Fictional Drug Abuse Case

Chemical Dependency

Jesse Bruce Pinkman is one of the most important characters in the popular TV series, 'Breaking Bad'. He plays the deuteragonist (2nd most important character) in the series, partnering with Walter White in his methamphetamine drug ring. Pinkman acts as a dealer and manufacturer of methamphetamine, and is also a methamphetamine user. Jesse was also a former student in White's chemistry class.

According to the program script, Pinkman was born September 14, 1984, into a middle income family in Albuquerque, New Mexico. While still in high school, he began using and dealing methamphetamine. After being thrown out of the house for his continued drug use, he moved into his Aunt Ginny's place, and looked after her until she died of lung cancer. After her death the ownership of the house fell to his parents who allowed him to continue staying there. The rift between Pinkman and his family continues throughout most of the series; this is apparently because of his drug use and the accompanying lifestyle. Jesse's character is modified throughout the series, from a laid back funnyman who provides comic relief in the early episodes, to a disturbed and sad shadow of his former self (Pinkman, n.d).

Assessment

Substance abuse examination is an assessment of patients who satisfy two conditions. The first condition is that the individual's drug screening results are positive, and signal possible substance abuse. The second condition is that the individual's answers to a brief assessment test indicate a variety of additional factors. These include: impaired control, a craving to use drugs, lack of social support, evidence that they are afflicted by 'other' psychosocial conditions; and the likelihood that these factors will render a brief intervention unsuccessful. Data collected via the assessment will give pointers to the type of problem the individual faces; it will also assist in determination of a suitable treatment plan.

Assessment:

Studies problems linked to use and/or abuse of drugs, such as clinical, social, financial, and behavioral factors

Provides information for official diagnosis of a likely problem

Determines the extent of, or severity of the diagnosed problem - mild, intermediate, or severe

Enables identification of suitable care level.

Provides a guide to the treatment plan, such as type of referral(s) needed and/or necessity for specialized care

Establishes a baseline in terms of the patient's status for later evaluation and comparison

Assessment Guidelines

Important Factors in Screening and Assessment

Information accuracy

Data continuity

Sharing of information

Necessity to rescreen and reassess

Scheduling of screening and assessment

When is an official diagnosis necessary?

Drug testing

Issues to Address in the Above Exercise

History of substance use and abuse

The need for detoxification

Physical health status

The willingness to commence treatment

Possible dual diagnosis

Trauma history

Psychopathy and possible danger for recidivism and violence

From the information provided, it is possible to observe that Pinkman suffers simultaneously from different addiction disorders. These may include severe depression as well as an eating disorder (ED) linked to substance abuse. Anxiety and mood disorders occur at relatively increased rates among individuals who have substance abuse disorders (SUDs). Major depression has also been identified as the most common co-occurring Axis I psychiatric disorder. Co-morbid major depression is linked to chronic and extended substance abuse disorders (Worley et al., 2012).

Various aetiological factors that could have led to co-occurring substance abuse disorders in Jesse Pinkman's scenario can be best understood from a biopsychosocial viewpoint. The theories of aetiological co-morbidity include: behavioral and addiction models; biological factors such as genetic risk; personality factors such as chronic dysregulation; novelty seeking; increased impulsivity; and possible co-occurring psychopathology, in addition to environmental influences. Biological aetiological models point to disorders in neurotransmitter function. These include serotonin, gamma aminobutyric acid (GABA), dopamine, and the final endogenous opiate systems in both substance abuse disorders (SUDs) and eating disorders (EDs). The common physical symptoms among these disorders and the relation between the increased effects of substances that are biologically reinforced and food deprivation are some of the evidences of this biological model. In terms of genetic risk factors, research has shown that genetic heritabilities for eating disorders and substance abuse disorders are independent. Additionally, co-morbidity is likely to be influenced by both genetics and the environment. Some individuals are more susceptible to dependency because their genetic makeup raises their sensitivity to drugs. Several types of substance use and dependence appear to be genetically predisposed or influenced by the environment; in several cases, the substance abuse can be a mix of both. Various twin studies suggest that there is a huge genetic factor in alcohol abuse and dependency (Gregorowski, Seedat & Jordaan, 2013).

The addiction aetiological co-morbidity model suggests chemical dependency in both substance abuse and eating disorders with personality, genetic, socio-cultural, and familial influences. Addictive disorders have similar underlying biopsychological processes that include personality and neurobiological factors. Evidence from addiction models show that personality susceptibility factors are considered likely causes for co-morbid substance abuse and eating disorders. These factors seem to differ based on the eating disorder subtype. There is a link between a family history in terms of alcoholism and dependence and the high prevalence of substance use among persons who have novelty seeking characters such as Jesse Pinkman.

Attention Deficit Hyperactivity Disorder (ADHD) is a possible mediating factor between his substance abuse and eating disorders. ADHD has several symptoms including lack of attentiveness, impulsivity, hyperactivity and others linked to personality factors and is usually present in persons suffering from eating disorders. Research has shown co-morbidity between attention deficit hyperactivity disorder and substance abuse and eating disorders. Environmental factors also play a part in the above co-morbid psychopathology. Cumulative early childhood trauma may cause various types of deregulation, often leading to psychopathology in adulthood (Gregorowski et al., 2013).

Substance abuse disorders are complicating factors in the screening, assessment and diagnosis and care of patients with eating disorders. Studies have proven that individuals who abuse substances and simultaneously suffer from eating disorders often have worse symptoms of their eating disorders, and lower functional outcomes than those with only eating disorders. As well, those patients with co-morbid eating and substance-abuse disorders have worse substance abuse. Co-morbidity results in medical complications, longer duration of recovery, lower functional outcomes, higher rates of attempted and successful suicide, and increased mortality rates. As soon as a co-morbid disorder has been diagnosed, a complete clinical and psychiatric evaluation should be conducted; it is possible that patients may have to be stabilized before commencement of treatment for the two disorders.

One of the main challenges to the diagnosis and treatment of co-morbid disorders is that patients suffering from substance abuse and eating disorders are often resistant to treatment and may possibly experience guilt. This guilt may result in reluctance to report symptoms. Substance abuse and alcoholism can also affect factors that are used to diagnose eating disorders, including appetite, weight, and diet. Therefore circumstantial information is important in the assessment of patients with eating disorders, while putting emphasis on a direct and open-minded approach (Gregorowski, Seedat & Jordaan, 2013).

Assessment tools

Standardized screening and assessment questionnaires

Assessment tools are important in evaluating the risk in primary care. The most successful technique for identifying co-morbid substance abuse disorders is the use of interviews. Obtaining comprehensive details of the substance abuse history, including details of current and previous drug use is recommended. Drug use history must also include information on the triggers, functions, and patterns of drug use. The questions in the interviews should concentrate on the abuse of substances. The role of alcohol and other psychoactive drugs in emotional control must also be explored (e.g. drinking of alcohol for the relief of depression, anxiety or shame). Some studies underscore the importance of behavioral assessment using questionnaires, role play, and self-monitoring so as to explore the link between substance abuse patterns and other behaviors (Gregorowski, Seedat & Jordaan, 2013).

Diagnosis According to DSM-5 Guidelines

Dual Diagnosis for Jesse Pinkman

The relationship between substance use and mental illnesses is a complex one. The two can be linked in various ways:

Heavy alcohol or drug use can cause mental illness by harming the brain.

Mental illness can also cause one to be susceptible to substance abuse to alleviate psychiatric stresses.

Several psychological impacts of substance use including anxiety, depression, mania, and mood swings often seem like mental illness.

The symptoms of several mental illnesses may also resemble side-effects of substance abuse.

An experienced therapist can evaluate the patient on different levels to determine the link between their substance use and their mental health. However, at times even the most skilled health care professionals may find it difficult to make a dual diagnosis. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5, for the current edition) addresses substance abuse disorders. Substance abuse disorder in DSM-5 utilizes both DSM-IV levels of substance use and dependence as one disorder; it is measured based on different severity levels. Every particular substance except caffeine is categorized as a separate use disorder (e.g. stimulant use disorder); however, almost all substances are assessed based on the same method. While previously the diagnosis of a substance use disorder required only the presence of one symptom, the DSM-5 protocols for a 'mild substance use disorder' requires 2-3 symptoms among the list of 11 in DSM-5 (DSM-5.pdf (PDFy mirror), n.d). In Jesse Pinkman's case, we can make the following observations:

He has a craving to utilize the substance.

He demonstrates tolerance - a need for significantly increased quantities of the substance in order to get the desired effect.

Treatment plan

To understand treatment, the therapy required for addiction, it is crucial to stress that health care professionals generally regard alcohol- and substance-dependence to be a condition that, while treatable, is chronic and degenerative. Since alcoholism and drug addiction results in challenges in psychological, physical, social, and financial functioning, treatment must be planned in such a way so as to tackle the difficulties in all these area. Dependency on drugs and its related difficulties can be effectively treated; however, there isn't a single treatment that works for all substances, or for all patients. It is crucial to note that not all substance abuse patients in recovery relapse. In fact almost one-third of the patients attain permanent abstinence from the initial recovery attempt. A further one-third temporary relapse for brief periods, however they eventually attain permanent abstinence. The other one-third can experience chronic relapses that cause premature death due to chemical dependence and related effects. These statistics are in harmony with the long-term recovery rates for many other lifestyle-related chronic illnesses (Landry, 2004).

Substance use treatment entails a wide range of care services. These include: determination of the problem and fully involving the patient in the treatment; short-term interventions; evaluation of substance abuse and related challenges, such as a history of different types of substance use; diagnosis of the disorder(s); and planning of the treatment. In terms of planning treatment, options may include: counseling therapy, medical interventions, psychiatric, psychological, and social services; and follow-up for individuals with alcoholism or other substance abuse problems.

Substance use treatment may be anchored on different types of conventional approaches. There is the clinical Medical Model which concentrates on the categorization of addiction as a biopsychosocial disease; this implies the necessity for permanent abstinence and the use of a continuous recovery program to uphold abstinence. There is the Social Model, which largely focuses on the need for permanent abstinence, and the necessity for self-help recovery communities to uphold sobriety. There is also the Behavioral Model, which largely focuses on the assessment and treatment of other conditions or problems that may present obstacles to recovery. Many programs utilize a combination of approaches to provide the most suitable treatment for the person and to provide the abusers options. Other programs entail utilization of innovative non-conventional treatment models including acupuncture and several alternative cultural healing practices linked to different ethnic groups (Landry, 2004).Treatment can be offered in different settings including: inpatient hospital-centered programs; short- and long-term residential plans; and outpatient programs. Each of these may be supported by 'self-help groups'. Treatment can also be provided as a combination of different therapies such as: use of medication to take care of particular addictions (e.g. methadone to treat heroin addiction); utilization of psychological therapy or behavioral and social learning theories; and non-conventional healing approaches such as acupuncture. The treatment period can be several weeks, months, or even years depending on the extent of the diagnosed problems and the level of burden due to the patient's co-occurring disorders and severe physical illnesses. The type of treatment chosen, and its intensity, will be based on the individual's physical, psychological, and social problems; the type and severity of his or her addiction; the individual's personality; and the individual's social skills prior to the onset of drug dependence. Treatment and recovery do not mean the same thing, even though treatment is a crucial part of the recovery process (Landry, 2004).

Some of the most crucial factors in the treatment of dual disorders include the method of screening and assessing of co-occurring disorders and the health-practitioner's decision whether to treat both disorders simultaneously, or alternatively, the decision concerning which disorder should be treated first. One of the main challenges in the treatment studies of comorbid substance abuse and eating disorders is that these studies often do not involve individuals with dual diagnoses. Thus, publication of data on successful management strategies is presently very rare for these dual cases.

However, there are several considerations that should be taken into account in these treatments. First, sequential treatment strategies may cause an increase in symptoms of one of the disorders as the other one improves. Second, symptoms of the disorder that is not currently under treatment may prevent obstacles to recovery from the disorder being currently treated. Third, insufficient management of both disorders may also increase symptoms of one or both of the disorders. Additionally, the presence of co-occurring mental diagnoses such as depression and anxiety may need simultaneous management (Gregorowski, Seedat & Jordaan, 2013).

Individuals such as Pinkman, who are acutely addicted to drugs, are unlikely to stop utilizing drugs even in situations where they are at risk of endangering themselves or those close to them. When intoxicated, they are not capable of making good judgments concerning their own health and safety. Several physicians and ethicists who have expertise on addiction have noted that the most humane act would be for the government to compel these people to be treated for their best interests. This argument has also been supported by relatives who want health care professionals to provide intervention halting the self-destructive behavior of their family members. At present, individuals who are most likely candidates for compulsory treatment are the homeless, and those who no longer have contact with their family members.

A compulsory treatment plan would be suitable for an individual like Pinkman. The idea of an involuntary addiction treatment program has many parallels with involuntary psychiatric treatment. The argument makes even more sense in situations where alcoholics and other drug addicted individuals put not only their own personal safety but also that of those close to them at risk, because they are chronically and acutely intoxicated. In these situations, brief and involuntary treatment to enable withdrawal from alcohol and other drugs and to treat possible serious physical health problems can save lives. Many such individuals would also likely meet the criteria for involuntary confinement to psychiatric institutions, because they suffer from drug-related mental disorders such as psychosis or delirium tremens that incapacitates them.

However, many jurisdictions have mental health regulations that specifically prevent involuntary confinement of alcoholics and other drug-addicted individuals to psychiatric institutions. Even in cases when such confinements are allowed, psychiatric institutions are often unwilling to admit such individuals due to the practical difficulties of handling their cases in the same settings as psychiatric patients. This is regardless of the fact that numerous psychiatric patients also have severe addiction problems. Proponents of involuntary confinement argue that the temporary loss of liberty is negated by the instant reduction of risk that it provides to individuals who are acutely addicted. They also argue that in the long run, the physical health of these individuals may be significantly improved and the independence restored, if they can be effectively treated in the institutions. The costs of carrying out involuntary treatment plans are huge for a relatively small number of people. The state usually pays for the cost of treatment of the less fortunate individuals. Public funding of such treatments is in turn supported by the economic savings the state can make through provision of early treatment of health conditions. This is because these conditions are likely to degenerate into severe conditions costing more in emergency and inpatient treatment if left untreated.

However, even with this argument there has been no substantive research in addiction or psychiatry to evaluate whether assertive, proactive community-based voluntary treatment is less successful or provides more financial savings than involuntary treatment. The only proof given for the success of involuntary treatment programs are the few patients who have been treated in this manner. The claim that these individuals have benefited due to the compulsory treatment is made without full knowledge concerning what might have happened if they had not been referred to involuntary treatment, or if they had been convinced to commence other forms of treatment. Proponents argue that involuntary treatment can also be justified by the financial savings that will likely be made by preventing possible expensive hospitalization such as use of the Intensive Care Unit (ICU) for liver failure. As mentioned above, there are presently insufficient scientific studies to evaluate this argument. The utilization of economic savings as a basis for involuntary treatment is not necessarily directed towards the best interests of the drug-addicted individual. It obviously gives a higher priority to social factors, such as decreasing the social and economic costs of treating acutely addicted individuals (Hall, Farrell & Carter, 2014).

Despite the lack of studies done on treatment outcomes, several researchers claim that effective treatments are those that target similar aetiological factors n both disorders. First, it is generally recommended that patients who have a substance abuse disorder should first commence detoxification before beginning any other treatment. If possible, detoxification should be used in conjunction with other forms of treatment such as residential treatment. Generally, a large body of scientific literature suggests that that eating and substance abuse disorders should be treated concurrently. The current 'best programs' appear to be those whose treatment is focused specifically on treating substance abuse and eating disorders. These programs also have combinations of individual, group, and family therapy offered by a multi-disciplinary team of professionals. Several treatment approaches are considered below (Gregorowski, Seedat & Jordaan, 2013).

Psychological treatments

Different forms of psychological interventions can be utilized in the treatment of co-occurring SUDs and EDs including personal and group therapy. Similar characteristics among these types of interventions include psychological education. This concerns: aetiological similarities; risks of simultaneous ED features and substance use; nutritional education; teaching of skills and coping mechanisms; and tackling hindrances to improvement and the deterrence of relapse. There is some evidence that supports the success of different types of cognitive behavioral therapy (CBT) in the treatment of EDs (Gregorowski, Seedat & Jordaan, 2013).

In the treatment of eating disorders and alcohol abuse, the use of cognitive behavioral therapy that focuses on both the alcohol usage/behavior and the pathogenic eating behavior is likely to be the most efficient. Specifically, helpful tactics such as self-monitoring, recognition of high danger/risk circumstances, and management skills are helpful in controlling the circumstances or emotions that may initiate loss of control. Frequently, a "stepped-care" method is advised where the patients start with self-help cognitive behavioral therapy. If required, the individuals then move to directed self-help interventions, and/or to personal or group treatment. Motivational interviewing (MI) can be utilized prior to CBT intervention. This process seeks to enhance the possibility of a patient engaging and carrying on with treatment through enhancing their insight into the personal addictive issues. Motivational interviewing is intended to establish dedication and improve the essential motive to change. MI merged with therapist-client responses concerning growth towards symptom improvement is referred to as motivational enhancement therapy (MET). Motivational enhancement therapy can be utilized as a personal or adjunctive treatment (Gregorowski, Seedat & Jordaan, 2013).

Dialectical behavior therapy (DBT) has also been examined as a treatment for co-morbid eating and substance abuse disorders. The outcomes from dialectical behavior therapy also provides positive initial indications for behavioral and cognitive treatment results. This is due to the inclusion of better eating disorder-related behaviors and mind-sets, decreased extent and gravity of drug usage, improved regulatory ability for negative emotions, and an enhancement in the depressive signs. Various researchers also describe the effectiveness of 12-step programs meant for the treatment of substance abuse disorders, mostly alcohol dependence. Those programs could only operate alongside and function efficiently with eating disorder treatment. Long-term personal psychotherapy has also been advised in the treatment of co-morbid eating and substance abuse disorders. However, this is perceived to be more suitable once recuperation from the substance abuse disorder has been upheld for a certain period of time. Cognitive behavioral therapy treatments are suggested for use only during, and/or following drug use recuperation treatment -- 'drying out' (Gregorowski, Seedat & Jordaan, 2013).

Deep Brain Stimulation

Deep brain stimulation (DBS) has attained considerable success as treatment for movement illnesses such as Parkinson's disease (Hall et al., 2014). The curative efficiency and significant absence of major side effects led to the expansion of deep brain stimulation into the treatment of several other illnesses, such as obsessive-compulsive disorder, depression, and Tourette's among others. Currently, a limited quantity of clinical studies reveals that deep brain stimulation might also be helpful in the treatment of certain addictions. The existing data point out that deep brain stimulation is a potential therapeutic mode for addiction treatment. So far, the subthalamic and accumbens nucleus are the most prominent locations of choice for deep brain stimulation and reversal of addiction features.

While there are limited drawbacks to the procedure, nonetheless, as many as 2% of patients who undergo deep brain stimulation have hemorrhage; the surgery is often critical up to 0.5% of the time (Hall et al., 2014). This raises a dilemma for the health practitioner. On the one hand, the deep brain stimulation is potentially brain-damaging; on the other hand, addiction and the high potential of relapse are also very serious consequences, if not wholly deleterious factors. The use of deep brain stimulation is favored by some health practitioners, but not all. Recent current clinical research has evaluated the efficiency and safety of using deep brain stimulation of the brain's nucleus acumbens as a form of 'healing' for drug addiction. One case study reports a six-year, total abstinence from heroin abuse by a particular male individual. Following deep brain stimulation, the individual remained sober (Hall et al., 2014). A related case study revealed that deep brain stimulation of the nucleus acumbens lead to an extended termination of the usage of heroin, with the exemption of a relapse episode of two weeks (Hall, Farrell & Carter, 2014).

Recovery plan for Jesse Pinkman

Abstinence: Acquisition and conservation of sobriety,

Live a drug-free life,

Handle life without any kind of drugs.

Organized drinking: Stick to patterns of usage which decrease damage.

Alleviate an individual's finances, health, career/school, employment, living arrangements.

Finish a stipulated physical test and abide by any medical advice. Improve fitness and health.

Settle and keep away from any sort of legal issues.

Establish sober free time skills. Alleviate an individual's intimate relations, family, marriage.

Incorporate other important people, for instance partner or spouse, relatives, friends, etc., in the recovery plan as arranged. Enhancement of social skills, boldness, communication, emotional conveyance.

Enhance social support, social interests and friendships. Deal with or settle emotional issues for example depression, rejection, humiliation, desertion, and feelings of guilt among others.

Enhancement of management abilities, stress coping abilities, relaxation skills, self-control.

Improvement of self-esteem, self-confidence and self-acceptance. Agreement to accountability for the outcomes of one's actions.

Enhance crisis-resolving capabilities, appropriate placement of priorities, and perseverance to frustration.