Discussion: Treatment Of Substance Use Disorders

Of the substance disorders, alcohol-related disorders are the most prevalent even though only a small percentage of individuals actually receive help. Recidivism in the substance treatment world is also very high. As research into treatment has developed, more and more evidence shows that genes for alcohol-metabolizing enzymes can vary by genetic inheritance. Women have been identified as particularly vulnerable to the impacts of alcohol. Native Americans, Asians, and some Hispanic and Celtic cultures also have increased vulnerability to alcohol misuse.

Even with these developments, treatment continues to spark debate. For many years, the substance use field itself has disagreed with mental health experts as to what treatments are the most effective for substance use disorders and how to improve outcomes. The debate is often over medication-assisted treatment (MAT) versus abstinence-based treatment (ABT). Recently the American Psychiatric Association has issued guidelines to help clinicians consider integrated solutions for those suffering with these disorders. In this Discussion, you consider your treatment plan for an individual with a substance use disorder.

To prepare: Read the case provided by your instructor for this week’s Discussion and the materials for the week. Then assume that you are meeting with the client as the social worker who recorded this case.

Post a 300- to 500-word response in which you address the following:

  1. Provide the full DSM-5 diagnosis for the client. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may need clinical attention). Keep in mind a diagnosis covers the most recent 12 months.
  2. Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis.
  3. Describe the assessment(s) you would use to validate the client’s diagnosis, clarify missing information, or track her progress.
  4. Summarize how you would explain the diagnosis to the client.
  5. Explain how you would engage the client in treatment, identifying potential cultural considerations related to substance use.
  6. Describe your initial recommendations for the client’s treatment and explain why you would recommend MAT or ABT.
  7. Identify specific resources to which you would refer the client. Explain why you would recommend these resources based on the client’s diagnosis and other identity characteristics (e.g., age, sex, gender, sexual orientation, class, ethnicity, religion, etc.).


Required Readings

Morrison, J. (2014). Diagnosis made easier (2nd ed.). New York, NY: Guilford Press.
Chapter 15, “Diagnosing Substance Misuse and Other Addictions” (pp. 238–250)

American Psychiatric Association. (2013r). Substance related and addictive disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm16

Gowin, J. L., Sloan, M. E., Stangl, B. L., Vatsalya, V., & Ramchandani, V. A. (2017). Vulnerability for alcohol use disorder and rate of alcohol consumption. American Journal of Psychiatry, 174(11), 1094–1101. doi:10.1176/appi.ajp.2017.16101180

Reus, V. I., Fochtmann, L. J., Bukstein, O., Eyler, A. E., Hilty, D. M., Horvitz-Lennon, M., … Hong, S.-H. (2018). The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. American Journal of Psychiatry, 175(1), 86–90. doi:10.1176/appi.ajp.2017.1750101

Stock, A.-K. (2017). Barking up the wrong tree: Why and how we may need to revise alcohol addiction therapy. Frontiers in Psychology, 8, 1–6. doi:10.3389/fpsyg.2017.00884

Discussion: Treatment of Substance Use Disorders






This is a voluntary admission for this 26 year old African-American male. This is

Brandon’s first psychiatric hospitalization. Brandon has been married for 2 years

and has been separated from his husband for the past three months. He has

currently been living with his sister in Atlanta, GA., where his husband and son

reside. Brandon has a two year degree in nursing. Brandon works as an RN.

Religious affiliation is agnostic.


“I need to learn to deal with losing my husband and son.”



This admission was precipitated by Brandon’s increased depression and agitation

which has been steadily increasing over the past year. In the past three months

prior to admission, it was unbearable. He identifies a major stressor of his husband

and son leaving him three months ago. Brandon reports that in the past three

months since separating from his husband, he has experienced sad mood and



Brandon reports his dedication to working out. He has used a cycle of steroids to

increase his body mass. During his most ambitious cycle, approximately 1 year

ago, he used testosterone cypionate, 600 mg per week; nandrolone decanoate, 400

mg a week; stanozolol (Winstrol), 12 mg a day; and oxandrolone (Anavar), 10 mg

a day. During each of the cycles Brandon has noted euphoria, irritability, and

grandiose feelings. These symptoms were most prominent during his most recent

cycle, when he felt “invincible.” During this cycle he also noted a decreased need

for sleep, racing thoughts, and a tendency to spend excessive amounts of money.

For example, he impulsively purchased a $2,700 stereo system when he

realistically could not afford to spend more than $500. He also became

uncharacteristically irritable with his husband and on one occasion put his fist

through the side window of their car during an argument, an act inconsistent with

his normally mild-mannered personality.





Brandon is 69 inches tall and presently weighs 204 pounds, with a body fat of 11

percent. He reports that he began lifting weights at age 17, at which time he

weighed 155 pounds. About 2 years after beginning his weight lifting, he

began taking steroids, which he obtained through a friend at his gymnasium. His

first “cycle” of steroids lasted for 9 weeks and involved methandienone

(Methanabol), 30 mg a day, orally, and testosterone cypionate, 600 mg a week,

intramuscularly. During these 9 weeks, he gained 20 pounds of muscle mass. He

was so pleased with these results that he took five further cycles of steroids over

the course of the next 6 years. Brandon exhibits characteristic features of muscle




Brandon was seen on an outpatient basis by Dr. S for a period of two months prior

to admission. He was being seen for individual counseling because of the marital

problems. Brandon reported to Dr S. that he was using steroids to increase his

body mass. He noted that after the most recent cycle ended, he became mildly

depressed for about 2 months. Brandon has used a number of drugs to lose weight

in preparation for bodybuilding contests. These include ephedrine, amphetamine,

triiodothyronine, and thyroxin. Recently, he has also begun to use the opioid

agonist–antagonist nalbuphine intravenously (IV) to treat muscle aches from

weight lifting. He also used oral opioids, such as controlled-release oxycodone

(OxyContin), at least once a week. He uses oral opioids sometimes to treat muscle

aches, but often simply to get high. He reports that use of nalbuphine and other

opioids is widespread among weight lifters.



Father and grandfather have a history of cardiovascular disease.



Brandon reports that while growing up his parents maintained a satisfactory

relationship. Father reportedly worked nights and slept during the day. Brandon did

not have much contact with his father but now enjoys a close relationship with

him. He states he has always had his parents support.


During Brandon’s school years, he reports he was an underachiever in elementary

school. He denies having had a history of discipline problems or hyperactivity. He

states he did well in high school and earned grades of A’s and B’s. Brandon played

football in HS. After completing high school, Brandon furthered his education and

earned his license as a registered nurse. He states he graduated at the top of his

class from nursing school.




Brandon’s husband reports that Brandon’s difficulties began to get worse a few

months ago when he decided to move out of the house due to Brandon’s increasing

erratic behavior. He moved into his parents’ house and Brandon is living with his

sister. Husband states that Brandon has been suffering from mood swings where he

is “very up” and feeling great, firm in his direction and then within the next few

hours, he is often out of control, arguing, throwing temper tantrums, pushing and

shoving, and becoming verbally abusive.


Husband describes Brandon as “extremely depressed” now and says Brandon

states, “life is over…I wish I was dead…don’t send my son over to visit because I

don’t want him to find my dead body…everything I touch turns to garbage.”

Husband adds that Brandon suffers from poor self-esteem. In terms of strengths,

he is a good father, compassionate, creative, and can be an outstanding person.


Brandon has been married for 2 years and has recently been separated for the past

three months. Brandon and his husband have one adopted son, age 4. Brandon

states he feels invested as a parent and feels close to his son.


Leisure time activities Brandon has enjoyed in the past include playing softball,

reading, playing poker, and watching football. Now his main focus is

weightlifting. Brandon states he has several close friends.



Brandon presents as a casually dressed male who appears his stated age of 26.

Posture is relaxed. Facial expressions are appropriate to thought content. Motor

activity is appropriate. Speech is clear and there is no speech impediments noted.

Thoughts are logical and organized. There is no evidence of delusions or

hallucinations. Brandon denies any hallucinations. Brandon denies suicidal or

homicidal ideation at the present time. His husband has observed a history of

notable mood swings. No manic-like symptoms are observed at the time of this



On formal mental status examination, Brandon is found to be oriented to three

spheres. Fund of knowledge is appropriate to educational level. Recent and

remote memory appear intact. Brandon was able to calculate serial 7’s. He reports

checking his appearance dozens of times a day in mirrors, or when he sees his

reflection in a store window or even in the back of a spoon. He becomes anxious if

he misses even one day of working out at the gym, and acknowledges that his

preoccupation with weight lifting has cost him both social and occupational



opportunities. Although he has a 48-inch chest and 19-inch biceps, he has

frequently declined invitations to go to the beach or a swimming pool for fear that

he would look too small when seen in a bathing suit. He is anxious because he has

lost some weight since the end of his previous cycle of steroids and is eager to

resume another cycle in the near future.



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