History, Policy & Public Health

Temperance Movement and Prohibition

The temperance movement was a reform initiative advocating moderation or abstinence from alcohol, heavily influenced by religious and social groups. Prohibition, enacted via the 18th Amendment and repealed by the 21st Amendment, marked a significant period in U.S. public health policy.

• Temperance Movement: Promoted moderation/abstinence; rooted in social and religious reform.

• Prohibition: Legal ban on alcohol; repealed after societal and policy shifts.

Addiction Models Evolution

Conceptual models of addiction have evolved from moral explanations to include disease, biological, psychological, family, developmental, biopsychosocial, and public health perspectives.

• Moral Model: Addiction seen as a weakness or moral failing.

• Disease Model: Addiction as a chronic disorder requiring treatment.

• Biopsychosocial Model: Integrates biological, psychological, and social/environmental factors.

Mental Health Parity & Addiction Equity Act (MHPAEA)

MHPAEA mandates parity between mental health/substance use and medical/surgical benefits, though treatment limits may still apply.

• Parity: Equal coverage for mental health and substance use disorders.

• Medical Necessity: Utilization rules may restrict unlimited treatment.

COVID-19 & Opioid Epidemic

The COVID-19 pandemic exacerbated addiction risks through isolation, stress, and treatment disruptions, while the opioid epidemic progressed through three waves: prescription opioids, heroin, and synthetic opioids (fentanyl).

• Wave 1: Prescription opioids.

• Wave 2: Heroin.

• Wave 3: Synthetic opioids (fentanyl).

• First-wave lesson: Misleading opioid marketing increased risk.

Neuro/Substance Foundations

Neurotransmitters and Addiction

Key neurotransmitters play distinct roles in addiction and mental health.

• Dopamine: Associated with reward, reinforcement, and motivation.

• Serotonin: Regulates mood, sleep, and impulse control.

• Norepinephrine: Involved in arousal, attention, and stress response.

Pharmacological Concepts

• Agonist: Activates a receptor.

• Antagonist: Blocks receptor activation.

• Partial Agonist: Partially activates a receptor.

• Tolerance: Increased substance needed for same effect.

• Withdrawal: Symptoms after reduction or cessation.

• Dependence: Physiological adaptation; not synonymous with addiction.

Alcohol Craving and Withdrawal

• Craving Categories: Reward-induced, relief/stress-reduction, obsessive/disinhibition.

• Withdrawal Risks: Seizures and delirium tremens (DTs), a medical emergency.

Addiction: Substances, Processes & Etiology

Models of Addiction

Multiple models explain addiction, each emphasizing different factors.

• Moral Model: Addiction as a choice or moral failing.

• Disease Model: Chronic disorder requiring treatment.

• Biological Model: Genetics, neurobiology, reward systems.

• Psychological Model: Learning, cognition, reinforcement, trauma.

• Developmental Model: Risk and behavior change across lifespan.

• Family Systems Model: Roles, boundaries, homeostasis, interaction patterns.

• Biopsychosocial Model: Integrates biological, psychological, and social factors.

Vulnerability Factors

• Genetics/family history

• Adverse Childhood Experiences (ACEs)/trauma

• Early initiation

• Mental illness

• Peer influence

• Chronic stress, poverty, unstable housing, marginalization

Process/Behavioral Addictions

• Rewarding behaviors (e.g., gambling) recognized in DSM.

Comorbidity

Co-occurring Disorders

Comorbidity refers to the presence of both mental health and substance use disorders.

• Integrated Treatment: Coordinates care for both conditions.

• Counseling & Psychoeducation: Core care needs.

• Empirically Supported Approaches: Cognitive Behavioral Therapy (CBT), Motivational Interviewing.

Assessment Components

• Psychiatric symptoms

• Substance use

• Trauma

• Medications

• Cognition

• Functioning

• Family, culture, legal, medical needs

Models of Care

Counseling Approaches

FRAMES Model

FRAMES is a brief intervention model for substance use counseling.

• Feedback

• Responsibility

• Advice

• Menu

• Empathy

• Self-efficacy

Motivational Interviewing

• Addresses ambivalence, supports autonomy, collaboration, and client-driven change.

Cognitive Behavioral Therapy (CBT)

• Focuses on thoughts, emotions, behaviors, triggers, and cognitive restructuring.

Solution-Focused Counseling

• Emphasizes strengths, exceptions, preferred future, miracle/scaling questions.

Customer Types in Counseling

• Visitor: Not seeking change.

• Complainant: Acknowledges problem but not ready for change.

• Customer: Ready for change.

Group Counseling & 12-Step Programs

Types of Groups

Common Groups and Focus

• Open AA Meeting: Broad attendance.

• Closed AA Meeting: For those with desire to stop drinking.

• Level I Sponsor: Helps sponsee become or stay sober.

• Self-help Groups: Self-selective; important for research selection bias.

• MAAEZ: Making Alcoholics Anonymous Easier; increases accessibility.

Intake, Assessment, Ethics

Key Terms and Processes

• Screening: Brief identification of possible problem.

• Intake: Initial information gathering.

• Assessment: Comprehensive biopsychosocial/cultural/substance/medical/psychiatric evaluation.

• Diagnosis: Clinical formulation.

• Treatment Plan: Problems, goals, objectives, interventions.

• Goal: Specific desired outcome; SMART framework.

Informed Consent & Confidentiality

• Informed Consent: Covers purpose, risks/benefits, alternatives, counselor qualifications, rights, confidentiality/limits.

• 42 CFR Part 2: Federal confidentiality protections for SUD records.

• HIPAA: Privacy/security for protected health information.

• Limits: Never promise absolute confidentiality; explain exceptions.

Cultural Fit

• Use cultural competence and humility.

• Assessment should be culturally specific, flexible, holistic.

• Explore language, identity, family, spirituality/religion, socioeconomic context, discrimination.

Treatment Planning & Relapse Prevention

SMART Goals

Relapse Prevention

• Identify triggers, high-risk situations, cravings.

• Coping/urge management, refusal skills, support network.

• Environmental changes, emergency plan, recovery routines.

• Self-efficacy: Belief in ability to perform recovery behaviors.

• Resilience: Capacity to adapt/recover from adversity.

Medication & Interventions

Alcohol Use Disorder Medications

Opioid Use Disorder Medications

• Counselor Role: Educate, reduce stigma, explore ambivalence, support informed choice, coordinate with prescribers, support adherence.

ASAM & Care Continuum

ASAM Dimensions

Levels of Care

• 0.5: Early intervention

• 1: Outpatient

• 2: Intensive outpatient/partial hospitalization

• 3: Residential/inpatient

• 4: Medically managed intensive inpatient

• Continuity: Assessment → placement → treatment → step-down → aftercare/recovery supports; coordination and warm handoffs.

Prevention

Prevention Programs and Concepts

• BASICS: Brief Alcohol Screening and Intervention for College Students; harm-reduction oriented.

• Information-only Prevention: Generally insufficient for durable behavior change.

• School Prevention: Skills/social competence/family and evidence-based curricula outperform simple fear/information approaches.

• Media/Social Marketing: May help as part of broader strategies; not sufficient alone.

Culture, Disability & Special Populations

Cultural Humility and Competence

• Cultural Humility: Lifelong learning, self-reflection, attention to power, respect for client expertise, correction of assumptions.

• Historical Trauma: Important for Native American communities.

• Structural Racism: Systemic policies/practices producing unequal outcomes.

• Disability: Culturally specific, flexible, holistic assessment recommended.

• D/deaf Language Dysfluency: Inability to communicate fluently in any language, including sign language.

• Inclusive Spirituality: Ask what gives meaning/support rather than assuming religion or spirituality.

Licensure, Accreditation & Burnout

Professional Practice

• Licensure: State authorization/credential to practice within a professional scope.

• Accreditation: External quality review of education/service programs (e.g., CACREP, CARF, The Joint Commission).

• Burnout Prevention: Supervision, consultation, boundaries, manageable workload, recovery time, peer support, self-care.

Key Concepts and Comparison Sheet

Practice Exam Concepts

• Assessment: Collects comprehensive history.

• Tolerance: More alcohol needed for same effect.

• Antagonist: Blocks receptor activation.

• Motivational Interviewing: Best for ambivalence.

• Self-efficacy: Confidence in ability to change.

• ACOA: Adult children of alcoholic/dysfunctional families.

• SMART Recovery: Secular, CBT-oriented group.

• Genogram: Maps multigenerational patterns.

• Triangulation: Redirecting conflict.

• Homeostasis: Dysfunctional family balance.

• Scapegoat: Blamed family member.

• Naltrexone: Opioid antagonist.

• Buprenorphine: Partial agonist.

• Methadone: Full agonist.

• Disulfiram: Aversive reaction with alcohol.

• Acamprosate: Supports abstinence.

• ASAM Dimension 4: Readiness to change.

• ASAM Dimension 6: Recovery environment.

• 42 CFR Part 2: SUD record confidentiality.

• MHPAEA: Parity law.

• Informed Consent: Explains risks, benefits, rights, confidentiality.

• Culturally Responsive Assessment: Specific, flexible, holistic.

• Cultural Humility: Lifelong self-reflection and learning.

• Information-only Prevention: Weak as stand-alone.

• BASICS: College students with alcohol risk.

• Self-efficacy: Belief in ability to perform behavior.

• Resilience: Ability to adapt/recover after adversity.

• Dopamine: Reward.

• Serotonin: Mood.

• Norepinephrine: Stress/arousal.

• Opioid Epidemic Waves: 1: Prescription opioids; 3: Synthetic opioids/fentanyl.

• Integrated Treatment: Coordinated care for comorbidity.

• Psychotherapeutic Group: Deeper psychological/interpersonal treatment.

• Psychoeducational Group: Teaching information/skills.

• Covert Rule: Implicit/unspoken family rule.

• Genogram: Family patterns across generations.

• Counselor Role with MAT: Educate, explore ambivalence, reduce stigma, coordinate care.

• Confidentiality: Explain limits; do not promise absolute confidentiality.

• Cultural Competence + Humility: Guide treatment.

Common Trick Questions

• Intake ≠ comprehensive assessment.

• Physical dependence ≠ addiction.

• Medication questions may test mechanism (agonist/antagonist).

• Integrated care preferred for co-occurring conditions.

• Cultural humility ≠ memorizing stereotypes.

• Self-help group ≠ professional psychotherapy.

• Information alone ≠ strongest prevention strategy.

• Family system questions: homeostasis, triangulation, blaming, rigid roles.

• Choose answer that most directly names counselor's primary activity.

7-Day Study Plan

Night-Before Cram Sheet

• FRAMES: Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy

• SMART: Specific, Measurable, Achievable, Relevant, Time-bound

• ASAM: 6 dimensions: withdrawal, biomedical, emotional/behavioral, readiness, relapse, recovery environment

• Agonist: Activates; Antagonist: Blocks; Partial Agonist: Partially activates

• Dopamine: Reward; Serotonin: Mood; Norepinephrine: Arousal/stress

• Tolerance: More needed; Withdrawal: Symptoms after reduction/cessation

• AA: Alcohol; Al-Anon: Family of alcohol use; Nar-Anon: Family of drug use; ACOA: Adult children

• SMART Recovery: Secular + CBT-oriented + four-point program

• Genogram: Multigenerational family map

• Triangulation: Third person pulled into conflict

• Homeostasis: Family balance, even if dysfunctional

• Scapegoat: Blamed member

• 42 CFR Part 2: SUD record confidentiality

• MHPAEA: Parity

• AUD Medications: Naltrexone, acamprosate, disulfiram

• OUD Medications: Methadone, buprenorphine, naltrexone

• Integrated Treatment: Coordinated care for co-occurring disorders

• Cultural Competence + Humility: Equitable practice

• Assessment: Comprehensive; Intake: Initial information; Treatment Plan: Goals/objectives/interventions

Final Test Strategy

• Read last sentence first: identify what the question asks.

• Circle mental keywords: BEST, FIRST, MOST, PRIMARY, MAIN, EXCEPT.

• Eliminate answers that are too absolute unless textbook uses that language.

• If two choices seem plausible, pick the one that most directly matches textbook term.

• For scenario questions, name the concept before looking at answer choices.

• Do not change an answer without a specific reason.