A Case Demonstrating the Need to Emphasize Wellness as a Treatment Focus for Substance Abuse Disorders

Citation: Baron DA, Lamb CS. A Case Demonstrating the Need to Emphasize Wellness as a Treatment Focus for Substance Abuse Disorders. J Drug Abuse. 2016, 2:4. The relationship between mood disorders and alcohol use/abuse is well documented in the extant literature. The patient may not view drinking as a relevant etiology of their mood complaints, and may not always appreciate alcohol use as a self-medicating “treatment” and cause of depressed mood. This situation is compounded by being in social or occupational organizations where drinking is an accepted (and expected) part of the “culture,” such as sports, certain business roles, and the military. Over the past few decades, significant advances have been made in gaining a better understanding of the etiology and treatment of alcohol and substance use disorders. As neuroscience continues to provide new data to better explain the etiology and treatment of these disorders, the need for clinicians to not forget the critical role of healthy living and wellness must not be neglected. This case report highlights the role of wellness strategies and an integrated approach in the treatment of substance use disorders.

The relationship between mood disorders and alcohol use/abuse is well documented in the extant literature. The patient may not view drinking as a relevant etiology of their mood complaints, and may not always appreciate alcohol use as a self-medicating "treatment" and cause of depressed mood. This situation is compounded by being in social or occupational organizations where drinking is an accepted (and expected) part of the "culture," such as sports, certain business roles, and the military. Over the past few decades, significant advances have been made in gaining a better understanding of the etiology and treatment of alcohol and substance use disorders. As neuroscience continues to provide new data to better explain the etiology and treatment of these disorders, the need for clinicians to not forget the critical role of healthy living and wellness must not be neglected. This case report highlights the role of wellness strategies and an integrated approach in the treatment of substance use disorders.

Case Presentation
A 28 year old Hispanic American woman (ML) presents with complaints of poor sleep, impaired concentration, inability to relax, and mood liability. ML recently returned from her second tour of duty in Afghanistan after receiving an honorable discharge from the Army. She reports having symptoms for the past year, but did not report them to her commanding officer for fear of negatively affecting her military career. Since discharge, ML has put on 15 pounds and has not been able to find a job. Her focus is on a number of vague somatic complaints, and is reluctant to discuss mental health issues despite encouragement from her family to seek counseling. ML makes it clear, she is not interested in taking any psychiatric medications, but admits to daily alcohol use to "help her sleep and cope." She gets annoyed when friends and family confront her on her drinking, and usually drinks alone. She reports having a Bloody Mary a few days a week to help her get going in the morning. She does not think her drinking is helping her dysphonic mood, but it allows her to "keep going." She reports being physically fit when in the Army, but no longer works out and frequently feels tired in the morning and throughout the day. She is aware her morning drinking is not helping her long term, but is at a loss for what to do to feel better and ease her emotional and physical pain.

Integrated Care Model
Over the past decade, much has been discussed about the important role of integrated care. Numerous models currently exist, and are beyond the scope of this case presentation. The key element in all of these models is having care providers work together in the diagnosis and treatment of the patient. A comprehensive bio-psycho-social approach requires practitioners of different specialties working under the coordination of a primary care provider. Social Work expertise is particularly relevant in treating substance abuse disorders. Every integrated care approach to treatment should emphasize healthy living and stress management.

Behavioral Health Model
Psychological and physical well-being requires consideration of the multi-dimensional aspects of life. Patterns related to sleeping, exercise, diet and stress coping strategies are but a few areas where empirical research provides evidence of connections to psychological improvements and, by extension, possible amelioration of substance abuse behavior. The following sections provide additional information, evidence and resources for care providers and applied researchers interested in learning more about the future direction of client-first psychiatry, wellness research, and potential linkages to mitigating substance abuse behavior.

Sleep Hygiene
One approach to increasing receptivity and efficacy of behavioral health treatments has been linked to assessing and treating issues related to poor sleep through improved sleep hygiene [1]. Initially explored to treat insomnia, recent research provides evidence improvements in sleep hygiene can be associated with improvements to substance use and overall mental health [2]. Other research suggests sleep and circadian disturbances may contribute to substance abuse [3], and the experience of sleep disturbances resulting from use and withdrawal from drugs and alcohol [4].
Little evidence is currently available informing the relationship between sleep hygiene and substance abuse behaviors. Compromised sleep hygiene may undermine treatment and intervention efficacy for substance abuse disorders in the form of circadian disturbances, insomnia, sleep apnea, and other disordered sleeping behaviors. Additional research is necessary to determine how adherence to substance abuse treatment can be improved, or whether aspects of sleep hygiene could be useful to mitigate treatment non-adherence.
Is increased exercise enjoyment associated with increased adherence to exercising? Greene and colleagues examined this premise and provide evidence increased enjoyment of exercise positively influenced participant adherence improving health, physical performance and self-efficacy [16]. Providing enjoyable exercise opportunities may be the most important step in creating opportunities to benefit from the positive effects of exercise on mental health. However, it is also important to consider barriers to exercise in the process of developing interventions for people with severe mental illness [17]. Extant clinical reports in this area show marked promise in improving mental health interventions and prevention strategies related to substance abuse behaviors.

Mental Health and Diet
An old saying claimed, "We are what we eat." Although the role of a well-balanced diet has been linked to a healthy life style, the impact of nutrition on treatment of substance use disorders is less well appreciated. Current research is expanding the understanding of the potential, mechanisms, impact of, and prevention strategies using nutritional interventions [18,19]. A recent special series in Clinical Psychological Science addresses issues pertaining to nutrition and mental health. This field of study has been labeled nutritional psychiatry [20]. Topics in this special issue cover the potential relationship between processed food on mood, essential fatty acids with attention-deficit hyperactivity behavior, and micronutrient treatments (singular and multinutrient) with insomnia and obsessive-compulsive behavior.
More research is necessary to explore the relationship between nutrition and substance abuse disorders. Given the comorbid nature of mood and anxiety disorders with substance abuse behaviors, it is reasonable to presume diet should be a potential area of interest to study substance abuse using a nutritional psychiatry framework. Blum and colleagues [21,22] have published extensively on Reward Deficiency Syndrome as a potent driver of craving and substance use disorders. Maintaining dopamine homeostasis through dietary supplementation has been shown to effectively reduce drug craving and help maintain sobriety in opioid addicted individuals.

Stress Reduction/Coping Strategies
Cognitively oriented theory on role of personal stress and coping processes [23] proposed believing an event is controllable does not always lead to stress reduction or to a positive outcome and believing an event is uncontrollable does not always lead to increased stress or to a negative outcome [24].
Shortly before the turn of the century, mindfulness-based stress reduction (MBSR) methods gained substantial accolades in their brief, cost-effective, and highly customizable applications to a variety of chronic illnesses, clinical ailments and with healthy individuals seeking further improvement. In short, mindfulness is a non-evaluative and sustained moment-to-moment awareness of mental states and processes and research provides evidence suggesting MBSR may be successful in helping a broad range of individuals coping with their clinical and non-clinical problems. Meta-analysis of mindfulness-based therapy also shows considerable promise in reducing anxiety, depression, and stress [25].

Case Implications
Considering the existing treatment literature, including using a nutritional psychiatry approach, optimal treatment of ML will be achieved with a comprehensive bio-psycho-social approach. ML may benefit from a wellness oriented intervention, targeting sleep hygiene, exercise, nutrition and stress coping strategies. Focusing on her holistic experience, and not treating her behavioral symptoms, could provide ML opportunity to engage in preventative self-care in the future, or equip her to react quickly and intervene early when she recognizes she is experiencing distress.
Examples of this could be to assess her sleep hygiene by asking her to participate in a sleep quality assessment. In complement to the sleep assessment, meeting with a nutritionist could also be helpful to examine the composition of her diet (e.g. caffeine intake, processed food consumption, nutrient complexity, etc.) and how this may contribute to her sleep and overall wellness. Additionally, it may be beneficial to assess her physical activity by asking her to commit to working with a personal trainer. She is familiar with being physically active in the military, but could benefit from working with a trainer directly to create a new Journal of Drug Abuse 2471-853X exercise routine, or joining an intervention study focusing on exercise as a treatment for substance abuse [26]. Lastly, all three of these perspectives, and continuing with therapy, may act in concert with mindfulness-based stress reduction strategies to help ML remedy her emotional and physical pain without the use of psychiatric medications.
However, if there is concern ML is experiencing comorbidities with substance abuse and post-traumatic stress, this may require special attention and a trauma-focused intervention [27]. Additionally, it may be beneficial to intermittently incorporate her family as they are part of her psychological ecology and can function as supportive agents of change and positive reinforcement.

Conclusion
Advances in neuroscience and pharmaceutical discoveries have provided additional treatment options for individuals suffering from substance use disorders. Despite these efforts, the importance of maintaining a comprehensive, integrated approach to care is essential. The attention to basic elements of health, including restful sleep, a well-balanced diet, enjoyable exercise, and improved stress resilience strategies are a necessary component of effective treatment. An approach which only focuses on presenting symptoms will miss factors which could be contributing to overall health and wellness and in/directly influencing psychological health and stress resilience.
Emphasizing prevention efforts such as working with nutritionists or fitness consultants could be cost-effective, less labor intensive and provide greater gains than current palliative approaches. Optimal treatment will result with the appropriate use of all available interventions available to the provider, but must be integrated into a wellness paradigm, and not exclusively focused on presenting symptoms.