Opiate Use and Vermont Youth

1. Opiate Use and Vermont Youth Working with youth and their families Annie Ramniceanu, LCMHC, LADC Associate Executive Director Spectrum Youth & Family Services

2. Welcome! • Take a few minutes and think about why you attended this workshop and what you want to make sure you learn before you leave.

3. Getting your needs met • Use all of that brain power and take a few minutes • think about what you really wanted to get information about before you leave the workshop today. • Report out and lets see what you your needs are and make sure we budget our time together so that we give you what you came here for….

4. How big is the Youth Opiate problem?

5. 2011 High School Youth Risk Behavior Survey - Vermont Department of Health • High School youth reported “ever using” • 14% prescription drugs not prescribed • 6% prescription pain killer • 2% stimulants only • 6% both stimulants and prescription pain killers • 3% used heroin • Middle School • 4% ever abused prescription drugs not prescribed

6. Drugs of choice • Opioids—usually prescribed to treat pain: Codeine, Oxycodone/Oxycontin/Percosen, Hydrocodone/ Vicodin, Morphine/Kadian/Avinsa • Central nervous system (CNS) depressants—used to treat anxiety and sleep disorders; Benzodiazapines: Valium; Xanax. Barbituates: Nembutal; Luminal • Stimulants—most often prescribed to treat attention deficit hyperactivity disorder (ADHD). Dexedrene/Adderall; Ritalin/Concerta

9. Signs and Symptoms of Opiate use and withdrawal

10. Use Pin Point pupils …. pupils become very small. Normally, the pupil will change in size depending upon the amount of light in the environment, becoming larger in the dark and smaller in the light. If someone's pupils are very small, especially in a dimly lit room, this may be a sign that they are using opiates. This effect on pupil size remains present even when someone has developed a tolerance to the other effects of opiates, making it a particularly useful sign of intoxication.

11. Use….. Nodding: Opiates are a central nervous system depressant. Users will be less alert and may appear sleepy. With higher doses of opiates people can become completely unconscious (and may stop breathing). “Nodding“ is when someone just falls asleep when they are not typically supposed to…like during a conversation or while standing. With prolonged use, people eventually develop a tolerance to the sedating effects of opiates and may seem completely alert despite being intoxicated. Therefore, just because someone is not nodding does not mean they are not using.

12. Withdrawal • Withdrawal is the process an opiate addict's body goes through when they stop using. Because opiate addicts may not always be able to get their drugs, they will often show signs of withdrawal. • Sweating • Goose bumps, • Nausea, • Vomiting, • Diarrhea, • Cramping.

13. If someone who you suspect may be using seems to suddenly come down with the flu and then spontaneously recover shortly afterward………… This may be a sign that they are abusing opiates. Pinpoint pupils, nodding, and withdrawal are all signs of opiate use and can help you determine if someone has been using opiates. Remember, however, that these are only guidelines and that a drug test is the most accurate way to tell.

14. Vermont Family and Youth trends • Half of all children live in a household where a parent or other adult uses tobacco, drinks heavily or uses illicit drugs. • Illicit drug use is higher in Vermont than both in New England and nationally, driven largely by the high rate of marijuana use. • Marijuana, tobacco and alcohol are the major challenges in Vermont. • Marijuana and alcohol are the predominant drugs in the 12-17 year old range. Those who first used alcohol before age 15 were four times as likely to meet the criteria for past year alcohol abuse and dependence than those who started using alcohol at or after age 18 (16% vs. 4%). • Fewer than 20% of those in need of treatment in all age groups receive help for their addiction. (Source: Vermont Department of Health)

15. Comprehensive Strategy • Information Dissemination • Education • Substance-free Activities • Early Intervention • Social Policy & Environmental Change • Community Mobilization (Source: Vermont Department of Health)

16. Services provided should be evidence based and include: • Screening. • Assessment of clients for appropriate level of care. • Substance abuse treatment with varied intensity depending on the needs of the client. • Family support and parent education. • Step down care after receiving more intensive levels of treatment such as residential services to improve success rates. • Support of recovery process and integration back into the community. (

17. Recovery from drug addiction requires effective treatment followed by management of the disorder over time A Chronic Care Approach to Drug Treatment “Prescription” for Services Screening and Brief Intervention Initial Services Sustain & Manage Clinical Practices Assessment Therapeutic Interventions Recovery/Chronic Care Management Behavioral Counseling and Medications Source: Vermont Department of Health

18. Cumulative Recovery Pattern at 30 months:(The Majority Vacillate in and out of Recovery) Source: Dennis et al, 2010

19. Adolescent Research Findings in a Nutshell • In the best treatment episode: 4 out of 10 will become abstinent. • One half may reduce the number of substance related problems significantly. • Equal to or greater efficacy rate than other chronic medical disorders such as hypertension, heart disease or diabetes. • Of the 4 abstinent , half could relapse within 90 days after treatment. • Need booster sessions to thwart continued pressure to use. Take home message: For youth with early onset age this is a chronic disease, not looking for a single treatment episode “fix it” model.

20. CoreTreatment Components • Consistent, Validated Screening • Structured, Validated Assessment with Urine Screens • Effective Age Appropriate Treatments • Clinical Supervision/Consultation • Case Management • Follow-up Care/Recovery Supports • Evaluation & Performance Monitoring (Source: Vermont Department of Health)

22. Motivational Interviewing Treatment Efficacy • Research on Motivational Interviewing indicates: • Brief MI (1 to 4 sessions) yields good effect sizes and maintenance over time in treatment of alcohol and other drug problems (Burke et al., 2001). • MI is effective as a stand-alone treatment and as a prelude to other treatments (Bien et al., 1993; Brown & Miller, 1993). • Drug and alcohol abstinence rates 3 months after MI treatment are significant (37% to 57%; Brown & Miller, 1993; Stephens et al., 2000).

23. Summary of Principles • Listening. • Eliciting the youth’s perspective about how they feel or think about substance use....do not expand on your own! • Reflecting what the youth has said, by thought or feeling. • Offer a menu of suggestions. • What can they or do they want to do....do not assign. • Understand ambivalence and do not push or judge if patient does not decide to change. • Avoid premature focus trap. • Listen for small changes or hesitancy. • Amplify ambivalence.

25. Challenges • Time constraints. • Multiple Priorities. • “Negotiation”...developing a rapid, directed line of inquiry that is not disrespectful. • Slow down and reflect that these are chronic lifestyle problems and changes that happen over time. • Resist urge to “solve” or “prescribe” solution.

26. Other Evidence Based practices • Cognitive Behavioral Treatment ( CBT) MET/CBT 5-12 (Cannabis Youth Treatment Series)protocol • Building rapport/ Asking for change • Refusal skills/assertive communication • Social supports • Replacement activities • Emergency planning for hi risk situations • Contingency Management ( CM) …incentivizing clean UA’s healthy activities…non-using behaviors…attendance • Mindfullness • NREP/ National registry for Evidence based practices

27. Families Psych-oeducation about addiction developmental issues Treatment and recovery Stages of Change Boundaries and expectations Compassionate contingency management

28. Family work: Guidelines: Don’ts and Do’s • Preaching or using cliché’s…“when I was your age” → keep it to here and now and their timeframe. • Talking in chapters→ask for what you want and keep it short and simple. • Labeling…generalizing with a negative label “you always...” → keep feedback to immediate situation and promote hope for change. • Futurizing with a negative framework … “you will never get into college”→ focus on specific feedback and specific concern.

29. Don’t and Do’s • Instant Problem Solving - jumping in with solutions and judgments →hold back, listen, demonstrate understanding by summarizing thoughts or feelings, ask what they need, don’t tell them. • Questioning restlessness and discontent… “what is the matter with you?” → Stay calm and tolerate, or give yourself a break/space.

30. Don’t and Do’s • Not tolerating (some or safe) experimental behavior… constant disapproval of hair, clothes →decide what experimentation is ok, model being tolerant without acceptance, and avoid power struggles over all behaviors. • Collecting criticisms …focusing over and over again by pointing out deficits and keeping a cumulative score card → Keep feedback simple, and “in the moment” to reduce chances of deeply reducing self esteem.

31. Where to find Partner Providers • Community Mental Health Centers • Youth Service Bureaus • Residential Treatment Providers • Provider list – 31 providers: http://healthvermont.gov/adap/treatment/treatment_county.aspx

32. Contact information and Resources • aramniceanu@spectrumvt.org • 802-864-7423 x 312 • Get your Loved one Sober: Alternatives to Nagging, pleading and threatening: Robert Meyers ( CRAFT) • Institute of Medicine ( IOM) National Academies of Science: Treating and Preventing Adolescent Mental Health Disorders • SAMHSA/CSAT Treatment Improvement Protocols ( TIP ) • Brain Spect:www.brainplace.com single photon emission tomography