A final substance abuse assisting those with substance dependence 6 22-07
Substance Abuse &Assisting Those WithSubstance DependencePresented by:Mitch KernsMeth SpecialistIDHSmkerns@dhs.state.ia.us515-956-2590June 18, 20 & July 9, 2007
The Impact of Addiction Can Be FarReaching•Cardiovascular disease•Stroke•Cancer•HIV/AIDS•Hepatitis B and C•Lung disease•Obesity•Mental disorders
The initial decision to take drugs is mostly voluntary.However, when drug abuse takes over, a persons ability toexert self control can become seriously impaired. Brainimaging studies from drug-addicted individuals showphysical changes in areas of the brain that are critical tojudgment, decision making, learning and memory, andbehavior control. Scientists believe that these changes alterthe way the brain works, and may help explain thecompulsive and destructive behaviors of addiction.Continued drug abuse- a voluntary behavior?
How Does the Brain Become Addicted?Typically it happens like this:•A person takes a drug of abuse, be it marijuana or cocaine oreven alcohol, activating the same brain circuits as do behaviorslinked to survival, such as eating, bonding and sex. The drugcauses a surge in levels of a brain chemical called dopamine,which results in feelings of pleasure. The brain remembers thispleasure and wants it repeated.•Just as food is linked to survival in day-to-day living, drugsbegin to take on the same significance for the addict. The need toobtain and take drugs becomes more important than any otherneed, including truly vital behaviors like eating. The addict nolonger seeks the drug for pleasure, but for relieving distress.
•Eventually, the drive to seek and use the drugis all that matters, despite devastatingconsequences.•Finally, control and choice and everything thatonce held value in a persons life, such asfamily, job and community, are lost to thedisease of addiction.How Does the Brain Become Addicted?
Repeated drug exposure changes brain function. Positron emission tomography (PET) images are illustrated showing similar brainchanges in dopamine receptors resulting from addiction to different substances - cocaine, methamphetamine, alcohol, or heroin. Thestriatum (which contains the reward and motor circuitry) shows up as bright red and yellow in the controls (in the left column), indicatingnumerous dopamine D2 receptors. Conversely, the brains of addicted individuals (in the right column) show a less intense signal,indicating lower levels of dopamine D2 receptors.
Source: From the laboratories of Drs. N. Volkow and H SchelbertAddiction is similar to other diseases, such as heart disease.Both disrupt the normal, healthy functioning of theunderlying organ, have serious harmful consequences, arepreventable, treatable, and if left untreated, can last alifetime.
No single factor determines whether a personwill become addicted to drugsScientists estimate that genetic factors account for 40-60% of a person’svulnerability to addiction including the effects of environment on these factorsThe influence of the home environment is usually most important in childhood.Parents or older family members who abuse alcohol or drugs, or who engage incriminal behavior, can increase childrens risks of developing their own drugproblemsThe earlier a person begins to use drugs the more likely they are to progress tomore serious abuseMethod of administration. Smoking a drug or injecting it into a vein increases itsaddictive potentialSome people will never develop diabetes because they never go over a certainweight –much like some people will never become drug dependent because theynever try drugs. If they did they would in both cases
Does drug abuse cause mental disorders, or vice versa?Drug abuse and mental disorders often co-exist. Insome cases, mental diseases may precedeaddiction; in other cases, drug abuse may trigger orexacerbate mental disorders, particularly inindividuals with specific vulnerabilities.
2004 National Survey on Drug Use and Health found thatthe percentage of the nations estimated 600,000 monthlymeth users who met the criteria for dependence rose from27.5 percent (164,000) in 2002 to 59.3 percent (346,000)in 2004
• The first meth epidemic occurred in Japan followingWWII when the government released large stockpiles ofmeth that had been held for use by factory workers duringthe war• Amphetamines were used by Allied and Axis armed forcesduring WWII and 1991 Operation Desert Storm• In Japan, meth use has surpassed that of all other drugs-meth users exceed users of all other substances combined• Worldwide, amphetamine and methamphetamine are themost widely abused illicit drug after cannabis- more usethan cocaine or heroin• From the WHO- over 35 million individuals regularlyuse/abuse amphetamine/meth• As of 2003, according to the National Survey on Drug Useand Health, 12.3 million Americans had tried meth at leastonce -up nearly 40% over 2000 and 156% over 1996
% Iowa Adults in Treatment w/Methas Primary Drug of AbuseFY ‘96–‘03 (Iowa Dept Public Health)The proportion of Iowa drug treatment clients citing meth astheir primary substance of abuse rose to an all-time high of 15.8% in 2004 and dropped only slightly in 2005.Prairie Ridge reports 28% of clients used meth.
Methamphetamine – The Drug• Speed, Ice, Meth, Crystal, Crank• Clandestine labs• Easily synthesized• Readily obtainable• Sold through networks• Abusers range widely in age, educational level,socioeconomic status and ethnic background
Forms of MethSpeed usually comes in the form of white or yellow powderPeople usually sniff it through the nose (snort), smoke or inject it.It can also be swallowed, in the form of tablets or capsulesSpeed is often mixed or ‘cut’ with other things that look the same to make thedrug go furtherSome mixed-in substances can have unpleasant or harmful effects
•Making ice, the smokable form of methamphetamine, from standard qualitymethamphetamine HCl is essentially a purification process. Methamphetamine HCl isadded slowly to water that has been heated 80-100°C until a supersaturated solution isobtained. When the slurry is cooled, pure HCl salt of methamphetamine (ice)precipitates. Methamphetamine HCl, unlike cocaine HCl, is volatile and can besmoked. Other solvents, such as isopropanol, have been used in place of water tospeed the process. Uncontrolled variations of this process can result in unreliableremoval or addition of impurities. The physical characteristics of the final productdepend on the quality and type of reagents used and on contaminants that may havebeen introduced. The lack of significant further processing of methamphetamine HClhas resulted in increased availability and popularity of smoking the drug.•One reason for the popularity of smoked methamphetamine is the immediateclinical euphoria that results from the rapid absorption in the lungs and depositionin the brain.•Smoking methamphetamine HCl powder, crystals, or ice occurs first by placingthe substance into a piece of aluminum foil that has been molded into the shapeof a bowl, a glass pipe, or a modified light bulb and heating it over the flame of acigarette lighter or torch. Then, the volatile methamphetamine fumes are inhaledthrough a straw or pipe.From emedincine.comICE
Methamphetamine• Toxicity: Moderate• Flammability: Low• Reactivity: Very Low• Powerful CNSstimulant• Highly addictive• Usually smoked orinjected• “High” lasts longerthan cocaine• Prescribed for weightloss, ADD-typebehaviorsCHCHNHCH3OHCH3EPHEDRINECH3CH CHNHCH32METHAMPHETAMINE
Atlanta DEA Seizes RecordAmount of Crystal Meth…large-scale Mexican drug ring withmembers believed to be in the Atlantaarea, involving importation anddistribution of multi-kilogram quantitiesof methamphetamine and cocaine fromMexico, moved through California andTexas, distributed into the United States……41 kilograms of suspected cocaine andin excess of 187 pounds of suspectedcrystal methamphetamine…
How is Methamphetamine Used?• May be smoked, snorted, orally ingested,injected or used rectally or vaginally• Alters moods in different ways dependingon how it is taken
Acute Positive Effects of Meth• Well-being to Euphoria• Increased Energy• Enhanced Mental Activity• Increased Sex Drive• Decreased Need for Sleep• Decreased Appetite• Increased Sensory Awareness and Alertness• Feeling of Omnipotence• Intensify Emotions• Alter Self-esteem• Increased aggressiveness
• Easily Available (strongest reason)66% females 59% males• 2nd reported reasonFemales: to be more productiveMales: curiosity• Males more likely because parents use drugsReasons for First Use of MethamphetamineMarch 1998- Nov 1998Review article M. Cretzmeyer, et al J. Substance Abuse Treatment24(2003) 267-277
Binge Pattern of Abuse CycleNORMALRUSH(5-30 Min.)HIGH (4-16 hrs.)BINGE (3-15 Days )TWEAKING(4-25 Hours)NORMAL(2-14 Days)WITHDRAWAL(30-90 DAYS)CRASH
Meth vs. Cocaine• Man-made• Daily use• Longer binges• Smoking produces ahigh that last 8-24hours• 50% of the drug isremoved from thebody in 12 hours• Plant-derived• Recreational use• Intermittent binges• Smoking produces ahigh that lasts 20-30minutes• 50% of the drug isremoved from thebody in 1 hour
Meth vs. Cocaine Effects on the BrainCocaineMethamphetamine
Measuring PleasureStimulants boost the normal brain levels of the neurotransmitterdopamine, which produces feelings of pleasure and increasesenergy. Methamphetamines causes an excessive spike indopamine. Scientists say the excessive release contributes to thedrugs destruction of the brain.Dopamine IndexCheeseburger 1.5Sex 2.0Nicotine 2.0Cocaine 4.0Methamphetamine 11.0Source: UCLA Integrated Substance Abuse Programs. Michael Mode/The Oregonian
Effects of Methamphetamine Use on the Brain• Direct dopamine effects:– Changes in mood– Excitation– Intensification ofemotions– Elevation of self esteem– Sensory perception– Decreased appetite– Elevation of libido– Unusual motormovements– Paranoia• Suspected serotonin effects:– Increase feelings ofempathy– Feelings of closeness– Bizarre mood changes– Psychotic behavior– Aggressiveness– Bruxism– Lack of appetite– Inability to sleep
Depleted dopaminetransporter levels inmethamphetamineabusers show recoveryafter prolongedabstinence.In these brain scans,high dopaminetransporter levels appearas red, while low levelsappear as yellow/green.Dr. Nora Volkow, Director ofNIDA(National Institute on DrugAbuse)
Brain Changes with Meth UsePET scans comparing control, Meth users with 6 mo-5 yearsabstinence, and patients with Parkinson’s Disease, showingdecreased dopamine transporter activity in the caudate andputamen. 25% decrease for Meth users, and 60% for PD.(McCann 1998)
Cognitive Deficits• Axons don’t always grow back correctly• Different parts of brain recover at different rates• Impairment of word and picture recall• Impaired ability to manipulate information• Ignore information• Inability to filter irrelevant information• Studies show impairment worse at 12 weeksof non-use than is evident in current user• Word recall gets worse, picture recall getsbetter
Behavior Changes –Psychotic Features• Paranoia• Visual and auditory hallucinations• Mood disturbances• Delusions (ex. The sensation of insects creeping onthe skin)• Homicidal thoughts• Suicidal thoughts• Out of control rages• Can persist for years after use discontinued
Other Effects of Chronic Meth Use• Tooth decay• Hepatitis B and C• STD’s : sexually transmitted disease• HIV : associated with needle use and unprotected sex• Sexual Impotence• Cognitive impairment (reduced ability to processinformation)• Unplanned pregnancy, victims of domestic violence
Cognitive Impairment in Individuals CurrentlyUsing MethamphetamineActive MA users demonstrate impairments in:– the ability to manipulate information– the ability to make inferences– the ability to ignore irrelevant information– the ability to learn– the ability to recall materialMatrix Institute on AddictionsMatrix Institute on Addictions
Effects of Methamphetamine Use -Addiction• Chronic, relapsing disease• Characterized by compulsive drug-seeking anddrug use• Functional and molecular changes in the brain• Stronger potential for addiction– rapid-acting routes of administration– higher dosages– higher purity
Effects of Methamphetamine Use - Tolerance• Take higher doses• Dose more frequently• Change their method of drug intake• “Run” - forego food and sleep while binging• No tolerance for effects on judgment,impulsivity, aggression, and susceptibility toparanoia, delusions, and hallucinations –opposite reaction
Effects of Methamphetamine Use - Withdrawal• Physical:Polyphagia (excessive hunger)Hypersomnolence (sleepiness)• Psychological:DepressionAnxiety/agitation “Free floating” anxietyDelusional state lasting up to a weekFatigue/malaiseParanoiaHallucinationsAggressionIntense craving for the drug
Abstinence SyndromeAfter awaking from the crash, symptoms continue:Psychological/Behavioral Symptoms• Dysphoric mood--that may deepen into clinical depressionand suicidal ideation• Persistent and intense drug craving• Anxiety and irritability• Impaired memory• Anhedonia--loss of interest in pleasurable activities• Interpersonal withdrawal• Intense and vivid drug-related dreams
Abstinence SyndromePhysiological symptoms• Thin, gaunt appearance with reported weight lossor anorexia• Dehydration• Fatigue and lassitude, with lack of mental orphysical energy• Dulled sensorium• Psychomotor lethargy and retardation--may bepreceded by agitation• Hunger• Chills• Insomnia followed by hypersomnia
Special Issues for Women andMethamphetamine• Affordable• Available• Appetite suppressor• Energy enhancer• Weight loss• Mood elevator• Libido enhancer• The growing illicit drug of choice among youngwomen• 47% of those presenting for meth treatment females,other substances 20-25% females
The impact on children may be connected to thefact that women are more likely to use meth thanother illegal drugs.For one thing, the drug is associated with weightloss.One federal survey of people arrested for allcrimes found that 11.3 percent of women had usedmeth within the prior month compared with 4.7percent of men.
Parenting Issues with Meth Involvement• Neglect during long periods of sleep• Inconsistent, paranoid behavior• Irritability, short fuse, potentially leading tophysical abuse• Exposure to violence, unsavory characters• Generally poor parenting skills• Mental health issues
Substance Abuse Affects Parenting[Blending Perspectives and Building Common Ground, A Report to Congresson Substance Abuse and Child Protection, April 1999]• Impaired judgment andpriorities• Inability to provide theconsistent care, supervisionand guidance children need• Substance abuse is a criticalfactor in child welfare
Children of Parentswith Substance Abuse Problems• Have poorer developmental outcomes(physical, intellectual, social and emotional)than other children• Are at an (eight-fold) increased risk ofsubstance abuse themselves
Substance Abuse and Child Abuse and Neglect• Substance abuse causes or exacerbates 7 outof 10 cases of child abuse and neglect• Children whose parents use drugs and alcoholare:– 3x more likely to be abused– More than 4x more likely to be neglected
Basic Meth Patient Treatment ConsiderationsMany stimulant dependent individuals demonstrate…1. Low Impulse Control2. Low Tolerance for Frustration3. High Likelihood of Psychiatric Complications(paranoia, delusions, agitated depression)4. High Risk for Explosive, Violent Behavior5. High Risk of Depression and High Risk of Suicide6. Very Strong Craving7. Cognitive and Memory Impairment8. Brief Attention Span
What doesn’t work?I. Shame: The addiction is a disease. You cannot scare a diseaseaway, you cannot threaten a disease away, and you cannot shame adisease away. Much like you cannot scare, threaten or shamediabetes away. These are people with a disease that must learn tocontrol the disease throughout the rest of their lives.II. Try to avoid statements such as “if you wanted it bad enough, youwould quit.” “if you loved your children you would quit.” Theaddict probably already has a lot of guilt and shame.III. Heavy front-loading of services. The client is coming out of achaotic world with an impaired sense of intellectual functioning andwill not be able to accommodate effectively all the services that mayeventually be called for if they are all provided early in the case.Don’t try to address all the deficiencies simultaneously.IV. There are no quick fixes in working with meth and drug using cases,in fact it appears the longer the client is engaged in services thebetter the outcome.
What does work?The first and foremost thing to remember is that meth addictscan become clean and sober and live a life of recovery.However, there are a few things to try with meth addicts thatmay help them get into recovery quicker.Treat them with respect, listen to their concerns and reasons forcontinued or reuse even though they may not seem logical tous in the beginning. It is important to meet our clients wherethey are at emotionally and intellectually, not where we are at.
Use encouragement with the addict. Continue totell them that they can do it. If we believe inthem, they will hopefully start to believe inthemselves. Clients have to be held accountableand have to face consequences for their actionsbut our job is also to help them work through whythey made those choices and what can be done sothey have different options next time.Have as much contact as you can work into yourschedule with the primary substance abusecounselor. It is very important that you and thecounselor become a team in helping the client inrecovery. Both have an important part of thepuzzle and those pieces must be put together.What does work?
I. Often when we become involved in a ‘meth’ casethere are a lot of issues that need to be addressed.Find a way to prioritize what needs to be worked onfirst. Try to think of it as a marathon and not a sprint.In most cases, sobriety and then recovery is the mostcritical obstacle. Without sobriety and recovery,parenting skills, employment, housing, etc. will nothappen. Try not to frontload services. Find two orthree things to address initially so that the client canbe successful and then move on to the rest of the list.II. Drug testing is also very important as a recovery tool.Many recovering addicts have indicated that drugtesting and fear of random drug testing played amajor tool in their recovery.What does work?
Visits with children are very important. This cannot bestressed enough. Do your best to line up visits immediately,preferable within a couple of days if the children are removed.It is very important to the addict and more importantly for thechildren that they have contact with their parents. These visitscan be supervised by a professional, family member orunsupervised if the case warrants. The point is no matter whatthe issues are; please look for a way to have safe visits for thechildren early and often.Trust is a very big issue with addicts. Be honest and upfrontwith them from the beginning. Chances are they are lookingfor an excuse not to trust in you and the system. If you saythat you are going to do something, do it. If you make apromise, keep it.What does work?
Support of self-help and 12-step groups canhelp maintain a clean and sober lifestyleAddressing cultural, ethnic, or languageissues and sensitivity to spiritual beliefs andvalues improves successAvoid an assumption that retention problemsreflect a lack of cooperationExamine and address issues that can createbarriers to treatment success, among them:transportation, childcare, health, and supportor sabotage from a partner or other familymember
Using family team meetings is a helpful way to help addresswhat needs to be looked at first. It is a great way to help theclient process what needs to be accomplished right away andalso what issues will need to be addressed at a later date. Theyare effective in providing organization where there was onlychaos. FTMS are also an excellent way to develop a safetyplan in case of relapse or reuse that the parents have some sayin that also ensures the child’s safety. Keep it simple anddoable.Family and 12-step and mutual support groups (MOM orDAD) can be great supports especially early in recovery.What does work?
Implications for practiceTry to find time for a quick phone call or a quick little noteof reassurance and encouragement. This will go a long wayin helping the addict be successful and will help the casemove quicker towards safe case closure.You can take exception to the person’s behavior but youmust accept the person in order to make progress.Determine the priorities for intervention in a case and thenmove slowly forward to implementation.Provide parent/child visitationProvide support and encouragementIf we take away their only solution to life’s problems weneed to follow that up with some other means of coping.
Can addiction be treated successfully?Yes. Addiction is a treatable disease. Discoveries in thescience of addiction have led to advances in drug abusetreatment that help people stop abusing drugs andresume their productive lives.Can addiction be cured?Addiction need not be a life sentence. Like otherchronic diseases, addiction can be managedsuccessfully. Treatment enables people to counteractaddictions powerful disruptive effects on brain andbehavior and regain control of their lives.
Relapse rates for drug-addicted patients are compared with those suffering from diabetes,hypertension, and asthma. Relapse is common and similar across these illnesses (as is adherenceto medication). Thus, drug addiction should be treated like any other chronic illness, with relapseserving as a trigger forRelapse rates for drug-addicted patients are compared with those suffering fromdiabetes, hypertension, and asthma. Relapse is common and similar across theseillnesses (as is adherence to medication). Thus, drug addiction should be treatedlike any other chronic illness, with relapse serving as a trigger for renewedintervention.
People Can and Do Recover from Meth AddictionOutcomes data provided by SSAs confirm that people can and do recover from methaddiction. Examples include:• Colorado’s Alcohol and Drug Abuse Division reported in FY 2003 that 80% ofmeth users were abstinent at discharge.• Iowa’s Division of Behavioral Health and Professional Licensure found, in a 2003study, that 71.2% of meth users were abstinent 6 months after treatment.• Tennessee’s Bureau of Alcohol and Drug Abuse reported in a 2002-2003 study thatover 65% meth clients were abstinent 6 months after discharge.• The Texas Department of State Health Services examined outcomes data forpublicly funded services from 2001-2004 and found that approximately 88% ofmeth clients were abstinent 60 days after discharge.• Utah’s Division of Substance Abuse and Mental Health reported that in StateFiscal Year 2004, 60.8% of meth clients were abstinent at discharge.National Association of State Alcohol and Drug Abuse Directors, Inc.
September 2005 ReportIowa Consortium for Substance Abuse Research and Evaluation,University of Iowa basedmeth addicts who received treatment had higher abstinence rates sixmonths later than any other group, including alcohol, cocaine andmarijuana users.• Meth users -abstinence rate of 65.4 percent(they hadnt taken meth or any other substance six monthsafter treatment)• Marijuana –abstinence rate of 49.3 percent• Alcohol –abstinence rate of 47.1 percent• Cocaine –abstinence rate of 50.1 percent"Compared to marijuana or alcohol, the people who are on meth tendto do better," says Stephan Arndt , the groups director.
“Statewide in Iowa our methamphetamine addicts have a betteroutcome than any other drug of primary choice," said KermitDahlen, president and CEO at Jackson Recovery Centers say that 82percent of meth addicts who complete treatment are still sober sixmonths later. Dahlen credited the adoption of evidence-basedpractices for the success.Jacksons Women and Childrens Center has a 73-percent completionrate, said program director Janelle Tomoson. "Some do comethrough more than one time. Relapse is part of the learning processand part of the disease. Its a chronic disease," she said, adding thatwomen tend to do better in gender-specific programs."The moms not only learn to get sober, but many of these womenhave never had an opportunity to learn how to parent," said Dahlen."They do love their children. Our programs show them they are nota bad person and are capable of loving their children and are capableof providing them with a good home."
Matrix Model -Treatment That WorksKey ElementsRelies primarily on group therapyTherapist functions as teacher/coachNot confrontational ( positive, encouraging relationship)Time planning and schedulingAccurate informationRelapse preventionFamily involvementSelf help involvementUrinalysis/Breath testingRelapse PreventionFamily and Group TherapyMotivational Interviewing12- Step InvolvementPsychoeducationSocial Support
Pre-Recovery Behaviors/ExcusesOccur with Increased Frequency• Old playmates andold playgrounds• Person not followingthrough with AA/NAmeetings or recoverysteps• Cross-addictions• “I will just stop over atJim’s and if they havedrugs, I will justleave”• “I’m too busy/tired togot to a meeting,”• I don’t have a problemwith alcohol so it isOK for me to drink.”
Reuse• can be the use of a drug “out of the blue”• person may be working an excellentrecovery program• may have had a long period of sobriety• may be avoiding the old friends and oldplaygrounds• They may be doing everything right but stillhave used
Reuse is very much a concern,but different than Relapse……• It is tends to be an isolated action• Can be the “shock” to one’s system thatdemonstrates the recovering person’scontinued vulnerability• Could show them that recovery is a life-long process• Studies support that reuse often is part ofrecovery (depending on how it is addressed)
Back to Basic Questions….• Are they willing to increase AA/NA/MOM/DAD support group meetings?• Are they willing to resume or stay in formaltreatment services longer?• Is the family cooperating with Family TeamMeetings and complying with Service Plan?• Revisit the Safety Plan.
Relapse Prevention Steps• Self-knowledge and identificationwarning signs. This process teachesclients to identify the sequence ofproblems that has led from stablerecovery to chemical use in the past, andthen to synthesize those steps into futurecircumstances that could cause relapse.
Step 2• Coping skills and warning signmanagement. This process involvesteaching relapse-prone clients how tomanage or cope with their warning signs asthey occur.
Step 3• Change and recovery planning.Recovery planning involves thedevelopment of a schedule of recoveryactivities that will help clients recognizeand manage warning signs as they occurin sobriety.
Step 4•Awareness and inventory training.Inventory training teaches relapse-proneclients to do daily inventories that monitorcompliance with their recovery programand check for the development of relapsewarning signs.
Step 5• Maintenance and relapse prevention planupdating. Ongoing treatment is necessaryfor effective relapse prevention. Evenhighly effective short-term inpatient orprimary outpatient programs will be unableto interrupt long-term relapse cycleswithout the ongoing reinforcement of sometype of outpatient therapy until sustainedrecovery is achieved.
Types of Relapse-Prone Clients• Transition- does not accept/recognize theiraddiction and are not able to accurately perceivereality due to chemical effects.• Unstabilized- lacks addiction interruption skills,recovery program support, and positive lifestylechange.• Stabilized- is aware of their addiction and thenecessity for ongoing recovery program tomaintain abstinence. However, they tend todevelop dysfunctional symptoms over timeleading back to substance usage.
Relapse or Reuse? • It is important to distinguish relapse fromreuse. They are two different things.• Relapse is a progressive psychological andbehavioral change• Can start hours, days, weeks or monthsbefore a person uses mood-alteringchemicals
Relapse ≠ Treatment FailureRecurrence of substance use can happen atany point during recoveryRecognize the difference between a lapse (aperiod of substance use) and relapse (thereturn to problem behaviors associated withsubstance use)Work with the client to re-engage intreatment as soon as possible
Part of effecting long-term change includesworking with clients to identify the specificfactors that preceded their substance use—What were the emotional, cognitive,environmental, situational, and behavioralprecedents to the relapse?Relapse ≠ Treatment Failure
One element in the process of recovery is todevelop a relapse prevention plan and strategies toavoid relapsePlan for the potential of relapse and for ensuringsafety of the child(ren)Parents who learn triggers can become empoweredto plan proactively for the safety of their childrenand to seek healthy ways to neutralize or mitigatethe triggerRelapse prevention includes: “What can a client dodifferently?”Relapse ≠ Treatment Failure
Implications for Practice• Make sure factors critical for recovery areaddressed by making client accountable.• Relapse does not necessarily mean thediscontinuation of visitation. Don’t stop visits aspunishment if the child’s safety and well-beingcan be assured.• Provide client with accurate information aboutrelapse process and the means to avoid it.• Encourage client through motivationalinterviewing and affirmations
Readiness for ChangeAmbivalence about change allows exploration of costs ofstatus quo, and benefits of change versus costs of changeand benefits of status quo.Readiness to change factors:• Perception of need to change• Belief that change is possible and can be positive• Sense of self-efficacy to make the change• Stated intention to change
Use of support groups may have greater benefitsfor women. In a study of pregnant addictedwomen, support group participation resulted inbetter outcomes for mothers and their infantsParticipation in group counseling appears toinfluence a lower rate of relapse for women. Inaddition more intense participation in treatment isrelated to lower rates of relapse
Often women in treatment have low self-esteem,little self-confidence, and feel powerless. It isimportant to address these issues to improvetreatment effectiveness.Since women appear to become addicted morerapidly than men, by the time they entertreatment, their addiction may be more severe,which affects the level and intensity of treatmentneeded.
In the general population, women have twice therate of depression as men, one-third ofwomen who enter SA treatment haveexperienced clinical depression in the past year30-60% of persons in treatment have aco-occurring mental disorder, including panicattack and other anxiety disorders; it is criticalthat women’s treatment identify and incorporatemental health services as needed.
Help identify and coordinate the various services neededto help reduce barriers to recovery and treatment successHelping develop aftercare step-down services is avaluable support that can help sustain recoveryChild visitation - Rather than a blanket rule regardingvisitation between parent and child, it may be moreappropriate to look at the factors affecting a specific caseto make an individual determinationFreedom and stability of recovery are benefits that personsin recovery have identified as important, helping a clientunderstand how his or her life is better is an importantsupport for recovery
Women in treatment relapse less frequently than menmore likely to engage than men, particularly in groupcounselingOne study of women cocaine users found that whenwomen relapse, they were more likely than men to reportnegative emotions or interpersonal problems before therelapseWomen appeared more impulsive in their return to useMen were more likely to report positive feelings and abelief they could control their drug use prior to relapse
Treatment TipsUse behaviorally oriented groups that stress problem solving andgroup buildingrole playspractice solving real life experiencesCreates excitement, focus, and has them do the work of their ownrecoveryRemember:Many started using alcohol and drugs at a very early ageMay be developmentally immatureCome from homes and environments where there is littlesupport for recoverymay not know what a healthy sponsor or positive recoveryoriented group should look like
www.drugfreeinfo.orgIowas 24/7 Drug and Alcohol Help Line: Tollfree 1-866-242-4111Iowa ResourcesAgencies, Studies, StatisticsDirectory of Services Lists types of services,population served, and links toeach provider
ResourcesTIP series from SAMHSA Substance Abuse and MentalHealth Services Administrationunder Publications atwww.samhsa.gov/index.aspxNCSACW National Center on Substance Abuse and Child Welfarewww.ncsacw.samhsa.govChildren of Alcoholics Foundationwww.coaf.org
RESOURCES COLLECTED FROM THE FOLLOWING• http://www.health.org/govpubs/PHD861• Kci.org (Formerly Koch Crime Institute)• Lifeormeth.org• Methabuse.net• Dr. Rizwan Shaw, Medical Director Regional Child Protection Center• Dr. Resmiye Oral U of I Child Protection Program & Child Health Specialty Clinic• SAMHSA http://www.ncsacw.samhsa.gov/files/understandingSAGuide.pdf• Judy Murphy -Meth Specialist Cedar Rapids Area Iowa DHS• Dr. Joyce Gilbert Medical Effects of Meth on Children -Idaho DEC Conference 2004• Brian Reed Decontamination of Meth Contaminated Residences -Idaho DEC Conference 2004• Dr. John Martyny Ph.D., CIH National Jewish Medical and Research Center Chemical ExposuresAssociated with Clandestine Meth Labs -Idaho DEC Conference 2004• Dr. Kathryn Wells & Dr. Wendy Wright Medical Summit -Idaho DEC Conference 2004• Captain Clark Rollins Idaho State Police Investigations Michelle Britton Regional Director Departmentof Health and Welfare DEC Successes -Idaho DEC Conference 2004• Dr. Kiti Freier Associate Professor Psychology & Pediatrics Loma Linda University, AssociateDirector, Center for Prevention Research Andrews University Psychological and Social Needs of theDrug Endangered Child -Iowa DEC Conference 2005• CC Nuckols PhD Methamphetamine Addiction: “Speed” Still Kills Counselor Magazine January 03• Iowa Division of Narcotics Enforcement• Matrix Institute www.matrixinstitute.org• Iowa Drug Endangered Children Program www.iadec.org• Iowa DHS• North Carolina Division of Social Services
Brain Changes with Meth Use• Rhesus and Vervet monkey studies• Given 3-6 months meth doses equivalent tohumans• Decreased dopamine levels in the caudateby 80% immediately after stopping methand up to 6 months later(Seiden 1975, Woolverton 1989, Melega 1996 and 1997)
Implications for practiceIf we take away their only solution to life’s problems we needto follow that up with some other means of coping.The result of that is that often we end up with parentifiedchildren who are used to taking care of themselves and theirsiblings. They may not respond to direction and consequentlyare problems in school because they have been makingdecisions themselves and have learned that adults aren’t goingto take care of them or can’t be trusted. We label them withsome DSM IV diagnosis rather than understanding where theyare coming from.The original home environment was characterized by chaos anddisorder. Some sense of order and routine must be establishedwhich may interfere with what household members are used toand how they liked to behave.There will be some turmoil because of some role changes as aresult of sobriety.
Motivational Interviewingfive general principles:Express empathy through reflective listeningDevelop discrepancy between clients’ goals orvalues and their current behaviorAvoid argument and direct confrontationAdjust to client resistance rather than opposing itdirectlySupport self-efficacy and optimism
Treatment TipsTell clients symptoms they are experiencing are common at givenstage of abstinenceAvoid 60 minute didactic sessions –meth addicts struggle tomaintain focus also may be developmentally too immature toparticipate15-20 minute video or didactic session followed withquestionnairewhat they thought about the presentationwhat they learnedhow their future behavior will changeSessions on how to participate in treatment & how to find a selfhelp group
Don’t overload/frontloadKeep lists shortAssist in prioritizingSafety plan for kids as part of relapse planDay plannersEncourage lots of supportEstablish “circles of support”Acknowledge and complimentSee more often shorter time periodsThings to Keep in Mind