Adolescent abuse and addiction - Information, Intervention & Treatment- Tad Sumner LCSW, CDCI & Nina Volkova CDCI, BA

Transcription

1 Adolescent abuse and addiction - Information, Intervention & Treatment- Tad Sumner LCSW, CDCI & Nina Volkova CDCI, BA

2 Schedule 6-7 Overview of substance abuse/addicton with teenagers 7-7:15 Break 7:15-8 Effective treatment interventions and strategies 8 8:15 Break 8:15 9:00 Case Examples/ Questions

3 4 things.. Here are the 4 things we hope are gained from this presentation. 1. Recognize and assess addiction vs abuse in teenagers. 2. When treating co-occurring disorders, treat both simultaneously. 3. Addiction is a life long disease that often begins in teen years (90% before the age of 18). 4. Recovery is possible.

4 National Statistics A recent analysis of national data finds that only 6.4% of high school students who meet clinical criteria for an alcohol or other drug use disorder actually received formal treatment in the past year (Rushford, 2012). Fewer teenagers in need of treatment receive it than any other age group, even though addiction is a developmental disorder originating often in adolescence (Rushford, 2012) 40-60% of an individuals vulnerability to addiction is attributable to genetics (Rushford, 2012) 60 percent of youth involved in the justice system were under the influence of alcohol or drugs at the time of their arrest (NIJ, 2003).

5 National Statistics A current study tested whether alcohol and marijuana use predicted suppressed growth in psychosocial maturity among a sample of male serious juvenile offenders (n = 1,170) who were followed from ages 15 to 21 years. Alcohol and marijuana use prospectively predicted lower maturity 6 months later. Moreover, boys with the greatest increases in marijuana use showed the smallest increases in psychosocial maturity. Finally, heterogeneity in the form of age-related alcohol and marijuana trajectories was related to growth in maturity, such that only boys who decreased their alcohol and marijuana use significantly increased in psychosocial maturity. Elevated alcohol and marijuana use in adolescence may suppress age-typical growth in psychosocial maturity from adolescence to young adulthood, but that effects are not necessarily permanent, because decreasing use is associated with increases in maturity. (Psychology of Addictive Behaviors, Vol 24(1), Mar 2010,

6 Recognize our own biases Most people tend to assume that teenagers are just experimenting and often fail to ask details about their use. Our society tends to accept recreational use of nicotine, alcohol and marijuana as experimental use, much more than other substances such as cocaine, crack, crystal meth, bath salts, etc. etc. Nicotine use kills more people than any other substance. Since it is often a slower death and people are able to function in our society it is much more accepted. Alcohol is second. It is not the same weed from the 60 s Well it is not even the same weed from The strain has become much more potent. Since 1983, marijuana potencyhas increased from 4%-9%. Also since the 70 s people have widely adopted smoking marijuana buds, rather than leaves and use more effective smoking devices such as bongs, opposed to pipes, etc. - ADA 2012 Marijuana potency appears to have almost doubled in the past 8 years. 8 years ago daily marijuana users had a THC level between when entering residential treatment at ARCH. As of 2012, THC levels are now ranging between

7 ASAM (PPC-2R) American Society of Addiction Medicine It is a system for assessment and patient placement It seeks to match intensity of treatment to severity of illness It treats patients in the least intensive level of service in which they can SAFELY meet their treatment goals and objectives It is the basis for comprehensive treatment planning It is a method for justifying clinical decisions It is a method for communicating among providers

8 How to treat.. what are we treating? Addiction vs Abuse require very different approaches, whether you are working with adults or adolescents. Recognize our own biases as therapists about acceptable drugs vs not acceptable substances. Many of us ASSUME teenagers are just experimenting. (Remember 90% of addictions begin under the age of 18)

9 Levels of Treatment Prime for Life Out Patient Intensive Out Patient Residential Continuing Care

10 Harm reduction vs abstinence What is the goal for the client / therapist? Is it harm reduction or abstinence? The approach is VERY different for each.

11 Treatment for Experimentation Primary focus is education and to increase awareness about substances. It is important you are increasing awareness though about the right substances for that individual. (Two different prime for life models now. One focuses on Marijuana and one focuses on Alcohol.) Understand social norms. (a lot of children do experiment)

12 Treatment for Abuse ASAM recommends 4-6 hours of treatment a week that consists of: 1. Family 2. Individual 3. Educational groups providing information about: - Abstinence, choices, consequences, progression to addiction.

13 Substance abusers may: Abstain from future use Return to non-problem substance use Remain substance abusers Repeatedly cycle between use and abuse Progress to substance dependence Substance Abuse is not enduring and a person may be diagnosed with substance abuse to drugs in the same class at different times in their lifetime

14 Treatment for Addiction Very rarely can it INITIALLY be treated in 1-2 sessions of weekly therapy. 1. Ensure the client is stabilized in a current environment. 2. Begin motivational interviewing to build rapport with client and guardian/ increase awareness of their addiction. 3. Continue to focus on safety & rapport with the client.

15 Treatment for Addiction cont. 4. Begin the education process A. Understanding the disease B. Triggers/ Cravings A. Sober support network B. Health/Nutrition C. Relapse Prevention

16 The DSM-IVTR criteria for dependency The devil is in the details of the criteria. Tolerance (increased use to achieve same effect) Using more than intended Withdrawal signs or symptoms Unsuccessful attempts to cut down or control use Excessive time related to obtaining or recovering the substance Impaired social or work activities due to substance Use despite physical or psychological consequences

17 Treatment Involve families and other providers. 60% of child and adolescent patients in need of mental health services fail to attend their scheduled intake or terminate treatment early. (Mensinger, American Journal of Addiction 2006) Be aware of cultural issues among families and the potential for their resistance to treatment The relationship/trust with the client is paramount to engage them, however information to cope with cravings and triggers is the most important information when treating addiction. (Chestnut Behavioral Health, 2006) Motivational interviewing and information has been shown to be the most effective strategy for treatment. Pick an intervention/program you believe works, can get the client to believe in and stick with it consistently. (see Lipsey research)

18 What we already know People enjoy drugs because they make people feel better in the moment. (see slide related to dopamine) Treatment is NOT don t do drugs, stay in school and listen to your parents. We must find out why the teenager enjoys substances and show understanding. (see slide related to dopamine)

19 Addiction Brain Disease/chronic illness Dr. Bob recognized addiction as an allergy in the Big Book for Alcoholics Anonymous in Addictions were first identified as a disease process rather than a mental disorder or moral failure by Dr. Benjamin Rush in In 1945 the American Medical Association formally adopted this definition as well, and most other professional organizations have followed its lead. The neuropharmacology professor, George F. Koob has found that the major component of the brain s stress system is corticotropin-releasing factor (CRF). He has found that Alcohol tends to activate the whole brain reward system and it may explain why percent of the population become Alcoholics, while the remainder of the population does not. He believes that a genetic makeup causes them to have higher than normal levels of activity in the CRF stress system, so they may drink to feel normal they may drink to tame a hyperactive CRF stress system in the brain. Substance Dependence is an enduring (permanent) diagnosis for all drugs in the same class. Polysubstance Dependence is reserved for dependence to at least three classes of drugs during the same twelve month period with no single substance dominating. Polysubstance use disorder is not a diagnosis in the DSM-IV. Substance Dependence and Substance Abuse can be diagnosed in the same individual at the same time as long as they are two different classes of drugs.

20 Natural Rewards Elevate Dopamine Levels % of Basal DA Output Empty FOOD Box Feeding NAc shell Time (min) Source: Di Chiara et al. DA Concentration (% Baseline) Sample Number ScrScr BasFemale 1 Present SEX Scr Mounts Intromissions Ejaculations Scr Female 2 Present Source: Fiorino and Phillips Copulation Frequency

21 Dopamine Neurotransmission 1500 METHAMPHETAMINE 500 COCAINE % of Basal Release hr Time After Methamphetamine % of Basal Release hr Time After Cocaine

22 Implementation is Essential (Reduction in Recidivism from.50 Control Group Rate) The best is to have a strong program implemente d well Thus one should optimally pick the strongest intervention that one can implement well Source: Adapted from Lipsey, 1997, 2005 The effect of a well implemented weak program is as big as a strong program implemented poorly 22

23 Principles of Motivational Interviewing (MET) Express Empathy- accurate empathy (Carl Rogers) and acceptance Develop Discrepancy- between present behavior and goals of what the patient wants Avoid Argumentation- avoid head-to-head confrontations Roll with Resistance- psychological judo (Jay Haley); patient as a valuable resource in finding solutions; perceptions can be shifted Support Self-Efficacy- Patient is responsible for choosing and carrying out personal change: belief in the possibility of change is a powerful motivator

24 Stages of Change and Therapists Tasks Client Stage Precontemplation Contemplation Preparation Action Maintenance Relapse Therapist s Motivational Tasks Raise doubt-increase the client s perception of risk and problems with current behavior Tip the balance-evoke reasons to change, risks of not changing: strengthen the client s self-efficacy for change of current behavior Help the client to determine the best course of action to take in seeking change Help the client to take steps toward change Help the client identify and use strategies to prevent relapse Help the client renew the process of contemplation, preparation and action, without becoming stuck or demoralized because of relapse

25 Stages of Change - Meet the client where they are at - We have all heard this, but it is important to meet them and have them WORK in the stage they are at!

26 AA for teenagers Every third year since 1968, AA has issued a pamphlet summarizing its latest survey of meeting attendants. The results from found that one quarter of attendees (26%) of those who first attend an AA meeting are still attending after one year. Furthermore, nearly one third (31.5%) leave the program after one month and by the end of the third month, over half (52.6) leave. (Alcoholics Anonymous World Services, December 1990) Study shows that teenagers did better with an older adult as a sponsor, even though initially they stated they wanted a young, cool sponsor/meeting. Personal experiences about AA/Sponsors for teenagers.

27 Co-occuring disorders Bartsch et al (1990) performed a comprehensive evaluation of 175 clients from two Colorado community mental health centers. A previously undiagnosed physical health problem was found in 20% of the clients. (16% had conditions that caused or exacerbated their mental disorder) In 2011, 84% of clients in the VOA ARCH program had co-occuring disorders. Substance abuse counselors tend to focus on addiction, mental health counselors tend to focus on mental health, nurse practitioners tend to focus on medical. A multi disciplinary team is therefore the BEST treatment for the client.

28 Case example Break apart into groups. What is your diagnosis (substance and menthal health)? What is your treatment recommendations? (out patient, in patient, how often, etc.?)

29 Case example A 16 year old male presents with the following: Came in for an assessment because of a recent MCA charge. Marijuana use since the age of 12. Began with 1 bowl every other month. Used every year. At age 16 is using every other day 3-4 bowls a day. Tried to cut down a few times. Mom wants him to stop. Began drinking Alcohol at 14, 1-2 shots twice a month. At age 16 drinking one time every weekend 4-5 shots and sometimes beer as well. Has one MCA charge for Alcohol a week ago. Has used cocaine 5-6 times. Began at 15, still uses a couple times a month. Smokes ½ pack a day of cigarettes. Started at 14. Reports difficulty running very far. Reports being worried often and more irritable over the past year, has difficulty concentrating, at times feels very motivated and at other times has difficulty getting out of bed. Used to be very active in art and snowboarding, but stopped doing both at 15, because he would rather be spending time with friends. Reports being beat up by his biological dad when he was younger, but was never close with him and is very close with his mom and step dad. Some general problems at home by not getting homework done sometimes, not getting chores done and staying at friends more then he should, but mom reports normal teenage stuff. Wishes he would stop drinking, but is ok with pot and cigarettes. Has never taken any medications, besides vitamins. Parents report grades are ok with C s and B s and favorite subject is History. Client does not think he has a problem and just wants to do what I need to, so I can get this behind me.

30 Relapse Rates Are Similar for Drug Dependence and Other Chronic Illnesses Percent of Patients Who Relapse to 60% Addiction Treatment Does Work 30 to 50% 50 to 70% 50 to 70% Drug Dependence Type I Diabetes HypertensionAsthma Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.

31 Summary Recovery is possible. Studies of lifelong patterns of recovery and relapse indicate that patients who relapse are NOT HOPELESS. A. Approximately one-third achieve permanent abstinence from their first serious attempt at recovery. B. Another third have a period of brief relapse episodes that eventually result in long term abstinence. C. Finally, one third have chronic relapses that result in eventual death from chemical dependency (Gorski, 1986)

32 4 things.. Here are the 4 things we hope are gained from this presentation. 1. Recognize and assess addiction vs abuse in teenagers. 2. When treating co occurring disorders, treat both simultaneously. 3. Addiction is a life long disease that often begins in teen years (90% before the age of 18). 4. Recovery is possible.

33 Questions?

34 Thanks for coming