ECHD 3170E Ultimate Summer Quizlet

Lakukan tugas rumah & ujian kamu dengan baik sekarang menggunakan Quizwiz!

Neurotransmitter Functions

Dopamine: Pleasure, pain, movement, motivation, emotion, and attention Serotonin: temperature, mood, sensory perception, sleep., appetite, sexual desire Norepinephrine: sleep, anxiety,. dreaming, mood Endorphins: pain regulation, relaxation, mood GABA: inhibitory function on neurons, anxiety, memory Glutamate: excites/activates neurons, memory, learning Acetylcholine: memory, arousal, attention, mood Endocannabinoids: mood, pain regulation, movement

Choosing the right treatment

Let's start with the question: How do we make sure we are getting the person who is struggling with substance abuse into the right treatment setting? First, we gather information about the history of substance use, types of drugs currently used, frequency, method of use, co-occurring mental health concerns, previous treatment experiences, support system, etc. We use formal and informal assessments to gather this information and connect the individual with the appropriate level of care. The appropriate level of care is the least restrictive option that matches the individual's need

Level 3: Residential Treatment

Residential treatment is a 24-hour, live-in facility (stay typically lasts for 28, 60, or 90 days). It provides a safe, stable environment for clients to learn to live with the disease of addiction. Residential treatment offers highly structured programs with individual, group, and family counseling, psychoeducation, recreation, and employment services. Some residential treatment facilities provide medically supervised detoxification. This level of care relies heavily on peer support and community.

Physical Effects of Alcohol abuse

• High blood pressure • Fatty liver, hepatitis, cirrhosis (irreversible scarring of the liver) • Malnutrition • Stomach ulcers • Cancer of esophagus • Sexual impotence • Inflamed pancreas • Weakened immune system • Peripheral neuropathy (nerve damage) • Irregular heart beat

Biopsychosocial Model

-Encompasses the complexity of addiction -takes a holistic view by considering: the addiction properties of substances an individual's genetic predisposition to addiction an individual's experience of trauma, transition, or psychological distress personal risk and protective factors in a person's environment access to drugs/alcohol in the environment the extent to which the individual has learned that drugs/alcohol ,ay be a mean s of coping (social learning) This model calls for integrative treatment

The Neurobiology of addiction Video Lecture notes

1. Take Home message: -Addiction is primary neurologic disease -Neurologic=Brain and spinal cord 2. When people first come into Pavollion, they are given assessments on their depression 3. The scores are plotted on a scale, usually high, repeated every 5 to 7 days: if the numbers get better over time, then it is a substance induced disorder. If the brain is away from the drug for a longer period of time, then the depression goes away over time3. If the numbers stay the same, then the person may have more than one primary disorder. It is not caused by ADHD, bad parenting., etc.... 4. Parkinson's disease: a dopamine deficiency disorder that affects the movement part of the brain. Primary disorder that differs from others as the others involve a primative part of the brain 5. 85 TO 95% of adult US population uses alcohol or other mood altering chemicals at any one time. The percentage that have an addiction may be 10-12%. 6. Different cultures have differences in alcohol addiction: Asian population 1-3%, the US population 10-12% and the Native American Population 50-80%. Low incidence of alcoholism in the Asian population because many are born with a lack of an enzyme that breaks down alcohol for some people, this can make them really sick. Native Americans may be able to process alcohol better 7. Genetics: Family studies show that children of alcoholics are 3-4 times more likely to be alcoholic than the general population.. Twin studies: identical are also known as monozygotic while fraternal are dizygotic 8. Genetics and twin studies: for identical twins there is a 60% concordance rate--> how likely a twin is to be an alcoholic if one twin is already an alcoholic and separated. There is a 30-35% concordance rate for fraternal twins 9. Adoption studies: children of alcoholics but are adopted by stable and non-alcoholic parents are still 3-4 times more likely to be an alcoholic than the general population. Kids with biological parents that do not have alcoholism and are raised in chaotic alcoholic households are no more likely to be alcoholic than the general population 10. Message from adoption studies: you cannot out-parent a genetic alcoholic. Bad parenting does not cause alcoholism/addiction and great parenting cannot fix it. 11. Brain scans of alcoholics are statistically significant as many alcoholics share commonalities 12. Being genetically predisposed to alcoholism may cause you to grow up and behave differently and feel like you are missing out on something until you experience the eurphoria of having your first drink of alcohol 13. Genes: inherited chemical recipes for proteins (RNA). Genes tell how much of each protein is needed when. Determine everything. Chromosomes are made up of thousands of genes, half from mom and dad 14. Addiction comes down to neurology and a lack of dopamine 15. Neurotransmitters are proteins. Allow neurons to communicate with each other -dopammine, serotonin, GABA, and endorphins 16. Corticoptropin-releasing factor: a protein hormone that manages stress responses in the body 17. A sense of well being: the right combination of neurotransmitters will lead to a sense of well being: normal sleep patterns, pain tolerance, anxiety levels, etc. A sense of unease might result from a lack of the right combination of neurotransmitters. 18. RDS: being deficient in one or more neurotransmitters 19. Old brain: primative brian. Does the involuntary functions like heartbeating and breathing. the reward pathway is in the primative part. flight or flight 20. New brain: the reason why humans are highly intelligent life form 21. Addiction to different drugs all has to do with what neurotransmitter is deficent in your brain 22. Neuroadapation: your primative brain adapts to certain dopamine levels. Too much dopamine can kill you so neuroadaptation changes the chemistry of your brain, as your primative brain will stop producing the natural dopamine cause you to need more of a drug in order to achieve the same dopamine levels and eventually you have to have the drug in order to survive. The reward system sees a dopamine deficiency developing... you are dying... this is the primative brain is at work 23. You learn how to deal with alcoholism in a recovery program but you will never be "normal" but always in recovery. The solution for so many years was self medicating but self medicating became the problem and seeking rehab is another way to find a solution 24.PAWS: Post acute withdrawl syndrome... can take 1-1.5 years to get to recovery. -Symptoms: Poor short term memory and short attention span, exaggerated startle reflex, dysphoria, inability to solve simple problems and abstratc reasoning impaired, rigid and repetitive thinking, sleeping disturbances, stress sensitivity, and can last 12-18 months after discontinuation of drug use 25. Amygdala: associated with fear and pleasure... connected to reward system 26. You are not safe from any other brain rewarding drug just because it is not your primary drug... you are just as inclined to become addicted to that drug because it is all connected---> dopamine is the final common chemcial in the reward pathway: serotonin, gaba, endorphins modulate dopamine release

barbiturates

Barbiturates • Popular in 1960s and 70s to treat anxiety and sleep disorders • Examples include Nembutal, Seconal, and Amytal • Extremely dangerous when mixed with alcohol • High overdose potential- dose that causes intoxication and dose that causes death are very close • Intoxication is similar to alcohol intoxication • Dangerous withdrawal symptoms (more so than alcohol) • Largely replaced by benzodiazepines in the 1980s • Marilyn Monroe and Judy Garland died from barbiturate overdoses

Hallucinogens

Examples of Hallucinogens -LSD -PCP -Ketamine -Psilocybin (shrooms) -dextromethorphan (DXM) -Salvia Effects on the Body -An "expereince" or "trip" -dream loike state -Perceptual distortions -delusions -hallucinations -Synesthesia (merging of the senses) -Flashbacks (even years after use) Withdrawal -No physical withdrawal symptoms

Fentanyl video

Fentanyl is now the most common drug in overdose deaths according to new CDC research 50-100 times more potent than mophine many drug overdose deaths include more than one drug... so it is more than just an opioid crisis

Why not pot? Copy and paste article

I n n o v a t i o n s i n C L I N I C A L N E U R O S C I E N C E [ V O L U M E 1 3 , N U M B E R 3 - 4 , M A R C H - A P R I L 2 0 1 6 ] 13 ABSTRACT In this review, we provide a historical perspective on marijuana, and survey contemporary research investigating its potential negative effects on the brain. We discuss the evidence regarding cannabis dependence, driving under the influence of cannabis, underachievement, inducing (or worsening) certain psychiatric conditions, and the potential for progression to use of more dangerous drugs—summarized by the acronym DDUMB, a cognitive tool that may help healthcare providers in their risk/benefit discussions with patients who use cannabis. We also review and discuss the impact of marijuana use on target populations, including adolescents (who are at increased risk of harm); heavy users; and people suffering from—or at high risk of— mental illness. While cannabis presents certain subjective, health- related, and pecuniary benefits to users, growers, and other entities, it is also associated with several brain- based risks. Understanding these risks aids clinicians and their patients in making informed and balanced decisions regarding the initiation or continuance of marijuana use. INTRODUCTION "I have argued that every human being is born with an innate drive to experience altered states of consciousness periodically . . . this drive is a most important factor in our evolution, both as individuals and as a species." Andrew Weil The Natural Mind: A Revolutionary Approach to the Drug Problem Marijuana, also known as cannabis or pot, is the most commonly used drug worldwide and is a fraught topic in contemporary society. 1 A variety of forces—economic, 2 legislative, 3 technological, 4 and even horticultural 5 —have markedly changed the politics, polemics, and public perception of pot. The resultant upsurge of cannabis use in some parts of the United States has already had a collateral impact on individual and societal health, 6 similar to that seen with the prescription opiate epidemic. 7 Balancing these myriad forces—all of which drive greater societal acceptance of marijuana and increased use—a growing body of by KAI MACDONALD, MD, and KATHERINE PAPPAS, BA D r . M a c D o n a l d a n d M s . P a p p a s a r e w i t h U C S a n D i e g o P s y c h i a t r y , S a n D i e g o , C A , U S A I n n o v C l i n N e u r o s c i . 2016;13(3-4):13-22 FUNDING: Dr. MacDonald's work is sponsored in part by the Goodenough Neuroscience Research Fund. FINANCIAL DISCLOSURES: The authors have no conflicts of interest relevant to the content of this article. ADDRESS CORRESPONDENCE TO: Kai MacDonald, MD, 3368 2nd Avenue, Suite B, San Diego, CA 92103; Phone: (619) 203- 7393; Fax: (619) 296-0199; E-mail: [email protected] KEY WORDS: Marijuana, cannabis, dependence, drug-related harms, mental health R E V I E W WHY NOT POT? A Review of the Brain- based Risks of Cannabis I n n o v a t i o n s i n C L I N I C A L N E U R O S C I E N C E [ V O L U M E 1 3 , N U M B E R 3 - 4 , M A R C H - A P R I L 2 0 1 6 ] 14 scientific research provides a clearer understanding of pot's potential harms. The aim of this paper is to review t he brain-based harms of cannabis. Awareness of the supporting evidence of marijuana's downsides can help augment the risk-benefit discussions clinicians may have with patients in a motivational interviewing model, the preferred therapeutic frame for approaching substance-use discussions. 8 To facilitate this end, we introduce a mnemonic, DDUMB, to help remind us of the five brain-based harms associated with marijuana use: dependence, driving impairment, underachievement, mental illness, and bad to worse (i.e., marijuana serving as a "gateway" function for other more dangerous drugs of abuse). Before reviewing the science behind these five dangers, we will provide a brief summary of several important aspects of marijuana's history, politics, chemistry, and psychopharmacology. THE HISTORY OF HEMP AND POLITICS OF POT The terms marijuana and cannabis are often used interchangeably. Strictly speaking, however, cannabis is a botanical term for the hemp plant, while marijuana denotes the psychoactive drug derived from it. Though research on the central effects of cannabis is relatively new, its medicinal use can be traced back to the Chinese Han dynasty, circa AD 25 to AD 220, when it was used to treat rheumatic pain, constipation, malaria, and female reproductive disorders. 9 Medical cannabis was introduced to the Western world in the 1800s, and was used as such until the 1900s, when its popularity diminished with the rise of pharmaceuticals that could be used for the same conditions (e.g., aspirin, barbiturates). 10 Legislation enacted in 1937 (the Marijuana Tax Act) decreased accessibility and pushed the drug further out of the public eye. A sterling demonstration of the swings of public opinion toward marijuana use is the pulp-propaganda film "Reefer Madness," 11 released shortly after the enactment of this legislation. Originally titled "Tell Your C hildren," this short film comically overdramatized marijuana's harms, describing cannabis as "the burning weed with its roots in Hell," and warning about the potential for pot- induced manslaughter, suicide, hallucinations, and "the ultimate end of the marijuana addict: hopeless insanity!" In the present day, more tolerant state-based legislation has led to decriminalization, legalization, and medicalization of cannabis in many states and the likelihood for more cannabis use. In turn, more frequent use by current users and more new users may lead to a greater frequency of cannabis-related harms. Specifically, in December of 2012, Washington state and Colorado both legalized marijuana; Washington DC, Alaska, and Oregon followed suit, with at least 23 states now allowing for its medical use. Importantly, this large cultural and legal pro-pot shift has already been shown to increase a variety of cannabis-related collateral harms, 6 and likely has contributed to an increase of adolescent-onset use. 1 2 This trend is especially worrisome, since adolescent-onset use is associated with greater cumulative negative consequences than later- onset use. 13 Bachman et al 13 demonstrated an inverse relationship between perceived risks/social disapproval and the prevalence of marijuana use among youth. 13 Data from a 2010 national survey on drug use and health have shown a correlation between adolescent cannabis use and lower levels of parental disapproval. 14 Additionally, "vaping," a term used to describe a popular method of smoking via an electronic device such as an e- cigarette, may encourage more illicit and dangerous use of marijuana: Vaping produces less smoke than marijuana or tobacco cigarettes, making its use harder to detect by smell (e.g., in a school bathroom) and implies that the person is vaping nicotine-related products (not illicit substances). 15 These relationships suggest a continuing trend toward public approval and, possibly, risk- m inimization of marijuana use, which may lead more at-risk youth and young adults to initiate use. Unfettered by more permissive laws and attitudes, capitalism has embraced cannabis as the newest cash crop. 16,17 Commercialization of cannabis has been shown to increase the number of medical marijuana licenses purchased. 21 Therewith, powerful economic forces have and likely will continue to add to legal and attitudinal shifts that elevate the role of cannabis in public and individual health. 23 Market research suggests that widespread legalization of marijuana has the potential to create a 35-billion dollar marijuana market. 18 Comparatively, this would make the marijuana industry as big as the United States National Football League (NFL), 10 times more profitable than the opioid drug OxyContin, and about a fifth the size of the United States alcohol market. 18,19 As witnessed in recent years in the United States, where a surge in opiate-related mortality has been partly attributed to high-dollar opiate sales, the promise of profits in the burgeoning industry of marijuana production— the "green" industry— may inform how the drug is marketed and researched. 7,20 And as more states move to legalize marijuana, we may see an increase in both anticipated and unanticipated cannabis-related harms in those who use it, as was observed on a smaller scale in Colorado. 6,21 As societal, legislative, and economic forces move toward the legalization of marijuana, there are three challenges that confront its scientific study. First, advances in cultivation techniques and grower knowledge have produced vastly more potent marijuana than was seen in previous decades. Tetrahydrocannabinol (THC), one of the main psychoactive components of marijuana (and the component associated with some of its brain- I n n o v a t i o n s i n C L I N I C A L N E U R O S C I E N C E [ V O L U M E 1 3 , N U M B E R 3 - 4 , M A R C H - A P R I L 2 0 1 6 ] 16 "dose" multiple times a day, the long half-life of THC (25 -57 hours) 26 means that the time intervals that mark its "compulsive use" can be s paced out longer than other shorter- acting drugs, such as nicotine, creating more of an illusion of control. The addicted marijuana user may only use pot at breakfast, lunch, and in the evening, whereas a person addicted to nicotine may need to smoke a cigarette every hour or two. A third factor supporting the myth of non-addiction is that marijuana withdrawal is often relatively mild. 27,29 Moreover, marijuana withdrawal presents without clear, "signature" physical symptoms, at least compared to the often-dramatic physical symptoms of withdrawal from depressants like alcohol and benzodiazepines (i.e., tremors, seizures, agitation) and opiates (i.e., sweating, gooseflesh, diarrhea). Instead, marijuana withdrawal symptoms are more occult: anorexia, irritability, anxiety, anger, restlessness, and sleep disruption. 1 3 En toto, this delayed, nondramatic withdrawal syndrome adds support to the misperception that cannabis addiction does not exist. For clinicians treating marijuana- addicted patients, it is important to be aware that cannabis withdrawal is both consequential and treatable. 2,37 In terms of its consequence, cannabis withdrawal symptoms clearly contribute to ongoing use, making cessation efforts aversive, 28,38,39 and to impairing both motivation and executive functions critical in decision making and treatment retention. 40,41 In terms of treatment, a seminal study by Mason et al 37 showed that in marijuana-dependent subjects, the commonly used calcium channel/GABA-modulating agent gabapentin—dosed 1200mg daily in divided doses—reduced both cannabis withdrawal symptoms and cannabis use. Though sustained recovery from cannabis addiction requires long-term, multimodal solutions, clinicians can help the process by utilizing available pharmacotherapies to attenuate withdrawal. It is important to highlight that the risk of negative effects from marijuana use—including dependence—have been shown to be r elated to the age of first exposure. 4 2,43 Specifically, compared to people who start marijuana use in adulthood, adolescent initiators are 2 to 4 times more likely to exhibit dependence within two years of their first use. 42 This is not surprising, given that key stress, reward, and executive/regulatory circuits that underlie addiction continue to develop during the teenage and early adult years of human growth. 28,44 Moreover, studies indicate that early exposure to THC may 1) potentiate the future effects of THC, increasing risk of dependence; 2) cause impaired regional connectivity, decreasing the moderating influence of regulatory brain regions; and 3) lead to lower dopaminergic activity in addiction-related circuits. 23,35,46 Coming from the perspective of harm reduction, then, a tractable goal to reduce the risk of future marijuana dependence is to delay the age of onset of first use. DRIVING Standing alongside the misconception that marijuana is not addictive is the misconception that driving while under the influence of marijuana is safe. Several factors make this latter untruth more challenging to refute than the former. Until very recently, drivers involved in accidents or infractions were rarely tested for THC levels, whereas assessing blood alcohol content via the less invasive breathalyzer has been routine for years. This situation will likely change over time as marijuana use increases, allowing more THC-related auto morbidity studies to be conducted and compared with those in other countries. A second factor complicating the THC-driving research is that, based on studies from driving fatalities, drivers frequently use marijuana and alcohol simultaneously. 45 This combination makes assigning causality to a single drug complex, and their different mechanisms of action lead to additive impairments. 47 Despite the abovementioned c hallenges to studying the topic, epidemiological and laboratory studies of the acute effects of marijuana on driving has demonstrated that drivers under the influence of marijuana are impaired. In fact, driving while under the influence of marijuana doubles or triples the risk of a crash. 4 7 Though people driving under the influence of marijuana tend to compensate by driving more slowly, as task intensity of driving increases, the person becomes more impaired. 4 8,49 Specifically, cannabis use increases lane weaving and impairs critical- tracking tasks, reaction time, and divided attention. 48,49 Though a discussion of the ethical issues of driving while impaired is beyond the scope of this article, it bears mentioning that collateral damages result from individual choice—every time an impaired motorist decides to get behind the wheel, he or she extends the risk of potential harms to other drivers, passengers, pedestrians, and cyclists. UNDERACHIEVEMENT Despite marijuana's known risks, the scientific reality is that marijuana is in many ways the least deadly drug of abuse. In meteorological terms, if methamphetamine—with its capacity for brain damage and strokes 50 —is a tsunami, and opioids—with their morbid respiratory depressive effects 7 —are an earthquake, marijuana can be likened to a heavy fog. Disruptive, yes. Deadly, no. Partly due to the lack of activity in vital brainstem areas controlling respiration, there has never been a reported lethal overdose of marijuana in humans. 51 In animals, the deadly dose of cannabis is extremely high: about 12,500 times the amount needed to cause subjective effects. 52 Though risks of marijuana use are real and consequential, it is neither deadly nor overly dramatic. In the pot polemic, the lack of direct organ I n n o v a t i o n s i n C L I N I C A L N E U R O S C I E N C E [ V O L U M E 1 3 , N U M B E R 3 - 4 , M A R C H - A P R I L 2 0 1 6 ] 17 toxicity, clearly consequent mortality, and extreme withdrawal symptoms likely contribute to the growing acceptance of marijuana use among t he American population. And as argued in a recent editorial by a pediatrician in the New York Times, support for marijuana use may come from the perspective, "Since people are going to use something, why not the least toxic something?" 53 From a wider social perspective of harm and risk reduction, this "low bar" argument has obvious merits: it is better to be alive and stoned than dead from a heroin or alprazolam overdose. That said, conscious of Weil's opening observation about our species' "innate drive to experience altered states of consciousness," we suggest that when considering effects on vulnerable future adults, professionals should focus not on what is the least toxic and not on merely accepting morbidity over mortality, but rather on the maximization and optimal development of human potential. From this vantage, the risk of cannabis promoting broad-spectrum underachievement (especially in teens) becomes more prominent. In point of fact, a large body of convergent data suggest that long- term use of marijuana may cause significant abridgement of one's potential. 33,44,54-59,60-67 Underachievement may be the most well-supported correlate of regular marijuana use. Though direct causality is challenging to ascribe due to the correlative nature of this research (random assignment of daily cannabis use to adolescents is unethical), the association of daily marijuana use with the pruning of human potential appears across a breadth of contemporary research. For example, earlier studies have already demonstrated that marijuana use during adolescence is associated with low academic achievement and increased rates of school drop-out. 54,55 More recently, several very large examinations of the issue have reinforced not only these academic consequences, but a broader swath of negative outcomes. In one of these studies, Fergusson et al 56 performed a longitudinal study of over 1,000 New Zealanders from birth to age 25 years, a nd found that elevated marijuana use between ages 14 and 21 years was associated with the lower likelihood of getting a bachelor's degree, lower income, higher unemployment and welfare dependence, and lower levels of relationship and life satisfaction. These correlations survived adjustments for a number of important covariates, including family socioeconomic status, maltreatment, academic achievement, and comorbid mental disorders. In a similar study, Meier et al 5 7 followed a cohort of 1,037 subjects from birth until age 38 years, performing neuropsychological assessments at ages 13 and 38 years, as well as ascertaining cannabis use at ages 18, 21, 26, 32, and 38 years. In this cohort, persistent cannabis use was associated with a decline in neuropsychological performance across domains, which survived controlling for years of education. Importantly, these results were the most prominent among participants with adolescent-onset cannabis use, and showed a dose effect: more persistent use was associated with a more severe performance decline. Adolescent-onset cannabis use was correlated with a 10-point decrease in measured IQ. Moreover, people who had discontinued cannabis use did not achieve a full return to their baseline level of performance, a finding which suggests that heavy adolescent-onset cannabis use may have a cumulative neurotoxic effect. One group of detractors argued that certain brain- based personality traits that bias people toward marijuana use as well as school dropout may explain these results, 58 but the original authors' results survived a control for such personality factors. 59 What are the putative mechanisms wherein adolescent cannabis use causes this pervasive underachievement and even cognitive decline? Adolescence, we know, is a neurodevelopmental stage of significant import in which neurobiological circuits critical to adult function develop, are pruned, and reinforced. 60 Moreover, adolescent brains have a stage- d ependent hypersensitivity to rewards 23 and underdeveloped prefrontal inhibitory structures. 44 Chronic cannabis use through this sensitive window of development may cause persistent disruptions in these developing prefrontal and reward pathways, impacting important intellectual functions like working memory, sustained attention, verbal memory, and general intellectual functioning. 61-63 These disruptions may persist longer—and the person may not fully recover—when experienced in the developmental window of adolescence rather than in adulthood. Aside from prefrontal cortex disruptions, chronic marijuana use has also been correlated with changes in the hippocampus, a vital brain structure involved with short-term memory, long-term memory, and spatial navigation. 64 Recent research on the effects of marijuana on brain function and structure (in both adolescents and adults) have shown other negative changes in the brain among chronic marijuana users. 6 5-67,35 In a study that compared chronic marijuana users with non-using adults (mean age 22-23 years), the chronic user group demonstrated poorer learning from errors, due in particular to lower levels of brain activity in the dorsal anterior cingulate cortex and hippocampus. 65 In another study, investigators found microscopic disturbances in the neural fibers that communicate between brain hemispheres (the corpus callosum) in heavy cannabis users (mean age 30 years) who started using at the age of 16 years. 66 In a 25-year follow-up study, investigators compared three domains of cognitive function (verbal memory, processing speed, and executive function) in three groups (aged 18-30 years at baseline): 1) current cannabis users, 2) individuals who used marijuana but stopped, and 3) individuals who never used marijuana. The researchers found that I n n o v a t i o n s i n C L I N I C A L N E U R O S C I E N C E [ V O L U M E 1 3 , N U M B E R 3 - 4 , M A R C H - A P R I L 2 0 1 6 ] 18 current marijuana users demonstrated lower verbal memory and processing speed compared to the other groups, and even when c urrent users were excluded, cumulative exposure was associated with worse verbal memory. 67 And in a study that examined brain functioning among chronic marijuana users (aged 21-33 years), investigators found impairments in dopamine release in the striatum that correlates with deficits in neurocognitive performance (memory, attention). 35. In summary, broad-spectrum, lasting underachievement—perhaps mediated by disruptions of critical developmental brain circuits—is a third potential harm from cannabis. Convergent evidence from several fields, including epidemiology and functional brain imaging, supports the idea that one of the more occult (but consequential) downsides of adolescent-onset marijuana use is a broad-spectrum abridgement of human potential. MENTAL ILLNESS Marijuana use has been associated with several specific brain-based illnesses. Much of this research has focused on the role of cannabis in psychotic illness. Though the details of this research arena are beyond the scope of this article (see references 64, 68, and 69 for more comprehensive treatment of this issue), the emerging theory follows a stress-diathesis model and posits that in genetically "at risk" individuals, marijuana use serves as a biological trigger that influences the full expression of what otherwise may have been a latent disorder. This body of research suffers the same shortcomings noted in the underachievement section: random assignment to the experimental condition—heavy cannabis use—is unethical. That said, a raft of studies have found strong support for a pot- psychosis link, indicating that cannabis use can increase the risk for the development of psychotic disorders 69 and worsen clinical outcomes in those at risk. 70 In a 35- year longitudinal study of more than 50,000 enlisted men, Manrique-Garcia et al 68 found that individuals who used cannabis frequently had an increased l ong-term risk for developing schizophrenia, whereas the risk declined for moderate users. Assessing the genetics of at-risk individuals, Caspi et al 71 reported that adolescent cannabis users carrying a permutation of the catechol-O- methyltransferase (COMT) gene were at highest risk of developing psychotic illness. Mechanistically, THC increases task-irrelevant neural "noise," which is associated with its psychosis-promoting effects 66 and has been implicated in brain maturation processes (marijuana users showed thinner cortices) in those at risk for schizophrenia. 72 Notable here is that the potential kindling effect of cannabis on psychotic illness is likely affected by the abovementioned changes in cannabis chemistry. As previously discussed, cannabidiol (CBD)—the component of marijuana that demonstrates antipsychotic properties—is found in smaller concentrations in many recent strains, whereas the percentage of the psychosis-prone component—THC— has increased. 7 3,74 Not only can early, heavy cannabis use potentially contribute to the development and expression of psychotic illness, but ongoing exposure after developing a psychotic disorder can make it worse. In people already suffering with schizophrenia, exposure to THC may lead to an increase in latent psychotic symptoms or relapse back into a psychotic episode. 64,73 Specifically, patients with psychotic illness who use marijuana, compared to those who do not, tend to have 1) earlier onset of symptoms, 2) more severe and persistent psychotic symptoms, 3) higher relapse rates, and 4) a worse prognosis due to poor treatment adherence. 70,73 Summarizing the research, Hall et al 36 document that cannabis use doubles the risk of developing psychosis from 7 in 1,000 to 14 in 1,000. Therapeutically, however, cessation is salutary: young people with psychosis who desist from pot have better outcomes, including fewer psychotic symptoms and better social functioning. 36 A lthough the bulk of research on the role of cannabis in severe mental illness is in psychotic disorders, recent research on patients with bipolar illness and posttraumatic stress disorder (PTSD) yields similar findings. Specifically, patients with bipolar disorder who used and then ceased use of marijuana have similar outcomes to those who never used, whereas continued use is associated with greater recurrence risk and functional impairments. 75 Veterans with PTSD who use marijuana have greater symptom severity of their disorder, use alcohol and other drugs more often, and exhibit more violent behavior than never-users. 76 Finally, growing evidence of the role of cannabis in other substance use disorders (SUDs) indicates that people with SUDs or who are at risk for developing them are uniquely vulnerable to developing negative effects of cannabis. Overall, this research suggests that healthcare providers should have targeted risk discussions about cannabis use with adolescents, who are at a higher risk of developing dependence, and individuals at risk for (or suffering from) psychotic illness, bipolar disorder, PTSD, or SUDs. What about the data on the role of cannabis in other common brain- based disorders (e.g., anxiety, depression), many of which are used by card-carrying medical marijuana users as the reason for their use? Here, unfortunately, research is limited. A few research groups have shown lower perceived quality of life among cannabis users, as well as finding a heightened occurrence of anxiety disorders among cannabis- dependent adults. 77-79 That said, these studies and others generally indicate that people who only use occasionally to moderately (i.e., who do not qualify for cannabis dependence, or as regular users) generally have the same mental health outcomes as non- users. 77,78,80 I n n o v a t i o n s i n C L I N I C A L N E U R O S C I E N C E [ V O L U M E 1 3 , N U M B E R 3 - 4 , M A R C H - A P R I L 2 0 1 6 ] 19 BAD TO WORSE Both Aldous Huxley and Jim Morrison famously opined that certain drugs open "the doors of perception." D oes cannabis open the gates of addiction? In short, the "gateway drug" theory posits that the recreational use of "softer" drugs like alcohol, tobacco, and marijuana serves as an easy port of entry into later use of "harder" drugs such as cocaine, heroin, or methamphetamine. The empirical support for this theory largely rests on the observation that most people who develop problems with the latter first experimented with the former. An examination of dairy use, however, exposes this argument's logical flaw. That is, though many people with opiate dependence have used cannabis prior to developing their heroin habit, a significant majority also ingested milk prior to the onset of their addiction, and yet no one posits a causal connection in this latter case. Rigorously proving that use of cannabis is consistently associated with a "bad to worse" progression-of- use phenomenon turns out to be methodologically challenging. 81 That said, efforts have been made to answer this question. For example, Olthius et al 82 looked at the actual circumstances under which people first experimented with a hard drug. This study showed that subjects tended to mix psychoactive substances the first time that they used a new drug. For example, people frequently reported that first-time use of cocaine, heroin, methamphetamine, or a hallucinogen like LSD was in conjunction with marijuana, alcohol, or tobacco, rather than experimenting with the hard drug by itself for the first time. Additional evidence in support of bad-to-worse causality comes from Agrawal et al, 46 who performed a twin study examining early cannabis use and later illicit drug use. This study showed a strong association between early cannabis use and later abuse/dependence of other illicit drugs, and—though a large percentage of the variance in illicit drug use was due to genetic and environmental factors—there was also evidence of a causal influence of e arly cannabis use. Finally, in a very recent, prospective study (which overcomes methodological limitations inherent in other examinations of this issue), cannabis use during the first sampling period was significantly associated with substance use disorders in a second sampling period three years later. 8 3 In sum, though empirical validation of a direct, causal role of early cannabis use in later addiction to harder drugs is methodologically challenging, and though correlation does not equal causation, several lines of evidence support that the association between early cannabis use and later problems with harder drugs is at least partly due to a causal relationship. 3 6,83,84 How would a gateway process actually work? At a behavioral and interpersonal level, cannabis use likely follows principles of the so- called social contagion seen with alcohol and tobacco, 85,86 creating "birds of a feather" networks of people with similar behaviors and greater likelihood of exposure to other drug use. At a neurobiological level, animal research points to THC's ability to change reward circuits in the brain. 32,33,86 Panlilio et al, 87 for example, found that exposing rats to THC increased likelihood of self- administration of the most highly addictive drug in humans: nicotine. This effect persisted even when the process to receive the nicotine became more arduous. Interestingly, this effect was not found when a similar experiment was performed with cocaine or heroin in place of nicotine. More recently, Volkow et al 32 examined 24 marijuana abusers using a methylphenidate challenge to probe the reactivity of the brain's dopamine system. They found that compared to normals, marijuana abusers (average 5 joints a day) displayed blunted dopamine responses in key brain areas associated with addiction (i.e., ventral striatum). In a very recent study using an amphetamine challenge, lower levels of dopamine release in key addiction areas (the striatum) were found in heavy cannabis users; these changes were c orrelated with inattention, negative symptoms, and poorer working memory. 35 These neurobiological differences, researchers hypothesize, may contribute to marijuana abusers' tendencies to negative emotionality (increased reactivity to stress and irritability) and addictive behaviors. 32 Research like this raises the possibility that part of the etiology of marijuana's bad-to-worse phenomenon is explained by its role in altering brain reward circuits in a way that increases the risk of future addiction. CONCLUSION Evaluating the potential harms of a commonly used drug—especially a complex substance like marijuana—is a challenging but vital task. Fully informed awareness of both the potential and proven benefits and the potential and proven harms of marijuana are necessary in order to have rational discussions with patients, teens, and decision makers regarding marijuana use. Based on a review of the current literature, we suggest the mnemonic DDUMB (dependence, driving, underachievement, mental illness, and "bad to worse") as a tool that captures several of the more well- supported, brain-based risks associated with marijuana. Using this mnemonic, we reviewed five research-supported harms related to marijuana use. First, cannabis dependence (addiction) is real. Second, driving while under the influence of marijuana is unsafe. Third, marijuana use has a strong association with global underachievement. Fourth, marijuana elevates the risk of developing a psychotic illness and worsens the course of several serious mental health conditions in certain individuals. Fifth, though proving causality is complex, evidence supports a "bad to worse" or "gateway" role of cannabis in the I n n o v a t i o n s i n C L I N I C A L N E U R O S C I E N C E [ V O L U M E 1 3 , N U M B E R 3 - 4 , M A R C H - A P R I L 2 0 1 6 ] 20 development of other substance use disorders. Important to note, most of these harms are more likely to be present when marijuana use is f requent and starts early (i.e., in adolescence). Though we don't always heed George Santayana's aphorism about learning from (and therefore being doomed to repeat) our past, a chapter of recent history informs the cannabis conversation. Like a string of white crosses on the shoulder of a dangerous stretch of road, deaths from the recent prescription opiate epidemic stand out as stark examples of the collateral damage from widespread availability of addicting substances and the powerful impact of market forces, medical culture, and societal mores on drug use. Though cannabis is less directly deadly than opiates, all of the factors that buoyed the recent opiate epidemic— availability, economic forces, changing cultural norms—inform the cannabis debate. Healthcare providers, educators, policy leaders, and parents will be well-served by keeping abreast of the burgeoning research on the potential harms

Why not pot? Article

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Chapter 9

This Chapter Covers Two Classes Of Substances (Hallucinogens And Inhalants) That Have Not Only Differing Pharmacological And Behavioral Effects But Also Overlapping Fea- Tures. Both Classes Include Their Tendency Be Used By Youth And Their Lesser Epide- Miological Magnitude Than Other Substances, Such As Alcohol Or Nicotine. In Addi- Tion, While For Each Class There Are "Core" Substances, Each Is A Dynamic Category In Which New Substances Are Constantly Being Developed And Utilized In The Community. Another Common Feature Is That Besides Immediate Supportive Care And The Preven- Tion Of Violence Or Injury During Intoxication, There Are Few Specific Treatments For Long-Term Problem Use Of These Substances. Short-Term Therapies Include Attention To General Supportive Care, As Well As Medical Conditions Induced By The Substance. Hallucinogens. Hallucinogens Are A Diverse Group Of Substances That Vary In Source (Plant Derived Or Synthetic), Chemical And Molecular Structure, Pharmacodynamic Effects, And Addic- Tive Liability Versus Potential For Anti-Addictive Effects And Toxic Effects (Medical, Neu- Rological, Psychiatric) Versus Therapeutic Applicability. Dsm-5, Like Dsm-Iv, Does Not Include The Cannabinoids In The Hallucinogen Category, Even Though They Produce Sub- Jective States Along The "Hallucinogenic" Spectrum But Are Considered Sufficiently Dif- Ferent In Their Psychological And Behavioral Effects To Merit Their Own Category (Dsm- 5). In Recognition Of The Need To Expand The Hallucinogen Drug Category, Dsm-5 Now Includes The Following Subtypes: The N-Methyl-D-Aspartate (Nmda) Antagonist Hal- Lucinogens Such As Phencyclidine (Pcp), Ketamine, And Dextromethorphan (Dxm); Serotonergic Hallucinogens Such As D-Lysergic Acid Diethylamide (Lsd), Psilocybin,. 152. 9. Hallucinogens And Inhalants 153. Ayahuasca, Ibogaine, And Mescaline; The 3,4-Methylenedioxymethamphetamine (Mdma) Subtype; And Another (Single-Substance) Subtype (I. E., Salvia Divinorum, Jimsom Weed). The Desired Drug Effect Of The "Hallucinogens" Falls Along A Phenomenological Spectrum Of Varying Intensity Of Consciousness Alteration, With Unique Changes In Perception, Cognition, Affect, And Spiritual States (I. E., Mystical States Of Conscious- Ness). Most Hallucinogens Are Included In The Schedule I Category As Originally Defined By The Controlled Substances Act Of 1970. As Such, By Definition, They Are Classified As Having No Currently Accepted Medical Use In The United States, As Lacking In Safety For Use Under Medical Supervision, And As Having A High Addictive Liability. From An Addiction Perspective, It Is Worth Examining The Evidence Base For This Classifica- Tion To Understand The True Addictive Liability Of This Class Of Agents And How It Dif- Fers Depending On The Type Of Hallucinogen. Moreover, Given The History Of Research Suggesting A Role For Certain Hallucinogen Treatment Models To Treat Psychiatric And Addictive Disorders, It Is Further Worth Exploring How Some Of These Agents May Con- Fer Their Therapeutic Effects And To Weigh This Against Potential Toxic Effects Depending On The Particular Hallucinogen. Given The Breadth Of This Topic, The Focus Will Be On The Nmda Antagonist Hallucinogens, Serotonergic Hallucinogens, And Mdma. Nmda Antagonist Hallucinogens: Pcp And Related Substances. Classification. The Nmda Antagonist Hallucinogens (Nahs) Are Hallucinogens Known As Disso- Ciative Anesthetics Because Of Their Ability To Disconnect Mental From Somatic Pro- Cesses (Domino & Miller, 2009). However, They Are More Psychotogenic Than The Serotonergic Hallucinogens (Shs) And Can Indeed Produce Frank Hallucinations. The Nahs Include The Arylcyclohexylamines (I. E., Pcp; Ketamine; Dxm And Its Active Metabolic Dextrorphan [Dxo]; Dizocilpine (Mk-801); And Cyclohexamine). There Are Other Agents That Are Known To Potently Antagonize The Nmda Receptor With Associ- Ated Psychedelic Properties (I. E., Nitrous Oxide, Ethanol, Propofol), But They Are Not Included In This Category. Administration And Pharmacokinetics. Pcp, A Schedule I Drug, Is Prepared Illicitly In Tablet, Powder, And Liquid Form, With The Liquid Sprayed Onto Leafy Plant Material, Such As Tobacco And Cannabis, And Smoked. Pcp Tends To Have A Wide Range In Plasma Half-Life (7-46 Hours), And Even With Normal Doses It Is Not Unusual For Effects To Persist For Days After A Period Of Diagnosable Intoxication (As Defined In Dsm-5) Has Passed. The Desired And Toxic Behavioral Effects Of Pcp Are Related To Serum Level, With Psychotomimetic Effects Seen At Approximately 0.05-0.2 Micromoles (Μm) Serum Concentration, Anesthetic Doses At Approximately 0.2-1.0 Μm, And Lethal Doses At 1.0 Μm And Above (Domino & Miller, 2009). Ketamine, A Schedule Iii Drug, Was Synthesized In 1962 For Use As A Novel Anes- Thetic Agent, And It Has A Well-Established Safety Profile Based On Greater Than 7,000. 154 Iii. Substances Of Abuse. Published Reports (Krupitsky, 2007). Available In Powder And Liquid Form, It Can Be Snorted Or Injected Intramuscularly Or Intravenously. Ketamine's Plasma Half-Life (Alpha T1/2 Approximately 7 Minutes; Beta T1/2 Of 3-4 Hours) Is Much Shorter Than That Of Pcp, Accounting For Its Diminished Psychiatric And Medical Toxicity Relative To Pcp (Domino & Miller, 2009). Dxm Was Patented In 1954 And Designed As A Substitute For Codeine As A Cough Suppressant. It Was Excluded From The 1970 Controlled Substance Act; Over The Years, Dxm Has Been Made Increasingly Available As A Part Of Over-The-Counter Cold Medi- Cine Preparations, Which Provided A Surge Of Abuse Starting In The Early 1990S. Dxm Gets Converted To Dxo, A Potent Nmda Antagonist That Produces Effects Similar To Ketamine And Pcp. To Produce Its Psychoactive Effects, Large Doses Of Dxm Are Needed (Typically 300-1,800 Mg, And Well Above The Recommended Antitussive Dose Of 15-30 Mg) To Produce A Sufficient Amount Of The Psychoactive Dxo. The Time Course Of Dxos Effects Depend On A Genetic Polymorphism For The Catabolism Of Dxm In Which Rapid Metabolizers (Representing Approximately 90% Of The Popula- Tion) Have A T1/2 Of Approximately 3 Hours And Slow Metabolizers Have A T1/2 Of Approximately 24 Hours Or More (Zawertailo Et Al., 1998). Epidemiology. The Peak Use Of Pcp In The United States Occurred During The 1970S And Has Decreased Considerably Since Then. For Instance, The Recreational Use Of Pcp In The Prior Year By High School Seniors In The United States Decreased From 7% In 1979 To 1% In 2008 (Johnston, O'malley, Bachman, & Schulenberg, 2013). Pcp Abuse Appears To Be Lim- Ited To Major Cities In The United States And Is Particularly Prevalent In Philadelphia, Washington, Dc, Los Angeles, And Houston. Since 1999, According To The Drug Abuse Warning Network, There Has Been A Marked Increase In Emergency Department Visits Associated With Pcp, With A 400% Increase From 2005 To 2011 (Which Was In Addition To Earlier Increases; Substance Abuse And Mental Health Services Adminis- Tration [Samhsa], 2013). The Reason Behind This Is Unclear, But It May Represent An Increase In Use Among People Not Typically Covered In Community Surveys. It Is Difficult To Establish The True Prevalence Of Ketamine Use Disorders, Because The Users Remain A Mostly Hidden Group. One Study In Britain Reported That Close To 30% Of Surveyed Club-Goers Reported A Lifetime Use Of Ketamine (Wolff & Winstock, 2006). Starting In The Early 1990S, Dxm Began To Emerge As A Drug Of Abuse Especially Among Teenagers And Young Adults. This Is Consistent With Data From The National Poison Data System, Which Indicated That Between 2000 And 2010, The Peak In Calls Related To Dxm Nationally Occurred In 2006, With Concerted Legislative And Educa- Tional Initiatives Likely Accounting For The Drop-Off In Use And Adverse Medical Events (Wilson, Ferguson, Mazer, Et Al., 2011). Neurobiology. The Nahs Primarily Exert Their Psychoactive Effects Via Noncompetitive Blockade At The Ionotropic Nmda Glutamate Receptor At The Pcp Binding Site (Located Inside The. 9. Hallucinogens And Inhalants 155. Calcium Channel And Leading To Blockade Of Calcium Influx Through The Channel), With Psychoactivity Directly Correlating With Receptor Affinity (Oye, Paulsen, & Maurset, 1992). Nahs Increase Glutamate Release And The Firing Rate Of Pyramidal Neurons In The Medial Prefrontal Cortex (Mpfc), An Effect Likely Due To Blockade Of Nmda Receptors On Gamma-Aminobutyric Acid (Gaba)-Ergic Interneurons In Cortical And Subcortical Structures, Which Normally Antagonize Cortical Glutamate Neurons, Lead- Ing To A Reduction Of Inhibitory Control Over Pfc Glutamatergic Neurons (Homayoun & Moghaddam, 2007; Jodo Et Al., 2005). In Turn, Cortical Glutamatergic Activation Stimulates Monoaminergic Terminals Within The Cortex, Limbic System, Midbrain, And Brainstem (Krystal Et Al., 2003). As Part Of This, Extracellular Dopamine (Da) Levels Are Increased In Reward-Related Areas (I. E., Ventral Tegmental Area [Vta] And Nucleus Accumbens [Na]) In The Mesolimbic System And Account For The Addictive Liability Of This Class Of Drugs (See Below). Regional Brain Activity. See Below In The Section "Classical Or Serotonergic Hallucinogens.". Addictive Liability. Several Converging Pieces Of Data Point To Nahs Having Real Addictive Liability. These Include Positron Emission Tomographic (Pet) Studies Demonstrating Increases In Da In The Vta In Humans Correlating With Elevated Mood (Vollenweider, Liechti, Gamma, Greer, & Geyer, 2000); Increases In Da In The Na Of Humans (Smith Et Al., 1998); Induction Of Self-Administration In Animal Models (Newman, Perry, & Carroll, 2007); Repeated Administration Leading To Tolerance In Animals (Benthuysen, Hance, Quam, & Winters, 1989) And Humans (Wolff & Winstock, 2006); And Heavy, Habit- Ual Use And Dependence Syndromes In Humans (Moore & Bostwick, 1999). Despite Having Known Addictive Liability, The Nahs Are One Of The Least "Addictive" Classes Of Abusable Substances. Only About 5% Of Individuals Who Try These Drugs Will Go On To Develop Dependence Syndromes (Anthony, Warner, & Kessler, 1994). Intoxication/Phenomenology. The Nahs Produce A Range Of Psychic And Toxic States That Can Be Grouped Into Three Stages. Stage I Is The Desired Rewarding State Characterized By Euphoria, Anxioly- Sis, Dissociation, And Psychedelic Effects. The Spiritual Or Mystical Type Experiences Induced By The Nahs, Separate From Their Dissociative Properties (I. E., Out-Of-Body Experiences) And Perhaps Overlapping With What Is Traditionally Understood As Psy- Chotic Phenomenon, May Include Feelings Of Ego Dissolution And Loss Of Identity; Expe- Rience Of Psychological Death And Rebirth; Emotionally Intense Visions And Dream-Like States; Enhanced Insight/Self-Reflection And Meaning In Life; And Feelings Of Unity With Humanity, Nature, The Universe, And Deity (Krupitsky & Kolp, 2007). With Respect To The Nahs, It Has Been Postulated That The Nmda Blockade Accounts For Their Nega- Tive And Cognitive Dysfunction Potential, While The Increased Glutamate Transmission Accounts For The Positive Symptoms Of Psychosis (Domino & Miller, 2009). 156 Iii. Substances Of Abuse. There Is A Narrow Difference Between The Desired Effects Of The Nahs And Psy- Chological Toxicity, Which Includes Psychosis (I. E., Positive, Negative, Cognitive Symp- Toms), Delirium, Catatonia, Depression, Mania, Agitation, And Violence Toward Self And Others. The Latter Stages Of Intoxication (I. E., Stages Ii And Iii), Especially With Pcp, Are Marked By Increasingly Serious Medical Complications, Including Death. Intoxi- Cation Due To A Nah May Include Many Different Symptoms And Signs, But Formal Diagnosis Requires Several Specific Findings Of Cardiac, Somatic, Pain, Or Neuro/Neuro- Muscular Systems As Noted In Dsm-5 (American Psychiatric Association, 2013). Adverse Psychiatric Effects. Psychiatric Conditions Recognized As Being Exacerbated By The Nahs Include Psy- Chotic, Bipolar, And Depressive Spectrum Disorders. In Addition, Hallucinogen Persist- Ing Perceptual Disorder (Hppd) May Result From Exposure To An Nah. Beyond The Acute Stage Of Intoxication, Heavy Chronic Pcp Use (With Its Potentially Long Half- Life), Can Engender Enduring Psychotic Symptoms Lasting Weeks To Months Even In The Absence Of Underlying Psychotic Spectrum Illness And As Such, Schizophrenia Should Not Be Ruled In Unless The Psychosis Continues Chronically And There Is Other Evi- Dence To Suggest Schizophrenia (I. E., History Of Psychotic Symptoms Predating Any Drug Use, [+] Family History Of Schizophrenia) (Ross, 2012). Psychiatric Treatment Of Nah Intoxication Depends On The Clinical Findings. Many Individuals, Especially Those Intoxicated With Pcp, Come To Clinical Attention Due To Extremely Violent Or Agi- Tated Behavior; Others Are Referred In Severe Conditions That Affect Consciousness, Such As Delirium. Behavioral Management Usually Requires Supportive Care In A Manner That Protects The Individual From Self And Others. This Can Include Not Only Placing Patients In A Quiet Environment With Little Environmental Stimuli But May Also Neces- Sitate Physical Restraints To Manage Violent Behavior. Benzodiazepines Or Antipsychot- Ics Are Often Necessary To Treat Symptoms Such As Violence, Agitation, And Psychosis. It Is Important To Avoid Low-Potency Typical Neuroleptics (I. E., Chlorpromazine) Due To Additive Increased Risks Of Seizures And Cardiovascular Effects. While It Is Important To Continue Antipsychotic Medication In Individuals With Subacute (Days To Several Months) Psychosis Due To Pcp Use, Unless There Is Other Evidence To Suggest An Inde- Pendent Psychotic Spectrum Illness, It Would Be Reasonable To Taper Off Antipsychotic Pharmacotherapy Once The Psychotic Symptoms Resolve. Adverse Medical Effects. The Serious Medical Toxicity Of The Nahs Is Mostly Associated With Pcp Due To Its Relatively Long Half-Life. The Potential Medical Toxicities Due To Pcp Are Wide Ranging And May Include Severe And Permanent Problems. As Noted Earlier, Stage I Intoxication Is Associated With Few Serious Physiological Or Medical Sequelae, But It Is Characterized By Ataxia, Dysarthria, Tachycardia, Hypertension, Increased Saliva- Tion, Hyperreflexia, And Nystagmus (Horizontal, Vertical, Rotary), With Both Rotary And Vertical Nystagmus Being Pathognomonic For Nah Intoxication. In Stage Ii, Patients Range From A Stuporous State To Mild Coma, Are Responsive To Pain, And Have Pupils In The Midposition And Responsive To Light. In Stage Iii, Patients Are Comatose. 9. Hallucinogens And Inhalants 157. And Unresponsive To Painful Stimuli. Stages Ii And Iii Are Associated With Serious Adverse Medical Outcomes, Including Malignant Hypertension And Hyperthermia, Sei- Zures, Rhabdomyolysis And Acute Renal Failure, Stroke, Heart Failure, Coma, And Death. Supportive Medical Treatment Should Be Provided Especially For Stages Ii And Iii Of Intoxication. The Medical Toxicity Associated With Dxm Use Includes Serotonin Syndrome (When Combined With Monoamine Oxidase Inhibitors [Maois], Selective Serotonin Reuptake Inhibitors [Ssris], Or Other Serotonergically Active Medications, Because Dxm Increases The Synthesis And Release Of The Serotonin Transporter 5-Ht And Blocks The 5-Ht Reuptake Transporter) And Toxicity Related To The Other Substances Contained In Cold Preparations (I. E., Pseudophedrine, Phenylephrine, Antihistamines, Acetaminophen). Therapeutic Applicability: Addiction, Mood Disorders, And Pain Syndromes. Despite The Known Addictive Liability Of Nahs, It Is Interesting That There Is Experi- Mental Evidence To Suggest Antiaddictive Or Antidepressant Effects Of Ketamine. For Example, Ketamine's Antiaddictive Properties Have Been Studied In Hundreds Of Par- Ticipants In Russia As Part Of Ketamine Psychedelic Therapy (Kpt; Krupitsky & Kolp, 2007). An Emerging Body Of Scientific Literature Has Demonstrated The Ability Of Single Or Repeated Subanesthetic Doses Of Iv Ketamine To Rapidly And Reproducibly Reduce Depressive Symptoms (Including Reductions In Suicidal Ideation) In Patients With Treatment-Resistant Major Depression Or Bipolar Depression, With Antidepres- Sant Responses Detected Within 1-2 Hours Postinfusion, Maintained In A Majority Of Patients For At Least 24 Hours, And Enduring For Up To Several Days To Several Weeks (Murrough Et Al., 2013; Lee, Della Selva, Liu, & Himelhoch, 2015). Research With Ketamine Has Also Strongly Supported A Role In Treating Refrac- Tory Pain Syndromes Such As Complex Regional Pain Syndrome (Crps; Goldberg Et Al., 2005) And Breakthrough Pain In Chronic Pain Syndromes Such As That Related To Advanced Cancer (Carr Et Al., 2004). Classical Or Serotonergic Hallucinogens: Lsd And Related Substances. Classification. Sh Plant-Derived Compounds Occur In Nature, Including Psilocybin Mushrooms, Pey- Ote Cacti, Iboga Alkaloids, And Ayahuasca. Shs Consist Of An Arylalkylamine Skeleton And Are Divided Into Two Main Categories: The Indolealkylamines And The Phenylal- Kylamines. The Indolealkylamines Have A Core Structure Similar To Serotonin And Include:. • Tryptamines, Such As N, N-Dimethyltryptamine (Dmt, Found In Ayahuasca), Psilocybin, And Its Psychoactive Metabolite Psilocin. • Semisynthetic Ergolines Or Lysergamides (The Ergot Lsd). • Iboga Alkaloids (Ibogaine). 158 Iii. Substances Of Abuse The Phenylalkylamines Have A Core Structure More Similar To Norepinephrine (Ne). And Include. • Phenylethylamines, Such As "Stp" (2,5-Dimethoxy-4-Methylamphetamine), Mescaline (From The Peyote Cactus Lophophora Williamsii), And The 2C Series Of Compounds (I. E., 2Cb, 2Ci). • Phenylisopropylamines, Which Are Amphetamine Derivatives Such As Dom (2,5-Dimethoxy-4-Methylamphetamine). This Group Also Includes "Ecstasy" Mdma (3,4-Methylenedioxymethamphetamine). Note That Mdma, Which Is Discussed In More Detail Below, Is Not A "Classical" Hallucinogen, Because It Does Not Appreciably Agonize The Serotonin 2A Receptor And Does Not Typically Induce Mystical States Or Psychosis. Administration And Pharmacokinetics. One Of The Simple Tryptamine Indolealkylamines, Dmt, Is Produced In The Pineal Gland (Barker, Mcilhenny, & Strassman, 2012) And Its Endogenous Function Remains A Mystery. Synthetic Dmt, Typically Smoked Or, Much Less Commonly, Injected By The User, Leads To A Rapid Onset Of Action Within Seconds To Minutes And Has A Short Dura- Tion Of Action Lasting Approximately 10-20 Minutes. The Major Route Of Catabolism Of Dmt Is Via Oxidative Deamination By Mao, And Because Of The Significant Present Of Mao In The Gastrointenstinal System, Orally Ingested Dmt Is Degraded In The Gut And Is Therefore Not Psychoactive. The South American Hallucinogen Aqueous Decoction Ayahuasca Was Designed To Account For This Process By Containing Two Plant-Derived Components: Psychotria Viridis (Which Contains Dmt) And Banisteriopsis Capii, Con- Taining Several Beta-Carbolines (Harmine, Harmaline, And Tetrahydroharmine) That Have Mao Inhibitory Properties That Prevent Gastrointestinal Degradation Of Dmt And Allow For Its Entry Into The Central Nervous System (Cns) (Dos Santos Et Al., 2011). Unlike Smoked Or Injected Dmts Rapid On-Off Effects, Ayahuasca Has A Delayed Onset Of Psychedelic Effects (20-60 Minutes), A Plateau Of 1-2 Hours, Dmt Half-Life Of Approximately 1 Hour, And A Gradual Return To Baseline Around 6 Hours Postingestion (Riba Et Al., 2003). Psilocybin, A Ring-Substituted Tryptamine Indolealkylamine, Is Considered A Pro- Drug. It Is Dephosphorylated To Psilocin, Which Is Considered Its Major Psychoactive Metabolite, With A Mean Elimination Half-Life Of 50 Minutes (Passie, Seifert, Schneider, & Emrich, 2002). Typical Hallucinogenic Doses Of Psilocybin Range From 8-30 Mg In Humans, With Onset Of Action At Approximately 30-60 Minutes, Which Coincides With When Psilocin First Appears In Plasma; Peak Effects Occur At Approximately 60-90 Minutes Postingestion, Plateau For Approximately 50 Minutes (Corresponding To A Pla- Teau Of Plasma Psilocin Over The Same Time Period), Followed By A Gradual Decline Of Psychoactive Effects Until About 360 Minutes Postingestion (Passie Et Al., 2002). Lsd Is Among The Most Potent Shs, With Pronounced Alterations In Consciousness At Doses As Low As 50-75 Μg, With A Typical Dose Of 100-200 Μg (Passie Et Al., 2008). It Is Synthetically Derived, Available As A Liquid, And Typically Ingested On "Blotter Paper," Microdots, Or Other Material (I. E., Sugar Cubes) Impregnated With Lsd Solu- Tion. Following Oral Intake And Complete Absorption Of Lsd In The Gastrointestinal. 9. Hallucinogens And Inhalants 159. Tract, Psychological Effects Begin Approximately 30-45 Minutes Postingestion, Peak At Approximately 1.5-2.5 Hours, With The Total Duration Of The Experience Lasting 6-10 Hours. In Humans, Lsd's Elimination Half-Life Is Approximately 4 Hours, And It Is Extensively Metabolized, With Less Than 1% Of Lsd Appearing In Urine. It Is Metabo- Lized By Nadh-Dependent Microsomal Liver Enzymes To Several Inactive Metabolites, Including 2-Oxy-Lsd, 2-Oxy-3-Hydroxy-Lsd, And Nor-Lsd; The Latter Two Are The Most Abundant In Urine And Detectable For 2-5 Days Postuse (Canezin Et Al., 2001). Ibogaine Is One Of The Longest Acting Hallucinogens. With Dose-Dependent Bio- Availability, The Onset And Peak Of The Hallucinogenic Effects Occur 1-3 Hours After Ingestion, With A Plateau Phase Of Approximately 4-8 Hours, And Residual Altera- Tions Of Consciousness That Can Last Another 12-24 Hours (Alper, 2001). The Major Metabolite Of Ibogaine, Nor-Ibogaine (Produced By Cytochrome P450 2D6 [Cyp2D6] Demethylation) Has A Longer Half-Life And Greater Binding At The Mu Opioid Receptor Than Ibogaine (Mash Et Al., 2000). Ibogaine's Estimated Half-Life In Humans Is 7.5 Hours, And Both Ibogaine And Nor-Ibogaine Are Excreted By The Kidneys And Gastroin- Testinal Tract (Alper, 2001). The Metabolism Of Most Of The Phenylalkylamines Has Not Been Well Researched And Documented In Humans, But Most Are Thought To Be Substrates For Cytochrome P450 And Mao (Glennon, 2009). Mescaline Is The Active Ingredient In The Peyote Cactus, With Documented Ceremonial And Sacramental Use By Native Americans For Hundreds Of Years. Mescaline Possesses Psychoactivity At Oral Doses Of 200-400 Mg/ Kg, Has A Relatively Slow Onset (1-3 Hours) And A Long Duration Of Action Up To 10 Hours (Glennon, 2009). Mescaline Is Approximately One-Tenth As Potent As Psilocybin And One-Thousandth As Potent As Lsd. The Approximate Half-Life Of Mescaline Is 6 Hours, And It Appears Not To Be Metabolized By The Cytochrome P450 System, With 20-50% Of Mescaline Excreted Unchanged In Urine And The Remainder Excreted As The Carboxylic Acid Form Of The Drug, Likely Due To Mao Degradation (Cochin, Woods, & Seevers, 1951). Epidemiology. There Is A Relative Lack Of Epidemiological Data Detailing The Course Of Hallucinogen Use Disorders Specific To The Shs, But They Are Among The Most Rare Of All Use Disorders And The Least Likely To Be Associated With Frank Addiction, If Any Addiction At All, And Are Associated With High Rates Of Recovery (Ross, 2012). They Typically Begin In Ado- Lescence, Peak At 18-29 Years (0.6%) And Decrease To 0% Among Those 45 And Older. Regarding The Dsm-Iv Hallucinogen Use Disorders, Past 12-Month Prevalence Among Age Groups Has Included Adults (0.14%), 12- To 17-Year-Olds (0.5%), And 18-Year- Olds And Older (0.1%) (Samhsa, 2011). Adolescents Have The Greatest Rates Of Use, With Approximately 8% Of Adolescents Ages 16-23 Using One Or More Shs In A Prior 12-Month Period, With Mdma By Far Being The Most Commonly Used Sh (Despite Its Inaccurate Characterization As An Sh) (Wu, Schlenger, & Galvin, 2006). Adult Men Are Twice As Likely To Meet Criteria, Although Girls Are More Likely To Use Than Boys Ages 12-17 (Samhsa, 2011). 160 Iii. Substances Of Abuse Neurobiology. All Of The Shs Have Marked Affinity As Agonists For The 2Ar But Also Interact To Some Degree With 5-Ht1, 5-Ht4, 5-Ht5, 5-Ht6, And 5-Ht7 Receptors. In Addition, The Semisynthetic Ergolines (I. E., Lsd) Display High Intrinsic Activity At D2 And Alpha- Adrenergic Receptors (Marona-Lewicka, Thisted, & Nichols, 2005). Ibogaine Has The Most Complicated Pharmacodynamic Profile Of The Shs, And In Addition To Its Agonist Effects At The Serotonin Receptors (2Ars), It Also Interacts With The Glutamatergic, Opi- Oidergic, And Cholinergic Neurotransmitter Systems (Alper, 2001). Converging Lines Of Evidence From Pharmacological, Electrophysiological, And Behavioral Research In Animals Strongly Suggest That Activation Of Cortical 2Ars Is The Most Critical Step In Initiating A Cascade Of Biological Events That Accounts For Their Hallucinogenic Proper- Ties (Vollenweider & Kometer, 2010). In Humans, Preadministration Of Ketanserin (A 2Ar Antagonist) Abolishes Almost All Of The Psilocybin-Induced Psychoactive Effects (Vollenweider, Vollenweider-Scherpenhuyzen, Et Al., 1998). There Is Also Evidence That 2Ar Agonists Activate Differing Intracellular Signaling Pathways Depending On Whether They Have Hallucinogenic Properties (I. E., Lisuride; Nichols, 2004). The 2Ar Is A Gq-Coupled G Protein-Coupled Receptor (Gpcr) That Responds To The Endogenous Neurotransmitter, Serotonin, Whereas The Metabotropic Glutamate Receptor (Mglur2) Is A Gi-Coupled, Pertussis Toxic-Sensitive Gpcr That Responds To Glutamate. It Has Been Demonstrated That 2Ar And Mglur2 Recep- Tors Form A Functional Heteromeric Complex Through Which Classical Hallucinogens Cross-Signal To The Gi-Coupled Receptor (Gonzalez-Maeso Et Al., 2008). Furthermore, Formation Of The Mglur2-2Ar Complex Establishes An Optimal Gi-Gq Balance In Response To Glutamate And Serotonin (Increase In Gi And Decrease In Gq) And The Clas- Sical Hallucinogens May Produce Their Propsychotic States By Effecting Decreases In Gi And Increases In Gq (Fribourg Et Al., 2011). 2Ar Activation By Classical Hallucinogens Modulates Prefrontal Network Activ- Ity By Causing Marked Increases In Extracellular Glutamate Levels That Account For Increased Activity Of Pyramidal Neurons, Most Pronounced In Layer V Of The Pfc (Béïque Et Al., 2007). Also, Activation Of 2Ar Receptors In The Mpfc Affects Subcorti- Cal Transmission By Increasing The Activity Of Serotonin Neurons In The Dorsal Raphe And Da Neurons In The Vta, The Latter Resulting In Increased Da Transmission In Mesocortical And Mesostriatal Areas (Puig Et Al., 2003). In A Human Study, Psilocybin Induced Increase In Striatal Da Was Correlated With Euphoria And Depersonalization (Vollenweider Et Al., 1999). This Is Interesting To Note In Light Of The Lack Of Psilocy- Bin's Ability To Produce Dependence Or Addiction (Ross, 2012). Regional Brain Activity. Shs And Nahs Both Produce Similar Altered States Of Consciousness In Human Stud- Ies (Vollenweider & Kometer, 2010). Both Are Capable Of Producing Mystical States Of Consciousness. Consistent With Similar Phenomenological States, Human Brain Imag- Ing Studies Have Demonstrated That Both Psilocybin And Ketamine Produce Similar Patterns Of Prefrontal-Limbic Activation. They Showed Marked Prefrontal Activation (Hyperfrontality): Frontomedial, Dorsolateral Cortices, Anterior Cingulate, Insula And. 9. Hallucinogens And Inhalants 161. Temporal Poles; Decreased Activation Of Areas Important For Gating Or Integrating Cor- Tical Information Processing, Such As The Bilateral Thalamus, Right Globus Pallidus, Bilateral Pons, And Cerebellum; And Decreased Activity In The Somatosensory Cortical Areas, Occipital Cortex, And Visual Pathways (Geyer & Vollenweider, 2008). Taken Together, Psilocybin And Ketamine Both Produce Hyperfrontality With Divergent Prefrontal-Subcortical Activation In Such A Way As To Increase Cognitive And Affective Processing In The Context Of Reduced Gating And Reduced Focus On External Stimulus Processing. Interestingly, The Dimension Of "Oceanic Boundlessness" On The Swiss Apz Scale (Translated As Altered States Of Consciousness Scale, Correlating With Mystical States Of Consciousness) Was Correlated With Ketamine And Psilocybin Activation Of A Prefrontal-Parietal Network And The Deactivation Of A Striatolimbic Amygdalocen- Tric Network (Vollenweider & Kometer, 2010). Other Similarities Between Psilocybin And Ketamine Are That Both Stimulate Cortical Glutamate Transmission, With Increased Activation Of Alpha-Amino-3-Hydroxy-5-Methyl-4-Isoxazolepropionic Acid (Ampa) Receptors Relative To Nmda Ones, And That Both Increase Brain-Derived Neurotrophic Factor (Bdnf) Levels In Prefrontal And Limbic Brain Areas In Rats (Vaidya Et Al., 1997; Cavus & Duman, 2003; Garcia Et Al., 2009). Addictive Liability. In Contrast To All Other Drugs Of Abuse, Shs Are Not Considered To Be Capable Of Pro- Ducing Sufficient Reinforcing Effects To Cause Dependence (Addiction) Syndromes Asso- Ciated With Compulsive Use (O'brien, 2006; Ross, 2012). Animal Models Have Failed To Reliably Demonstrate Addictive Liability Of The Shs, Suggesting That They Do Not Pos- Sess Sufficient Pharmacological Properties To Initiate Or Maintain Dependence (Fante- Grossi, Woods, & Winger, 2004; Nichols, 2004; Poling & Bryceland, 1979). All Of The Shs (Except Lsd; Watts Et Al., 1995; Giacomelli Et Al., 1998) Lack Affinity For Da Receptors Or Dopamine Transporters (Dats) And Do Not Directly Affect Dopaminergic Transmission. Interestingly, Despite Evidence That Shs Have Been Shown To Increase Da Transmission In Striatal Areas In Humans, They Fail To Activate The Nucleus Accum- Bens Significantly In Pet Imaging Studies. This Is Consistent With The Lack Of Evidence Linking Classical Hallucinogens With Addiction Syndromes (Vollenweider Et Al., 1999; Geyer & Vollenweider, 2008). In Fact, In Animals, Ibogaine (As Well As Nor-Ibogaine And 18-Methoxycoronaridine [18-Mc]) Has Been Shown To Decrease Dopamine Efflux In The Nucleus Accumbens In Response To Opioids (Maisonneuve Et Al., 1991; Glick, Maissoneuve, & Dickinson, 2000; Taraschenko Et Al., 2007) And Nicotine (Benwell Et Al., 1996; Maisonneuve Et Al., 1997). Furthermore, Rapid Tachyphylaxis Occurs With Repeated Administration Of The Shs (With The Exception Of Dmt) And With Repeated Daily Dosing, Psychological Effects Disappear Within Several Days, An Effect Correlated With And Likely Mediated By 5-Ht2A Downregulation (Buckholtz Et Al., 1990). The Lack Of A Withdrawal Syndrome Eliminates Another Avenue Toward Addiction, That Of Negative Reinforcement To Avoid Painful Withdrawal States (I. E., Opioids, Alcohol). In Addition To The Lack Of Biological Evidence, Epidemiological Studies Have Also Failed To Reliably Demonstrate A Link Between Shs And Their Ability To Engender Enduring Dependence Syndromes, And The National Institute On Drug Abuse (Nida; 2001,. 162 Iii. Substances Of Abuse. 2005) Does Not Consider The Shs Drugs Of "Addiction" Because They Do Not Produce Compulsive Drug-Seeking Behavior, And Most Recreational Users Decrease Or Stop Their Use Over Time. Intoxication/Phenomenology. The Acute Psychological And Behavioral Effects Of The Shs Are Greatly Influenced By Set (Personality And Expectations Of The Individual), Setting (Environmental Conditions And Context Of Use) And Dose, With The Factors Combining To Influence The Valence (Positive Or Negative) Of The Experience (Ross, 2012). Affective Changes Can Range From Euphoric Or Ecstatic Spiritual States To Anxiety, Terror, And Panic. Perception Is Intensified And Amplified, With Alterations In Time, Space, And Boundaries Between Self And Others. Synesthesia Is Common, With Mixing Of Various Sensory Stimuli (I. E., Hearing Colors). Sensory Illusions (I. E., Walls Breathing) Are Common And Frank Hal- Lucinations Occur But Less Frequently. Thought Processes Are Loosened, With Effects Ranging From Increased Creativity To Thought Disorder. Cognition Is Altered And Can Range From Increased And Sudden Insight ("Noetic" Effect) To Confusion And Disori- Entation (Wilkins, Danovitch, & Gorelick, 2009). The Sum Total Of The Experience Can Range From Positive Mystical-Type Experiences Associated With Enduring Positive Changes In Affect-Cognition-Behavior To "Bad Trips" Or Hallucinogen Persisting Per- Ceptual Disorder (Hppd) (See Below) (Griffiths, Richards, Mccann, & Jesse, 2006; Griffiths, Richards, Johnson, Mccann, & Jesse, 2008; Griffiths Et Al., 2011; John- Son, Richards, & Griffiths, 2008). When Lsd Was First Discovered In 1943, Its Effects Were Thought To Be Similar To Endogenous Psychotic States And The Term "Psychotomimetic" Was Coined. The Shs Cause States That Resemble Acute Positive Symptoms Of Psychosis (I. E., Illusions, Hallucinations, Thought Disorder); However, Reality Testing Tends To Remain Intact Dur- Ing Intoxication With These Agents, And They Rarely Cause Frank Hallucinations, Delu- Sions, Or Prominent Negative Or Cognitive Symptoms In Individuals Without Underly- Ing Psychotic Spectrum Illness Or Major Affective Psychoses (Ross & Peselow, 2012). The Vague Term "Psychedelic," Meaning Mind Manifesting, Has Remained As The Most Commonly Used Term In Popular Culture (Osmond, 1957). The Term "Hallucinogen" Is A Misnomer, Because The Shs Are Less Likely To Cause Frank Hallucinations Than To Cause Illusions. Perhaps A More Precise Phenomenological Descriptor, "Mysticomi- Metic," Comes From The Psychology Of Religion Literature. Adverse Psychiatric Effects. Acute Effects. Severe Adverse Psychological Experiences ("Bad Trips") Tend To Occur In Poorly Pre- Pared Individuals Who Use The Particular Sh In An Uncontrolled Setting And Who Have Psychological Risk Factors (I. E., Severe Mental Illness, Recent Trauma) (Johnson Et Al., 2008). These Experiences Typically Include Anxiety, Panic, Dysphoria, Depersonaliza- Tion, Paranoid Ideation, And Fear That The Experience Will Never End Or That One Will Lose One's Mind. Despite Such Adverse Reactions, Users Usually Retain Insight Into The. 9. Hallucinogens And Inhalants 163. Fact That Their Symptoms Are Related To Drug Ingestion And Usually Respond To Verbal Reassurance. Shs Can Acutely Engender Frank Psychosis Marked By Hallucinations, Thought Disorder, And Delusions, Although This Is Rare In Individuals Without Under- Lying Psychotic Spectrum Illnesss (Ross, 2012). Such Adverse Psychological Experi- Ences Can Potentially Lead To Dangerous Behavior Toward Self Or Others (Strassman, 1984). First-Line Treatment Of Acute Panic Reactions And Psychotic Phenomena (I. E., Paranoid Ideation, Hallucinations), Engendered By Shs, Should Include Placement In A Quiet Setting And "Talking Down" The Patient With Verbal Reassurance About The Time- Limited Nature Of The Experience. Pharmacological Interventions Can Also Be Used, If Necessary, Including Fast-Acting Oral Or Parenteral Benzodiazepines (I. E., Diazepam, Lorazepam) And Antipsychotics. The Atypical Antipsychotics May Be Especially Helpful Because Of Their Antagonist Effects At The 5-Ht2A Receptor. Prolonged Effects. Psychosis. It Is Well-Established That Shs Use Can Provoke Sustained Psychosis In Vulnerable People With Psychotic Spectrum Illnesses (I. E., Schizophrenia, Schizoaf- Fective Disorder, Bipolar Disorder With Psychotic Features). However There Is Little To No Evidence Linking Sh Use To Prolonged Psychosis In Individuals Without A Psychotic Diathesis (Ross & Peselow, 2012). Estimates Of The Prevalence Of Lsd-Induced Psy- Chosis As Assessed By Early Psychedelic Researchers And Clinicians (Many Working With And Administering Lsd To Psychiatric Inpatients) Were As Follows From Two Reports: 0.8/1000 Research Volunteers And 1.8/1000 Psychiatric Patients (Cohen, 1960); And 0/170 Research Volunteers And 9/1000 Psychiatric Patients (Malleson, 1971). A Recent Cross-Sectional Study Evaluating Data Taken From Years 2001-2004 Of The National Survey On Drug Use And Health With A Sample Of 130,152 (Representing A Random Sample Of The U. S. Population Living In Households) Did Not Find Any Significant Asso- Ciations Between Lifetime Use Of Any Psychedelic Or Past Year Use Of Lsd And Increased Rates Of Any Psychiatric Symptoms (Including Psychosis) Or Mental Health Outcomes (Krebs & Johansen, 2013). Hallucinogen Persisting Perception Disorder. In Hppd, Users Experience Per- Ceptual Effects ("Flashbacks") Similar To Those Experienced During Previous Halluci- Nogen Use; These Flashbacks Must Cause Distress And Impair Functioning (Dsm-5). Flashbacks Can Occur Spontaneously Or Be Triggered By Stress, Exercise, Or Use Of Another Drug (I. E., Cannabis). Although The Exact Prevalence Of Hppd Is Unknown, It Is Thought To Be A Rare Condition And Less Common In Research Settings With Careful Screening And Preparation (Johnson Et Al., 2008; Halpern & Pope 2003). The Longi- Tudinal Course Tends To Be Brief, And The Condition Usually Remits On Its Own Over Time (Strassman, 1984). Supportive Psychotherapy Is Warranted To Reassure Individuals. There Is No Established Evidence-Based Pharmacologic Algorithm To Treat Hppd With Most Of The Trials Coming From Case Reports, Case Series, And Open Label Trials With Little In The Way Of Randomized Controlled Trials. Benzodiazepines (E. G., Alprazolam, Clonazepam), Naltrexone, And Typical Antipsychotics (Haloperidol, Trifluoperazine, Perphenazine) Have Been Shown To Reduce Some Symptoms Of Hppd Without Leading. 164 Iii. Substances Of Abuse. To Disease Remission; Data On The Utility Of Ssris To Ameliorate Symptoms Of Hppd Is Mixed, With Some Data Supporting Their Efficacy And Some Suggesting A Worsening Of Symptoms; Risperidone (And Possibly The Atypical Antipsychotics In General) Should Be Avoided As A Treatment Option In Hppd As There Is Evidence That Risperidone Worsens Hppd Symptoms (Wilkins Et Al., 2009). More Controlled Trials Are Needed To Establish Better Pharmacologic Treatments For Hppd, Which Could Help Further Elucidate The Pathophysiology Of The Illness. Adverse Medical Effects. In General, Shs Possess Low Physiological Toxicity And Are Not Typically Associated With End Organ Damage, Carcinogenicity, Teratogenicity, Lasting Neuropsychological Deficits, Or Overdose Fatalities (Johnson Et Al., 2008; Halpern Et Al., 2005, 2008). An Exception To This Is Ibogaine Which Has Been Associated With Fatalities And Is Known To Induce Cardiac Arrhythmias: Bradyarrhythmias, Qt Prolongation Possibly Leading To Torsade De Points (Alper, Staji, & Gill, 2012). Also Some Relatively New Designer Phenethylamine Shs (Bromo-Dragonfly And 2,5-Dimethoxy-N-[2-Methoxybenzyl] Phenylethylamine—Referred To As Nbome), With Very High Potency At The Serotonin 2Ar, Have Been Associated With Fatalities (Baumann Et Al., 2012). The Shs Produce Sympathomimetic Effects And Can Moderately Increase Pulse, As Well As Diastolic And Systolic Blood Pressure, But This Has Not Been Associated With Cardiac, Neurological, Or Other Organ Damage (Griffths & Grob, 2010). Common Physiological Side Effects Of The Shs Include Mydriasis, Blurry Vision, Dizziness, Tremors, Weakness, Paresthe- Sias, And Increased Deep Tendon Reflexes (Johnson Et Al., 2008). Therapeutic Applicability. Although Often Forgotten And Not Part Of Modern Psychiatric Training, From Approxi- Mately The Late 1950S To The Mid-1970S, There Was Extensive Research On The Therapeu- Tic Applicability Of Hallucinogen Treatment Models. Much Of The Research Centered In The United States And Europe. Two Treatment Models Emerged: Psycholytic And Psy- Chedelic (Ross, 2012). The Psycholytic Model Predominated In Europe, Where Lower Doses Of Lsd (30-200 Mg) And Psilocybin (3-15 Mg) Were Used As Tools To Activate And Enhance The Psychoanalytic Process By Allowing Greater Access To Unconscious Material To Effect Personality Changes In Disease States Such As Personality Disorders, Neurotic Spectrum Disorders, And Psychosomatic Illness. The Psychedelic Model Uti- Lized High Doses Of Lsd (400-1,500 Mcg) And Psilocybin (20-40 Mg) To Access Novel Dimensions Of Consciousness Remarkably Similar To Mystical States Of Consciousness, With Oneness, Illuminative Insight, A Sense Of The Sacred, And Ecstatic Joy As Core Parts Of The Experience. This New Therapeutic Model With No Previous Basis Within The Field Of Mental Health Research Had More Parallels Toward Religion And Mysticism. By The End Of Nearly Three Decades Of Research, Over 1,000 Articles Were Published In The Literature And Over 40,000 Participants Were Included In Basic Or Therapeutic Clinical Hallucinogen Research (Malleson, 1971). A Treatment Model That Established The Parameters Of Set (Psychological Frame Of Mind, Intention, Excluding Participants With Major Mental Illness Or Family History Of Such Illness), Setting (Environment/. 9. Hallucinogens And Inhalants 165 Room On Dosing Days), Dose, Preparation With Therapeutic Dyad Teams, And Integra-. Tion Of The Experience Was Established. Lsd/Psilocybin And Addiction Treatment Studies. Overall, The Studies Of Lsd's Effect In Alcoholism During The 1950S And 1960S Varied Widely, From Astonishingly Positive Results To Worsening Of The Alcoholism, Depend- Ing On The Design Of The Study, Set, And Setting Of The Dosing Sessions And The Degree To Which Preparatory And Integrative Psychotherapy Was Used. While A 1971 Meta- Analysis Reduced Enthusiasm For This Line Of Investigation (Abuzzahab & Anderson, 1971), A 2012 Review (Krebs & Johansen, 2012) Found New Evidence Supporting This As A Potential Therapy. Recently, A Re-Emergence Of Research Has Occurred Utilizing Psilocybin-Assisted Psychotherapy To Treat Addiction With Two Recently Published Open Label Trials Suggesting Efficacy Of Psilocybin Treatment For Alcoholism (Bogenschutz Et Al., 2015) And Tobacco Addiction (Johnson Et Al., 2014). Randomized Controlled Trials Utilizing A Similar Model To Treat Alcoholism, Tobacco Addiction, And Cocaine Addic- Tion Are Underway At Several Academic Medical Centers In The United States. Ibogaine, Iboga Congeners, And Opioid Withdrawal. Ibogaine, A Psychoactive Indole Alkaloid That Is The Most Abundant Alkaloid Found In The Root Bark Of The Apocynaceous Shrub Tabernathe Iboga In West Central Africa, Has Been Studied As A Substance That May Attenuate Opioid Withdrawal In Nonhumans (Maisonneuve & Glick, 2003). Anecdotal Reports And Several Case Series Have Indi- Cated That Ibogaine Diminishes Or Eliminates Opioid Withdrawal Symptoms In Humans And May Be Associated With Longer Term Abstinence Even After A Single Dose (Alper, 2001). The Ability Of Ibogaine And Related Congeners To Attenuate Or Suppress Opi- Oid Withdrawal Is Unique Among The Shs, And There Is No Evidence Of Other, Similar Agents (I. E., Lsd, Psilocybin, Dmt, Mescaline) Having Any Efficacy In Diminishing Opioid Withdrawal. Agonism At The Mu Opioid Receptor Has Been Considered A Poten- Tial Mechanism (Maciulaitis Et Al., 2008). Ibogaine Remains Unavailable For Use In The United States Because Of Concerns Regarding Its Safety, Specifically, Cardiotoxic And Neurotoxic Issues, Which Is Consis- Tent With Anthropological Reports Of Fatalities During Initiation Rites Of The Fang Peo- Ple Of West Africa; There Have Been At Least A Dozen Deaths Reported Within 72 Hours Of Ibogaine Use Since 1990 (Alper Et Al., 2012). Mdma. Classification. Mdma Is A Ring-Substituted Analog Of Methamphetamine In The Phenylisopropyl- Amine Category Of Substances, Which Includes A Variety Of Sh With Amphetamine-Like Effects. However, Mdma Is Not Considered A "Classical" Sh, Because It Does Not Appreciably Agonize The 5-Ht2A Receptor To The Same Extent As The Shs And Does Not Typically Induce Mystical States Or Psychosis (Vollenweider Et Al., 2002). It Exists. 166 Iii. Substances Of Abuse. In A Unique Category, Described As An "Entactogen" (Nichols, 2004), Producing A Diverse Set Of Effects (Amphetamine, Prosocial/Empathogen, Anxiolytic, Mild Psyche- Delic). "Bath Salts" Should Not Be Unduly Confused With Mdma. "Bath Salts," A Group Of Synthetic Derivatives Of The Cns Stimulant Cathinone, Have Rewarding Effects Somewhere Between Mdma And Methamphetamine And Are Associated With Adverse Psychological (I. E., Mania, Psychosis) And Medical (I. E., Seizures, Arrhythmias, Deaths) Effects (Spiller, Ryan, Weston, & Jansen, 2011). Administration And Pharmacokinetics. Mdma Is Almost Exclusively Available In Pill Form, Is Usually Taken Orally But It Can Be Snorted And Rarely Is Injected Intravenously. The Usual Single Recreational Dose Is 50-150 Mg. Mdma Possesses Good Oral Bioavailability, Easily Crosses The Blood- Brain Barrier, Has An Onset Of Action 20-40 Minutes After Ingestion, Which Is Often Experienced With Immediacy Or A "Rush" That Lasts Approximately 30-45 Minutes, And Is Associated With Peak Plasma Concentrations Achieved In 1-3 Hours Postinges- Tion; The Next Phase (Plateau) Typically Lasts Several Hours, Is Somewhat Less Pleasur- Able Than The Initial Phase, And Is Usually Accompanied By Heightened Motor Activity (I. E., Dancing); The Elimination Half-Life Of Mdma Is 7-8 Hours, And Most Users Expe- Rience A "Coming Down" 3-6 Hours After Drug Intake (Wilkins Et Al., 2009). Mdma's Major Metabolic Pathway In Humans Involves O-Demethylenation By Cyp2D6 To 3,4-Dihydroxymethamphetamine (Hhma) And Subsequent Methyla- Tion Of Hhma By Catechol-O-Methyltransferase (Comt) To 4-Hydroxy-3-Methoxy- Methamphetamine (Hmma) (De La Torre Et Al., 2004). A Minor Pathway Involves N-Demethylation Of Mdma By Cyp3A4 To 3,4-Methylenedioxyamphetamine (Mda), Which Possesses Psychoactive Effects Similar To Mdma And Has A Longer Half-Life Of 16-40 Hours (Monks Et Al., 2004). Mdma Displays Nonlinear Kinetics In Humans Whereby Increasing Doses, Or Multiple Doses Taken In A Single-Use Episode, Leads To Unpredicatbly High Plasma Levels Of The Drug, Which Could Account For The Serious Adverse Medical And Psychiatric Toxicity Reported With Multiple-Dose Usage (Baumann, Wang, & Rothman, 2007). Epidemiology. Adolescents Are Frequent Users Of Mdma And The Population Most Likely To Present With This As The Drug Causing The Most Problems For Them. Furthermore, They Are More Likely To Be Involved With The Subculture (I. E., Clubs, Raves, Circuit Parties) That Is Enmeshed With Mdma, And More Likely To Have A Decreased Perception Of Harm Of The Drug That Is Associated With A Greater Likelihood Of Using Mdma (Pentney, 2001). According To Monitoring The Future (Johnston, O'malley, Bachman, & Schulenberg, 2013) Data, Mdma Use Peaked Among Adolescents In 2001, With Annual Prevalence Of Use As Follows: Eighth Graders 3.5%, 10Th Graders 6.2%, And 12Th Graders 9.2%. A Marked Reduction Of Use In All Grades Occurred From 2001 Until Approximately 2005-2006, With A Rebound In Use Among 8Th And 10Th Graders Occurring Over The Next 2 Years; After 2007, Usage Became Flat In All Grades; Annual Use Increased Signifi- Cantly From 2009-2010 In 8Th Graders (1.3 → 2.4%) And 10Th Graders (3.7 → 4.7%). 9. Hallucinogens And Inhalants 167. But Then Declined Over The Next 2 Years, And Annual Use Among 12Th Graders Increased From 2010 To 2011 (7.3 → 8%) But Then Significantly Decreased Back To 7.2% In 2012 (Johnston Et Al., 2013). It Is Of Concern That From 2004 To 2011, The Perceived Risk Of Mdma Use Declined In All Grades And Likely Accounted For Some Of The Previ- Ously Mentioned Rebound In Usage Patterns (Johnston Et Al., 2013). The Most Recent National Survey On Drug Use And Health (Samhsa, 2011) Data Indicate That In 2011, An Estimated 555,000 Individuals (0.2% Of The Population) In The United States Over The Age Of 12 Had Used Mdma In The Month Prior To The Survey. Lifetime Use In This Same Demographic Group Was Significantly Increased From 4.3% In 2002 To 5.7% In 2011. The 18-25 Age Range Represents The Highest Lifetime Use Rates, With Rates At Approximately 12% In The Last Several Years. Regarding Past Year Initiates Of Mdma In Those 12 And Older, The Peak In 2002 (1.2 Million New Users) Decreased To 607,000 In 2004, And Has Significantly Increased From 2005 (615,000) To 2011 (922,000); The Majority (61%) Of New Users In 2011 Were 18 Or Older (Nsduh, 2011). Regarding Mdma Use And Use Syndromes, There Appear To Be Two Main Groups Of Individuals Who Ingest Mdma. The Vast Majority Of Humans Who Try Mdma Will Not Progress To Compulsive, Addictive Use. In One Of The Few Epidemiological Studies That Analyzed The Rates Of Mdma Use Disorders In A General Population Sample In The United States (Analyzed From The 2005 Nsduh), Among Past-Year Ecstasy Users, Only 3.6% Met Criteria For Dsm-Iv Hallucinogen Dependence (Wu, Howard, & Pilowsky, 2008). This May Be Explained By Attenuation Of Mesolimbic Dopaminergic Release By Antagonist Mdma-Induced Increased Serotonergic Activity (Bankson & Yama- Moto, 2004) Or Due To The Phenomenon Of Chronic Tolerance, Whereby Most People Who Continue To Use Mdma Report A Precipitous Decline In The Pleasurable Effects Of The Drug And An Increase In The Undesirable Effects Such As Psychomotor Agitation (Parrott, 2005). First-Time Users Are Often Instant Advocates Of Mdma Only To Have Their Enthusiasm Dampen With Time. However, There Does Appear To Be A Small But Significant Group Of Chronic Mdma Users That Develop Frank Addiction To The Drug. For Example, In An Epidemiological Study Looking Examining Use Syndromes Among 600 Mdma Users In 2 U. S. Cities And One City In Australia, Mdma Dependence Was Found In 83% Of Moderate (100-499 Doses Per Lifetime) Or Heavy (Greater Than 500 Doses Per Lifetime) Users And In 48% Of Light Users (1-99 Doses Per Lifetime) (Cottler Et Al., 2006; Leung & Cottler, 2008). Furthermore, An Mdma Withdrawal Phenom- Enon Has Been Described. In Another Epidemiological Study Of 52 Club Drug Users In St Louis, 34% Met Criteria For Mdma Abuse, 43% Met Criteria For Dependence, And 59% Met Criteria For Withdrawal-Related Symptoms (Cottler Et Al., 2001). Neurobiology. Mdma Has A Variety Of Effects On Several Neurotransmitter Systems: Mdma Increases Monoaminergic Signaling By Interacting With Monoamine Transporters To Stimulate Nonexocytotic Release Of Da, Ne, And 5-Ht, As Well As Inhibit The Dat, 5-Ht Trans- Porter (Sert), And Ne Transporter (Net) (Baumann Et Al., 2007); Mdma Has Espe- Cially Pronounced Effects On The 5-Ht System In Addition To Stimulating Presynaptic Release Of 5-Ht; It Also Increases 5-Ht Transmission By Inhibiting Sert, Reversibly Inhibiting Monoamine Oxidase A (Mao-A) And Slowing Down The Degradation Of. 168 Iii. Substances Of Abuse. 5-Ht, And Inhibiting Tryptophan Hydroxylase, Which Slows Down The Production Of 5-Ht (Hasler, Studerus, Lindner, Ludewig, & Vollenweider, 2009), With Increases In Extracelluar 5-Ht That Are Greater In Magnitude Those That For Da (Baumann Et Al., 2007) But Less So Than Its Effects On Ne (Verrico, Miller, & Madras, 2007). Some Conclusions Can Be Drawn From These Varying Effects:. 1. Some Of The Psychological And Physical Effects Of Mdma Are Due To Sert- Mediated Increases In Presynaptic Release Of 5-Ht (Vollenweider Et Al., 2002). In Animal Studies, Ssris Inhibit Mdma-Induced 5-Ht Release And Block The Behavioral Effects Of Mdma (Gudelsky & Nash, 1996; Geyer & Callaway, 1994). In A Human Laboratory Study, Pretreatment With Citalopram Significantly Reduced The Spectrum Of Psychological Effects (I. E., Positive Mood, Self-Confidence, Extraversion, Derealization, Depersonalization, And Thought Disorder), As Well As Cardiovascular And Side Effects Associated With Mdma Administration (Liechti, Baumann, Gamma, & Vollenwei- Der, 2000). 2. The Net Plays A Key Role In Stimulant And Cardiovascular Effects (I. E., Sympa- Thomimetic) Of Mdma. In A Human Study, Reboxetine (A Net) Pretreatment Reduced The Effects Of Mdma On Increases In Plasma Levels Of Ne, Increases In Blood Pressure (Bp) And Heart Rate (Hr), Subjective Drug High, And Emotional Excitation (Hysek Et Al., 2011). In A Recent Study That Further Confirms The Role Of The Sert And Net In Mediating Mdma Effects, Duloxetine (A Dual Sert And Net Inhibitor) Markedly Decreased The Psychological And Cardiovascular Responses To Mdma In Human Par- Ticipants (Hysek, Simmler, Et Al., 2012). 3. 5-Ht2A Activation Is Responsible For The Mild Perceptual And Hallucinogen- Like Properties Of Mdma. Mdma Has Relatively Mild To Moderate Affinity For The 5-Ht2A Receptor In Animal Studies (Vollenweider Et Al., 2002) And Although Not Con- Sidered A Classical Hallucinogen, It Does Possess Mild Hallucinogenic Properties Along The Spectrum With The Shs, With Increased Hallucinogenic And Psychotic Experiences Reported At Higher Doses (Solowij, Hall, & Lee, 1992). Furthermore, In A Human Labo- Ratory Study, Pretreatment With Ketanserin (A 5-Ht2A Antagonist) Led To A Significant Reduction In Hallucinogenic Perceptual Phenomenon Associated With Mdma Admin- Istration (Liechti, Saur, Gamma, Hell, & Vollenweider, 2000). 4. Dopamine Activation Is Responsible For The Addictive Liability And Some Of The Mood-Elevating Effects Of Mdma (Kehr Et Al., 2011). In A Human Laboratory Study, Pretreatment With Haloperidol Selectively Reduced The Euphoric Effects Of Mdma While Increasing Certain Negative Psychological Effects (I. E., Anxiety And Derealiza- Tion), And Having No Effect On Physiological Responses (Liechti & Vollenweider, 2000). 5. With Regard To Neurohormonal Effects, Mdma Increases Prolactin And Corti- Sol Levels Acutely (Harris, 2002) And Can Diminish Cortisol Reactivity In Chronic Users (Parrott Et Al., 2014); Mdma Increases Levels Of Oxytocin In Animals And Humans. Serotonin Release, Directly Or Indirectly, Causes An Increase In Oxytoxin Transmission, Possibly Due To 5-Ht1A Stimulation (Thompson Et Al., 2007; Dumont Et Al., 2009; Wolff & Winstock, 2006). Mdma-Induced Increases In Oxytocin Signaling Likely Mediate The Prosocial And Empathic Properties Of Mdma In Humans (Thompson Et. 9. Hallucinogens And Inhalants 169. Al., 2007; Hysek, Domes, & Liechti, 2012). In Human Ecstasy Users, Mdma Admin- Istration Diminishes The Accuracy Of Facial Fear Recognition (Bedi, Hyman, & De Wit, 2010) And Attenuates Amygdaloid Activity In Response To Threatening Faces, While Increasing Ventral Striatal Activity In Response To Happy Facial Expressions (Bedi Et Al., 2009). Together, Mdma May Increase Prosocial Or Approach Behavior By Enhanc- Ing Responsivity To Positive Social Stimuli And Decreasing Reactivity To Negative Social Stimuli Leading To Higher Social Risk Behavior (Hysek, Domes, Et Al., 2012). It Is Plau- Sible That Mdma's Ability To Reduce Fear Acutely And Increase Interpersonal Trust And Bonding May Make It A Useful Adjunct To Psychotherapy And Might Particularly Be Helpful For Certain Conditions Such As Posttraumatic Stress Disorder (Ptsd) And Attachment Disorders (I. E., Asperger's Syndrome; See Below). Regional Brain Activity. Imaging Studies (I. E., Pet) In Human Participants Who Ingest Mdma Have Demon- Strated The Following In Differential Regional Brain Activity: (1) Cerebral Blood Flow (Cbf) Increases Bilaterally In The Ventromedial Pfc, The Anterior Cingulate Cortex (Acc), And The Cerebellum; (2) Cbf Decreases Bilaterally In Motor And Somatosensory Cortices, Superior Temporal Lobe, Posterior Cingulate Cortex, Insula, And Thalamus; And (3) Unilateral Cbf Decreases In The Left Amygdala, Right Parahippocampal Forma- Tion, And Uncus (Vollenweider Et Al., 2002). In One Study, Lower Activity In The Left Amygdala Was Correlated With Lower Scores In Anxiety-Related Measures (Gamma, Buck, Berthold, Liechti, & Vollenweider, 2000). This Is Interesting Because Mdma, At Typical Recreational Doses, Is Known To Have Anxiolytic-Type Properties Despite Hav- Ing Stimulant Effects. In The Same Imaging Study By Gamma Et Al., Activity In The Tem- Poral Cortex, Amygdala, And Orbitofrontal Cortex Was Correlated With "Extraversion" Ratings, Which Is Interesting Given Mdma's Known Effects At Increasing Prosocial Behavior And Evidence That These Brain Regions Are Involved In Aspects Of Social Com- Munication (Vollenweider Et Al., 2002). Addictive Liability. Mdma's Addictive Liability Appears To Be Lower Than That Of Other Drugs Of Abuse, As Demonstrated In Both Animal Models (Degenhardt, Bruno, & Topp, 2010) And Human Epidemiological Studies (Parrott, 2012). For Example, A Significant Number Of Rats Fail Repeatedly To Self-Administer Mdma Even After Extended Periods Of Train- Ing (Schenk Et Al., 2007), And Unlike Cocaine And Methamphetamine, Low Fixed-Ratio Operant Paradigms Fail To Sustain Mdma Self-Administration (Fantegrossi, 2007). (One Possible Explanation For Mdma's Relative Lack Of Addictive Liability, Especially Compared To Other Stimulants (I. E., Cocaine, Methamphetamine), Is Likely Related To Its Serotonergic Effects; It Has Been Demonstrated In Animals That Mesoaccumbens Dopaminergic Release Is Attenuated By Antagonistic Mdma-Occasioned Serotonergic Signaling (Bankson & Yamamoto, 2004) And Further Evidenced By Studies Demon- Strating That Coadministration Of Mdma Attenuates The Reinforcing Effects Of Meth- Amphetamine (Clemens Et Al., 2007), And Cocaine (Diller Et Al., 2007) In Rats. 170 Iii. Substances Of Abuse Intoxication/Phenomenology. Mdma Produces A Diverse And Unique Profile Of Psychological And Behavioral Effects At Typical Recreational Doses That Includes An Affective State Marked By Mood Elevation, Sense Of Well-Being, Low Anxiety, Increased Emotional Sensitivity, Height- Ened Openness, A Sense Of Being Close And Connected To Others, Increased Sociabil- Ity, Increased Sexual Desire, Stimulant Effects (E. G., Increased Heart Rate And Blood Pressure, Increased Core Body Temperature, Decreased Appetite, Increased Alertness, Decreased Speech Fluency, Jaw Clenching, And An Increase In Sleep Latency), Mild Hal- Lucinogenic Effects That Include Mild Perceptual Changes (I. E., Heightened Sensory Per- Ception), Depersonalization, Derealization, And A Loosening Of Ego Boundaries (Vol- Lenweider, Gamma, Et Al., 1998; Baylen & Rosenberg, 2006; Burgess, O'donohoe, & Gill, 2000). In Summary, Mdma Could Be Uniquely Classified Across Drug Categories As An Anxiolytic, Amphetaminergic Stimulant With Mild Psychedelic Properties That Enhance Sociability And Empathy. Its Previously Described Diverse Pharmacological Effects (Increased Monoaminergic Signaling, 5-Ht-Da-Ne; Increased Oxytocin Sig- Naling) Account For Its Spectrum Of Subjective Effects. Adverse Psychiatric/Neurological Effects. Acute/Subacute Effects. Acute Adverse Psychological Effects From Mdma That Can Occur With Single Doses But Are More Likely Seen With Repeated Dosing Or Use At Higher Doses May Include Anxiety, Agitation, Dysphoria, Hyperactivity, Mental Fatigue, Depersonalization, Derealization, Confused Thinking, Decreased Appetite, And Insomnia (Baylen & Rosenberg, 2006). High-Dose Mdma Can Rarely Cause Transient Panic Attacks, Brief Psychotic Episodes, And Delirium Even In Individuals Without Underlying Psychiatric Illness (Vecellio, Schopper, & Modestin, 2003). Mdma Can Acutely Exacerbate Or Precipitate Relapse In Vulnerable Individuals, Especially Those With Psychotic Or Bipolar Spectrum Dis- Orders. Although Typical Recreational Doses Are Associated With An Anxiolytic State, Associated With Decreased Amygdaloid Activity, And There Is Some Evidence To Sug- Gest The Efficacy Of Mdma-Assisted Psychotherapy For Ptsd (Mithoefer Et Al., 2011, 2013), Higher Doses Of Mdma Can Be Anxiogenic And Exacerbate Underlying Anxiety Spectrum Disorders (I. E., Panic Disorder). Following The Acute Effects Of Mdma Intoxication (Typically 3-6 Hours), Sub- Acute Persisting Psychological Symptoms In The 24- To 48-Hour Period Postingestion Include Depression, Irritability, Anxiety, Difficulty Concentrating, Headache, Fatigue, And Muscle Aches (Peroutka, Newman, & Harris, 1988; Verheyden, Henry, & Cur- Ran, 2003). These Symptoms Usually Subside With Support And Reassurance, Which Often Are All That Is Needed. If The Symptoms Are Severe, Brief Pharmacotherapy To Alleviate Symptoms Is Recommended. A Minority Of Mdma Users Continue To Expe- Rience These Symptoms For More Than 3 Days After A Single Ingestion Of Mdma (Liechti, Baumann, Et Al., 2000; Liechti, Saur, Et Al., 2000; Liechti & Vollenwei- Der, 2000; Huxster, Pirona, & Morgan, 2006). However, Individuals Who Are Heavy/ Chronic Users Of Mdma Are At Higher Risk Of Experiencing Such Adverse Psychological. 9. Hallucinogens And Inhalants 171. Symptoms Over A Longer Period Of Time, Especially If They Have Underlying Psychiatric Illness. This Group Is Also Likely To Be At Higher Risk Of Experiencing Sustained Cogni- Tive Impairment (See Below). As Mentioned, A Small Group Of Patients Chronically And Compulsively Use Mdma And Develop Addiction To It. For These People, The Standard Psychosocial Treatments For Addictive Disorders Should Be Employed. There Are No Known Pharmacological Treatments For Mdma Addiction. Prolonged Effects. In Animal Studies, Single High Doses Or Repeated Dosing Of Mdma Is Usually Assessed 1-2 Weeks After Final Drug Administration; These Studies Have Consistently Revealed Major Reductions In 5-Ht, 5-Hiaa, 5-Ht Uptake, And Sert Binding, With The Most Pronounced Effects In Certain Brain Regions Such As The Cortex, Hippocampus, And Striatum (Battaglia Et Al., 1991). Whether These Serotonergic Changes Reflect Neuro- Degenerative Neurotoxicity Or Simply Neuroadaptations Is A Matter Of Debate. One Hypothesis Is That These Changes Reflect Neurodegenerative Distal Axotomy In The Long Ascending 5-Ht Axons And Their Synaptic Terminals In Higher Brain Regions. Early Studies Demonstrated Mdma-Induced Swelling And Fragmentation Of 5-Ht Fibers In Rat Forebrain Followed By Loss Of These Fibers (O'hearn Et Al., 1988; Molliver Et Al., 1990) And While Some Long-Term Studies (I. E., 8 Weeks To Over A Year) Showed Recov- Ery Of These Serotonergic Changes (Battaglia, Yey, & De Souza, 1988; Battaglia Et Al., 1991), Other Ones Showed An Incomplete Recovery (Fischer Et Al., 1995; Scanzello Et Al., 1993). Some Have Interpreted These Findings As Reflective Of "Neurotoxicity" And A Neurodegenerative Process. Others Have Challenged These Interpretations By Looking At Whether Mdma Causes Glial Responses That Are Characteristic Of Cns Damage. There Is Now Substantial Evidence From The Animal Literature That Long-Lasting Reduc- Tions In Serotonergic Markers Are Not Reliably Associated With Microglial Or Astroglial Responses, Causing Some To Conclude That Mdma Does Not Necessarily Lead To Struc- Tural Damage To The Serotonergic System (Biezonski & Meyer, 2011). In Humans, The Argument For Mdma-Induced Serotonergic "Neurotoxicity" Has Been Made Based On Neuroimaging Studies And Cognitive/Psychological Assessments In Long-Term Ecstasy Users. Neuroimaging Studies Have Consistently Shown That Repeated Mdma Use In Humans Is Associated With Chronic Reductions In Cortical Serotonin Sig- Naling, As Evidenced By Reductions In Sert, Up-Regulation In 5-Ht2A Receptors, And Increased Neocortical Excitability; Although There Is Some Evidence For Sert Recovery In Subcortical Areas With Extended Abstinence, The Reductions In Sert In The Neocor- Tex Appear Long-Lasting (Benningfield & Cowan, 2013). A Number Of Studies Have Examined Functional Problems In Abstinent Individuals With A History Of Substantial Ecstasy Use, And A Variety Of Pathological Conditions Has Been Reported, Including Neurocognitive Impairment, Especially Related To Frontal And Hippocampal Regions (Retrospective-Prospective-Procedural-Working Memory, Simple-Complex Cogni- Tion, And Social Intelligence); Visual And Psychomotor Deficits; Greater Pain Percep- Tion; Changes In Appetite; And Psychopathology (I. E., Depression, Anxiety, Disturbed Sleep, Impulsivity, Increased Stress Reactivity (Parrott, 2012). It Is Important To Note. 172 Iii. Substances Of Abuse. That None Of These Studies Was Designed To Conclude Definitively That Mdma Is The Causative Agent (Such A Study Would Be Unethical To Conduct) And It Cannot Be Ruled Out That Preexisting Differences, Polydrug Use, Or Other Unknown Factors May Account For These Effects. We Cannot Conclude At This Point That Mdma Causes Irreversible Neurological And Psychiatric Pathology. However, Given The Animal And Human Data, Heavy Prolonged Use Of Mdma Is Highly Concerning And Should Be Assumed To Cause Enduring Cognitive Impairment, Although The Functional Implications And Impact Of These Deficits Are Unclear At Present. Adverse Medical Effects. Serious Adverse Medical Sequelae Related To Mdma Ingestion Are Uncommon And Predominantly Relate To Its Stimulant-Sympathomimetic Effects And Include Cardio- Vascular Toxicity (I. E., Tachyarrhythmias, Malignant Hypertension, Myocardial Infarc- Tion), Neurological Toxicity (I. E., Seizures, Ischemic Or Hemorrhagic Strokes, Delirium), Malignant Hyperthermia, Hyponatremia, Hepatotoxicity, Renal Failure, And Death (Kalant, 2001). Malignant Hyperthermia Is Caused By Mdma-Induced Sympathetic Activation, Exacerbated By Excessive Motoric Activity (I. E., Dancing) In A Warm And Crowded Club Setting, And Associated With An Array Of Serious Adverse Events Such As Rhabdomyolysis (Also Exacerbated By Excessive Motoric Activity) Leading To Myoglo- Binuria/Acute Tubular Necrosis/Renal Failure, Disseminated Intravascular Coagulation, Hepatic Failure, Seizures, And Death (Ricaurte & Mccann, 2005). Hyponatremia, A Serious Adverse Medical Event That Can Lead To Seizures, Coma And Death, Is Likely Related To Mdma-Induced Syndrome Of Inappropriate Antidiuretic Hormone Secre- Tion (Siadh; H

Synthetic drug raid reveals scary reality

Very potent and dangerous highs---> suicidal tendencies chemicals sprayed on plants--> not supposed to be for chemical consumption---> designed to mimic the high of cocaine, weed. etc... hallucinations result and permanent mental health issues can result from putting these drugs in your body not legal and not safe

Salvia Divinorum

alvia Divinorum is a naturally occurring hallucinogen • It is an herb in the mint family grown in Mexico and South America • Most often used by smoking dried leaves or chewing the leaves • Dissociative properties and potential for unpleasant hallucinations (many do not repeat the experience) • Effects lasts 30 mins (smoked) to an hour (chewed) • Salvia use is legal in some states in the U.S. • Sold for $50-100 per ounce

Chapter 7: Opioids

ince The Early 19Th Century, When Sertürner (1817) Isolated Morphine From Opium, Opioids Have Been A Mainstay In The Implementation Of Surgical Procedures And In The Management Of Acute And Chronic Pain. Opioids Exert Their Effects Primarily Through Their Action At The Opioid Mu, Kappa, And Sigma Receptors. Mu Opioid Receptors Are Involved In The Perception Of Pain And In Reward. Opioid Receptors Located In The Brainstem Are Involved In Control Of Critical Automatic Processes, Such As Blood Pres- Sure, Arousal, And Respiration. Opioids May Be Categorized As (1) Naturally Occurring, (2) Semisynthetic, Or (3) Synthetic. Morphine, Codeine, And Thebaine Are Phenanthrene Alkaloids That Occur Naturally In The Opium Plant. Thebaine Is Converted Into Medically Useful Compounds Such As Codeine, Hydrocodone (Vicodin), Oxycodone (Oxycontin, Percodan, Perco- Cet, Tylox), Oxymorphone (Numorphan), Nalbuphine (Nubain) And Diacetylmorphine (Heroin). Thus, Raw Opium, Morphine, Codeine, And Thebaine Are Referred To As "Natu- Rally Occurring Opioids." In Contrast, Compounds Such As Hydrocodone And Oxyco- Done, Which Are Produced From Naturally Occurring Compounds, Are Referred To As "Semisynthetic Opioids." Attempts To Synthesize Compounds Have Produced A Variety Of Agents, Referred To As The "Synthetic Opioids," Which Are Chemically Distinct From Morphine Yet Exert Their Effects Via Similar Mechanisms And Demonstrate Cross-Tolerance. These Include, For Example, Methadone (Dolophine), Meperidine (Demerol), Propoxyphene (Dar- Von), And Levo-Alpha-Acetylmethadol (Laam). Fentanyl (Sublimaze) And Sufentanil (Sufenta) Are Potent And Short-Acting Opioids That Are Used Mainly In Anesthesia. Buprenorphine Is A Partial Mu Agonist That Is Used In The Treatment Of Opioid Depen- Dence And Has Recently Received Approval For Pain Management. Most Opioids, With The 112 7. Opioids 113 Exception Of Methadone And Laam, Have Short Half-Lives. However, Extended Release Preparations Of Morphine (Ms Contin), Oxycodone (Oxycontin), And Buprenorphine Have Become More Widely Used In Pain Management Because They Result In Fewer Peaks And Troughs Over A 24-Hour Period. The Majority Of Prescription Opioids Are Used Legitimately For Pain Management Or To Treat Physical Ailments. However, Prescription Opioids Are Increasingly Being Used Nonmedically For Alternative Reasons (E. G., Euphoric Effects). In This Chapter, We Review The Scope Of The Problem Of Nonmedical Prescription And Nonprescription (I. E., Heroin) Opioid Use, Important Issues Concerning Assessment And Diagnosis, Clinical Features And Pharmacology, As Well The Treatment Of Opioid Use Disorders. Table 7.1 Table 7.1. Commonly Used Oral Opioid Analgesics Medication Hydrocodone Oxycodone, Immediate Release Oxycodone, Controlled Release Codeine Hydromorphone Morphine, Immediate Release Morphine, Extended Release Methadone Oxymorphone, Immediate Release Oxymorphone, Extended Release Brand Name Examples Lortab, Vicodin, Various Roxicodone, Oxyir, Percocet, Various Oxycontin, Various Tylenol With Codeine No. 2, Various Dilaudid Msir, Roxanol, Various Ms Contin Kadian, Avinza Dolophine, Various Opana, Various Opana Er, Various Onset Of Action 30 To 60 Min 10 To 15 Min 1 Hr 30 To 60 Min 15 To 30 Min 30 To 60 Min 30 To 90 Min 30 To 90 Min 30 To 60 Min 30 To 60 Min 30 To 60 Min Duration Of Action 4 To 6 Hr 4 To 6 Hr 12 Hr 4 To 6 Hr 4 To 6 Hr 3 To 6 Hr 8 To 12 Hr 12 To 24 Hr (Kadian) 24 Hr (Avinza) >8 Hr (Chronic Use) 3 To 6 Hr 8 To 12 Hr Equianalgesic Dosing 30 Mg 20 Mg 20 Mg 200 Mg 7.5Mg 30 Mg 30 Mg 30 Min Variable With Chronic Dosing 10 Mg 10 Mg Note. Adapted From The Medical University Of South Carolina's Opioid Analgesic Comparison Chart, Updated June 2013. Equianalgesic Dosing Is Based On Morphine 10 Mg Administered Parenterally (I. E., Intravenously/Subcutane- Ously) In Opioid-Naive Persons. For Our Purposes In This Chapter, This Information Is Meant To Be General And Not As A Guide To Patient Care Or As An Opioid Conversion Chart. For Clinical Information, It Is The User's Responsibility To Examine All Available Information On Opioid Conversions And To Integrate This With Knowledge About The Patient (I. E., Tolerance, Cross-Tolerance, Medical Issues, And Other Medications). The Clinician Should Always Use Good Clinical Judgment When Making Decisions For An Individual Patient. 114 Iii. Substances Of Abuse Provides Examples Of Commonly Used Oral Opioid Analgesics, Including Their Onset And Duration Of Action And Equianalgesic Dosing. Nonmedical Use Of Prescription Opioids The Nonmedical Use Of Prescription Opioids Is A Serious Public Health Concern. As The Number Of Legitimate Prescriptions For Opioids Has Increased, So Has The Incidence Of Nonmedical Use And Adverse Events. Over The Past Two Decades, The Number Of Opioid Prescriptions Has Increased Significantly, From Approximately 76 Million In 1991 To Over 210 Million In 2010, Making Opioid Analgesics The Most Commonly Prescribed Medication Category In The United States (Volkow, Mclellan, Cotto, Karithanom, & Weiss, 2011). Prescription Opioids Are Now One Of The Most Commonly Initiated Drugs, Second Only To Marijuana (Substance Abuse And Mental Health Services Administra- Tion [Samhsa], 2012). Epidemiological Data From The National Survey On Drug Use And Health (Nsduh; N = 55,279) Demonstrate That 14% Of Individuals In The Gen- Eral Population Endorse Lifetime Nonmedical Use Of Prescription Opioids (I. E., Using A Prescription Opioid That Was Not Prescribed To That Individual Or Using It Only For The Experience Or Feeling It Caused; Back, Payne, Simpson, & Brady, 2010). Similarly, In A Nationally Representative Sample Of College Students (N = 10,904), Mccabe, Teter, And Boyd (2005) Observed A 12% Lifetime Prevalence Rate Of Prescription Opioid Non- Medical Use. Among 18- To 25-Year-Old Young Adults In The General Population (N = 22,931), 18.2% Endorsed Lifetime Nonmedical Use Of Prescription Opioids (Samhsa, 2003). Among Users For Nonmedical Reasons, A Substantial Percentage (13%) Met Dsm-Iv Diagnostic Criteria For An Opioid Use Disorder (Back Et Al., 2010). Serious Adverse Consequences Are Associated With Nonmedical Use Of Prescrip- Tion Opiates (Bohnert Et Al., 2011; Cicero, Surrat, Inciardi, & Munoz, 2007; Man- Chikanti Et Al., 2012). For Example, Rates Of Opioid-Related Emergency Department Vis- Its Increased 219% Over A 5-Year Period (Samhsa, 2010). In Addition, Prescription Opioids Are Implicated In More Overdose Fatalities Than Heroin And Cocaine Combined (Warner, Chen, Makuc, Anderson, & Minino, 2011). Although More Men Die From Prescription Opioid Overdose Than Women, The Death Rate From Prescription Opioid Overdose Increased More Than Fivefold Among Women From 1999 To 2010 (Centers For Disease Control And Prevention [Cdc], 2013). Finally, Prescription Opioids Are The Most Commonly Implicated Drug In Unintentional Overdose Fatalities, Usually In Combination With Other Substances. In One Study Of Unintentional Pharmaceutical Overdoses (N = 295), Hall And Colleagues (2008) Found That 93% Of Decedents Had Consumed Prescription Opioids, And Only 44% Had Ever Been Prescribed The Medica- Tion. In 80% Of The Decedents, Multiple Substances In Addition To Opioids Contributed To Their Fatal Overdoses, The Most Common Being Benzodiazepines (38%). The Most Common Types Of Opioids Used Nonmedically Include Oxycodone And Hydrocodone Compounds, And The Most Common Sources Are Physicians And Family/ Friends (Back, Lawson, Singleton, & Brady, 2011; Barth Et Al., 2013; Osgood, Eaton, Trudeau, & Katz, 2012). When Queried About Motives For Engaging In Nonmedical Opioid Use, Individuals Typically Report Using To Reduce Pain, To Experience A "High," To Increase Energy, And To Improve Sleep (Barth Et Al., 2013; Rigg & Ibañez, 2010). 7. Opioids 115 Gender Differences Have Been Noted, With Men Being More Likely To Use Prescription Opioids Via Alternative Routes (E. G., Crushing And Snorting Pills), And Women Being More Likely To Use In Response To Negative Emotions Or Interpersonal Stress (Back Et Al., 2010, 2011). Heroin Use Heroin Is An Opioid Drug That Is Synthesized From Morphine And Usually Appears As A White Or Brown Powder Or As A Black Sticky Substance, Known As "Black Tar Heroin." It Can Be Injected, Inhaled By Snorting Or Sniffing, Or Smoked, And It Is Rapidly Deliv- Ered To The Brain By All Routes Of Administration. When Heroin Enters The Brain, It Is Converted Back Into Morphine, Which Binds To Mu Opioid Receptors. After An Intra- Venous Injection Of Heroin, Users Feel A Surge Of Euphoria ("Rush") Accompanied By Dry Mouth, Flushing Of The Skin, Heaviness Of The Extremities, And Clouded Mental Functioning. Following This Initial Euphoria, The User Generally Goes "On The Nod," An Alternately Wakeful And Drowsy State. Users Who Do Not Inject The Drug May Not Experience The Initial Rush, But Other Effects Are The Same. Heroin Abuse Is Associated With A Number Of Serious Health Conditions, Including Fatal Overdose, Spontaneous Abortion, And Infectious Diseases Such As Hepatitis And Hiv. Chronic Users May Develop Collapsed Veins, Endocarditis, Abscesses, Constipa- Tion And Gastrointestinal Cramping, And Liver Or Kidney Disease. Pulmonary Compli- Cations, Including Various Types Of Pneumonia, May Result From The Poor Health Of The User, As Well As Heroin's Effects On Pulmonary Function. In Addition, Street Heroin Often Contains Contaminants Or Additives That Can Damage Blood Vessels And Vital Organs. In 2011, 4.2 Million Americans Age 12 Or Older (Or 1.6%) Had Used Heroin At Least Once In Their Lives (Samhsa, 2012). It Is Estimated That About 23% Of Individuals Who Use Heroin Become Dependent. While The Percentage Of Individuals With Heroin Dependence In The United States Has Been Fairly Consistent Over The Last 20 Years, Research Suggests That Abuse Of Prescription Opiate Drugs May Provide A Pathway To Heroin Abuse. Some Individuals Reported Taking Up Heroin Because It Is Cheaper And Easier To Obtain Than Prescription Opioids (Peavy Et Al., 2012). As Such, An Increase In Heroin Use May Be Yet Another Consequence Of The Recent Increases In Prescription Opiate Misuse. Assessment And Diagnosis The Fifth Edition Of The Diagnostic And Statistical Manual Of Mental Disorders (Dsm-5; American Psychiatric Association, 2013) Defines A Substance Use Disorder (Sud) As A Problematic Pattern Of Use Resulting In Significant Distress Or Impairment Of Major Role Functioning In Social, Occupational, And/Or Recreational Areas Of Life. Whereas The Previous Dsm Edition (Dsm-Iv) Divided Suds Into Two Discrete Cat- Egories, Abuse And Dependence, Dsm-5 Rates Severity Of An Sud On A Dimensional Scale Based On The Number Of Criteria Individuals Have Experienced In The Previous 12 116 Iii. Substances Of Abuse Months: Mild (Two To Three Criteria), Moderate (Four To Five Criteria), Or Severe (Six Or More Criteria). Dsm-5 Diagnostic Criteria Include A Newly Added Craving Criterion, In Addition To All Previous Dsm-Iv Criteria For Abuse And Dependence, And It Removes Legal Problems. Empirical Evidence, Albeit A Limited Amount, Suggests A High Cor- Respondence Between Dsm-Iv Opioid Dependence And Dsm-5 Moderate Or Severe (Four Or More Criteria) Opioid Use Disorder (Compton, Dawson, Goldstein, & Grant, 2013; Peer Et Al., 2013). Thorough Assessment Facilitates Identification And Diagnosis Of Individuals Pre- Senting With Opioid Use Disorder And Can Result In Links With Appropriate Treatment Resources. Initial Assessment Strategies That Are Helpful In Diagnosing Opioid Use Disor- Ders, Including History And Physical, Laboratory, And Standardized Assessments (Self- Report And Clinician Administered) Are Reviewed Subsequently. In Addition, Attention Is Given To Strategies For Ongoing Assessment And Monitoring Of Abuse Risk Among Individuals Receiving Opioid Therapy Under The Care Of A Physician. Initial Assessment Includes A Thorough History Of The Individual's Major Medical Conditions, Onset And Course Of Opioid Use, And The Interaction Between Significant Medical History And Use Over The Lifespan. Particular Attention Should Be Given To The Progression Of Opioid Use Over Time And The Impact That Opioid Use Has Had On The Individual's Ability To Function Across Multiple Life Domains (E. G., Social, Occu- Pational, Leisure, Family). Determination Of The Most Recent Use Or Time Since The Last Use, And Type And Amount Of Opiate (And Potentially Other Substances) Used Is Critical In Determining The Impact Of Intoxication Or Withdrawal On The Immediate Clinical Presentation. Assessing For Additional Substances Of Abuse, Including The Use And Misuse Of Prescription Medications, Is Warranted Given Documented High Rates Of Multiple Substance Dependences Among This Population (Conway Et Al., 2013), As Well As The Increased Risks Of Overdose And Death Associated With Concomitant Substance Use (Calcaterra, Glanz, & Binswanger, 2013). In Addition, Collecting Information Regarding The Individual's Family History, Social Support, Legal Problems, And Involve- Ment In Activities Unrelated To Substance Abuse May Be Useful In Determining Treat- Ment Readiness And Selecting Appropriate Levels Of Intervention. A Standard Medical Review Of Systems, Including A Neurological Examination, Mental Status Examination, And Physical Examination, Is Also Recommended. Physical Examination Of The Indi- Vidual May Reveal Indications Of Opioid Use Disorder Such As Needle Marks From Injec- Tion (I. E., Tracks), Skin Abscesses, Thrombosis Of The Veins, And Weight Loss, As Well As Medical Conditions, Such As Enlarged Or Tender Liver, Bowel Disruptions (Hypoactive Or Hyperactive), And Endocarditis. As With Other Substance-Abusing Populations, It Is Important To Corroborate The Individual's Self-Reported History Via Collateral Reports Or The Use Of Laboratory Stud- Ies When Possible. Useful Laboratory Studies Include Serum Liver Function Studies (E. G., Serum Aspartate Aminotransferase, Serum Alanine Aminotransferase, Alkaline Phos- Phatase, Bilirubin, Clotting Factors, Immunoglobulin, And Reduction In Total Protein), As Well As Testing For Conditions Commonly Associated With Injection Drug Use, Includ- Ing Hepatitis A, B, And/Or C, And Human Immunodeficiency Virus (Hiv). Urine Drug Screening (Uds), Or Urinalysis, Is The Most Common And Preferred Method For Detect- Ing Illicit Drug Use (Richter & Johnson, 2001). Uds Is Minimally Invasive And Cost- Effective, And It Facilitates Measurement Of An Individual's Pattern, Frequency, And 7. Opioids 117 Amount Of Use (Preston, Silverman, Schuster, & Cone, 1997). However, Limitations Of Uds Testing Include Its Relatively Narrow Window Of Detection (Usually 3 Days Or Less For Most Substances), Susceptibility To False Positives, And Easy Alteration With Chemi- Cals Or Clean Urine Samples (Jaffe, 1998), Making Observed Uds Testing Preferable. Initial Assessment Of Symptoms And Subsequent Diagnosis Of Opioid Dependence May Also Be Aided By The Use Of Standardized Assessments. These Assessments Vary With Respect To Degree Of Clinician Involvement And Time For Completion. Screening Instruments Such As The Drug Use Disorder Identification Test (Dudit; Berman, Bergman, Palmsteirna, & Schlyter, 2005), The Drug Abuse Screening Test (Dast; Gavin, Ross, & Skinner, 1989), And The Alcohol, Smoking, And Substance Involve- Ment Screening Test (Assist; Humeniuk Et Al., 2008), Offer Low-Cost, Quick Options For Identifying A Range Of Potential Suds, Including Opioid Use, And Are Commonly Used. In Addition, Screening Instruments Have Been Designed To Assist In Medical Set- Tings With Identification Of Patients Presenting For Treatment Of Chronic Pain Who Are At Risk For Abuse Of Prescription Opioids. Examples Of Screeners For Prescription Opioid Misuse Include The Screener And Opioid Assessment For Patients With Pain—Revised (Soapp-R; Passik, Kirsh, & Casper, 2008) And The Opioid Risk Tool (Ort; Webster, 2005). Structured Diagnostic Assessments Include The Structured Clinical Interview For Dsm-Iv Axis I Disorders (Scid; First, Spitzer, Gibbon, & Williams, 1996); The Mini-International Neuropsychiatric Interview (Mini; Sheehan Et Al., 1998); And The Composite International Diagnostic Interview-2 (Cidi-2; Robins Et Al., 1989), Which Serves The Criteria Of Both Dsm-Iv And The Icd-10. Finally, Several Standard- Ized Assessments Exist To Monitor The Characteristics, Motives, And Impact Associated With Opioid Use. These Include The Timeline Followback (Tlfb; Sobell & Sobell, 1995), An Assessment That Uses A Calendar To Record Estimates Of Daily Drug Use Over Long Periods Of Time, And The Addiction Severity Index (Asi; Mclellan Et Al., 1992), A Semistructured Interview That Assesses The Severity Of Use And Consequences On Psy- Chological And Health Functioning. Self-Report Forms Specific To Prescription Opioid Misuse Include The Current Opioid Misuse Measure (Comm; Butler Et Al., 2007), A 17-Item Self-Report Measure To Monitor Pain Patients On Opioid Therapy And Identify Potential Misuse, And The Nonmedical Use Questionnaire (Mccabe, Cranford, Boyd, & Teter, 2007), A Six-Item Instrument That Evaluates Motives For Opioid Analgesic Mis- Use, Sources, And Routes Of Administration. Use Of Standardized Assessment Measures, Such As Those Mentioned In This Chapter, Have Been Found Useful Across Varying Levels Of Opioid Use Disorder Severity And Can Be Informative In Treatment Planning; How- Ever, It Should Be Noted That To Date, These Measures Have Not Been Updated To Reflect Altered Dsm-5 Criteria. Physical Dependence And The Treatment Of Withdrawal Regular Opiate Use Is Associated With Tolerance, Which Means More Of The Drug Is Needed To Achieve The Same Intensity Of Effect, And Physical Dependence, Which Is Manifested By A Characteristic Set Of Signs And Symptoms When Drug Taking Is Abruptly Stopped. The Amount And Duration Of Use Associated With Physical Dependence Is 118 Iii. Substances Of Abuse Variable, But Daily Use For More Than 2-3 Weeks Is Often Accompanied By Some Signs/ Symptoms Of Withdrawal. Early Symptoms Of Opioid Withdrawal Include Yawning, Agitation, Anxiety, Muscle Aches, Lacrimation, Insomnia, Rhinorrhea, And Sweating. Late Symptoms Include Abdominal Cramping, Diarrhea, Dilated Pupils, Piloerection, Nausea, And Vomiting. Opioid Withdrawal Is Very Uncomfortable But Generally Not Life Threatening. The Course Of The Symptoms Depends On The Half-Life Of The Drug From Which The Individual Is Withdrawing. In Heroin Withdrawal, Symptoms Usually Begin Within 12 Hours Of Last Use. Methadone Withdrawal Symptoms Generally Begin Within 30 Hours Of Last Use. The Goal Of Medically Supervised Detoxification Is To Limit Patient Discomfort By Decreasing Or Ameliorating Withdrawal Symptoms. Medications Commonly Used To Treat Acute Opioid Withdrawal Include The Alpha2-Adrenergic Agonist Clonidine (Catapres), Cyclobenzaprine (Flexeril) Or Benzodiazepines For Muscle Cramps, The Antispasmodic Dicyclomine (Bentyl) For Abdominal Cramping, Antidiarrheals Such As Loperamide, Antiemetics Such As Prochlorperazine (Compazine), And Sedatives Such As Benzodiazepines. If An Individual Is Using Heroin Or Another Form Of Opiate, Another Option Is To Convert The Patient To An Equivalent Dose Of Either Methadone Or Buprenorphine, Then Gradually Reduce The Dose To Minimize Withdrawal (Described Below). If The Goal Is To Expedite The Withdrawal Process, Particularly In The Case Of A Long-Acting Opioid, Administration Of An Opioid Antagonist, Such As Naloxone (Nar- Can) Or Naltrexone (Revia), Hastens The Onset Of The Withdrawal Syndrome. However, Caution Must Be Taken When Using This Approach Because Of The Discomfort Associated With The Abrupt Onset Of Withdrawal Symptoms That Can Appear In Precipitated With- Drawal. As Mentioned Earlier, Adjunctive Medications May Also Be Used For Symptom- Atic Treatment Of Withdrawal. The Use Of Ultrarapid Opioid Detoxification Involving The Administration Of Gen- Eral Anesthesia Or Heavy Sedation In Individuals Undergoing Withdrawal, While Effec- Tive In Reducing Physiological Dependence, Has Been Demonstrated To Lead To A Greater Number Of Serious Adverse Events Compared To Approaches Without Superior Outcomes, So It Is Not Recommended (Laheij, Krabbe, & De Jong, 2000). Methadone Methadone Is An Opiate Agonist That Was Originally Developed For The Treatment Of Opioid Dependence In The Mid-1960S (Dole, Nyswander, & Kreek, 1966). Metha- Done's Dramatic Efficacy In Reducing Heroin Use, Decreasing Crime, And Improving Mortality Rates Made It A Prosocial And Lifesaving Intervention For Countless Opioid- Dependent Persons. Methadone Continues To Be Used Worldwide In The Treatment Of Opiate Dependence. Methadone's Primary Therapeutic Effect Is Through The Mu Opioid Receptor. It Is 70-80% Bioavailable When Swallowed, But It Can Also Be Administered Rectally Or By Injection (Walsh & Strain, 2006). Peak Effects With Oral Administration Vary; In A Nondependent Person, The Peak Generally Occurs In About 2-3 Hours, While In An Opioid-Dependent Person, The Peak May Last Longer. The Half-Life Can Vary Consid- Erably As A Function Of Genetic Differences In Enzymatic Activity, Duration Of Treat- Ment, And Urinary Ph (Eap, Buclin, & Baumann, 2002). In Addition, As A Person 7. Opioids 119 Stabilizes On Methadone, Metabolism Increases With A Resultant Half-Life Decrease. In General, Half-Life Is 15-36 Hours (Average Is 24 Hours), Permitting Once Per Day Dosing. Methadone Is Primarily Metabolized In The Liver, With A Small Percentage Excreted Unchanged In The Urine. Methadone Was Initially Developed As An Analgesic. The Duration Of Its Analge- Sic Effects Is Shorter Than The Half-Life Would Suggest, Necessitating Dosing 2-3 Times Per Day For Pain Control. Methadone Is Also A Respiratory Depressant, Reflecting Its Mu Agonist Function. Such Effects Are More Likely To Be Seen In Nondependent Per- Sons Receiving A Relatively High Dose. Other Acute Effects Include Miosis, Nausea, And Vomiting (Especially In A Nondependent Person), Histaminic Effects (Itching, Flushing, Sweating), And Constipation. Treatment Of Opiate Dependence Most Of The Studies Investigating The Treatment Of Opiate Dependence Were Conducted With Individuals Who Were Primarily Heroin Users. As Such, The Treatment Of Prescrip- Tion Opiate Dependence Is Relatively Underexplored. However, The Principles Of Opiate Agonist And Antagonist Treatment As Described Below Should Apply Across Both Heroin And Prescription Opiate Dependence. Methadone Maintenance Treatment Methadone Maintenance Treatment (Mmt) For Opioid Dependence In The United States Is Provided At Clinics That Are Regulated By The Drug Enforcement Agency And The Center For Substance Abuse Treatment. The Clinics Provide Medications And Other Services Such As Counseling, Urine Testing, And Vocational Assistance. Mmt Clinics Have A Medical Director, Counseling Staff (With The Patient: Counselor Ratio Determined By Local Regulations), Nursing Staff, And Other Support Staff. Federal Eligibility Require- Ments For Mmt Stipulate That Individuals Entering Treatment Have A Minimum 1-Year History Of Opioid Dependence. While The Minimum Age Requirement For Mmt Is 18 Years Of Age, Under Certain Conditions, Individuals Between 16 And 18 Years Of Age May Receive Mmt. Individuals With Major Medical Conditions And Polydrug Abusers Are Eligible For Mmt. Patients Initially Attend The Clinic 6 Or 7 Days Per Week (Some Clinics Are Routinely Closed On Sundays) To Receive A Supervised Dose Of Methadone, Typically Delivered In A Flavored Liquid Form. While In Clinic, The Patient May Be Asked To Provide A Urine Sample For Drug Testing, Have Minor Medical Problems Addressed, And/Or Attend An Individual Or Group Counseling Session. For Days On Which The Patient Is Not Required To Attend The Clinic, A "Take-Home" Dose Of Medication Is Provided. The Maximum Number Of Take-Home Doses Allowed Per Week Is Tied To The Patient's Response And Time In Treatment. Counseling In Mmt Clinics Can Vary Depending On Clinical Stability Indicators Such As Drug And Alcohol Use, Level Of Social Needs, Effectiveness Of Coping Skills, And Vocational/Legal Status. Early In Treatment There Is Usually An Emphasis On Drug Use, Education Regarding Risk Behaviors, And Assistance In Obtaining Other Needed Services (E. G., Medical Care, Social Services, Other Psychiatric Services). As The Patient Stabilizes 120 Iii. Substances Of Abuse In Treatment, Counseling May Decrease In Frequency And Intensity, And Shift In Focus (E. G., Familial Relationships, Work And Education Needs). The Approaches Used In Coun- Seling (E. G., Motivational Enhancement) Are Addressed In Other Chapters. Contingency Management Is Particularly Useful In The Context Of Methadone Treatment, Where The Availability Of Methadone Take-Home Doses Can Serve As A Powerful Reward For Behav- Ior Change (Brooner & Kidorf, 2002). Outcomes In Mmt Are Dose Related, And There Is Great Individual Variability In The Effective Dose. Lower Doses (20-40 Mg Per Day) That Are Effective At Suppressing Opioid Withdrawal May Not Suffice In Decreasing Craving Or Blocking The Effects Of Other Opioids (Strain, Stitzer, Liebson, & Bigelow, 1993). Maintenance Doses Are Gen- Erally In The Range Of 70-120 Mg/Day, Although Some Patients May Require More Than 120 Mg/Day For Optimal Therapeutic Response. The Blood Level Of Methadone Does Not Correspond Well To Dose, However; There Is Value In Checking A 24-Hour Blood Level In Patients On A Dose Of 120 Mg/Day Or Higher, Or In Those Taking Medications Known To Alter Serum Methadone Levels. There Do Not Appear To Be Problems With Performance Or Clinically Significant Cognitive Impairment In Individuals Maintained On A Steady Dose Of Methadone. There Is Some Controversy As To Whether Methadone Can Produce Prolongation Of The Qtc Interval, But Studies To Date Have Been Quite Variable In Their Electrocardiographic (Ekg) Findings On This Matter. For Patients Who Have Other Risk Factors For Qtc Prolongation (E. G., Other Medications That Can Prolong The Qtc, Pre- Existing Cardiac Conditions, Electrolyte Abnormalities), Closer Monitoring Of The Ekg May Be Warranted (Cruciani Et Al., 2005). While Methadone Can Be Very Useful For Suppressing Withdrawal And Blocking The Effects Of Other Opioids, Mmt Provides A Context In Which A Number Of Prosocial Activities And Health Issues Can Be Addressed. Studies Using Outcomes Of Treatment Retention And Rates Of Illicit Opioid Use (E. G., As Measured By Urine Testing) Have Clearly Demonstrated That Mmt Can Be Highly Effective (Strain Et Al., 1993; Ling, Wesson, Charuvastra, & Klett, 1996; Sees Et Al., 2000). In Addition, Mmt Is Associated With Decreases In Criminal Activity, Illicitly Obtained Income, And Nonopioid Illicit Drug Use. Buprenorphine Buprenorphine Was Initially Developed And Marketed As An Analgesic In The 1970S. In 2002, The U. S. Food And Drug Administration (Fda) Approved It For The Treat- Ment Of Opioid Dependence. Buprenorphine Has Become A Widely Used Medication For Treatment Of Opioid Dependence Worldwide, And Its Availability Outside The Traditional Methadone Clinic System Has Transformed The Treatment Of Opioid Dependence In The United States. Buprenorphine Is Classified Among "Mixed Agonist-Antagonist Opioids" (Oth- Ers Include Butorphanol, Nalbuphine, And Pentazocine) And Has A High Affinity For And Slow Dissociation From The Mu Opioid Receptor. Buprenorphine Has A Bell-Shaped Dose-Response Curve, Such That Initially As The Dose Of Buprenorphine Is Increased, The Effects Increase (I. E., Analgesia, Decreased Gastrointestinal [Gi] Motility, Or Respiratory Depression); However, With Increases Beyond A Certain Dose Of Drug, The Response Curve Begins To Descend, So That Increasing The Dose Produces Less Of An Effect. While This Profile Has Been Shown In A Number Of Animal Models (Lizasoain, Leza, & Lorenzo, 7. Opioids 121 1991), It Has Not Been Clearly Demonstrated In A Human Study. However, Pharmaco- Logical Profile Suggests That There Should Be Relative Safety With Buprenorphine, In Comparison To A Full Mu Agonist Opioid Such As Methadone (I. E., That There Would Be Less Respiratory Depression With Very High Doses Of The Medication). While Initially Approved In The United States As A Parenteral Analgesic In The Treatment Of Opioid Dependence, Buprenorphine Is Taken By The Sublingual Route, Pro- Viding Slightly Better Bioavailability Than Oral Administration. Buprenorphine Has A Long Duration Of Action, Which Allows Once-Daily Dosing. A Number Of Studies Have Shown That It Can Be Dosed Less Than Daily (E. G., Every 48-72 Hours, And Perhaps Even Less Frequently), Although The Most Common Practice Appears To Have Patients Take It Daily. It Is Metabolized By Cytochrome P450 3A4, With A Primary Metabolite (Norbu- Prenorphine) That Has Some Bioactivity. As With Methadone, There Can Be Wide Vari- Ability Between Patients In The Blood Level For A Given Dose (Strain, Moody, Stoller, Walsh, & Bigelow, 2002), Although It Is Not Common In Clinical Practice To Check Buprenorphine Blood Levels. A Formulation Of Buprenorphine Containing Naloxone (Initially Marketed Under The Trade Name Suboxone And Marketed As A Tablet, And Now Available As A Soluble Film) Is Commonly Used. Naloxone Is An Opioid Antago- Nist That Will Precipitate Opioid Withdrawal If Injected By A Person Who Is Physically Dependent On Typical Mu Agonist Opioids (E. G., Heroin, Oxycodone). The Inclusion Of Naloxone In Buprenorphine Tablets And Soluble Film Is A Pharmacological Strategy To Decrease Parenteral Misuse Of Buprenorphine. While Sublingual Naloxone Has Poor Bioavailability (Preston, Bigelow, & Liebson, 1990), Injected Naloxone Has Good Bio- Availability. As Such, There Is No Naloxone Effect If The Buprenorphine-Naloxone Is Taken As Indicated (Sublingually), But If The Combination Is Dissolved And Injected By An Opioid-Dependent Person, The Person Will Experience Precipitated Opioid With- Drawal (Stoller, Bigelow, Walsh, & Strain, 2001). Buprenorphine-Naloxone Tablets And Soluble Film Are Marketed In A Dose Ratio Of 4:1 (I. E., 12/3 Mg, 8/2 Mg, 4/1 Mg, And 2/0.5 Mg), And Buprenorphine Tablets Without Naloxone Are Marketed In 8- And 2-Mg Doses. Trials Have Established The Safety And Efficacy Of Buprenorphine In Opioid Dependence Maintenance Treatment In Doses Ranging From 2-32 Mg Per Day. Because Buprenorphine Is A Partial Agonist, A Dose Of Buprenorphine Admin- Istered To A Person Who Is Physically Dependent On A Full Agonist Opioid, Such As Heroin, Could Result In Opioid Withdrawal (Rosado, Walsh, Bigelow, & Strain, 2007). In Order To Minimize The Risk Of Buprenorphine-Precipitated Withdrawal, It Is Best To Begin With A Low Dose (E. G., 2-4 Mg) That Is Given Well After The Last Dose Of Opioid Agonist (Early Opioid Withdrawal). The First Dose Is Generally Monitored In An Office Setting. In Contrast To Methadone, A Physician In An Office-Based Setting In The United States Can Prescribe Buprenorphine For The Treatment Of Opioid Dependence. In 2000, The Drug Addiction Treatment Act (Data 2000) Marked The Beginning Of A Pro- Cess Designed To Allow Qualified Physicians To Prescribe Approved Narcotic Drugs For The Treatment Of Opioid Dependence In Office-Based Settings. There Are A Number Of Approved Training Programs In Place To Teach Physicians About The Use Of Buprenor- Phine. There Is A Limit In The Number Of Patients A Physician Can Concurrently Treat With Buprenorphine (30 In The First Year, Then Up To 100 In Subsequent Years After Requesting This Increase). This Is The First Time In Modern Medicine That Physicians 122 Iii. Substances Of Abuse In The United States Practicing In A Variety Of Clinical Settings, Including Office-Based Practice, Are Able To Treat Opioid Dependence Adequately With Pharmacotherapy. It Is Our Hope That This Will Greatly Increase Access To Treatment For Opioid-Dependent Individuals. As Noted Earlier, Patients Started On Buprenorphine Should Begin With A Rela- Tively Low Dose (Either 2 Or 4 Mg), And Ideally Should Be Experiencing Slight Opioid Withdrawal. A Second Dose Can Be Given The Same Day, After 1-2 Hours, If The First Dose Is Tolerated Without Problems. The Individual Should Be Monitored During Initial Dosing. If The Person Is Not Physically Dependent On Opioids (E. G., A Person Who Was On Buprenorphine Previously, Then Incarcerated, And Now Returns To Restart Buprenor- Phine), Low Doses (2 Mg) Should Be Started And Stabilization Should Be Slowed. Typical Maintenance Doses Of Buprenorphine Are In The Range Of 8-16 Mg/Day, Although Some Patients Have Required Higher Doses (E. G., 24 Mg/Day). If A Patient Seems To Require High Doses (E. G., 24-32 Mg/Day), Risk Of Diversion Or Misuse Of The Medication Must Be Assessed. As With Methadone, Buprenorphine Can Be Used For Medically Supervised With- Drawal, As Well As Maintenance Treatment. When Tapering Buprenorphine, 2 Mg Incre- Ments Are Typically Used. The Tablets Are Not Made To Be Broken, And The Soluble Films Are Not Designed To Be Cut (Although Some Clinicians Cut Them, And It Is A Convenient Mechanism To Produce Doses That Contain Less Than 2 Mg Of Buprenorphine). While There Is Limited Research On Buprenorphine Tapering Schedules, Gradual Rather Than Rapid Withdrawal Is Likely To Be More Effective. Maintenance On Buprenorphine Can Occur For Years (Similar To Methadone), And Physicians Can Prescribe A Month's Worth Of The Medication At A Time, With Up To Five Refills. Providing Nonpharmacological Treatment Along With Buprenorphine Is Recommended For Most Patients (Especially Early In Treatment), But Data 2000 Only Requires That The Physician Have Access To Such Services And Does Not Require That On-Site Services Be Provided. In General, Studies Show That Buprenorphine Outcomes In Opioid Dependence (Treatment Retention, Illicit Opiate Use) Are Superior To Placebo Or Placebo-Like Doses Of Medication (Johnson Et Al., 1995) And Are Similar To Daily Methadone Doses Of About 50-60 Mg/Day. However, Responses Seen With Higher Doses Of Methadone (80 Mg/ Day Or Greater) Have Generally Not Been Seen With Daily Buprenorphine In Controlled Trials (Ling Et Al., 1996). Clinical Trials Suggest That A Dose Of About 12-16 Mg/Day Of Sublingual Buprenorphine Produces Outcomes Similar To A Dose Of About 50-60 Mg/ Day Of Methadone (Strain, Stitzer, Liebson, & Bigelow, 1994). Despite Initial Con- Cerns That Buprenorphine May Cause A Slight Increase In Liver Function Tests (Lfts) In Persons With A History Of Hepatitis (Petry, Bickel, Piasecki, Marsch, & Badger, 2000), A Large, Multicenter Trial Did Not Find Any Problems With Lfts In Individuals Being Treated With Buprenorphine Or Methadone Over The First 6 Months Of Treatment (Saxon Et Al., 2013). There Are Not Significant Cognitive Or Performance-Impairing Effects Associated With Buprenorphine Treatment Of Opioid Dependence. A Recent Multisite Trial Compared A Short Versus Extended Taper Of Buprenorphine- Naltrexone Combination In A Group Of Prescription-Opiate-Dependent Individuals (Weiss Et Al., 2011). They Found That Both Groups Reduced Opiate Use During Treat- Ment; However, When Tapered Off Buprenorphine-Naloxone, Even After 12 Weeks Of 7. Opioids 123 Treatment (Extended Taper Group), The Likelihood Of An Unsuccessful Outcome Was High, Even In Patients Receiving Counseling In Addition To Standard Medical Manage- Ment. This Study Suggests That Buprenorphine Is An Effective Treatment For Prescrip- Tion Opiate Dependence, But The Necessary Duration Of Treatment And Best Strategy For Transition To Medication-Free Treatment Remains An Open Question. Buprenorphine Has Expanded The Capacity For Opioid Dependence Treatment Into Mainstream Medical Practice In The United States. Despite This, Only A Small Num- Ber Of Physicians Prescribe Buprenorphine (Less Than 2% Of U. S. Physicians). Despite This Relatively Small Number, A Substantial Number Of Patients Are Currently Receiving Buprenorphine. Treatment Of Opioid Dependence In Pregnancy Mmt Is The Recommended Treatment For Opioid Dependence During Pregnancy. However, Prenatal Exposure To Methadone Is Associated With A Neonatal Abstinence Syndrome, Which Is Characterized By Central Nervous System Hyperirritability And Autonomic Nervous System Dysfunction That Often Require Medication And Extended Hospitalization. A Study Comparing Methadone And Buprenorphine Treatment Dur- Ing Pregnancy Found A Slightly Higher Dropout Rate But Better Neonatal Outcomes In The Buprenorphine-Treated Group (Jones Et Al., 2010). There Were No Significant Differences Between Groups In Other Primary Or Secondary Outcomes, Or In Rates Of Maternal Or Neonatal Adverse Events. As Such, It Is Likely That Either Methadone Or Buprenorphine (Subutex) Can Safely Be Used In The Treatment Of Opiate Dependence During Pregnancy. Naltrexone Treatment Naltrexone Is An Opioid Antagonist That Has No Euphoric Effects And May Provide A Nonaddicting Treatment For Opioid Users. In A Recent Cochrane Review Of 10 Controlled Studies Of Oral Naltrexone Compared With Placebo (Minozzi Et Al., 2011), Naltrexone Was Clearly Associated With Superior Results. Despite The Strong Theoretical Poten- Tial Of Naltrexone For Treating Opioid Dependence, Clinical Experience Has Been Disap- Pointing Because Of High Dropout Rates And Poor Compliance. People Such As Health Professionals, Business Executives, And Those Who Are Under Probation In The Legal System Have Strong Incentives To Complete Treatment And May Be Good Candidates For Naltrexone Treatment. Prior To Starting Naltrexone, A Naloxone Challenge Test Should Be Performed To Ensure That No Residual Physiological Dependence Remains, Or Nal- Trexone Could Cause A Prolonged, Precipitated Withdrawal Episode. Naltrexone May Be Dosed At 50 Mg/Day Or 100-150 Mg Two To Three Times A Week. A Long-Acting (4 Weeks) Injectable Form Of Naltrexone Was Tested In 60 Heroin- Dependent Adults. There Was A Dose-Dependent Increase In Retention In The Naltrexone- Treated Group, And Individuals Who Attended Treatment In All Groups Had High Rates Of Urine Drug Screens That Were Negative For Opioids (75-80%) (Comer Et Al., 2006). Other Studies Exploring The Use Of This Promising Agent In The Treatment Of Opiate Dependence Are In Progress. 124 Iii. Substances Of Abuse Treatment Of Prescription Opioid Overdose As Discussed Previously, Prescription Opioid Overdose Deaths Have Increased Steadily Over The Past Decade. While Improvements Are Being Made In Treatment For Prescrip- Tion Opioid Dependence And In Access To Care, Many Communities Are Faced With Over- Dose Fatalities That Occur Prior To Access To Treatment. Since The 1990S, Community- Based Programs That Have Developed In Response To This Growing Issue Have Provided Opioid Overdose Prevention Services And Education To Opioid-Dependent Individuals, Their Families And Friends, And Service Providers. There Are Now Over 180 Local Pro- Grams Across The Unites States That Provide Training In The Use Of The Opioid Antago- Nist Naloxone Hydrochloride To Reverse The Fatal Respiratory Depression That Occurs During An Opioid Overdose. These Community-Based Programs Have Provided Nalox- One To Over 50,000 Persons, Resulting In Approximately 10,000 Drug Overdose Rever- Sals Using Naloxone (Intranasal Or Intramuscular) (Cdc, 2012). Preliminary Evidence Supports A Reduction In Opioid Overdose Death Rates In Communities That Implement Overdose Education And Naloxone Distribution Compared To Those With Low Rates Of Implementation (Walley Et Al., 2013). This Suggests That Training Family, Friends, And Care Providers To Recognize, Prevent, And Respond To Opioid Overdoses Can Be Effective In Reducing Opioid Overdose Mortality. Conclusions In Conclusion, The Public Health Importance Of Opiate Dependence Has Taken On Increasing Significance With The Increase In Prescription Opiate Misuse Over The Past 10 Years. Fortunately, Treatment Options Have Also Increased With The Introduction Of Buprenorphine And A Long-Acting Formulation Of The Opiate Antagonist, Naltrexone. In The Treatment Of Opiate Dependence, Medication Therapy Must Be Coupled With Psy- Chosocial Rehabilitation For Optimal Results.

Stimulants

1. Types of Stimulants -cocaine -amphetamines -methamphetamine -nicotine 2. Effects on the body -excite the central nervous system -energy -euphoria -increased movement and talkativness -decreased appetite -insomia 3. Withdrawal -hyperdepression -crash in energy -depression -fatigue/sleepiness -increased appetite -paranoia -sleep disturbance -anhedonia-inability to experience pleasure

limbic system

A doughnut-shaped system of neural structures at the border of the brainstem and cerebral hemispheres; associated with emotions such as fear and aggression and drives such as those for food and sex. Includes the hippocampus, amygdala, and hypothalamus.

Advantages and Disadvantages of the Moral Model

Advantages: Simple cause of addiction with a simple solution, empowers individual to make change, communities offer support to help individual make better choices Disadvantages of the Moral Model: Creates social stigma and shame, if the solution is increased willpower, a relapse is devastating (individual may believe. "I am not strong enough to stop"), and research confirms that criminal punishment is not an effective deterrent for drug use

Chapter 8: Cannabis

Cannabis Has Been Used Since Ancient Times. The Cannabis Plant Has A Long History Of Use As Medicine, With Historical Evidence Dating Back To 2737 B. C. E. (Ben Amar, 2006). The Cultivation And Sale Of Cannabis Continued Unfettered Until The Marijuana Tax Act Of 1937 Legislated A Tax On The Sale Of Cannabis. It Was Drafted By Harry Anslinger And Levied A Tax On Anyone Who Commercially Sold Cannabis, Hemp, Or Marijuana, And Included A Penalty And Enforcement Provisions To Which Marijuana, Cannabis, Or Hemp Handlers Were Subject. Violation Could Result In A Fine Of Up To $2,000 And Up To 5 Years Imprisonment. Some Have Suggested The Act Was Implemented Because Of Increased Reports Of Smoked Cannabis (Bonnie & Whitebread, 1974), Although Oth- Ers Have Argued That The Aim Of The Act Was To Reduce The Size Of The Hemp Industry. This Act Was Overturned In 1969 In Leary V. United States, And Was Repealed By Con- Gress The Next Year. Subsequently, The Controlled Substances Act Of 1970 Classified Cannabis Along With Heroin And D-Lysergic Acid Diethylamide (Lsd) As A Schedule I Drug (I. E., Having The Relatively Highest Abuse Potential And No Accepted Medical Use (Erowid Vaults, 2010). Marijuana's Peak Use Was In 1979, When Approximately 51% Of High Schools Seniors Admitted To Trying It. Cannabis Use Declined In The 1980S, Pos- Sibly Due To Newly Emerging Laws On Drugs And Increased Perceived Risk (Bachman, Johnston, & O'malley, 1998; Johnston, O'malley, Bachman, & Schulenberg, 2009). Its Use Then Increased Again In The Mid-1990S, Especially Among Young Adults, Which May Have Been Due To The Public Perception That Cannabis Is A Benign Drug And View It As Relatively Safe Compared To Alcohol, Cocaine, Or Heroin (Raphael, Wooding, Stevens, & Connor, 2005). Despite This Perception, Early And Heavy Use Of Cannabis Has Been Associated With A Greater Likelihood Of Developing Certain Mental Health Problems, Such As Psychosis And Depression. Additionally, Poorer Treatment Outcomes Have Been Noted Among Those With Co-Occurring Mental Disorders (Agosti, Nunes, & Levin, 2002). We Review In This Chapter The Neuropharmacology Of Cannabis, Prevalence Of. 128. 8. Cannabis 129 Use, Cannabis's Role As A Possible "Gateway" Drug, Its Relationship To Mental Health. Disorders, Treatment Strategies, And Future Areas Of Research. Overview Of Cannabis And Epidemiology Of Use. Marijuana Consists Of The Dried Leaves, Stems, And Seeds Of The Hemp Plant And Has Been Used For Religious And Medicinal Purposes For More Than 1,000 Years. It Is Most Commonly Smoked But May Be Ingested Via Multiple Routes. Cannabis Cigarettes Have A Variety Of Names, Including Joints, Nails, Herb, Pot, And Reefers; Pipes For Smoking Are Also Known As Bongs And Bowls (Neuspiel, 2007). Cannabis May Also Be Incor- Porated Into Food Items Or Brewed As Tea. A Powerful Resin Of Marijuana (Hashish) Is Usually Smoked In Pipes Or In Cigarette Form; Its Potency May Vary Due To Its Cul- Tivation. Marijuana's Active Ingredient Is Thc (Delta-9-Tetrahydrocannabinol) And Because Of Creative Agriculture, The Thc Content Of Cannabis Has More Than Qua- Drupled, From 0.5 To 2.0% In The 1970S To 6 To 10% In 2000 (Neuspiel, 2007). This Increase In Thc Potency And Increase In Availability Of Cannabis May Contribute To Recent Increases In Dependence On Cannabis. Cannabis Is The Most Widely Used Illicit Drug In United States, As Well As Through- Out The World. Globally, Its Use Appears To Be Increasing, With An Estimated 162 Mil- Lion (4%) Of The World's Adults Using It In 2004, And Approximately 0.6% (22.5 Mil- Lion) People Using Cannabis Daily (United Nations Office On Drugs And Crime, 2006), A 10% Increase In Use From The Mid-1990S (Hall & Degenhardt, 2007). In 2009, More Than 28 Million Americans (11.3%) Age 12 Or Older Reported Abusing Cannabis, And 4.3 Million Met Dsm-Iv Criteria For Abuse Or Dependence (National Institute On Drug Abuse, 2011). In The 2013 National Survey On Drug Use And Health (Nsduh), 5.7 Million Persons Ages 12 Or Older Used Marijuana On A Daily Or Almost Daily Basis In The Past 12 Months (I. E., On 300 Or More Days In That Period), Which Was An Increase From The 3.1 Million Daily Or Almost Daily Users In 2006. In Addition, 8.1 Million Persons Ages 12 Or Older Used Marijuana On 20 Or More Days In The Past Month, Which Was An Increase From The 5.1 Million Daily Or Almost Daily Past Month Users In 2005 To 2007. (National Center For Health Statistics, 2013) The Number Of Daily Or Almost Daily Users In 2013 Represented 41.1 Percent Of Past Month Marijuana Users. The 2009 The Nsdhu Reported That Of The More Than 16 Million Americans Who Use Cannabis On A Regular Basis, Most Started Using Cannabis And Other Drugs During Their Teenage Years. The Nsudh Recently Reported That 78% Of The 2.4 Mil- Lion People Who Began Using In The Last Year Were Ages 12 To 20 (National Center For Health Statistics, 2013). According To The Monitoring The Future Study (Terry- Mcelrath, O'malley, & Johnston, 2014), Over A 1-Month Period, 6.5% Of Eighth Graders, 16.6% Of Sophomores, And 21.2% Of High School Seniors Reported Using Marijuana, With 6% Of High School Seniors Smoking Marijuana Daily; This Number Has Increased Slightly Since 2000. The Only Substance That Was Found To Be Reduced Among Teens During This Period Was Nicotine. Reported Lifetime Use Among 10Th And 12Th Graders Is 34.1 And 44.8%, Respectively, And Daily Use Of Cannabis Is 3.1 And 5%, Respectively (Harvey, Sellman, Porter, & Frampton, 2007; Wallace Et Al., 2009). 130 Iii. Substances Of Abuse. According To The Drug Abuse Warning Network (Dawn) For 2009, 973,591 Emer- Gency Room Visits Involved An Illicit Drug. Cannabis Was Involved In 376,467 Visits, Or 38.7%, And Cannabis-Related Visits Were Highest For Those Ages 18-20 (Owens, Mut- Ter, & Stocks, 2007). Many Tend To Think Of Cannabis Use As An "Adolescent Problem." But, In Fact, A Substantial Subset Of Individuals Continue To Have Problems Into Adulthood. Of Note, The Prevalence Of Cannabis Use Among 45- To 64-Year-Olds Has Also Increased In The Last 10 Years. Perhaps Of Greater Concern Is The Increased Rate Of Cannabis Abuse/ Dependence. The National Comorbidity Survey Observed A 4.2% Lifetime Prevalence Rate For Cannabis Dependence, And Among Those Treated For Substance Abuse, 13% Of Admissions Were For Cannabis Dependence (Agosti Et Al., 2002). Consistent With This, A Recent Substance Abuse And Mental Health Services Administration (Samsha) Survey Found That 16% Of All Patients Admitted To Public-Sponsored Treatment Facili- Ties Reported Cannabis As Their Primary Drug Of Abuse, More Than A Twofold Increase Over A Similar Survey Conducted More Than 10 Years Earlier (National Survey On Drug Use And Health [Nsduh], 2009). Compton, Grant, Colliver, Glantz, And Stinson (2004) Found That More Adults In The United States Had A Cannabis Use Disorder In 2001-2002 Than In 1991-1992. They Found That Increased Prevalence Rates Of Cannabis Use Disorders Were Most Nota- Ble Among Young Black Men And Women, And Young Hispanic Men. The Rates Among Young White Men And Women Also Remained High (Compton Et Al., 2004). Effects Of Cannabis On The Central Nervous System. When Smoked, Thc Passes Quickly From The Respiratory Tract To The Bloodstream And Binds To Cannabinoid Receptors In The Brain. Within Minutes, The Active Component Of The Drug Changes Brain Chemistry And Peaks 15-30 Minutes Later. The Effect Lasts 2-3 Hours, And Thc Has A Serum Half-Life Of Approximately 19 Hours (Ameri, 1999). Thc Passes Readily Across The Blood-Brain Barrier, Because It Is Lipid Soluble (Iversen, 2003). The Acute Psychoactive Effects Of Cannabis Can Produce Pleasant And Unpleasant Reactions That Include Euphoria; Perceptual Disturbances; The Subjective Effect Of Time Being Slowed Down; And A Sense Of Calm And Relaxation, But Also Depres- Sion, Paranoia, Anxiety Or Panic Attacks. Studies Have Shown That High-Dose Intra- Venous Thc Given Acutely Produces Transient Symptoms Such As Perceptual Altera- Tions, Anxiety, Deficits In Working Memory And Recall, And Impairment Of Executive Functioning That Resembles Symptoms Of Psychosis (D'souza Et Al., 2004). Yucel Et Al. (2008) Found Significant Reductions In Brain Volume In Both The Hippocampus And Amygdala In Chronic Heavy Cannabis Users Likely Related To Cumulative Cannabis Expo- Sure. Yucel Found These Reductions To Also Be Associated With Psychosis And Related Cognitive Deficits (Yucel Et Al., 2008). There Are More Than 60 Different Cannabinoids Found Within Cannabis Sativa. The Two Most Abundant Naturally Occurring Cannabinoids Are Thc And Cannabidiol (Cbd), Which Have Different Effects. Thc Is Psychotomimetic And Accounts For The "High" Associated With Cannabis Use; Cbd Has Been Found To Be Anxiolytic And To Have Antipsychotic Properties (Zuardi, Crippa, Et Al., 2006A; Zuardi, Hallak, Et Al.,. 8. Cannabis 131. 2006B; Ameri, 1999). Cannabis Cultivated With Variations In The Ratio Of These Two Cannabinoids, As Well As Numerous Others, Likely Impacts The Intensity And Quality Of The Associated Experience. A Recent Study Examining Levels Of Thc And Cbd In Hair Samples Of Cannabis Users And Nonusers Found That Users With Thc Alone Reported Higher Levels Of Positive Schizophrenia-Like Symptoms, While The Thc And Cbd Group Reported Less Anhedonia (Morgan & Curran, 2008). Of The Cannabinoid Receptors Throughout The Brain, Two Types Of Cannabinoid Receptors (Cb1 And Cb2) Have Been Characterized. The Cb1 Receptor Is Most Abundant In The Nerve Terminals Of The Frontal Regions Of The Cerebral Cortex, Hippocampus, And Basal Ganglia. Cb2 Receptors Are Found Mainly On Cells Of The Immune System. When Cb1 Receptors Are Activated Presynaptically, They Modulate The Release Of Other Neu- Rotransmitters Such As Gamma-Aminobutyric Acid (Gaba), Glutamate, And Serotonin In These Brain Regions. Thc Is Reinforcing Because Of Its Ability To Indirectly Release Dopamine Within The Brain's Reward System By Switching Off Gaba Interneurons That Normally Inhibit These Dopaminergic Pathways (Ameri, 1999). There Are Three Different Groups Of Cannabinoids: The Phytocannabinoids, The Endocannabinoids, And The Synthetic Cannabinoids. The Phytocannabinoids Are Produced Within The Cannabis Plant. There Are Several Dozen Different Phytocannabinoids That Have Not Been Detected In Any Other Plant, And New Phytocannabinoids Continue To Be Isolated (Radwan Et Al., 2009). The Endocannabinoid Neurotransmitter System Consists Of Two Known Cannabinoid Receptor Types (Cb1 And Cb2) And Endogenous Ligands (Endocan- Nabinoids), The Best Known Being 2-Arachindonoylglycerol (2-Ag) And Anandamide. The Endocannabinoids Are Ligands Targeted To Interact With Cannabinoid Receptors. The Most Well-Known Cannabinoids Include (1) Cannabidiol, A Cb1 And Cb2 Antago- Nist; (2) Delta-9-Tetrahydrocannabivarin (Thcv), Which Acts As A Partial Agonist In Vitro, And An Antagonist In Vivo; And (3) Thc, Which Is A Cb1 And Cb2 Receptor Par- Tial Agonist (Pertwee, 2008). The Synthetic Cannabinoids Do Not Occur Naturally, But They Interact With Can- Nabinoid Receptors (Sun & Bennett, 2007). There Are Currently Two Cannabinoids Available By Prescription In The United States: Dronabinol And Nabilone. Dronabinol Is Synthetically Made And Chemically Identical To Thc In The Cannabis Plant. It Is A Schedule Iii Drug And Is Approved For Refractory Treatment Of Anorexia Associated With Aids And Nausea Associated With Chemotherapy And Cancer. Nabilone Acts As A Partial Agonist At Cannabinoid Receptors And Is Also Approved To Treat Nausea And Vomiting Due To Chemotherapy Not Responsive To Standard Treatments. Nabilone Is Controlled As A Schedule Ii Drug In The United States, Although Reports Of Abuse Of Nabilone Are Extremely Rare (Ware & St. Arnaud-Trempe, 2010). Rimonabant Is Also A Synthetic Compound With Cannabinoid Antagonist Activity That Acts As An Inverse Agonist At Cb1 Receptors. It Was Evaluated As An Antiobesity Drug In Europe, But It Was Rejected By The U. S. Food And Drug Administration (Fda) Because Of An Adverse Psychiatric Symptom Profile (Butler & Korbonits, 2009). K2 Or "Spice" Refers To A Series Of Synthetic Cannabinoid Products That Are Adver- Tised And Sold Legally As Herbal Blend Incense. They Produce Similar Effects To Those Of Marijuana When Smoked. They Are Intentionally Sprayed On Dried Herbs Before Pack- Aged And Sold As K2. They Mimic Intoxication With Marijuana, With Longer Duration And Poor Detection On Typical Urine Screens (Hu, Primack, Barnett, & Cook, 2011). 132 Iii. Substances Of Abuse. These Herbs Have Emerged As Popular Legal Alternatives To Marijuana Among Adoles- Cents And Young Adults. In Response To The Dangers Of These Products, On March 1, 2011, The Drug Enforcement Agency (Dea, 2011) Issued The Final Order To Tempo- Rarily Ban Five Synthetic Cannabinoids (Jwh-018, Jwh-073, Jwh-200, Cp 47,497 And Cp 47,497 C8), Following 18 States That Had Already Implemented Their Own Law Or Policy Of Controlling One Or More Of These Five Synthetic Cannabinoids. According To The American Association Of Poison Control Centers (Aapcc), More Than 2,500 Calls Related To K2 Were Reported In 2010, Compared With Only 53 In 2009 (Muller Et Al., 2010). In 2011 This Number Jumped To 2,906 Calls (Www. Whitehouse. Gov/ Ondcp). Smoking K2 May Produce Several Adverse Health Events, Such As Hallucinations, Severe Agitation, Extremely Elevated Heart Rate And Blood Pressure, Coma, Suicide Attempts, And Drug Dependence (Schneir, Cullen, & Ly, 2011). Synthetic Cannabi- Noids Have Been Associated With Both Seizures (Schneir Et Al., 2011) And Heart Attacks (Mir, Obafemi, Young, & Kane, 2011). Greater Awareness Of The Adverse Effects Of These Synthetic Cannabinoids Is Needed To Stem The Tide Of Growing Use. Governments Around The World Are Taking Actions To Ban Or Control Synthetic Cannabinoids. At Present, Standard Toxicology Testing Does Not Detect The Most Commonly Available Synthetic Cannabinoids. Diagnosis Of Cannabis Dependence. The Classifications Of Cannabis Dependence In The Dsm-Iv-Tr And Icd-10 Are Very Similar. The Dsm-5 (American Psychiatric Association, 2013) Cannabis Use Disorder Criteria Are Nearly Identical To The Dsm-Iv Cannabis Abuse And Dependence Criteria Combined Into A Single List, But With The Deletion Of Recurrent Legal Problems And The Addition Of Craving/Urge Or Strong Desire To Use Cannabis. The Most Pertinent Diagnostic Change In Dsm-5 Is The Addition Of The Diagnosis Of Cannabis Withdrawal, Which Reflects Ongoing Recognition Of Such A Condition. Its Diagnosis Requires Cessation Of Cannabis Use, A Resulting Period Of Clinical Signifi- Cance, And At Least Three Other Symptoms Within 1 Week Of Cessation (Wiesbeck Et Al., 1996; Kouri, Pope, & Lukas, 1999; Kouri & Pope, 2000; Pope, Gruber, & Yurgel- Lun-Todd, 2001; Budney & Moore, 2002; American Psychiatric Association, 2013). The National Comorbidity Study (Ncs) Conducted In The United States Reported That For Those Meeting Criteria For Cannabis Dependence At Some Time In Their Lives, With- Drawal Symptoms And A Persistent Desire Or Attempts To Control Use Were Among The Most Commonly Reported Symptoms (Swendsen Et Al., 2010). Cannabis As A Gateway Drug. Many Studies Have Indicated That Adolescent Cannabis Use Is Often Related To The Sub- Sequent Use Of Other Illicit Substances. As The Data Indicate, There Is The Widespread Use Of Cannabis Among Young People. The "Gateway Hypothesis" Suggests That Adoles- Cent Cannabis Use Increases Risk For Later Use And Abuse Of Other Illicit Substances, And. 8. Cannabis 133. Public Health Research Appears To Support This Idea (Kandel & Davies, 1986). What Is Unclear Is The Degree To Which The Link Between Early Cannabis Use Causes The Later Use Of Other Drugs (Morral, Mccaffrey, & Paddock, 2002). Research Suggests That Cannabis's Gateway Effect Remains Significant When Researchers Control For Stress Exposure, Age, And Age-Linked Social Roles. This Provides Some Supporting Evidence For The Hypothesis That The Use Of Cannabis, Independent Of Other Factors, Increases The Use Of Other Illicit Substances (Van Gundy & Rebellon, 2010). Research Focused On The Initiation And Continuation Of Cannabis Use In Young People Has Indicated That Use Usually Begins In High School, With The Possibility Of Occasional Use Progressing Into Dependence. However, Other Factors May Need To Be Taken Into Account, Such As Access To Drugs, Supply, And Cost, Which May Have Greater Influence On Patterns Of Subsequent Drug Use And Continuation (Raphael Et Al., 2005). Males Have A Greater Likelihood Of Becoming Regular Users Due To Availability And Peer Use (Coffey, Lynskey, Wolfe, & Patton, 2000). In Support Of The "Gateway Hypothesis" In A Recent Australian Study Of Over 30,000 Students, 38.75% Of Regular Cannabis Users Also Reported Use Of Other Illicit Substances, Compared With 4.7% Of Nonregular Cannabis Users (Lynskey, White, Hill, Letcher, & Hall, 1999). In A Large-Scale Birth Cohort Study In New Zealand, Research- Ers Observed That 70% Of Subjects Had Used Cannabis And 26% Had Used Other Illicit Substances. With The Exception Of Three Subjects (I. E., In More Than 99% Of Cases), Can- Nabis Use Had Preceded The Use Of Other Illicit Drugs (Fergusson & Horwood, 2000). On The Other Hand, When Researchers Examine Initiation Of Drug Use Across Other Countries And Cohorts, The Strength Of Associations Between Substance Use Progres- Sion May Be Due More To Background Prevalence Or Cultural Factors Than To Causal Mechanisms (Hall & Degenhardt, 2007). Differences In Patterns Of Gateway Drug Use Seen Across Countries In The World Mental Health Survey (Wmhs) Support The Likely Influence Of Attitudes Toward Substance Use In Influencing Order Of Initiation. For Example, Higher Levels Of Other Illicit Drug Use Before Cannabis Were Related To Lower Levels Of Cannabis Use In Japan And Nigeria. Similarly, First Use Of Other Illicit Drugs Before Alcohol And Tobacco Was Found To Be Most Prevalent In Japan And Nige- Ria, Countries With Relatively Low Rates Of Alcohol And Tobacco Use Compared To Other Wmhs Countries (Degenhardt Et Al., 2010). Notably, Cannabis Use Before Alcohol And Tobacco Use Was Extremely Rare In Countries With Some Of The Highest Rates Of Cannabis Use, Such As The United States And New Zealand. Moreover, Cannabis Users In The United States Were Also Much More Likely To Progress To Other Illicit Drug Use Than Those In The Netherlands. Studies Also Indicate That Early-Onset Drug Use And Mental Health Problems Are Risk Factors For Later Dependent Drug Use (Lubman, Allen, Rogers, Cementon, & Bonomo, 2007), And That Comorbid Mental Health Problems Escalate Risk Of Develop- Ing Dependence Once Drug Use Begins. This Suggests That Prevention Efforts Are Probably Better Targeted At All Types Of Drug Use, Particularly Among Young People Who Are Already Dealing With Other Chal- Lenges Such As Comorbid Psychiatric Issues, Deviance (Osgood, Johnston, O'malley, & Bachman, 1988), And Other Unmeasured Developmental Factors, Since It May Be This Group That Is Most At Risk Of Developing Problems Later On (Degenhardt Et Al., 2010). 134 Iii. Substances Of Abuse. Comorbid Disorders. Cannabis Use And Affective Disorders. Anxiety And Mood Disorders Are Among The Most Common Psychiatric Disorders. About 10% Of The U. S. Adult Population Experiences These Disorders Over A 1-Year Period (Merikangas Et Al., 1998; Kessler, Chiu, Demler, & Walters, 2005). The Possi- Ble Relationship Between Cannabis Use And The Development Of Anxiety And Mood Dis- Orders, Such As Depression, Has Received Less Attention Than The Relationship Between Cannabis And Psychosis. Some Studies Suggest That As Cannabis Use Increases, Episodes Of Depression And Mood Or Anxiety Problems Increase (Troisi, Vicario, Nuccetelli, Ciani, & Pasini, 1995; Alpert, Maddocks, Rosenbaum, & Fava, 1994), Although Not All Studies Support This Relationship (Kouri, Pope, Yurgelun-Todd, & Gruber, 1995). Cheung Et Al. (2010) Found That Regular Cannabis Users Have Increased Levels Of Anxiety And Mood Disorders In Comparison With 12-Month Abstainers. This Finding Is Consistent With Results From The Ncs, Which Indicate That Increased Cannabis Use Is Associated With A Higher Risk Of Having Experienced A Major Depressive Episode (Hao Et Al., 2002). Patton Et Al. (2002) Found That Early-Onset Weekly Cannabis Use In Ado- Lescent Women Predicts A Twofold Increase In Rates Of Depression Later On, With Daily Use Increasing The Risk Fourfold. Several Other Epidemiological Studies Have Also Reported Higher Levels Of Depres- Sion Among Those Who Chronically Use Marijuana, Although A Recent Systematic Review Highlighted That The Association Is Modest, And Noncausal Explanations Often Remain Unaddressed In These Studies. Others Have Suggested That These Inconsistencies In The Literature May Be Due To Several Factors: Small Sample Sizes; Inconsistencies In The Measurement Of Marijuana Use, Including Failure To Differentiate Different Levels Of Use; And Divergence In Measures Of Mood And Anxiety Disorders (Degenhardt, Hall, & Lynskey, 2003). Despite These Limitations, Evidence From Longitudinal Studies Sug- Gests That Heavy Cannabis Use May Increase Depressive Symptoms In Some Users, And That Using Cannabis To Cope With Negative Affect Is Commonly Reported By Young People Seeking Mental Health Services For Mood Or Anxiety Disorders (Degenhardt Et Al., 2003). This Highlights The Importance Of Targeting Coping Skills During Treat- Ment. Adolescents And Young Adults With Co-Occurring Affective And Substance Use Disorders (Suds) Continue To Experience Significant Problems With Their Symptoms And Their Functioning 6 Months After Presentation To Mental Health Services, Which Suggests That Integrated Approaches Addressing Both Mental Health And Cannabis Use Simultaneously Should Be Considered (Hall, 2006B). Although The Role Of Anxiety In Cannabis Treatment Is Largely Unexplored, Patients Seeking Treatment For Cannabis Problems Report Significantly More Elevated Anxiety Than Do Nonpatient Samples (Copeland, Swift, Roffman, & Stephens, 2001). A High Level Of Anxiety In Individuals With Suds Is Noteworthy, Because The Co-Occurrence Of Elevated Anxiety And Cannabis Dependence May Result In Greater Impairment Than That In Either Condition Independently (Buckner & Carroll, 2010). Anxiety May Also Increase The Risk Of Relapse. Among Patients Receiving Treatment For Cannabis Depen- Dence, History Of Being Treated For An Anxiety Disorder Is Associated With Reentry Into Cannabis Treatment Following Cannabis Treatment Completion (Arendt, Rosenberg, Foldager, Perto, & Munk-Moffitt, 2007). 8. Cannabis 135. Individuals Often Report Using Cannabis To Cope With Stress And Anxiety, And To Help Them Relax Or Relieve Tension (Reilly, Didcott, Swift, & Hall, 1998). More- Over, Cannabis Users With Elevated Anxiety (E. G., Social Anxiety, Anxiety Sensitivity, Or Fear Of Anxiety-Related Sensations) Report Using Cannabis To Cope With Negative Affect (Buckner, Bonn-Miller, Zvolensky, & Schmidt, 2007). These Data Suggest That The Elevated Anxiety Associated With Withdrawal May Increase The Risk Of Using Cannabis To Manage Anxiety, Thereby Increasing Relapse Vulnerability. Buckner Et Al. Used Data From A Large, Multisite, Randomized Trial Of 450 Cannabis Users Who Entered Treatment And Were Randomly Assigned To One Of Three Psychosocial Treatment Conditions: Moti- Vational Enhancement Therapy (Met) Alone, Combined Cognitive-Behavioral Therapy (Cbt) And Met, And Delayed Treatment. At Baseline, Anxiety Was Linked To More Cannabis-Related Problems. At Follow-Up, Reduction In Anxiety Was Related To Less Can- Nabis Use (Buckner Et Al., 2007). Thus, Anxiety May Be An Important Characteristic That Deserves Further Attention In Cannabis Dependence Treatment. Cannabis Use And Panic Disorder. The Lifetime Rates Of Panic Disorder Among The General Population Are Approximately 5-8% (Katerndahl & Realini, 1993). Studies Suggest That More Frequent Cannabis Use And/Or More Severe Cannabis Problems May Be Related To An Increased Risk Of Panic Attacks (Realini & Katerndahl, 1993). Macdonald Et Al. (2003) Found That Among Weekly Users Of Cannabis, Approximately 40% Reported Having Had At Least One Panic Attack Related To Such Use. Other Investigations Show That Daily Or Weekly Users Of Cannabis Report A Greater Level Of Somatic Tension And Arousal Symptoms, Such As Feel- Ing Dizzy And Cognitive Dyscontrol Symptoms (E. G., Depersonalization) Compared To Nonusers (Buckner & Schmidt, 2008). Zvolensky And Colleagues (2006) Report That Cannabis Dependence, But Not Use, Was Associated With An Increased Risk Of Panic Attacks. A Substantial Percentage (30.1%) Of Cannabis-Related Visits To Emergency Rooms Results From Unexpected Reactions To The Drug. These Findings Collectively Sug- Gest That Either Cannabis Use And/Or Dependence May Be A Risk Factor For Panic Psy- Chopathology. Alternatively, Some Individuals With Panic Disorder May Be More Likely To Abuse Cannabis. It Is Important For Future Research To Understand The Mechanisms Linking Cannabis Use And Dependence And Panic Psychopathology. Cannabis Use And Posttraumatic Stress Disorder. The Ncs Demonstrated That Those With Posttraumatic Stress Disorder (Ptsd) Are Three Times More Likely To Have Cannabis Dependence As Those Without Ptsd (Kilpatrick Et Al., 2003). In A Recent Study By Tepe, Dalrymple, And Zimmerman (2012), Patients With Comorbid Social Anxiety Disorder And Cannabis Use Disorder Were More Likely To Have A Lifetime Diagnosis Of Ptsd And Specific Phobia Than Patients Without Canna- Bis Use Disorders. Cougle, Bonn-Miller, Vujanovic, Zvolensky, And Hawkins (2011) Found That Lifetime And Current Ptsd Diagnoses Were Associated With Increased Odds Of A Lifetime History Of Cannabis Use, As Well As Past-Year Daily Cannabis Use. Lifetime Diagnosis Of Ptsd Also Was Associated With Increased Risk For Past-Year Cannabis Use. These Relationships Remained Statistically Significant After Cougle Et Al. Adjusted For. 136 Iii. Substances Of Abuse. Co-Occurring Other Anxiety And Mood Disorders And Trauma Type Frequency. Agosti Et Al. (2002) Found That Ptsd Was The Second Most Common Anxiety Disorder, Following Generalized Anxiety Disorder, In Those With Cannabis Dependence. Studies Evaluating The Relationship Between Ptsd And Cannabis Use Disorders Are Particularly Scarce Among Adolescent Populations, Despite The Fact That Cannabis Use Typically Has Its Onset During Adolescence. Ptsd Is Often Neglected In Clinical Evaluations Of Adoles- Cents With Suds (Clark & Power, 2005; Driessen Et Al., 2008). Cornelius Et Al. (2010) Evaluated The Effect Of Ptsd On The Rates Of Development Of Cannabis Use Disorders Among Teenagers Transitioning To Young Adulthood. They Controlled For Variables Associated With Cannabis Use (E. G., Affiliation With Deviant Peers, Gender, Race), And Found That Ptsd Contributes To The Etiology Of Cannabis Use Disorders Among Teenagers Making The Transition To Young Adulthood, Regardless Of Deviant Peers Or Other Demographic Factors. These Findings Emphasize The Impor- Tance Of Adequately Assessing For Ptsd Among Those At Risk For Cannabis Dependence. Cannabis Use And Attention‐Deficit/Hyperactivity Disorder. Recent Literature Suggest That There Is Overrepresentation Of Attention-Deficit/Hyper- Activity Disorder (Adhd) In Cannabis-Abusing Populations (Riggs Et Al., 2011), With Adhd Rates Of Up To 35%. Perhaps Because Of The Availability And Social Acceptabil- Ity Of Cannabis Use (Biederman Et Al., 1995), Cannabis Seems To Be The Preferred Drug Of Abuse In Participants With Adhd (Biederman Et Al., 1995). Anecdotally, Canna- Bis Users With Adhd Report That Cannabis Helps To Reduce Emotional Dysregulation, Inner Restlessness, And Excessive Arousal (Sobanski, 2006). While Some Studies Have Found That Chronic Cannabis Use Exacerbates Signs And Symptoms Of Adhd, Other Studies Have Not Found Differences Between Participants With And Without Adhd, And Adolescents And Adults Without Adhd Who Abuse Cannabis (Clure Et Al., 1999; Biederman Et Al., 1997; Thompson, Riggs, Mikulich, & Crowley, 1996). Several Studies That Have Considered The Impact Of Stimulant Treatment On Sub- Sequent Substance Abuse (Often Cannabis) Found That Stimulant Treatment Prior To The Initiation Of Substance Use Is Associated With A Significant Reduction In The Likelihood Of Substance Abuse/Dependence In Adolescence And Adulthood (Biederman, 2003; Wilens, 2004). While Adhd May Occur In A Minority Of Cannabis-Dependent Indi- Viduals, Most Cannabis Users Do Not Have Adhd. However, Even In The Absence Of A Diagnosis, Some Cannabis Users Have Impairment Of Attention, Even When They Are Not Intoxicated (Fergusson & Boden, 2008; Lundqvist, 2005; Pope Et Al., 2001). Harvey Et Al. (2007) Found That Adolescents Who Used Cannabis At Least Once A Week Performed More Poorly On Cognitive Tasks Requiring Attention And Spatial Working Memory. Another Study Indicated That Long-Term Cannabis Users Have Attention And Process- Ing Speed Impairments When Using A Battery Of Neuropsychological Tests (Messinis, Kyprianidou, Malefaki, & Papathanasopoulos, 2006). Similarly, Solowij, Stephens, Roffman, And Babor (2002) Reported That Heavy Cannabis Users Showed Impaired Attention And Executive Functioning Across Several Neuropsychological Tests, And That The Degree Of Impairment Of Attention Was Associated With Increasing Years Of Heavy Cannabis Use. Notably, Ehrenrich Et Al. (1999) Found That Impairments In Attention Were More Persistent And Significant For Those Individuals Who Began Using Cannabis Prior To Age 16 Years. Other Studies Indicate That These Effects Are Short-Lived. Pope Et. 8. Cannabis 137. Al. (2001) Found That About 1 Month After Cessation Of Use, Neuropsychiatric Deficits Diminished. Although Several Studies Have Indicated An Association Between Cannabis Use And Attention Problems, A Number Of The Studies Were Cross-Sectional Or Retro- Spective, Making It Difficult To Determine Whether Cannabis Use Or Underlying Adhd Were Causal Factors. More Research Is Needed To Determine If These Neuropsychiatric Effects Are Long-Lasting If The Individual Stops Using Cannabis. Cannabis Use And Psychosis. Various Hypotheses Have Been Developed Concerning The Association Between Can- Nabis Use And Psychosis (Swift, Hall, Didcott, & Reilly, 1998; Hall & Degenhardt, 2000; Degenhardt Et Al., 2007). First Is That Cannabis Use Precipitates Psychosis Among Those Vulnerable To Developing The Disorder; Second, Cannabis Use Exacerbates Symptoms Or Prolongs The Illness; Third, Those With Schizophrenia, Or A Vulnerabil- Ity To It, Use Cannabis To Self-Medicate Premorbid Psychiatric Symptoms Or Medica- Tion Side Effects; And, Finally, The Association Results From Either Common Risk Factors Such As Family History Of Schizophrenia, Drug Use, Or Poor Adherence To Antipsychotic Medication. Because Cannabis Use May Increase The Risk Of Psychotic Disorders And Result In A Poorer Prognosis For Those With A Vulnerability To Psychosis, It Has Been Sug- Gested That Some Cases Of Psychosis May Be Prevented By Discouraging Cannabis Use, Particularly Among Those Who Are Vulnerable (Arseneault, Cannon, Witton, & Mur- Ray, 2004). Epidemiological Studies Indicate That Cannabis Use Among Adolescents Increases The Relative Risk Of Developing Schizophrenia By 2.4 Times And Up To 6.0 Times In Heavy Users (Arseneault Et Al., 2002). The Hypothesis That Cannabis Use Is A Risk Factor For Psychosis Has Received Support From A Number Of Recent Longitudinal Cohort And Population-Based Studies. Moore Et Al. (2007) Reported That Regular Can- Nabis Use May Be Associated With An Approximate Twofold Increase In The Relative Risk Of Developing Schizophrenia Or Other Psychoses, With Greater Risk Among Those Who Use Cannabis More Frequently. Many Of The Existing Longitudinal Studies Indi- Cate A Significant Association Between Cannabis Use And A Higher Risk Of Developing Schizophrenia Or Relapse Of Psychotic Symptoms (Andreasson, Allebeck, Engstrom, & Rydberg, 1988; Linszen, Dingemans, & Lenior, 1994). A Longer Term Follow-Up Of The Cohort In The Study By Andreassonet Et Al. (1988) Confirmed The Earlier Findings That Cannabis Is Associated With Later Schizophrenia And That This Is Not Explained By Prodromal Symptoms (Andreasson & Allebeck, 1990). Other Researchers Have Reported That Cannabis Use Increased Both The Risk Of Psychosis In Individuals Without Psychosis And A Poorer Prognosis In Those With An Established Vulnerability To Psy- Chotic Disorders. In This Study, Duration Of Cannabis Use Predicted The Severity Of The Psychosis, Which Was Not Explained By Other Drugs. Those With Psychotic Symptoms Who Smoked Cannabis At Baseline Had A Worse Outcome (Van Os Et Al., 2002). There Is Also Evidence To Suggest That Individuals Use Cannabis To Treat Their Posi- Tive And Negative Symptoms And Also The Side Effects Of Antipsychotic Medication. As Discussed Earlier, Thc Increases Dopamine In The Nucleus Accumbens And Has There- Fore Been Considered A Potential Cause Of Psychosis Or Relapse. However, Increased Dopamine In This Area Also Has An Arousing, Anti-Anhedonic Effect That Individuals With Schizophrenia Or Other Psychotic Illnesses May Actively Seek (Negrete, 2003). 138 Iii. Substances Of Abuse. For Those Who Have Already Developed Psychosis, Chronic Cannabis Use May Nega- Tively Impact The Course Of The Illness And Treatment Outcome. These Individuals Are Likely To Have Poor Medication Compliance, More Severe Psychotic Symptoms, More Hospitalizations, And Earlier Relapses (Hall, 2006A). Most Research And Clinic Data Sug- Gest That Cannabis Intoxication Can Lead To Acute Transient Psychotic Episodes In Some Individuals (Lambert Et Al., 2005) And That It Can Produce Short-Term Exacerbation Or Recurrences Of Preexisting Psychotic Symptoms (Mathers & Ghodse, 1992; Kil- Patrick Et Al., 2000). Although, It Remains Controversial Whether Cannabis Use Causes Psychotic Illness Over The Long Term, Some Review Articles Reach No Solid Conclusions About Causality And Stress The Importance Of Prospective Longitudinal, Population- Based Cohort Studies To Elucidate A Possible Causal Association (Thornicroft, 1990). A Recent Study By Frischer, Crome, Martino, And Croft (2009) Suggests That While Early Onset Of Heavy Cannabis Use Is A Risk Factor For Later Psychosis, The Incidence Of Schizophrenia (In The United Kingdom) Does Not Appear To Be Increasing Despite Elevated Rates Of Cannabis Use In The General Community. Conversely, Large, Sharma, Compton, Slade, And Nielssen (2011) Published A Meta-Analysis Providing Evidence To Support The Hypothesis That Cannabis Use Plays A Causal Role In The Development Of Psychosis In Some Patients And Suggested The Need For Renewed Warnings About The Potentially Harmful Effects Of Cannabis. Other Data Indicate That The Vulnerability To Develop Psychosis Can Come From Common Risk Factors, Such As Family History Of Schizophrenia, Drug Use, Or Poor Adherence To Psychotropic Medication (Stowkowy, Addington, Liu, Hollowell, & Addington, 2012). This Suggests That The Relationship Between Cannabis Use And Psychosis Is Complex, And It Highlights The Need For Future Research To Develop Longitudinal Studies With Larger Cohorts And Prospective Studies That Examine Cannabis Use During Adolescence And Young Adulthood. Treatment Of Cannabis Use Disorders. The Mainstay Of Cannabis Treatment Is Psychotherapy. Most Of The Clinical Trials Target- Ing Cannabis Dependence Have Evaluated The Efficacy Of Psychotherapeutic Interventions Rather Than Pharmacotherapies. Unlike Alcohol Or Opiate Dependence, There Are No Fda- Approved Medications For Cannabis Dependence. Although The Finding Are Not Exhaus- Tive, We Present In This Section The Major Critical Findings From Some Of The Larger, Well- Controlled Psychotherapeutic Treatment Trials, As Well As The Laboratory And Outpatient Treatment Trials Assessing Emerging Pharmacotherapies For Cannabis Dependence. Psychotherapeutic Approaches. Data Indicate That Various Psychotherapeutic Approaches Are Effective In Reducing Cannabis Use. The Most Common Approaches Have Been Motivational Interviewing, 12-Step Facilitation Counseling, Cbt, And Contingency Management Strategies. Most Studies Looking At Psychotherapeutic Approaches For The Treatment Of Cannabis Abuse And Dependence Have Focused On Reduction Of Use, Not Necessarily Abstinence. Met And Cbt Have Been Evaluated In Several Clinical Trials. One Of The Largest Tri- Als Compared A Nine-Session Met/Cbt Intervention, A Two-Session Met Intervention,. 8. Cannabis 139. And A Delayed Treatment Condition In 450 Adult Cannabis Abusers. The Met/Cbt And Met Interventions Exhibited Greater Cannabis Use Reduction And Abstinence Than The Control Condition. Additionally, The Nine-Session Met/Cbt Treatment Was Superior To The Brief Met-Only Intervention In Reducing Cannabis Use (Marijuana Treatment Project Research Group, 2004). Several Research Groups Have Found That Contingency Management Strategies That Provide Vouchers For Thc-Negative Urines Are Most Effective Either Alone Or In Combination With Met/Cbt In Promoting Abstinence. However, The Reduction Of Cannabis Use With Contingency Management Is Often Not Maintained Unless There Is Concurrent Cbt (Carroll & Rounsaville, 2007; Budney & Hughes, 2006; Budney, Vandrey, & Stanger, 2010). For Adolescents, Most Of The Available Treatment Studies Include Youth Who Use Multiple Substances, Most Commonly Cannabis And Alcohol. Combined Met/Cbt Interventions Studied Have Been Found To Be Beneficial In Reducing Cannabis Use, Although, Similar To Adults, Their Abstinence Rates Are Relatively Low (Waldron & Turner, 2008). Several Randomized Trials Have Found Family-Based Treatments To Be Efficacious. This Included Brief Strategic Family Therapy (Szapocznik, Kurtines, Foote, Perez-Vidal, & Hervis, 1983), Family Behavior Therapy (Azrin Et Al., 1994), Family Support Network Intervention And Community Reinforcement Approach Counseling (Dennis Et Al., 2004). These Family Interventions Attempt To Unite Parents, Schools, And Other Social Agencies To Help Motivate Change And Recognize The Problem Areas And Maladaptive Coping Patterns In Both The Child And Parents. It Has Been Suggested That Family Approaches May Produce More Effective Outcomes Than Those Without Family Involvement (Budney Et Al., 2010). Contingency Management (Cm) Has Also Been Studied In Young Adults With Hopes Of Improving Outcomes Of Already Established Treatments. Although, The Addition Of Abstinence-Based Incentive Cm Programs To Drug Court Did Not Improve Outcomes (Henggeler Et Al., 2006). However, When Integrated With Met/Cbt, Cm Was Found To Be Superior To Met/Cbt Alone In Promoting Abstinence, But It Was Not As Robust During Posttreatment Assessments (Kamon, Budney, & Stanger, 2005; Stanger, Bud- Ney, Kamon, & Thostensen, 2009). Similar To The Adult Studies, Cm Strategies Used Alone Or In Combination With Met/Cbt In Youth Seem To Be Most Effective In Pro- Moting Abstinence. Unfortunately, The Reduction Or Cessation Of Cannabis Use Elic- Ited By Cm Is Often Not Maintained After Active Treatment Is Ended. Several Studies Indicate That Cm Helps Promote Abstinence Initially And Cbt Maintains It, Leading To Greater Improvement After Cm (Carroll & Rounsaville, 2007). In Both Adults And Young Adults, Abstinence Is Difficult To Achieve With Psychotherapy Alone. Thus, The Combination Of Both Psychotherapy And Medications Might Enhance This Goal. The Overall Conclusion In Most Adolescent Studies Is That Psychotherapies Are Helpful, But Superior When Cm Is Implemented With The Psychotherapy. Pharmacotherapies. There Is A Growing Interest In Developing Pharmacological Treatments For Cannabis Dependence. Several Laboratory And Clinical Studies Have Been Conducted To Date Eval- Uating Various Pharmacological Agents For Treatment Of Cannabis Dependence. We Discuss In This Section The Different Pharmacological Agents Studied By Class. 140 Iii. Substances Of Abuse Mood Stabilizers. Both Lithium And Valproate Have Been Studied As Treatments For Cannabis Dependence And Have Produced Mixed Results. In A Small (N = 9) Community-Based, Open-Label Study Of The Effects Of Lithium On Non-Treatment-Seeking Individuals Meeting Dsm-Iv Criteria For Cannabis Dependence, A Variable Response Was Reported (Bowen, Mcil- Wrick, Baetz, & Zhang, 2005). In A Subsequent Open Trial Winstock, Lea, And Cope- Land (2009) Provided Evidence That Lithium Has Potential As A Safe, Acceptable, And Clinically Useful Treatment Modality For The Alleviation Of Many Commonly Experi- Enced Symptoms Of Cannabis Withdrawal. Follow-Up Of Study Participants Showed A High Rate Of Abstinence From Cannabis Use And Also Reductions In Symptoms Of Depres- Sion And Anxiety, And Cannabis-Related Problems. However, Placebo-Controlled Trials Are Needed To Determine Lithium's Clinical Efficacy. Alternatively, Valproate Has Not Been Found To Be Useful In Reducing Cannabis Withdrawal Symptoms. In A Randomized, Double-Blind, Placebo-Controlled Crossover Laboratory Trial Of Depakote In Seven Non-Treatment-Seeking Cannabis Users, The Inves- Tigators Found Decreased Ratings Of Cannabis Craving During Withdrawal But Increased Ratings Of Anxiety, Irritability, And Tiredness (Haney Et Al., 2004). When Levin Et Al. (2004) Conducted A Small (N = 25), Double-Blind Treatment Trial Comparing Depakote Sodium To Placebo, Both Groups Reduced Their Cannabis Use, But There Was No Differ- Ence Between The Groups, And Medication Adherence Was Poor. Gabapentin Was Studied In A 12-Week, Randomized, Double-Blind, Placebo- Controlled Clinical Trial Of 50 Treatment-Seeking Outpatients Diagnosed With Current Cannabis Dependence. Subjects Received Either Gabapentin (1,200 Mg/Day) Or Matched Placebo. Although Study Completion Was Low (36%), Gabapentin Was Found To Signifi- Cantly Reduce Cannabis Use, Decrease Withdrawal Symptoms, And Improve Overall Per- Formance On Tests Of Executive Function (Mason Et Al., 2012). While This Is Promising, Larger Controlled Trials Are Needed To Determine Whether Gabapentin Is An Effective Treatment For Cannabis Dependence. Antidepressants And Anxiolytics. Several Antidepressants Have Been Studied To Assess Their Effectiveness In Treating Both Withdrawal And Relapse. Laboratory Studies Have Been Conducted In Non-Treatment- Seeking Heavy Cannabis Users, Whereas Outpatient Trials Have Been Primarily Con- Ducted In Cannabis-Dependent Treatment Seekers. Bupropion Is An Effective Treatment For Nicotine Dependence, And It Was Hypothesized That Bupropion Might Be Effective In Treating Cannabis Dependence. Using A Randomized, Double-Blind, Placebo-Controlled, Crossover Design, Bupropion Sr Was Found To Worsen Irritability, Restlessness, Depres- Sion, And Sleeping Difficulties Associated With Withdrawal (Haney Et Al., 2001). In Another Trial, Haney (2002) Evaluated Nefazodone And Found That It Reduced Anxiety But Not Other Withdrawal Symptoms, And It Did Not Change Subjective Effects Of Smoked Cannabis. A Subsequent Treatment Study Compared Nefazodone And Bupro- Pion To Placebo In A Randomized Controlled Trial Of 106 Cannabis-Abusing Adults. While All Three Treatment Arms Demonstrated Improvement, None Was Superior (Car- Penter, Mcdowell, Brooks, Cheng, & Levin, 2009). Haney Et Al. (2010) Evaluated. 8. Cannabis 141. The Effects Of Mirtazapine In The Laboratory And Found That It Improved Sleep During Abstinence And Increased Food Intake But Had No Effect On Other Withdrawal Symp- Toms; Moreover, It Did Not Decrease Self-Administration After A Period Of Cannabis Abstinence. Finally, Mcrae, Brady, And Carter (2006) Conducted A Double-Blind Treatment Trial In 50 Cannabis-Dependent Adults, Comparing Buspirone To Placebo, And Found That The Active Treatment Group Had Greater Reductions In Craving And Irritability, And A Trend Toward A Greater Percentage Of Negative Urinalyses. However, The High Dropout Rate Makes It Difficult To Draw Conclusions Regarding The Medication's Utility. Taken Together, Antidepressants Might Have Clinical Utility, Particularly Those With Sedative Properties, And Anxiolytic Agents Might Reduce Cannabis Use, But Further Investigation Is Needed. Adhd Medications/Stimulant‐Like Drugs. Individuals With Cannabis Dependence Often Have Difficulties With Concentration And Executive Functioning (Solowij Et Al., 2002), And Some Individuals Are Likely To Have Adhd. Atomoxetine, Approved For The Treatment Of Adult Adhd, Was Shown To Reduce Cannabis Use In An Open Clinical Trial Of Cannabis-Dependent Individuals With- Out Adhd, But It Was Poorly Tolerated And Produced Marked Gastrointestinal Side Effects (Tirado, Goldman, Lynch, Kampman, & O'brien, 2008). In A Double-Blind, Placebo-Controlled Outpatient Study, Modafinil Has Also Been Found To Reduce The Euphoria Associated With Oral Thc (Sugarman, Poling, & Sofuoglu, 2011) But More Investigation Is Needed. Antagonists. Antagonist Medications Have Been Extensively Studied For Other Drug Classes And Have Been Found To Be Effective As Long As Adherence Is Ensured (Garbutt, West, Carey, Lohr, & Crews, 1999). While Naltrexone Is Not Necessarily Considered An Antagonist For Cannabis Dependence, There Is Evidence That Some Of Cannabis's Subjective And Potential Amelioration Of Pain Is Mediated Through The Opiate System (Haney, 2007). Notably, Naltrexone Was Found To Reduce The Discriminative Effects Of Thc In Animals (Solinas & Goldberg, 2005) And Also Self-Administration (Justinova, Tanda, Munzar, & Goldberg, 2004). Contrasting This, In Human Laboratory Studies, Naltrexone Did Not Reduce The Effects Of Oral Thc In Participants Pretreated With Naltrexone (Wach- Tel & De Wit, 2000). Similarly, At Both Low And High Doses, Pretreatment With Naltrex- One In Non-Treatment-Seeking Cannabis Users Did Not Reduce The Subjective Effects Of Oral Thc (Haney, 2007) And Actually Enhanced Thc's Pleasurable Effects (Cooper & Haney, 2010). However, A Recent Study Indicated That When Naltrexone Was Given A Couple Hours Prior To Smoking Cannabis, It Did Not Change The Subjective Effects Of Thc (Ranganathan Et Al., 2012). While Naltrexone May Indirectly Act As A Cannabi- Noid Antagonist, Rimonabant, A Partial Cb1 Receptor Antagonist, Has Been Evaluated In Heavy Cannabis Users Under Laboratory Conditions. An Initial Study Indicated That Rimonabant Significantly Reduced The Subjective And Physiological Effects Of Smoked Cannabis (Huestis Et Al., 2001). However, A Subsequent Study Showed Inconsistent. 142 Iii. Substances Of Abuse. Effects (Huestis Et Al., 2007). Rimonabant Is Unlikely To Be Available For Future Use, Because It Was Not Approved For Treatment Of Obesity, Due To Its To Its Propensity To Produce Depressive Symptoms And Suicidal Ideation. Agonists. The Primary Psychoactive Cannabinoid In Cannabis Is Thc. Therefore, Using Oral Thc (Dronabinol), A Partial Agonist, May Be An Effective Substitution Agent To Treat Cannabis Withdrawal And Facilitate Abstinence. Laboratory Studies Have Shown That Oral Thc Reduces The Positive Subjective Effects Of Smoked Cannabis (Hart Et Al., 2002) And Also Decreased Rates Of Cannabis Withdrawal And Craving (Haney Et Al., 2004). In An Outpatient Study Of Non-Treatment-Seeking Heavy Cannabis Users, Bud- Ney, Vandrey, Hughes, Moore, And Bahrenburg (2007) Found That High-Dose Oral Thc Significantly Alleviated Withdrawal Symptoms. However, Oral Thc Has Not Been Found To Reduce Self-Administration (Hart Et Al., 2002), Even After A Period Of Abstinence (Haney Et Al., 2008). Two Case Reports Of Outpatients Suggest That Oral Thc May Be Effective In Reducing Cannabis Use And Facilitating Abstinence (Levin & Kleber, 2008). In The Largest Randomized Controlled Pharmacological Trial To Date, Oral Thc Was Compared To Placebo In Cannabis-Dependent Adults (Levin Et Al., 2011). Those Receiving Oral Thc Had Greater Treatment Retention And Reduction In With- Drawal Symptoms. However, There Were No Group Differences In Reductions In Can- Nabis Use Or Abstinence Rates. Combination. Since Oral Thc Has Shown Some Promise, And Lofexidine, An Alpha2 Receptor Agonist, Has Been Useful For Opiate Withdrawal, These Medications Were Evaluated Alone And In Combination In A Laboratory Setting With Eight Heavy Users Of Cannabis. The Com- Bination Was Superior To The Other Conditions In Alleviating Withdrawal Symptoms. Moreover, Both The Combination And Lofexidine Alone Were Superior To Placebo In Reducing Self-Administration After A Period Of Abstinence (Haney Et Al., 2008). This Promising Combination Is Currently Being Investigated Among Treatment Seekers In An Outpatient Setting. Other. N-Acetylcysteine (Nac) Has Also Been Investigated For The Treatment Of Cannabis Dependence. Nac Has Been Shown To Reduce Reinstatement Of Drug-Seeking Behav- Ior In Animals, Possibly Through Modification Of Glutaminergic Transmission Via The Cystine-Glutamate Exchanger (Larowe Et Al., 2006; Kau Et Al., 2008). An Open Trial In Adolescents Found That The Agent Was Well-Tolerated, With A Reduction In Self-Reported Use, Although Urinalysis Results Did Not Change. A Larger Trial In Adolescents Found That Those On Nac, Along With Contingency Reinforcement For Negative Urinalyses, Were More Likely To Provide Negative Urine Results Than The Placebo Arm That Also Received Contingency Reinforcement (Gray, Watson, Carpenter, & Larowe, 2010). Because Cm Was The Behavioral Platform, It Is Unclear Whether These Findings Will. 8. Cannabis 143. Apply To Cannabis-Dependent Individuals Who Are Administered Nac Without Cm Interventions. Baclofen, A Gaba-B Receptor Agonist And Antispasmodic Medication, Has Sedating Properties And Has Been Hypothesized To Improve Agitation And Sleep Dis- Ruption. In A Placebo-Controlled Laboratory Study, Baclofen Was Found To Reduce Crav- Ing, But Mood Symptoms Were Not Affected, And It Did Not Reduce Self-Administration After Cannabis Abstinence (Haney Et Al., 2010). Thus, The Data Supporting The Poten- Tial Benefit Of Baclofen As A Treatment For Cannabis Dependence Are Limited. Dual Diagnosis. There Is A Strong Association Between Cannabis Dependence And Psychiatric Disorders. This May Be Due To Attempts At Self-Medication (Cornelius Et Al., 1999), Or Psychiatric Symptoms May Be A Direct Effect Of The Cannabis Use. Although Few Clinical Treatment Trials Have Looked Directly At Cannabis Dependence And Psychiatric Comorbidity, Some Studies Have Indicated That Medications Are Effective In Reducing Cannabis Use And Craving. For Example, In A Small, Open Trial Of Cannabis-Dependent Individuals With Bipolar Illness Or Schizophrenia, Quetiapine Reduced Their Cannabis Use (Potvin, Stip, & Roy, 2004). In A Secondary Analysis Of Adult Cannabis Users Entering A Double- Blind, Randomized, Placebo-Controlled Trial For Depressed Alcoholics, Those Receiving Fluoxetine Were More Likely Than The Placebo Group To Reduce Their Amount And Fre- Quency Of Cannabis Use (Cornelius Et Al., 1999). However, Another Study That Evaluated Depressed Adolescents Seeking Treat- Ment For Their Problematic Cannabis Use Indicated That Fluoxetine Was Not Superior In Reducing Depressive Symptoms Compared To Placebo, And There Was No Reduction In Cannabis Use. A Recent Double-Blind Trial Of Cannabis-Dependent Adults With Depres- Sive Disorders Found That Venlafaxine Extended Release Was Not Superior To Placebo In Reducing Depressive Symptoms (Levin Et Al., 2012). Strikingly, The Venlafaxine Group Had Greater Severity Of Withdrawal Symptoms Than The Placebo Group And Were Less Likely To Achieve Abstinence. To Date, There Has Been Little Research Evaluating Treat- Ment Options For Patients With Adhd And Cannabis Use Disorders. In A Small, Double- Blind, Randomized Trial Of Cannabis-Dependent Adolescents With Adhd, Atomoxetine Was Not Superior To Placebo In Reducing Adhd Symptoms Or Cannabis Use (Thur- Stone, Riggs, Salomonsen-Sautel, & Mikulich-Gilbertson, 2010). The Small Sample Size And High Dropout Rate May Have Precluded Finding Significant Differences. Non- Stimulants, Which Usually Have Smaller Effect Sizes Compared To Stimulant Adhd Medications, May Be Less Effective In Drug-Abusing Populations. Furthermore, In Another Study Of Adult Cannabis Abusers With Adhd, Atom- Oxetine Was Not Superior To Placebo In Reducing Adhd Symptoms Or Cannabis Use (Mcrae-Clark Et Al., 2010), Suggesting That Atomoxetine May Not Be Useful In This Dually Disordered Population. Riggs Et Al. (2011) Studied The Effects Of Osmotic-Release Oral System (Oros) Methylphenidate Treatment In Adolescent Substance Abusers With Adhd And Found That The Active Treatment Was Superior To Placebo On Secondary Outcome Measures Of Adhd But Not On Primary Outcome Measures. While There Were No Differences In Drug Use For The Oros Methylphenidate Or Placebo Arms, There Was Significantly Greater Improvement In The Clinician Global Improvement Scale And Less Positive. 144 Iii. Substances Of Abuse. Urinalyses For Those Receiving Oros Methylphenidate (Riggs Et Al., 2011). Although The Findings Are Not Wholly Positive, The Data Suggest That Improvement Of Adhd Symptoms May Lead To Reduction In Use Among Those Receiving Active Medication. Conclusion. Cannabis Use Is A Public Health Concern That Is Steadily Worsening In Terms Of The Extent Of Use, The Perception Of Risk, And The Costs Associated With It. With The Wide- Spread Availability Of Cannabis, It Is Important To Note The Added Risks That Chronic Cannabis Use May Pose In Those With Comorbid Psychiatric Disorders. There Is Growing Evidence Of An Association Between Chronic Cannabis Use And The Onset Or Exacerbation Of Mental Illness. Discouraging Cannabis Use In Vulnerable Populations May Improve Overall Functionality. As Described Earlier In The Treatment Section, Several Controlled Cannabis Treatment Trials Have Reported Results Support- Ing The Use Of Cognitive-Behavioral Interventions, Met, And Cm. While There Are No Definitve Pharmacological Treatments For Cannabis Dependence, Several Pharmaco- Therapies Appear To Be Helpful In Alleviating Withdrawal Symptoms And Reduce Use. Due To The High Prevalence Of Regular Cannabis Use In The United States, Particularly Among Young People With Comorbid Mental Illness, It Is Important To Focus On Both Prevention And Treatment.

Codeine

Codeine can come in tablet or liquid form Street names syrup, lean, purple drank -these are cocktails typically made with codeine cough syrup, soda, and jolly ranchers -Euphoric high of codeine lasts 3-6 hours -codeine, like most opioids, has fatal overdose potential -1 pint of cough syrup with codeine sells for $250-$400 -commonly mixed with other drugs -can cause feelings of dissociation from the body

Choosing the right treatment option PowerPoint

Choosing The Right Treatment Option - Let's Start With The Question: How Do Wemake Sure We Are Getting The Person Who Is Struggling With Substance Abuse Into The Righttreatment Setting? - First, We Gather Information About The Historyof Substance Use, Types Of Drugs Currently Used, Frequency, Method Of Use, Cooccurring Mental Health Concerns, Previoustreatment Experiences, Support System, Etc. - We Use Formal And Informal Assessments Togather This Information And Connect The Individual With The Appropriate Level Of Care. The Appropriate Level Of Care Is The Least Restrictive Option That Matches The Individual's Need. Levels Of Care: A Stepped System There Are Four Levels Of Care In Addictions Treatment. They Are: Level 4: Inpatient Hospitalization (Most Restrictive) Level 3: Residential Treatment Level 2: Php And Iopphp (Partial Hospitalization Program): Day Treatment Top (Intensive Outpatient Program): Partial Daytreatment - Level 1: Outpatient Services (Least Restrictive) Let's Talk About Each One In Detail. Level 4: Inpatient Hospitalization Inpatient Hospitalization Is Medically Managed, 24-Hour Care. - It Takes Place In A Hospital Or Psychiatric Hospital Setting. The Focus Is On The Stabilization Of The Client (Client May Have Suicidal Ideation, Have Extreme Withdrawal Symptoms, Or Haveexperienced An Overdose). - In This Setting, Practitioners Attend To Medical And Mental Health Needs Simultaneously. The Inpatient Hospital Offers Group Substance Abuse Counseling And 12-Step Meetings. Physicians, Psychiatrists/Psychologists, Nurses, And Counselors Contribute To Care. Typically Short-Term. Level 3: Residential Treatment Click On The Hyperlink To Tour A Residential Facility Residential Treatment Is A 24-Hour, Live-In Facility (Stay Typically Lasts For 28, 60, Or 90 Days). It Provides A Safe, Stable Environment For Clients To Learn To Live With The Disease Of Addiction. Residential Treatment Offers Highly Structured Programs With Individual, Group, And Family Counseling, Psychoeducation, Recreation, And Employment Services. Some Residential Treatment Facilities Provide Medically Supervised Detoxification. This Level Of Care Relies Heavily On Peer Support And Community. Level 3: Sober Living Environments Another Level 3 Treatment Option Is Sober Living Environments (Formerly Known As Half-Way Houses). Sober Living Environments Are Voluntary Housing For Clients Seeking A Supportive, Drug And Alcoholiree Setting. They Are Often Used To Help Individuals In Recovery Transition Back To Independent Living - Expectations Of Living In A Sober Living Environment Include: - 12-Step Meeting Attendance - Maintain Employment Attend Substance Abuse Counselling Groups Abstinence From All Substances Oxford Living Level 2: Partial Hospitalization (Php) Or Intensive Outpatient (Iop) Level 2 Options Of Treatment Are Different From Levels 3 And 4 Because The Client Does Not Live At The Facility. Instead, They Live At Home And Attend Structured Programs During The Day. Two Types Of Level 2 Treatment Are Php And Iop. Php Is A Structured Day Treatment (7-8 Hours A Day) Inhospital Or Treatment Facilities. - Iop Typically Consists Of Three Group Sessions Per Week (3 Hours Each), Individual Sessions, And 12-Step Program Attendance. Often Php/Iop Are Step Down Programs From Residential Treatment. Less Restrictive Than Residential, But Offers More Support Than Standard Outpatient Services. Level 1: Outpatient Services The Least Restrictive Level Of Care For Addictionstreatment Is Level 1 Outpatient Services. - Standard Outpatient Services Are The Leastrestrictive And Consist Of Meeting With A Counselor Or Therapist One Time Per Week For One Hour. Outpatient Services May Consist Of Group Counseling, Family Counseling, And/Or Individual Counseling Sessions (One Time Per Week). Individual Counselors May Require Or Recommendthat Their Clients Attend 12-Step Meetings. - Lowest Form Of Monitoring - Typically A Goodoption For Those Who Have Attended Higher Levels Of Care And Are Now Maintaining Their Recovery. Criteria For Placement So How Do Counselors Decide The Best Level Of Care For Their Clients? The American Society Of Addiction Medicine (Asam) Provided Criteria To Help Professionals Make The Best Decision About Their Clients' Level Of Care. These Criteria Include: Client's Acute Intoxication And/Or Withdrawal Potential (Need For Detoxification) Biomedical Conditions And Complications Emotional, Behavioral, Or Cognitive Conditions And Complications Client's Readiness/Motivation To Change History Of Relapse, Continued Use Potential Nature Of Their Living Environment (Supportive?)

Neurotransmitters and related drugs of abuse

Dopamine: Cocaine and amphetamines Serotonin: Hallucinogens, ecstasy Norepinephrine: cocaine and amphetamines Endorphins: opiods GABA: benzodiazepines, alcohol Glutamate: Alcohol Acetylcholine: Nicotine Endocannabinoids; Marijuana

When clients are in precontemplation, counselors will:

Establish a trusting relationship based on unconditional positive regard. Communicate empathy. Work to understand the client's perspective of the problem. Perhaps use a substance abuse assessment and discuss results with the client in a non-evaluative way.

Disease Model

Finally, let's consider the disease (or biological) model of addiction: From the disease model, addiction is conceptualized as: A primary disorder; progressive, chronic, predictable, leads to death if untreated Individual with addiction is conceptualized as: Sick; they were born with a genetic predisposition making them vulnerable to addiction Solution to the problem of addiction is conceptualized as: Treatment to manage the chronic disorder The disease model is the most popular model used in treatment facilities Some refer to the genetic predisposition as Reward Deficiency Syndrome

Finally

Finally, let's end by reviewing the Drug Schedule. This is a way in which drugs are classified. It is a federal drug classification system resulting from the Controlled Substances Act of 1970. It classifies drugs based on medical use and abuse potential. Drug laws often consider the schedule of the drug to determine severity. The drug schedule was created in the 1970s, thus some drugs may seem out of place today

Cannabis

Forms of Cannabis -Blunts/Joins Hashish (resin from hemp plant) • Hash oil (dabbing) • Baked goods containing marijuana Effects on the body Sedation • Dreamy relaxation • Interpersonal closeness • Impair memory and learning • Paranoia/delusions • Poor coordination, reaction time, and judgment Withdrawl Irritability, insomnia, anxiety, headaches, nausea, mood swings, nightmares

huffing

Inhaling solvents and aerosols is called "huffing" • Huffing is popular among adolescents because it is easily accessible and affordable • Intoxication of inhalants is similar to alcohol intoxication, yet short lived (few minutes) • Solvents and aerosols contain dangerous chemicals • High toxicity • Blocks oxygen from getting into the lungs • Huffing can cause blackouts (loss of memory formation) • Fatal overdose potential (risk of death even with first use due to toxicity of chemicals, freezing the lungs, and suffocation

Level 4: Inpatient Hospitalization

Inpatient hospitalization is medically managed, 24-hour care. It takes place in a hospital or psychiatric hospital setting. The focus is on the stabilization of the client (client may have suicidal ideation, have extreme withdrawal symptoms, or have experienced an overdose). In this setting, practitioners attend to medical and mental health needs simultaneously. The inpatient hospital offers group substance abuse counseling and 12-step meetings. Physicians, psychiatrists/psychologists, nurses, and counselors contribute to care. Typically short-term.

Ketamine

Ketamine is a dissociative anesthetic used in veterinary medicine • Often snorted in powder form, can be injected, mixed in drinks, or smoked • Ketamine is a "party drug" and has been used as a date-rape drug • Users describe feelings of dissociating from their bodies, a near death experience, and alternate realities when using • May cause comatose state in higher doses • Risk of injury: because it is an anesthetic, ketamine users are unaware if they have sustained an injury and thereby make it worse (e.g., continue walking on a broken ankle) • Effects last from 45 mins to 2 hours • On the street: sold for $50 per gram

Meth mouth video

Meth use can destroy your mouth: poor mouth hygiene Meth dries the mouth, horrible drug, etc.... not much hope for your teeth when they are damages so much

Marijuana clip

Pot potency on the rise in Colorado Screaming Gorilla is at 25.73% thc ALL flower is tested at a 3rd party labs---> the thc potency of flowers in Colorado are the highest in the country as the national average is 6% emergency room visits have skyrocketed 29%

The process of Neurotransmission

o let's review how neurons talk to each other using neurotransmitters (a process called neurotransmission ). ■ Step 1: The axon of a neuron releases neurotransmitters into the synapse. ■ Step 2: The neurotransmitters travel across the synapse (by transporter cells) and bind to the appropriate receptors of the dendrite of the next neuron. ■ Step 3: When the neurotransmitters bind to the right receptors a chemical reaction is triggered which starts the process over in the receiving neuron.

60 different neurotransmitters

Researchers have discovered over 60 different neurotransmitters, all of which have unique purposes.

DMX video

Robo Tripping may cause cough medicine crackdown Millions of teens known to abuse these medicines It is seen as a cheap way to get high DXM can be a gateway to other drugs, changes to vision, heartbeat, breathing, etc... Can be obtained without a perscription

Nicotine

Smoking is responsible for about 480,000 deaths per year in the US • Withdrawal symptoms include: headache, nausea, constipation, insomnia, and agitation • Can come in the form of cigarettes, chewing tobacco, dip, snuff, hookah, e-cigarettes • Smoked tobacco products cause health problems related to carcinogens in the products including carbon monoxide, tar, formaldehyde, and ammonia • Nicotine is the addictive substance • Smoking can cause cancer of lungs, esophagus, mouth, heart disease, tooth decay, etc. • There is danger in second-hand smoke exposure (especially for children) • E-cigs- heat up liquid containing nicotine and inhale it as a vapor (called vaping) • Nicotine replacement therapy (patch, gum, lozenge, nasal spray, or inhaler) can be used to help an individual quit smoking. • Contain only nicotine and allow individuals to taper off

Marijuana

The psychoactive ingredient of marijuana is tetrahydrocannabinol (THC) • Potency is an issue; many cannabis users do not know the potency of what they are using • Potency of THC continues to increase each year from 4% THC concentration in 1995 to 14.75% in 2017 • High-potency marijuana use has been linked with psychiatric hospitalizations (15% of users have a psychotic-like experience) • For some (especially those with pre-existing mental health symptoms), marijuana can cause paranoia or hallucinations • A common symptom of chronic marijuana use is amotivational syndrome, or the decreased motivation to pursue other activities or goals • Cannabis use causes changes in the reward pathway of the brain---user finds cannabis most rewarding to the detriment of other life pursuits • Cannabis use has been linked to less earnings, unemployment, academic disengagement, and skipping classes (evidence of "high-jacking" the reward pathway in the brain)

Synapse

the junction between the axon tip of the sending neuron and the dendrite or cell body of the receiving neuron

Advantages and disadvantages of the biopsychosocial model

-Advantages: Considers multiple facets of the individual; holistic, uniqueness addiction is part of the individual's experience rather than defining feature takes into account multiple points of view for more accurate assessment and treatment -Disadvantages of the biopsychosocial model: Treatment may be confusing overwhelming, client and counselor may not agree on cause of addiction or treatment plan, and difficult to decide on primary issue or starting place in treatment

Drug Schedule

1. No accepted medical use; high abuse potential LSD, Heroin, MDMA, Marijuana, Chemicals used to make synthetic marijuana (Spice, K2) 2.Accepted medical use; high potential for abuse Cocaine, Morphine, Oxycodone, Methadone, Methamphetamines, Amphetamines (Adderall, Ritalin) 3. Accepted medical use, moderate abuse potential PCP, Opium, Ketamine, Vicodin,Barbiturates 4. Accepted medical use, mild abuse potential Xanax, Valium, Soma, Ambien, Ativan, Klonopine 5.Accepted medical use, low abuse potential Codeine in small amounts (Robitussin), over the counter drugs

Depressants

1. Types of Depressants -Alcohol -Barbiturates -Benzodiazepines 2. Effects on the Body -Euphoria -Decreased anxiety -Reduced distressed -memory impairment -sense of calm -relaxation -slowed reaction time -lowered inhibitions -poor coordinations 3. Withdrawal -hyperexcitability -agitation -insomnia -irritability -racing heart -seizures -hallucinations/delusions -tremors/shakes

Neurotransmisison and drugs

Drugs of abuse directly influence neurotransmission by mimicking specific neurotransmitters or changing their effects. Just to reiterate: drugs of abuse mimic and change neurotransmitters---directly influencing the neurotransmission process .

Opioids

Examples of Opioids -Natural: opium, morphine, codeine -Semi-synthetic: Heroin, hydrocodone, oxycodone, percocet, vicodin -fully-synthetic: methadone, fentanyl Effects on the body -Euphoria -Dream-like state -sedation -drowsiness -pain-relief withdrawl -painful flu-like symptoms -nausea -diarrhea -total body aches and pain -severe and distressing but not fatal

E-cig nicotine Poisoning on the rise

Expected to keep growing along with the popularity of e-cig signs of nicotine poising: Flushed skin, increased heart rate, blood pressure, nausea, vomiting Only takes a small amount of e-cigarette juice to harm a child

When clients are in contemplation, counselors will:

Explore the pros and cons of changing their substance using behavior. Explore client's personal goals and values. Is substance use helping or hindering them reach their goals? Is substance use consistent or inconsistent with their values? Explore client's feelings (rather than just thoughts) about substance use.

Oxycodone Video

Exposes children taking their parents prescription drugs' perscription meds are the most abused drug for 12 and 13 year old children there is not much education among parents and children because they often share meds with them like pain killers

Advantages and Disadvantages of the Psychological Model

Advantages: The model addresses a range of issues rather than addiction only, it removes the sense of shame and stigma when individual is "self-medicating", and there is hope for a full recovery if underlying psychological issue Disadvantages: The individual may encounter additional diagnostic labels (substance use disorder and mental health diagnoses), the belief that the psychological issue is primary, but the psychological issues may be consequences of addiction, and the model does not account for biological or social components

Advantages and disadvantages of the social cultural model

Advantages: less stigma: does not hold the individual responsible ( the individual is a product of the environment), calls for community involvement and structural change and change influenced by this model may reach more people Disadvantages of the sociocultural model: Does not offer clear treatment plan at individual level; requires systemic change, focus on external locus of control (rather than internal focus of control), and change requires more people, is slower, and more complex

Different settings

All of the models of addiction are popular in different settings. Unfortunately, many people still endorse the moral model, although there is scientific evidence of genetic predispositions that make certain people more vulnerable to addiction. However, not everyone who uses substances has a genetic predisposition, but can still face issues with substance use (may be self-medicating or may have been raised in an environment where substance use is common). Therefore, the biopsychosocial model may be the most comprehensive model, as it considers multiple factors.

Cocaine

Extracted from coco plant in South America; Street names: Coke, Crack, Snow, Blow • On the street: $60-$100 per gram • Short acting - 15 minute high; leads to binge use • Can be snorted as "lines" (powder cocaine), smoked (crack), or injected • Crack cocaine- blocks that crackle when heated and smoked (cheapest form) • Legal use: anesthetic for eye surgery • Possible effects: panic attacks, paranoia, psychosis, severe weight loss, loss of sense of smell, heart rhythm disturbances, chest pain, stroke, cognitive impairment • Can cause death- stroke or heart attack • Withdrawal symptoms: dysphoric mood, fatigue, unpleasant dreams, increased appetite, sleep disturbance

Fentanyl

Fentanyl • Fentanyl is a drug used to relieve pain post surgery • Fentanyl patches/pills abused on the street • Gel removed from patch and injected • Heroin is now often cut with fentanyl in powder form (which is extremely dangerous because fentanyl is much more potent than heroin) • Fentanyl is 50-200 times more potent than morphine • Sold for $1 per microgram (100mcg patch = $100) • Fatal overdose potential (respiratory depression) • Recently identified as the most common drug in U.S. overdose deaths (according tp the CDC)

Hazelden Tour

Located 45 min from Minneapolis Saint-Paul Go to admissions area so that they can make you feel welcomed and more comfortable during the whole stay MSU: Staffed by doctors and nurses that help with treatment and mental health follows treatment process as well as mental health and physical screenings and detox process Various facilities to help you stay in shape and on top of your physical health Can clear your mind and think about your future as you recover from addiction

MDMA

MDMA is a synthetic drug and the key ingredient in ecstasy • It is both a hallucinogen and a stimulant • Popular at clubs, parties, night life venues • Causes a release of the body's natural hormones (i.e., oxytocin), which are involved in emotional closeness, trust, love, and sexual desire • This is why MDMA is referred to as the "love drug", because it stimulates oxytocin release • Street ecstasy is rarely pure MDMA; ecstasy is often cut with other drugs (such as synthetic cathinones), thus the effects often are unpredictable • Most frequently taken orally or snorted • Effects last 3-6 hours • MDMA crash can last 2-5 days • One primary risk in MDMA use is overheating (the drug compromises the body's ability to regulate temperature and it is often used in crowded, enclosed spaces) • On the street: sold for $10-$25 per pill/tablet

Methamphetamine

Methamphetamine • Highly euphoric- long lasting high • Made in laboratories (meth labs) • Ingredients include amphetamines, cold medicine, battery acid, drain cleaner, antifreeze, lighter fluid, paint thinner • White powder that can be injected, smoked, or snorted • Crystal meth- ice crystals, most commonly smoked • On the street: 1 hit - about ¼ gram = $25 • Can cause psychosis, paranoia, hallucinations, and delusions • Crank bugs- feeling of bugs over body; caused by random nerve firings in the brain • Meth mouth- poor dentition from meth use • Tweaking- coming down off a high; bizarre behavior, irrational thoughts, paranoia, impulsivity

Levels of care: a stepped system

here are four levels of care in addictions treatment. They are: Level 4: Inpatient hospitalization (most restrictive) Level 3: Residential treatment Level 2: PHP and IOP PHP (Partial Hospitalization Program): Day treatment IOP (Intensive Outpatient Program): Partial day treatment Level 1: Outpatient services (least restrictive) Let's talk about each one in detail.

How Drugs of Abuse Impact Neurotransmission

let's get specific about how this happens: ■ Drugs of abuse can cause neurotransmitter dysregulation by: - Disrupting the release of neurotransmitters. - Disrupting the reception of neurotransmitters. ■ This dysregulation occurs in a particular part of the brain called the reward pathway or mesolimbic dopamine system, which contains several neural structures (i.e., the ventral tegmental area, nucleus accumbens, and prefrontal cortex).

Sociocultural Model

m the sociocultural model, addiction is conceptualized as: A learned behavior; influenced by the environment Individual with addiction is conceptualized as : A product of the environment; a person who learned to use substances through social learning and modeling Solution to the problem of addiction is conceptualized as: Systemic change; if substance use is not the norm in particular settings, it will not be modeled for future generations Substance use is promoted through social and cultural norms, availability of substances, and expectations about substance use

The Reward Pathway

member, this neurotransmitter dysregulation is happening in a particular part of the brain called the reward pathway, which is the brain's natural pleasure center. ■ Specifically, this is the area where dopamine, the pleasure neurotransmitter, is released. ■ Dopamine is released to reinforce behavior necessary for survival (e.g., eating, fighting/exercising, and sex). ■ Drugs of abuse trigger a spike in dopamine release by hijacking the natural reward system. ■ The spike of dopamine caused by drugs of abuse is higher than the spike of dopamine caused by naturally-rewarding behaviors. ■ This spike tricks the brain into believing that the drugs of abuse are necessary for survival.

dopamine transporter

membrane protein that enables the presynaptic neuron to reabsorb dopamine after releasing it

The Basics of Brain

st let's define some key terms: ■ The central nervous system consists of the brain and spinal cord. - It is the communication network for the body and controls everything we do. ■ Neurons are a special type of cell found in brain, spinal cord, and nerves. - They are specialized communication cells that send and receive information. ■ Neurons fire messages to each other to cause every thought, feeling, and action of the body.

Identifying Change talk

"I don't understand what the big deal is. I work hard, I take care of my family, I am a good citizen....Who cares if I pop a Xanax every now and again? It helps me keep up with the pressure and deal with all the crap on my plate everyday. Sure, there is a part of me that would like set a better example for my kids, but everyone has their issues and this is the best way for me to get through the day. I know a lot of other people who use it too." The change talk is in red. Here, she gives you a reason for wanting to make a change (to set a better example for her kids). This is the change talk. MI counselors listen for change talk specifically so they can reflect (repeat or summarize) it back to the client.

Moral Model

's start with the moral model of addiction. This is the oldest model and still prevalent among people today. From the moral model, addiction is conceptualized as: A personal choice The individual with addiction is conceptualized as: Irresponsible and morally weak; bad (not sick) The solution to the problem of addiction is conceptualized as: Punishment, increase the individual's willpower, deter them from using (the belief is that the user can stop if they wanted to) The moral model was prominent during prohibition periods The moral model is still utilized within the criminal justice system (those who use illegal

Stages of change model

-represents a person's readiness to change -TTM: 6 stages (Refer to previous terms) -identifying where a person is in the cycle may fall to help them in their recovery process -Replase means you start using the drug again -a lapse is a slip up... does not always lead to a relapse. lapses and relapses allow people to learn from their mistakes and should not be seen as failure

Amphetamines: Adderall Abuse

-Adderall the most abused and legal drug in America -Affects teens -Popular among students to focus and pulled all nighters -used to help people study and stay up all night for parties -Dangerous because it is not perscribed for you -These are typically used to treat adhd. -Adderall is a derivative of methamphetamine -most patients need to go to an evaluation for their own good so they would be kept out of harm's way

Lysergic Acid Diethylamide (LSD)

-LSD is an extremely potent drug -Tolerance develops quickly (second hit will have less of an effect than the first) and disappears quickly after 7 days -typical trip lasts 12 hours -LSD uses have reported experiences of hyper-spirituality while using the durg -A "bad trip" is described as a disturbing or frightening sensory experience -LSD has high risk of injury as users engage in erratic behaviors during a trip -A blotter is a decorated absorbent paper (About the size of a stamp) dipped in LSD liquid and dried 1 sheet=100 hits -on the street: 1 hit sold for $5-1$10

derstanding Online Gaming Addiction and Treatment Issues for Adolescents

364 K. Young However, self-esteem in real life is fragile or non-existent. Treatment must focus on ways to build or rebuild their identities within a non-gaming envi- ronment. It is important to consider an adolescent's individual situation when treating their addiction. It is necessary to look at family dynamics such as family history of addiction, background, communication dynamics, or con- flict and how these factors may be impacting a teen's developmental stages, emotional well-being, and esteem (Yen et al., 2007). As part of intervening with an adolescent gamer, communication skills may also need to be learned. Many adolescent gamers cannot communicate well in face-to-face situations (Leo Sang-Min, 2007). This is part of why they game in the first place. Communicating online seems safer and easier for them. However, lack of communication skills can cause poor self-esteem, feelings of isolation and create additional problems in life among adolescents, so part of therapy needs to help adolescents communicate with others offline. Family therapists can apply several strategies to increase communication skills among adolescent clients suffering from gaming addiction. Enlisting the aid of an older child may help to engage an adolescent client in short conversations and to help develop skills. This may be a sibling or older friend. It is important to find someone the client feels comfortable with. Using books, magazines, and television to teach an adolescent client about facial expressions can also be helpful, especially to have them learn others' body language to help them understand what the other person is feeling. Role playing conversations is helpful to build their confidence. This helps an adolescent practice using eye contact when speaking to other people and develops listening skills, things they can't do online. PARENTING EFFORTS As the addiction develops, adolescent gaming addicts may experience symp- toms of withdrawal, which include anxiety, depression, irritability, trembling hands, restlessness, and obsessive thinking or fantasizing about the Internet. While online they may feel uninhibited and experience an increased sense of intimacy. Relationships in the real world may be neglected as those in the virtual world increase in importance. Academic performance is also likely to suffer. In a two-parent household, it is critical that both parents take the issue seriously and agree on common goals. Discuss the situation together and if necessary, parents must compromise on their desired goals so that when they approach their child, they will be coming from the same page. If parents do not, a child will appeal to the more skeptical parent and create division between them. Parents often fall into an enabling role with a gaming-addicted ado- lescent. They cover up or make excuses for their children when they miss Online Gaming Addiction and Treatment Issues for Adolescents 365 school or fail to meet deadlines, and in the name of keeping peace they give in to their children's demands when they complain loudly. It is important for parents to learn effective intervention efforts that support but not enable addictive behavior. Set Limits on Play Time Parents need to establish clear time limits with a child. How long they can play a game must be decided by the parent not the child. This is an important step. Often, adolescence is a time of experimentation with new freedoms such as going out with friends or learning to drive. Internet use is considered a normal part of growing up, which makes it even harder for parents to establish clear time limits. Even if a son or daughter argues that all their friends are online whenever and however much they like to be, as a parent, setting limits will help control playing time. Software is even available to help monitor and control their use. Rest Tired Eyes and Muscles Between reality breaks, it is wise to have a child take a brief eye-focusing break every 20 minutes to prevent eyestrain. Have her look up from the game and focus on something in the distance for several seconds. While they are it, encourage her to get up and move around for a minute or two to relieve muscle tension. These posture breaks will also help remind a child there is a world beyond the video monitor. Push for Computer Games Instead Encourage a son or daughter to switch over to playing educational-type games on computers. Even if hand-eye coordination is what he values most in video games, there are computer games that provide this and are more worthwhile than most of the video games such as ''Concentration,'' ''Jeop- ardy,'' and ''Sesame Street" depending upon the age. Change the Power Source Kids get a sense of power from playing and mastering video games, but there are many more positive ways to help give a child a sense of powerfulness. It is helpful for parents to look for interactive activities that give a child power through participation and learning, rather than through zapping little men or cars on a video screen. If a son excels athletically, he will get that kind 366 K. Young of empowerment through participation in his favorite sport. For a child who gets a lot of gratification from games, mastering a sport, a musical instrument, or challenging board game like chess can be very satisfying. Look for the School Connection Is a child turning to online games because they are not doing well at school? It is hard to tell which came first: the bad grades or the game. Not performing well at school impacts a child's self-esteem. They may retreat more into the game to cope with negative feelings about themselves. Parents should get him a tutor to engage him more into school topics. This will do more for his self-esteem. The important thing is to attack the problem at its source instead of condoning substitute ways of dealing with the frustration. Family Therapy For therapists, it is important to educate the entire family on ways that they can help the addict, whether or not he or she is in individual counseling or treatment. This may include counseling for family members, education on problem/compulsive gaming for the family, strategies on how to cope with anger and loss of trust from the addicted loved one, and education on the emotional costs of online gaming. Often, gaming addiction will be addressed as a part of a weekly family program. Each week topics related to addiction can be addressed to help family members understand the process of recov- ery, relapse triggers and the importance of keeping healthy boundaries. This is especially important for parents as they struggle to understand a child's compulsive need to game and the underlying dynamics associated with their addiction. Brief Strategic Family Therapy (BSFT) is a short-term, problem-focused therapeutic intervention, targeting children and adolescents 6 to 17 years old, that improves youth behavior by eliminating or reducing drug use and its associated behavior problems and that changes the family members' behav- iors that are linked to both risk and protective factors related to substance abuse. This model can also be applied to online gaming addiction among adolescents. The therapeutic process uses techniques of: • Joining—forming a therapeutic alliance with all family members • Diagnosis—identifying interactional patterns that allow or encourage prob- lematic youth behavior • Restructuring—the process of changing the family interactions that are directly related to problem Online Gaming Addiction and Treatment Issues for Adolescents 367 Joining BSFT assumes that each family has its own unique characteristics and prop- erties that emerge and are apparent only when family members interact. This family "system" influences all members of the family. Thus, the family must be viewed as a whole organism rather than merely as the composite sum of the individuals or groups that compose it (Minuchin, 1974). In BSFT, this view of the family system assumes the family is a system with inter- dependent/interrelated parts. The behavior of one family member can only be understood by examining the context (i.e., family) in which it occurs. Interventions must be implemented at the family level and must take into account the complex relationships within the family system. Individuals from families that include youth with behavior problems are very difficult to engage in treatment, which may lead to family resistance and a lack of participation in treatment. Engagement or joining begins from the very first contact with the family. Resistance can be understood in the same way as any other pattern of family interaction (Minuchin, 1974). In BSFT, joining occurs at two levels. First, at the individual level, joining involves establishing a relationship with each participating family member. Second, at the level of the family, the therapist joins with the family system to create a new therapeutic system. Joining thus requires both sensitivity and an ability to respond to the unique characteristics of individuals and quickly discern the family's governing process. A number of specific techniques can be used to join the family, including maintenance (e.g., supporting the family's structure and entering the system by accepting their rules that regulate behavior), tracking (e.g., using what the family talks about (content) and how their interactions unfold (process) to enter the family system), and mimesis (e.g., matching the tempo, mood, and style of family member interactions). Diagnosis In BSFT, diagnosis refers to identifying interactional patterns (structure) that allow or encourage problematic youth behavior. In other words, diagnosis determines how the nature and characteristics of family interactions (how family members behave with one another) contribute to the family's failure to meet its objective of eliminating youth problems. Addictive gaming behavior, especially among youth, may be a symptom of a dysfunction within a family. In this model, problematic behaviors serve a purpose for the family. Poor communication, aggressive parenting styles, a family's inability to operate productively, or symptomatic patterns handed down across generations may serve as a root cause of addictive gaming among adolescents. Gamers immerse themselves into captivating virtual worlds that seem more exciting and interesting than their real lives. This often serves to 368 K. Young reinforce the addictive behavior and can be used as a coping mechanism to deal with missing or unfulfilled needs. In this way, gaming can allow the gamer to forget his or her problems. In the short term, gaming may be a useful way to cope with the stress of a hard situation, however, addictive behaviors used to escape or run away from unpleasant situations in the long run only end up making the problem worse. For the gaming addict, situations such as a death of a loved one, a divorce, or problems at school may trigger using the game as a mental distraction that temporarily makes such problems fade into the background. Since the escape is only temporary, players return to gaming as a means of making themselves feel better without dealing with and resolving the underlying problems in their lives. In this way, the game produces a type of drug "high" that provides an emotional escape or an altered state of reality or mental rush (Ng & Wiemer- Hastings, 2005). That is, online gaming, the excitement of becoming someone new in a role-playing game, the challenge of winning a new weapon or potion, or the ability to make new friends through the game, provides an immediate mental escape from their problems and serves to reward future behavior. Diagnosis not only investigates gaming behavior and its abstinence but it must assess the way the family functions and engages in treatment activities. Therapists should evaluate how the family externalizes problem behaviors, the level of pro-social activities the family engages in, family communication styles, and the overall level of family functioning. Patterns to look for are watching for signs that family members are critical about and negative toward the adolescent gaming addict. The addicted gamer may be using the virtual world to escape the pressure and stress from being seen as a failure to feel good about themselves in the game. Another family system pattern to examine is the level of denial or avoidance of family conflict. Does the family jump from conflict to conflict without achieving any real depth of one particular issue? This may be a symptom of poor conflict resolution among the family or diffusion of problems that are sustaining the addictive behavior. An adolescent may be compensating for family problems that are not being discussed openly at home. Fearing rejection, an adolescent may use the game as a safe place to share feelings and confront conflicts with other players. Other patterns in family therapy to observe are enmeshment, triangulation, or disengagement (Minuchin, 1974), which may be creating pressure on the adolescent to turn to the game as a means of escape. Restructuring As therapists identify what a family's patterns of interaction are and how these fit with the adolescent's addictive behavior, therapists develop specific plans for changing the family interactions and individual and social factors Online Gaming Addiction and Treatment Issues for Adolescents 369 that are directly related to the child's behavior. The ultimate goal of treatment in BSFT is to change family interactions that maintain the problems to more effective and adaptive interactions that eliminate the problems. Adolescence is known to be a period of exploratory self-analysis and self-evaluation culminating in the establishment of a cohesive and integrative sense of self or identity. Adolescent gaming addicts can use the game to explore and test alternative ideas, beliefs, and behaviors, marking this period as one of both dramatic change and uncertainty. Restructuring means understand how the child may use the game to form identity (through personas and virtual worlds) and encourage healthy family interactions by working in the present, reframing, and working with boundaries and alliances. Working in the present not only involves creating positive lifestyle changes that take clients away from the computer but that improve their emotional and family well-being (Young, 2007). This varies depending upon the client's family situation. Within BSFT, family enactments are a critical feature of working in the present. Enactments encourage, help, and/or allow family members to behave or interact as they would if the therapist were not present. Very frequently, family members will spontaneously behave in their typical way when they fight, interrupt, or criticize one another. Therefore, when families become rigidly focused on speaking to the therapist, the ther- apist should systematically redirect communication to encourage interactions between session participants. Encouraging enactments help the therapist ob- serve problematic interactions directly rather than relying on stories about what happens when the therapist is not present. The family may blame the gamer for the problem, deny the problem, or triangulate the gamer into a marital problem—this root cause will vary among families. Enactment will enable the therapist to see clearly how these relationships have been main- tained and give them the tools necessary to restructure the family system in a healthy manner. Perhaps one of the most interesting, useful, subtle, and powerful tech- niques in BSFT is reframing (Minuchin & Fishman, 1981). Reframing creates a different sense of reality; it gives family members the opportunity to per- ceive their interactions or situation from a different perspective. Reframing is a restructuring technique that typically does not cause the therapist to lose his or her rapport with the family. For this reason, reframing should be used liberally in the treatment process, especially at the beginning of treatment when the therapist needs to bring about changes but is still in the process of building a working relationship with the family. Adolescent gamers may be using the Internet and the game as a form of mental escape from stress and tension in the family. Poor family alliances or parent-child relationships may cause the adolescent to turn to the game as a safe place to vent about problems going on at home. The child may be the family scapegoat and suffer from poor relationships with others only to use the game as a safe place to make friends and socialize. Instead of turning 370 K. Young to the game, therapists must reframe an adolescent's negative distortions, enabling the family to develop new ways of communicating and relating without hostility, anger, or blame. The therapist must reframe situations of family tension so that the gamer doesn't see the game as the only safe place to express feelings. The family will learn new ways of communicating, allowing the adolescent gaming addict to share more openly and honestly with family members instead of online friends. One major goal of therapy is to create the opportunity for the family to behave in constructive new ways. Working with alliances and boundaries the therapist is able to examine the social "walls" that exist around the family who are allied with one another and that stand between individuals and others that are not allied with one another. A common situation of a youth addicted to online games is a strong alliance with only one parent. This alliance may cross generational lines. For example, there may be a strong bond between a youth and her or his mother (or mother figure). Whenever the youth is punished by the father (or father figure) for inappropriate behavior, the youth may solicit sympathy and support from the "mother" to undermine the "father's" authority and remove the sanction. In a single-parent family, it may be the grandmother who overprotects the youth and undermines the parent's attempts at discipline. Shifting boundaries to create equality in parenting involves creating a more solid bond between the parents so they will make executive decisions together. Removing the inappropriate parent-child alliance and replacing it with an appropriate alliance between either parents or parent figures will meet the youth's need for support and nurturance (decreasing their need to find it through the game). Understanding the alliances the youth has formed inside the game will also help the youth rely less upon the game for desired attention not being met in real life. Questions to ask the gamer may be: How much time do you spend customizing your character during character creation? How important is it to you that your character is unique or looks different from other characters? Does your character have many friends? Do you try out new roles and personalities with your characters? Do you enjoy making up stories and histories for your characters? Do you role-play with your character? What do you like about your character? The answers will re- veal the virtual world the gamer has created including alliances, friendships, and quality of those relationships. Therapists can begin to merge the outside family system with the inside game support system, once an understanding the kind of alliances the gamer seeks. Therapy involves a parallel form of intervention among adolescents. First, family dynamics, interactions, and communications impact addictive gaming behavior. Second, the virtual world inside the game impacts addictive gaming behavior. If the game provides a more appealing, exciting, and supportive environment than does the family, the adolescent will continue to gravitate to the game to meet unmet needs. Once the family system can Online Gaming Addiction and Treatment Issues for Adolescents 371 be realigned to provide these needs, the game becomes less important and more irresistible, allowing the gamer to form his or her identity within the context of a normal childhood development scheme

Salvia video

A hallucinogen herb pyscho-tropic the most powerful naturally occurring hallucinogen strong dissociative properties illegal in a lot of states but is only labeled as drug of concern it is not really comparable to other drugs because of its unique effects can be synethized to treat pain or alzheimers

Lapse or Relapse

A lapse is also known as a slip: when an individual in recovery reverts to using alcohol or drugs and stops again within a short time. Relapse entails a full-blown resumption or return to the addiction or behavior that someone wanted to stop or moderate.

Consequences of Porn Addiction

A number of young adults enter treatment to address porn addiction due to: Sexual dysfunction ◦With chronic porn use, sexual conditioning occurs- the porn user is conditioned to become aroused by images or videos, rather than a real-life partner. This can lead to sexual dysfunction among those in their 20s and 30s. Relationship issues Loss of time (time spent viewing porn rather than engaging in other life activities) Secrecy and shame Porn use interferes with other major life tasks (work, school, family, relationships, hobbies, sleep, etc.) Financial issues Job loss (e.g., viewing porn at work) Depressive symptoms (Wilson, 2014)

Science of Pornography Addiction

ASAP Science Video

Is relapse part of recovery?

According to the National Institute of Drug Abuse, the relapse rate for substance use disorders is 40-60%. With addiction relapse being a common struggle, the claim that "relapse is part of recovery" has been made to normalize this experience. That being said, eventual relapse is a myth. Relapse does not have to be a part of the recovery process. It can be harmful to normalize and/or excuse returning to old patterns. Keep in mind the difference between lapse and relapse. Recovery involves significant lifestyle and behavior change. Setbacks can occur. Lapse and relapse do not equal failure. The person can always return to their recovery plan.

Addictions Treatment

Addictions treatment typically consists of three components: group counseling, individual counseling, and support group attendance (e.g., Alcoholics Anonymous). Each type of support is helpful in different ways.

Religious/Spiritual Considerations

Additionally, some religious/spiritual groups incorporate drugs/alcohol into their practices. ◦Christian traditions - wine in communion ◦Rastafarianism - cannabis in religious practices ◦Some Native American spiritual practices— peyote Moreover, some religious traditions prohibit drug/alcohol use of any kind (Islam; Jainism; Buddhism) or teach against intoxication (Judaism; Christianity). These topics are likely to come up in treatment with religious/spiritual clients

Advantages and disadvantages of the disease model

Advantages: Removes social stigma from addiction (individual isn't morally corrupt, individual has a disease) Treatment goal is clear: abstinence from all substances provides steps for managing life with the disease Disadvantages: May decrease personal responsibility for actions, dichotomous view of addiction (you have the disease or you don't rather than considering substance use on a continuum Lack of scientific evidence for an addiction gene

Age Considerations

Age is an important factor in addictions treatment. Consider older adult problem drinkers: ◦With age, the body's ability to metabolize alcohol decreases (therefore, the same amount of alcohol can have more powerful effects as one ages). Additionally, marijuana has been found to be the most commonly abused illegal substance by older adults. ◦Typically used for chronic pain alleviation. Furthermore, prescription drugs are the second most commonly abused substances by older adults. ◦Typically used for chronic pain alleviation. ◦Abuse may occur because medications are taken incorrectly by older adults. ◦Additionally, combining prescription drugs with alcohol can be dangerous.

When clients are in preparation counselors will:

Help the client increase confidence. Foster the client's sense of self-efficacy. Work with client to develop a plan for action. What will change actually look like? How will you say "no" when your buddy calls to go drinking? Identify possible obstacles for change. Troubleshoot and plan for how client will respond. Enlist the support of significant others in client's life.

Craig Ferguson: Alcohol abuse

Alcoholism: recalls story from the 90s about his addiction and alcoholism. Christmas eve in a bar... suicidal thoughts and attempted suicide that day Tells a friend that he was going to kill himself on Christmas day but transportation was closed for that day due to the holiday. The friend offers him another drink of alcohol---> forgets about suicidal thoughts.... Alcohol saved his life but it was killing him because he was an addict Went to rehab and has been sober for 15 years. Claims to not have a drinking problem but a "Thinking problem" certain types of people cannot drink alcohol... it is embarrassing to admit that you are an alcoholic... but you are still responsibility to deal with your addiction This is something you cannot buy your way out... you need help. seek help

ACA Ethical Principles

All counselors adhere to the following six ethical principles. Consider how they apply specifically to addictions treatment: 1. Autonomy (Client independence) ▫Clients have the right to control their own lives. 2. Nonmaleficence (Do no harm) ▫Counselors do not cause harm to clients. 3. Beneficence (Do good) ▫Counselors enhance client wellness. 4. Justice (Fairness) ▫Counselors treat clients impartially and with respect. 5. Fidelity (Honesty and trustworthiness) ▫Counselors fulfill professional obligations. 6. Veracity (Truthfulness) ▫Counselors are honest with clients.

Multicultural Considerations in Addictions Treatment

Along with understanding bias in drug laws and charges, it is important for counselors to consider cultural views/norms regarding substance abuse. ◦Different cultural groups perceive substances in nuanced ways (for example, Peyote, a hallucinogen, has been used during spiritual ceremonies among some Native American tribes). Additionally, being a member of a marginalized or oppressed cultural group can be a source of psychological distress (due to discrimination, acculturative stress, and institutional oppression), which may increase the risk of coping with that distress through substance use. Let's discuss other cultural factors that should be considered when providing addictions treatment.

Proposed DSM-5 Criteria for Hypersexual Disorder

Although not included in the DSM-5, criteria were proposed for "Hypersexual Disorder". Those criteria were: For a duration of at least 6 months, individual experiences at least 4 of the following: ◦Time consumed by sexual fantasies, urges, or behaviors interferes with other important activities ◦Sexual fantasies, urges, or behaviors used to respond to dysphoric mood ◦Sexual fantasies, urges, or behaviors used to respond to stressful events ◦Unsuccessful efforts to control or reduce sexual fantasies, urges, or behaviors ◦Disregarding risk for physical or emotional harm (self or others) Sexual behavior causes significant distress or impairment. Sexual acting out is not caused by drugs of abuse or medication. More research is needed to support the inclusion of this diagnosis in the DSM.

What is Ambivalence?

Ambivalence is feeling two-ways about something simultaneously. Example: "I want to exercise, but I don't want to exercise." Wanting to change and not wanting to change at the same time. Both sides have a "voice" in the individual's thoughts (the pro-change side and the no-change side). Miller and Rollnick (2013) said, "People who are ambivalent about change already have both arguments within them---those favoring change and those supporting the status quo" (p. 11). For clients with substance use disorders, they recognize the risks of drug/alcohol use, but are attracted to it as well (thus, they are ambivalent).

Level 3: Sober Living Environments

Another level 3 treatment option is Sober Living Environments (formerly known as Half-way Houses). Sober living environments are voluntary housing for clients seeking a supportive, drug and alcohol-free setting. They are often used to help individuals in recovery transition back to independent living. Expectations of living in a Sober Living Environment include: 12-step meeting attendance Maintain employment Attend substance abuse counseling groups Abstinence from all substances

Engaging Continued

Another part of the engaging process is exploring the client's values and goals (which are internal sources of motivation). Counselors may ask, "What matters most to you?" or "How do you hope your life will be different 10 years from now?" to identify goals and values. Once the counselor and client identify goals and values, they can explore how the substance using behavior relates to these goals and values. This is called exploring discrepancy. Miller and Rollnick stated, "Our experience is that when people are invited to reflect on their values and actions within a safe, nonjudgmental atmosphere they are usually well aware of discrepancies" (2013; p. 87).

Signs and Symptoms of Internet Gaming Addiction

Below are a list of potential signs of Internet Gaming Addiction. If a client demonstrates these signs, a formal IGD assessment can be used. Preoccupation with gaming: Fantasizing, mental obsession, fixation on gaming. Hide use: Lie about amount of time spent gaming, game on phone or at friend's houses. Loss of interest in other activities. Social withdraw/isolation: Prefer virtual relationships over off-line relationships. Withdrawal symptoms when not gaming: irritability, restlessness, craving to game, anxiety. Escape in game: Avoiding negative emotion states by gaming. Continued despite negative consequences (school, work, family, relationships, physical health, etc.).

Benzodiazepines

Benzodiazepines • Prescription drugs used to treat anxiety and insomnia (examples include Xanax, Valium, Ativan, Klonopin, Librium, Restoril, Ambien) • Largely replaced barbiturates • How is it abused? • By taking drugs without a prescription, taking more than prescribed, taking for longer durations than prescribed (typical prescription is for 30-60 days) • Dangerous if taken with alcohol (can be fatal) • Long half-life (amount of time needed for ½ of drug to leave the body), so detox could take up to a month • Can get a DUI for driving with benzos in system • On the street: 2mg Xanax bar and 10mg Ambien pill sells for $5 • Ambien can cause blackouts (meaning a person is active, but has no memory of events)

Blood Alcohol Content Effects

Blood Alcohol Concentration (BAC)- grams of alcohol per 100 grams blood .05- Impaired judgment, decreased inhibitions .10- Impaired motor functioning .20- Intoxicated, impaired functioning .30- Staggering, lacks comprehension .35- Unconscious .40- Lethal for half of population .60- Lethal for almost all people • Alcohol poisoning: can lead to death; alcohol is a depressant, and in large amounts it can slow the central nervous system down to a stop. • .08 BAC or higher- illegal to operate a vehicle for individuals 21 years old+; .02 BAC or higher-illegal to operate a vehicle for individuals under 21 years old

Four processes of MI

MI counselors use their core skills (OARS) within the four processes of MI. These processes are: Engaging: Establishing a connection with client and developing a strong working relationship. Focusing: Developing a specific direction for the clinical work (constructing a common goal). Evoking: Eliciting the client's own motivation for change and allowing the client to provide her/his reasons for changing. Planning: Developing a specific plan for action. How will the change actually take place? Rather than happening in a linear fashion, these processes build upon each other like stair steps.

Chapter 25

Broadly Defined, Matching Individuals To Treatment Means Providing The Individual With The Treatment Approach That Is Likely To Maximize Outcome. As Seen In The Ear- Lier Chapters In This Volume, The Past 20 Years Have Been Marked By Both Tremendous Progress And Increasing Methodological Rigor In Substance Abuse Research, And There- Fore The Development Of A Much Wider Range Of Empirically Supported Pharmaco- Therapies And Behavioral Therapies. Availability Of A Broader Range Of Therapies Has Likewise Heightened Interest In Differential Treatment Research, Whether It Be Matching Individuals To Specific Treatment Approaches, Matching Patients To Different Levels Of Services, Or Identifying Predictors Of Response To Specific Therapies (Insel, 2012). To Date However, Empirical Evidence Supporting Specific, A Priori Matching Strat- Egies Has Been Modest At Best (Magura Et Al., 2003; Mckay, Cacciola, Mclellan, Alterman, & Wirtz, 1997; Mclellan & Mckay, 1998; Project Match Research Group, 1993, 1997; Ukatt Research Team, 2008), In Part Due To The Complexity Of Treatment Decisions For Many Patients, Who Typically Present For Treatment With A Complex Array Of Substance Use, Psychiatric, Legal, Medical, And Social Problems, As Well As Limits Of The Service Delivery System In Accommodating The Needs Of Diverse Patients (Gastfriend, Lu, & Sharon, 2000; Mclellan, 2006). There Is A Bit More Con- Sistency In The Literature, However, Regarding Prognostic Variables That Have Emerged Across Patient Populations. Briefly, Greater Severity Of Substance Dependence, Pres- Ence And Severity Of Comorbid Psychiatric Problems, Lower Levels Of Social Support, And Unemployment Have Consistently Related To Outcome (Reviewed In Mclellan & Mckay, 1998). Larger Scale Studies Have Also Demonstrated With Some Consistency That Addressing Comorbid Issues And Problems In Treatment Is Generally Associated. 531. 532 V. Treatments For Addictions. With Improved Outcome (Mclellan, Arndt, Metzger, Woody, & O'brien, 1993; Mclellan, Grissom, Zanis, & Randall, 1997). Thus, For Our Purposes In This Chapter, Rather Than "Matching" Per Se, We Instead Focus On Strategies Tailoring Treatments To Meet The Needs Of The Individual. In General, Appropriate Treatment Tailoring Implies Adequate Provision Of An Effective, Empiri- Cally Supported Therapy With Adjunct Therapies That Are Appropriate To The Specific Co-Occurring Problems As Dictated By Careful, Thorough Assessment Of The Patient Functioning And Status Across A Range Of Domains. Thus, This Review Summarizes Empirically Supported Therapies Across The Most Common Substance Use Disorders (Suds), With Special Emphasis On How Pharmacological And Behavioral Therapies Can Be Combined To Enhance Outcome. When Available, Data Regarding The Types Of Individuals Who May Respond Particularly Well Or Poorly To Specific Approaches Are Reviewed. First, However, It Is Important To Understand The Respective Roles Of Pharmaco- Therapy And Behavioral Approaches In Terms Of How These May Be Tailored, Or Com- Bined, To Meet The Needs Of Specific Individuals. Pharmacotherapy In The Treatment Of Suds. The Target Symptoms Addressed And Roles Typically Played By Pharmacotherapy Differ From Those Of Behavioral Treatments In Their Course Of Action, Time To Effect, Target Symptoms, And Durability Of Benefits (Elkin, Pilkonis, Docherty, & Sotsky, 1988). In General, Pharmacotherapies Have A Much More Narrow Application Than Do Most Behavioral Treatments For Suds; That Is, Most Of The Behavioral Therapies Described Below Are Applicable Across A Range Of Treatment Settings (E. G., Inpatient, Outpatient, Residential), Modalities (E. G., Group, Individual, Family), And A Wide Variety Of Popu- Lations, And Are Therefore Readily Tailored To The Needs And Preferences Of Specific Individuals. For Example, Disease Model, Behavioral, Or Motivational Approaches Have Been Used, With Relatively Minor Modifications, Regardless Of Whether The Patient Is An Opiate, Alcohol, Cocaine, Or Marijuana User. On The Other Hand, Most Available Pharmacotherapies Tend To Be Applicable Only To A Single Class Of Substance Use And Exert Their Effects Over A Narrow Band Of Symptoms. For Example, Methadone Pro- Duces Cross-Tolerance For Opioids But Has Little Effect On Concurrent Cocaine Abuse; Disulfiram Produces Nausea After Alcohol Ingestion But Not After Ingestion Of Other Illicit Substances. A Notable Exception Is Naltrexone, Which Is Used To Treat Both Opioid And, More Recently, Alcohol Dependence (Bouza, Angeles, Munoz, & Amate, 2004; Johansson, Berglund, & Lindgren, 2006; Oslin Et Al., 2008). Common Roles And Indications For Pharmacotherapy In The Treatment Of Sub- Stance Dependence Disorders Include The Following (Carroll, 2001; Rounsaville & Carroll, 1997). Detoxification. For Those Classes Of Substances That Produce Substantial Physical Withdrawal Syn- Dromes (E. G., Alcohol, Opioids, Sedatives/Hypnotics), Medications Are Often Needed To. 25. Matching And Differential Therapies 533. Reduce Or Control The Often-Dangerous Symptoms Associated With Withdrawal. Benzo- Diazepines Are Often Used To Manage Symptoms Of Alcohol Withdrawal. Agents Such As Methadone, Clonidine, Naltrexone, And Buprenorphine Are Typically Used For The Man- Agement Of Opioid Withdrawal. Typically, The Role Of Behavioral Treatments During Detoxification Is Typically Extremely Limited Due To The Level Of Discomfort, Agitation, And Confusion The Patient May Experience. However, Recent Studies Have Suggested The Effectiveness Of Behavioral Strategies In Increasing Retention And Abstinence In The Course Of Longer-Term Outpatient Detoxification Protocols (Bickel, Amass, Higgins, Badger, & Esch, 1997; Tuten, Defulio, Jones, & Stitzer, 2012). Stabilization And Maintenance. A Widely Used Example Of The Use Of A Medication For Long-Term Stabilization Of Drug Users Is Methadone Maintenance For Opioid Dependence, A Treatment Strategy That Involves The Daily Administration Of A Long-Acting Opioid (Methadone) As A Substitute For The Illicit Use Of Short-Acting Opioids (Typically Heroin). Methadone Maintenance Permits The Patient To Function Normally, Without Experiencing Withdrawal Symp- Toms, Craving, Or Side Effects. The Large Body Of Research On Methadone Maintenance Confirms Its Importance In Fostering Treatment Retention, Providing The Opportunity To Evaluate And Treat Other Problems And Disorders That Often Coexist With Opioid Dependence (E. G., Medical, Legal, And Occupational Problems), Reducing The Risk Of Hiv Infection And Other Complications By Reducing Intravenous Drug Use, And Pro- Viding A Level Of Stabilization That Permits The Inception Of Psychotherapy And Other Aspects Of Treatment (Ball & Ross, 1991; Lowinson, Marion, Joseph, & Dole, 1992; Sees Et Al., 2000). However, Methadone Maintenance In And Of Itself Is Rarely Sufficient Treatment For Most Chronic Heroin-Addicted Individuals. Multiple Studies Indicate That Addition Of Empirically Supported Therapies Can Broaden And Strengthen The Effectiveness Of Maintenance Therapies (Mclellan Et Al., 1993; Woody Et Al., 1983). As Described At Greater Length In The Later Sections On Behavioral Therapies, Specific Behavioral Thera- Pies Can Be Used To Tailor Treatment For Specific Individuals With Specific Co-Occurring Problems. For Example, Contingency Management Has Been Shown In Multiple Stud- Ies To Be Effective In Reducing Concurrent Cocaine Dependence Among Methadone- Maintained Cocaine Users, A Group With Particularly Poor Outcomes (Peirce Et Al., 2006; Silverman, Higgins, Et Al., 1996). Behavioral Therapies Can Also Target Other Problems Among Agonist-Maintained Populations, Such As Silverman's Model Of Work- Based Therapy, In Which Individuals Are Provided Access To Paid Work That Is Contin- Gent On Regular Submission Of Cocaine-Free Urine Specimens (Silverman, 1999; Silver- Man Et Al., 2002). Antagonist And Other Behaviorally Oriented Pharmacotherapies. A More Recent Pharmacological Strategy Is The Use Of Antagonist Treatment, That Is, The Use Of Medications That Block The Effects Of Specific Drugs. An Example Of This Approach Is Naltrexone, An Effective, Long-Acting Opioid Antagonist. Naltrexone Is Nonaddicting, Does Not Have The Reinforcing Properties Of Opioids, Has Few Side Effects. 534 V. Treatments For Addictions. And, Most Important, Effectively Blocks The Effects Of Opioids. Therefore, Naltrex- One Treatment Represents A Potent Behavioral Strategy: As Opioid Ingestion Will Not Be Reinforced While The Patient Is Taking Naltrexone, Unreinforced Opioid Use Allows Extinction Of Relationships Between Conditioned Drug Cues And Drug Use. For Exam- Ple, A Naltrexone-Maintained Patient, Anticipating That Opioid Use Will Not Result In Desired Drug Effects, May Be More Likely To Learn To Live In A World Full Of Drug Cues And High-Risk Situations Without Resorting To Drug Use. On The Other Hand, The Efficacy Of Naltrexone Treatment, Particularly For The Treatment Of Opioid Dependence, Has Been Undercut By Problems Of Adherence Since Its Inception (Anton, Hogan, Jalali, Riordan, & Kleber, 1981; Grabowski Et Al., 1979; Rounsaville, 1995). Thus, For Many Years, Clinical Use Of Naltrexone Was Limited To Groups Such As Professionals (E. G., Medical Care Providers) Who Agreed To Supervised Naltrexone Treatment As A Condition Of Their Continued Licensure Or Employment (Rounsaville, 1995). Longer Acting Depot Formulations Of Naltrexone Have Addressed This Issue To A Large Extent; However, Attrition Still Remains A Problem (Kranzler, Wes- Son, & Billot, 2004; Krupitsky & Blokhina, 2010). Again, Behavioral Therapies Such As Contingency Management (Carroll Et Al., 2001) And Family Therapy (Fals-Stewart & O'farrell, 2003) May Have Utility In Facilitating Adherence And Outcome With Naltrex- One Treatment, As Well As Other Medication Approaches In Which Efficacy Is Limited By Problems In Compliance (Carroll & Rounsaville, 2007A). Treatment Of Coexisting Disorders. Another Important Role Of Pharmacotherapy In Addictive Disorders Is As Treatment For Coexisting Psychiatric Syndromes That May Precede Or Play A Role In The Main- Tenance Or Complications Of Drug Dependence. The Frequent Co-Occurrence Of Psy- Chiatric Disorders, Particularly Affective And Anxiety Disorders, With Suds Is Well Documented In A Variety Of Populations And Settings (Kessler Et Al., 1997; Regier Et Al., 1990). Given That Psychiatric Disorders Often Precede Development Of Suds, Several Researchers Have Hypothesized That Individuals With Primary Psychiatric Dis- Orders May Be Attempting To Self-Medicate Their Psychiatric Symptoms With Drugs And Alcohol. Thus, Effective Pharmacological Treatment Of The Underlying Psychiatric Dis- Order May Improve Not Only The Psychiatric Disorder But Also The Perceived Need For And Therefore The Use Of Illicit Drugs. Overall, However, Studies Evaluating The Effect Of Antidepressant Treatment On Comorbid Depressive Disorders And Suds Have Shown Very Modest Effects On Levels Of Substance Use (Reviewed In Nunes & Levin, 2004). Fostering Compliance With Pharmacotherapy. The Difficulties Of Fostering Adequate Levels Of Treatment Compliance With Substance Users Is Well Known (Skolnick & Volkow, 2012), So Much So That Substance Users Are Typically Excluded From Clinical Trials Of Treatments For Other Disorders. Thus, When Pharmacotherapies Are Used In The Treatment Of Substance Use, It Is Not Surprising To See High Rates Of Noncompliance. A Major Role That Behavioral Treatments Play When Pharmacotherapies Are Used In The Treatment Of Substance Use Is In Fostering Compli- Ance, Because Most Strategies To Improve Compliance Are Inherently Psychosocial. 25. Matching And Differential Therapies 535. These Include, For Example, Regular Monitoring Of Medication Compliance Through Pill Counts And Medication Serum Levels; Encouragement Of Patient Self-Monitoring Of Compliance (E. G., Through Medication Logs Or Diaries); Clear Communication Between Patient And Staff About The Study Medication, Its Expected Effects, Side Effects And Benefits; Repeatedly Stressing The Importance Of Adherence; Contracting With The Patients For Adherence; Directly Reinforcing Adherence Through Incentives Or Rewards; Providing Telephone Or Written Reminders About Appointments Or Taking Medication; Preparing And Educating Patients About The Disorder And Its Treatment; And Frequent Contact And The Provision Of Extensive Support And Encouragement To The Patient And His Or Her Family (Haynes, Mcdonald, & Garg, 2002; Haynes, Mcdonald, Garg, & Montague, 2000; Weiss, 2004). Behavioral Treatments For Suds. We Present In The Following Sections A Brief Overview Of The Major Categories Of Behav- Ioral Therapies That Are Typically Considered To Be Evidence Based (Carroll & Onken, 2005; Derubeis & Crits-Christoph, 1998; Dutra Et Al., 2008; National Institute On Drug Abuse, 2007; Roth & Fonagy, 2005). These Focus On Categories That Have Been Found To Be Effective In Multiple Randomized Clinical Trials And On The Major Types Of Suds (Alcohol, Opioid, Cocaine, And Marijuana Dependence). Many Of These Were Described In More Detail In Earlier Chapters In This Volume; They Are Discussed Here Primarily In Terms Of Their Focus (E. G., Earlier Vs. Later Phases Of Treatment) And How They Can Be Tailored To Improve Outcomes In Specific Individuals. Motivational Interviewing And Brief Approaches. Motivational And Brief Approaches Tend To Be Those Best Suited For The Initial Phases Of Treatment And Those With Lower Levels Of Problem Substance Use (E. G., Nondependent Users In Ambulatory Settings). As Such, They Are An Excellent "First-Line" Approach In A Number Of Settings, So That More Intensive Resources Can Be Reserved For Individu- Als Who Do Not Respond To Brief Motivational Interventions (Carroll & Rounsaville, 2007B). They Are Often Delivered In Settings In Which Problems Related To Suds Are Addressed But The Individual Is Not Necessarily Seeking Treatment For A Substance Use Problem. These Include Screening And Brief Intervention Approaches In Emergency And Primary Care Departments (Babor Et Al., 2007; D'onofrio Et Al., 2008; Saitz Et Al., 2007). Motivational Approaches Are Brief Treatments That Are Designed To Produce Rapid, Internally Motivated Change In Addictive Behavior And Other Problem Behaviors. Motivational Interviewing (Mi), Developed By William Miller And His Colleagues, Best Represents These Types Of Treatment Approaches. Grounded In Principles Of Moti- Vational Psychology And Client-Centered Counseling, Mi (Miller & Rollnick, 1991, 2002) Arose Out Of Several Recent Theoretical And Empirical Advances (Miller, 2000). First, Several Studies Of Problem Drinking Indicated That Very Brief Interventions (E. G., One Or Two Sessions In Duration) Were Associated With Reductions In Drinking That Were As Robust And Enduring As Those Associated With Much More Intensive Treatments. 536 V. Treatments For Addictions. (Bien, Miller, & Tonigan, 1993). These Studies Highlighted That Change In Addictive Behavior Can Happen With Relatively Little Treatment. Second, Research On How People Change Problem Behaviors Led To Greater Interest In Natural Recovery And The Trans- Theoretical Model (Prochaska, Diclemente, & Norcross, 1992), Also Called The Stages Of Change Model, In Which Individuals Who Are Attempting To Change Problem Behav- Iors Move Through A Reliable Sequence Of Stages, From Precontemplation (Associated With Individuals Who Are Not Considering Changing Their Behavior) To Contemplation (Recognition Of The Need To Change And Consideration Of The Costs And Feasibility Of Behavior Change) To Determination (Making The Decision To Take Action And Change) To Action And Maintenance. Motivation For Change Was Seen As A Critical Variable For Understanding How People Move From One Stage To Another (Diclemente, Bellino, & Neavins, 1999). Likewise, The Model Emphasized The Need For Developing Interven- Tions Matched To Different Stages Of Change. Mi Was Seen As Very Well Suited For The Early Stages (Diclemente & Velasquez, 2002). Third, Research On Substance Users Indicated That Patient Drinking Outcomes Were Associated With Therapist Style, With High Levels Of Therapist Confrontation Associated With Poorer Outcomes, And High Lev- Els Of Empathy Associated With Better Outcomes (Miller, Benefield, & Tonigan, 1993). Empathic Listening Became A Central Feature In The Development Of Mi. Mi Typically Occurs Over The Course Of One To Four Sessions, With Earlier Work Focusing On Building The Patient's Motivation For Change And Subsequent Work Strengthening The Patient's Commitment To Change. The Core Of Each Of These Phases Is The Therapist's Consistent Use Of Mi Techniques, Summarized By The Acronym Oars (Open-Ended Questions, Affirming, Reflecting, And Summarizing; Miller & Rollnick, 2002). Mi Has A High Level Of Empirical Support Across A Wide Range Of Suds, With Par- Ticularly Strong Support Among Alcohol-Abusing And -Dependent Populations (Miller & Wilbourne, 2002; Swanson, Pantalon, & Cohen, 1999; Wilk, Jensen, & Havi- Ghurst, 1997) And Good Support For Adolescent Substance Users And Smokers (Heck- Man, Egleston, & Hofmann, 2010; Jensen Et Al., 2011). Although Some Studies Have Suggested The Effectiveness Of Brief Motivational Approaches For Enhancing Engage- Ment And Outcome Among Users Of Illicit Drugs, There Have Been Several Negative Stud- Ies In This Area, Suggesting More Mixed Support For Mi As A Sole Treatment For More Severely Dependent Drug-Using Populations (Budney, Roffman, Stephens, & Walker, 2007; Burke, Arkowitz, & Menchola, 2003; Dunn, Deroo, & Rivara, 2001; Miller, Yahne, & Tonigan, 2003; Rubak, Sandbaek, Lauritzen, & Christensen, 2005). Some Meta-Analyses Also Suggest Larger Effect Sizes Among Members Of Ethnic/Minority Groups (Hettema, Steele, & Miller, 2005). Thus, For Patients Seeking Treatment For Marijuana, Cocaine, Or Alcohol Dependence, Mi Is Typically Used In The Early Phases Of Treatment Or Combined With Another Behavioral (Often Cognitive-Behavioral Therapy [Cbt]) Or Pharmacological Approach For More Severely Dependent Populations. Cognitive‐Behavioral And Skills Training Therapies. As A Next Line Of Treatment For Those Who Do Not Respond To Brief Motivational Approaches, A Reasonable Next Step Would Be Those Approaches That Seek To Improve Skills And Control Over Use. These Approaches May Also Be Useful After More Inten- Sive Approaches (E. G., Inpatient Programs, Detoxification) To Prevent Relapse. 25. Matching And Differential Therapies 537. Cognitive-Behavioral Approaches Have Also Been Demonstrated To Be Compatible With Pharmacotherapies And Are Often Combined With Medication-Assisted Therapies Such As Methadone Or Naltrexone Maintenance. Cognitive-Behavioral Approaches Are Grounded In Social Learning Theories And Principles Of Operant Conditioning. The Defining Features Of These Approaches Are (1) An Emphasis On Functional Analysis Of Drug Use (I. E., Understanding Drug Use Within The Context Of Its Antecedents And Consequences) And (2) Skills Training, Through Which The Individual Learns To Recognize The Situations Or States In Which He Or She Is Most Vulnerable To Drug Use, Avoid Those High-Risk Situations Whenever Possible, And Use A Range Of Behavioral And Cognitive Strategies To Cope Effectively With Those Situa- Tions If They Cannot Be Avoided. Meta-Analyses And Extensive Reviews Of The Literature Have Established That Cognitive-Behavioral Approaches Have Strong Empirical Support For Use In Treatment Of Alcohol Use Disorders And Several Non-Substance-Related Psy- Chiatric Disorders, And That These Approaches Have Been Demonstrated To Be Effective In Drug-Using Populations As Well (Tolin, 2010). Several Research Groups Have Dem- Onstrated The Efficacy Of Cbt In The Treatment Of Cocaine-Dependent Outpatients, Particularly Depressed And More Severely Dependent Cocaine Users, And Have Shown That Cbt Is Compatible And Possibly Has Additive Effects When Combined With Phar- Macotherapies Such As Disulfiram. Furthermore, Cbt Is Characterized By An Emphasis On The Development Of Skills That Not Only Can Be Used Initially To Foster Abstinence But Can Also Be Applied To A Range Of Co-Occurring Problems. This Feature May Be A Factor In Emerging Evidence For The Long-Term Durability Of The Effects Of Cbt. Several Studies Have Demonstrated That Cbt's Effects Are Durable And That Continuing Improvement May Occur Even After The End Of Treatment. These Findings Are Consistent With Evidence That Cbt May Have Enduring Effects For Other Disorders, Such As Panic Disorder And Depression (Hol- Lon, 2003; Tolin, 2010). Delayed Emergence Of The Effects Of Cbt Was Highlighted In Two Studies That Directly Compared Group Cbt And Contingency Management Among Cocaine-Dependent Patients In A Methadone Maintenance Program. Although End-Of- Treatment Outcomes Favored Contingency Management Over Cbt, 1-Year Follow-Up Indicated Significant Continuing Improvement For Patients Assigned To Cbt, In Con- Trast To Weakening Effects For Contingency Management, Which Resulted In Compa- Rable, Or Slightly Better, Outcomes For Cbt At The End Of Follow-Up (Epstein, Hawkins, Covi, Umbricht, & Preston, 2003; Rawson Et Al., 2006). Data Suggest That Acquisi- Tion Of Specific Coping Skills Conveyed Through A Computerized Cbt Program Medi- Ated Continued Improvements In Outcome Through A 6-Month Follow-Up In A Mixed Group Of Substance Users (Kiluk, Nich, Babuscio, & Carroll, 2010). Another Multi- Site Study Involving 450 Marijuana-Dependent Individuals Demonstrated That A Nine- Session Individual Approach That Integrated Cbt And Mi Was More Effective Than A Two-Session Mi Approach, Which In Turn Was More Effective Than A Delayed-Treatment Control Condition (Mtp Research Group, 2004). Despite The Emerging Empirical Support For Use Of Cbt In Drug-Dependent Popu- Lations, Additional Research Is Needed To Address Its Limitations. There Are Few Data On Specific Patient Predictors Of Outcome For Cbt, Although Completion Of Homework Assignments Is Emerging As A Marker Of Better Long-Term Response (Addis & Jacobson, 2000; Bryant, Simons, & Thase, 1999; Burns & Spangler, 2000; Carroll, Nich, &. 538 V. Treatments For Addictions. Ball, 2005; Gonzalez, Schmitz, & Delaume, 2006; Kazantzis, Deane, & Ronan, 2000). In Addition, There Are Several Reports Of Poorer Response To Cbt Among Sub- Stance Users With Higher Levels Of Difficulty In Cognitive Functioning (Aharonovich Et Al., 2006; Aharonovich, Nunes, & Hasin, 2003). Thus, When The Individual Has Problems In Maintaining Attention, And Following And Remembering Explanations And Tasks, Adaptations Of Cbt May Be Needed (Repetition, Simplification On Concepts). Cbt Is Also A Comparatively Complex Approach, And Training Clinicians To Imple- Ment This Approach Effectively Can Be Challenging (Sholomskas Et Al., 2005). Strate- Gies For Addressing These Issues Include Greater Emphasis On Understanding Cbt's Mechanisms Of Action, So That Ineffective Components Can Be Removed, And Treatment Delivery Can Be Simplified, Shortened, And Perhaps Even Accomplished By Computer Or Other Automated Means. Contingency Management Therapies. As A Next-Level Approach For Individuals Who Have More Severe Substance Use Or Social Problems, Contingency Management, In Which Patients Receive Incentives Or Rewards For Meeting Specific Behavioral Goals (E. G., Verified Abstinence), Has Particularly Strong, Consistent, And Robust Empirical Support Across A Range Of Types Of Drug Use. Contingency Management Approaches Are Based On Principles Of Behavioral Pharma- Cology And Operant Conditioning, In Which Behavior That Is Followed By Positive Con- Sequences Is More Likely To Be Repeated. For Example, Allowing A Patient The Privilege Of Taking Home Methadone Doses, Contingent On The Patient's Providing Drug-Free Urine Specimens, Is Associated With Significant Reductions In Illicit Drug Use, And This Strategy Can Be Used Address A Number Of Other Problems, Such As Benzodiazepine Use, That Are Common In Methadone Maintenance Programs. This Body Of Work Also Sup- Ports The View That Positive Incentives (E. G., Rewards For Desired Behaviors) Are More Effective In Producing Improved Substance Use Outcomes And In Retaining Patients In Treatment Than Negative Consequences (E. G., Methadone Dose Reductions, Restriction Of Clinic Privileges, Or Termination Of Treatment). Despite Consistent Findings On The Efficacy Of Contingent Take-Home Privileges In Methadone Maintenance Programs, Contingency Management Procedures Proved Difficult To Implement Outside Of Metha- Done Programs Until The Early 1990S, When Budney, Higgins, And Their Colleagues Demonstrated The Efficacy Of Vouchers Redeemable For Goods And Services, Contingent On The Patient's Providing Cocaine-Free Urine Specimens, In Reducing Targeted Drug Use And Enhancing Retention In Treatment (Higgins, Budney, Bickel, & Hughes, 1993; Higgins Et Al., 1991; Higgins & Silverman, 1999). Voucher-Based Incentives Have Been Shown To Be Effective In Improving Reten- Tion And Abstinence In Outpatient Opioid Detoxification (Chutuape, Silverman, & Stitzer, 1999), In Reducing Illicit Substance Use Among Opioid Addicts In A Methadone Maintenance Program (Stitzer, Iguchi, Kidorf, & Bigelow, 1993), In Reducing The Fre- Quency Of Marijuana Use (Budney, Higgins, Radonovich, & Novy, 2000), And In Improving Medication Compliance Among Opioid-Dependent Individuals Treated With Naltrexone Maintenance (Carroll Et Al., 2001). Iguchi And Colleagues (1996) Expanded Voucher-Based Contingency Management To Outcomes Other Than Drug-Negative Urine Specimens, Demonstrating That Reinforcement Of Tasks Outlined In An Individualized,. 25. Matching And Differential Therapies 539. Verifiable Treatment Plan Was Associated With Greater Reductions In Illicit Drug Use Than Reinforcement Of Drug-Free Urine Specimens. Voucher-Based Contingency Man- Agement Has Also Been Shown To Reduce Cocaine And Opioid Use In The Context Of Methadone Maintenance, Thus Extending The Availability Of Contingency Management Procedures To Methadone Programs In Which The Ability To Offer Take-Home Privi- Leges Is Restricted. Silverman And Colleagues (1998; Silverman, Higgins, Et Al., 1996) Demonstrated The Efficacy Of A Therapeutic Workplace For Pregnant And Postpartum Drug-Abusing Women In A Methadone Maintenance Program. Access To The Therapeu- Tic Workplace, Which Provided Job Training And A Salary, Was Linked To Abstinence And Was Contingent On The Participants' Producing Drug-Free Urine Specimens (Silverman, Chutuape, Bigelow, & Stitzer, 1996; Silverman, Svikis, Robles, Stitzer, & Bigelow, 2001; Silverman Et Al., 2002). Despite These Findings, Questions Have Arisen Regarding The Applicability And Sus- Tainability Of Contingency Management In Clinical Practice, Especially In Community- Based Treatment Programs In Which The Cost Of The Vouchers And The Need For Frequent Urine Monitoring Can Be Prohibitive. These Issues Have Been Addressed In Part By The Work Of Petry Et Al., Who Developed A Lower-Cost Contingency Management Procedure In Which Vouchers Are Not Given But Participants Receive The Opportunity To Draw Prizes Of Varying Value, Contingent On Verifiable Target Behaviors Such As Provision Of Drug-Free Urine Specimens (Petry, 2000; Petry, Alessi, Marx, Austin, & Tardif, 2005; Petry Et Al., 2004). This Approach Has Been Effective In Reducing Drug Use Among Both Methadone Maintenance Patients And Cocaine-Dependent Outpatients (Petry, Kolod- Ner, Et Al., 2006; Petry, Peirce, Et Al., 2006). Although The Consistent Findings Of Effectiveness In Contingency Management Interventions Are Compelling, Some Limitations Have Been Noted. First, The Effects Tend To Weaken After The Contingencies Are Terminated. This Problem Might Be Addressed By Evaluating Combinations Of Contingency Management With Approaches That Have More Enduring Effects, For Example, By Transferring Rewards From Monetary Reinforc- Ers To Behaviors That, In And Of Themselves, Are Reinforcing, Or By Exploring Novel Discontinuation Strategies, Such As Lengthening Periods Between Reinforcement Or Offering More Intermittent Reinforcements. Also, Because A Substantial Proportion Of Substance Users Do Not Respond To Contingency Management, There Is A Need To Under- Stand And Address Individual Differences In Response To These Approaches. In General, Contingency Management Appears To Be Effective For Individuals With A Wide Range Of Demographic Characteristics (Race, Education, Employment Status); For More Severely Dependent Individuals, Higher Levels Of Rewards May Be Necessary To Achieve Good Outcomes (Barry, Sullivan, & Petry, 2009; Rash, Alessi, & Petry, 2008A, 2008B). Couple And Family Treatments. A Final Class Of Empirically Validated Therapies That Can Be Applied In A Large Range Of Settings Includes Couple And Family Treatments, Described In More Detail By Kaufman (Chapter 29, This Volume). The Defining Feature Of Family And Couple Treatments Is That They Treat Drug-Using Individuals In The Context Of Family And Social Systems In Which Substance Use May Develop Or Be Maintained. The Engagement Of The Indi- Vidual's Social Networks In Treatment Can Be A Powerful Predictor Of Change; Thus, The. 540 V. Treatments For Addictions. Inclusion Of Family Members In Treatment May Be Helpful In Reducing Attrition (Par- Ticularly Among Adolescents) And Addressing Multiple Problem Areas. Meta-Analyses Have Strongly Supported The Efficacy Of These Approaches For Both Adult And Ado- Lescent Substance Users (Baldwin, Christian, Berkeljon, & Shadish, 2012; Stanton & Shadish, 1997). It Is Important To Note That Family-Based Approaches Are Quite Diverse, And It Is Unlikely That All Are Equally Effective. Moreover, Many Family-Based Approaches Combine A Variety Of Techniques, Including Family And Individual Thera- Pies, Skills Training, And Communication Training. Behavioral Couple Therapy And Behavioral Family Counseling Combine Absti- Nence Contracts And Behavioral Principles To Reinforce Abstinence From Drugs; These Approaches Require The Participation Of A Non-Substance-Abusing Spouse Or Cohabi- Tating Partner (O'farrell & Fals-Stewart, 2006). Several Family Therapies Have Been Demonstrated To Be Effective Among Drug-Using Adolescents. Azrin's Family Behav- Ior Therapy, Which Combines Behavioral Contracting With Contingency Management, Was Found To Be More Effective Than Supportive Counseling In A Series Of Compari- Sons Involving Adolescents With Suds, With And Without Conduct Disorder (Azrin Et Al., 1996). Multisystemic Therapy, A Manual-Based Approach That Addresses Mul- Tiple Determinants Of Drug Use And Antisocial Behavior And Is Intended To Promote Fuller Family Involvement By Engaging Family Members As Collaborators In Treatment, Emphasizes The Strengths Of Youth And Their Families, And Addresses A Broad And Comprehensive Array Of Barriers To Attaining Treatment Goals (Henggeler Et Al., 2008; Henggeler, Melton, Brondino, Scherer, & Hanley, 1997; Henggeler, Pickrel, Bron- Dino, & Crouch, 1996). Henggeler And Colleagues Have Demonstrated The Efficacy And Durability Of Multisystemic Therapy In Retaining Patients And Broadly Improving Outcomes Among Substance-Using Juvenile Offenders, Compared With Similar Juvenile Offenders Who Received The Usual Community Treatment Services. Brief Strategic Family Therapy Has Also Received A Substantial Level Of Empirical Support. In Contrast To The Other Family Therapies For Adolescents Reviewed Here, Brief Strategic Family Therapy Is Somewhat Less Intensive, As It Targets Fewer Systems And Can Be Delivered Through Once-Weekly Office Visits. Brief Strategic Family Therapy Has Been Associated With Improved Retention, As Well As Significant Reductions In The Frequency Of Externalizing Behaviors (E. G., Aggression, Delinquency) (Robbins Et Al., 2011; Santisteban Et Al., 2003; Szapocznik & Williams, 2000). Multidimensional Family Therapy (Mft) Is A Multicomponent, Staged Family Therapy That Incorporates Both Individual And Family Formats, And Targets The Substance-Using Youth, The Family Members, And Their Inter- Actions. Liddle And Colleagues (2001) Demonstrated That Mft Is More Effective Than Group Therapy Or Multifamily Education Among Substance-Using Adolescents Referred To Treatment By The Criminal Justice System Or By Schools. Conclusions. Recent Years Have Been Marked By Enormous Progress In The Identification Of A Wide Range Of Empirically Validated Pharmacological And Behavioral Therapies For Suds. Important New Treatment Options, Such As Naltrexone And Acamprosate For Alcohol Use Disorders, And Buprenorphine For Opioid Dependence, Were Unavailable 25 Years. 25. Matching And Differential Therapies 541. Ago, As Were Behavioral Therapies Including Contingency Management, Behavioral Marital Counseling, Mi, And Cbt, All Of Which Have Demonstrated Efficacy Across A Range Of Suds And Populations. Equally Promising Are Results Demonstrating That Combining Pharmacotherapies With Behavioral Therapies Can Extend, Strengthen, And Make Treatment Effects More Durable. Increasing Attention To Adaptive Therapies (Murphy, Collins, & Rush, 2007), As Well As The Promise Of Developing Treatment- Matching Algorithms Based On Markers Such As Genetic Or Cognitive Characteristics (Kranzler & Mckay, 2012; Ray & Hutchison, 2007) May Result In More Effective, Personalized Treatments (Mcmahon & Insel, 2012). Nevertheless, The Recent Progress In The Identification Of Efficacious Therapies Has Not Been Matched By Identification Of Moderating Variables Or Consistent Patient Predictors Of Response To Specific Treatment Approaches That Can Guide Researchers' And Clinicians' Efforts To Match Individuals To Optimal Treatment Strategies. Identification Of Moderators Of Response To Efficacious Therapies, As Well As Identification Of The Specific Mechanisms By Which Those Treat- Ments Achieve Their Effects, Should Be A Primary Focus Among Clinical Researchers In The Years That Lie Ahead.

What are co-occuring disorders (COD)?

COD are the presence of both a substance use disorder (SUD) and serious mental illness (SMI) occurring simultaneously. The individual is experiencing both psychiatric symptoms and substance-induced symptoms: vPsychiatric symptoms ◦Those resulting from SMI (anxiety, depression, loss of interest, sleep disturbance, weight fluctuation, etc.) vSubstance-induced symptoms ◦Those resulting from substance intoxication or withdrawal (irritability, restlessness, hallucinations, hyperactivity, anxiety, sleep disturbance, etc.) Treating a COD is more challenging than treating either disorder alone.

No desire to change, change, ambivalence

Change is a process, not an instantaneous event. Thus, we all go through similar stages starting with not wanting to change, then feeling ambivalent about change, and finally, changing. Some people get stuck in the ambivalent stage. This is where MI can be most helpful.

Collegiate Prevention Efforts

Changing the drug and alcohol culture of college campuses will take effort from students, college administration, and the surrounding community. Bars make considerable profits around colleges, thus drawing more bars to college towns. Some colleges try psychoeducation programs in which they teach students about potential risks of drugs and alcohol abuse. For example, teaching college students about the rising potency of THC in marijuana and resulting mental health risks. Some colleges have developed alcohol/drug-free locations on campus (including dorms and tailgate locations), as well as Collegiate Recovery Communities/ Programs (*see videos in module for examples.) Some colleges have tried campus-wide awareness campaigns to change misperceptions about substance use. For example, correcting misperceptions. Most college students assume their peers are using much more drugs/alcohol than they actually are. Research tells us that if college students are taught effective coping strategies to manage distress, substance use declines.

When Clients are in action, Counselors will:

Come up with rewards for making changes (e.g., 12-step programs use chips to mark periods of time in recovery). Make substitutions for problematic behavior. Now that substances are gone, what can the client replace them with (positive coping strategies)? Help clients build and invest in a support system. Identify high-risk situations and triggers for relapse and create plans to avoid them.

Example 2: An MI Approach

Counselor: I hear you describing a lot of problems caused by drinking. Client: Yah, I guess it isn't the best way to deal with things, but it gets me through the day. Counselor: In some ways alcohol gives you something, and at the same time, it doesn't seem like the best strategy. Client: Yah, like it helps temporarily, but probably not long-term. Counselor: In the moment, your drinking seems to solve the problem, but when that wears off, you are left with the same issues. Client; Right. Like it is just a quick fix. Counselor: There is a part of you that is dissatisfied with quick fixes. After this exchange, the client is more likely to change. What makes it different from the previous slide?

Example 1: The Opposite of MI

Counselor: It sounds like your drinking is really causing a lot of problems in your life. Client: Yah, I guess it isn't the best way to deal with things, but it gets me through the day. Counselor: You want to feel better. There are lots of positive ways to do that rather than turning to alcohol. Client: I'm sure there are, but this is what works for me right now. It is the only way I can relax and forget about all these problems. Counselor: Even though drinking is causing you a lot of physical harm and relational problems? Client: It's my boss and my wife that are causing my problems.... After this exchange, the client is less likely to change.

Intoxication, Withdrawl or mental illness

Counselors must assess whether the symptom a client is experiencing is due to substances, mental illness, or both. Remember, substance intoxication and withdrawal can mimic mental health symptoms. ◦Consider a client who reports experiencing hallucinations. ◦It could be the result of intoxication on a hallucinogen (like LSD), a stimulant (like cocaine or meth), or a synthetic drug (like bath salts or spice). ◦It could be the result of alcohol withdrawal. ◦It could be the result of schizophrenia or another mental illness (depression, bipolar) with psychotic features. It is important to assess and take a thorough history of mental illness symptoms and substance use patterns to identify the cause.

Chapter 15

Co‐Occurring Substance Use Disorders And Other Psychiatric Disorders Benjamin C. Silverman Lisa M. Najavits Roger D. Weiss Determining Better Ways To Identify And Treat Individuals With Co-Occurring Sub- Stance Use Disorders (Suds) And Other Psychiatric Disorders Has Become Increasingly Important From Clinical, Research, And Policy Perspectives. Several Observations Have Driven This Imperative: (1) Co-Occurring Suds With Other Psychiatric Disorders Are Prevalent (Conway, Compton, Stinson, & Grant, 2006; Kessler Et Al., 1996; Regier Et Al., 1990; Swendsen Et Al., 2010) And Associated With Worse Clinical And Functional Outcomes Than Either Suds Or Other Psychiatric Disorders Alone (Hser Et Al., 2006; Mueller Et Al., 1994; Ritsher Et Al., 2002); (2) Many People With These Co-Occurring Disorders Do Not Receive Adequate Treatment (Substance Abuse And Mental Health Services Administration [Samhsa], 2002); And (3) Compared To Psychiatric Patients Without Co-Occurring Suds, Patients With Co-Occurring Disorders Tend To Use More Costly Treatments Such As Emergency And Hospital Care (Dickey & Azeni, 1996; Mark, 2003). Together, These Observations Have Led To The Development Of Specific New Treat- Ments Designed Or Adapted For This Population. Within Sud Populations, Multiple Suds Are Common (Conway Et Al., 2006; Kessler Et Al., 1997; Regier Et Al., 1990; Swendsen Et Al., 2010). While These Indi- Viduals Also May Be Considered "Dually Diagnosed," This Chapter Focuses Exclusively On Patients Who Have An Sud Plus A Non-Sud Co-Occurring Psychiatric Disorder. We Refer To Non-Sud Psychiatric Disorders Simply As "Psychiatric Disorders" To Dis- Tinguish Them From Suds. Additionally, This Chapter Excludes Co-Occurring Nicotine Dependence And Psychiatric Disorders, A Topic That Is Important And Broad Enough To Require Independent Attention (Ziedonis Et Al., 2008; See Chapter 6, This Volume). In This Chapter, We Review Psychosocial And Psychopharmacological Treatments For Patients With Co-Occurring Suds And Other Psychiatric Disorders. Epidemiology Studies In Sud And Psychiatric Treatment-Seeking Populations (Mclellan & Druley, 1977; Ross Et Al., 1988) Have Suggested High Prevalence Rates Of Co-Occurring Suds And Psychiatric Disorders. However, Treatment-Seeking Samples May Not Be Represen- Tative Of Community Populations, Since They Tend To Have Higher Rates Of Comorbidity And May Have More Severe Manifestations Of The Disorder For Which They Are Seeking Treatment. Thus, Epidemiological Studies Of Prevalence Rates In Community Popula- Tions Are Important In Assessing The True Comorbidity Prevalence Rate. The National Epidemiologic Survey On Alcohol And Related Conditions (Nesarc) Is The Largest And Most Recent Study To Date That Examines The Epidemiol- Ogy Of Suds And Co-Occurring Psychiatric Disorders In A Community Sample. Con- Ducted In 2001-2002, With A Follow-Up Reinterview Wave Carried Out In 2004-2005, Nesarc Specifically Sought Out Data On Co-Occurring Conditions, Asking Questions About Alcohol, Tobacco, And Other Substance Use, Along With Inquiries On Psychiatric/ Psychological Disorders, Family History And Medical Conditions, And Gambling, Among Others. Data Were Collected From Randomly Selected Individuals Based On Household Data From The 2000 Census, With An 81% Response Rate. Nesarc Results Demon- Strate That Suds And Psychiatric Disorders Are Commonly Co-Occurring In Community Populations (Compton Et Al., 2007; Hasin Et Al., 2007; Hasin & Kilcoyne, 2012). When Adjusted For Other Sociodemographic Factors, Lifetime Alcohol Use Disorder Was Significantly Associated With Mood Disorders (Odds Ratio [Or] = 2.4), Anxiety Dis- Orders (Or = 2.3), And Personality Disorders (Or = 2.8). Likewise, 12-Month And Lifetime Drug Use Disorders Were Significantly Associated With Alcohol Use Disorders, Nicotine Dependence, And Mood, Anxiety, And Personality Disorders (Ors = 2.2-9.0). The Two Previous Major Psychiatric Epidemiological Studies, The Epidemiologic Catchment Area (Eca) Study (Regier Et Al., 1990) And The National Comorbidity Study (Ncs), Carried Out From 1990 To 1992 (Kessler Et Al., 1996), Similarly Demon- Strate That Co-Occurring Suds And Psychiatric Disorders Are Prevalent In Community Populations. Methodological Advancements Of The Ncs Included An Expanded Scope Of The Community Sample (E. G., The Eca Sampled From Within Five U. S. Communities; The Ncs Sampled Nationally Representative Households) And An Advanced Version Of The Diagnostic And Statistical Manual Of Mental Disorders (I. E., Dsm-Iii-R; Ameri- Can Psychiatric Association, 1987). Also, While Both Studies Surveyed Most Of The More Common Psychiatric Disorders, The Eca Did Not Include Posttraumatic Stress Disorder (Ptsd), Whereas The Ncs Did. Neither Epidemiological Survey Included Axis Ii Disorders Other Than Antisocial Personality Disorder. Despite These Limitations And Differences Between The Two Studies, Their Results Were Often Qualitatively Similar, Although The Magnitude Of Their Estimates Differed Somewhat At Times. Among Per- Sons With Psychiatric Disorders, The Eca Estimated That 30% Had A Co-Occurring Sud. The Prevalence Varied By Diagnosis, However; Co-Occurring Suds Were Most Common In Individuals With Antisocial Personality Disorder, Followed By Those With Bipolar I Disorder. In Sud Populations, The Eca And Ncs Estimated That Over Half Would Experience Psychiatric Disorders In Their Lifetime. These Lifetime Estimates Do Not Merely Reflect Rare Or Historical Periods In An Individual's History; The 12-Month Comorbidity Prevalence Rate Of These Disorders Was Also Quite High. For Example, The Ncs Estimated That Over 33% Of Those With Bipolar Disorder Experienced An Sud Within 12 Months, Followed By Nearly 20% Of Those With Major Depression And 15% Of Those With An Anxiety Disorder. From 2001 To 2003, A Substantial Portion (87.6%) Of The Ncs Study Population Was Reinterviewed In The National Comorbidity Sur- Vey-2 (Ncs-2; Swendsen Et Al., 2010), Allowing For Updated Diagnostic Assessments (I. E., Based On Dsm-Iv-Tr; American Psychiatric Association, 2000) And Demon- Strating Significant Prospective Risks Posed By Baseline Mental Disorders For The Onset Of Suds In The Follow-Up Time Frame. In Australia, The 2007 National Survey Of Mental Health And Wellbeing (Nsmhwb) Revealed Similarly High Rates Of Comorbidity Compared To The U. S. Surveys, With 25.4% Of Individuals With An Anxiety, Affective, Or Suds Having At Least One Other Class Of Disorder (Teesson, Slade, & Mills, 2009). In Particular, The Nsmhwb Estimated That Individuals With An Alcohol Use Disorder Were More Than Twice As Likely To Have An Anxiety Disorder And Were 4.5 Times More Likely To Have Any Mental Disorder Compared To The Rest Of The Sample (Teesson Et Al., 2010). The Relationship Between Substance Abuse And Psychopathology While Determining Which Disorder Is Primary In Patients With Co-Occurring Suds And Psychiatric Disorders Can Be Useful In Clinical Research, It May Provide Little Ben- Efit In The Clinical Management Of These Patients. Patients With Two Disorders Typically Require Treatment For Both. In Patients With Co-Occurring Cannabis Dependence And Psychosis, For Example, It Is Interesting Scientifically To Consider Whether Cannabis Use Led To The Development Or Earlier Onset Of Psychotic Illness Or Vice Versa (Moore Et Al., 2007), But Clinically, Patients Require Both Sud And Psychiatric Treatment To Be Helped Most Effectively. On The Other Hand, The Exception Is Patients Who Present With Temporary Psychiatric Symptoms Caused By The Substance Use Or Its Withdrawal, Which Resolve With Treatment; An Example Of This Would Be Psychosis Induced By Methamphetamine Use (Grelotti, Kanayama, & Pope, 2010). Meyer (1986) Offered A Now-Classic Framework To Consider Six Possible Ways In Which Sud And Other Psychopathology May Be Related: 1. Psychopathology May Be A Risk Factor For Suds. As Described Previously, Stud- Ies Of Patient And Community Samples Indicate That The Risk Of Having A Co-Occurring Sud Is Elevated In Persons With Psychiatric Disorders. For Example, Dopaminergic Dysfunction In Patients With Schizophrenia Has Been Hypothesized To Increase Their Risk Of Suds—Particularly Cocaine Use Disorders (Green Et Al., 1999; Smelson Et Al., 2002B). Another Theory, Widely Known As The "Self-Medication Hypothesis" (Khant- Zian, 1989, 1997; Khantzian & Albanese, 2008), Suggests That Psychopathology Leads Patients To Use Substances In An Attempt To Decrease Unwanted Psychiatric Symptoms. For Example, A Patient With Insomnia Due To Ptsd Nightmares May Use Alcohol Or Marijuana To Induce Sleep. Although Research Has Not Found Direct Connections Between Particular Psychopathological Symptoms And Specific Substances (Rather, Patients Tend To Misuse A Wide Variety Of Substances To "Treat" A Range Of Symptoms), The General Principle Is An Important One. It Is Discussed In More Detail In The Next Item. 2. Psychiatric Disorders And Co-Occurring Suds May Serve To Modify The Course Of Each Other In Terms Of Symptomatology, Rapidity Of Onset, And Response To Treat- Ment. Also, As We Described More Below, There Is Considerable Evidence That Comor- Bidity Is Associated With Worse Outcomes. For Example, There Is Evidence That Patients With Schizophrenia And Co-Occurring Suds Do Not Respond As Well To Similar Doses Of First-Generation Antipsychotic Medications As Those Without Suds (Bowers Et Al., 1990). 3. Psychiatric Symptoms May Result From Chronic Intoxication. Drug And Alco- Hol Use Can Result In A Variety Of Psychiatric Symptoms, Such As Depression, Anxiety, Euphoria, Psychosis, And Dissociative States. Most Such Symptoms Disappear, How- Ever, Within Hours (E. G., Cocaine-Induced Paranoia; Satel Et Al., 1991) To Weeks (E. G., Alcohol-Induced Anxiety Or Depression; Brown Et Al., 1991; Brown & Schuckit, 1988). 4. Long-Term Substance Use Can Lead To Psychiatric Disorders That May Not Remit. Alcohol-Induced, Long-Term Cognitive Changes, Such As Those Seen In Alcohol- Induced Persisting Dementia, Exemplify One Way In Which Chronic Use Of A Substance Can Create Enduring Change. 5. Substance Abuse And Psychopathological Symptoms May Be Meaningfully Linked. Some Individuals May Use Alcohol Or Drugs In Ways That Enhance Their Psychi- Atric Symptoms. For Example, Patients With Antisocial Personality Disorder Who Seek Disinhibition And Aggression May Use Alcohol Or Cocaine, And Patients With Bipolar Disorder May Use Cocaine Or Other Stimulants To Augment A Euphoric Mood (Weiss Et Al., 1986, 1988). 6. The Sud And Psychiatric Disorder May Be Unrelated. The Presence Of Two Dis- Orders Within An Individual Does Not Imply A Causal Link. For Example, Both Alcohol Dependence And Depressive Disorders Are Common In The General Population; Many People With Both Disorders Are Not Depressed Because They Drink, Nor Do They Drink Because They Are Depressed. As Another Example, Brunette Et Al. (1997) Studied The Relationship Between Severity Of Substance Abuse And Severity Of Schizophrenic Symp- Toms In Patients Diagnosed With Both Disorders, And Found Weak Relationships And No Consistent Patterns Of Relationships Between The Two Sets Of Symptoms. The "Self‐Medication Hypothesis" One Potential Explanation For The Increased Prevalence Rate Of Co-Occurring Suds Among Patients With Psychiatric Disorders Has Been The "Self-Medication Hypothesis" (Khantzian, 1985, 1997; Khantzian & Albanese, 2008), Which Postulates That Cer- Tain Drugs May Be Particularly Reinforcing For Particular Patients Because Of Their Specific Psychopathology. Two Fundamental Assumptions Underlie This Hypothesis: First, That Substances Are Abused To Relieve Psychological Pain, Not Just To Create Euphoria; And Second, That There Is Specificity Between Patients' "Drug Of Choice" And The Particular Intolerable Emo- Tions Or Symptoms That They Are Attempting To Alleviate. For Example, Patients With Social Anxiety May Be Drawn To Alcohol To Decrease Their Symptoms, While Patients Who Are Prone To Violence And Anger Outbursts May Prefer The Calming Effects Of Opioids To The Potentially Disinhibiting Effects Of Alcohol. Another Recently Discussed Example Might Be The High Prevalence Of Nicotine Use In Patients With Schizophrenia, Who Might Be Drawn To Smoking Cigarettes (Due To Biological Predispositions Based On Alterations In Nicotinic Acetylcholine Receptors) As A Way To Modulate Antipsychotic Medication Side Effects Or To Self-Medicate Negative Symptoms And Cognitive Deficits (Dalack Et Al., 1998; Winterer, 2010). A Major Criticism Of The Self-Medication Hypothesis Has Been Its Heavy Reliance On Anecdotal Data From Patients In Psychotherapy And The Relative Paucity Of Empiri- Cal Studies Testing It (Aharonovich Et Al., 2001). Additionally, Intoxicants May Pro- Duce Very Different Effects Acutely Compared To The Effects Of Chronic Administra- Tion. Studies Of Individuals With Heroin (Meyer & Mirin, 1979), Cocaine (Post Et Al., 1974), And Alcohol (Mendelson & Mello, 1966) Use Disorders Have Indicated A Dichotomy Between The Acute Effects Of These Drugs In Producing Euphoria Or Tension Relief And The Chronic Or High-Dose Effects In Producing Dysphoria. Several Research- Ers Have Sought To Test Empirically The Self-Medication Hypothesis In Larger Samples. The Results Have Tended Not To Support The Specificity Of Using A Particular Addictive Substance To Alleviate Specific Psychopathology Or Mood States (Aharonovich Et Al., 2001; Weiss, Griffin, Et Al., 1992). However, While Not Necessarily A Validation Of The Theory That Patients Use Addictive Substances To Alleviate Certain Mood States, There Is Evidence That Treating A Co-Occurring Psychiatric Disorder (Cornelius Et Al., 1997; Greenfield Et Al., 1998) And Remission Of Its Symptoms (Hasin Et Al., 1996) Can Improve Sud Outcomes. Other Theories Weiss (1992) Suggests Three Additional Mechanisms By Which Psychopathology Can Make An Individual More Vulnerable To Suds. 1. Psychopathology May Interfere With An Individual's Judgment Or Ability To Appreciate Consequences. Individuals With Psychiatric Disorders May Be More Vul- Nerable To Suds, Because The Impaired Judgment That Is Often Present In Many Psy- Chiatric Syndromes Can Interfere With One's Ability Or Willingness To Understand Or Change One's Behavior. For Example, Severely Depressed Patients May Have Insight Regarding The Destructive Effect Of Their Drinking But Continue To Drink Due To The Pes- Simism About The Possibility And Value Of Change That Is Part Of Their Depressive Dis- Order. Similarly, The Recklessness, Irritability, And Grandiosity Of Patients With Mania Or Hypomania May Interfere With Their Capacity To Appreciate The Harmful Nature Of Their Substance Use. 2. Psychopathology May Accelerate The Process Of Substance Dependence By Leading To More Dysphoria Either During Chronic Use Or Early Abstinence. It Is Possible That Patients With Underlying Psychopathology May Experience More Dysphoria From Chronic Substance Use Or More Severe Withdrawal Symptoms When Discontinuing Drugs Or Alcohol. Although This Potential Mechanism Has Received Little Study, There Is Some Evidence That Cocaine Abusers With Major Depressive Disorder May Report More Severe Mood Symptoms During Abstinence Compared To Cocaine Abusers Without Depression (Gawin & Kleber, 1986). 3. Psychopathology May Reinforce The Social Context Of Drug Use. Some Patients With Severe Psychiatric Illness May Be Drawn To A Drug-Using Subculture Because They Feel It Facilitates Socialization Or A New Peer Group. For Example, Some Patients With Schizophrenia Have Described Using Substances To Socialize Or Be Accepted By Peers, Even Though Substances Increased The Risk Of Psychosis (Drake Et Al., 1989; Spencer Et Al., 2002). Thus, Multiple Possible Motivations And Causes Contribute To The Initiation And Maintenance Of Problematic Alcohol And Drug Use In Patients With Psychiatric Disor- Ders. Diagnosing Psychiatric Disorders In Patients With Suds The Task Of Determining Whether A Patient Is Suffering From A Substance-Induced Disorder Or An Independent Psychiatric Disorder Can Be Complicated And Has Not Been Well-Studied (Morojele Et Al., 2012; Torrens Et Al., 2011). Substances Of Abuse Can Cause A Wide Range Of Psychiatric Symptoms. Clinicians Evaluating Such Patients Need To Determine Whether The Disturbance Is Independent Of Substance Use Or Related To Intoxication Or Withdrawal. For Example, When Examining A Patient Who Has A Long History Of Alcohol Dependence And Depressive Symptoms, It Can Be Difficult To Deter- Mine Whether The Depressive Symptoms Result From The Direct Pharmacological Effects Of Alcohol, The Many Losses Experienced As A Result Of The Alcohol Use, Feelings Of Dis- Couragement About The Inability To Stop Drinking, Or An Independent Mood Disorder. Other Etiologies, Such As Metabolic Disturbances, Head Trauma, And Personality Dis- Orders, Must Also Be Considered In The Differential Diagnosis Of Depressive Symptoms In Alcohol-Dependent Patients (Jaffe & Ciraulo, 1986). In A Recent Study, Torrens Et Al. (2011) Compared Risk Factors For Substance-Induced Versus Independent Psychiatric Disorders In A Population With Co-Occurring Suds And Psychiatric Disorders. They Found That Mood And Anxiety Disorders Were More Likely To Be Independent. Subjects Recruited From Nontreatment Setting Were More Likely To Have Substance-Induced Dis- Orders Than Were Subjects Recruited From A Treatment Setting (Or = 3.5). Given These Considerations, One Could Ideally Establish Diagnostic Rules To Assist In Determining Whether A Psychiatric Syndrome Is Due To Substance Use Or Represents A Separate And Independent Disorder. For Example, Some Clinicians May Establish A Rule That A Patient Must Be Abstinent From Alcohol And Drugs For At Least 4 Weeks Before One Can Make A Diagnosis. Unfortunately, One Does Not Always Have The Luxury Of Observing Such Lengthy Abstinent Periods (Either By Historical Report Or In The Pres- Ent) In Which To Assess This. In Such Circumstances, Guidelines, As Opposed To Strict Rules, Can Be Helpful. For Example, Several Studies Have Observed That For Alcohol- Dependent Patients With Major Depressive Disorder, Treating The Depression Can Have A Positive Impact On Drinking (Cornelius Et Al., 1997; Greenfield Et Al., 1998). Thus, While Dsm-5 (American Psychiatric Association, 2013) Criteria For Substance- Induced Depressive Disorder Suggest At Least 4 Weeks Of Symptom Persistence During Abstinence Before A Clinician Can Diagnose An Independent Depressive Disorder, It Also Notes That Clinicians Can Diagnose An Independent Disorder If Other Convincing Factors Are In Place (E. G., A History Of Recurrent Non-Substance/Medication-Related Episodes Or Symptoms That Preexisted Before Onset Of Substance Use). Certain Disorders, Such As Eating Disorders And Ptsd, Can Be Diagnosed Readily, Even In The Context Of Substance Use Or Withdrawal, Since Their Symptoms Do Not Closely Resemble Substance-Related Syndromes. Indeed, For A Diagnosis Such As Ptsd, Which Tends To Be Underdiagnosed In Patients With Suds, The Greater Danger Is To Delay Diagnosis; Waiting For A Period Of Abstinence May Prevent Needed Treatment For The Co-Occurring Disorder (Najavits, 2004). Finally, Clinicians Should Consider Whether The Patient's Symptoms Are What Would Be Expected Upon Discontinuation Of The Abused Substance. If There Is Consider- Able Overlap Between The Observed Symptoms And What One Would Expect From The Drug Discontinuation Syndrome, Then The Clinician Should Wait Until (1) The Symp- Toms Resolve, Or (2) No Longer Are Consistent With What Would Be Expected With Drug Cessation (I. E., The Syndrome One Would Expect To See After 1 Week Versus 1 Month Of Alcohol Abstinence). Alternatively, If There Is Little Overlap Between The Symptoms Observed And The Expected Abstinence Syndrome (E. G., Bulimia Nervosa In An Opioid- Dependent Patient), Then The Diagnosis Can Be Made Without Waiting For An Extended Abstinent Period. Diagnosing Suds In Patients Seeking Treatment For Psychiatric Disorders Co-Occurring Suds Are Often Overlooked In Patients Seeking Treatment For Psychi- Atric Disorders. The First Step In The Accurate Diagnosis Of Suds Is Systematically To Ask The Patient About The Presence Of Substance Use. Structured Clinical Assess- Ments Have Been Demonstrated To Improve Detection Of Suds Compared To Routine Assessment In Outpatient Severe And Persistently Mentally Ill (Spmi; Breakey Et Al., 1998) And Inpatient (Albanese Et Al., 1994) Populations; They Have Also Outperformed Urine Toxicology Testing (Albanese Et Al., 1994). Unfortunately, The Increasing Acu- Ity Of Patients On Inpatient Units And The Demanding Time Constraints Of Outpatient Psychiatric Practice (Woodward Et Al., 1991) May Pose Challenges To The Systematic Assessment Of Suds. In One Outpatient Study, Combining Multiple Standardized Clini- Cal Instruments Improved Rates Of Detection But Raised Similar Concerns About Time Constraints Of Routine Clinical Work And Resultant Underdetection (Wusthoff Et Al., 2011). In Another Outpatient Study, Adding The Four-Item Cage (Cut Down, Annoyed, Guilty, Eye-Opener) Questionnaire (Ewing, 1984) Improved The Sensitivity Of Detect- Ing Suds From 62 To 97% In An Spmi Population (Breakey Et Al., 1998). However, Self-Report Alone, Without Urine Toxicology, Can Also Lead To Underdetection Of Sub- Stance Use (Claassen Et Al., 1997). Finally, Contingencies Play An Important Role In Patients' Willingness To Self- Report Substance Use. If Patients Are Repeatedly Encouraged To Be Honest In Their Self- Reports, And If They Are Told (And More Importantly, If They Believe) That There Will Be No Negative Consequences Of Reporting Use (E. G., Being Discharged From A Treatment Program Or Reported To A Probation Officer Or Employer), Then They Are More Likely To Be Forthcoming In Reporting Their Use. If, However, They Are Concerned That There Will Be Negative Consequences, Then They Are Less Likely To Do So. Thus, Self-Reports Of Use In An Emergency Department, Where A Patient Is Unlikely To Know The Clinician And Will Probably Not Believe (Whether It Is True Or Not) That There Will Be No Negative Consequences For Disclosing Use, Are Likely To Be Suspect. However, In An Outpatient Treatment Setting, In Which A Patient Has An Opportunity To Build A Relationship With A Clinician Or Treatment Team, And Perhaps Sees Other Patients Self-Disclosing And Bene- Fiting From That Disclosure, Self-Reports Are Likely To Be More Valid (Weiss Et Al., 1998). Treatment Of Patients With Co‐Occurring Suds And Other Psychiatric Disorders Association Between Co‐Occurring Disorders And Treatment Outcome In Both Sud And Psychiatric Treatment-Seeking Populations, Patients With Co- Occurring Suds And Psychiatric Disorders Typically Experience Worse Outcomes Than Their "Singly Diagnosed" Peers (Ritsher Et Al., 2002; Schaar & Oejehagen, 2001; Najavits Et Al., 2007). However, There Are Specific Populations In Which The Evidence Is Mixed, Such As Populations With Spmi (Farris Et Al., 2003; Gonzalez & Rosen- Heck, 2002) And Antisocial Personality Disorder (Cacciola Et Al., 1995; Kranzler Et Al., 1996). The Effect Of Other Psychiatric Disorders On Sud Outcomes May Vary By Sud Type. For Example, Whereas Co-Occurring Major Depression Appears To Predict Worse Alcohol Outcomes (Brown Et Al., 1998; Greenfield Et Al., 1998), There Is Less Evidence For Its Predicting Worse Cocaine Outcomes (Mckay Et Al., 2002; Rohsenow Et Al., 2002). There Is Also Evidence (Albeit Somewhat Inconsistent) That Gender May Play A Role In Mediating The Effect Of Co-Occurring Psychiatric Disorders On Sud Outcome. Major Depression In Men Has Been Associated With Worse Sud Outcome (Compton Et Al., 2003; Rounsaville Et Al., 1987), Although This Is Not A Consistent Finding (Kranzler Et Al., 1996; Powell Et Al., 1992). In Contrast, Some Studies Suggest That Female Gen- Der Has Been Associated With Similar Or Better Sud Outcomes Among Patients With Co-Occurring Psychiatric Disorders (Compton Et Al., 2003; Rounsaville Et Al., 1987), Except For Phobia, Which Was Associated In One Study With Worse Sud Outcome In Women (Compton Et Al., 2003). Finally, Whereas Antisocial Personality Disorder In Men Has Been Associated With Worse Outcomes (Compton Et Al., 2003; Kranzler Et Al., 1996), The Evidence In Women Has Been Mixed (Compton Et Al., 2003; Rounsaville Et Al., 1987). A Heterogeneous Population Since Patients With Co-Occurring Disorders Comprise A Heterogeneous Population, It Follows That Their Treatment Should Perhaps Reflect That Heterogeneity (Weiss, Mirin, Et Al., 1992); A "One Size Fits All" Approach Therefore Will Likely Not Be Optimal. How- Ever, Providing Group Treatments Tailored To Patients With Some Degree Of Diagnostic Homogeneity (E. G., Patients With Bipolar Disorder And Suds) Can Be A Difficult Strat- Egy To Implement If One Is Unable To Recruit A Large Enough Clinical Population For These Groups. Similarly, Even Within Diagnostically Homogeneous Groups, Consider- Able Heterogeneity In Illness Severity And Functioning May Still Exist. Ries Et Al. (1997) Have Suggested A Conceptual Approach That Divides Patients With Co-Occurring Suds And Psychiatric Disorders Into Four Major Subgroups, According To The Severity (I. E., Major Or Minor) Of Each Disorder. Although This Is A Somewhat Crude Way To Classify Patients, It May Be Helpful In Developing An Outpatient Group Treatment Program For Patients With Co-Occurring Disorders. An Additional Consideration Is That Not All Patients Are Similar In Terms Of Insight Regarding Their Sud, Nor Are They Similarly Ready To Address It. Thus, Patients Who Cannot Decide Whether To Address Their Substance Use May Do Better In A Group Focused On Resolving That Issue, As Opposed To A Group In Which All Participants Are Actively Engaged In Treatment And Making Lifestyle Changes To Support Sobriety. We Know Of No Studies, However, That Have Tested This Idea Empirically. It Is Possible, For Example, That Having A Mix Of Patient Severity Levels In One Group Gives Patients The Opportu- Nity To Learn From Those Further Along In Their Recovery. This Is A Central Principle Of Alcoholics Anonymous, And It Appears To Have Strong Anecdotal Support. Treat- Ments That Focus On Particular Co-Occurring Diagnoses (E. G., Bipolar Patients With Suds) Also Have Not Been Directly Compared To More General Thematic Groups (E. G., Co-Occurring Disorder Groups That Are More General, Encompassing A Wide Variety Of Diagnoses). Thus, It Remains An Empirical Question How The Heterogeneity Of Patients With Co-Occurring Suds And Psychiatric Disorders Should Best Be Addressed Within The Realistic Constraints Of Specific Clinical Settings. Sequential, Parallel, And Integrated Treatment Models There Are Three Major Models In Which Patients With Co-Occurring Suds And Psychi- Atric Disorders Are Treated: Sequential, Parallel, And Integrated Treatment. We Discuss Each Below. In Sequential Treatment, The More Acute Condition Is Treated First, Followed By The Less Acute Co-Occurring Disorder. Often, This Sequential Approach Is Attempted When One Condition Is Perceived To Be More Acute Than Another. Sometimes, However, It May Occur Because Of The Perception That One Condition Is Secondary To Another, That Staff May Not Be Trained To Treat It, Or Because The Condition Is Perceived As Iatrogenic And Must Be Addressed At The Start Of Treatment. Historically, Ptsd Was Perceived In These Ways Until Quite Recently, For Example (Najavits Et Al., 2008). When Sequential Treatment Does Occur, The Same Staff May Treat Both Disorders Or The Second Disorder May Be Treated After Transfer To A Different Program Or Facility. For Example, A Patient With Mania And A Cocaine Use Disorder Needs Mood Stabilization Before Initiating Substance Abuse Treatment. Conversely, A Patient With Major Depression And Alcohol Withdrawal Delirium Is Not In A Position To Discuss Treatment Adherence To Antidepres- Sant Medication. Instead, This Issue Is Best Addressed When The Patient Is More Stable (I. E., When The Delirium Has Been Fully Treated And Has Subsided). Although Sequential Treatment Has The Advantage Of Providing An Increased Level Of Attention To The More Acute Disorder, A Typical Disadvantage Of This Model Is That Patients Are Often Trans- Ferred To Different Clinicians To Address The Less Acute Disorder, And The Interrelation- Ship Between The Two Disorders May Never Be Adequately Addressed. In Parallel Treatment, Both Disorders Are Treated Simultaneously, But Not By The Same Treatment Team. For Example, A Patient May Receive Treatment For An Sud In An Addiction Treatment Program And For A Psychiatric Disorder In A Mental Health Clinic. Typically, Staff Members Of Each Program Are Very Well-Versed In Their Own Areas Of Expertise, But Not In The Other. However, Major Cross-Training Efforts Relative To Co-Occurring Disorders Have Improved This Situation In The Past Decade. The Differ- Ent Treatment Programs May Also Have Different Treatment Philosophies, Which May Be Confusing To The Patient (Mueser Et Al., 1992; Ridgely Et Al., 1990). For Example, In Sud Treatment Programs, Clinicians May Attribute Psychiatric Symptoms (E. G., Depression And Anxiety) To Substance Use; When A Patient Attempts To Obtain Relief, The Clinician May View This As "Drug-Seeking" Behavior. Alternatively, Staff Members In Psychiatric Programs May Tend To Minimize The Importance Of Substance Use And Not Stress Its Potential Negative Consequences. Unfortunately, Patients Treated In Parallel Or Sequential Programs Often Have Dif- Ferent Experiences Based On The Treatment Settings They Enter. The Two Different Pro- Grams May Provide Patients With Different Feedback On The Relationship Between Their Substance Use And Psychological Symptoms. Patients In These Situations Are Then Left To Attempt To Integrate These Sometimes Disparate Approaches Themselves. In These Circumstances, Patients May Be Accused Of "Manipulating" And "Splitting Staff" When They Present Information Obtained In One Program That Is Contradictory To Another. In Integrated Treatment, The Management Of Both Disorders Occurs In One Treat- Ment Setting, And The Same Clinician Or Team Of Clinicians Manages Both Illnesses. Integrated Treatment Has Become Increasingly Interesting To Researchers And Clini- Cians, Fostered By The Belief That It Is More Effective Than The Other Treatment Models Described Earlier. Integrated Behavioral Therapies For Patients With Co‐Occurring Disorders Integrated Psychosocial Treatments Have Been Developed For Diverse Patient Popu- Lations With Co-Occurring Suds And Psychiatric Disorders, Including Patients With Severe And Persistent Mental Illness (Drake Et Al., 2001; Mchugo Et Al., 1999), Depres- Sion (Brown Et Al., 2006; Lydecker Et Al., 2010; Cornelius Et Al., 2011); Bipolar Disor- Der (Weiss Et Al., 2000, 2007, 2009; Weiss & Connery, 2011), Personality Disorders (Ball, 1998; Linehan Et Al., 2002), And Anxiety Disorders Such As Ptsd (Brady Et Al., 2001; Najavits Et Al., 1998; Najavits, 2002; Mills Et Al., 2012), Obsessive-Compulsive Disorder (Fals-Stewart & Schafer, 1992), Social Phobia (Randall Et Al., 2001), And Suicidal Patients (Esposito-Smythers Et Al., 2011). We Describe Here Some Examples Of The Many Interventions Developed, Limiting Our Discussion To Treatments With An Evidence Base Of At Least One Randomized Controlled Clinical Trial, In An Effort To Be Illustrative Rather Than Comprehensive. Integrated Group Therapy Integrated Group Therapy (Igt) For Bipolar Disorder And Substance Abuse, Developed By Weiss And Connery (2011) And Colleagues (Weiss Et Al., 2000, 2007, 2009), Is A Manual-Based Group Psychotherapy Based On Cognitive-Behavioral Therapy (Cbt) Principles, Intended For Patients With Co-Occurring Bipolar Disorder And Suds, And Focused On The Relationship Between Mood Symptoms And Substance Use Or Abstinence. Arranged Around A "Central Recovery Rule" Of Maintaining Abstinence And Adherence To Prescribed Medications, Igt Takes Into Account The Essential Link Between These Two Behaviors In This Traditionally Difficult-To-Treat Population. Igt Has Had Three Positive Trials, Including Two Randomized Controlled Trials (Rcts) In Which It Out- Performed Standard Group Drug Counseling (Weiss Et Al., 2000, 2007, 2009); In The Most Recent Study, Igt Led To Decreased Substance Use, Increased Likelihood And Rate Of Achieving Abstinence, And Increased Rates Of "Good Clinical Outcome," A Composite Measure Of Substance Use And Mood Simultaneously (Weiss Et Al., 2009). Seeking Safety Seeking Safety (Ss; Najavits, 2002; Najavits Et Al., 1998) Involves A Phase-Based Framework For Ptsd And Sud Recovery In Which Safety Is Defined The First Stage Of Treatment. In Ss, Safety Is The Overarching Goal: Helping Clients Attain Safety In Their Relationships, Thinking, Behavior, And Emotions. It Is A Present-Focused, Cbt Approach Focused On Psychoeducation And Coping Skills, And Designed For Flexible Use: Group Or Individual Format; Both Genders; All Settings (E. G., Outpatient, Inpatient, Residential); All Types Of Trauma And Substances; And Any Clinician. It Offers Up To 25 Topics, Each Representing A Safe Coping Skill, Such As Asking For Help, Compassion, Setting Boundaries In Relationships, Taking Good Care Of Yourself, Creating Mean- Ing, Coping With Triggers, Healing From Anger, And Detaching From Emotional Pain (Grounding). The Topics Can Be Conducted In Any Order, Using As Few Or As Many As Are Possible Within The Available Time Frame. It Strives To Be Emotionally Engaging, With Simple, Humanistic Language, A Quotation To Start Each Session, And Interac- Tive Exercises (For Additional Details, See The Website Www. Seekingsafety. Org). Ss Has Had Positive Outcomes In Rcts Including Male Veterans (Boden Et Al., 2012) And Adolescent Girls (Najavits Et Al., 2006), And Is The Only Model Thus Far To Outperform A Control On Both Ptsd And Suds (See Najavits & Hien, 2013, For A Review Of The Points Covered Here). Studies Of Full-Dose Ss Have Shown More Positive Outcomes Than Partial-Dose Ss. The Largest Study Of Ss To Date Was Conducted As Part Of The National Institute On Drug Abuse Clinical Trials Network. That Study, Despite Being A Partial- Dose Of Ss (Less Than Half The Model) Found That At End Of Treatment Ss Outperformed The Comparison Of Women's Health Education (Whe) On Therapeutic Alliance, Hiv Risk, And Eating Disorder Symptoms, As Well As Eight Out Of Nine Secondary Analyses Focused On Subsamples Of The Study (Including Heavy Stimulant Users And Alcohol Misusers) (Ruglass Et Al., 2012). In Main Outcomes, Ptsd In Both Ss And Whe Patients Improved; Suds Improved In Neither Ss Nor Whe, But The Study Was Under- Powered To Detect Sud Outcomes (I. E., Over 45% Of The Sample Was Abstinent From Substances At Baseline; Hien Et Al., 2009). More Research Is Warranted, Especially In Light Of Recent Consistent Results Showing That Exposure-Based Ptsd Treatment Has Not Outperformed Less-Intensive Controls At End Of Treatment In Four Recent Rcts For Ptsd-Sud Samples (Foa Et Al., 2013; Mills Et Al., 2012; Sannibale Et Al., 2013; Van Dam, Ehring, Vedel, & Emmelkamp, 2013; For A Summary See Najavits, 2013). Integrated Dual Disorders Treatment Integrated Dual Disorders Treatment (Iddt; Drake Et Al., 2001) Focuses On Provid- Ing Mental Health And Sud Treatment Concurrently By A Team Of Interdisciplinary, Cross-Trained Clinicians Within The Same Program. Additional Features Include Asser- Tive Community Outreach; Stagewise Interventions That Are Determined By The Client's Stage Of Recovery (Engagement, Persuasion, Active Treatment, And Relapse Prevention); Provision Of A Wide Range Of Ancillary Services; Time-Unlimited Services; And Motiva- Tional Interventions. The Model Has Had Various Positive Outcomes For Patients With Schizophrenia And Sud, When Compared To Treatment As Usual (Tau), For Example (Morrens Et Al., 2011). Dialectical Behavior Therapy Dialectical Behavior Therapy (Dbt) Is A Cbt Approach Designed For Patients With Bor- Derline Personality Disorder. It Has Four Key Modules: Mindfulness, Distress Tolerance, Emotion Regulation, And Interpersonal Effectiveness. It Uses A Conceptual Approach From Applied Behavior Analysis, "Chain Analysis," To Identify Sequential Events That Form The Behavior Sequence. It Relies On A Combination Of Group Therapy, Individual Therapy, And, For The Clinician, Peer Supervision And Support. Dbt Organizes Treat- Ment Into Stages And Targets That Are Strongly Adhered To So As To Promote Effective Outcomes, First Addressing Behaviors That Could Lead To The Patient's Death (E. G., Sui- Cide), Then Behaviors That Could Lead To Premature Termination From Therapy, Then Behaviors That Destroy The Quality Of Life, And Then Addressing The Need For Alternative Skills. Dbt For Substance Abusers (Dimeff & Linehan, 2008) Is A Modified Version Of Dbt For Patients With Suds To Promote Abstinence And Reduce Relapse. There Have Been Numerous Research Studies Of Dbt, Including A Meta-Analysis That Found Moder- Ately Positive Effects For The Model; It Has Been Studied In Some Sud Samples As Well, With Modest Positive Results (Linehan Et Al., 1999, 2002; Harned Et Al., 2008; Dimeff & Linehan, 2008; See Also Www. Behavioraltech. Org). Motivational Interviewing/Motivational Enhancement Motivational Interviewing (Mi), Developed By Miller And Rollnick (1991, 2002), Uti- Lizes Theory Derived From Several Psychotherapeutic Models: Systems, Client-Centered, Cbt, And Social Psychology. Mi Is Also Called "Motivational Enhancement Therapy" (Met), Because It Is Often A Brief Treatment, Conducted In As Few As Two Sessions, Sometimes Aimed At Helping The Patient Accept Other Psychotherapy (E. G., Cbt). Guide- Lines For Modifying Mi In Patients Diagnosed With Suds And Psychotic Disorders Have Been Published (Carey Et Al., 2001; Martino Et Al., 2002). Recent Randomized Pilot Trials Of Mi In Diverse Populations With Co-Occurring Disorders Suggest That Mi May Improve The Likelihood Of Making The Transition To Outpatient Treatment (Swanson Et Al., 1999), Improve Sud Outcomes (Graeber Et Al., 2003), And Decrease Psychiatric Hospitalization (Daley & Zuckoff, 1998). A Recent Review On The Application Of Mi To Various Mental Health Disorders Co-Occurring With Suds, Including Anxiety, Depres- Sion, And Eating Disorders, Suggest Promise But Also Needs Further Study, With More Rigorous Scientific Testing (Westra Et Al., 2011). In Recent Years, Too, Met Has Often Been Combined With Cbt To Improve Outcomes, Including Studies Addressing Comor- Bidity (E. G., Easton Et Al., 2012; Cornelius Et Al., 2011). Overall Issues In Comorbidity Behavioral Therapies The Past Several Decades Have Seen Remarkable Progress In Attending To Co-Occurring Disorders. Various Novel And Creative Approaches Have Been Developed And Tested In Outcome Trials. However, Conclusions At This Point Are Mixed And Further Research Is Warranted. First, More Research Is Needed To Compare Integrated Versus Single, Sequential, Or Parallel Treatment Approaches. In General, Research On Manualized Behavioral Therapies For Suds Consistently Find That They Do Not Outperform Each Other (Car- Roll & Rounsaville, 2007; Imel Et Al., 2008; Sellman, 2010), And Certain Integrated Approaches May Not Necessarily Outperform Single-Diagnosis Approaches (Torchalla Et Al., 2012; Donald Et Al., 2005). Yet Integrated Treatments May Have Other Virtues Beyond Just Outcomes: They May Increase Engagement, May Be Perceived As Highly Relevant, May Be Easier To Implement Or Teach, Or Be Of Lower Cost Than Single, Sequen- Tial, Or Parallel Approaches. Second, It Is Important To Note That Results Have Sometimes Been Surprising. Some Studies Indicate Either No Difference In Sud Outcomes Between Co-Occurring Versus Non-Co-Occurring Treatment (E. G., Mills Et Al., 2012; Schadé Et Al., 2008; Ball, 2007) Or Worse Outcomes (E. G., Randall Et Al., 2001). Many Factors May Play Into The Het- Erogeneity Of Findings, Including Methodology Issues (Horsfall Et Al., 2009), Who Conducts The Study (E. G., The Treatment Developer Or Independent Scientists), And The Nature Of The Treatments Themselves. More Research With High-Quality Treatments And Study Designs Are Needed. Also, There Are Encouraging New Treatment Developments, Including The Burgeoning Technology-Based Approaches, Such As Computer-Delivered Care (E. G., Kelly Et Al., 2012). Self‐Help Groups And Individuals With Co‐Occurring Suds And Psychiatric Disorders As In Other Substance-Using Populations (Miller Et Al., 1997; Ritsher Et Al., 2002), Self- Help Group Attendance Has Been Associated With Improved Substance Use Outcomes In Populations With Co-Occurring Suds And Psychiatric Disorders (Brooks & Penn, 2003; Ritsher Et Al., 2002). Whether This Is A Reflection Of Self-Help Groups' Improv- Ing Outcomes Directly Or A Self-Selection Bias (I. E., Patients Attending Self-Help Groups May Be More Likely To Remain Abstinent Because They Are More Motivated) Is Unclear. Despite The Fact That Self-Help Groups Are Both Free Of Charge And Geographically Accessible (Kurtz, 1997), Many Patients With Co-Occurring Disorders Do Not Attend These Meetings (Noordsy Et Al., 1996). Some Clinicians May Be Reluctant To Recom- Mend Self-Help Groups To Patients With Co-Occurring Disorders Because Of Concerns That Self-Help Group Members Might Express Negative Attitudes Towards Psychotropic Medication (Humphreys, 1997). However, Recent Research Indicates That While This Sometimes Occurs (Noordsy Et Al., 1996), It Is Not Prevalent (Meissen Et Al., 1999). Moreover, Official Alcoholics Anonymous (Aa; 1984) Literature States That Psychiat- Ric Medication, When Legitimately Prescribed, Is Appropriate. When Educating Patients About The Interaction Between Psychiatric Symptoms, Drug And Alcohol Use, And Med- Ications, Clinicians Should Inform Patients That While Some Self-Help Group Members May Criticize The Use Of Medications, This Contradicts Official Aa Policy. Clinicians May Also Be Concerned That These Groups Only Focus On Suds (Hum- Phreys, 1997) And May Therefore Not Be As Helpful To Patients Who Are Struggling With Other Psychiatric Disorders. Recent Research Suggests That Some Patients And Aa Con- Tacts (I. E., Persons Listed In The Aa Directories As Experienced Members) Agree (Meis- Sen Et Al., 1999; Noordsy Et Al., 1996). However, By Encouraging Patients To Focus On Obtaining What Aa And Similar Groups Offer, And Not Expecting Aa To Provide Services Outside Of Its Stated Mission, Clinicians Can Help Patients With Co-Occurring Disorders To Take Advantage Of These Groups. To Address Some Of The Concerns Described Earlier, Several Dual Focus Self-Help Groups Have Emerged For Participants With Co-Occurring Suds And Psychiatric Disor- Ders (E. G., Double Trouble In Recovery, Dual Recovery Anonymous, And Dual Dis- Orders Anonymous; Bogenschutz Et Al., 2006; Magura Et Al., 2003). Similar To The Literature On Self-Help Groups In The Sud Population, Positive Associations Have Been Found Between Attendance At Dual Focus Self-Help Groups And Abstinence (Magura Et Al., 2003), As Well As Psychiatric/Quality Of Life (Magura Et Al., 2002) Outcomes. Again, Whether This Is A Result Of Self-Selection Bias Regarding The Characteristics Of Patients Who Attend These Meetings Is Unclear. General Treatment Themes For Patients With Co‐Occurring Suds And Psychiatric Disorders Because Of The Limitations Of The Empirical Literature Described Earlier Regarding Psy- Chosocial Treatments, It May Be Helpful To Draw On General Recommendations Pro- Vided By Various Writers On This Subject (Bellack & Diclemente, 1999; Carey, 1995; Drake Et Al., 2001; Drake & Mueser, 2000; Najavits Et Al., 1996; Rounsaville & Carroll, 1997; Ziedonis Et Al., 2000; Najavits, 2002; Najavits & Capezza, 2014). Although Treatment Modalities Differ, Some Common Themes Can Help Guide Clinicians Who Must Decide How To Intervene With Their Patients. The Suggestions Are As Follows: • • • • • • • • • • • • • • • • • Be Empathic And Provide Support For The Difficulty Of Living With Two Dis- Orders, But Also Emphasize Accountability (E. G., The Presence Of A Psychiatric Disorder Is Not An Excuse To Use Substances). Assist Patients In Setting A Goal To Stop Substance Use. Explore Patients' Per- Ceptions Of The Relationship Between Their Substance Use And Their Psychiatric Disorders. As Part Of This Process, Also Explore The Longer-Term Relationship Between The Two (E. G., An Individual May Report Drinking To Reduce Social Anxi- Ety And Initially Feel Better, Then Feel Worse The Following Day) And Discuss The Advantages Of A Substance-Free Life. Educate Patients And Their Family Members About The Symptoms Of Both Disor- Ders, And The Causal Connections Between Them. Monitor Symptoms Of Both Disorders And How They Interact Over Time (Includ- Ing The Use Of Biological Measures Such As Urine Screens For Substance Use When Indicated). Monitor Adherence To Medications, Since Nonadherence Is A Significant Risk For Relapse. To Improve Functioning And Foster The Rewards Of Abstinence, Assist Patients In Developing Social, Relationship, Or Vocational Skills. Attend To Patient Safety, Including Attention To The Human Immunodeficiency Virus (Hiv) And Suicidality, Both Of Which Have Been Found To Be Increased In Patients With Co-Occurring Disorders (Mahler, 1995; Weiss & Hufford, 1999). Have Available Resources To Refer Patients To Self-Help Groups For Each Disorder. Discuss With Patients What To Do And Whom To Call In Case Of Emergency. Provide Positive Reinforcement For Improvements, However Small, In Each Dis- Order. For Patients Who Have Had Significant Periods Of Recovery, Acknowledge These Successes And, In A Positive Way, Ask Them How They Accomplished It. Doing So Reminds Patients Of Prior Successes And Can Mitigate The Feelings Of Hopeless- Ness And Discouragement That Often Accompany Relapse. Take A Relapse History To Help Identify Triggers To Relapse (E. G., Discontinuing Medications Or Treatment, Engaging In High-Risk Behaviors Such As Socializing Where Alcohol Is Present). Expect Occasional Breaks In Treatment Attendance, And Engage In Active Out- Reach. Recognize That Patients May Be More Motivated To Work On One Disorder Than The Other, And May Need Encouragement To Attend To Both. Understand That The Clinician Too May Feel More Connection Or Engagement With One Disorder Over The Other. For Example, Depression May Evoke More Sympathy Than An Sud. Be Aware Of Subtypes And Subpopulations Even Within A Particular Comorbid- Ity. For Example, Treatment Of Depression-Sud Comorbidity May Differ Based On Whether Psychotic Symptoms Are Present; Based On Age (E. G., Adolescent Vs. Geriatric), And So Forth. Provide Referral To Additional Treatments And Conduct A Thorough Assessment Of Case Management Needs, Including Treatment Of Physical Health Problems. Pharmacotherapy For Patients With Co‐Occurring Suds And Other Psychiatric Disorders The Literature Regarding When To Prescribe Pharmacotherapy For Patients With Co- Occurring Disorders Has Evolved Considerably In The Past 20 Years. Previous Consensus In The Field Reflected Reluctance To Prescribe Psychotropic Medications In This Popula- Tion, In Part Based On Methodologically Flawed Studies. For Example, Older Studies Examining The Use Of Antidepressants In Alcoholics Often Did Not Use Standardized Methods To Assess The Depressed Population, Had Inadequate Dosing Or Duration Of Antidepressants, And Sometimes Measured Mood Or Drinking Outcomes, But Not Both (Ciraulo & Jaffe, 1981). More Recently, Integrated Pharmacological And Psychosocial Treatments Have Been Increasingly Accepted And Are Now Often Provided To Patients As Standard Care. However, Few Trials Have Integrated Novel Psychosocial Treatments With Novel Pharmacotherapies, And Most Treatments Instead Either Focus On New Pharmacological Or New Psychosocial Interventions. In Spite Of This, Clinical Practice And More Recent Research Have Emphasized The Importance Of Integrating Pharmaco- Logical And Psychotherapeutic Treatment Options. Major Depression Multiple Meta-Analyses Of Antidepressant Medication Efficacy In Patients With Co- Occurring Depression And Suds Have Examined Both Mood And Sud Outcomes (Iovi- Eno Et Al., 2011; Nunes & Levin, 2004; Torrens Et Al., 2005). Results Have Shown Mixed Efficacy Of Antidepressants In This Population, With Better Outcomes On Depres- Sive Measures (Comparable To Results Seen In Patients With Depression Alone) Than Substance Use Outcomes, And Without Clear Evidence To Suggest Use Of One Particular Agent. Studies That Required At Least 1 Week Of Abstinence Before Treating The Depression Yielded Larger Effect Sizes And Lower Placebo Response, Suggesting That Requiring Even 1 Week Of Abstinence Before Initiating Medication Treatment Can Successfully Screen Out Transient Depressive Symptoms. Studies That Exhibited Better Depression Outcomes As A Result Of Antidepressants Also Showed Decreased Quantity Of Substance Use, And Best Outcomes Occurred In Studies Combining Antidepressants With Psychotherapy. One Such Study Used Fluoxetine And Cbt In Depressed Alcoholics, With Improved Depression And Drinking Outcomes (Cornelius Et Al., 1997). In Another Study, Combin- Ing Sertraline And Cbt Led To Less Drinking And Improved Depression Compared To Placebo (Moak Et Al., 2003). One Study Showed Efficacy For Desipramine In Improving Depression Scores And Length Of Abstinence From Alcohol In A 6-Month, Double-Blind, Placebo-Controlled Trial (Mason Et Al., 1996). In A Single-Site Trial, Pettinati Et Al. (2010) Found That A Combination Of Sertraline And Naltrexone Led To Improved Drink- Ing Outcomes And Reduced Depression Compared To Either Sertraline Or Naltrexone Alone, Indicating That This Combination May Have Value For The Depressed And Actively Drinking Patient. Most Studies Examining Use Of Antidepressants In Patients With Co- Occurring Depression And Cocaine Use Disorders Have Shown Some Effectiveness In Antidepressant Outcomes But Little Impact On Cocaine Use (Torrens Et Al., 2005). Some Evidence Suggests That Stimulating Antidepressants (E. G., Tricyclics And Bupropion) Are Preferred For Treating Depression In The Context Of Cocaine Use Disorders (Rounsaville, 2004). Although Antidepressants Have Been Studied In Patients With Co-Occurring Depression And Opioid Use Disorders, Mostly In Patients Receiving Methadone Main- Tenance Treatment, Most Studies Have Shown No Improvement In Outcomes Of Either Illness (Nunes & Levin, 2004). An Exception Might Be The Tricyclic Antidepressants Imipramine And Doxepin, Which In This Population Have Shown Some Benefit In Reduc- Ing Substance Use, Likely Indirectly Via Positive Effects On Depression (Nunes Et Al., 1998; Nunes & Levin, 2004; Titievsky Et Al., 1982). Bipolar Disorder Although Face Validity Would Suggest That Stabilizing Mania Or Hypomania In Patients With Bipolar Disorder Would Improve Impulse Control And Judgment, And Would There- Fore Lead To Decreased Substance Use, The Literature Is Thin Regarding The Efficacy Of Mood-Stabilizing Medications On Bipolar And Sud Outcomes. A Number Of Open-Label Prospective Trials Using Medications For Patients With An Sud And A Bipolar Or Bipo- Lar Spectrum Disorder Have Been Conducted (I. E., With Lithium, Anticonvulsants, And Antipsychotics), With Results Generally Showing Improvements In Mood Symptoms But Inconclusive Or Unclear Results Regarding Sud Outcomes (Brady Et Al., 1995; Brown Et Al., 2002, 2003A, 2003B; Calabrese Et Al., 2001; Gawin & Kleber, 1984; Geller Et Al., 1998; Nunes Et Al., 1990). An Open-Label Pilot Trial By Gawin And Kleber (1984) Indicated That Lithium May Be Effective In Reducing Cocaine Use In Patients With Cyclo- Thymia And Cocaine Abuse. However, An Open-Label Trial Of Lithium In Patients With Bipolar Spectrum Disorders And Cocaine Abuse (Nunes Et Al., 1990) Demonstrated Little Efficacy In Mood Or Cocaine Outcome Measures. An Open-Label Trial With Val- Proate In Patients With Bipolar Disorder And An Sud (Brady Et Al., 1995) Resulted In Improvement In Mood And Substance Use Measures. An Open Trial Of Lithium Plus Valproate In Patients With Rapid-Cycling Bipolar I Or Ii Disorder And Alcohol, Cannabis, And/Or Cocaine Dependence (Calabrese Et Al., 2001) Showed Improvement In Mood Symptoms And A 25% Remission Rate In Suds After 6 Months. Open-Label Trials Of Lamotrigine (Brown Et Al., 2003A) And Quetiapine (Brown Et Al., 2002) In Patients With Bipolar Disorder And Cocaine Dependence Suggest That These Medications May Be Associated With Improved Mood Symptoms And Cocaine Craving, Although Not With Significant Reductions In Cocaine Use. An Add-On Rct Of Citicoline (Brown Et Al., 2007) In This Same Population Resulted In Decreased Cocaine Use And No Changes In Mood. Several Double-Blind, Placebo-Controlled Studies Assessing The Efficacy Of Mood Stabilizers Or Antipsychotic Medications In Patients With Bipolar Disorder And Suds Have Been Conducted (Brady Et Al., 2002; Brown Et Al., 2008, 2012; Geller Et Al., 1998; Salloum Et Al., 2005). Geller Et Al. (1998) Conducted A Double-Blind, Placebo-Controlled, 6-Week Trial Of Lithium In Adolescents With Bipolar Disorder And Substance Dependence, And Found Lithium To Be Efficacious For Outcomes In Both Dis- Orders (Geller Et Al., 1998). Brady Et Al. (2002) Compared Carbamazepine In Cocaine- Dependent Individuals With And Without A Co-Occurring Affective Disorder (Note That Less Than Half Of The Sample With Affective Disorders Had Bipolar I Disorder, Bipolar Ii Disorder, Or Cyclothymia) In A 12-Week, Double-Blind, Placebo-Controlled Trial. The Affective Disorder Group Treated With Carbamazepine Showed A Nonstatistically Sig- Nificant Trend Toward Less Cocaine Use, While Treatment With Carbamazepine Did Not Have Any Impact On Individuals Without Affective Disorders. In A 24-Week, Double- Blind, Placebo-Controlled Trial, Salloum Et Al. (2005) Randomized 59 Patients With Bipolar Disorder And Alcohol Dependence Receiving Lithium Carbonate And Psycho- Social Interventions To Also Receive Valproate Or Placebo. Mood Symptoms Improved In Both Groups, While Patients In The Lithium Plus Valproate Group Had Significantly Fewer Heavy Drinking Days. In A 10-Week, Double-Blind, Placebo-Controlled Trial, Brown Et Al. (2012) Compared Lamotrigine To Placebo In 120 Outpatients With Bipolar Disorder, Depressed Or Mixed Mood State, And Cocaine Dependence. No Difference In Mood Symptoms Occurred Between The Groups, And Lamotrigine Was Associated With A Decrease In The Amount Of Money Spent On Cocaine (Though Without A Significant Difference In Urine Drug Screen Results). Two Double-Blind, Placebo-Controlled Trials Administering Quetiapine To Patients With Alcohol Dependence And Bipolar I Disorder (Treated With Mood Stabilizers) Resulted In No Improvement Over Placebo In Measures Of Alcohol Use (Brown Et Al., 2008; Stedman Et Al., 2010). Generally Speaking, The Results Of All Of These Trials Confirm The Safety And Effectiveness Of Mood Stabilizers In Improving Psychiatric Symptoms In Patients With Co-Occurring Disorders, But Fewer Data Objectively Demonstrate A Decrease In Substance Use, And Results Of Most Trials Can Be Seen As Preliminary. Schizophrenia Most Of The Literature On The Pharmacological Treatment Of Patients With Schizo- Phrenia And Suds Is Limited To Retrospective Or Open-Label Prospective Studies, Often With Small Sample Sizes And/Or Lacking Comparison Groups. For Example, An Open Trial Of Desipramine Added To Antipsychotic Treatment In An Integrated Dual Diagnosis Relapse Prevention Program Showed Promise In Reducing Cocaine Use And Improv- Ing Psychiatric Symptoms (Ziedonis Et Al., 1992). Two Open-Label Trials Have Found The First-Generation Depot Antipsychotic Flupenthixol Deconoate To Decrease Cocaine (Levin Et Al., 1998B) And Alcohol (Soyka Et Al., 2003) Use In Patients Diagnosed With Schizophrenia And Suds. Multiple Preliminary Reports Suggest The Potential Benefit Of Second-Generation Antipsychotic Medications Such As Clozapine, Olanzapine (Lit- Trell Et Al., 2001; Smelson Et Al., 2006), Risperidone (Smelson Et Al., 2002A; Rubio Et Al., 2006), Quetiapine (Brown Et Al., 2003B), And Aripiprazole (Beresford Et Al., 2005) In Improving Substance Use Outcomes In Populations With Co-Occurring Schizophre- Nia, Though No Conclusive Data Support The Efficacy Of First- Or Second-Generation Antipsychotic Agents Over The Other (Petrakis, Leslie, Et Al., 2006; San Et Al., 2007; Sayers Et Al., 2005). Generally Speaking, The Atypical Antipsychotic Clozapine Has Shown The Most Promise In The Treatment Of Patients With Schizophrenia And Suds (Buckley Et Al., 1994; Drake Et Al., 2000; Green Et Al., 2003; San Et Al., 2007; Lybrand & Caroff, 2009; Zimmet Et Al., 2000). In One Rct (Enrolling 31 Patients With Co- Occurring Schizophrenia And Cannabis Use Disorder), Clozapine Treatment Was Asso- Ciated With Decreased Cannabis Use Compared To Other Antipsychotic Medications, Though Without Differences In Symptoms Or Functioning (Brunette Et Al., 2011). The Unique Pharmacological Receptor Activity Of Clozapine May Correct Underlying Reward System Deficits Of Patients With Schizophrenia And Suds (Green Et Al., 1999, 2008; Leduc & Mittleman, 1995). Additionally, When Administered In Low Doses (50 Mg Or Ess) To Normal Volunteers, Clozapine Has Been Shown To Attenuate The Subjective High And Rush Associated With Cocaine, As Well As Its Pressor Effect (Farren Et Al., 2000). In One Naturalistic Study, Drake Et Al. (2000) Prospectively Followed 151 Patients With Schizophrenia Or Schizoaffective Disorder And Co-Occurring Suds For 3 Years. At The Conclusion Of The Study, Of The 36 Patients Who Received Treatment With Clozapine, 79% Were In Remission From Alcohol Use Disorder, Compared To Only 33.7% Of Those Not Taking Clozapine. Despite These Encouraging Findings, Evidence From Normal Study Volunteers Suggests That Low-Dose Clozapine May Increase Cocaine Blood Levels And Cause Near-Syncope (Farren Et Al., 2000). To Our Knowledge, However, No Case Reports Or Studies Have Documented Clinically Significant Syncopal Episodes In Patients With Schizophrenia And Stimulant Use Disorders Who Are Prescribed Clozapine. Thus, While The Introduction Of Second-Generation Antipsychotics Is Encouraging With Regard To Potential To Improve Sud Outcomes In This Population With Co-Occurring Disorders, Well-Designed Controlled Trials Are Needed To Establish Safety, Tolerability, And Efficacy In This Population. Anxiety Disorders The Use Of Benzodiazepines In Populations With Suds And Co-Occurring Psychiatric Disorders Is Controversial. This Issue Has Been Explored Almost Exclusively In Popula- Tions With Anxiety And Alcohol Use Disorders. The Prevalence Of Benzodiazepine Use In Patients With Alcohol Use Disorders Is Greater Than In The General Population But Comparable To That In Populations With Psychiatric Disorders (Ciraulo Et Al., 1988). Clinicians Are Often Understandably Concerned That Prescribing Benzodiazepines To These Patients May Lead To Either A Worsening Of The Alcohol Use Disorder, The Develop- Ment Of A Benzodiazepine Use Disorder, Or Potentiation Of The Benzodiazepine Effect When Combined With Alcohol. Preliminary Evidence From Case Reports (Adinoff, 1992) And A Prospective Naturalistic Study (Mueller Et Al., 1996) Suggests That There May Be A Carefully Selected Subpopulation Of Patients With Co-Occurring Alcohol Use And Anxiety Disorders For Whom Long-Term Prescription Of Benzodiazepine May Not Affect Sobriety Or Result In Benzodiazepine Misuse. However, It May Not Improve Outcomes Either. For Example, A Retrospective Naturalistic Study Of Veterans With Ptsd And Suds Found That Physicians Were Less Likely To Prescribe Benzodiazepines For Those With Suds (Kosten Et Al., 2000). While Those With Prescribed Benzodiazepines Did Not Have Worse Outcomes, Chronic Benzodiazepine Treatment (Independent Of A Co- Occurring Sud) Did Not Improve Anxiety Or Social Functioning In These Patients Either. Similarly, Brunette Et Al. (2003) Followed Spmi Patients With Suds Annually For 6 Years And Found That The Rate Of Benzodiazepine Prescribing Was High (Up To 43%), But It Was Not Associated With Differences In Substance Use Remission, Hospitalization, Or, Interestingly, Reductions In Anxiety Or Depression. Also, Unsurprisingly, Patients Prescribed Benzodiazepines Were More Likely To Abuse Them Than Those Who Were Not Prescribed Them. While Controlled Trials Are Needed To Explore These Issues More Fully, The Findings From These Reports Add Further To Concerns That The Long-Term Use Of Benzodiazepines In These Populations Perhaps Offers The Risk Of Abuse Or Dependence Without Great Potential For Clinical Benefit. Another Pharmacological Alternative In This Population Is Buspirone, Which Does Not Have Abuse Potential. Thus Far, There Have Been Three Double-Blind, Placebo- Controlled Studies Of Buspirone In Patients With Alcohol Dependence And Anxiety— Either Generalized Anxiety Disorder (Gad; Tollefson Et Al., 1992), Gad And "Other Nonpanic Anxiety" (Malcolm Et Al., 1992), Or "Anxious Alcoholism" (Kranzler Et Al., 1994). Two Of The Studies Found That Buspirone Was Associated With Improvements In Anxiety And Alcohol Use Outcomes (Kranzler Et Al., 1994; Tollefson Et Al., 1992). Although There Have Been Concerns That Buspirone's Antianxiety Effect Is More Lim- Ited In Patients With A Prior History Of Benzodiazepine Use (Schweizer Et Al., 1986), A Pooled Analysis Of Eight Placebo-Controlled, Randomized Trials Of Patients With Gad (Demartinis Et Al., 2000) Indicated That Patients With Either Remote (Defined As At Least 1 Month Duration) Or No Prior Benzodiazepine Treatment Experienced Improved Anxiolysis, Fewer Adverse Events, And Clinical Improvement Similar To That On Ben- Zodiazepines Compared To Patients With Recent Benzodiazepine Treatment. Thus, Patients Who Have Not Received Benzodiazepines For At Least 1 Month May Benefit From Buspirone. An Rct Of Buspirone For Patients With Co-Occurring Opioid Dependence (On Methadone Maintenance Treatment) And Anxiety Found That Buspirone Did Not Significantly Reduce Anxiety Symptoms, Though Was Associated With Trends Toward Decreased Depressive Symptoms And Slowed Relapse Rates (Mcrae Et Al., 2004). In Patients With Co-Occurring Ptsd And Suds, One Rct Indicated That Certain Subtypes Of Patients Might Benefit From Selective Serotonin Reuptake Inhibitor (Ssri) Treatment (Brady Et Al., 2005). In 94 Patients With Current Alcohol Dependence And Ptsd Randomly Assigned To Receive Sertraline Or Placebo For 12 Weeks, Those Partici- Pants With Less Severe Alcohol Dependence And Earlier-Onset Ptsd Had Significantly Fewer Drinks Per Drinking Day. The Ssri Paroxetine Has Similarly Been Found To Be Effective In One Randomized, Placebo-Controlled Trial In Patients With Co-Occurring Social Anxiety Disorder And Alcohol Dependence (Randall, Johnson, Et Al., 2001). Par- Ticipants Receiving Paroxetine Showed Improvements In Anxiety And Alcohol Depen- Dence Symptoms. A Follow-Up Randomized, Placebo-Controlled Trial In Patients With Co-Occurring Social Anxiety Disorder And Alcohol Dependence (Thomas Et Al., 2008) Found Paroxetine To Be Effective In Decreasing Social Anxiety And Self-Reported Use Of Alcohol For Self-Medication Purposes (I. E., To Cope In Order To Engage With Others In Social Settings), Though It Did Not Correlate With Decreases In Overall Alcohol Use. Attention‐Deficit/Hyperactivity Disorder Although Stimulants Have Been The Most Extensively Studied Treatment For Adult Attention-Deficit/Hyperactivity Disorder (Adhd; Levin Et Al., 1999), There Are Con- Cerns That In Populations With Co-Occurring Suds And Psychiatric Disorders, They May Worsen The Course Of The Suds Or Be Subject To Abuse Themselves (Gawin Et Al., 1985). At The Same Time, It Has Also Been Observed That A Childhood History Of Adhd Worsens Outcomes For Cocaine Dependence (Carroll & Rounsaville, 1993). Therefore, Improving A Patient's Difficulties With Inattention And Hyperactivity May Have Ben- Eficial Effects On Substance Abuse As Well (Levin Et Al., 1999). Consistent With This, Prospective Studies Of Children Who Received Stimulant Treatment For Adhd Indicate That Stimulants Have A Protective Effect Against Future Development Of Suds As An Adult (Wilens, 2003; Mannuzza Et Al., 2003). Although Not As Well-Studied As Stimulants, Nonstimulant Medications That Lack Abuse Potential Are Possible Alternatives In The Treatment Of Adhd. In Adult Popula- Tions, Bupropion (Wilens Et Al., 2002) Desipramine (Wilens Et Al., 1996), And Atom- Oxetine (Michelson Et Al., 2003) Have Undergone Double-Blind, Placebo-Controlled Studies And Have Demonstrated Effectiveness In The Treatment Of Hyperactivity And Inattention. Little Research On These Medications, However, Has Included Patients With Active Suds. In One Rct Of Atomoxetine, Adults With Adhd And Alcohol Abuse Or Dependence (Wilens Et Al., 2008) Showed Clinically Significant Improvement In Adhd Symptoms With Atomoxetine Compared To Placebo,

Alexander 2011 Article

Cruel And Unequal Black And Whites Use Drugs At About The Same Rate, Yet African Americans Are 10 Times As Likely To Be Imprisoned For Drug Offenses. The Unbalanced Effects Of The "War On Drugs." So Much About Our Racial Reality Today Is Such As Chicago, Obama's Hometown, The Majorlittle More Than A Mirage. The Promised Land Of Sy Of Working-Age African-American Men Have Racial Equality Quivers Just Out Of Our Reach In Criminal Records And Are Thus Subject To Legalized The Barren Desert Of Our New, "Colorblind"Politi. Discrimination For The Rest Of Their Lives. Millions Cal Landscape. It Looks So Good From A Distance: Of People In The United States, Primarily Poor Barack Obama, Our Nation's First Black President, People Of Color, Are Denied The Very Rights Supposstanding Behind A Podium In The Rose Garden Edly Won In The Civil Rights Movement: The Right Looking Handsome, Dignified, And In Charge. Flip To Vote, To Serve On Juries, And To Be Free From Disthe Channel And There's The Whole Obama Family Crimination In Employment, Housing, Access To Exiting Air Force One, Waving To The Crowd-A Education, And Public Benefits. Branded Criminals" And "Felons, Such People Now Find Themselves Relegated To A Permanent Second-Classstatus. They Live In A Parallel Gorgeous Black Family Living In The White House, Social Universe: The Other America, Where They Cheered By The World. Will Stay For The Rest Of Their Lives. Drive A Few Blocks From The White House We, As A Nation, Are In Deep Denial About How And You Find The Other America. You Find You're This Came To Pass. On The Rare Occasions When Still In The Desert, Dying Of Thirst, Wondering What The Existence Of Them"—The Others, The Ghetto Wrong Turn Was Made And How You Managed To Dwellers, Those Locked Up And Locked Out - Is Pubmiss The Promised Land, Though You Reached For Licly Acknowledged, Standard Excuses Are Trotted It With All Your Mightout. We're Told Black Culture, Bad Schools, Po Va Vast New Racial Undercaste Now Exists Erty, And Broken Homes Are To Blame. Almost No In America, Though Their Plight Is Rarely Men One Admits: We Declared War. We Declared A War Tioned. Obama Won't Mention It; The Tea Party On The Most Vulnerable People In Our Society And Won't Mention It, Media Pundits Would Rather Talk Then Blamed Them For The Wreckage. About Anything Else. The Members Of The Under Caste Are Largely Invisible To Those Of Us Who Have And Yet That Is Precisely What We Did. The Sojobs, Live In Decent Neighborhoods, And Zoom Called War On Drugs Has Driven The Quintupling Of Around On Freeways, Passing By The Virtual And Our Prison Population In A Few Short Decades. The Literal Prisons In Which They Live. Vast Majority Of The Startling Increase In Incarbut Here Are The Facts: There Are More Ceration In America Is Traceable To The Arrest And African-American Adults Under Correctional Imprisonment Of Poor People Of Color For Nonvicontrol Today In Prison Or Jail, On Probation Olent, Drug-Related Offenses. Families Have Been Or Parole--Than Were Enslaved In 1850. A Decade Torn Apart, And Young Lives Shattered, As Parents A Human Rights Nightmare Is Occurring On Our Watch. 1 14 Om Wi Og Hegnendeadlakas Han N Ininau Lti Rnasspolitics Claim That The Enemy In The Would Be Publicerages De Vended Car E-Atm Sampus | Sam Awin Ple . 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Further Reproduction Prohibited Without Permission The 1St Drunk Driving Was A Regular Tople Drunk Drivers And Drug Offenders Speaks In The Media And The Term Vestgated Deliver Volumes Regarding Who Is Viewed As Dispos. Necame Part Of The American Lexicon Able Someon E To Be Purged From The Bod Yat The Claw Of The Decade, Drunk Drivers Politie And Who Is Not. Drunk Drivers Are Were Responsible For Approximately 22,000 Predominately White And Male White Men Deatles Annually And Overall Alcohol Related Comprised 78 Percent Of The Arrests For Drunk Deaths Were Close To 100.000 A Year. By Con Driving When The New Mandatory Minitrant, During The Same Time Period, There Mums For The Offense Were Being Adopted. Were No Prevalence Statisties At All On Crack. They Are Generally Charged With Misdemean Much Less Crack-Related Deaths. In Fact, The Ons And Typically Receive Sentences Involving Number Of Deaths Related To All Illegal Drugs Fines, License Suspension, And Community Combined Was Tiny Compared To The Num. Service Ber Of Deaths Caused By Drunk Drivers. The Although Drunk Driving Carries A Far Total Of All Drug Related Deaths, Whether Trom Greater Risk Of Violent Death Than The Use Or Aids Drug Overdose Or The Violence Asset Sale Of Illegal Drugs, The Societal Response To There Are More African-American Adults Under Correctional Control Today Than Were Enslaved In 1850. Ated With The Illegal Drug Trade Was Estimated Drunk Drivers Has Generally Emphasized Keep At 21,000 Annually Less Than The Number Of Ing The Person Functional And In Society While Deaths Directly Caused By Drunk Drivers, And Attempting To Respond To The Dangerous Behov A Small Fraction Of The Number Of Alcohol For Through Treatment And Counseling, People Related Deaths That Occur Every Year. Charged With Drug Offenses, Though, Are Disin Response To Growing Concern-Fueled Proportionately Poor People Of Color. They Are By Advocacy Groups Such As Madd And By Typically Charged With Felonies And Sentenced The Media Coverage Of Drunk Driving Fatal To Prison. If And When They're Released, They Ities-Most States Adopted Tougher Laws To Become Members Of The Undercaste, No Lonpunish Drunk Driving. Numerous States Now Ger Locked Up But Locked Out--For The Rest Of Have Some Type Of Mandatory Sentencing For Their Lives This Offense Typically Two Days In Jail For A This Is Not A Problem Begging Merely First Offense And Two To 10 Days For A Second For Policy Reform. Much More Is Required Of Offenseus. If We Fail, As A Nation, To Awaken To Thebasic Humanity Of All Those Cycling In And New Laws Governing Crack Cocaine Out Of Prison Today, And If We Fail To Comwere Passed At The Same Time Legislatures Were Mit Ourselves To Ending Mass Incarceration, "Getting Tough" On Drunk Drivers. But Notice Future Generations Will Judge Us Harshly A The Contrast: While Drunk Driving Results Human Rights Nightmare Is Occurring On Our In A Few Days In Prison Possession Of A Tiny Watch. Amount Of Crack Carries A Mandatory Mini We Must Do More Than Bring Water To Mum Sentence Of Five Years In Federal Prison. Those Stranded In The Desert. We Must Act With In Fact, Some People Are Serving Life Sentences Courage And Tell The Truth About What Is Hap For Minor Drug Offenses. In Harmelin Vs. Pening In The Other America. In The Words Of Michigan, The U. S. Supreme Court Upheld Cornel West, "Justice Is What Love Looks Like A Sentence Of Life Imprisonment For A Defen In Public. If We Aim To Show Love, We Must Be Dant With No Prior Convictions Who Tried To Willing To Work For Justice Sell 2) Ounces Of Crack Cocaine. The Court Concluded That Life Imprisonment Was Not Michelle Alexander, A Longtime Civil Rights "Cruel And Unusual Punishment" In Viola Advocate And Litigator, Is An Associate Profes Tion Of The Eighth Amendment, Despite The Sor Of Law At The Moriz Callige Of Law And Fact That No Other Developed Country In The The Kinwan Institute For The Study Of Race And World Imposes Life Imprisonment For A First Lovity At Ohio State University Artions Of Time Drug Offensethis Article Are Alaped From Her Book The New "The Vastly Different Sentences Afforded Lim Cmnp Min

Dextromethorphan (DXM)

DXM is found in over-the-counter cough and cold medicines such as Robitussin, Zicam, Delsym • DXM use is often called "Robo-tripping" • DXM in large quantities produces sensory distortion, hallucinations, and feelings of dissociation from one's body, alternate reality • Effects can last 4-6 hours • Large quantities of the chemicals in cough syrup can be toxic and dangerous • Popular among adolescents and young adults • Legal to buy and sell in US

ASAM Definition of addition

Definition of Addiction Background Clear language and terminology in medicine is critically important in communicating current understandings of disease, risk factors, diagnosis, prognosis, treatment options, health, and wellness to patients, the public, policy makers, media, and others. Given the stigma associated with substance use and addiction, this is especially true for addiction medicine. Terminology in this area has long presented challenges to clinicians, patients, family members, policy makers, the media, and the general public. Even the name of the American Society of Addiction Medicine has evolved from previous terms found in the titles of predecessor organizations: alcoholism, alcohol and other drug dependencies, addictionology, and , finally, addiction medicine. To help clarify the meaning of addiction -related terms as used by ASAM, the ASAM Board in 2007 endorsed the establishment of a Descriptive and Diagnostic Terminology Action Group (DDTAG). This group conducted extensive research and deliberated at length to develop ASAM 's 2011 long and short definitions of addiction * as well as definitions for terms related to treatment, recovery, and the spectrum of unhealthy substance use. The DDTAG noted that variations in assumptions about what constitutes the desired outcomes of rec overy, whether facilitated by professional treatment or not, were inherent in terminology challenges. Since 2011, the public understanding and acceptance of addiction as a chronic brain disease and the possibility of remission and recovery have increased . At the same time, there is growing acknowledgment of the roles of prevention and harm reduction in the spectrum of addiction and recovery. In response, ASAM's Board in 201 8 recognized the need for an updated definition of addiction that would be more ac cessible to many of ASAM's stakeholder groups, including patients, the media, and policymakers. Accordingly, the Board appointed a Task Force to Update Terms Related to Addiction and the Treatment of Addiction. With the input of internal and external stake holders, the Task Force revised the definition of addiction for use in ASAM's policy statement s. The Task Force also recommended that definitions for "medication -assisted recovery (MAR)" and "medication -assisted treatment (MAT)," which had been identified by the DDTAG as transitional terms, be retired from use in ASAM documents. With the evolution of addiction treatment and its increasing integration with general medical care, the Task Force recommended ASAM adopt general medical terminology to describe addiction treatment. Therefore, ASAM recommends using the term "medication" to refer to any FDA -appr oved medication used to treat addiction. However, ASAM recognizes the continued widespread use of the acronym "MAT" in laws, regulations, academic literature, the media, and the vernacular, and ASAM suggests "MAT" be read and understood as "medi cations for addiction treatment. " *archived in 2019 Definition : Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual's life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases

Prevalence of COD

Many people with substance use disorders also have mental illnesses. ◦Approximately half of those in addiction treatment have a mental health diagnosis. Many of those with serious mental illness also use substances. ◦The most common co-occurring disorder is SUD and SMI. People with SMI are more likely to have a SUD than those without SMI. In one research study, among 141 adults in a substance abuse outpatient treatment program, 56% reported a co-occurring mental illness: ◦43.3% had a mood disorder (e.g., Depression/Bipolar) ◦35.5% had an anxiety disorder ◦12.8% had ADHD

When clients are in Relapse/lapse, counselors will

Discourage the client from internalizing failure and self-degradation. Identify and re-frame all-or-nothing thinking (e.g., "I will never achieve lasting sobriety" to "I can get back on track with my sobriety.") Support the client's immediate return to the recovery plan, affirm sobriety. Process the lapse/ relapse to fortify the recovery plan (e.g., If there was a new trigger, how will the client respond differently next time? What additional skills or resources are needed to be successful?)

A Generation of Sexual Addiction

ENNIFER RIEMERSMA and MICHAEL SYTSMA Richmont Graduate University, Atlanta, Georgia Sexual addiction has been an increasingly observed and re- searched phenomenon within the past 30 years. "Classic" sexual addiction emerges from a history of abuse, insecure attachment patterns, and disordered impulse control, often presenting with cross addictions and comorbid mood disorders. In contrast, a "con- temporary" form of rapid-onset sexual addiction has emerged with the explosive growth of Internet technology and is distinguished by "3Cs": chronicity, content, and culture. Of particular concern is early exposure to graphic sexual material that disrupts normal neurochemical, sexual, and social development in youth. Treat- ment modalities for "classic" and "contemporary" forms are over- lapping yet distinct, reflecting their unique etiologies and similar presentations. The phenomenon of atypically high sexual appetite has been the subject of clinical discussion for some time (Eisenstein, 1956; Orford, 1978; von Krafft-Ebing, 1898), yet it wasn't until Carnes (1983) that "sexual addiction" as a potential diagnosis began to move into mainstream awareness and come under vigorous debate (Karim & Chaudhri, 2012). Underlying robust discussion regarding the legitimacy of "sexual addiction," and whether it is a medical "disease" or merely a "social/experiential construct" (Kwee, 2007), is concern regarding overdiagnosis, misdiagnosis, and unhelpful labeling (Cloud, 2012; Coleman, 1995). Despite the strident nosological, philosophical, and clinical debate, it is evident by the number of distressed individuals seeking treatment for out-of-control sexual behavior that a type of compulsive, pathologic sexual behavior does exist (Garcia & Thibaut, 2010; Young, 2008). What this article describes as "classic" sexual addiction typically presents in the adult male, although female sexual addiction is a very real and Address correspondence to Jennifer Riemersma, Richmont Graduate University, School of Counseling, McCarty Building, 2055 Mt. Paran Road NW, Atlanta, GA 30327. E-mail: [email protected] 306 A New Generation of Sexual Addiction 307 increasing but understudied phenomenon (Ferree, 2003, 2010, 2012). "Clas- sic" sexual addiction has its etiology in a history of abuse (Carnes, 1991), insecure attachment patterns (Butler & Seedall, 2006; Creeden, 2004; Flo- res, 2004; Schachner & Shaver, 2004; Zapf, Greiner, & Carroll, 2008), and disordered impulse control (Blankenship & Laaser, 2004; Reid, 2007; Yen, Ko, Yen, Wu, & Yang, 2007). It typically evidences gradual onset, is often a companion to cross-addictions (Carnes, 1991; Irons & Schneider, 1994), and is speculated to function as the addict's self-soothing "solution" to comorbid mood disorders such as depression and anxiety (Bancroft, 2004; Coleman- Kennedy & Pendley, 2002; Weiss, 2004). Shame and a profound sense of personal worthlessness are among the toxic emotions that have been ob- served to both catalyze and maintain patterns of "classic" sexual addiction (Carnes, 1983; Ferree, 2010; Laaser, 2004). This article suggests that a second, distinctive form of sexual addiction has emerged in the wake of the explosive growth of Internet-accessible technology and the immediate entr ́ ee to explicit sexual material that it pro- vides (Delmonico & Griffen, 2008). It is proposed that this "contemporary" sexual addiction is a "rapid-onset" addiction distinguished by chronicity, content, and culture. Etiology stems from chronic exposure to sexually graphic online content, the uniqueness and intensity of which are theo- rized to facilitate rapid-onset addiction and to disrupt normal neurochemi- cal, sexual, emotional, and social development (Creeden, 2004; Schneider, 2005; Sunderwirth, Milkman, & Jenks, 1996), particularly when occurring early in the developmental process. Chronicity and content interact with, and are underscored by, rapidly changing cultural sexual norms trending toward virtual and nonrelational sex (Melby, 2010). While this toxic cock- tail of contemporary addiction may result in comorbid mood disorders, at- tachment ruptures, and cross-addictions, it is not necessarily catalyzed by them. It is suggested that treatment modalities for "classic" and "contemporary" sexual addiction are overlapping yet distinct, with the former emphasizing family of origin (Willingham, 1999), attachment (Flores, 2004), and trauma resolution work (Ferree, 2010; Laaser, 2004), and the latter emphasizing pre- vention, early intervention to promote neurochemical reprogramming (Kate- hakis, 2009), social and relational skills training, and in some instances, adolescent clinical specialization. HISTORY AND CONTROVERSY Sexually addictive behavior has been recorded even in the most an- cient texts (Judges 13-16 and; Prov. 5: 7, Holy Bible: New International Version) and has gone by many different names, including satyriasis in men (Bigelow, 1859; Moore & May, 1982) and nymphomania in women 308 J. Riemersma & M. Sytsma (Ellis & Sagarin, 1965). In 1892, Richard Krafft-Ebing discussed the point at which hyperesthesia (abnormally high sexual desire) reached pathological levels in Psychopathia Sexualis, and Eisenstein (1956) observed "hypersex- ual" behavior that progressed into "an addiction" in the 1950s. It was Patrick Carnes, however, who first popularized the concept with his landmark publication Out of the Shadows: Understanding Sexual Addiction (Carnes, 1983). Since that time, sexual addiction (Joannades, 2012; Reece, Dodge, & McBride, 2006) has gained increasing acceptance within portions of the professional community (Coleman-Kennedy & Pendley, 2002; Ferree, 2010; Laaser, 2004; Willingham, 1999). Unfortunately, clinical research and profes- sional dialogue have been impaired by the absence of robust scientific data, common nosology, or diagnostic consensus. Labels have ranged from "sexual addiction" (Carnes, 1983), "sexual impulsivity" (Barth & Kinder, 1987), and "nonparaphilic hypersexuality" (Kafka, 2001), to "compulsive sexual behav- ior" (Coleman, 1991; Quadland, 1985) and "dysregulated sexuality" (Win- ters, Christof, & Gorzalka, 2010). Diagnostic considerations have proven similarly controversial, reflecting larger philosophical concerns over pathol- ogizing normal sexuality or creating responsibility-dodging excuses for poor self-control (Cloud, 2011). Today, professional consensus is slowly materializing. "Excessive sex- ual drive" (nymphomania and satyriasis) is identified as a medical diagno- sis (F52.7) in ICD-10, the most recent international medical code (World Health Organization, 2008). While only indirectly addressed in the text of DSM-IV-TR as an example of a Sexual Disorder NOS (302.9) (Ameri- can Psychiatric Association, 2000; Schneider, 2004), "hypersexual disorder" was originally identified for inclusion in the DSM-5 (www.dsm5.org; Reid et al., 2012). Even without this inclusion, the movement toward profes- sional acceptance and diagnostic coherence accomplished by the DSM-5 working group and other field leaders has laid the groundwork for future consensus. Professionals in the behavioral sciences have observed: "The interactive features and availability online can be addictive ... Given the widespread availability of sexually explicit materials online, Internet sex ad- diction is the most common form of online behavior among users" (Young, 2008). It is important to note the diagnostic considerations for sexual addiction. Not all non-traditional sex-seeking behavior is addictive or necessarily prob- lematic. It is when behavior becomes life-dominating and volitional control is diminished that addiction may be present and professional intervention may be warranted. For the purposes of this article, "sexual addiction" is broadly defined as a disorder characterized by compulsive sexual behav- ior that results in tolerance, escalation, withdrawal, and a loss of volitional control despite negative consequences. A New Generation of Sexual Addiction 309 "CLASSIC" SEXUAL ADDICTION Among those authors and researchers who subscribe to the construct of sex- ual addiction, an image of the "classic" sex addict has begun to emerge within the literature. Certain themes notably repeat themselves as the histories of sex addicts are examined. Sexual, Physical, and Emotional Abuse Stories of abuse are stunningly prevalent among "classic" sex addicts. Patrick Carnes's well-known research with n = 1,000 sex addicts revealed that 97% had experienced emotional abuse, 72% were victims of physi- cal abuse, and 81% had been sexually abused (Carnes, 1991). Other re- searchers have corroborated these findings, noting a strong predictive cor- relation between a childhood history of abuse and later sexual addiction (Opitz, Tsytsarev, & Froh, 2009). Early trauma such as physical, emotional, and sexual abuse has been shown to dramatically impact neurodevelop- ment, which in turn has been associated with sexual behavior problems (Creeden, 2004; Katehakis, 2009). Trauma "blunts" the right hemisphere of the brain, which controls insight, regulation of emotion, and capacity for in- terpersonal connection (Katehakis, 2009). Not coincidentally, these impaired qualities are some of the very attributes that characterize the "classic" sexual addict. Impaired Attachment and Shame Insecure attachment (Ainsworth, 1969) and chaotic relationships within the family of origin are a second hallmark of "classic" sex addicts' histories (Butler & Seedall, 2006; Schachner & Shaver, 2004; Zapf, Greiner, & Carroll, 2008). Neglect, abuse, and/or abandonment leave the developing child with basic unmet needs, dysfunctional relational skills, fear of intimacy, and inappropri- ate or underdeveloped communication and conflict resolution skills (Earle & Crow, 1998). Chronic boundary violations, a family history of addiction, and rigid "roles" further impair development, producing shame, loneliness, isola- tion, anger, anxiety, and a profound sense of personal worthlessness (Ferree, 2010; Laaser, 2004). These dynamics create relational impairment and a toxic sense of shame that fuel the self-soothing mechanisms of "classic" sexual addiction (Carnes, 1983, 1989; Flores, 2004). Impulse Control Disorders Untreated attention deficit and hyperactivity disorder (ADHD) appears to be highly correlated with sexual addiction. It is speculated that the hallmark 310 J. Riemersma & M. Sytsma impulse dysregulation of ADHD is catalytic in the compulsive acting-out of the sex addict. Several telling parallels exist between persons with ADHD and those with sexual addiction. Both have stimulus-seeking brains, both gravi- tate toward high-risk behavior, and both have a low threshold for boredom (Blankenship & Laaser, 2004). Neurochemical dysregulation is implicated in both contexts (Blankenship & Laaser, 2004). The presence of ADHD has even been found to influence the sex addict's readiness to address compul- sive behaviors (Reid, 2007). Researchers suggest that trauma work, relevant to both disorders, is a treatment priority for joint resolution (Blankenship & Laaser, 2004). Comorbid Mood Disorders and Co-Addictions Finally, comorbid mood disorders and addictions have been widely observed to play an interrelated role in "classic" sexual addiction. Chemical addic- tions, compulsive gambling, shopping, working, and eating are among the "crossover" addictions that not only coexist but may even play a role in the ritualistic behavior leading up to addictive sexual acting out (Carnes, 1991; Irons & Schneider, 1994). Research further demonstrates that depression and anxiety are significantly higher in the sexually addicted population than in the population in general (Bancroft, 2004; Weiss, 2004). This correlation is surely multidimensional, but sexual compulsivity is suggested to be a causal mood-altering "solution" that mediates the anxious or depressive affect of the addict. In summary, a "classic" sex addict in the literature is typically an adult male with a history of abuse, insecure attachment, and impulse dysregulation, along with typically comorbid addictions, concurrent mood disorders, and a profound sense of personal shame and worthlessness. Addictive patterns as "solutions" to the "classic" addict's pain often progress along developmental timelines and typically become increasingly entrenched over a period of years. "CONTEMPORARY" SEXUAL ADDICTION This article suggests that "contemporary" sex addiction is the product of a toxic trilogy: chronicity, content, and culture. Repeated and chronic (over time) exposure to sexually graphic content that is reinforced by a highly sexualized culture creates a "perfect storm" in which addictive sexual be- havior may arise. Rapid-onset features are a hallmark of "contemporary" sex addiction, due to the powerful interaction of these "3Cs." Because exposure is the pivotal variable, "contemporary" demographics are highly diverse, do not conform to the markers of previous addiction models, and may not be A New Generation of Sexual Addiction 311 well served by traditional formulaic interventions (Cantor et al., 2013). "Con- temporary" sexual addiction is unique in that, where access to technology is present, all ages, cultures, genders, races, socioeconomic levels, and ed- ucation levels appear to be equally affected. "Classic" precursors to sexual addiction, such as impaired attachment, abuse, or mood disorders, are no longer implicated as causal, though they may serve as moderators for the degree of severity of the developing addiction. Interestingly, "classic" ad- dicts are particularly vulnerable to cyber-exacerbation of existing addictive patterns, since the disembodied and nonrelational qualities of Internet sex are uniquely alluring to individuals with attachment disorders. Of particular concern is the impact of "contemporary" sexual addiction on youth (what this article calls the "GenText" generation: roughly aged 26 years and under) whose neurologic, social, sexual, and emotional devel- opment are dramatically shaped by early and chronic exposure to sexually explicit content on the Web. While distinct from the abusive traumas in the "classic" addict's history, this early exposure in itself may constitute a "trauma," the severity of which is likely inversely related to the age of first exposure. Neurochemical alterations associated with addiction profoundly influ- ence the young adults' developing brain, and may well set the young addict up for more intense and dangerous forms of sexually addictive behavior (Daneback, Ross, & Mansson, 2006; Leshner, 2001). Children and youth are uniquely at risk for significant impairment due to neurobiologic alteration, undeveloped executive-functioning and impulse-regulating functions of the prefrontal cortex, and social isolation resulting from consuming online be- havior that displaces normal relational development, learned courtship, and romantic behaviors (Boies, Cooper, & Osborne, 2004). Social isolation, lone- liness, and relational regression are strongly correlated with Internet pornog- raphy use (Yoder, Virden, & Amin, 2005), as are depression and impaired sexual and interpersonal relationships (Corley & Hook, 2012; Morgan, 2011). Thus, neurochemical, social, and mental health implications for the youngest addicts are of significant concern. Chronicity Estimates of the average age of first exposure to Internet pornography are challenging to calculate and range from 10 to 14 years (Johnson, 1997; Melby, 2010; Sabina, Wolak, & Finkelhor, 2008), though it is probable that the av- erage age is declining due to the widespread use of Internet devices such as phones and gaming systems among preteens and children. First expo- sure, particularly with very young children, is often accidental, as a result of encountering typosquatting (pornography websites with names that mirror common misspellings of children's Web searches), inadvertent clicking on a link, or stumbling across sexual photos or websites brought up by a Web 312 J. Riemersma & M. Sytsma search for homework or school projects. Adolescents and adults may evi- dence more intentional cybersex-seeking behavior for initial exposure, but the rapid onset of addictive features is a common response among all age groups (Carnes, 1983). Given that the addictive qualities of Internet pornography have been likened to that of crack cocaine (Mary Anne Layden, U.S. Senate Testimony, October 18, 2004), it is reasonable to anticipate that exposure may lead to repetitive pornography-seeking behavior. Compulsive patterning has been observed to rapidly become obsessive, with swift fixation occurring to new and more extreme behaviors (Carnes, 1983), due to the "anonymity, afford- ability, and accessibility" of graphic Internet content (Cooper, 1998). A recent Harvard Mental Health Newsletter (July 2011) underscores the way in which addiction "co-opts" the brain, noting that the speed and re- liability of dopaminergic release in cybersex exposure overload the reward circuitry of the brain. "The brain responds by producing less dopamine or eliminating dopamine receptors ... as a result ... dopamine has less impact on the brain's reward center." Overproduction of dopamine requires height- ened risk and intrigue to sustain pleasure levels (tolerance). Subsequently, increasing amounts of time and energy are invested in cybersex-seeking be- havior in search of an elusive "high," which quickly leads to chronic, and often addictive, behavior. Of particular concern is the manner in which chronic exposure to graphic images profoundly alters the arousal template of affected individuals. Patrick Carnes articulates a stepwise progression involved in the "addictive neuronal adaptation to cybersex" (Carnes, 2007) in which chronic exposure to cybersex leads to prolonged brain stimulation and dopamine production (Carnes, 2003). "Machine-enhanced sexual arousal" creates a new "sexual set point" and alteration of synaptic connections with the evolution of new arousal neuronal networks that fundamentally alter the "arousal template" (Carnes, Murray, & Charpentier, 2005; Leshner, 2001). Preoccupation and heightened obsession incorporate "distorted normality" (Boies, Cooper, & Osborne, 2004; Cooper, Delmonico, Griffin-Shelley, & Mathy, 2004), and the ability to have/enjoy normal sex is diminished, as is the capacity to in- hibit riskier sexual behavior (Daneback, Ross, & Mansson, 2006). Computer behavior becomes highly ritualized, and detachment from real-life sexual partner(s) leads to relational disturbance, disruption in life functions, and escalated high-risk/novelty-seeking behavior (Philaretou, Mahfouz, & Allen, 2005; Schneider, 2003). Thus, chronicity of exposure is linked to a wide variety of social, neurobiological, sexual, and relational consequences. Content Internet sexual content is distinctive in its graphic, explicit nature. Any com- bination of number, gender, orientation, age, human, or nonhuman sexual 318 J. Riemersma & M. Sytsma early and chronic exposure to graphic cybersexual content within a highly sexualized culture drives sexual compulsivity, whereas the "classic" addict is driven by trauma, abuse, disordered attachment, impulse control impairment, shame-based cognitions, and mood disorders. While both may share similar presentations (compulsive behavior, mood disorders, relational impairment), etiology and some facets of treatment will likely be distinct. "Classic" sexual addiction, while very much debated, has received a great deal of attention in the research, in the professional community, and in the popular culture. Treatment options, while not widespread, are varied and available, even to the extent that certified sexual addiction therapist (CSAT) training is conducted across the United States (www.iitap.com), allowing mental health professionals to receive extensive credentialing in work with "classic" sexual addiction. "Contemporary" sexual addiction, however, is an underexplored phe- nomenon, particularly with children and adolescents. Research and litera- ture are scarce and, interestingly, often published from countries outside the United States (He, Li, Guo, & Jiang, 2010; Yen et al., 2007). Research on young women and sexual addiction is virtually nonexistent. Specialized treatment with child and adolescent therapists trained in sexual addiction is extremely uncommon. Yet significant numbers of children, adolescents, and young adults are in need of just such specialized treatment, and the professional community is delayed in responding. Research, dialogue, and education are urgently needed in order to appropriately meet the needs of those youngest among our population who are struggling with sexually compulsive behavior.

The Addictive Nature of Rewarding Behaviors

Email KEY POINTS Many scientific communities and accrediting bodies have officially recognized behavioral addictions. Addiction can take the form of alcohol and other drug misuse as well as compulsive engagement in rewarding behaviors. For vulnerable individuals, a rewarding behavior can be compulsive, out of control, continue despite negative consequences, and induce cravings. Potentially addictive behaviors activate reward circuitry in the brain and are both positively and negatively reinforcing. Historically, when people heard the word "addiction" they immediately thought of an individual misusing illicit drugs or alcohol. The concept of addiction was always linked to the ingestion of a substance—specifically, a substance that was pleasure-inducing (e.g., marijuana, opioids, nicotine). As a mental health profession, we have come a long way in our understanding of addiction. Rather than only referring to the compulsive misuse of substances, we now know that addiction can manifest in compulsive engagement in rewarding behaviors. Indeed, addiction is a disorder with many different faces. article continues after advertisement Now, some individuals may question the idea of behavioral addictions and wonder how someone could be addicted to drug-less activity. The purpose of this post is to illuminate the nature of behavioral addictions so that we as clinicians (and as a society), will be more prepared to identify and respond to addictive behaviors in effective ways. Behavioral addiction and the scientific community First, it is important to note that a variety of scientific communities have recognized the existence of behavioral addictions. Gambling addiction is widely accepted (first introduced in the Diagnostic and Statistical Manual of Mental Disorders, third edition, as an impulse control disorder) and other addictive behaviors have been proposed with varying degrees of empirical support (e.g., sex, gaming, shopping, social media, food, pornography, exercise, nonsuicidal self-injury). The American Society of Addiction Medicine (ASAM) first included behaviors in their official definition of addiction in 2011 and retained that inclusion in the newest version released in 2019. Additionally, the DSM-5 (American Psychiatric Association, 2013), includes a chapter titled, Substance-Related and Addictive Disorders, which, by its name, acknowledges that not all addictive disorders include substances. Moreover, the International Classification of Diseases, 11th revision (World Health Organization, 2018), includes a section titled, Disorders Due to Addictive Behaviours, again, giving credence to behavioral addictions. Finally, accrediting bodies of professional training programs, such as the Council for Accreditation of Counseling & Related Educational Programs (CACREP; 2016), include standards mandating that students be familiar with addiction and addictive behaviors. Although debate exists regarding which behaviors constitute addictions, and if the best conceptualization is an addiction model or an impulse control model, clinicians and 12-step programs have been responding to addictive behaviors for decades. Indeed, for a small subset of the population, engagement in certain activities can become compulsive, out of control, continue despite negative consequences, and induce cravings when the individual is not engaging (Griffiths, 2005; Kardefelt-Winther et al., 2017; Sussman & Sussman, 2011). These individuals likely have a behavioral addiction. Yet, how is it possible to be addicted to an activity devoid of drug use? The answer lies in the brain. Addictive behaviors and the brain Drugs of abuse, like alcohol and cocaine, are extremely rewarding, meaning they activate the brain's reward circuitry (which involves the mesolimbic dopaminergic pathway and several structures such as the ventral tegmental area, nucleus accumbens, and prefrontal cortex). Illicit drugs and alcohol are exogenous chemicals, meaning they originate outside of the body. article continues after advertisement When individuals engage in rewarding behaviors, they trigger the release of endogenous chemicals, which originate inside the body (specifically, in the same reward circuitry activated by drugs of abuse; Berridge & Kringelbach, 2015; Karim & Chaudhri, 2021; Wise & Robble, 2020). These endogenous chemicals often are neurotransmitters such as dopamine, opioids, endocannabinoids, serotonin, and GABA, which are implicated to various degrees in the experience of reward. In essence, individuals with behavioral addictions use pleasurable behaviors to activate their reward system in the brain as a means of changing the way that they feel. Indeed, potentially addictive behaviors both induce pleasurable feelings and ward off distressing feelings, thus, like drugs of abuse, addictive behaviors are both positively and negatively reinforcing (Goodman, 2001; Parylak et al., 2011; Wise & Koob, 2014). THE BASICS What Is Addiction? Find a therapist to overcome addiction Vulnerabilities to behavioral addiction Now, it is important to reiterate that not everyone who engages in a rewarding behavior develops a behavioral addiction. Likewise, not all behaviors have the same degree of addiction potential. Instead, when a vulnerable individual engages in a highly rewarding behavior, there is a risk of developing a behavioral addiction (Schüll, 2012). article continues after advertisement So, what makes an individual vulnerable? There are many hypothesized factors including genetic predispositions (such as reward deficiency syndrome; Blum et al., 1996), adverse childhood experiences, specific personality traits, psychological distress or mental health concerns, or the availability and social modeling of particular behaviors. In sum, there is no one determining factor to identify those at risk of developing a behavioral addiction. Instead, the biopsychosocial model of addiction asserts that many factors could play a role and clients should be conceptualized holistically. ADDICTION ESSENTIAL READS "Could It Happen to Me?" Our Personal Risk Factors 3 Reasons Therapy Can Fail With Addiction Okay, but which behaviors have high degrees of addiction potential? Types of addictive behaviors Potentially addictive behaviors are those that stimulate the reward circuitry in the brain and are associated with natural or learned rewards (e.g., gambling, sex, pornography, internet gaming, shopping, social media, food; Comings & Brum, 2000). Some of these behaviors involve what has been coined supernormal stimuli (Barrett, 2010), which refer to artificial exaggerations of natural instincts such as processed foods high in fat and sugar, internet pornography with enhanced sexual partners, highly stimulating virtual worlds of Massively Multiplayer Online (MMO) games, or fast-paced electronic gambling machines. Importantly, depending upon the susceptibility of an individual, engagement in a particular behavior can lead to varying degrees of reward (e.g., one person may play an MMO and feel extremely euphoric while another may play and feel mildly entertained). Thus, both the traits of the individual and features of the rewarding behavior contribute to the development of behavioral addictions. article continues after advertisement In conclusion, behavioral addictions are a global phenomenon affecting individuals across the lifespan (many first engagements in potentially addictive behaviors begin in adolescence and can continue throughout older adulthood). Like chemical addiction, it is proposed that individuals with behavioral addictions lose control over their behavior, engage compulsively in the behavior, crave the behavior when not engaging, and continue to engage despite negative consequences (ASAM, 2019; Griffiths, 2005; Kardefelt-Winther, 2017; Sussman & Sussman, 2011). As we become more informed about behavioral addictions, we can provide effective prevention, intervention, and advocacy efforts for those with addictive behaviors. Raising awareness about behavioral addictions is one of the first steps toward destigmatizing the disorders and reducing the shame that may keep affected individuals from seeking treatment. To learn more, consider exploring the references listed below.

Engaging

Engaging is the process of creating a strong working relationship built on understanding and empathy. To do this, MI counselors use: Reflective Listening - building trust by letting clients know the counselor hears and understands their experience. Trust is built when the client feels heard and valued. Reflections - Counselors use reflections, or stating back what they heard the client say, to communicate understanding. Client: "I've been to treatment before. I started using again in three months." Counselor: "You were disappointed before and expect to be disappointed again."

Additional Synthetic

Example of Synthetic Bath salts • Synthetic marijuana • Flakka • Krokodil • MDMA Effects on the Body Varied and unpredictable; may include: bizarre behaviors, increased heart rate, high blood pressure, dysregulation of body temperature, adrenalin rush, violent behavior, euphoria, hallucinations, psychosis Withdrawal Varied and may include: depression, anxiety, irritability, poor concentration, poor memory, fatigue, tremors, paranoia, flu-like symptoms

Inhalants

Examples of Inhalants Aerosols or Solvents: • Gasoline • Paint thinner • Glue • Nail polish remover • Degreaser • Spray paint • Rubber cement Effects on the body An "experience" or "trip" • Dream-like state • Perceptual distortions • Delusions • Hallucinations • Synesthesia (merging of the senses) • Flashbacks (even years after use) Withdrawal No physical withdrawal symptoms

Amphetamines

Examples: Dexedrine, Adderall, Ritalin, Concerta - used to treat ADHD • Synthetic drugs (made from chemicals), typically powder or pills • Taken orally, smoked, crushed and snorted, or dissolved in water and injected • Speed- Amphetamine sulfate • Used to stay alert and awake (higher prevalence of use among students, pilots, truck drivers, etc.) • Longer acting - 6-12 hours • On the street: $5-$10 per pill • Possession without a prescription is a felony (because it is a controlled substance, specifically a schedule 2 drug)

adolescent counseling family

Family And Adolescent Counseling For Addiction. Module 6. Echd 3170. This Module Is All About The Impact Of Active Addiction On The Family. Given What You Have Learned About Addiction Thus Far, Consider How Family Members Also Are Impacted By The Disease Of Addiction. For Those Who Have Addiction In Their Families, This Module May Be Challenging At Times Or Trigger Powerful Emotions. If You Find Yourself In That Place, You Are Encouraged To Seek Support And I Can Direct You To Counseling Resources If Needed. Just Send Me An Email. Let's Dive In. Loading.... Experiences Of Non-Addicted Family Members. •Let's Start By Watching A Scene From The Movie, Shattered Spirits. Pay Attention To Each Of The Family Members As You Watch The First 11 Minutes And 30 Seconds. •After Viewing The Clip, Consider The Following Questions:. •What Comes Up For You As You Watch This Family's Experience? •What Are The Characteristics Of The Family? •The Father In This Family Has An Alcohol Use Disorder. How Are The Other Family Members Impacted? Click On The Hyperlink. Active Addiction In The Family. •There Are Several Predictable Characteristics Of A Family With Active Addiction:. •Family Is Marked By Secrecy, Denial Of The Addiction, Shame For "Causing" The Addiction, And Self-Blame. •Family Members Are In A Constant State Of Readjustment And Adaptation In Response To The Member With Addiction. •Family Members Are Alert And Hypervigilant As They Monitor The Family Member With Addiction. •Active Addiction In The Home Increases The Risk Of:. •Intimate Partner Violence; Child Abuse; Criminal Behavior. Loading.... Effects Of Addiction On Family Members. •The Spouse/Partner Of The Addicted Family Member Often Exhibits These Traits:. •Low Self-Esteem. •Compromises Personal Goals Or Values To Focus On Partner With Addiction. •Higher Risk Of Mental Health Issues. •Financial Stress (Due To Partner's Addiction). •Tries To Control The Partner With Addiction. •The Parents Of An Addicted Teen/Young Adult Often Exhibit These Traits:. •Overly Attentive To Addicted Child (Possibly To The Neglect Of Other Children). •Self-Blame— "What Did We Do Wrong That Led To This?". •Higher Risk Of Mental Health Issues. •Thoughts Revolve Around Child With Addiction. Effects Of Parental Substance Abuse On Children. •A Parent's Active Addiction Can Have A Negative Impact On The Physical And Emotional Development Of Children:. •If One Or More Parent Is Incapacitated Due To Intoxication, They Likely Will Not Respond To A Child Who Is Crying Or In Need. After Time, Babies Stop Providing Cues (Crying) And Disengage Because They Have Learned That Their Cries Do Not Elicit A Parental Response. •Children May Experience Parentification, In Which They Are Forced To Take On Responsibilities And Behave Like Adults To Compensate For One Or More Parent With Addiction. •One Or More Parent With Addiction May Not Be Able To Provide Supervision Or Appropriate Monitoring Of Children. •Living In A Home With Active Addiction Can Lead To Adverse Childhood Experiences Or Aces, Which Are Linked To Negative Physical And Psychological Consequences. Child Abuse Or Neglect. •Active Addiction In The Family May Contribute To Child Abuse And/Or Neglect. •Types Of Abuse: Physical, Emotional, Sexual, Spiritual, Or Exploitation. •Parental Substance Abuse May Lead To "Failure To Provide" In Which The Child Experiences Physical Neglect, Emotional Neglect, Medical/Dental Neglect, And/Or Educational Neglect. •Parental Substance Abuse May Lead To "Failure To Supervise" In Which Children Are Left Alone For Extended Periods Of Time Or In Harmful Environments (E. G., Settings With Access To Drugs). •Endangering A Child Is Another Form Of Abuse. This Occurs When A Child (Under 18 Years Of Age) Is Allowed To Witness A Felony, Battery, Or Family Violence, Or Allows A Child To Be Present When Making Methamphetamine, Or Driving Under The Influence. Child Abuse Or Neglect. •Counselors Are Mandated Reporters (Along With Almost Every Professional Who Works With Children, Including Teachers, Social Workers, Clergy, Nurses, Police, And Youth Program Volunteers). •When A Mandated Reporter Becomes Aware (Or Has Suspicions) Of Child Abuse Or Neglect, They Make A Report To The Division Of Family And Children Services (Dfcs) Within 24 Hours. •Mandated Reporters Don't Need To Investigate The Validity Of The Abuse---They Just Report It And Allow Dfcs To Complete An Investigation. •Medical Staff Are Required To Report When It Is Suspected (Or Confirmed) That Infants Were Exposed To Drugs And Alcohol While In Utero. •Fetal Alcohol Spectrum Disorders (Fasds) Can Occur If Alcohol Is Consumed During Pregnancy (Characterized By Low Birth Weight, Central Nervous System Issues, Learning Impairments, And Distinct Facial Characteristics). Facial Characteristics Of Fasds. Support For Family Members Of An Individual With Addiction. •Many People Have Heard Of Aa, Or Alcoholics Anonymous, Which Is A Support Group For Those With Addiction. Support Groups Also Exist For The Family And Friends Of Those With Addiction:. •Al-Anon Family Groups Is A 12-Step Program For The Family And Friends Of Those With Addiction. •Alateen Is A Fellowship For Young People Who Have Been Affected By Someone Else's Addiction. •Family Members Of Those With Addiction Also Benefit From Individual, Group, And Family Counseling. Click On The Hyperlink To And Read The Frequently Asked Questions About Al-Anon. Detachment With Love. •Let's Talk A Little Bit More About Al-Anon, Which Can Be A Great Resource For The Family And Friends Of Those Who Have Addiction. •The 3 Cs Of Al-Anon Are:. •I Didn't Cause It ("It" Being The Loved One's Addiction). •I Can't Control It. •I Can't Cure It. •Al-Anon Promotes The Idea Of "Detachment With Love":. •"Detachment With Love Means Caring Enough About Others To Allow Them To Learn From Their Mistakes. It Also Means Being Responsible For Our Own Welfare And Making Decisions Without Ulterior Motives-The Desire To Control Others" (Hazelden, 2014). Loading.... •Read The Poem To The Left, Which Is Often Read In Al-Anon Meetings. What Stands Out To You? What Are Your Reactions? Family Roles In Addicted Family. •Sometimes, In Families In Which A Parent Has Addiction, The Children Can Take On Particular "Roles" To Distract From The Addiction:. •Typologies Of Children In A Family With Active Addiction Often Include:. •Hero Child: Typically The Oldest, Becomes Very High Achieving To Compensate For The Chaos At Home. Distracts From Addiction By Being The Best (At School, Sports, Hobbies, Work, Etc.). •Scapegoat: This Child Is Seen As The "Problem Child" Although The Child Is Typically Acting Out As A Result Of The Chaos In The Home. The Child May Blame Him/Herself For The Parent's Addiction. •Lost Child: This Child Is Often Not Noticed Due To The Chaos In The Home. The Child May Engage In Imaginative, Solitary Play, Reading, Or Spending Time Alone. •Mascot: Often The Youngest Child, The Child Uses Humor Or Silliness To Distract The Family From The Chaos Caused By Addiction. May Be The "Class Clown" At School And Has Learned To Diffuse Tense Situations With Humor. Adolescent Substance Abuse. Click On The Hyperlink To Watch The Video. Now Let's Talk Specifically About Substance Use Among Teenagers And Youth. Adolescent Substance Abuse Statistics. •According To The Monitoring The Future Survey:. •1 In 16 High School Seniors Use Marijuana Daily. •Among 8Th-12Th Graders, 37.9% Have Used An Illicit Drug. •Among 8Th-12Th Graders, 35.9% Have Been Drunk. •In 2008, There Were Over 141,000 Admissions For Adolescents Into A Substance Abuse Treatment Program. •The Leading Referral Source For Adolescents To Get Into Substance Abuse Treatment Programs Is The Criminal Justice System. Risk Factors For Substance Abuse Among Adolescents. •Below Are A List Of Potential Risk Factors For Substance Use Among Teens:. •Early Behavior Problems. •Low Commitment/Involvement In School. •Substance-Using Peer Group. •Low Parental Attachment/Involvement. •Family History Of Substance Abuse. •Poverty. •Low Self-Esteem/Self-Worth. •Exposure To Violence. •Bullying. •Abuse. Considerations For School Counselors. School Counselors Can Help Recognize Adolescent Substance Abuse By Considering The Following:. 1. Has There Been A Change In The Student's Behavior? 2. Has There Been A Change In The Student's Attitude? 3. Has The Student's Appearance Changed? 4. Has The Student's Peer Group Changed? 5. Has The Student Stopped Previous School Activities? 6. Is The Student Frequently Tardy Or Absent? 7. Does It Appear The Student Has Lost Interest In School? 8. Does The Student Demonstrate Symptoms Of Intoxication? 9. Is The Student's Gpa Dropping? 10. Does The Student's Present To Counseling Under The Influence (Slurring Words, Bloodshot Eyes, Drowsy, Etc.)? Adolescent Addiction Treatment •There Are Many Options For Substance Abuse Treatment Services For Adolescents, Including Outpatient Treatment And Residential Treatment. These Treatment Programs May Include: •Family Counseling/Home Visits •Individual And Group Counseling (Outpatient Or Residential Treatment) •Recovery High Schools (High Schools Specifically For Teens In Recovery) •Equine Therapy/Pet Therapy •Art Therapy •Lyric Interpretation (In Group Counseling, Adoles.

The Cycle of NSSI

Feel bad (Negative affect)>Begin thinking of NSSI (Rumination)>Engage in NSSI (Temporary relief)>Shame, isolation, fear, anxiety (Crash)

Social Class Considerations

Finally, let us consider socioeconomic status in addictions treatment. A correlation exists between poverty and substance use. ◦Many illegal drugs are expensive (thus abuse can lead to financial problems). Additionally, lack of education, unemployment, and financial strain have been associated with substance use. Some alcohol and tobacco companies target poorer areas for ads, marketing, and stores. Moreover, those in poverty may have difficulty accessing treatment: For example, without insurance, residential treatment is approximately $1,000.00per day

Stages of change/TRanstheoretical model (TTM)

First, let's provide some context. The TTM was developed by Prochaska and DiClemente in 1983. It was used to conceptualize clients' readiness for change. It is conceptualized as a spiral rather than linear movement. Clients move forward and back through the stages Procontemplation-Contemplation-Preparation-Action-Maintenance (Replace---start over)

When Clients are in maintenance, counselors will:

Focus on relapse prevention strategies. Continue to build reinforcers for positive change in client's life. Help client practice coping strategies for challenges in life. Explore client holistically and work to enhance overall wellness. Work through feelings about the past (regrets, guilt, and shame about substance use and behavior while intoxicated).

Integrated Treatment

For clients with COD, the answer is integrated treatment in which practitioners attend to whole person by addressing substance use and mental heath simultaneously. Integrated treatment has better outcomes than treating each issue separately (for example, meth abuse and then depression). Integrated treatment includes both psychological interventions and substance abuse interventions (more complex treatment, but more effective). There are also 12-step recovery programs for those with COD: Dual Recovery Anonymous, Double Trouble in Recovery (DTR), Dual Diagnosis Anonymous.

Gender Considerations

Gender also is an important factor in addictions treatment. Males ◦Overall, males are more likely to develop substance dependence than females. (Pause to consider, why might this be? What aspects of gender role socialization might contribute to this trend?) ◦Males also may be more likely to struggle with the emotional aspects of treatment and recovery. Females ◦Females experience more stigma associated with substance abuse than males. ◦Additionally, pregnant women who use substances pose many risks for their unborn children. For example, fetal alcohol syndrome is caused by alcohol consumption during pregnancy; it is characterized by neurological impairment and physical abnormalities among infants due to alcohol exposure. Transgender, Non-Binary, and Gender Fluid Individuals ◦Minority stress from prejudice and discrimination. ◦Lack of cultural competence in treatment and healthcare options (ex: residential facility that only has a male and female unit). Bars and clubs utilized as "safe spaces" for socialization

Guidelines for Professional Referral to Alcoholics anonymous and other 12 step groups

Guidelines For Professional Referral To Alcoholics Anonymous And Other Twelve Step Group Sruchard I. Riordan And Lani Walsh Tekig Heller Who Have Always In Addition To The Stag Problem, Agine Non Report Grouse Val "Twelve Seperup Bane Bere Self The Purpuar. In This And For Share Review Alahlar Afyans Mal Heel And Larger Welve Roup Theyyam Banoren And Jew Guidelines For Controllerat Elf-Help Groups Have Been Treasingly By Councis As An Adjunct In The Work Riordan & Beggs, 1987). The Various Popular Because Of Their Perceived Effect Rss Creating Addictive Disorders. Indeed, Akohol Treatment Centers Almeaniformy Evolve Their Patients In Such Groups Daring Both Treatment And Adrese. More Over, Counseling On Other Issues May Be Countereductive If Addiction Goes Addressed (Ruit, 1987). Although Most Counselors Are Aware Of Therapeutic And Psychoeducational Group Respumain Their Communio. Many May Not Understand Or Be Sure Of The Mechanics Of Twelve Step Groups Sach Groups Often Me A Low Profile In The Menul Health Community, Because They Do Not Involve Prychlogical Service Poca Ess. Funkemore. Counckes Chen Rely On Word Of Mouth For Any Detailed Information Tecise Than Meeting Place And Time. Even If A Counselor Is Regularly Involved In Addictive Trement Programs, Little Is Available In The Testing Literature To Guide The Process Of Referal Us Anonymous Groups. In This Aniele We Presente E Criticisms Profes Sionals May Have Regarding Telve Step Programs, And More Specific Ally. Akoholics Anonymous (Aa). Furthermore, We Provide Some Guidelines For Referral Of Clients To Aa Criticismes Of Twelve Styp Programes Twelve Seep Poups Have Their Roors In The 1935 Founding Of Aa. Since Then, Many Groups That Were Fomed To Deal With The Addictions Have Bomowed The Aa Twelve Step Program Of Recovery Narcotics Anony Mous, Sex Addicts Anonymous One Cers Anonymous, And Al-Anon Are A Few Of These Groups. Perhaps The Most Scholarly And Complete History And Analysis Of Aa And The Twelve Stop Recovery Principles Is Karta's Nor God (1979). The Title "Twelve Step' Cfers To A Series Of 12 Stunements Beginning With "We Admited We Were Powerless Over Alcohol Other Substance, Condition Of Bravishdha Our Lives Had Become Unmanageable (Aa World Services, 1951. P. 991. A Twelve Step Group For The Purpose Of This Articles To Group That Adheres Specifically To The Twelve Steps And Velve Traditions Des Forth By Aa There Are Numerous Other Mutaal Help Groups That Have Either Werd The Twelve Wep Program (Such As Alcoholics Victorious And Secular Organization For Sobriety) Or Have Developed Auferent Programs Mely (Such As Recovery, Inc.)The Twee Steps Are A Group Of Principles That Are Spiritual In Nature" (Aa World Services, 1953, P. 15). These Principles Set Out Specific Actions Assist An Individual In Obtaining Striety And Making Changes In His Or Her Life To Maintain Sobriety. Ang With Aa Slogans The Twelve Steps Are Frequently Referred To As Ool Of Recovery. The Twelve Traditions Set Forth The Philosophy And Structure Of The Groups. They Mandate That The Groups Keep A Singleness Purpose, Be Self-Supporting, Have A Torprofessional Lay Leadership. Be Nonpolitical, And Have Nombership Requirements Except The Desire To Quit Drinking. Gambling. Overeating, And So Fo Rththe Twelve Step Program A Commonly Cited By Professias As One Of The Most Effective Treatments For Aloolise (Brown. 1985. Flores, 1988, Glasser. 1975, K. 1979. Matern, 1974. Royce, 1981; Zamberg. Wallace & Blume, 1965). Many Authors, However, Believe That If A Person Is An Achte, He Or She Is Unlikely To Be Diagnosed By A Professional And If Diagnosed, Is Unlikely To Receive An Appropriate Neferl(Brows, 1985. Fores. 1988. According To Antz And Chambers (1947), Twelve Step Groups Are Inadequately Referred By Because Of Kek Of Information, Understanding, And Appreciation. Much Of This Irs Deguate Referral Could Be The Result Of Misconceptions And Disagree Menes About The Twelve Sep Program's Philosophy And Basic Concepts Flores (1988) Noted That Cities Of Aa Fail To Understand The Subtleties Of The Aa Pregun And Often Redusly Tribute Qualities And Char Acteristics To The Organization That Are One-Dimensional, Miskading, And Even Border En Slanderous P. 203). Fer Couper To Make A Fequace Referral To Twelve Step Groups, It Is Important To Be Ware Of One's Own Ascimento De Convensis And Whether It Is Accurry Wounded In The Facts The Discis Mode A Frequenterities Of The Groups And Alcoholism Treatment Centers Is Their Adherence To The Medically Be Disease Concept (Richards, 1986 Stein, 1986. Critics Often Object To A Medical Model, Which Makes The Physician The Primary Therapist. This Criticisa Objects To A Biogenic View On The Grounds That It Places The Dividual In A Passive Role Which Only Discourages Peonal Responsibility. The Competing Metora Recunies That The Disease Concept May Be Plied By Some Individuals In This Way But Notes That Self-Countability Is A Requirement In The Trement Of Many Diseases. For Example, Diagnosing Diabetes As A Disease Is Absolve The Individual Of Responsibility For Self Care. La Ma Insecure, However, To See The Aa Adheres To The Disease Concept, At Least In The Medicale. A Literature Uses The Millors And Walay, But It Does Not Use The Term Dira. A Has Avoided The Term Uw Intentionally To Avoid It And Has Considered The Corcioncry Over The Tistegy Of Alcoholism Superous (Kurta. 1929). Aa's Sidestepping On This Issue Apparently Serves A Important Pour Keeping Function For The Organization. The Tenth Tradition Of Aa States That Alcoholics Anonymous Has No Opinion On Be Issues, Bence The Aa. Name Might Never Be Drawn Into Public Antroversy (Aa Journal Of Counseling & Development - March Apr 1994. Volume 72 Riordon And Waist World Series, Inc., 1953, P. 1763. Other Twelve Step Praps Have Followed This Appr Oac Hmany Individual Members Do Use The Term Diuvat, But In A Different Content Than A Purely Medical One. Members Think Of Alcoholismus Four Fold Den Involving Physical, Mental Emotional, And Peritaal Eaters Flores. 1948. Other Individual Members Of Twelve Stry Groups Openly Reject The Disease Concept. This Is Represented In Aa. For Instance, By Sach Comments As I Makohole Because I Drank O Much Alcohol Too Long For The Wrong Reasons." In Summary Aa Seems To Leave The Debate About Causes To The Professionals And Work Instead On Solutions. Altesagt Individuals Have A Variety Of Opinion, Aa Mempos To Take A Sestral Stance Regarding Etileg Abstinen Another Criticismoften Heard Of Aa Is Prescription Of Notal Abstence As A Tanto Alleninking Poden Aa Calls For Abstinence For Those Who Have Experienced A Loss Of Control And Want To Join The Program The Best Text Alcoholics Anonymous (Aa Word Senices, Inc. 1953) Stated The Maderate Drinkers Have Little Trouble In Giving Up Liquor Etmey. They Can Take It Or Leave" (Aa World Services, Inc. 1955 P. 203. Aa Encourages A Person To Tempo Control Drinking Prior Membership And Salutes Those Who Gaa World Services, Inc. 1955). The Organisation Recommends Its Program Arly For Those Who Have Failed To Control Their Drinking This Is The Aa Definition Of Kotois. The Behaviorst Assertion That Slechts Can Return To Contend Drinking Has Caused A Sir Both In The Treatment Field And In The Aa Community (Wars, 1986). Rascarch That Supports These Chain (Sobel & Sebel. 1973) Has Been Challenged In Kong Term Follow-Up Stades Pendery. Mazmun & Wes, 1982). There Is Also An Ampion That Controlled Drinking Is Pleasant And Free Of Adverse Consequences. Once Again, There Is A Split Between Arts Of The Profession Researchers In The Laboratory Document Cause Controlled Drinking, Whereas Clinicians In The Field Seestseinence As The Only Goal Treatment (Flores, 1988. Vaillant, 1983) Vaillant (1953) Fethinded The Professional Thaathough It Is Theoretically Possible For All Dependent Individuals To Be Taught To Return To Wympistic Drinking. It Is Equally Important For Them To Appreciate That Abstinence May Be Nice Practical And Stars Cally More Useful Therapeutic Foxus" (P. 235) Substituting Dependencies Glasser (1 976 ) Waa S Positive Addition And The Single Moe Successful Andistanorganizationthat We Have. Another Frequent Criticism & Aahowever, Is That It Is A "Cratch Reakcholks Are Just Substituting Dependenc Ies (Beanbayos. 1985. Vailant, 1945, Wallace, 1984). Inherent In This Criticism * A Belief That There Is Something Undesirable About All Dependence. Flores (1985) Was Puticularly Bettered By Eis Criticism Is That * Reflects A Professional Attade That Anything Less Than Complete Autom My And Independence Is A Problem. La Fact. Limited Dependence On Ders Allows For Intimacy That Can Encourage The Self To Expand Beyond Is Own Limitations, Thas Strengthening One's Own Identity, Now Weakenng (Kan. 1982 Spirituality Versas Religion Pertups The Most Common Rean Given For Dismissing Aa And Other Twee Step Groups Is That They Are Mistakenly Thought Of As Esposing A Religion (Wallace. 1984. Twelve Step Groups Do Use A Spiritual Program With An Emphasis On Spiritual Growth. Abstinence Is Not The Goal Of Twelve Step Groups, But It Is The Means To An End, Which Is Spiritual Growth Small (1990) Described Aloholics As Very Deep People, They Have The Qualities Of The Mystic, The Artist, And The Sage" (P. 140 Small Said That The Urge For A Life With Spiritual Meaning Is Behind The Urge 10 Drink, And The Recovering Alcohol In Search Of Another Poch To Wholeness And T Rin Sidencereligionella Person How To Believe, Whercas Twelve Sa Prop Della Person Of The Need To Believe In A Power Grewer Than Yourself. Or Buguer Power. Twelve Map Suyu Emphasize That This Power Is 25 You Understand Hans. Such An Apprunach Emphasizes The Distinction Between Being Spiritual In The Sense Of Being A Positive And Creative Human Being A Divine From Following Religious Doctrine. Flores (1998) Noted That Aa I Elearly Not A Religious Program--At Least So Meet So Than The Way William James And Carl Jung Applied Spiritual Or Religious Chemes In Their Approach Toset In 2019 Labding Many Professional Object To The Signa And Isolation Which They Believe, Reaks From An Individual's Labeling Hitisell Or Herself As A Saying 'I Am A Aleshold (Brown, 19851. Many Ho Believe That Twelve Step Groups Force This Kind Of Label On Member Wallace, 1984). This Assertion Notre Of Masa Whole, Though Individual Members And Groups May Vary In Their Adherence To The Traditions. The Only Requirement For Membership Is A Desire To Slap Drinking. * (Aa World Services, Inc. 1955, P. 3) Sisted In Aa's Preamble. Within Aa. Considered Bud Manden To Diagnose Someone Eble As A Wholic Or Other Type Of Dependent Person. Diagnosing Someone Else Is Gmerally Known As Ting Someone Else's Inversory. Individuals Are Encour Aged To Evaluate Their Own Stochol History For A Loss Of Control And To Diagnose Themacises. There However, Considerable Peer Pressure To Belones. The Group Som For Introductions In Aa Is "Hi, I'm Joe. And I Am An Alcoholic:"Lass Common, But Acceptable Is The Statement *Hi, I'm Joc, And I Have A Desire To Stop Drinking. Many Members Seeas A Promotion To Identify Themselves As An Alcoholicos Ering Person With A Drunk" - So That A Person Can Experience A Sense Of Relief, Dignity, And Belonging In Accepting The Label. Brown (1985) Believed That In Accepting The Label Cholka Persos Accepts A New Identity That Provides A Frame Of Reference Forporting The Past And Adopting New Behaviors And Attitudes Referral Guidelines Which Clients To Reler Until Recently, Some Studies Had Indicated That A Certain Perunality Type Responded To The Twelve Step Approach And That These Individuals Should Be Selected By Counselors For Referral So Riveste Programs For Sale. Ogbome And Glaser (1981) Presented The Followingis In Alcoholies Aliated With Aa Rangi Years Of Age Whisk Midde-Or Upper-Class And Cally Who Aria Personality, Strong And Promeness O Paikan Email Loco Acono, Field Dependenceprave Simply Formal Thinking Is Conceptualne Mis A Religious Orientation, Aut Anda Deney To Conform 625 A Recent Aa Membership Survey (Aa World Servic Es. 1987) Conindicts Such A Type: 345 Of Aa's Members Are Women, 21 Are Under 30 Years Of Age, And 52% Are Under 50 Years Of Age. Also, More Recent Research And Views Refute Earlier Research Claims Of An "Aa Personality." Bradley (1968) Provided An Excellent Summary Of The Journal Of Counseling & Development - Marcapny 1994. Vorme 72 Cosynnt 2001 Rights Reserved Gudeines For Protocond Ratonal To Alcoholics Anonymous Ond Other Twelve Stop Groups Research And Concluded That There To Clear Profile That Emerged Of Too Dow In Referring In Pral And Noted The Importance Of Adgment The Scholic Mos Likely To Come A Emrick (1989) Came To The On The Part Of The Counselor. With Slech Problems The Danger Of Same Conclusion In His Review Of The Literature Since 1976. He Also Noted Waiting Leakecholam Causing Harm To Self Or Family Has To Be That All Skool-Troubled Patients Could Wisely Be Regarded As Possible Bulanced Against The Possible Damage To Trust In The Relationship. Waitmembers Of Aa And At Least Need To Be Informed Of The Organico's Ing Looking To Address The Wae, However, Can Be Interpreted As Perial Benefitscondoning The Behavior And May Add To The Severity Or The Progression Similarly, Vaillant (1963) Concluded That There Are Many Alcohol Of The Condition Dependent Individuals Regardless Of Social Or Psychological Make Up Who Find Help For Alcoholism Through Aa T Seems Prudent To Consider The "A" Word Referral To Aa Batall Alcohol Clients Except For Those With Unificahar As Professionals May Believe The Labeling Ipales A Person, Poslogy. Many Clients Are Offered The Use Of The Word "Koholic." Brown (1985) Warned Against An Intellectual Bias The Sees Aa : Important To Be Mindful Of This When Counseling Clients Initially. De Less Ideal Choice Than Counseling She Warned And Communicating Sodiens Citat Sobriety Obtained Through Ma Is Somehow Interiorpending On The Situation, The Counselor May Choose To We The Termskohol Problem S Alcohol Abree And Coconnage The Client To Make The Straty Stained Without Aa, And She Rejected The Idea That Mis Mox For Bright, Cupable People Who Can Make Use Of Counselor Nokingdiagnosis Of Alcoholism For Himself Or Herself Through Mendance Aa That Not Everyone Will Accept The Referal, She Sees The Difficulties Thatmeetings And Lectures. This Approach Can Be Facilitated In Counseling Individuals Have In Acceping Referral Or In Attending Mus Part Of Thesessions By Exploring Cumples Of Kons Of Control Thera Peutic Proces Smany Clients Will Deny The Need For Outside Support Or Believe They . In This Regard Support Groups Such A Mas Serve Several Adanccan Quk Or Control Their Drinking On Their Own. When This Occurs. Clientsshould Outline A Specific Plan And Goal To Control Their Drinking Or Stain The Goals In A Counser's Treatment Plan. In The Early Phases Clients May Be Very Needy As They Work Through The Ceil, Pull, And Share, Completely. This Kind Of Plan Is Helpful If It Is Written In A Contingency As Well As The Craving They May Need Almost Constant Support. Thecontre And Supported Holeheanedly By The Counselor With Me Counselor Cannot Realistically Be Available On 7-Day Week Basis; Mer To Utend A Twelve Stap Program D The Plan Faile Aa, However Is. Likewis, In A Longtem Conscling Relationship, Aaclients Are Usually We Receive To Welve Step Programs After They Can Be An Ally To The Counselor, Providing Extra Foundation And Supporthave Failed Temps Sell. Com. Part Of The Referral Process Is The Client Works Through More Deeply Sealed Isases. Motivation And Working Through Resistance Mak Ing The Refer Ralpersonal Izing The Ref Erralit Is Important That The Referred To A Twelve Wep Program Be Personally In Making The Referral To A Tutte Wep Group Is Important Fint To Be Tailored To The Client. This Can Be Done In A Variety Of Ways And Prees. Sure There Is No Need For Inpatient Trainent. Bean-Bayog (1985) At The Least It Should Include Urring Down The Number That The Client Is Saygested Using Patient Treatment Only If (A) Patient Treatment Has To Call To Get Information. It Would Be More Helpful To Have The Chien Failed, B) Curent Drinking Is Life Threatenine. Ce There Is Impaired Establish Contact From The Connector's Office. It Could Be Helpful To Have Neurologie Functioning. Or D) There Is Massive Denial. Of Course, If The Cliene Las Medical Problems (E. Daberes, History Of Its)Thezome Pamphlets And Meeting Books In The Office F Or The Client To Takehenk. Counsel Will Want To Coedinte Treatment Recommendations With A Physician. If In Doubt About An Appropr Iate Treatmen T Secondathe First Meeting Sually Difficult For The Dient We Wend. Frequently Arrangements Can Be Made Through The Aa Central Office For A May So Want An Sent From An Independent Center. In This Case. Temporary Corect To Meet Newcomer Ut A Meeting Or Take Me Te 2 Sest Set Asxiated With A Recovery Facility Can Help Proid Bias. For Alcohol Problema Coniglicated By The Aforementioned Feecer There Personally. It Would Be Beneficial To Have A Resin Severaldays After The Client's First Meeting To Process The Experience. The Counseling As The Treatment Ofreferral When Discussing Akoholism With Clients. * Is Important To Beprocess Does Not End With M Aking The Rec Ommendationankety Is Likely To Be High Carly In Recovery For A Variety Of Reasons Forthright With Any Facts And Concem. To Minimise Or Underszate The Facts Could Seed In The Client's Denial. When Referring To A Specificwithdrawal Newness Of The Station, Lack Of A Familiar Coping Tool(Alcohol And Unconscious Conflicts Brows (1983) Sew The Counselor Twelve Step Group, A Counselor Should Provide A Realistisessment Of Is Providing A Framework Through Which The Patient Can Compare Pecuble Benefits To The Client. To Avoid Rejection, The Referral Should Bedance Without Sacrificing Other Long-Held Beliefs. Presented As An Additional S Ource Of Helppreparing Th E Client Timi Ng The Referralmany Refers To Twelve Hep Groups Can Be Successful The Client Timing Is Important In Making The Femal. The Color Needs To Make Does Not Have A Realistic Expectation Of What He Or She Will Find At The Independent Decision Concerning Many Different Variables, Such As Worting. The Counselorshold Make The Client Want That It Is A Spiritual Severity Of Drinking And The Trust Established In The Therapeutic Relation Program And Should Assist The Client In Gisteguishing Between Religious Ship. A Grennukefub Is That The Earlier The Referral, The Better, Und Spiritual Programs. Referred Clients Should Also Be Aware That The To Avoid More Adverse Comoquences Of Drinking Morcover The Benefits Twee Steps We Suggestions To Rules. The Counselor Should Also O Continand Counseling Sessions Will Be In Todas Long As A Drinking Explain The Anonymous Part Of The Program Newcomers May Be Asked Problem Persist. To Identify Themselves By Their First Name So That They Can Be Welcomed. Frequently, The Alcoholic Is More Receptive Referatera Bing But This Is Not Mandatory. Also, The Client Does Not Need To Identify Or Some Adverse Concebus Occurred, And He Or She Is Remorseful Rimself Or Herself As A Skei. When Newcomers Do Drify Them. Overdrisking. Oglesby (1967) Discussed The Of Being Too Quick Or Scles, Some Groups Will Have A Newcomers Meeting," Where Various Journal Of Counsing & Development. March/Apr 1994. Volume 72353 Riordon And Was Ces 2001 Al Ray Reserved Riordon And Wash Ces 2001 All Rights Reserved Esebels Atempo Reach Out To The Individuals By Sharing Their Early Experiences In Aa. It Is Most Important To Usure The Client That Although Mtendance At Meetings Might Be Unpleasant Or Uncomfortable. This Is Nox Related To Possible Benefits. The Counselor Should Cautice The Client Nex So Make A Decision On Involvement Based On One Or Two Meeting. The Client Should Sample A Variety Of Meer Geld A Different Times And Locations. It Is Useful For The Course To Know The Cachentare Te Recommend Specific Groups With Whom The Clients More Likely To Deney Attending Meeting The Best Way To Understand Twelve Step Groups To Attend A Wide Anging Of Meetings To See The Diversity Of Groups And Individual Members. Professionals Are Welcome As Guests At "Oper" Aa Meetingschsel" Meetings Are Reserved For Aa Members Only. It Is A Good Idea O Send Newcomers To Open' Meetings, Especially While They Work Through Any Reservations About Whether They Choose To Call Themselves Alcoholics. Seme Group After All, Ase This Bei Desp Re Aa World Service Guideline Sthere Are Three Us Types Of Aa Meetings Aa World Services, 1990). "Speaker Meetings Avalve Individual Members Sharing Their Personal Aery Ef Drinking And Recovery. These Meeting Can Be Useful To Individuals In Identifying And Breaking Through Their Denial Systems. The Speaker Meetings Can Also Be Less Intimidating Nommers Because The Vision Experience Ne Fear Of Being Called On To Talk Although Some Swomen Object To This Style. They View Istening To Someone Else's Peetiem." These Individuals Might Bereferred To Discussion Meetings Where Topics Relating To Me My Can Be Discussed By The Wh Olethe Format In Soncefront Tonal, And Individuals May Suggest Sopics For Discussie Sandy Services, Inc., 1955), Or The Twelve Step And Twelve Trainers (1953) Groups Focus On Aa Basic Teal Alcoholics Anonymous A Word And Follow A Discussion Fomat. Although Study Groups May Be Helpful For Early Rowery, They Are Not Recommended For The File Meetings Or Until The Newcomer Has Acted Himselt Or Herself As A Member Professionals Should Be Familiar With All Three Formats Of Meetings. Soup Dnes Mas Clubhouses Many Cities Kohave Twelve Step Clubhouse A Clubhouse Is A Nonprofit Organization Whose Purpose Is To Provide A Meeting Place For Tweelep Poups And For Socializing Berwards. These Clubhouse Can Be Very Exful For Newcomers, Especially For Those With Poor Support Systems Or Socializacion Skills. The Clubs Are Frequently Open For Long Hours And Provide Extravide Extra Support. Some Clubhouses Have Three Or Four Meetings A Day. It Is Important To Note That These Clubes Are In By The Twelve Ep Groupsin Making Referrals. T Is Importante Be Familiar With The Tous Clubhouses A Particular Catchen Se To Make An Appropriate Refert. For Example, One Aa Clubhouse On To The Authors Frequented During The Day By Many Older Retired Akoholics When 11:30 Am Meetings And Dies Have Lunch In The Club's Restaurant. The Une Club's 3:45 Meetings Fried By Busy Professionals Catching A Meeting On The Way Home From Work. The Club's Members Are Intolerant Of Drugs Other Than Alcohol Being Discussed. Another Local Aa Clubhouse Atracts Younger Members (3050 40) Mengs, These Members Are More Lean Of Dial Diction. A Third Aa Clubhouse Is Frequented By, But Not Limited To Pay Members Of Ma. A Fourth Aa Clubhouse Is Right Off A Row Area And Attracts Abolic From 354 The Working Class. These Are Import Considerations To Keep In Mind When Making Referral For Obvious Reasons Of Identification Networking With Aa Aa's Central Offen In Most Cies. A Has A Central Office Run By Volunteers, Paid Office Workers, Or Both. A Counselor Visit Would Be Useful To Meet Stall, Establish Contacts, And Buy Iterature And Meeting Books. Potential Members Can Offices To Get Directions To A Meeting To Speak To Aa Member (Usually 24 Heers A Day) Or To Arrange For An Aa Member To Make A Home Visit Twelve Step Call). Many Of The Services Of A Central Office Are Not Available To A Professional For Seases Of Anonymity Or Aa's Singleness Of Purpose O Carry Its Message To The Alsha (Fifth Tradinion Cooperation With The Profesional Community Contrary To Many Professionals Impressions, Aa Has A Clear Com Men To Working In The Profesional Community. In 1970. Aa's General Service Office Approved A Commitee Called Cooperation With The Professional Community Icpc). According To Cpc's Work Book Is Purpose Is To Invae Communication Between A And Pro Fessionals And To Inform Them About What Aa Ds And Does Not De, So Assist Groessionals Working With Akoholics By Being An Mailable Community Resource Members Of Crc Will Meer With Professional Or Og Nations, Praside Speakers, And Amend As Per Meeting Win The Cpc Contact Can Also Assist The Professional In Working Withwith Special Needs For Example, Aa's Busic Text. Alcoholics Andryceri Aa World Services, Inc. 1953. Is Wailable In 13 Foreign Languages To All Of 27 Acestral Offices Have Teletype Machines By The Hearing Impaired The Crc Can Also Provide Information On How To Contact Loners Niemational An Aa Meeting By Mail. Published Six Umes Yeuriy) For Alcoholics Slated Geographically Or Within Their Own Beres. Cfc Is An Invaluable Resource To Professionals To Facilitate An Wormed Trienal A Professional Can Contact A Cpc Committee Member Through A Local Central Office. Cetarting Other Twelve Step Groups Many Her Twelve Soep, Groups Besides Aa. Such As Al-Anon Overca On Anonymous. Nautica Anonymous, And Codependents Anony M. May Have Chat Offices In Larger Cities. It Wasld Be Advisable To Visit These Tees, As Obtain Information And Literature, And To Make Con Facilitate Referals. Less Popular Iwelve Step Groups Of Rural Areas May Have Only An Answering Machine Or A Member's Homme Elephone Number, And May Choose To Speak Only To The Potential M Emberthere We 80 Local Self-Help Clearinghouses Antionally The Can Assist Professional Contacting Uche Step Groups In The Catchment Areas Contact Sumber Should Be Listed In The Local Telephone Directory. For Those Areas Without A Self-Help Clearinghouse Or For Additional Infometion On A Twelve Step Group's Nacional Organization, Send A Selfaddressed Envelope To National Self-Help Clearinghoes, 25 West Ged Street. Room 620, New York, Ny 10036 References Aa World Service, Inc. (1983. A. New York Auler Aa World Services, Inc (195517 And Emotion. New York: Author Journal Of Counsaing & Development. March April 1994. Volume 72 Cosyante 2001 All Rights Reser.

NSSI Reading Article

IH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript oneself with a knife or razor; typically begins in early adolescence; occurs among people with a wide range of psychiatric disorders (and in some cases in those with no disorder); is associated with an increased risk of suicide attempt; and does not appear to differ as a function of sex, ethnicity, or socioeconomic status (Hilt, Nock, Lloyd-Richardson, & Prinstein, 2008; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006). Despite the prevalence of NSSI, little is known about why people engage in this behavior. WHY DO PEOPLE HURT THEMSELVES? Many theoretical models of NSSI have been proposed. Psychodynamic theorists suggest that NSSI is performed as a way of gaining control over urges for sex or death. Folk explanations invoke concepts like manipulation of other people, impulsiveness, and low self-esteem. Empirical work on NSSI has aimed at identifying correlates of this behavior, with childhood abuse and psychiatric disorders emerging most consistently in the literature. The strong relation between psychiatric disorders and NSSI has led many to conceptualize NSSI as a symptom of a psychiatric disorder. However, such a perspective is unsatisfying given that NSSI occurs across many disorders and is not symptomatic of any one disorder (Nock et al., 2006). Moreover, suggesting that people engage in NSSI because it is a symptom of a disorder provides little explanatory power. This article presents an alternative explanation for the development and maintenance of NSSI. The proposed theoretical model integrates findings from several different areas of the literature, explains why factors such as childhood abuse and psychiatric disorders are associated with NSSI, and highlights new questions and directions for research on this topic. This model proposes that (a) NSSI functions as a means both of regulating one's emotional/ cognitive experiences and of communicating with or influencing others, (b) risk for NSSI is increased by the presence of distal risk factors (e.g., childhood abuse) that contribute to problems with affect regulation and interpersonal communication, and (c) several more specific factors (e.g., social modeling) explain why some people specifically use NSSI to serve these functions (see Fig. 1). What Are the Functions of NSSI? A functional approach assumes that behaviors are determined by their immediate antecedents and consequents. By focusing on local determinants, this approach cannot account for the full range of causal factors that influence a behavior. Nevertheless, research using a functional perspective has led to significant advances in the understanding and treatment of various forms of psychopathology, including depression, anxiety, substance use, and child conduct problems (e.g., Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). A functional approach suggests that NSSI is maintained by several reinforcement processes: intrapersonal negative reinforcement (i.e., NSSI decreases or distracts from aversive thoughts or feelings), intrapersonal positive reinforcement (i.e., NSSI generates desired feelings or stimulation), interpersonal positive reinforcement (i.e., NSSI facilitates help- seeking), or interpersonal negative reinforcement (i.e., NSSI facilitates escape from undesired social situations). Several lines of research provide empirical evidence for each of these four processes. First, experimental studies among people with developmental disabilities have shown that applying and removing desired and aversive stimuli immediately following NSSI increases or decreases this behavior in patterns consistent with the functional model I outlined (e.g., Iwata et al., 1994). Second, studies among typically developing adolescents and adults have demonstrated that the motives cited by self-injurers for their behavior fit closely (e.g., in confirmatory factor analyses) with the four-function model (Nock & Prinstein, 2004) and that the four functions correlate in expected ways with other clinical constructs (see Nock & Prinstein, 2005). Third, studies have supported Nock Page 2 Curr Dir Psychol Sci . Author manuscript; available in PMC 2010 April 1. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript hypotheses derived directly from this model. For instance, self-injurers show decreases in physiological arousal following imaginary exposure to NSSI (Haines, Williams, Brain, & Wilson, 1995) and improvements in familial relationships following engagement in NSSI (Hilt, Nock et al., 2008). Although these studies provide information about the functions served by NSSI, they do not address the etiologic question of why some people experience the affective and social dysregulation that serve as antecedents to NSSI. What Factors Increase the Risk of NSSI? The proposed model suggests that some people develop intra- or interpersonal vulnerabilities that predispose them to respond to challenging or stressful events with affective or social dysregulation, creating a need to use NSSI or some other extreme behavior to modulate their experience. Preliminary evidence for such vulnerabilities comes from laboratory-based studies. For instance, relative to noninjurers, self-injurers display elevated physiological arousal (skin conductance) in response to a laboratory-based stressor (Fig. 2), and this effect is especially pronounced for those who report that they engage in NSSI in response to high aversive arousal (Nock & Mendes, 2008). Self-injurers also elect to discontinue or escape the stressful task significantly sooner than do noninjurers (Nock & Mendes, 2008) and report greater efforts to suppress aversive thoughts and feelings in their everyday life (Najmi, Wegner, & Nock, 2007). Most of this work has focused on intrapersonal correlates of NSSI; however, evidence for interpersonal vulnerability factors has been revealed in studies showing deficits in social problem solving and communication among self-injurers (e.g., Nock & Mendes, 2008). These vulnerability factors are believed to be caused by more distal risk factors such as childhood abuse and genetic predispositions to high emotion reactivity. For instance, childhood maltreatment is associated with subsequent neurobiological abnormalities characterized by reduced activity in the frontal cortex and an increased stress response (e.g., Kaufman & Charney, 2001). Such abnormalities represent a pathway through which childhood abuse may lead to increased emotional reactivity and an inability to manage such a response, which is then (maladaptively) managed using NSSI. Factors such as childhood abuse also can prevent the developing child from learning effective social-problem-solving or communication skills, thus contributing to the interpersonal vulnerabilities I mentioned. Of course, these vulnerability factors are not specific to NSSI and have been shown to increase the risk of a number of psychiatric disorders. This model suggests that NSSI is related to psychiatric disorders because they share these etiologic pathways. In fact, when factors such as high emotional or physiological reactivity are statistically controlled, childhood abuse (Weierich & Nock, 2008) and psychiatric disorders (Nock, Wedig, Holmberg, & Hooley, 2008) are no longer associated with NSSI. If NSSI and some psychiatric disorders share an etiologic pathway and represent different forms of behavior that can serve the same function, one is left wondering why some people select NSSI rather than another pathological behavior to regulate their affective and social experiences. Why Use NSSI to Serve These Functions? There are many noninjurious ways to regulate emotions (e.g., exercise, alcohol) or communicate with others (e.g., talking, gesturing). So why use NSSI? Below I present several specific processes proposed to increase the likelihood that a person will use NSSI to serve these functions. These hypothesized processes each have preliminary empirical support and represent some of the most intriguing current directions for NSSI research. Social Learning Hypothesis— The decision to engage in NSSI undoubtedly is influenced by observing the behavior being used by others. Indeed, most self-injurers report Nock Page 3 Curr Dir Psychol Sci . Author manuscript; available in PMC 2010 April 1. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript first learning about the behavior from friends, family, and the media. Interestingly, there has been a sharp increase in references to NSSI in movies, songs, print media, and the Internet over the past decade (Whitlock, Purington, & Gershkovich, 2009), which may help explain the apparent increase in this behavior over the same period. Self-Punishment Hypothesis— Self-punishment or self-deprecation also may motivate NSSI, with NSSI representing a form of self-directed abuse learned via repeated abuse or criticism by others. This would explain further how and why childhood abuse is associated with the behavior. Recent research supports this hypothesis, by showing that the relation between childhood abuse and NSSI is mediated by adolescent self-criticism (Glassman, Weierich, Hooley, Deliberto, & Nock, 2007). Moreover, many self-injurers endorse self- punishment as a primary motivator for NSSI (Nock & Prinstein, 2004). Social Signaling Hypothesis— NSSI can be especially effective as a means of social communication and influence precisely because it is a harmful, and thus costly, behavior (Hagen, Watson, & Hammerstein, 2008; Nock, 2008). As demonstrated in research on animal communication, signaling behaviors that are costly to perform are more likely to be believed by other animals because otherwise producing them would not pay off (Hauser, 1996). Translating this principle to humans, high-intensity or high-cost behaviors (e.g., aggressive gestures, NSSI) are more likely to elicit desired responses from others than are low-intensity or low-cost behaviors (e.g., verbal requests). NSSI may be especially likely when other communication strategies have failed due to poor quality or clarity, or when less costly behaviors have not produced the desired effect due to an unresponsive or invalidating environment (Wedig & Nock, 2007). Pragmatic Hypothesis— Perhaps the most parsimonious explanation for why some people choose NSSI is that it is a relatively fast and easily accessible method of serving the proposed functions. NSSI can be performed quickly in virtually any context and does not require the time and materials involved in other behaviors that may serve a similar function (e.g., exercise, alcohol), making it an attractive behavior for adolescents and young adults who lack the executive control to regulate their emotions and behavior and who may not have ready access to alcohol or drugs. Pain Analgesia/Opiate Hypothesis— It also is important to consider what stops some people at risk for NSSI from engaging in this behavior: the pain involved in the act. Interestingly, self-injurers report little or no pain during NSSI and show pain analgesia on lab-based tests of pain tolerance. It is unclear if this pain analgesia is a dispositional factor perhaps resulting from elevated levels of endorphins in the body, emerges via habituation as a result of earlier abuse, or is a by-product of the release of endogenous opiates that results from repeated NSSI. The presence of pain analgesia has been reported consistently across studies of NSSI and represents one of the most intriguing directions for future research on this topic. Implicit Identification Hypothesis— Once NSSI is performed, some people may come to identify with NSSI and value it as an effective means of achieving one of the functions described. This identification may foster selection of this behavior over other behaviors, thereby maintaining it. For instance, when I want to regulate my emotions (e.g., decrease anxiety), I do not smoke cigarettes because I am not a smoker, instead I go for a run because I see myself as a runner—perhaps because that behavior has served me well when attempting to regulate my emotions in the past. In the same way, some people may select NSSI because they identify with this behavior. Consistently with such a view, we recently demonstrated that self-injurers hold a stronger implicit identification with self-injury than do Nock Page 4 Curr Dir Psychol Sci . Author manuscript; available in PMC 2010 April 1. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript non-injurers, as shown by their performance on the Implicit Association Test—a brief, computerized reaction-time test of the associations people hold about different constructs (Fig. 3a; Nock & Banaji, 2007a). Interestingly, a similar identification with self-injury emerged among those with suicidal thoughts, with an especially strong identification among those making suicide attempts (Fig. 3b;Nock & Banaji, 2007b). It is not yet clear if implicit identification with self-injury influences the initial decision to use the behavior or develops as a result of the behavior. This represents one key question for future research. FUTURE DIRECTIONS Recent research has answered many of the basic questions about NSSI, but many important questions and exciting directions remain. First, the evidence for the apparent increase in the behavior comes largely from anecdotal reports and estimates from small cross-sectional studies. Epidemiologic and longitudinal studies are needed to provide more accurate estimates of the base rate, trends, and long-term course of NSSI. Second, most of the evidence for the etiology of NSSI is from cross-sectional or retrospective studies. Research examining factors influencing the development of NSSI will increase the understanding of this behavior and improve prevention efforts. Third, although a consensus is emerging on the functions of NSSI, the mechanisms through which NSSI influences affective and social events remain unknown. For instance, although it is clear that NSSI results in decreased negative affect, it is unclear if this occurs via the release of endorphins, distraction from a distressing thought/feeling, or some other process. Fourth, most studies have relied on retrospective self-report of NSSI or experimental manipulation of hypothesized processes in the laboratory. Studies examining episodes of this behavior as it occurs in real life—such as studies using ambulatory monitoring devices—are sorely needed. Fifth, although it has been proposed that NSSI and other potentially harmful behaviors serve similar functions, few studies have carefully examined their co-occurrence—a necessary step in testing this conceptualization. Sixth, initial evidence suggests that family and cultural factors influence NSSI, offering an important direction for additional investigation. Finally, there are currently no evidence-based treatments for NSSI. Efforts to prevent and treat NSSI may be most effective and efficient with the incorporation of recent findings from psychological science. Recommended Reading Favaz za, A.R. (1996). Bodies under siege: Self-mutilation and body modification in culture and psychiatry (2nd ed.). Baltimore, MD: Johns Hopkins University Press. The seminal book on NSSI; presents a comprehensive historical, anthropological, and clinical review of the topic. Hooley, J.M. (2008). Self-harming behavior: Introduction to the special series on non- suicidal self-injury. Applied and Preventive Psychology , 12 , 155-158. Introduction to a special issue of this journal, each article in the issue provides an empirically based theoretical review of some aspect of why people hurt themselves and how to prevent these behaviors. Klonsky, E.D. (2007). Non-suicidal self-injury: An introduction. Journal of Clinical Psychology , 63 , 1039-1043. A special issue devoted to NSSI; provides brief literature reviews geared primarily toward practicing clinicians. Nock, M.K. (Ed.). (2009). Understanding nonsuicidal self-injury: Origins, assessment, and treatment. Washington, DC: American Psychological Association. A comprehensive edited volume on NSSI geared toward researchers, scholars, and clinicians. Nock Page 5 Curr Dir Psychol Sci . Author manuscript; available in PMC 2010 April 1. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Prinstein, M.J. (2008). Introduction to the special section on suicide and nonsuicidal self- injury: A review of unique challenges and important directions for self-injury science. Journal of Consulting and Clinical Psychology , 76 , 1-8. A special issue of this journal devoted to NSSI and suicidal behavior that contains representative original research on this topic. Acknowledgments The writing of this paper was supported by funding from the National Institute of Mental Health (MH077883). Thanks to Richard McNally, Jill Hooley, Irene Janis, and Christine Cha for providing helpful comments on an earlier draft of this paper. REFERENCES Glassman LH, Weierich MR, Hooley JM, Deliberto TL, Nock MK. Child maltreatment, non-suicidal self-injury, and the mediating role of self-criticism. Behaviour Research and Therapy. 2007; 45:2483-2490. [PubMed: 17531192] Hagen EH, Watson P, Hammerstein P. Gestures of despair and hope: A view on deliberate self-harm from economics and evolutionary biology. Biological Theory. 2008; 3:123-138. Haines J, Williams CL, Brain KL, Wilson GV. The psychophysiology of self-mutilation. Journal of Abnormal Psychology. 1995; 104:471-489. [PubMed: 7673571] Hauser, MD. The evolution of communication. MIT Press; Cambridge, MA: 1996. Hayes SC, Wilson KG, Gifford EV, Follette VM, Strosahl K. Experimental avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology. 1996; 64:1152-1168. [PubMed: 8991302] Hilt LM, Nock MK, Lloyd-Richardson E, Prinstein MJ. Longitudinal study of non-suicidal self-injury among young adolescents: Rates, correlates, and preliminary test of an interpersonal model. Journal of Early Adolescence. 2008; 28:455-469. Iwata BA, Pace GM, Dorsey MF, Zarcone JR, Vollmer TR, Smith RG, et al. The functions of self- injurious behavior: An experimental-epidemiological analysis. Journal of Applied Behavior Analysis. 1994; 27:215-240. [PubMed: 8063623] Jacobson CM, Gould M. The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: A critical review of the literature. Archives of Suicide Research. 2007; 11:129-147. [PubMed: 17453692] Kaufman J, Charney D. Effects of early stress on brain structure and function: Implications for understanding the relationship between child maltreatment and depression. Development and Psychopathology. 2001; 13:451-471. [PubMed: 11523843] Najmi S, Wegner DM, Nock MK. Thought suppression and self-injurious thoughts and behaviors. Behaviour Research and Therapy. 2007; 45:1957-1965. [PubMed: 17074302] Nock MK. Actions speak louder than words: An elaborated theoretical model of the social functions of self-injury and other harmful behaviors. Applied and Preventive Psychology. 2008; 12:159-168. [PubMed: 19122893] Nock MK, Banaji MR. Assessment of self-injurious thoughts using a behavioral test. American Journal of Psychiatry. 2007a; 164:820-823. [PubMed: 17475742] Nock MK, Banaji MR. Prediction of suicide ideation and attempts among adolescents using a brief performance-based test. Journal of Consulting and Clinical Psychology. 2007b; 75:707-715. [PubMed: 17907852] Nock MK, Joiner TE Jr. Gordon KH, Lloyd-Richardson E, Prinstein MJ. Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Research. 2006; 144:65-72. [PubMed: 16887199] Nock MK, Mendes WB. Physiological arousal, distress tolerance, and social problem-solving deficits among adolescent self-injurers. Journal of Consulting and Clinical Psychology. 2008; 76:28-38. [PubMed: 18229980] Nock Page 6 Curr Dir Psychol Sci . Author manuscript; available in PMC 2010 April 1. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Nock MK, Prinstein MJ. A functional approach to the assessment of self-mutilative behavior. Journal of Consulting and Clinical Psychology. 2004; 72:885-890. [PubMed: 15482046] Nock MK, Prinstein MJ. Clinical features and behavioral functions of adolescent self-mutilation. Journal of Abnormal Psychology. 2005; 114:140-146. [PubMed: 15709820] Nock MK, Wedig MM, Holmberg EB, Hooley JM. Emotion reactivity scale: Psychometric evaluation and relation to self-injurious thoughts and behaviors. Behavior Therapy. 2008; 39:107-116. [PubMed: 18502244] Wedig MM, Nock MK. Parental expressed emotion and adolescent self-injury. Journal of the American Academy of Child and Adolescent Psychiatry. 2007; 46:1171-1178. [PubMed: 17712240] Weierich MR, Nock MK. Posttraumatic stress symptoms mediate the relation between childhood sexual abuse and non-suicidal self-injury. Journal of Consulting and Clinical Psychology. 2008; 76:39-44. [PubMed: 18229981] Whitlock, J.; Purington, A.; Gershkovich, M. Media and the internet and non-suicidal self-injury. In: Nock, MK., editor. Understanding nonsuicidal self-injury: Origins, assessment, and treatment. American Psychological Association; Washington, DC: 2009. p. 139-155. Nock Page 7 Curr Dir Psychol Sci . Author manuscript; available in PMC 2010 April 1. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Figure 1. An integrated theoretical model of nonsuicidal self-injury (NSSI). This model proposes that NSSI is maintained because it is an effective means of immediately regulating aversive affective experiences and social situations. The risk of NSSI is increased by the presence of distal factors (e.g., childhood maltreatment) that can lead to intrapersonal and interpersonal vulnerabilities (e.g., poor communication skills) to respond to stressful life events in an ineffective manner (e.g., inability to effectively communicate the need for help). Although these risk factors could predispose a person to a number of forms of psychopathology, the likelihood of engaging in NSSI is increased by an additional set of NSSI-specific vulnerability factors (e.g., social learning). Nock Page 8 Curr Dir Psychol Sci . Author manuscript; available in PMC 2010 April 1. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Figure 2. Change in skin conductance level (SCL) during a distressing/frustrating card-sorting task for those with a recent history of NSSI ( n = 62) compared to a non-injurious control group ( n = 30). The full study is reported in Nock and Mendes (2008). Nock Page 9 Curr Dir Psychol Sci . Author manuscript; available in PMC 2010 April 1. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Figure 3. Results of an Implicit Association Test (IAT) measuring the strength of associations between self-injury and the self for those with and without a history of nonsuicidal self- injury (NSSI; A) and for those with or without a history of suicidal thoughts or suicide attempts (regardless of NSSI status; B). In both experiments, self-injury was represented by images of cut skin (versus images of non-cut skin) and the self was represented by words related to the self ("I," "mine," "me") (versus words related to others, e.g., "they," "them," "their"). Positive scores represent a stronger association between self-injury and the self (i.e., faster responding on a computer-based test when self-injury and the self are paired on the same computer key), and negative scores represent a stronger association between non- injury and the self. The difference between self-injurers and non-injurers was large and statistically significant, as was the differences between each of the three groups in panel B. The full studies are reported in Nock and Banaji (2007a & b

Narcotics Anonymous

If a client struggles with a drug addiction (beyond alcohol), they may benefit from attending NA. Since the formation of AA, other 12-step groups have developed. One such group is Narcotics Anonymous (NA), which is based on the AA model and developed in 1953 by Jimmy Kinnon. NA is for all those struggling with any drug or alcohol addiction. Currently, there are 67,000 weekly NA meetings in 139 countries. NA has its own text called, Narcotics Anonymous. Like AA, Narcotics Anonymous is based on working the 12-steps and abstaining from all drugs/alcohol. Step one of NA: We admitted that we were powerless over our addiction, that our lives had become unmanageable

Contemplation

In contemplation, the individual is aware that a problem exists, but there is no commitment to take action. The person is in a state of ambivalence. The individual is struggling to accept the effort it will take to make the change. Individual may be seriously considering changing in the next 6 months. Client may say: "I know my drinking has gotten out of control, and I probably need to do something about it, but I'm not sure

Precontempaltion

In precontemplation, the client has no intention to change and does not see substance use as a problem. Has "blinders on", or sometimes called "in denial." May have been pressured into counseling from external sources (spouse, employer, parent, etc.) No recognition that a problem exists, thus no need to change behavior. Client may say: "My husband wants me to be here... but he doesn't understand why I need the pills. What I am doing is just fine."

Preparation

In preparation, the client intends to make a change in the next month. Client may already be taking smaller steps towards change. During this time, client is seriously considering how to make behavioral changes. Client may say: "I know the cocaine use has to stop. I've talked to my wife about it and I am going to take a different route to work so I don't pass where I usually score

Action

In the action stage, the client makes the behavioral change (e.g., stops using drugs and/or alcohol). Action requires a plan, commitment, and effort (it is hard work!) Integrate change into rest of life. Client may say: "It really feels good to not just say I'm going to quit, but actually quit. My friends don't understand why I don't want to hang out anymore, but this is worth it."

Maintenance

In the maintenance stage, the client made a behavior change (e.g., stopped drinking) and has sustained this change for at least six months. The individual is now free from problematic behavior and engaging in new, healthy behaviors. Exploring identity without problem behavior and increasing overall wellness. Pursuing goals and values. Client may say: "I know I've made a lot of progress and haven't used in months. I want to keep moving forward and figure out what I want out of life."

There is another way

Instead, we know that internal motivation to make a change is much more effective that external pressure. Consider a significant change you've made in your life. What contributed to making that change? What was the most influential factor to you making the change? How effective was external pressure? How effective was internal motivation?

The Pornography Industry

It is estimated that 30% of all data on the internet is pornographic (although these estimates are difficult to ascertain). ◦Cookies and tracking strategies are used to promote pornographic sites. The porn industry makes about 5 billion dollars per year---yet profits are declining due to free internet pornography. The average age of first porn exposure in the United States is 11-years-old. ◦Often, this happens accidentally as a child is surfing the Internet or playing online, or is exposed to pornography by a peer at school, on the bus, or at a friend's house. Pornography apps can hide as calculators or seemingly unproblematic icons on one's phone. Hard for parents to find

Prevalence and Consequences of Sex Addiction

It is estimated that sex addiction impacts up to 6% of the general population (Carnes, 2005) and begins in adolescence or early adulthood (Goodman, 2005). There are a range of negative consequences associated with sex addiction including: §Injury/high-risk situations §Disease/HIV §Unintended pregnancy §Relationship problems §Sexual dysfunction §Time wasted (neglecting other obligations) §Legal issues §Financial issues §Job loss (e.g., viewing pornography at work) §Suicidal ideation: 72% of those with sex addiction have had thoughts of suicide and 17% have attempted suicide

Negative Consequences of Collegiate Substance Abuse

It is no surprise that substance abuse can lead to negative consequences. Take a look at the list below for risks associated with collegiate substance abuse: Driving after drinking/drug use Alcohol poisoning or drug overdose Sexual victimization (97,000 per year among college students according to NIAAA) Incapacitated rape occurs when the victim is unable to give consent Poor academic performance Legal/academic disciplinary consequences Unprotected sexual activity Aggression Alcohol/drug induced injury or death Engaging in behavior one would not choose to engage in while sober

Karim & Chaudhri (2012)

Karim & Chaudhri Behavioral Addictions abuse and disordered gambling have more severe problems than individuals with either disorder alone. (Langenbucher et al. 2001) The research base on pathological gambling is not sub- stantial but there are comparative studies looking at drug addiction and pathological gambling (PG). From a clinical perspective, gamblers report subjective cravings as pow- erful as drug abusers, they report "highs" similar to drug highs, they show withdrawal symptoms and autonomic instability when not gambling, and they may throw away everything in their life to gamble. The behaviors that characterize problematic gambling (chasing losses, preoccupation with gambling, inability to stop) are impulsive in that they are often premature, poorly thought out, risky, and result in deleterious long-term out- comes (Chamberlain & Sahakian 2007). Deficits in aspects of inhibition, working memory, planning, cognitive flexi- bility and time management or estimation are more com- mon in individuals with pathological gambling problems than healthy volunteers (Hodgins, Stea & Grant 2011). Distorted cognitions in gambling disorders may include: magnification of gambling skill, superstitious beliefs, inter- pretative biases, temporal telescoping, selective memory, predictive skill, illusions of control over luck, and illusory associations. (Hodgins, Stea & Grant 2011) Research studies looking at the relationship between gambling and substance use disorders reveal similar per- formance on personality and neurocognitive assessments of impulsivity, with both groups having high scores on self- reported measures of impulsiveness and sensation seeking (Petry 2001). Both show similar clinical courses and simi- lar clinical characteristics including things like tolerance, withdrawal, craving states and repeated attempts to cut back or quit. Thus there appears to be substantive simi- larities between the systems and circuits associated with chemical and gambling addictions. Among those who do seek treatment, Gamblers Anonymous (GA) is the most commonly utilized approach. GA is a 12-Step support group based on the principles of Alcoholics Anonymous (Petry 2009). In many epidemio- logical studies, an estimated 36% to 46% of pathological gamblers are in recovery (Hodgins, Wynne & Makarchuk 1999). Treatment for pathological gambling and problem gambling is varied and may include: GA, cognitive behav- ioral therapy, pharmacotherapy, motivational enhancement therapy, family therapy, brief therapy, residential treatment and for some, natural recovery. Neuroimaging studies reveal decreased activation of the ventro-medial prefrontal cortex (vmPFC) in patholog- ical gambling subjects during presentation of gambling cues (videos), which resembles cocaine addicts watching a cocaine video, with relatively less activation in regions implicated in judgment and motivation (Potenza et al. 2003). This suggests that the decision-making faculties are inhibited in these individuals. Neuroimaging studies in pathological gamblers have indicated diminished ventral striatum, ventromedial prefrontal cortex and ventrolateral prefrontal cortex activity during rewarding events, sugges- tive of a blunted neurophysiological response to rewards and losses (Reuter et al. 2005). The work of Slutske and colleagues (2000) strongly suggests that pathological gam- bling is genetically related to substance addictions. Low 5-HIAA levels have been found to correlate with high lev- els of impulsivity and sensation seeking and have been found in pathological gambling and substance use disorders (Potenza, Kosten & Rounsaville 2001). Baseline decreases in serotonergic tone have been observed in comparison to nongambling controls (Linnoila et al. 1983) and a euphoric "high" in gamblers is seen after administration of 5HT 2C agonists (Potenza 2008). Also, PG has been shown to lead to elevations in noradrenaline and comparatively elevated heart rates (Potenza 2008). Currently, there are no FDA-approved medications to treat pathological gamblers. It appears that three types of medications have some efficacy in treating PG: opiate antagonists, mood stabilizers and antidepressants. Results from two double-blind, placebo controlled studies of naltrexone and two multicenter double-blind, placebo- controlled trials of nalmefene suggest efficacy of opioid antagonists in reducing the intensity of urges to gamble, gambling thoughts, and gambling behavior (Hodgins, Stea & Grant 2011). Opiate antagonists have been shown to decrease the craving for gambling in a similar fashion to craving in alcoholics, and elevated rates dopamine in individuals with PG and alterations in the A1 allele of the dopamine D2 receptor gene suggest that the reward associated neurotransmitter systems are playing a signifi- cant role in driving the addiction process in this disorder (Goodman 2008; Potenza 2008). The use of paroxetine and other SSRIs, lithium and other mood stabilizers for patho- logic gamblers with bipolar symptoms, and the glutamate modulator N-acetyl cysteine have shown some positive effects. Because improvement in glutamatergic tone in the nucleus accumbens has been implicated in reducing the reward-seeking behavior in addictions (Kalivas, Peters & Knackstedt 2006), N-acetyl cysteine has been studied in the treatment of pathological gambling and has had posi- tive effects on urges and gambling behavior (Grant, Kim & Odlaug 2007). HYPERSEXUAL DISORDER Sex addiction (also known as compulsive sexual behavior or hypersexual disorder) is a controversial topic in both science and media. There is a lot of press but not much scientific evidence. Sex addiction could be described as a debilitating problem which may include impairment in physical health function, cognition, impulse control, attach- ment, intimacy and mood or it could simply be a convenient excuse for an individual's indiscretions. There will always be controversy when any class of behaviors, including sexual behaviors, that are considered Journal of Psychoactive Drugs 9 Volume 44 (1), January - March 2012 Karim & Chaudhri Behavioral Addictions to be intrinsically "normal" are medically "pathologized." (Money 1994) The primary criticism of compulsive sex- ual behavior or hypersexual disorder is that it may simply be a symptom of an underlying Axis I disorder and not a true disorder itself. In one study of compulsive sexuality, 88% of the sample met diagnostic criteria for an Axis I disorder at the time of the interview and 100% met crite- ria for an Axis I disorder at some time in their lives, with the most common diagnoses being mood and anxiety dis- orders (Raymond, Coleman & Miner 2003). Compulsive sexual behavior has been estimated to have a prevalence of between 3% and 6% in the United States (Black 2000). Most individuals with hypersexuality are male but studies that have examined both sexes report a proportion of 8% to 40% female (Kaplan & Krueger 2010). Sexuality is dependent on many factors, including individual and relationship variables, societal values, cul- tural mores, and ethnic and religious beliefs. In dis- cussing hypersexuality, these contexts need to be consid- ered (Kaplan & Krueger 2010). The challenge is in defining abnormal and pathological sexual practices. For example, a Swedish study found that simple frequency of sexual activity alone was insufficient to establish pathology; high frequency of sexual behavior with a stable partner was associated with better psychological functioning, whereas solitary or impersonal sexual behavior was associated with psychiatric disorders and psychosocial dysfunction (Langstrom & Hanson 2006) In defining aberrant sexual behavior, Carnes and Wilson (2002) proposed that sexually addictive behaviors include compulsive masturbation, affairs, use of prostitutes, pornography, cybersex, prostitution, voyeurism, exhibi- tionism, sexual harassment and sexual offending. Coleman, Raymond and McBean (2003) defined compulsive sex- ual disorders as compulsive cruising and multiple partners, compulsive fixation on an unattainable partner, compulsive autoeroticism, compulsive use of erotica, compulsive use of the Internet, compulsive multiple love relationships, and compulsive sexuality in a relationship. Hypersexual Disorder has been proposed as a new psy- chiatric disorder for consideration in the Sexual Disorders section for DSM-V. Hypersexual Disorder is conceptu- alized as primarily a nonparaphilic sexual desire dis- order with an impulsivity component (Kafka 2010). Proposed diagnostic criteria for Hypersexual Disorder (American Psychiatric Association DSM-5 Development 2010) include: A. Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, and sexual behavior in asso- ciation with four or more of the following five criteria: 1. Excessive time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior. 2. Repetitively engaging in these sexual fantasies, urges, and behavior in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability). 3. Repetitively engaging in sexual fantasies, urges, and behavior in response to stressful life events. 4. Repetitive but unsuccessful efforts to control or sig- nificantly reduce these sexual fantasies, urges, and behavior. 5. Repetitively engaging in sexual behavior while disre- garding the risk for physical or emotional harm to self or others. B. There is clinically significant personal distress or impair- ment in social, occupational or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges, and behavior. C. These sexual fantasies, urges, and behavior are not due to direct physiological effects of exogenous substances (e.g., drugs of abuse or medications) or to Manic Episodes. D. The person is at least 18 years of age. Specify if: Masturbation, Pornography, Sexual Behavior With Consenting Adults, Cybersex, Telephone Sex, Strip Clubs, Other. There is a paucity of literature on brain imaging during conventional or pathological sexual functioning. Research utilizing neuropsychological testing with self- reported behavior has shown a positive correlation between hypersexual behavior and global indices of executive dys- function including features of impulsivity, cognitive rigid- ity, poor judgment, and deficits in emotional regulation (Reid et al. 2009). Also, diffusion tensor imaging, psy- chometric testing and the Go-No-Go procedure revealed higher impulsivity scoring in compulsive sexual behav- ior patients than controls, with hypersexual patients hav- ing higher superior frontal region mean diffusivity than controls (Miner et al. 2009). Patients with hypersexual disorder do report feeling out of control and anxious, with obsessional thinking, mood instability and significant impairment in their daily lives. Reward circuits such as dopaminergic and endogenous opiate systems have been implicated in the process of sex- ual behavior in much the same way as substance abuse (Goodman 2008). An interesting piece of evidence around the role of the reward system in these disorders comes out of the Parkinson's field, where treatment with dopamine agonists leads to increased vulnerability to impulse con- trol disorders such as pathological gambling, hypersexu- ality, compulsive shopping and compulsive eating (Vilas, Pont-Sunyer & Tolosa 2012). A case study of Internet-based sex addiction involv- ing preoccupation with Internet pornography, extended and frequent masturbation and unprotected sex with cyber con- tacts revealed interesting diagnostic and treatment-based findings. The patient was initially prescribed an antide- pressant (sertraline) with both individual and group therapy and 12-Step work with Sex Addicts Anonymous with little improvement. After the addition of naltrexone (an opiate antagonist), the patient reported significant improvement in his cravings. When the naltrexone was discontinued, the patient's cravings returned and when he was put back on the medication, the urges diminished (Bostwick & Journal of Psychoactive Drugs 10 Volume 44 (1), January - March 2012 Karim & Chaudhri Behavioral Addictions Bucci 2008). Two double-blind, placebo-controlled studies reveal decreased symptoms using medication compared to baseline. The first, by Kruesi and colleagues (1992), com- pared clomipramine versus desipramine, with a two-week, single-blind placebo lead in. Both drugs decreased para- philic symptoms. The second study by Wainberg (2006) compared citalopram with a placebo for the treatment of compulsive sexual behaviors in gay and bisexual men. In the study, results included a significant decrease in sex- ual desire and drive as well as frequency of masturbation and pornography use. Additional treatment includes: cog- nitive behavioral therapy psychodynamic psychotherapy (exploring family of origin, trauma and underlying factors) and 12-Step groups with a focus on sexual behav- ior, including Sex and Love Addicts Anonymous, Sex Addicts Anonymous and Sexaholics Anonymous (Kaplan & Krueger 2010). COMPULSIVE BUYING DISORDER Like other behavioral addictions, shopping addiction is a controversial idea. Many experts recoil at the idea that excessive spending can constitute an addiction, believing there has to be physical tolerance and withdrawal to be diagnostically classified as such. One of the unifying com- ponents of all addictions lies in the reinforcing properties of these behaviors and substances. Although there is vari- ability in the definition of pathological spending, experts define compulsive buying disorder (CBD) as a disorder associated with compulsive thoughts or impulses to pur- chase unnecessary or large amounts of items despite its negative consequences. The classification of compulsive buying disorder remains unclear; however, McElroy and colleagues (1995) have developed diagnostic criteria for compulsive shopping in research settings, which include: (1) frequent preoccupation with shopping or intrusive, irre- sistible, "senseless" buying impulses; (2) clearly buying more than is needed or can be afforded; (3) distress related to buying behavior; and (4) significant interference with work or social functioning. Epidemiological reports suggest that there is a 2% to 8% prevalence of compulsive shopping in the U.S. based on results of a survey in which the Compulsive Buying Scale (CBS) was administered to 292 individuals in Illinois (Claes et al. 2011; Black at el. 2001). The data on gen- der differences with compulsive buying disorder is mixed; however, some estimate that the gender ratio is nine to one (female to male) (Claes et al. 2011; Black at el. 2001). However, Koran and colleagues (2006) report that compulsive buying disorder is nearly equal in men and women (5.5% and 6.0%), respectively. This finding implies that the gender disparity may be smaller than previous reports suggest and that men may be underrepresented in samples. Compulsive buying is typically chronic or intermittent, with an age of onset that ranges from 18 to 30 years and a greater proportion of these individuals reporting incomes under $50,000 (Black 2007). Psychiatric comorbidities often include mood disorders (21% to 100%), eating dis- orders (8% to 85%), substance abuse disorders (24% to 46%) and other impulse control disorders. Furthermore, some studies suggest that nearly 60% of compulsive buy- ers meet criteria for at least one personality disorder (Black 2007). Although widespread consumerism has escalated in recent years, compulsive shopping is not a new disorder but rather was identified over a century ago. Kraepelin gave it the name oniomania, which is roughly translated as "buying mania." As such, it has been a long-known phenomenon but only recently suggested to fit into the behavioral addiction spectrum (Brewer & Potenza 2008). Although this concept has historical recognition, there is no clear consensus on the difference between normal shop- ping, occasional splurges and shopping addiction. Black and colleagues (2001) report that individuals with compul- sive buying disorder are preoccupied with shopping and spending and typically spend hours each week engaged in these behaviors. They identified four distinct phases of compulsive buying disorder, including anticipation, prepa- ration, shopping, and spending. Many compulsive buy- ers describe an escalating level of anxiety that can only be relieved when they engage in the act of spending. Lee and Miltenberger (1997) reported that negative emo- tions, such as anger, anxiety, boredom and self-critical thoughts, were the most common antecedents to shopping binges, while euphoria or relief of the negative emo- tions were the most common consequences. They reported that there are several characteristics that compulsive buy- ing shares with other addictions. For instance, shopping addicts become preoccupied with spending, and devote significant time and money to the activity. Similar to drug abuse, shopping addiction is highly ritualized and follows an addictive course where the individual is con- sumed by thinking and planning the next shopping trip, and engaging in the act of buying itself or returning purchases leads to pleasure and relief of negative feel- ings. The frequency of pathological shopping episodes can range from once a month to once a day, depending on available funds. Similar to substance abuse, after the act of compulsive shopping, the individual may experience exhaustion or a let down. Once the purchase is com- plete, it often leads to feelings of guilt, disappointment and shame. The etiology and mechanisms of action behind com- pulsive spending are poorly understood; however, new research is shedding light on shared addiction associated circuitry that may mediate this behavior. There is a distinc- tion to be made between window-shopping and compulsive spending; the actual addictive process in this disorder is Journal of Psychoactive Drugs 11 Volume 44 (1), January - March 2012 Karim & Chaudhri Behavioral Addictions driven by the process of spending money. The act of compulsive spending subsequently requires recruitment and possible dysregulation of distinct decision-making cir- cuits in the brain. The role of opiate, serotonergic and dopaminergic systems have all been suggested in compulsive buying disorder (Mueller et al. 2010), however at present no defini- tive evidence has strongly linked these systems with it. Although clinical studies suggest that citalopram, a selec- tive serotonin reuptake inhibitor (SSRI), may have some beneficial effects in preventing relapse to compulsive buy- ing disorder patients, use of other SSRIs like fluvoxam- ine has proven inconclusive (Koran et al. 2006). A key indicator seems to stem from the field of Parkinson's disease, where patients maintained on a dopamine precur- sor L-DOPA or dopamine agonists tend to have higher rates of compulsive shopping, as well as other behav- ioral addictions (Djamshidian et al. 2010; Nirenberg & Waters 2006). In fact it has been shown that L-DOPA increased reward learning and risk taking in human imag- ing data (Pessiglione et al. 2006). This suggests that dopamine may play a distinctive role in driving crav- ing and seeking, reward prediction, and decision-making aspects of behavioral addictions in a similar manner to drugs of abuse (Berridge 2007; Volkow & Wise 2005). As shown in previous sections, these systems play a significant role in regulating emotional affect as well as reward systems in the brain and thus represent key components in the addiction process. Compulsive buy- ing disorder shares behavioral features such as escalation and tolerance, in the form of needing to spend more money in order to receive fulfillment from a shopping binge—both hallmarks of addiction. It is clear that the behavioral traits associated with these maladaptive behav- iors share a substantial homology with substance abuse and it stands to reason that similar brain systems are recruited and altered during the etiology of the disorder. However, a more rigorous approach is needed to understand the neurobiological mechanisms underlying compulsive buying disorder. The social, psychological and biological factors sur- rounding compulsive spending make it an interesting and complex condition. Additional studies are needed to better understand the etiology, differential diagnosis and treat- ment of this disorder. There are no published reports describing psychotherapy-focused trials for compulsive buying disorder. However, some preliminary findings sug- gest that cognitive behavioral therapy and dialectical behavioral therapy may have promising effects. Treatment outcome studies using SSRIs such as citalopram and flu- voxamine also seem to show a therapeutic benefit for individuals with compulsive buying disorder. However, fur- ther research is needed to identify the mechanisms that drive this behavior in order to create more efficacious treatment options. INTERNET ADDICTION DISORDER There is increasing attention on cyberspace social pathologies, which some would call technical addictions. As with other behavioral addictions, Internet abuse has been a controversial idea and one of the most challeng- ing tasks has been to arrive at a comprehensive definition of the concept. Experts have not been able to come to a consensus on a name, however, there are as many as six different terms associated with Internet addiction, includ- ing "Internet Addiction Disorder (IAD)," "Pathological Internet Use," "Excessive Internet Use," and "Compulsive Internet Use" (Widyanto, Griffiths & Brunsden 2011). Internet addiction is a relatively new concept in psy- chiatry and not yet recognized by the DSM-IV . However, some definitions of compulsive Internet use in the litera- ture have been derived from DSM-IV criteria for addiction and impulse control disorder. First introduced by Goldberg (1995) and made popular in Young's (1996) pioneering research, the term Internet addiction disorder (IAD) has been defined as "the compulsive overuse of the Internet and the irritable or moody behavior when deprived of it" (Mitchell 2000). Some prefer a more holistic def- inition that suggests that an individual's psychological state, which includes both mental and emotional states, as well as scholastic, occupational and social interactions, is impaired by the overuse of the Internet (Beard 2005). Shapira and colleagues (2003) state that in order to diag- nose the presence of Internet addiction disorder, individuals must meet the following criteria: (1) the excessive use of the Internet beyond the time allotted and / or irresistible urge to be preoccupied with the Internet; (2) an impair- ment, distress or poor functioning in social settings caused from a preoccupation with the Internet; and (3) the exces- sive use of the Internet is not associated exclusively with periods of hypomania or mania and cannot be entirely accounted for by Axis I clinical disorders. Griffiths (2000) believes that technical addictions are a branch of behavioral addictions that satisfy six criteria for addiction: salience, mood modification, tolerance, withdrawal, conflict, and relapse. The true prevalence of Internet addiction in the U.S. is unknown; however, Young (1998) estimated the figure to be between 5% and 10% of all online users, which is approx- imately two and five million Internet addicts. Other esti- mates vary greatly, from as low as 3% reported by Mitchell (2000) and Whang, Lee, and Chang (2003), to as high as 80% in Young's original study (1998). The demographic on who is more likely to be affected by Internet addic- tion is mixed and not a homogenous group. However, Mafe and Blas (2006) constructed a profile of Internet-dependent users as young, highly educated individuals having a close connection with the Internet. Other researchers have iden- tified Internet addiction-prone individuals as single, males, college students, gays, middle-aged females and the less Journal of Psychoactive Drugs 12 Volume 44 (1), January - March 2012 Karim & Chaudhri Behavioral Addictions educated (Soule, Shell & Kleen 2003). There is mixed data on gender disparities, although, more recent research suggests that that there is no correlation between gender and length of Internet use (Soule, Shell & Kleen 2003). Common psychiatric comorbidities with Internet addic- tion include depression, bipolar disorder, substance abuse disorder, pathological gambling and sexual compulsions (Morahan-Martin 2005). After a decade or more of academic research, the etiology and mechanisms of action behind pathological Internet use are not well developed. Research in this area is limited, with few studies using control groups, random- ization, or well-validated measures. The reward-deficiency hypothesis suggests that those who achieve less satisfac- tion from natural rewards turn to substances to seek an enhanced stimulation of reward pathways (Blum et al. 1996). Internet use provides immediate reward and grati- fication, similar to substance use. Individuals with certain personality attributes such as impulsivity, low self-esteem and introversion have a greater propensity to Internet addic- tion. Internet use may be used as a compensatory tool for certain deficiencies with social skills and interpersonal rela- tionships. There has been a range of psychological and behavioral theories that have been proposed to explain Internet addiction. Hammersley (1995) has suggested a number of psychological reasons why the Internet is highly reinforcing for some people: (1) it allows correspondence with people who share mutual interests; (2) it puts peo- ple in touch with other people who would otherwise never meet; (3) the costs of communicating is low; (4) there is a substantial "puzzle" element to using the Internet, and many people find puzzling tasks reinforcing; (5) people can download software toys, some of which are reinforcing; (6) people can keep in touch with friends with minimal time and financial costs; (7) it gives people feelings of status and modernity, which may bolster self-esteem; (8) it allows people to be taken seriously and listened to; and (9) it allows people to present a "well-managed" persona, which may deviate in significant ways from one's everyday, face- face persona. Others have described a cognitive behavioral model (Davis 2001) where Internet addiction may result when some psychological factor causes an individual to be vulnerable to dependence on new online content, which is followed by obsessive thoughts and then the perception that the Internet is a "friend." This may be reinforced by the decade-long trend of people spending increasingly more time with technology than with humans. There has been a shift away from family and peers to mass media technology as the primary socialization agents. Treatment strategies for pathological Internet use are under-researched and there is limited published data on effective therapeutic modalities. Young (1999) points to the usefulness of cognitive behavioral therapy for compul- sive Internet use. He suggests that catastrophic thinking might contribute to compulsive Internet use in proving a psychological escape mechanism to avoid real or perceived problems. He also hypothesized that those who suffer from negative core beliefs and cognitive distortions may be more drawn to anonymity of the Internet in order to overcome perceived adequacies. Cognitive behavioral therapy and psychoeducation seem to have promising results for the treatment of Internet addiction (Young 2007). Unfortunately, there are no published controlled trials to evaluate pharmacological interventions. Some experts believe that a similar pattern of cortical arousal exists in pathological gamblers, substance abusers and Internet abusers, and naltrexone may mitigate problematic impulse control behaviors in some individuals (Yellowless & Marks 2007). Research has shown adding naltrexone to a media- tion regimen that already includes an SSRI coincided with a decline in symptoms of Internet addiction (Bostwick & Bucci 2008). More research is needed to clarify the mech- anism by which naltrexone and SSRIs extinguish addictive behavior. There is no doubt that the Internet usage among the general population will continue to increase over the next few years. Future studies are needed to examine the quan- titative and qualitative effects of Internet abuse, while also investigating treatment differences among the various types of Internet addictions. VIDEOGAME ADDICTION Video games have been a part of American culture since the late 1950s, and their prominent role in the lives of American youth has led to increased public scrutiny of the effects and potential harms of video game usage, including the potential of socially maladaptive behaviors such as increased short-term aggressiveness and overuse syndromes (CSAPH Report 2006). In June of 2007, the American Medical Association Council on Science and Public Health considered whether "videogame addiction" could be a disorder. In the U.S. alone, the sale of video games and related products reportedly grossed between $7 and $10 billion in 2004. Although 70% to 90% of U.S. youth play video games, in 2005 a national survey identified the prototype gamer as a 30-year-old male who averages between 6.8 and 7.6 hours weekly playing video games (ESA 2006, 2005). Using World Health Organization criteria, a gaming addiction rate of 12% was found by researchers in the United Kingdom who polled 7,000 gamers (Grusser et al. 2007). Research in the United States has estimated that any- where from a small minority to as much as 10% to 15% of players may be affected (Chak & Leung 2004). Psychosocial effects of video games are varied. Some studies have found that exposure to video game violence may promote increased aggressive behaviors and decreased prosocial behaviors in social interactions. (Sheese& Graziano 2005; Vastag 2004) Although overuse Journal of Psychoactive Drugs 13 Volume 44 (1), January - March 2012 Karim & Chaudhri Behavioral Addictions can be associated with any type of video game, it is most commonly seen among those using massively multi-player online role-playing games (MMORPG), who represent approximately 9% of gamers (ESA 2005). The MMORPG are very interactive, social and competitive and primarily focused on fantasy. Researchers have attempted to exam- ine the type of individual most likely to be susceptible to such games, and current data suggest these individuals are somewhat marginalized socially, perhaps experiencing high levels of emotional loneliness and / or difficulty with real life social interactions. (Allison et al. 2006) Current theory is that these individuals achieve more control of their social relationships and more success in social relation- ships in the virtual reality realm than in real relationships (CSAPH Report 2006). Symptoms of time usage and social dysfunction / disruption appear in patterns similar to that of other addictive disorders (Tejeiro et al. 2002). Additionally, dependence-like behaviors are more likely in children who start playing video games at younger ages (Grusser et al. 2007). Although there are very few research studies looking at imaging or treatment, evidence for striatal dopamine release during video game playing was detected in a positron emission tomography study (Koepp et al. 1998). Areas of research on potential health effects of video games that are receiving increasing attention include atten- tion deficit / hyperactivity disorders (ADHD) and neurology (Chan & Rabinowitz 2006). OTHER BEHAVIORAL ADDICTIONS There are many other potential behaviors that may have addictive properties, but there is little published data on these conditions. The terms "love addiction or patholog- ical attachment," "work addiction," "exercise addiction" and others have been discussed. And of course, the current impulse control disorders listed in the DSM-IV classifica- tion need more data. There is very little research to support any of these "other" conditions that are not currently in the DSM being a true disorder, but clinically there are many individuals who report symptoms that warrant further discussion. CONCLUSION We live in an overstimulated society and rapid advances in technology and abundant availability to stimuli and resources may play a role in the increased prevalence of behavioral disorders. The use of repetitive actions, initiated by an impulse that can't be stopped, causing an individual to escape, numb, soothe, release tension, lessen anxiety or feel euphoric, may redefine the term addiction to include experience and not just substance. The core feature of these behaviors as well as substance use disorders appears to be impulsivity. Impulse control disorders primarily involve a hedonic quality—sex, gambling and stealing are all associated with a rush or a high (Grant, Brewer & Potenza 2006). The difficult part of defining impulse control disorders involves comorbidity and the complex relationship between affect and impulsivity. How do you know if the symptoms originate from the proposed primary disorder? Some crit- ics argue that behavioral conditions are simply secondary manifestations of underlying psychiatric illnesses includ- ing mood disorders, anxiety disorders, ADHD, personality disorders and other disorders. The repetitive behavior is simply an adaptation or compulsion to avoid discomfort. As research in nondrug addiction progresses, knowl- edge gained from the fields of drug addiction, motivation and obsessive-compulsive disorder will contribute to the development of therapeutic strategies for nondrug addic- tions (Olsen 2011). There is emerging clinical evidence that medications used to treat chemical dependency may be successful in treating nondrug addictions. For example, naltrexone, nalmefine, N-acetyl-cysteine and modafanil have all been reported to reduce craving in pathologi- cal gamblers (Grant et al. 2006). Opiate antagonists have also shown promise in the treatment of pathological gam- bling and compulsive sexual behavior (Grant & Kim 2001) and topirimate has shows some success in reducing binge episodes (McElroy et al. 2007). Similarities between nondrug and drug addictions include craving, impaired control over the behavior, tol- erance, withdrawal and high rates of relapse (Potenza 2006). It makes sense that natural rewards can cause neuroadaptation since learned associations between things such as food or sexual opportunities and the conditions which maximize availability is beneficial from a survival standpoint and is a natural function of the brain (Alcock 2005). In some individuals, this plasticity may contribute to a state of compulsive engagement in behaviors that resembles drug addiction (Olsen 2011). Similar to chem- ical addictions, there appears to be a transition period between moderate and compulsive use (Grant, Brewer & Potenza 2006). Extensive data suggests that eating, shop- ping, gambling, playing video games, and spending time on the Internet are behaviors that can develop into compulsive behaviors that are continued despite devastating conse- quences (Davis & Carter 2009). Clinically, patients may shift from a normative behavioral set point to a pathologi- cal one when influenced by comorbidities or environmental stimuli. These addiction and related disorders appear to work on a spectrum. It is clear there is a substantial amount of over- lap between behavioral addictions and substance abuse. Despite this commonality, there haven't been many studies evaluating shared neurobiology, although the research in binge eating and pathological gambling is slowly growing. At a minimum, we need researchers to better define these Journal of Psychoactive Drugs 14 Volume 44 (1), January - March 2012 Karim & Chaudhri Behavioral Addictions conditions with uniform diagnostic criteria and develop universal, valid screening measures. Awareness is build- ing and research is beginning to coalesce around defining the biological systems that drive these types of disorders. The National Institute on Drug Abuse (NIDA 2002), a research-funding agency in the United States, has cited the importance of studying nondrug behaviors / disorders (obesity, pathological gambling, etc.) in understanding sub- stance dependence. Indeed, in gaining a better understand- ing of behavioral addictions it may prove that we gain a stronger theory of the overall mechanisms that comprise our perception of "addiction

Sexual Orientation Considerations

Let's consider sexual orientation considerations in addictions treatment. LGBTQ+ adults are at greater risk for substance abuse than their heterosexual counterparts. Potential contributing factors include: ◦Stigmatization/marginalization for sexual orientation. ◦Hate-crime prevalence among LGBTQ+ community members. ◦Distress associated with coming out process. ◦Limited support system. ◦Socialization offered at gay bars. Multiple minority statuses

Al-Anon

Let's revisit Al-Anon (from the previous module). Al-Anon is a 12-step support group for friends and family of those struggling with addiction. It was started by the wives of men with alcohol addiction who met while their husbands were at AA meetings. Al-Anon provides peer support for those affected by a problem drinker. The focus of Al-Anon meetings is on the self, rather than the loved one with addiction (how the individual can increase wellness). Al-Anon can be a great resource for parents, children, partners, friends, and others in relationship with someone with addiction.

College Students and Substance Abuse

Let's start by talking about some statistics. According to research, the two most commonly abused substances among college students are alcohol and marijuana. Alcohol-related deaths among college students: 1,519 per year (according to the National Institute on Alcohol Abuse and Alcoholism- NIAAA). Binge drinking: 42.8% of college students in a national sample reported binge drinking in the prior 2 weeks (CORE, 2013). New trend: combining alcohol with energy drinks (which can be very dangerous—mixing a stimulant with a depressant). 32.5% of college students in a national sample reported using marijuana in the previous year (CORE, 2013).

Interplay between substances and mental health issues

Let's talk about the unique relationship between substance use and mental health. ◦Individuals with mental illness may start using drugs as a means to cope with symptoms (which can cause neuroadaptations as a result of prolonged substance use). ◦Individuals can use drugs and experience symptoms that resemble mental health symptoms. ◦Individuals with a predisposition to mental illness may be triggered by drugs of abuse and experience a first episode or exacerbate symptoms.

Marijuana

Like other substances, cannabis can be addictive for some users (Cannabis Use Disorder is a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders [DSM-5]) • Medical marijuana is used to treat pain, used during cancer chemotherapy treatment, and used as an AIDS treatment (for weight stimulation) • Currently, recreational marijuana use is legal in many U.S. states • In Colorado, traffic fatalities involving drivers impaired by THC increased from 10% to 19% since its legalization • Colorado earned $135 million in marijuana taxes in 2015

How we get it wrong?

Lots of professionals are in the business of helping people change...but not all approaches are helpful. We know that extrinsically influenced behavior modification is generally less effective for producing lasting change. Information and advice-giving is often insufficient to producing change. Pressuring, shaming, or advising someone to change their behavior often leads to push-back. Motivation does not typically grow out of threats and confrontation.

Questions to evoke change talk

MI counselors use questions intentionally. They ask questions to which the answer is change talk: What would you like to be different? What is the downside of how things are now? What might be the advantages of making a change? What would you be willing to do differently? What concerns you about your drinking? Consider the following question. Why is it incongruent with MI? Why haven't you changed up to this point?

Systemic Oppression and the War on Drugs

Michelle Alexander wrote a book, The New Jim Crow, that details how mass incarceration (largely due to drug charges) is another form of racial oppression (you are reading her article and watching her Ted Talk in this module). She is amazing. Although drugs are used by all racial groups (with White males using slightly more than the national average), more Black and Latino males are charged with drug crimes than Whites. ◦So the question is, why are some individuals sent to rehab or treatment, while others are arrested and imprisoned? Research also confirms that potential job applicants with a drug charge on their record, have a significantly harder time obtaining employment. The effects of drug-related charges are expansive

Xanax

Most prescribed drug for mental health in the country "just pop a Xanax" takes the edge of, quick solution, "just a pill"., extremely addictive Anxiety is chronic worry... helps you stop spinning... huge relief that is associated with taking Xanax 46 million prescriptions a year

Motivational interviewing

Motivational Interviewing (MI) is a clinical approach to helping people change that emerged in 1980s (from the addictions counseling field). MI is a communication style that can be utilized in many disciplines. It has been applied to nutrition and healthy eating, medication compliance, problem gambling, problem gaming, eating disorders, health and medical issues, anxiety and worry, treatment compliance, offender counseling, etc. The developers of MI (Miller and Rollnick) defined it as: "A person-centered counseling style for addressing the common problem of ambivalence about change" (p. 21).

Chapter 8: Legal and Ethical issues

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health. Center for Substance Abuse Treatment. Treatment of Adolescents with Substance Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 32.) Chapter 8 — Legal and Et hical Issues by Margaret K. Brooks, Esq. 1 Providers of adolescent treatment for substance use disorders must sometimes grapple with these two questions: 1. Can the provider admit an adolescent into the treatment program without obtaining the consent of a parent, guardian, or other legally responsible person? 2. How can substance use disorder treatment programs communicate with others concerned about a n adolescent's welfare without violating the stringent Federal regulations protecting confidentiality of information about clients? The answers to these questions are especially complex for those who treat adolescents for substance use disorders because a mix of Federal and State laws govern these areas; "adolescence" spans a range of ages and competencies; and the answer to each question may require consideration of a matrix of clinical as well as legal issues . This chapter will examine the factors treatme nt service providers should consider in deciding whether a particular adolescent may consent to treatment in the absence of parental consent or notification and how communications with other systems can be accomplished without violating the adolescent's ri ght to privacy. The first section discusses the consent issue in the context of the legal constraints imposed by Federal and State law and the clinical issues that may have an impact on the decision. The second section discusses how providers can communica te with others concerned about the adolescent's welfare without violating either the Federal confidentiality rules or the adolescent's heightened sense of privacy. Consent to Treatment Americans attach great importance to being left alone. They pride themselves on having perfected a social and political system that limits how far government and others can control what they do. The principle of autonomy is enshrined in the Constitution, a nd U.S. courts have repeatedly confirmed Americans' right to make decisions for themselves. This tradition is particularly strong in the area of medical decisionmaking: An adult with "decisional capacity" 2 has the unquestioned right to decide which treatment he will accept or to refuse treatment altogether, even if that refusal may result in death. The situation is somewhat different for adolescents because they do not have the l egal status of full - fledged adults. There are certain decisions that society will not allow them to make: Below a certain age (which varies by State and by issue), adolescents must attend school, may not marry without parental consent, may not drive, and c annot sign binding contracts. Adolescents' right to consent to medical treatment or to refuse treatment also differs from adults'. Whether a substance use disorder treatment program may admit an adolescent without parental consent depends on State statutes governing consent and parental notification in the context of substance use disorder treatment and a number of fact - based variables, including the adolescent's age and stage of cognitive, emotional, and social development. Although it may make clinical se nse to obtain consent for treatment from an underage adolescent, it is relevant to consider the wide range of factors that contribute to a program's decision to admit an adolescent for treatment without parental consent. State Laws More than half the State s, by law, permit adolescents less than 18 years of age to consent to substance use disorder treatment without parental consent. In these States, providers may admit adolescents on their own signature. (The important question of whether the provider can or should inform the parents is discussed below.) In States that do require parental consent or notification, a provider may admit an adolescent when there is parental consent or (in those States requiring notification) when the adolescent is willing to have the program communicate with a parent. Presumab ly, a parent whose child seeks treatment will consent. (A parent or guardian who refuses to consent to treatment that a health care professional believes necessary for the adolescent's well - being may face charges of child neglect.) The difficulty arises wh en the adolescent applying for admission refuses to permit communication with a parent or guardian. As is explained more fully below, with one very limited exception, the Federal confidentiality regulations prohibit a program from communicating with anyone in this situation, including a parent, unless the adolescent consents. The sole exception allows a program director to communicate "facts relevant to reducing a threat to the life or physical well - being of the applicant or any other individual to the mino r's parent, guardian, or other person authorized under State law to act in the minor's behalf," when • The program director believes that the adolescent, because of extreme youth or mental or physical condition, lacks the capacity to decide rationally whethe r to consent to the notification of her parent or guardian • The program director believes the disclosure to a parent or guardian is necessary to cope with a substantial threat to the life or physical well - being of the adolescent applicant or someone else. _ _2.14(c) and (d) Note that _2.14(d) applies only to applicants for services. It does not apply to minors who are already clients. Thus, programs cannot contact parents of adolescents who are already clients without the adolescent's consent even if counselo rs are concerned about adolescent's behavior. This is the point at which things become more complicated. If the adolescent refuses to consent to communication with a parent in a State that requires parental consent or notification, and the situation does n ot fit within the exception in __2.14(c) and (d), the program has two clear choices: It can refuse to admit the adolescent, 3 or it can admit the adolescent despite what the law seems to require. In making this decision, the program should consider the following factors (see Figure 8 - 1 ). Figure 8 - 1: Decision Tree Other Variables The adolescent's age. Society accords adolescents increased autonomy a s they get older. Although the details of the rules vary from State to State, adolescents in the middle age range may obtain a driver's license, often with limitations, and may work during their high school years, if they obtain work permits. It follows th at a treatment provider that might refuse to admit a 14 - year - old without parental consent in a State requiring it might have little concern admitting an 18 - year - old in similar circumstances. The adolescent's maturity . Chronological age is clearly not the o nly concern. There are 14 - year - olds who have maturity beyond their years, and there are emotionally immature 18 - year - olds with poor social skills and reasoning ability. Thus, a provider pondering whether to admit an adolescent without parental consent in a State requiring it should assess the adolescent's maturity as well as her chronological age. The adolescent's family situation . This TIP has emphasized the importance of family involvement in treatment. However, involving an adolescent's parents or notify ing them to obtain their consent may be impractical and clinically unwise in some cases. Adolescents who refuse to permit parental notification may have good reasons; requiring them to do so may not be ethical or very good clinical practice. Reconciliation with the family may be vital to an adolescent's recovery, but circumstances may dictate that it be abandoned or postponed until a later stage of treatment. The kind of treatment to be provided . The more intrusive and intensive the proposed treatment would be, the more risk the program assumes in admitting the adolescent without parental consent. An outpatient program is on firmer ground admitting an adolescent without parental consent than an intensive outpatient or a residential program would be. Federal confidentiality restrictions . As has already been mentioned, the Federal confidentiality regulations require substance use disorder treatment programs that wish to communicate with an adolescent's parents to obtain the adolescent's written consent. The pro gram's possible liability for refusing admission . State law may impose a duty on a program to treat clients in need. The program's possible liability for treating the adolescent without parental consent . It is theoretically possible that a provider could b e sued for treating an adolescent without obtaining parental consent in a State that requires it. It is, however, unlikely. If the treatment provided is uncontroversial and relatively nonintrusive, does not put the adolescent at risk, and is carried out in a responsible, nonnegligent manner, it would be hard for a parent to show that any harm was done. This is particularly so if the provider made a reasoned decision (relying on the factors discussed here) and acted in good faith and out of concern for the a dolescent. Of course, there is a slim possibility that a parent might sue a provider, claiming that treatment harmed the youngster or turned the adolescent away from the family. However, success in such a case would require proof that treatment harmed the adolescent or that family relationships were good prior to treatment and treatment caused the adolescent's alienation. These are extraordinarily difficult things to prove. Despite popular belief, most lawyers do not chase after cases that are complex, time - consuming, expensive, and difficult to win. Convincing an attorney to take on such a case would not be easy. The program's financial condition . If the program admits an adolescent without parental consent, it may not be paid for its treatment services. An y effort to bill the parent over the objections of the adolescent would violate the Federal confidentiality regulations. If a program is publicly funded, support for services for adolescents who do not want their parents notified may not be a problem. Beca use of the complexity of this issue, programs in States with laws that do not clearly allow admission of adolescents without parental consent or notification should develop an admissions policy. The policy should be based on the variables discussed above, vis - _ - vis: • State law regarding treatment of adolescents (i.e., is parental consent and/or notification required?) • State law regarding program liability if adolescent clients in need are turned away • The family circumstances as related by the adolescent -- verifying the adolescent's view of his family, with his consent, by contacting an adult who knows the family well • The adolescent's age and emotional, cognitive, and social maturity • The nature, severity , and complexity of presenting problems, and the kind of treatment the program provides • The program's financial capacity to provide treatment without reimbursement from the family • Potential for exposure to a lawsuit should the program admit the adolescent • With the above factors in mind, an assessment of the potential liability of the program if the adolescent is admitted The admission policy need not be rigid. For example, a provider could develop a policy permitting treatment of limited duration for adoles cents of sufficient maturity who are in need of treatment and who refuse to consent to parental notification. During that period of time, the program would provide treatment of light or moderate intensity and, at the same time, work with the adolescent on the notification issue. If the adolescent consents to parental notification after a period of time, the problem may be resolved. If the adolescent remains adamantly opposed to communication with her parents and if the program is convinced there is ample ju stification, it could assist the adolescent in finding another adult relative to bring into the picture or help find legal assistance that would permit the adolescent to gain "emancipated minor" status or simply continue treatment. If an adolescent's famil y situation poses a real threat to her well - being, it may be appropriate for the program to report that fact to child welfare officials. 4 This option is also available to the provider who determines that it is inappropriate to admit an adolescent to treatment without parental consent because of the youngster's age or maturity. 5 The entire decisionmaking process, including reasons for exceptions to the policy, should be noted in the client's medical records. Privacy and Confidentiality Those who treat adolescents with substance use disorders are naturally concerned about their clients' privacy and confidentiality. For an adolescent, disclosure of a substance use disorder may contribute to negative stigma. Disclosures of information about an adolescent's substance use disorder might result in his having to deal with i nquisitive peers, who may feel uncomfortable around him or subject him to ridicule. Adolescents in recovery have much to overcome, without having to face their peers before they are ready. Given the importance of respecting adolescent clients' privacy, how can a program that assesses and treats adolescents approach family, school, and other sources that have information it may need? Can the program contact a parent or guardian without an adolescent's consent? If an adolescent tells a program staff member th at she has been abused, can the program report it? If the adolescent tells a counselor she has committed a crime, should the counselor notify the police? If the adolescent is threatening harm to herself or another, can the program call the authorities? Are there special rules regarding confidentiality for programs operating in the juvenile justice system or for child welfare programs? This section attempts to answer these and related questions. It has five parts. First, there is an overview of the Federal l aw protecting a youth's right to privacy when seeking or receiving treatment services. Next is a detailed discussion of the rules regarding the use of consent forms to get an adolescent's permission to release information about his seeking or receiving sub stance abuse services. The third reviews the rules for communicating with others about various issues concerning a youth who is in treatment for a substance use disorder (including rules for communicating with parents, guardians, and other sources; reporti ng child abuse ; warning others of an adolescent's threats to harm herself or another; and special rules for use within the criminal and juvenile justice systems). The next part discusses a number of exceptions to the general rule barring disclosure such as medical emergencies. This section ends with a few additional points concerning a youth's right to confidential services and the need for programs to obtain legal assistance. Federal Law Protects Adolescents' Right to Privacy Concerned about the adverse ef fects social stigma and discrimination have on clients in recovery and how that stigma and discrimination might deter people from entering treatment, Congress passed legislation, and the Department of Health and Human Services issued a set of regulations t o protect information about clients' substance use disorder treatment. The law is codified at 42 U.S.C. _290dd - 2. The implementing Federal regulations, Confidentiality of Alcohol and Drug Abuse Client Records , are contained in 42 C.F.R. Part 2 (Vol. 42 of the Code of Federal Regulations, Part 2). The Federal law and regulations severely restrict communications about identifiable clients by "programs" providing substance use/ abuse diagnosis, treatment, or referral for treatment (42 CFR _2.11). The purpose of the law and regulations is to decrease the risk that information about individuals in recovery will be disseminated and that they will be ostracized or subjected to discriminati on. The regulations restrict communications more tightly in many instances than, for example, either the doctor - client or the attorney - client privilege. Violating the regulations is punishable by a fine of up to $500 for a first offense and up to $5,000 fo r each subsequent offense (_2.4). 6 Some may view these Federal regulations governing communication about the adolescent and protecting privacy rights as an irritation or a barri er to achieving program goals. However, most of the nettlesome problems that may crop up under the regulations can easily be avoided through planning ahead. Familiarity with the regulations' requirements will assist communication. It can also reduce confid entiality - related conflicts among the program, adolescent client, parent, and outside agencies so that they occur only in a few relatively rare situations. What Types of Programs Are Governed by the Regulations? Any program that specializes, in whole or in part, in providing treatment, counseling, and/or assessment and referral services for adolescents with substance use disorders must comply with the Federal confidentiality regulations (42 C.F.R. _2.12(e)). Although the Federal regulations apply only to pr ograms that receive Federal assistance, this includes indirect forms of Federal aid such as tax - exempt status or State or local government funding coming (in whole or in part) from the Federal Government. Coverage under the Federal regulations does not dep end on how a program labels its services. Calling itself a "prevention program" does not excuse a program from adhering to the confidentiality rules. It is the kind of services, not the label, that will determine whether the program must comply with the Fe deral law. The General Rule: Overview of Federal Confidentiality Laws The Federal confidentiality laws and regulations protect any information about an adolescent who has applied for or received any substance use/ abuse - related assessment, treatment, or referral services from a program that is covered under the law. Services applied for or received can include assessment, diagnosis, individual counseling, group counseling, treatment, or referral for treatment. 7 The restrictions on disclosure (the act of making information known to another) apply to any information that would identify the adolescent as having a substance use disorder either dire ctly or by implication. The general rule applies from the time the adolescent makes an appointment. It also applies to former clients. The rule applies whether or not the person making an inquiry already has the information, has other ways of getting it, h as some form of official status, is authorized by State law, or comes armed with a subpoena or search warrant. When May Confidential Information Be Shared With Others? Information that is protected by the Federal confidentiality regulations may always be d isclosed after the adolescent has signed a proper consent form. (As will soon become clear, parental consent must also be obtained in some States.) The regulations also permit disclosure without the adolescent's consent in several situations, including med ical emergencies, reporting child abuse , and communications among program staff. Nevertheless, obtaining the adolescent's consent is the most commonly used exception to the general rule prohibiting disclosure. The regulations' requirements regarding consen t are strict and somewhat unusual and must be carefully followed. Consent: Rules about obtaining adolescent consent to disclose treatment information Most disclosures are permissible if an adolescent has signed a valid consent form that has not expired or been revoked (_2.31). 8 A proper consent form must be in writing and must contain each of the items specified in _2.31: • The name or general description of the program(s) making t he disclosure • The name or title of the individual or organization that will receive the disclosure

Conceptualizing NSSI

NSSI is difficult to understand as it goes against the natural instinct for self-preservation. Below are a few broad trends/themes to note: The most common age of onset for NSSI is adolescence. For many, NSSI is a means of coping with life's difficulty (thus a form of emotion regulation); others use NSSI as a means of anti-dissociation (especially among those who have experienced trauma). Understanding NSSI requires a holistic conceptualization: Biological influence: Genetic predisposition (high emotional reactivity); abnormal serotonin levels (which creates impulsivity). Psychological influence: Trauma history or psychological distress can make an individual vulnerable to coping through NSSI. Social influence: NSSI is a learned behavior (social modeling on TV or movies or peers at school; becoming more common on social networking sites). NSSI may be a preferred means of emotion regulation among teenagers because it is easy to access and easy to hide (Nock, 2009).

Religion/Spiritual Considerations

Next let's consider religion and spirituality. Research indicates that religion and spirituality are protective factors against substance abuse. Across the lifespan, those with higher levels of religiousness and spirituality have lower levels of alcohol and drug use and more positive treatment outcomes. Literature is replete with examples of the robust correlation between religiousness/spirituality and lowered substance abuse.

Cannabis Use Disorder Criteria

Next, read through the criteria for Cannabis Use Disorder below. Remember- if 2-3 criteria are met, it is considered mild, 4-5 moderate, and 6+ severe. In the past 12 months: 1. Cannabis taken in larger amounts than intended 2. Unsuccessful efforts to cut down use 3. Great deal of time spent in activities related to use 4. Cravings 5. Failure to fulfill obligations at work, home, or school 6. Continued use despite social or interpersonal problems 7. Important activities given up due to use 8. Recurrent use in hazardous situations 9. Continued use despite knowledge of physical or psychological problems 10. Tolerance 11. Withdrawal

Tolerance and Novelty

Pornography causes significant neuroadaptations in the brain's reward pathway. ◦It becomes a supernormal stimuli (artificial, exaggerated version of a true rewarding stimulus) releasing excessive amounts of dopamine. ◦"With multiple tabs open and clicking for hours, you can 'experience' more novel sex partners every ten minutes than your hunter-gatherer ancestors experienced in a lifetime" (Wilson, 2014, p.61). ◦Because of the excessive dopamine releases, the brain erroneously links pornography with survival (leading to compulsive use). The brain responds by decreasing dopamine production and receptors, and tolerance begins. ◦Pornography users need more novel porn to achieve the desired effect (users move from softcore to hardcore porn, more violent porn, etc.) ◦The porn industry is aware of the issue of tolerance and continually looks for new ways to produce porn (to increase novelty). ◦Long-term pornography use causes an overall decrease in sexual pleasure.

Quotes from Those who Self-Injure

The Heart of MI

Rather than confrontational, MI is a "guiding" approach in which the counselor works with the client toward positive change. MI counselors believe that their clients already have reasons to change their behavior within them (this is the definition of ambivalence). MI creates a space where clients talk themselves into change by relying on their own motivation. Miller and Rollnick said, "If you as the helper are arguing for change and your client is arguing against it, you've got it exactly backwards" (p.9).

Relapse Prevention

Relapse Prevention Module 6 Echd 3170 In This Powerpoint We Are Going To Learn About Relapse And Relapse Prevention Strategies. Given What You Know About The Neurobiology Of Addiction And The Biopsychosocial Model, Consider All Of The Factors That Contribute To A Relapse. Let's Learn About How To Prevent Or Respond To Relapse. Loading... The Experience Of Relapse •Consider An Individual In Recovery From A Substance Use Disorder. After A Period Of Abstinence, A Relapse Occurs (Relapse Simply Means A Return To Use After A Period Of Abstinence). What Effect Does This Relapse Have On: •The Individual With Addiction? •Family Members? •Employer And Coworkers? •Friends? •The Counselor Or Treatment Provider? Conceptualizing Relapse •First, A Few Truths About Relapse: •Addiction Is Referred To As A "Relapsing Disease." •About 80% Of Clients Relapse At Least Once After Treatment For A Substance Use Disorder. •Relapse Is Part Of The Disorder, Thus Counselors Should Help Their Clients Create A Relapse Prevention Plan. •We Have All Experienced Relapse, Which Means, A Return To Previous Behavior After Making A Change. •Consider Starting A New Diet, Beginning A New Exercise Regimen, Adopting A New Spiritual/Meditative Practice, Limiting Time On Social Media, Waking Up Earlier, Studying Longer Etc.--- We Often "Relapse" When We Are Trying To Make A Change. •Relapse Is A Learning Opportunity Rather Than Failure. •A Relapse Does Not Negate All The Treatment, Work, And Effort Up To That Point. •Instead, It Highlights An Area That Needs To Be Addressed Or Strengthened. Loading... Conditioning And Relapse •Have You Ever Heard Of Classical Conditioning? This Is A Concept From Behaviorism And Has To Do With Our Involuntary Behaviors. •Pavlov's Dogs, Which He Conditioned To Salivate At The Sound Of A Bell, Is One Of The Most Famous Examples Of Classical Conditioning. If You Pair Two Stimuli Together Enough Times, Our Minds Create An Association (E. G., Hear A Bell Ring, Salivate At The Expectation Of Food). •With Substance Use, Individuals Condition Themselves To Expect The Reward (Dopamine Release) When They See, Smell, Or Hear Things That They Regularly Paired With Substance Use (Like Needles, Beer Mugs, Bar Signs, Certain Street Corners, Etc.) •That Is Why, Those With Addiction, May Experience Cravings Simply From The Sight Of Things That Remind Them Of Their Substance Use. Conditioning And Relapse •Remember The Amygdala? It Is The Part Of The Brain Responsible For Emotional Memory. It Remembers What Caused An Emotion (Like Fear Or Pleasure). •Even In The Absence Of A Substance, Stimuli Continuously Paired With A Drug Of Abuse (Like A Location, Smell, Or Object) Can Trigger A Small Reaction In The Reward Pathway. •Small Release Of Dopamine (Among Other Neurotransmitters). •This Small Activation Of The Reward Pathway Results In Urges And Cravings. •The Individual Thus Has An Increased Probability Of Relapse. What Is Relapse Prevention? •So What Do Treatment Providers Do To Help Prevent Relapse? •Relapse Prevention Is The Act Of Helping Individuals With Addiction Prepare For The Potential Of Returning To Use. •This Often Includes Psychoeducation About The Neurochemistry Of Addiction. •Like The Role Of The Amygdala And Reward Pathway. •Relapse Prevention Helps Individuals With Addiction Develop Alternative, Adaptive Coping Strategies: •By Anticipating Difficulties In Life And Developing New Ways Of Emotion Regulation. •Identifying And Building A Support System. Relapse Prevention Model (Rpm; Marlatt & George, 1984) •A Popular Method Of Relapse Prevention Is The Relapse Prevention Model (Rpm). •The Old Way Of Thinking About Relapse Was A Dichotomous View: •All Or Nothing---An Individual Is Either Abstinent Or Using, Winning Or Failing, With No In-Between. •Now, Counselors Think About Relapse Using A Continuous View (The Rpm Model): •Relapse Is A Single Event On The Road To Long-Term Abstinence. •Just Like A Skater Slipping On The Ice During Competition—It Doesn't Negate Their Entire Performance. They Get Up And Keep Going. •A Single Return To Use Is Often Called A "Lapse", Which Can Lead To A Full-Blown Relapse Or A Return To Abstinence. Return To Abstinence Full -On Relapse Lapse Every Lapse Is A Choice-Point. The Individual With Addiction Can Either Think, "Oh Well, I Blew It!" And Continue Using, Or The Person Can Follow The Relapse Prevention Plan And Call A Support Person (Counselor, Sponsor, Peer) After A Lapse To Help Them Return To Abstinence Components Of The Rpm Model •The Rpm Model Suggests That When An Individual In Recovery Reaches A High-Risk Situation (Like A Stressful Event, Interpersonal Difficulty, Or Peer Pressure To Use), They Have Some Options: •They Can Employ A Coping Strategy To Deal With The High-Risk Situation. •The Coping Strategy Is Effective And They Feel Empowered. •They Choose Not To Use A Substance (No Relapse). Or •They Employ A Coping Strategy To Deal With The High-Risk Situation. •The Coping Strategy Does Not Work And They Being Thinking About The Positive Emotions That Came With Substance Use. •They Take The First Drink/Drug (Lapse) And Experience The Abstinence Violation Effect (The Idea That They Have Violated Their Abstinence So What Is The Point Of Trying To Continue). •This Leads To A Full Blown Relapse. Loading... Rpm Model In A Graphical Form •Review The Chart Below To See The Two Possible Responses To A High-Risk Situation: Rpm Counseling Strategies •According To The Rpm, There Are Several Ways To Help Clients Prevent Relapse: •Help The Client Find A Balanced Life With Limited High-Risk Situations. •Stress Is Inevitable, But It Can Be Reduced And Balanced With Pleasurable Activities. •Create A Repertoire Of Effective Coping Strategies. •Ways The Client Can Deal With Negative Emotions (Like Breathing Techniques, Journaling, Exercise, Connecting With Support Network, Spiritual Practice, Positive Self-Talk, Etc.) •Combat Positive Outcome Expectancies With Realistic Perceptions Of Drug And Alcohol Use ("Using May Make Me Feel Ok Temporarily, But In The Long Run It Makes My Life Harder And More Complicated"). •Plan For A Response To A Lapse. •In The Event Of A First Drink Or Drug (Lapse), The Client Will Call The Counselor, Go To A12-Step Meeting, Call A Support System Member, Employ A Coping Strategy, Etc.) Mindfulness-Based Relapse Prevention (Bowen, Chawla, & Marlatt, 2010) •Another Relapse Prevention Approach Is Based On Mindfulness Principles. •Mindfulness Encourages Awareness And Acceptance Of The Self. •Mindfulness Calls For Attention To The Present Moment •What Is The Individual Feeling And Thinking Right Now? •Mindfulness Encourages A Nonjudgmental Stance Toward One's Thoughts, Feelings, And Experiences. •Individuals In Recovery Are Mindful Of Their Cravings- They Demonstrate Awareness Without Judgment. •Practice A Technique Called "Urge Surfing": The Individual Visualizes Riding A Craving Like A Wave Until It Crests And Falls (Cravings Do Not Last Forever). •In This Approach, Clients In Recovery May Practice Mindful Meditation Or Guided Imagery To Deal With Stress And Find Balance. Gorski's (1989) Cenaps Model •A Final Relapse Prevention Approach Is The Cenaps Model •In This Model, The Client Identifies Relapse Warning Signs. •These Are Thoughts, Feelings, Or Behaviors That Occur Just Before A Relapse Such As Reconnecting With Old Using Buddies, Feelings Of Boredom, Or The Thought "I Am Not Good Enough." •Next, The Counselor And Client Develop Coping Strategies In Response To Each Warning Sign: •One By One, What Would The Individual Do In Response To The Warning Sign? (Refusal Strategies, Motivational Self-Talk, Call A Sponsor, Go To A 12-Step Meeting, Engage In A Healthy Alternative Behavior Etc.) •Finally, The Counselor And Client Create A Holistic Recovery Plan: •The Plan Includes Lifestyle Changes To Increase Overall Wellness. Identifying Triggers •Relapse Prevention Planning Includes The Identification Of Things That Trigger A Desire To Use Substances. •Counselors Ask Clients To Consider The Purpose Or Function Of Their Previous Substance Use. •For Example: Self-Punishment, To Feel Good, To Avoid Feeling Bad, Social Pressure, Etc. •Like Dominos, The Counselor And Client Examine All Of The Thoughts, Feelings, And Behaviors That Set Off The Cascade To Use Substances. •This Helps Identify What Might Trigger The Urge To Use In The Future. •Next, The Counselor And Client Find Healthy, Adaptive Ways To Meet The Client's Needs (Or Fulfill The Purpose Of The Substance). Developing Coping Strategies •Recovery Is More Than Just Not Using Substances. It Requires The Development Of New Coping Strategies, Such As: •Drug Refusal Skills •Cognitive Restructuring And Positive Self-Talk •Emotion Regulation Strategies Like Breathwork, Journaling, Spiritual Practices, Healthy Distractions, Problem Resolution Skills •Communities Of Support Like 12-Step Fellowships, Non-Using Peer Groups, Faith Communities •Self-Care Practices •Professional Counseling

Secular Organizations for Sobriety

Chapter 16

Several Behavioral Problems Have Been Hypothesized As Having Similarities To Sub- Stance Addictions And Are Referred To As "Behavioral Addictions." These Behaviors Involve Short-Term Rewards That May Engender Persistent Behaviors Despite Knowl- Edge Of Adverse Consequences (I. E., Diminished Control Over The Behavior). Diminished Control Is A Core Defining Concept Of Psychoactive Substance Dependence Or Addiction (Potenza, 2006). The Concept Of Behavioral Addictions Has Some Scientific And Clinical Heuristic Value But Remains Controversial (Grant, Brewer, & Potenza, 2006). Although Which Behaviors To Include As Behavioral Addictions Is Still Open For Debate (Holden, 2010), The Behaviors That Have Received The Most Research Atten- Tion Include Gambling Disorder, Kleptomania, Compulsive Buying, Compulsive Sex- Ual Behavior, And Internet Addiction. In The Hope Of Contributing To This Debate, We Review In This Chapter The Evidence For Similarities Between Behavioral Addictions And Substance Use Disorders (Suds) And Identify Areas Of Uncertainty That Warrant Future Research. It Seems Increasingly Important That Individuals Involved In The Prevention And Treatment Of Suds Have A Current Understanding Of These Behavioral Addictions, And The Potential For Future Research Findings To Guide Prevention And Treatment Efforts For Addictions In General. Core Features Of Behavioral And Drug Addictions Behavioral And Drug Addictions Share Common Core Qualities: (1) Repetitive Or Compul- Sive Engagement In A Behavior Despite Adverse Consequences; (2) Diminished Control 327 328 Iv. Special Populations Over The Problematic Behavior; (3) An Appetitive Urge Or Craving State Prior To Engage- Ment In The Problematic Behavior; And (4) A Hedonic Quality During The Performance Of The Problematic Behavior. These Features Have Led To A Description Of Behavioral Addictions As "Addictions Without The Drug." Clinical Similarities Between Behavioral Addictions And Suds Are Best Reflected In The Diagnostic Criteria For Gambling Disorder. Criteria For Gambling Disorder (Gd) Share Common Features With Those For Substance Dependence (American Psychiatric Association, 2013), Including Aspects Of Tolerance, Withdrawal, Repeated Unsuccess- Ful Attempts To Cut Back Or Stop, And Impairment In Major Areas Of Life Functioning (Blanco, Moreyra, Nunes, Saiz-Ruiz, & Ibanez, 2001). Epidemiological Data Also Support A Relationship Between Gd And Suds, With High Rates Of Co-Occurrence In Each Direction (Potenza, Fiellin, Heninger, Rounsaville, & Mazure, 2002). Phenom- Enological Data Further Support A Relationship Between Behavioral And Drug Addic- Tions; For Example, High Rates Of Gd And Suds Have Been Reported During Adolescence And Young Adulthood (Chambers & Potenza, 2003), And The Telescoping Phenomenon (Reflecting The More Rapid Progression From Initial To Problematic Behavioral Engage- Ment In Women As Compared With Men) Initially Described For Alcoholism Has Been Applied To Gd (Potenza, Steinberg, Et Al., 2001; Hernandez-Avila, Rounsaville, & Kranzler, 2004). Emerging Biological Data, Such As Those Identifying Common Genetic Contributions To Alcohol Use And Gambling Disorders (Slutske Et Al., 2000; Grant, Kushner, & Kim, 2002), And Common Brain Activity Changes Underlying Gambling Urges And Drug Cravings (Hodgins, Stea, & Grant, 2011; Leeman & Potenza, 2012), Provide Further Support For A Shared Relationship Between Gd And Suds. Epidemiology Arguably The Best Data On The Prevalence Of Behavioral Addictions Exist For Gd. Approximately 0.4 To 1.6% Of Individuals In The United States Meet Criteria For Gd (National Opinion Research Center, 1999; Petry, Stinson, & Grant, 2005). Rates Of Problem Gambling, A Less Severe Form Of Disordered Gambling Than Gd (Not Presently Included Among Psychiatric Classifications), Have Been Estimated At An Additional 3-5% Of The General Adult Population (Hodgins Et Al., 2011). As With Suds, Higher Rates Of Problem Gambling And Gd Have Been Reported In Males, Particularly During Adolescence And Young Adulthood. Although No Large-Scale Epidemiological Studies Have Assessed The Prevalence Of Many Other Behavioral Addictions In The General Population, Smaller Community Studies Indicate That These Behaviors Are Present To Varying Degrees. A Survey Of Col- Lege Students (N = 791) Indicated That Three Individuals (0.38%) Met Dsm-Iv Criteria For Kleptomania, And 3.44% Reported Symptoms Consistent With The Proposed Criteria For Compulsive Sexual Behavior (Odlaug & Grant, 2010). The Estimated Prevalence Of Compulsive Buying Based On A Random Digit Dialing Telephone Survey In The United States Was 5.8% (Koran, Faber, Aboujaoude, Large, & Serpe, 2006). Worldwide, Internet Addiction Has Been Estimated To Have A Prevalence Rate Of 1-14% (Block, 2008; Park, Kim, & Cho, 2008; Tsitsika Et Al., 2009; Bakken, Wenzel, Götestam, 16. Gambling Disorder And Other "Behavioral" Addictions 329 Johansson, & Øren, 2009), Although Lower Rates Of 0.3-0.7% Have Been Reported In The United States (Shaw & Black, 2008). Gambling Disorder Clinical Characteristics Gd Shares Many Features With Suds. Gambling Behavior Usually Begins In Child- Hood Or Adolescence, With Males Tending To Start At An Earlier Age (Auger, Lo, & O'loughlin, 2012; Rahman Et Al., 2012; Chambers & Potenza, 2003; Grant & Kim, 2001A). Higher Rates Of Gd Are Observed In Men, With A Telescoping Phenomenon Observed In Females (Nelson, Laplante, Labrie, & Shaffer, 2006; Tavares Et Al., 2003). Gd Has Been Described As A Chronic, Relapsing Condition (Potenza, Kosten, & Rounsaville, 2001). High Rates Of Gd In Adolescents And Young Adults Suggest A Natural History Similar To That Observed With Suds (Chambers & Potenza, 2003). Other Gender-Related Differences In Gd Have Been Described. Female, Compared With Male Gamblers, Tend To Have Problems With Nonstrategic Forms Of Gambling, Such As Slot Machines And Bingo, Whereas Men Are More Likely Than Women To Have Problems With Strategic Forms, Such As Sports And Card Gambling (Potenza, Steinberg, Et Al., 2001; Blanco, Hasin, Petry, Stinson, & Grant, 2006; Odlaug, Marsh, Kim, & Grant, 2011). As Is The Case For Suds And Specific Substances, Further Investigation Is Needed To Determine How Problems From Specific Forms Of Gambling Might Relate To Prevention And Treatment Efforts. Both Female And Male Gamblers Report That Adver- Tisements Are A Common Trigger Of Their Urges To Gamble, Although Females Are More Likely To Report That Feeling Bored Or Lonely May Also Trigger Their Urges To Gamble (Grant & Kim, 2001A; Ladd & Petry, 2002). As With Suds, Financial And Marital Problems Are Common (Dowling, Smith, & Thomas, 2009; Grant, Schreiber, Odlaug, & Kim, 2010) And Often Include Illegal Behaviors, Such As Stealing, Embezzlement, And Writing Bad Checks (Grant & Potenza, 2007; Ledgerwood, Weinstock, Morasco, & Petry, 2007). Findings Of Similar Cogni- Tive Features In Gd And Suds Have Also Been Reported (Brewer & Potenza, 2008); For Example, Both Groups Have Been Found To Display Rapid Temporal Discounting Of Rewards And To Perform Disadvantageously On Decision-Making Tasks (Bechara, 2003; Hodgins Et Al., 2011). Furthermore, Goudriaan, Oosterlaan, De Beurs, And Van Den Brink (2006) Found That Similar Cognitive Deficits (I. E., Poor Inhibition, Time Estima- Tion, Cognitive Flexibility, And Planning) Were Found In Both Individuals With Gd And Those With Alcohol Dependence, Although Lawrence, Luty, Bogdan, Sahakian, And Clark (2009A, 2009B) Found More Severe Deficits In Individuals With Alcohol Use Problems Than In Those With Gambling Problems. Co‐Occurring Disorders Patients With Gd Have High Rates Of Lifetime Mood (50-76%) And Anxiety (16-41%) Disorders (Erbas & Buchner, 2012; Petry Et Al., 2005; Black & Moyer, 1998; Crock- Ford & El-Guebaly, 1998). Elevated Rates Of Compulsive Buying, Compulsive Sexual 330 Iv. Special Populations Behavior, And Intermittent Explosive Disorder Have Also Been Found (Black & Moyer, 1998; Grant & Kim, 2001A). High Rates Of Co-Occurrence Have Been Reported For Suds (Including Nicotine Dependence) And Gd, With The Highest Odds Ratios Generally Observed Between Gam- Bling And Alcohol Use Disorders (Cunningham-Williams, Et Al., 1998; Welte, Et Al., 2001; Petry, Stinson, & Grant, 2005). A Canadian Epidemiological Survey Estimated That The Relative Risk For An Alcohol Use Disorder Is Increased 3.8 Fold When Disordered Gambling Is Present (Grant, Kushner, & Kim, 2002), And Odds Ratio Ranging From 3.3 To 23.1 Have Been Reported Between Gd And Alcohol Abuse/Dependence In U. S. Population-Based Studies (Cunningham-Williams, Cottler, Compton, & Spitznagel, 1998; Welte, Barnes, Wieczorek, Tidwell, & Parker, 2001). Treatment Although No Medication Has Received Regulatory Approval In Any Jurisdiction As A Treat- Ment For Gambling Disorders, There Have Been 18 Double-Blind, Placebo-Controlled Tri- Als Of Various Pharmacological Agents (Opioid Antagonists, Glutamatergic Agents, Anti- Depressants, Mood Stabilizers) For The Treatment Of Gd (Hodgins Et Al., 2011). Given The High Rates Of Placebo Response Often Observed In Treatment Trials Of Gd, We Focus In This Section On Findings From Double-Blind, Placebo-Controlled Trials. A Meta-Analysis Of 16 Pharmacological Treatment Trials, Published Between 2000 And 2006, Found That Compared To Placebo, Pharmacological Trials Were Significantly More Effective At Reducing Gambling Symptomatology (Pallesen Et Al., 2007). However These Results Need Careful Interpretation Due To Studies Reporting High Subject Attrition Rates And Placebo Response, As Well As Treatment Trials Published Since 2006. Opioid Antagonists Given Their Ability To Modulate Dopaminergic Transmission In The Mesolimbic Path- Way, Opioid Receptor Antagonists (Naltrexone, Nalmefene) Have Been Investigated In The Treatment Of Gd. Two Double-Blind, Placebo-Controlled Studies Of Naltrexone (Kim, Grant, Adson, & Shin, 2001; Grant, Kim, & Hartman, 2008) And Two Mul- Ticenter Double-Blind, Placebo-Controlled Trials Of Nalmefene (Grant, Potenza, Et Al., 2006; Grant, Odlaug, Potenza, Hollander, & Kim, 2010) Suggest The Efficacy Of Opi- Oid Antagonists In Reducing The Intensity Of Urges To Gamble, And Gambling Thoughts And Behaviors. Pooled Analyses Of Those Who Responded To Opioid Antagonists Demon- Strated Significant Reduction In Gambling Urges, Particularly Among Participants With A Positive Family History Of Alcohol Dependence (Grant, Kim, Hollander, & Potenza, 2008). Antidepressants Most Studies Of Antidepressants In Gd Have Focused On Selective Serotonin Reup- Take Inhibitors (Ssris). Fluvoxamine Demonstrated Mixed Results In Two Placebo- Controlled, Double-Blind Studies—One 16-Week Crossover Study Supporting Its Efficacy At An Average Dose Of 207 Mg/D (Hollander Et Al., 2000), And A Different 6-Month, 16. Gambling Disorder And Other "Behavioral" Addictions 331 Parallel-Arm Study With High Dropout Rates That Found No Significant Difference In Response To Active Or Placebo Drug (Blanco, Petkova, Ibanez, & Saiz-Ruiz, 2002). Similarly, Paroxetine At Doses Between 20 And 60 Mg/D (Average End-Of-Study Dose = 52 Mg/D) Demonstrated Efficacy In One Placebo-Controlled, Double-Blind Study (Kim, Grant, Adson, Shin, & Zaninelli, 2002), But A 16-Week, Multicenter Study Of Par- Oxetine Did Not Find A Statistically Significant Difference Between Active Drug And Placebo (48% Of Individuals Showing A Positive Response To Placebo, 59% To Active Drug; Grant Et Al., 2003). Currently, The Only Non-Ssri Antidepressant Examined For Gd Is Bupropion, Which Has Not Been Found Superior To Placebo (35.7 And 47.1% Of Those On Active Medication And Placebo, Respectively, Reported "Much" Or "Very Much" Improvement On The Clinical Global Improvement Impression Scale); However, These Results Are Complicated By A High Noncompletion Rate Of 43.6% And A Small Sample Size (Black Et Al., 2007). Mood Stabilizers A Double-Blind Study Found Sustained-Release Lithium Carbonate Superior To Placebo In 29 Bipolar-Spectrum Pathological Gamblers Over 10 Weeks (Hollander, Pallanti, Allen, Sood, & Rossi, 2005). Bipolar Spectrum Disorders Were Defined As Including Dsm-Iv Diagnoses Of Bipolar Ii Disorder, Bipolar Disorder Not Otherwise Specified, And Cyclothymia, And Mood Swings That Occurred At Times Unrelated To Gambling Urges/Behavior. Topiramate, However, Was Not Found To Reduce Gambling Behavior Or Urges Significantly In A Sample Of 42 Subjects With Gd Enrolled In A 14-Week Double- Blind, Randomized Study (Berlin Et Al., 2013). Antipsychotics Olanzapine, An Atypical Antipsychotic Drug, Was Not Significantly Different From Placebo In The Treatment Of Nonpsychotic Pathological Gamblers (Fong, Kalechstein, Bernhard, Rosenthal, & Rugle, 2008; Mcelroy, Nelson, Weldge, Kaehler, & Keck, 2008). Typical Antipsychotic Drugs Have Not Been Examined In The Treatment Of Gd, Although They Have Been Associated With Increasing Gambling-Related Motivations In Individuals With Gd (Zack & Poulos, 2007). As Individuals With Psychotic Disorders Frequently Experience Gd (Desai & Potenza, 2009), Trials Investigating The Efficacy And Tolerability Of Medications In Targeting Pg-Related Thoughts And Behaviors In This Population Are Needed. Other Agents Because Improving Glutamatergic Tone In The Nucleus Accumbens Has Been Implicated In Reducing Reward-Seeking Behaviors In Addictions (Li, Xi, & Markou, 2013; Kali- Vas, Lalumiere, Knackstedt, & Shen, 2009; Kalivas, Volkow, & Seamans, 2005), N-Acetyl Cysteine, An Amino Acid And Glutamate-Modulating Agent, Has Been Studied In The Treatment Of Gd And Has Demonstrated Positive Effects On Urges And Gambling Behavior (Grant, Kim, & Odlaug, 2007). Based On Existing Data On Subgroups Of 332 Iv. Special Populations Individuals With Gd, A Pharmacotherapy Treatment Algorithm Has Been Proposed (Bullock & Potenza, 2012). Psychotherapy Multiple Behavioral Treatments Have Been Investigated (Hodgins Et Al., 2011). A Meta- Analysis Using 22 Randomized Psychological Treatment Trials (Mainly Behavioral, Cog- Nitive, And Cognitive-Behavioral Formats) Published Between 1968 And 2004, Revealed That Psychological Treatments Were More Effective Than Not Receiving Treatment, Event After A Follow-Up Period Averaging 17 Months (Pallesen, Mitsem, Kvale, Johnsen, & Molde, 2005). Cognitive Therapy Focuses On Changing The Patient's Beliefs Regarding Perceived Control Over Randomly Determined Events. Case Reports Have Demonstrated Success With Cognitive Therapy (Ladouceur, Sylvain, Legate, Giroux, & Jacques, 1998), And Further Support Is Derived From Three Randomized Trials. In The First, Indi- Vidual Cognitive Therapy Resulted In Reduced Gambling Frequency And Increased Per- Ceived Self-Control Over Gambling When Compared With A Wait-List Control Group (Syl- Vain, Ladouceur, & Boisvert, 1997). A Second Trial That Included Relapse Prevention Also Produced Improvement In Gambling Symptoms Compared To A Wait-List Group (Ladouceur Et Al., 2001). A Third Trial That Evaluated The Efficacy Of Cognitive Inter- Vention In A Group Format Found That Group Cognitive Treatment Significantly Reduced Gd Severity Compared To A Control Condition (Ladouceur Et Al., 2003). Cognitive-Behavioral Therapy (Cbt) Has Also Been Used To Treat Gd. In One Ran- Domized Trial, Echeburua, Baez, And Fernandez-Montalvo (1996) Compared Four Groups: (1) Individual Stimulus Control And In Vivo Exposure With Response Preven- Tion, (2) Group Cognitive Restructuring, (3) A Combination Of 1 And 2, And (4) A Wait- List Control. At 12 Months, Rates Of Abstinence Or Minimal Gambling Were Higher In The Individual Treatment (69%) Compared With Group Cognitive Restructuring (38%) And The Combined Treatment (38%). More Recent Studies Indicate That Cbt Is More Efficacious Than A Referral To Gamblers Anonymous (Petry Et Al., 2006); Internet- Delivered Cbt Reduces Gd Severity Significantly More Than No Treatment (Carlbring & Smit, 2008); And Individualized Cbt May Be More Effective Than Group Cbt For Treating Gd (Dowling, Smith, & Thomas, 2007). Brief Interventions In The Form Of Workbooks Have Also Been Studied. One Study Assigned Gamblers To A Workbook Alone (The Workbook Included Cognitive-Behavioral And Motivational Enhancement Techniques) Or To The Workbook In Addition To One Clinician Interview (Dickerson, Hinchy, & England, 1990). Both Groups Reported Sig- Nificant Reductions In Gambling At A 6-Month Follow-Up. Similarly, A Separate Study Assigned Gamblers To A Workbook, A Workbook Plus A Telephone Motivational Enhance- Ment Intervention, Or A Wait List. Compared To The Workbook Alone, Those Gamblers Assigned To The Motivational Intervention And Workbook Reduced Gambling Through- Out A 2-Year Follow-Up Period (Hodgins, Currie, & El-Guebaly, 2001; Hodgins, Cur- Rie, El-Guebaly, & Peden, 2004). Two Studies Have Investigated Brief Motivational Interviewing. Hodgins, Currie, Currie, And Fick (2009) Compared A Wait-List Control Group To Two Brief Motivational- Interviewing Groups (With And Without Six Booster Phone Calls) And Found That Both Treatment Groups Were Effective In Reducing Gambling Frequency And Money Lost. 16. Gambling Disorder And Other "Behavioral" Addictions 333 Petry, Weinstock, Ledgerwood, And Morasco (2008) Found That One Session Of Moti- Vational Enhancement Therapy Plus Three Sessions Of Cbt Significantly Reduced Gam- Bling Compared To A Wait-List Control Group In A Sample Of 180 Problem And Patho- Logical Gamblers (60% Of Subjects Were Pathological Gamblers). In Addition, Three Studies Have Tested Aversion Therapy And Imaginal Desensitiza- Tion In Randomized Designs. In The First Study, Both Treatments Resulted In Improve- Ment In A Small Sample Of Patients (Mcconaghy, Armstrong, Blaszczynski, & All- Cock, 1983). In The Second Study, 120 Pathological Gamblers Were Randomly Assigned To Aversion Therapy, Imaginal Desensitization, In Vivo Desensitization, Or Imaginal Relaxation. Participants Receiving Imaginal Desensitization Reported Better Outcomes At 1 Month And Up To 9 Years Later (Mcconaghy, Blaszczynski, & Frankova, 1991). Imaginal Desensitization With Motivational Interviewing Has Also Been Found To Be Significantly More Efficacious In Reducing Gd-Related Urges And Behaviors Than Gamblers Anonymous Referrals. This Treatment Effect Was Largely Maintained After 6 Months Of Treatment Cessation (Grant, Donahue, Et Al., 2009; Grant, Donahue, Odlaug, & Kim, 2011). Kleptomania Kleptomania Was Formally Designated A Psychiatric Disorder In Dsm-Iii, And The Core Features Include (1) Recurrent Failure To Resist An Impulse To Steal Unneeded Objects; (2) An Increasing Sense Of Tension Before Committing The Theft; (3) An Experience Of Pleasure, Gratification Or Release At The Time Of Committing The Theft; And (4) Stealing That Is Not Performed Out Of Anger, Vengeance, Or Due To Psychosis (Dsm-5; American Psychiatric Association, 2013). Clinical Characteristics Kleptomania Usually Appears First During Late Adolescence Or Early Adulthood (Grant & Kim, 2002A). The Course Is Generally Chronic, With Waxing And Waning Of Symp- Toms. Women Are Twice As Likely As Men To Suffer From Kleptomania (Grant & Kim, 2002A), To Have A Later Age Of Onset, Hoard Stolen Items, And To Have A Co-Occurring Eating Disorder Or Other Psychiatric Illness (Grant & Potenza, 2008). Like Individuals With Suds, Most With Kleptomania Try Unsuccessfully To Stop. In One Study, All Participants Reported Increased Urges To Steal When Trying To Stop (Grant & Kim, 2002A). Most (77.3%) Report A Diminished Ability To Stop That Often Leads To Feelings Of Shame And Guilt (Grant & Kim, 2002A). Of Married Subjects, Less Than Half Had Disclosed Their Behavior To Their Spouses Due To Shame And Guilt (Grant & Kim, 2002A). Although People With Kleptomania Often Steal Various Items From Multiple Places, The Majority Steals From Stores. In One Study, 68.2% Of Patients Reported That The Value Of Stolen Items Had Increased Over Time (Grant & Potenza, 2008), A Find- Ing That Is Suggestive Of Tolerance. Patients May Keep, Hoard, Discard, Gift, Or Return Stolen Items (Mcelroy, Pope, Hudson, Keck, & White, 1991). Many (64-87%) Have Been Apprehended At Some Time Due To Their Behavior (Mcelroy Et Al., 1991), And 334 Iv. Special Populations 15-23% Report Having Been Jailed (Grant, Odlaug, Davis, & Kim, 2009). Although The Majority Of The Patients Who Were Apprehended Reported That Their Urges To Steal Were Diminished After The Apprehension, Their Symptom Remission Generally Lasted Only A Few Days Or Weeks (Mcelroy Et Al., 1991). Together, These Findings Demonstrate A Continued Engagement In The Problematic Behavior Despite Adverse Consequences, A Core Feature Of Addiction. Co‐Occurring Disorders And Family History High Rates Of Other Psychiatric Disorders Have Been Found In Patients With Kleptoma- Nia. Rates Of Lifetime Comorbid Affective Disorders Range From 38.9% (Grant & Kim, 2002A; Grant & Potenza, 2008) To 100% (Mcelroy Et Al., 1991). The Rate Of Comor- Bid Bipolar Disorder Has Been Reported As Ranging From 9% (Grant & Kim, 2002A) To 60% (Mcelroy Et Al., 1991). Studies Also Indicate High Lifetime Rates Of Comorbid Anx- Iety Disorders (21.1-80.0%; Grant & Potenza, 2008; Mcelroy Et Al., 1991; Mcelroy, Hudson, Pope, Keck, & Aizley, 1992), Impulse Control Disorders (20.0-47.4%; Grant & Potenza, 2008; Grant, 2003), Suds (15.8-50.0%; Grant & Kim, 2002A; Grant & Potenza, 2008; Mcelroy Et Al., 1991), And Eating Disorders (13.7-60.0%; Grant & Potenza, 2008; Mcelroy Et Al., 1991). Individuals With Kleptomania Are More Likely Than Non-Affected Controls To Have A First-Degree Relative With A Psychiatric Disorder (Grant, 2003). In Addition, High Rates Of Mood Disorders (20-35%) And Suds (15-20%) Have Been Observed In First- Degree Relatives Of Patients With Kleptomania (Mcelroy Et Al., 1991). Treatment Pharmacotherapy Case Reports, Two Small Case Series, And Two Open-Label Studies Of Pharmacother- Apy Have Been Performed For Kleptomania. Given The High Placebo Responses Rates Observed In The Treatment Of Impulse Control Disorders, Findings From These Stud- Ies Should Be Interpreted Cautiously. Various Medications Have Been Studied In Case Reports Or Case Series, And Several Have Been Found Effective: Tolcapone, Fluoxetine, Nortriptyline, Trazodone, Clonazepam, Valproate, Lithium, Fluvoxamine, Paroxetine, And Topiramate (Grant, 2011; Grant & Kim, 2002B). Two Open-Label Studies Of Kleptomania Have Been Published. A Trial Of Naltrexone For Kleptomania Involved 10 Subjects In A 12-Week, Open-Label Study. Using A Mean Dose Of 150 Mg/D, Medication Resulted In A Significant Decline In The Intensity Of Urges To Steal, Stealing Thoughts, And Stealing Behavior (Grant & Kim, 2002B). Koran, Aboujaoud, And Gamel (2007) Examined Open-Label Escitalopram And Found A High Response Rate (79%); However, In The Double-Blind Discontinuation Period, Rates Of Relapse Did Not Differ Between Escitalopram (43%) And Placebo (50%). Only One Double-Blind Study That Has Been Published Assesses Pharmacological Treatment For Kleptomania. In A Sample Of 25 Subjects With Kleptomania, Naltrexone (Mean Dose Of 117 Mg/D) Was Significantly More Effective In Reducing Stealing Urges And Behaviors In An 8-Week Randomized Trial (Grant, Kim, & Odlaug, 2009). 16. Gambling Disorder And Other "Behavioral" Addictions 335 Psychotherapy Although Multiple Types Of Psychotherapies Have Been Described In The Treatment Of Kleptomania, No Controlled Trials Exist In The Literature. Forms Of Psychotherapy Described In Case Reports As Demonstrating Success Include Psychoanalytic, Insight- Oriented, And Behavioral (Goldman, 1991; Mcelroy Et Al., 1991). As No Controlled Trials Of Therapy For Kleptomania Have Been Published, The Efficacies Of These Interven- Tions Are Difficult To Evaluate. Compulsive Buying Originally Termed "Oniomania" By Kraepelin And Bleuler, Compulsive Buying Has Been Described For Over A Century (Christenson Et Al., 1994). Although Not Specifi- Cally Recognized In Dsm-5, The Following Diagnostic Criteria Have Been Proposed: (1) Maladaptive Preoccupation With Or Engagement In Buying (Evidenced By Frequent Pre- Occupation With Or Irresistible Impulses To Buy; Or Frequent Buying Of Items That Are Not Needed Or Not Affordable; Or Shopping For Longer Periods Of Time Than Intended); (2) Preoccupations, Or The Buying Lead To Significant Distress Or Impairment; And (3) The Buying Does Not Occur Exclusively During Hypomanic Or Manic Episodes (Mcelroy, Keck, Pope, Smith, & Strakowski, 1994). Clinical Characteristics As With Other Behavioral Addictions And Suds, The Onset Of Compulsive Buying Appears To Occur During Late Adolescence Or Early Adulthood, Although The Full Disor- Der May Take Several Years To Develop (Christenson Et Al., 1994; Black, 2007). Koran Et Al. (2006) Estimated That About 5.8% Of The U. S. Population Has Lifetime Preva- Lence Compulsive Buying. Unlike Most Substance Abuse Disorders, Compulsive Buying Shows A Female Preponderance Ranging From 80 To 95% In Clinical Samples (Black, 2007; Christenson Et Al., 1994; Mcelroy Et Al., 1994; Schlosser, Black, Repertinger, & Freet, 1994). Compulsive Buying Is Characterized By Repetitive Urges To Shop That Are Most Often Unprovoked But May Be Triggered By Being In Stores. These Urges May Worsen During Times Of Stress, Emotional Difficulties, Or Boredom. Urges Are Generally Intru- Sive, And Most Patients Attempt To Resist Them, Although Usually Unsuccessfully. Even Though Purchased Items Are Usually Not Exceptionally Expensive, Individuals With Compulsive Buying Typically Purchase Items In Large Quantities (Black, 2007), Which Often Results In Large Debts, Marital Or Family Disruption, And Legal Consequences (Christenson Et Al., 1994). Although The Behavior Is Pleasurable And Momentarily Relieves The Urges To Shop, Guilt, Shame, And Embarrassment Generally Follow Buying Episodes. Individuals With Compulsive Buying Also Report Experiencing Significantly Increased Negative Affect And Decreased Positive Affect Before A Buying Episode, As Well As A Significant Decrease In Negative Affect Postbuying (Müller Et Al., 2012). Fur- Thermore, These Individuals Report Low Quality Of Psychological Well-Being Compared To Those Do Not Buy Compulsively (Williams, 2012). 336 Iv. Special Populations A Positive Interaction With Salespeople Is Often Described As A Motivating Factor In Compulsive Buying. The Items Bought Vary Considerably, And May Include Clothing, Jewelry, Books, And Auto Parts. Most Items Are Not Used Or Removed From The Packag- Ing, And Many Are Given Away, Returned, Or Hoarded (Christenson Et Al., 1994). Co‐Occurring Disorders And Family History Rates Of Co-Occurring Mood Disorders Range From 28 To 95% (Christenson Et Al., 1994; Mcelroy Et Al., 1994; Schlosser Et Al., 1994; Müller Et Al., 2012), With The Mood Disorder Often Preceding The Compulsive Buying By At Least One Year (Christenson Et Al., 1994). Lifetime Histories Of Anxiety (41-80%), Substance Use (21-46%), Eating (17-35%), And Impulse Control (21-40%) Disorders Are Fairly Common (Christenson Et Al., 1994; Mcelroy Et Al., 1994; Müller Et Al., 2012; Schlosser Et Al., 1994). High Rates Of Personality Disorders (60%) Have Also Been Found In Individuals With Com- Pulsive Buying. Most Commonly Observed Are Avoidant Disorder (15%), Obsessive- Compulsive Disorder (22%), And Borderline Personality Disorder (15%) (Schlosser Et Al., 1994). In Addition, Individuals With Compulsive Buying Frequently Report Having First-Degree Relatives With Suds (25%), Mood Disorders (20%), Or Compulsive Buying (10%), And They Are Significantly More Likely Than Healthy Controls To Have A First- Degree Family Member With One Or More Psychiatric Disorders (Black, Repertinger, Gaffney, & Gabel, 1998). Treatment Pharmacotherapy The Effectiveness Of Pharmacotherapies In Treating Compulsive Buying Is Beginning To Be Systematically Investigated. Case Reports And Open-Label Studies Have Suggested That The Following Agents May Be Beneficial: Nortriptyline, Fluoxetine, Bupropion, Lithium, Clomipramine, Naltrexone, Fluvoxamine, Citalopram, And Valproate (Black, Monahan, & Gabel, 1997; Koran, Bullock, Hartson, Elliott, & D'andrea, 2002; Mcelroy Et Al., 1994). In The First Of Two Double-Blind Fluvoxamine Studies, 37 Subjects Were Treated For 13 Weeks. Only Nine Out Of 20 Patients Assigned To Medication Were Responders (Mean Dose Of 215 Mg/D), And This Rate Did Not Differ Significantly From That In The Placebo Group (Eight Out Of 17 Were Responders) (Ninan Et Al., 2000). In The Second Double- Blind Study, Black, Gabel, Hansen, And Schlosser (2000) Treated 23 Patients For 9 Weeks Following A 1-Week Placebo Lead-In Phase. Using A Mean Dose Of 200 Mg/D, No Differences In Response Rates Were Observed Between The Groups Treated With Active And Placebo Drug. A Double-Blind Study Using Citalopram, However, Suggested The Possible Efficacy Of Ssris In Treating Compulsive Buying. Open-Label Treatment For 7 Weeks Was Fol- Lowed By Randomization Of Responders To Medication Or Placebo For Another 9 Weeks. Patients Taking Active Citalopram Demonstrated Statistically Significant Decreases In Terms Of The Frequency Of Shopping, As Well As The Intensity Of Thoughts And Urges 16. Gambling Disorder And Other "Behavioral" Addictions 337 Concerning Shopping (Koran, Chuong, Bullock, & Smith, 2003). However, In A More Recent Study With An Identical Research Design, Escitalopram Was No More Effective Than Placebo (Koran, Aboujaoude, Solvason, Gamel, & Smith, 2007). There Has Been Only One Trial Using A Medication Other Than An Antidepres- Sant. Memantine, An N-Methyl-D-Aspartate Receptor Antagonist, Was Examined In A 10-Week, Open-Label Trial Of Nine Individuals With Compulsive Buying. Eight Of The Nine Subjects Reported Significantly Reduced Symptoms, Such As Time And Money Spent Shopping Per Week (Grant, Odlaug, Mooney, O'brien, & Kim, 2012). Psychotherapy Several Case Reports Suggest That Possible Effective Psychotherapeutic Interventions Might Include Exposure And Response Prevention, And Supportive Or Insight-Oriented Psychotherapy (Mcelroy Et Al., 1994). Three Randomized Controlled Studies Indicated That Cbt, Using Either An Individual Or Group Format, Is More Significantly Effective Than Wait-List Or Telephone-Guided Self-Help In Reducing The Frequency And Duration Of Buying Episodes, As Well As Overall Compulsive Buying Severity (Mitchell, Burgard, Faber, Crosby, & De Zwaan, 2006; Müller Et Al., 2012, 2013). Internet Addiction Internet Addiction Is Not Currently Recognized By Dsm-5 (American Psychiatric Asso- Ciation, 2013) As A Psychiatric Disorder (Internet Gaming Disorder Is Included In The Section "Conditions For Further Study") And Valid, Reliable Diagnostic Instruments Have Not Been Developed For An Internet Addiction Diagnosis (Weinstein & Lejoy- Eux, 2010). Tao And Colleagues (2010), However, Have Recommended The Following Criteria For Internet Addiction, Which Mirror Those Used For Gd Or Suds: Preoccu- Pation With The Internet; Withdrawal; Increased Tolerance For Internet Use; Inability To Control Internet Use; Continuation Of Internet Use Despite Negative Consequences; Loss Of Interest In Other Activities; And Using The Internet To Relieve Dysphoric Mood States. Furthermore, Block (2008) Has Suggested That Three Subcategories Exist For Internet Addiction: Excessive Gaming, Sexual Preoccupations, And Excessive E-Mail/ Text Messaging. Young, Pistner, O'mara, And Buchann (2000) Have Suggested Five Subtypes Of Internet Addiction: Cybersexual Addiction, Cyberrelational Addiction, Net Compulsions, Information Overload, And Computer Addiction. However, Some Argue That Internet Addiction Does Not Require A New Diagnostic Categorization, That It Is Rather An Addiction To The Behaviors Associated With Internet Usage, Such As Sex Or Gaming (Yellowlees & Marks, 2007). Clinical Characteristics Researchers Estimate That Internet Addiction Has A Prevalence Rate Of 0.3-0.7% In The United States (Shaw & Black, 2008). Internet Addiction Has An Age Of Onset Between The Late 20S And Early 30S, And Typically There Is About A 10-Year Span Between First 338 Iv. Special Populations Use And Problematic Internet Use (Shaw & Black, 2008). Internet Addiction Also Appears To Be More Prevalent In Males (Shaw & Black, 2008; Ko Et Al., 2012). Even Though Time Spent Online Is Not A Discerning Marker Of Internet Addiction, Research Has Suggested That Individuals With Internet Problems Typically Spend 38-80 Hours Per Week Online (Young, 1995, 1996), And That They Spend More Time On The Internet For Nonessential Use (I. E., Pleasure Or Personal Use) Compared To Essential Use (I. E., Required For School Or Job Functions) (Young, 1995; Shapira, Goldsmith, Keck, Khosla, & Mcelroy, 2000). Personality Variables, Such As A High Degree Of Novelty Seeking And Harm Avoid- Ance, Have Been Associated With Excessive Use Of The Internet (Ha Et Al., 2007; Ko Et Al., 2006; June, Sohn, So, Yi, & Park, 2007). Additionally, Young (1998) Found That Some May Be Drawn To The Internet Due To The Mental Stimulation Provided By The Substantial Amount Of Information Available Online, As Well As The Ability To Be Social Without Having Face-To-Face Interactions With Others And While Remaining By Oneself. Problems Associated With Problematic Internet Use Include, But Are Not Limited To, Decreased Academic Performance, Social/Relational And Occupational Impairment, Financial Problems, And Legal Problems (Shapira Et Al., 2000). Research Also Indi- Cates That Individuals With Internet Addiction May Face Health Concerns, Such As Sleep Deprivation, Carpal Tunnel Syndrome, Dry Eyes, And Headaches (Choi Et Al., 2009; Coniglio, Muni, Giammanco, & Pignato, 2007). Furthermore, In South Korea There Were A Series Of 10 Cardiopulmonary-Related Deaths In Internet Cafés (Choi, 2007, As Referenced In Block, 2008) And A Game-Related Murder (Koh, 2007, As Referenced In Block, 2008). Co‐Occurring Disorders And Family History Like Other Addictions, Internet Addiction Frequently Co-Occurs With Other Psychiatric Disorders, Such As Affective, Anxiety, Substance Use, And Impulse Control Disorders (Bai, Lin, & Chen, 2001; Shapira Et Al., 2000; Treur, Fábián, & Füredi, 2001; Te Wildt, Putzig, Zedler, & Ohlmeier, 2007; Kratzer & Hegerl, 2008; Shaw & Black, 2008; Black, Belsare, & Schlosser, 1999). For Example, A Study Of 20 Individuals With Problematic Internet Use Indicated That All Subjects Met Dsm-Iv Criteria For An Impulse Control Disorder Not Otherwise Specified, As Well As An Additional Lifetime Dsm-Iv Axis I Diagnosis (Shapira Et Al., 2000). Additionally, High Rates Of Personal- Ity Disorders Have Been Found In Those With Internet Addiction, Most Commonly Bor- Derline (24%), Narcissistic (19%), And Antisocial (19%; Black Et Al., 1999). Shapira Et Al. (2000) Reported That The Majority (95%) Of Individuals With An Internet Addiction Reported A Psychiatric Family History, Most Commonly An Affective Disorder Or An Sud. Treatment Currently, There Is Limited Evidence Regarding Effective Treatments For Internet Addic- Tion; However, Both Psychotherapy And Psychopharmacology Have Been Used To Treat The Behavior (Weinstein & Lejoyeux, 2010). 16. Gambling Disorder And Other "Behavioral" Addictions 339 Pharmacotherapy A Small Sample Of 19 Individuals With "Compulsive-Impulsive Computer Usage" Was Treated With 10 Weeks Of Open-Label Escitalopram Followed By A Week Of Double-Blind Discontinuation. No Significant Differences Were Found Between Those Receiving Esci- Talopram And Those Receiving Placebo (Hadley, Baker, & Hollander, 2006). Another Open-Label Study (Han Et Al., 2009) Examined Extended-Release Methyl- Phenidate In 62 Korean Children With Internet Video Game Addiction And Attention- Deficit/Hyperactivity Disorder (Adhd). They Found That After 8 Weeks Of Treatment, Daily Duration Of Internet Use Was Significantly Reduced, And This Finding Correlated With An Increase In Attention. Shapira And Colleagues (2000) Reported That While Only 35.7% Of Individuals Using An Antidepressant Reported Moderate Or Marked Reduction In Problematic Inter- Net Use, 58.3% Of Individuals With Problematic Internet Use Reported A Favorable Response When Taking A Mood Stabilizer. Psychotherapy No Randomized Clinical Trials Have Assessed The Efficacy Of Psychotherapy In Internet Addiction. However, Treatments That Have Utilized Aspects Of Cbt, As Well As Marital And Family Therapy, And Online Self-Help Books And Tapes, Have Been Found To Be Help- Ful (Young, 2007; Shaw & Black, 2008). Compulsive Sexual Behavior Compulsive Sexual Behavior (Csb), Also Termed "Sexual Addiction" And "Hypersex- Ual Behavior," Is Characterized By An Excessive, Uncontrollable, Culturally Norma- Tive Sexual Behaviors, Urges, And/Or Thoughts Resulting In Functional Impairment And Distress (Black, Kehrberg, Flumerfelt, & Schlosser, 1997; Coleman, 1992; Gerevich, Treuer, Danics, & Herr, 2005). In 1775, De Bienville Published Nymphomania Or Dissertation Concerning Furor Uterinus, Arguing That Excessive Sexual Desire May Be A Product Of The Overstimulation Of Women's Nerves Through Impure Thoughts, Consuming Too Much Chocolate Or Rich Food, Or Reading Novels. About A Century Later, Krafft-Ebbing (1886/1927) In His Book Psychopathia Sexualis, Described The Negative Impact Of Excessive Sexual Behavior On Life. Similar To Some Of The Other Behavioral Addictions, Csb Is Not Currently Recog- Nized By Dsm-5. The Following Diagnostic Criteria Have Been Proposed By Martin Kafka (2010): (1) Intense, Recurrent Sexual Fantasies, Urges, Or Behaviors That Are Associated With At Least Three Of Following: (A) Interference With Life; (B) Relief Of Dys- Phoric Mood Or Stressful Life Events; (C) Inability To Control Fantasies, Urges, Or Behav- Iors; (D) Disregard To Negative Consequences Of Sexual Fantasies, Urges, And Behaviors To Self Or Others; (2) Frequent And Intense Sexual Fantasies, Urges, And Behaviors Asso- Ciated With Clinically Significant Distress Or Impairment In Social, Occupational, Or Other Important Life Areas; And (3) Sexual Fantasies, Urges, Or Behaviors Not Caused 340 Iv. Special Populations By An Exogenous Substance's (E. G., A Drug Of Abuse Or Prescribed Medication) Direct Physiological Effect. Clinical Characteristics The Estimated Prevalence Rate For Csb In The United States Has Ranged From 3 To 6% (Black, 2000; Carnes, 1991; Coleman, 1992; Kuzma & Black, 2008). A Study Revealed That 3.44% Of College Students Reported Symptoms Consistent With The Proposed Cri- Teria For Csb (Odlaug & Grant, 2010). Higher Rates Of Csb Have Been Reported In Sexual Offenders And Individuals With Hiv (Marshall & Marshall, 2006), As Well As In Those Who Identify As Homosexuals (Qualand, 1985; Parsons, 2005). The Majority Of Individuals With Csb Report Being Preoccupied With Sexual Fantasies, Behaviors, Or Urges For Over 60 Minutes A Day (Raymond, Coleman, & Miner, 2003). Typically, And Similar To The Other Behavioral Addictions And Suds, Individuals Develop Csb During Late Adolescence (Black, Kehrberg, Et Al., 1997; Kafka, 1997), And Most Who Present For Treatment Are Males (Black, Kehrberg, Et Al., 1997; Carnes, 1991; Raymond Et Al., 2003). Interestingly, Females With Csb Are More Likely To Have Multiple Sexual Partners And Lower Relationship Satisfaction Than Females Who Do Not Meet Csb Criteria. Males With Or Without Csb, However, Do Not Differ In Terms Of Number Of Sex- Ual Partners Or Relationship Satisfaction (Skegg, Nada-Raja, Dickson, & Paul, 2010). Mood States, Such As Depression, Happiness, Or Loneliness, May Trigger Csb (Black, Kehrberg, Et Al., 1997; Kafka & Prentky, 1997). While Engaging In Csb- Related Behaviors, Some Individuals Report Feelings Of Dissociation, While Other Report Feeling Important, Powerful, Excited, And Gratified (Black, Kehrberg, Et Al., 1997; Kafka & Prentky, 1997). After Engaging In Activities, However, The Majority Feels A Negative Mood, Such As Shame And Guilt (Black, Kehrberg, Et Al., 1997; Raymond Et Al., 2003; Reid, Stein, & Carpenter, 2011). Reid, Carpenter, And Lloyd (2009) Found Elevated Rates Of Interpersonal Sensitivity, Depression, Obsessiveness, And Isolation In A Sample Of Hypersexual Individuals Compared To Controls. Additionally, Many Indi- Viduals Report Significant Marital, Occupational, And Financial Problems Associated With Sexual Behavior (Coleman, Raymond, & Mcbean, 2003). Co‐Occurring Disorders And Family History Co-Occurring Medical And Psychiatric Disorders Are Common In Individuals With Csb. Medical Sequelae From Csb May Include Pregnancy, Sexually Transmitted Infections, Hiv/Aids, And Physical Injury Due To Repetitive Sexual Activities (E. G., Anal And Vagi- Nal Trauma, Burns From Overuse Of A Vibrator; Carnes, 1991; Coleman, 1992; Cole- Man Et Al., 2003). High Rates Of Lifetime And Current Psychiatric Comorbidity Have Also Been Documented In Individuals With Csb, Most Commonly Anxiety (50-96%, Especially Social Phobia [21-42%]), And Suds (64-71%; Especially Alcohol [63%], And Cannabis [38%]), And Mood Disorders (39-71%; Especially Major Depression [58%]; Raymond Et Al., 2003; Black, Kehrberg, Et Al., 1997). Personality Disorders Are Also Common, With Studies Revealing Rates Of 44-46% Within The Csb Population (Black, Kehrberg, Et Al., 1997; Raymond Et Al., 2003). 16. Gambling Disorder And Other "Behavioral" Addictions 341 A Family History Of Substance Abuse And Mental Illness Is Also Common. One Study Indicated That Recovering Sexual Addicts Report Having At Least One Parent With A Chemical Dependency (46%), Sexual Addiction (36%), Eating Disorder (30%), Or Gam- Bling Problem (7%; Schneider & Schneider, 1996). Most Individuals With Csb (87%) Also Have A Family History Of Addiction (Carnes,1998). Treatment Pharmacotherapy There Is A Dearth Of Research Examining Pharmacotherapies For Csb. Many Phar- Macological Agents Used To Treat Paraphilias Have Been Used To Treat Csb, Due To Their Similar Sexual-Related Characteristics (Krueger & Kaplan, 2002). These Data, However, Are Largely Case Reports: Naltrexone (Bostwick & Bucci, 2008; Grant & Kim, 2001B), Naltrexone And Ssris (Raymond, Grant, Kim, & Coleman, 2002), Citalopram (Malladi & Singh, 2005), Leuprolide Acetate (Saleh, 2005), Nefaxodone (Coleman, Gratzer, Nesvacil, & Raymond, 2000), Clomipramine, And Valproic Acid (Gulsun, Vulcat, & Aydin, 2007), Psychostimulants Or Bupropion (Kafka, 2000), And Psychostimulant Augmentation Of Ssris (Kafka & Hennen, 2000). The Only Double-Blind Study That Has Been Published For Nonparaphilic Csb Examined Citalopram In 28 Gay And Bisexual Men, And Found Significant Treatment Effects In Regards To Sexual Desire And Drive, Masturbation Frequency, And Pornogra- Phy Use. However, Groups Did Not Differ In Their Reduction In Risky Sexual Behavior (Wainberg Et Al., 2006). Psychotherapy Research Suggests That Cognitive-Behavioral Strategies (Penix Sbraga & O'donohue, 2003; Mcconaghy, Armstrong, & Blaszczynksi, 1985) And Psychodynamic Psycho- Therapy (Cooper, Putnam, Planchon, & Boies, 1999; Goodman, 1998) May Be Help- Ful With This Population. Couple Therapy May Also Be Helpful Due To The Negative Impact Csb May Have On The Trust And Intimacy In Relationships (Brown, 1999). In The Only Randomized Study Of Psychotherapy For Csb, 20 Subjects Were Ran- Domized To Either Imaginal Desensitization Or Covert Sensitization. Mcconaghy And Colleagues (1985) Found That Both Interventions Were Effective In Reducing Csb At 1-Month And 1-Year Follow-Up Visits. Conclusions Behavioral Addictions Have Historically Received Relatively Little Attention From Cli- Nicians And Researchers. As Such, Our Understanding Of The Basic Features Of These Disorders Is Relatively Primitive. Future Research Investigating Behavioral Addictions And Their Relationship To Suds Holds Significant Promise In Advancing Prevention And Treatment Strategies For Addiction In General.

Criteria for Placement

So how do counselors decide the best level of care for their clients? •The American Society of Addiction Medicine (ASAM) provided criteria to help professionals make the best decision about their clients' level of care. These criteria include: •Client's acute intoxication and/or withdrawal potential (need for detoxification) •Biomedical conditions and complications •Emotional, behavioral, or cognitive conditions and complications •Client's readiness/motivation to change •History of relapse, continued use potential •Nature of their living environment (supportive?)

Causes of Symptoms

So how do counselors make these distinctions? One way to determine whether a symptom is psychiatric (caused by mental illness) or substance-induced (caused by the use drugs and/or alcohol) is to wait until the client has been abstinent for 30 days (or 4 weeks) and re-assess. ◦If the symptom goes away after 30 days of abstinence, it is likely substance-induced. ◦If the symptom remains after 30 days of abstinence, it is likely psychiatric (caused by mental illness).

Alcohol

Standard drink: 12 oz bottle of beer, 5 oz glass of wine, 1.5 oz liquor • Binge drinking- 5 or more drinks in one sitting • Alcohol withdrawal is extremely dangerous for chronic, heavy drinkers (20% mortality rate without medical detox) and can include: • Delirium tremens (hallucinations, tremors, disorientation, fear) • Seizures • Detoxification often includes tapering off with benzodiazepines • Alcohol consumption can cause blackouts • Blackout is not "passing out", in which a person is unconscious • The person is active, but brain is unable to record memories of the events (brain cannot create short-term memories

12 Step Support Groups

Stemming from Alcoholics Anonymous, 12-step support groups exist for those with sex addiction. These include: ◦Sex Addicts Anonymous, Sexaholics Anonymous, Sex and Love Addicts Anonymous, Sexual Compulsives Anonymous, and Sexual Recovery Anonymous The first step of Sex Addicts Anonymous reads: ◦"We admitted we were powerless over addictive sexual behavior—that our lives had become unmanageable." What is the goal of a 12-step program for sex addiction? ◦To help individuals abstain from compulsive sexual behavior (often referred to as "acting out"). Recovery in 12-step programs for sex addiction is not abstinence from all sexual behavior. Instead, it is abstinence from the out-of-control, problematic, compulsive sexual behavior that has led to negative consequences

Synthetic Cathinones

Synthetic Cathinones are a synthetic drug also known as Bath Salts. Synthetic cathinones are synthetic versions of natural cathinones found in the Khat plant • Most common: 3,4-methylenedioxypyrovalerone (MDPV) • The compounds often resemble amphetamines and hallucinogens, which means they are energizing with sensory distortion and hallucinatory effects • Bath salts come in a crystal-like powder marketed as "not for human consumption" • Can be taken orally, snorted, smoked, or injected • Intoxication on bath salts includes: hallucinations, paranoia, panic, increased sex drive, hyper-excitability, erratic behaviors • Fatal overdose potential • Withdrawal includes: depression, paranoia, insomnia, tremors

Transtheoretical Model (TTM)

The TTM is a way to conceptualize the change process. Rather than assuming change is instantaneous, the TTM proposes that people go through predictable stages to reach change. Those stages are summarized below: Stage 1: Precontemplation: No intent to change. Stage 2: Contemplation: No decision made, thinking about making change in next 6 months. Stage 3: Preparation: Planning to change in next month; making a plan. Stage 4: Action: Behavioral change is made. Stage 5: Maintenance: Begins 6 months after the behavior change; continues indefinitely, as long as change is sustained.

Synthetic Marijuana

Synthetic marijuana consists of a combination of chemicals (synthetic cannabinoids) sprayed onto dried plant material (looks like potpourri) • Chemicals used to manufacture the drug are constantly changing • Synthetic cannabinoids include over 700 different chemicals • Synthetic cannabinoids affect same receptors in brain as THC • Much more powerful • Can activate other receptors as well • Synthetic marijuana can be smoked, brewed in tea, or vaped • Effects often are unpredictable • High blood pressure, psychosis, extreme anxiety, vomiting, panic, aggressive behavior • Sold for $20-$30 per 3 gram packet • Marketed as herbal incense (not for human consumption) • Common names: Spice, K2, Crazy Clown, Original Shamrock, Mojo, Kush,

CENAPS Article

The CENAPS Model of Relapse Prevention Planning Tcrcncc T. Gorski Relapse is a serious problem facing the chemical dependency treatmcnt field. This fact often goes unrecognized. As a result many therapists expect Un£Cal ist iCally high rccovcry rates. When these recovery raits fail to materializc they tend to either blame the pa- tient al1d/or harshly judge their own clinical skills. Therapists who blame patients for rclapse often use this rationale: '"lf the patients were motivated and did What I tOId them they would not have rclapsed. We all know that 'it works if you work it.' " This blflflli ng Ihe patient strategy is based upon the mistaken belief that lreatmcnt is 1007 effective for any patient who is motivated to t0C0Vcr and willing to follow directions. Unfortunately this belief is nOt true. Many highly motivatcd patients fail to recoVfl r becaUSe ihe t£Catmçn( (hey rcccivc docs not tcach them to identifi or manage many probJcrr s ihat lcaJ to rcJaps¢. High rclapsc ratcs may causc therapists to blame thcmsclvcs. The F8tiO0gll2ltiOfl gocfi likc this: "Since compctcnt thcrapists produce high rccovcry rates (at lcast 809a-90%) and I don't I m ust either be an incompcent thcrapist or have some personal problems that pre- vent me from working effcctively with thèse patients." As a result many therapists develop guilt and shame. The guilt is based upon thC bclicf they are doing something wrong with thèse patients. The shame is based upon the belief there is something inherently wrong with them as professionals because their patients relapse. The shame and guilt motivates therapists and treatment centers to avoid measuring or hiding relapse tates. lt is possible for therapists and the treatment industry as a whole to rationally examine the process of relapse without reverting to either irrational blame of the patient or irrational self-blame. In AA O 1989 by The Haworth Press, Inc. All rights reserved. 153 154 RELAPSE.- Conceptual, Research ond Clinical Perspectives this process is called a Fourth Step — a fearless and searching inven- tory of self in relation to a problem. With this in mind let us review a brief summary of the outcome literature pertaining to chemical dependency treatment. For the purpose of this review relapse is defined as a return to alcohol and drug use. This definition of relapse is a limited one but it is the only criterion consistently used in the current outcome liter- ature. The overall rate of improvement among alcoholism patients var- ies from 20% to 809a dependent upon the type of treatment adminis- tered and the criteria used to determine improvement (Laundergan, 1982). The improvement rates for patients with a good prognosis (high socio-economic status and social stability) arc bctween 327a and 68%, while other programs that treated patients wilh poor prog- nosis (largely skid row alcoholics) had iccovery rates ranging from 0% to 18% (Baekelan ct a1., 1975). Patients who successfully completed treatment had higher recov- ery rates than those who did not. In one stufiy 61% of the respon- dents who completed the Hazeldcn program had maintained absti- nence throughout the twelve month follow-up petiod while only 38% of the non-regular (AMA) discharges had sustained abstinence during that same period (Patton, 1979). By combining the results of two large outcome studies (Hoffman and Harrison, 1986; Com p Care, Care Unit, 1988) a range of expected tccovery rates for pri- vate sector inpatient treatment can be deicrmined. Fifty four percent (t5ll%) of all patients can be expected lo maintain total abstinence, 46'7 (i5117 ) can be expected to relapse. About 3970 of those who relapse (189c of the total population) can be expected to have brief relapses and rapidly return to abstinence whilg 6l No of those who relapse (28% of the rclapsers) will have multiple relapses. About 717s (t513 No) of thc patients will be improved. This improved cate- gory combines the abstinent patients with those who had brief Re- lapse episodes. This information is summarized on Table 1. In the studies cited above between 307a and 40% of the patients had been previously treated in a chemical dependency program on at least one occasion (Hoffman and Harrison, 1986; Comp Care. Care Unit, 1988). As a result these are not measures of lifelong relapse history but only of aggregate relapse rates after treatment. RelaysC Pf•C $'Cft IiOn Treatment ñfodefi Table 1: Range of Relapse Incidence 155 1.Abstinent 43% 66% 54% +-11% 2. Relapse 34% 57% 46% +-11% a.Brief 16% 18% 17% +-1% b. Multiple 18% 39% 28% -I-- 10% 3.Improved 59% 84% 71% -1--13% Studies of lifclong gattcrns of rccovcry and relapse indicate that paticnts who r¢Ia SC 2rC not hopeless. Approximalcly one-third 8ch1eVc p¢rm8ncnt 2bstinc ncc from thcir first .scrious attcmpt at re- covery. Another third have a period of brief relapse episodes that tVentualJy rcsoll in long term ubstincnce. And an additional one- third have chronic rclapsc S that result in evcntual death from chemi- cal dcpcndcncy (Gorski, 1986D). This is consistent with lifclong rccovery rates from any chronic Jif¢st}'le related illness. About onc half of all rclapse prone persons evcntual ly find C mancDt 2hstincncc. Many oihers improve in spite 0( the p¢riodic rclapsc c pisodcs (Vaillant, Pickens et al., 1985). 1983; Marlatt, 1985; CE SSIFICATION OF RECOVER ¥/RELAPSE IIIS T'OR V For the purpose of relapse prcvention therapy, chemically depen- dent patients can be catcgorized according to their recovery/relapse hlstory (Gorski, l986B). Thcsc categories are recovery prone, tran- tltional|y relapse prone, and chronically relapse prone. These cate- g0fies correspond to the outcome categories of continuous absti- ncnce, bricf r¢lapse, and chronic relapse. Relapse prone patients can be further divided into two distinct subgroups -- unmotivated and motivated. IJnmotivated relapse P one p Items fail to recognize or accept that they are suffering from chemical dependcncy in spite of initial treatment. As a result, cy refuse to adhcre to a recovery program requiring abstinence, /56 RFP PPE: Conceptual. Research ond Clinical I ersyecii es physical and psychological rehabilitation, and lifestyle change. In these cases, the treatment fails to motivate these patienis to interrupt their disease progression and alter their chemical use and lifestyle. Motivated relapse prone patients recognize that they are chemi- cally dependent, need to maintain abstinence in order to recover, and need Io maintain an ongoing recovery program in oidci io stay abstinent. They use AA or other twelve step programs plus ongoing professional treatment. They also make sincere attempts at psycho- logical and physical rehabilitation and attempt recommended life- site changes during abstinence. Despite their efforts, however, these individuals develop symptoms o£ dysfunction that eventually lead them back to alcohol and drug use. Many therapists mistakenly belicvc that most relapse prone per- sons are not motivated to recover. Clinical experience has not sup- ported this perception. More than 807a of all relapse prone patients admitted lo three national relapse prcvcntion centcrs had a history of bolh recognition of their chemical dcpendcnce and motivation to follow aftercarc recommendations at time of dischar6 e. In spite of this they were unable to maintain abstinence and sought treatment in a specialty relapse prevention program. The literature suggests that current treatment mcifiods are effec- tive with a high perccntage of patients entering trcatment for the 'first time. they are not adequate Io meet ffi¢ challenges ot the re- lapse prone patient. This would suggest the need to dcvclop a model of chemical dependence Ireatmenl Ihat would build upon current strengths while effectivcly dealing wilh the problem of relapse. THE MENA PS âfOD£L OF RELAPSE PREVENTIO.V The CENAPS model has been under development since the early 1970s and integrates ite fundamcnial principlcs of Alcoholics Anonymous (AA) and Minnesota Model Treatment to meet the needs of relapse pronr patients. Ii is based upon lhe biopsychosocial model of addictive disease. Chemical addiction causes brain dys- function that disorganizes personality and causes social and occupa- iional problems. Total abstinence plus personality and lifestyle change are essential for full recovery. People raised in dysfunc- tional families oitrn develop self-de fearing personality styles Relapse Prevention Treatment Modèle 157 (which AA calls charactcr dcfccts) that interfere with thcir ability to recover. The CENAPS Model views addiction as a chronic disease that has a icndcncy ioward relapse. Relapse is more than using alcohol or Other drugs. It is the process of becoming dysfunctional in recov- ery that ends in physical Or emotional collapse, suicide, or self-medi- Cätion with alcohol or drugs. The CENAPS Model incorporates the role of br2in dysfunction, personality disorganization, so¢ial dys- function, and family of origin issues to the problems of recovery afld relapse. Brain dysfunction occurs during periods of intoxication, short team withdrawal, and long tcrm withdrawal. Patients with a genetic history of adJiCilO0 2 Car to be morc susceptible to this brain dys- function. As lhc aJJiction progresses the symptoms of this brain dysfunction cause difficulty in thinking clearly, managing feelings and emotions, rcmcmbcring things, sleeping restfully, recognizing afld managing stress, and with psychomotor coordination. The sympioms arc most severc during the first 6-18 months of sobriety but thcre is a lifelong tcndcn¢y of these symptoms to return during tiffles of physical or psychosocial stress. PBfSOflflllÇ dlsofganization occurs because the brain dysfunction interfercs with normal thinking, feeling, and acting. Some of the personality disorganization is temporary and will spontaneously subside wiih abstinence as the brain recovers from the dysfunction. Other pcrsonality traÎtS WiH bccome deeply habituated during the addiction and will require trcatmenl in order to subside. Social dysfunction, including family, work, lcgal and financial probleme emcrgc as a conscqucncc of the brain dysfunction and résultant pcrsonality disorganization. Addiction can be influenced, not caused, by self-defeating per- sonality traits that result from being raised in a dysfunctional fam- ily. Personality is thc habitual way of thinking, feeling, acting and relating io others that dcvclops in childhood and is unconsciously perpctuated in adult living. Pcrsonality develops as a result of an ihtüï0Ci MOA between geneiiCalfy inherited traits and family environ- ment. Being raiscd in a dysfunctional family can result in self-de- feating personality traits or disorders. Thèse tra its and disorders do not causc the addiction to occur. They can cause a more rapid pro- 158 RELAPSE: Concepmal, Research and Clinical Perspectives giession of the addiction and make it difficult to recognize and seek treatment during the early stages of the addiction or to benefit from treatment. Self-defeating personality traits and disorders also in- crease the risk of relapse. As a result family of origin problems need to be appropriately addressed in treatment. The CENAPS Model views abstinence from alcohol and other mood altering drugs as the most effective goal for all chemical de- pendence treatment including relapse prevention therapy. There is no convincing evidence that controlled drinking is a practical treat- ment goal for persons who have been physically dependent upon alcohol (i.e., meet DSM-IIIR criteria fot alcohol dependence). The Sixth Special Reports To The U.S. Congress On Alcohol And Health (NIAAA, 1987, p. 136) states that in general, the bulk of the clinical and scientific evidence ap- pears to support the interpretation that once significant physi- cal dependence has occurred the alcoholic no longer has ltte option of returning to social drinking: Hence, abstinence is the most appropriate goal for alcoholic persons. Abstinence, however, should not be the exclusive goal. The commonly accepted treatment goal of the National Institute Of Al- cohol Abuse and Alcoholism (NIAAA) is abstinence plus improve- ment in biopsychosocial health (NIAAA, 1987). This approach has been called the biopsychosocial disease model (Gorski, 1986a, 1986b). There is a relapse syndrome that is an integral part of the addic- tive disease process. The disease is a double edged sword with two cutting edges — drug-based symptoms which manifest themselves during active episodes of chemical use and the sobriety-based symptoms which emerge during periods of abstinence. The sobri- ety-based symptoms create a tendency toward relapse that is part of the disease itself. Relapse is the process of becoming dysfunctional in sobriety due to sobriety-based symptoms that leads to either renewed alcohol or drug use, physical or emotional collapse, or suicide. The relapse process is marked by predictable and identifiable warning signs that begin long before alcohol drug use or collapse occurs. Relapse Pre- Relapse Prevention Treatment Models vention Thcrapy teaches patients to recognize and manage warning signs so they can interrupt the relapse progression and rcturn to a positive progression rccovery. these early The CENAPS Modcl intcgratcs recent advanccs from the medi- cal, psychologiC2l and social sciences. Tt consists of a theoretical model, educational materials, therapy procedures, and self-help methods. Th¢ treatment and sell-help technologies arc directed in three areas: 1. Assessment: Methods have been developed for both self-as- sessment and professional diagnosis Of the type and stage of addic- live diseasc, the stage of recovery, and the type and severity of relapse warning signs. 2. Recover}' £'lanning: A dcvclopmental model of recovery (DMR) has bcen developed to help recovcring people and treatment professionals devclop appropriate recovery plans, set treatment gOalS, and measure progress. 3. Relapse Prevention Planning: A nine-step relapse prevention planning process has been developed to identify and manage relapse Warning signs. Abstincnce plus a full return to biopsychosocial functioning is the indicator of successful recovery. Relapse is de- fined as lhg process of becoming dysfunctional in recovery that leads to a return to chemical use, physical or emotional collapse, or suicide. Relapse episodes ate preceded by a series of observable warning signs. The typical relapse progression moves from biopsy- chosocial stability through a period of progressively increasing psy- chosocial distress to physical or emotional collapse. The symptoms COntinue to intensify unless the patient turns to use alcohol or drugs for relief. The CENAPS Model of Relapse Prevention planning teaches re- Covering people to recos nize and intervene upon these warning signs before chemical use or collapse has occurred. Special tech- niques have been developed for involving the family (Family Re- lapse Prevention) and the employee assistance counselor at work (Occupational Relapse Prcvcntion Planning). Special applications of relapse prevention planning have been developed for adult and adolescent chemical dependence and codependency. The CENAPS Model defines a broad base of factors that are as- sociated with recovery and Relapse. It permits development of a f60 RELAPSE: Concepmal, Research and Clinical l'erspeclives patient profile based upon a variety of factors and it allows for spe- cific treatment plans to be developed to reduce each of the factors that create risk. The CENAPS Model of Relapse Preveniion planning has been fully operationalized in a patient education guide (Gorski and Mi!!er, 1986) and a clinical workbook (Gorski, 1988a). Treatment programs that use the CENAPS model often organize their treat- ment into three basic programs: a stabilization and assessment program, a primary recovery program, and a relapse prevenlion program. The stabilization and asscssmcnt progr2m providcs d¢t0K- il›cat›on and psychosocial stabilization. lt then evaluates the paticnt to dctcrminc if hc or she is most appropriate for primary trcatmcnt or rclapse prcvention therapy. This propcr cV2lUation is essentiel. Patients who have alrcady complctcd primary trCltmcnt and rclapse tequire rel2pse prcvcntion thcrapy. Î'atients who havc not 2cfiieved the major competencics as a rcsull of primary trcalm¢nt will not benefit from rclapsc pr¢vcntion thcrapy bcc2USc thcy lack an under- standing and abiliry to utilizc thc basic building blocks of cficmical d pcndency rccovcry. As a rCSUlt it IS ÎI l§0ft2nt to cvaluatc eac5 patient using standard admission criteria to dctcrmine appropriate treatment. After stabilization and asscssmcnt patients are admitted to eithcr a primary recovcry program or a rcl2pse prévention program. Both of thèse programs can be dclivcrcd on an inpztient or an oulpatienf basis depcndcnt upon the scverity of the patient's condition. Thcrc arc four goals for the primary trC2tmenl où cfiemîcal depcn- dence. Tficse arc: 1. The recognition thai chemical dependency is a biopsychoso- cial disease, 2. The recognition of the necd for litelong abstinence from all mind altering drugs, 3. The dcvelopment and use of an ongoing recovery program t0 maintain abstinence, and 4. The diagnosis and treatment of other problems or conditiOflS that can interfere with recovery. It is not hclpful to describe patients as relapse prone unless they haVe aCcomplished the four goals of primary recovery and return to Hrlayse I'reveniion Treatment Models 16 I chemical use or bccnmc dysfunctional in sobriety in spite of that goal complction. In thc ahscncc of thesc prcrcquisitcs alcohol and drug usc episodes cannot be considered relapse, they must be con- sidered thc continuation of an untreated disease progression. Pa- ti¢nts who lack motivation to recover bCc2use they do not believe th¢y havc the discasc of chcmical dcp¢ndcncy need to be separated from the patients who believe they have the disease, nced absti- nence, and use recovery tOOlS. Not all paticnts arc good candidates for rclapse prcvention ther- apy. There are Your gcncr2l admission criteria that can be used in selecting apgropriatc canJidatcs. Thcsc are (1) integration of chem- iCDI dcpcndcncy information, (2) past efforts at recover}', (3) a his- tory of relapse warning signs luring past periods of abstinence, and (4) motivation and 2hllity to particip2tc in relapse prevention ther- apy (Gorski, 1?88b). OnCc appropri2tc candidates are idcntificd the process of relapse prevention therapy itsCl f is init iatcd. To understand this process it is hclpful to look at the specific principles that underlie the practice of The CENAPS Model of Relapsc Prevention Therapy. THE MENU PS DIODES — DASJC PRIPIC 'JPL.ES AND PROCED IRES A number of principles can be isolated that underlie the CENAPS Model of Relapse Prevc ntion Thcrapy. Each principle forms the basis of specific relapse prevention therapy procedures. Therapists Can usc thc following principles and procedures to develop appro- priate t reatment plans for rclapse prone patients. Each principle is dCScribed followed by the Relapse Prevention Therapy Procedures Ifia( arc based upon that principle. Principle 1: Self-re$•iilntion: The risk of relapse goes down as the patients' abilities to self-regulate their thinking, feeling, acting, and relating does up. This principle is operationalized in RP Proce- dure 1. RP Procedure 1: Stabflization: An initial treatment plan is estab- lished that will allow the rclapse prone patients to get back in con- trol of themselves. Thc specific criteria of self-control ate measured by the patients' ability to manage their basic physical and psycho- logical functions wcll enough to avoid interference with the com- lb2 REL4 f's£- Conceptual, Reseo•ch «nd Clinical Perspectives pletion of basic acts of daily living. Since the symptoms of with- drawal are str¢ss sensitive it is important to evaluate the patient's level of stability both under high and low stress. Many patients who appear stable in a low stress environment become unstable when placed in a more stressful therapy environment. This stabilization process often includes detoxification ftom alco- hol and drug use, recuperation from the effects of debilitating sires.s that precede the chemical usc, and the establishment of a daily structure that includes proper diet, proper cxercisc, proper stress management, and regular contact with both professional trCatment and self-help groups. Principle 2: Understanding of the Reco‹cry Relapse Pt ocess: The risk of relapse goes down as the lcvcl of conscious understanding of the recovery process, relapse warning signs and the high risk situa- tions that act ivate or trigger them goes up. This principJe is opera- tionalized in RP Procedures 2 and 3. RP Procedure 2: Self-nssessment: Self-asscssment involves a de- tailed reconstruction of the alcohol and drug use history and the relapse history to identify last causes of relapses. Patients fre- quently return to chemical use because for one of two reasons: they experienced problems or relapse warning signs that they had not learned to recognize or manage or they failed to complete recovery tasks that were necessary to maintain sobriety. With this in mind Ihe therapist examines each period of QaSt abstinence and probes for specific problems, high risk situations and warning signs that pre- ceded a return to chemical use. The therapist also probes for basic recovery tasks that the patient completed ot failed to complete duI- ing each pcriod of abstinence. Thc assessment is most effective if the therapist reconstructs the relapse history using homework as- signments such as constructing a list of all rcla§Sc episodes and identifying the problems that led to relapse. These assignments are reviewed in group and individual therapy sessions. RP Procedure 3: Relapse £d«corion: As the assessment process is being conducted in group and individual therapy session, the pa- tients are involved in structured patient education sessions that §i0- vide specific information about the rccovcry and relapse process and relapse prevention planning methods. This information in- cludes: The biopsychosocial model of addictive disease, the devel- opmental model of recovery, the common "stuck points" and com- fte/O .$e Pre$'t•Htion Treatment Models 163 plicating faciors that can lead to rclapse, the common coping StF8tCÇlCS ÎI8t gFC aSfiOC Ïdtcd with rcCOVC â0d rclapse, r¢lapse warning sign idcntificat ion, relapse warning sign management strat- egics, 2nd 2Ctiun planning principlcs for dcvcloping a more effec- vive recoveiy plan. Expcricncc has .shown that lecture is thc least cffcctive w2y to transmit information to patients. The most cffcctive paiient educa- tion sessions arc structured in a manncr that accommodates adult l¢lrning sales and compcnsates for the common cognitive impair- ments prescrit in chef iCalIy clcpcndcnt pcoplc. The recommended format for a rclapsc cducation session is: (I) Introduction and Prc- ICst (l'i Minutcs); (2) Educational Prcscnt2tion Lecture or Film (30 \1inutcs); (.3) Educatirinal Excrcisc Conducted in Dyads of Small Groups (IN minutcs); (4) Large Group Discussion (15 minutes); (5) Session f'osl Test and ftcvicw of Corrcct Answers (IN minutes). PrincipIc 3: I‹I‹'iitificniiuii of fiielapsc K'ai ing Signs: The risk of FClapsc go¢s duwn as thc paticnt's ability to rccognizc rclapse warn- ing signe gocs up. RP ProccJurc 4: tYrirning Sign Identification: Warning sign iden- tifiC2tion is thc proccs's où tcaching paticnts to rccognizc their per- S0rlfll warning signe that lead to relapse and the high risk situations that aCtlvatc thosc warning signs. Thc specific goal each patient W0rks toward is the dcve lopment of a list of pcrsonal rclapse warn- ing signs. Each speci fic warning sign identifies a gcneral descrip- tion and specific irrational thought, unmanageable feelings and self- dCfcating behaviors that accompany it. For example: Siim Jnary Title: Euphoric Recall. DCsci-iption: I know I am in trouble with my recovery when I begin thinking aboul how good it was to use alcohol and drugs and begin to block out memories of the paifl and problems 1 expcrienced while using. !rrational Tlioiigltts: When 1 experience euphoric recall I think: 1. WaSn't it great when 1 was using alcohol and drugs. 2. Lifc was easier and everything always went well when I was using alCohol and drugs. 3. The problems 1 had with alcohol and drug use weren't so bad. 4. The pleasure I experienced more than made up for the pain. ) R @pSE: Conceptual, Research and Clinical T'erspectives Unmanageable Feelings: When I experience euphoric recall I feel: 1. Scared that I will go back to chemical use. 2. Angry because I can't drink and use drugs like oiher people. 3. Craving or drug hunger. My body actually aches for alcohol and drugs. Self-defeating Be1iai'iors: When I txpciience euphoric recall I feel an urge to: 1. Call my dealer. 2. Go back to the bar where I used to drink to visit friends. 3. Invitc my drinking friends over to h3VC ;\ 2F/. 4. Call an old girlfricnd who iS still using Jrugs. The list of warning signs needs to be sequential (listed in thc sequence in which thcy typiC2lly occur) 2nd lightly linkccl (c2ptur¢ each major step in Ihc progression from stablc rccovcry to rclapsc). This warning sign list nc¢ds to captur¢ the typical ur gcncralizcJ sequcncc of cvcnls that IC2ds patients from stablc sobricty to pro- gressive dysfunction that ends in alcohol and drug use. The com- plete warning sign list would contain a dcscription and iJcntifica- tion of thc irrational thoughts, unmanagcablc fcc ling and self-defeating behaviors that accompany the warning sign in addi- tion to the summary title. The bettcr the quality of thc final warning sign list the more precisely thc clinician can develop interventions to tcach thc paticnt how to manage this warning sign and assign thc pali¢nt appropriate recovery activities. For example: Argument it if/i wife: I know I am in trouble with my recovery when I argue with my wife over littlc things and become rc- scntful. 2. Doubts nboiit being addicted: I know I am in troublc with my rccovery when I began to think that maybe F'm nof addiclcd and that the only reason I drank and used drugs abusively was because of my marital problems. 3. Euphoric recall: 1 know I am in trouble with my recovery when I begin to remember how good it felt to go out and drink afid 1 bcgin to minimize or block out all of the bad mcmories. 4. Dissatisfaction with sobriety: t know I am in trouble with my Iö5 rccovcry when T feel dissatisficd with my sobriety and start to think I might bv better off drinking and drugging. 5. Positie'e cxf›ccIancy: \ know f ann in trouble with my recovery when I begin to be I icvc Ihe probIemS I äm having will get b¢tter if I start to use alcohol or drugs. 6.Obsession: I know 1 ann in troublc with my recovery when I bCgin Io constantly think about drinking and drugs and find 1 can't bush thosc thoughts out of my mind. 7. Coinpalsion: 1 know I ann in trouble with my recovery when I begin to feel an irrational urge to usC alcohol or drugs when 1 know it will be disastrous to do so. 8. Craviny: I know I am in trouble with my rccovery when I bCgin Io cxpcricncc physical cF2V1ng accompanied by body achcs, anxiety, anJ vivid drcams about alcohol and drug use. 9. Loss nf ccnlrol: I know I am in troublc wilh my rccovcry when I hcgin to do things that I madc commitments I would no longcr do such a* s• into hers, call old drinking buddies, or skip AA mcctings I flannel tO attCnd. PrloClblc 4: Manngeinent of Rclayse lf'arztffJg Signs: The risk of F¢Iap$ dccrcascs as Ihc paticnt's ability to manage rclapsc warning SghS §OCS U/. RP Proccéurc 5: IVar-ning Sign Management: This involves I¢6¢hing rclapse prune pa ttcnts flew fo managc or cops with warn- if\g signs as lhcy occur. The bclter ahlc paticnts are to cope with wafting signs thc hcttcr thcir ability to stay sobcr. This procedure l8V0lvCs tic esc of mcntal rchcarsal, role playing, and thcrapcutic assignmcnts. Thc thcrapist focuses the management training on thrcc di. tinct lcvcls. Thc first is the situational-behavioral lcvel v.'here thC patient is taught to avc›id situations that triggcr warning SÏgns and m‹›dify their l›chavicral rcsponsc should thcy havc to be involvcd in thosc siluations. Thc sccond Icvcl is the cognitive-affcc- tive lcvcl 'here tlJc gaticnt is taught to ch2ngc the irr2tional b¢licfs and dcal v•'ith thc unmanagcable fcclings that accompany the ram- ing Sign. This involvcs changing scJf-balk pattcrns, learning to use imag¢ry tcchniqucs, and learning to cope with associated fcclings and cmotions. Thc lhird level is the core issue level when the pa- ticnt is taught to idcntify the core mistaken beliefs that cause distor- tions of anJ ov¢rrclctions to relapsc raming signs. It is the core 166 RELA PSE.- Coflcepiuaf Research and CM'cal yers. ' rciii es issues that cause the patient to use the cmCf@Iag War£t1n@ SlgflS In th¢ service of thcir p¢rsonality stylc and lifcstyle. Principle 5: fiecorcry Planni'ng: The risk of relapse goes down as the relationship between relapse warning signs and recovery pro- gram recommendations goes up. Each relapse warning sign o spe- cific high risk situation must have a treatment plan ihat is specifi- cally directed towards its resolution. RP Procedure 6: Recovery Planning: Rccovcry Planning involves helping the relapse prone patient to dcve lop a recovery program that supports inventory and warning sign managemc ni mcthods. Each warning sign and its rclatcd coping strategies arc rcvicwed and spe- cific ways in which the patient can use the rccovery program to implement those strat°s 'cs arc idcntificd. Principle 6: Daily lnventory: The risk of rclapsc goes dow'n as the use of daily inventory techniques dcSl 6" cd to monitor compliance witfi the basic recovcry pro s••< and to chuck for the prcsence of rclapse warning sig°• s es up. The more active a patient is in com- pleting a daily inventory the lcss likely they are to rclapse. RP Procedure 7: Inc enrory Traîiiing: Inveniory Training invofvcs teaching rclapse prone patients to complets daily inventorics to help them become consciously awate of compliance with their rccovery program and the émergence of re lapsC warn i°r 's ns. Patients are cncouraged to usc a morning planning inventory where they plan their day and an evening rcview invcntory where they review pro- gress and problems and discuss the results of the invcntory with a sponsor beforc going to bcd. Principle 7: Significant Oiliers: The risk of rclapse goes Jown as the responsible involvemcnt of significant ollicrs in recovcry from codepcndency and in the rclapse prevention planning process itself goes up. The healthier the significant others are the more likely they are to be a positive help to the relapse proue a[coholic. The more directly the significant others are invo[ved in the rclapse prcvention planning process the more like Iy they are to bccome productively involved in supporting positive efforts at recovery and intervening upon rclapse warning signs or initial chemical use. RP Procedurc 8: fnv'ofremeni of Others: Relapse prone patients cannot rccovcr alone. lt is the therapist's rcsponsibil ity to involvt signi ficant others in the structurcd process of relapse prcvcnti0n Relay se Prévention Treatment Modèle 167 planning. Family members and EAP counselors are two significant resourccs that need to be involved. A protocol for family involve- lfltflt ln relapse prevention planning has been developed (Gorski, 1986 and 1988a). There has also bccn a parallel model of recovery in relapse prcvention planning dcvc!oped by Jan Smith for use with family rnembcrs involved with chemical dependency (Smith, 1986). Principle 8: Relafise Prei'cntion Plan Updates: The risk of re- 1a§Se goes down as the numbcr of rcgular revisions of the rclapse warning sign and high risk situation lists, managcment strategies, and recovery program goes up. It is important to recognize the need IO ICgu]flrly modify the relapse prevention plan during the first two to thrcC ycars of rccovcry. Thc first update is typically required wiihin thC first 90 days of recovcry. The more active a person is in FCViSlf}@ and updating thc rclapsc prcvcntion plan as the conditions of thcir rCcovcry changc lhc lowcr the risk of rclapse. RP Procedure 9: Folloiv-up: lt is important to recognize that nearly two thirds of all rclapses occur within the first six months of • p liam's rccovcry. lt ha.s bccn ¢slimaæd chat iess than 25Yr of lhe VäFl8blCs that actually causc rclapse Can be predicted during the IÜ1tIÂ] T Fçatmcnt phase. This mcans that ongoing outpatient treat- ment is rrcssary for effective rclapse prevention. Even the most effective short tcrm inpatic nt or primary outpatiCnt £OgrafRS WlH fôil to intcriupt long term rclapse cycles without the ongoing rein- *OFCCTrnt Of OUtgaticnt thcrapy. Plinciplc 10: Tlliiikitlÿ fft Ùrinciyles: The risk of rclapse goes dou'n as luc ability to iJcntify undc lying principles, patterns, and key conccpis ih t causcd pasi high Risk situations and rclapse warn- ing signs goes up. RP Proccdurc 10: lJetitifying Core lssaes; It is important that a §aliflnt |cain to think clcarly about the underlying patterns that re- Cat lhcmsclvcs in rccovcry. This requises the identification of the COfC issues or undcrlying mistakcn Reliefs that fuel the irrational thinking, unmanagcablc fcclings and self-destructivc behaviors ihat crcatc dysfunciion in rccovcry. Principlc 11: Stngc of Fecoi'ei . A different profile of rclapse warning signs will cmcrgc during cach discrccl developmental stage of rccovcry. The cmcrgc ncc of a ncw profilc of warning signs will Jd8 RELAPSE: Conceptual, Research and Clinical Perspectives require the development of new and more sophisticated coping strategies. The better able a paticnt is to anticipatc and monitor their progress in recovery and identify the shifts in warning signs that emerge in each new stage the lower the risk of rclapse. REFERENCES Davies, D. L. (1962) "Normal Drink ins • nd Recovered Alcohol Addicts." 9«r- ierly Journal of 5iudies on Alcohol, 23: 94-104. Baekeland, F., Lundwall, L., and Kissen, B. (1975) "Methods for the Treatment of Chronic Alcoholism; A Critical Appraisal.'' In: Gibbons, J. G.. Israel, Y., Kalant, H., Popham, R. E., Schmidt, W., anfi Smart, R. G., Eds. Research Advances in Alcohol and Drug Problems. VoJume 2. u ew York: John \Viley, 1975. pp. 247•327. Comp Care Corporation, Care Unit. (1988) Evaluation of Treainienl Outcome. lrvine, CA: Comprehensive Care Corporation, 1988. Donavon, D. M., and Ch • y, E. F. ti g 8) Alcoholic Relapsc Prevention and Intervention: Models and Methods. In: Marlet, G. A., and Gordon, J. R., Eds. Relapse Prevention - 5lainienance Strategies in the Treatment of Addictive Belts viar. New York: Guilford Press, pp. 351 -41 6. Donovan, I. M. (1986) "An Ideologic Model of Alcohol ism." American Journal of Psychiatry, 143: 1- 1 1. Gorski, Terence T., and Miller, Merlene M. (l9g6a) Sro)'ing Sober - Guide to Relapse Prevention. Independence, MO: Harold House. Gorski, Terence T. (1986a) "Relapse Prevention Planning — A New Recovery Tool." Alcohol Health and Research tI'orId, Yz II, 1986b. Gorski, Terence T. (1988a) The Staying Sober tI'arlbooh -A Serious Solution for the Problem of Relapse. Independence, MO: In‹Iependcnce Ptess, l9S8a. Gorsk i. Terence T. (1988b} Manual # 1: Assessing The Relapse Prone Pa iient. Prepared for The National Ceriificai ion Program for Relapse Prevention Spe- cialists, Clinical Intensive I, 1986, revised March, 19fi8, The Cenaps Corpora- tion, P.O. Box 184, hazel Crest, IL 60429. Helser, J. E., Robins, L. N.. Taylor, J. R., Carey, K., Miller, R. H., Comhs- Orme, T., and Farméf, A. (1985) "The Exieni of Long Term I\4c'derate Drink- ing Among Alcoholics Discharged from I.1cdical and Psychiatric Treatment Facilities." New England Journal of medicine, 312: 1678- 1682. Hoffman, Norman G., and Harrison, Patricia A. (1956) Ca/r›r 1986 Report - Findings Tw'o ¥ears Afier Treatment, CATOR, SI. Paul, If N: CATOR. Laundergan, I. Clark. { 1986) Easy Does li - Alcoholism Treumient Outcomes, Hazelden and the hlinnesoia âfode/. Cenier City, MN: Hazeldc n Foundation. Lnvibond, S. H., and Caddy, G. f 1970) "Discriminalive Aversive Control in ite Modcrat ion oI Alcoholics Drinking Behavior." Beliavior Tlierapy 1:437-444. Mar latl, G. Alan, and Gordon, Judith n. t i 985) fi‹ ,se Pres «riori Relapse T'ret'enlion Trealmeni Models 169 nance Slratt'¿ies in tlte Treatment of Addictive Behaviors. The Guilford Press, Stiller, \\'illiam R., and Heste r, Reid K. (1986) "The Effectiveness of Alcohol- ism Trcalmcnl — V•'hat the Research R¢v¢als." In: MiIICF, William E., and Hcalhcr, Nice, Treating A ddictive Behav iors, Processes of Change, New York: Clcmon Press. National Insiituic on Alcohol Abuse and Alcoholism.(1987) Sixth Special RepoMs to rfie t/. S. Congress on zflcoliol and flealih from the Secretary of Healih and human Sen'ices. U.S. Departmc nt of Hcalth and Human Services, January. Patton, Michael Q. ( 1979) The Outcomes of Treatment.- A Siudy of Patients Ad- mitted ro Ha-•elden in 1976. Center City. MN: The Ilazelden Foundation, Inc. Pickens, Roy \V., I lalsukami, Dorothy K., Spicer, Jerry W., and Svikis, Dace S. (1985 j Relapse by Alcohol Abusers, Alcoholism, Clinical and Experimenia I Research, Vol. 9, No. 3 pp. 244-247. Sch8g {gr. H. H., Sobe11, M. G., and Sobell, L. C. (1972) "Follow Up of Hospi- lalizcd Alcoholics Given Self-Confrontation Exper iencc by Video Tape." Be- hai'ior Therapy, 3:283-285. Sm fth d. , and Gorsli, T. ( 1985a) The Progressive Sympioms of Codependency. The CENA PS Corporation, t4azcl Crest, IL. Smilh }. and Gorse i, T. (!98Sb) Codependenl Recovery. The CENAPS Cofpo- ration, Hazel Crest, IL. Smile d., and Gorski, T. (1986) Relapse WafTtitt$ Si n$ For The Codependent. be CENAPS Corporat ion, I lazcl Crest, IL. Sobell, M. D., i°d Sobcll, L. C. (1973) "Individualized Behavior Therapy for Alcoholics." Brliavior Therapy, 4: 49-72. Vailla ni. G. E. (1983) The Natural History of Alcoholism - Causes, Paltems, aIJd f'atlis to Recover. Cambr idge, MA: Harvard University Pfrss.

Menu of options

The counselor can help the client come up with the plan, but it is a collaborative effort. The counselor can provide a menu of options for the client to choose from, like this: "It sounds like you want to cope with your anxiety in a way other than drinking. There are a lot of options that seem to be helpful to people... relaxation techniques, breathing exercises, developing a network of support, or spiritual practices. You've also mentioned some strategies you would like to try like going for walks in the park and calling your best friend...which of those sound like something you think you could do?"

How is the TTM Helpful for Addictions Counselors?

Holistic Treatment

The bottom line: Addictions counseling is not one-size-fits-all. Instead, counselors must consider their clients' unique cultural identities when providing treatment. For example: ◦What is the client's experience with privilege and oppression? ◦Does the client have a collectivist or individualistic family structure? ◦What are the client's cultural norms regarding substances? ◦How are drugs and alcohol perceived by members of the family? ◦What are the client's feelings about various treatment modalities (12-step programs, individual counseling, group counseling, family counseling, etc. )

Planning

The final MI process is to plan for making the change. Counselors move into this stage when the client's change talk becomes more frequent than their sustain talk. Once the client is ready to make a change, the client and counselor develop a specific change plan. What is the client's goal? What is the first step? How will the client deal with potential obstacles? Who can help the client maintain her/his goal?

Hidden Quadrant

The hidden quadrant consists of information known to self, yet unknown to others. The information in the hidden quadrant could be secrets, undisclosed information, things that people are ashamed of, or parts of an individual's story that the person does not share with others. Hidden information could be what clients are really feeling (behind the "mask" they might wear to group) or thoughts about relapse that they are too ashamed to talk about. As trust increases in the group, clients take risks and share information from the hidden quadrant. This gives group members the opportunity to respond to hidden information (through validation, affirmation, empathy, and support).

Johari Window

The key concepts of the Johari Window are feedback and self-disclosure. When a group members self-discloses (or share something about themselves), the open quadrant gets larger and the hidden quadrant gets smaller. When group members give each other feedback (or respond to what others have disclosed), the open quadrant gets larger and the blind spot quadrant shrinks. This is growth in group counseling.

Level 1: Outpatient Services

The least restrictive level of care for addictions treatment is Level 1 outpatient services. Standard outpatient services are the least restrictive and consist of meeting with a counselor or therapist one time per week for one hour. Outpatient services may consist of group counseling, family counseling, and/or individual counseling sessions (one time per week). Individual counselors may require or recommend that their clients attend12-step meetings. Lowest form of monitoring - typically a good option for those who have attended higher levels of care and are now maintaining their recovery.

Evoking

The process of evoking is unique to MI. It based on the belief that the client already has arguments for change within. Thus, the counselor's job is to draw them out (like drawing water from a well). MI counselors recognize that ambivalence is a normal part of the change process. Clients use both change talk and sustain talk in reference to their substance use. MI counselors work to reflect and summarize the change talk so that clients hear their own reasons for wanting to make a change.

Focusing

The process of focusing involves setting an agenda for the clinical work that the counselor and client will do together. What is the goal and the focus of counseling? Clients may not identify substance use as their goal---they may say things like stress, anxiety, or relationship issues. The work of focusing is to collaboratively land on addressing substance use in counseling. Counselors respect the autonomy of the client and also work with them to come up with helpful clinical goals. Counselors may use a substance abuse assessment to provide direction for their work (i.e., if the client scores in the problematic range of an assessment, it can help emphasize the need to address drug and alcohol use in counseling).

Types of Cybersex Addiction

The rise of the internet has changed the landscape for sex addiction treatment. Cybersex is prevalent and can become an addictive behavior for some individuals. Internet pornography has been called the "Triple A Engine" due to the fact that it is accessible, affordable, and offers anonymity (Cooper, 1998). The Internet offers a range of sexually arousing online behaviors (i.e., cybersex) including: ◦Sexual chatting/communication ◦Viewing pornographic images or videos ◦Engaging in partnered online sexual experiences ◦Sharing sexual images/files ◦Sexual activities among avatars in games ◦Online sex shows (Cooper & Griffin-Shelly, 2002)

Identifying change talk

The role of the MI counselor is to identify the change talk amidst the sustain talk . Read the paragraph below. Can you identify the change talk? "I don't understand what the big deal is. I work hard, I take care of my family, I am a good citizen....Who cares if I pop a Xanax every now and again? It helps me keep up with the pressure and deal with all the crap on my plate everyday. Sure, there is a part of me that would like set a better example for my kids, but everyone has their issues and this is the best way for me to get through the day. I know a lot of other people who use it too."

Change Talk

There are four aspects that make up what is called the "spirit" of MI: Partnership: MI works when there is a collaborative relationship between the counselor and client. Acceptance: The counselor believes in the absolute worth of the client, affirms the client, respects the client's autonomy, and communicates empathy for the client. Miller and Rollnick said, "This involves letting go of the idea and burden that you have to (or can) make people change. It is, in essence, relinquishing a power you never had in the first place" (2013, p.19). Compassion: The counselor is motivated solely by the welfare of the client. Evocation: The MI process is one of drawing out rather than imparting knowledge and forcing a client to change. MI counselors believe clients already have much of what they need within themselves.

Examples of Pharmaceutical Options

•To help clients addicted to nicotine: ▫Nicotine patches or gum: The goal is to gradually taper off with less and less nicotine. ▫Varenicline (Chantix): Contains a partial nicotine agonist (binds to receptor to produce a response). •To help clients addicted to alcohol: ▫Disulfiram (Antabuse): Formerly used as "aversion" therapy; taken in the morning and causes individual to become very ill if alcohol is consumed (effectiveness of Antabuse is currently debated in the field). ▫Acamprosate (Campral): Used to facilitate GABA and inhibit glutamate—has produced mixed results in research.

Spirit of MI

Core Skills of MI

There are some basic counseling skills that MI counselors use. The acronym for these skills is OARS: Open questions: Counselors only ask open questions (questions that start with "what" or "how" rather than "do" or "is") and allow the clients to talk more than 50% of session. Example, "What would you like to be different with regard to your drinking?" Affirming: Counselors recognize the client's strengths. Counselors try to catch the client doing something good. Example: "It must be really hard to talk about your drug history, and I appreciate your courage." Reflective Listening: Counselors communicate to the client that they heard and understood what the client said. Example: "It sounds like you are afraid of life without alcohol." Summarizing: Counselors make a note of client change talk and summarize it for them. Example: "So, let me see if I understand. You are concerned about your marijuana use because lately you have seen an increase in your anxiety and a lack of motivation. Is that right?"

Types of Sexual Addiction

There are two different kinds of sex addiction: First, the classic type. Traditionally, individuals with compulsive sexual behavior had a history of trauma, attachment issues in their family of origin, a history of sexual abuse (especially among females), and impulse control issues. Recently, however, individuals have been seeking treatment for sex addiction who do not fit this profile. Instead, they have the contemporary type of sex addiction; one that is brought on by chronic exposure the sexually graphic material (most commonly, Internet pornography). Thus, early exposure to pornography could lead to sex addiction in some individuals, even without the traditional trauma/abuse history.

What Sex Addiction is Not:

There is a lot of confusion about what "sex addiction" means. Is it just too much sexual activity? Or a certain type of sexual activity? Let's clarify what it is NOT: ◦Poor sexual decision-making ◦Sexual behavior that goes against one's personal beliefs or values ◦A specific type of sexual behavior ◦A specific amount of sexual behavior ◦A "man's issue"- sex addiction does not discriminate based on gender Although the above list could be problematic, those features alone don't constitute "sex addiction." Instead, sex addiction is sexual behavior that meets the 4 Cs of addiction: compulsive sexual behavior, loss of control over sexual behavior, continuing sexual behavior despite negative consequences, craving or mental preoccupation with sexual behavior

A culture of Substance ABuse

Think about college culture. What aspects of the college environment contribute to substance use? What are the social norms and expectations about drugs and alcohol? Consider how the factors below may contribute to the culture o f substance use: Fraternity/Sorority traditions related to drinking (hazing) Game Day/Tailgating traditions related to drinking "Thirsty Thursdays" with no classes on Fridays Spring break norms and media portrayals Easy access and availability of alcohol surrounding college campuses Media portrayals of college Can you think of other aspects ofthe college environment that contribute to substance use?

Chapter 17

This Chapter Highlights Psychosocial And Clinical Issues In The Treatment Of Addictive Disorders In African Americans, Hispanic Americans, Asian Americans, And Native Americans. Cultural Competency Of Caregivers In Treatment Programs Is Vital But Often Lacking (Westermeyer, 2008). Substantial Knowledge Gaps Still Exist In Minority Substance Abuse, And Continued Research In This Area Is Needed. The Growing Ethnic Diversity Of The United States Makes The Significance Of These Issues Even Greater. According To The 2010 Census, Hispanics Make Up 16.3% Of The Population; African Americans, 12.6%; Asian Americans/ Pacific Inlanders, 4.8%; Native Americans And Alaska Natives, 0.9%; And European Americans, 72.4% (U. S. Bureau Of The Census, 2011). The Fastest Growing Ethnic Groups Are Hispanics And Asian Americans. The Hispanic Group Increased 43% Between The 2000 And 2010 Census, Also Increased Was The Asian American Group. It Is Estimated That By 2060, The Non-Hispanic White Population In The United States Will Be A Minority. This Chapter Reviews Selected Data On Addictive Disorders In Minority Populations. One Important Caveat Is That Today Many People Report Being Of Mixed Race, And The Importance Of This Factor Should Be Clearly Acknowledged, But It Is Not Discussed In Any Detail In This Chapter. Data For Substance Abuse In Minorities Come From Numerous Sources: The National Household Survey On Drug Abuse, The National Longitudinal Survey Of Youth, Monitoring The Future, American Indian/Alaskan Native Statistics, And The Dawn Abuse Warning Network, To Name A Few. According To The 2010 National Survey On Drug Use And Health, Among Persons Age 12 And Older, 10.7% Of African Americans, 9.1% Of Whites, 8.1 % Of Hispanics, And 3.5% Of Asians Had Past-Month Illicit Drug Use. Whites Reported 56.7% Current Alcohol Use, Blacks Reported 42.8%, Hispanics Reported 41.8%, Asians Reported 38.4%, And American Indian/Alaska Natives Reported 36.6%. Binge Drinking Was Reported In 24% Of Whites, 19.8% Of Blacks, 25.1% Of Hispanics, 24.7% Of American Indian/Alaska Natives, And 12.4% 350 17. Substance Abuse In Minority Populations 351 Of Asians. The Rate Of Heavy Use Was Highest For Whites, Followed By American Indi- Ans/Alaska Natives, Hispanics, Blacks, And Asians. Twelve-Month Substance Depen- Dence Disorder Was 8.9% For Whites, 8.2% For Blacks, 9.7% For Hispanics, And 16% For American Indians/Alaska Natives (National Survey On Drug Use And Health, 2011). Heavy Alcohol Use Peaked In The 20S Then Declined Among White Men. Divisions Along Ethnic Lines Can Be Complicated By Variations In Country Of Ori- Gin, Tribal Affiliation, Religious And Spiritual Orientation, And Political And Economic Conditions. These Differences May Influence The Clinical Presentation And Therapeutic Needs Of The Patient. Other Variables Include Socioeconomic Status, Educational Level, Occupational Stability, Dwelling Situation, Marital Status, Family Of Origin, And Age. Thus, A Middle-Class African American Woman With A College Degree And Stable Employment, Dwelling In A Reasonably Safe Neighborhood, May Share A Daily World Outlook Toward The Future That Is More Similar To That Of A European American Woman With A Similar Background Than To That Of A Single, Unemployed African American Mother Dwelling In An Inner City. A First-Generation Mexican Immigrant May Have Different Risk Factors For Substance Abuse Than Someone Who Is A U. S. Native. Experi- Ences Within Different Asian Cultural Groups Can Be Vastly Different. There Are Scant But Increasing Data Regarding Differences In Biological Vulnerability For Substance Abuse Between Ethnic Groups (Nielson Et Al., 2010; Ittiwut Et Al., 2012; Du & Wan, 2009; Ehlers, Gilder, & Phillips 2008; Ehlers, Phillips, Gizer, Gilder, & Wilhelmsen, 2010, Ehlers, Phillips, Gizer, Gilder, & Yehuda, 2013; Gizer, Edenberg, Gilder, Wil- Helmsen, & Ehlers, 2011; Ray, Bujarski, Chin, & Miotto, 2012; Duranceaux Et Al., 2008; Luczak Et Al. 2006; Cook Et Al., 2005; Hendershot, Macpherson, Myers, Carr, & Wall, 2005; Chan, Mcbride, Thomasson, Ykenney, & Crabb, 1994; Goldman Et Al., 1993; Berrettini & Persico, 1996). Substance Use Among Minority Adolescents Ethnic Differences In The Prevalence, Age Of Onset, Gender, Lifetime Trajectory, Service Utilization, And Medical And Psychosocial Consequences Of Substance Use Disorders (Suds) Have Been Reported. Adolescents Have A 15% Prevalence Of Having An Sud (Swendsen Et Al., 2012). Several Recent Studies Have Reported Racial/Ethnic Differences In Adolescent Substance Use And Their Consequences. Native American Adolescents Have Been Reported To Have The Highest Prevalence Of Illegal Substance Use (47.5%). In Analysis Of The 2008 National Survey On Drug Use, Adolescents In Native Ameri- Can, Multiple Race/Ethnicity, And Whites Groups Had Elevated Rates Of Substance-Related Disorders Compared To African Americans And Asians (Wu, Woody, Yang, Pan, & Blazer, 2011). Hispanic Youth May Have The Earliest Initial Use, And White Adolescents Have The Highest Rate Of Decreased Use Over Time. Whites Are Generally Younger Than Blacks At Onset Of Drinking, And They Progress To Alcohol Dependence Faster (Alvanzo Et Al., 2011). Low Parental Education May Be More Of A Risk Factor For White Kids Than It Is For African American Or Hispanic Children (Bachman Et Al., 2011). Asian American College Students Who Are Heavy Drinkers May Have Higher Developmental Risk For Later Dependence (Iwamoto, Takamatsu, & Castellanos, 2012) There May Be Different Cofactors Among Ethnic Groups That Make Them Vulnerable To The Misuse Of 352 Iv. Special Populations Prescription Drugs (Harrell & Broman, 2009; Green, Zebrak, Robertson, Fothergill, & Ensminger, 2012). Black Youth, In Contrast To Whites, May Initiate The Use Of Can- Nabis Before The Use Of Cigarettes (Vaughn, Wallace, Perron, Copeland, & Howard, 2008). A Recent Longitudinal Study Of A Cohort Of Inner-City, Black Children In Chicago Reported Less Church Attendance And Extraversion, Increasing Risk Of Later Cocaine And Cannabis Use (Fothergill, Ensminger, Green, Robertson, & Juon, 2009). Similarly, An Increased Number Of Conduct Problems May Lower The Onset Of Drinking In Black Youth. Black Youth Are More Likely Than White Youth To Be Arrested For Drug Offenses Despite Being Less Likely To Use Drugs. This Disparity In The Legal System Can Have Long- Lasting Negative Effects On Black Youth (Kakade Et Al., 2012). Black Adolescents May Be Less Prone To Use Inhalants (Nonnemaker, Crankshaw, Shive, Hussin, & Farrelly, 2011). However, By Age 30, Most Racial/Ethnic Differences In Substance Use Rates Dis- Appear (Chen & Jacobson, 2011). Despite Comparable Prevalence Of Alcohol Use And Alcohol Use Disorders, And Higher Severity, Blacks And Hispanics Report Increased Social Consequences Of Heavy Drinking Compared To Whites And Have Lower Levels Of Private Insurance Service Utili- Zation (Chartier & Caetano, 2011; Mulia, Zemore, & Greenfield, 2008; Marsh, Cao, Guerrero, & Shin, 2009). Treatment Utilization Among Ethnic Groups Is Equivalent, However. This May Be The Consequence Of Different Rates Of Incarceration And More Publically Funded Treatment Among Blacks And Latinos. Black Substance Users, How- Ever, Compared To Whites, Receive Less Treatment For Psychiatric Comorbidities (Keyes Et Al., 2008). Blacks And Hispanics Are Exposed To Greater Social Disadvantages Of Poverty, Discrimination, And Stigma, And These Factors Are Associated With Problem Drinking (Smith, Dawson, Goldstein, & Grant, 2010; Mulia Et Al., 2008). Asians With Lower Incomes Suffer From Effects Of Discrimination And This Is A Risk Factor For Substance Use In That Group, As May Be Low Education In Hispanics (Lo & Cheng, 2012). In Black Adolescents, Effects Of Perceived Racism On Anger And Self-Control May Correlate With Increased Substance Use (Gibbons Et Al., 2012). School Dropout Rates Have Been Associated With Injection Drug Use In Blacks; Dropout Rates Should Be Tar- Geted For Intervention (Obot, Hubbard, & Anthony, 1999; Obot & Anthony, 2000). Substance Abuse Among Minority Women African American Families Produce More Alcohol Abstainers Than Do European And Hispanic American Families. African American Women May Express More Conserva- Tive Drinking Norms (Herd, 1989). African American Women May Have Eventual Rates Of Heavy Drinking Comparable To That Of European Americans; However, They Report Fewer Social And Personal Problems. African American, Asian American, And Latin American Women May Be More Insulated From Alcohol-Related Social Problems By Their Families, Communities, And Churches. A Larger Proportion Of African Ameri- Can Women, However, Experience Alcohol-Related Health Problems Than Do European- American Cohorts (Herd, 1989). One Study Of African American And Native Ameri- Can Pregnant Women Indicated That African American Women Exhibit Higher Rates Of Fetal Alcohol Syndrome. These Findings May Be Attributed To Issues Such As Nutrition 17. Substance Abuse In Minority Populations 353 And Access To Health Care. Concurrent Illicit Drug Use May Also Be A Contributing Factor. A Substantially Higher Percentage Of American Indian/Alaska Native Women Drink Compared To European American, African Americans, Or Hispanics. There Are Higher Rates Of Cocaine Use In African American And Hispanic Women Compared To Asian Or European American Women. Among Heroin And Cocaine Abusers, African American Women Woman Have Higher Rates Of Sexually Transmitted Diseases (Stds) And Different Risk Factors For Use (Cavanaugh Et Al., 2011). Younger Hispanic Women Are More Likely Than European American Women To Abstain, Though There Is A One- Sided Convergence With Increasing Acculturation. For Example, In One Study, 75% Of Mexican Immigrant Women Abstained From Alcohol, Whereas 38% Of Third-Generation Mexican American Women Were Abstainers (Gilbert, 1991). American-Born Hispanic Women Are More Likely To Report Moderate To Heavy Drinking Than Their Immigrant Cohorts. Mexican American Women Who Use Substances Suffer Significantly Higher Lifetime Rates Of Physical And Sexual Assault (Lown & Vega, 2001). African American Women In Treatment Often Have Myriad Needs: Employment, Child Care, Treatment For Victimization, And Psychiatric Symptoms. Personal Losses Such As Death Of Loved Ones, Separation, And Loss Of Child Custody Have A Profound Impact On Drug Use In African American Women. Women In Substance Abuse Treat- Ment Are Oversampled In Terms Of Sexual Abuse. In A Study Of 1,272 Randomly Selected Women In A Jail With Predominantly Women Of Color, 8% Had A Comorbidity Of Severe Mental Disorder And Substance Abuse (Abram, Teplin, & Mcclelland, 2003). Life Stress Has Been Found To Be A Strong Correlate Of Crack Cocaine Use In African- American Women (Boyd, Guthrie, Pohl, Whitmarsh, & Henderson, 1994), As Is Gang Affiliation In Women. Child Care Has Traditionally Been A Major Obstacle To Substance Abuse Treatment But Especially For Minorities, Although This Is Not Unique To Ethnic Minorities. Financial Restriction Is A Fundamental Barrier To Treatment For Women, With Added Hardship For Women Belonging To Ethnic Minority Groups. Supportive Networks Are Important To Substance Abuse Recovery Irrespective Of Child Care Needs. A Strong Focus On The Development Of Supports Is Indicated In The Treatment Of Addicted Women. Isolation Among Addicted Women Occurs For Multiple Reasons And Include Feelings Of Shame And Guilt, And Depression. Minority Women May Experience Double Stigma. Social Networks Should Be A Strong Focus Of Recovery For Addicted Minority Women. It May Be Necessary To Utilize Extended Family, As Well As Supports Outside The Family. Respect For Family Systems Is Especially Important In Treating Hispanic Women (Langrod, Alksne, Lowinson, & Ruiz, 1981). Substance Abuse Among African Americans As With All General Ethnic/Racial Categories, African Americans Are Not A Monolithic Group. Important Differences May Be Evidence Between Rural And Urban Folks And County Of Origin (Broman, Neighbors, Delva, Torres, & Jackson, 2008; Gibbons Et Al., 2007). Using 1-Month Prevalence Data, Compared To White Teens Of Similar Age, African American Teens Ages 12-17 Drink Heavily Less Often, 0.7 Versus 3.4%. How- Ever, By Age 26, Heavy Use Of Alcohol Is Similar, 7.8% In Blacks Versus 7.1% In Whites. Heavy Use Among Black Men Is Relatively Low In The Early Years, But It Peaks In The 354 Iv. Special Populations Middle Age Before Declining (Herd, 1990). One Hypothesis Is That Issues Of Racism And Limited Opportunities Become More Evident As Blacks Mature Into Adulthood. Strong Pro-Black Racial Identity Maybe An Important Protective Factor Against Ado- Lescent Substance Use (Stock, Gibbons, Walsh, & Gerrard, 2011). Higher Levels Of Posttraumatic Stress Disorder (Ptsd) Maybe An Added Risk Factor For Alcohol Use In Blacks (Williams, Jayawickreme, Sposato, & Foa, 2011). The Factors Involved In The Later Onset Of Heavy Alcohol Use In Blacks And The Subsequent Rise In Alcohol Use Need Further Research. Diagnostic Screening Instruments For Substance Abuse In African-Americans Have Been Shown To Be Valid (Duncan, Duncan, & Strycker, 2002). In A Large Inpatient Sample, African-Americans Were Found To Have Later Onset Of Use But Earlier Onset Of Alcohol-Related Problems (Hesselbrack, Hesselbrock, Segal, Schuckit, & Bucholz, 2003). African Americans Appear To Have Worse Health Outcomes With Moderate Alco- Hol Use And Achieve Lower Occupational Attainment (Sloan & Grossman 2011). In Addition, The Prevalence Of Alcohol-Related Problems In Black Men Indicates Signifi- Cant Differences In Psychosocial Distress Compared To That Of White Men (Herd, 1994). The Greatest Differences Between The Groups Are Found In Scores For Loss Of Control, Symptomatic Drinking, Binge Drinking, Health Problems, And Problems With Friends And Relatives. Blacks And Whites Had Similar Drinking Patterns, As Measured By Fre- Quency And Maximum Amounts Consumed. Black Men Were Significantly Less Permis- Sive In Attitudes Toward Alcohol Use In Particular Situations, Such As Driving A Car Or Spending Time With Small Children In A Parental Role. Further Analyses Showed That The Higher Rates Of Alcohol-Related Problems Were Not Fully Accounted For By Social And Demographic Differences Between Black And White Men. An Earlier Study By Herd (1990), Reporting On Data From A 1984 National Survey, Showed Similar Findings Of Greater Alcohol-Related Problems Among Black Men Than White Men In The Past Year. The Exception Was Drunk Driving, In Which White Men Scored Higher. Black Men Scored Higher On Symptoms Of Physical Dependence And Health Problems. Here The Rates Of Frequent Heavy Drinking Were Lower, Not Higher, For Black Men. Limited Financial Resources And Access To Health Care Likely Contributed To The Higher Prevalence Of Alcohol-Related Health Problems In Black Men. Blacks May Be At Higher Risk For Hepatic Damage And Cirrhosis From Drinking (Singh & Hoyert, 2000). Herd (1994) Suggests That This Finding May Represent A Longer Duration Of Heavy Use, As Opposed To More Discrete Phases Of Heavy Alcohol Use Seen In White Men. The Body, It Is Hypothesized, Is Less Resilient To Alcohol Toxicity At Older Ages. Binge Alcohol Use Is Associated With Increased Risky Sexual Behavior And Increased Stds In Black Men (Raj Et Al., 2009). Several Studies Have Indicated That Lower Socioeconomic Status Seems To Have A More Profound Influence On Alcohol-Related Problems For Black Men Compared To White Men (Barr, Farrell, Barnes, & Welte, 1993; Herd, 1994; Jones, 1989; Jones- Webb, Hsiao, & Hannan,1995). Black Men Of Lower Socioeconomic Status May Expe- Rience More Overt Forms Of Discrimination And May Be More Likely To Reside In Com- Munities In Which There Is More Police Surveillance. Group Norms May Be Predictive Of Problematic Alcohol Use In African-Americans (Jones-Webb Et Al., 1995). Greater Ethnic Identity May Be Protective Against Problematic Drinking (Herd & Grube, 17. Substance Abuse In Minority Populations 355 1996). In Addition, Lower Neighborhood Cohesion Has Been Associated With Adolescent Drug And Alcohol Problems. Polymorphism Of The Adh2*3 Alcohol Dehydrogenase Metabolic Enzyme May Play Role In Alcohol Expectations In African Americans (Ehlers, Carr, Betancourt, & Montane-Jaime, 2003). Lower P3 Amplitudes During Event-Related Potentials Have Also Been Reported In Alcoholic African Americans (Ehlers Et Al., 2008). The Asso- Ciation Of Alcohol Use And Hypertension May Be Particularly Problematic In African American Men. The Association Between Hypertension And Illicit Drug Use Has Also Been Reported (Kim, Dennison, Hill, Bone, & Levine, 2000). Ziedonis, Rayford, Bry- Ant, And Rounsaville (1994) Have Reported On Differential Rates Of Lifetime Psychiatric Comorbidity In African American And European American Cocaine Addicts: Euro- Pean Americans Have Significantly Higher Rates Of Lifetime Depression, Alcohol Depen- Dence, Attention Deficits, And Conduct Disorders; African Americans Often Exhibit Significant General Coping Skills But Fewer Treatment Resources Than European Ameri- Cans (Walton, Blow, & Booth, 2001). There Is Some Evidence That Substance Abuse In European Americans May Be Associated With Greater Underlying Psychopathology, Whereas African Americans May Have Greater Social And Environmental Factors. Early Initiation Of Sexual Activity May Be Predictive Of Later Substance Abuse In African Americans (Stanton Et Al., 2001). Illicit Drug Use Historically, A Greater Proportion Of Blacks Abstain From Illicit Drug Use Than Do Whites. This Difference Is Especially Pronounced In 12- To 25-Year-Olds. However, Public Databases Such As The Client Data Acquisition Process And Drug Abuse Warn- Ing Network (Dawn; 2012) Suggest That Blacks And Hispanics Are Overrepresented In Categories Of Heroin And Cocaine Use. Since The 1980S, We Have Seen Up-And-Down Patterns Of Perceived Harm Among High School Students. However, Data Still Show A Higher Overall Prevalence Of Illicit Drug Use In Blacks (10.5%) Versus Whites (9.5%) (Nsduh: Substance Abuse And Mental Health Services Administration, 2014). Higher Rates Of Marijuana And Cocaine Use Account For The Difference. In The 1998 Nhsda Survey, Blacks Had Higher Prevalence Of Marijuana (5 Percent V. 6.6 Percent) And Cocaine (0.7 Vs. 1.3%) (Nhsda, 2000). The Gap Between Whites' And Blacks' Adolescent Marijuana Use Has Disappeared. Blacks Have Higher Rates Of Marijuana Use By Age 20 (Reardon & Buka, 2002). Also, Emerging From Epidemiological Studies Is A Somewhat Higher Concentration Of Heroin Use Among Blacks Compared To Whites. The Nsduh: Substance Abuse And Mental Health Services Administration (2014) Indicated That Past-Month Use Of Any Illicit Drug Is Higher For Whites Between Ages 12 And 25, And Higher For Blacks From Age 26 And Up. As With Alcohol, Illicit Drug Use Appears To Take A Greater Toll On African Ameri- Cans' Health, As Measured By Emergency Department Data. African Americans Are Overrepresented, As A Percentage Of The Population, In Emergency Department Vis- Its. European Americans Represent 50% Of Emergency Department Visits For Illicit Drugs Compared To 30% For African Americans And 11% For Hispanics (Dawn, 2010). However, Dawn Data Are Derived From Large Cities, Where African American 356 Iv. Special Populations Populations Are Proportionally High And May Represent An Overrepresentation Of Emer- Gency Department Visits. African Americans Are More Likely Than European Ameri- Cans To Be Treated And Released Rather Than Hospitalized. The 2010 Nhsda Survey Indicated That Cocaine Is The Primary Drug Leading To The Emergency Department Visits For African Americans. African Americans Are Also Overrepresented In The Medical Examiners' Morbidity Data. They Account For 30% Of Drug-Related Deaths, While Mak- Ing Up 23% Of The Population Of The Cities Surveyed In Dawn. Cocaine Is The Most Frequent Cause Of Death (48.5%), Followed By Heroin And Morphine. Much Of The Data About Hard Core Drug Use Comes From Similar Information Derived From Public Facilities. These Data May Seriously Underestimate The Persons Who Obtain Alternative Treatment For Medical And Psychosocial Problems. Literature Reviewed By Brown, Alterman, Rutherford, Cacciola, And Zaballero (1993) Suggests That Correlates Of Heroin Abuse May Be Educational Impairment, Poor Employment History, History Of Legal Problems (Including Incarceration), And Possibly Psychiatric Problems. African Americans Appear To Be More Closely Scrutinized In Primary Care Settings In Terms Of Treating Pain (Becker Et Al., 2011). Differences Exist Between African Americans Requesting Buprenorphine Vs. Methadone And Presenting For Public Sector Treatment. Women And People Who Are Less Likely To Inject, Prefer Buprenorphine (Mitchell Et Al., 2011). A National Sample (Kandel & Davies, 1991) Indicated That Early Sexual Intercourse Was Associated With Elevated Lifetime Cocaine Use Among All Ethnic Groups; And That Cocaine Use Correlates With Daily Marijuana Use (Defined By Use At Least 20 Times In The Last 30 Days). Low Condom Use Among Cocaine, Marijuana, And Alcohol Abusers May Be A Risk Factor For Hiv Among African Americans (Timpson, Williams, Bowen, & Keel, 2003). Cocaine Use Contributes To Intracerebral Bleeds, Renal Failure, Chest Pain, And Myocardial Infarctions. In Addition, The Severity Of Asthma Exacerbation, With Drug Use, Seems To Be Worse In African Americans (Rome, Lippmann, Dalsey, Taggart, & Pomerantz, 2000). Several Groups Are Also Studying Strategies To Decrease Cigarette Smoking In African Americans (Okuyemi, Ahluwalia, Richter, Mayo, & Resnicow, 2001; Ahluwalia, Harris, Catley, Okuyemi, & Mayo, 2002). A Coarse Reading Of This Literature Might Imply That There Is Some Intrinsic Nature To The Ethnic Groups That Accounts For Differences In Patterns Of Drug Use. Lillie- Blanton, Anthony, And Schuster (1993) Regrouped Participants According To Neigh- Borhood Rather Than Race Or Ethnicity, Holding Constant Social And Environmental Risk Factors That Likely Influenced The Racial Comparisons And Applied This Design To The Apparent Differences In Crack Cocaine Use Among European Americans, Hispan- Ics, And African Americans. This Interesting Analysis Revealed That The Odds Ratios Did Not Vary Significantly Among The Ethnic Groups. Being African American Did Not Place Individuals At Higher Risk For Crack Use. Though This Analysis Does Not Refute The Epidemiological Findings Of The Study, It Does Suggest That The Apparent Differences May Be More A Product Of Social Conditions, Including Availability Of Drugs, Than Issues Intrinsic To Ethnicity. Drug Trafficking, Often Concentrated In Minority Neigh- Borhoods, Is A Risk Factor For Use. Among African American And European Americans, There May Be Differences In Mu Receptor Polymorphisms (Crowley Et Al., 2003). However, Strong Evidence Has Yet To Established That These Gene Findings Are Associated With Actual Drug Use (Kranzler 17. Substance Abuse In Minority Populations 357 Gelernter, O'malley, Hernandez-Avila, & Kaufman, 1998). One Report Indicated No Association Between Particular Dopamine Receptor Alleles And Cocaine Dependence In African Americans (Gelernter, Kranzler, & Satel, 1999. Negative Findings Have Also Been Reported For The Association Between Serotonin Transporter Polymorphisms And Aggression In African Americans With Cocaine Dependence (Patkar Et Al. 2002). One Study Indicated No Increased Genetic Risk For Addiction In Persons With African Heri- Tage (Ducci Et Al., 2009). The "War On Drugs" And Other Pressures Have Resulted In Overrepresentation In Jails And Prisons Of African Americans Arrested For Drug-Related Charges (Wood, Werb, Marshall, Montaner, & Kerr, 2009). Inequalities In Criminal Sentencing May Indicate Subtle Racism. For Example, The Differential Sentencing For Crack Cocaine Use, Which Is More Prevalent In African American Communities Than Powder Cocaine, Has Been A Matter Of National Debate. Recent Laws Have Been Enacted To Mitigate Some Of These Disparities In Sentencing. Prevention And Treatment Issues Access To Treatment Is A Problem For African Americans (Zule Et Al., 2008). There Is Low Retention Of African-American Youth In Clinical Research Trials (Magruder, Ouyang, Miller, & Tilley, 2009). Some Argue That Prevention And Treatment Of Sub- Stance Abuse And Hiv In African American Communities Must Recognize And Address Institutional Racism, Sociopolitical Exploitation, Patterns Of Drug Distribution, Limited Employment Opportunities, And African Americans' Coping Strategies (Agar & Reis- Inger, 2002). Gainful Employment Is A Particularly Powerful Intervention. Neighbor- Hood Poverty In African Americans, Compared To That In European Americans, May Have A Greater Impact On Sense Of General Well-Being (Ludwig Et Al., 2012). Neigh- Borhood Perception Of Lack Of Safety And Negative Peer Effects Can Increase Risk For Depression And Drug Use (Zule Et Al., 2008; Reitzel Et Al., 2012; Fite, Wynn, Loch- Man, & Wells, 2009). Many In The African American Community Stress The Issues Of Self-Help And Community Empowerment To Combat Divisive Elements Leading To Drug And Alcohol Use. As A Result, Network Therapy May Have A Particular Role In More Distressed Communities. In A Large Veterans Administration (Va) Residential Study, African Americans Had Similar Rates Of Program Participation But Tended To Do Better In Aftercare Programs With Greater African American Staff Presence (Rosenheck & Seibyl, 1998). Friedman And Glassman (2000), Using Data From The National Collab- Orative Study, Found That Social And Peer Relationship Problems Predicted 18.8% Of The Variance For Future Substance Use In An Urban Adolescent Population. Standard Treatment Approaches Are Certainly Effective For African Americans. In A National Institute On Drug Abuse (Nida) Clinical Trials Network Random- Ized Controlled Trial (Rct) Of Motivational Enhancement Therapy, African American Women Fared Better Than African American Men (Montgomery, Burlew, Kosinski, & Forcehimes, 2011). Several Rcts Have Shown That Cognitive-Behavioral Treatment And Other Smoking Cessation Techniques Are Effective With African Americans (Webb, 2008; Webb, De Ybarra, Baker, Reis, & Carey, 2010). One Study, However, Indicated That The Combination Of Bupropion, Nicotine Patch, And Counseling Was Less Effective In African Americans (Covey Et Al., 2008), And Another Indicated Negative Effects 358 Iv. Special Populations For The Use Of Varenicline In African American Smokers (Nollen Et Al., 2011). In Both Clinical And Laboratory Studies, The Use Of Naltrexone To Decrease Alcohol Consump- Tion May Be Less Efficacious In African Americans (Ray & Oslin 2009; Plebani, Oslin, & Lynch, 2011). African American Adolescents Maybe Disproportionately Referred To Restrictive Environments For Treatment In Comparison To European American Adoles- Cents (Feaster Et Al., 2010). Pro-Black Attitudes And Awareness Of Racial Oppression Have Been Associated With Negative Substance Use Attitudes (Gary & Berry, 1985). Strong Ethnic Identity May Protect Against Substance Abuse And Should Be Incorporated Into Treatment Programs, Especially For Adolescents (Longshore, Grills, & Annon, 1999). However, James, Kim, And Armijo (2000) Reported A Positive Association Between High Levels Of Cul- Tural Identity And Heavy Drug Use. Culturally Sensitive Interventions Have Been Shown To Enhance Getting People Into Treatment And Improving Outcomes (Dushay, Singer, Weeks, Rohena, & Gruber, 2010; Longshore Et Al., 1999). There Is No Question That The Standard Treatment Approaches Highlighted In The Rest Of This Book Can Readily Be Applied To All Ethnic Groups. Standard Cognitive-Behavioral Treatments Have Been Shown To Be As Effective For African Americans As For European Americans (Milligan, Nich, & Carroll, 2004). Computer-Based Prevention Strategies Have Also Been Found To Be Effective For African American Girls (Schinke, Fang, Cole, & Cohen-Cutler, 2011). Misdiagnosis Of Psychiatric Comorbidities In African Americans Can Limit Treat- Ment Effectiveness (Baker & Bell, 1999). There Is An Association Between Substance Abuse And Suicide In African Americans, But It May Be Less Robust Than In European American Men (Garlow, 2002). The Core Features Of Loss Of Control And Compulsivity That Characterize A Drug Abuser Or Alcoholic Are Not Dissimilar Between Ethnic Groups. However, As We Continue To Tailor Treatment To Individuals, Racial And Cultural Factors Have To Be Addressed. Should Programs In Primarily African American Communities Be Especially Designed To Promote Cultural Sensitivity? In Some Sense This Goes On Naturally; The Feel, Look, And Language Of An Alcohol Anonymous (Aa) Meeting In An African American Community Is Different From That In A European American Self-Help Group. Aa Had Its Beginnings In The Oxford Movement And Was Initially For Middle-Class European Americans. However, The Church And Spiritual Dimensions Of African American Life Are Integral Aspect Of Black Culture, And It Is Not Surprising That Aa Has Been Success- Fully Transplanted To The Black Community. There Have Been Attempts To Develop And Describe Culturally Sensitive Mental Health Facilities (Deitch & Solit, 1993; Rowe & Grills, 1993). These Attempts Often Are Trapped In A Quagmire Of Definitions Of Cul- Ture, Race, And What Is Crucial To A Culturally Relevant Program. Culturally Relevant Programs Might Promote Positive Racial And Cultural Identity, Enhance Self-Esteem, Increase Self-Determination, And Appreciate Traditional African American Values. Afrocentric Values Stress Relationships, Verbal Fluidity, Emotional Expressiveness, And Spirituality. A Study Of Substance Abuse Programs, Using The National Drug Abuse Treatment System Survey, Suggests That Culturally Competent Treatment Is Holistic, Emphasizing Employment, Spiritual Strength, And Physical Health (Howard, 2003). Programs That Hire Staff Members Who Mirror The Patients' Ethnic Background May Minimize Racial Bias. In Addition, Knowledge Of African American History And Culture 17. Substance Abuse In Minority Populations 359 Is A Component Of A Culturally Competent Program (Howard, 2003; Reizel Et Al., 2012). Research Questions Related To Primary Hypotheses That Especially Address Ethnic Concerns Are Needed. There May Be Dimensions To An All-Black Treatment Program That Go Beyond Variables Currently Thought To Be Important. Blacks' Ethnic Biologi- Cal Differences, If Any Exist, Need Further Work. Differences In Health Outcome And Possibly Medication Responses Need Further Consideration. The Issue Of Matching Or Nonmatching Of Therapist Or Patients Along Racial And Ethnic Dimensions Has Been A Subject Of Considerable Discussion In Mental Health And Has A Role In The Substance Abuse Field. Matching Of Racial And Cultural Attributes Between Therapist And Client May Enhance Empathy Or In Some Cases Result In An Overidentification With The Client On The Part Of The Therapist. Empathy And Respect Of Others' Cultural Norms Are Essen- Tial Components Of Any Discussion Of Cultural Sensitivity. Substance Abuse Among Hispanic Americans Hispanics Comprise A Heterogeneous Group, Including Mexican Americans, Puerto Ricans, Cuban Americans, And Others. As With Other Ethnic Groups, A Greater Num- Ber Of Hispanic Men Drink Alcohol And Use Drugs Than Do Hispanic Women. Mexi- Can American Men Were More Likely To Abstain Than Other Hispanic Men. However, They Drank More Heavily And Reported More Alcohol-Related Problems. The "Preven- Tion Paradox" Is That Binge Drinkers Who Drink More Moderate Amounts, On Whole, Cause More Public Health Problems Than The Smaller Percentage Of Hispanics Who Drink More Heavily (Caetano & Mills, 2011). This Observation May Have Important Public Health Consequences. The Mexican Americans Living Near The Mexico-U. S. Border May Have Higher Rates Of Drinking Compared Other U. S. -Mexican Residents (Maldonado-Molina And Delcher 2012, Caetano, Mills, & Vaeth,. 2012). All His- Panic Groups, With The Exception Of Cubans, Have Twice The Rate Of Liver Cirrhosis Compared To European Americans (Stinton, 2001; Yoon, Yi, & Thomson, 2011). Puerto Rican Men Have The Highest Prevalence Of Illicit Drug Use (10%) Versus Mexi- Can Americans (5%) (Nsduh: Substance Abuse And Mental Health Services Admin- Istration, 2011). Self-Reported Rates Of Drinking And Driving Are Highest In Hispan- Ics And European Americans (Caetano & Clark, 2000). Also, Latinos And African Americans Have Higher Rate Of Overdose Deaths. Cuban Men Had Fewer Abstainers, A Smaller Proportion Of Heavy Drinkers, And Fewer Alcohol-Related Problems. Drinking Increases With Education And Income For Both Sexes (Caetano, 1989). Although His- Panic Men Have Higher Rates Of Injection Drug Use (Idu), In Hispanic Men Idu Is In Decline (Pouget, Friedman, Cleland, Tempalski, & Cooper, 2012). In New York City, Cocaine And Opiate Positive Urine Results In Victims Of Firearms Deaths Are Highest In Latino Men (Galea, Ahern, Tardiff, Leon, Vlahov, 2002). Illicit Drug Use And Alcohol Use Disorder According To The 2010 Nhsda For All Age Groups Except 12-17, Hispanics Had The Fewest Members In The "Ever Used Any Illicit Drug" Category As Compared To European 360 Iv. Special Populations Americans And African Americans. Hispanics Were More Likely To Binge-Drink And Use More Heavily. Caetano And Medina-Mora (1990) Compared The Drinking Pat- Terns Of Mexican Americans And Mexicans Living In Mexico. A More Permissive Atti- Tude About Alcohol Use Is Associated With Acculturation (Myers Et Al., 2011). Alcohol Use Increased With Acculturation In Mexican Men And Woman. However, Mexican Americans Reported Fewer Alcohol-Related Problems Than Did Mexican Men Living In Mexico. Data Derived From The 2005 National Alcohol Survey, Which Represented Predominately Mexican Americans, Indicated That High Acculturation Is Associated With Drinking Only In Men With Higher Incomes (Karriker-Jaffe & Zemore, 2009). Acculturation Effects Families, Which Has Impact On Adolescent Mental Health And Substance Abuse (Buchanan & Smokowski, 2011). First-Generation Hispanic Youth Have Been Reported To Have Lower Rates Of Driving Under The Influence (Dui) Compared To Second- And Third-Generation Hispanic Youth (Maldonado-Molina, Reingle, Jen- Nings, & Prado, 2011). Perceived Discrimination Toward Mexican-Born Adolescents In The United States Is Associated With Increased Substance Abuse And Permissive Atti- Tudes (Kulis, Marsiglia, & Nieri, 2009). Positive Parent-Child Attachment, Peer Influ- Ence, And Strong Ethnic Identification May Be Mitigating Factors (Kopak, Chen, Haas, & Gillmore, 2012; Prado Et Al., 2009; Ndiaye, Hecht, Wagstaff, & Elek, 2009). For Mexican Women Born In The United States, Abstention Rates Steadily Decreased And Rates Of Infrequent Drinking Steadily Increased With Acculturation. This Pattern Is Not Seen In Mexican-Born Women Living In The United States (Caetano & Medina- Mora, 1990). Hispanic Women In Women-Only Treatment Centers Report Greater Men- Tal Health And Criminal Justice Problems On Admission (Hser, Hunt, Evans, Chang, & Messina, 2012). Similarly, In South Florida, U. S.-Born Hispanic Young Adults Have Increased Rates Of Substance Abuse And Mental Health Problems Compared To Hispanic Immigrants. In The National Latino And Asian American Study, U. S.-Born Mexicans Had Higher Rates Of Mental Health Disorder Compared To Cubans And Other Immigrants (Alegria Et Al., 2008). Substance Abuse Comorbidity In Latinos With Schizophrenia Is Related To U. S. Immigration Status, Depression, And Unemployment (Jiménez-Castro Et Al., 2010), Although Latinos' Overall Rates Of Dual Diagnosis Are One-Fourth Lower Than That Of The General U. S. Population (Vega, Canino, Cao, & Alegria, 2009). Inhal- Ant Use Is Reported To Be High Among Hispanic Youth In Southwestern Border States. Polymorphism Of The Alcohol Dehydrogenase 2 Gene And P450 2E1 Has Been Reported To Contribute To Development Of Alcoholism In Mexican American Men (Konishi Et Al., 2003). Treatment Issues Among People Of Need, Hispanics And African Americans, Compared To European Americans, Have Greater Unmet Need For Alcohol And Drug Abuse Treatment. Hispan- Ics Receive Active Treatment 22.4% Of The Time And African Americans, 25%, Versus European Americans, 37%. One Study Using Data From The 2005 U. S. National Alco- Hol Survey Reported That Latino Women Have Particular Problems With Treatment Underutilization That May Be Related To Greater Sense Of Stigma (Zemore, Mulia, Yu, Borges, & Greenfield, 2009). In The State Of Massachusetts, Latinos Are One-Third Less Likely To Enter Residential Treatment (Lundgren, Amodeo, Ferguson, & Davis, 2001). 17. Substance Abuse In Minority Populations 361 Hispanics, Despite Higher Intravenous Drug Use Compared To European Americans, Enroll Less Often In Methadone Maintenance, And This May Be Partly Related To Greater Shame Associated To Methadone Use In Hispanic Men (Zaller, Bazazi, Velazquez, & Rich, 2009). In Los Angeles County, Guerrero, Cepeda, Duan, And Kim (2012) Found That Cubans And Puerto Ricans Used More Opiates And Cocaine Compared To Other Latinos, And Despite Being More Educated, Were Less Likely To Complete Substance Abuse Treatment. Language Can Be The Most Concrete Barrier To Adequate Treatment For Hispanics In Communities Without Adequate Spanish-Speaking Facilities. However, Cultural Sensitivity Is Not Guaranteed By Just Speaking The Language. Tools Have Been Developed To Assess The Overall Cultural Competency Of Treatment Centers For Hispanic Clients (Shorkey, Windsor, & Spence, 2009). In A Secondary Analysis Of Data From The Clinical Network's Motivational Enhancement Therapy Trial, Suarez-Morales Et Al. (2010) Found That Client-Therapist Matching Of Birthplace And Acculturation Did Not Make A Difference In Outcome. Language Matching Had A Modest Effect For Alcohol Abusers Only (Carroll Et Al., 2009). Spanish-Speaking Male Staff Must Also Be Able To Treat Female Clients With Respect And Sensitivity To Sexual, Family, And Childrearing Issues. A Number Of Authors (E. G., Szapocznik & Fein, 1995) Identify Family Issues As Being Perhaps The Most Important Component Of Addiction Treatment Of Hispanic Clients. Gfroerer And De La Rosa (1993) Found That Parents' Attitudes And Use Of Drugs, Licit Or Illicit, Played An Important Role In The Drug Use Behavior Of 12- To 17-Year-Old Hispanic Youth. Parents Need To Be Informed Clearly And Honestly About Their Influ- Ence. Also, The Role Of Family Should Be Well Understood By Treatment Staff. Each Fam- Ily Member Has A Function Within The Family. If Properly Educated, The Family Members Can Each Provide Support Using Their Already Established Role. Some Of The Traditional Roles According To Langrod Et Al. (1981) Are To Esteem Older Adults For Their Wisdom, The Father For His Authority, The Mother For Her Devotion, And Children For Their Future Promise. Denial Of Alcoholism May Be Extensive In Hispanic Fathers Who Drink Only On The Weekend And Fulfill Work Obligations. Szapocznik And Fein (1995) Include The Cultural Tradition Of Interdependence With Extended Family Made Up Of Uncles, Aunts, Cousins, And Lifelong Friends. Basically, The Functional Family Does Include Any Person Who Has Day-To-Day Contact With And A Role In The Family. The Family Is An Important Resource And Must Be Integrated Into The Treatment. Substance Abuse Among Asian Americans People Of Asian Heritage Make Up Nearly 4.8 % Of The U. S. Population According To U. S. Bureau Of The Census (2011). The Largest Group Is Chinese Americans (22.8%), Followed By Asian Indians (19.4%), Filipinos (17.4%), Koreans (9.7%), And Vietnam- Ese (10.6%); Japanese As A Group Constitute 5.2%, Although Counted As Mixed With Other Races, The Japanese Are 13.9%. Countries Of Asian Immigration Include Mon- Golia, Pakistan, Nepal, Bangladesh, Burma, Thailand, Cambodia, Malaysia, And Sin- Gapore, And Others. Many Languages, Cultures, And Political Systems Are Represented. Most Of The World's Major Religions Are Represented, Including Buddhism, Hindu- Ism, Judaism, Christianity, And Islam. These Religions Have Varying Views Regarding 362 Iv. Special Populations Alcohol Use. Alcohol Use Is Prohibited In The Moslem Teachings. Hinduism And Bud- Dhism Suggest Avoidance Of Alcohol And Other Mind-Altering Substances. The Judeo- Christian Perspective Is More Lenient And Incorporates Alcohol Use Into Some Reli- Gious Ceremonies. These Views Affect The Way The Society, The Family, And The Problem Drinker Deal With The Concept And Acceptance Of Alcoholism. The Acceptance And Availability Of Treatment For Individuals Also Have An Impact. The Well-Described "Flushing " Reaction In Some Asian People Has Been Linked To Variations Of Aldehyde Dehydrogenase Isoenzymes. The Reaction Occurs Because Of A Limited Ability To Degrade Acetaldehyde To Acetic Acid. The Toxic Acetaldehyde Is Responsible For The Flushing, Headache, Nausea, And Other Symptoms With Alcohol Use That Are Estimated To Occur In 47-85% Of Asians (U. S. Department Of Health And Human Services, 1993). This Was Thought To Explain The Lower Rates Of Alcohol Abuse Among Asians. The Aldh2*2 Allele Has Been Found To Be Protective Against Experiencing Alcohol-Related Blackouts In Asian American College Students (Luczak Et Al., 2006). However, Studies Have Shown That Sociocultural Factors Also Play A Substantial Role In Alcohol Use Within This Population (Johnson & Nagoski, 1990; Newlin, 1989). Some Databases On Alcoholism In Ethnic/Minority Populations Do Not Include Information On Asian Americans. The Epidemiologic Catchment Area (Eca) Study Placed Asian Americans In The "Other" Category. Two National Studies That Do Survey Asians As A Specific Category Are Dawn And Nhsda (National Institute On Drug Abuse, 1990). The Percentage Of Past-Month Use Among Asian/Pacific Islanders Is 2.8%, The Lowest Among The Major Ethnic Groups. The 1-Month Prevalence In Native Hawaiians And Other Pacific Islanders Is 6.2% Versus Asians At 2.7%. However, The Korean Subgroup Of Asians Has A 6.9% Prevalence Rate, Similar To African Ameri- Cans. Groups Of The Same Ethnic Origin That Live In Different Regions Of The Country Can Manifest Different Risk Factors For Abuse (Kim, Kim, & Nochajski, 2010). The Avail- Able Research Literature Is Mostly Described As Community Based Or It Pertains To Spe- Cific Subgroups Within The Asian American Community, Such As Students. Given These Limitations, A Number Of Studies Indicate That There Is Significant Variation In Drink- Ing Patterns Among The Different Asian Groups. There Is Some Evidence That Rates Of Heavy Drinking Is Higher For Filipino Americans And Japanese Americans, Followed By Korean Americans And Chinese Americans: 29.0, 28.9, 25.8, And 14.2%, Respec- Tively (Kitano & Chi, 1989). The Breakdown By Sex Found Heavy Drinking In 11.7% Of Japanese Women, 3.5% Of Filipino Women, And 0.8% Of Korean Women, Whereas Chinese Women Registered Near Zero. Filipinos Who Self-Report Unfair Treatment In The United States Report More Illegal Prescription Drug And Alcohol Abuse (Gee, Delva, & Takeuchi, 2007). Asian American Alcohol Abuse Has Been Associated With Reported Unfair Treatment And Low Ethnic Identification (Chae Et Al., 2008) A More Recent Study Of 1,575 Asian American College Undergraduates Indicated That Japanese Students Had The Highest Rate Of Alcohol Binging, Followed By Filipino, Korean, And Chinese Students (Iwamoto Et Al., 2012). Asian American Drug Users, Once Identified, May Have More Persistent Drug Use Disorders Compared To Non-Hispanic Whites (Xu Et Al., 2011). Interestingly, There Is A Japanese Aa-Like Organization Called The All Nippon Sobriety Association. 17. Substance Abuse In Minority Populations 363 Potential Treatment Problems In The Asian American Community Begin With The Lack Of Acceptance Of Alcoholism And Drug Addictions As Treatable Illnesses. Ja And Aoki (1993) Wrote About The Typical Chain Of Events In The Life Of An Intact Asian Family When Substance Abuse Begins To Appear. Often Substance Abuse Problems Are Ignored Or Denied With The Hope That They Will Disappear. Also, The Family Will Make Efforts To Conceal It From The Community To Avoid Embarrassment And Shame. Pre- Vention Or Early Treatment Is Unlikely In This Family And Community Dynamic. When Denial Is Overwhelming, The Family Breaks Down And May Resort To Shaming And Other Attempts At Punishment. The Family May Also Turn To Extended Family Mem- Bers And Elders, Basically Moving Gradually Outward From The Nuclear Family To The External Community. There Is A Deep Sense Of Failure On The Part Of The Family By The Time Members Resort To Outside Professional Help. It Is Not Uncommon At This Point To Have The Family Members Completely Turn Over The Alcoholic Or Addict And Resist Participation Themselves. The Client Is Often Still In Denial And Resistant To Treatment Until An Alliance With Staff Is Facilitated. As With Other Ethnic Groups, When Culturally Competent Care Is Available, Service Utilization Improves (Yu, Clark, Chandra, Dias, & Lai, 2009). Asian Americans Represent 1.3% Of Patients In Publicly Funded Treatment Enter- Ing Treatment For The First Time; Stimulants Are The Major Drug Of Abuse (Wong & Barnett, 2010). New Treatment Approaches Have Been Shown To Be Adaptable To Asian Americans. A Family Web-Based, Mother-Daughter Substance Abuse Prevention Pro- Gram Has Been Reported To Be Efficacious (Fang, Schinke, & Cole, 2010). There Are Many Alternative Medicine Treatment Approaches, Such As Traditional Herbs And Acu- Puncture. Some Alternative Treatments Have Shown Scientific Promises; Others Have Not (Lu Et Al., 2009). Treatment Barriers Begin With Ignorance About The Actual Extent Of Drug And Alcohol Problems In The Asian American Community. Asians Are Thought Of By Many As Model Immigrants. The 1960S Brought In A Large Wave Of Educated And Skilled Asian Professionals. Migration Since The 1970S Has Resulted In People With Less Educa- Tion And Fewer Language And Work Skills Immigrating To The United States (Varma & Siris, 1996). Many Of Them Entered As Refugees From War-Ravaged Countries. Poverty, Overcrowded Domiciles, Discrimination, And Other Social Problems Are Present In The Lives Of Asian Americans; However, Documentation Of These Problems Is Sparse. This Notion Of "Model" Immigrant May Be Hurting The Asian American Community From Outside And Within. It Also Lends Itself To The Denial Within The Community And Ampli- Fies The Elements Of Shame And Embarrassment Felt By The Family. Better Documentation Of The Extent Of Drug And Alcohol Abuse In The Asian Amer- Ican Population, Ideally, Would Enhance The Funding For Culturally Sensitive Education And Treatment. Education At The Community Level Is Needed To Foster Awareness And Acceptance, And Assist In Prevention (Wooksoo, Isok, & Nochajski, 2010). Treatment Programs That Target Asian Americans Might Consider The Insular And Private Style Of The Asian American Family. Also Essential Is Recognition Of The Dominance Of The Family And Community Over The Psychological And Social Needs Of The Individual. An Acceptance Of These Differences Would Decrease Conflict Between The Family And Treatment Personnel. This Show Of Respect For Their Values May Facilitate The Family's 364 Iv. Special Populations Participation In The Treatment. A Treatment Goal For All Individuals Should Be Reinte- Gration Back Into The Family And Community, If At All Possible. Substance Abuse Among Native Americans American Indians Often More Appropriately Self-Identify As Native Americans And First Nations. There Are More Than 200 Native American Tribes That Have A Differen- Tial Use Of Illicit Substances. Studies Show That American Indian/Alaska Native Youth Have Twice The Prevalence Of Cigarette, Alcohol, Marijuana, And Cocaine Use Than Hispanics, Blacks Or Whites. Alcohol Abuse Is Recognized As A Significant Problem Among Native Americans. The Cage Questionnaire (Cut Down, Annoyed, Guilty, Eye-Opener), However, Has Not Been Particularly Useful In Native American Samples (Saremi Et Al., 2001). Conduct Disorder Has Been Found To Be A Significant Risk Factor For Alcohol Dependence In Navajo Indians (Kunitz, 2008). In A Michigan Monitor- Ing The Future Study, Native American Adolescents Had The Highest Levels Of Tobacco, Alcohol, And Illicit Drug Use (Wallace Et Al., 2002). The Fluctuating Pattern Of Drug Use Among American Indians Mirrors The Larger Adolescent Culture (Beauvais, Jumper- Thurman, & Burnside, 2008). Age Of First Onset Maybe A Particular Risk Factor For Alcohol And Drug Dependence In Native Americans (Kunitz, 2008). A Recent Study Indicates That Greater Income Supplements From Casinos May Lower Substance Abuse Risk In Native Americans Adolescents (Costello, Erklani, Copeland, & Angold, 2010). However, The Recent Increase In Indian-Owned Casinos Has Offered Not Only Monetary Opportunities But Also The Possibilities Of Increased Gambling And Substance Abuse. In A Large Inpatient Sample, Alaska Native Men And Women Had Earlier Onsets Of Alcohol Dependence (Hesselbrack, Hesselbrock, Segal, Schuckit, & Bucholz, 2003). American Indian/Alaska Native Youth May Also Participate In More Risky Behaviors (Frank & Lester, 2002) In References. The Morbidity And Mortality Weekly Report (Centers For Disease Control And Prevention, 2009) Found That The Highest Rate Of Suicides During Alcohol Intoxication Were Among American Indians/Alaska Natives (37%). Age-Adjusted Alcohol-Related Deaths And Years Of Potential Life Lost Are Significantly Higher Than Those In The General Population (Centers For Disease Control And Preven- Tion, 2008). Although The Alcohol Mortality Rate For Native Americans Was Three- To Fourfold The National Average, Recent Evidence Indicates That There Has Been A Decrease In Mortality Since 1969 (Burns, 1995). This Drop Seems To Be In Concert With The Dou- Bling Of Alcohol Treatment Services By The Indian Health Service In The 1980S. Illicit Drug Use Among Native Americans Is Less Clear Because Of Poor Data Avail- Able. The Use Of Hallucinogens Has An Important Role In Some Native American Reli- Gious Rituals. Peyote And Mescaline Has Been Use By Native American In Spiritual Exercises For Years But Can Have Toxic Effects, As Reported By Poison Control Cen- Ters (Carstairs & Cantrell, 2010). Increases In The P3 Component Of The Event-Related Potential Have Been Reported In Native American Cannabis-Dependent Users (Ehlers Et Al., 2008). The Heterogeneity Of Native American Cultures Is Plainly Evident And Fur- Ther Discourages Simplistic Discussions Of Indian Culture. The "Firewater" Myth States That Alcohol Introduced To Native Americans By White Settlers Produced Exaggerated 17. Substance Abuse In Minority Populations 365 Biological Effects In Such Persons. Garcia-Andrade, Wall, And Ehlers (1997) Found Less Subjective Intoxication Among Nonalcoholic Mission Indian Men With Greater Native American Heritage. The Same Researchers Implicate Alcohol Expectancy And Metabolism Rates As Possible Differential Effects Among Tribes (Wall, Garcia-Anrade, Thomasson, Cole, & Ehlers, 1996; Garcia-Andrade Et Al., 1997). Native Americans Share A Belief In The Unity And Sacredness Of All Nature. An Individual Or Ethnic Group May Be More Or Less Familiar With Its Own Culture. Con- Frontation Approaches, Successful To Many Anglo Programs, May Cause Native Ameri- Cans To Shy Away. Risk Factors For Alcohol And Drug Use In Native Americans Parallel Many Of The Same Issues Of Other Disenfranchised Groups. Attempts At Assimilation Of Native Americans, In The Context Of Isolation From Mainstream Opportunities, Has Contributed To Further Cultural Stress. Six-Month Remissions Rates From Alcohol Dependence Have Increased Significantly In Native American Communities, Reported To Be A High As 59% (Gilder, Lau, Corey, & Ehlers, 2008). Being A Woman, And Being Older And Married Are Associated With Better Outcomes. Traditional Healing Methods Are Treatment Tools In This Population And May Be Used Alongside Other Best Practices (Coyhis And Simonelli, 2008). More Local Intervention And Attention To Culturally Rel- Evant Treatment Is Needed (Dickerson & Johnson, 2011; Gone & Calf Looking, 2011; Gone, 2011). Interventions That Use Traditional Healing And Spirituality Combined With More Standard Cognitive-Behavioral Therapy And Contingency Management Mod- Els May Bridge The Best Of Both Worlds, Although Challenges Remain (Novins Et Al., 2011; Novins Et Al., 2012). Resistance To, And Mistrust Of Evidenced Based Medicine And Research Still Exists In These Communities (Larios, Wright, Jernstrom, Lebron, & Sorensen, 2011). Traditional Sweat Lodge Treatments Are Increasingly Being Used Again For Treatment. Heart Disease And Alcohol Use Beforehand Are Contraindicated For Sweat Lodge Treatment (Livingston 2010). In An Rct, Naltrexone Alone And With Sertraline Has Been Used Effectively In Rural Alaska Natives (O'malley Et Al., 2008). The Breakdown Of Native American Culture, A Factor That Allowed Alcohol To Take A Foothold, Has Been Reversing In Recent Years. Self-Determination And A Return To Tra- Ditional Spiritual And Healing Beliefs Have Helped Springboard Alternative Indigenous Models Of Alcohol And Drug Recovery.

Chapter 30: Motivational Interviewing

This Chapter Provides A Brief Overview Of The Counseling Style Known As Motivational Interviewing (Mi). Mi Is An Essential Skill For Clinicians, As It Provides A Way Of Work- Ing With Clients Who Are Ambivalent About Changing Their Behavior, Seeking Help, Or Following Treatment Recommendations—A Typical Scenario With Substance-Abusing Clients. As Clinicians, And Particularly As Physicians, We Are Trained To Take A History, Make A Diagnostic Assessment, Formulate A Treatment Plan, And Prescribe It To The Client (E. G., "I Recommend That You Stop Drinking And Attend Aa Meetings"). Unfor- Tunately, If This Client Is Struggling With Drinking (Wanting To Stop On The One Hand, But Wanting A Drink On The Other), Which Is Often The Case With Substance Dependent Clients, This Approach Is Not Likely To Engender Change. The Clinician-Client Interac- Tion Becomes A Standoff, Or, Worse, Confrontational ("Come Back When You Are Ready To Do Something About Your Problem"). It Is Frustrating For Both Parties—The Client Who Does Not Feel Understood, And The Clinician Who Does Not Know What Else To Do. Mi Provides A Way Of Talking With Clients That Is More Collaborative (As Opposed To Prescriptive Or Authoritative), More Conducive To Building A Treatment Alliance, And Ultimately A More Supportive Context For Change. Mi Is A Complex Skill That Cannot Be Fully Conveyed By An Overview. Ongoing Study, Training (E. G., Participation In Workshops), And, Ideally, Continued Supervision And Feedback Are Needed To Develop This Skill (De Roten, Zimmermann, Ortega, & Despland, 2013; Martino, Canning-Ball, Carroll, & Rounsaville, 2011; Miller & Rose, 2009; Miller, Sorensen, Selzer, & Brigham, 2006; Miller, Yahne, Moyers, Mar- Tinez, & Pirritano, 2004; Schoener, Madeja, Henderson, Ondersma, & Janisse, 2006; Smith Et Al., 2012). A Chapter Like This One Provides An Introduction And Encourages 629 630 V. Treatments For Addictions The Reader To Pursue Further Training. Readers Are Encouraged To Study The Work Of Miller And Rollnick (1991, 2002, 2013), Which Presents More In-Depth Discussions Of How Mi Was Developed, Its Implementation, And How It Can Be Utilized In Different Clinical Contexts. Detailed Descriptions And Guidelines For Implementing, Mentoring, And Supervising Mi In Clinical Settings Are Provided In The Manual, Motivational Interviewing Assessment: Supervisory Tools For Enhancing Proficiency (Mia: Step; Martino Et Al., 2006). Internet-Based Resources Can Be Accessed On, For Example, The Websites Of Two Organizations, Each Promoting The Development And Dissemination Of Mi-Related Materials: The Motivational Interviewers Network Of Trainers (Mint; Motivationalinterviewing. Org) And The Center On Alcoholism, Substance Abuse, And Addictions At The University Of New Mexico (Casaa; Http://Casaa. Unm. Edu). Mi Was Originally Developed To Treat Nicotine And Other Substance Dependencies. However, It Is Equally Applicable To Supporting Other Psychiatric Or Medical Treat- Ments And Other Health Behaviors Related To Clients' Struggles With Changing Their Behavior (E. G., Diet, Exercise, Medication Adherence, Or Treatment Plan Adherence More Generally) (Hettema, Steele, & Miller, 2005). A Significant Challenge In The Substance Abuse Treatment Field Is Creating A Con- Text For Promoting And Maintaining Clients' Committed Action Toward Change. All Too Often, Clients And Professionals Embrace The Hopefulness Associated With The Initia- Tion Of A Treatment Episode Only To Experience The Disappointment And Frustration Of Clients' Broken Resolutions And The Resurgence Of Troubling Behaviors. The Change Process Is Often Characterized By Peaks And Valleys And By Periods Of Motivation For Change Interspersed With Periods Of Reverting To Old Behaviors. However, The Famil- Iarity Of This Changing Landscape Offers Little To The Clinician In Terms Of How To Effec- Tively Guide Individuals Attempting To Make A Behavior Change. A Conceptual Frame- Work That Elucidates The Factors That Influence The Change Process, And Highlights How They Are Manifested During Clinical Interactions, Can Provide An Important Clinical Lens For The Health Care Professional. Furthermore, The Utility Of Such A Conceptual Framework Is Best Demonstrated By How Well It Can Effectively Guide Clinician Behav- Ior To Influence The Outcomes Of Clinical Interactions. Mi, Which Has Been An Evolving Practice Over The Past Three Decades, Offers Such A Conceptual Framework For Understanding The Process Of Change And Recogniz- Ing Indicators Of A Client's Movement Toward Or Away From Change During Clinical Encounters. Mi Also Identifies Specific Skills A Clinician May Utilize To Facilitate A Cli- Ent's Movement Toward Change When Ambivalence About Behavior Change Is A Central Issue. Together, The Conceptual Framework Of Behavior Change And The Specific Mi Skills Can Provide Clinicians An Effective Mechanism For Guiding Clients During Their Pursuit Of Important Lifestyle Changes. In This Chapter We Provide An Overview Of The Mi Counseling Style. This Discus- Sion Will Highlight The Factors That Influenced Its Development, As Well As The Specific Elements That Define The Behavior Of A Clinician During An Mi Guided Clinical Interac- Tion. To Place Mi In The Broader Context Of Psychological Theories Of Motivation, We Touch On Some Of The Processes That May Account For The Effectiveness Of Mi. Fur- Thermore, We Outline Some Of The Important Parameters For Successfully Learning And Becoming Proficient In The Mi Counseling Style. 30. Motivational Interviewing 631 Mi Born Of Utility Rather Than Theory Traditional Conceptualizations Of Motivation And Treatment Failure Have Utilized The- Ories That Emphasize The Importance Of A Client's Dispositional Characteristics (Miller, 1985). This Class Of Theories Attributes Poor Motivation To Defense Mechanisms, Such As Denial, That Prevent An Individual From Seeing That He Or She Has A Substance Use Problem Or Needs To Change. Intervention Strategies From This Perspective View Moti- Vation For Change As Arising From Events That Override Or Undermine The Substance User's Elaborate Defense System. "Hitting Bottom," Or Experiencing A Significant Num- Ber Of Negative Substance-Related Events, Is Seen As A Process And As A Place From Which A Substance Abuser's Defense Systems Can Be Broken Down, And In Which He Or She May Recognize And Accept That There Is A Problem. In The Field Of Addiction Counseling, Confrontational Techniques Have Been Utilized To Accelerate The Disman- Tling Of Elaborate Defense Mechanisms. This Approach, Although Promoting Change For Some Individuals, Has Not Garnered Empirical Support Over Time (Miller, 1985; White & Miller, 2007). In Contrast, The Mi Counseling Style Was Initially Formalized By Examining And Drawing From The Characteristics And Styles Of Counseling That Pro- Mote Better Treatment Outcomes. Mi Differs From Traditional Confrontational Treat- Ment Approaches And Offers Guidelines For Interacting With Individuals In A Manner That Helps To Promote Treatment Engagement And Resolve Ambivalence About Change. Defining Mi Mi Is An Empirically Supported Counseling Style That Has Been Employed As A Stand- Alone Brief Behavioral Intervention, As Part Of Structured Interactions That Focus On The Provision Of Medical And Behavioral Feedback, And As A Precursor To Longer Term Treatment Programs (E. G., Brown & Miller, 1993; Burke, Dunn, Atkins, & Phelps, 2004; Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010; Miller & Rollnick, 2002, 2009, 2013; Rubak, Sandbaek, Lauritzen, & Christensen, 2005; Vasilaki, Hosier, & Cox, 2006; Wain Et Al., 2011). It Has Demonstrated Efficacy Across A Range Of Health Related Issues And Behaviors, Such As Managing Hypertension, Diabetes, And Reducing Illicit Drug Use (Burke, Arkowitz, & Menchola, 2003; Hettema Et Al., 2005; Rubak Et Al., 2005). Mi Has Been Described As A "Collaborative Conversational Style For Strengthening A Person's Own Motivation And Commitment To Change" (Miller & Rollnick, 2013, P. 12). More Technically, "Mi Is A Collaborative, Goal-Oriented Style Of Communica- Tion With Particular Attention To The Language Of Change. It Is Designed To Strengthen Personal Motivation For And Commitment To A Specific Goal By Eliciting And Exploring The Person's Own Reasons For Change Within An Atmosphere Of Acceptance And Com- Passion" (P. 29). While Mi Adopts A Person-Centered Therapeutic Stance, The Goal- Oriented Framework And The Special Emphasis On Change Talk Differentiate Mi From More Traditional Person-Centered Counseling Approaches. Miller And Rollnick (2013) Have Identified Four Processes Underlying Discussions About Change: Engaging, Focusing, Evoking, And Planning. "Engaging" Highlights 632 V. Treatments For Addictions The Process Of Developing A Helping Relationship. "Focusing" Is The Process By Which A Clear Direction Of Change Is Developed Or Clarified. Engaging And Focusing Occur In Many Clinical Consultations And Therapeutic Styles, And Are Not Unique To An Mi Approach. "Evoking" Is A Means Of Educing Change Talk, Recognizing It When It Occurs During An Interaction, And Skillfully Responding To It When It Is Present. Evoking Is Central To The Mi Approach. "Planning" Is What Happens When A Discussion About Change Transitions From Evoking An Individual's Motivation For Making Change To Developing A Specific Change Plan That Can Be Carried Out. The Mi Counseling Style And Skills Outlined In This Chapter Can Be Employed Throughout All Four Processes Of A Clinical Discussion (I. E., Engaging, Focusing, Evoking, And Planning). The Directional Components Of Mi Are More Evident During The Evoking Process. Prochaska And Diclemente's (1983) Transtheoretical Model (Ttm) Of Change, While Not Directly Related To Mi (Miller & Rollnick, 2009), Provides A Useful Heu- Ristic For Conceptualizing The Normative Process Of Change. It Describes The Process Individuals Go Through While Considering Change, Independent Of The Type Of Problem. Decisions About Change Can Be As Simple As "Do I Want To Go Back To School?" Or As Complex As "Can I Give Up Heroin Use?" For The Purposes Of Mi, It Is Helpful To Keep In Mind Where The Client Is In Terms Of Stages Of Change. This Frame Of Reference Can Help To Sensitize The Clinician To The Particular Process That May Be Most Applicable (E. G., Engaging Vs. Focusing Or Evoking). For Example, A Client In The Precontemplation Stage Is Not Yet Considering Change. During The Process Of Engagement, A Clinician Employ- Ing An Mi Style May Begin To Build A Treatment Alliance And Guide The Conversation Toward A Focusing Process That Explores The Client's Reasons For Attending The Con- Sultation. A Person In The Contemplation Stage May Already Be Experiencing A Lot Of Ambivalence, Which May Be Moved In The Direction Of Change By The Clinician During The Evoking Process. An Mi Style May Be Employed To Explore What Has Worked In The Past, To Evoke Change Talk, And To Support Self-Efficacy. Mi Is Intended To Help Guide Clients Toward Making A Commitment To Important And Personally Valued Lifestyle Changes. If Individuals Have Already Committed To Change Or Have Already Started To Make That Change, Mi Skills May Be Useful For Developing A Change Plan And Outlin- Ing The Steps Needed To Meet The Goals Of The Individual. However, It Should Be Kept In Mind That Commitment To Change Is A Dynamic Phenomenon And A Solidly Committed Client Today May Not Necessarily Feel The Same Tomorrow. Thus, The Clinician May Need To Revisit The Processes Of Focusing Or Evoking To Meet The Client Where He Or She Is At During Any Given Moment And Help Guide The Session Back To A Path Of Meaningful Change. While The Goals Of The Interaction May Vary Depending On The Client's Stage Of Change, The Mi Counseling Style Is Applicable Throughout All Four Processes. The Spirit And Principles Of Mi The Spirit Of Mi Is Fundamental And Defines The Overarching Context In Which A Clini- Cian Practices Mi Techniques. The Spirit In Which Mi Is Implemented Is What Defines The Mi Approach And Differentiates It From Being Merely A Collection Of Techniques. The Spirit Of Mi Also Dictates That The Clinician Ultimately Lets The Client Set The Goals 30. Motivational Interviewing 633 And That Mi Is Not Used In An Attempt To Manipulate The Client Into Doing What The Clinician Thinks Is Best. Mi Spirit Consists Of Four Interrelated Elements: Partnership, Acceptance, Compassion, And Evocation. Partnership An Mi Counseling Style Is Based On A Collaborative Partnership Between The Clinician And Client. From This Perspective, Clinician And Client Are Viewed As Each Possessing Valuable Expertise. It Is Through A Collaborative Process And Partnership With The Clinician That Clients Can Explore Their Reasons For Change And Utilize Their Expertise To Activate Their Own Motivation For Change. The Clinician Does Not Adopt An Expert Stance Or Communicate That He Or She Has The Right Or Best Answer. Instead The Clini- Cian Provides An Atmosphere That Is Conducive To Change Rather Than Coercive. The Collaborative Stance Of An Mi Clinician Is Best Exemplified In The Use Of Open Questions And Strong Listening Skills To Help Him Or Her Understand The World From The Client's Perspective. Acceptance Acceptance Stems From The Humanistic, Person-Centered Nature Of The Mi Counseling Style That Is Significantly Influenced By The Work Of Carl Rogers (Miller & Rollnick, 2013). This Element Of Mi Spirit Refers To The Clinician's Openness To What The Client Brings To The Interaction. Acceptance Consists Of Four Elements That Are Realized In The Clinician's View Of Others And In His Or Her Counseling Behaviors. First, From An Accepting Stance, The Clinician Views Clients As Being Fundamentally Trustworthy And Having Worth (I. E., Absolute Worth). Clinicians Do Not Counsel From A Place Of Judg- Ment Or Conditional Acceptance. It Is From A Place Of Genuine Acceptance That Mi Fosters A Context For Change. Second, The Expression Of Accurate Empathy Is Essential For Developing Good Rapport With A Client. To Be Empathic Is To Have An Appreciation Of Another's Perspective; It Does Not Mean The Clinician Necessarily Agrees With The Client's Perspective, Nor Does It Mean The Clinician Feels One Way Or The Other About The Person's Situation (I. E., It Is Not Sympathy). It Refers To An Objective Appreciation Of The Person's Perspective. It Takes A Very Nonjudgmental Stance To Be Truly Empathic. In Mi, Being Empathic Is Not Enough; It Is The Expression Of Empathy That Makes The Clinical Interaction So Moving. When The Clinician Can Accurately Summarize The Cli- Ent's Meaning From Verbal And Nonverbal Communication, The Client Is More Likely To Feel Understood And, In Turn, Develop Self-Understanding. Third, Acceptance Involves Respecting And Supporting A Client's Autonomy. Ultimately, It Is The Client Who Decides To Change, And An Mi Counseling Style Supports The Individual's Freedom To Choose. The Mi Counseling Style Does Not Coerce, Control, Or Force Change On An Individ- Ual. It Is Through The Process Of Explicitly Acknowledging An Individual's Freedom To Choose A Direction That Mi Reduces Defensiveness And Opens Up The Possibility Of Change. Finally, Mi Explicitly Acknowledges A Client's Strengths, Efforts, And Suc- Cesses. Affirming An Individual's Strengths And Efforts Distances An Mi Counseling Style From Counseling Strategies More Closely Aligned With Deficit Models. From The 634 V. Treatments For Addictions Deficit Perspective, Clinical Interactions Focus On Delineating Shortcomings And Fail- Ures, Then Attempting To Develop A Plan To Fix These Problems. The Aim Of Mi Is To Mobilize The Strength And Wisdom Assumed To Reside Within The Individual. Compassion The Clinician Utilizing The Compassion Component Of Mi Spirit Acknowledges That The Process Of Counseling Is Ultimately For The Client's Benefit, Not The Clinician's. The Clinician Explicitly Embraces The Commitment To Pursue What Is In The Best Interests Of The Client And Gives Priority To The Client's Needs. Thus, Mi Is Not Implemented As A Counseling Strategy To Influence An Individual's Behavior In Order To Meet The Goals Or Desires Of Others. Evocation Mi Embraces The Idea That The Individual Often Has The Motivation And Resources To Change Under The Right Circumstances (E. G., The Resolution Of Ambivalence). Thus, The Individual Is Not Deficient And Does Not Need Fixing. Instead, Mi Operates From A Strengths-Focused Perspective; The Resources And Motivation For Change Are Consid- Ered To Reside Within The Client, And The Clinician's Role Is To Evoke The Client's Wisdom And Motivation During Clinical Interactions. Discussions About Change That Draw On The Client's Own Perceptions, Goals, And Values Are Seen As Being Central To Enhanc- Ing Intrinsic Motivation To Change. Individuals Know What They Are Willing To Do And What They Are Not Willing To Do, What They Have Tried, And What Has Not Worked In The Past. Thus, While The Clinician Evokes The Client's Perspective, The Client Does Most Of The Talking And Builds His Or Her Own Case For Making Behavior Change. Mi Technique: Defining The Microskills Mi Spirit Defines The Therapeutic Stance, Overarching Context, Or Mindset Of The Clini- Cian Adopting This Counseling Style. The Technical Implementation Of Mi Is Character- Ized By The Strategic Use Of Several Communication Skills: Open-Ended Questions, Affir- Mations, Reflective Listening, And Summary Statements (Oars; Table 30.1). These Core Communication Skills Are Initially Employed During The Processes Of Engaging And Focusing. Once The Client Has Identified A Target Behavior (The Outcome Of The Focusing Process), The Oars Skills Are Utilized To Educe A Client's Motivation And Commitment To Change (Evoking Process) And To Develop A Change Strategy (Planning Process). Open‐Ended Questions Open-Ended Questions Have A Large Variety Of Potential Responses, As Opposed To Closed-Ended Questions That Have A Very Limited Number Of Answers (E. G., Yes Or No; Number Of Hours Sleeping; Number Of Days Using). Closed-Ended Questions Yield 30. Motivational Interviewing 635 Table 30.1. Microskills Of Motivational Interviewing Microskill Open-Ended Questions Affirmations Reflections Summaries Definition Questions With An Unlimited Set Of Possible Responses Clinician Statements Pointing Out Positive Behavior Or Trait Of Client Clinician Statements That Echo Client Statements And May Add Meaning To Client Statements Clinician Statements That Tie Together Important Points Or Themes Shared By Client Limited Information And Run The Risk Setting A More Passive Role For The Client Dur- Ing A Clinical Discussion. Open-Ended Questions Are Useful In An Mi Counseling Style Because They Garner More Information And Are More Likely To Invite The Client To Be An Active Collaborator During A Clinical Discussion. The Strategic Use Of Open-Ended Questions Can Help Guide A Discussion Toward What Is Particularly Important About Making A Change Or Help To Clarify The Client's Life Goals Or Values (E. G., "What Are The Most Important Reasons Why You Want To Stop Using?" Or "How Is Your Drug Use A Problem For You?"). Discussing The Discrepancy Between Where Clients Are In Their Lives, And Where They Would Like To Be, Can Help Build Intrinsic Motivation For Change And May Help To Guide Individuals Toward Resolving Their Ambivalence About Making A Commitment To Change. Affirmations Clinicians Adopting An Mi Counseling Style Strive To Support And Encourage Individu- Als Throughout The Process Of Change. "Affirmations" Are Statements That Accentuate The Positive, Help Build Self-Efficacy, And Acknowledge The Worth Of An Individual. Affirmations May Involve Pointing Out Something Positive An Individual Does, Even If It Is As Simple As Coming To The Appointment, And May Offer Hope And Support To Clients Considering Behavior Change. Clinicians Need To Be Sincere; An Affirmation Is Not A Patronizing Falsehood. A Good Affirmation Reflects Something The Clinician Has Observed Or Heard, Supports The Client's Autonomy, And Is Not A Value Judgment. For Example, "I'm Proud Of You For Getting A Clean Urine" Is Not An Affirmation But An Expression Of The Clinician's Judgment And It Exemplifies The Differential Between Clinician And Client. An Example Of An Mi-Consistent Affirmation Might Be "You've Really Worked Hard To Comply With Parole So That You Can See Your Children Again." It Is Easy To Neglect The Use Of Affirmations If The Clinician Tends To Think In Terms Of Problems And Solutions; However, Affirmations Can Help Clients See Their Own Poten- Tial For Change. For Example, An Individual Has Left An Abusive Relationship But May Ask, "How Did I Get Myself Into This?" The Clinician Can Choose To Affirm The Change: "You Got Yourself Out Of A Very Difficult Situation." It Is Important For Individuals To Hear And Take Away A Positive Message, So That They Continue To Strive For Positive 636 V. Treatments For Addictions Change. It Should Be Noted That Affirmations Are Not Used To Bypass Difficult Situa- Tions; If A Client Is Grappling With A Difficulty, It Should Be Not Overlooked In The Clini- Cian's Effort To Find Something To Affirm. It Is Up To The Clinician To Find A Therapeutic Balance Between Being Present With The Client And Affirming Strengths And Capacities The Client May Have Difficulty Recognizing In Him- Or Herself. Reflective Listening Listening Skills Are Fundamental To The Practice Of Mi. A Counselor Utilizes Reflective Listening To Develop A Deeper Understanding Of A Client's Perspective, To Help Clarify The Meaning Of What A Client Has Said, And To Guide The Discussion Strategically Toward The Resolution Of Ambivalence. There Are Two Levels Of Reflective Listening Statements: Simple And Complex. A Simple Reflection Can Be Either A Straight Repeat Or A Paraphrase Of What The Client Has Said. Simple Reflections Do Not Significantly Alter The Meaning Of What Was Said. Why Make Simple Reflections? Simple Reflections Demonstrate To The Client That The Clinician Is Listening And Offer The Client An Opportunity To Correct The Clinician, If The Clinician Misunderstood. A Client Is More Likely To Share Information If He Or She Feels Heard. Simple Reflections Can Also Serve To Set The Pace Of The Session; Simple Reflections Help To Slow The Client Down, Which Can Be Useful When Working With Manic Or Anxious Individuals. Clinicians Can Use Simple Reflections Throughout The Conversation To Make Certain That They Are "On The Same Page" As The Client. Complex Reflections Are Higher-Level Reflective Statements That Add To Or Change The Meaning Of What The Client Has Said In A Significant Way. There Are Several Differ- Ent Types Of Complex Reflection (Table 30.2). Complex Reflections Express Empathy; They Convey To The Client That The Clinician Understands At Perhaps A Deeper Level Than What Was Communicated By The Words The Client Used. Summary Statements Summarizing Allows The Clinician To Bring Together What The Client Has Said Over The Course Of A Discussion In A Meaningful, Effective Narrative. A Summary Statement Is A Particular Type Of Reflection That Encompasses More Of What The Client Has Said Than Just What Was In The Immediately Preceding Statement. Summaries Serve To Jux- Tapose Several Ideas Expressed By The Individual. As With Reflections, Summaries Are Useful For Keeping The Clinician And Client On The Same Page. Furthermore, They May Frame Things In A Way That Can Extend The Client's Understanding Of The Situation. For Example, A Summary Juxtaposing Some Of What The Client Has Said Regarding Sub- Stance Use, Along With Some Difficulties The Client Is Currently Experiencing, May Help The Client To See A Relationship Between Those Two Things. When Creating A Summary Statement, It Is Not Necessary To List Every Bit Of Information Discussed Over A Period Of Time. Bill Miller Describes The Summary As A Bouquet That The Clinician Presents To The Client, And The Flowers In The Bouquet Are Bits Of Information The Individual Has Shared Throughout The Session. An Example Of A Summary Might Be "You Are Con- Cerned About Your Increased Alcohol Use In Recent Weeks, And Also About The Fights You Have Been Having With Your Wife And About Your Boss Confronting You Over Days Missed At Work." 30. Motivational Interviewing 637 Table 30.2. Complex Reflection Examples Complex Reflection Continuing The Paragraph Metaphor And Simile Double-Sided Reflection Reflection Of Feeling Amplified Reflection Example The Clinician States The Next Thought Or Idea That The Client Has Not Yet Said. For Example, If The Client Has Finished Talking About A Troubling Interaction With A Significant Other, The Clinician Could Continue The Paragraph And Say, "That Conversation Really Upset You And Almost Served As A Trigger For Relapse, Which Was Scary For You." This Is Done To Lead The Client To See Connections Between Emotions And Behaviors. The Clinician Might Say, "It Seemed As Though The Rug Was Pulled Out From Under You." Metaphors May Convey To The Client That The Clinician Has Heard Beyond The Client's Words, To The Client's Meaning. A Double-Sided Reflection Is A Type Of Complex Reflection That Contains Two Ways Of Thinking Or Feeling In One Statement: "On The One Hand, The Alcohol Helps You To Sleep, And On The Other Hand, You Wake Up Groggy And Confused Every Day." This Is Done To Reduce Ambivalence. Or "On The One Hand, You Feel You're A Good Son, And On The Other, You've Taken Your Parent's Meds." This Is Done To Highlight The Discrepancy Between Values And Behaviors. This Involves Describing Emotions And Other Feelings That That Client Has Not Yet Stated Directly. Many Clients Do Not Readily Identify Their Feelings, Perhaps Because They Are Reluctant To Admit Their Emotions Or Because They Are Unaware Of Their Emotions. For Example, The Client May Describe A Number Of Barriers He Or She Experienced In Getting To The Clinic That Day, And The Counselor Might Reflect: "It Was A Frustrating Morning." When The Clinician Labels The Client's Emotions, Those Emotions May No Longer Feel So Overwhelming. It Can Also Be An Expression Of Empathy For A Clinician To Reflect An Emotion About Which The Client Has Not Yet Spoken. This Occurs When The Clinician Alters A Client's Statement So That The Client Hears An Exaggerated Reflection: For Example, The Clinician Might Respond To The Client's Statement That His Drinking Is Under Control By Reflecting "Your Alcohol Use Isn't A Problem For You At All." This Is Done To Prompt The Client To Argue The Opposite. It Is Important That The Clinician Not Deliver The Amplified Reflection With Any Trace Of Sarcasm Or Disbelief. The Evoking Process: Strengthening Change Talk How Clients Talk About Their Behavior And Their Commitment To Making Change Is An Important Indicator For Assessing The Level Of Ambivalence And Motivation In A Given Moment. From An Mi Perspective, Client Speech Offers The Clinician Real-Time Feedback About The Motivation-Enhancing Or Motivation-Depleting Effects Of The Clinician's Style And Responses. Client Talk Also Helps Guide The Clinician's Responses Throughout The Course Of A Clinical Discussion. From The Perspective Of Mi, It Is Assumed That Individuals May Be Ambivalent About Change. This Ambivalence Can Be Expressed As Either Sustain Talk Or Change Talk. Sustain Talk, The Non-Change Side Of Ambivalence, Presents Arguments Against Change (I. E., Pro-Status Quo), May Highlight The Pros Of Engaging In A Problem Behavior And The Cons Of Change, May Defend The Client's Actions, And May Signal A Commitment For Maintaining Current Behavioral Patterns. Decreasing The Frequency Of Sustain Talk Is 638 V. Treatments For Addictions A Goal Of The Evoking Process. However, An Increase In Sustain Talk May Signal To The Clinician That The Current Approach Is Not Working And He Or She Should Try Something Else. Change Talk Is An Argument In Favor Of Change; It Highlights The Pros Of Alterna- Tive Actions And The Cons Of Inaction, And Signals A Commitment To Change. Increasing The Frequency And Strength Of Change Talk Is A Central Goal Of The Evoking Process, And An Increase In Change Talk Offers The Clinician Important Feedback On The Effec- Tiveness Of The Interaction. Identifying, Evoking, And Selectively Responding To Change Talk (Using The Oars Skills) Is Central To The Goal-Oriented Aspect Of An Mi Approach. Several Coding Schemes Have Been Developed To Categorize Client Language During Mi Interventions (Clear; Glynn & Moyers, 2012; The Motivational Interview- Ing Skill Code [Misc]; Miller, Moyers, Ernst, & Amrhein, 2008). Amrhein, Miller, Yahne, Palmer, And Fulcher (2003) Outlined A Psycholinguistic Framework That Cat- Egorizes The Type And Quantifies The Strength Of Different Categories Of Change And Sustain Talk. Client Change Talk Can Be Conceptualized As Preparatory Change Talk Or Mobilizing Change Talk (Miller & Rollnick, 2013). Preparatory Change Talk Consists Of Statements Expressing Desire, Ability, Reasons, And Need To Change. Mobilizing Change Talk Consists Of Statements Of Commitment, Activation, And Taking Steps To Change (The Acronym For Both Is Darn-Cat). It Is Important To Note That Prepara- Tory Language (Darn) And Mobilizing Language (Cat) May Be Associated With Both Change And Sustain Talk. For Example, Individuals May Express Strong Reasons For Continuing Their Substance Use ("Smoking Really Helps Me Cope With The Stress Of My Day": Sustain Talk), As Well As Reasons For Altering Their Behavior ("I Want To Stop Smoking So I Can Live Longer And See My Kids Grow Up": Change Talk). The Goal Of The Evoking Process Is To Implement The Oars Skills To Increase The Frequency And Strength Of Change Talk And Guide The Discussion Toward The Planning Process. Identifying Preparatory Talk As It Occurs During A Discussion About Change Is An Important Skill. Preparatory Change Talk Signals An Increased Likelihood That Mobiliz- Ing Change Talk Will Occur. Mobilizing Change Talk Predicts Positive Treatment Out- Come (Amerhein Et Al., 2003; Table 30.3). Thus, Clinicians Should Strive To Strengthen Preparatory And Mobilizing Change Talk During A Clinical Interaction. A Clinician Who Can Effectively Discriminate Between Change Talk And Sustain Talk Is In The Position To Selectively Reinforce Change Talk When It Occurs. If Client Change Talk Is Not Responded To Or Is Directly Challenged, The Client May Shift Toward Sustain Talk. For Example, Operating From A Deficit Model May Bias The Clinician To Evoke Sustain Talk By Probing What Is Not Going Well Or Focusing On The Reasons For Current Behavior Problems. It Is The Skillful Discrimination Between Change Talk And Sustain Talk, And The Differential Response To Change Talk Within The Spirit Of Mi, That Defines A Proficient Mi Style Throughout The Evoking Process. Preparatory Change Talk (Darn) Desire Statements Indicate Something The Client Wants, Wishes For, Or Is Willing To Do. Usually They Express A General Level Of Desire Rather Than Contain Specific Reasons. "I Really Want To Lose Weight (E. G., "I Want . . . ," "I Wish . . . ," "I Would Like To . . ."). A Useful Tool To Generate Desire Talk In A Session Is The "Desire Ruler." The Clinician Asks The Client, "On A Scale Of 1 To 10, With 10 Being The Highest, How Much Do You 30. Motivational Interviewing 639 Table 30.3. Change Talk Element Preparatory Change Talk Desire Ability Reasons Need Mobilizing Change Talk Commitment To Change Action Taking Steps Definition Client Desire Related To Target Behavior (Note. This Could Be The Desire To Stop Or The Desire To Continue Target Behavior) Client Sense Of Ability To Change Target Behavior Client Reasons Related To Target Behavior (To Continue Or To Stop) Client-Identified Needs Related To Target Behavior Client Statements Describing Expected Future Behavior Client Statements Indicating A Shift Toward Action But Not A Commitment To Do It Client Statements Indicating That The Client Has Already Started To Move In The Direction Of Change Want To Make This Change?" When The Client Responds With A Number, The Clinician Explores That Further. If The Client Responds With, For Example, A 5, The Clinician Asks, "Why Are You At A 5 Instead Of A 3?" This Gets The Client Thinking About Why The Change Is Important, And About Why His Or Her Desire Is As High As It Is. Then The Clini- Cian Asks, "What Would It Take To Get You From A 5 To, Say, An 8 Or A 9?" The Client May Then Respond By Talking About What It Would Take To Increase The Importance Of The Change. Note That These Questions Are Worded Carefully So As Not To Evoke Sustain Talk; A Question Such As "Why Are You Only At A 5 And Not An 8?" Would Focus The Client On Deficits Or Problems, And This Type Of Question Is Ill-Advised. The Clinician Elicits Specific Information From The Client To Help Build A Case For Change. Ability Statements Indicate Perceptions Of Capability Or Possibility Of Change. Usually They Do Not Contain Specifics; Rather, They Express A General Level Of Ability Or Inability. For Example, "I Know I Can Do This. I Will Start Exercising Again." Strategic Open-Ended Questions From The Clinician Can Elicit Statements Of Optimism From Clients (E. G., "What Have You Done In The Past That Led To Sobriety?"; "What Other Challenges In Your Life Were You Able To Overcome?"; "What Do You Think Would Work For You If You Decided To Change?"). The Clinician Then Listens To The Client's Response And Finds Key Elements To Reflect Or Affirm. Another Way To Elicit Statements Of Ability From The Client Would Be To Use The "Confidence Ruler." In The Course Of The Mi Session, The Clinician Guides The Client To Identify A Smart Goal (Small, Measurable, Achievable, Relevant, And Timed). Once The Smart Goal Has Been Identified, The Clinician Asks, "On A Scale Of 1 To 10, With 10 Being The Highest, How Confident Are You In Being Able To Make This Change?" The Strategic Open-Ended Follow-Up Question ("Why Are You At A 5 And Not A 3?") Elicits Statements Of Ability From The Client. The Client Responds With All The Strengths And Resources He Or She Has Within Him- Or Herself. The Clinician 640 V. Treatments For Addictions Can Then Ask, "What Would It Take To Get That 5 Up To An 8?" This Prompts The Client To Think About What Is Needed For An Increase In Confidence To Occur. Reasons Are A Particular Rationale, Justification, Or Motive For Making The Behav- Ior Change (E. G., "It's Important For Me To Lose Weight For My Health"). Reasons Are Elicited Throughout The Therapeutic Interview By Getting The Cons Of The Target Behav- Ior (E. G., Possibility Of Arrest, Cost), The Pros Of Change (E. G., Ability To Save Money, Improved Health), Problem Recognition Through Open-Ended Questions (E. G., "Why Is Your Wife Worried About You?" Or "In What Ways Has Your Drug Use Been A Problem For You?"), The Client's Intentions Regarding The Target Behavior (E. G., "What Are You Thinking About Your Drug Use At This Point?"), And Exploring The Client's Goals And Val- Ues (E. G., "What Matters To You? How Do You See Yourself? What Do You Hope For?"). Need Statements Indicate Necessity, Urgency, Or Requirement For Change. They Do Not Usually Contain Specific Reasons But Instead Express A General Level Of Need (E. G., "I Really Need To Lose Weight" Or "I Must Stop Eating This Way Or I'm Going To Give Myself Another Heart Attack"). The Clinician Can Elicit Statements Of Need By Exploring Problem Recognition (E. G., "What Makes You Think You Need To Make This Change?"). Mobilizing Change Talk (Cat) Commitment Statements Imply Agreement, Intention, Or Obligation Regarding Future Target Behavior Change, And Client Commitment Language Has Been Correlated With Positive Clinical Outcomes. Commitment Statements Vary In Strength And Direction. For Example, "I Am Stopping My Use" Is A Very Strong Statement Of Positive Change; "I Will Try To Stop Using" Is A Weaker Statement Of Positive Change. When Eliciting Statements Of Change From A Client, The Clinician Should Strive For The Strongest Level Of Commitment. Questions That Ask For Small And Clear Commitments Often Can Evoke Commitment Statements (E. G., "What Will You Do This Week?"). Activation Statements Indicate Movement Toward Change But Do Not Necessarily Reflect A Solid Commitment To Make Change. A Client May State A Willingness Or Readi- Ness To Change ("I'm Ready To Stop Drinking") But May Not Express A Commitment (E. G., "I Will Not Drink This Week"). The Clinician May Reflect The Client's Readiness ("You Have Decided To Stop") Or Probe How The Client May Accomplish This ("You Have Made Up Your Mind. What Do You Have To Do To Make This Happen?"), Which May Help Guide The Client From Activation To Commitment. Statements About Taking Steps Highlight Behaviors In Which The Client Engages That Are In The Direction Of Change, Although A Commitment To Change Has Not Yet Occurred. For Example, Looking At Alcoholics Anonymous (Aa) Meeting Locations Is A Step Toward A Change In Drinking Behavior, Even Though It Does Not Include A Com- Mitment To Stop Drinking. From An Mi Perspective, Taking Steps Signals The Process Of Resolving Ambivalence In The Direction Of Change, And The Clinician May Want To Further Reflect, Probe, Or Affirm This Activity. Evidence Suggests That The Relative Distribution Of Change Talk And Sustain Talk During A Conversation About Change Has Prognostic Significance. A Discussion That Includes More Client Sustain Talk Or Equitable Levels Of Sustain And Change Talk Is Predictive Of Poor Outcome. In Contrast, Discussions That Include A Greater Propor- Tion Of Client Change Talk Predict Future Behavior Change (Moyers, Martin, Houck, 30. Motivational Interviewing 641 Christopher, & Tonigan, 2009). Thus, The Strategic Use Of Mi Skills To Increase Change Talk During A Clinical Discussion Has Direct Relevance To The Overall Efficacy Of An Mi Counseling Session. The Process Of Evoking Change Talk Involves The Strategic Use Of The Mi Microskills (Oars). One Of The Simplest Ways To Elicit Change Talk Is To Use Open-Ended Questions To Explore A Client's Perceptions Or Concerns. It Is Assumed That A Certain Amount Of Ambivalence Is Associated With Change, And Open-Ended Questions Can Set The Occa- Sion For Probing This Assumption. It Is Important To Note The Need For Elaboration. Indeed, Once A Reason For Change Has Been Elicited, It Is Often The Clinician's Tendency To Move On And Find Other Reasons For Change. It Can Be Quite Useful To Ask The Client To Elaborate Further On A Topic Before Moving On. The Clinician Can Also Reflect The Client's Stated Reasons, Which May Also Elicit Elaboration And Further Change Talk, Making The Possibility Of Change More Realistic For The Client. Several Other Strategies Can Be Used To Generate Change Talk. Clinicians Can Employ A Decisional Balance Exercise During Which Clients Discuss The Positive, As Well As The Negative, Aspects Of A Target Behavior. In This Exercise, The Client Lists The Posi- Tives Of The Behavior (E. G., Benefits Of Drug Use) First, Followed By The Downsides (E. G., Negative Consequences Of Drug Use). Note That Ending The Exercise On The Negatives Of The Problematic Behavior Is Advised As It Will Prompt The Client To Remember That Portion Of The Exercise More Strongly. In Contrast, Ending With A Discussion Of The Positives Of The Problem Behavior Is Not Recommended As It Increases The Probability That The Client Will Focus On That Portion Of The Exercise And Engage In Sustain Talk. It Can Also Be Useful For Clients To Discuss The Positives And Negatives Of Both Staying The Same And Making The Behavior Change; This May Help Prepare The Client For The Struggles That Giving Up A Certain Behavior May Entail. In Such A Discussion, The Clini- Cian Would Want To Start By Exploring The Positives Of Staying The Same, And End With Exploring The Negatives Of Staying The Same. This Type Of Decisional Balance Should Always End With The Side Of The Argument That The Clinician Most Wants The Client To Adopt. Exploring Goals And Values With The Person Can Be Another Useful Strategy. Inviting The Client To Discuss What Is Important In Life And To Envision How To Achieve Those Things Can Help Increase Change Talk And Motivation. Reflective Listening Can Be Very Helpful For Highlighting A Client's Change Talk. Unpacking Resistance: Sustain Talk And Discord Early Formulations Of Mi Conceptualized Client Resistance As A Function Of The Clini- Cal Interaction (Miller & Rollnick, 1991, 2002). This Framework Differed From More Traditional Theoretical Perspectives That Viewed Resistance As A Characteristic Of The Client Or Of The Clinical Condition (E. G., Denial In Substance Dependence). However, A More Recent Formulation Of Mi (Miller & Rollnick, 2013) Has Moved To Deconstruct The Concept Of Resistance Further. From This Perspective, Resistance Comprises Two Dis- Tinct Processes: Sustain Talk And Discord. It Is Important To Note That Counseling Style Influences Both Processes. Thus, The Clinician's Stance And Communication Skills Are Important Parameters In Understanding And Influencing What Has Traditionally Been Labeled As "Resistance." 642 V. Treatments For Addictions As Previously Noted, Sustain Talk Represents One Side Of Ambivalence. From An Mi Perspective, Ambivalence Is A Natural Part Of The Change Process And Is To Be Expected To Occur As Clients Contemplate Change. It Is Not Pathological. However, Sustain Talk Is Predictive Of Poor Outcome, And The More Individuals Engage In Sustain Talk, The Greater The Chance That They Will Talk Themselves Out Of Change. Thus, Recog- Nizing Sustain Talk And Responding To It Effectively Has Important Treatment Implica- Tions. Reflective Listening, Reinforcing Autonomy, And Reframing Can Help Minimize The Chances Of A Confrontational Interaction, Guide The Discussion Fruitfully Toward Reduced Sustain Talk, And Begin To Evoke Change Talk. Discord Signals The Disruption Of A Collaborative Relationship (Low Mi Spirit). The Presence Of Discord May Provide Feedback To The Clinician That His Or Her Therapeutic Stance Or Style Has Shifted Away From An Mi-Adherent Position. Discord Can Arise At Any Stage During The Processes Of Engaging, Focusing, Evoking, And Planning. The Client May Feel Coerced Into Change; The Client May Disagree With The Clinician About The Target For Change; The Clinician May Directly Challenge Sustain Talk; Or The Clini- Cian May Be Overly Instructive About What The Client Needs To Do. These Are But A Few Examples Of Occurrences That Can Disrupt The Collaborative Nature Of The Interaction And Promote An Increase In Client Defensiveness, Disengagement, And Verbal Jousting (Interrupting, Arguing). Significantly, An Increase In Discord May Be Accompanied By A Decrease In Motivation. A Clinician Can Effectively Respond To Discord And Shift The Session Back To A More Collaborative Process. The Use Of Reflective Listening, Affirm- Ing, Reinforcing Client Autonomy, Shifting The Focus Of The Conversation, And Reframing Can Be Utilized To Rebuild A More Effective Working Alliance. While There Is No Single Correct Response To Discord Or Sustain Talk, The Overarching Goal Of The Clinician Is To Establish A Collaborative Working Relationship That Reinforces The Client's Autonomy In The Change Process, Makes Clear The Nonjudgmental Stance Of The Clinician, And Reduces The Client's Defense Of The Status Quo. Formulation Of A Theory Mi Has Been Developed And Refined Over The Past Three Decades. A Significant Amount Of Writing Has Been Devoted To Outlining The Therapeutic Stance And The Mi Microskills (Miller & Rollnick, 1991, 2002, 2013), Testing Mi's Efficacy In Numerous Random- Ized Clinical Trials (E. G., Brown & Miller, 1993: Burke Et Al., 2004; Hettema Et Al., 2005; Lundahl Et Al., 2010; Miller & Rollnick, 2002, 2009, 2013; Rubak Et Al., 2005; Vasilaki Et Al., 2006: Wain Et Al., 2011), And Highlighting The Predictors Of Change During Mi Sessions (Amrhein Et Al., 2003). The Increasing Body Of Evidence That Sup- Ports Mi As An Effective Counseling Style Has Also Prompted Formal Discussions About The Theoretical Underpinnings Of The Strategy And The Mechanisms By Which Mi May Guide Behavior (Miller & Rose, 2009). Mi Explicitly Acknowledges Three Fundamentally Important Parameters Of Dis- Cussions About Change: The Clinician's Interpersonal Stance, The Clinician's Verbal Behavior, And The Client's Verbal Behavior. All Three Parameters Are Proposed To Be Important Mechanisms Or Signals By Which Clinicians Can Influence Conversations About Change That In Turn Help To Resolve Ambivalence And Promote Lifestyle Changes (Miller & Rose, 2009). 30. Motivational Interviewing 643 The Spirit Of Mi Has Been Hypothesized To Play A Central Role In The Efficacy Of Mi (Rollnick & Miller, 1995; Miller & Rose, 2009). Evidence Supports A Positive Link Between Therapist Empathy And Treatment Outcome (Miller, Taylor, & West, 1980), As Well As A Link Between Clinician Interpersonal Skills And Client Engagement During Mi Sessions (Moyers, Miller, & Hendrickson, 2005). Furthermore, Clinician Behavior That Is Consistent With Mi Is More Likely To Engender Change Talk, While A Counsel- Ing Style That Is Inconsistent With Mi (E. G., Directing, Confronting) Is Associated With Sustain Talk (Moyers & Martin, 2006). Other Studies Have Examined The Relative Importance Of Clinicians' Microskills Versus The More Global Elements Of Mi (Empathy And Spirit). These Findings Suggest That The Global Elements Of Mi May Be More Pow- Erful Than The Specific Skills In Engendering Client Engagement And Treatment Alliance (Moyers Et Al., 2005; Boardman, Catley, Grobe, Little, & Ahluwalia, 2006). Thus, The General Pattern Of Findings To Date Supports The Contention That Therapist Style Is An Active Ingredient In The Overall Efficacy Of This Counseling Approach. Psycholinguistic Studies Of Client Speech During Mi-Guided Discussions About Change Demonstrate That The Way Individuals Talk About Their Behavior During An Mi Session (I. E., Commitment Language Or Change Talk) Predicts Treatment Outcome (Amrhein Et Al., 2003; Moyers Et Al., 2007). Furthermore, The Relationship Between Change Talk And Drug Treatment Outcome Has Been Demonstrated In Counseling Styles Other Than Mi (Cognitive-Behavioral Therapy [Cbt]; Aharonovich, Amrhein, Bisaga, Nunes, & Hasin, 2008) And For Other Behavioral Problems (Gaume, Gmel, & Daeppen, 2008; Hodgins, Ching, & Mcewen, 2009; Strang & Mccambridge, 2004). Overall, The Increasing Evidence Has Supported An Important Link Between Cli- Ent Talk And Future Behavior Change. The Significant Relationships Between (1) Counseling Style And Client Change Talk And (2) Client Change Talk And Treatment Outcome Suggest An Important Mediating Role Of Change Talk. That Is, The Clinician's Counseling Style Influences Treatment, Because It Increases Change Talk. However An Important, Although Unanswered, Ques- Tion Remains. How Does Increasing Change Talk Help Resolve Ambivalence And Promote Changes In Behavior? Several Psychological Theories Have Been Utilized To Understand How The Process Of Mi Engenders Change. Bem's (1972) Self-Perception Theory Hypoth- Esizes That The Beliefs One Develops About Oneself Result From Observing Oneself: "As I Hear Myself Talk, I Learn What I Believe." In Mi, The Client's Verbal Commitment To Change Serves As A Precursor To Change. Thus, When A Clinician Evokes Change Talk, Which Is Understood To Be An Important And Facilitative Part Of The Change Process, He Or She May Enhance The Client's Motivation To Change. Festinger's Cognitive Disso- Nance Theory (1957) States That When A Person Is Enticed To Speak In A New Way, Some Discomfort Is Experienced Due To The Discrepancy Between The Newly Voiced Beliefs And Long-Held Thought And Behavior Patterns. An Individual's Beliefs And Values Tend To Shift In The Same Direction As The Spoken Words To Help Reduce This "Dissonance." Accordingly, In The Process Of Focusing And Evoking, Clients May Offer Statements About What Is Important To Them And How Their Current Behavior Interferes With A Lifestyle That Is Consistent With Their Values And Goals. Engaging In This Process May Motivate Individuals To Reduce This Discrepancy. Also Apparent In Mi Is Decisional Conflict Theory From Janis And Mann (1977), In Which "Ambivalence" Is Defined As A Cognitive Conflict. Clients Struggling With Addiction Are Almost Always Struggling 644 V. Treatments For Addictions With Ambivalence About Change. In Order To Address And Resolve The Ambivalence, Clinicians Engage Clients In A Rational Decision-Making Process Rather Than Avoid, Or Attempt To Avoid, The Ambivalence. In Summary, Increasing Empirical Evidence Has Highlighted The Mechanistic Links Between A Clinician's Style And Skills And In-Session Client Speech. In Turn, In-Session Client Speech Has Predicted Treatment Outcome. These Investigations Have Provided The Empirical Scaffolding Upon Which A Deeper Understanding Of The Relationship Between Change Talk And Behavior Change Can Be Investigated. This Knowledge Has The Potential To Yield A Comprehensive Understanding Of How Mi Influences The Process Of Change. A Note On Learning Mi Mi Has Been Described As A "Simple But Not Easy" Counseling Style To Learn (Miller & Rollnick, 2009). It Is A Complex Combination Of Therapeutic Stance And Behavioral Practice, For Which It Is Difficult To Develop Sustained Competence (Forsberg, Berman, Kallmen, Hermansson, & Helgason, 2008; Hettema Et Al., 2005; Smith Et Al., 2012). Training Formats Can Vary From Brief Educational Lectures That Provide An Overview Of The Counseling Style To More In-Depth Training Workshops That Are Followed By A Supervised Practice Schedule. Interactive Training Workshops Remain The Primary Context For Learning Mi. However, An Increasing Body Of Evidence Suggests That While Training Workshops (Approximately 16 Hours Of Training) Can Facilitate The Acquisi- Tion Of An Mi Counseling Style, They Do Not Promote Long-Term Proficiency (Miller & Mount, 2001; Walters, Matson, Baer, & Ziedonis, 2005). Evidence Generally Sup- Ports Combining Training Workshops With Postworkshop Supervision That Includes Opportunities To Practice Mi With The Provision Of Objective Feedback And Coaching (Miller Et Al., 2004; Smith Et Al., 2012). Thus, It Is Recommended That In The Process Of Learning Mi, Clinicians Both Receive Didactic Instruction And Participate In Super- Vised Practice That Includes Constructive Feedback On Their Clinical Interaction. The Resources Presented At The Beginning Of This Chapter Provide Important Didactic And Supervisory Resources That Can Facilitate The Development Of A Proficient Mi Counsel- Ing Style. Clinical Corner: The "Mi Sandwich" Medical Clinicians May Find It Challenging To Implement Mi Due To The Factual Data Collection That Is Necessary For Clinical Practice And Record Keeping. Medical Person- Nel Also Frequently Feel Pressed For Time And Find It Difficult To Add "One More Thing" To An Already Pressured Schedule. However, There Are Times When A Doctor May Wish To Incorporate An Mi Counseling Style. This Style May Be Particularly Useful If There Is A History Of Substance Abuse Or Other Behavior Patterns That Are Negatively Impact- Ing An Individual's Health And Ability To Comply With Health Care Recommendations. In These Circumstances, The Physician May Choose To Use The "Mi Sandwich," Which Refers To Opening And Closing A Clinical Encounter With Mi And Gathering The More Factual Data In The Middle. In A Collaborative Atmosphere, One That Supports A Stance 30. Motivational Interviewing 645 Consistent With The Spirit Of Mi, The Physician Can Begin A Discussion By Asking The Cli- Ent Open-Ended Questions, Respecting The Client's Perspective, And Offering Reflections. The Middle Of The Session Does Not Need To Be A True Mi Session; This Is When The Phy- Sician May Ask A Lot Of Closed-Ended Questions For Differential Diagnostic Purposes, Discuss Prescriptions, And Collect Other Factual Data. Then, The Physician Resumes The Mi Stance For The Closing Minutes Of The Session. During The Opening And The Clos- Ing Of The Medical Appointment, The Physician Assumes The Role Of Mi Therapist To Build Rapport, To Engage The Client, And To Increase The Client's Motivation For Making Change. The Client Should Feel Empowered By The Experience And May Be More Willing To Consider Making The Identified Behavior Change. The Client Needs To Know That, Whether He Or She Succeeds Or Fails At Making The Change, The Physician Will Remain Receptive And Supportive. Acknowledgments This Work Was Supported In Part By The National Institute On Drug Abuse Grant Nos. R01 Da016950 (To Edward V. Nunes), K24 Da022412 (To Edward V. Nunes), And K23 Da021850 (To Kenneth M. Carpe

Drugs of Abuse: terms

Tolerance - Needing more of the substance to achieve the same effect (this is evidence that the brain has become less sensitive to the substance, or neuroadaptations). • Cross-tolerance - If a person develops tolerance for one substance in a class of drugs, the person will experience tolerance for other drugs in that class. (For example, the person may experience tolerance for both alcohol and Xanax). • Withdrawal - The body's physical response to being without the substance it has come to expect (usually the opposite effect of the drug). • Cross-addiction - Two or more addictive drugs or behaviors (e.g., gambling addiction and alcohol addiction). • Drugs of abuse - Not all substances are drugs of abuse. Drugs of abuse are those that the brain finds rewarding (affects the dopamine system)

Treatment for Sex addiction

Treatment for sex addiction can take place in a residential facility, in a outpatient group counseling, in outpatient individual counseling, or in couples counseling. Typically, treatment is long-term, taking 3-5 years to work a recovery plan and allow the brain to heal (un-condition the brain). Treatment may include cognitive behavioral work, psychodynamic work, family counseling, Motivational Interviewing, and relapse prevention work. Counselors can pursue training to become a certified sex addiction therapist (CSAT). See this website for more information: https://iitap.com/page/csat

Pharmaceuticals in Relapse Prevention

•To help clients addicted to opioids, mental health professionals consider: ▫Methadone (Dolophine): Synthetic opiate agonist; a safer replacement drug that is controlled and used to block opioid withdrawal. ▫Buprenorphine (Suboxone): Used as a replacement drug to block opioid withdrawal. ▫Naltrexone (Revia or Vivitrol): Blocks opiate receptors so you do not feel the effects of opioids. ▫Naloxone (Narcan): Opioid antagonist; used in the event of a opioid overdose.

Nonmedical Prescription Stimulant Use

What about prescription stimulants like Adderall? A rising concern among college students are the nonmedical use of psychostimulants (drugs used to treat ADHD like Adderall, Concerta, and Ritalin; click on hyperlink to learn more). Some college students refer to prescription stimulants as "study drugs" and perceived them as more justified than other drugs. However, research reveals that prescription stimulant abuse does not lead to higher GPAs among college students. Instead, those who abuse prescription stimulants are more likely to abuse other drugs, skip classes, experience depressive symptoms, and experience health problems. Many students are unaware that there are legal ramifications for distributing prescription stimulants or possessing them without a prescription (as a Schedule II controlled substance).

Sustain talk

When people are ambivalent about change, they do not use only change talk (or else they wouldn't be ambivalent!); they also use sustain talk, or speech supporting not changing. Sustain talk may sound like this: "I don't know what I would do without cocaine." "I can't quit...it would hurt too bad." "Marijuana helps me calm my nerves. I need it." "Drinking is the only thing I do to have fun. I deserve it." "I tried to quit before and it didn't last."

Progression of Drug tolerance

e. The first time a person takes a drug of abuse, the euphoria (or high) is at its peak. As neuroadaptations occur in the brain, the euphoria decreases. Also, since the brain is cutting back natural dopamine production, the person begins to experience depressed feelings at baseline (just waking up in the morning). So individuals begin using substances just to feel "normal:---> not experiencing a high

Etiology of addiction

each model proposes a different cause of addiction: Moral model: individual character flaw Psychological model: Underlying psychological distress Disease model: genetic predisposition sociocultural model: society

Marlatt and George

elapse Prevention: Introduction and Overview of the Model G. Alan Marlatt and William H. George Department of Psychology, University of Washington, Seattle, Washington 98193, USA Summary As an introductory overview of the Relapse Prevention (RP) model, this article briefly describes the conceptual and clinical features of the RP approach to altering excessive or addictive behaviour patterns. In contrast xuith traditional approaches that overemphasize initial habit change, RP focuses more on the maintenance phase of the habit change process. From this perspective, relapse is not viewed merely as an indicator of treatment failure. Instead, potential and actual episodes are key targets for both proactive and reactive intervention strategies. RP treatment procedures include specific intervention techniques designed to teach the individual to effectively anticipate and cope with potential relapse situations. Also included are more global lifestyle interventions aimed at improving overall coping skilk and promoting health and well being. Important questions raised by this relatively recent alternative to traditional approaches are discussed. What is Relapse Prevention? Relapse Prevention (RP) is a self-control programme designed to teach individuals who are trying to change their behaviour how to anticipate and cope with the problem of relapse. In a very general sense, relapse refers to a breakdown or failure in a person's attempt to change or modify any target behaviour. Based on the principle of social-learning theory [1], RP is a psychoeducational programme that combines behavioural skill-training procedures with cognitive intervention techniques. Because the RP model combines both behavioural and cognitive components, it is similar to other cognitive- behavioural approaches that have been developed in recent years as an outgrowth and extension of more traditional behaviour therapy programmes. Descriptions of related cognitive-behavioural research and treatment approaches with a variety of clinical problems are available in a number of recent publications [2, 3, 4, 5, 6]. The RP model was initially developed as a behavioural maintenance programme for use in the treatment of addictive behaviours [7]. In the addictions, the typical goals of treatment are either to refrain totally from performing a target behaviour (e.g., to abstain from drug use), or to impose regulatory limits or controls over the occurrence of a behaviour (e.g., to diet as a means of controlling food intake). Relapse prevention procedures can be applied either in the form of a specific maintenance strategy to prevent relapse or as a more general programme of lifestyle change. In the former case, the aim of the procedure is to anticipate and prevent the occurrence of a full-blown relapse following a period of improvement or after the initiation of a new behaviour change programme (e.g., to prevent a recent ex-smoker from returning to habitual smoking). As such, the procedures are designed to enhance the maintenance of behaviour change and may be applied regardless of the theoretical orientation or intervention methods applied during the initial treatment phase. Once an alcoholic has stopped drinking, for example, RP methods can be applied toward the effective mainterumce of abstinence, regardless of the methods used to initiate abstinence (e.g., attending AA meetings, aversion therapy, voluntary cessation, or some other means). In the second application of the RP model, the purpose is a more general one: to facilitate changes in personal habits and lifestyle so as to reduce the risk of physical disease or psychological stress. Here, the aim of the RP programme is much broader in scope: to teach the individual how to achieve a balanced lifestyle and to prevent the formation of unhealthy habit pattems. A balanced lifestyle is characterized by a harmonious balance between work and play activities and the development of 'positive addictions' [8] such as physical exercise and medication. The central theme or motif of this approach is embodied in an underlying principle of moderation: A balanced lifestyle is one that is centred on the fulcrum or midpoint of moderation (in contrast with the opposing extremes of behavioural excess or restraint). Viewed from this more global perspective, RP can be 264 G. Alan Marlatt and William H. George may engage in preventive alternative behaviours? Toborrow a term from the medical model, can we develop prevention procedures that would 'inoculate' the individual against the inevitability of relapse? In order to answer these and other questions, it b necessary to engage in a detailed micro-analysis of the relapse process itself. This fine- grained approach focuses upon the various determinants of relapse, both in terms of the immediate precipitating circumstances and the longer chain of events that may or may not precede the relapse episode. In addition, the role of such cognitive factors as expectation and attribution are examined in detail, particularly in terms of the individual's reactions to the relapse. A micro-analysis of the relapse process is justified by the old maxim that we can learn much from our mistakes. Rather than being seen as an indication of failure, a relapse can more optimistically be viewed as a challenge, an opportunity for new learning to occur. Overview of the Relapse Model In the following overview, only the highlights of the model are presented, since further details are presented elsewhere; background research and theory leading to the development of this model can be found in Cummings, Gordon, & Marlatt [12], Marlatt [13, 14, 15], and Marlatt and Gordon [7, 16]. The following overview draws extensively from those previously published accounts of the model. To begin, we are assuming that the individual ex- periences a sense of perceived control while maintaining abstinence (or complying with other rules governing the target behaviour). The behaviour is 'under control' so long as it does not occur during this period — the longer the period of successful abstinence, the greater the individual's perception of self-control. This perceived control will continue until the person encounters a high- risk situation. A high-risk situation is defined broadly as any situation which poses a threat to the individual's sense of control and increases the risk of potential relapse. In a recent analysis of 311 initial relapse episodes obtained from clients with a variety of problem behaviours (problem drinking, smoking, heroin addiction, compulsive gambling, and overeating), we identified three primary high-risk situations that were associated with almost three-quarters of all the relapses reported [12]. A brief description of the three categories associated with the highest relapse rates follows. (a) Negative emotional states (35 per cent of all relapses in the sample): situations in which the individual is experiencing a negative (or unpleasant) emotional state, mood, or feeling such as frustration, anger. anxiety, depression, boredom, etc., prior to or at the same time the first lapse occurs. For example, a smoker in the sample gave the following description of a relapse episode: 'It had been raining and I had the basement filled with a good three inches of water. To make things worse, as I went to turn on the light to see the extent of the damage, I got shocked from the light switch. Later that same day I was feeling real low and knew I had to have a cigarette after my neighbour, who is a contractor, assessed the damage at over $400. I went to the store and bought a pack.' (b) Interpersonal conflict (16 per cent of the relapses): situations involving an ongoing or relatively recent conflict associated with any interpersonal relationship, such as marriage, friendship, family members, or employer-employee relations. Arguments and inter-personal confrontations occur frequently in this category. A gambler who had been abstaining from betting on the horses described his relapse in the following terms: 'I came home late from a horrible day on the road and I hadn't stepped in the house five minutes before my wife started accusing me of gambling on the horses. Racetrack, helll I told her if she didn't believe me, I'd give her a real reason to file for divorce. That night I spent $450 at the Longacres track.' (c) Social pressure (20 per cent of the sample): situations in which the individual is responding to the infiuence of another person or group of people who exert pressure on the individual to engage in the taboo behaviour. Social pressure may either be direct (direct interpersonal contact with verbal persuasion) or indirect (e.g. being in the presence of others who are engaging in the same target behaviour, even though no direct pressure is involved). Here is an example of direct social pressure given by a formerly abstinent problem drinker in our sample: 'I went to my boss's house for a surprise birthday dinner for him. I got there late and as I came into the living room everyone had a drink in hand. I froze when my boss's wife asked me what I was drinking. Without thinking, I said 'J&B on the rocks.' In our analyses of relapsed episodes to date (12, 7), we have found that there are more similarities than differences in relapse categories across the various addictive behaviours we studied. These same three high- risk situations are frequently found to be associated with relapse, regardless of the particular problem involved (problem drinking, smoking, gambling, heroin use, or overeating). This pattem of findings lends support to our hypothesis that there is a common mechanism underlying the relapse process across different addictive behaviours. If the individual is able to execute an effective 270 G. Alan Marlatt and William H. George that for most clients, drug use has come to be viewed as a source of immediate gratification and a method for restoring balance to an 'unfairly' lopsided equation. This desire for indulgence translates into urges, cravings, and distortions that permit one to 'unintentionally' meander closer to the brink of relapse. The first step in preempting this progression, is to raise the person's consciousness as to the dynamics of this analysis and to sharpen their awareness of the want/should imbalance. An effective way to start this process is by having the client employ self-monitorihg techniques to inventory the wants and shoulds that prevail in their life. By keeping a daily record of duties and obligations on one hand and indulgences on the other, the client can soon become acutely aware of the discrepancy between their shoulds and wants. Next, the client should be encouraged to seek a restoration of balance by making time each day to eligage in worthwhile indulgences. The emphasis here is on including more positive addictions. Glasser [8] described negative addictions (e.g., excessive drinking) as activities which initially feel good but produce long-term harm. Conversely, positive addictions (e.g., running) produce short-term discomfort while yielding long-range benefits. After short-range disincentives have been surmounted, a positively addicting activity acquires a great deal of attraction value for the individual and comes to be perceived as a want. At this point, the person feels deprived if prevented from engaging in the activity. The advantage of this shift from negative to positive addiction lies in the latter's capacity to contribute toward the person's long-term health and well-being while also providing an adaptive coping response for life stressors and relapse-risk situations. As long-range health benefits accrue, the person begins to feel better about him/herself and his or her life. Activities having potential for positive addiction include meditation, relaxation inductions, and regular exercise. Meditation and other relaxation techniques [23] offer an easily leamable and readily available method for achieving a constructive 'high' experience. Jogging and regular exercise regimes require more physical exertion and perhaps more attention to scheduling (particularly if done with others), but also provide sources of constructive personal indulgence. Recent research in our laboratory has shown that a regular programme of aerobic exercise (running) is associated with a significant reduction in drinking behaviour among heavy drinkers [24]. Despite the efficacy of these techniques for counteracting feelings of deprivation that would otherwise predispose the individual toward relapse. occasional urges and craving may still surface from time to time. For this reason, various urge control procedures are recommended. Sometimes urges and cravings are directly triggered by external cues like the sight of one's favourite beer mug or wine goblet in the kitchen cabinet, or meeting an old friend who is a heavy smoker. The frequency of these externally triggered urges can be substantially reduced by employing simple stimulus control techniques aimed at minimizing exposure to these cues. In some instances, avoidance strategies offer the most effective way of reducing the frequency of externally triggered urges. Certain events or situations like the biweekly poker games or the wine section of the local grocery may just have to be avoided temporarily while the individual develops more coping skills. Generally, avoidance strategies can often come in handy for dealing with unexpected high-risk situations that emerge. A selection of viable avoidance strategies can enhance the individual's sense of choice when confronted with dangerous situations. In teaching clients to cope with urge and craving experiences, it is important to emphasize that the discomfort associated with these internal events is natural. Often, people undergoing cravings have a tendency to feel as though the discomfort will continue to mount precipitously until their resistance collapses under the overwhelming weight of a ballooning urge. In working with this concern, we stress that urges and cravings are in fact determined, that is they are triggered by environmental or endogenous cues, they rise in intensity, reach a peak, and then subside. In this respect, urges can be likened to waves in the sea: they rise, crest, and fall. Using this perspective, we encourage the client to wait out the urge, to look forward to the downside, and to endure that slice in time when the urge discomfort is peaking. In drawing an analogy to surfing, we commonly refer to this cognitive strategy as urge surfing. The client presumably learns to 'ride out' urges in the same manner that the surfer learns to maintain his or her balance without 'wiping out' as the wave swells and crests. Recall that urges and cravings may not always operate at a conscious level, but may become masked by cognitive distortions and defence mechanisms. As such they can still exert a potent infiuence by allowing for 'apparently irrelevant decisions' (AIDS) that inch the person closer to relapse. To counter this, we train the client to 'see through' these self-deceptions by recognizing their true meanings. Explicit self-talk can help in making AIDs seem more relevant. By acknowledging to oneself that certain 'mini-decisions' (e.g., keeping a bottle at home in case friends drop over) actually represent urges Relapse Prevention 271 and cravings, the client becomes able to use these experiences as early warning signals. An important objective in these urge control techniques is to enable the individual to externalize urges and cravings and to view them with detachment. Another way to achieve this detachment is to encourage the client to deliberately label the urge as soon as it registers into consciousness. Urges should be viewed as natural occurrences that happen in response to environmental and lifestyle forces rather than as signs of treatment failure and indicators of future relapse. Empirical Support and Future Directions in Research The RP model outlined in this paper is still in the formative stages of development. The empirical underpinnings of this approach have been reviewed in a recent book on this topic [ 16]. In terms of treatment efficacy, only a few outcome studies have appeared in the literature that have compared the RP model with other approaches to the treatment of addiction or the prevention of relapse, although research is currently underway on this issue. The few outcome studies that have appeared, alongwithresearchontheroleofexpectancies(self- efficacy and outcome expectancies) and coping skills in the habit-change process, have provided general support for the model. Some of the highlights of this research are presented in this section, along with some questions for future research. Researchers who wish more detailed information on research support are referred to the Marlatt and Gordon [16] text. Most research has been conducted in the areas of alcohol dependency and smoking, although work is underway applying the RP model to other addictive behaviours. In the alcohol field, the pioneering work of Litman and her colleagues at the Addiction Research Unit at the Maudsley Hospital has provided valuable insight into the role of coping with high-risk situations as a factor that discriminates between alcoholics who relapse after treatment from those who 'survive' or show a good treatment outcome. Litman and her co-workers have provided extensive documentation of relapse situations and associated coping responses related to treatment outcome [25, 26, 27, 28]. Similar research on the role of coping as a factor reducing relapse risk among ex-smokers has been described by Shiffman and his colleagues at the University of South Florida [29, 30, 31, 32]. Related studies in the smoking area have shown that self-efficacy ratings made on or near the date for smoking cessation are valid predictors of subsequent treatment outcome [33, 34]. In the Condiotte and Lichenstein study, it was not only found that overall efficacy ratings served as an accurate predictor of relapse rates in general, but also that ratings of efficacy in specific situations were frequently predictive of the actual relapse episode in which the client resumed smoking. Self-efficacy ratings can thus be used as aids to treatment planning: therapists can focus their energies on working with low-efficacy situations reported by clients at the tim^^f intake. A similar approach to assessing self- efficacy'with alcoholics in treatment has been reported by Annis and .her colleagues at the Addiction Research Foundation in Toronto [35]. Skill-traiping approaches have also received (some attention in Ittie treatment outcome literature. To take a specific example from our own skill-training research with alcoholic clients [20], the client's responses to the Situational Competency Test are first taken into j^ccount in planning the specific skill-training programme. For one particular client, the problem may involve an inability to resist social pressure to indulge; for another, the problem may involve a deficit in coping with feelings of loneliness or depression. In the skill-training programme described in the Chaney et al. study, alcoholics in treatment met together in small group format for a series of treatment sessions. Each group was led by two therapists, who began by describing a particular high-risk situation. The group membei' then discussed the situation and generated various ways of responding to it. The therapists then modeled an appropriate coping response and practiced it in front of the group. Using this procedure, each client received individualized feedback from grou^ members and specific coaching and instructions from the therapists. The client was then required to repea't the coping response until it matched the therapists' criteria for adequacy. This particular skill-training programme was evaluated in a year-long follow-up study in comparison with two control groups: a group that spent an equivalent amount of time discussing their emotional reactions with regard to the same high-risk situations (as in psychodynamic group therapy), and a no-treatment control condition (regular hospital programme only). The skill-training condition proved to be more successful than either control group, showing a significant improvement at the one-year follow-up period for such variables as amount of posttreatment drinking, duration of time spent drinking before regaining abstinence, and frequency of periods of intoxication. Similar positive results for skill- training with alcoholics have been reported in recent studies by Jones and Lanyon [36] and Oei and Jackson [37]. Despite this emerging empirical support, many of the basic tenets of the model and the effectiveness of the RP approach vnth various addictive behaviours have yet to be firmly established. Refinement of the basic assumptions and clinical applications of the model will 272 G. Alan Marlatt and William H. George undoubtedly occur on the basis of future research. Many questions remain unanswered at this point. To name but a few: — What is the role of motivation in habit change and how can it be enhanced? If relapse prevention is designed for the maintenance stage or 'back end' of the habit-change process, there is a strong need for a corresponding 'front end' emphasis on motivation and self-efficacy enhancement. — What is the time course of relapse across various addictive behaviours? Do certain high-risk situations occur earlier than others for most people, and, if so, what is the expected course of such risk situations over time? Ilxamination of relapse rates (based on survivor analysis of time periods preceding initial lapses and/or subsequent relapses) may reveal a distribution of periods of differential risk (e.g., within successive weekly periods after a commitment to abstinence). If so, it may turn out that various RP intervention strategies are effective at different time periods. — What is the optimum format for the delivery of RP strategies? To what extent is the assistance of trained professional or paraprofessional therapists or counselors necessary or helpful? Can the RP model be effectively applied in the form of self-help manuals, correspondence courses, or other formats? What about individual counseling as opposed to a group treatment format? — Perhaps the most intriguing question that arises from a comparison of the self-control and disease models of addiction is this: Is one approach more effective than the other for some clients, and vice versa? Do the self- control and disease models reflect the principle of 'different strokes for different folks?' It does seem to be the case that the population differs with regard to people's basic orientation toward personal causation and locus of control. Evidence is mounting that people can be placed along a continuum of 'perceived personal causation,' with those at one extreme believing that they are capable of exercising choice and free will to determine the direction and course of their lives, in contrast with those on the other end who believe that their lives are under the deterministic control of external forces, such as fate, change, and luck [38]. Most people, of course, fall somewhere between these extremes of internal or external control. It remains an open question as to the extent to which these personal differences in perceived control are modifiable for any given individual. Can we change the underlying belief orientation of an individual who is high on the 'external' side of this dimension? Can a therapist facilitate a change in such a person by the careful application of procedures designed to enhance self

Social Media and NSSI

uPosting NSSI images on social media can create opportunities for reinforcing the behavior (if the user receives "likes" for the image). uThese NSSI images can also create curiosity among those who have never engaged in NSSI (high risk among vulnerable youth). Along with social media, movies, television shows, and music may normalize, glorify, or promote NSSI

Article

change. As a result, they return to the precontemplation stage and can remain there for various periods of time. Approximately 15% of smokers who relapsed in our self- change research regressed back to the precontemplation stage (Prochaska & DiClemente, 1986). Fortunately, this research indicates that the vast ma- jority of relapsers—85% of smokers, for example—recycle back to the contemplation or preparation stages (Pro- chaska & DiClemente, 1984). They begin to consider plans for their next action attempt while trying to learn from their recent efforts. To take another example, fully 60% of unsuccessful New Year's resolvers make the same pledge the next year (Norcross, Ratzin, & Payne, 1989; Norcross & Vangarelli, 1989). The spiral model suggests that most relapsers do not revolve endlessly in circles and that they do not regress all the way back to where they began. Instead, each time relapsers recycle through the stages, they potentially learn from their mistakes and can try something different the next time around (DiClemente etal., 1991). On any one trial, successful behavior change is lim- ited in the absolute numbers of individuals who are able to achieve maintenance (Cohen et al., 1989; Schachter, 1982). Nevertheless, in a cohort of individuals, the number of successes continues to increase gradually over time. However, a large number of individuals remain in con- templation and precontemplation stages. Ordinarily, the more action taken, the better the prognosis. Much more research is needed to better distinguish those who benefit Figure 2 Percentage Abstinent Over 18 Months for Smokers in Precontemplation (PC), Contemplation (C), and Preparation (P/A) Stages Before Treatment (N = 570) Pretest 1 6 12 ASSESSMENT PERIODS from recycling from those who end up spinning their wheels. Additional investigations will also be required to ex- plain the idiosyncratic patterns of movement through the stages of change. Although some transitions, such as from contemplation to preparation, are much more likely than others, some people may move from one stage to any other stage at any time. Each stage represents a period of time as well as a set of tasks needed for movement to the next stage. Although the time an individual spends in each stage may vary, the tasks to be accomplished are assumed to be invariant. Treatment Implications Professionals frequently design excellent action-oriented treatment and self-help programs but then are disap- pointed when only a small percentage of addicted people register, or when large numbers drop out of the program after registering. To illustrate, in a major health mainte- nance organization (HMO) on the West Coast, over 70% of the eligible smokers said they would take advantage of a professionally developed self-help program if one was offered (Orleans et al., 1988). A sophisticated action-ori- ented program was developed and offered with great pub- licity. A total of 4% of the smokers signed up. As another illustration, Schmid, Jeffrey, and Hellerstedt (1989) com- pared four different recruitment strategies for home-based intervention programs for smoking cessation and weight control. The recruitment rates ranged from 1% to 5% of those eligible for smoking cessation programs and from 3% to 12% for those eligible for weight control programs. The vast majority of addicted people are not in the action stage. Aggregating across studies and populations (Abrams, Follick, & Biener, 1988; Gottleib, Galavotti, McCuan, & McAlister, 1990; Pallonen, Fava, Salonen, & Prochaska, in press), 10%-15% of smokers are prepared for action, approximately 30%-40% are in the contem- plation stage, and 50%-60% are in the precontemplation stage. If these data hold for other populations and prob- lems, then professionals approaching communities and worksites with only action-oriented programs are likely to underserve, misserve, or not serve the majority of their target population. Moving from recruitment rates to treatment out- comes, we have found that the amount of progress clients make following intervention tends to be a function of their pretreatment stage of change (e.g., Prochaska & DiClemente, 1992; Prochaska, Norcross, Fowler, Follick, & Abrams, 1992). Figure 2 presents the percentage of 570 smokers who were not smoking at four follow-ups over an 18-month period as a function of the stage of change before random assignment to four home-based self-help programs. Figure 2 indicates that the amount of success smokers reported after treatment was directly related to the stage they were in before treatment (Pro- chaska & DiClemente, 1992). To treat all of these smokers as if they were the same would be naive. And yet, that is what we traditionally have done in many of our treatment programs. September 1992 • American Psychologist 1105 If clients progress from one stage to the next during the first month of treatment, they can double their chances of taking action during the initial six months of the pro- gram. Of the precontemplators who were still in precon- templation at one month follow-up, only 3% took action by six months. For the precontemplators who progressed to contemplation at one month, 7% took action by six months. Similarly, of the contemplators who remained in contemplation at one month, only 20% took action by six months. At one month, 41% of the contemplators who progressed to the preparation stage attempted to quit by six months. These data demonstrate that treatment programs designed to help people progress just one stage in a month can double the chances of participants taking action on their own in the near future (Prochaska & DiClemente, 1992). Mismatching Stage and Treatment A person's stage of change provides proscriptive as well as prescriptive information on treatments of choice. Ac- tion-oriented therapies may be quite effective with indi- viduals who are in the preparation or action stages. These same programs may be ineffective or detrimental, how- ever, with individuals in precontemplation or contem- plation stages. An intensive action- and maintenance-oriented smoking cessation program for cardiac patients was highly successful for those patients in action and ready for action. This same program failed, however, with smokers in the precontemplation and contemplation stages (Ockene, Ockene, & Kristellar, 1988). Patients in this special care program received personal counseling in the hospital and monthly telephone counseling calls for six months fol- lowing hospitalization. Of the patients who began the program in action or preparation stages, an impressive 94% were not smoking at six-month follow-up. This per- centage is significantly higher than the 66% nonsmoking rate of the patients in similar stages who received regular care for their smoking problem. The special care program had no significant effects, however, with patients in the precontemplation and contemplation stages. For patients in these stages, regular care did as well or better. Independent of the treatment received, there were clear relationships between pretreatment stage and out- come. Twenty-two percent of all precontemplators, 43% of the contemplators, and 76% of those in action or pre- pared for action at the start of the study were not smoking six months later. A mismatched stage effect occurred with another smoking program. An HMO-based self-help smoking cessation program for pregnant women was successful with patients prepared for action but had negligible im- pact on those in the precontemplation stage. Of the women in the preparation stage who received a series of seven self-help booklets through the mail, 38% were not smoking at the end of pregnancy (which was approxi- mately 6 months posttreatment). This was triple the 12% success rate obtained for those who received regular care of advice and fact sheets. For precontemplators, however, 6% of those receiving special care and 6% receiving regular care were not smoking at the end of pregnancy (Ershoff, Mullen, & Quinn, 1987). These two illustrative studies portend the potential importance of matching treatments to the client's stage of change (DiClemente, 1991; Pro- chaska, 1991). Stage Movements During Treatment What progress do patients in formal treatment evidence on the stages of change? In a cross-sectional study we compared the stages of change scores of 365 individuals presenting for psychotherapy with 166 clients currently engaged in therapy (Prochaska & Costa, 1989). Patients entering therapy could usually be characterized as pre- pared for action because their highest score was on the contemplation scale and second highest was on the action scale. The contemplation and action scores crossed over for patients in the midst of treatment. Patients in the middle of therapy could be characterized as being in the action stage because their highest score was on the action scale. Compared with patients beginning treatment, those in the middle of therapy were significantly higher on the action scale and significantly lower on the contemplation and precontemplation scales. We interpreted these cross-sectional data as indi- cating that, over time, patients who remained in treatment progressed from being prepared for action into taking action. That is, they shifted from thinking about their problems to doing things to overcome them. Lowered precontemplation scores also indicated that, as engage- ment in therapy increased, patients reduced their defen- siveness and resistance. The vast majority of the 166 pa- tients who were in the action stage were participating in more traditional insight-oriented psychotherapies. The progression from contemplation to action is postulated to be essential for beneficial outcome, regardless of whether the treatment is action oriented or insight ori- ented (also see Wachtel, 1977,1987). This crossover pattern from contemplation to action was also found in a longitudinal study of a behavior ther- apy program for weight control (Prochaska, Norcross, et al., 1992). Figure 3 presents the stages of change scores at pre- and midtreatment. As a group, these subjects en- tering treatment could be characterized as prepared for action. During the first half of treatment, members of this contingent progressed into the action stage, with their contemplation scores decreasing significantly and their action scores increasing significantly. The more clients progressed into action early in therapy, the more successful they were in losing weight by the end of treatment. The stages of change scores were the second best predictors of outcome; they were better predictors than age, socioeconomic status, problem se- verity and duration, goals and expectations, self-efficacy, and social support. The only variables that outperformed the stages of change as outcome predictors were the pro- cesses of change the clients used early in therapy. 1106 September 1992 • American Psychologist Figure 3 A Longitudinal Comparison of Stages of Change Scores for Clients Before (Week I) and Midway Through (Week 5) a Behavioral Program for Weight Reduction STAGES OF CHANGE-WEIGHT 35 33 29 27 - CONTEMPLATION ACTION MAINTENANCE N=53 WEEKS Processes of Change The stages of change represent a temporal dimension that allows us to understand when particular shifts in attitudes, intentions, and behaviors occur. The processes of change are a second major dimension of the transtheoretical model that enable us to understand how these shifts occur. Change processes are covert and overt activities and ex- periences that individuals engage in when they attempt to modify problem behaviors. Each process is a broad category encompassing multiple techniques, methods, and interventions traditionally associated with disparate theoretical orientations. These change processes can be used within therapy sessions, between therapy sessions, or without therapy sessions. The change processes were first identified theoreti- cally in a comparative analysis of the leading systems of psychotherapy (Prochaska, 1979). The processes were se- lected by examining recommended change techniques across different theories, which explains the term trans- theoretical. At least 10 subsequent principal component analyses on the processes of change items, conducted on various response formats and diverse samples, have yielded similar patterns (Norcross & Prochaska, 1986; Prochaska & DiClemente, 1983; Prochaska & Norcross, 1983; Prochaska, Velicer, DiClemente, & Fava, 1988). Ex- tensive validity and reliability data on the processes have been reported elsewhere (Prochaska et al., 1988). The processes are typically assessed by means of a self-report instrument but have also been reliably identified in tran- scriptions of psychotherapy sessions (O'Connell, 1989). Our research discovered that naive self-changers used the same change processes that have been at the core of psychotherapy systems (DiClemente & Prochaska, 1982, 1985; Prochaska & DiClemente, 1984). Although dis- parate theories will emphasize certain change processes, the breadth of processes we have identified appear to cap- ture basic change activities used by self-changers, psy- chotherapy clients, and mental health professionals. The processes of change represent an intermediate level of abstraction between metatheoretical assumptions and specific techniques spawned by those theories. Gold- fried (1980, 1982), in his influential call for a rapproach- ment among the therapies, independently recommended change principles or processes as the most fruitful level for psychotherapy integration. Subsequent research on proposed therapeutic commonalities (Grencavage & Norcross, 1990) and agreement on treatment recom- mendations (Giunta, Saltzman, & Norcross, 1991) has supported Goldfried's view of change processes as the content area or level of abstraction most amenable to theoretical convergence. Although there are 250-400 dif- ferent psychological therapies (Herink, 1980; Karasu, 1986) based on divergent theoretical assumptions, we have been able to identify only 12 different processes of change based on principal components analysis. Similarly, al- though self-changers use over 130 techniques to quit smoking, these techniques can be summarized by a much smaller set of change processes (Prochaska et al., 1988). Table 1 presents the 10 processes receiving the most theoretical and empirical support in our work, along with their definitions and representative examples of specific interventions. A common and finite set of change pro- cesses has been repeatedly identified across such diverse problem areas as smoking, psychological distress, and obesity (Prochaska & DiClemente, 1985). There are striking similarities in the frequency with which the change processes were used across these problems. When processes were ranked in terms of how frequently they were used for each of these three problem behaviors, the rankings were nearly identical. Helping relationships, consciousness raising, and self-liberation, for example, were the top three ranked processes across problems, whereas contingency management and stimulus control were the lowest ranked processes. Significant differences occurred, however, in the ab- solute frequency of the use of change processes across problems. Individuals relied more on helping relation- ships and consciousness raising for overcoming psycho- logical distress than they did for weight control and smoking cessation. Overweight individuals relied more on self-liberation and stimulus control than did distressed individuals (Prochaska & DiClemente, 1985). Processes as Predictors of Change The processes have been potent predictors of change for both therapy changers and self-changers. As indicated earlier, in a behavioral weight control program, the pro- September 1992 • American Psychologist 1107 Table 1 Titles, Definitions, and Representative Interventions of the Processes of Change Process Definitions: Interventions Consciousness raising Self-reevaluation Self-liberation Counterconditioning Stimulus control Reinforcement management Helping relationships Dramatic relief Environmental reevaluation Social liberation Increasing information about self and problem: observations, confrontations, interpretations, bibliotherapy Assessing how one feels and thinks about oneself with respect to a problem: value clarification, imagery, corrective emotional experience Choosing and commitment to act or belief in ability to change: decision-making therapy, New Year's resolutions, logotherapy techniques, commitment enhancing techniques Substituting alternatives for problem behaviors: relaxation, desensitization, assertion, positive self-statements Avoiding or countering stimuli that elicit problem behaviors: restructuring one's environment (e.g., removing alcohol or fattening foods), avoiding high risk cues, fading techniques Rewarding one's self or being rewarded by others for making changes: contingency contracts, overt and covert reinforcement, self-reward Being open and trusting about problems with someone who cares: therapeutic alliance, social support, self-help groups Experiencing and expressing feelings about one's problems and solutions: psychodrama, grieving losses, role playing Assessing how one's problem affects physical environment: empathy training, documentaries Increasing alternatives for nonproblem behaviors available in society: advocating for rights of repressed, empowering, policy interventions cesses used early in treatment were the single best pre- dictors of outcome (Prochaska, Norcross, et al., 1992). For self-changers with smoking, the change processes were better predictors of progress across the stages of change than were a set of 17 predictor variables, including de- mographics, problem history and severity, health history, withdrawal symptoms, and reasons for smoking (Pro- chaska, DiClemente, Velicer, Ginpil, & Norcross, 1985; Wilcox, Prochaska, Velicer, & DiClemente, 1985). The stages and processes of change combined with a decisional balance measure were able to predict with 93% accuracy which patients would drop out prematurely from psychotherapy. At the beginning of therapy, pre- mature terminators were much more likely to be in the precontemplation stage. They rated the cons of therapy as higher than the pros, and they relied more on willpower and stimulus control than did clients who continued in therapy or terminated appropriately (Medieros & Pro- chaska, 1992). Integrating the Processes and Stages of Change The prevailing Zeitgeist in psychotherapy is the integration of leading systems of psychotherapy (Norcross & Gold- fried, 1992; Norcross, Alford, & DeMichele, 1992). Psy- chotherapy could be enhanced by the integration of the profound insights of psychoanalysis, the powerful tech- niques of behaviorism, the experiential methods of cog- nitive therapies, and the liberating philosophy of existen- tialism. Although some psychotherapists insist that such theoretical integration is philosophically impossible, or- dinary people in the natural environment can be re- markably effective in finding practical means of synthe- sizing powerful change processes. The same is true in addiction treatment and re- search. There are multiple interventions but little inte- gration across theories (Miller & Hester, 1980). One promising approach to integration is to begin to match particular interventions to key client characteristics. The Institute of Medicine's (1989) report on prevention and treatment of alcohol problems identifies the stages of change as a key matching variable. A National Cancer Institute report of self-help interventions for smokers also used the stages as a framework for integrating a variety of interventions (Glynn, Boyd, & Gruman, 1990). The transtheoretical model offers a promising approach to in- tegration by combining the stages and processes of change. A Cross-Sectional Perspective One of the most important findings to emerge from our self-change research is an integration between the pro- cesses and stages of change (DiClemente et al., 1991; 1108 September 1992 • American Psychologist Table 2 Stages of Change in Which Particular Processes of Change Are Emphasized Precontemplation Contemplation Preparation Action Maintenance Consciousness raising Dramatic relief Environmental reevaluation Self-reevaluation Self-liberation Reinforcement management Helping relationships Counterconditioning Stimulus control Norcross, Prochaska, & DiClemente, 1991; Prochaska & DiClemente, 1983,1984). Table 2 demonstrates this in- tegration from cross-sectional research involving thou- sands of self-changers representing each of the stages of change for smoking cessation and weight loss. Using the data as a point of departure, we have interpreted how particular processes can be applied or avoided at each stage of change. During the precontemplation stage, in- dividuals used eight of the change processes significantly less than people in any of the other stages. Precontem- plators processed less information about their problems, devoted less time and energy to reevaluating themselves, and experienced fewer emotional reactions to the negative aspects of their problems. Furthermore, they were less open with significant others about their problems, and they did little to shift their attention or their environment in the direction of overcoming problems. In therapy, these would be the most resistant or the least active clients. Individuals in the contemplation stage were most open to consciousness-raising techniques, such as obser- vations, confrontations, and interpretations, and they were much more likely to use bibliotherapy and other educa- tional techniques (Prochaska & DiClemente, 1984). Contemplators were also open to dramatic relief expe- riences, which raise emotions and lead to a lowering of negative affect if the person changes. As individuals be- came more conscious of themselves and the nature of their problems, they were more likely to reevaluate their values, problems, and themselves both affectively and cognitively. The more central their problems were to their self-identity, the more their reevaluation involved altering their sense of self. Contemplators also reevaluated the effects their addictive behaviors had on their environ- ments, especially the people with whom they were closest. They struggled with questions such as "How do I think and feel about living in a deteriorating environment that places my family or friends at increasing risk for disease, poverty, or imprisonment?" Movement from precontemplation to contemplation and movement through the contemplation stage entailed increased use of cognitive, affective, and evaluative pro- cesses of change. Some of these changes continued during the preparation stage. In addition, individuals in prepa- ration began to take small steps toward action. They used counterconditioning and stimulus control to begin re- ducing their use of addictive substances or to control the situations in which they relied on such substances (DiClemente et al., 1991). During the action stage, people endorsed higher lev- els of self-liberation or willpower. They increasingly be- lieved that they had the autonomy to change their lives in key ways. Successful action also entailed effective use of behavioral processes, such as counterconditioning and stimulus control, in order to modify the conditional stim- uli that frequently prompt relapse. Insofar as action was a particularly stressful stage, individuals relied increas- ingly on support and understanding from helping rela- tionships. Just as preparation for action was essential for suc- cess, so too was preparation for maintenance. Successful maintenance builds on each of the processes that came before. Specific preparation for maintenance entailed an assessment of the conditions under which a person was likely to relapse and development of alternative responses for coping with such conditions without resorting to self- defeating defenses and pathological responses. Perhaps most important was the sense that one was becoming the kind of person one wanted to be. Continuing to apply counterconditioning and stimulus control was most ef- fective when it was based on the conviction that main- taining change supports a sense of self that was highly valued by oneself and at least one significant other. September 1992 • American Psychologist 1109 A Longitudinal Perspective Cross-sectional studies have inherent limitations for as- sessing behavior change, and we, therefore, undertook research on longitudinal patterns of change. Four major patterns of behavior change were identified in a two-year longitudinal study of smokers (Prochaska, DiClemente, Velicer, Rossi, & Guadagnoli, 1992): (a) Stable patterns involved subjects who remained in the same stage for the entire two years; (b) progressive patterns involved linear movement from one stage to the next; (c) regressive pat- terns involved movement to an earlier stage of change; and (d) recycling patterns involved two or more revolu- tions through the stages of change over the two-year pe- riod. The stable pattern can be illustrated by the 27 smokers who remained in the precontemplation stage at all five rounds of data collection. Figure 4 presents these precontemplators' standardized scores (M = 50, SD = 10) for the 10 change processes being used at six-month intervals over the two-year period. All 10 processes re- mained remarkably stable over the two-year period, demonstrating little increase or decrease over time. This figure graphically illustrates what individuals resistant to change were likely to be experiencing and doing. Eight of 10 change processes, like self-reevaluation and self-liberation, were between 0.4 and 1.4 standard deviations below the mean (i.e., 50). In brief, these subjects were doing very little to control or modify themselves or their problem behavior. This static pattern was in marked contrast to the pattern representing people who progressed from con- templation to maintenance over the two-year study. Sig- nificantly, many of the change processes did not simply increase linearly as individuals progressed from contem- plation to maintenance. Self-reevaluation, consciousness raising, and dramatic relief—processes most associated with the contemplation stage—demonstrated significant decreases as self-changers moved through the action stage into maintenance. Conversely, self-liberation, stimulus control, contingency control, and counterconditioning— processes most associated with the action stage—evi- denced dramatic increases as self-changers moved from contemplation to action. These change processes then leveled off or decreased when maintenance was reached (Prochaska, DiClemente, et al., 1992). Progressive self-changers demonstrated an almost ideal pattern of how change processes can be used most effectively over time. They seemed to increase the partic- ular cognitive processes most important for the contem- plation stage and then to increase more behavioral pro- cesses in the action and maintenance stages. Before over- idealizing the wisdom of self-changers, note that only 9 of 180 contemplators found their way through this pro- gressive pattern without relapsing at least once. The longitudinal results of the 53 clients completing a behavior therapy program for weight control provide additional support for an integration of the processes and stages of change (Prochaska, Norcross, et al., 1992). As mentioned earlier, this group progressed from contem- plation to action during the 10-week therapy program. Figure 5 presents the six change processes that evidenced significant differences over the course of treatment. As predicted by the transtheoretical model, clients reported significantly greater use of four action-related change processes: counterconditioning, stimulus control, inter- personal control, and contingency management. They also increased their reliance on social liberation and de- creased their reliance on medications, wishful thinking, and minimizing threats. In other words, these clients were substituting alternative responses for overeating; they were restructuring their environments to include more stimuli that evoked moderate eating; they reduced stimuli that prompted overeating; they modified relationships to en- courage healthful eating; and they paid more attention to social alternatives that allow greater freedom to keep from overeating. Integrative Conclusions Our search for how people intentionally modify addictive behaviors encompassed thousands of research participants attempting to alter, with and without psychotherapy, a myriad of addictive behaviors, including cigarette smok- ing, alcohol abuse, and obesity. From this and related research, we have discovered robust commonalities in how people modify their behavior. From our perspective the underlying structure of change is neither technique-ori- ented nor problem specific. The evidence supports a transtheoretical model entailing (a) a cyclical pattern of movement through specific stages of change, (b) a com- mon set of processes of change, and (c) a systematic in- tegration of the stages and processes of change. Probably the most obvious and direct implication of our research is the need to assess the stage of a client's readiness for change and to tailor interventions accord- ingly. Although this step may be intuitively taken by many experienced clinicians, we have found few references to such tailoring before our research (Beutler & Clarkin, 1990, Norcross, 1991). A more explicit model would en- hance efficient, integrative, and prescriptive treatment plans. Furthermore, this step of assessing stage and tai- loring processes is rarely taken in a conscious and mean- ingful manner by self-changers in the natural environ- ment. Vague notions of willpower, mysticism, and bio- technological revolutions dominate their perspectives on self-change (Mahoney & Thoreson, 1972). We have determined that efficient self-change de- pends on doing the right things (processes) at the right time (stages). We have observed two frequent mismatches. First, some self-changers appear to rely primarily on change processes most indicated for the contemplation stage—consciousness raising, self-reevaluation—while they are moving into the action stage. They try to modify behaviors by becoming more aware, a common criticism of classical psychoanalysis: Insight alone does not nec- essarily bring about behavior change. Second, other self- changers rely primarily on change processes most indi- 1110 September 1992 • American Psychologist Figure 4 Use of Change Processes (T scores) for 23 Smokers Who Remained in the Precontemplation Stage at Each of Five Assessment Points Over Two Years 64 62 60 58 56 54 O Z 50 LJJ ID O 48 W PRECONTEMPLATORS *- - -# CONSCIOUSNESS RAISING Q O HELPING RELATIONSHIPS A- - -A S6LF LIBERATION £ & ENVIRONMENTAL REEVALUATION •- - -• DRAMATIC RELIEF O—-<> SOCIAL LIBERATION _ V- — •• COUNTER CONDITIONING V V SELF REEVALUATION • • STIMULUS CONTROL D Q REINFORCEMENT MANAGEMENT Process 46 44 42 40 38 36 h 34 3 4 ROUND cated for the action stage—reinforcement management, stimulus control, counterconditioning—without the req- uisite awareness, decision making, and readiness provided in the contemplation and preparation stages. They try to modify behavior without awareness, a common criticism of radical behaviorism: Overt action without insight is likely to lead to temporary change. We have generated a number of tentative conclusions from our research that require empirical confirmation. Successful change of the addictions involves a progression through a series of stages. Most self-changers and psy- chotherapy patients will recycle several times through the stages before achieving long-term maintenance. Accord- ingly, intervention programs and personnel expecting September 1992 • American Psychologist 1111 Figure 5 Change Processes That Significantly Increased or Decreased During a 10-Week Behavioral Program for Weight Reduction on a Likert Scale Ranging From 1 (Newer Use; to 5 CAImost Always Use; (N = 53) 4 r WISHFUL THINKING z LU Z> o COUNTER- CONDITIONING SELF-LIBERATION REINFORCEMENT MANAGEMENT MINIMIZING THREATS STIMULUS CONTROL INTERPERSONAL CONTROL MEDICATIONS WEEK ) WEEK 5 WEEK 10 people to progress linearly through the stages are likely to gather disappointing and discouraging results. With regard to the processes of change, we have ten- tatively concluded that they are distinct and measurable both for self- and therapy changers. Similar processes ap- pear to be used to modify diverse problems, and similar processes are used within, between, and without psycho- therapy sessions. Dynamic measures of the processes and stages of change outperform static variables, like demo- graphics and problem history, in predicting outcome. Competing systems of psychotherapy have promul- gated apparently rival processes of change. However, os- tensibly contradictory processes can become comple- mentary when embedded in the stages of change. Spe- cifically, change processes traditionally associated with the experiential, cognitive, and psychoanalytic persuasions are most useful during the precontemplation and con- templation stages. Change processes traditionally asso- ciated with the existential and behavioral traditions, by contrast, are most useful during action and maintenance. People changing addictive behaviors with and without therapy can be remarkably resourceful in finding practical means of integrating the change processes, even if psy- chotherapy theorists have been historically unwilling or unable to do so. Attending to effective self-changers in the natural environment and integrating effective change processes in the consulting room may be two keys to un- locking the elusive structure of how people change

The Neuron

ake a look at the picture to the right, which depicts the components of the neuron. ■ Neurons communicate by sending chemical signals from the axon of one neuron to the dendrite of another (which is an electrochemical process). ■ The brain has over 100 billion neurons.

Level: Partial Hospitalization (PHP) or Intensive Outpatient (IOP)

level 2 options of treatment are different from Levels 3 and 4 because the client does not live at the facility. Instead, they live at home and attend structured programs during the day. Two types of Level 2 treatment are PHP and IOP. PHP is a structured day treatment (7-8 hours a day) in hospital or treatment facilities. IOP typically consists of three group sessions per week (3 hours each), individual sessions, and 12-step program attendance. Often PHP/IOP are step down programs from residential treatment. Less restrictive than residential, but offers more support than standard outpatient services

Psychological Model

m the psychological model, addiction is conceptualized as: A secondary issue (a symptom of something else); The primary issue is psychological distress (trauma, mental illness, life difficulties, etc.) Individual with addiction is conceptualized as: Psychologically distressed; the person is using substances as a coping mechanism The solution to the problem of addiction is conceptualized as: Therapy/help to address the underlying psychological issue and the substance use will stop From this perspective, the distressed individual is self-medicating with substances

Neurotransmitters

ow do neurons communicate and send messages? ■ A space exists between the axon of one neuron and the dendrite of another neuron. This space is called the synapse. ■ To communicate, the axon releases a chemical, called a neurotransmitter , to travel across the gap and bind to the receptors of the next neuron's dendrite. ■ Receptors only receive the neurotransmitter for which it was designed (like a lock and key). ■ See the graphic to the right to get a visual of this process.

Hagedorn Group Counseling

same times. If there are persons who are left with a lot of remaining text, they should continue reading the text until they have finished. The counselor has several tasks to complete during the reading of the letters. A coleader can be a tremendous asset in this process. First, the flow of the spoken statements needs to be maintained; do not allow clients to start processing their statements during the activity. Second, pay atten- tion to participants' nonverbal behaviors (tears, looks of anger, empathie gestures such as head nodding) because these can be addressed during the postevent processing. Third, the counselor may choose to give one of the following directives at different times during the readings to ground participants' experiences in the present: 1. "Let's all take a deep breath in through the nose and out through the mouth, breathing deeply from your diaphragm." Then, "Con- tinue where we left off." This directive can be given several times throughout the exercise because (a) participants tend to breathe shallowly and (b) the act of taking a deep breath can help partici- pants release pent-up emotions. 2. "Make an effort to connect with others in the group by making eye contact with them when you're not reading your letter." This directive helps participants to connect on deeper levels and helps alleviate some of the shame involved with what they are sharing. Depending on the number of people in the group, the length of the written letters, and the amount of highlighted text, this first period of the group experience can last anywhere from 30 to 45 minutes. In the next phase, the postevent processing, the skilled group leader can spend between 45 to 90 minutes processing the thoughts and emotions that evolve from the activity. Postevent Processing Once the participants have finished reading their letters, the leader should transition into group processing mode. One simple way to track the vari- ous levels of processing is to use a What? So what? Now what? sequence of questions (Reed & Koliba, 1996). Beginning with the What? line of ques- tions, the leader can ask someone in the group to concretely explain what just occurred in the group. This might be an opportunity to encourage a previously silent member of the group to speak about something impersonal (thus not requiring any disclosure on his or her part). The leader might prompt with, "Jessie, would you describe in general what just happened in the group, beginning with my passing out everyone's letters?" Should Jessie begin to describe specific content or processes that occurred during the letter reading, the leader should intervene with a comment about how the group will wait to explore specific content and encourage her to pro- ceed step by step in her description of the activity. The leader should then 118 journal of Addictions & Offender Counseling • April 2011 • Volume 31 summarize what Jessie shared. The next level of What? questions involves inviting each parficipant to share What? feelings and/or thoughts he or she had during the reading of his or her letter. If there were any group members who did not participate in the activity, these individuals may be invited to share their own reacfions first, as a way to invite them into the overall group processing. A prompt such as, "I wonder if anyone would be willing to share your reactions to what you read from your letter" works well. After everyone has had an opportunity to share their reactions to what they individually wrote or read, additional What? questions can include the following: • What feelings did you experience as you listened to what was read in the circle? • What did you notice about others in the group? • Was there something that someone else shared that had a signifi- cant impact on you? • What happened to you when I asked you to take a deep breath? • What happened when I asked you to make eye contact with others? Depending on the leader's style and orientation, sharing his or her reac- tions would be appropriate. This might be important as a model for how others can share. For example, the leader might share the following reacfions: As I listened to each of you reading in the circle, I almost experienced a sense of diz- ziness with the ongoing dialogue I heard between you and your addictions. Hearing the struggle between love and hate, between what the addiction has done for you and, at the same time, what it has cost you, it had a very strong impact on me. Did anyone else experience something similar? The leader might share personal insights as well, but is cautioned to facili- tate the parficipants' insights before sharing his or her own. The intent of So what? questions is to move the group out of the processing of their current thoughts and emotions about the event and into a discus- sion of what the experience meant to them. Prompts such as the following can help facilitate this processing: • Given what you've just shared, what does this mean to you? • Why did that have a strong impact on you? • Mona, I noticed you having a personal reaction to what Paul said. Would you be willing to share what that meant to you? If necessary, the discussion can be shifted from individuals' meaning mak- ing to a focus on what the event meant to the group itself. This can be a particularly important part of building cohesion in the group. Finally, Now what? questions move the group into discussions of applica- tion: "What are you/we going to do with these new insights and observa- fions?" The leader can ask things such as. journal of Addictions & Offender Counseling • April 2011 • Volume 31 119 • Given what you've just shared with the group, are you comfortable with where you are in your life? • If you are not satisfied with your current situation, what will need to change in your life in order to get what you want? • What type of resources will you need to accomplish your goals? • How will you know when you have regained control of your life? These discussions are particularly important for those stuck in any one of the early stages of change and/or for those navigating the gap between stages. For example, for those in the precontemplation stage, these discus- sions can help them to move beyond their denial and resistance to change, to recognize that a problem does exist, and to understand their role in that problem. For those in the contemplation stage, it can rouse them out of their tendency to substitute thinking for behaviors, get unstuck from chronic procrastination, and begin to make a concrete plan for change. For those in the preparation stage, the insights gained from this activity help foster the need for creating a detailed plan of action and to seek feedback about the feasibility of the plan. Now what? discussions can foster the working stage of group development, where members begin to hold one another accountable for change-worthy behaviors in the group (e.g., honesty, reduc- tions of minimization, increases in assertiveness) and outside of the group (e.g., ending a damaging relationship, finding a new job, making amends with someone who has been hurt). Next Steps Given time and the inclination of the group leader, an additional com- ponent of the group experience is to have members share their thoughts, emotions, and reactions to a song ("Addicted," by Simple Plan, 2002). The group leader introduces the last portion of the activity. I'd like to play a song for you. As you listen, imagine that this song represents a letter that your addiction is writing back to you in response to the letter that we just discussed. At the end of the song, I'd like to hear your reactions. At this point, the song is played and a set of lyrics can be distributed (found on such Internet sites as Lyrics.com). The essence of the song is that the vocalist (a) cannot accept the fact that the listener broke off a relationship, (b) wants the listener to return to him, and (c) recognizes that he is addicted to the listener. The lyrics are particularly poignant given the content just discussed in the participants' letters to their addiction. Following the same line of processing questions introduced earlier, par- ticipants are asked about the messages they heard in the song (using What? questions), what these mean to them {So what? questions), and how this will affect their future decisions {Now what? questions). In response to the What? questions, participants typically share insights related to how their addiction will not easily give up on its relationship with them and will do 120 Journal of Addictions & Offender Counseling • April 2011 • Volume 31 all that it can to reengage them. So what? questions evoke discussions of the importance of maintaining one's resolve in saying goodbye and include following through on any behaviors that support the recovery process. Concluding with Now what? questions results in concrete discussions of what each individual will do to solidify the self-motivational statements made during the group activity, such as regular attendance at a support group; seeking a connection with a higher power; and avoiding those people, places, and things that trigger addictive use. The song can be an effective way to bring participants out of a pervasive affective state that the reading of the Letters can evoke. Overall, this additional activity can take between 30 to 45 minutes. There are several possible avenues to follow after the letters and song have been processed in the group. Eirst, group members can hold onto their let- ters as a reminder of their various commitments to change. Members have noted the positive reinforcement that these letters provided them when they felt tempted to return to old behavior patterns. The leader may also choose to collect the letters, to place them in the clients' files, and to use them at the end of the treatment period as a way to measure progress. Additional creative steps can be taken with the song and letters, such as the following: 1. Participants can use various media to visually or audibly represent the break-up between themselves and their addiction. Collages, us- ing images from magazines, that designate the end of the relation- ship; songs that speak to the loss experienced after a break-up; or journals that chronicle the process of letting go can all be valuable ways to help clients cope with their continued struggles. 2. The letters can be written on magicians' flash paper, which can be purchased at most magic stores. After the group has processed the letters, the leader uses a match or lighter to ignite a corner of the paper, which will flame up and disappear almost instantly. Obvi- ously, the leader should use all necessary safety precautions (e.g., conducting this activity outdoors, away from buildings and trees, with water and/or a fire extinguisher close at hand). Process what occurs with participants as they see their letters go up in flames and vanish (e.g., "Is the relationship really over that quickly?"). 3. The letters can be placed in small cardboard boxes (such as those used to package jewelry) and buried in an "addiction cemetery." Participants can write a eulogy to their addiction, a ceremony can be held with others in attendance, and then each individual can bury his or her boxed letter in the ground. Process with the group what burying their addiction means to them. Participants who relapse and later return to treatment might be encouraged to dig up their letter, hold the dirty and decaying cardboard box in their hands, and discuss what they need to do to bury the addiction once and for all. journal of Addictions a Offender Counseling • April 2011 • Volume 31 121 4. The letters can be placed in an envelope, tied to a helium-filled balloon, and then released into the air. Or, they can be placed in cardboard boxes (or other biodegradable packages) and released into the water. There are endless possibilities for follow-up activities regarding the emo- tional impact of the letter-writing activity. A case study follows, including an actual letter written by a participant, as an example of how this activ- ity can be used. (The writer provided informed consent to use the letter and all identifying information has been altered to maintain anonymity) Case Study: Enrique Enrique is a 45-year-old Cuban man who sought treatment for his ad- dictive sexual behaviors. The intensive outpatient program that he chose focused on treating all addictions simultaneously; addictions to chemicals, eating, sex, relationships, the Internet, and work were common among the clientele. This was Enrique's first time in treatment. The Sexual Addiction Screening Test (Carnes, 1992) and the Withdrawal, Adverse Consequences, Inability to Stop, Tolerance or intensity. Escape, Time Spent, and Time Wasted Interview (Hagedorn & Juhnke, 2005) were used to assessed the magnitude of his addictive behaviors. Both instruments indicated that Enrique's behaviors met criteria for sexual addiction. In completing the intake process, it was determined that he was at the contemplative stage of change in that he recognized that he had a problem, but still felt that he had little control over his behaviors. As a result of his assessment results, Enrique was placed in an open beginner's group for a 3-week treatment period. The Letter to My Substance/Behavior exercise was assigned to his group during the fourth session (which occurred on a Friday), was turned in during the fifth session (on Monday), and processed during the sixth session (on Tuesday). Enrique's letter is included in the following section. The words in bold were those that were highlighted by the group counselor. There were 11 participants (presenting with a variety of addictive disorders) in the group on the day that the letters were processed; after the directions were given, members began reading the highlighted portions of their letters aloud. Prompts related to taking deep breaths and making eye contact were initiated. Following the reading of the letters, the What? So what? Now what? lines of questioning were used, which resulted in using the next group session (the seventh session on Thursday) to process the material. Enrique and the rest of the group experienced a wide range of emotions and insights during the sixth session, between the sixth and seventh session, and again in the seventh session. Group members viewed their discussion of the letters, which took place later in the treatment process, as one of their most meaningful experiences during treatment. 122 journal of Addictions & Offender Counseling • April 2011 • Volume 31 Goodbye to an Old Friend: Sexual Addiction Sexual addiction, how long have I known you? We first met when I was 8; my Dad made it possible to meet you in a powerful way. He kept you as a secret but I found you, and that was how I treated you, as a secret, and I wanted you for myself. I was immediately attracted to you, your beauty, your will- ingness to please me, and smile for me made me feel as if I were your lover. Looking at you fílled me with an excitement I had not experienced before. My heart would race, my breathing would quicken, and I felt that I was desired. With your help I quickly discovered I could bring myself pleasure, without risking any kind of rejection. This only increased my desire to spend more time with you. At first I had to be covert to see you and spend time with you; that intro- duced me to the excitement of pursuing you. I would plan our meeting hours before I was able to get alone with you; and you were always ready with your naked acceptance. Then I soon discovered that you were in my thoughts, I could recall images of you as if you were there. I called on you whenever I felt lonely, rejected, sad, or frightened. You made it so I did not have to deal with those uncomfortable feelings, and replaced it with instant gratification. I was so willing to accept and use your gift of pleasure. Even though you were there to accept me and offer your sexual gifts for my pleasure, you were still a secret lover. I could not share you with anyone and that drove me away from developing relationships that would fill me in a better way. I was ashamed of my relationship with you and dependence on you. I was becoming aware of your emptiness, but could not stop wanting to see you. The price of keeping you as a mistress was beginning to take its toll. My feelings of shame of knowing you kept me away from being truly intimate with others. I was so used to using you as a magic potion to heal my feelings that I went straight to your arms. I no longer left our times together feeling loved but felt ashamed and hating myself for not being strong enough to reject you. You are a powerful lover who is not easily dismissed. My relationship with you has cost me dearly. I lost the innocence of dis- covering sex with a wife. I have lost the love of my first wife and our marriage. My children have suffered the pain of their Mom and Dad divorcing. Yet even with these traumas, your hold on me drove me to your arms recently and has driven a wedge betw^een my current wife and myself. You are a patient and unrelenting force; you do not care or respect me or others but demand attention at any cost. I am saying goodbye my friend, my first love. I no longer wish to be united to you. I know you will not say farewell easily, and I will struggle at times to let you go. You will be there to tempt and lure me in many ways and forms, possibly for the rest of my life. I have exposed you for what you are. I have admitted that you are a stronger force than me. I know that there is a Power that is greater than you; that one is God. With His help and the friendship of those that know and understand that God is able to fill my desires, you will lose your hold on me. I cannot say I wish you well; you will have to be satisfied that I know who you are— a deceiving substitute for true intimacy. Goodbye and good riddance, Enrique journal of Addictions & Offender Counseling • April 2011 • Volume 31 123 Conclusion and Future Directions The letter-writing group activity is a powerful way to help addicted clients to work through resistance and ambivalence. This activity can (a) decrease resistance as members talk about their letters rather than talk about themselves; (b) address ambivalence by fostering increased insight into the positive and negative experiences behind their addictive acfivifies; (c) increase cohesion among group members; (d) circumvent common defense mechanisms (e.g., minimization and rafionalization) as members hear their own thoughts and behaviors reflected in others' letters regardless of the type of addicfion; and (e) "offer creative right-brained opportunities for clients to explore their feelings, mofivations, and insights as they relate to their past experiences, current ineffective coping mechanisms, and the development of more adap- tive problem-solving strategies" (Hagedorn & Hirshhorn, 2009, p. 63). Next, given the creative and subjective nature of preparing and processing the letter-writing activity as well as the affective nature of the exercise itself, clinicians should have the necessary emotional and professional maturity to (a) manage a wide range of group members' emotional expressions, (b) set applicable group rules to help guide members' behaviors (and intercede when necessary), and (c) examine their own cognitive and/or emotional reactions to what occurs during the activity. If clinicians are not well- grounded and prepared for what can evolve from an experiential activity such as letter writing, the results for clients could be counterproductive at best and disastrous at worst. Finally, it is important to remember that clinicians need to always pracfice in an ethical marvner. Pursuant to the American Counseling Associafion's (2005) ACA Code of Ethics (Standard C.6.e.), although this technique is grounded in theory, it does not have a lot of empirical support for this population. There is a need for future research that would provide support for this activity, perhaps with a focus on how it fosters client growth, decreases resistance, and resolves ambivalence as compared to other modalities and exercises. If readers choose to use this acfivity with a group of addicted clients, they are highly encouraged to pracfice the acfivity first with nonclients and to seek direct supervision and consultation, both during practice and during implementation. Such diligence will help clinicians to use the letter-writing activity accurately, thus learning an effective and powerful way to draw out the necessary client emotions and insights to help decrease resistance and resolve ambivalence

Drugs and Neurotransmitters

specific drugs of abuse influence specific neurotransmitters by mimicking them or changing their effects. Look at the chart on the next slide to see which drugs of abuse influence which neurotransmitters.

Disease of Addiction

t's review. Given what we know about the brain and drugs of abuse, let's answer the following questions: ■ Does everyone who uses drugs have a disease? - No. About 10% of those who try a drink or drug have the disease of addiction, meaning they are genetically predisposed. The disease of addiction is characterized by a loss of control over use and continued use despite negative consequences. These individuals need help to stop using and the goal of treatment is total abstinence. ■ Can drug use be harmful even to those without the disease? - Yes. Prolonged exposure to drugs of abuse can cause lasting changes in the brain (called neuroadaptations) and lead to negative physical and neurological consequences (for example, one use of methamphetamines can cause psychosis in some users).

Group Counseling vs. 12-Step Groups

u Group counseling is different from support groups in several ways: uGroup counseling is led by a licensed professional while support groups are typically led by a peer (someone in recovery). uCounseling groups are limited in size (typically 8-12 people) and support groups have no limit. uSupport groups are free while group counseling has a fee associated with it (clients can pay out of pocket or through insurance). uGroup counseling encourages group members to give feedback to one another and ask questions, but support groups have a "no cross-talk" policy, meaning people do not receive feedback for what they share.

Experiential Activities in Group Counseling

uAlong with talk therapy, addictions counseling groups are ideal settings for experiential activities (or activities to promote learning, reflection, and insight). Some experiential activities include: uWriting a goodbye letter to one's addiction (you will get more information from the associated article in this module) uIdentifying obstacles to one's recovery (typically by navigating through an obstacle course or similar scenario—the second Hagedorn article explains additional activities) uGraduation ceremonies (when a group member finishes treatment and receives a certificate or symbolic gift and words of affirmation from others) uExperiential activities can foster new insights by engaging in an experience rather than relying on dialogue only.

Adolescent Motives Study

uResearchers wanted to understand more about why adolescents engage in NSSI. Of 108 adolescents in inpatient treatment (12-17 years old), researchers found that 82.4% engaged in self-harm. uAverage age of onset of NSSI behavior was 12.8 years old. uAmong the adolescents in the study, the motives for self-harm included: u52.9% to stop bad feelings u34.1% to feel something, even if it was pain u31.8% to punish themselves u30.6% to relieve feeling numb or empty (Nock & Prinstein, 2004)

NSSI and Suicide: A Complex Relationship

uAlthough NSSI is distinct from a suicide attempt, there is a relationship between NSSI and suicidality. uNSSI is a significant predictor of suicide (those who self-harm are more likely to attempt suicide) uThoughts of NSSI and suicide do not typically occur at the same time uDifferences between NSSI and suicide attempts: uNSSI- more frequently performed by any one individual, average 2-3 NSSI methods, does not typically require medical attention, intent is to cope with emotional distress and continue living uSuicide attempts- less frequent per person, includes same method for multiple attempts, requires medical attention, intent is to end life Some suggest that self-harm and suicide are on the same continuum; others suggest a third variable influences both self harm and suicide (the two are not necessarily related with each other, but both with the third variable like depression; Wester & Trepal, 2017

Proposed Diagnosis for NSSI Disorder

uAlthough not an official diagnosis, below are the proposed criteria for NSSI Disorder in the DSM-5 (listed in section in need of further research): uIn the last year engaged in NSSI for 5+ days uEngages in NSSI with one or more of the following expectations: 1) obtain relief from negative feeling or cognitive state, 2) resolve interpersonal difficulty, 3) induce a positive feeling state uNSSI associated with one or more of the following: 1)interpersonal difficulties (negative feelings, depression, anxiety, self-criticism, etc.), 2) Preoccupation with self injury making it difficult to control, 3) thinking about self injury frequently (rumination) uNot socially sanctioned behavior (piercings, tattoos, religious/cultural rituals) uCauses distress and impedes functioning uNot trichotillomania (hair pulling) or excoriation (skin picking)

SMART Recovery

uAnother non-12-step based support group for addiction is SMART recovery, or Self-Management and Recovery Training. uSMART Recovery focuses on self-empowerment and self-reliance. uThere is no central spiritual component or belief in powerlessness. uThey do not use terms like "addict" or "alcoholic." uSMART Recovery is based on a 4-point program: u1) Building and maintaining motivation to change, 2) Coping with urges to use, 3) Managing thoughts/feelings/behaviors without addictive behaviors, and 4) Living a balanced, positive, healthy life. uSMART Recovery utilizes cognitive behavioral therapy approaches and problem-solving methods to help members sustain recovery. Meetings are led by trained volunteers. Currently, there are 3,000 SMART Recovery meetings in 24 countries

Women for Sobriety (WFS)

uAnother non-12-step program is Women for Sobriety (WFS) which was started by Jean Kirkpatrick in 1976. uThis program relies on behavioral strategies to overcome the disease of addiction. uWFS focuses on empowering women through self-reliance. uWFS exists as an alternative to mixed gender support groups or groups with a spiritual component. uWFS relies on 13 statements of what life can be like in recovery.

Adolescent Motives Study

uAnother study investigated motives for NSSI among 856 students in Ireland (15-17 years old). u12% of the sample engaged in self-harm uThe students reported their motives for their last self-harm experience: u79% I wanted to get relief from a terrible state of mind u38% I wanted to punish myself u35% I wanted to show how desperate I was feeling u14% I wanted to frighten someone u12% I wanted to find out whether someone really loved me u11% I wanted to get attention uThus as opposed to the idea that adolescents engage in NSSI for "attention", the researchers found strong support for motives of affect regulation and little support for motives of manipulating others (Doyle, Sheridan, & Treacy, 2017).

Consider the Following Group Counseling Scenario:

uGary just joined the group and has been silent for the first few sessions. Suddenly, in the middle of another group member's story, Gary beings to sob. He chokes out that he does not think he can do this and nothing has ever been as hard as staying clean. uJamal, who has two months of sobriety, tells Gary that he felt the same way when he first joined the group, but assured him that it does get better with time. uGrace also comments that she still has her doubts, but with a good support network, she seems to be able to get through the day. uGary seems relieved to hear that he is not alone and others have had similar experiences. He becomes hopeful that if these individuals can find a way to continue in recovery, he can too. uGroup counseling provides opportunities to normalize and validate experiences among group members.

Varying Quadrant Sizes

uIn a group counseling setting, there will be clients with a variety of quadrant sizes. Group counselors can use this information to help facilitate the group process. uClients with large open quadrants uThis is the ideal scenario. Open quadrants grow as trust grows in the group. uClients with large hidden quadrants uThese clients tend to avoid self disclosure, talk about others rather than themselves, asks questions, and offer a lot of advice. uClients with large blind spot quadrants uThese clients don't know how they are perceived by others, are uninterested in feedback, and can be poor listeners. uClients with large unknown quadrants These clients do not speak often in group, have low self-awareness, do not know others well, and seem lost

Alcoholics Anonymous

uLet's start by learning about AA, the 12-step group that started them all... uAlcoholics Anonymous (AA) is the largest 12-step program with over 2,000,000 members around the world and 90,000 meetings in 180 countries. uAA was founded in 1935 by Bob Smith and Bill Wilson, both in recovery from alcohol addiction. uThere are no fees associated with AA. To be a member, one only needs to have the desire to stop drinking. uAA is not affiliated with an institution, political group, or religious denomination. uAA purports that meeting together and working the 12-steps is a way, for many, to overcome addiction. It is a spiritual program in which members rely on a higher power. The primary text of AA is called the Big Book

What is NSSI?

uNSSI is not a new behavior. It was recorded as early as the document written by Mark in the New Testament (described a man who cut himself with stones). uNSSI is defined as: "Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is no evidence, whether implicit or explicit, of suicidal intent" (Centers for Disease Control, p. 21). uTherefore, NSSI is different from a suicide attempt. uMany names: self-harm, self-injury, self-mutilation, self-abuse, cutting, self-injurious behavior, deliberate self-harm (DSH), self-directed violence (SDV). uNSSI includes, cutting one's skin (thighs and forearms most common), burning, rubbing, banging one's head, hitting oneself, breaking one's bones, preventing wounds to heal, pricking with needles, scratching oneself, biting oneself.

Group Counseling vs. Individual Counseling

uSometimes clients want to know how group counseling is different from individual counseling. Group and individual are complementary forms counseling. There are important differences between these two modalities: uGroup counseling helps normalize the struggles of recovery and allows group members to hear from people going through similar experiences. uGroup counseling provides interactions with both licensed professional counselors as well as peers to strengthen interpersonal skills. uGroup counseling offers an opportunity for clients to receive feedback from multiple people. uGroup counseling confirms the idea that clients are not alone and others are experiencing what they are currently experiencing (provides support). uA client in very early recovery often feels hopeful when listening to a group member in later recovery (as they witness firsthand that recovery is possible).

The Twelve Steps

uStep 1 - We admitted we were powerless over alcohol- that our lives had become unmanageable. uStep 2 - Came to believe that a Power greater than ourselves could restore us to sanity. uStep 3 - Made a decision to turn our will and our lives over to the care of God, as we understood Him. uStep 4 - Made a searching and fearless moral inventory of ourselves. uStep 5 - Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. uStep 6 - Were entirely ready to have God remove all these defects of character. uStep 7 - Humbly asked God to remove our shortcomings. uStep 8 - Made a list of all persons we had harmed, and became willing to make amends to them all. uStep 9 - Made direct amends to such people wherever possible, except when to do so would injure them or others. uStep 10 - Continued to take personal inventory and when we were wrong promptly admitted it. uStep 11 - Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out. uStep 12 - Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

Blind Spot Quadrant

uThe blind spot quadrant consists of information known to others, yet unknown to self. uThis may include characteristics others notice about us (e.g., personality traits or quirks) that we fail to recognize within ourselves. uThis also may include clients who are in denial about their addiction, but others are aware of the problem. uThis quadrant gets smaller as clients receive feedback from other group members.

The 12-steps

uThe steps are guiding principles for recovery from addiction based on spiritual aspects and character development (spirituality is defined by the individual and all spiritual paths are accepted and respected). uMembers of 12-step fellowships work the steps in order to remain in recovery from addictive behaviors. uThe 12-steps become a way of life and often new members of 12-step programs work the steps with a sponsor (a more seasoned member of the program). uThere is research supporting the effectiveness of 12-step program as a means to help those with addiction.

Unknown Quadrant

uThe unknown quadrant consists of information that is unknown to self and unknown to others. uThis information could include a person's undiscovered potential or even unconscious information. uFor clients in recovery from addiction, the unknown quadrant can consist of their identity without drugs and alcohol, hobbies and interests they have yet to discover, and ambitions and goals they have yet to pursue.

Types of Addictions Counseling Groups

uThere are different types of counseling groups for clients with addiction. All are helpful and all are needed at different times. These groups are: uPsychoeducational Groups uThese groups are designed to impart information, like the neurobiology of addiction, the progression of the disease of addiction, types of resources and services offered by the treatment center, etc. uSkill Development Groups uThese groups are designed to help clients develop coping skills (like drug refusal skills) and life skills (like fair fighting rules or assertive communication skills). They typically consist of modeling the skills, role-playing, and practicing the skills to increase efficacy. uProcess Groups uThese groups do not have a pre-planned agenda, but instead invite group members to share their experiences, feelings, and thoughts. The focus of the process group is on interpersonal dynamics and healing through empathy and validation.

Motives for NSSI

uThere are many different reasons why individuals may engage in NSSI. Some of the most prevalent motives are: uRelief from emotional pain (shift attention from emotional pain to physical pain; symbolically let the emotional pain out via blood). uCommunicate with others (use blood and wounds to express one's pain to other people). uFeel something (alleviate numbness or feelings of dissociation). uA sense of control (individual can control pain even if the person can't control other areas of life) uFeel good (trigger a release of endorphins by cutting skin) uSelf-punishment (some individuals believe they deserve to be hurt)

Types of Support Groups/Programs

uThere are many different types of support groups---some based on the 12-steps and some that are not; some for those with addiction and some for the loved ones of those with addiction; some for drugs of abuse and some for addictive behaviors. See a few examples below: uAlcoholics Anonymous (AA) uNarcotics Anonymous (NA) uAl-Anon (for family and friends of those with alcohol addiction) uAlateen (peer support group for teens) uNar-Anon (for family and friends of those with drug addiction) uSecular Organizations for Sobriety (SOS; non 12-step program) uSMART Recovery (non 12-step program) uGamblers Anonymous (GA) uSex Addicts Anonymous (SAA) uOvereaters Anonymous (OA)

Types of NSSI

uThere are several different types of NSSI: uMajor: self-castration, removal of a body part such as an eye, substantial injury; may occur with psychosis or drug/alcohol intoxication; could have religious motives (purification from sin). uStereotypic: repetitive, monotonous behavior; head banging, scratching, biting, punching self; may occur with autism, Tourette's, or mental challenges; often little to no thoughts associated with behaviors. uModerate/superficial: careful, intentional injury to skin; preoccupied with thoughts of self-injury; way to relieve mounting distress; correlated with trauma/abuse; cutting, burning, skin picking, hair pulling, breaking own bones; most common; typically begins in adolescence. uModerate/superficial NSSI is the most likely to be conceptualized as an addictive behavior.

Open Quadrant

uhe open quadrant consists of information that is known to self and known to others. In group counseling, you typically want this quadrant to grow among each group member. uThe open quadrant consists of public information and information that is voluntarily disclosed by the client. uOpen quadrants increase as trust in the group increases. In other words, group members begin to share more when they feel like the group is a safe space. uExamples of the open quadrant in addictions counseling may include a client disclosing a personal history of alcohol and drug use, a client disclosing fears about recovery, and a client reporting participation in Alcoholics Anonymous.

Drugs and Neurotransmitter Dysregulation

w does neurotransmitter dysregulation happen? It could be a genetic vulnerability or occur as a result of prolonged substance use. ■ As a genetic vulnerability, neurotransmitter dysregulation could be present prior to first drink or drug use. - This occurs among those who are born with a genetic predisposition for addiction. ■ Or, if not predisposed, neurotransmitter dysregulation could be the result of prolonged substance use. - Substance misuse over time can lead to neurotransmitter dysregulation even for those who are not predisposed. ■ Drug use causes neuroadaptations, which is when the brain changes in response to the unnatural release of neurotransmitters caused by drugs of abuse. ■ Drugs can mimic natural neurotransmitters and bind to the appropriate receptors, trap the neurotransmitters in the synapse so they bind repeatedly to receptors, or block receptors.

hagedorn experiments

will be drawing for the exercise, then the drawing materials (paper, crayons, erasers, pencils, etc.) should be easily accessible. The activity. Before moving into the activity, the facilitator should begin a discussion of the possible roadblocks to recovery. This would likely occur by asking group members to briefly share some of their own experiences and examples of the roadblocks they have encoun- tered at various points of their recovery. Next, group members would be invited to participate in an experiential exercise that will help them to find creative solutions to better manage their roadblocks. The facil- itator should share, ''We are going to use the sand-tray and the minia- tures to create a 'picture' or 'story' that best represents the roadblock that you are struggling with at this time.'' The activity begins when the first participant volunteers to create a ''picture'' in the sand of his = her roadblock (agreeing to process this experience with the group). The facilitator should keep the member focused on a roadblock with which he = she is currently struggling. (Note that all members do not have to create a scene: it should be their choice to participate or not. It is just as powerful an experience for those who choose to observe). If several group members want to volunteer, the group can decide the order that they will go. The first participant to create the scene of his = her Roadblock to Recovery in the sand is instructed to use the miniatures in whatever way they choose. Individuals can use the figures in literal (e.g., a male miniature to represent a father figure) or abstract (e.g., a lion to represent a force with which to be reckoned) ways. The time allotted to the creation of the scene should be dependent on the group member; if external time constraints are a factor, these should be explained before the person begins. Once the participant has created the scene, ask him = her to describe the scene to the group and what it means in regards to his = her recovery. Many interesting details about the group member and his = her recovery process will emerge; the facilitator should be inquisitive and ask questions about the scene (e.g., ''Who is this figure, what does it represent?'', ''Why is this figure placed so far away?'', and ''What does this figure need right now?''). Allow the other group members to ask questions and = or to give feed- back about what they see. It is important to stress that no interpreta- tions should occur, neither from the facilitator nor from the other group members. Once the group has processed the initial scene, the participant is encouraged to change the scene in such a way that would depict a solu- tion or resolution to the roadblock. Prompts such as ''What needs to happen to create a positive change?'', ''Do you need to introduce new figures to the scene?,'' ''Do you need to take something out of the Hagedorn and Hirshhorn/EXPERIENTIAL GROUP ACTIVITIES 57 scene?'' and ''Do you need to change the positions of any of the figures?'' can help someone who is unsure of how to proceed. After the participant has made his = her desired changes, he = she is asked to describe what has changed and how this change will facilitate his = her progress through the roadblock. Often many implicit strengths and resources will emerge, so it is important to ''ground'' the learning by inquiring how the participant might transfer these insights into the real ''here and now'' world of recovery. Finally, to further ground the awareness of the participant's strengths and resources (as well as to improve the group's cohesion), encourage each observing member to choose one miniature that they feel would provide some additional strength or resource (e.g., a heal- ing symbol) to help the participant to overcome the roadblock that was portrayed in the original scene. Once the other members have chosen the miniature and explained why they feel it would be a helpful image, they should place that miniature in the sand along with the initial participant's ''scene.'' Out of respect for the partici- pant, members should not alter the original scene in any way; rather, they should place their miniature unobtrusively in the sand tray. Process this part of the exercise with the participant by asking ''How will you carry and use these additional strengths offered to you?'' Repeat the entire process over again with each group member who desires to participate until all members have completed the activity. Process questions. Given that the goal of this exercise is to help participants experience, share, experiment with, change, and learn from their roadblocks, each of these should be processed. One method is to use the ''what,'' ''so what,'' ''now what'' series of questions. ''What'' questions ask participants to explain concretely what occurred during the sand-tray experiences. ''So what'' questions address meaning: ''How does what happened during the exercise relate to your recov- ery?'' Finally, the ''Now what'' questions are directed toward applica- tion: ''With what you've just learned, what do you need to do to avoid = circumvent = address the roadblock when it appears in your life?'' The facilitator can close the activity by taking a photograph of the sand tray and giving the picture to the client to take with away with him = her, thus ''grounding'' the experience. Finally, if drawings were used instead of the sand tray, members can draw a picture of a strength or support for those clients who presented their roadblocks. These pictures (either those from the camera or those drawn by cli- ents) can then be taken home and placed on the refrigerator or mirror to serve as a reminder of clients' strengths and commitment to the recovery process. 58 THE JOURNAL FOR SPECIALISTS IN GROUP WORK/ March 2009 Navigating the Blind Maze of Recovery Ed Brand, from Florida State University, created an activity to help adolescents and adults to apply well-known recovery slogans to the realities of their lives. This exercise has worked well for a variety of clinical concerns and is appropriate for the different developmental levels of recovery. Given that the activity involves clients being blind- folded, facilitators should be cognizant of the possible impacts of this on those clients who have experienced such things as rape or other traumatic losses of control. Materials and set-up. The Blind Maze requires little in the way of materials: blindfolds, chairs, several lengths of masking tape, and a large room are all that are necessary. Scarves or cut pieces of fabric can serve as the blindfolds. Folding or stackable chairs work best as they can be easily moved and manipulated; approximately 25-50 chairs are needed. Tear off nine pieces of tape approximately 3 to 4 feet in length and set them aside. Finally, whereas a 50 by 50 foot room would be ideal for this activity, tighter mazes for smaller rooms may be constructed. (Note: it is possible to use masking tape or lengths of rope to set up the maze along the floor if chairs are not available). Now that the materials have been gathered, it is time to create the maze. This is done by placing the chairs next to one another with their backs toward the area in which the group members will be walking. Leave approximately three feet between the chair backs (chairs are represented by the letter ''h'' in Figure 1). Lay out a maze-like struc- ture using the chairs, providing enough twists and turns (and even some dead-ends) to make it challenging (see Figure 1). At three spots along the maze, lay a length of tape across an area that members must cross. Label these areas as ''crisis points.'' Finally, clearly mark the beginning and end of the maze. You are ready to begin the activity. The activity. Ideally the group (12-15 members works best) will meet somewhere (e.g., the ''prep'' room) other than the room where the maze has been created so that they cannot anticipate the challenge set before them. Before moving into the maze room, the facilitator should open with a psycho-educational discussion about how the task before them will be similar to what it is like to begin a new life of recov- ery. This new life can be exciting (ask the group members what would make it exciting for them) as well as scary (again, prompt discussion). The pre-activity discussion would finish with the facilitator impress- ing upon the group the need for an intentional plan for their trip through recovery, one that includes both a guide (i.e., a sponsor) and a connection with fellow travelers (i.e., a support group). Hagedorn and Hirshhorn/EXPERIENTIAL GROUP ACTIVITIES 59 The rules are next shared with the group members. First, the group should be split into three smaller groups of equal size — be mind- ful of the subgroups that may have already formed in the group and use = split these as needed. Designate who will be blindfolded first, who will serve as the guide, and who will observe. Given time and at the facilitator's discretion, members can experience each of the various roles. Each sub-group should enter the maze on their own while the other sub-groups wait in the ''prep'' room. Members are told that the blindfolded individual will need to tra- verse the entire maze solely with the vocal help of the guide. Another rule to share is that when the blindfolded member reaches any of the three taped off points in the maze (designated as a ''crisis point''), he = she must correctly answer a question posed by the facilitator before breaking the tape and moving forward. Whereas members are given the instruction that only the guide can assist them through the maze, they are not informed that they may utilize their other group members to answer the questions that are posed at the crisis points. Figure 1 Setting up the Maze. 60 THE JOURNAL FOR SPECIALISTS IN GROUP WORK/ March 2009 In order to add a little competitive spirit to the activity, the next set of rules involves the number of points that can be accrued. The only time a team loses points is when the blindfolded member touches the maze (i.e., a chair). Teams gain (a) one point each time the blind- folded member stops and asks the guide for assistance, (b) one point for each ''crisis point'' question answered correctly by the blindfolded member (but five points if he = she asks for help from the observers on team), and (c) one point if the blindfolded member receives help from an observer without asking for such assistance. (Note: whereas the blindfolded member may receive help from the observers, he = she must be the one who actually gives the answer to receive the allotted points). The group at the end with the most points ''wins'' (the facilita- tor should designate some sort of reward beforehand). The three designated ''crisis points'' are created to represent those times in recovering addicts' lives when they are faced with a dilemma that causes them to slip into addictive thinking, the result of which will lead to a relapse if they do not rely on newly learned coping mechanisms. It is at these taped-off areas of the maze where the blind- folded member must stop and answer a question, the aim of which is to focus them on imbedded recovery slogans. The following is a short list of possible questions that can be posed by the facilitator: (a) What does the acronym H.A.L.T. mean? How does it apply to your recovery? (b) What does the phrase, ''No major changes for one year'' mean? (c) What does the phrase, ''Every relapse is planned'' mean? (d) What does the phrase, ''Our sickness is between our ears'' mean? (e) What does the phrase, ''There's no one too dumb for this program, but it's possible to be too smart'' mean? (f) What does the phrase, ''Your mind is out to get you'' mean? Additional questions can be generated as they evolve out of whatever has been addressed up to that point in the members' treatment pro- gram. Remember that the blindfolded member may receive help from the observers to answer these questions, but this fact is not shared at the outset. Once the question has been answered correctly, the mem- ber is instructed to break the tape and proceed through to the rest of the maze. Process questions. Whereas most everyone has a fun time traver- sing the maze, the real learning occurs during the post-activity follow-up discussion. To begin, each member that participated would be encouraged to share what his = her experience was like. Be sure to explore each role (blindfolded, guide, observer) and how they felt in each role. If they had been in a different role, what would they have Hagedorn and Hirshhorn/EXPERIENTIAL GROUP ACTIVITIES 61 done differently? Next, be sure to note those who became upset at their guides = team and relate this to an individual's tendency to (a) ''assume one knows the best answer'' and = or (b) ''blame others when life does not turn out like I expect.'' Finally, process the experience for those who got so frustrated that they moved chairs (and = or quit). Ask what prompted these behaviors and relate it to how they may approach their recovery. These questions can easily move into a discussion of the coping skills that need further development for each group member. Finally, process the various elements of the activity. Such questions might include: (a) ''What did touching the chair symbolize?'' Possible answers might include coming in contact with old ''using'' friends, driving past loca- tions where one used to drink = drug, falling to a temptation, or the actual use of an addictive drug or behavior. (b) ''What were the 'crisis points' about, to include the tape and the time where you had to answer a recovery question?'' The ''crisis points'' were explained above, but hopefully members will recognize that the tape was nothing but a superficial barrier that could easily be bro- ken through with enough forward momentum. This might symbolize clients' tendencies to ''catatrophize'' their experiences, when in reality allthatisrequiredisanhonestevaluationofwhatisoccurringin their lives. Members should also discuss what the posed questions caused them to do (i.e., focus on their coping mechanisms, reach out for help, etc.). (c) ''Why did the blindfolded member have to provide the answer to the questions that were posed?'' Possible answers might include the need to own one's answers, avoid codependent relationships, and to accept responsibility for one's recovery. The facilitator should allot at least 45 minutes to process this activity, focusing on the generalization of one's experiences to a life in recovery. To conclude, one might use this activity as a pre- and post-evalua- tion of the skills learned in a treatment program. That is, if clients all start a treatment program at the same time, they might participate in the Blind Maze at the beginning of the program, see how much time it takes and the feelings = behaviors that evolve, and then traverse the maze toward the end of their program and compare the results. Newly developed skills (e.g., communication, relationship, anger manage- ment, coping) should be evident and solidified. CONCLUSIONS AND FUTURE DIRECTIONS The authors would like to reiterate several points. First, we assert that experiential group activities are the ''gold standard'' for working 62 THE JOURNAL FOR SPECIALISTS IN GROUP WORK/ March 2009 with addicted clients. These activities (a) increase group cohesion, (b) by-pass the defense mechanisms and ineffective thought processes common to addicted individuals, (c) meet clients ''where they are 'at''' in terms of their stage of change, and (d) offer creative right-brained opportunities for clients to explore their feelings, motivations, and insights as they relate to their past experiences, current ineffective coping mechanisms, and the development of more adaptive problem- solving strategies. Another important point is that whereas these activities are outlined in such a fashion that they are ready to use with groups of addicted clients, clinicians should take all the necessary pre- cautions in order to implement them in a competent fashion. Given the active nature of these act ivities, as well as the affective nature inherent to experiential exercises, counselors should be ready to (a) facilitate clients' strong emotional expressions, (b) set appropriate rules and boundaries for group members' beha- viors, (c) intercede when it is deemed necessary (e.g., should a client's personality disorder become a concern), and (d) examine one's own emotional and = or cognitive reactions to what occurs during an activity. The authors also note that future research should be directed at providing empirical support for how well these (and other) activities facilitate client growth and = or goal attainment. For example, whereas the first author has used the Crossing the Swamp activity for several years as a means to demonstrate the utility of the 12-steps as an important part of the recovery process, it might be important to assess how effective this activity is in attaining this goal over another method, say a purely psycho-educational approach. Data gathered through such an endeavor may lead to improved treatment protocols, thus resulting in enhanced client outcomes. Finally, the last piece that warrants restating is that readers are highly encouraged to practice any new exercise = activity before using it with clients. This would include requesting supervision and = or feedback from other colleagues. I t may also include seeking addi- tional training in some of the techniques and therapies that we reviewed in the literature review (e.g., psychodrama, play therapy, art therapy, etc.). This will help guarantee that counselors are ade- quately prepared to (a) facilitate a n activity for a group, (b) accu- rately process the events that occur, and (c) generalize what happens in group to the real world of clients. For it is in this way that addicted clients will be motivated to move from a lack of aware- ness (Precontemplation) to awareness without change (Contempla- tion) to active involvement in the changes necessary to improve their lives.

Gaming Terminology

§It is important for clinicians to understand gaming terminology in order to work with clients with IGD. See a few examples below: §Avatar - user's persona or online representation §Clan and/or guild - a team or group of players in virtual space §Grinding- engaging in a repetitive task to advance in the game §Patches/updates- periodical upgrades within the game to provide new challenges §MMO- Massively Multiplayer Online Games §MMORPG- Massively-Multiplayer Online Role-Playing Game - play as an avatar §MMOFPS- Massively Multiplayer Online First Person Shooters- skill/action games §MMORTS- Massively multiplayer Online Real-Time Strategy- oversee troops and territories

What to Know About MMORPGs

§MMORPGs started in 1980s with MUD (multiuser dungeons, which were text based role playing games). §They have advanced to games like: World of Warcraft, Guild Wars, Final Fantasy, Elder Scrolls, The Lord of the Rings, RuneScape. §MMORPGs are games without an end, so there are always new quests and challenges. §Patches keep the gaming experience exciting and novel. §MMORPGs offer players the opportunity to be competitive and successful (develop skills, achieve goals, increase self-efficacy) §Players can connect with others in team play (using voice or text). §MMORPGs invite players to immerse themselves in virtual worlds. They have the strongest correlation with IGD.

Internet Gaming Disorder Scale

§Pontes and Griffiths (2015) developed a scale to assess for IGD. Read the scale items below: §Do you feel preoccupied with your gaming behavior? (Some examples: Do you think about previous gaming activity or anticipate the next gaming session? Do you think gaming has become the dominant activity in your daily life?) §Do you feel more irritability, anxiety or even sadness when you try to either reduce or stop your gaming activity? §Do you feel the need to spend increasing amount of time engaged gaming in order achieve satisfaction or pleasure? §Do you systematically fail when trying to control or cease your gaming activity? §Have you lost interests in previous hobbies and other entertainment activities as a result of your engagement with the game? §Have you continued your gaming activity despite knowing it was causing problems between you and other people? §Have you deceived any of your family members, therapists or others because the amount of your gaming activity? §Do you play in order to temporarily escape or relieve a negative mood (e.g., helplessness, guilt, anxiety)? §Have you jeopardized or lost an important relationship, job or an educational or career opportunity because of your gaming activity?

New Trends in Diagnoses

§Psychologists, psychiatrists, social workers, and counselors use the Diagnostic and Statistical Manual of Mental Disorders (5th edition) to diagnose mental health concerns. -One behavioral addiction, namely, Gambling Disorder, is included in the DSM-5. -The DSM-5 also includes a diagnosis for Binge Eating Disorder, which some argue is similar to food addiction. -Finally, although not official diagnoses yet, the DSM-5 includes Internet Gaming Disorder and Nonsuicidal Self-Injury as diagnoses needing more research. §The International Classification of Diseases (ICD-11; World Health Organization) is another tool used for diagnosing. It includes the following behavioral addictions: -Pathological Gambling, Gaming Disorder, Compulsive Sexual Behavior Disorder, Nonsuicidal Self-Injury.

Diversity Considerations in Gaming

§Researchers have examined diversity considerations in Internet gaming. With the option to choose your own avatar, players may select different races, genders, or appearances while they game. §Marginalized group members may avoid discrimination/oppression in virtual social settings. §Research indicates that Black adolescents use video games at higher rates than their White counterparts (Carson, Cook, Chen, & Alegria, 2012). §83% Black teenage boys game compared to 71% White and 69% Hispanic. §Dietrich (2013) studied avatars and found that only 39 out of 65 MMORPGs (60%) allowed for skin tone adjustment from the White standard avatar. §Only 16 of those 39 (41%) adjusted to the darkest category of skin tone according to von Luschan's skin tone scale.

Hidden Quadrant

§The hidden quadrant consists of information known to self, yet unknown to others. §The information in the hidden quadrant could be secrets, undisclosed information, things that people are ashamed of, or parts of an individual's story that the person does not share with others. §Hidden information could be what clients are really feeling (behind the "mask" they might wear to group) or thoughts about relapse that they are too ashamed to talk about. §As trust increases in the group, clients take risks and share information from the hidden quadrant. This gives group members the opportunity to respond to hidden information (through validation, affirmation, empathy, and support).

Prevalence and Growing Acceptance of Behavioral Addictions

■Behavioral addictions are prevalent in the general population. It is estimated that: -Gaming addiction: affects 1-15% of the population -Social media addiction: affects 4% of the population -Sex addiction: affects 3-6% of the population -Eating disorders: affect 3% of the population -Problem gambling: affects 2-3% of the population ■National training standards in counseling programs now mandate students learn about behavioral addictions as well as chemical addiction: -Counselors in training will learn theories and etiology of addictions and addictive behaviors (2.F.3.d; CACREP, 2016).

Ethical Considerations

•Licensed Professional Counselors adhere the American Counseling Association's (ACA) Code of Ethics. The preamble of the ACA Code of Ethics identifies 5 professional values of the counseling profession: 1.Enhancing human development 2.Honoring diversity 3.Promoting social justice 4.Safeguarding the integrity of the counseling relationships 5.Offering competent and ethical services • Counselors refer to the Code of Ethics to ensure they are offering ethical services related to things like maintaining confidentiality, boundaries within the counseling relationship, conducting assessments, acquiring informed consent, making referrals, and more. All of these ethical standards apply to addictions treatment

Can Pharmaceuticals Help?

•Many clients with addiction want to know if there are medications that can help them with cravings or to lessen withdrawal symptoms. •There are some medications with research support, but they do not have the same effects on all people. ▫There is no "silver bullet" medicine to cure addiction. Counseling, professional treatment, and aftercare are necessary for most people. •Ultimately, medication does not replace counseling, but can assist with treatment. •Some counselors may refer a client with addiction to a psychiatrist or medical doctor to prescribe medication. However, like all medicine, it is important to consider side effects and risks of use.

Oxycodone

•Oxycodone is a drug prescribed for pain relief •Common brands: OxyContin, Percocet •This prescribed medication can be abused by taking it without a prescription, taking more than prescribed, or taking longer than prescribed •It is often called "hillbilly heroin" because it is cheaper than heroin and produces a similar high •Can be taken orally, crushed and injected, or snorted •High lasts 3-5 hours, or 12-hours with extended release tablets •Many users start with prescription pain killers (i.e., oxycodone, hydrocodone) and transition to heroin •Oxycodone has been gaining popularity among adolescents and young adults •Sold on the street for approximately $1 per milligram (30mg tablet = $30) •Fatal overdose potential

Substance Use Disorder Diagnosis

•The DSM does not use the word "addiction," but instead, the newest edition (DSM-5) uses the term "Substance Use Disorder" for diagnostic purposes. •According to the DSM-5, an individual could receive three different diagnoses related to addiction: ▫Substance use disorder diagnosis ▫Intoxication diagnosis ▫Withdrawal diagnosis •When giving a Substance Use Disorder diagnosis, the severity is noted by how many criteria are met: ▫If 2-3 criteria: Mild Substance Use Disorder ▫If 4-5 criteria: Moderate Substance Use Disorder ▫If 6 or more criteria: Severe Substance Use Disorder

What is the DSM?

•Let's start with the topic of diagnosing. Many mental health professionals will provide diagnoses for clients. •The Diagnostic and Statistical Manual of Mental Disorders describes criteria for mental health diagnoses. •It is published by the American Psychiatric Association and is commonly used by counselors, psychologists, psychiatrists, doctors, social workers, and others who diagnose mental health concerns.

Why are Diagnoses Important?

•A substance use diagnosis can be helpful by identifying and labeling a client's condition. •Once a diagnosis is given, the clinician can implement the most effective treatment strategy. •Oftentimes, insurance companies require a diagnosis to reimburse treatment.

Alcohol Withdrawal Criteria

•An individual may receive an alcohol withdrawal diagnosis if they meet the following criteria: •Cessation of alcohol use that has been prolonged •Experience two or more of the following: ▫Autonomic hyperactivity (increased pulse, sweating); Hand tremor; Insomnia; Nausea; Hallucinations; Psychomotor agitation; Anxiety; Seizures •Signs/symptoms cause clinically significant distress/impairment •Signs/symptoms not attributable to another medical condition

Legal Considerations

•Finally, let's consider some ethical and legal issues related to addictions treatment. •In the 1970s, congress passed CFR (Code of Federal Regulations) 42 Part 2 to eliminate barriers to addiction treatment. •CFR 42 Part 2 protects the confidentiality of those seeking drug and alcohol treatment. ▫It protects confidentiality of client records in substance abuse treatment including identity, assessment, diagnosis, and prognosis. ▫It does not, however, protect information related to child abuse. •Records may be disclosed by the clinician if a client gives consent, to a medical professional in the event of an emergency, or with a court order. •Clinicians are very careful not to break the confidentiality of their clients in addictions treatment.

Alcohol Use Disorder Criteria

•For example, consider the criteria for Alcohol Use Disorder below. Remember- if 2-3 criteria are met, it is considered mild, 4-5 moderate, and 6+ severe. •In the past 12 months: ▫1. Alcohol taken in larger amounts than intended ▫2. Unsuccessful efforts to cut down use ▫3. Great deal of time spent in activities related to use ▫4. Cravings ▫5. Failure to fulfill obligations at work, home, or school ▫6. Continued use despite social or interpersonal problems ▫7. Important activities given up due to use ▫8. Recurrent use in hazardous situations ▫9. Continued use despite knowledge of physical or psychological problems ▫10. Tolerance ▫11. Withdrawal

Heroin

•Heroin can be snorted, smoked, or injected •Black tar heroin refers to a sticky tar-like substance dissolved and injected •Intravenous heroin users are at risk for injection-site infections, HIV, and Hepatitis C •Heroin is considered a highly dangerous drug because the amount it takes to get you high is very close to amount that can kill you •Overdose occurs when the substance depresses breathing until it stops •Naloxone (Narcan) is a medication that can reverse an opioid overdose •Pure heroin is expensive ($100-$200 a gram) it is rare to find it in pure form. More frequently, it is cut with other substances (e.g., powdered milk, chalk, caffeine, opioids, amphetamines, fentanyl). •Tolerance can be deadly among heroin users: •A heroin user continues to increase the amount of heroin to achieve the desired effect (tolerance increases) •Now imagine this person gets into treatment and is abstinent for 4 months (tolerance decreases) •Then, this person relapses, and uses the same amount used right before entering treatment (when tolerance was high). This amount leads to a fatal overdose (because the person was no longer tolerant). •A tolerant heroin user typically uses 30-60mg a day, which would kill a non-tolerant adult •Withdrawal from heroin begins 1-2 days after last use and can last for one week •Withdrawal is very unpleasant and painful (many heroin users return to use before withdrawal ends because it is so unpleasant---like a violent flu. Prescription medications like methadone and suboxone block withdrawal for heroin users who are seeking to quit). •Although painful and unpleasant, heroin withdrawal is not as life threatening as withdrawal from chronic alcohol abuse.

Alcohol Intoxication Criteria

•If an individual is intoxicated in the presence of a diagnosing practitioner, they may receive an alcohol intoxication diagnosis characterized by: •Recent ingestion of Alcohol •Clinically significant problematic behavior or psychological changes •1 or more of the following signs/symptoms ▫Slurred speech; Incoordination; Unsteady gait; nystagmus (rapid eye movement); Impaired attention/memory; Stupor or coma •Signs/symptoms not attributable to another medical condition

Repetitive Behavior vs. Addiction

■Consider a college student who games everyday or a teenager who checks her social media account 150 times per day. How do you know if a behavior is an addiction? First, consider the 4Cs of addiction: -Compulsive: The individual feels compelled to engage in the behavior. -Loss of control: The individual may have tried to limit or stop behavior, but was unsuccessful -Continued despite negative consequences: Engaging in the behavior may lead to educational, employment, relational, physical, psychological, or financial negative consequences, but the individual continues to engage. -Craving or mental preoccupation: When the individual is not engaging in the behavior, they are thinking about it or feel a strong urge to engage.

Internet Gaming Disorder (IGD) Criteria

■Criteria have been proposed for the DSM-5 for Internet Gaming Disorder (IGD). This diagnosis is included in a section for "conditions in need of further study" and may be added to the next revision. ■IGD consists of five or more of the following in a 12 month period: -Preoccupation with gaming -Withdrawal symptoms when not gaming (e.g., irritability, anxiety, sadness) -Tolerance (need to spend more time engaged in games) -Unsuccessful attempts to control gaming -Loss of interests in other hobbies/entertainment -Continued use despite knowledge of psychosocial problems -Deception of others regarding time spent gaming -Game to escape negative mood -Jeopardized relationship, job, education, or career opportunities due to gaming The gaming behavior causes significant distress and impairment.

Neurobiology of Drugless Addictions

■How can you be addicted to something if you are not ingesting a substance? ■Certain behaviors trigger neurotransmitter release in the reward pathway of the brain. In essence, individuals become addicted to the release of their own neural chemicals. ■Thus, excessive or chronic engagement in naturally rewarding behaviors (like eating, sexual acts, "thrilling" behaviors, etc.) can alter the brain's neurochemistry leading to neuroadaptations: -Chronic dopamine release from these behaviors overloads the reward pathway. -The brain's response to overstimulated dopamine release is to decrease dopamine production or reduce dopamine receptors. -Addictive behaviors activate the same brain regions activated by drug/alcohol cues.

Proposed Process Addictions

■Researchers and clinicians have proposed several potential addictive behaviors. There are varying levels of support and acceptance of these behaviors as authentic process addictions. The list includes: -Gambling -Internet -Social media -Gaming -Sex -Pornography -Nonsuicidal self-injury -Food -Love -Exercise -Work -Tanning -Shopping/buying

Redefining Addiction

■The American Society of Addiction Medicine defines addiction this way: -"Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors." (ASAM, 2011, p.1) -It has been well established that some behaviors can be addictive ■Along with substances, individuals can become addicted to naturally-rewarding behaviors (or behaviors that affect the dopamine system in the brain). -We know that behavioral addictions affect the same brain regions as drugs of abuse (Karim & Chaudhri, 2012). ■Remember the reward pathway in the primitive part of the brain. This mesolimbic dopamine system reinforces behaviors necessary for survival through dopamine release. -Repeated stimulation of dopaminergic system can lead to neuroadaptations that can increase the likelihood that a behavior becomes compulsive. ■Addictive behaviors are positively and negatively reinforcing: -Positive reinforcement: causes pleasure (euphoria from neurotransmitter stimulation). Negative reinforcement: relief from pain or negative emotions.

What is a Behavioral Addiction?

■What makes something addictive? Can a person become addicted to anything? The short answer is, no---a person cannot become addicted to ANY behavior. However, behaviors that are naturally rewarding can become addictive for some people (those with a genetic vulnerability

IGD Prevalence and Correlates

■Without formal criteria, the prevalence of IGD is hard to ascertain. Researchers have found estimates ranging from 0.7% to 15.6% of the population (Feng, Ramo, Chan, & Bourgeois, 2017). ■IGD has been linked to: -Poorer family relationships (Bonnaire & Phan, 2017) -Neglect of other social relationships (Wartberg et al., 2017) -Depression (Burleigh, Stavropoulos, Liew, Adams, & Griffiths, 2017) -Lower life satisfaction and more anxiety (Bargeron & Hormes, 2017) -Less gray matter and hyperactivation of anterior cingulate cortex, which is responsible for emotion regulation (Yao et al., 2017)

Criteria for Generalized Anxiety Disorder (GAD)

◦Let's take another example. Below are the criteria for the mental illness, Generalized Anxiety Disorder (GAD). Read the criteria below: ◦Excessive anxiety/worry, which causes impairment. ◦3 or more of the following symptoms in the last 6 months: ◦1. Restlessness, feeling keyed up or on edge. ◦2. Being easily fatigued. ◦3. Difficulty concentrating or mind going blank. ◦4. Irritability. ◦5. Muscle tension. ◦6. Sleep disturbance (difficulty falling or staying asleep, or restless, sleep). ◦Counselors must determine if these symptoms are the result of GAD or substance use (given that the ssymptoms could be a sign of either).

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GEOG313

Psychology Final

Micro Quiz 4

Chapter 28 - Reproductive System