Grace Belt_U5A1_ Assessment of Addiction and Co-occurring Disorders (1)

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Running head: ASSESSMENT OF ADDICTION 1 Unit 5 Assignment: Assessment of Addiction and Co-occurring Disorders Grace C. Belt COUN5108: Foundations of Addiction and Addictive Behavior Dr. Lawrence Pennington November 14, 2021

ASSESSMENT OF ADDICTION 2 An opioid use disorder can be diagnosed by a clinician if the client meets at least two of the eleven criteria, occurring within a year. Clinical features can be distinguished by determining when the client began using it, how long they have used it, whether it is self-administered, why they take it, and patterns of usage. People with opioid use disorders often experience opioid-related disorders. The symptoms of opioid-induced disorders may mimic those of primary mental disorders. Compared to other opioid-induced disorders, opioid intoxication and opioid withdrawal have more severe symptoms that call for independent medical treatment. Interacting with patients who are suspected to suffer from a substance use disorder (SUD) - and who may deny they have such a disorder - can often result in a confrontational, emotional situation (Ducharme & Moore, 2019). It may be stressful to both the caregiver and the patient. Minimizing such an emotional response and avoiding escalation of situations are critical in providing compassionate and optimal care. A high prevalence of comorbid conditions is associated with opioid use disorder. A toxicology test is therefore necessary to find out if there are other drugs present as well as to check levels of opioids. People who have opioid use disorder are at risk for developing mild to moderate symptoms of depression, which meet the criteria for persistent depression or, in some cases, major depression. Depressive symptoms may be a result of opioid use or a manifestation of primary depression. People with opioid use disorder are more likely to experience periods of depression during chronic intoxication or as a result of physical or psychological stressors. Most commonly, people with opioid use disorder experience insomnia during withdrawal (Morgen, 2017). These communities continue to be affected by the opioid epidemic. Combining a validated risk assessment tool with standardized clinical examinations, along with urine drug

ASSESSMENT OF ADDICTION 3 screening, improves the ability to detect opioid misuse. Tools such as the COMM, ORT, PMQ, and SOAPP®-R can be useful to assess risk (Whiston, 2020). Assessment Tools Assessment requires the caregiver to use a standardized systematic approach to all clients who will be receiving (or are at risk of misusing) opioids. Practitioners are encouraged to embrace a “universal precautions'' and rational approach to the treatment of pain (Whiston, 2020). Many studies have examined the prevalence of SUD and non-medicinal opioid use in specific populations, including those suffering from chronic pain. Important risks to patients who are prescribed opioids for pain include death, overdose and the development of an OUD. Given the enormous burden of opioid addiction, chronic non-cancer pain guidelines strongly suggest screening all patients for risk of substance abuse, misuse, and addiction before prescribing opioids (Whiston, 2020). Quantifying that risk can be challenging, especially in regards to Ji-woo’s accident and the immense pain she was in afterwards, even as a young healthy female. There are various assessments that are relevant to Ji-woo’s case. The Current Opioid Misuse Measure (COMM) is a 17-question patient assessment tool designed to identify ADRB’s during chronic opioid therapy (Marsden, et al., 2019). The Opiod Risk Tool (ORT) is a 5-question screening tool designed for use in adults to assess the risk for opioid abuse or ADRB (Marsden, et al., 2019). A score is given for a range of responses on each of the 5 items and the total used to predict for low, moderate or high risk for ADRB. The Patient Medication Questionnaire (PMQ) is a 26-question assessment tool using 0–4 point scale to assess ADRB in patients already taking opioid medications for pain (Marsden, et al., 2019). The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP®-R) is a 24-question screening tool, and is a revision of the original SOAPP®. It is designed to predict ADRB prior to initiation of

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ASSESSMENT OF ADDICTION 4 long-term opioid therapy (Varney, et al., 2018). Clinicians should also consider risk assessments such as urine drug monitoring to prevent opioid misuse (Whiston, 2020). Applicability of Assessments to Diverse Populations Opioid use disorder risk assessment tools cannot be used in isolation. In combination with standardized clinical examination, and, when indicated, urine drug screening, a validated risk assessment tool, improves the ability to detect opioid misuse (Whiston, 2020). Even though no single tool has been shown to have both high interobserver reliability and high sensitivity, the standardized approach has still been shown to be superior to subjective care giver assessment (Ducharme & Moore, 2019). None of the risk assessment tools are able to predict perfectly which patients will ultimately suffer from Opiate Use Disorder (OUD) if prescribed opioids in their pain management. Of the tools used to assess risk for Aberrant Drug Taking Behaviors (ADRBs) in patients being considered for opioid therapy, such as Ji-woo, the SOAPP-R, and ORT most accurately add to the clinician’s ability to predict OUD risk. Each instrument has unique limitations and validity across different populations is unclear. Ji-woo’s Korean decent is a factor in treatment and should be considered throughout the counseling and assessment process. Once clients such as Ji-woo have initiated opioid therapy and transitioned to long-term opioid therapy, the PMQ and the COMM appear to be somewhat better than other tools to predict the development of ADRB in that setting. Despite relatively weak evidence to support the use of any one tool for specific cultures or ethnicities, recommendations strongly encourage use of risk assessment tools prior to initiating opioid therapy (Ducharme & Moore, 2019). Risk assessment should be repeated regularly during the course of opioid therapy. To optimize a combination of universal precautions and risk assessment prior to prescribing, clinicians should also make use of urine drug screening to provide the most consistent approach for opioid risk assessment

ASSESSMENT OF ADDICTION 5 (Ducharme & Moore, 2019). Ji-woo’s familial ties and Korean culture will impact the course of treatment no matter the assessments utilized, but picking the most effective assessment tools is crucial for the individual success of Ji-woo in opioid addiction recovery. Differential Diagnosis Differential diagnosis is a process of removing diagnoses based on the common factors. A differential diagnosis includes as many of the diseases or conditions that could cause the patient's condition or symptoms that you can think of (APA, 2014). The clinician will try to narrow the list down (there's usually a few "usual suspects" at the top of a differential diagnosis list) to get to the diagnosis. Once the clinician has a firm grasp of where the client’s issues stem from, they can establish a treatment plan. Sometimes the most common issues that could cause the client's symptoms are not what they actually have, so the clinician has to go down the differential diagnoses list and test for those. Each time the clinician picks one of those 'differential diagnoses' and says to themselves, "I think that is what my client has, we will start treating for this condition,” then they have a "provisional diagnosis” (APA, 2014). Ji-woo has pain in regards to her memories of the incident and the grief associated with losing her friend during the accident. Ji-woo’s sleeping problems and flashback memories are numbed when she takes opiates. The differential diagnosis list is smaller, since Ji-woo’s situation is specific enough to dismiss other substances such as alcohol and cannabis. The below provisional diagnosis list briefly formulates possible diagnostics for Ji-woo’s case. After the clinician has gone through their differential diagnosis, they will obtain a provisional diagnosis, which is “a hypothesized, yet unproven diagnosis” (APA, 2014). If the issue isn't alleviated or controlled by the proposed treatment, the clinician might have presumed the provisional

ASSESSMENT OF ADDICTION 6 diagnosis incorrectly. The clinician will need to get more information, and review their differential diagnoses list until the outcome suffices. Systemic Approach When she was physically well enough to travel, Ji-woo’s grandparents invited her to visit because they were anxious to see her. To everyone’s shock, she refused to travel to Korea. One of her cousins suggested that it might be “because Ji-woo couldn’t get enough pain pills to be away that long.” This alarmed Ji-woo’s parents, who did not know how or where she could be getting the pills. Searching Ji-woo’s room, they found plastic vials tucked in odd places, some empty and some with pills. At their insistence, Ji-woo agreed to meet with a counselor to help explore how she was really handling the accident. It is a positive sign that Ji-woo’s parents are open to Ji-woo receiving counseling. This systemic support is proven to help clients with substance use disorders undergo treatment effectively (Davis, et al., 2017). Alcohol and drug problems affect and cause harm to many people as well as the individual user, and in turn the social context can influence continued substance use behaviour or change. Hence, addiction models that ignore the influence of the social environment can offer at best partial explanations and are limited. Ji-woo’s clinician must consider the types of social contexts and networks of opiate users entering treatment, before exploring what research has shown in terms of the impact that addiction problems can have on those concerned, i.e. the significant people close to those with the alcohol or drug problem (Davis, et al., 2017). Families have been studied to a greater extent than other people (such as friends) in research, so the clinician must explore models that have been put forward to explain the impact and consequences of addiction problems on families. The Stress-Strain-Coping Support (SSCS) model is a psychological way of understanding these problems before we turn to the practical aspects of treatments that attempt to either involve, or

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ASSESSMENT OF ADDICTION 7 provide help directly to, both families and also wider social networks (Davis, et al., 2017). Finally, the clinician must consider the implementation and the development of family-responsive addiction services. Provisional DSM Diagnosis List: Opioid Use Disorder, Opioid Intoxication, Opioid Withdrawal, Opioid Use Depressive Disorder Principal DSM-5 Diagnosis: Opioid Use Disorder Additional DSM-5 Diagnoses: Post-Traumatic Stress Disorder (PTSD) Relevant Medical Diagnoses: Chronic Back Pain Note: Opioid use disorder includes signs and symptoms that reflect compulsive, prolonged self-administration of opioid substances that are used for no legitimate medical purpose or, if another medical condition is present that requires opioid treatment, that are used in doses greatly in excess of the amount needed for that medical condition. (For example, Ji-woo was prescribed analgesic opioids for pain relief at adequate dosing, but uses significantly more than prescribed and not only because of persistent physical pain.) Individuals with opioid use disorder tend to develop such regular patterns of compulsive drug use that daily activities are planned around obtaining and administering opioids (APA, 2014). Assessment Tools: Current Opioid Misuse Measure (COMM), Patient Medication Questionnaire (PMQ), Opioid Risk Tool (ORT), the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R). Assessment Summary

ASSESSMENT OF ADDICTION 8 Among individuals in the United States ages 12–17 years, the overall 12-month prevalence of opioid use disorder in the community population is approximately 1.0 (Morgen, 2017). Opioid use disorder can begin at any age, but problems associated with opioid use are most commonly first observed in the late teens or early 20s. Once opioid use disorder develops, it usually continues over a period of many years, even though brief periods of abstinence are frequent. In treated populations, relapse following abstinence is common. Even though relapses do occur, and while some long-term mortality rates may be as high as 2% per year, about 20%–30% of individuals with opioid use disorder achieve long-term abstinence (Morgen, 2017). The proper steps to diagnose OUD is to list differential diagnosis then decide on a provisional diagnosis to form a treatment plan. Once substance and general medical etiologies have been ruled out, the next task is to determine whether clinically significant mood symptoms are also present. For example, in Ji-woo’s case, PTSD is a provisional diagnosis upon further examination of her symptoms over time. The risk for opioid use disorder can be related to individual, family, peer, and social environmental factors. Despite small variations regarding individual criterion items, opioid use disorder diagnostic criteria perform equally well across most race/ethnicity groups. Individuals from ethnic minority populations living in economically deprived areas have been overrepresented among individuals with opioid use disorder (Morgen, 2017). Ji-woo has a support system for her Opioid Use Disorder, possible Post Traumatic Stress Disorder &/or Opioid Induced Depressive Disorder.

ASSESSMENT OF ADDICTION 9 References American Psychiatric Association (2014). Differential diagnosis by the trees. In DSM-5 Handbook of Differential Diagnosis (pp. 17-156) . Arlington, VA: Author. Davis, P., Patton, R., & Jackson, S. (Eds.). (2017). Addiction : Psychology and treatment . John Wiley & Sons, Incorporated. Ducharme, J., & Moore, S. (2019). Opioid Use Disorder Assessment Tools and Drug Screening. Missouri medicine , 116 (4), 318–324. Marsden, J., Tai, B., Ali, R., Hu, L., Rush, J., Volkow, N., (2019). Measurement ‐ based care using DSM ‐ 5 for opioid use disorder: can we make opioid medication treatment more effective? Addiction. , 114 (8), 1346–1353. https://doi.org/10.1111/add.14546 Morgen, K. (2017). Substance use disorders and addictions. Thousand Oaks, CA: SAGE Publications. ISBN:9781483370569 Varney, S. M., Perez, C. A., Araña, A.,A., Carey, K. R., Ganem, V. J., Zarzabal, L. A., Bebarta, V.S. (2018). Detecting aberrant opioid behavior in the emergency department: A prospective study using the screener and opioid assessment for patients with pain-revised and provider gestalt. Internal and Emergency Medicine, 13 (8), 1239-1247. doi:http://dx.doi.org/10.1007/s11739-018-1804-3 Whiston, S. C. (2020). Principles and Applications of Assessment in Counseling (5th Edition). Cengage Limited.

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