Introduction
This paper aims to analyze a case study involving Francesca, a 50-year-old woman who presented to counseling upon the request of her employer, who believes that her frequent absences from work are concerned with alcohol or substance use. The client reveals that she has been taking Mersyndol Forte for the last 15 years, prescribed to her to manage migraines and insomnia. Mersyndol Forte contains codeine, an opioid drug that can cause dependence, which is why it is not recommended for long-term use, and the daily intake should not exceed eight tablets (Mersyndol Forte, 2020). Yet, the client used the drug for a very long period, and her daily dose has increased to about 30 tablets. In addition, the patient reports not being able to stop using the drug because it results in worsening migraines, nausea, and stomach cramps. According to Nielsen et al. (2018), these are the symptoms of codeine dependence, which requires pharmacological treatment and addressing underlying psychological issues. This paper will discuss key biological, social, and psychological factors involved in the case and propose a comprehensive treatment plan to address the identified factors.
Key Biological Factors
One biological factor involved in the case is structural and functional changes in the brain resulting in opioid craving. Since Francesca has not been able to abstain from using Mersyndol Forte for more than two weeks, one may conclude that she craves the drug. The client states that she takes the drug to manage her chronic pain caused by migraines, back pain that emerged after a recent accident, and pain from developing stomach ulcers. One might assume that the client’s opioid craving is related to the intensity of her pain. However, according to Bruneau et al. (2021), in opioid-dependent patients with chronic pain, opioid craving results from neuroadaptations in the prefrontal cortex, insula, and amygdala rather than from high pain levels. In particular, opioid use causes changes in the reward circuit, resulting in opioid craving and decreased responsiveness to non-opioid stimuli (Martel et al., 2021). Since the client has been taking the drug for years and developed tolerance, evidenced by the need to increase the dose because of decreasing drug effectiveness, she is likely to have undergone neuroadaptations that result in her opioid craving.
Another biological factor contributing to the client’s maintenance of codeine-containing drug use is opioid withdrawal symptoms. Francesca’s withdrawal symptoms include headaches, nausea, vomiting, muscular pain, and restlessness, and their emergence after attempts to quit using the drug prevented the client from stopping taking the medication. Bruneau et al. (2021) state that opioid withdrawal symptoms are linked to opioid craving and stem from dysregulations in the neurohormonal system, particularly the hypothalamic-pituitary-adrenal axis. Changes in the neurohormonal system also increase individuals’ autonomic responses to opioid cues, such as prescription bottles, which raise their craving for drugs (Martel et al., 2021). Thus, withdrawal symptoms and simultaneous opioid craving lead the client to maintain her drug use.
Key Social Factors
Among key social factors contributing to the client’s maintained drug use is the widespread acceptance of using opioids for pain management. As the client noted, she believed that her drug use was “well-managed” because her GP always complied with her requests to return prescriptions. In part, Francesca’s codeine dependence is maintained due to the so-called “opioid crisis” that stems from physicians’ overprescribing of opioid drugs for pain management and the abundance of such medications on the supply side (Wiss, 2019). The popularity of opioid treatments has increased in recent decades because of the scientific evidence of their effectiveness for short-term pain management (Marshall et al., 2019). At the same time, evidence shows that opioids are ineffective for chronic pain management, but, despite that, many physicians and patients believe in these drugs’ ability to reduce pain and improve quality of life (Marshall et al., 2019). Living in a society where opioid use for pain management is commonly accepted among patients and physicians, Francesca may see her use of the codeine-containing drug as justified.
Another important factor influencing the client’s drug use is stigma and a lack of social support. The client reports concealing her drug use from her family and feeling ashamed of her past when she used to consume heroin. As Cooper et al. (2018) state, high levels of perceived stigma are common among opioid users and act as a barrier to seeking treatment. In the given client, the level of experienced stigma is so high that she would rather quit her job than let the information about her drug dependence come out. Since her family members are unaware of her drug use problem, she does not have enough social support to help her cope. Moreover, the client reports not having “time for much of a social life,” implying that she does not get enough social support from outside of her family either. Research shows that low levels of support are associated with opioid dependence and mental health conditions, and high levels, on the contrary, improve opioid users’ treatment outcomes (Cooper et al., 2018). Thus, addressing the client’s stigma and insufficient social support is vital for treatment effectiveness.
Key Psychological Factors
Several psychological factors contribute to the client’s maintenance of drug use, including the client’s perception of pain. Patients with chronic pain use opioid drugs not simply because they experience pain of high-level intensity but because of the involvement of psychological factors as well (Bruneau et al., 2021; Martel et al., 2021). Evidence shows that negative affect and pain catastrophizing contribute to individuals’ opioid cravings with little connection to the experienced pain intensity (Bruneau et al., 2021; Martel et al., 2021). It means that opioid-dependent patients tend to crave drugs whenever they feel negative emotions, such as nervousness, fear, or distress, and exaggerate their pain experiences. In Francesca’s case, negative affect and pain catastrophizing may have contributed to her opioid dependence since she stated she used the drug for different types of pain (headaches, back pain, ulcers), and the medication helped her cope with stress.
Another key psychological factor present in the case is the client’s lack of effective coping skills. Coping skills are conscious efforts to minimize or deal with stress (Lewis et al., 2018). As Wiss (2019) notes, individuals may use opioid drugs not only for physical but also for psychological pain, and, in this case, drug misuse serves as a coping mechanism to handle emotional pain. In the client’s words, the codeine-containing drug helped her cope with stressful life situations: “It made me feel like I could cope with the work and family balance. The stresses were still there, but I could cope with them much better.” It implies that the client lacks effective coping skills to deal with stress in more adaptive ways than taking drugs. Furthermore, Martel et al. (2021) report that patients with chronic pain who limit their pain coping skills to chemical coping and do not use cognitive coping, such as pain reappraisals, often have increased negative affect and catastrophic thinking and develop opioid dependence. Thus, the client’s codeine dependence is maintained because she lacks effective skills for dealing with stress and pain.
Finally, the client’s expectations and beliefs regarding drug use and pain influence her opioid use. In terms of attitudes toward pain, patients with chronic pain may have misconceptions about their experiences, believing that their pain should be completely gone before they can proceed with their daily activities (Gilbert, 2021). Regarding drug use, individuals’ expectations about the drug effect, which are based on their previous experiences with the substance, professional descriptions, and mass media accounts, can shape their response to drugs (Lewis et al., 2018). In the given case, the client seems to believe that she has to be free from pain to perform her everyday activities since she does not tolerate unpleasant experiences and takes sick leaves whenever she feels bad. Further, her expectations regarding Mersyndol Forte appear to be positive based on her past experiences with the drug that made her sleep “like a baby” and helped her cope with migraines. Thus, because of her attitudes toward the medication and pain, the client has been maintaining her drug use for a long time.
Intervention Plan
An intervention plan for opioid-dependent individuals should be developed concerning the biological, psychological, and social factors involved in each case. Opioid dependence is a complex biopsychosocial disorder affecting an individual’s physical and mental health and social well-being (NSW Ministry of Health [NSW], 2018). As such, it requires addressing multiple needs of the client, not only his or her substance use (Lewis et al., 2018). Therefore, the treatment plan discussed further will include interventions addressing the identified biological, psychological, and social factors influencing the client’s use of the codeine-containing drug.
First, there is a need to address the client’s biological factors of opioid craving and withdrawal symptoms. The first-line treatment for opioid dependence is opioid agonist treatment (OAT) with methadone or buprenorphine (NSW, 2018). It leads to psychological stability, increased control over substance use, and subsequent abstinence (NSW, 2018). Buprenorphine, in particular, is also effective for managing opioid withdrawal symptoms (Nielsen et al., 2018). Yet, OAT is a long-term treatment, showing significant positive effects after three months and bringing major benefits after one year (NSW, 2018). It can be considered a weakness since efforts to retain the client in treatment will be required. Additionally, some physicians may be reluctant to prescribe these medications, assuming that they replace one addiction with another (Patel et al., 2021). Despite these weaknesses, this intervention has an undeniable strength of proven effectiveness, and it is likely to decrease the client’s opioid craving and withdrawal symptoms, eventually leading to complete abstinence. Therefore, it is necessary to refer the client to a GP for getting OAT and managing concurrent health problems such as ulcers.
Psychological interventions are also required to address the client’s psychological factors and ensure retention in treatment. The patient may benefit from cognitive-behavior therapy (CBT) interventions as they have demonstrated effectiveness in treating opioid dependence and chronic pain (Marshall et al., 2019; Patel et al., 2021). Among CBT interventions, several proven effective options can be considered for the given client: patient education, motivational interviewing, coping skills training, and contingency management (Martel et al., 2021). Patient education is necessary to raise the client’s awareness about the harm of opioid misuse, while motivational interviewing should enhance the client’s motivation to pursue behavior change. Coping skills training is essential for the given client to help her develop effective ways of dealing with stress and pain. Coping skills training will help the client build self-efficacy which has a critical significance in relapse prevention (Sureshkumar et al., 2021). Finally, contingency management involves rewarding patients for remaining in treatment.
There are several strengths and limitations to the use of the proposed interventions in managing opioid dependence. In particular, although contingency management is one of the most effective interventions in substance use disorders, it is rarely practiced because there is a question of who should be responsible for funding it (Patel et al., 2021). Regarding CBT, when combined with OAT, it shows significantly greater effectiveness in the form of group therapy rather than as an individual intervention (Gregory & Ellis, 2020). Group CBT not only reduces opioid use and improves coping skills and reduces perceived stigma (Gregory & Ellis, 2020). Therefore, one may conclude that group CBT can be more appropriate for the client because of its high effectiveness and the possibility of addressing social factors present in the case, including stigma and a lack of social support.
Other interventions to deal with the client’s social factors include couples therapy and the referral to leisure activities. Couples therapy has been shown to increase individuals’ rates of abstinence, reduce substance use problems, and improve relationships (Klostermann & O’Farrell, 2021). However, despite its potential benefits for decreasing the client’s drug use and increasing social support, the client or their partner may refuse to participate. Therefore, another way of addressing the client’s social factors is to refer her to participate in leisure activities of her choice or engage in self-help groups (Torrens et al., 2021). These interventions are likely to benefit the client’s psychological state by increasing her emotional support and life satisfaction.
Conclusion
This paper aims to analyze the biopsychosocial factors involved in the case of Francesca, who appears to have codeine dependence and propose a comprehensive intervention plan addressing these factors. The identified factors include opioid craving, withdrawal symptoms, stigma, a lack of social support, pain catastrophizing, the deficit of effective coping skills, and positive expectations of drug use. OAT is recommended for the client as the first-line treatment to reduce her drug use, opioid craving, and withdrawal symptoms. Since this treatment is long-term and the client has underlying psychological issues, CBT interventions have been suggested to reduce the client’s stigma and improve coping skills. Group CBT can be particularly effective for the client because it can also address the social factors involved in the case. Overall, the case shows that substance use is a complex problem involving multiple aspects of the patient’s life. It requires a comprehensive approach dealing with different biopsychosocial dimensions.
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