Psychiatric Care After Drug Overdose: Case Study

Case Scenario: Marcella

Helen Farel

Marcella is a 15 year old bi-racial female who was admitted to the local community hospital in Chester, Pennsylvania for a drug overdose. The attending psychiatrist, Dr. Miller has referred Marcella to me to be evaluated for a possible substance use disorder and to be screened for the potential risk of future substance use disorder.

Carefully describe the client’s demographic characteristics.

Marcella is a 15-year-old bi-racial (Caucasian and African American) female who attends high school full-time.

What is the presenting problem?

Marcella has been referred for screening of a possible substance use disorder and the possible risk of future substance use problems after being treated at a local community hospital for attempting suicide with prescription pain medications.

What is the pertinent family history?

Marcella is being raised by her grandparents with sporadic input from her single mother. Bethany, Marcella’s mother, has never been married and has raised Marcella as a single mom since her birth.

What is the substance use history of the client’s family?

Marcella’s grandparents both drank alcohol throughout their adult lives and also experimented with various other drugs. Her stepfather uses marijuana on a daily basis because he feels that it helps with the pain from a back injury. Her mother developed a substance use problem at the age of 14, shortly after her father killed himself, and it rapidly progressed.

What are some of the direct and indirect messages Marcella may have received from her family about substance use?

Children and teenagers are heavily influenced by their parents. Having a parent who uses drugs is a strong predictor of adolescent substance abuse. The messages that Marcella may have received are my parents and grandparents use drugs so therefore it is okay for me to use them as well.

What is Marcella’s education and employment history?

Marcella is a full-time high school student and has not had any type of employment at this point but has done some babysitting.

What is significant in terms of risk factors, about Marcella’s academic history?

Marcella has done well academically throughout elementary school but for the last four years her grades in high school have been steadily dropping.

Describe Marcella’s social history?

Marcella can name only two friends and also states that she doesn’t like people so having only two friends is fine with her.

What is Marcella’s self-report of her substance use history?

Marcella states that she has used alcohol a few times with her friends and also used alcohol on special occasions at family gatherings. She also states that her suicide attempt was the first time she used pain pills or any non-prescribed drugs.

What is significant in terms of risk factors about Marcella’s description of her relationships with family members?

When asking Marcella about her relationship with her family members she stated that she never had a father and she isn’t sure if her mother even knows who her father was. She also states that he has never been a part of her life. She bluntly states that she hasn’t had a mother for the past few years as well. She describes her grandmother as the only one who would care if she had succeeded in her suicide attempt.

Accurately identify risk and protective factors for developing a substance use disorder as related to the client in the case scenario.

“Many factors have been identified that help determine” which individuals “are likely to abuse drugs.” The factors that are associated with the “greater potential for drug abuse are” known as “risk” factors, and those associated with the least potential for drug abuse are known as “protective” factors. (NIDA, 2003. pg. 6). Risk factors influence drug use in many ways. The more risks the adolescent is exposed to the more likely he or she is to use and abuse drugs. (NIDA, 2003. pg. 7). “Having a family history of substance abuse puts” the adolescent at risk for drug abuse. “The presence of protective factors can lessen the impact” of some risk factors, “such as parental support and involvement”; this “can reduce the influence of strong risks, such as having substance abusing peers.” (NIDA, 2003. pg. 7).

Some risk factors that could have an influence on Marcella are:

Substance use among parents.
Poor attachment with parents.
Social difficulties
Negative emotionality
Early substance use
Academic failure
Low commitment to school

Some protective factors that could lessen the impact of a few of the risk factors are:

Positive physical development
Family connectedness (attachment and bonding with grandmother)
Living in a stable home (grandparents)
Supportive relationship with family (grandmother).

(NIDA, 2003).

Discuss other relevant factors in the case scenario that could lead to the development of a substance use disorder.

Other risk factors often “relate to the quality of relationships outside” of “the family, such as in their schools, with their peers, teachers, and in the community.” (NIDA, 2003. pg. 9). “Difficulties in these settings can be crucial to” the adolescent’s “emotional, cognitive, and social development. Some of” the risk factors are academic failure and poor coping skills. (NIDA, 2003. pg. 9).

Other risks that can influence adolescents to start using drugs are the availability of the drugs and the belief that drug abuse is generally tolerated. (NIDA, 2003. pg. 9).

“Screening and assessment are” part “of a process that aims to identify and measure the mental health and substance use related needs and” behaviors of adolescents. It is

“difficult to determine where screening ends and assessment begins. Screening” “determines the need for a” more comprehensive assessment but does not provide actual information about the diagnosis or possible treatment needs. The screening “process should take no longer than” thirty minutes and in some instances will be shorter. (NCBI, 1999. pg. 9). An appropriate screening procedure must” take into consideration “several variables pertaining to the client, such as” their “age, ethnicity, culture, gender, sexual orientation, socioeconomic status, and literacy level.” (NCBI, 1999. pg. 10). It “is important that the” contents of the test be “appropriate for clients from a variety of backgrounds and” cultures. (NCBI, 1999. pg. 10). “There are three primary components to preliminary screening: content domains, screening methods, and information sources. The screening procedure focuses on verified indicators of substance related problems among adolescents.” These “indicators fall into two categories: those that indicate substance use problem severity and those that are

psychosocial factors.” (NCBI, 1999. pg. 11). There is no set number of uncovered red flags or indicators that mandate “a referral for a comprehensive assessment. Many” of the screening questionnaires provide a set of scores to assist with the decision in obtaining a comprehensive assessment. (NCBI, 1999. pg. 11). Regardless, “if there are several red flags or a few that” are meaningful, it is recommended “to refer the adolescent for a” more comprehensive assessment. (NCBI, 1999. pg. 11). The “comprehensive assessment follows a positive screening for a substance use disorder and may lead to long term intervention efforts such as” treatments. (NCBI, 1999. pg. 11). The screening procedures identify if the adolescent has “a significant substance use problem” and “the comprehensive assessment confirms the problem and helps” to clarify other problems that may be “connected with the adolescent’s substance use disorder. Comprehensive information can be used to develop” a proper set of interventions. (NCBI, 1999. pg. 17).

There are many different purposes of the comprehensive assessment.

To report in more detail the vicinity, nature, and unpredictability of substance utilization reported amid a screening, including whether the pre-adult meets symptomatic criteria for abuse or dependence. (NCBI, 1999. pg. 17).
To focus the particular treatment needs of the client if substance misuse or substance dependence is confirmed, so that limited resources are not misdirected. (NCBI, 1999. pg. 17).
To allow the evaluator to take in more about the nature, connects, and results of the adolescent’s substance-utilizing conduct. (NCBI, 1999. pg. 17).
To guarantee that related issues not hailed in the screening procedure (e.g., issues in medicinal status, mental status, social functioning, family relations, educational performance, and delinquent behavior) are recognized. (NCBI, 1999. pg. 17).
To inspect the degree to which the adolescent’s family (as characterized prior) might be included in the comprehensive assessment but also in possible subsequent interventions. (NCBI, 1999. pg. 17).
To distinguish particular qualities of the adolescent, family, and other social backings (e.g., coping skills) that could be utilized within creating a fitting treatment plan (financial information is significant here as well). (NCBI, 1999. pg. 17).
To develop a written report that:
Identifies and accurately diagnoses the severity of the use.
Identifies factors that contribute to or are related to the substance use disorder.
Identifies a corrective treatment plan to address these problem areas.
Details a plan to ensure that the treatment plan is implemented and monitored to its conclusion.
Makes recommendations for referral to agencies or services. (NCBI, 1999. pg. 17).

“A valid, standardized, and clinically relevant assessment is” crucial “for effective intervention with adolescent substance abusers.” (NIH, 2005. para. #6). “The advantages of standardized assessments are that they:

Provide a benchmark against which clinical decisions can be compared and validated;
Are less prone to clinician biases and inconsistencies than more traditional assessment methods; and
Provide a common language which improved communication in the field can develop.” (NIH, 2005. para #6).

“Until recently clinicians have relied on clinical judgment or locally developed procedures to diagnose adolescent substance use problems. This has begun to change since standardized and clinically valid instruments such as The” Drug Use Screening Inventory Revised (DUSI-R), The Teen-Addiction Severity Index (T-ASI), “have been introduced into the literature. Developmental appropriateness is critical to the effectiveness of using these instruments in work with adolescents.” (NIH, 2005. para. #7).

The Drug Use Screening Inventory-Revised (DUSI-R) is a 159-item instrument that documents the level of involvement with a variety of drugs and quantifies severity of consequences associated with drug use. The profile identifies and prioritizes intervention needs and provides an informative and facile method of monitoring treatment course and aftercare. The DUSI-R is a self-administered instrument. (NCBI, 1999. pg. 69).

The purpose of this instrument is “to comprehensively evaluate adolescents and adults who are suspected of using drugs; to identify or “flag” problem areas; to quantitatively monitor treatment progress and outcome; and to estimate likelihood of drug use disorder diagnosis.” (NCBI, 1999. pg. 69). A decision tree approach is used and the information acquired “should be viewed as implicative and not definitive in that the findings should generate hypotheses regarding the areas requiring comprehensive diagnostic evaluation by using other instruments.” The “DUSI-R is structured and formatted for self-administration using paper and pencil or computer.” The areas assessed are: “substance use behavior, behavior patterns, health status, psychiatric disorder, social skill, family system, school work, peer relationship, leisure” and recreation. This assessment takes 20-40 minutes to complete depending on the subject. (NCBI, 1999. pg. 69).

The Teen Addictions “Severity Index (T-ASI) is a brief assessment instrument developed for use when an adolescent is being admitted to inpatient care for substance use related problems.” (NCBI, 1999. pg. 78). “The purpose of this instrument is to provide basic information on an adolescent prior to entry into inpatient care for substance use related problems.” (NCBI, 1999. pg. 78). This assessment is an “objective face to face interview combined with opportunity for assessor to offer comments, confidence ratings” (indication “whether the information may be distorted), and severity ratings (indicating how severe the assessor believes is the need for treatment or counseling).” (NCBI, 1999. pg. 78). The areas assessed are: “chemical use, school status, employment/support, family relationships, peer/social relationships, legal status (involvement with criminal justice program), psychiatric status,” and “contact list for additional information. The” number of” questions asked for each area are fewer in number than many” of the other instruments used. (NCBI, 1999. pg. 78). These “screening tools are brief self-reports or interviews that are used as the first step in the process of evaluating whether an adolescent may or may not have a drug problem. The outcome of a screening is to determine the need for further, more comprehensive assessment. (NCBI, 1999. pg. 78).

I would use the DUSI-R to assess Marcella’s potential drug use because it is a self-report inventory that is available in paper or online that deals with both drugs and alcohol. It is utilized for measuring current status, recognizing areas in need of prevention, and evaluating the degree of change after treatment.

Substance use disorder in the “DSM-5 combines the DSM-IV categories of substance abuse and substance dependence into a single disorder” using a measurement of mild to severe. The “diagnosis of dependence caused” some confusion. Most people think that dependence is “addiction” when in fact dependence could be the body’s “normal response to a substance. In” order for a patient “to be diagnosed with Substance Use Disorder the patient must meet at least” two of the eleven criteria for the diagnosis. A patient meeting “2-3 of the criteria indicates mild substance use disorder, meeting 4-5 criteria indicates moderate” substance use disorder and meeting 6-7 criteria indicates severe substance use disorder. (BupPractice, 2014).

The Diagnostic Criteria are as follows:

Continuing to use opioids despite negative personal consequences.
Repeatedly unable to carry out major obligations at work, school, or home due to opioid use.
Recurrent use of opioids in physically hazardous situations.
Continued use despite persistent or recurring social or interpersonal problems caused or made worse by opioid use.
Tolerance as defined by either a need for markedly increased amounts to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount.
Withdrawal manifesting as either characteristic syndrome or the substance is used to avoid withdrawal.
Using greater amounts or using over a longer time period than intended.
Persistent desire or unsuccessful efforts to cut down or control opioid use.
Spending a lot more time obtaining, using, or recovering from using opioids.
Stopping or reducing important social, occupational, or recreational activities due to opioid use.
Consistent use of opioids despite acknowledgement of persistent or recurrent physical or psychological difficulties from using opioids.
Craving or a strong desire to use opioids. (This is a new criterion added since the DSM-IV-TR). (BupPractice, 2014).

During the assessment and evaluation with Marcella she stated that she tried alcohol a few times with friends and on special occasions at family gatherings and she denies having ever been intoxicated. She also states that the pain pills she took in the suicide attempt were her only use of non-prescribed drugs. According to the DSM-5, Marcella does not meet any of the criteria for the diagnosis of a substance use disorder. In order to be diagnosed with a substance use disorder Marcella must meet 2 of the 11 criteria for the diagnosis. After my assessment and evaluation of Marcella I have come to the conclusion that she does not meet any of the criteria to be diagnosed with a substance use disorder. While she did take prescription pain medication in an attempt to commit suicide it was the first and only time that she took any type of drug prescription or otherwise. Marcella continues to work on her other medical issues with the hospital psychiatrist.

References

American Psychiatric Association. (2005). Substance-Related and addictive disorders. Retrieved from www.dsm5.org/Documents/Substance%20Use%20Disorder%20Fact%20sheet.pdf

BupPractice. (2014). DSM-5 Substance use disorder. Diagnostic criteria. Retrieved from www.dsm5.org/Documents/Substance%20Disorder%20Fact%20sheet.pdf

Centers for Substance Abuse Treatment. (1999).Screening and assessing adolescents for substance use disorders. Substance abuse and mental health services administration (US); (Treatment Improvement Protocol (TIP) Series, No. 31 Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK64364/pdf/TOC.pdf

National Institute on Drug Abuse. (2003). Chapter 1: Risk and Protective Factors. In Preventing Drug Use Among Children and Adolescents. Retrieved from http://drugabuse.gov/publications/preventing-drug-abuse-among-children-and-adolescents?chapter-1-risk-factors-protective-factors.

Miller, W.R., Forcehimes, A. A., & Zweben, A. (2011). Treating addiction: A guide for professionals. New York, NY: Guilford

National Institute on Drug Abuse. (n.d.). Risk and protective factors. Retrieved from http://drugabuse.gov/sites/default/files/preventingdruguse_2.pdf