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Running head: LITERAURE REVIEW FOR PDE 1

Positive Psychology and Treatment for Substance Use Disorders in Nicaragua

Javier D. Ley

Mississippi College

LITERATURE REVIEW FOR PDE 2

Positive Psychology and Treatment for Substance Use Disorders in Nicaragua

Positive Psychology (PP) theory and interventions have a place in the treatment and recovery of

individuals with SUD’s considering the negative affect and life situations that are a common

consequence of this condition. In relation to the emotional aspect, Koob and Volkow (2010)

describe drug addiction as being characterized by the “emergence of a negative emotional state”

(p. 217) Also, research has shown that people in recovery from drug addiction scored higher on

measurements of shame, depression, and maladaptive guilt (Meehan et al., 1996). Having been

engulfed in these negative affective consequences for many years, it can prove a challenging task

for the individual to identify and acknowledge positive aspects in their personalities and in their

lives. In the following literature review, aspects related to concepts and definitions of addiction

are described, as well as diagnostic criteria, screenings and assessments, prevalence and

populations of interest, co-occurring disorders, suicides and mortality, development of the

disorder, negative affect and emotions, evidence based practices, self-help or mutual-help, long

term recovery, positive psychology and its possible integration with addiction.

Addiction – Concepts and Definitions

The conceptualization of addiction as it relates to substance use disorders need to be

considered. There are two relevant current definitions of addiction that are noteworthy. First is

the definition of addiction utilized by the National Institute on Drug Abuse (NIDA), who, in their

publication “Drugs, Brain, and Behavior: The Science of Addiction”, share that “addiction is

defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking

and use, despite harmful consequences” (NIDA, 2010, p. 5). The relevance of NIDA and their

definition stems from the fact that the agency is the largest funding source for research on the

field (Satel & Lilienfeld, 2014). The second definition that is noteworthy is the one utilized by


the American Society of Addiction Medicine (ASAM). In a public policy statement adopted in

2011, ASAM shared as part of their short definition that

Addiction is a primary, chronic disease of brain reward, motivation, memory and related

circuitry. Dysfunction in these circuits leads to characteristic biological, psychological,

social and spiritual manifestations. This is reflected in an individual pathologically

pursuing reward and/or relief by substance use and other behaviors (ASAM, 2011, p. 1).

The relevance of ASAM is due to their being the largest professional group of medics

specialized in the field (Satel & Lilienfeld, 2014).

Both definitions share the central role of the brain in their explanations. This view is a

consensus generally accepted throughout the addiction science world (Levy, 2013). Imaging

technology of the human brain has been at the forefront of this perspective on addiction.

Significant increases in dopamine levels during drug use are related to the reinforcement effects

of drugs (repetition of drug using behavior), while there are also effects on motivation

(orbitofrontal cortex), memory (amygdala), and cognitive control (prefrontal cortex) (Volkow,

Fowler, & Wang, 2003).

Specifically, it has been shown that drug addicted individuals, while not using drugs,

present a reduction in dopamine activity, reduction in orbitofrontal activity (motivation and

compulsivity), and in the cingulate gyrus (impulsivity). These reductions in dopamine lead to a

decreased sensitivity to natural rewards or other non-drug rewards and also to an inappropriate

functioning of the inhibitory frontal cortex. The value of the drug and related stimuli are

increased in relation to these other rewards. When these individuals are presented with stimuli

related to drugs, these areas and functions of the brain related to dopamine, motivation, and

memory become hyperactive and strongly drive these individuals to seek drugs without the


inhibitory control necessary to avoid a corresponding compulsive drug use. (Volkow, et al.,

2003; Volkow, Fowler, Wang, & Swanson, 2004).

Although the consensus stands among scientists that addiction is a brain disease, there are

also some that are not in agreement with this perspective. Levy (2013) states that addiction is

better understood as a disorder of a person within a social context and not as a brain disease. He

goes on to argue that the neural adaptations and changes in the addicted person’s brain also occur

in all behavior and the fact that it is true for an addict’s brain does not make it a brain disease. In

relation to the involvement of the social context described above, Levy (2013) furthers his view

by describing the social inabilities of the addicted person to remove himself or herself from the

risky environment, the stress, demands, and even poor nutritional factors. He also mentions the

lack of other resources that can compete in value with the drugs.

Satel and Lilienfeld (2014) also argue against the brain disease model of addiction. They

state that the brain is not the most relevant unit of analysis in the comprehension and treatment of

addiction while adding that the brain disease model takes away focus on the following aspects:

(a) a dimension of choice in addiction; (b) a capacity to be responsive to incentives; and (c) the

fact that people have reasons to use drugs. In relation to the aspect of choice, they add that

people can improve if they have a desire to get well, an aspect that is not shared by other diseases

such as multiple sclerosis or schizophrenia.

In regard to the responsiveness of incentives, the authors share the examples of

physicians who would have their licenses revoked if they do not present negative laboratory

testing of drug use and the positive outcomes of contingency management in which participants

receive a reward for drug free urine samples--something also that cannot be done with someone,

for example, with Alzheimer’s. As for the fact that people use drugs for reasons, Satel and


Lilienfeld (2014) describe examples of reasons to use drugs not related to brain mechanisms,

such as forgetting, and dealing with fear, anxiety, and doubt.

Diagnostic Criteria

The shift in 2013 from the Diagnostic and Statistical Manual of Mental Disorders from

the American Psychiatric Association (APA) in their fourth edition and revised text (DSM-IV-

TR) into the fifth edition (DSM-5) led into a change from two different disorders related to

addiction in DSM-IV-TR-- those of substance abuse and substance dependence--towards one

disorder in DSM-5: substance use disorder (SUD). DSM-5 lists the essential characteristic of

SUD as a “cluster of cognitive, behavioral, and physiological symptoms indicating that the

individual continues using the substance despite significant substance-related problems” (APA,

2013, p. 483) The DSM-5 description of SUD also has inclination towards the brain disease

model, stating that another important characteristic of SUD is “an underlying change in brain

circuits that may persist beyond detoxification, particularly in individuals with severe disorders”

(APA, 2013, p. 483)

Categories of substances for which the DSM-5 has diagnostic criteria for SUD are:

alcohol, cannabis, phencyclidine, other hallucinogens, inhalants, opioids, sedative (hypnotic or

anxiolytic), stimulants, tobacco, and a category for other (or unknown) SUD. The diagnostic

criteria are the same for each of the nine categories of substances mentioned above with 11

diagnostic criteria per substance. One difference is that there is no diagnostic criterion for

withdrawal for phencyclidine, other hallucinogen, or inhalants; therefore these SUDs contain

only 10 diagnostic criteria. The other categories contain all 11 criteria, with specific

particularities for characteristic withdrawal symptoms of each substance or substance group

(APA, 2013).


As an example of a specific substance, the diagnostic criteria for alcohol use disorders are

described. The diagnostic criteria are the same for the other substances, with only the name of

the substance changing in their specific criteria. In this case, an alcohol use disorder is described

as a “problematic pattern of alcohol use leading to clinically significant impairment or distress,

as manifested by at least two of the following, occurring within a 12-month period:

1. Alcohol is often taken in larger amounts or over a longer period than was intended.

2. There is persistent desire or unsuccessful efforts to cut down or control alcohol use.

3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or

recover from its effects.

4. Craving, or a strong desire or urge to use alcohol.

5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work,

school, or home.

6. Continued alcohol use despite having persistent or recurrent social or interpersonal

problems caused or exacerbated by the effects of alcohol.

7. Important social, occupational, or recreational activities are given up or reduced because

of alcohol use.

8. Recurrent alcohol use in situations in which it is physically hazardous.

9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical

or psychological problem that is likely to have been caused or exacerbated by alcohol.

10. Tolerance, as defined by either of the following:

a. A need for markedly increased amounts of alcohol to achieve intoxication

or desired effect.


b. A markedly diminished effect with continued use of the same amount of

alcohol.

11. Withdrawal, as manifested by either of the following:

a. The characteristic withdrawal syndrome for alcohol.

b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken

to relieve or avoid withdrawal symptoms” (APA, 2013, p 490-491).

Other important specifiers for the diagnostic process of SUD include the current severity,

state of remission, and if in a controlled environment. As for the current severity, SUD is now

thought of as a continuum in which the individual can present a classification of the severity of

their SUD in accordance to the number of criteria met. If the individual meets two to three

criteria, the SUD is specified as “mild”. If the individual meets four to five criteria, the SUD is

specified as “moderate” and if the individual meets six or more criteria, the SUD is classified as

“severe”.

In relation to the state of remission, if the person with a SUD and who previously met

criteria as such, has not met any of the criteria (except for Criterion 4: Craving) for at least three

months but less than 12, then the diagnosis is specified as “in early remission.” If the person with

a SUD and who previously met criteria as such has not met any of the criteria (except for

Criterion 4: Craving) for 12 months or more, then the diagnosis is specified as “in sustained

remission”. A final specification of “In a controlled environment” results if the person is in an

environment where the substance related to their SUD is restricted (APA, 2013).

Knowledge of DSM-IV-TR criteria of abuse and dependence is also currently relevant

since most research findings used in the present review of literature are based on these diagnostic


criteria. Therefore, the inclusion of the diagnostic criteria for both disorders in DSM-IV-TR is

needed for a better understanding in this literature review.

The criteria for Substance Abuse are defined 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:

1. Recurrent substance use resulting in a failure to fulfill major role obligations at work,

school, or home (e.g. repeated absences or poor work performance related to substance

use; substance-related absences, suspensions, or expulsions from school; neglect of

children or household).

2. Recurrent substance use in situations in which it is physically hazardous (e.g. driving an

automobile or operating a machine when impaired by substance use).

3. Recurrent substance-related legal problems (e.g. arrests, disorderly conduct).

4. Continued substance use despite having persistent or recurrent social or interpersonal

problems caused by or exacerbated by the effects of the substance (e.g., arguments with

spouse about consequences of intoxication, physical fights).” (APA, 2000, p. 228)

The criteria for Substance Dependence are defined as “a maladaptive pattern of substance

use leading to clinically significant impairment or distress, as manifested by three (or more) of

the following, occurring within a 12-month period:

1. Tolerance, as defined by either of the following:

a. a need for markedly increased amounts of the substance to achieve intoxication

or desired effect

b. markedly diminished effect with continued use of the same amount of the

substance


2. Withdrawal, as manifested by either of the following:

a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of

the criteria set specific substances)

b. the same (or a closely related) substance is taken to relieve or avoid withdrawal

symptoms

3. The substance is often taken in larger amounts or over a longer period than was intended.

4. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

5. A great deal of time is spent in activities necessary to obtain the substance, use the

substance, or recover from its effects.

6. Important social, occupational, or recreational activities are given up or reduced because

of substance use.

7. The substance use is continued despite knowledge of having a persistent or recurrent

physical or psychological problem that is likely to have been caused or exacerbated by

the substance.” (APA, 2000, p. 223).

Screenings and Assessments

With the significant prevalence of SUD’s, their impact on the individual, on families, on

morbidity, mortality, and society as whole, the importance of screening and assessment cannot

be understated. Screening tools help with the identification of individuals with hazardous

substance use. Other screening instruments also aid in categorizing a level of severity of problem

use in the individual, while others also point towards level of care. A positive screen of a

problem substance user also point towards more detailed assessments. These thorough

assessments provide a more complete context of the individual’s circumstances and areas of life


impacted by the substance use, more information for diagnostic purposes, and a guide for

treatment planning (Samet, Waxman, Hatzenbuehler, & Hasin, 2007).

Early detection of problem substance users is a main concern. There has been

advancement in the early identification of problem drinkers of alcohol through brief intervention

instruments such as the Alcohol Use Disorders Identification Test (AUDIT), which was

developed by the World Health Organization (WHO). The AUDIT is a 10-item instrument

which had been designed for use in primary health care settings. It has also been validated in

relation to diverse languages and gender (Sims and Iphofen, 2003). Among the languages in

which AUDIT has been officially translated is Spanish (Babor et al, 2001).

In relation to the screening of substances other than alcohol, the WHO also developed the

Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). This instrument has

been validated for screening of alcohol, but also for tobacco, cannabis, cocaine, amphetamine-

like stimulants, inhalants, sedatives, hallucinogens, opioids, and other (unspecified) drugs

(Humeniuk et al., 2008). The resulting score provided by the ASSIST is categorized in three

levels of risk: low, moderate, high. The screening tool provides a maximum of eight items per

substance. Not all items for a substance need to be answered if an individual does not use this

particular substance.

There are other commonly used screening instruments utilized in the United States that

are not known in Nicaragua. These include the Substance Abuse Subtle Screening Inventory

(SASSI), the Michigan Alcoholism Screening Test (MAST), the Drug Abuse Screening Test

(DAST), and the CAGE (Acronym for: Cutting down, Annoyance by criticism, Guilty feeling,

and Eye-openers). All of these, except the MAST, are found in Spanish but none has been widely

disseminated in Nicaragua. Other relevant information regarding these instruments includes the


fact that the SASSI is one of the most widely used instruments in SUD treatment facilities

because of addiction counselor preference to this instrument (Feldstein & Miller, 2007). Also,

there is an importance to the DAST as it is one few instruments that are specific to drugs other

than alcohol (Maisto, Carey, Carey, Gordon, & Gleason, 2000).

In relation to SUD assessments, the Addiction Severity Index (ASI) is one of the better

known. It is utilized widely in research, as it is used in NIDA’s Clinical Trial and in clinical

settings Networks (Samet et al., 2007). The format of the ASI is that of a semi-structured

interview which focuses on diverse domains of life functioning, including medical,

employment/support, alcohol and drug use, legal, family history, social, and the psychiatric

domain. By the concentration in these domains, clinicians can better tailor interventions, areas of

treatment, and referrals (Samet et al, 2007). The instrument is also found in Spanish but it has

also not been widely disseminated in Nicaragua.

For a summary of the above mentioned screening and assessment instruments for SUD,

see Table 1 below.

Table 1

Common screening and assessment instruments for SUD

Instrument Description Comments

Alcohol Use Disorders Identification Test (AUDIT)

- Screening for alcohol use

- 10 items

- Early identification of problem drinkers

- Developed by World Health Organization

- Available in Spanish for free

Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)

- Screening for alcohol, tobacco, cannabis, cocaine, amphetamine-like stimulants, inhalants, sedatives, hallucinogens, opioids, other drugs

- Maximum of 8 items per substance

- Developed by World Health Organization

- Available in Spanish for free


- Classification of risk levels per substance: low, moderate, high

Substance Abuse Subtle Screening Inventory (SASSI)

- Screening for SUD

- 93 items (adult version SASSI 3)

- Widely used in SUD treatment facilities

- Available in Spanish for purchase

Michigan Alcoholism Screening Test (MAST)


- 25 item version and 10 item version (Brief MAST or bMAST)

- Not available in Spanish

Drug Abuse Screening Test (DAST)

- Screening for substance use other than alcohol

- 20 item version and 10 item version

- Available in Spanish

CAGE (Acronym for: Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers)


- Version for screening other substance use CAGE-AID

- 4 items in both versions


Addiction Severity Index (ASI)

- Semi-structured assessment interview

- Seven domains: medical, employment/support, alcohol and drug use, legal, family history, social, psychiatric


Prevalence and Populations of Interest

SAMHSA sponsors a yearly survey called The National Survey on Drug Use and Health

(NSDUH). To inform the public of its findings, SAMHSA published the “Results from the 2012

National Survey on Drug Use and Health: Mental Health Findings” in 2013. In its introduction,

the document states that “NSDUH is the primary source of statistical information on the use of

illegal drugs, alcohol, and tobacco by the civilian, noninstitutionalized population of the United


States aged 12 years or older” (SAMHSA, 2013, p. 3). Since 1971, the surveys have been

conducted on a yearly basis and are administered in households throughout the United States

(US). As a result of the 2012 survey and its 68,309 completed interviews, it was estimated that

22.2 million people 12 years or older fell under the category of substance abuse or dependence

during the last year and based on DSM-IV criteria. This represented 8.5% of the 12 years and

older population. The distribution of these 22.2 million people with SUD in relation to a broad

category of substance use included 2.8 million people classified with abuse or dependence to

both alcohol and illicit drugs (1.1%), 4.5 million people classified with abuse or dependence to

only illicit drugs (1.7%), and 14.9 million people classified with abuse or dependence to only

alcohol (5.7%) (SAMHSA, 2013).

The WHO through the World Mental Health (WMH) Survey Initiative administered the

surveys and presented data on lifetime prevalence of mental health issues including SUD in

various countries around the globe. The findings were presented by Kessler, Angermeyer, and

Anthony (2007) as part of the WHO World Health Survey Consortium. In relation to the

administration of the surveys in the US, these were done from 2002 until 2003 and realized in

households and with a population of 18 years and older. Over 9,200 interviews were held to

initiate the survey process. This resulted in a lifetime prevalence at age 75 of 14.6% (Kessler et

al., 2007).

Also in relation to prevalence, a systematic literature review by Sussman, Lisha, and

Griffiths (2011) analyzed studies dealing with various types of addiction including addiction to

alcohol and addiction to illicit drugs. In their review, the authors included 22 studies with at least

500 subjects that examined alcohol abuse/dependence. Also, the authors included 20 studies with

at least 500 subjects that examined drug abuse/dependence. The studies included were found in


four databases including PsycINFO, OVID Medline (1950 through first 2 weeks of April 2010),

PubMed, and Google Scholar. The inclusion criteria for analysis started with sample sizes of 500

subjects or more, the age range of subjects in years was 16 to 65, prevalence studies that

considered both male and female, the studies presented a measure of addiction, and studies with

last year prevalence data. After filtering all findings from searches through these inclusion

criteria, 83 studies were included in the review. Out of these, 22 studies dealt with alcohol

abuse/dependence and 20 studies dealt with drug abuse/dependence. The resulting estimates for

last year prevalence provided by the authors were 10% for alcohol abuse/dependence and 5% for

drug abuse dependence.

To conclude the general prevalence review of the literature, results from the National

Epidemiologic Survey on Alcohol and Related Conditions (NESARC) are presented. The

NESARC was conducted from 2001 to 2002 with a representative sample of the Unites States

adult, 18 and older, population. Interviews were conducted in a face to face format and there

were 43,093 participants. Prevalence results of this survey included a lifetime alcohol abuse rate

of 17.8% and a past year alcohol abuse rate of 4.7%. Also, there was a lifetime prevalence of

alcohol dependence of 12.5% and a past year prevalence of alcohol dependence of 3.8%. Other

results included higher prevalence “among men, whites, Native Americans, younger and

unmarried adults, and those with lower incomes (Hasin, Stinson, Ogburn, & Grant, 2007).

See Table 2 for a summary of prevalence data from the above mentioned sources.

Table 2

Summary of Prevalence data for SUD in US

Source Method Prevalence % SUD Comments

Substance Abuse and Mental Health Services Administration. Results from the 2012 National

Survey is administered on the civilian, noninstitutionalized population 12 years or

- 22.2 million people with SUD in past year (8.5% of population 12 or older)

- Based on DSM-IV abuse and dependence criteria

- 261 million people in US


Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-47, HHS Publication No. (SMA) 13-4805. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013

older in US (N=68,309) in relation to meeting criteria in the past year

- 2.8 million alcohol and illicit drugs (1.1%)

- 4.5 million illicit drugs but not alcohol (1.7%)

- 14.9 million alcohol but not illicit drugs (5.7%)

12 years or older

Kessler et al., (2007). Lifetime prevalence and age-of-onset distributionsof mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry 2007;6:168-176

Survey is administered on population 18 years or older in US between 2002 and 2003 (N=9,200). In relation to SUD aspects, lifetime prevalence as of age 75 was measured

- 14.6% lifetime prevalence for any SUD

- Based on DSM-IV abuse and dependence criteria

Sussman, S., Lisha, N., Griffiths, M. (2011). Prevalence of the Addictions: A Problem of the Majority or theMinority? Evaluation and the Health Professions. 2011 March; 34(1): 3–56.

Systematic review of literature. 22 studies with at least 500 subjects that examined alcohol abuse/dependence and 20 studies with at least 500 subjects that examined drug abuse/dependence. Age range 16-65 years old.

- Authors’ estimate of 10% prevalence in last 12 months for alcohol abuse/dependence in general US adult population

- Author’s estimate of 5% prevalence in last 12 months for illicit drug abuse/dependence in general US adult population

Hasin, D.S., Stinson, F.S., Ogburn, E., Grant, B.F. (2007). Prevalence, Correlates, Disability,and Comorbidity of DSM-IV Alcohol Abuseand Dependence in the United States: Results From the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2007; 64(7):830-842

Face to face interviews with 18 an over US population (N=43,093). Lifetime and past year prevalence on alcohol abuse and alcohol dependence were measured.

- Prevalence lifetime alcohol abuse 17.8%

- Prevalence past year alcohol abuse 4.7%

- Prevalence lifetime alcohol dependence 12.5%

- Prevalence past year alcohol dependence 3.8%

Additional Factors

There are other aspects of importance when addressing SUD prevalence and specific

populations. These include gender issues, race/ethnic issues, criminal justice population, co-

occurring disorders, and suicides. In relation to gender issues, the NSDUH of 2012 found that the


rate of abuse or dependence in that year for males 12 years old and older (11.5%) was about

twice that for females (5.7%) of the same age range. This relationship of about two times was

also the case for the years from 2002 until 2011. When looking at past year users of alcohol, it

was found that an estimated 56.5% of males 12 and older were users in 2012 while 47.9% of

females 12 and older were users in the same period. In relation to illicit drug use, it was found

that an estimated 11.6% of males 12 and older were users in 2012 while 6.9% of females 12 and

older were users in the same period.

In a study by Lev-Ran, Le Strat, Imtiaz, Rehm, and Le Foll (2013), the researchers looked

at differences due to gender in relation to SUD’s in individuals with lifetime exposure to 11

different substances. The data researched was originated in the National Epidemiologic Survey

on Alcohol and Related Conditions. The study results showed that males had significant higher

SUD (abuse and dependence) prevalence than females in regards to alcohol, sedatives, cannabis,

tranquilizers, opioids, hallucinogens, and cocaine (Lev-Ran et al., 2013). When focusing only on

substance dependence (without abuse), the results of the present research showed that males had

higher prevalence rates for alcohol dependence, hallucinogen dependence, and cannabis

dependence while females had higher prevalence for amphetamine dependence (Lev-Ran et al.,

2013).

Race/Ethnicity. In regards to race/ethnic differences and their relation to SUD’s, the

2012 NSDUH found that the highest rate for substance abuse or dependence for the 12 and older

population was among American Indians or Alaska Natives (21.8%). This was followed by

individuals with two or more races (10.1%), by blacks (8.9%), Hispanics (8.8%), and whites

(8.7%). In the lower end of the spectrum, the survey results showed that Native Hawaiians had a

rate of 5.4% while Asians had the lowest rate of substance abuse or dependence in the United


States with 3.2% in 2012. As far as alcohol users 12 and older for 2012, the NSDUH results

demonstrated that whites had the highest rate of current use of alcohol with 57.4%, individuals

reporting two or more races had a rate of 51.9%, blacks had a rate of 43.2%, Hispanics had a rate

of 41.8%, American Indians or Alaska Natives had a rate of 41.7%, and Asians had a rate of

alcohol use of 36.9%. For illicit drug users 12 and older in 2012, the NSDUH results showed

individuals reporting two or more races had the highest rate of current illicit drug use with a rate

of 14.8%, American Indians or Alaska Natives had a rate of 12.7%, blacks had a rate of 11.3%,

whites had a rate of 9.2%, Hispanics had a rate of 8.3%, Native Hawaiians had a rate of 7.8%,

and Asians had a rate of 3.7% of current illicit drug use in 2012.

Criminal justice population. Another specific population of interest in relation to SUD

is the criminal justice population. About half of all prisoners meet diagnostic criteria for

substance abuse or dependence. This fact is also coupled with the estimate that only 15% to 20%

of those in this population who need SUD treatment receive it (Chandler, Fletcher, & Volkow,

2009). The 2012 NSDUH also reports a significant difference in substance abuse or dependence

between the criminal justice population and the general population. Adults 18 years of age and

older who were in parole, supervised release, or probation had an estimated 4 times higher

probability of meeting criteria for substance abuse or dependence than the general population

(SAMHSA, 2013). There is also a strong relationship between drug use and crime with the

probability of offending being 3 to 4 times higher for drug users than for non-users (Bennett,

Holloway, & Farrington, 2008). When differentiating among types of drugs, it was found that

this probability of offending was highest for users of crack than for other drugs (Bennett et al.,

2008).


Co-occurring disorders. A very relevant topic related to SUD’s is that of co-occurring

disorders (COD)—a SUD that co-occurs with another mental disorder. The prevalence of COD

is significant and it requires much attention. Results from the National Epidemiologic Survey on

Alcohol and Related Conditions (NESARC) suggest that co-occurring psychiatric disorders, such

as mood and anxiety disorders can increase the risk for SUD (Conway, Compton, Stinson, &

Grant, 2006). Specifically, data has shown that individuals with mood or anxiety disorders have

about twice the likelihood to also have SUD’s as compared to the general population, while

individuals with SUD’s are also about two times more probable to have mood or anxiety

disorders. There is also gender differentiation, as antisocial personality disorder is more common

in males, while major depression, post-traumatic stress disorder, and other anxiety disorders are

more common in females (NIDA, 2010).

According to the 2012 NSDUH, 8.4 million adults 18 and older with any mental illness

(AMI) during the past year in the United States met diagnostic criteria for substance abuse and

dependence (19.2% of the 43.7 million individuals with AMI). In contrast, about 6.4% of adults

without AMI met criteria for substance abuse and dependence. These adults with COD were

twice as likely to use illicit drugs as were adults without AMI. This relationship was similar

among different types of illicit drugs. When differentiating AMI into categories of severity (such

as serious mental illness, moderate mental illness, and low mental illness), the data showed that

the higher the severity of the mental illness, the higher was the rate of illicit drug use. For

example, the rate of illicit drug use among individuals with serious mental illness was 32.1%

compared to 13.2% amongst those without AMI. Adults 18 and older with AMI also had higher

rates of binge drinking in the past month (27.6%) and heavy alcohol use in the past month


(9.2%) than individuals without AMI (23.9% for binge drinking and 6.6% for heavy alcohol use)

(SAMHSA, 2013).

In regards to meeting criteria for substance abuse and dependence, there was also a direct

relationship of higher rates amongst individuals with serious mental illness (27.3%), followed by

individuals with moderate mental illness (18.9%), and individuals with low mental illness

(15.9%); all these compares with 6.4% rate of meeting the above mentioned criteria amongst

individuals without AMI (SAMHSA, 2013). When categorizing age groups, the rate of

individuals with AMI who met criteria for SUD was highest among those age 18 to 25 (34.5%),

and declining in older age categories. The data points to the necessity of more specific research

of COD among the age group of 18 to 25 considering the higher rates of prevalence in this group

(Sheidow, McCart, Zajac, Davis, 2012).

Mood and anxiety disorders. Mood disorders and anxiety disorders are frequent when

looking at specific mental disorders that are most commonly associated with SUD (NIDA,

2010). It is estimated that about fifty percent of those receiving treatment for an alcohol use

disorder (AUD) also experience a depressive or anxiety disorder (Hobbs, Kushner, Lee, Reardon,

& Maurer, 2011). Within the mood disorders, depression has been found to be associated with

alcohol and/or drug use (Conner, Pinquart, & Gamble, 2009). The 2012 NSDUH found that

individuals with past year major depressive episode (MDE) were almost two times more likely to

use illicit drugs than those without a MDE (28.5% vs. 14.8%). As far as a comparison with

alcohol use, it was found that individuals 18 and older with past year MDE also had higher rates

of heavy alcohol use versus those without MDE (10.0% vs. 6.9%). There is also a significant

difference of individuals with past year MDE who met criteria for substance abuse or

dependence versus those individuals without past year MDE (20.8% vs. 7.9%). In regards to


youth between the ages of 12 and 17 who had last year MDE, their rates of illicit drug use were

also higher than those without MDE (34.0% vs. 16.3%) (NSDUH, 2012).

In relation to anxiety disorders co-occurring with SUD, there are commonly found among

those with alcohol use disorders (AUD) (Smith & Randall, 2012). In a review of prevalence

surveys conducted by Smith and Randall (2012), it was found that both anxiety disorders and

AUD co-occurred between two and three times as frequently as would be expected by mere

chance. Also as part of these results, a stronger association was found between anxiety disorders

and alcohol dependence versus alcohol abuse. This finding was also supported in a prevalence

study by Grant and colleagues (2004) in which anxiety disorders were more strongly related to

alcohol and/or drug dependence than to alcohol and/or drug abuse. In the same prevalence study

(Grant et al., 2004), it was found that out all those with any SUD, almost 18% had at least one

anxiety disorder in the past year.

Post-traumatic Stress Disorder (PTSD). Another relevant mental disorder commonly

co-occurring with SUD is PTSD. Results of prevalence of PTSD among those with a SUD vary

greatly and are difficult to compare due to the diverse results arising from the use of different

measuring instruments (Gielen, Havermans, Tekelenburg, & Jansen, 2012). In a comparison

study (Gielen et al., 2012), PTSD prevalence was measured from a SUD sample and with a

comparison control group, utilizing the same instrument for both. The results of this comparison

of prevalence data were 36.6% testing positive for PTSD among the SUD sample versus 10.2%

in the control group. The results from the SUD group are comparable with prior research, but the

results from the control group are higher than prior results which are below 4% (Gielen et al.,

2012). In a cross-sectional and multi-center investigation from SUD populations, higher rates of

PTSD were found among those with drug (other than alcohol) dependence (30%) and combined


alcohol and drug dependence (34%) when compared to those with only alcohol dependence

(16%) (Driessen et al., 2008).

Suicides and mortality. There has also been a known association between SUD and

suicides which include alcohol and other drugs (Wilcox, Conner, & Caine, 2004). In relation to

completed suicides, substance related disorders were commonly found in these individuals

(Yoshimasu, Kiyohara, & Miyashita, 2008). In the United States, over 32,000 people a year die

due to suicide while men have 4 times higher probability to die from suicide than females

(CSAT, 2008). It is also estimated that of all those that die from suicide, about 25% also have

alcohol related disorders. Including alcohol and other drug disorders, the risk of suicide for these

individuals is more than 6 times the average risk for suicide (CSAT, 2008). In relation to suicide

attempts, SAMHSA’s Drug Abuse Warning Network reports that almost 33% of drug related

visits to emergency departments tested positive for alcohol and 19% tested positive for other

drugs (CSAT, 2008).

Societal Impact

Deaths related to alcohol and other drugs for other reasons are also a burden to our

society. Around the world, there are about 3.3 million deaths per year, equaling 5.9% of all

deaths, attributed to alcohol related issues (WHO, 2014). There are notable gender differences in

this regard. For example, 7.6% of deaths in males were attributed to alcohol while 4% of deaths

in females were attributed to alcohol. For males 15-59 years of age, alcohol represents the

leading risk factor for death (WHO, 2014). As far as other drugs are concerned, it was estimated

that there were 211,000 deaths in the world due to drug related issues (UNODC, 2013). Most of

these drug related deaths occurred among the younger population and opioids were the most

frequently related substance group in these deaths (UNODC, 2013). Adding deaths related to


both alcohol and other drugs, more than 3.5 million people per year lose their lives around the

world.

SUD prevalence data specific to the country of Nicaragua is not kept up to date as much

as it is for the United States. For example, according the World Health Organization, Nicaragua

had a 5.49% last year prevalence rate for SUD in 2004 for individuals age 15 and older. This was

divided as 4.41% last year prevalence for alcohol use disorder and 1.08% last year prevalence for

other drug use disorders. These prevalence rates were also both higher for men than for women.

In the case of alcohol use disorders, the last year prevalence rate for men was more than five

times larger than for women. In the case of other drug use disorders, the last year prevalence rate

was three times larger for men than for women. These prevalence data results in Nicaragua were

smaller than those shown for the United State population in the 2012 NSDUH.

Development of the Disorder

There are diverse risk factors that can lead to the development of AUD (Gilbertson,

Prather, & Nixon, 2008). These factors include gender, family, psychiatric disorders, and age of

onset among others. In regards to gender, data has shown that females progress faster than males

going from regular use to treatment of the disorder. This could be due to higher costs endured by

woman and to physiological reasons that result in women acquiring higher blood alcohol levels

than men after drinking the same volume (Gilbertson et al., 2008). Family history also plays a

role in the development of AUD. It is estimated that 40% to 60% of the risk of developing AUD

can be attributed to genetics. Children of alcoholic parents are about four times more likely to

develop alcoholism than children from non-alcoholic parents (Gilbertson et al., 2008).

Next, psychiatric disorders are another risk factor, as described in the above section of co-

occurring disorders. These risk factors can include mood disorders, anxiety disorders, and


attention deficit disorder with hyper-activity (NIDA, 2010). Following, and in relation to age of

onset, it has been shown that those who drink before age fifteen have a significantly higher

probability to develop an AUD (Gilbertson et al., 2008). The rate of alcohol dependence is far

greater for those who drink at fourteen years of age and before as compared to those who start

drinking after age nineteen (Chorlian et al., 2013). Related to this data are results from other

studies centered on the neurobiological development of child and adolescent brains. These data

shows an increased activity in the mesolimbic system that occurs at the same time as the slower

developing prefrontal cortex, a combination which can lead to risk taking activities (Chorlian et

al., 2013).

The role of stress early in life also deserves mention in the development of a SUD. It has

been found in a review that experiencing early life stress in the form of maltreatment or other

stressful events can be associated with early problem drinking and substance dependence in the

early adult years (Enoch, 2010). In this same review of studies, it was found from NESARC data

that those with at least two stressful life events experienced during childhood had significantly

higher risk of developing an alcohol disorder. It was also found in another study that men with

more experiences of maltreatment had three times more risk of an alcohol disorder, while women

with more experiences of maltreatment had seven times more risk of an alcohol disorder (Enoch,

2010).

In a study with a sample from an Australian population, it was concluded that those that

reported age of onset of cannabis use before 15 years of age had mothers that were younger, with

lower levels of education, and were more probable to be without a partner when the child was

born (Hayatbakhsh, Williams, Bor, & Najman, 2013). In this same study, it was also found that

mothers of these early onset cannabis users had higher rates of drinking alcohol and smoking


cigarettes, while also being more likely to be depressed or anxious in the early years of the

child’s life (Hayatbakhsh et al., 2013).

Negative Affect / Emotions

Experiencing negative affect and/or emotions can also be a characteristic of individuals

with a SUD. As stated previously, co-occurring psychiatric disorders are common when dealing

with individuals with SUD. These, in turn, can have a negative effect in the emotional state of

the individuals. Also, for those without co-occurring psychiatric disorders, or for those with SUD

in general, it is commonly accepted that these individuals can have difficulty in regulating and

coping with negative emotions (Meehan et al., 1996). Kolb and Volkow (2010) describe drug

addiction as being characterized by the “emergence of a negative emotional state” that is

prevented if, and when, the drug is consumed by an individual. Shame plays a central role in

these negative emotions for people with SUD. Individuals in recovery from drug addiction

scored higher on measurements of shame, depression, and maladaptive guilt (Meehan et al.,

1996). The issue of shame was also found in another study to be linked to problematic drug and

alcohol use. Shame in this sense is related to negative emotions directed to the self (Dearing,

Stuewig, & Tangney, 2005). It is also known that shame is more common in those with a

substance use problem when compared to those who do not have a substance use problem

(Luoma, Kohlenberg, Hayes, & Fletcher, 2012).

Evidence Based Practices

The field of addiction treatment has evolved into a more widely accepted support for

evidence based practices (EBP), as manifested by extensive research on psychosocial practices

considered EBP such as motivational interviewing (MI), cognitive behavioral therapy (CBT),

and contingency management (CM), as well as readily available manualized treatment models


(Carroll, 2012). Despite this evolution in the field, there is still much room for improvement. For

instance, many clinicians state their use of EBP, but when this is verified by revisions of video

tape of clinical encounters, it has been found that not much use of the EBP is taken place. “There

is growing consensus that monitoring, supervision and feedback are needed until the clinician

can demonstrate adequate fidelity and skill, as randomized training studies of clinicians have

highlighted that workshops are necessary, but clearly insufficient in teaching clinicians to

implement evidence-based treatments effectively” (Carroll, 2012, p. 1031).

Another important clinical aspect in regards to the advancement of EBP is the shift from

a highly confrontational style of counseling towards a more respectful and ethical way to treat

the client through a new view of addiction itself and the people that suffer from it. Confrontation

has played an important role in treatment history. A premise behind the use of confrontation is

that people with SUD are in such strong denial that they need to be broken down to then built

them back up (White & Miller, 2007). The use of confrontation seems to lack support of

evidence for its use as it relies heavily on counselor’s own experience in recovery, for those that

it applies to, and intuition (Polcin, 2003). In another study (Miller, Benefield, & Tonigan, 1993)

found better outcomes for people with SUD who were counseled by professionals with an

empathic and supportive style versus a more confrontational style. Alternatives to confrontation

are now in place in the form of EBP such as MI, which has much similarity in regards to the

view of the client to the person centered approach of Carl Rogers (White & Miller. 2007).

Project Match

One landmark study in the field of SUD treatment has been Project Match (PM), the

largest multi-site randomized controlled clinical trial regarding alcohol treatment. PM was based

on the hypothesis that it could be proven beneficial to match client characteristics with specific


treatment modality (Project Match Research Group, 1997). Basically, the study consisted of two

populations, an outpatient population (n=952) and an aftercare population (n=774), at different

sites and being randomly assigned to one of three different treatment modalities: Motivational

Enhancement Therapy (MET), Cognitive Behavioral Therapy (CBT), and Twelve Step

Facilitation (TSF). The central outcome variables being measured in regards to alcohol

consumption were (a) Percent Days Abstinent (PDA) to measure drinking frequency and (b)

Drinks per Drinking Day (DDD) to measure drinking severity. The randomly assigned clients

were also measured on different client characteristics in the attempt to find matches between

these, treatment modality, and drinking outcome (Project Match Research Group, 1997).

The results of the one year follow up in PM demonstrated that there was insignificant

support that matching client characteristics to treatment modality would produce differentially

beneficial drinking outcomes. At the same time, all three approaches produced significant

reductions in drinking frequency and severity at 12 month post treatment follow up. Important to

note is the following: Clients without severe psychopathology placed in TSF had better outcomes

that those in placed in CBT. Clients with higher meaning seeking fared better with TSF than with

the other treatment alternatives. Also, clients with lower motivation did better in MET than in

CBT by the end of the one year post treatment follow up. Finally, clients in TSF showed

improved outcomes if abstinence was looked for and not just reduction in drinking (Project

Match Research Group, 1997).

At the three year follow up, one significant match was that clients high in anger fared

better in MET than in the other two approaches. In regards to drinking outcomes, at this follow

up, almost 30% of subjects remained abstinent and those who drank significantly reduced their

drinking (Project Match Research Group, 1998). There were no statistically significant


difference overall in the three approaches, although TSF continued showing a slight advantage

when abstinence was the goal (Project Match Research Group, 1998). Currently, all three of

these therapeutic approaches utilized for SUD are considered EBP and all form part of

SAMHSA’s National Registry of Evidence Based Practices and Programs (NREPP).

Other Psychotherapeutic Comparisons

In relation to other comparisons of psychosocial approaches for SUD, Imel, Wampold,

Miller, and Fleming (2008) conducted a meta-analysis to examine outcome differences of

diverse therapeutic alternatives, specifically for alcohol use disorders. In their meta-analysis, the

authors also focused on “researcher allegiance” as a possible explanation of conflicting results in

outcomes. In this sense, “researcher allegiance” reflected biases that can exist in relation to

therapist preference to particular approaches. As a result of their literature search filter, this study

included 30 different studies, with 3,503 patients, in which two psychotherapies for alcohol use

disorders were compared. The results of the study were that there was no difference in one

therapy being inferior to any another, as effect sizes were distributed around zero (Imel et al.,

2008). These findings support findings in Project Match as well as other comparative findings in

the field of psychotherapy.

Of significant importance was the fact that the authors found evidence of an effect of

allegiance. As allegiance between a therapist/researcher increased for a particular type of

therapy, the differences between therapies also increased in favor of that which the

therapist/researcher preferred (Imel et al., 2008). Another review related to alcohol use disorders

conducted by Martin and Rehm (2012), also supported the view that when EBPs, such as MI,

CBT, or Brief Interventions (BI) were compared to one another, their effectiveness was similar.

The authors also mentioned an interesting point in that TSF is warranted more


consideration based on Project Match results as well as the study conducted by the US

Department of Veterans Affairs which compared TSF and CBT in randomized trials and in

which TSF was comparable to CBT. More research support has been dedicated to other

approaches such as MET, CBT, BI, Community Reinforcement Approach (CRA), and others

(Martin & Rehm, 2012). A Cochrane Collaboration review (Ferri, Amato, & Davoli, 2009) on

Alcoholics Anonymous (AA) and other 12 Step approaches also did not demonstrate their

effectiveness over other approaches in the reduction of alcohol use or achievement of abstinence.

In a review as such, it is important to differentiate clearly between AA and TSF, the latter being

a professionally led intervention (an EBP) and the former a subjective experience that can differ

greatly from context to context. Research on AA or 12 Steps should be performed in a

differentiated manner than research on TSF.

Specifically in the realm of treatment of SUDs other than alcohol, Dutra and colleagues

(2008) conducted a meta-analysis of diverse psychosocial treatments for substances such as

cannabis, opiates, cocaine, and polysubstance abuse and dependence. In all, there were 34 studies

including 2,340 patients. The interventions, all EBP, that were included in the analysis were

Contingency Management (CM), Cognitive Behavioral Therapy (CBT), Relapse Prevention

(RP), and other approaches which combined CM with CBT. The results of the meta-analysis

showed that effect sizes (using Cohen’s standards) were in the moderate range, from low-

moderate to high-moderate in dependence to the SUD and approach utilized. As for specific

SUD, the effect sizes were larger for cannabis use and smaller for polysubstance use. For the

approach utilized, CM showed the largest effects. A point of relevance is that all patients across

all psychosocial approaches completed treatment in a more significant proportion than the

control group with which they were compared. Also in regards to abstinence, the meta-analysis


showed that about 31% of patients achieved clinically significant abstinence versus only 13% in

control groups (Dutra et al., 2008).

Cognitive Behavior Therapy

In relation to specific EBP and their comparison in meta-analysis with control groups,

Magill and Ray (2009) conducted a study of Cognitive Behavioral Therapy (CBT) for alcohol

use disorder and illicit drug use disorder in which 53 controlled trails were included with 9,308

adult individuals. In this case Hedge’s g was utilized to measure effect size instead of Cohen’s d.

Resulting from the analysis, CBT demonstrated a small but statistically significant effect over

comparisons. As illustration of this effect size, the authors also use the Index U3 to transform

effect size to “success percentage”. This value in this meta-analysis shows that 58% of

individuals in the CBT group did better than those in control groups. When looking at treating

specific SUDs, CBT fared better when treating cannabis than other drugs, showing a moderate

effect size in this population. Also of relevance is that CBT proved more effective when

combined with other psychosocial approaches versus CBT as stand-alone treatment or CBT with

pharmacotherapy. In regards to the duration of CBT effects, it was found that these diminished

with time at 6 month, 9 month and 12 month follow ups. As for client specific characteristics,

gender seemed to play a role in the sense that women appear to benefit more from CBT than

men. Finally, there was no difference found in the format, group counseling or individual

counseling, in which CBT was provided. This leads to the assumption that a group format

provides for a cost benefit advantage (Magill & Ray, 2009).

Motivational Interviewing

Now turning to another specific EBP, a review on Motivational Interviewing (MI) is

considered. First, there is the review by Lundahl, Kunz, Brownell, Tollefson, & Burke (2010) of


four meta-analyses of MI. In these studies many behaviors were addressed, but for the present

purpose the focus will be on MI as it relates to substance use disorders. Overall, MI proved more

effective than no treatment (between 10% and 20%) and comparable to other treatments. This

seems true for MI on alcohol and other drugs. One observation in relation to its comparability of

effectiveness is that MI achieves this with less duration of treatment (Lundahl et al., 2010). As

for the duration of positive effects, the authors estimate that these can last up to one year, similar

duration as meta-analysis dealing with CBT. In relation to format of delivery, it was shown that

MI works positively as a pre-treatment to be followed by another approach, whereas the MI

manual (with feedback) MET can work better as a stand-alone treatment (Lundahl et al., 2010).

Specifically in regards to alcohol use, Vasilaki, Hosier, & Cox (2006) in their meta-analysis

showed that MI worked more effectively with young adults in the heavy to low moderate

drinking problems versus an older and more severe drinking issue. In relation to drug use, it was

found that MI was better than no treatment at all and similar to treatment as usual (Smedslund et

al., 2011). Hettema, Steele, and Miller (2005) found that effect sizes were larger for ethnic

minorities, specifically for Native Americans and also that MI worked best without a treatment

manual giving more freedom to the counselor to focus on the therapeutic alliance. One important

factor is the consideration of MI within the context of SUD treatment history. “It is perhaps no

accident that MI arose within the addiction field at a time when harsh, confrontational, even

abusive treatment practices were acceptable, if not normative” (White & Miller, 2007). It is an

approach that fosters respect, ethical and professional interchange in a historically

confrontational arena where there is risk for harm.

Psychopharmacology


There are also medications that have shown positive effects in the treatment of SUD and

which have evidence support. Specifically, positive effects have been shown for alcohol use

outcomes when combining psychosocial interventions with certain medications (Jonas et al,

2014). In a meta-analysis by Jonas and colleagues (2014), it was found that acamprosate and oral

naltrexone had evidence supporting their use for improving alcohol use outcomes. When

compared to one another in the same meta-analysis, no differences were found between both

medications. Another well-known medication used in the field, disulfiram, did not show relevant

improvements in drinking outcomes. In relation to medications utilized off-label, moderate

benefits were found with nalmefene and topiramate (Jonas et al., 2014). In another meta-

analysis, it was found that acamprosate had a higher efficacy in the promotion of abstinence

while naltrexone had a higher efficacy in the reduction of cravings and of heavy drinking

(Maisel, Blodgett, Wilbourne, Humphreys, & Finney, 2013). It was also found in the same study,

that longer abstinence periods before treatment with both acamprosate and naltrexone were

associated with more positive effects.

Other medications have also shown evidence in the treatment of opioid use disorders.

Methadone maintenance treatment (MMT) has been shown to reduce opioid abuse, reduce

criminality, and increase retention in treatment (Johansson, Berglund, & Lindgren, 2007).

Despite MMT success rates, there are many obstacles to a more widely used acceptance, such as

stigma associated with it, the subjective effects of methadone, and the structure of treatment

(Barnett, Rodgers, & Bloch, 2001). Buprenorphine is an alternative to MMT that provides some

advantages, such as less physical dependence and less probability of an overdose (Barnett et al.,

2001) and it is used as a detoxification method for maintenance or for opioid withdrawal.

Another medication used for treating opioid use disorders is naltrexone which acts as a blocking


agent. In another meta-analysis by Johansson, Berglund, and Lindgren (2006), naltrexone for

opioid use disorders was found effective if retention in treatment was high. In the same study, it

was also found that contingency management was well suited for increasing retention in opioid

users in treatment.

Self-Help or Mutual-Help

The self-help movement, called mutual-help movement by others, has historically been a

major alternative to recovery from SUD. Amongst these self-help options, Alcoholics

Anonymous (AA) is the most commonly known. AA was founded in 1935 by two alcoholic

individuals who wanted to help others in their same situation. Nowadays, AA is a self-help

fellowship, organized internationally, and that offers support through a model of abstinence and

help among recovering alcoholics (Ferri et al., 2009). According to estimates of AA’s General

Service Office, there are currently more than 2.1 million members worldwide who meet in more

than 115,000 groups in 170 countries around the world (AA General Service Office, 2014). Also,

principles found in AA have been used in professionally led treatment, starting with what is

known as the Minnesota Model (White, 1998). AA is based on its 12 Step program of recovery

(see below for details on 12 Steps).

ACurrently, about 58% of those entering SUD treatment had attended AA meetings

(Magura, 2007), showing a relationship between formal treatment and self-help groups. In

another study, it was shown that attending both AA and treatment improves abstinence, resulting

in higher rates of abstinence for those who attended both formal treatment and 12 Step programs

versus those who attended only one or the other (Fiorentine & Hillhouse, 2000). As far as

outcomes in the long run, AA involvement following treatment also resulted in better outcomes

16 years after (Moos & Moos, 2006). Another 12 step alternative is provided by Narcotics


Anonymous (NA), a fellowship that also centers on recovery from drugs, alcohol included. 12

step programs might not be a right match for everyone who seeks recovery from SUD, but they

do offer an alternative with a long standing history for many.

The 12 Steps are a spiritual program with specific practices and principles which attempt

to affect cognitive and emotional aspects of the individual, as well as attempting to change

behavior through reinforcements (DiClemente, 1993). As other spiritual programs, one of the

fundamental objectives is to obtain self-knowledge and inner peace (Magura, 2007) as a way to

achieve abstinence and sustain it. The 12 Steps and its principles provide the framework through

which to achieve this. The application in one’s life of the 12 Steps is known by AA members as

“working the steps”. The 12 steps of AA are:

1. We admitted we were powerless over alcohol—that our lives had become unmanageable.

2. Came to believe that a Power greater than ourselves could restore us to sanity.

3. Made a decision to turn our will and our lives over to the care of God as we understood Him.

4. Made a searching and fearless moral inventory of ourselves.

5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.

6. Were entirely ready to have God remove all these defects of character.

7. Humbly asked Him to remove our shortcomings.

8. Made a list of all persons we had harmed and became willing to make amends to them all.

9. Made direct amends to such people wherever possible, except when to do so would injure

them or others.

10. Continued to take personal inventory and when we were wrong promptly admitted it.

11. Sought through prayer and meditation to improve our conscious contact with God, as we

understood Him, praying only for knowledge of His will for us and the power to carry that out.


12. Having had a spiritual awakening as the result of these steps, we tried to carry this message

to alcoholics, and to practice these principles in all our affairs.

Note. Narcotics Anonymous (NA) substitutes the term “addiction” and “addicts” for “alcohol”

and “alcoholics.”

There are also many principles that are associated with the work of these steps in many

local AA groups and literature material. These include honesty, hope, faith, courage, integrity,

willingness, humility, brotherly love, justice, perseverance, spirituality, and service. Also, NA

publishes a book called the NA Step Working Guide (NA World Service Office, 1998) with

information specific to all twelve steps. Each step is devoted a chapter and in each chapter there

is a section called “Spiritual Principles” which describes principles that are specific to each step.

For example, in step one, the principles described are honesty, open-mindedness, willingness,

humility, and acceptance (NA WSO, 1998). It is suggested that members practice these

principles in their daily lives.

Long Term Recovery

Addiction has been defined as chronic, relapsing disease (NIDA, 2010), yet despite this,

there is not sufficient research on longer term recovery (Laudet, Savage, & Mahmood, 2002).

Much of the research focuses on short-term outcomes and the effects of modalities up to this

time frame (Laudet et al., 2002). This results in a not congruent perspective of addiction

treatment in which an acute model of care is supposed to resolve a chronic condition. Now there

has been a shift in this direction towards a model of care emphasizing sustained recovery

(Groshkova, Best, & White, 2013). This requires further research in the areas of long term

recovery. In a preliminary attempt to research addiction recovery (Laudet et al., 2002), it was

found that community and social resources were important in maintaining recovery, as well as


motivational factors, such as the reminder of the negative consequences of using drugs. In a later

survey of individuals recovering from SUD, Laudet, Morgen, and White (2006) found that levels

of stress decrease and life satisfaction increases as recovery progresses. Also in the same survey,

it was found that social supports, life meaning, spirituality and religiousness, and affiliation to 12

Step fellowships serve as buffers for stress, therefore increasing life satisfaction through these

means.

In the first ever national survey of individuals in recovery from SUD and organized by

the organization “Faces and Voices of Recovery”, it was estimated that over 23.5 million

Americans were people in recovery (Laudet, 2013). The survey results showed the burden of

addiction in relation to the domains of finance, legal, employment, physical health, mental

health, and function of family, but it also showed the other side of the coin through the benefit of

recovery to the individual, the family, and society at large. Specific benefits of recovery were

found in all areas of an individual’s life when compared to their time of drug use. Examples of

these findings included that people in recovery paid more taxes than while using drugs, their

planning for the future increased, participation in family activities increased, untreated mental

health issues decreased, involvement in illicit activities and those related to the justice system

decreased, use of emergency rooms decreased, employment increased, those who continue their

education increased, and involvement in domestic violence decreased (Laudet, 2013). More

research in the area of recovery resources and benefits seems warranted.

Positive Psychology (PP)

Positive Psychology (PP) is a field that represents a supplementary perspective to

traditional psychology’s concentration on psychopathology and human deficit. This

supplementary perspective directs its focus to the positive aspects of human experience above


and beyond the removal of suffering, psychopathology, or deficit. In this sense, PP does not seek

to substitute psychology as usual, but to provide a more complete vision of human beings and

their experience (Seligman, Steen, Park, & Peterson, 2005). Specifically, PP initiated with a

concentration on the improvement of quality of life and well-being through the areas of positive

subjective experience, positive traits of character, and positive institutions (Seligman &

Csikszentmihalyi, 2000). These three areas become a way to which achieve happiness and

provide for a better way to, not only understand these positive aspects, but also to assess and

measure them. They were also categorized as the pleasant life (positive subjective experience),

the engaged life (positive traits of character), and the meaningful life (positive institutions)

(Duckworth, Steen, & Seligman, 2005).

One of the basic assumptions of PP lies in the idea that the positive is not just the absence

of the negative. This means that there are some positive experiences or traits that are independent

of negative experiences or traits (Duckworth et al., 2005). This translates into the knowledge that

alleviating the deficit is not enough for well-being. For example, well-being is more than just the

absence of anger, anxiety, or depression. It is all which makes life worth living (Duckworth et

al., 2005).

From the above described assumption, it follows that the interventions for achieving well-

being are different, and work through different processes, than those designed to relieve

psychopathology. Seligman and colleagues (2005) designed five PP exercises and one placebo

control. Each of these exercises was to be completed in one week and was delivered through the

Internet. One exercise dealt with gratitude, two dealt with increasing awareness of what is most

positive about oneself, and two dealt with the identification of character strengths. The placebo

control exercise asked participants to journal about early life memories each day for a week.


Participants were measured on depression and happiness for six months. The five active PP

exercises were (a) gratitude visit, (b) three good things in life, (c) you at your best, (d) using

signature strengths in new way, and (e) identifying signature strengths. The exercise on “three

good things in life” and the exercise on “using signature strength in a new way” proved to

increase happiness and decrease depression for the six months of the study. The gratitude visit

exercise resulted in large positive outcomes for one month after intervention. Also, the gratitude

visit intervention resulted in the largest increase in happiness and the largest decrease in

depression at post-test out all other interventions and placebo. The other two exercises, along

with the placebo control exercise, resulted in short-lived, but positive, changes (Seligman et al.,

2005). See Table 3 for description of these exercises.

Table 3

Description of Positive Psychology Interventions (Seligman et al., 2005)

Name of Intervention Description Results

Gratitude visit

- Write a gratitude letter to a person who had been kind but had never been properly thanked

- Contact the person and make an appointment to visit

- Visit the person and read the letter

- Largest positive outcomes in happiness and depression at post-test and 1 month after

Three good things in life

- Write down three things that went well each day for a week

- Also write down the cause of each thing that went well

- Large positive outcomes in happiness and depression 6 months after

- Ranked No. 1 out of all interventions and placebo at 6 months after in increasing happiness and lowering depression

You at your best - Write about a time the person was at their best

- Identify the strengths displayed in

- Positive outcomes in both happiness and depression that were short-lived (at post-test and 1 week after)


the story

- Review the story each day for a week and reflect on the identified strengths

Using signature strengths in a new way

- Take the VIA survey on character strengths

- Receive individualized feedback on their top five strengths (signature strengths)

- Use one of the top five strengths in a new and different way each day for one week

- Large positive outcomes in happiness and depression 6 months after

- Ranked No. 2 out of all interventions and placebo at 6 months after in increasing happiness and lowering depression

Identifying signature strengths

- Take the VIA survey on character strengths

- Identify their top five strengths (signature strengths)

- Use signature strengths more often for a week

- Positive outcomes in both happiness and depression that were short-lived (at post-test and 1 week after)

There are two meta-analyses which are noteworthy in the field of PP. The first was

realized by Sin and Lyubomirsky (2009) and in which 51 interventions (N = 4,266) were

included in the aim at finding out if PP interventions increased well-being and decreased

depression. The evidence from the results of this meta-analysis was that PP interventions were

indeed more effective than control groups in both tasks. The resulting effect sizes were medium

for both the increase in well-being (mean r = 0.29) and decrease in depression (mean r = 0.31).

The study also resulted in moderating factors of the effectiveness of the interventions that are

relevant to clinical practice and implementation. First, individuals that were depresses exhibited

a higher increase in well-being versus those that were not depressed. Second, those who self-

selected their treatment received more benefits from treatment. Third, older individuals benefited

more from the interventions than younger individuals. Fourth, the format of delivery was also


relevant, indicating that individual format was more effective, followed by interventions

provided in a group format, and lastly those interventions which the individuals administered

themselves. Finally, other relevant findings included are the importance of applying high effort

in the practice of the interventions, practicing the intervention for longer than asked to, practice

of multiple PP interventions, and considerations of cultural influences on the effectiveness of the

interventions (Sin & Lyubomirsky, 2009).

The second meta-analysis on PP interventions was conducted by Bolier and colleagues

(2013) and it included 40 different articles (N = 6,139). The outcomes being measured in this

study were subjective well-being, psychological well-being, and depression. In this sense,

subjective well-being refers to both affective and cognitive reactions to one’s own life, while

psychological well-being refers to individual functioning at an optimal level. The study

concluded that PP interventions can be effective in increasing both subjective well-being (mean

= 0.34) and psychological well-being (mean = 0.20), and decrease depression (mean = 0.23). The

effect sizes were in the small to moderate range for all outcome measures, relatively lower than

those in the Sin and Lyubomirsky meta-analysis (2009) but still confirming of the positive

effectiveness of PP interventions. Moderating factors in the increased effectiveness of the

interventions included longer interventions, delivered in an individual format, delivered to

individuals with specific psychosocial conditions, and when delivered to those who were referred

by a health care professional or by a hospital (Bolier et al., 2013).

Seligman is considered by many as the father of PP. His initial theory of happiness

(authentic happiness) classified the paths to happiness into three alternatives: positive emotion

(the pleasant life), engagement (the engaged life), and meaning (the meaningful life) (Duckworth

et al., 2005). According to this perspective, the goal of PP is happiness and the main


measurement is life satisfaction. In this regard, Seligman (2011) later described that the

measurement of life satisfaction was influenced heavily by the individual’s mood, therefore

coming to believe that a more complete perspective was needed. As a response to this, Seligman

developed and proposed the theory of well-being and its measurement of human flourishing.

The five components of well-being then become positive emotion, engagement, positive

relationships, meaning, and accomplishment (PERMA). The first element of positive emotion is

maintained from Seligman’s original authentic happiness theory. The second element,

engagement, is also maintained. Engagement is related with the concept of flow; a state in which

the individual is absorbed in an activity and time seems to stop for the person. The third element

is that of positive relationships. The fourth element in well-being theory is meaning; in this

sense, serving something that is bigger than the self. The fifth and final element is

accomplishment; mastery, competence, or achievement. Each of these five elements contributes

to well-being, are pursued for their own sake, and are defined and measured independent of each

other (Seligman, 2011).

Another relevant topic in regards to PP is that of character strengths. In 2004 Seligman

and colleague Christopher Petersen published the book “Character Strengths and Virtues: A

Handbook and Classification”. This volume was intended to be to PP what the DSM has been for

psychopathology (Seligman et al., 2005). The character strengths are considered to exist in

people in varying degrees and not as present or lacking. There are six main virtues that were

found to be common around the world. These are wisdom, courage, humanity, justice,

temperance, and transcendence. Then, twenty four character strengths were identified as

belonging under one of the six virtues (Seligman et al., 2005), as described below in Table 4:

Table 4


Classification of 6 Virtues and 24 Character Strengths (Peterson & Seligman, 2004)

Virtue and strength Definition

1. Wisdom Cognitive strengths that entail the acquisition and use of

knowledge

Creativity Thinking of novel and productive ways to do things

Curiosity Taking an interest in all of ongoing experience

Open-mindedness Thinking things through and examining them from all

sides

Love of learning Mastering new skills, topics, and bodies of knowledge

Perspective Being able to provide wise counsel to others

2. Courage Emotional strengths that involve the exercise of will to

accomplish goals in the face of opposition, external or internal

Authenticity Speaking the truth and presenting oneself in a genuine

way

Bravery Not shrinking from threat, challenge, difficulty, or pain

Persistence Finishing what one starts

Zest Approaching life with excitement and energy

3. Humanity Interpersonal strengths that involve “tending and befriending”

others

Kindness Doing favors and good deeds for others

Love Valuing close relations with others

Social intelligence Being aware of the motives and feelings of self and others

4. Justice Civic strengths that underlie healthy community life

Fairness Treating all people the same according to notions of


fairness and justice

Leadership Organizing group activities and seeing that they happen

Teamwork Working well as member of a group or team

5. Temperance Strengths that protect against excess

Forgiveness Forgiving those who have done wrong

Modesty Letting one’s accomplishments speak for themselves

Prudence Being careful about one’s choices; not saying or doing

things that might later be regretted

Self-regulation Regulating what one feels and does

6. Transcendence Strengths that forge connections to the larger universe and

provide

meaning

Appreciation of beauty Noticing and appreciating beauty, excellence, and/or

skilled performance in all domains of life

Gratitude Being aware of and thankful for the good things that

happen

Hope Expecting the best and working to achieve it

Humor Liking to laugh and tease; bringing smiles to other people

Religiousness Having coherent beliefs about the higher purpose and

meaning of life

An important essential factor in the development and growth of PP has been the creation

of instruments that measure its constructs. Among these instruments, there are those that measure


happiness, emotions, grit, gratitude, character strengths, optimism, life satisfaction, and meaning

in life. See Table 54 for a summary of these instruments.

Table 54

Instruments used in Positive Psychology

Name of instrument What it measures Comments

General Happiness Scale - Assesses enduring happiness - Developed by Lyubomirsky & Lepper (1999)

- 4 items

- Each item with 7-point Likert Scale

- Available in Spanish at www.authentichappiness.com

Fordyce Emotions Questionnaire - Measures current happiness - Developed by Michael Fordyce

- 2 items


The Center for Epidemiological Studies-Depression Scale (CES-D)

- Measures depressive symptoms - Developed by L.S. Radloff, National Institute of Mental Health

- 20 items (4 options each)


Grit Survey - Measures the character strength of perseverance

- Developed by Angela L. Duckworth Seligman Research Alliance, University of Pennsylvania

- 12 items


Gratitude Survey - Measures appreciation about the past

- Developed by Michael McCullough and Robert Emmons

- 6 items



VIA Survey of Character Strengths - Measures 24 character strengths - Developed by Seligman and Peterson

- 120 items in www.viacharacter.org

- 240 items in www.authentichappiness.com

- Available in Spanish at both sites

Optimism Test - Measures optimism about the future

- Developed by Seligman

- 32 items


Satisfaction with Life Scale - Measures life satisfaction - Developed by Ed Diener, University of Illinois at Urbana-Champaign

- 5 items


Meaning In Life Questionnaire - Measures meaningfulness - Developed by M. F. Steger, P. Frazier, & S. Oishi

- 10 items


Addiction and Positive Psychology

Presently, the literature related specifically to PP, its theory and practice, in relation to

treatment and recovery of SUD is scarce. In a search, the resulting article “Review of the

Application of Positive Psychology to Substance Use, Addiction, and Recovery Research”

(Krentzman, 2013) was noteworthy. Despite the fast rate of growth of PP, its integration into

http://www.viacharacter.org/


SUD research and practice has not followed suit (Krentzman, 2013). In terms of specific

collaboration of both PP and addictions, the author states potential for integration within the

recovery movement due to their shared view away from merely pathology and towards a more

positive, and complete, outlook of individuals. In relation to specific interventions that could be

utilized in an integrative manner, it is mentioned that two PP interventions with potential for

benefit among those with SUD are the “Three Good Things” exercise and the “Best Future Self”

exercise, both as described in the previous section. Also, it is stated that those with low affect,

physical illness, or highly self-critical, could benefit more than healthier individuals from

gratitude interventions (Krentzman, 2013). This could add to the reasoning behind seeking

integration of PP and SUD treatment and recovery, as many who suffer from SUD, also exhibit

those traits describing those that can benefit more from gratitude exercises. Also of relevance for

this literature review, is the fact that these PP interventions are more effective for those who are

motivated and can continue exercising the interventions for longer than required by the formal

exercise (Seligman et al., 2005).

Krentzman (2013) also offers in the review, a conceptual map of PP and its application to

addictions. In this map of PP and its three domains, described as the three lives, are the pleasant

life (positive emotions), the engaged life (character strengths), and the meaningful life (positive

institutions). The pleasant life, as related to addictions, is seen as instant gratification that brings

pleasure but without the use of virtues or meaning (Seligman & Pawelski, 2003) thus becoming a

shortcut to real happiness. The engaged life in the realm of addiction is mentioned in terms of the

disease and of recovery and recapture of character strengths (Krentzman, 2013). Finally, the

meaningful life relates to addiction recovery through the meaning found in positive institutions,

such as AA and/or treatment programs. In this sense, the service activities found in AA and in


the recovery movement are essential to the meaningful life as it relates to addiction.

(Krentzman, 2013).

The search of Krentzman’s review (2013) resulted in the inclusion of nine published

works on PP and addictions. From this total of works included in the review, some are

specifically relevant here. There are the results presented by Galanter (2007) in which the

experience in AA is described in terms of recovery based on spirituality. It is suggested in this

study that AA can have an effect in well-being, happiness, flow, purpose in life, social support,

and strengths of character. There are also the findings from Logan, Kilmer, and Marlatt (2010) in

which they “surveyed 424 undergraduate students, and assessed them for the presence of 24

character strengths using the Values in Action Classification of Character Strength and Virtues

instrument.” The findings showed that those students who abstained from consuming alcohol in

the past month presented statistically significant higher scores in justice, temperance, and

transcendence. They also had higher scores, although not statistically significant, on wisdom,

courage, and humanity. Also, among all drinkers, those with high risk scored lower on

temperance, a virtue related to the character strengths of humility, forgiveness, self-regulation,

and prudence. These findings can lead the way into trying to predict outcomes for people

entering treatment and can even have impact on the realm of drug and alcohol prevention.

In another study included in Krentzman’s review (2013), a questionnaire was

administered to 126 individuals in recovery in an attempt to find out if, and how, hope, flow, and

spiritual transcendence relate to relapse (McCoy, 2009). As a result, it was found that only hope

strongly associated with better outcomes. Following, Zemansky (2006) found through a survey

of 164 AA members, that AA affiliation was significantly related to gratitude, optimism, purpose


in life, and spirituality. These findings can also relate the importance of the relational aspect of

AA as social support as this is one of the components of well-being.

Finally, the review presented the original article on “Applying positive psychology to

alcohol-misusing adolescents: A group intervention” (Akhtar & Boniwell, 2010). This was the

only article found on specific interventions applied to people with SUD of any age, on any

setting, making it of particular relevance. The authors assumed that PP could be an alternative

route to seeking happiness, resilience, and positive emotions for young people, instead of

drinking and/or drugging. As far as the sample is concerned, the experimental group of 10 was

compared with a control group (no intervention) of 10, making up a very small sample as it was

a pilot study.

The experimental group was presented with eight weekly workshops with PP thematic,

including positive emotions and savoring, gratitude and optimism, strengths, relaxation and

meditation, change and setting goals, relationships, nutrition and physical activity, and resilience

and growth. The findings from quantitative and qualitative measurement instruments, suggested

a significant increase in well-being and decrease in alcohol use. Specifically, the experimental

group presented increases in happiness, optimism, and positive affect, while also presenting a

reduction in negative affect and in drinking outcome. From the qualitative interviews, it was

shown that gratitude interventions resulted in strongest effects, especially with female

participants. Through these findings, the authors recommend that gratitude become an essential

aspect of future PP interventions for youth. The potential benefit of the findings deserves a

further look into the application of PP interventions into the realm of prevention, treatment, and

recovery of SUD.


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