Chapters 1-5
Chapters 6-8
Chapter 9, Appendixes, and Exhibits

 

Chapter 9 -- Pharmacologic Management

Pharmacologic Risk Factors

Addiction is not a fixed and rigid event. Like psychiatric disorders, addiction is a dynamic process, with fluctuations in severity, rate of progression, and symptom manifestation and with differences in the speed of onset. Both disorders are greatly influenced by several factors, including genetic susceptibility, environment, and pharmacologic influences. Certain people have a high risk for these disorders (genetic risk); some situations can evoke or help to sustain these disorders (environmental risk); and some drugs are more likely than others to cause psychiatric or AOD use disorder problems (pharmacologic risk).

Pharmacologic effects can be therapeutic or detrimental. Medication often produces both effects. Therapeutic pharmacologic effects include the indicated purposes and desired outcomes of taking prescribed medications, such as a decrease in the frequency and severity of episodes of depression produced by antidepressants.

Detrimental pharmacologic effects include unwanted side effects, such as dry mouth or constipation resulting from antidepressant use. Side effects perceived as noxious by patients may decrease their compliance with taking the medications as directed.

Some detrimental pharmacologic effects relate to abuse and addiction potential.For example, some medications may be stimulating, sedating, or euphorigenic and may promote physical dependence and tolerance. These effects can promote the use of medication for longer periods and at higher doses than prescribed.

Thus, prescribing medication involves striking a balance between therapeutic and detrimental phar-macologic effects. For instance, therapeutic antianxiety effects of the benzodiazepines are balanced against detrimental pharmacologic effects of sedation and physical dependency. Similarly, the desired therapeutic effect of abstinence from alcohol is balanced by the possibility of damage to the liver from prescribed disulfiram (Antabuse).

Side effects of prescription medications vary greatly and include detrimental pharmacologic effects that may promote abuse or addiction. With regard to patients with dual disorders, special attention should be given to detrimental effects, in terms of 1) medication compliance, 2) abuse and addiction potential, 3) AOD use disorder relapse, and 4) psychiatric disorder relapse (Ries, 1993a).

Psychoactive Potential

Not all psychiatric medications are psychoactive. The term psychoactive describes the ability of certain medications, drugs, and other substances to cause acute psychomotor effects and a relatively rapid change in mood or thought. Changes in mood include stimulation, sedation, and euphoria. Thought changes can include a disordering of thought such as delusions, hallucinations, and illusions. Behavioral changes can include an acceleration or retardation of motor activity. All drugs of abuse are by definition psychoactive.

In contrast, certain nonpsychoactive medications such as lithium (Eskalith) can, over time, normalize the abnormal mood and behavior of patients with bipolar disorder. Because these effects take several days or weeks to occur, and do not involve acute mood alteration, it is not accurate to describe these drugs as psychoactive, euphorigenic, or mood altering. Rather, they might be described as mood regulators.Similarly, some drugs, such as antipsychotic medications, cause normalization of thinking processes but do not cause acute mood alteration or euphoria.

However, some antidepressant and antipsychotic medications have pharmacologic side effects such as mild sedation or mild stimulation. Indeed, the side effects of these medications can be used clinically. Physicians can use a mildly sedating antidepressant medication for patients with depression and insomnia, or a mildly stimulating antipsychotic medication for patients with psychosis and hypersomnia or lethargy (Davis and Goldman, 1992). While the side effects ofthese drugs include a mild effect on mood, they are not euphorigenic. Nevertheless, case reports of misuse of nonpsychoactive medications have been noted, and use should be monitored carefully in patients with dual disorders.

While psychoactive drugs are generally considered to have high risk for abuse and addiction, mood- regulating drugs are not. A few other medications exert a mild psychoactive effect without having addiction potential. For example, the older antihistamines such as doxylamine (Unisom) exert mild sedative effects, but not euphoric effects.

Reinforcement Potential

Some drugs promote reinforcement, or the increased likelihood of repeated use. Reinforcement can occur by either the removal of negative symptoms or conditions or the amplification of positive symptoms or states. For example, self-medication that delays or prevents an unpleasant event (such as withdrawal) from occurring becomes reinforcing. Thus, using a benzodiazepine to avoid alcohol withdrawal can increase the likelihood of continued use.Positive reinforcement involves strengthening the possibility that a certain behavior will be repeated through reward and satisfaction, as with drug-induced euphoria or drug-induced feelings of well-being. A classic example is the pleasure derived from moderate to high doses of opiates or stimulants.Drugs that are immediately reinforcing are more likely to lead to psychiatric or AOD use problems.

Tolerance and Withdrawal Potential

Long-term or chronic use of certain medications can cause tolerance to the subjective and therapeutic effects and prompt dosage increases to recreate the desired effects. In addition, many drugs cause a well-defined withdrawal phenomenon after the cessation of chronic use. Patients' attempts to avoid withdrawal syndromes often lead them to additional drug use.Thus, drugs that promote tolerance and withdrawal generally have higher risks for abuse and addiction.

A Stepwise Treatment Model

As can be seen, there are pharmacologic as well as hereditary and environmental factors that influence the development of AOD use problems. All of these factors should be considered prior to prescribing medication, especially when the patient is at high risk for developing an AOD use disorder. High-risk patients include people with both psychiatric and AOD use disorders, as well as patients with a psychiatric disorder and a family history of AOD use disorders.

One aspect of this issue relates to the pharmacologic profile of certain medications that are used in the treatment of specific psychiatric disorders. For instance, many medications used to treat symptoms of depression and psychosis are not psychoactive or euphorigenic. However, many of the medications used to treat symptoms of anxiety, such as the benzodiazepines, are psychoactive, reinforcing, have potential for tolerance and withdrawal, and have an abuse potential, especially among people who are at high risk for AOD use disorders. Other antianxiety medications, such as buspirone (BuSpar), are not psychoactive or reinforcing and have low abuse potential, even among people at high risk.

Thus, decisions about whether and when to prescribe medication to a high-risk patient should include a risk-benefit analysis that considers the risk of medication abuse, the risk of undertreating a psychiatric problem, the type and severity of the psychiatric problem, the relationship between the psychiatric disorder and the AOD use disorder for the individual patient, and the therapeutic benefits of resolving the psychiatric and AOD problems.

For example, the early and aggressive medication of high-risk patients who have severe presentations of psychotic depression, mania, and schizophrenia isoften necessary to prevent further psychiatric deterioration and possible death.For these patients, rapid and aggressive medication can shorten the length of the psychiatric episodes. In contrast, prescribing benzodiazepines to high-risk patients with similarly severe anxiety involves a substantial risk of promoting or exacerbating an AOD use disorder. For these high-risk patients, the use of psychoactive medication should not be the first line of treatment.

Rather, for some high-risk patients, treatment efforts should involve a stepwise treatment model that begins with conservative approaches and progressively becomes more aggressive if the treatment goals are not met (Landry et al., 1991a). For example, the stepwise treatment model for treating high-risk patients with anxiety disorders may involve three progressive levels of treatment: 1) nonpharmacologic approaches when possible; 2) nonpsychoactive medication when nonpharmacologic approaches are insufficient; and 3) psychoactive medications when other treatment approaches provide limited or no relief (Landry et al., 1991).


Pharmacologic Risk Factors
A medication may have:
  • Psychoactive potential (causes acute psychomotor effects)
  • Reinforcement potential (decreases negative symptoms and increases positive symptoms)
  • Tolerance and withdrawal potential (a higher does is needed to gain the effect or to avoid ill effects).


A Stepwise Management Approach For Mild and Moderate Mental Disorders *
Step One:
Try nonpharmacologic approaches
Step Two:
Add nonpsychoactive medications if Step One is unsuccessful
Step Three:
Add psychoactive medications if Steps One and Two are unsuccessful.
* For severe conditions, such as psychotic depression, mania, and schizophrenic disorders, rapid and aggressive use of medications is needed to prevent danger to self or others and further psychiatric deterioration.

Nonpharmacologic Approaches

Depending upon the psychiatric disorders and personal variables, numerous nonpharmacologic approaches can help patients manage all or some aspects of their psychiatric disorders (Weiss and Billings, 1988). Examples include psychotherapy, cognitive therapy, behavioral therapy, relaxation skills, meditation, biofeedback, acupuncture, hypnotherapy, self-help groups, support groups, exercise, and education.

Nonpsychoactive Pharmacotherapy

Some medications are not psychoactive and do not cause acute psychomotor effects or euphoria. Some medications do not cause psychoactive or psychomotor effects at therapeutic doses but may exert limited psychoactive effects at high doses (often noteuphoria, but sometimes dysphoria).

For practical purposes, all of these medications can be described as nonpsychoactive, since the psychoactive effect is not prominent.Medications used in psychiatry that are not euphorigenic or significantly psychoactive include but are not limited to the azapirones (for example, buspirone), the amino acids, beta-blockers, antidepressants, monoamine oxidase inhibitors, antipsychotics, lithium, antihistamines, anticonvulsants, and anticholinergic medications.

Psychoactive Pharmacotherapy

Some medications can cause significant and acute alterations in psychomotor, emotional, and mental activity at therapeutic doses. At higher doses, and for some patients, some of these medications can also cause euphoric reactions. Medications that are potentially psychoactive include opioids, stimulants, benzodiazepines, barbiturates, and other sedative-hypnotics.

Stepwise Treatment Principles

One of the emphases of stepwise treatment is to encourage nondrug treatment strategies for each emerging symptom before medications are prescribed. Nondrug treatment strategies alone are inappropriate for acute and severe symptoms of schizophrenia and mood disorders, but nondrug strategies do have their place in the treatment of virtually any psychiatric problem, and may provide partial or total relief of some symptoms related to severe psychiatric disorders. For example, relaxation therapy can minimize or eliminate somatic symptoms of anxiety that may accompany an agitated depression.

A second emphasis of stepwise treatment is to encourage the use of medications that have a low abuse potential. This conservative approach must be balanced against other therapeutic and safety considerations in acute and severe conditions, such aspsychosis or mania. On the other hand, a conservative approach is not the same as undermedication of psychiatric problems. Undermedication often leads to psychiatric deterioration and may promote AOD relapse. There should be a balance between effective treatment and safety.

A third emphasis of stepwise treatment is to encourage the idea that different treatment approaches should be viewed as complementary, not competitive. For example, if psychotherapy or group therapy does not provide complete relief from a situational depression (such as prolonged grief), then antidepressants should be considered as an adjunct to the psychotherapy, but not as a substitute for psychotherapy.

In practice, treatment providers often use a combination of drug and nondrug strategies. This practice includes medication to treat the acute manifestations of the disorder while the individual learns long-term management strategies. For example, an individual may be prescribed nonpsychoactive buspirone to reduce anxiety symptoms while learning stress reduction techniques and attending group therapy.

These guidelines are broad, general, and more applicable to chronic than to acute psychiatric problems. Also, these guidelines have limited application to very severe psychiatric problems.

Specific Medications and Recovery

Antihistamines

Several antihistamines are approved for sale as over-the-counter hypnotics, including diphenhydramine (Nytol, Benadryl), doxylamine (Unisom), and pyrilamine (Quiet World). The efficacy of these drugs is not uniform, and tolerance to the anxiolytic and hypnotic effects is rapid, limiting their utility for episodic use. Antihistamines are frequently prescribed for mild anxiety and insomnia, particularly for patients in general hospitals, patients with physical illness (Salzman, 1989), and elderly patients.

Antihistamines and Recovery

In general, the early antihistamines exert very mild anxiolytic and hypnotic effects, but lack euphoric properties and do not promote physical dependence (Meltzer, 1990). While lacking significant abuse potential themselves, antihistamines may cause problems for some patients by reinforcing the idea of self-medication of insomnia and anxiety. Taken in high doses, antihistamines may cause acute delirium,alter mood (often causing dysphoria), or cause morning-after depression. Under close medical supervision, the conservative use of antihistamines can be valuable in treating brief episodes of insomnia during an otherwise drug-free recovery process. Patients in recovery should be discouraged from purchasing and using over-the-counter antihistamines.

Antidepressants

The antidepressants include several types of medication, such as tricyclics, monoamine oxidase inhibitors (MAOIs), and other, newer, antidepressants such as trazodone (Desyrel), bupropion (Wellbutrin), sertraline (Zoloft), and fluoxetine (Prozac). Antidepressants are effective for the treatment of depression, and several are valuable for the treatment of anxiety disorders, including generalized anxiety disorder, phobias, and panic disorder.

Antidepressants and Recovery

The antidepressants are not euphorigenic, and do not cause acute mood alterations. Rather, they are mood regulators and diminish the severity and frequency of depressive episodes; they also have anti-panic capabilities unrelated to sedation.

While the general effects of most of the older tricyclic antidepressants are similar, they differ considerably with regard to side effects. For example, some antidepressants such as doxepin (Sinequan) exert a mild sedating effect, while others such as protriptyline (Vivactil) exert a mild stimulating effect. These side effects can be clinically useful. For example, clinicians might give antidepressants with slight sedating effects to depressed patients with insomnia or give those with mild stimulating effects to depressed patients who experience low energy and hypersomnia (Davis and Goldman, 1992).

Other side effects of tricyclic antidepressants are common. Anticholinergic effects such as dry mouth, blurred vision, constipation, urinary hesitancy, and toxic-confusional states are common anticholinergic effects. Adrenergic activation symptoms may include tremor, excitement, palpitation, orthostatic hypotension, and weight gain. These noxious side effects are frequently the cause of requests to switch from one medication type to another. Also, side effects often prompt discontinuation of medication, which may provoke reemergence of the psychopathology. Tricyclics unfortunately are quite toxic when combined with AODs. Therefore use of tricyclic antidepressants in early recovery should be carefully monitored.

More expensive, but much less toxic when used with AODs, are the newer serotonin reuptake inhibitors including fluoxetine, paroxitine (Paxil), and sertraline. These agents also have anticompulsive effects, and their side effects tend to be slight to moderate stimulation rather than sedation. They are much safer to use in early recovery.

Overall, the use of antidepressants is consistent with a psychoactive-drug-free philosophy, does not compromise recovery from addiction, and enhances recovery from depressive and panic disorders. However, patient information must include clear explanations of the reasons for prescribing, the expected results, and the risks of adverse effects, including overdose. The risk-benefit analysis must include the risk of lethal overdose with tricyclic antidepressants, especially for depressed patients (Reid, 1989).

Beta-Blockers

The beta-blockers such as propranolol (Inderal) are well-recognized medications for the treatment of hypertension, cardiac arrhythmias, and angina pectoris.They also have clinical efficacy as an adjunct in the treatment of anxiety (Lader, 1988). The b-blockers may reduce or eliminate the adrenergic discharge associated with panic attacks, thus blocking the somatic components of some anxiety states, especially when somatic symptoms predominate (Trevor and Way, 1989). b-blockers diminish the tremor and restlessness related to lithium or antipsychotics in some patients.

Beta-Blockers and Recovery

The Beta-blockers are not psychoactive, euphorigenic, or mood altering. Since tolerance to the anti-panic effects of b-blockers develops rapidly, they cannot be used for extended periods of time for this purpose. Rather, they are often used prophylactically for anticipated panic-producing situations, or for episodes of anxiety that may last a few days. The b-blockers are also used to decrease acute and subacute anxiety symptoms during detoxification from sedative-hypnotics such as the benzodiazepines.Overall, the use of b-blockers is consistent with a psychoactive-drug-free philosophy, does not compromise recovery from addiction, and can be an important adjunct to anxiety management.

Benzodiazepines

While all of the benzodiazepines have anxiolytic characteristics, they differ in their effectiveness in treating generalized anxiety disorder, mixed anxiety and depression, panic attacks, phobic-avoidancebehaviors, and insomnia. In general, the benzodiazepines promote sedation, central nervous system depression, and muscle relaxation, and thus are effective for anxiety reduction and, at higher doses, for short-term management of insomnia.

The Benzodiazepines and Recovery

The benzodiazepines are psychoactive, mood altering, and reinforcing. Chronic use and subsequent cessation can cause withdrawal symptoms. Studies have shown that the benzodiazepines are not uniformly euphorigenic. Also, patients with a family and personal history of AOD abuse and addiction are more likely to experience euphoria with the benzodiazepines (Ciraulo et al., 1988, 1989).

Benzodiazepines are the most commonly used agents to moderate alcohol withdrawal and prevent dangerous withdrawal conditions such as delirium tremens and seizures. They are also widely used during detoxification from sedative-hypnotics. The benzodiazepines are frequently prescribed for use alone and in combination with antipsychotics during the treatment of acute psychotic symptoms caused by mania, schizophrenia, and drugs of abuse such as cocaine. Such treatment should be limited to the acute episode for most patients with dual disorders, so that one problem (psychosis) is not replaced by another problem (physical dependence or addiction). The benzodiazepines are not usually recommended for long-term use in patients with dual disorders unless all nonpsychoactive approaches have failed. That is, if all other less potentially adverse medications have proven inadequate and the benzodiazepines are indicated, then careful dispensing, regulation of dose, and scrupulous monitoring are required.

Overall, the use of benzodiazepines after the medical management of withdrawal is not consistent with a psychoactive-drug-free philosophy and may compromise recovery from addiction (Zweben and Smith, 1989). However, they can be used in the management of acute and severe withdrawal, panic, and psychosis with special guidelines in nonroutine situations.

Buspirone

Buspirone is the most well known of a new group of drugs (the azapirones) that selectively diminish multiple symptoms of anxiety without the acute mood alteration, sedation, or associated somatic side effects seen in the sedative-hypnotic anxiolytics.Buspirone is useful for generalized anxiety disorder, chronic anxiety symptoms, anxiety with depressive features, and anxiety among elderly patients. Buspirone isgenerally equivalent to the benzodiazepines with regard to anxiety management (Petracca et al., 1990; Strand et al., 1990). However, it takes several weeks for the maximal therapeutic effect of buspirone to occur.

Buspirone and Recovery

Buspirone is not psychoactive, mood altering, or euphorigenic (Balster, 1990). In particular, buspirone does not cause the mood alteration, central nervous system depression, sedation, and muscle relaxation associated with the benzodiazepines. However, many people with experience taking benzodiazepines may associate these mood alterations with relief of anxiety. As a result, patients who have experience with the benzodiazepines may misinterpret the absence of these side effects as evidence that the medication is ineffective. Educating patients about the distinction between anxiety reduction and sedation and about treatment expectations can avoid these misinterpretations.

Overall, the use of buspirone is consistent with a psychoactive-drug-free philosophy, does not compromise recovery from addiction, and enhances recovery from anxiety disorders.

Clonidine

Used in the form of a patch (Catapres Transdermal Therapeutic System patches) or tablets (Catapres), clonidine is well recognized as a treatment for symptoms of hypertension, including hypertensive symptoms that occur during withdrawal from depressant drugs, especially the opioids. In addition, clonidine appears to have anxiolytic and anti-panic properties comparable to the antidepressant imipramine. Patients may become less anxious but remain symptomatic. Some patients who have anxiety-depression or panic-anxiety experience significant antianxiety effects from clonidine. The anti-panic effect is the result of clonidine's ability to decrease locus ceruleus firing and thus decrease adrenergic discharge. Thus, clonidine may be useful for short-term use in the treatment of refractory anxiety with panic (Domisse and Hayes, 1987; Uhde et al., 1989).

Clonidine and Recovery

Clonidine is not psychoactive, euphorigenic, or mood altering. Clonidine may have significant antianxiety effects when administered to patients with anxiety-depression and panic-anxiety. However, tolerance to the anti-panic effects of clonidine can develop within several weeks. Thus, clonidine may be most useful forshort-term use in the treatment of refractory panic disorder.

Overall, the use of clonidine is consistent with a psychoactive-drug-free philosophy, does not compromise recovery from addiction, and may be an adjunct in the treatment of anxiety symptoms.

Neuroleptic (Antipsychotic) Medications

The neuroleptic medications are most effective in suppressing the positive symptoms of psychosis such as hallucinations, delusions, and incoherence. In addition, they may help reduce disturbances of arousal, affect, psychomotor activity, thought content, and social adjustment (Africa and Schwartz, 1992). These psychotic symptoms may accompany schizophrenia, brief reactive psychosis, schizophreniform disorder, mania, depression, and organic mental disorders induced by AODs and medical conditions (Ries, 1993a).

Although neuroleptic medications are equally effective in suppressing psychotic symptoms, individuals may respond to one medication better than another. The chief differences among the neuroleptics relate to dosage, onset of effects, and (especially) side effects. Some side effects may be clinically useful, such as nighttime sedation with chlorpromazine or avoidance of appetite stimulation with molindone (Moban) (Africa and Schwartz, 1992).

In general, low-potency neuroleptics, for example, chlorpromazine, thioridazine (Mellaril), and clozapine (Clozaril), have significant sedative and hypotensive properties. Tolerance to these properties may develop within a few weeks. Also, low-potency neuroleptics are inherently anticholinergic, so that the use of additional anticholinergic drugs to prevent extrapyramidal symptoms may be unnecessary. The high-potency neuroleptics such as fluphenazine (Prolixin) and haloperidol (Haldol) cause more extrapyramidal side effects than the low-potency medications.

Neuroleptic Drug-Induced Extrapyramidal Symptoms

The extrapyramidal system is a network of nerve pathways that links nerves in the surface of the cerebrum (the deep mass of the brain), the basal ganglia deep within the brain, and parts of the brain stem. The extrapyramidal system influences and modifies electrical impulses that are sent from the brain to the skeletal muscles.

When this system is damaged or disturbed, execution of voluntary movements and muscle tonecan be disrupted, and involuntary movements, such as tremors, jerks, or writhing movements, can appear. These disturbances are called extrapyramidal syndromes, which can be caused by all of the neuroleptic medications except clozapine.

Medicating Extrapyramidal Symptoms

Extrapyramidal symptoms are unwanted, noxious, and uncomfortable. Compliance with neuroleptic medications is worsened because of the onset of these drug-induced symptoms. A class of medications called anticholinergic agents can eliminate the muscle spasms in the neck, oral, facial, cheek, and tongue regions. Several other types of medications may also be helpful, including amantadine and beta-blockers.

Anticholinergic agents can also reduce the extrapyramidal movement disorder called akathisia, which consists of purposeless movements, usually of the lower extremities, often accompanied by the experience of severe, uncomfortable restlessness. These medications include benztropine (Cogentin), biperiden (Akineton), diphenhydramine (Benadryl), trihexyphenidyl (Antitrem), and procyclidine (Kemadrin). Patient response should be monitored because some anticholinergic medications may be mildly psychoactive for some AOD patients.

Neuroleptic Medications and Recovery

Neuroleptic drugs are not euphorigenic and do not cause acute mood or psychomotor alterations.However, side effects are common. Most of the neuroleptics cause sedation as a side effect, although adaptation to the sedative (but not the antipsychotic) effects develops within days or weeks. The anticholinergic side effects of neuroleptic medications can include dry mouth, constipation, and blurred vision. The neuroleptics can also cause extrapyramidal symptoms. The adverse side effects of neuroleptic medications are a frequent cause of medication compliance problems. These adverse effects can also prompt patients to use AODs to self-medicate noxious symptoms.

Because patients with psychotic symptoms often experience significant biopsychosocial problems, the neuroleptics allow them to engage in problem-solving and recovery-oriented interpersonal activities. Overall, the use of neuroleptics is consistent with a psychoactive-drug-free philosophy, does not compromise recovery from addiction, and enhances recovery from psychotic disorders.

Lithium

Lithium is the standard and first-line treatment formanic episodes, even though 10-14 days may be required before full effect is achieved. The initial symptoms managed by lithium include increased psychomotor activity, pressured speech, and insomnia. Later, lithium diminishes the symptoms of expansive mood, grandiosity, and intrusiveness. Lithium also treats signs related to disorganization of the form of thought such as flight of ideas and loosening of association.

Lithium and Recovery

Lithium does not cause acute mood alteration, and is not psychoactive or mood altering.Rather, lithium is a mood regulator, and diminishes symptoms of acute mania. The common adverse effects of lithium include thirst, urinary frequency, tremor, and gastrointestinal distress. Lithium allows patients who may have seriously disabling symptoms to engage in problem-solving and recovery-oriented interpersonal activities. Overall, the use of lithium is consistent with a psychoactive-drug-free philosophy, does not compromise recovery from addiction, and enhances recovery from bipolar disorders.

Anticonvulsants

Anticonvulsants have a role in the management of bipolar disorders, mania, schizoaffective disorder, and alcohol and benzodiazepine withdrawal. In addition, these medications may be prescribed for "flashbacks" related to drug use or post-traumatic stress disorder. These medications, such as carbamazepine (Tegretol) and valproic acid, are not psychoactive. The typically minor side effects of sedation and nausea may emerge as treatment is initiated. Rarely, carbamazepine causes a decrease in white blood cell count. Both medications are monitored according to blood levels. For the treatment of bipolar disorder, the anticonvulsants are most often used when lithium has failed. However, they are occasionally used by highly skilled physicians as first-line treatment. These medications are consistent with a psychoactive-drug-free philosophy, and may enhance the abilities of those who need them to participate in the recovery process.

Drug Interaction Cautions

There are certain risks associated with AOD use and withdrawal among patients who are also being administered medications to treat psychiatric disorders. Because of these risks, serious consideration should be given to inpatient treatment for withdrawal.

  • Alcohol and barbiturates can cause increased tolerance by increasing the amount of liver enzymes responsible for their metabolism. These same liver enzymes are also responsible for metabolizing many antidepressant, anticonvulsant, and antipsychotic medications. Thus, serum levels of medications will be decreased, possibly to subtherapeutic levels. Without assessing for possible AOD use, some physicians may mistakenly increase medication doses.
  • Alcohol interferes with the thermoregulatory center of the brain, as do antipsychotic drugs. Patients taking both medications may be unable to adjust their body temperature in response to extremes in the external environment.
  • The interaction of stimulants in a person taking monoamine oxidase inhibitor antidepressants can lead to a life-threatening hypertensive crisis.
  • Alcohol and cocaine enhance the respiratory depression effects of opioids and some neuroleptics such as the phenothiazines. This effect can increase vulnerability to overdose death.
  • Marijuana has anticholinergic effects. In combination with the anticholinergic medications such as Cogentin, marijuana use can lead to an anticholinergic (atropine) psychosis.
  • Patients who are vulnerable to hallucinations, such as schizophrenic patients, are at high risk for having hallucinations during the withdrawal from alcohol and other sedative-hypnotics.
  • Antipsychotics and antidepressants lower the seizure threshold and enhance seizure potential during withdrawal from sedative-hypnotics and alcohol.
  • Alcohol intoxication and withdrawal disturbs the fluid electrolyte balance in the body, which can lead to lithium toxicity.

[Back Matter]

Appendix A -- Bibliography

Africa, B., and Schwartz, S.R.
Schizophrenic disorders. In: Goldman, H.H., ed. Review of General Psychiatry, Third Edition. Norwalk, Connecticut: Appleton & Lange, 1992. pp. 226-241.
American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Washington, D.C.: American Psychiatric Association, 1987.
American Psychiatric Association.
DSM-IV Draft Criteria, 3/1/93. Washington, D.C.: American Psychiatric Association, 1993.
Anthenelli, R.M., and Schuckit, M.A.
Affective and anxiety disorders and alcohol and drug dependence: diagnosis and treatment. Journal of Addictive Diseases 12(3):73-87, 1993.

Baker, F.
Coordination of alcohol, drug abuse, and mental health services. Technical Assistance Publication Series Number 4. Washington, D.C.: Office for Treatment Improvement, Alcohol, Drug Abuse, and Mental Health Administration, 1991.
Balster, R.L.
Abuse potential of buspirone and related drugs. Journal of Clinical Psychopharmacology 10(3, Suppl.):31S-37S, 1990.

Beck, A.T., and Ward, J.
Beck Depression Inventory. In: Beck A.T., ed., Depression: Causes and Treatment. Philadelphia: University of Pennsylvania Press, 1972.
Bernadt, M.W., and Murray, R.M.
Psychiatric disorder, drinking and alcoholism: what are the links? British Journal of Psychiatry 148:393-400, 1986.

Blume, S.B.
Dual diagnosis: Psychoactive substance dependence and the personality disorders. Journal of Psychoactive Drugs 21(2):139-144, 1989.

Brown, R.L.
Identification and office management of alcohol and drug disorders. In: Fleming, M.F., and Barry, K.L., eds. Addictive Disorders. St. Louis: Mosby Yearbook, 1992.
Brown, V.B., Ridgely, M.S., Pepper, B., Levine, I.R., and Ryglewicz, H.
The dual crisis: Mental illness and substance abuse, present and future directions. American Psychologist 44(3):565-569, 1989.

Bryant, K.J., Rounsaville, B., Spitzer, R.L., and Williams, J.B.
Reliability of dual diagnosis, substance dependence and psychiatric disorders. Journal of Nervous and Mental Disease 180(4):251-257, 1992.

Burns, D.D.
The Feeling Good Handbook. New York: Penguin Books, 1989.
Carmen, E., and Brady, S.M.
AIDS risk and prevention for the chronic mentally ill. Hospital and Community Psychiatry 41(6):652-657, 1990.

Castaneda, Casteneda, R., Galanter, M., and Franco, H.
Self-medication among addicts with primary psychiatric disorders. Comprehensive Psychiatry 30(1):80-83, 1989.

Castaneda, R., Galanter, M., Lifshutz, H., and Franco, H.
Effects of drugs of abuse on psychiatric symptoms among hospitalized schizophrenics. American Journal of Drug and Alcohol Abuse 17(3):313-320, 1991.

Caton, C.L., Gralnick, A., Bender, S., and Simon, R.
Young chronic patients and substance abuse. Hospital and Community Psychiatry 40(10):1037-1040, 1989.

Ciraulo, D.A., Barnhill, J.G., Ciraulo, A.M., Greenblatt, D.J., and Shader, R.I.
Parental alcoholism as a risk factor in benzodiazepine abuse: A pilot study. American Journal of Psychiatry 146:1333-1335, 1989.

Ciraulo, D. A., Barnhill, J.G., Greenblatt, D.J., Shader, R.I., Ciraulo, A.M., Tarmey, M.F., Molloy, M.A., and Foti, M.E.
Abuse liability and clinical pharmacokinetics of alprazolam in alcoholic men. Journal of Clinical Psychiatry 49:333-337, 1988.

Clark, H.W., and Zweben, J.E.
Legal vulnerabilities in the treatment of chemically dependent dual diagnosis patients. Journal of Psychoactive Drugs 21(2):251-257, 1989.

Davis, G.C., and Goldman, B.
Somatic therapies. In: Goldman, H.H., ed. Review of General Psychiatry, Third Edition. Norwalk, Connecticut: Appleton & Lange, 1992. pp. 370-390.
Dixon, L., Haas, G., Weiden, P., Sweeney, J., and Frances, A.
Acute effects of drug abuse in schizophrenic patients: clinical observations and patients' self-reports. Schizophrenia Bulletin 16(1):69-79, 1990.

Domisse, Dommisse, C.S., and Hayes, P.E.
Current concepts in clinical therapeutics: anxiety disorders, Part 2. Clinical Pharmacy 6:196-215, 1987.

Drake, R.E., Osher, F.C., and Wallach, M.A.
Homelessness and dual diagnosis. American Psychologist 46(11):1149-1158, 1991.

Evans, K., and Sullivan, J.M.
Dual Diagnosis: Counseling the Mentally Ill Substance Abuser. New York: Guilford Press, 1990.
Evans, K., and Sullivan, J.M.
Step Study Counseling With the Dual Disordered Client. Center City, Minnesota: Hazelden Educational Materials, 1990.
Fischer, P.J., and Breakey, W.R.
The epidemiology of alcohol, drug, and mental disorders among homeless persons. American Psychologist 46(11):1115-1126, 1991.

Gold, M.S.
The Good News About Depression. New York: Villard Books, 1987.
Gold, M.S.
The Good News About Drugs and Alcohol. New York: Villard Books, 1990.
Gold, M.S.
The Good News About Panic, Anxiety, and Phobias. New York: Villard Books, 1989.
Goldman, M.S.
Neuropsychological recovery in alcoholics: endogenous and exogenous processes. Alcoholism: Clinical and Experimental Research 10(2):136-144, 1986.

Gordon, S.M., Kennedy, B.P., and McPeake, J.D.
Neuropsychologically impaired alcoholics: assessment, treatment considerations, and rehabilitation. Journal of Substance Abuse Treatment 5:99-104, 1988.

Gorelick, D.A.
Serotonin uptake blockers and the treatment of alcoholism. In: Galanter, M., ed. Recent Developments in Alcoholism. New York: Plenum Press, 1989. pp. 267-281.
El-Guebaly, N.
Substance abuse and mental disorders: the dual diagnoses concept. Canadian Journal of Psychiatry 35:261-267, 1990.

Hasin, D.S., Endicott, J., and Keller, M.B.
Alcohol problems in psychiatric patients: 5-year course. Comprehensive Psychiatry 32(4):303-316, 1991.

Hedlund, J.L., and Vieweg, M.S.
The Michigan Alcoholism Screening Test (MAST). Journal of Operational Psychiatry 15:55-64, 1984.
Hendrickson, E.L.
Treating the dually diagnosed (mental disorder/substance use) client. Tie Lines 4(4):1-6, 1988.
Jensen, K.L.
Family issues in treating the "dually diagnosed" client. Tie Lines 7:6-8, 1990.
Kofoed, L., Kania, J., Walsh, T., and Atkinson, R.M.
Outpatient treatment of patients with substance abuse and coexisting psychiatric disorders. American Journal of Psychiatry 143(7):867-872, 1986.

Kofoed, L., and Keys, A.
Using group therapy to persuade dual-diagnosis patients to seek substance abuse treatment. Hospital and Community Psychiatry 39(11):1209-1211, 1988.

Kranzler, H.R., and Liebowitz, N.R.
Anxiety and depression in substance abuse: clinical implications. Medical Clinics of North America 72(4):867-885, 1988.

Lader, M.
Beta-Adrenoceptor antagonists in neuropsychiatry: an update. Journal of Clinical Psychiatry 49:213-223, 1988.

Landry, M.J., Smith, D.E., McDuff, D.R., and Baughman, O.L., 3rd.
Anxiety and substance use disorders: the treatment of high-risk patients. Journal of the American Board of Family Practice 4:447-456, 1991.

Landry, M.J., Smith, D.E., and Steinberg, J.R.
Anxiety, depression, and substance use disorders: diagnosis, treatment, and prescribing practices. Journal of Psychoactive Drugs 23(4):397-416, 1991a.

Lehman, A.F., Myers, C.P., and Corty, E.
Assessment and classification of patients with psychiatric and substance abuse syndromes. Hospital and Community Psychiatry 40(10):1019-1030, 1989.

Mayfield, D., McLeod, G., and Hall, P.
The CAGE questionnaire: validation of a new alcoholism screening instrument. American Journal of Psychiatry 131(10):1121-1123, 1974.

McLellan, A.T.
Predicting response to alcohol and drug abuse treatments: the role of psychiatric severity. Archives of General Psychiatry 40:620-625, 1983.

McLellan, A.T., Luborsky, L., Woody, G.E., and O'Brien, C.P.
An improved diagnostic evaluation instrument for substance abuse patients: the Addiction Severity Index 168:26-33, 1980.
Meek, P.S., Clark, H.W., and Solana, V.L.
Neurocognitive impairment: the unrecognized component of dual diagnosis in substance abuse treatment. Journal of Psychoactive Drugs 21(2):153-160, 1989.

Meltzer, E.O.
Performance effects of antihistamines. Journal of Allergy and Clinical Immunology 86(4, Part 2):613-619, 1990.

Meyer, R.E.
How to understand the relationship between psychopathology and addictive disorders: another example of the chicken and the egg. In: Meyer, R.E., ed. Psychopathology and Addictive Disorders. New York: Guilford Press, 1986.
Meyer, R.E. Prospects for a rational pharmacotherapy of alcoholism.
Journal of Clinical Psychiatry 50(11):403-412, 1989.
MICA Advisory Committee, State of New Jersey. Glossary of terms common in MICA treatment.
Trenton, New Jersey: State of New Jersey, 1992.
Miller, N.S., and Ries, R.K.
Drug and alcohol dependence and psychiatric populations: the need for diagnosis, intervention, and training. Comprehensive Psychiatry 32(3):268-276, 1991.

Minkoff, K.
An integrated treatment model for dual diagnosis of psychosis and addiction. Hospital and Community Psychiatry 40(10):1031-1036, 1989.

Minkoff, K., and Drake, R.E., eds.
Dual Diagnosis of Major Mental Illness and Substance Disorder. San Francisco: Jossey-Bass, Inc., 1991.
Mooney, A.J., Eisenberg, A, and Eisenberg, H.
The Recovery Book. New York: Workman Publishers, 1992.
Morris, S.K., and Schinke, S.P.
Treatment needs and services for mothers with a dual diagnosis: substance abuse and mental illness. In: Chaneles, S., and Pallone, N.J., eds. Clinical Treatment of the Criminal Offender in Outpatient Mental Health Settings: New and Emerging Perspectives. New York: Haworth Press, 1990. pp. 65-84.
Nace, E.P., Davis, C.W., and Gaspari, J.P.
Axis II comorbidity in substance abusers. American Journal of Psychiatry 148(1):118-120, 1991.

Nace, E.P., Saxon, J.J., and Shore, N.
Borderline personality disorder and alcoholism treatment: a one-year follow-up study. Journal of Studies on Alcohol 47(3):196-200, 1986.

Osher, F.C., and Kofoed, L.L.
Treatment of patients with psychiatric and psychoactive substance use disorders. Hospital and Community Psychiatry 40(10):1025-1030, 1989.

Padgett, D., Struening, E.L., and Andrews, H.
Factors affecting the use of medical, mental health, alcohol, and drug treatment services by homeless adults. Medical Care 28(9):805-821, 1990.

Penick, E.C., Powell, B.J., Liskow, B.I., Jackson, J.O., and Nickel, E.J.
The stability of coexisting psychiatric syndromes in alcoholic men after one year. Journal of Studies on Alcohol 49:395-405, 1988.

Pepper, B., and Ryglewicz, H.
The young adult chronic patient and substance abuse. Tie Lines 1(2):1-5, 1984.
Pepper, B., and Ryglewicz, H.
Dual-disorder treatment. Maine Dual Disorders Monographs, Volume 3. Maine Department of Mental Health and Mental Retardation, 1989.
Petracca, A., Nisita, C., McNair, D., Melis, G., Guerani, G., and Cassano, G.B.
Treatment of generalized anxiety disorder: preliminary clinical experience with buspirone. Journal of Clinical Psychiatry 51(9, Suppl.):31-39, 1990.

Quinnet, P.
When Self-Help Fails. New York: Crossroads, 1991.
Regier, D.A., Boyd, J.H., Burke, J.D., Rae, D. S., Myers, J.K., Kramer, M., Robins, L.N., George, L.K., Karno, M., and Locke, B.Z.
One-month prevalence of mental disorders in the United States: based on five Epidemiologic Catchment Area sites. Archives of General Psychiatry 45:977-986, 1988.

Regier, D.A., Farmer, M.E., Rae, D.S., Locke, B.Z., Keith, S.J., Judd, L.L., and Goodwin, F.K.
Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) study. Journal of the American Medical Association 264(19):2511-2518, 1990.

Regier, D.A., Narrow, W.E., and Rae, D.S.
The epidemiology of anxiety disorders: the Epidemiologic Catchment Area (ECA) experience. Journal of Psychiatric Research 24(Suppl. 2):3-14, 1990a.

Reid, W.H.
The Treatment of Psychiatric Disorders. New York: Brunner/Mazel, 1989.
Reus, V.I.
Mood disorders. In: Goldman, H.H., ed. Review of General Psychiatry, Third Edition. Norwalk, Connecticut: Appleton & Lange, 1992. pp. 226-241.
Rickels, K., Weisman, K., Norstad, N., Singer, M., Stoltz, D., Brown, A., and Danton, J.
Buspirone and diazepam in anxiety: a controlled study. Journal of Clinical Psychiatry 43(12, Sec. 20):81-86, 1982.

Ries, R.
Clinical treatment matching models for dually diagnosed patients. Psychiatric Clinics of North America 16(1):167-175, 1993.

Ries, R.K.
The dually diagnosed patient with psychotic symptoms. Journal of Addictive Diseases 12(3):103-122, 1993a.

Ries, R.K., and Ellingson, T.
A pilot assessment at one month of 17 dual diagnosis patients. Hospital and Community Psychiatry 41(11):1230-1233, 1990.

Robins, E., Helzer, J.E., and Przybeck, T.R.
Alcohol disorders in the community: a report from the Epidemiologic Catchment Area study. In: Rose, R., and Barret J., eds. Alcoholism: Origins and Outcome. New York: Raven Press, 1988. pp. 15-28.
Rosenheck, R., Massari, L., Astrachan, B., and Suchinsky, R.
Mentally ill chemical abusers discharged from VA inpatient treatment: 1976-1988. Psychiatric Quarterly 61(4):237-249, 1990.

Ross, H.E., Glaser, F.B., and Germanson, T.
The prevalence of psychiatric disorders in patients with alcohol and other drug problems. Archives of General Psychiatry 45:1023-1031, 1988.

Rounsaville, B.J., Anton, S.F., Carroll, K., Budde, D., Prusoff, B.A., and Gawin, F.
Psychiatric diagnoses of treatment-seeking cocaine abusers. Archives of General Psychiatry 48:43-51, 1991.

Ryglewicz, H.
Psychoeducation: A wave of the present. Tie Lines 6(2):1-5, 1989.
Salloum, I.M., Moss, H.B., and Daley, D.C.
Substance abuse and schizophrenia: impediments to optimal care. American Journal of Alcohol Abuse 17(3):321-336, 1991.

Salzman, C.
Treatment with antianxiety agents. In: Treatments of Psychiatric Disorders. Washington, D.C.: American Psychiatric Association, 1989. pp. 2036-2052.
Schorske, B., and Bedard, K.
One State's role in building a continuum of care for severe mental illness and chemical dependency. Community Support Network News 6(2):10, 1989.
Schuckit, M.A.
Genetic and clinical implications of alcoholism and affective disorder. American Journal of Psychiatry 143(2): 140-147, 1986.

Spitzer, R.L., Williams, J.B.W., Gibbon, M., and First, M. B.
Structured Clinical Interview for DSM-III-R. Washington, D.C.: American Psychiatric Press, 1990.
Strand, M., Hetta, J., Rosen, A., Sorensen, S., Malmstrom, R., Fabian, C., Marits, K., Vetterskog, K., Liljestrand, A.-G., and Hegen, C.
A double-blind, controlled trial in primary care patients with generalized anxiety: a comparison between buspirone and oxazepam. Journal of Clinical Psychiatry 51(9, Suppl.):40-45, 1990.

Stoffelmayr, B.E., Benishek, L.A., Humphreys, K., Lee, J.A., and Mavis, B.E.
Substance abuse prognosis with an additional psychiatric diagnosis: understanding the relationship. Journal of Psychoactive Drugs 21(2):145-152, 1989.

Teague, G., Mercer-McFadden, C., and Drake, R.E.
Dual diagnosis and continuity of care: New Hampshire's integrated initiatives for dual diagnosis patients. Tie Lines 6(1):1-3, 1989.
Thacker, W., and Tremaine, L.
Systems issues in serving the mentally ill substance abuser: Virginia's experience. Hospital and Community Psychiatry 40(10):1046-1049, 1989.

Torrey, E.F.
Surviving Schizophrenia: A Family Manual. New York: Harper & Row, 1983.
Trevor, A.J., and Way, W.L.
Drugs used for anxiety states and sleep problems. In: Goldman, H.H., ed. Review of General Psychiatry, Second Edition. Norwalk, Connecticut: Appleton & Lange, 1989.
Turner, W.M., and Tsuang, M.T.
Impact of substance abuse on the course and outcome of schizophrenia. Schizophrenia Bulletin 16(1):87-95, 1990.

Uhde, T.W., Stein, M.B., Vittone, B.J., Siever, L.J., Boulenger, J.P., Klein, E., and Mellman, T. A.
Behavioral and physiologic effects of short-term and long-term administration of clonidine in panic disorders. Archives of General Psychiatry 46(2):170-177, 1989.

Wallen, M., and Weiner, H.
The dually diagnosed patient in an inpatient chemical dependency treatment program. Alcoholism Treatment Quarterly 5(1/2):197-218, 1988.
Weiss, D.S., and Billings, J.H.
Behavioral medicine techniques. In: Goldman, H.H., ed. Review of General Psychiatry, Second Edition. Norwalk, Connecticut: Appleton & Lange, 1989. pp. 574-579.
Weiss, R.D., M.L. Griffin, and Mirin, S.M.
Drug abuse as self-medication for depression: an empirical study. American Journal of Drug and Alcohol Abuse 18:121-129, 1992.

Weissman, M.M.
The epidemiology of anxiety disorders: rates, risks and familial patterns. Journal of Psychiatric Research 22(Suppl. 1):99-114, 1988.

Winter, A.S.
When Self-Help Isn't Enough. Washington, D.C.: Psychiatric Institutes of America Press, 1990.
Wolfe, H.L., and Sorensen, J.L.
Dual diagnosis patients in the urban psychiatric emergency room. Journal of Psychoactive Drugs 21(2):169-175, 1989.

Yeary, J.R., and Heck, C.L.
Dual diagnosis: eating disorders and psychoactive substance dependence. Journal of Psychoactive Drugs 21(2): 239-249, 1989.

Zweben, J.E.
Issues in the treatment of the dual-diagnosis patient. In: Wallace, B., ed. The Chemically Dependent: Phases of Treatment and Recovery. New York: Brunner/Mazel, 1992.
Zweben, J.E.
Counseling issues in methadone maintenance treatment. Journal of Psychoactive Drugs 23(2):177-190, 1991.

Zweben, J.E., and Smith, D.E.
Considerations in using psychotropic medication with dual diagnosis patients in recovery. Journal of Psychoactive Drugs 21(2): 221-226, 1989.

Appendix B -- Treatment of Patients With Dual Disorders: Sample Cost Data

To provide readers with illustrative data on the costs of running programs for patients with dual disorders, the consensus panel Chair obtained data on actual costs during fiscal year 1991-1992 from three programs in urban areas. One program, on the West Coast, provided day and evening intensive outpatient services. The second, in the Northeast, provided intensive outpatient services during the day. In the third program, in the Northwest, daytime intensive outpatient services,partial hospitalization, and intensive case management were provided.

Included in the tables below are descriptive data for each program, including institutional status (for example, private for-profit or public), payer mix (for example, Medicaid or self-pay patients), number of clients served (at 100 percent capacity), salary ranges of various levels of staff, and other expenses (for example, facility costs). Total expenses and total revenues for each program are listedat the end.

TREATMENT OF PATIENTS WITH DUAL DISORDERS SAMPLE COST DATA

Program 1 Program 2 Program 3
PROGRAM TYPE
Evening Intensive Outpatient X
Day Intensive Outpatient X X X
Partial Hospitalization X
Other Day treatment and intensive case management
REGION West Coast Northeast Northwest
LOCALE Urban Urban Urban
INSTITUTIONAL STATUS
Private for-profit X
Private nonprofit
Public X X
Other
PAYER MIX (BY PERCENT)
Insurance/Managed Care X
Medicaid 66% 30%
Medicare X 25%
Self-pay X 4%
HMO contract X
State grant/purchase of care 30% 45%
Program 1 Program 2 Program 3
NUMBER OF PATIENTS SERVED (AT 100 PERCENT CAPACITY)
Daily 50+ 45 100
Weekly 320 225 300
SALARY RANGES
Administrators/managers $60,000 to 70,000 $38,000 to 50,000 $35,000 to 60,000
Physicians $70/Hour to 100/Hour $85,00 $70,000 to 90,000
Social workers $30,000 to 50,00 $30,000 $26,000 to 35,000
Psychologists $50,000 to 60,000 n/a $50,000 to 70,000
Support staff $18,000 to 27,000 $20,000 to 29,000 $22,000 to 28,000
Other Addiction counselors, $23,000 to 35,000 Nurses, counselors and recreational therapists, $25,000 to 38,000 Addiction mental health specialists, $23,000 to 33,000
Nurses $32,000 to 48,000
Program 1 Program 2 Program 3
OTHER EXPENSES (BY PERCENT)
Administrative overhead 7.1% 24% 20%
Personnel (including fringe benefits) 80.5% 60% 70%
Facility costs 12.4% 16% 10%
TOTAL EXPENSES FY 1991-1992 TOTAL REVENUES FY 1991-1992
Program 1 $482,000 $489,000
Program 2 $811,052 $561,052
Program 3 $2,200,000 $1,980,000

Appendix C -- Federal Resource Panel

John J. Ambre, M.D., Ph.D.
American Medical Association
Robert Anderson
Director
Criminal Justice Service
National Association of State Alcohol and Drug Abuse Directors
Richard J. Bast
Public Health Advisor
Quality Assurance and Evaluation Branch
Division of State Programs
Center for Substance Abuse Treatment
Sandra M. Clunies, M.S., N.C.A.D.C.
President, Maryland Addiction Counselor Certification Board
Dorynne Czechowicz, M.D.
Associate Director
Medical and Professional Affairs
Division of Clinical Research
National Institute on Drug Abuse
Walter L. Faggett, M.D.
National Medical Association
Rita Goodman, M.S., R.N.C.
Nurse Consultant
Division of Primary Care Services
Health Resources and Services Administration
John Gregrich
Policy Analyst
Office for National Drug Control Policy
Executive Office for the President
Claudia Hart
American Psychiatric Association
Ruth H. Carlsen Kahn, D.N.Sc.
Special Projects Section
Division of Medicine
Bureau of Health Professions
Health Resources and Services Administration
Saul M. Levin, M.D.
Director
Office of Health Care Linkage
Center for Substance Abuse Treatment
Cherry Lowman, Ph.D.
Health Scientist Administrator
Treatment Research Branch
Division of Clinical and Prevention Research
National Institute on Alcohol Abuse and Alcoholism
Anna Marsh, Ph.D.
Associate Director for Evaluation
Office of Applied Studies
Center for Substance Abuse Treatment
Fred C. Osher, M.D.
Deputy Director
Office of Programs for the Homeless Mentally Ill
National Institute of Mental Health
Deborah Parham, Ph.D., R.N.
Chief
Special Initiatives
Policy and Evaluation Branch
Bureau of Primary Health Care
Health Resources and Services Administration
Kay Pearson, R.Ph., M.P.H.
Senior Health Policy Analyst
Agency for Health Care Policy and Research
Public Health Service
Bert Pepper, M.D.
The Information Exchange
New City, New York
Richard K. Ries, M.D. (Chair)
Director of Inpatient Psychiatry and Dual Disorder Programs
Harborview Medical Center
Seattle, Washington
Harry Schnibbe
Executive Director
National Association of State Mental Health Program Directors
Sarah Stanley, M.S., R.N., C.N.A, C.S.
American Nurses Association
Patricia M. Weisser
National Association of Psychiatric Survivors

Appendix D -- Field Reviewers

Arthur I. Alterman, Ph.D.
Scientific Director
Center for Studies of Addiction
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Robert Anderson
Director, Criminal Justice
National Association of State Alcohol and Drug Abuse Directors
Gloria J. Baciewicz, M.D.
Director
Alcoholism and Drug Dependency Program
University of Rochester Medical Center
Rochester, New York
Stephen J. Bartels, M.D.
Medical Director
West Central Services, Inc.
Research Associate
N.H. Dartmouth Psychiatric Research Center
Lebanon, New Hampshire
Richard J. Bast
Public Health Advisor
Center for Substance Abuse Treatment
Joseph J. Bevilaqua, Ph.D.
Director
South Carolina Department of Mental Health
Dolores M. Burant, M.D.
Program Director and Medical Director
University Outpatient Recovery Services
Madison, Wisconsin
Ricardo Castaneda, M.D.
Director
Inpatient Psychiatry at Bellevue Hospital
New York Medical Center
Nancy C. Carter
Director
Special Division for Alcohol and Drug Abuse Services
South Carolina Department of Mental Health
Maureen Connelly, Ph.D.
Professor
Department of Sociology and Social Work
Frostburg State University
Frostburg, Maryland
Marcelino Cruces, L.I.C.S.W.
Administrative Coordinator
Andromeda Transcultural Mental Health Center
Substance Abuse Treatment Division
Washington, D.C.
Dorynne Czechowicz, M.D.
Associate Director for Medical and Professional Affairs
Division of Clinical Research
National Institute on Drug Abuse
Robert E. Drake, M.D., Ph.D.
Professor/Director
N.H.-Dartmouth Psychiatric Research Center
Dartmouth Medical School
Lebanon, New Hampshire
Mary Katherine Evans, C.A.D.C., N.C.A.C. II
Treatment Coordinator
Evans and Sullivan
Beaverton, Oregon
Walter L. Faggett, M.D.
Pediatrics/Health Care Consultant
Capitol Area Health Services
National Medical Association
Denis Ferguson, M.A., C.S.A.D.C.
Program Manager
Substance Abuse Services
DuPage County Health Department
Wheaton, Illinois
James Fine, M.D.
Director
Addictive Disease Hospital at Kings County Hospital Center
Clinical Associate Professor
Department of Psychiatry
State University of New York
Health Service Center at Brooklyn
Brooklyn, New York
Agnes Furey, L.P.N., C.A.P.
Primary Care Coordinator
Florida Drug and Alcohol Abuse Program
Department of Health and Rehabilitation Services
Tallahassee, Florida
Harry W. Haverkos, M.D.
Acting Director
Division of Clinical Research
National Institute on Drug Abuse
Elizabeth A. Irvin, M.S.W.
Director of Service Integration
Department of Mental Health
Commonwealth of Massachusetts
Edward K. Katz, M.D., M.P.H.
Mind Science
Consultation for Problems in Thinking and Feeling
Stow, Ohio
Ruth H. Carlsen Kahn, D.N.Sc., R.N.
Special Projects Section
Division of Medicine
Bureau of Health Professions
Health Resources and Services Administration
George Kolodner, M.D.
Kolmac Clinic
Silver Spring, Maryland
Susan Krupnick, R.N., M.S.N., C.A.R.N., C.S.
Psychiatric Consultation Liaison Nurse
Department of Psychiatric Nursing
Hospital of the University of Pennsylvania
Fox Chase Manor, Pennsylvania
Robert M. Lichtman, Ph.D., C.A.C.
Associate Psychologist/Program Coordinator
Richmond Hill Outpatient Division
Creedmoor Psychiatric Center
Richmond Hill, New York
Herbert J. McBride
President and Medical Director
Re-Enter, Inc.
Philadelphia, Pennsylvania
Catherine Devaney McKay, M.D.
Chief Executive Officer
Connections Community Support Programs, Inc.
Wilmington, Delaware
Norman S. Miller, M.D.
Associate Professor of Psychiatry
Department of Psychiatry
University of Illinois at Chicago
Thomas Neslund
Executive Director
International Commission for the Prevention of Alcoholism and Drug Dependency
Silver Spring, Maryland
John Nielsen, L.P.C., C.C.D.C., M.S.S.
Alcohol and Other Drugs Counselor
Threshold Youth Services
Sioux Falls, South Dakota
Robert E. Nikkel, M.S.W.
Coordinator
Adult Program Services Team
Mental Health and Development Services Division
Office of Mental Health Services
State of Oregon
Fred C. Osher, M.D.
Acting Director for Demonstration Programs
Center for Mental Health Services
William C. Panepinto, A.C. S.W.
Assistant Director
Homelessness/Housing Unit
New York State Office of Alcoholism and Substance Abuse Services
T. Allan Pearson, M.S.W.
Mental Health, Alcohol, and Other Drug Abuse Counselor
Ozaukae County Department of Community Programs
Port Washington, Wisconsin
Walter E. Penk, Ph.D.
Chief
Psychology Services
Edit Nourse Rogers Memorial Veterans Hospital Bedford, Massachusetts
Harold I. Perl, Ph.D.
Public Health Analyst
Homeless Demonstration and Evaluation Branch
National Institute on Alcohol Abuse and Alcoholism
Ernest Quimby, Ph.D.
Assistant Graduate Professor
Department of Sociology and Anthropology
Howard University
Washington, D.C.
Kathleen Reynolds, M.S.W., A.C.S.W.
Associate Coordinator
Livingston/Washtenaw Substance Abuse Coordinating Agency
Washtenaw Community Mental Health
Ypsilanti, Michigan
Henry Jay Richards, Ph.D.
Associate Director for Behavioral Sciences
Patuxent Institution
Jessup, Maryland
Richard K. Ries, M.D.
Director of Inpatient Psychiatry and Dual Disorder Programs
Harborview Medical Center
Seattle, Washington
Bruce J. Rounsaville, M.D.
Associate Professor of Psychiatry
Division of Substance Abuse
Yale School of Medicine
New Haven, Connecticut
Harry Schnibbe
Executive Director
National Association of State Mental Health Program Directors
Bonnie Schorske, M.A.
Coordinator
Special Populations
New Jersey Division of Mental Health and Hospitals
Candace Shelton, M.S., C.A.C.
Clinical Director
Pascua Yaqui Adult Treatment Home
Tucson, Arizona
Elizabeth C. Shifflette, Ed.D.
Staff Development and Training Coordinator
South Carolina Commission on Alcohol and Drug Abuse
Virginia Stiepock, R.N., A.C.S.W., C.S.
Assistant Center Director/Clinical Director
Northern Rhode Island Community Mental Health Center, Inc.
Woonsocket, Rhode Island
Mathias E. Stricherz, Ed.D., C.D.C. III
Director
Student Counseling Center
University of South Dakota
Vermillion, South Dakota
J. Michael Sullivan, Ph.D.
Clinical Director
Evans and Sullivan
Beaverton, Oregon
Johnie L. Underwood, B.S., C.S.W.
Assistant Deputy Director
Division of Mental Health and Addictions
Indiana Family Social Services Administration
Mark C. Wallen, M.D.
Medical/Clinical Director
Livengrin Foundation, Inc.
Bensalem, Pennsylvania
Linda M. Washington, M.S.N., R.N., C.S.-P.
Psychiatric Nurse Clinical Specialist
Outpatient Addictions Services
Montgomery County Department of Addictions, Victims, and Mental Health Services
Rockville, Maryland
Patricia M. Weisser
National Association of Psychiatric Survivors
Sioux Falls, South Dakota
Sonya Cornell Yarmat, M.A.
Consultant
Division of Alcohol and Drug Abuse Services
Department of Social Rehabilitation
Topeka, Kansas
Doug Ziedonis, M.D.
Assistant Professor
Department of Psychiatry
Medical Director, Substance Abuse Treatment Unit
Outpatient Services
Yale University
New Haven, Connecticut
Joan Ellen Zweben, Ph.D.
Executive Director
East Bay Community Recovery Project
14th Street Clinic and Medical Group
Berkeley, California

Exhibits

Exhibit 2-1 DSM-III-R and DSM-IV Draft Criteria for AOD Dependence

DSM-III-R Criterion No. DSM-IV Draft Criterion No. Diagnostic Criterion (language from DSM-III-R)
No. 1 No. 3 AODs are often taken in larger amounts or over a longer period of time than the person intended.
No. 2 No. 4 The person has a persistent desire or has made one or more unsuccessful efforts to cut down or control AOD use.
No. 3 No. 5 The person spends a great deal of time in activities necessary to obtain, consume, or recover from AOD effect
No. 4 Deleted The person experiences frequent intoxication or withdrawal symptoms when expected to fulfill major role obligations at work, school, or home, or when AOD use is physically hazardous.
No. 5 6 Important social, occupational, or recreational activities are given up or reduced because of AOD use.
No. 6 7 AOD use continues despite knowledge of having a persistent or recurrent social, psychological, or physical problem that is caused or exacerbated by AOD use.
No. 7 1 There is evidence of marked tolerance: a need for markedly increased amounts of AODs to achieve intoxication or a desired effect, or markedly diminished effect with continued use of the same amount.
No. 8 2 Evidence of characteristic withdrawal symptoms.
No. 9 2 AODs are often taken to relieve or avoid withdrawal symptoms.

Exhibit 3-1 Treatment Approach Similarities and Differences

Mental Health System Dual Disorders Approach Addiction System
Medications Central to the management of severe disorders in acute, subacute, and long-term phases of treatment: antidepressants, antipsychotics, anxiolytics, mood stabilizers. Central to the treatment of many patients with dual disorders. Caution is used when prescribing psychoactive, mood-altering medications. Central for acute detoxification; less common for subacute phase. Few used during long-term treatment: disulfiram, naltrexone, methadone, and LAAM.
Therapeutic Confrontations Minimal to moderate use, depending upon setting, patient, and problem. Not central to therapy. Generally used, but use is modulated according to fragility of mental status. Use by staffand peers is one of the central techniques in AOD treatment.
Group Therapy Central to treatment. Central to treatment. Central to treatment.
12-Step Groups Although historically underused, use is growing. Examples include: Emotions Anonymous, Obsessive-Compulsive Anonymous, and Phobics Anonymous. Dual Disorders Anonymous groups not yet widespread. Use of 12-step groups for AOD problems is central, but actively psychotic or paranoid patients may not mix well in meetings. "Double Trouble" AA groups are becoming more numerous. Use of 12-step groups is central to AOD treatment. Great availability. Examples include: Alcoholics Anonymous, Narcotics Anonymous, and Cocaine Anonymous.
Other Self-Help Groups Numerous national organizations. Growing numbers of local groups. Use depends upon availability and awareness. Examples include: Anxiety Disorders Association of America, National Depressive & Manic-Depressive Association, Recovery, Inc., and National Association of Psychiatric Survivors. Use of self-help groups regarding AOD and mental health problems is increasing. Numerous organizations and groups, often specialized. Examples include: Women for Sobriety, Rational Recovery, Secular Organizations for Sobriety, International Doctors in AA, Recovering Counselors Network, and Social Workers Helping Social Workers.

Exhibit 3-2 The CAGE and CAGEAID Questionnaires

The CAGE Questionnaire:

  • Have you ever felt you should cut down on your drinking?
  • Have people annoyed you by criticizing your drinking?
  • Have you felt bad or guilty about your drinking?
  • Have you ever had a drink first thing in the morning to steady your nervesor get rid of a hangover (eye-opener)?
Source: Mayfield et al., 1974.

The CAGE Questions Adapted to Include Drugs (CAGEAID):

  • Have you felt you ought to cut down on your drinking or drug use?
  • Have people annoyed you by criticizing your drinking or drug use?
  • Have you felt bad or guilty about your drinking or drug use?
  • Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover or to get the day started?
Source: Brown, 1992.

Exhibit 5-1 Drugs That Precipitate or Mimic Mood Disorders

Mood Disorders During Use [Intoxication] After Use [Withdrawal]
Depression and dysthymia Alcohol, benzodiazepines, opioids, barbiturates, cannabis, steroids (chronic), stimulants (chronic) Alcohol, benzodiazepines, barbiturates, opiates, steroids (chronic), stimulants (chronic)
Mania and cyclothymia Stimulants, alcohol, hallucinogens, inhalants (organic solvents), steroids (chronic, acute) Alcohol, benzodiazepines, barbiturates, opiates, steroids (chronic)

Exhibit 7-1 Characteristics of People With Passive-Aggressive, Antisocial, and Borderline Personality Disorders

Characteristic Passive-Aggressive Antisocial Borderline
Affect Overcontrolled hostility Angry intimidation Angry self-harm
World-view I do everything right and they still act this way. I don't deserve this. I'm fine; ignore the tears. If you don't do what I want, you'll be sorry. I deserve it all. They're the ones with the problem. I've got to get you, before you get me. I don't deserve to exist. Help me, help me, but you can't.
Presenting problem Depression, somatization, sedative dependence, codependency relationships Legal difficultie polysubstance abuse and dependence, parasitic cold relationships Self-harm, impulsive behavior, episodic polysubstance abuse.
Social functioning Consistent underachievement Episodic achievement Gross dysfunctioning
Motivation Belonging Self-esteem Safety
Defenses Repression Rationalization, projection Splitting, projection
Adapted with permission from Evans, K., and Sullivan, J.M.Step Study Counseling With the Dual Disordered Client. Center City, Minnesota: Hazelden Educational Materials, 1990.

Exhibit 7-2 Step Work Handout For Patients With Borderline Personality Disorder

Step One: "We admitted we were powerless over alcohol-that our lives had become unmanageable."

  • Describe five situations where you suffered negative consequences as a result of drinking or using other drugs.
  • List at least five "rules" that you have developed in order to try to control your use of alcohol or other drugs. (Example: "I never drink alone.")
  • Give one example describing how and when you broke each rule.
  • Check the following that apply to you:
    • I sometimes drink or use other drugs more than I plan.
    • I sometimes lie about my use of alcohol or other drugs.
    • I have hidden or stashed away alcohol or other drugs so I could use them alone or at a later time.
    • I have had memory losses when drinking or using other drugs.
    • I have tried to hurt myself when drinking or using other drugs.
    • I can drink or use more than I used to, without feeling drunk or high.
    • My personality changes when I drink or use other drugs.
    • I have school or work problems related to using alcohol or other drugs.
    • I have family problems related to my use of alcohol or other drugs.
    • I have legal problems related to my use of alcohol or other drugs.
  • Give two examples for each item that you checked.

Step Two: "We came to believe that a Power greater than ourselves could restore us to sanity."

  • Give three examples of how your drinking or use of other drugs was insane. (One definition of insanity is to keep repeating the same mistake and expecting a different outcome.)
  • Check which of the following mistakes or thinking errors that you use:
    • Blaming
    • Lying
    • Manipulating
    • Excuse making
    • Beating up yourself with "I should have" statements
    • Self-mutilation (cutting on yourself when angry)
    • Negative self-talk
    • Using angry behavior to control others
    • Thinking "I'm unique."
  • Explain how each thinking error you checked above is harmful to you and others.
  • Give two examples of something that has happened since you stopped drinking or using other drugs that shows you how your situation is improving.
  • Who or what is your Higher Power?
  • Why do you think your Higher Power can be helpful to you?

Step Three: "Made a decision to turn our will and our lives over to the care of God as we understood Him."

  • Explain how and why you decided to turn your will over to a Higher Power.
  • Give two examples of things or situations you have "turned over" in the last week.
  • List two current resentments you have, and explain why it is important for you to turn them over to your Higher Power.
  • How do you go about "turning over" a resentment?
  • What does it mean to turn your will and life over to your Higher Power?
  • Explain how and why you have turned your will and life over to a Power greater than yourself.

Step Four: "Made a searching and fearless moral inventory of ourselves."

  • List five things you like about yourself.
  • Give five examples of situations where you have been helpful to others.
  • Give three examples of sexual behaviors related to your drinking or use of other drugs, which have occurred in the last 5 years, about which you feel bad.
  • Describe how beating yourself up for old drinking and other drug-using behavior is not helpful to you now.
  • List five current resentments you have, and explain how holding on to these resentments hurts your recovery.
  • List all laws you have broken related to your drinking and use of other drugs.
  • List three new behaviors you have learned that are helpful to your recovery.
  • List all current fears you are experiencing, and discuss how working the first three Steps can help dissolve them.
  • Give an example of a current situation you are handling poorly.
  • Discuss how you plan to handle this situation differently the next time the situation arises.

Adapted with permission from Evans, K., and Sullivan, J.M. Step Study Counseling With the Dual Disordered Client. Center City, Minnesota: Hazelden Educational Materials, 1990.

Exhibit 7-3 Recovery Model for the Treatment Of Borderline Personality Disorder

Stage Indications Goal Interventions
I. Crisis Behavior out of control; risk of harm to self or others; extreme withdrawal or intrusiveness Safety and health through structure and support
  • Inpatient stay
  • Contracts for safety
  • Case manager or support groups
  • Identify triggers for relapse or stress to plan for crisis
  • Make daily or weekly schedule to structure time
II. Building Routine attendance at therapeutic sessions, meetings, appointments; some ability to stay focused on here and now Increasing coping skills and self-esteem
  • Develop an assets or accomplishments list
  • Positive self-talk and affirmations
  • Skills training in time management, assertiveness, and so on
III. Education Expresses, exhibits increased self-efficacy Reframe self-perceptions and history from victim to survivor
  • Read or debrief clinician-prescreened ACOA or incest-survivor literature
  • Classes on dysfunctional families, survivor issues
  • Written assignments on strengths and limitations of "survivor behaviors"
IV. Integration Able to express feelings Integrate past, present, and regulate thinking and actions behaviors
  • Art therapy, journal work, current feelings, thoughts, other expressive modalities
  • Psychodynamic therapy, here-and-now interpretations
  • Grief and child-within work, marital, sex, or family therapy
Adapted with permission from Evans, K., and Sullivan, J.M.Step Study Counseling With the Dual Disordered Client.Center City, Minnesota: Hazelden Educational Materials, 1990.

Exhibit 7-4 Antisocial Thinking-Error Work

The group facilitator will present thinking errors and then ask each group member to identify two thinking-error examples that apply to him or her and to choose one to focus on with group help.

  1. Excuse making -- Excuses can be made for anything and everything. Excuses are a way to justify behavior. For example: "I drink because my mother nags me," "My family was poor," "My family was rich."
  2. Blaming -- Blaming is an excuse to avoid solving a problem and is used to excuse behavior and build up resentment toward someone else for "causing" whatever has happened. For example: "They forced me to drink it!"
  3. Justifying -- To justify an antisocial behavior is to find a reason to support it. For example: "If you can, I can," "I deserve to get high," "I've got 30 days clean."
  4. Redefining -- Redefining is shifting the focus on an issue to avoid solving a problem. Redefining is used as a power play to get the focus off the person in question. For example: "I didn't violate my probation. The language is confusing and the order is full of typos."
  5. Superoptimism -- "I think; therefore it is." Example: "I don't have to go to AA. I can stay sober on my own."
  6. Lying -- There are three basic kinds of lies: (1) lies of commission -- making things up that are simply not true; (2) lies of omission -- saying partly what is so, but leaving out major sections, and (3) lies of assent -- pretending to agree with other people or approving of their ideas despite disagreement or having no intention of supporting the idea.
  7. "I'm Unique" -- Thinking one is special and that rules shouldn't apply to one.
  8. Ingratiating -- Being nice to others, and going out of one's way to act interested in other people, can be used to try to control situations or get the focus off a problem. Apple polishing.
  9. Fragmented Personality -- Some people may attend church on Sunday, get drunk or loaded on Tuesday, and then attend church again on Wednesday. They rarely consider the inconsistency between these behaviors. They may feel that they have the right to do whatever they want, and that their behaviors are justified.
  10. Minimizing -- Minimizing behavior and action by talking about it in such a way that it seems insignificant. For example: "I only had one beer. Does that count as a relapse?"
  11. Vagueness -- This strategy is to be unclear and nonspecific to avoid being pinned down on any particular issue. Vague words are phrases such as: "I more or less think so," "I guess," "probably," "maybe," "I might," "I'm not sure about this," "it possibly was," etc.
  12. Power Play -- This strategy is to use power plays whenever one isn't getting one's way in a situation. Examples include walking out of a room during a disagreement, threatening to call an attorney or report the group facilitator to higher-ups.
  13. Victim Playing -- The victim player transacts with others to invite either criticism or rescue from those around him.
  14. Grandiosity -- Grandiosity is minimizing or maximizing the significance of an issue, and it justifies not solving the problem. For example: "I was too scared to do anything else but sit," "I'm the best there is, so no one else can get in my way."
  15. Intellectualizing -- Using an emotionally detached, data-gathering approach to avoid responsibility. For example, when faced with a positive urine drug screen the patient states: "When was the last time the laboratory had their equipment calibrated?" or "What is the percentage of error in this testing procedure?"

Adapted with permission from Evans, K., and Sullivan, J.M.Step Study Counseling With the Dual Disordered Client.Center City, Minnesota: Hazelden Educational Materials, 1990.

Exhibit 7-5 Step Work Handout For Patients With Antisocial Personality Disorder

Step One: "We admitted we were powerless over alcohol -- that our lives had become unmanageable."

  • Give five examples of ways you have tried to control your use of chemicals and failed.
  • Give five examples of people you have tried and failed to control, and explain why your controlling behavior was unsuccessful (minimum of 150 words each).
  • Give five examples of situations not associated directly with drinking or using other drugs where you have tried to control things and failed (minimum of 100 words each).
  • Give two examples of people who currently have control over you, and explain how that is helpful to you (minimum of 100 words each).
  • Give ten examples of how your drinking and using other drugs caused you problems (minimum of 25 words each).
  • Give five examples of negative consequences that await you should you continue using or abusing alcohol or other drugs (minimum of 50 words each).

Step Two:"Came to believe that a Power greater than ourselves could restore us to sanity."

  • Repeating the same mistake over and over when you continually receive negative consequences is one definition of insanity. From the list below, identify your "mistakes" (place a check mark on the line next to each "mistake" that applies). Then, below the list, explain how each of these mistakes in your thinking has caused you problems.
    • Excuse making
    • Minimizing
    • Blaming
    • Intentionally being vague
    • Using anger and threats
    • Superoptimism
    • Using power plays
    • Playing the victim
    • Making fools of others
    • Love for drama and excitement
    • Assuming what others think and feel
    • Not listening to others and being closed-minded
    • Thinking "I'm unique"
    • Maintaining an "image"
    • Being ingratiating (kissing up)
    • Being grandiose
    • Lying: commission, omission, assent
  • List three people with whom you are angry and explain how they can be helpful.
  • List five people more powerful than you who can help you stay clean and sober. Explain why and how each person can help.
  • Who or what is your Higher Power?
  • Describe how this Higher Power can help you with your mistakes in thinking.

Step Three: "Made a decision to turn our will and our lives over to the care of God as we understood Him."

  • How did you decide that you needed to turn your will over to a Higher Power?
  • Why is it important for you to turn your will and life over to a Higher Power?
  • Explain how you go about "turning it over."
  • Give three examples of things you have had to "turn over" in the last week.
  • Give three examples of things you have yet to turn over and explain how and when you plan to do so.
  • What does it mean to "turn your will and life over to your Higher Power"?
  • Without displaying any thinking errors, explain how and why you have turned your will and life over to a Power greater than yourself.

Step Four: "Made a searching and fearless moral inventory of ourselves."

  • List any and all law violations you have committed regardless of whether or not you were caught for these crimes.
  • List every person you have a resentment against, and explain how this resentment is hurting you.
  • Give ten examples of sexual behavior you engaged in that was harmful to your partner, and explain the negative consequences to you of this behavior.
  • Give five examples of aggressive behavior (either verbal or physical) you have been involved in, and explain how it was hurtful to the other person and to you.
  • List five major lies you have told, and explain how that lying was hurtful to you.
  • List three lies you have told within the last 48 hours, and explain how this lying hurts your recovery program.

Adapted with permission from Evans, K., and Sullivan, J.M.Step Study Counseling With the Dual Disordered Client.Center City, Minnesota: Hazelden Educational Materials, 1990.

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Chapters 1-5
Chapters 6-8
Chapter 9, Appendixes, and Exhibits