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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
Entrance into System

Arrest

Psych Emergency

Emergency Room

Assessment

Domestic Violence

Family Court

Probation - Parole

Schools

abuse versus addiction

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.

slide4

Monitoring and Treatment

In-custody Treatment

Residential Treatment

IOP + Sober Living

Intensive Outpatient

IOP

Addict

Re-entry

Monitoring

Random UDS 6 months

(Positive UDS)

Entry

Assessment

Monitoring

Random UDS

6 tests/90 days

?

Discharge

Unsure

Discharge

epidemic
Epidemic

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

prescription drug abuse

Prescription Drug Abuse

Opiate pain medications

Benzodiazepine tranquilizers

Prescription stimulants

(Adderall, Ritalin)

Sleeping pills, muscle relaxants

definition of addiction
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.

surveillance

Surveillance

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

slide13

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

sentinel event

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.

sentinel events in prescription drug abuse

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

slide20

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

prescription opiates
Prescription Opiates

Generic: Brand Name Non Tolerant 24 hr. dose

Codeine w/acetaminophen 500 mg

Hydrocodone:Vicodin, Lortab, Norco 20mg-60 mg

Hydromorphone: Dilaudid 20 mg-60 mg

Oxycodone: Percodan, OxyContin 20 mg-60 mg

Morphine sulfate: MS Contin 30 mg-60 mg

Fentanyl: Duragesic (transdermal), Actiq 25 mcg-50 mcg

Tolerant Users only Tolerant 24 hr. dose

Morphine sulfate: MS Contin 60 mg-upward

Fentanyl: Duragesic (transdermal) 75 mcg-300 mcg

Methadone: Methadose 60 mg-300 mg

Buprenorphine: Suboxone, Subutex 6 mg-32 mg

opiate progression from pills to the needle
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
overview of buprenorphine suboxone and subutex
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

prescription tranquillizers
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
sedative hypnotic effects
Effects

Calm Euphoria

Release of Inhibitions

Sleep Inducing

Sedation/Sleepiness

Slurred Speech

Unsteady gait (Ataxia)

Confusion

Forgetfulness

Slows heart rate

Decreases blood pressure

* Symptom may continue for months

Withdrawal

Dysphoria *

Anxiety *

Insomnia *

Sweating (Diaphoresis) *

Tremor

Tachycardia

Hypertension

Hyperventilation

Elevated temperature

Hallucinations

Seizures

Delirium tremens

Sedative-Hypnotic Effects
prescription stimulants

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.

medications for stimulant dependence
Antidepressants (anhedonia/anergia)

Effexor XR 150-300 mg

Cymbalta 60 mg

Wellbutrin XL 150-300 mg

Desipramine 100-200 mg

Anti-Craving Medications

Modafinil 100-200 mg

Methylphenidate LA 10-40 mg

Buproprion 150-300 mg

Concerta 18-54 mg

Dexedrine SR 20-30 mg

Disorders of Sleep

Trazedone 50-300 mg

Seroquel 25-100 mg

Imipramine 100-200 mg

Disorders of Thought

Abilify 2-10 mg

Haldol 1-2 mg Risperdal 1-3 mg

Medications for Stimulant Dependence
c i m model treatment causes of craving
C I M Model TreatmentCauses of Craving

E W M S

  • 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
environmental cueing conditioned craving
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.

c i m model treatment components of treatment
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
    • 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
community response to methamphetamine pregnant and parenting families
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

WIC

• Nutritionist

• Nurse Practitioner

Community Support

• 12-Step Programs

• Church/Pastoral counseling

Housing

• Halfway housing that

accepts children

• Section 8

Mental Health Treatment

• Medication Management

• Therapy

Offender Supervision

• Probation

• Parole

• Jail

references
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.
  • 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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