S. Alex Stalcup, M.D.

900
-1

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
900
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
3
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • Chang L, Smith LM, LoPresti C, Yonerura ML, Kuo J. Walot I, Ernst T. Smaller subcortical volumes and cognitive deficits in children with prenatal methamphetamine exposure. Psychiatry Research: Neuroimaging 132 (2004) 95-106
  • NOTES: Data presented are from initial results of the Infant Development, Environment, and Lifestyle (IDEAL) study, an ongoing longitudinal multi-site study of prenatal methamphetamine exposure being conducted in Los Angeles, CA; Des Moines, IA; Tulsa, OK; and Honolulu, HI (NIDA Grant R01DA014948; P.I.: Dr. Barry Lester). Staff members at each site were responsible for monitoring hospital delivery logs and attempting to approach every mother who delivered a baby within the last 48 hours. An average of 75% of mothers who recently delivered were approached for consent and screened for eligibility. Substance use was determined by either self-report or meconium testing.
  • S. Alex Stalcup, M.D.

    1. 1. S. Alex Stalcup, M.D. New Leaf Treatment Center 251 Lafayette Circle, Suite 150 Lafayette, CA 94549 Tel: 925-284-5200 Fax: 925-284-5204 alex@nltc.com www.nltc.com
    2. 2. Predictors of Treatment Outcome • Length of time in treatment Less than 3 months in treatment has no effect. After treatment for 4 - 6 months 35% achieve sobriety. (Sobriety = 30 days consecutively methamphetamine-free.) • Retention in treatment is the most important factor influencing outcome. • Drug Court participation doubles the number of clients retained in treatment.
    3. 3. What is a Drug? A drug is a pleasure producing chemical. Drugs activate or imitate chemical pathways in the brain associated with feelings of well-being, pleasure, and euphoria.
    4. 4. Neuroadaptation • The process by which receptors in the reward and pleasure centers of the brain adapt to high concentrations of neurotransmitters. • Under unstimulated conditions (without drugs) there is profound interference with the ability to experience pleasure. The user feels as if s/he is experiencing an unmet instinctive drive: dysphoria anxiety, anger, frustration and craving. • Damage caused by neurotransmitter insensitivity leads the user to feel, when sober, the opposite of feeling high. For the user sobriety becomes the opposite of euphoria. • Length of use and intensity of the drug are factors predicting the extent of the damage.
    5. 5. Principles of Addiction Biology • Drugs and alcohol activate the pleasure-producing chemistry of the brain. • Over-stimulation of pleasure pathways causes them to neuroadapt, interfering with the normal experience of pleasure. • Addiction is a disease of the pleasure-producing chemistry of the brain; neuroadaptation is the mechanism of the disease. • Transition to addiction from substance abuse arises from the development of tolerance and withdrawal. • Once neuroadaptation occurs, cessation of drug use leads to ‘inversion of the high’; sobriety becomes pleasureless.
    6. 6. Addiction Pathophysiology • Hedonic Dysregulation – Dysphoria – Persistent boredom – Drug hunger ∀↓D2 Hypofrontality – Decreased recall of adverse consequences – Impaired impulse control – Impaired reasoning – Over value reward -- Under value risk
    7. 7. Definition of Addiction • Compulsion: loss of control The user can’t not do it. S/he is compelled to use. Compulsion is not rational and is not planned. • Continued use despite adverse consequences An addict is a person who uses even though s/he knows it is causing problems. Addiction is staged based on adverse consequences. • Craving: daily symptom of the disease The user experiences intense psychological preoccupation with getting and using the drug. Craving is dysphoric, agitating, and feels very bad. • Denial: distortion of perception caused by craving Under the pressure of intense craving, the user is temporarily blinded to the risks and consequences of using.
    8. 8. Psychoactive DrugPsychoactive Drug Drug-Seeking Behavior Drug Use Failed Impulse Suppression Drug Euphoria Positive Reinforcement Activates Reward Pathways Neuroadaptation Tolerance Physical Dependence Hedonic Dysregulation Environmental cues Limbic Activation + _ Drug Craving Negative Reinforcement Dysregulated Reward Pathways Loss of Control Denial/Impaired decision-making Overvalue Reward Undervalue Risk ↓ Low D2 Hypofrontality Mental Illness Stress
    9. 9. Therapeutic Jurisprudence Assessment Treatment & Monitoring Monitoring Entry into System Discharge Diagnostic Monitoring
    10. 10. Copyright Revenant Technical and Dr. Alex Stalcup 2006 AssessmentAssessmentAssessmentAssessment Emergency RoomEmergency RoomEmergency RoomEmergency Room Domestic ViolenceDomestic ViolenceDomestic ViolenceDomestic Violence Family CourtFamily CourtFamily CourtFamily Court Probation - ParoleProbation - ParoleProbation - ParoleProbation - Parole DependencyDependency HearingHearing DependencyDependency HearingHearing Psych EmergencyPsych EmergencyPsych EmergencyPsych Emergency Entry into System ArrestArrestArrestArrest
    11. 11. Copyright Revenant Technical and Dr. Alex Stalcup 2006 Goals of Assessment Is the client an addict? What combination of factors led to addiction? What factors perpetuate the addiction? What are the barriers to sobriety?
    12. 12. Bio-Psycho-Social Model • Predisposition Genetics Childhood Sexual Abuse Mental Illness • The Drug / Circumstances of First Use • Enabling System
    13. 13. Causes of Craving • Environmental cues (Triggers) immediate, catastrophic, overwhelming craving stimulated by people, places, things associated with prior drug-use experiences • Drug withdrawal inadequately treated or untreated • Mental illness symptoms inadequately treated or untreated
    14. 14. Attention Deficit Disorder & Addiction Prospective four-year study of 15 year-old boys. • 75% Un-medicated ADD boys started abusing alcohol/drugs (N=19) • 25% Medicated ADD boys started abusing alcohol/drugs (N=56) • 18% (Controls) Non-ADD boys started abusing alcohol/drugs (N=137) • 84% Risk Reduction when ADD treated with medications. Adapted from Biederman J, et al. Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder. Pediatrics 104(2):20, 1999
    15. 15. Dual Diagnosis • Mental Illness symptoms interact with drug effects. • Intoxication: relieves symptoms of mental illness • Tolerance: exacerbates symptoms of mental illness • Withdrawal: exacerbates symptoms of mental illness
    16. 16. Addiction: Risk & Resilience • Inherited predisposition (genetics) • Childhood trauma or abuse • Unwanted sexual involvement before age 13 • Mental Illness: depression, anxiety, personality disorder • Attention Deficit Disorder (ADD) • Learning disabilities/school failure • Subjected to teasing, bullying • Acne and/or obesity • Other than heterosexual orientation • Social rejection • Early sexual involvement • Onset of drug use before age 16 • Enabling environment • Ignorance • No family history of addiction • Good mental health • Academic competence • Positive relationship with an adult • Family eats dinner together 5 days/wk • Peer group participation (clubs) • Participation in sports • Participation in music, drama or dance • Involvement in faith-based activities • Taking care of pets • Volunteer activities • Social acceptance • Environment disapproves of drug use • Immediate, appropriate scaled consequences for alcohol/drug use. • Early intervention for alcohol/drug use
    17. 17. Promoting Resilience • Positive relationship with an adult • Positive peer group activities • Involvement in faith-based activities • Participation in Drama or Music or Dance • Taking care of pets • Volunteer activities • Finding pleasure in daily activities
    18. 18. Toxic Psychosis • DELUSIONS usually of the paranoid type • HALLUCINATIONS usually auditory, occurring with intact reality testing or in the absence of intact reality testing, sometimes with • DISORGANIZATION of speech and behavior.
    19. 19. Treatment of Toxic Psychosis • Observation Vital signs every 2 hours until stable, then 3 times daily for 5 days Seek immediate medical attention if temperature is higher than 102 F Reduce environmental stimuli: darkened room, quiet until stable, then gradually increase activities • Medications Intramuscular: combined injection Haloperidol 5 mg + Cogentin 1 mg + Ativan 5 mg Oral: combined dosing every 8 hours Haloperidol 2 mg + Cogentin 0.5 mg + Ativan 2 mg Push Fluids: 500cc over dietary intake every 8 hours
    20. 20. Meth Environments-Risks for Children • Parenting – Attachment: inconsistent discipline, irritable response – Safety: sexual assault, physical assault, verbal abuse – Neglect: poor hygiene, day/night reversal, inconsistent sleep – Nutrition: irregular mealtimes, fast food diet • Developmental Risks – Older children parenting younger children – Unintended observation of sexual activity – Unintended observation of physical violence – Sexualized environment • Environmental Risks – Exposure to toxic chemicals – Exposure to illicit drugs
    21. 21. In-utero exposure to Methamphetamine • 13 in utero meth-exposed children compared with 15 non-exposed children; ages in both groups ranged from 3 to 16 years • Using quantitative MRI, smaller size was seen in subcortical structures responsible for information processing and attention. • Using a battery of neuropsychologic tests, significant deficits were seen in attention, visual motor integration, verbal memory, and long-term spatial memory; clinically, these changes are the same as those seen in ADHD. • This study agrees with previous developmental studies (Billing, l994) showing disorders of executive function manifested by aggressive behavior and hyperactivity. • Chang L, Smith LM, LoPresti C, Yonerura ML, Kuo J. Walot I, Ernst T. Smaller subcortical volumes and cognitive deficits in children with prenatal methamphetamine exposure. Psychiatry Research: Neuroimaging 132 (2004) 95- 106
    22. 22. 5% of Pregnant Women Use Meth in Methamphetamine-Prevalent Areas Tobacco Alcohol Any Illicit Drug Marijuana Meth- amphetamine 0% 20% 40% 60% 80% 100% 25% 23% 11% 6% 5% SOURCE: Adapted by CESAR from Arria, A.M.; Derauf, C.; LaGasse, L.L.; Grant, P.; Shah, R.; Smith, L.; Haning, W.; Huestis, M.; Strauss, A.; Della Grotta, S.; Liu, J.; and Lester, B. “Methamphetamine and Other Substance Use During Pregnancy: Preliminary Estimates from the Infant Development, Environment, and Lifestyle (IDEAL) Study,” Maternal and Child Health Journal Online First, 1-10, January 5, 2006. For more information, contact Dr. Amelia Arria of CESAR at aarria@cesar.umd.edu. Percentage of Women Using Substances At Least Once During Pregnancy, Los Angeles, CA; Des Moines, IA; Tulsa, OK; and Honolulu, HI; 2004 (n=1,632)
    23. 23. Moment of Clarity • Crisis creates a temporary reduction in distortion of thought. • Motivation for treatment is increased.
    24. 24. Therapeutic Jurisprudence Assessment Treatment & Monitoring Monitoring Entry into System Discharge Diagnostic Monitoring
    25. 25. Copyright Revenant Technical and Dr. Alex Stalcup 2006 MonitoringMonitoringMonitoringMonitoring Urine/Hair TestingUrine/Hair TestingUrine/Hair TestingUrine/Hair Testing Telephone SupervisionTelephone SupervisionTelephone SupervisionTelephone Supervision Web-cam SupervisionWeb-cam SupervisionWeb-cam SupervisionWeb-cam Supervision Counseling VisitsCounseling VisitsCounseling VisitsCounseling Visits Parole/Probation VisitsParole/Probation VisitsParole/Probation VisitsParole/Probation Visits
    26. 26. Monitoring and Treatment •Monitoring with drug testing: 3-6 mo. – Negative drug test results = Discharge •Positive Drug Test Result – Extend monitoring (drug test) to 12 mo. – Assess for Mental Health and Environmental problems – Peer support meetings twice weekly for 6 mo. (documented) – Negative drug test results = Discharge •Brief Treatment – Intensive outpatient treatment- minimum 3 mo. (documented) – Peer-support meetings twice weekly for 6 mo. (documented) – Extend monitoring (drug test) to 12 mo. – Negative drug test results = Discharge •Long-term Treatment –Intensive outpatient treatment- minimum 3 mo. (documented) PLUS sober living environment –Residential treatment –In-custody treatment •Re-entry –Peer-support meetings twice weekly for 12 mo. (documented) –Extend monitoring (drug test) to 24 mo. –Negative drug test results = Discharge
    27. 27. Therapeutic Jurisprudence Assessment Treatment & Monitoring Monitoring Entry into System Discharge Diagnostic Monitoring
    28. 28. Copyright Revenant Technical and Dr. Alex Stalcup 2006 DRUG COURT SUPERVISION SanctionsSanctionsSanctionsSanctions IncentivesIncentivesIncentivesIncentives IntensiveIntensive OutpatientOutpatient TreatmentTreatment IntensiveIntensive OutpatientOutpatient TreatmentTreatment AwardsAwards •• Certificates/TokensCertificates/Tokens •• Sport/movie ticketsSport/movie tickets AwardsAwards •• Certificates/TokensCertificates/Tokens •• Sport/movie ticketsSport/movie tickets Positive Judicial FeedbackPositive Judicial FeedbackPositive Judicial FeedbackPositive Judicial Feedback Reduced StructureReduced StructureReduced StructureReduced Structure Recognition CeremoniesRecognition CeremoniesRecognition CeremoniesRecognition Ceremonies Graduated Reinstatement ofGraduated Reinstatement of PrivilegesPrivileges Graduated Reinstatement ofGraduated Reinstatement of PrivilegesPrivileges Shock IncarcerationShock IncarcerationShock IncarcerationShock Incarceration FinesFinesFinesFines Lengthening SupervisionLengthening SupervisionLengthening SupervisionLengthening Supervision Termination from ProgramTermination from ProgramTermination from ProgramTermination from Program
    29. 29. Causes of Craving • Environmental cues (Triggers) immediate, catastrophic, overwhelming craving stimulated by people, places, things associated with prior drug-use experiences • Drug withdrawal inadequately treated or untreated • Mental illness symptoms inadequately treated or untreated
    30. 30. Components of Treatment Initiation of Abstinence: Stopping Use • Drug Detoxification: Use of medications to control withdrawal symptoms • Avoidance Strategies: Measures to protect the client from environmental cues • Schedule: Establishing times for arising, mealtimes, and going to bed • Mental Health Assessment and Treatment Relapse Prevention • Drug Detoxification: Continued use of medications to control withdrawal • Avoidance Strategies: Controlled re-entry to cue-rich environments • Schedule: Adherence to a regular daily lifestyle - HUNGRY Three regularly spaced meals each day - ANGRY Separate feelings of anger from losing control of behavior - LONELY One positive social contact per day minimum - TIRED Daily practice of sleep hygiene • Tools: Behaviors that dissipate craving Exercise Spiritual Practice Talk Peer Support Groups Counseling Having Fun • Mental Health Treatment
    31. 31. Copyright Revenant Technical and Dr. Alex Stalcup 2006 IntensiveIntensive OutpatientOutpatient TreatmentTreatment IntensiveIntensive OutpatientOutpatient TreatmentTreatment Mental Health ServicesMental Health ServicesMental Health ServicesMental Health Services Detoxification ServicesDetoxification ServicesDetoxification ServicesDetoxification Services Individual CounselingIndividual CounselingIndividual CounselingIndividual Counseling Urine/Hair TestingUrine/Hair TestingUrine/Hair TestingUrine/Hair Testing Peer SupportPeer SupportPeer SupportPeer Support Relapse Prevention WorkshopRelapse Prevention WorkshopRelapse Prevention WorkshopRelapse Prevention Workshop
    32. 32. CIM Treatment Model Craving Identification and Management • Relapse Prevention Workshop • Individual Counseling • Medical Services • Alcohol/drug testing
    33. 33. Detoxification Use of medications to treat withdrawal symptoms.
    34. 34. Medications for Meth Withdrawal • Disorders of Mood • Mood Stabilizers  Antidepressants (anhedonia/anergia) Lithium 300-1200 mg Effexor XR 75-225 mg Abilify 5-20 mg Wellbutrin XL150-300 mg Desipramine 100-200 mg • Disorders of Sleep Trazedone 50-300 mg Seroquel 100 mg Imipramine 100-200 mg  Disorders of Thought Abilify 5-20 mg Haldol 1-2 mg Risperdal 1-3 mg
    35. 35. Special Requirements for Treatment of Methamphetamine Dependence • Sleep, Food, Exercise • Meticulous control of environmental exposure to methamphetamine • Prompt treatment of paranoia with antipsychotic medication • Antidepressant treatment of prolonged anhedonia and anergia
    36. 36. Relapse Prevention Workshop Principles • Addicted persons relapse because of craving. • Craving has causes that can be predicted, recognized and analyzed. • Craving can be managed with the use of program activities. Essential Questions • What is your craving score? • Where does your craving come from? – Environmental cues – Stress – Drug withdrawal – Mental health problems • What will you do to take care of yourself? – Avoidance strategies – Stress – Tools – Program activities
    37. 37. Copyright Revenant Technical and Dr. Alex Stalcup 2006 Individual Therapy Individual Therapy Individual Therapy Individual Therapy Intensive Outpatient Treatment Early Recovery Monday Tuesday Wednesday Thursday Friday Saturday Sunday Medication Monitoring Medication Monitoring Peer Support Peer Support Peer Support Peer Support Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention
    38. 38. Copyright Revenant Technical and Dr. Alex Stalcup 2006 Intensive Outpatient Treatment Intensified Early Recovery Monday Tuesday Wednesday Thursday Friday Saturday Sunday Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention Relapse Prevention Individual Therapy Individual Therapy Individual Therapy Individual Therapy Medication Monitoring Medication Monitoring Peer Support Peer Support Peer Support Peer Support Home Exercise Home Exercise Home Exercise Home Exercise Home Exercise Home Exercise Home Exercise Home Exercise Home Exercise Home Exercise Home Exercise Home Exercise Home Exercise Home Exercise Home Exercise Home Exercise
    39. 39. Copyright Revenant Technical and Dr. Alex Stalcup 2006 Work/ School Work/ School Work/ School Work/ School Work/ School Work/ School Work/ School Work/ School Work/ School Work/ School Work/ School Work/ School Peer SupportPeer Support Peer SupportPeer Support Peer SupportPeer Support Peer SupportPeer Support Individual Therapy Individual Therapy Individual Therapy Individual Therapy Intensive Outpatient Treatment Intermediate Recovery Monday Tuesday Wednesday Thursday Friday Saturday Sunday Medication Monitoring Peer Support Peer Support Peer Support Peer Support Home Exercise Home Exercise Home Exercise Home Exercise Home Exercise Home Exercise Home Exercise Home Exercise Process Group Process Group Process Group Process Group Process Group Process Group Process Group Process Group
    40. 40. Avoidance Strategies Measures to Protect the Client From Exposure to Environmental Cues • Identification of environmental cues • Development of avoidance strategies-specific plan to avoid each cue • Rehearsal of avoidance strategies • Implementation of avoidance strategies • changing phone numbers • seeking safe housing • avoiding old using haunts • separating from old using partners/situations • plans for handling money • Enforced isolation-strict avoidance of conditioned cues and total isolation from the using environment during the first four to six weeks of recovery.
    41. 41. Structure Detailed hour-to-hour planning of each day in which the client makes a consistent effort to make the same things happen at the same time each day. H ungry Three regularly spaced, scheduled meals daily A ngry Separate feelings of anger from losing control L onely At least ONE positive social contact daily T ired Daily practice of sleep hygiene-establishing the same bedtime and wake-up time. Initially the judicious use of non-habit forming medication for sleep may be needed.
    42. 42. Daily Schedule 7:00: Get up, Walk my dog 8:00: Shower, Breakfast 9:00: Bus to New Leaf 9:30: Work out at Gym 10;30 Relapse Prevention Group at New Leaf 12:00: Lunch 1:30: Bus home 2:00: Follow-up job applications 3:00: 4:00: 5:00: Peer support meeting 6:30: Dinner at 6:30 7:15: Walk my dog 8:00: Watch TV 9:00: 10:00: Bed
    43. 43. Recovery Tools Behaviors that dissipate craving • Exercise: Two 20 minute exercise periods daily • Spiritual practices: Meditation Prayer • Talk Treatment groups Peer support groups Individual counseling Journal writing Narcotics Anonymous Alcoholics Anonymous • Psychological tools Acceptance Letting go • Baths/Showers: hot or cold • Orgasm: safe sex/self sex • Relaxation exercises: using audio tapes or learned behavioral techniques
    44. 44. Use Episode • In the community setting the client is constantly buffeted by environmental cues. • Drugs are readily available, and often the client has frequent, early use episodes.
    45. 45. Relapse • In Relapse the client disappears from treatment and returns to using drugs. • Losing control is not shameful • Returning to treatment is an act of courage and is praise worthy.
    46. 46. REFERENCES • --- Responsibility and choice in addiction. Psychiatric Services. 53(6):707-13 (2002). • Bechara A. Decision making, impulse control and loss of willpower to resit drugs: a neurocognitive perspective. Nature Neuroscience. 8:1458-63 (2005) • Dackis C, O’Brien C. Neurobiology of addiction: treatment and public policy ramifications. Nature Neuroscience. 8(11):1431-6 (2005). • Nestler EJ, Malenka RC. The addicted brain. Scientific American.com February 9, 2004. • Volkow ND, Fowler JS, Wang GJ. The addicted human brain: insights from imaging studies. The Journal of Clinical Investigation. 111(10:1444-51 (2003). • Weinberger DR, Elvevag B, Giedd JN. The adolescent brain: a work in progress. National Campaign to Prevent Teen Pregnancy. June 2005.
    47. 47. Therapeutic Jurisprudence Assessment Treatment & Monitoring Monitoring Entry into System Discharge Diagnostic Monitoring
    48. 48. Copyright Revenant Technical and Dr. Alex Stalcup 2006 AssessmentAssessmentAssessmentAssessment Emergency RoomEmergency RoomEmergency RoomEmergency Room Domestic ViolenceDomestic ViolenceDomestic ViolenceDomestic Violence Family CourtFamily CourtFamily CourtFamily Court Probation - ParoleProbation - ParoleProbation - ParoleProbation - Parole DependencyDependency HearingHearing DependencyDependency HearingHearing Psych EmergencyPsych EmergencyPsych EmergencyPsych Emergency Entry into System ArrestArrestArrestArrest
    49. 49. Copyright Revenant Technical and Dr. Alex Stalcup 2006 MonitoringMonitoringMonitoringMonitoring Urine/Hair TestingUrine/Hair TestingUrine/Hair TestingUrine/Hair Testing Telephone SupervisionTelephone SupervisionTelephone SupervisionTelephone Supervision Web-cam SupervisionWeb-cam SupervisionWeb-cam SupervisionWeb-cam Supervision Counseling VisitsCounseling VisitsCounseling VisitsCounseling Visits Parole/Probation VisitsParole/Probation VisitsParole/Probation VisitsParole/Probation Visits
    50. 50. Monitoring and Treatment •Monitoring with drug testing: 3-6 mo. – Negative drug test results = Discharge •Positive Drug Test Result – Extend monitoring (drug test) to 12 mo. – Assess for Mental Health and Environmental problems – Peer support meetings twice weekly for 6 mo. (documented) – Negative drug test results = Discharge •Brief Treatment – Intensive outpatient treatment- minimum 3 mo. (documented) – Peer-support meetings twice weekly for 6 mo. (documented) – Extend monitoring (drug test) to 12 mo. – Negative drug test results = Discharge •Long-term Treatment –Intensive outpatient treatment- minimum 3 mo. (documented) PLUS sober living environment –Residential treatment –In-custody treatment •Re-entry –Peer-support meetings twice weekly for 12 mo. (documented) –Extend monitoring (drug test) to 24 mo. –Negative drug test results = Discharge
    51. 51. Copyright Revenant Technical and Dr. Alex Stalcup 2006 IntensiveIntensive OutpatientOutpatient TreatmentTreatment IntensiveIntensive OutpatientOutpatient TreatmentTreatment Mental Health ServicesMental Health ServicesMental Health ServicesMental Health Services Detoxification ServicesDetoxification ServicesDetoxification ServicesDetoxification Services Individual CounselingIndividual CounselingIndividual CounselingIndividual Counseling Urine/Hair TestingUrine/Hair TestingUrine/Hair TestingUrine/Hair Testing Peer SupportPeer SupportPeer SupportPeer Support Relapse Prevention WorkshopRelapse Prevention WorkshopRelapse Prevention WorkshopRelapse Prevention Workshop
    52. 52. Copyright Revenant Technical and Dr. Alex Stalcup 2006 DRUG COURT SUPERVISION SanctionsSanctionsSanctionsSanctions IncentivesIncentivesIncentivesIncentives IntensiveIntensive OutpatientOutpatient TreatmentTreatment IntensiveIntensive OutpatientOutpatient TreatmentTreatment AwardsAwards •• Certificates/TokensCertificates/Tokens •• Sport/movie ticketsSport/movie tickets AwardsAwards •• Certificates/TokensCertificates/Tokens •• Sport/movie ticketsSport/movie tickets Positive Judicial FeedbackPositive Judicial FeedbackPositive Judicial FeedbackPositive Judicial Feedback Reduced StructureReduced StructureReduced StructureReduced Structure Recognition CeremoniesRecognition CeremoniesRecognition CeremoniesRecognition Ceremonies Graduated Reinstatement ofGraduated Reinstatement of PrivilegesPrivileges Graduated Reinstatement ofGraduated Reinstatement of PrivilegesPrivileges Shock IncarcerationShock IncarcerationShock IncarcerationShock Incarceration FinesFinesFinesFines Lengthening SupervisionLengthening SupervisionLengthening SupervisionLengthening Supervision Termination from ProgramTermination from ProgramTermination from ProgramTermination from Program
    1. A particular slide catching your eye?

      Clipping is a handy way to collect important slides you want to go back to later.

    ×