S. Alex Stalcup, M.D.

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. 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. (67% versus 35%)

3. What is a Drug? A drug is a pleasureproducing chemical. Drugs activate or imitate chemical pathways in the brain associated with feelings of well-being, pleasure, and euphoria.

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. 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. • Once neuroadaptation occurs, cessation of drug use leads to ‘inversion of the high’; sobriety becomes pleasureless.

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. The addict can’t not use. • 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: 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. Physical Dependence • Physical Dependence When the user stops the drug, physical illness results. • Abstinence Syndrome Name of the illness caused by withdrawal symptoms. • Tolerance Neuroadaptation forces the user to increase the dose to maintain the effect of the drug. Using an inadequate dose causes withdrawal: symptoms occur when the amount used is less than the tolerance level.

9. 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 • Stress equals Craving

12. Bio-Psycho-Social Model Predisposition Genetics Childhood Sexual Abuse Mental Illness The Drug / Circumstances of First Use Enabling System

14. Reward Deficiency Syndrome • Clinical Presentation Substance Abuse Disorders Compulsive Disorders Attention Deficit Disorder • Supportive Observations • All drugs of abuse augment dopamine function. • Persons with Reward Deficiency Syndrome predominantly have the A1, D2 allele. • Persons with the A1, D2 allele have 20% to 30% fewer D2 (reward) receptors. • The A1 allele confers a 74% increase in risk of having one or more Reward Deficiency Syndrome disorders. Adapted from Blum K, Cull JG, Braverman ER, comings DE. Reward deficiency syndrome. Am Sci. 1996;84:132-145.

16. Attention Deficit Disorder and Addiction Treatment of ADD with medications reduced the risk of alcohol/drug abuse 84 % Prospective four-year study of 15 year-old boys. • 75% Unmedicated ADD boys started abusing alcohol/drugs (N=19) • 25% Medicated ADD boys started abusing alcohol/drugs (N=56) • 18% Non-ADD boys started abusing alcohol/drugs (N=137) Adapted from Biederman J, et al. Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder. Pediatrics 104(2):20, 1999

18. Dual Diagnosis Co-occurrence of Mental Illness and Substance Abuse • Consider dual diagnosis if • Onset of addictive disease in early or mid-teens • Indiscriminate poly-substance use • Frequent drug use despite engagement in treatment • Client dislikes sobriety • Mental health symptoms worsen over time. • Most common mental illness diagnoses are anxiety disorders, depression, posttraumatic stress disorder (PTSD), and personality disorders.

19. 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

20. Promoting Resilience • Positive relationship with an adult • Positive peer group activities • Involvement in faith-based activities • Participation in pleasurable activities • Music (playing, singing, dancing) • Taking care of pets • Volunteer activities

27. 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.

28. 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

29. Meth EnvironmentsRisks 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 • Needle exposure • Physical hazards

30. 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 • Stress equals Craving

31. 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 as needed • 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 Pleasurable Activities Treatment Groups Individual Counseling • Mental Health Assessment and Treatment

32. 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. (67% versus 35%)

33. 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

34. CIM Treatment ModelCraving Identification and Management • Relapse Prevention Workshop • Individual Counseling • Medical Services • Alcohol/drug testing

35. DETOXIFICATION Use of medications to treat withdrawal symptoms.

36. Medication Guidelines • Consider the use of medications if the client has insomnia, anxiety, or depression that interferes with daily function. • 1/3 to 1/2 of patients will require medication during the first weeks of treatment. • A therapeutic trial using a flow chart focuses attention on symptom management. • Symptom monitoring validates patient distress, and puts a name and boundaries on otherwise generalized unhappiness in early recovery.

37. Medications for Meth Withdrawal • Disorders of Mood • Stabilizers Antidepressants • Lithium 300-1200 mg Effexor XR 75-225 mg • Abilify 5-20 mg Wellbutrin XL 150-300 mg Desipramine 100-200 mg • Disorders of Sleep • Trazedone 50-300 mg • Seroquel 100 mg • Imipramine 100-200 mg • Anhedonia/Anergia Disorders of Thought • Effexor XR 75-225 mg Abilify 5-20 mg • Wellbutrin XL 150-300 mg Haldol 1-2 mg • Desipramine 100-200 mg Risperdal 1-3 mg

38. 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 are you going to do to take care of yourself? Avoidance strategies Structure Tools Program activities Relapse Prevention Workshop

39. Relapse Prevention Guidelines • Exercise: Two 20 minute exercise periods daily. • Avoidance Strategies: Measures to protect the client from exposure to environmental cues. • Structure: Detailed hour-to-hour planning each day in which the client makes a consistent effort to make the same things happen at the same time each day. • Tools: Behaviors that dissipate craving.

41. Methamphetamine Treatment Project Number of Subjects CIM Model Matrix Model N=155 N=78 N=77 Mean No. of sessions attended 22/45 (49%) 26/55 (47%) Retention (completed treatment) 42 (54%) 52 (68%) p=0.026 (Chi-square) Methamphetamine free for 30 days discharge 27 (35%) 28 (36%) p=0.82 (Chi-square) 6 months after Intake 29 (37%) 29 (38%) p=0.95 (Chi-square) Craving: the desire to use a psychoactive substance CIM=Craving Identification and Management Model

44. 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 • Stress equals Craving

45. 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 as needed • 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 Pleasurable Activities Treatment Groups Individual Counseling • Mental Health Assessment and Treatment

46. Role of Sleep in the Treatment of Methamphetamine Abuse • Phase 1 Abstinence begins with 3 to 5 days of nearly continuous sleep to correct chronic sleep deprivation. Client may require medication for paranoia to initiate sleep • Phase 2 Sleep may become restless, sporadic, disturbed by nightmares and using dreams. • Phase 3 Ongoing attentiveness to sleep hygiene is required. Client may require instruction to develop regular, consistent sleep habits.

47. 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

48. 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 are you going to do to take care of yourself? Avoidance strategies Structure Tools Program activities Relapse Prevention Workshop

50. 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.