WILLIAM WHITE INTERVIEW CAREER REFLECTIONS: DR. CLAUDIA BLACK
INSIDE BOOKS: OMG! HOW CHILDREN SEE GOD
SPECIAL ISSUE
ADOLESCENTS &
YOUNG ADULTS THE TRAUMA TREATMENT MODEL EXPERIENTIAL APPROACHES EATING DISORDERS Mar/Apr 2016 Vol. 2 No. 2
HARM REDUCTION
TREATMENT & RECOVERY
INDUSTRY INSIDER
Reimbursement , Business Practice s: Key Issues in 2016
FLIP OVER
The Legal Beat
pg. 7
Testing Matters
pg. 8
pg.4
Mergers & Acquisit ions - Arcadia, RiverMe nd pg. 10 National Advocac y for California Programs pg. 12 Treatment Professi onals Alumni Services
Crossroads An tigua’s Rokelle Lerner and Inkspiration s pg. 2
Ken Seeley and
in
pg. 14
the
Independent Coalition of Treatment Provider s pg. 5
April 2016 Vol. 17 | No. 2, $6.95
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CONTENTS Letter from the Editor
34
By Gary Seidler Consulting Executive Editor
Utilizing an AbstinenceBased Model for Adolescents with Eating Disorders
CCAPP
The ICD-10 and the DSM-5 Made Simple . . . Kind of, Part II
Presents an abstinence-based model for treating eating disorders in adolescents, discusses how to deal with bulimia and binge eating, and provides case studies.
NACOA
CoAs and Opioid Addiction
12
Cultural Trends
14
By Sis Wenger
40 Using Experiential Approaches to Increase Engagement in Adolescents By David Laing, MA, MFT-I, Jennifer Golick, LMFT, and Scott Sowle Offers an overview of evidencebased residential treatment, introduces Tae Kwon Do as an experiential therapy, and provides a case study.
The Benefits of Harm Reduction in Adolescents
Mexican Meth: Crossing the Border By Maxim W. Furek, MA, CADC, ICADC
Opinion
Music and the Arts in Recovery
16
By George “Butch” Warner, MA, MFT, CADC-II
From Leo’s Desk Beyond Religion
20
By Rev. Leo Booth
Wellness
Aging and Wellness in Recovery, Part III
22
By John Newport, PhD
The Integrative Piece Puppy Tails and Other Tender Mercies
24
By Sheri Laine, LAc, Dipl. Ac
By Robert Roth, MFCC, MAC Lists the benefits of harm reduction approaches, describes the importance of empathy in treating adolescents, and gives examples from personal experience.
10
By Roland Williams, MA, LAADC, NCAC-II, CADC-II, ACRPS, SAP
By Rachel Fortune, MD, FAAP, and Barbara Nosal, PhD, MFT, LAADC
46
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Topics in Behavioral Health Care
26
The Thirteen P’s: A Comprehensive Approach to Addiction and Recovery, Part I By Dennis C. Daley, PhD
www.counselormagazine.com
3
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E-mail: editor@counselormagazine.com Website: www.counselormagazine.com Counselor (ISSN 1047 - 7314) is published bimonthly (six times a year) and copyrighted by Health Communications, Inc., all rights reserved. Permission must be granted by the publisher for any use or reproduction of the magazine or any part thereof. Statements of fact or opinion are the responsibility of the authors alone and do not represent the opinions, policies or position of COUNSELOR or Health Communications, Inc.. Health Communications, Inc., is located at 3201 S.W. 15th St., Deerfield Beach, FL 33442 - 8190. Subscription rates in the United States are one year $41.70, two years $83.40. Canadian orders add $15 U.S. per year, other international orders add $31 U.S. per year payable with order. Florida residents, add 6% sales tax and applicable surtaxes. Periodical postage rate paid at Deerfield Beach, FL, and additional offices. Postmaster: Send address changes to Counselor, P.O. Box 15009, North Hollywood, CA 91615 - 5009 © Copyright 2015, Health Communications, Inc.. Printed in the U.S.A.
President & Publisher PETER VEGSO Consulting Executive Editor GARY S. SEIDLER Managing Editor LEAH HONARBAKHSH Director of Editorial Communications STEPHEN COOKE Advertising Sales JAMES MOORHEAD Art Director DANE WESOLKO Production Manager GINA JOHNSON Director Pre-Press Services LARISSA HISE HENOCH Managing Editor LEAH HONARBAKHSH Phone: (800) 851-9100 ext. 211 or (954) 360-0909 ext. 211 Fax: (954) 570-8506 E-mail: leah.honarbakhsh@ counselormagazine.com
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Call (800) 851-9100 ext. 211 or e-mail leah.honarbakhsh@counselormagazine.com 4 Counselor · April 2016
3201 S.W. 15th Street Deerfield Beach, FL 33442-8190 Advertising Sales JAMES MOORHEAD Phone: (949) 706-0702 E-mail: jamesm@counselormedia. com
Director of Editorial Communications STEPHEN COOKE Phone: (800) 851-9100 ext. 222 E-mail: stephen.cooke@usjt.com Conferences & Continuing Education LORRIE KEIP Phone: (800) 851-9100 ext. 220 Fax: (954) 360-0034 E-mail: Lorriek@hcibooks.com Website: www.usjt.com Advisory Board ROBERT J. ACKERMAN, PHD, CHAIRMAN JOAN BORYSENKO, PHD RALPH CARSON, PHD TIAN DAYTON, PHD BOBBY FERGUSON DAVID MEE-LEE. MD DON MEICHENBAUM, PHD PETE NIELSEN, CADC-II CARDWELL C. NUCKOLS, PHD MEL POHL, MD MARK SANDERS, LCSW DAVID E. SMITH, MD
CONTENTS Research to Practice Ah, Wondrous Science
28
By Michael J. Taleff, PhD, CSAC
Counselor Concerns
A Typology of SubstanceAbusing Adolescents
30
By Gerald Shulman, MA, MAC, FACATA
Ask the LifeQuake Doctor
33
Inside Books
72
By Toni Galardi, PhD
OMG! How Children See God By Monica Parker Reviewed by Leah Honarbakhsh
52 Vulnerability and Resilience of Children Affected by Addiction: Career Reflections of Claudia Black, PhD By William L. White, MA Discusses Dr. Black’s early career, her early work with children, and her involvement with The Meadows.
From the Journal of Substance Abuse Treatment
ALSO IN THIS ISSUE Ad Index
68
CE Quiz
70
56 Treatment Outcomes for A-CRA Participants with Co-Occurring Problems By Susan H. Godley, RhD, Mark D. Godley, PhD, and Lori L. Passetti, MS Describes the Adolescent Community Reinforcement Approach (A-CRA), presents a study on adolescents with co-occurring disorders, and provides clinical implications for counselors.
60 Trauma Model Therapy: A Treatment Approach for Traumatized Adolescents By Colin A. Ross, MD Presents trauma model therapy (TMT), describes the problems of attachment to the perpetrator and locus of control shift, and gives advice for treating adolescents with trauma.
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Counselor · April 2016
• • • • • •
Assessment Driven Length of Stay - 30 Days to 6 Months The Only CARF accredited Caribbean Facility Evidence Based Clinical Programing Holistic Modalities Infusing 12 Step Philosophy Comprehensive Family Program Extensive After Treatment Support
LETTER FROM THE EDITOR
Adolescents Are Not “Short Adults” Fortunately, substance abuse has been a media headline for months. News reports, magazine features, television specials, documentaries, and social media are abuzz. On the campaign trail, the country’s presidential candidates are coming to a common understanding that drug and alcohol addiction is a disease, not a moral failing, and we must treat it as such. Let’s hope they’ll follow through and put money where their mouths are. This issue of Counselor is packed with informative and useful articles to benefit all professionals in our field, most especially those in the trenches.
Our annual special issue on adolescents and young adults could not come at a more critical time. With the current and highly publicized opioid epidemic, the move toward decriminalization of marijuana, and more and more young lives lost from drug overdoses and suicides, the prevention and treatment field is being challenged like never before. Heroin addiction is once again in the headlines, except this time it is not just an urban problem in minority ghettos. This time it is an equal opportunity scourge, affecting predominantly white, middle-class kids in middle America. At the same time, legislation loosening restrictions on marijuana use is becoming more prevalent. Regardless of one’s position on decriminalization and legalization, there can be no argument that we will need more innovative treatment modalities to meet what surely will be increased demand.
In his “Counselor Concerns” column, Gerald Shulman (page 30) reminds us what we learned long ago— adolescents are not “short adults” and treatment programs needed to be tailor-made. Even so, adolescents with substance abuse disorders are not a single category of people and Shulman presents a useful typology of substance-using adolescents. While agreeing that adolescent clients require a different approach due to their developing brains and a developmental need to differentiate from authority figures, the clinical team at Muir Wood Adolescent and Family Services (page 40) advocate alternative forms of therapy, particularly experiential and adventure therapy. In this issue’s Journal of Substance Abuse Treatment adaptation article, Susan Godley and colleagues (page 56) point out that the majority of youth in adolescent treatment programs have co-occurring mental health problems, most commonly ADHD, depression, anxiety, and disorders related to traumatic stress.
harm reduction approach to treating adolescents, while Colin Ross (page 60) offers a treatment approach for traumatized adolescents. In her new column, NACoA President and CEO Sis Wenger (page 12) reminds us all that in-depth family programs offer the best hope to create transformation in individuals and whole family systems, begin intergenerational healing, and help to halt the generational transmission of addiction. Dr. Claudia Black, a long-time advocate for adolescent and family treatment, discusses both the vulnerability and resilience of our future generation in an interview with William White (page 52). And finally, in this issue we bid farewell to “Research to Practice” columnist Michael Taleff, who has been writing for Counselor for almost two decades. The thorough examinations of new research and the expert advice he provided to clinicians will be sorely missed. Our sincere thanks go to Dr. Taleff for his outstanding contributions.
Gary Seidler
Consulting Executive Editor Counselor, The Magazine for Addiction & Behavioral Health Professionals, A Health Communications, Inc. Publication
In addition, Robert Roth (page 46) advocates an always controversial www.counselormagazine.com
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CCAPP
The ICD-10 and the DSM-5 Made Simple . . . Kind of, Part II Roland Williams, MA, LAADC, NCAC-II, CADC-II, ACRPS, SAP
I
think it’s very important for us addiction counselors to have the most current and relevant information as we work with our clients. Our clients come to us because they believe we are experts in addiction treatment, and many of us like to think of ourselves as experts. The fact is we are actually the most educated professionals when it comes to working with addicts and alcoholics. Medical doctors, psychologists, psychiatrists, marriage and family therapists, and licensed clinical social workers rarely get more than one months’ worth of training in addiction treatment unless they seek it out as a specialty. So we are the “experts,” and as such we have a responsibility to know what we’re talking about. In my last column I addressed the DSM-5. Now let's move on to the ICD-10.
The ICD-10
The International Classification of Diseases, Tenth Revision (ICD-10) is a clinical cataloging system that went into effect for the US health care industry on October 1, 2015, after a series of lengthy delays. On claims with that date of service, all HIPAA-covered health care entities had to begin using ICD-10 codes in place of the ICD-9 codes. Accounting for modern advances in clinical treatment, the ICD-10 offers fifty-four thousand more codes than its predecessor, the ICD-9. It is produced by a global health agency, The World Health Organization (WHO), with a public health mission to help countries reduce the disease burden of mental and physical disorders. The ICD is available for free on the Internet at the WHO website. The ICD’s development is global, multidisciplinary, and multilingual. The ICD-10 was delivered in two parts: the ICD-10-CM (for all providers in all health care settings) and ICD-10PCS (for hospital claims and inpatient hospital procedures). Be sure you are 10
Counselor · April 2016
using the CM version, which stands for “clinical modification” for the US. The PCS version is just for hospitals and contains procedure codes. Now, the ICD-10-CM contains a list of codes corresponding to diagnoses and procedures recorded in conjunction with health care in the United States. These codes may be entered onto a patient’s medical record and used for diagnostic, billing, and reporting purposes. Related information also classified and codified in the system includes symptoms, patient complaints, causes of injury, and mental disorders. The ICD was designed to provide a common language around the world for practitioners to describe all kinds of diseases and causes of death. The thought was that if doctors in Zimbabwe diagnosed a person with hepatitis, they would be using the same language and diagnostic criteria as doctors in Rome and in Chicago. You may think you have no experience with the ICD codes, but you do! The DSM doesn’t have codes, and never has. The two sets of codes you see listed after every diagnosis are ICD codes; the first one (303.9) is the ICD-9 code and the second one in parenthesis starting with the letter F (e.g., F10.20) is the ICD-10 code. So that’s one more reason to use the DSM-5; it already provides you with ICD-10 codes.
The Breakdown
The ICD-10 is divided into twenty-six sections, one for each letter of the alphabet. Each lettered section has a different area of medicine that it covers. Sections A and B cover infectious diseases, section C is oncology, section D is hematology, and so forth. The mental health codes are in section “F.” Thus, virtually all the mental health codes begin with the letter “F,” as I previously mentioned. Luckily for a mental health practitioner, it is fairly straightforward
once you understand the coding system. This is mostly because mental health does not have different body parts that are affected, and most mental illnesses have no clearly defined etiology. Thus, the majority of the old ICD-9 mental health codes have a one-to-one correlation with their newer ICD-10 codes, although there are several more options. ICD-10’s section for mental illness is broken down into ten subsections as shown in the top part of the text box. The section that affects addiction counselors the most is the F10–F19. Our section of the ICD-10 is relatively small compared to the many sections that describe other medical and physical diseases. As you can see, those of us in SUD treatment will focus primarily on only one section: mental and behavioral health disorders. Our section of the ICD-10 that deals with SUDs is listed at the bottom of the text box. Now the whole coding process is too complicated to explain in this article— the code changes from the ICD-9 to the ICD-10 are like a different language—but once you spend some time looking at it you will see a pattern. For example, all ICD-10 codes start with a letter, and mental health and behavioral health both start with the letter F. Substances all start with the letter F followed by the number 1, and the third digit represents the specific drug (e.g., F10 is alcohol and F11 is opioids). That will be followed by a period and the fourth digit, which is always a number, will describe one of the following: • 0. Use (intoxication) • 1. Harmful Use (abuse) • 2. Dependence • 3. Withdrawal So alcohol use disorder with withdrawal would be coded as F10.3. The next one to two digits get more
CCAPP ICD-10 Section for Mental Illness
F01–F09: Mental disorders due to clear physiological conditions F10–F19: Mental disorders due to substance abuse F20–F29: Schizophrenia, schizotypal, delusional, and other psychotic processes F30–F39: Mood disorders F40–F48: Anxiety, dissociative, stressor-related, and somatoform disorders F50–F59: Behavioral syndromes with physical factors F60–F69: Personality Disorder F70–F79: Intellectual disabilities F80–F89: Pervasive developmental disorders F90–F98: Disorders of childhood and adolescence F99–F100: Unspecified Mental Disorders
ICD-10 Section for Substance Use Disorders
F10: Mental and behavioral disorders due to use of alcohol F11: Mental and behavioral disorders due to use of opioids F12: Mental and behavioral disorders due to use of cannabinoids F13: Mental and behavioral disorders due to use of sedative hypnotics F14: Mental and behavioral disorders due to use of cocaine F15: Mental and behavioral disorders due to use of other stimulants, including caffeine F16: Mental and behavioral disorders due to use of hallucinogens F17: Mental and behavioral disorders due to use of tobacco F18: Mental and behavioral disorders due to use of volatile solvents F19: Mental and behavioral disorders due to multiple drug use and use of other psychoactive substances
descriptive about the presentation, such as if the patient in remission, in a controlled environment, is having convulsions, and so forth. There are many options for each drug in each stage of use, abuse, dependence, and withdrawal. Take a look: • F1x.0: Acute intoxication ·. · 00 Uncomplicated ·. · 01 With trauma or other bodily injury ·. · 02 With other medical complications ·. · 03 With delirium ·. · 04 With perceptual distortions ·. · 05 With coma ·. · 06 With convulsions ·. · 07 Pathological intoxication • F1x.1: Harmful Use • F1x.2: Dependence Syndrome ·. · 20 Currently abstinent ·. · 21 Currently abstinent, but in a protected environment ·. · 22 Currently on a clinically supervised maintenance or replacement regime (controlled dependence) ·. · 23 Currently abstinent, but
receiving treatment with aversive or blocking drugs ·. · 24 Currently using the substance (active dependence) ·. · 25 Continuous use ·. · 26 Episodic use (dipsomania) • F1x.3: Withdrawal State ·. ·30 Uncomplicated ·. ·31 With convulsions
• F1x.4: Withdrawal state with delirium So for example, opioid dependence, currently abstinent but receiving supervised maintenance or replacement drug (methadone), would be coded as F11.22. Finally, the diagnostic criteria and language for SUDs is different, but similar from the DSM-5 to the ICD-10, so compare the two. In the simplest terms, anyone who meets the diagnostic criteria for “substance use disorder (severe)” will meet the diagnostic criteria for substance dependence.
Conclusion
My hope is that this introduction and overview of the DSM-5 and the ICD-10 will provide you with enough information to prompt you to learn more. I would strongly suggest that you determine how your practice has been impacted by these updates, and do the research you need to do in order to be current and proficient. c Roland Williams, MA, LAADC, NCAC-II, CADC-II, ACRPS, SAP, the founder and CEO of Free Life Enterprises and VIP Recovery Coaching, is a world renowned addiction specialist, counselor, interventionist, lecturer, trainer, teacher, author, and consultant. He has been passionately working in substance abuse treatment since 1986.
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NACOA
CoAs and Opioid Addiction Sis Wenger
T
hirty-five years ago, the Henry Ford Health System (HFHS) in Southeastern Michigan had an inpatient addiction treatment program at its main hospital in Detroit, and it included a family education program. That year HFHS decided to build a stand-alone treatment facility called Maplegrove, and include a family therapy component at the urging of the newly hired medical director, who had been a medical school professor sponsored by the NIAAA career teacher program to educate medical students about alcoholism. Across the country, treatment programs were including some form of family education and treatment, and insurance tended to cover it with the strong belief that the addict’s prognosis was much more positive if the family began to heal as well. Shortly after that , Maplegrove established a very effective adolescent addiction treatment program. Because it was already well known that alcoholism and other drug addictions tended to run in families, and that addicted individuals—adolescent and adults alike— are at much greater risk of relapse when the family to which they return has not also begun its road to recovery; because patients do not recover in isolation; and because painful family relationships nurtured in the addictive family do not mend without their own recovery work, Maplegrove refused to accept any adolescent patients unless the parents 12
Counselor · April 2016
agreed to participate in the related family program. Today we have our latest addiction epidemic: opioids. This one has been made more important in the public eye as the children of the middle class and higher economic and social classes are being buried. The label “addict” has come home to those who couldn’t imagine that possibility. Parents who have lost a child to an overdose are speaking out and expect to be heard; those with substantial resources are investing them in supporting access to treatment and specialty recovery support programs; Congress has added large funds to multiple programs for the treatment of this dreadful disease and for medical education about it; the FDA has approved widespread availability of naloxone, the life-saving emergency antidote for use in the event of an overdose; and 2016 presidential candidates have “programs” to address it. But there are several questions not brought up in all of this. What about the addict’s children? What about the family history of alcoholism and or other drug addictions? What is it about those young adults fortunate enough to get treatment that made it easy for them to take the first pill removed from a parent’s or grandparent’s medicine cabinet? Who is studying the family environment of the majority who refuse to try it from the very first versus those who succumb? Are we scrambling from emergency
to emergency to treat what might have been prevented and forgetting that epidemics don’t die by themselves? Where are the prevention efforts and funding, especially for those at risk for addiction? As I considered the theme of this issue of Counselor magazine, I thought back to the lesson of the Maplegrove youth treatment program and then, thinking back to the present, remembered that last year, Dr. Claudia Black, noted author and clinician well known to Counselor readers, has developed and is running a treatment program specifically for young adults at The Meadows in Arizona, and I wondered if she was seeing what I was guessing—that the victims of opioid addiction, for the most part, are from middle-income
with insurance or upper-income families and are mostly white, helping to account for the strong media and public attention surrounding this tragedy (i.e., the affected population gets attention when it is an empowered population). I was fortunate to reach Dr. Black, explained what I was thinking, and she answered the following questions. Sis Wenger: In your new program, are you finding that the adage claiming that “addiction tends to run in families” still manifests itself and is a contributing factor in the addiction of young adults presenting for treatment? And do you see a predominance of relatively privileged young people involved? How is that manifested? Dr. Black: Yes, we see this
NACOA a lot. At the Claudia Black Young Adult Center, we work with young adults from a range of socioeconomic backgrounds. But many of our clients grew up with the privileges that come with being from upper-middle-income and high-income families. Despite their advantages, children of affluence are experiencing disproportionately high levels of emotional problems today. These young adults experience the highest rates of depression, substance abuse, anxiety disorders, somatic complaints, and unhappiness of any group of children in the country. This is not meant to minimize the problems children from other economic backgrounds face, but we cannot ignore, dismiss or downplay what is happening to a very sizable portion of our young adult population.
The Role of Depression, Anxiety, and Drugs
Dr. Black: Studies from public schools show that as many as 22 percent of adolescent girls from financially comfortable families suffer from clinical depression. That’s three times the national rate for adolescent girls. By the end of high school, one-third of the girls from these families exhibit clinical signs of anxiety. Boys from similar backgrounds also show elevated rates of anxiety and depression early in high school, though the difference is more pronounced with girls. By late high school, many of these children may begin to use drugs and alcohol regularly to self-medicate their depression and anxiety. In addition to depression, anxiety, substance use, rule breaking, and psychosomatic disorders are all elevated
among affluent teens. These teens are also prone to eating disorders and cutting.
Isolation
Dr. Black: Feelings of isolation seem to be especially common among children from wealthier families. Research is now beginning to tell us that there is an inverse relationship between closeness and high income. Children from lower income homes are far more likely to report feeling close to their parents than those from higher income homes. Material advantages do not lessen the sting of parents’ unavailability. Friends, nannies, housekeepers, au pairs, and older siblings cannot substitute for a concerned and involved parent. In my current work, I see a lot of what I refer to as “father hunger,” meaning that dad’s not involved in a manner that makes the child feel valued or supported. Many fathers are caught up in their highly demanding work schedules and often act as financial providers for the family but do not have an emotional connection with their kids. Or, in many cases, they are absent and only attempt to connect through messages about the child’s value being directly related to their performance in school or sports. Finally, and to the point of your questions, many parents end up absent in their own addictions. Many young adults, regardless of their socioeconomic background, have parents who are preoccupied with something other than parenting. They may have a father or mother who is rarely present not only because of work, but also because of a substance use disorder, gambling, sexually acting out or their many
boyfriends or girlfriends. Many times these parents’ absence is due to their own untreated depression.
Healing the Family is Critical
Dr. Black: All of this simply reinforces the need for strong family programming in treatment programs, in drug court programs, and in what we have traditionally called “aftercare.” I have seen throughout the process of family treatment that family members share an abounding love for one another in spite of a history of challenging family dynamics. As the country is calling for ongoing recovery resources for the young adult, I strongly encourage it for other family members as well.
Conclusion
With the concepts of family history and parent child relationships so prevalent in Dr. Black’s comments, I propose an additional dimension to prevention for the population of individuals being sucked into the opioid epidemic. Dr. Donald Ian Macdonald, a pediatrician and former director of the United States Public Health Service, published a book entitled A Pediatrician’s Blueprint: Raising Happy, H e a l t h y, M o r a l , a n d Successful Children (2014). An endorsement of the book by Hoover Adger, Jr., MD, MPH, MBA, professor of pediatrics at Johns Hopkins University Medical School and director of adolescent medicine at Johns Hopkins Hospital, states, “This book is must reading for parents who want their children to grow into healthy, productive, and caring adults who have a clear-minded and principled perspective.” Drug use prevention
begins long before a child first goes to school. What we have learned over recent years is that parents matter greatly and that caring, nurturing parents are listened to by their children, especially if the parents have listened to them from early childhood. The greatest deterrents to taking the first drink, the first pill or the first puff is not wanting to disappoint one’s parents and having an honest and trusting relationship with them. Dr. Black tells us that the eighteen- to twenty-six-yearold young adults she sees in her treatment program “so want to know they are valued by their parents in spite of the difficulty their addictions have caused the family; and these parents . . . so love their kids.” A dynamic and in-depth family program can create transformation in individuals and whole family systems, and can begin intergenerational healing and help to halt the generational transmission of addiction. If we are to arrest the scourge of opioid addiction, addressing the possibilities of preventing it through supportive parenting on the front end and through whole family recovery on the back end seems incredibly logical. c Sis Wenger is NACoA’s President and CEO.
References
Macdonald, D. I. (2014). A pediatrician’s blueprint: Raising happy, healthy, moral, and successful children. Petaluma, CA: Roundtree Press.
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CULTURAL TRENDS within the US. The cartels that so efficiently established super labs in the west coast in the mid-1990s have moved operations to Mexico, where restrictions on the precursor chemical, pseudoephedrine, have until very recently been nonexistent. In 2004, Mexico imported 224 tons of pseudoephedrine, a figure estimated to be double the national demand for cold medicine and quadruple the sixty-six tons imported in 2000. To supply their super labs, the cartels are obtaining the chemical in mass quantities, either in bulk directly from overseas suppliers, from local pharmaceutical companies making legitimate cold pills or via bogus pharmacy fronts (“Mexican meth,” 2006).
The Impending Drug Epidemic
Mexican Meth: Crossing the Border Maxim W. Furek, MA, CADC, ICADC
L
aw enforcement has been waging war on methamphetamine (meth) cookers for decades. But as lab seizures and restrictions on pseudoephedrine dry up homegrown production, there is increasing concern that Mexican drug cartels are filling the void. Although meth can be made in small, illegal laboratories, most of the meth abused in the United States comes from domestic or foreign super labs (NIDA, 2012). Mexican meth now accounts for as much as 80 percent of the meth sold here, according to the Drug Enforcement Administration (DEA), and it is as much as 90 percent pure, a level that offers users a faster, more intense, and longer-lasting high (Stevenson & Sherman, 2012). Cooking meth is a dangerous endeavor, but nonetheless this is a marketable product that can ring up billions of dollars in sales. Mexican cartels are professional and savvy— they use the same business model proven to be successful with heroin and cocaine. Additionally, they use the same pipelines: sophisticated distribution networks that have funneled marijuana and cocaine into the US for years. The Mexican meth problem has been with us for a long time. Documentation from earlier DEA reports indicates its progressive intrusion into the states. According to a 2006 report, 65 percent of all meth consumed in the US came from Mexican drug cartels—53 percent from super labs in Mexico itself and 12 percent from Mexican-run super labs 14
Counselor · April 2016
Like the US, Mexico has tightened laws and regulations on pseudoephedrine. Nevertheless, some labs circumvent the restrictions, obtaining large amounts of these chemicals from China and India. Furthermore, cartel chemists have turned to an old recipe that first appeared in the 1960s and 1970s in some parts of the western US. Known as P2P, that older recipe uses the organic compound phenyl acetone. Because of its use in meth production, the US government made it a controlled substance in 1980, essentially stopping that form of meth in the US. But in Mexico, the cartels can get phenyl acetone from other countries. According to the DEA, in the third quarter of 2011, 85 percent of lab samples taken from US meth seizures came from the P2P process—up from 50 percent little more than a year earlier (Salter, 2012). DEA reports are alarming and may be a portent of an impending drug epidemic. Records show that seizures of Mexican meth along the Southwest border have jumped substantially over a four-year span. During that period, officials confiscated over four thousand pounds in 2007 to more than sixteen thousand pounds in 2011, a dramatic increase of 400 percent. Seizures of Mexican meth coming across the southwest border have increased nearly fivefold between 2008 and 2012, from 2,282.6 kilograms in 2008 to 10,636.5 kilograms in 2012 (DEA, 2013). US Customs and Border Protection officers have confiscated more meth at Arizona ports of entry in fiscal year 2015 than they did the entire previous year, continuing an upward trend. Officers seized more than 3,240 pounds of meth between October and May 2015, compared with 3,200 pounds for the entire last fiscal year. “We started noticing the increase with meth in fiscal year 2014, so we noticed an increment on crystal meth and obviously it all starts from the demand, you know. They’re demanding this drug,” agency spokeswoman Marcia Armendariz said (Associated Press, 2015).
Characteristics of New Meth
The new Mexican meth is chemically stronger. The drug is more potent and, unsurprisingly, highly addictive. Purity increased from 39 percent in 2007 to 88 percent in 2011. Cost-wise, it is much cheaper than previous batches. The street price of meth has dropped 69 percent, from $290 per pure gram to less than $90. That makes the production even
CULTURAL TRENDS more competitive. American drug traffickers often receive free samples of meth as part of their shipment, which is an effective marketing strategy to entice new consumers. Disturbing numbers indicate that meth prices have decreased more than 70 percent between the third quarter of 2007 and the second quarter of 2012. During that time meth purity increased almost 130 percent. Officials say that the drug is easier and cheaper to manufacture in Mexico, where meth is produced on an industrial scale using formulas developed by professional chemists. Mexican drug cartels continue to ramp up production and global distribution of their product. A recent New York Times article reported that the problem may be more serious than previously estimated: Mexican authorities have busted a meth super lab and seized a staggering amount of pure methamphetamine— fifteen tons, more than double the amount of all meth seizures made at the border last year, and more than one hundred times the biggest-ever meth bust in the USA. The drugs have an estimated street value of $4 billion— experts believe Mexico’s cartels have moved beyond the US to supply users around the entire world (Cave, 2012).
lucrative drug corridor because of the large volume of trucks that pass through the area, and the multiple, exploitable ports of entry. Every year, more than 5 million cars, 1.5 million commercial trucks, and 3.8 million pedestrians cross northbound from Mexico into the US here, bringing with them a ton of hidden narcotics (Fantz, 2012). Another reality is about the money. The estimated amount that Mexican and Colombian drug trafficking organizations make in wholesale profits annually comes to $39 billion, according to a 2009 Justice Department report (Fantz, 2012). Things are getting worse. A 2011 Justice Department study revealed that Mexican traffickers control the flow of most of the cocaine, heroin, foreign-produced marijuana, and methamphetamine in the US (Fantz, 2012). A lot of drugs are heading north and a lot of pesos are heading south. Something needs to be done. Our “Drug Czar” appears to be missing in action. c Maxim W. Furek, MA, CADC, ICADC, is an avid researcher and lecturer on contemporary drug trends. His rich background includes aspects of psychology, addictions, mental health, and music journalism. His latest book, Sheppton: The Myth, Miracle, & Music, explores the psychological trauma of being trapped underground and is available at Amazon.com.
References
Availability indicators reflect that the supply of Mexican meth is increasing in the US. Price, purity data, and increased meth flow across the southwest border indicate rising domestic availability, most of which is the result of high levels of meth production in Mexico.
Associated Press. (2015). Spike in meth seen from Mexico as US production low. Retrieved from http://www.azcentral.com/story/ news/local/arizona/2015/06/17/mexican-meth-spike-border-patrol-arizona/28865509/
Liquid Meth
Fantz, A. (2012). The Mexico drug war: Bodies for billions. Retrieved from http://www.cnn.com/2012/01/15/world/mexico-drug-war-essay/
Yet another concern surrounds the latest version of the stimulant drug. A sixteen-year-old Mexican high school student, Cruz Marcelino Velazquez, drank highly concentrated liquid meth at a San Diego border crossing (“Teen died,” 2014), attempting to persuade inspectors that it was only apple juice. Velazquez died hours later at a hospital from acute meth intoxication. San Ysidro, the nation’s busiest border crossing, has emerged as a major corridor for smuggling meth in the past five years, as Mexico’s Sinaloa cartel has increased its presence in the area. To avoid detection, crystal meth is dissolved in water and disguised in juice bottles, windshield wiper fluid containers, and gas tanks. It is later converted back to crystals. Children are caught with meth several times a week at San Diego crossings, an “alarming increase,” an assistant special agent in charge of US Immigration and Customs Enforcement investigations in San Diego, said. These mules are typically paid $50 to $200 a trip (“Teen died,” 2014).
Harsh Realities
The DEA’s relationship with Mexico embraces a number of harsh realities. One such reality can be measured in miles. There is a two-thousand-mile border that separates both countries. It is vulnerable and porous. The border town of Nuevo Laredo, ten minutes from Laredo, Texas, is a classic example. It is a
Cave, D. (2012). Mexico seizes record amount of methamphetamine. The New York Times. Retrieved from http://www.nytimes.com/2012/02/10/world/ americas/mexico-seizes-15-tons-of-methamphetamine.html?_r=1
“Liquid meth pours into north Texas.” (2014). Retrieved from http://dfw.cbslocal.com/2014/10/10/liquid-meth-pours-into-north-texas/#.vhtry5hes2w.mailto “Mexican meth.” (2006). Retrieved from http://www.pbs.org/ wgbh/pages/frontline/meth/etc/updmexico.html National Institute on Drug Abuse (NIDA). (2012). Methamphetamine. Retrieved from http://www.drugabuse.gov/drugs-abuse/methamphetamine Salter, J. (2012). Mexican cartels flooding US with cheap meth. Retrieved from http://www.komonews.com/news/national/Mexicancartels-flooding-US-with-cheap-meth-173703751.html Smith, S. (2014). Meth pours into central California as liquid. Retrieved from http://news.yahoo.com/meth-pours-central-california-liquid-134903155.html;_ylt=AwrBT7t3SrxU6IwAYwtXNyoA;_ylu=X3oDMTB yZDBpbXI5BHNlYwNzcgRwb3MDNQRjb2xvA2JmMQR2dGlkAw-Stevenson, M., & Sherman, C. (2012). Mexican cartels fill demand for meth in USA. USA Today. Retrieved from http://www.usatoday.com/ story/news/nation/2012/10/11/mexico-cartels-meth/1626383/ “Teen died after drinking liquid methamphetamine.” (2014). Retrieved from http:// www.cbsnews.com/news/teen-died-after-drinking-liquid-methamphetamine/ US Drug Enforcement Administration (DEA). (2013). 2013 National drug threat assessment summary. Retrieved from http://www.dea.gov/resource-center/DIR-017-13%20NDTA%20Summary%20final.pdf US Drug Enforcement Administration (DEA). (2015). Three members of Mexican cartel sentenced to prison for conspiracy involving liquid methamphetamine. Retrieved from http://www.dea.gov/divisions/atl/2015/atl010615.shtml
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OPINION
Music and the Arts in Recovery George “Butch” Warner, MA, MFT, CADC-II
T
here are few things sadder than walking into a rehab and seeing patients who have “that look.” “That look” is a combination of ennui, sadness, guilt, helplessness, and hopelessness caused by the fact that patients are generally trying to recover from the most disastrous years, months or days of their lives. And as if life wasn’t bad enough in the last days of their ripping and running, now they’re stuck in a place filled with some of the unhappiest people they’ve ever met. It doesn’t have to be that way. My mentor Dr. Lee Bloom used to say to clients, “Hey, let’s have some fun while we’re here! You’re in the most beautiful place in the country, you’re clean and sober, and you’ve got your 16
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whole life ahead of you.” That has been my basic philosophy for the thirteen years I’ve been in this field. If you can’t be happy in recovery, then why the hell did you stop? To be unhappy in a new place?
The Cure
Anhedonia, the inability to experience pleasure, is an almost inevitable consequence of stopping all your drug use at once, and moping around with a bunch of other anhedonics doesn’t make it any better. There are scientific explanations for this phenomenon, including reduced dopamine, endorphins, and alterations in serotonin levels. The antidote to anhedonia, then, lies at least partially in stimulating
dopamine, serotonin, and endorphins, which reduce the intensity of both physical and mental pain. Besides ameliorating the experience of pain, these neurotransmitters affect other psychological activities, including euphoric feelings, appetite, and the release of sex hormones. Two very good ways to overcome anhedonia are music therapy and the arts, which have been integral parts of every program I’ve ever been associated with. We all know and instinctively understand that artistic activities can be extremely soothing, and drug addicts are notoriously bad at self-soothing. Extended, continuous immersion in focused activities contributes to a sense of well-being that may represent
OPINION increased production and release of endorphins. But this isn’t an article about neurotransmitters. It’s about music, art, laughter, joy, and learning to love life without drugs and alcohol.
The Value of Music and the Arts
There are many nonpharmacological ways to deal with the inevitable anhedonia associated with early recovery— exercise, meditation, camaraderie, mindfulness, yoga, and acupuncture, to name a few—but it is my belief that music and the arts are two of the best. Although we’re not quite sure where they came from and what their true purpose is in human survival, music and the arts have been a part of the human experience for a long time. A bone flute that could probably play a modern melody was unearthed from a site in France dating back at least thirty-two thousand years (“Development of Flutes,” 2015). I try to impress upon my clients that music and the arts are truly
mind-altering “substances” that not only offer diversion in our darkest hours, they also have the power to literally change our mood and attitude, much like drugs and alcohol did. For me, listening to a silly song like “Sugar, Sugar” by The Archies always makes me smile and brightens my mood. On the other hand, the song “Creep” by Radiohead makes me feel, well, creepy, while at the same time morphing my mood into something dark and twisted, which can be a good thing when it serves as a reminder of those days when I felt unworthy and less than. Edvard Munch’s The Scream is a painting often brought up in art therapy classes, because it has the power to make us feel those wretched moments when all we could do was cry out in our hopeless, twisted despair. Ryan Hampton, a former client who is now in recovery at a rehab near Los Angeles, says, “Music and the arts are my medicine. They are the best replacement therapy out there.” It rankles me to no end when I see
counselors or administrators take away clients’ musical instruments, secular books, digital music players, and crafts materials, hand them a Big Book and program booklets, and proclaim, “This is all you’ll need while you’re here. That other stuff is what got you here in the first place.” That is so wrong! Facilities that embrace this philosophy are thankfully on the decline, principally because a good music and arts therapy program can have countless benefits (see the text box).
Emotional Connection
We’re not quite sure where it comes from, but that thing that uses rhythm, percussion, and wide ranges of pitch, melody, and harmony—that is, music— is a part of every culture. And the expression or application of human creative skill and imagination, typically in a visual form such as painting, sculpture, literature, and dance, are archetypal across almost all cultures too.
The Benefits of Music and Art Therapy
• It’s been conclusively established that the pleasurable experience of listening to music or engaging in artistic endeavors releases dopamine, a neurotransmitter associated with other rewards like sex, drugs, and food. Even the anticipation of pleasurable music induces dopamine release (McGill University, 2011). • Music and the arts can lower stress levels (Novotney, 2013). The soothing power of music is well-established. • Music and the arts actually lower and raise blood pressure! In addition, it can help protect the heart from heart disease (Donnelly, 2015). • Music and the arts help improve communication abilities for people with autism. “Our current results provide intriguing preliminary evidence for a possible molecular link between dopamine DRD4 receptor, music, the arts, and autism,” concludes a study published in the journal Neuroendocrinology Letters (Emanuele et al., 2010). • In the same way that music helps with depression, music and the arts can help people deal better with anxiety. • Icons and paintings are almost universal adjuncts to meditation, which reduces stress and increases mindfulness. They are used in almost all religions and are indispensable components of most religious and spiritual ceremonies. • Music and the arts can give the body’s immune system a boost (Novotney, 2013), therefore promoting healing and helping the body ward off illness. • Music and the arts can help people cope better with the pain of detox and legitimate chronic pain. Researchers found that people who listened to excerpts of music judged by most to be pleasant reported less pain than those who listened to “unpleasant” music (Bates, 2013). The more pleasing the listeners found the music to be, the less pain they felt. Other studies suggest that music can interfere with pain signals at the level of the spinal cord—this is before they even reach the brain (Bates, 2013). • Music and the arts reduce feelings of loneliness. Elizabeth Singer, a client at a California rehab in 2014 says, “I was moved by your music therapy class. I was able to inspire and express myself with motivational music of my choice. It made me feel that I was not alone, that life was worth living again.” • Music is one of the last vestiges of a link to the “real world” in patients with Alzheimer’s disease and other forms of dementia, including drug psychosis (Novotney, 2013). www.counselormagazine.com
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OPINION
Some scientists conclude that music and the arts’ influence may be a random event, arising from their ability to “liberate” brain systems built for other purposes such as speech, feelings, and muscle movement. Music and the arts seem to offer an extraordinary system of communication rooted more in feeling rather than in content. It is clear that music and the arts are much more than pleasantly distracting, useless human activities. As advances in neurology and brain scans develop, we will probably learn as much about the physics and physiology of music and the arts in the next twenty years as we have learned previously in all of recorded history. New scientific evidence shows that music and art bring out predictable responses across cultures and among people of widely varying musical or cognitive abilities. Music and art unfailingly convey certain emotions. What we feel when we hear a piece of music or look at a Picasso painting is probably close to what others from other cultures are experiencing. The arts in general—body art, cinema, dance, digital art, drawing, engraving, 18
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opera, painting, photography, poetry, pottery, sculpture, singing, theatre, reading, writing, and even graffiti— have mysterious roots. Why did the first Māori chief carve images into his skin, later seen by Captain Cook and his crew? Why did the first Paleolithic cavewoman decide to use charcoal to draw the image of her daughter on a cave wall? Why did the first African mother sing to her child fifty thousand years ago? So making art and music are primitive things, and like drug addiction they reside in parts of the brain that we just don’t know a lot about. Perhaps that’s why music and the arts are such effective, indispensable treatments for addicts in early recovery. They exercise the part of the brain that drugs and alcohol have rendered flabby and useless. This is why they should be integral parts of all drug and alcohol programs. Adding music and art therapy to your program is money well spent, and will guarantee that people will speak well of your program when they leave. c
George "Butch" Warner, MA, MFT, CADC-II, is an addiction therapist and music therapist at Pasadena Recovery Center in Pasadena, CA; a psychotherapist with a private practice; and a writer of scholarly and consumer articles about music, addiction, pharmacology, veganism, entertainment, and other topics.
References
Bates, M. (2013). A dose of music for pain relief. Retrieved from http://www.brainfacts.org/sensing-thinking-behaving/senses-and-perception/ articles/2013/a-dose-of-music-for-pain-relief/ “The development of flutes in Europe and Asia.” (2015). Retrieved from http://www.flutopedia.com/dev_flutes_euroasia.htm Donnelly, L. (2015). Verdi, Beethoven, and Puccini could help beat heart disease. The Telegraph. Retrieved from http://www.telegraph.co.uk/ news/health/news/11660663/classical-music-blood-pressure-heart-disease.html Emanuele, E., Boso, M., Cassola, F., Broglia, D., Bonoldi, I., Mancini, L., . . . Politi, P. (2010). Increased dopamine DRD4 receptor mRNA expression in lymphocytes of musicians and artistic individuals: Bridging the music-autism connection. Neuroendocrinology Letters, 31(1), 122–5 McGill University. (2011). Musical chills: Why they give us thrills. Retrieved from http://www.sciencedaily.com/releases/2011/01/110112111117.htm Novotney, A. (2013). Music as medicine. Monitor on Psychology, 44(10), 46.