According to a study conducted by the World Health Organization in 2010, it was found that alcohol is the third largest risk factor when looking at disability and disease, and is the fourth leading cause of preventable deaths (APA, 2013; Grant et al., 2015). In the United States alone, almost 90% of the population encounters experiences with alcohol, while a great number of these individuals go on to develop alcohol related problems (Craighead, 2017; Grant et al., 2014). 13.9% of the United States suffers from alcohol use disorder in a given year, which translates to around 32.9 million people (Craighead, 2017). White and Native American populations are the groups with the highest risks of alcohol use disorder, with Native Americans reporting more alcohol related health problems, compared to low risk groups liked Asian Americans, African Americans, and Hispanics (Craighead, 2017). Males also report higher drinking frequencies, quantities, and rates of heavy drinking when compared to females, with lifetime prevalence rates between males and females at 36% and 22.7% respectively (APA, 2013; Craighead, 2017; Grant et al., 2015).
The mean age of alcohol use disorder is around 26 years of age, however the mean age onset for a severe diagnosis is around 23-24 years of age, while mean age of the first treatment is around 29 years of age (Craighead, 2017). Alcohol use typically occurs in early adolescence, but intensifies in late adolescence, with 72% of adolescents reporting experiences drinking alcohol by 12th grade (APA, 2013; Craighead, 2017). Drinking before the age of 15 also increases the probability of developing alcohol dependence in later years, and increases with the risk factors of associating with substance-using peers, having decreased parental monitoring, experiencing abuse (APA, 2013; Craighead, 2017; Langdon et al., 2016). Alcohol use disorder also has a high heritability rate that varies around 40-60%, is higher among first-degree relatives, and is exacerbated by high rates of impulsivity (APA, 2013). In addition to these factors is the comorbidity of bipolar disorders, schizophrenia, and several anxiety and depressive disorders with alcohol use disorder (APA, 2013; Craighead, 2017), as well as an increased risk of infections or cancers due to the suppression of immune mechanisms in relation to alcohol use (APA, 2013).
What we know of Hope is that she is female and started drinking during her late adolescent years. However, we do not know her race or ethnicity, nor do we know if there is a family history of alcohol use or if she associated with substance-using peers. While she has smoked cannabis frequently since the age of 15, Hope has not been hospitalized or admitted to an inpatient program due to smoking marijuana, unlike her alcoholism. It is also known that there is comorbidity between substance use disorders and PTSD (APA, 2013; Craighead, 2017; Debell, 2014), and that sometimes people drink as a coping mechanism (Highland, et al., 2014). Hope was also sexually assaulted as an adult, and when combined with her traumatic past, can increase alcohol use (Langdon, et al., 2016).
From this, we can associate the impairment of her social and occupational functioning due to her PTSD and subsequent substance use, resulting from her parents’ lack of effort to protect her from her brothers during her childhood. Her alcoholism resulted in several visits to the hospital and one admission at an inpatient facility, and possibly affected her performance to the point that she lost her job as a teacher and stage director. As mentioned above, it is wise to get her drinking and smoking under control and eradicated before treating her PTSD.
Assessments
According to a paper published by Shogren, Harsell, and Heitkamp in 2017, there are several screening assessments that look for at-risk alcohol use in primary care. One is a single-question instrument developed by the National Institute on Alcohol Abuse and Alcoholism that asks if an individual drinks; should they answer “yes”, a follow-up question about how many times the individual drinks 4 (women), 5 (men), or more drinks a day throughout the last year (Shogren et al., 2017). Another alcohol screening test is the Alcohol Use Disorders Identification Test (AUDIT), which is a 10-item multiple-choice questionnaire that results in a score between 0-40 that focuses on frequency of alcohol intake through hazardous use, dependence symptoms, and harmful use, while the AUDIT-Consumption (AUDIT-C) is a 3-item version of AUDIT that only assesses for hazardous drinking risk (Shogren et al., 2017). There is also CRAFT (Car, Relax, Alone, Forget, Friends, Trouble) 9-item measure that looks at high-risk use in adolescent populations, T-ACE (Tolerance, Annoyed, Cut-Down, Eye-Opener) which is a 4-item measure used for maternity care and gynecologic practices, TWEAK (Tolerance, Worried, Eye-Opener, Amnesia, and Cut-Down) a 5-item measure that screens for drinking that occurs with pregnancy, and the One-Question Prenatal Alcohol Use Assessment that asks “When was your last drink?” (Shogren et al., 2017).
There are also cannabis psychometric instruments, though some of them use the DSM-4 or the ICD-10 criterion. A systematic study conducted by Piontek, Kraus, and Klempova in 2008 assessed the reliability and validity four scales: the SDS (Severity of Dependence Scale), CUDIT (Cannabis Use Disorders Identification Test), CAST (Cannabis Abuse Screening Test), and PUM (Problematic Use of Marijuana). The SDS is a 5-item scale that measures the dependence of the individual on cannabis, the CUDIT assesses cannabis use disorders using the DSM-4 criterion, the PUM measures harmful use using the ICD-10 criterion, and the CAST identifies patterns in cannabis use in adolescents; all four are relatively short questionnaires (Piontek et al., 2008). Other scales include the Marijuana Screening Inventory (MIS), the Substance Dependence Severity Scale (SDSS), and the Cannabis Problems Questionnaire (CPQ), though these measurements take longer to fill out or require clinical training and experience (Piontek et al., 2008).
As Hope is no longer in adolescence, the CRAFT and CAST measurements can be ruled out for assessing her alcohol and cannabis use. We also don’t know if she has a partner or desires to be pregnant, or even has children, so the T-ACE and TWEAK questionnaires on alcohol do not need to be filled out either. That leaves the single question NIAAA questionnaire, AUDIT and AUDIT-C for her alcohol use, and the SDS, CUDIT, PUM, MIS, SDSS, and CPQ for her cannabis use. In order to see the different domains that have been affected by her drinking, it might be better to give Hope the AUDIT, while the SDSS should be used to measure her cannabis use; this is due to the SDSS specifically measure the severity of her dependence on marijuana, while also being one of the longer cannabis measurements. Once these measurements have been taken into account, then it would be best to assess Hope for the severity of her PTSD using either the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) or the Structured Clinical Interview for DSM-5 (SCID-5), which take a long time to administer, but will give a general idea of whether her PTSD symptoms are the driving force behind her addictions (Craighead, 2017).
Treatments
The typical treatments for substance use disorders are either psychosocial treatments or pharmacological treatments. As Hope has been on several medications (depakote, lamotrigine, gabapentin, and mood stabilizers) without any improvement, and has expressed that she will only take all natural remedies rather than conventional medications, the focus of the treatment will focus more on the psychosocial treatments.
There are numerous psychosocial treatments in the literature, some of which are empirically supported. The better known treatments include interventions, which focus on negotiating behavioral changes, and twe
lve-step therapies like Alcoholics Anonymous (AA), which is widely used and has a long-term goal of complete abstinence (Craighead, 2017). Others include motivational interviewing or motivational enhancement therapy (MET), which focuses on an individual’s motivation and commitment to change, cognitive behavioral therapies (CBT) and mindfulness-based therapies that focus on teaching coping skills for cravings and urges by bringing awareness to them, and behavioral treatments and cure-exposure therapies that focus on exposing individuals to alcohol cues in order to decrease the reinforcement of the cues (Craighead, 2017).
Since AA tends to have a religious connotation to the program and we do not know Hope’s background in regards to religion, it might not be the best fit for her, however it doesn’t hurt to mention it to her in case it does sound like a treatment she would like to try. I would recommend a combination of MET, CBT, mindfulness-based therapy, and behavioral and cure-exposure therapy. If Hope is motivated and willing to commit to give up her substance use, then she can be taught coping behaviors to help her identify, acknowledge, and be exposed to her triggers in order to decondition her urges.