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SKH

Substance Use Disorders And Social Work Interventions

2/5/2016

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Special Articles / Shanthi Ranganathan / Social Work Profession in India: An Uncertain Future
Alcohol and other psycho-active drugs that can lead to addiction are collectively referred to as ‘substances’. Substances like alcohol  are viewed  in some countries  or cultures as legal whereas drugs like cannabis and heroin are  considered  illegal. Medically used drugs such as pain killers and sleeping tablets can also lead to addiction when used without the doctor’s advice or in a larger quantity or frequency than prescribed.
Substances Used in India: 
  • Alcohol and cannabis (ganja) 
  • Opiate drugs such as heroin (brown sugar), buprenorphine, codeine based cough syrups and pain killers 
  • Sleep inducing drugs which are medically prescribed
  • Volatile solvents such as adhesives, and eraser fluids  
  • Stimulants such as cocaine and other amphetamine type substances  
  • Tobacco    

The National Household Survey on Drug Abuse in India by the United Nations Office on Drugs and Crime (UNODC) in 2004 reported that India at the time of the survey had 62.46 million alcohol users, about 8.7 million cannabis users and about 2 million opiate users. Buprenorphine, propoxyphene and heroin were commonly injected drugs .  The survey notes several areas of concern –  the practice of  Intravenous Drug Use(IDU) , associated multiple high risk behaviour, drug abuse in rural settings, and a significant time lag between the onset of drug dependence and subsequent treatment seeking (Ray et al, 2004). Besides  the effect of globalization, growth of service sectors (IT sector) changing working patterns (BPOs), high level of stress, and mass media influence on youth glamourizing alcohol and tobacco lead to use and abuse of alcohol and drugs leading to substance use disorders. 

Substance Abuse and Dependence 
Diagnostic and Statistical Manual of Mental Disorders (DSM –IV, 1994) prepared by the American Psychiatric Association, defines substance abuse as a “maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period”:
  • failure to meet obligations at work, school, or home 
  • use of alcohol or drugs in hazardous situations, such as driving 
  • legal problems, like arrests for public intoxication
  • social or interpersonal problems, like fights

Substance  dependence is defined as ‘a maladaptive  pattern of  substance use, leading to clinically significant impairment or distress,  as manifested by three or four of the following occurring at anytime in the same 12-month period’. 
  • Tolerance - use of more of the substance to get the same effect
  • Withdrawal symptoms when one is not using the substance (eg. shakes, delirium ,tremors )
  • Use of more of the substance than one intended
  • Unsuccessful efforts to cut down
  • Increasing amounts of time spent using and recovering                  
  • Decreased involvement  in social, occupational or recreational activities
  • Continued use despite persistent physical or psychological problems.  Even misuse of alcohol (sometimes called risk drinking) or drugs that does not meet diagnostic criteria can result in life-threatening problems like overdose or accidents. 

Substance Use Disorders and Social Work Practice
Social workers regularly encounter individuals, families and communities affected by substance use disorders (SUDs) and they can play vital roles in addressing their problems.  A few may work in specialized centres for addiction treatment and many work in non-speciality settings in which SUDs are often integral to the clients’ presenting  problems.  These settings include primary health  centres, mental health centres, general hospitals, child welfare organizations, correctional facilities, educational institutions, industries and corporate sectors,   urban slums and rural communities. 

In the 90s, Mary Richmond, the mother of social work, called inebriety as a ‘disease that could be treated’  and she encouraged early identification and treatment (DiNitto, et al, 2007).  In 1970,  National Institute of Alcohol Abuse and Alcoholism (NIAAA) , and National Institute of Drug Abuse (NIDA, now called SAMHSA)  lent  legitimacy to work on alcohol / drug  problems. In 1995, an important step was taken by the formation of  National Association of Social Workers  (NASW)  in the USA with a speciality  practice section of alcohol, tobacco and other drugs.  Thereafter, NASW developed a certification for social workers specializing in the  field of addiction (DiNitto, et al, 2007). In the 21st century, social workers play a significant role. The social work profession’s unique, biopsycho-social perspective, its flexibility in adapting to new  streams of thought and incorporating them into practice, and its ability to integrate  dissimilar programmes  into a systemic  whole  make it a profession extremely well suited to the ever changing field of addictions (Straussner, 2012).

In India, when brown sugar addiction was identified as  a  problem in 1986, the Ministry of Welfare, Government of India initiated a few  de-addiction clinics through non-governmental agencies in several parts of the country.  The majority of these centres were located  in big cities and towns (Government of India,  1994). At present (2012), there are more than 400  integrated rehabilitation centres for addiction (IRCA)  funded by the Ministry of Social Justice and Empowerment (MSJE). There are equal or more number of privately managed centres which are providing some kind of a treatment. The Federation of Indian NGOs for Drug Abuse Prevention (FINGODAP) was initiated  at New Delhi in 1991 which organizes  conferences once in two years. To improve the quality of the services, ‘Minimum  Standards of  Care in Addiction Treatment’  were developed by the TTK Hospital, Chennai  (Addiction Treatment Centre) in the year 2001. These  standards have been approved and adopted by MSJE to provide grants for non-governmental organizations (NGO) which are running treatment centres.  In 2013, in collaboration with the Colombo Plan, a certification programme was introduced  and for the first time in the history of    Colombo Plan, TTK Hospital was given the status of  Education Provider for the entire  region of Asian countries. 

Tasks Undertaken By Social Worker 
  1. Prevention
  2. Early identification  - screening and diagnosis 
  3. Enhancing motivation,  and providing  treatment and follow-up

Prevention
  • Dissuade people from trying alcohol / other drugs, and  discourage and postpone early initiation  to alcohol and drugs
  • Help them recognize risks associated with alcohol and alter their drinking pattern before problems are experienced
  • Build understanding of dangers associated with use of illegal drugs as well as prescription drugs taken without the doctor’s  advice
  • Facilitate development of healthy alternatives to alcohol and drug use
  • Motivate them to seek help at an early stage  to handle problems if any
  • Messages need to be repeatedly presented. Just one or two programmes do not help. Bringing about a shift in attitude towards drug use and behaviour takes time.
  • The content and methods used to undertake prevention need to be tailored according to the group. The type of drug used, the excuses cited and the alternatives suggested vary depending upon the group addressed. 
  • Different approaches such as lectures, role plays, poster displays, puppet shows or street plays  can be used appropriately.
  • Just providing information about alcohol and drugs is not sufficient. When addressing students, teaching them how to say “No” to drug offers by peer groups, building decision making skills, and helping to strengthen self esteem are also significant. With adult working men and women, discussing ways to handle celebrations, stress or tiredness after a day’s hard work without resorting to use of alcohol or drugs is crucial. 
  • Awareness programmes need to be undertaken for all groups  and for both genders in the community. In schools, programmes should be conducted for parents and teachers as well as for students.  When prevention is undertaken in work places, programmes should be conducted for all levels of employees – workers, supervisors and executives.  A study conducted by NIMHANS, Bangalore, for a large public sector corporation revealed the importance of including various levels of employees in awareness programme for effective intervention and involvement (Murthy & Sankaran , 2009).

Screening  and  Diagnosis
Some individuals may seek help to deal with alcohol and drug problems on their own initiative or due to the persuasion of their families and friends. But many fail to recognize the problem and do not seek help in the early stages of substance use.  Professionals who are familiar with alcohol / drug use related issues can help identify addiction in the early stages and persuade individuals  to seek help. It is important to remember that the earlier the intervention, the lesser the  harm likely to be caused by substance abuse and better the chances of a favourable outcome of the intervention. 

Given below is a list of hidden indicators.  However  these indicators  alone cannot be taken as proof of substance use related problems, but can alert one to the possibility so that early intervention becomes effective (Thirumagal , 2012). 

•    Work Place Indicators
-        Absenteeism 
-        Reduction in the  quality and  quantity of work output
-        Increased involvement in accidents
-        Frequent demand for loans 
-        Poor interpersonal relationships
-        Poor grooming (unshaven, not being well dressed )

•    Health  Indicators
-        Gastritis, neuritis and liver disorders  (commonly 
          associated with  hazardous levels of alcohol use) 
-         Abscesses or ulcers in injection sites  common
          among intravenous drug users. 
-        Sleep problems, irritability, violence and physical 
         deterioration with no known medical problems 
-        Poor compliance with medications and repeated 
         hospital admissions
-        Frequent falls or accidents 

•    Indicators Based on Spouse’s Behavior
-        Socially withdrawn and depressed
-        Poor care of self
-        Bruises(due to domestic violence)
-        Standard of living not in keeping with the income
          level
-        Attempts at suicide

•    Indicators Based on Child’s Problems
The stressful dysfunctional family can affect the children and they may
-        Appear dull and withdrawn
-        Lack concentration
-        Lack  punctuality and have irregular attendance
-        Have problems in getting along with others
-        Display behaviour problems like hyperactivity, 
         rebelliousness and aggression
-        Perform poorly in their studies in spite of adequate
         IQ levels 
-        Be poorly  groomed (cleanliness, neatness) and
         display other signs of child neglect such as delayed
         payment of fees

Screening
Social workers in nearly all practice areas need skills to screen for alcohol and drug related problems, and refer to treatment providers. Screening tools are generally short questionnaires administered by the social worker or completed by the client (self report). There are many screening tools. For example, the CAGE (Cut, Annoyed, Guilty and Eye-opener) is a four-item screening device for alcohol problems that social workers can administer.  But helping requires more than asking clients questions about whether they have tried to reduce their drinking or have felt guilty about their drinking. Developing rapport, asking questions in a non-judgmental way, and ensuring confidentiality  are also important (Lesieur & Blume,  1987).

The Alcohol Use Disorders Identification Test (AUDIT) is available in several languages and can be adjusted for drinking norms in different cultures (Babor, et al, 2001). Screening may suggest that an individual has a particular problem, but the social worker needs additional knowledge and skills to support or confirm a diagnosis. Patients who indicate little or no risky behaviour and have a low screening score may not need an intervention. Those who have moderate risky behaviour or reach a moderate threshold on the screening instrument may be referred for brief intervention.  Brief intervention focuses on increasing a person’s insight into and awareness of substance use and behavioural changes. This intervention  is provided through  single or multiple sessions by general practitioners and other primary health workers including social workers.  Screening takes 5 -10 minutes and can be repeated at various intervals as needed to determine changes in patients’ progress over time.

Referral: Patients who score high may need further diagnostic assessment and more intensive, long term speciality treatment. Social workers need to be familiar with the facilities available in the community and refer them to centres which offer professional services with the essential treatment components.

 Providing information about the self help groups such as Alcoholics Anonymous (for alcohol dependants) and Narcotics Anonymous (for other drugs) helps. Explaining the philosophy and help available at these meetings, and details related to the time, frequency and places where the meetings are held in the area are important.

Treatment and Rehabilitation
Substance dependence is a treatable disease. Treatment has been defined by WHO as “the process that begins when psycho active substance abuser comes into contact with a health provider or community services and may continue through a succession of specific interventions until the highest attainable level of health and well being is reached”.  Recovery is defined as a process of continuous growth and improved functioning over a person’s life time. Individuals work to improve their health and wellness, and live a meaningful life in a community while striving to achieve their full potential  (WHO, 1998).

Key Principles (Volkow, 1999):  
No single treatment is appropriate for all individuals  and treatment needs to be readily available 

Effective treatment attends to multiple needs; hence treatment needs to be flexible  

Remaining in treatment for an adequate period of time is critical for treatment effectiveness 

Individual and/or group counselling and other behavioural therapies are critical components of effective treatment for addiction 

Medication is an important element of treatment for many patients

Drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way 

Medical detoxification is only the first stage of addiction treatment

Treatment does not need to be voluntary to be effective 

Possible drug use during treatment must be monitored continuously 

Treatment programmes should provide assessment for HIV/AIDS, Hepatitis B and C, tuberculosis and other infectious diseases 

Recovery from drug addiction can be a long-term process 
These principles overlap with social work principles which are  treatment  to be based on the needs of individual client, addressing multiple problems, and maintaining confidentiality.  Approaches which are more in tune with social work practice, such as  ‘interpersonal skills of counsellors’ as, ‘a key factor in treatment effectiveness’ (Najavits & Weiss, 1994),  motivational enhancement therapy, community reinforcement approach which alters  the client’s environment, comprehensiveness of finding employment, community support are all in  the same wave length of  social work practice (Meyers & Miller, 2001). 

Components of Addiction Treatment:
  • Medical help needs to be provided to make the withdrawal process safe and comfortable. Health problems caused or made worse due to substance use and mental health problems need to be treated. Some medications can also help alcohol and opiate users to stay drug free thereby providing additional support during early recovery.  
  • Psychological therapy is essential to help the patient recognize the damage caused by substance use, identify areas that need to be changed, develop a plan to handle triggers for substance use leading to relapse and improve quality of life.
  • Addiction affects the family members also. During treatment it becomes important to provide information as well as support to family members to help them recover and also build a supportive family environment for the patient.
  • Follow up services or continuum of care at least for a period of two years are necessary to support continued abstinence from alcohol and drugs. Relapses which may happen need to be addressed as quickly as possible to stabilize recovery. Introduction to  self help groups is an important component  towards long term recovery. 

Twelve Core Functions of Professionals (SAMHSA, 2000):
  • Screening:  Determining whether the client is appropriate and eligible for admission to the programme.  
  • Intake:  Completing admission, assessment and other programme forms,  release of information, and assigning a primary counsellor  to the client. 
  • Orientation:  Explaining to the client the goals of the programme; rules of conduct and consequences of violation of rules that can lead to disciplinary action or discharge from the programme.
  • Assessment: The purpose of assessment is to determine if an addiction is present, the extent of the addiction, if there are co-occurring conditions, identifying and evaluating an individual’s strengths, weaknesses, problems and needs, and the development of a treatment plan. This usually results from a combination of clinical  interviews, interviews of collateral sources (family, friends, employer),  and laboratory reports.
  • Treatment planning: It is an outline for treatment and services : a blue print and a projected strategy individualized to  each client. It is based on the client’s specific needs determined from the assessment process, and ranking problems needing solutions in order of priority. This is  reviewed on a regular basis for current needs and effectiveness. 
  • Counselling: Basically, the relationship in which the counsellor helps the client mobilize resources to resolve his problem and/or modify attitudes and values.
  • Case management:   A co-ordinated approach  to the delivery of  medical, mental health and social services for the benefit of clients and their family members.  Advocacy is a tool used by the social worker to speak out the issues of concerns on behalf of the client.  
  • Crisis intervention: Knowing how to  respond to an alcohol and/or other drug abuser’s needs during acute emotional and/or physical distress that threatens to compromise or destroy the rehabilitation effort.
  • Client education:  Education that supports recovery can be provided as a sequence of formal classes.
  • Referral:  Identifying the needs of a client that cannot be met by the counsellor or agency  along with assisting the client to access  the support systems and community resources available.
  • Documentation:  Charting the results of treatment; writing reports, progress notes, discharge summaries and other client-related data. 
  • Consultation: Relating with in-house staff or outside professionals to assure comprehensive, quality care for the client.
 
Some of the tasks of social workers in IRCAs are  assessment, counselling, conducting group therapy, re-educative sessions, family therapy, case management, referrals and home visits.  Maintaining records and documentation of the services  provided by  social workers, conducting research projects and training are other obligations. 

Evidence Based Therapies
Practices for which the evidence is strongest and most accepted and that are most likely to have significant impact on improving care are called evidence based therapies.  There are  a few evidence based therapies  which are practised in many treatment and rehabilitation centres in India –Pharmacotherapy, Cognitive Behavioural Therapy (CBT), Motivational Enhancement Therapy,  and Family Therapy. Social workers need to note that these therapies help in modifying  attitudes and behaviour related to substance  abuse. 

Pharmacotherapy and Substitution Therapies 
Pharmacotherapy is defined as the use of medically prescribed psychoactive substances to treat psychiatric and behavioural conditions. Medications are used  to treat withdrawal symptoms and also  the  associated medical and psychiatric problems.  For opiate  addiction,  substitution therapy in the form of buprenorphine and methadone are used in a few centres. While pharmacological opioid treatment  allows patients to lead more normal lives, just providing such medications is not enough and they need a variety of additional psycho social services ( Friedman & Wilson, 2004). Disulfiram is a medication  widely used in India for alcohol dependence.  It produces extremely unpleasant side effects if the individual after taking it drinks alcohol. Disulfiram is given for a period of two years till recovery is stabilized. Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking and studies have documented that naltrexone with cognitive behaviour therapy decreases craving and reduces relapse risk (Srisurapanont & Jarusuraisin, 2005).  Acamprosate  acts on the neurotransmitter system  and reduces withdrawal  and craving to some extent.  

Cognitive Behaviour Therapy (CBT)
According to CBT, thoughts and interpretations cause feelings and behaviours,  and  are not caused by external things. People can change the way they think (and feel and act), even if the situation does not change. CBT reduces self defeating  behaviour by modifying cognitive distortions, maladaptive beliefs and teaches techniques of thought control.  It is a collaborative, active and highly structured approach.  Emotional and behavioural disorders are learned responses that can be replaced by healthy ones with appropriate training .  Social workers through CBT prepare  clients  to acquire skills that help them recognize and learn strategies to reduce risks of relapse,  solve problems, maintain abstinence and enhance self-efficacy.  Home work is part of CBT approach, viz.,  reading assignments, keeping track of certain thoughts and behaviours, and practising new skills (Colombo Plan,  2011).

Motivational Enhancement Therapy
It is based on the stages of change model of  Prochaska, et al (1992) and the clinical techniques of motivational interviewing (Miller & Rollnick , 1991).   There are five stages: pre contemplation, contemplation, preparation, action and maintenance.  The therapist helps the client weigh the advantages and disadvantages of changing (decisional balance) in order to resolve the  client’s ambivalence about changing. Motivational approaches can help move clients along the stages of change, from pre-contemplation, where they may not recognize a problem (“I drink like everyone else,”  “I can control my drug use”) or its cause (“I wouldn’t drink like this if my work weren’t so stressful”), to contemplation  where they recognize the problem and consider changing, to preparation where they make plans to change, to action, where they make behavioural changes, and maintenance, where they continue to change and prevent relapses. The therapy emphasizes motivational techniques such as expressing empathy, developing discrepancies, avoiding arguments and rolling with resistance. Being client centered and nondirective, helps clients resolve ambivalence about treatment and stopping substance use and facilitates treatment entry. The ‘FRAMES approach’ is also utilized : F- giving feedback to the client on his problem behaviour; R-recognizing the individual’s personal responsibility to change; A-providing advice on how to alter the behaviour; M-offering a menu of choices about how to change; E-counselling in a warm and empathetic way  emphasizing self efficacy (Miller & Sanchez, 1994).

Relapse Prevention and Recovery Management 
The social worker should note  that recovery from alcohol and drug related problems is a process of change through which   an individual deals with relapses, achieves abstinence, and improves his health, wellness and quality of life. 

Relapse prevention and sustaining recovery efforts include  
  • Teaching coping strategies (constructive ways of thinking and behaving) to deal with the immediate problems that arise in the early stages of the behaviour change  such as coping with the urges and craving.  
  • Giving information to avoid high-risk situations where possible and helping to acquire the skills to cope with challenges. 
  • Alerting one about the early warning signals of relapse so that the individual can take the necessary steps and prevent a return to drinking / drug use.
  • Warning  about the seemingly irrelevant decisions that will bring  the person closer to situations that are extremely tempting and difficult to resist and increase the danger of relapse; and offering methods to identify and cope with these cognitive distortions.  
  • Encouraging the individual  to take a realistic approach to recovery, to learn to anticipate and cope with the conditions that might otherwise cause a relapse or a breakdown. 
  • If relapse  occurs, teaching  specific methods to handle it  and continue on the recovery path (Jayaraman & Ranganathan, 2010a).

Group Therapy and Individual Counselling
These are two effective  methods practised in most of the treatment centres in  India and can be part of social workers’ tasks. Individuals who share a common problem or concern are often placed in therapy groups where they can share their mutual struggle and feelings.  Group therapy creates an environment in which clients help, support and confront one another. It also helps clients broaden understanding of the damage caused and barriers to recovery.  Groups provide  positive peer support and exert pressure to  abstain from substances. It  enables them to learn new coping skills, see how others deal with similar problems and witness the recovery of  others.  A client who feels isolated  realizes that he is not alone in his problems and experiences a sense of relief. Group also provides opportunities for catharsis or  a release of feelings through sharing  followed by feelings of relief. 

The optimal size of a group is between 8 and 15 , and therapy session lasts for one  to  one and half hours, facilitated by a trained social worker. 

Individual counselling is a skilled dialogue through which the client is helped to resolve problems, avoid potential problems and make positive changes.  Counselling enables him to take personal responsibility for  his actions and consequences , pursue realistic goals and identify satisfying solutions to his problems. Some of the goals of individual counselling are to  motivate client to continue in treatment with  total involvement, offer support to handle medical and psychological problems, keep the focus on the problem of addiction and provide hope and confidence about recovery. Building rapport , assessing situations, ensuring client’s acceptance of addiction, exploring resources, developing individualized treatment plan, and maintaining follow-up with focus on further growth  are some of the responsibilities of the social worker in consultation with the client. A few other tasks are scheduling sessions, recording, networking, advocacy and working  as a team member. 

Substance users  are positive about social workers who develop a meaningful relationship with them based on empathy, can be trusted and treat them with respect and dignity, focus on their abilities and strengths, support them to make informed choices and decisions, help them get the services and benefits they are entitled to, are dependable and don’t give up on them where others have.

Family Therapy
Addiction also affects the family members who develop  a dysfunctional  pattern of functioning . Hence they need help.  Family therapy programme is conducted for spouses and parents of clients including children. The therapy includes re-educative sessions,  group therapy, individual counselling with the family and couple counselling. Family therapy is a collection of therapeutic approaches that include family level assessment and interventions with an understanding  that a change in any part of the system may bring about changes in other parts of the system. Family therapy in substance abuse treatment has two main purposes:  to help the family  (1) to see the inappropriate coping patterns adopted by them  and make qualitative changes that enhance well being ; (2) to develop  a positive frame of mind and support the patient in his recovery. Broad goals of family therapy are to provide information about addiction and its effects on the family system;  to provide a safe and acceptable environment for the family to discuss their problems ; to provide optimism and a supportive environment; and to improve interactions among family members (Jayaraman & Thirumagal,  2010b).

Self-help Groups
Self help groups such as Alcoholics Anonymous (AA) , Narcotics Anonymous (NA)  and Al-anon offer programmes of recovery  on a voluntary basis, principally through a 12- step programme for personal change. AA and NA are for  substance users and  Al-anon are for families.  The meetings are conducted in places affording privacy such as  churches and school premises at times when the activities of the institution are suspended. Attending meetings help recovering users and their families share their experiences  and  support one another in a drug  free  lifestyle, and in turn provide  long-term support.

Ethical Standards
Social work practice encompasses  a supportive approach and is  aligned  with the  core values of  the social work profession. Listed below are some of the ethical principles to be followed by social workers. 
  • Non-discrimination : non-discrimination of clients regardless of any religion, community, age, gender, sexual orientation or economic conditions.
  • Treating with dignity and respect : justice, dignity, worth of the individual and  displaying the importance of  human relationships and integrity . It also includes respecting the client’s rights to choose his preferred course of action.
  • Professional competency:‘When clients put their trust in us  as professionals, one of their most fundamental expectations is that we will be competent’  (Pope & Vasquez, 1991). 
  • Updating knowledge through refresher  programmes and getting feedback from colleagues and supervisors  will enhance the knowledge and skills. Some of the  competencies  include understanding SUDs including the causes, progression of disease, consequences, recovery and prevention; understanding the biopsycho-social, cultural, and spiritual dimensions of SUDs; and understanding other family, health and social problems like violence and crime.  
  • Ongoing assessment:  Conducting on going assessment in order to provide clients  with appropriate diagnosis and treatment plans. 
  • Client welfare: Maintaining confidentiality regarding the client is of prime importance. Getting informed consent begins when the counselling relationship is initiated and continues throughout the relationship. Services to be provided in an environment which will ensure privacy and safety of the client  at all times, and make certain the appropriateness of service delivery.  As part of client welfare one should  not exploit relationship with current or former clients for personal gain and not to engage in sexual relationships. 
  • Advocacy : Engaging in advocacy to ensure that the clients and the families have equal access  to the services in a timely manner is significant.  Promoting networking and collaboration to enhance and deliver effective services to clients and their families is important. 
  • Record keeping : Maintaining timely , accurate data and records that are relevant for planning, implementation and evaluation of the services (Chapman, 1997).

Overcoming Challenges in SUD Care
  • Failure to identify a substance use problem and /or not to respond appropriately after recognition are major challenges faced by the social workers.  Providing specific knowledge  about the nature and range of addiction   related problems, understanding  the role of social workers, and instilling  confidence   to identify and respond are the key issues.
  • A substance  user  loses most of the support system and he needs many services to get back to a holistic life. Evidence shows that  the more stable the environment, the better the chances of dealing with his substance problem. Social workers  should have the  ability to have a  holistic view of the client’s life and offer services  through networking with other agencies. 
  • Addiction is a stigmatized disease and the substance user is likely to be rejected by the family and community even after treatment.  This results in inability to get a job, not able to get a house to stay, etc.   Advocacy and creating awareness  about the nature of addiction and recovery by the social worker is  yet another  challenge and a task.  
  • Addiction is a relapsing  disease. When there are repeated relapses , a feeling of failure is experienced  by the client and his family members.  Anger  and frustration of the social workers will  only complicate the problem further.  Accepting the chronicity of addiction and providing specific help to deal with relapses are important issues. Many de-addiction centres conduct specific relapse prevention and recovery management programmes. 
  • Addiction affects the family as much as it affects the users.  In case the client is not recovering, providing support  to empower the family members and make their  lives functional is another challenge for social workers. 
  • Staff supervision and peer review are sadly lacking in our system. Clinical supervision is defined as the process of ensuring that personnel involved in operation of a treatment centre are able to undertake their responsibilities appropriately and effectively. It results in improvement in the quality of work, increased  staff satisfaction and prevent burnout.  Supervision should  be conducted on a regular basis; and it helps use successes and mistakes as learning opportunities.
  • Social work schools give low preference  to training on substance use disorders and  at most, the students visit a de-addiction centre for half a day. The salary package given is also not attractive (most of the centres are run with grants  given by MSJE which are low and minimal).  The entire scenario makes the field very unattractive. Introducing certification programme for social workers and professionalizing the field will increase the  ‘employability status’ and career prospects of the individual practitioner.  Introducing certification programme for social workers is yet another challenge.

To Sum Up 
Social workers  can play a vital role in delivering services which encompass early intervention, treatment and rehabilitation . By applying evidence based approaches that  integrate established interventions  and also by incorporating  12 core functions, social workers can markedly improve treatment services. This in turn requires that social workers be knowledgeable and acquire needed skills. Social work practice has certain core values or ethics which need to be followed to maintain high standards of personal conduct.

References
  1. Babor Thomas F.; John C. Higgins-Biddle, John B. Saunders, Maristela G. Monteiro, (2001) : “The Alcohol Use Disorders Identification Test Guidelines for Use in Primary Care”, World  Health Organization.
  2. Chapman Charlotte M S., (1997):  “Ethics manual and work book”, NAADAC, USA.
  3. Colombo Plan, (2011):  “Treatment for Substance use Disorders-The Continuum of Care for Addiction Professionals”, The Colombo Plan Asian Centre for Certification and Education of Addiction Professionals Training Series.
  4. DiNitto,  Dianna M & C. Aaron Mc Neece, (2007): “Addiction and Social work practice”, Chapter 8 (page 171-192), The many problems called addictions, Chicago :Lyceumbooks.
  5. Friedman E.G and Wilson R, (2004):  “ Methadone maintenance in the treatment of addiction”.   In S.L.A Straussner (Ed). Clinical work with substance abusing clients, 2nd edition, pp.187-208, Guilford Press , New York,
  6. Herdman  John W ,(2000):  “Global Criteria: The 12 Core Functions of the Substance Abuse Counselor”, U.S.Health Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, SAMHSA, 
  7. Jayaraman Rukmani and  Shanthi Ranganathan,(2010): “I Plan .. & I can – Tips and Tools for a Comfortable Recovery”,  T T Ranganathan Clinical Research Foundation, Chennai.
  8. Jayaraman Rukmani and Thirumagal V, (2010): “The Family’s Journey through Alcoholism into Recovery- The Professional’s Guide”,  T T Ranganathan Clinical Research Foundation, Chennai.
  9. Lesieur  H.R, & Blume. S (1987): “The South Oaks Gambling Screen, A new instrument for the identification of pathological gamblers”, American Journal of Psychiatry, 144, 1184-1188.
  10. Meyers, R.J., & Miller, W.R. (2001). “A Community Reinforcement Approach to addiction treatment”. Cambridge, UK: Cambridge University Press.
  11. Miller, W.R. and Rollnick, S. (1991): “Motivational Interviewing :  Preparing  people to change addictive bahaviour”, Guilford Press, New York.
  12. Miller, W.R., and Sanchez, V.C., (1994): “Motivating young adults for treatment and lifestyle change”. In: Howard, G., and Nathan, P.E., eds. Alcohol Use and Misuse by Young Adults. Notre Dame, IN: University of Notre Dame Press.
  13. Ministry of Welfare, Government of India, (1994): “A report on de-addiction and rehabilitation”, New Delhi.
  14. Murthy Pratima & Sankaran Lakshmi (2009). “Workplace well being: Integrating psycho-social issues with health”. National Institute of 
  15. Mental Health and Nero Sciences (NIMHANS), Bangalore.
  16. Najavits, L.M, and Weiss, R.D., (1994): “Variations in therapist effectiveness in the treatment of patients with substance use disorders- An empirical review”. Addiction 89 (6): 679-688. 
  17. Pope Kenneth and Vasquez M.J.T, (1991): “Ethics in Psychotherapy  and Counselling – A practical guide for psychologist”, San Fransico:  Jossey-Bass, p-51.
  18. Prochaska, J.O., DiClemente, C.C. & Norcross, J.C. (1992). “ In search of how people change: Applications to addictive behaviors”.  American Psychologist, 47(9), 1102-1114. 
  19. Ray R, Mondal AB, Gupta K, Chatterjee A and Bajaj P, (2004): “National survey on extent, pattern and trends of drug abuse in India”. Ministry of Social Justice and Empowerment and United Nations Office on Drugs and Crime ROSA, Delhi.
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  21. Straussner Shulmith  Lala Ashenberg (2012): “Clinical treatment of substance abusers: Past, present and future”. Clinical Social Work Journal, 40: 127-133.  
  22. Thirumagal.V, (2012): “Dealing with Alcohol and Drug use - Role of Social Workers / Psychologists”, T T Ranganathan Clinical Research Foundation, Chennai.
  23. Volkow Nora D, (1999) : “Principles of Drug addiction treatment-A Research Based Guide” NIH Publication, No.12-4180, NIDA, USA.
  24. WHO  Expert Committee on Drug Dependence, (1998): “WHO Technical Report Series -30th report”,  page 3, no.873, WHO, Geneva.
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