Case Assignment:

Please read the following case study. Once completed, please utilize the information to discuss, in a 5-8 page paper, the following:

1) which substances are involved

2) how might you assess further

3) whether this appears to be characteristic of abuse or dependence and why

4) the likely course of the addiction if treatment or untreated

5) any concurrent psychiatric disorders to consider, if so, how might it be
assessed and addressed

6) your recommendations for treatment.

THE CASE:

Al Santini, a 39-year-old restaurant owner, is referred by a marriage counselor to a private outpatient substance abuse treatment program for evaluation and treatment of a possible “cocaine problem.” According to the counselor, attempts to deal with the couple’s marital problems have failed to produce any signs of progress over the past 6 or 7 months. The couple continues to have frequent, explosive arguments, some of which have led to physical violence. Fortunately, neither spouse has been seriously injured, but the continuing chaos in their relationship has led to a great deal of tension at home and appears to be contributing to the acting-out behavior and school problems of their two children, ages 9 and 13.

Several days ago, Al admitted to the counselor and to his wife that he had been using cocaine “occasionally” for at least the past year. The wife became angry and tearful, stating that if her husband failed to obtain treatment for his drug problem, she would separate from him and inform his parents of the problem. He reluctantly agreed to seek professional help, insisting that his cocaine use was “not a problem” and that he felt capable of stopping his drug use without entering a treatment program.

During the initial evaluation interview, Al reports that he is currently using cocaine, intranasal, 3–5 days a week, and that this pattern has been continuing for at least the past 2 years. On average, he consumes a total of 1–2 g of cocaineweekly, for which he pays $80 per gram. Most of his cocaine use occurs at work, in his private office or in the bathroom. He usually begins thinking about “coke” while driving to work in the morning. When he arrives at work, he finds it nearly impossible to avoid thinking of the cocaine vial in his desk drawer. Although he tries to distract himself and postpone using it as long as possible, he usually snorts his first “line” within an hour of arriving at work. On some days, he may snort another two or three lines over the course of the day. On other days, especially if he feels stressed or frustrated at work, he may snort a line or two every hour from morning through late afternoon. His cocaine use is sometimes fueled by offers of the drug from his business partner, whom the patient describes as a more controlled, infrequent user of the drug.

Al rarely uses cocaine at home, and never in the presence of his wife or children. Occasionally, he snorts a line or two on weekday evenings or weekends at home when everyone else is out of the house. Al denies current use of any other illicit drug but reports taking 10–20 mg of an antianxiety drug, Valium (diazepam) (prescribed by a physician friend), at bedtime on days when cocaine leaves him feeling restless, irritable, and unable to fall asleep. When Valium is unavailable, he drinks two or three beers instead.

He first tried cocaine 5 years ago at a friend’s party. He enjoyed the energetic, euphoric feeling and the absence of any unpleasant side effects, except for a slightly uncomfortable “racing” feeling in his chest. For nearly 3 years thereafter, he used cocaine only when it was offered by others and never purchased his own supplies or found himself thinking about the drug between episodes of use. He rarely snorted more than four or five lines on any single occasion of use. During the past 2 years his cocaine use escalated to its current level, coincident with a number of significant changes in his life. His restaurant business became financially successful, he bought a large home in the suburbs, he had access to lots of cash, and the pressures of a growing business made him feel entitled to the relief and pleasures offered by cocaine.

He denies any history of alcohol or drug abuse problems. The only other drug he has ever used is marijuana, which he smoked infrequently in college but never really liked. He also denies any history of other emotional problems and, except for marriage counseling, reports that he has never needed help from a mental health professional.
During the interview, Al remarks several times that although he thinks that his cocaine use “might be a problem,” he does not consider himself to be “addicted” to it and is still not sure that he really requires treatment.

In support of this view, he lists the following evidence:

1) his current level of cocaine use is not causing him any financial problems or affecting his standard of living

2) he is experiencing no significant drug-related health problems that he is aware of, with the possible exception of feeling lethargic the next day after a day of heavy use

3) on many occasions, he has been able to stop using cocaine on his own, for several days at a time

4) when he stops using the drug, he experiences no withdrawal syndrome and no continuous drug cravings.

On the other hand, he does admit the following:

1) he often uses much more cocaine than intended on certain days

2) the drug use is impairing his functioning at work because of negative
effects on his memory, attention span, and attitude toward employees and customers

3) even when he is not actively intoxicated with cocaine, the aftereffects of the drug cause him to be short-tempered, irritable, and argumentative with his wife and children, leading to numerous family problems, including a possible breakup of his marriage

4) although he seems able to stop using cocaine for a few days at a time, somehow he always goes back to it

5) as soon as he starts to use cocaine again, the craving and the preoccupation with the drug are immediately as intense as before he stopped using it.

At the end of the interview, Al agrees that although he came for the evaluation largely under pressure from his wife, he can see the potential benefits of trying to stop using cocaine on a more permanent basis. With a saddened expression, he explains how troubled and frightened he feels about the problems with his wife and children. He says that although marital problems existed before he started snorting cocaine, his continuing drug use has made them worse, and he now fears that his wife might leave him. He also feels extremely guilty about notbeing a “good father.” He spends very little time with his children and often is distracted and irritable with them because of his cocaine use.

Case retrieved from:

Spitzer, R.L., et.al, (2002). DSM-IV-TR Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. American Psychiatric Publishing. Arlington, VA.

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