“from here to eternity” special issues in alcohol and other drug treatment:

“From Here to Eternity”Special Issues in Alcohol and other

Drug Treatment:Part 1: Addiction, Recovery

& RelapsePart 2: Treating Co-Occurring

Disorders in Youth

Terrence D. Walton, MSW, CSACTerrence D. Walton, MSW, CSACDirector of TreatmentDirector of Treatment

District of Columbia Pretrial Services AgencyDistrict of Columbia Pretrial Services Agency

1. Biological predisposition

2. Childhood experiences; modeling; neglect & abuse; detachment; excessive stress; shame

3. Culture; social norms; beliefs & values

4. Lack of socio economic barriers

5. Underlying mood, anxiety or personality disorders; Post traumatic stress disorder (PTSD)

6. Pharmacology

How Do Drugs Work?

1. Legal & Illicit 2. Street Drugs and

Prescribed Drugs3. Hard Drugs & Soft

Drugs4. Very Addictive &

Less-Addictive5. Natural and

Synthetic

1. Stimulants2. Depressants3. Opioids4. Cannabinols5. Hallucinogens/

Dissociatives6. Inhalants/

Deliriants/Other

Bottle to Blood to Brain Route of Administration:

Smoke Sniff Snort Shoot Swallow

The Blood Brain Barrier Neuro-compatibility

1. Get Ready (preparatory)

2. Break Free3. Break the Connection4. Choose the Right Path5. Deal with Temptation

1. Self-assess change readiness2. Determine if change is

warranted3. Resolve ambivalence about

change4. Become committed to

change

1. Breaking the cycle of compulsive use (e.g. detoxification, residential, jail, contracting, accountability, force of will)

2. Cutting the ties to & reminders of addiction across all life situations

3. Begins on the first day of the attempt to quit or modify the behavior

4. Acting on the commitment to change (e.g. quit date)

5. 3 to 6 months

Pre-Contemplation

Contemplation

Preparation

Action

Maintenance

1. Stimulus Generalization (addiction) 2. Stimulus Control (avoiding the

cue/stimulus or simply refusing to respond to the cue/stimulus)

3. Counter Conditioning (changing the response to the cue/stimulus; new skills; replacement behaviors)

4. Reinforcement (essential to compete with the immediate reward of drug use)

1. Out of Addiction (treatment, church, support groups, will power)

2. Of Treatment (treatment options)

3. Throughout Recovery Choices made daily and moment by

moment Constantly aware of which path I’m on Activating recovery-oriented neural

pathways

1. Break the connection between temptation and use

2. As temptations persist and intensify, self-efficacy and confidence decline

3. As temptations decrease, self-efficacy and confidence increase

4. As self-efficacy and confidence increase, temptations may either decrease or increase

In conjunction with a day-by-day commitment to remain abstinent, the

ongoing process of overcoming physical and psychological dependence on mood

altering chemicals and learning to live in a state of total abstinence, without the need

for those substances. In recovery, the individual relies on healthy, constructive activities and experiences for happiness

and fulfillment.

Sobriety

1. When a person in recovery returns to the self-prescribed, non-medical use of any mood altering chemical (MAC) and the risk of the problems associated with that use

2. The return to use after a period of abstinence that interrupts the addicts ongoing attempts to recover

3. A return to drug use that is precipitated by and/or leads to the lessening of commitment to recover

Is it “relapse” or “continued use”?

1. Recent studies demonstrate relapse rates of 40% relapse rates of 40% to 60% to 60% at one year follow-up

2. Most relapses occur in the first year of recovery, with two thirds occurring in the first 90 days

3. Clients who remain in treatment the longest generally have the best outcomes

An unfolding process in which the resumption of substance abuse is the

last event in a long series of maladaptive responses to internal or

external stressors or stimuli

Therapy designed to teach people to recognize, anticipate, and manage the relapse warning signs so that they can interrupt the relapse process early and return to the process of recovery.

1. Written, specific, and rehearsed plans2. Reiterates commitment to and

rationale for recovery3. Outlines and schedules recovery

supportive activities4. Identifies warning signs, cues, and

high risk situations (triggers)5. Details preventive and progressive

responses to all triggers

Responding to Responding to and and

Recovering Recovering from Relapsefrom Relapse

1. Analysis2. Assessment3. Assistance4. Accountability5. Assurance

Wellness Illicit Use

Problematic Use

Abuse

Dependence

A pattern of use of any substance for

mood or perception altering purposes that

causes recurrent problems in major life

areas

Substance use that has an appetitive nature, has

a compulsive and repetitive quality, is self-

destructive, and is experienced as difficult

to modify or stop

Wellness MH Problems

Common MH Problems

Disorders

Serious Emotional Disturbance

Axis I Disorders Serious Emotional Disturbance Developmental Disorders

Axis II Disorders Personality Disorders Mental Retardation

Diagnosable disorders in children and adolescents that severely disrupt

their daily functioning in the home, school, or community.

These disorders include depression, attention-deficit/hyperactivity,

anxiety disorders, conduct disorder, eating disorders (and others)

Includes every mental diagnosis except the personality disorders and mental retardation

Symptoms are often severe and disabling if untreated

Often can be treated with psychotropic medication in combination with psychotherapy (except developmental disorders)

Attention Deficit Disorder Disruptive Disorders

Conduct Disorder Oppositional Defiant Disorder Child or Adolescent Antisocial

Behavior Disruptive Behavior NOS

Anxiety Disorders Panic Disorders Phobias Obsessive Compulsive Disorder (OCD) Post Traumatic Stress Disorder (PTSD)

Mood disorders Major Depressive Disorder Dysthymic Disorder Bipolar Disorder

Psychotic Disorders Schizophrenia Schizoaffective Disorder Mood Disorder with Psychosis

Pervasive Developmental Disorders Autism Asperger’s Disorder Rett’s Disorder Childhood Disintegrative Disorder

Significantly below average general intelligence functioning accompanied

by significant limitations in adaptive functioning in major skill areas.

Onset must occur before age 18.

•Less likely to be capable of benefiting from cognitive-based, insight oriented treatment interventions

•More likely to be victimized in drug using, criminally involved peer groups

Addiction

Abuse MH Disorder

SED

Prescription drugs are the 2nd most commonly abused drugs—behind only marijuana (ONDCP 2007).

20.6% of U.S. population over 12 reports misuse of a psychotropics (NSDUH 2009)

7 million report currently misusing (SAMHSA 2010)

ER visits for opiate misuse doubled from 2004 to 2008 (CDCP 2010)

Those under 18 are among the fastest growing group misusing

Alcohol Marijuana Inhalants Ritalin Benzodiazepines Other prescription meds

A Lifetime of Self Medicating

Pain

Discomfort

Pain Relieving

Distracting

Heroin

Opiates

Numb

Empty

Bored

Risk, Stimulation, Adrenaline

Cocaine

Meth

Ecstasy

Anxious

Stimulated

Hyper

Self Soothing

Behaviors

THC

Alcohol

1. Exclusionary Treatment2. Sequential Treatment3. Parallel Treatment4. Integrated Treatment

• Stand-alone psychotropic medication treatment may be indicated for adults

• Many youth benefit from stand-alone psycho-social treatment

• Stand-alone psychotropic treatment is rarely the best course for the young

Debriefing or psychological first aid Professional therapy, counseling, and/or support

Individual, family and/or “survivor group therapy”

Cognitive-behavioral therapy, Exposure therapy, Support groups, Play therapy

Eye Movement Desensitization and Reprocessing (EMDR)

Medicines Selective Serotonin Reuptake Inhibitors (e.g.

Zoloft, Paxil) Mood stabilizers (in conjunction with anti-

depressants) Anti-psychotics (used experimentally as last

resort)

Seeking Safety:A Treatment Manual for

PTSD and Substance Abuse

Lisa M. Najavits

National Registry of Evidenced-based Programs and Practices:

www.nrepp.samhsa.g

ov

Over the Past Decade:Psychotropic medication use in youth has increased 2 to 3 foldPoly-pharmacy use has increased up to 8 foldFrom 13% to 52% of youth in foster care on meds, compared to 4% of the general population

According to University of Maryland professor of pharmacy and psychiatry, Julie Zito PhD:

More than 75% of psychotropic medication used for children is off-

label.

1. Increased use of antipsychotics, antidepressants, and ADHD meds

2. Increased poly-pharmacy3. Increased medication use among

young children4. Increased reliance on PRN meds and

blanket authorizations in residential facilities

1. Use in very young children (3-6 years)

2. Poly-pharmacy before mono-pharmacy

3. Use of 3 to 5 medications simultaneously

4. Use of multiple medication in the same class for more than 30 days

5. Exceeds maximum dosage

6. Use of newer, non-approved meds over FDA-approved meds

7. Primary care physician prescribing meds for DX other than ADHD, ODD, Adjustment Reaction, or Depression

8. Anti-psychotic meds use for longer than 2 years without Psychotic Disorder of Bipolar

9. No documentation of informed consent

.

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“From Here to Eternity”Special Issues in Alcohol and

other Drug Treatment:Part 1: Addiction, Recovery

& RelapsePart 2: Treating Co-Occurring

Disorders in Youth

Terrencewalton@aol.comTerrencewalton@aol.com