Treatment of the Young Adult and their Family

1. Treatment of the Young Adult and their Family Presented by: Dr. Steven R. Lee, MD

2. Summary • Developmental and Neurological Considerations • Age-specific Treatment needs • Co-Occurring Disorders (Dual Diagnosis) • Medication issues • Family Treatment • Counter Transference

3. Young Adult Addiction Program Ridgeview Institute Ages 18 to 26 99% have completed high school 50% are living at home 99% are dependent on parents 60% are in college 90+% have a addiction diagnosis and a separate psychiatric disorder

4. Characteristics of Addiction Substance Dependence (addiction) is a Major Medical Disease Incurable (life) Progressive Relapsing Potentially fatal if not treated

5. Addiction is Treatable • Addictive Disease is as treatable as most of the other chronic Major Medical Diseases. • Compare addiction relapse rates to Hypertension, Asthma, and Diabetes

6. Relapse Rates are Similar for Addiction and Other Chronic Illnesses 100 90 80 70 60 Percent of Patients Who Relapse 50 40 30 50 to 70% 50 to 70% 40 to 60% 30 to 50% 20 10 0 Drug Addiction Type I Diabetes Asthma Hypertension McLellan et al., JAMA, 2000.

7. Addiction Assessment • “Deciding if your Addicted Questionnaire” – Terence Gorski Passages Through Recovery. • “The Thinking Man’s Drinking Test” – Bert Pluymen The Thinking Person’s Guide to Sobriety

8. Developmental Issues • Social, interpersonal, spiritual and psychological maturity greatly affect the amount of time needed to reach recovery. • Ericksonian stages of development • The developmental stages that have been arrested by addiction during adolescence will be acted out during treatment. • The Young Adult is a separate developmental stage from an Adult. Why?

9. Arrested Development

10. Neurological Issues • NIMH study in 1991 proved that the brain continues to develop after puberty • The Prefrontal cortex and cerebrum (cortex) does not fully mature until 25 yo. • The cortex is the location of our higher-order cognitive functioning (problem solving). • Also, the cortex is the location of memories of potential consequences learned through past behavior as well as what was taught. .

11. Who Has the Final Word • The limbic system is our most primitive part of our brain essential for survival. • It is responsible for our fight or flight responses to danger. It has no concern about “collateral”, bad consequences . • When a young adult is intoxicated, social inhibitions and the risk of dangerous consequences is secondary to obtaining immediate pleasure or relief of stress.

12. Adaption to our Environment • All living things are capable of continuing to adapt better to their environment even after they stop growing. • The brain begins a process of pruning of synapses so that we can involuntarily respond quickly to environmental stimuli. • Stimulus-response behavior is literally structurally etched into our brain.

13. Speed of Learning • A 25 year old brain has grown as much as it is going to grow but continues to evolve. • Pruning of synapses begins to slow down after 25 yo making it harder to change a conditioned stimulus-response behavior. • Every year that a young adult is using a drug to cope, the harder it is to change that behavior and replace it with a more healthy one.

14. Genetically Prewired • 8% of the population has a paradoxical reaction to opioids • Mental clarity, motivation, decreased anxiety and depression, feeling of control. • After 6 months tolerance always develops • An alcoholic can drink 5x as much alcohol as a non-alcoholic and not get sick. • Many alcoholics have anxiety relief when drinking and can finally be able to sleep.

15. “Imprinting” • Most opiate addicts can tell you the first time they experienced their first opiate. • It takes one pill for the limbic system to choose opiates as the answer to all stress • It takes a year to replace it with recovery. • The limbic system is the source of primitive drives and it is in the driver’s seat for an addicted young adult. The cortex is in the back seat making suggestions.

16. Age Specific issues and needs • The young adult today is not the same as the young adult in 1980. • Higher education than parents encourages young adult’s that they can make their own decisions without their parents counsel. • More disrespect of adults in authority whom young adults see as behind the times and not as intelligent as them.

17. The reality that the young adult may be better educated and have more knowledge collides with the reality that they have no experience in the real world and they cannot find a job on the supervisor level. • Young adults are shocked to learn how much it cost to live the good life that was provided to them by their parents. • They feel entitled to have what they want without having to start at the bottom and work for what they have.

18. Young adults do not marry nor have children for at least 6 to 8 years later than they did in 1980. • No job, no responsibility of marriage and children does not foster maturity. • They have to return home, dependent on their parents. They feel worthless. • Opiates, sedatives, and marijuana allow the young adult to not worry about the realization they cannot take of themselves.

19. Current Trends Local and national trends and treatment

20. Percentage of Positive Employee Drug Tests Containing Marijuana and Cocaine Decreases; Sedatives, Amphetamines, and Opiates Increases In 2009, Quest Diagnostics conducted drug tests on more than 5.5. million urine samples collected from workers across the nation. According to the most recent drug testing index, 3.6% of all tests conducted in 2009 were positive for at least one illicit drug. Marijuana continues to be the drug most frequently detected. However, the percentage of positives for marijuana has decreased significantly over the past 10 years. Drugs Detected in Positive Urine Tests Among U.S. Workers, 1999 and 2009 1999 2009

21. Better Opiates and Pain Management • Oxycontin in the 90’s was a tremendous advancement as a more effective pain medication with less side effects. • Availability of opiates dramatically increased giving chronic pain suffers relief. • As the street price of these drugs have increased, it is cheaper to use heroin. • Young adults out of work, single, frustrated + more opiates available = an epidemic.

22. Other Trends • Synthetic Drugs • “Spice” – Synthetic Marijuana • “Bath Salts” – Stimulant which causes • delusions and hallucinations

23. Co-Occurring Disorders Psychiatric Medical 1 – Anxiety Disorders 1- Chronic Pain 2 – Depressive Disorders 2 - Diabetes 3 – Personality Disorders 3 - Orthopedic 4 – Bipolar Disorders 5 – Eating Disorders 6 – Attention Deficit Disorder

24. History and Creation of YAA Program at Ridgeview Institute

25. Young Adult Program 2009 Random snapshot of 28 patients • 60% Opioid Dependent • 29% heroin dependent • 60% of opioid dependent patients were women • 58% of opioid dependent discharged AMA or Administrative

26. Young Adult Program 2011 50 admissions (Random snapshot) • 72% Opioid Dependent 1% primary heroin • 28% of opioid dependent were women 37 Dispositions (Random) • 35% left AMA or Administratively • 35% were referred to extended treatment • 30% completed program and followed recommendations

27. 2012 Outcome Study Included all patients who completed the program in 2012. Out of those we could contact: • 57% in recovery • 43% had relapsed at least once • ~90% had a dual diagnosis • ~90% had to be “incentivized” to start

28. Opioid Dependency is a Lethal Disease • 6 patients died after discharge from the program from 2009 through 2012 • All had diagnosis of Opioid Dependence • One had done very well in the program and completed the program and went to a ¾ way house • 5 left the program before recommended or were administratively discharged

29. Young Adult Addiction Program • 51% Addiction and 49% Psychiatric • Largest Psychiatric Diagnosis is Anxiety Disorders followed by Depression • Highest relapse risk factor for those with a Dual Diagnosis is their Psychiatric Problem. • Treat aggressively with individual, group, and family therapy as well as medication.

30. YAA Program • Ridgeview Institute website, click Program Services then click Young Adult Addiction Program then click Parents Guidebook • drleemd.org has the following booklets: - Young Adult Psychiatric Disorders - Young Adult Dual Diagnosis (addiction with Psych)

31. Young Adult Addiction • First, inpatient detoxification of Opiates, Sedatives, Alcohol for 3 to 7 days • Second, 12 Step PHP program with Residence for 4 to 6 weeks • Third, ¾ Way House while in PHP • Fourth, IOP while at ¾ Way House for 2 weeks • Fifth, ¾ Way House for 6 to 12 months

32. Young Adult Addiction Program Better containment in mainstream milieu More open to peer confrontation Different rule structure than adults Use only staff who are committed to the young adult population Provides environment to discuss age specific issues (vs. job, wife, children) Easier engagement and longer retention

33. The Therapeutic Milieu • Structure and Safety (phones, visitations, internet, staff with patients at all times) • Clear Expectations With Consistent Consequences • Less Tolerance of Toxicity (anger, romancing drug past, basic acting out) • Avenues To Reveal Collusion-Secrets Group • Newcomers can see people graduate

34. Medications that cause Relapse • Mood altering Medications • Benzodiazepines (Xanax, Klonopin) • Opioids (Roxy, heroin, Oxycontin) • Tramadol (Ultram) • Suboxone/Subutex • Amphetamines (Vyvanse, Adderall, Ritalin) • Ambien, Lunesta, Restoril, Halcion and Benadryl • Provigil/Nuvigil • Soma

35. Treatment For Individual and Families

36. Family Assessment Identification of dynamics • Related to Addiction and Co-Occurring Disorders • Knowledge of the disease • Substance Use of and among family members • Cultural/Beliefs/Spirituality • Separation and Individuation • Enmeshed-detached pathology • Motivation, agendas, and resistance

37. Family Resistance • Work with who will come • Confront how family members may attempt to protect unhealthy family patterns they believe is their identity • De-shame and De-blame • Communication, communication • Alanon/Naranon – Requirement of at least 5 meetings in order to experience the higher power

38. Family Education • Disease Concept and family recovery • Structural growth of the brain in relation to ego development • Dual Disorders as the #1 relapse risk factor • Relapse happens • Naltrexone/Vivitrol as essential for Opioid • Collusion between family members and patient • Educate how patient may sabotage treatment as a means to return to use • Time needed to be in a sustained recovery