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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.

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Entrance into System

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

  2. 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.

  3. 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

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

  5. Prescription Drug Abuse Opiate pain medications Benzodiazepine tranquilizers Prescription stimulants (Adderall, Ritalin) Sleeping pills, muscle relaxants

  6. National Survey on Drug Use and Health Statistics 2007

  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 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.

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

  9. 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

  10. 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.

  11. 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

  12. National Survey on Drug Use and Health Statistics 2007

  13. National Survey on Drug Use and Health Statistics 2007

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

  15. 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

  16. 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

  17. A 33-year follow-up of narcotics addicts .

  18. 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

  19. 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

  20. 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

  21. 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.

  22. 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

  23. 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

  24. 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.

  25. 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

  26. 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

  27. 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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