decline and a disregard for financial consequences. These observations collectively point to clear indications of opioid misuse. Applicable Theory Roberta's reliance on opioids originated with prescribed pain medication from her doctor following a leg injury. Despite the cessation of medication from her original doctor, Roberta continues to obtain the pain medication illicitly through peers, emphasizing persistent pain and an inability to engage in sports. Expressing the desire for a prescription from another doctor due to her current inability to obtain it from the initial prescriber, Roberta exhibits clear signs of drug-seeking behavior. Her insistence on ongoing pain, despite being discontinued from the medication by a doctor, raises concerns about opioid-induced hyperalgesia, a phenomenon where prolonged opioid use may amplify pain perception (Boyaji, 2019). The combination of drug-seeking behavior, academic decline, illicit acquisition of the drug, evident withdrawal symptoms, and developing tolerance collectively indicates a severe opioid use disorder. Sociocultural Factors Roberta discloses an absence of substance use disorder (SUD) in her personal history before her involvement with opioids, and there's no indication of SUD within her parents. Despite the noticeable concerns expressed by significant adults in her life – evident through declining academic performance, a shift from being a star athlete to non-participation, and the depletion of funds from her part-time job – Roberta remains oblivious to the gravity of her opioid use. Her parents, alarmed by her behavior, strongly recommend seeking professional help, underscoring that SUD was not a pre-existing issue within the household. Despite these concerns and recommendations, Roberta continues to socially accept her ability to purchase opioids from friends. Unfazed by spending all her money on medication, she holds the belief that doctors should persist in prescribing the medication. Strikingly, she places blame on the medical professionals for her resorting to obtaining opioids from peers, showcasing a concerning lack of awareness regarding the severity of her situation and its impact on her well-being. Motivation for Change and Relapse Prevention Roberta displays a notable lack of concern for her opioid use and exhibits little interest in altering her behavior. The fact that she actively seeks a prescription and insists on the continued necessity of the medication suggests an understanding on her part of the severity of her opioid addiction. Recognizing the potential benefits of familial support and substance use disorder (SUD) treatment, I plan to initiate discussions with Roberta about the risks associated with opioid abuse. By exploring her willingness to cut down and evaluating her responses, I aim to gain insights into Roberta's readiness to address her SUD. Encouraging her to involve her parents in therapy and motivating her to explore available treatment options, I intend to collaborate with both Roberta and her family in addressing her SUD ("Fundamentals of Addiction: Motivation and Change," n.d.). 3

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However, despite these efforts, it appears that Roberta is currently resistant to change and remains inclined to continue purchasing opioids. I have communicated to her that I will be available when she is ready to seek help. Unfortunately, her current unwillingness to acknowledge the severity of her opioid disorder suggests a likelihood of relapse within the treatment process. Ethical Considerations In addition to delineating specific ethical standards, NAADAC proposes the consideration of the following factors when making ethical decisions: 1. Autonomy: Upholding the principle that individuals have the right to make choices and determine their own paths. 2. Obedience: Acknowledging the responsibility to adhere to legal and ethical directives. 3. Conscientious Refusal: Recognizing the obligation to decline carrying out directives that are illegal or unethical. 4. Beneficence: Embracing the duty to contribute to the well-being and assistance of others. 5. Gratitude: Committing to passing forward the goodness received to others. 6. Competence: Ensuring possession of the requisite skills and knowledge for effective client treatment, and staying current with treatment modalities, theories, and techniques. 7. Justice: Upholding the values of fairness and equal treatment, treating others justly and equitably. 8. Stewardship: Utilizing available resources judiciously and conscientiously, with a commitment to giving back. 9. Honesty and Candor: Maintaining truthfulness in all interactions with clients, colleagues, business associates, and the community. 10. Fidelity: Remaining true to one's word, honoring promises and commitments. 11. Loyalty: Acknowledging the responsibility not to abandon those with whom one works. 12. Diligence: Committing to hard work, mindfulness, and thoroughness in the chosen profession and in the delivery of services. 13. Discretion: Exercising good judgment, respecting confidentiality, and upholding the privacy of others. 14. Self-improvement: Committing to continuous professional and personal growth, striving to reach one's maximum potential. 15. Non-malfeasance: Adhering to the principle of doing no harm to the interests of the client, ensuring actions prioritize the well-being of those under care. 16. Restitution: Recognizing the responsibility to make amends when necessary, particularly to those who have been harmed or injured as a result of professional activities. 4

17. Self-interest: Acknowledging the importance of protecting oneself and personal interests while maintaining ethical standards and responsibilities (Code of Ethics, n.d.). Confidentiality In addiction treatment, confidentiality is the cornerstone, with privacy and protection being the foremost responsibilities of addiction professionals. We are committed to securely maintaining documentation in accordance with HIPAA and 42 CFR Part 2 regulations. It is our duty to inform clients about how their records will be stored, maintained, and accessed, ensuring compliance with federal and state guidelines. Access to records is limited to authorized professionals only. We prioritize safeguarding the confidentiality of individuals mentioned in the records and grant clients limited access upon written request. As part of our ethical practice, we create and adhere to treatment plans. Keeping clients informed about how information is shared is integral to our approach. We strictly adhere to confidentiality norms, ensuring that mandated disclosure only occurs with written consent, not verbal. Furthermore, we are dedicated to protecting the rights of minors or adults lacking the capacity to provide consent. For clients like Roberta, who is a minor, I will steadfastly maintain confidentiality, refraining from disclosing records to parents and explaining the constraints of confidentiality within the ethical framework (Code of Ethics, n.d.). Appropriate Relationships When professionals agree to offer services to an individual through a third party, it is imperative to clearly define the relationship with each involved party and establish the limitations of confidentiality. Providers will exert every effort to steer clear of developing relationships with the immediate family, coworkers, or close friends of the client or the client's family. In instances where a dual relationship is unavoidable, professionals will take meticulous steps to safeguard the client's privacy. They must acknowledge the potential risks associated with taking on a client with whom they share a previous personal relationship. Seeking consultation or supervision, professionals will document the recommendations provided. It is crucial for professionals to ensure that their judgment remains unimpaired and that they do not exploit the client, adhering to the ethical principles outlined in the Code of Ethics (n.d.). References Code of Ethics. (n.d.). NAADAC . https://www.naadac.org/code-of-ethics Fundamentals of Addiction: Motivation and Change. (n.d.). CAMH . https://www.camh.ca/en/professionals/treating-conditions-and-disorders/fundamentals-of-addiction/f-of-4 addiction---motivation-and-change#:~:text=Increasing%20motivation%20involves%20exploring%20with %20patients%20their%20answers,be%20ready%20to%20cut%20down%20or%20stop%3F%22%20 Jacques, E. (2020). How Long Does Withdrawal from Opioids Last? Verywell Mind . https://www.verywellmind.com/opioid-withdrawal-2564485 Boyaji, S., MD. (2019). More opioids, more pain: Fueling the fire. Harvard Health . https://www.health.harvard.edu/blog/more-opioids-more-pain-fueling-the-fire-2019070817024 5

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