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Entrance into System. Arrest. Psych Emergency. Emergency Room. Assessment. Domestic Violence. Family Court. Probation - Parole. Schools. Abuse versus Addiction.

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Entrance into System

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Entrance into system l.jpg

Entrance into System


Psych Emergency

Emergency Room


Domestic Violence

Family Court

Probation - Parole


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Abuse versus Addiction

Substance Abuse is distinguished from Addiction by the appearance of tolerance and withdrawal, leading to loss of control over use.

Substance abusers require motivation to stop.

Addicts require treatment to stop.

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Monitoring and Treatment

In-custody Treatment

Residential Treatment

IOP + Sober Living

Intensive Outpatient





Random UDS 6 months

(Positive UDS)




Random UDS

6 tests/90 days





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Rapidly spreading outbreak of disease that affects an unexpectedly large number of people within a very short period.

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Prescription Drug Abuse

Opiate pain medications

Benzodiazepine tranquilizers

Prescription stimulants

(Adderall, Ritalin)

Sleeping pills, muscle relaxants

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National Survey on Drug Use and Health Statistics 2007

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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 it feels very bad.

  • Denial/hypofrontality: distortion of cognition caused by craving

    Under the pressure of intense craving, the user is temporarily blinded to the risks and consequences of using.

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A system of data collection to monitor disease (drug use) in the community

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Prescription Drug Surveillance Surveillance: a system of data collection for monitoring drug use in the community

Opiate mis-prescribing by local providers

Diversion of prescription opiates/ doctor shopping

Schoolyard sales

School drop out rates, expulsions and suspensions

Emergency room/hospital admissions

Pharmacy thefts/Fake prescriptions

Street sales

Increased local availability of heroin

Public health clinics monitoring for HIV, Hepatitis B&C, Abscesses

Admissions to local treatment facilities

Jail admissions for possession, car break-ins, residential burglaries

Increased appearance of opiate addicted prostitutes

Data on causes of death from death certificates

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Sentinel Event

Clusters of deaths in a community, school, facility, work site or other institution over a short period.

Clusters of drug use in a community, school, facility, work site or other institution, usually three or more cases over a short period.

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Sentinel Events in Prescription Drug Abuse

Overdoses in younger individuals

DUI arrests with low BAL

Youth falling asleep in school

Youth stealing from parents and friends

Increased schoolyard drug and pill sales

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National Survey on Drug Use and Health Statistics 2007

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National Survey on Drug Use and Health Statistics 2007

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“You’ve Got Drugs V” Prescription Drug Pushers on the Internet. National Center on Addiction and Substance Abuse, Columbia University 2008

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Prescription Opiates

Generic: Brand NameNon Tolerant 24 hr. dose

Codeine w/acetaminophen500 mg

Hydrocodone:Vicodin, Lortab, Norco20mg-60 mg

Hydromorphone: Dilaudid20 mg-60 mg

Oxycodone: Percodan, OxyContin20 mg-60 mg

Morphine sulfate: MS Contin30 mg-60 mg

Fentanyl: Duragesic (transdermal), Actiq25 mcg-50 mcg

Tolerant Users onlyTolerant 24 hr. dose

Morphine sulfate: MS Contin60 mg-upward

Fentanyl: Duragesic (transdermal)75 mcg-300 mcg

Methadone: Methadose60 mg-300 mg

Buprenorphine: Suboxone, Subutex 6 mg-32 mg

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Opiate progression from pills to the needle

Historically, untreated dependence on prescription opiates led to a trajectory from

  • Pills ingested orally

  • Pills crushed and snorted or smoked

  • Heroin snorted or smoked

  • Heroin used intravenously

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A 33-year follow-up of narcotics addicts


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Overview of Buprenorphine:Suboxone and Subutex

  • Highly safe medication (acute & chronic dosing).

  • Primary side effects: like other mu agonist opioids (e.g.,nausea, constipation) but may be less severe.

  • No evidence of significant disruption in cognitive or psychomotor performance with buprenorphine maintenance.

  • No evidence of organ damage with chronic dosing.

    Use of Buprenorphine in the Pharmacologic Management of Opioid Dependence: A Curriculum of Physicians. (eds: Strain EC, Trhumble JG, Jara GB) CSAT. 2001

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Prescription Tranquillizers

Dose Equivalent To Alcohol

(2oz liquor or 2 glasses of wine or 2 cans of beer)

  • Alprazolam (Xanax®)0.5- 1mg

  • Diazepam (Valium®)10mg

  • Chlordiazepoxide (Librium®)25mg

  • Clonazepam (Klonopin®)1-2mg

  • Lorazepam (Ativan®)2mg

  • Temazepam (Restoril®)30mg

  • Butalbital (in Fiorinal®)100mg

  • Carisoprodol (Soma ®)350mg

  • Zolpidem (Ambien®) 10 mg

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Calm Euphoria

Release of Inhibitions

Sleep Inducing


Slurred Speech

Unsteady gait (Ataxia)



Slows heart rate

Decreases blood pressure

* Symptom may continue for months


Dysphoria *

Anxiety *

Insomnia *

Sweating (Diaphoresis) *





Elevated temperature



Delirium tremens

Sedative-Hypnotic Effects

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Prescription Stimulants

Adderall is a brand-name pharmaceutical psychostimulant composed of mixed amphetamine salts. Adderall is widely reported to increase alertness, concentration and overall cognitive performance while decreasing user fatigue.

Prescription Stimulants are Schedule II drugs under the Controlled Substance Act for the United States.

Concerta, Vyvanse, Dexedrine are similar, often abused, prescription psycho-stimulants.

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Antidepressants (anhedonia/anergia)

Effexor XR150-300 mg

Cymbalta60 mg

Wellbutrin XL150-300 mg

Desipramine100-200 mg

Anti-Craving Medications

Modafinil100-200 mg

Methylphenidate LA 10-40 mg

Buproprion150-300 mg

Concerta18-54 mg

Dexedrine SR20-30 mg

Disorders of Sleep

Trazedone50-300 mg

Seroquel25-100 mg

Imipramine100-200 mg

Disorders of Thought

Abilify2-10 mg

Haldol1-2 mg Risperdal1-3 mg

Medications for Stimulant Dependence

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C I M Model TreatmentCauses 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

  • Stress equals craving

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Environmental Cueing =Conditioned Craving

Drug pleasure becomes associated with specific people, places, and things; to encounter any of those things in the environment is to trigger craving for the drug. Such triggers persist for decades after use.

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C I M Model TreatmentComponents 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

    • HUNGRYThree regularly spaced meals each day

    • ANGRYSeparate feelings of anger from losing control of behavior

    • LONELY One positive social contact per day minimum

    • TIREDDaily practice of sleep hygiene

  • Tools: Behaviors that dissipate craving

    Exercise Spiritual Practice Talk Peer Support Groups Counseling Having Fun

  • Mental Health Treatment

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Community Response to MethamphetaminePregnant and Parenting Families

Drug Treatment

• Outpatient 1:1 and group

• Dependency Court

Child Protective Services

• Child Welfare worker

• Dependency Court

Educational Interventions

• Parenting Class

• Anger Management Class

• Battered Women’s support

Public Health Nursing


• Nutritionist

• Nurse Practitioner

Community Support

• 12-Step Programs

• Church/Pastoral counseling


• Halfway housing that

accepts children

• Section 8

Mental Health Treatment

• Medication Management

• Therapy

Offender Supervision

• Probation

• Parole

• Jail

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  • --- 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.

  • Stalcup SA, Christian D, Stalcup JA, Brown M Galloway GP. A treatment model for craving identification and management. Journal of Psychoactive Drugs. 38:235-44, 2006

  • 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.

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