Disease or Willful Misconduct DEFINITION OF ADDICTION

Transcription

1 Understanding Substance Abuse in Individuals with Developmental Disabilities: an Approach to Reducing Consequences Disease or Willful Misconduct Implication Therapeutic Approach Punitive Approach Judith C. Bjorndal, M.D. Medical Director Sonoma Developmental Center March 6, 2009 CHARACTERISTICS OF THE DISEASE OF ADDICTION Chronic Progressive Incurable Prone to relapse DEFINITION OF ADDICTION Continued use of a substance despite negative consequences related to that use 1

2 DENIAL D on t E ven k N ow I A m L ying CHARACTERISTICS OF THE DISEASE OF ADDICTION Withdrawal Tolerance Denial Loss of Control Synapse Nerve Impulse COCAINE Synaptic Vesicle Three effects Synapse Sympathomimetic Anesthetic Euphoric Increases dopamine Neurotransmitters Receptors Receiving cell INDIRECT stimulation of neuron Prevents reabsorption of dopamine 2

3 COCAINE With increased use, brain adapts (tolerance) Decreases # of receptors Dopamine stores depleted Causes increased craving, depression WHO GETS THE DISEASE AND WHY? A = P x E Predisposition Genetics Exposure risk factors environment stresses RESPONSIBILITY No one wants a chronic, progressive disease Once the diagnosis is made, it is the responsibility of the patient to control it, using the tools available Fault vs. Responsibility 3

4 ABSTINENCE Chemicals address a need Must replace them with something Dry drunk Recovery Program TWELVE-STEP PROGRAMS History of success Improved prognosis Availability AA, NA, OA, Alanon, Alateen Sponsor STEP ONE STEP TWO We admitted we were powerless over alcohol -- that our lives had become unmanageable. Foundation of recovery Social unmanageability Legal, vocational, family loss Personal unmanageability Self-centeredness, immaturity, control Came to believe that a power greater than ourselves could restore us to sanity. A promise of hope Insanity blaming circumstances distorted self-image Evidence that the program works for others 4

5 SPIRITUALITY vs RELIGION I am seeking it now, in the way I try to live my life, so that those who value what I am will have profited by my time on earth and be left with comforting recollections of what we have meant to each other. --Sherwin Nuland, How We Die STEP THREE Made a decision to turn our will and our lives over to the care of God as we understood him. Turning it over -- Act of faith Issues self-will trust asking for help OTHER RECOVERY CONCEPTS Enabling Honesty Discretion Asking for help Resentments Entitlement HARM REDUCTION Definition Methadone 5

6 TREATMENT - PHARMACOTHERAPY Agonists Gives similar sensations in therapeutic context Stimulates same receptors, less stimulation of neurons Decreases cravings Methadone TREATMENT - PHARMACOTHERAPY Antagonist Occupies and blocks receptor sites No stimulation Naltrexone ANTABUSE ANTABUSE Ethanol Acetaldehyde Ethanol Acetaldehyde CO 2 + H 2 O Acetic Acid CO 2 + H 2 O Acetic Acid 6

7 OTHER TREATMENT ISSUES Comorbidities Psychiatric illness, e.g. Untreated, barriers to sobriety Families Alanon, family therapy Environment Clean and sober friends, activities Risk Factors in DD Population Unemployment Lack of recreational options Social isolation Homelessness Victimization - abuse Attitudinal Barriers Do not abuse substances Should receive identical treatment protocol Inability to respond to treatment indicates noncompliance Make other clients uncomfortable Not capable of learning how to stay sober Deserve pity 7

8 Attitudinal Barriers Ford & Moore Issues in the DD Population Individuals close to a person with DD focus on the disability, missing the warning signs of SA. SA professionals are not trained to look for disability and focus solely on potential SA problems. Behaviors often attributed to SA are attributed to the disability and v.v. Connection between use of chemicals and negative consequences Societal enabling Sexual abuse Conflict between philosophies Independent living: maximize options SA prevention: limit choices, circumscribe behavior Issues in the DD Population Disconnection from society Desire to fit in Susceptible to peer pressure Short attention span Co-morbid mental illness Multiple medications Difficult to diagnose attributed to disability Issues in the DD Population Access to treatment resources Difficult to identify their triggers Other Addictions (more susceptible) Avenues to Self- Esteem Sex Gambling Food Shopping 8

9 Vulnerability of people with DD to trauma and PTSD Institutional care Relatively less control over their lives Non-verbal Neurological compromise Difficulty understanding social/situational context Vulnerability of people with DD to trauma and PTSD Trouble identifying unsafe situations Trouble securing help Difficulty setting limits, defending self, running away May not be believed Barriers to Effective Treatment (Annand) Difficulty with reading & writing Don t understand words & concepts Poor memory recall Use story-telling Recall = re-chastisement Long learning curve Need more time in treatment Poor socialization skills Use anger as defense against confusion Less extrinsic motivation - domestic Barriers to Effective Treatment Poor group-bonding skills Mascoting, resentments Poorly-developed sense of self and of values Source of intrinsic motivation Hitting bottom Lack of external support for recovery 9

10 Barriers to Effective Treatment Enabling social structures Negative consequences Difficulty learning from past experiences Difficulty making cause and effect connections Effect needs to be immediate Barriers to Effective Treatment Impaired cognition and insight Patience & persistence Difficulty transferring learning from one situation to another Outpatient treatment Poor abstract reasoning skills Concrete input Implications for Facilitating Recovery Behavioral approach incremental goals, rewards Translate cognitive realities into behaviors tools Connect negative consequences to chemical use concrete examples Instructional Techniques Ford & Moore Helpful Lessen group time Focus on one small issue Role playing Repetition Less Helpful Direct confrontation Peer feedback Abstract concepts 10

11 Implications for Facilitating Recovery Avoid re-traumatizing Deal with grief and loss Clean and sober activities Model recovery behaviors Implications for Facilitating Recovery Alanon for families and staff Medications? Educate care home staff to recognize signs and symptoms of substance abuse Outcome Expectations Relapse Common Learning tool Not reason for discharge Quality of life may not change much Finances, employment, relationships Enabling environment Life satisfaction improves Outcome Expectations Emphasis on progress Harm reduction Ratio of using to abstinent days Life-long abstinence may never be achieved 11

12 Self-Advocacy Think Plan Do DDS CAC Twelve Step Programs Abstinence supportive Not true peer support groups Helpful ideas Accompany to meetings Sponsor Short meetings Simplified steps 12

13 The 12 Steps for Everyone (Hazelden) We admitted our lives were out of control Accepted that a Higher Power could help us Got out of the way and let it happen Regional Center Programs San Diego North Bay INFORMATION RESOURCES National Clearinghouse for Drug and Alcohol Information Treatment Improvement Protocols (TIP) Hazelden.org INFORMATION RESOURCES National Association on Alcohol, Drugs, and Disability Substance Abuse Resources & Disability Issues (SARDI) Program Wright State University, Ohio Resource Center on Substance Abuse Prevention and Disability (202)

14 14