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