Question 1

A population health perspective of addiction recognizes that addiction's causes, symptoms, and recovery outcomes occur at what level?
A) Individual
B) Family
C) Community
D) Societal

Accepted Answer

Social determinants of health, health inequities, and occupational injustice are particularly visible in addiction etiology and outcomes, suggesting the necessity of a population health approach. A population health approach to occupational therapy in addiction recovery moves beyond individual addiction treatments and addresses the social, cultural, and environmental factors responsible for health disparities and occupational injustices among and within populations. Shifting to a population health approach to treating addiction does not simply mean including family members in addiction recovery or utilizing group-based therapies, although both of these are evidence based practices with a significant amount of supporting literature (Substance Abuse and Mental Health Services Administration [SAMHSA], 2018). A true population health approach to the problem of addiction alters not only the level at which intervention needs to occur but also the fact that addiction's causes, symptoms, and recovery outcomes are understood as societal, rather than individual.

Question 2

Through the lens of Alexander's dislocation theory of addiction, people adopt addictive behaviors when they feel:
A) Isolated
B) Included
C) Mentally ill
D) Unsure

Accepted Answer

Alexander (2010, 2015) and others have emphasized that addiction is a societal, rather than an individual, problem. Through the lens of Alexander's dislocation theory of addiction, people adopt addictive behaviors when they feel deeply isolated, detached, fragmented, or dislocated from meaningful participation in life. Abuse, trauma, natural disasters, cultural assimilation, globalization met with disruption of local economies, and numerous other factors may contribute to the onset and pains of dislocation. Of note is his claim that modernization and postmodernization expand worldwide dislocation by undercutting local economies via free market trade and celebrating immediate and limitless gratification. The growing prevalence of addictive behavior despite modest improvements in addiction medicine and individual treatment approaches are, for Alexander, indicators of larger social problems (Alexander, 2010). Dislocation theory provides a framework within which innovative population health approaches to addiction recovery focused on reducing dislocation and creating supportive, inclusive societal contexts can be conceptualized. The need for such innovation is evident in the growing number of drug-related deaths despite the billions of dollars invested in reducing addiction-related problems (Centers for Disease Control and Prevention [CDC], 2018b).

Question 3

A school-based occupational therapist develops a stress-management regimen using yoga and meditation to help children vulnerable to addiction due to historical trauma and adverse childhood experiences adopt adaptive coping strategies. This an example of which level of intervention?
A) Microlevel
B) Mesolevel
C) Macrolevel
D) Not a population health intervention

Accepted Answer

An understanding of addiction from a population health perspective can translate into interventions at multiple levels, including interventions designed for individual clients (microlevel), community-based interventions (mesolevel), and population-based interventions (macrolevel). For the occupational therapy practitioner, the ecological model of human performance (EHP; Dunn, Brown, McGuigan, 1994) may be a useful framework for adopting a population health approach to addiction prevention and intervention. The EHP encourages practitioners to consider how temporal, social, societal, historical, political, and other contexts influence task performance and thus participation in life. In addition, the model suggests skills, perceived roles, and abilities (all influenced by contextual factors) shape the occupations (tasks) available to a person and/or the way in which a person perceives and engages (or not) in those tasks. At the microlevel, an occupational therapist may assist a client in identifying contextual factors that have an impact on skill development, role identification, abilities, and availability of resources. Thus, even when treating at the individual level, addiction is viewed as a larger contextual problem. To apply a population health approach at the mesolevel, occupational therapists may develop community-based interventions designed to address the needs of a specific group within their local community context(s). A macrolevel population health approach using the EHP might aim to reduce health disparities and/or health-care inequities by examining, exposing, and correcting the social and occupational injustices that are contributing to the global substance use epidemic.

Question 4

Mr. Smith, a 67-year-old male, has liver disease due to a history of severe substance use disorder. According to the DSM-5, Mr. Smith meets how many of the criteria in the DSM to qualify as "severe"?
A) 1
B) 2
C) 4
D) 6

Accepted Answer

To be diagnosed with a mild substance-related or addictive behavior, a person must demonstrate at least two diagnostic criteria in any of the following groups: impaired control, social impairment, risky use, and pharmacological criteria such as neurobiological changes related to tolerance (see Box 19-2). Four to five criteria indicate a moderate SUD, and six or more suggest a severe SUD. In addition to the 10 substance-specific disorders, the DSM-5 also includes a heading for addictive behaviors, although the only addictive behavior listed is gambling disorder. Both substance use and gambling disorder are thought to change neurobiological structure and function in maladaptive ways, producing the behavioral phenomena seen in addiction (APA, 2013).

Question 5

Historically, more black women using drugs during pregnancy have been arrested, despite higher rates of whites using the illegal substances. This higher rate of arrest is due to which societal issue?
A) Intentional discrimination
B) Implicit bias by health-care providers
C) Blatant racism
D) Stigma

Accepted Answer

When literature first began to examine the impact of illicit substances on newborns, the women arrested in delivery rooms and charged with endangering their infants were almost exclusively poor and black crack users, despite the prevalence of white, pregnant powder cocaine users at the time (Acker, 2010, p. 84). Likewise, "longer sentences for crack possession compared to equivalent weights of powder cocaine contributed to disproportionate levels of African Americans incarcerated for drug convictions (Currie, 1993). These periods of incarceration, in turn, further reduced young black men's engagement in education or legitimate employment and deepened their criminal involvement" (p. 84). Such policies not only increased the direct harms associated with drug use (e.g., incarceration, financial impacts) but also further increased risk factors by imposing barriers to meaningful and efficacious participation in life. Highlighting the relevance of race in discussions of addiction and health, Krieger (2014) emphasizes: "An important gap in current research concerns the racialized health consequences of contemporary legal discrimination such as the legally color-blind, albeit racially motivated, U.S. War on Drugs and its role in producing or exacerbating health-debilitating racial/ethnic inequalities" (p. 688).

Question 6

Which of the following is most vulnerable to opioid addiction?
A) A person who has had a hip replacement for osteoarthritis
B) A person who has had a carpal tunnel release for chronic CTS
C) A person with a shoulder replacement who had preoperative pain
D) A person who had their wisdom teeth removed

Accepted Answer

Who is most affected by the opioid epidemic in the United States? According to recent literature, postsurgical patients, adolescent athletes, and people with chronic pain who have been prescribed opioids are among those most affected (Brummett et al., 2017; NIDA, 2018a). According to NIDA (2018a), 21-29% of people with chronic pain with opioid prescriptions misuse them, and 8-12% develop an opioid use disorder. Approximately 4-6% of those who misuse their prescribed opioids transition to heroin use; conversely, 80% of heroin users first misused prescribed opioids. Brummett et al. (2017) reported that 5.9-6.5% of people who were prescribed opioids following a major or minor surgery demonstrated new, persistent opioid use-defined as those new to opioid use filling opioid prescriptions 90-180 days after surgery, long after post-surgery pharmacological pain relief would typically be needed. Incidences of persistent opioid use did not correlate with whether the participants of the study had a major or minor surgery. Instead, persistent opioid use was significantly linked to the presence of another SUD, anxiety, depression, or preoperative pain disorders, such as chronic neck or back pain or arthritis. Literature suggests that the duration of use (22.1 months or more) positively affects the likelihood of developing an addiction (Fishbain, Cole, Lewis, Rosomoff, & Rosomoff, 2007).

Question 7

Persons most likely to develop an opioid addiction are those who:
A) Had a major surgery
B) Had a minor surgery
C) Have a long duration of opioid use
D) Have chronic pain

Accepted Answer

Who is most affected by the opioid epidemic in the United States? According to recent literature, postsurgical patients, adolescent athletes, and people with chronic pain who have been prescribed opioids are among those most affected (Brummett et al., 2017; NIDA, 2018a). According to NIDA (2018a), 21-29% of people with chronic pain with opioid prescriptions misuse them, and 8-12% develop an opioid use disorder. Approximately 4-6% of those who misuse their prescribed opioids transition to heroin use; conversely, 80% of heroin users first misused prescribed opioids. Brummett et al. (2017) reported that 5.9-6.5% of people who were prescribed opioids following a major or minor surgery demonstrated new, persistent opioid use-defined as those new to opioid use filling opioid prescriptions 90-180 days after surgery, long after post-surgery pharmacological pain relief would typically be needed. Incidences of persistent opioid use did not correlate with whether the participants of the study had a major or minor surgery. Instead, persistent opioid use was significantly linked to the presence of another SUD, anxiety, depression, or preoperative pain disorders, such as chronic neck or back pain or arthritis. Literature suggests that the duration of use (22.1 months or more) positively affects the likelihood of developing an addiction (Fishbain, Cole, Lewis, Rosomoff, & Rosomoff, 2007).

Question 8

An EMS team comes upon a young woman experiencing an opioid overdose. They are likely to provide which intervention?
A) Transport her to detox
B) Administer naloxone
C) Contact her provider to address opioid prescribing
D) Administer methadone

Accepted Answer

According to CDC Principal Deputy Director Anne Schuchat, MD, "all branches of the federal government are working together to reduce the availability of illicit drugs, prevent deaths from overdoses, treat people with substance-use disorders, and prevent people from starting using drugs in the first place" (CDC, 2018b, para. 4). Reducing the availability of opioids, as mentioned above, has largely been accomplished by educating providers to modify prescribing practices. Preventing deaths from opioid overdose has been addressed via widespread generic naloxone distribution. Naloxone (brand name Narcan) is an opioid antagonist that can prevent death from overdose by counteracting the central nervous system and respiratory system depression resulting from excessive opioid use (CDC, 2018b).

Question 9

Which of the following is an evidence based intervention for addiction?
A) Education on impact of substance use
B) Monitoring provider prescribing habits
C) Mindfulness training
D) Community-based programs for youth

Accepted Answer

SAMHSA (2018) suggests using a recovery-oriented approach that includes evidence based practices for addiction (Box 19-4). Additionally, SAMHSA emphasizes that addiction treatment programs should provide options for long-term treatment, such as "ongoing counseling or recovery coaching and support [that] helps in meeting other basic needs like sober housing, employment supports, and continued family involvement" (SAMHSA, 2018, p. 1). Other evidence based practices include contingency management (Prendergast, Podus, Finney, Greenwell, & Roll, 2006), housing first (Padgett, Stanhope, Henwood, & Stefancic, 2011), and mindfulness training (Garland, Roberts-Lewis, Tronnier, Graves, & Kelley, 2016).

Question 10

Julia is a 28-year-old with depression and an opioid addiction. She would be benefit from what type of intervention?
A) Detox
B) Administration of naloxone
C) Contingency management
D) Integrated dual disorder treatment

Accepted Answer

Addiction rarely occurs in the absence of comorbid conditions. Dual-diagnosis refers to a person with an addiction and a severe mental illness (SMI). The literature suggests that dually diagnosed clients have had difficulties accessing care because some addiction treatment facilities are ill-equipped to treat persons with SMI, and conversely, SMI facilities are ill-equipped to address problems inherent in addiction recovery. Often SMI treatment centers require drug abstinence, which may not be realistic for someone with an SUD. Integrated Dual Disorder Treatment (IDDT) is an evidence based practice developed to concurrently address addiction and SMI (Kubek, Kruszynski, & Boyle, 2003). Providers are trained to address all aspects of addiction and SMI and understand the ways in which SMI may influence addictive behaviors while also recognizing how substance use may affect SMI symptoms and recovery. IDDT uses a stage-based approach to care and facilitates stable housing (despite drug use), harm reduction, employment, family involvement, continuity of care, and perhaps most importantly, true integration of services (Drake et al., 2001). IDDT treatment stages are described in Table 19-1. All providers are trained to treat both addiction and SMI. In addition to IDDT, widespread federal funding supports the development of integrated community behavioral health clinics that, recognizing the frequency with which physical and mental health conditions co-occur, bring together physical and mental health evaluation and treatment (Barnett et al., 2012).

Question 11

Greg is a 32-year-old male addicted to gambling. His gambling addiction is considered a:
A) Personality disorder
B) Behavioral addiction
C) Psychotic disorder
D) Emotion management deficit

Accepted Answer

Over the past decade, the literature has noted an increasing prevalence of behavioral addictions, also referred to as process addictions (Sussman et al., 2011). The DSM-5 lists gambling disorder as the only non-substance-related addictive behavior, on the basis that research has illustrated similar neurobiological alterations in both SUD and problematic gambling (Ross et al., 2008). Behavioral phenomena resembling SUD have also been observed, such as a preoccupation with gambling, the development of tolerance (a need to gamble with larger amounts of money to evoke excitement), symptoms of withdrawal when abstaining from gambling (restlessness, irritability), and repeated unsuccessful attempts to abstain (APA, 2013).

Question 12

From an occupational therapy perspective, addiction is considered a:
A) Substance use problem
B) Behavioral addiction
C) Personality disorder
D) Maladaptive occupation

Accepted Answer

Wasmuth et al. (2014) suggest that addiction is an occupation that requires new, meaningful opportunities for participation in early recovery to sustain recovery efforts. In the framework, "the term occupation denotes life engagements that are constructed of multiple activities. Both occupations and activities are used as interventions by practitioners" (AOTA, 2014, p. S6). Wasmuth, Pritchard, and Kaneshiro (2016) examined the effectiveness of occupation- and activity-based interventions for SUD implemented by a wide range of practitioners and found that all social participation interventions elicited superior outcomes compared to non-occupation-based treatment-as-usual methods. A narrative review of psychosocial occupational therapy interventions for SUD found that occupational therapy life skills interventions could "enhance functional independence and occupational performance for individuals recovering from SUD" (Amorelli, 2016, p. 167).

Question 13

An appropriate occupational therapy assessment tool used for clients with addiction to understand occupational performance is a:
A) Role checklist
B) Sensory profile
C) COPM
D) Skilled observation

Accepted Answer

The AOTA has highlighted several occupational therapy screening and assessment tools that can be uniquely helpful in uncovering functional limitations accompanying an SUD and in developing an intervention plan. During the administration of an occupational profile, "the client, with the assistance of the occupational therapy practitioner, identifies priorities and desired targeted outcomes that will lead to the client's engagement in occupations that support participation in life" (AOTA, 2014, p. S13). Occupational therapy practitioners can examine current and future roles via the role checklist (Oakley, Kielhofner, Barris, & Reichler, 1986) to help people in recovery restructure their identity and participation as they embark on their recovery journeys. Assessing factors such as sensory processing, volition, and cognition (e.g., the capacity for planning, organizing and performing daily routines, and sequencing tasks to engage in community events) can provide helpful information about challenges a person might face in recovery efforts. Occupational therapy practitioners can also uncover valuable information via functional assessments that break performance of occupations down into discrete steps that can be practiced and observed, to determine the potential need for assistance or intervention (AOTA, 2017).

Question 14

Ariel is a 29-year-old addicted to prescription pain medications from an old ballet injury. She says she wants to recover from her addiction. As the occupational therapist, intervention may be more successful if you understand which aspect during evaluation?
A) Role function
B) Stages of change
C) Leisure interests
D) Family history

Accepted Answer

Some literature has suggested that assessing readiness to change can be useful in determining what type of interventions would be most helpful to a person with an SUD at a given time. The University of Rhode Island Change Assessment (URICA) is a 32-item questionnaire (McConnaughy, DiClemente, Prochaska, & Velicer, 1989) that helps categorize a person into one of four change-readiness stages (precontemplation, contemplation, action, or maintenance) and is, according to Norcross, Krebs, and Prochaska (2011), the most commonly used readiness-to-change assessment. The Stages of Change and Treatment Eagerness Scale (SOCRATES) is also frequently used for this purpose (Miller & Tonigan, 1996). Additionally, one item on the Occupational Circumstances Assessment Interview and Rating Scale (OCAIRS) examines readiness to change based on feedback from others about the effectiveness or ineffectiveness of one's thoughts and actions (Forsyth et al., 2005).

Question 15

One benefit of the normative scale of occupations in the context of population health and addiction is that it:
A) Cures addiction
B) Promotes readiness to change
C) Removes stigma
D) Provides a population health intervention for addiction

Accepted Answer

Wasmuth (2015), building on the concept of occupational balance (Matuska & Christiansen, 2008), introduced the concept of focused flexibility to describe the middle of the scale, in which a person participates in a variety of meaningful occupations that can provide some structure and focus while still maintaining a degree of flexibility and adaptiveness. The person is not rigidly tied to any one all-encompassing occupation, such as an addiction. In a space of focused flexibility, if an injury or contextual factor prevents participation in one occupation, the person is afforded a degree of flexibility to continue participation in other meaningful occupations in order to maintain a consistent but fluid sense of meaning and personal identity, matched with activities that can structure time and contribute to established routines and roles.
While this figure suggests the center of the scale to be indicative of wellness, it is essential to recognize that many individuals may operate successfully at different points on this scale, given supporting environmental circumstances. It is also important to note that the degree to which an occupation or set of occupations constrains an individual (or promotes flexibility and wellness) may be a result of the demands/dictates of the occupation, the impact it has on the individual's psyche, the temporal constraints it imposes, the associated environments, or some combination of these and other factors, such as the person's stage of recovery.
One benefit of this normative scale in the context of population health and addiction is that it conceptualizes addiction in the context of everyday occupations that vary in the degree to which they foster focused flexibility and therefore wellness. Such a scale can be used to remove stigma from conversations about addictive behaviors and their potential harms and benefits by placing addiction on a spectrum with other nonstigmatized activities as they relate to flexibility. The scale can be used to guide discussions about wellness goals and can help occupational therapy practitioners and clients identify alternative occupations that have the potential to promote wellness by focusing on the construct of focused flexibility. Likewise, the scale can assist individuals and societies in reflecting about the degree to which their current occupational lives or societal structures facilitate the desired degree of flexibility and freedom while avoiding overemphasis on the direct health-related harms of addictive substances that research literature suggests can actually impede recovery efforts (Constanza et al., 2017).

Quiz 19: Community-Based Approaches to Substance Use Epidemics Introduction

A population health perspective of addiction recognizes that addiction's causes, symptoms, and recovery outcomes occur at what level?

Through the lens of Alexander's dislocation theory of addiction, people adopt addictive behaviors when they feel:

A school-based occupational therapist develops a stress-management regimen using yoga and meditation to help children vulnerable to addiction due to historical trauma and adverse childhood experiences adopt adaptive coping strategies. This an example of which level of intervention?

Mr. Smith, a 67-year-old male, has liver disease due to a history of severe substance use disorder. According to the DSM-5, Mr. Smith meets how many of the criteria in the DSM to qualify as "severe"?

Historically, more black women using drugs during pregnancy have been arrested, despite higher rates of whites using the illegal substances. This higher rate of arrest is due to which societal issue?

Which of the following is most vulnerable to opioid addiction?

Persons most likely to develop an opioid addiction are those who:

An EMS team comes upon a young woman experiencing an opioid overdose. They are likely to provide which intervention?

Which of the following is an evidence based intervention for addiction?

Julia is a 28-year-old with depression and an opioid addiction. She would be benefit from what type of intervention?

Greg is a 32-year-old male addicted to gambling. His gambling addiction is considered a:

From an occupational therapy perspective, addiction is considered a:

An appropriate occupational therapy assessment tool used for clients with addiction to understand occupational performance is a:

Ariel is a 29-year-old addicted to prescription pain medications from an old ballet injury. She says she wants to recover from her addiction. As the occupational therapist, intervention may be more successful if you understand which aspect during evaluation?

One benefit of the normative scale of occupations in the context of population health and addiction is that it: