CISUR – Page 11 – Matters of Substance

Sometimes we seek escape and solace from a pint of beer, a smoke, or even a bucket of Ben & Jerry’s to help us deal with life’s challenges. For some, it’s a daily routine of self-management; for others, it’s a battle between life and death. How we use substances is often linked to how we manage our mental health.

According to the Canadian Mental Health Association (CMHA), about half of those with addictions have mental illnesses and vice versa. Depression and anxiety are known risk factors and consequences of substance use problems.

A common and effective approach to managing substance use, as well as depression and anxiety, is cognitive-behavioural therapy (CBT). CBT helps provide a set of positive coping skills, and is the principle behind CMHA’s Bounce Back^TM: Reclaim Your Life program, funded by the BC Ministry of Health, and available for free across BC by doctor referral.

The program uses a telephone-based adaptation of CBT to teach participants how thoughts, emotions, behaviours, and the external environment affect one another in every situation. It is designed to help people experiencing symptoms of mild to moderate depression, but also helps them learn to build a healthy relationship with substance use. Participants explore questions such as: Why do I feel the way I do? Am I using alcohol or other drugs just to get a good night’s sleep? What would recovery look like?

By exploring these and other questions participants learn to identify positive and negative consequences of actions, gain insight into what might be leading them to turn to substances, develop problem-solving skills and take more control of their own lives.

CBT has been shown to be effective but freely accessible CBT treatments are mostly limited to online information rather than practitioner-guided therapy.

Programs like Bounce Back^TM offers a way to make CBT more available to people. The program provides province-wide, community-based access and integrates with primary care through family physician referral. Keys to the success of the program include support from the Ministry of Health and Doctors of BC Practice Support Program, making CBT a standard resource for BC residents.

Like any intervention, CBT and Bounce Back^TM have their limitations While these types of low-intensity CBT treatment that use the relapse-prevention approach and behavioural strategies, may only have a small effect on substance use, they do show a large improvement in overall psychosocial adjustment . Therefore, making the benefits of CBT available to people across the province is a worthy goal.

To learn more about CBT visit Visions Journal’s issue on CBT from Here to Help.
To learn more about Bounce Back^TM, visit www.bouncebackbc.ca.

Author: Sophy Zhang, Bounce Back Program Assistant at Canadian Mental Health Association, BC Division

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC.

A central disorder?

At one level understanding, substance use disorders is simple. These are disorders which are caused by the use of a psychoactive substance which has abuse and dependence properties. Whether there is a central mental or behavioural disorder of repetitive substance use is where debate, disagreement and controversy arise. Indeed, such are the varying opinions and philosophies (“models”) that a visitor from another planet might think human beings are incapable of coherent thinking about the nature of conditions that affect them.

Some people view persistent substance use as representing an underlying biological disorder where some people become “addicted” and are utterly different from the rest of the human race. Some regard substance-use-related problems as simply a consequence of the availability of particular substances in our society. Others view repeated substance use as a behaviour which is mostly driven by the same mechanism as other human behaviours and habits. Others regard them as an acquired disorder of addiction caused by abnormal brain processes.

Making sense of this

A highly influential construct is the “dependence syndrome,” introduced principally by Griffiths Edwards in the mid-1970s. This described what people with a long history of repetitive substance use experienced in terms of symptoms, behaviours, thoughts and observed physiological features. Importantly, it did not seek to ascribe a cause for the disorder other than substance use.

The dependence syndrome concept was taken up widely by the clinical community and incorporated into the two major international diagnostic systems, the International Classification of Diseases (10^th Revision), published in 1992, and the US Diagnostic and Statistical Manual , 3^rd Edition Revised and 4^th Edition, published in 1987 and 1994 respectively. For nearly 30 years, these international diagnostic systems have formed the basis of disease characterisation and morbidity and mortality statistics. The concept of a dependence syndrome has been accepted for nearly all psychoactive substances which have abuse potential, and it has been supported by the burgeoning evidence on the neurobiological changes that underpin its clinical manifestations. I describe it as a “powerful internal driving force” to use and continue to use a psychoactive substance.

What has DSM-5 done?

It was a surprise to many when the latest version of the Diagnostic and Statistical Manual of Mental Disorders (the 5^th Edition or DSM-5, published in 2013), amalgamated dependence with the non-dependence DSM-IV diagnosis of substance abuse. Now there is one central diagnosis for repeated substance use which is causing problems. Examples include “alcohol use disorder”, “cannabis use disorder” and “opioid use disorder”.

Does this composite disorder aid epidemiological and clinical practice? It is a very broad concept, although it is subdivided into “mild”, “moderate” and “severe”.

My view is that it is too broad. It also does not take into account our developing knowledge of the mechanisms of development of dependence. Some questions for consideration:

Does it help communicate the nature and severity of the disorder amongst clinicians?
Does this new diagnosis mean anything other than the person uses the substance repeatedly and periodically experiences problems?
Does it alert the clinician to a patient who may develop a withdrawal state?
Does it point to the goal of treatment (abstinence from the substance, controlled or moderated use or periodic use)?
Does it assist the clinician in identifying appropriate treatments for discussion with the patient/client?
Does it help identify whether patients who use heroin and other illicit opioids would be appropriately treated with agonist maintenance such as buprenorphine and methadone? As I have commented before, if an opioid user is not addicted to an opioid prior to treatment, they certainly will be addicted after they commence on methadone or buprenorphine!

These are some of the practical concerns that many clinicians and researchers have about the conceptualisation of substance use disorders in DSM-5. How these might be addressed and current developments in the next version of the International Classification of Diseases (ICD 11) will be the subject of my next commentary.

Author: John B. Saunders, Faculty of Medicine and Biomedical Sciences, University of Queensland; Disciplines of Psychiatry and Addiction Medicine, Sydney Medical School, University of Sydney, Australia.

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC.

Author: CISUR

Building healthier habits with accessible CBT

Understanding substance use disorders