Counselor - April 2017 Issue Preview

OPINION: “DAY 001: VOICES OF RECOVERY”

INSIDE BOOKS: ESSENTIAL LIVING

BY TIFFANY HALL

BY SHELLEY URAM, MD

SPECIAL ISSUE:

ADOLESCENTS AND YOUNG ADULTS SUD Treatment for Emerging Adults Cost-Effective Adolescent Recovery Nonsuicidal Self-Injury and Eating Disorders Reclaiming Parenting with Addicted Teens Dr. Andrea Barthwell Interviews William White 〈 〈 〈 FLIP OVER

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L E A D E R S I N P S Y C H I AT R I C M E D I C A L L I A B I L I T Y I N S U R A N C E

CONTENTS

29

Letter from the Editor

7

CCAPP

8

By Gary Seidler Consulting Executive Editor

Substance Use Disorder Treatment for Emerging Adults

California Begins a Worldwide Treatment Revolution

By Mark Sanders, LCSW, CADC, & Katie Richie, AM

By Sherry Daley

Describes various interventions that work with emerging adults, lists the developmental tasks emerging adults face, and presents alternative therapies.

11

NACOA

Will Changing the Language of Addiction Help?

By Sis Wenger

14

Cultural Trends

33 A Cost-Effective, Evidence-Based Approach to Adolescent Recovery

By Mark Sanders, LCSW, CADC, & Katie Richie, AM Introduces an intervention that is effective with adolescents in substance use treatment, describes the cannabis youth treatment study, and presents additional evidence-based practices for this population.

Storm Warning: Carfentanil’s Impending Tsunami of Death

By Maxim W. Furek, MA, CADC, ICADC

Opinion

“Day 001: Voices of Recovery”: Why Recover Alaska is Highlighting Alaskans’ Stories of Recovery

16

By Tiffany Hall

From Leo’s Desk

What is Religious Agnosticism?

18

By Rev. Leo Booth

37

Wellness

Major Depression and Substance Abuse in Teens, and Fostering Environments Supportive of Recovery

Treating Eating Disorders and Self-Injury in Adolescents

By John Newport, PhD

By Nicole Garber, MD

The Integrative Piece

Defines nonsuicidal self-injury (NSSI), presents various risk factors for NSSI in adolescents, and discusses eating disorders and how they are related to NSSI.

The Path Forward

20

22

By Sheri Laine, LAc, Dipl. Ac

www.counselormagazine.com

3

C

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ADVERTORIAL

Healing and Recovery: It’s a Matter of the Heart

“Healing is less about ‘saving’ or ‘fixing’ and more about ‘allowing’ ourselves to ease into the remembering that there’s a wholeness that has been there all along.”

–Emmanuel Dagher After years working in the treatment field, we’ve come to believe that clients benefit from a program that helps them “remember that there’s a wholeness that has been there all along.” This means creating a healing environment grounded in respect and empowerment; where clients begin to make their own decisions and choices again, and are encouraged to believe in themselves as whole rather than damaged or defective.

The Healing Environment

The word healing comes from the AngloSaxon word haelen, which means to make whole. A healing environment cannot be created through fear, working from a “one up” or expert position or control and manipulation. It can only be created through respectful practices such as nonjudgment, kindness, compassion, healthy boundaries, and mutual respect. We cannot demand respect, we must earn it. We cannot empower others, we can only create an environment that supports clients to believe in and empower themselves to risk trying something new. We must respect where clients are in terms of their readiness to change, and remember that they are usually afraid, wounded, stuck, sad, and angry.

In treatment, clients often act out these emotions and are labeled “resistant,” “noncompliant,” and “not caring.” We don’t want to view clients through this lens and instead see

them as human beings who are suffering, not as addictions, eating disorders or depression.

We may suffer from those things, but they do not define what we ARE. Labels tend to inhibit the creation of a healing environment. In contrast, “holding space” (being fully present with others without judgment) for clients invites them to settle in and feel safe enough to let go of these adaptive behaviors. Holding space allows clients to have their own experience without someone else trying to “fix it” or affect a specific outcome, which enables clients to gain confidence in themselves as they work out their struggles themselves with the support of the group community.

This provides the foundation for them to begin to believe that they are good enough and can live a great life.

Structure vs. Control

“Fear focuses on what you don’t want; love focuses on what you do want. Fear controls, love structures. Fear judges, and love notices.”

–Becky Bailey Author of Easy to Love, Difficult to Discipline Intrinsic motivation does not rely on external pressure like fear, rewards/approval or punishment/disapproval from peers or health professionals. It exists within the individual, and is driven by interest or enjoyment in the task itself. This is the basis of self-determination theory. Contrary to rewards and incentives, research supports the idea that intrinsic motivation is stable and lasting as the individual is making changes based on what is

enjoyable or compatible with their “sense of self,” core values, and life goals.

Establishing an environment that supports choice over control and promotes intrinsic motivation has been a cornerstone for us at ILC. People need to feel a sense of choice and responsibility for their actions, to feel capable of achieving their goals and also understood, cared for, and valued by others. Our staff understand this and help guide clients along a path of change of their choice. We offer opportunities for them to learn by living life and being accountable (Real World, Real Life, Real Recovery). They are supported in recovering faith in self instead of looking to others for approval. We do not view the self as a bad thing or something to be avoided or shunned and believe that until we are in alignment with our self we cannot be in alignment in life. What we ARE and what we DO are not the same.

What we ARE are human beings; reflections of our creator. What we DO is largely inherited when we are born into this world. By supporting clients in recovering faith in and reclaiming their authentic selves, life (recovery) becomes interesting again and clients become intrinsically motivated for change.

Our commitment is to support those who walk through our doors in their journey by providing a healing environment, the highest quality care and holding a space of re spect for them until they can reclaim that for themselves. That’s how we roll. One day at a time.

— Holly Cook, executive director & Lee McCormick, CEO 877-334-6958 www.integrativelifecenter.com

CONTENTS Topics in Behavioral Health Care

Substance Use among College Student-Athletes

23

By Dennis C. Daley, PhD

Counselor Concerns

The Recovery Stool

26

By Gerald Shulman, MA, MAC, FACATA

Ask the LifeQuake Doctor

28

43 Recovery’s Historian: An Interview with William L. White, MA

By Andrea G. Barthwell, MD, DFASAM, & Megan Crants, BA Describes William L. White’s early career, presents his achievements in the field, and shares some of his insights.

By Toni Galardi, PhD

Inside Books

Essential Living: A Guide to Having Happiness and Peace by Reclaiming Your Essential Self

64 From the Journal of Substance Abuse Treatment

By Shelly Uram, MD Reviewed by Leah Honarbakhsh

Is Normative Feedback Bad for Adolescents in Substance Use Treatment?

ALSO IN THIS ISSUE Ad Index CE Quiz

47

59 62

By Jordan P. Davis, MS, & Jon M. Houck, PhD Examines motivational interviewing (MI) and normative feedback for adolescents and describes a study on MI versus MI with normative feedback for this population.

54 Reclaiming Parenting with Addicted Teens and Young Adults

By Barbara Krovitz-Neren, MA Presents the results of a survey on adolescents and young adults, describes the five steps of foundational parenting, and provides information for counselors on how to help parents of addicted youth.

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Counselor | April 2017

LETTER FROM THE EDITOR

News from the Political Front

2017.

Has there ever been a new year when national headlines have been so dominated by significant developments affecting our societal attitudes toward substance abuse and addiction?

Let’s review.

Almost lost just prior to the holiday season was the Surgeon General’s “Report on Alcohol, Drugs and Health,” marking the first time the top health official in the US has submitted a report on substance abuse and correlating issues. The report, titled “Facing Addiction in America,” discusses findings about alcohol, illegal drugs, and prescription drug abuse, while also discussing neurobiology, prevention, treatment, recovery, health systems integration, and advice for the future.

It also takes an in-depth look into the chemistry of substance abuse and addiction, addressing the need for a paradigm shift in the way Americans talk about the issue to end the cycle of stigma and shame. It goes on to recommend actions for prevention and treatment for those who need help. The report represents the first attempt by anyone in any US administration to approach substance use and addiction not as an ethical issue or a matter of criminality, but as a human experience to be understood, as a human dilemma calling for a humane response.

“Once viewed largely as a moral failing or character flaw,” the report says, addictions are “now understood to be chronic illnesses characterized by clinically significant impairments in health, social function, and voluntary control over substance use” (US Department of Health and Human Services, 2016).

It sees addiction as a chronic illness, to be treated as other medical conditions such as diabetes or asthma.

Most importantly, “Facing Addiction in America” is a sure sign of progress in the efforts to eliminate the stigma of addiction and recovery—a comprehensive take on recovery that will help to better inform policymakers, the medical community, and the public from an authoritative standpoint. A comprehensive approach

like this is crucial in addressing alcohol and drug addiction, as it includes the expanding role of recovery housing, recovery communities in education (both high school and college), and recovery organizations around the nation.

In the same week as the release of the Surgeon General’s report, Congress passed the Twenty-First-Century Cures Bill, a sweeping $6.3 billion medical innovation bill. Alongside the Cures Bill, the Comprehensive Addiction and Recovery Act (CARA) also passed, providing $1 billion over two years in grants to states to address the opioid addiction crisis through prevention, treatment, prescription drug monitoring programs, and workforce development.

The Cures Bill passed with bipartisan congressional support and with the support of the White House. The bill also creates federal drug courts and programs for alternatives to incarceration for individuals with SUDs. It also encourages integration of care for SUDs with primary care.

These are major victories for our field.

As noted by Marvin Ventrell, executive director of the National Association of Addiction Treatment Providers (NAATP), in his year-end message, These are remarkable advances in terms of society’s recognition of addiction as a health care matter, and policy-makers’ willingness to act.

They provide the service provider with real tools. Rarely, if ever, have we seen this quantity and quality of addiction service public policy (2016).

As of this writing, there is far less certainty about the future of the Affordable Care Act (ACA), also known as “Obamacare.”

An article by the Partnership for DrugFree Kids states, Almost 30 percent of people who received coverage through the ACA’s Medicaid expansion have a mental disorder or a substance use disorder,

according to the Substance Abuse and Mental Health Services Administration.

Partially repealing ACA would do away with Medicaid expansion, and would most likely replace it with block grants that would require states to make cuts in what is covered, how much is spent and how many people can receive coverage (2017).

Let’s hope the glass remains at least half full. c References Partnership for Drug-Free Kids. (2017). Repeal of Obamacare could reduce coverage for addiction treatment. Retrieved from http://www.drugfree.org/newsservice/repeal-obamacare-reduce-coverage-addictiontreatment/ US Department of Health and Human Services. (2016).

Facing addiction in America: The Surgeon General’s report on alcohol, drugs, and health. Retrieved from https://addiction.surgeongeneral.gov/surgeongenerals-report.pdf Ventrell, M. (2016). 2016: A year of progress and positioning. Retrieved from https://www.naatp.org/resources/ news/2016-year-progress-positioning/dec-21-2016

Gary Seidler

Consulting Executive Editor Counselor, The Magazine for Addiction & Behavioral Health Professionals, A Health Communications, Inc. Publication Editor’s Note In the last issue of Counselor, it was noted that Richard Froilán-Dávila, PhD, is the “campus director for Springfield College, School of Human Services, in Tampa Bay, FL.” This was an error, as Dr. FroilánDávila is no longer the campus director and the school’s name has been changed to the School of Professional and Continuing Studies.

www.counselormagazine.com

7

CCAPP

California Begins a Worldwide Treatment Revolution Sherry Daley

F

rom one hundred people and one Big Book to millions of recovering people spanning the globe, the history of addiction treatment and recovery has now come to converge in one place: California. After decades of constructive attempts to change the way people and policy makers view addiction and treatment, addiction profession leaders in California have seized upon a new approach to policy making that has the potential to lead the nation—and perhaps communities throughout the world—to a revolutionary way of approaching the disease: timely access to universal, on-demand treatment in every community.

California lawmakers are joining together to introduce a package of legislative bills addressing everything from insurance reform, to workforce professionalization, to the literal building (i.e., construction) of facilities to increase capacity in California until there are no more waiting lists for treatment.

“The idea is quite simple,” said California Consortium of Addiction Programs and Professionals (CCAPP) CEO Pete Nielsen.

“We are no longer going to stand by while our brothers, sisters, daughters, and sons die from a treatable disease,” he added.

Although addiction treatment is as old as Bill Wilson’s inklings from the 1930s, the thought that society can and should demand that no one dies from it is a relatively new concept.

CCAPP has drawn together treatment experts from throughout California to draft multiple bills that, as a package, are known as the California Comprehensive Addiction

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Counselor | April 2017

CCAPP Recovery Act (C-CARA). The bills cover four main areas (pillars) aimed at making addiction treatment available to all Californians: physical capacity expansion, workforce capacity expansion, workforce professionalization, and payment reform/stigma reduction. The groundbreaking package proposes to bring addiction treatment on par with treatment for other ailments in every sense.

“C-CARA will raise quality, expand access, and create an environment where people are free to come forward for treatment without fear of backlash from communities they live and work in,” said Nielsen.

Bills addressing each of the four pillars were drafted and submitted to the legislative counsel in Sacramento.

Several authors considered which pieces they would like to take a leadership role in and a press conference to unveil the package was scheduled. Celebrities who support recovery were contacted to attend the press conference and lend their voices to the passage of C-CARA. A legislative conference on March 21–22 drew supporters from throughout California to march the halls and draw attention to the monumental effort to reshape treatment. All of the measures will be trackable at ccara.info, where news releases, updates, and ways to support are detailed.

C-CARA Pillars: The Bedrock of a New Beginning

communities, legislation for this pillar adds addiction treatment and recovery as a category for density bonuses in new developments. To discourage illegal and costly local ordinances that conflict with state and federal disability laws, the legislation for this pillar gives groups of treatment and recovery residence owners the ability to seek injunctive relief from city and county ordinances that target addiction programs for special and conditional use permits. To assist communities and local governments in achieving capacity expansion, a local government guide for regulating addiction treatment and recovery will be created.

This pillar would also create a voluntary certification program for recovery residences in California and would prohibit referrals from addiction treatment programs to noncertified recovery residences. It defines a recovery residence as a residential property that meets specified requirements and is operated as a cooperative living arrangement to provide an alcohol- and drug-free environment for persons recovering from alcoholism or drug abuse, or both, who seek a living environment that supports ongoing recovery. The legislation for this pillar would state that a recovery residence may be certified by an organization approved by the State Department of Health Care Services, defined as “an approved certifying agency,” and would

Pillar Two: Workforce Capacity Expansion

The workforce capacity pillar seeks to establish workforce expansion programming to increase the number of alcohol and other drug (AOD) counselors in California for the purpose of filling critical shortages and to prepare for the expansion of youth treatment created by the passage of Proposition 64. The legislation for this pillar would set priorities for the $10 million allotment earmarked by the initiative for professionalization of the workforce. To achieve this purpose, the legislation for this pillar would imitate the state’s outdated definition of “mental health providers” as it pertains to loan forgiveness and other educational incentives, to align with federal terminology like “behavioral health,” which includes mental health and substance use disorder careers, by renaming the “Licensed Mental Health Service Provider Education Program” the “Behavioral Health Service Provider Education Program.” This would provide access to federal critical shortage funding for AOD counselors. Additionally, the

CCAPP is unifying the addiction field

Pillar One: Physical Capacity Expansion

The physical capacity pillar seeks to create the mechanisms necessary to finance construction and expand physical capacity for addiction treatment to meet requirements of the Affordable Care Act (ACA) and in preparation of the implementation of Proposition 64.

It would maximize current capacity by removing inpatient licensing fees and providing per-bed bonuses for additional beds until capacity in the state reaches 150 percent of current levels. The legislation for this pillar begins the process of awarding grants and loans for construction of new treatment, detoxification, and recovery residence facilities.

To combat NIMBY ordinances that constrict the establishment of new treatment and recovery programs in

provide that a residence housing persons who purport to be recovering from drug or alcohol abuse would be presumed to be a recovery residence if the residence has been certified by an approved certifying organization.

2400 Marconi Avenue P.O. Box 214127 Sacramento, CA 95821

Education “CCAPP is educating addiction counselors by supplying quality options for schools and providers”

Membership “CCAPP is supporting and advocating for programs and professionals in the addiction field.”

Recovery Residences “CCAPP recognizes quality sober living by registering recovery residences.”

T (916) 338-9460 F (916) 338-9468 www.ccapp.us

Credentialing “CCAPP is the largest, most respected SUD counselor and prevention specialist certifying organization in California.”

www.counselormagazine.com

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CCAPP legislation for this pillar would address barriers to entry into the field of addiction counseling by providing waivers for certification and testing fees required to obtain state required certification.

Pillar Three: Workforce Professionalism

The workforce professionalism pillar seeks to license AOD counselors in California; provide for state-approved certification of peer-support specialists, interventionists, and recovery coaches; and create a uniform career ladder for the profession. The legislation for this pillar would create a bureau to conduct many important functions related to licensure, including prohibiting practicing AOD counseling outside of a licensed or certified facility without a license (with some exceptions); standardizing criteria for qualifications for education, training, and experience for licensed counselors; allowing the Department of Consumer Affairs to conduct background checks on all individuals applying for a license to be an AOD counselor; and imposing sanctions on AOD counselors for misconduct and implementing an appeals process for those sanctions.

The licensure program would “grandparent” current counselors who are at an advanced level and have passed the IC&RC Advanced Alcohol Drug Counselor Examination within a specified time period. The license would be voluntary, allowing certified counselors to continue to work in licensed and certified facilities in California.

Pillar Four: Payment Reform and Stigma Reduction

The goal of the payment reform and stigma reduction pillar is to end waste and improve financial allocation to quality programs in reimbursement systems, while reducing overall stigma by increasing the public’s understanding of addiction as a public health issue. The legislation for this pillar would reform the private payment market for addiction treatment by prohibiting kickbacks to referring agents; regulating addiction treatment call centers; and prohibiting dangerous, direct, “pay-to-patient” policies that result in large cash payments 10

Counselor | April 2017

being made to addicts in early recovery.

It also brings experts in private industry and government together for taskforce meetings to share information about the current state of access to addiction care and parity implementation efforts in California.

The taskforce created by the legislation for this pillar would provide important data about the way in which treatment is approved, methods for approving continuing or “step down” treatment, and the way in which disputed claims are managed.

“Appropriate funding is kind of the point,” said Nielsen. “As a society we never asked if we could afford to treat heart disease or diabetes.”

The Eternal Question: Who is Paying for This?

The interesting facet of the C-CARA is its insistence that the state dedicate adequate financing to treatment. It puts forward some easy concepts for financing and some highly controversial ones, but does not begin with the premise that it goes away for lack of funding.

“Appropriate funding is kind of the point,” said Nielsen. “As a society we never asked if we could afford to treat heart disease or diabetes. People would have been outraged. I believe we are there with this disease now,” he explained.

The funding bill created for C-CARA draws revenue from several sources.

California passed Proposition 64, the Adult Use of Marijuana Act, in November 2016. Sixty percent of the tax revenue from the initiative is allocated to addiction treatment. With an estimated $600 million in treatment dollars, per year, forever, C-CARA relies on revenue from the Proposition for a number of priorities. Workforce capacity and physical capacity are earmarked directly by

the initiative and C-CARA plans to lay claim to funding for these purposes.

In advance of the initiative, it calls for general fund borrowing with payback from marijuana tax revenue.

Having experienced the promises and pitfalls of funding from a previous proposition—Proposition 36, a treatment alternative to incarceration—addiction leaders are wary of putting all of C-CARA’s eggs in one basket.

Proposition 64 directs funding to youth prevention, education, and treatment, meaning that more than one department and a vast array of stakeholders will be in pursuit of its revenue. Given this reality, C-CARA proposes additional funding sources that can be adjusted should marijuana tax revenue not fill the needs.

Included in its funding provisions are a nominal administrative fee collected at admission to treatment in California—with an exemption for clients who have incomes less than 150 percent of the federal poverty level—and increased penalties for narcotics convictions. In addition to proposition funding, a treatment surcharge, and increased penalty assessments, CCAPP is working with stakeholders and legislative leaders to develop a long-term funding mechanism that may include increasing alcohol excise taxes or expanding the state’s CRV (bottle tax) to collect revenue dedicated to treatment.

On Being Bold, Not Told

C-CARA is an ambitious plan to move the disease and its treatment to a place that matches the changing views of the American public. Yet, at a time when every presidential candidate campaigned with platforms for better treatment, there are still no guarantees that lawmakers will deliver on C-CARA. Win, lose or draw, 2017 will be the year that California faces addiction head on. As policy changes and develops, California demonstrates that, bit by bit, it can discard the old—the one that did not work—for the new, that can and does work under any conditions. c About the Author Sherry Daley is in charge of external affairs for counselors and marketing for the California Consortium of Addiction Programs and Professionals (CCAPP). She is also a freelance writer from the Sacramento area.

NACOA

Will Changing the Language of Addiction Help?

Sis Wenger

M

ichael Botticelli, in his term as director of the White House Office of National Drug Control Policy (ONDCP), has been a powerful example of recovery in action, especially by moving the needle of public perception of substance use disorders (SUDs) to being understood as the brain disease it is versus a personal or moral failing. He has had a substantial impact on previously skeptical legislators, corporate leaders, law enforcement, and faith communities, and also on average Americans who could also comprehend and begin to support treatment over incarceration as a major solution, halting the irrational filling of America’s prisons with sick people, not bad people.

One of the last public documents released on Botticelli’s watch addressed the terminology related to alcoholism, drug addiction, substance abuse, and recommending, with clear rationale, changing the language to “substance use,” “substance

misuse,” and “substance use disorders.” Botticelli’s “Changing the Language of Addiction” was developed through consultation with research, policy, provider, and consumer stakeholders, as well as federal agencies to assist the culture to use more accurate and less stigmatizing language that has developed over the years.

These evolving language changes have been steadily sliding into our policy discussions, our scientific journals, and our treatment and education programs. For the most part they are being accepted and perfected, and can be expected to continue to foster the downslide of stigma which has often held people struggling with the disorder and their loved ones from seeking help. The recovery movement has grown in numbers and clarity of message and in giving back to help others. The increase in awareness about the nature of SUDs, from misuse to addiction, and the recognition that early interventions through such programs as the evidence-based Screening and Brief Intervention and Referral to Treatment (SBIRT) in the general medicine world work to halt the development of the disorder early in its process. Similarly, the student assistance programs in our schools, including the educational support programs for elementary-age children of parents with SUDs, played an SBIRT-type role in hundreds of school districts for nearly thirty years, saving thousands of young lives. Without student assistance or an effective preventive intervention, the young people who are most at risk for developing their parents’ disease will too often become the depressed adolescents and young adults with a SUD. The growing awareness that words can seriously affect hurting individuals and families is steadily leading to positive changes www.counselormagazine.com

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NACOA in how our government, our criminal justice system, our schools, and our society in general respond to SUDs, including the current opioid/heroin epidemic. It is helping to change the language, and changing the language is helping to create a greater understanding that propels the recovery movement forward, with its thousands of volunteers staffing recovery centers, helping one struggling person and one concerned family at a time to grab the recovery railing and keep pulling up. Most of this is fueled by America’s leading and strongest advocacy and recovery community support organization, Faces and Voices of Recovery, with centers across the country affecting policy and programs across multiple federal agencies as well as supporting the growing recovery movement on the ground.

The role that Recovery Month has played for over twenty-five years in creating a nurturing platform and supporting a remarkable public and private partnership between SAMHSA and over two hundred planning partner organizations is an ongoing and remarkable collaborative that supports thousands of recovery awareness projects throughout the year and especially during September, when Recovery Month is observed. The changing language, initially brought to the country through Recovery Month, has been a powerful motivator for the new understanding that is saving lives and families in increasing numbers each year because it is destroying shame, reducing stigma, and freeing concerned family members and colleagues to take action.

and learn that there is an official medical name for it, is helpful language.

When parents are up against a toxic brain, it is a strange thought that they are not the solution, but that they can slip into being part of the problem with well-intentioned and ineffective efforts.

They keep expecting rational thinking and awareness, but the brain is hijacked.

When parents themselves grew up with a parent or parents suffering from addiction, the past merges into the present and too often they behave as though they are solving an unresolved problem from the past in response to their child. This is a family disease—generational shame and stigma traps every member of the family.

Without recovery, these well-intentioned parents continue the cycle of multigenerational disease and trauma. With gentler and more definitive language, denial can soften into seeing reality and accepting it. It can also free them to ask for help for the entire family.

It’s Different with Younger Children

For younger children, however, such language is confusing and confounds their feelings of abandonment and fear.

For children the concept of addiction—a disease of the brain that can be treated and from which parents can be rescued—can be readily understood, as can the behavior that it engenders. Imagine eight-year-old children in an educational support group where the topic of the day is the disease

12

Counselor | April 2017

About the Author Sis Wenger is NACoA’s President and CEO.

Offer your patients

For Parents and Adolescent Siblings

When we discuss adolescents and young adults with SUDs, too often the stigma is most felt by their parents and adolescent siblings. Driven by the denial that stigma fosters, parents disbelieve, cover, make excuses, cajole, and try to rescue and give one more chance to their grown children, feeding their denial in their compulsive efforts to control and protect them. Nonpejorative language that concerned and desperate parents can use to look objectively at their adolescent or young adult son or daughter and see that a toxic brain is driving attitude, demands, accusations, irresponsibility, and emotional and verbal abuse,

that is hurting a parent, where they are learning that a parent has a disease that stops them from loving their children and from giving them the support they need.

The lesson calls for writing a letter to the disease, telling the disease how they hate it and want the disease to get away from their family, but the letter is to begin, “Dear Substance Use Disorder.”

Child development experts use the term “age-appropriate” for a reason.

Let’s help the adults, young adults, and their parents use the language that will be medically correct and, at the same time, help diminish the stigma that has dogged both alcohol and drug addiction, and has paralyzed parents in helping “just one more time” rather than recognizing and arranging an appropriate and effective intervention to save their child’s life from a SUD. But let’s help their young children or siblings to understand and heal in language that works for them.

For them, let’s keep it simple!

As government and the general community adjust to the new language, and as it becomes common knowledge over the ensuing years, we must remember to be sensitive to how individuals in recovery self-identify as we work for uniformity and simplicity to remove stigma as an obstacle to recovery for the whole family. c

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CULTURAL TRENDS

Storm Warning:

Carfentanil’s Impending Tsunami of Death Maxim W. Furek, MA, CADC, ICADC

A

ddiction specialists are bracing for the impact of a new killer drug, what some fear represents an impending tsunami. The drug is one of the most potent synthetic opioids known to man and has worsened an unrelenting opioid drug crisis. Carfentanil, a Schedule II controlled substance, is an extremely powerful narcotic used primarily as an animal tranquilizer. Already, it has caused countless overdoses and may prove to be the deadliest drug of them all.

It is one hundred times stronger than its analog, fentanyl, a drug notorious for its high potency and high frequency of associated overdoses including the death of pop star Prince last year. Carfentanil is stronger still, recognized as the most potent opioid used commercially and dangerous because it can slow breathing significantly. Kounang and Marco state that, “It’s not approved for human use, but is used commercially to sedate large animals, such as elephants. About two milligrams can knock out a nearly twothousand-pound African elephant” (2016).

An article on CNN.com explains that the opiate “. . . is dangerous not just to users, but also to anyone who comes into contact with it. Grains of it can be absorbed through the skin or inhaled” (Kounang & Marco, 2016). First responders and medical personnel should use extreme caution when handling drugs, syringes or other evidence since as little as a microgram (i.e., 1/1,000,000 of a gram) can affect a human.

Franko writes that, Carfentanil is so powerful that zoo veterinarians typically wear a face shield, gloves, and other protective gear—“just a little bit short of a hazmat suit”—when preparing the medicine to sedate animals because even one drop splattered into a person’s eye or nose could be fatal (2016).

Side Effects

According to the National Center for Biotechnology Information, Carfentanil was first synthesized in 1974 by a team of chemists at Janssen Pharmaceutica . . . It has a quantitative 14

Counselor | April 2017

potency approximately ten thousand times that of morphine and one hundred times that of fentanyl, with activity in humans starting at about one microgram. It is marketed under the trade name “Wildnil” as a general anesthetic agent for large animals. Carfentanil is intended for large animal use only as its extreme potency makes it inappropriate for use in humans. Currently sufentanil, approximately ten to twenty times less potent (five hundred to one thousand times the efficacy of morphine per weight) than carfentanil, is the maximum strength fentanyl analog for use in humans (NCBI, n.d.).

Side effects of fentanyl analogs are similar to those of fentanyl itself, which include itching, nausea, and potentially serious respiratory depression, which can be life threatening. Fentanyl analogs have killed hundreds of people throughout Europe and the former Soviet republics since the most recent resurgence in use began in Estonia in the early 2000s, and novel derivatives continue to appear (Mounteney, Giraudon, Denissov, & Griffiths, 2015).

Naloxone

According to a report by the US Centers for Disease Control and Prevention (CDC), deaths due to fentanyl- and carfentanil-laced heroin increased by 79 percent from 2013 to 2014 (Gladden, Martinez, & Seth, 2016). These overdoses have prompted a pair of Food and Drug Administration (FDA) panels to recommend that the agency authorize higher minimum dosages for new Narcan (naloxone) products to better counteract the more potent street drugs (Valentino, 2016).

Valentino writes that some FDA comittees “. . . voted, 15-14, in favor of increasing the minimum amount for an injectable or intravenous dose of naloxone products used outside a hospital setting,” and that “. . . multiple doses of naloxone are sometimes required to revive an individual in overdoses associated with fentanyl and carfentanil, especially at the current minimum standard of 0.4 milligrams.”

An October 2016 article in Scientific American stated, A recent wave of overdoses in states including Ohio and Kentucky has taught law enforcement officers and first responders that the medication used to reverse opioid overdoses—a powerful chemical called Narcan, or naxolone— often fails to rouse patients who have taken too much carfentanil. This is because the drug binds so tightly to the brain’s opioid receptors that naloxone, at currently common doses, is unable to dislodge that bond and reverse its

CULTURAL TRENDS sedating effects to get patients breathing again, says Michael Lynch, the medical director of the Pittsburgh Poison Center.

As a result, hard-fought state efforts to make naloxone available over the counter to drug users or their friends or families—to quickly address overdoses and save lives—could be rendered useless in cases when heroin is cut with carfentanil. At standard doses of one or two milligrams, naloxone may not be powerful enough to counteract the drug. “It just takes micrograms of this stuff [carfentanil] to potentially cause an overdose,” Lynch says. “D rug user s who unwittingly use the substance (thinking they are consuming only heroin) may overdose and die before paramedics can arrive” (Maron, 2016).

Joseph writes that, Some officials say they are concerned about what’s known as “renarcotization.” The idea is that a drug like carfentanil lasts in people’s systems so long that they can overdose, be revived with an antidote, and then hours later pass out without using drugs again (2016).

Manufactured in China

Kounang and Marco state that, “According to the DEA, most fentanyl analogs in the United States are being manufactured in China and transported through Mexico” (2016). Drug traffickers combine illicit drugs like fentanyl and carfentanil with heroin or other illicit drugs to increase the potency and to intensify the high experienced by drug users.

In the same way that fentanyl has been mixed into bags of heroin, causing a slew of deaths nationally, carfentanil has emerged as an additional deadly adulterant. Dealers are using carfentanil to “cut” heroin in order to intensify its effect. Another synthetic painkiller known as W-18 has also been discovered in heroin seizures and is connected with recent overdoses and deaths. W-18 is similar to carfentanil in its extreme potency.

The synthetic opiate W-18, developed in the 1980s as a potential painkiller, is

believed to be one hundred times more powerful than fentanyl. Although it was developed decades ago as an experimental pain reliever, the most recent batch appears to have been manufactured in China. W-18 is extremely dangerous, as it depresses the central nervous system causing blood pressure to drop and heart rate and respiration to slow (Furek, 2016).

Sober Nation notes that, Man y opioid user s de velop a tolerance to the opioids that they use regularly, so they begin chasing more intense highs. But, most users don’t even know that a heroin batch is mixed with carfentanil or W-18, nor that the “intensified effect” promised by a heroin dealer could actually have the potential to kill (Sheikh, 2016).

DEA warning

The DEA recently issued a warning to police and the public about the dangers of these drugs: Carfentanil and other fentanyl-related compounds are a serious danger to public safety, first responder, medical, treatment, and laboratory personnel.

These substances can come in several forms, including powder, blotter paper, tablets, and spray—they can be absorbed through the skin or accidental inhalation of airborne powder. If encountered, responding personnel should do the following based on the specific situation: Exercise extreme caution. Only properly trained and outfitted law enforcement professionals should handle any substance suspected to contain fentanyl or a fentanyl-related compound. If encountered, contact the appropriate officials within your agency.

Be aware of any sign of exposure.

Symptoms include: respiratory depression or arrest, drowsiness, disorientation, sedation, pinpoint pupils, and clammy skin. The onset of these symptoms usually occurs within minutes of exposure.

S e e k I M M E D I AT E m e d i c a l attention. Carfentanil and other Continued on page 17

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OPINION

“Day 001: Voices of Recovery” Why Recover Alaska is Highlighting Alaskans’ Stories of Recovery Tiffany Hall

A

s treatment professionals, recovery advocates, and addiction specialists, we are often challenged with the notion that recovery is ineffective and unattainable for most addicts. Unfortunately, the general public’s understanding of addiction is riddled with misconceptions and stigma. That is why it is so important and beneficial to bring attention to the countless success stories that do exist—to focus on the fact that recovery can work and that life for recovered alcoholics can be rewarding and full of purpose.

This was the driving force behind the “Day 001: Voices of Recovery” video series launched in January 2016 by Recover Alaska, an action group that aims to reduce the harm caused by excessive consumption of alcohol in Alaska. The series was produced with funding from Doris Duke Charitable Foundation in collaboration between Recover Alaska and Koahnic Broadcast Corporation, an Alaska-Native-governed and -operated radio station in Anchorage, Alaska.

“Day 001: Voices of Recovery” is a series of eight minidocumentaries featuring personal stories of addiction and recovery. Alcoholism is often seen as a taboo subject and the individuals who chose to share their stories for the project are brave for speaking out. But one of Recover Alaska’s goals is to encourage the conversation; we hope that one day soon, alcohol abuse and overconsumption will be widely recognized as the public health issue it is and addressed as such—with adequate resources and compassion rather than funding cuts and stigmatization.

The stories in the “Day 001” project are diverse—from students to artists to professionals— underscoring the fact that alcohol addiction 16

Counselor | April 2017

is a battle anyone can face. The project represents the diversity of alcoholics. While each story is unique, they share the same theme: the pain of being in the grip of alcohol and the moment that led to their first step toward recovery. The hope is that the personal stories will be more relatable than a list of statistics, and will reach someone in need. A cobenefit is for the tellers themselves; as video participants some have described the experience of sharing their story as cathartic.

It is exciting to fathom the reach of the “Day 001” project. By releasing each video via social media and on national Native radio programming, there is great potential for the stories to touch the lives of people all over the world. We encourage others to share the stories on their social media platforms, spread the word about the project, and not lose sight of the power of talking about recovery. The feedback we’ve received so far has been amazing; people are hungry for this conversation and the energy around it is palpable.

While the “Day 001” project is significant, it is only one piece of what Recover Alaska is working on. Alaska has a long-time problem with alcohol. In fact, a recent health survey identified alcohol use and abuse as the top health issue important to Alaskans (State of Alaska Department of Health and Social Services, n.d.). Although our efforts are Alaska-based, we believe that the approach to combatting excessive alcohol use anywhere is to find new strategies and solutions for a problem that has great economic, health, and social impact. The strategies that we’ve identified include: changing laws, changing norms, polling, and creating a comprehensive online recovery resource center and call line. We have also focused on media partnership projects, such as “Day 001,” to bring more attention

OPINION to the issues. Identifying and working with media partners has been effective in highlighting stories of alcohol abuse, treatment options, social effects of addiction, and successful recovery experiences.

As the executive director of Recover Alaska, I often hear comments that recovery does not work, that people fall in and out of treatment, wasting money and time. Along with the mission of finding solutions to Alaska’s alcohol problems, one of Recover Alaska’s strategic goals is to change social norms surrounding alcohol addiction and recovery. I know first-hand that recovery can happen—my story is featured in a “Day 001” video. I also know that stories of recovery are powerful and inspiring; in fact, if it was not for hearing another woman’s very personal experience with alcoholism and recovery, I may not have made the decision to seek help and change the destructive habits in my own life.

For experts in the field of behavioral health and substance abuse, it is important to focus on the positive and highlight hope. For addicts, reaching that turning point and finding their own day one— whether it’s for the first time or for the hundredth—is an immense challenge and it’s only the beginning of what is often a lifelong fight for sobriety.

I hope many others will have the chance to see the “Day 001” videos, share them with friends and family, and engage in the important conversation of alcoholism and recovery.

To view and share the videos in the “Day 001: Voices of Recovery” project, visit www.day001.org. All of Recover Alaska’s media partnership projects are at recoveralaska.org and are available for viewing and redistribution. c About the Author Tiffany Hall is the executive director of Recover Alaska, an organization with a mission to reduce excessive alcohol use and harm through individual, social, and systemic change.

Actively involved in the Anchorage community, she volunteers for Story Works Alaska, ChildFirst Alaska, and the Pride Foundation, currently chairs the Anchorage Women’s Commission, and sits on the board of directors for the YWCA Alaska.

References State of Alaska Department of Health and Social Services. (n.d.). Healthy Alaskans 2020: Twenty-five leading health priorities. Retrieved from http://hss. state.ak.us/ha2020/25LHI.htm

Cultural Trends fentanyl-related substances can work very quickly, so in cases of suspected exposure, it is important to call EMS immediately. If inhaled, move the victim to fresh air. If ingested and the victim is conscious, wash out the victim’s eyes and mouth with cool water.

Be ready to administer naloxone in the event of exposure. Naloxone is an antidote for opioid overdose.

I m m e d i a t el y a d m i n i s t e r i n g naloxone can reverse an overdose of carfentanil, fentanyl or other opioids, although multiple doses of naloxone may be required.

Continue to administer a dose of naloxone every two to three minutes until the individual is breathing on his/her own for at least fifteen minutes or until EMS arrives.

Remember that carfentanil can resemble powdered cocaine or heroin. If you suspect the presence of carfentanil or any synthetic opioid, do not take samples or otherwise

Continued from page 15

disturb the substance, as this could lead to accidental exposure. Rather, secure the substance and follow approved transportation procedures (DEA, 2016).

Conclusion

The conclusion of this text is short on optimism. The opioid epidemic is getting worse and the rapid emergence of carfentanil presents yet another unforgiving challenge to officials battling the opioid crisis. This is a sad and tragic way to start a new year, but unfortunately the floodgates have been opened and that “impending tsunami” is upon us. c About the Author 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 Drug Enforcement Administration (DEA). (2016). DEA issues carfentanil warning to police and public.

Retrieved from https://www.dea.gov/divisions/hq/2016/hq092216.shtml Franko, K. (2016). Elephant sedative, carfentanil, poses new threat in fight against overdoses. Retrieved from http://www.nbcphiladelphia.com/news/health/Elephant-Sedative-W-18-Drug-Overdose-Deaths-388519832.html Furek, M. W. (2016). Uncharted waters: Navigating the madness of designer drugs, part II. Counselor, 17(6), 13–4.

Gladden, R. M., Martinez, P., & Seth, P. (2016). Fentanyl law enforcement submissions and increases in synthetic opioid-involved overdose deaths—twenty-seven states, 2013–2014. Retrieved from https://www. cdc.gov/mmwr/volumes/65/wr/mm6533a2.htm Joseph, A. (2016). As new opioids spread, coroners face a wave of medical mysteries. Retrieved at https:// www.statnews.com/2016/11/22/opioids-autopsies-medical-examiners/ Kounang, N., & Marco, T. (2016). Heroin laced with elephant tranquilizer hits the streets. Retrieved from http://www.cnn.com/2016/08/24/health/elephant-tranquilizer-carfentanil-heroin/ Maron, D. F. (2016). Wave of overdoses with little-known drug raises alarm amid opioid crisis. Scientific American. Retrieved from https://www.scientificamerican.com/article/wave-of-overdoses-with-little-knowndrug-raises-alarm-amid-opioid-crisis/?utm_campaign=Enews&utm_source=hs_email&utm_ medium=email&utm_content=35947223&_hsenc=p2ANqtz-83r8IBUzj1UFa05vCr2P02Fx2O30ksJsrmXpn9tigkec3QRfrqqJyF_EMQfw1TuzYHBcbwIDi9gYr72Zq6D0fnOkOrw&_hsmi=35947223 Mounteney, J., Giraudon, I., Denissov, G., & Griffiths, P. (2015). Fentanyls: Are we missing the signs?

Highly potent and on the rise in Europe. International Journal of Drug Policy, 26(7), 626–31.

National Center for Biotechnology Information (NCBI). (n.d.). Carfentanil. Retrieved from https://pubchem.ncbi.nlm.nih.gov/compound/carfentanil#section=Top Sheikh, N. (2016). Deadly carfentanil: One hundred times stronger than fentanyl. Retrieved from https:// www.sobernation.com/deadly-carfentanil/ Valentino, T. (2016). Fentanyl, carfentanil prompt higher naloxone dosage. Behavioral Healthcare.

Retrieved from http://www.behavioral.net/article/policy/ fentanyl-carfentanil-prompt-higher-naloxone-dosage

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FROM LEO’S DESK

What is Religious Agnosticism?

Rev. Leo Booth

I

’ve been reading the private writings of Mother Teresa called Come Be My Light (2009) where she talks about a “darkness” that came upon her towards the end of her life. She says that “If they ever made me a saint, I would be the saint of darkness” (Mother Teresa, 2009).

It is interesting to think that someone who is so connected with a “faith” or seen as a deeply “spiritual” person should write about a feeling that God had moved away from her; she was unable to feel His presence.

Why? She didn’t know. She was agnostic.

I’ve been coming to the conclusion for many years that when we speak about God, His will for us or what He wants, we are invariably agnostic—“gnostic” means to know; “agnostic” means to not really know. Now, it’s important for me to stress that this is my opinion and probably the opinion of many other people who wouldn’t claim the title “atheist,” but who are consciously aware that when it comes to issues concerning God, they don’t “know.” They have ideas, opinions, beliefs, insights, but they wouldn’t want to swear on the Bible that they actually know. Indeed, because I’m not a fundamentalist, I hold the view that what’s written in the Bible is a collection of ideas and opinions written by people at different times in history. It’s important to note that Jesus didn’t write a gospel; Matthew, Mark, Luke, and John wrote a biography of his life. And I’m agnostic about whether they actually quoted him correctly or wrote exactly about the events that took place.

I’m sure that most religious people don’t hold the aforementioned views, including all the religions in the world; indeed, they would probably call me a heretic! And that’s what I am. I wrote a book about this very topic called The Happy Heretic (2012).

I wrote, If I reflect upon the changing beliefs I’ve made in my life, they revolve around my disinterest with church dogma and my growing fascination with how the divine cocreates with nature.

It wasn’t a conscious formulation, as I’m presenting in this book, but rather a feeling that an exclusive preoccupation with what God is doing in our lives can take us away from realizing the human response. It increasingly seemed that the prayers I recited and the sermons I heard didn’t fit with 18

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FROM LEO’S DESK what I was actually experiencing and believed. I developed a growing agnosticism with “churchianity” (Booth, 2012, p. 3–4).

This is what I believe today. I haven’t always had these views; there was a

time when I would quote the Bible or the church teachings and if you didn’t agree I would condemn you or worse, send you to hell! I wasn’t exactly a fundamentalist, but I was extremely dogmatic. Like so many others, I believed what I was told and I learned to quote what I was told, and I quoted emphatically.

I resist the idea that people know, actually know, what God wants from us or His will for us other than in the most general way: God wants us to be loving and kind.

This is what I see so many people doing today, from all religions, and I happily stand in the minority of people who are called “heretics.” In the August 2015 issue of Counselor, I wrote the following concerning religious extremism: Let’s step back for a moment and examine how something as pious as a belief in God can become so twisted that it allows for the persecution, rape, and killing of hundreds of thousands, potentially millions.

Here is an excerpt from When God Becomes a Drug, In his book To Have or To Be, Erich Fromm describes religion as “not necessarily having to do with a concept of God, but as any groupshared system of thought and action that offers the individual a frame of orientation and an object of devotion.”

As Fromm suggests, religions and belief systems seem to be divided into two camps: those that believe that human nature is essentially good and focus on our innate dignity, and those that maintain that humans are inherently evil and base.

This corresponds with my own definition of religion as being essentially a set of man-made principles about God, focusing on a teacher or prophet, in

contrast to spirituality, which is the process of becoming a positive and creative person. Moreover, this definition allows us to look not only at organized religion, but also any group or belief system that either generates dysfunction or is used dysfunctionally.

When those beliefs inspire us to develop our creative potential, whether spiritually as individuals or culturally as a society, those beliefs move us forward and may be seen as healthy.

When they limit or paralyze us, or are used by ourselves or others to oppress and victimize us, they can be regarded as unhealthy (Booth, 1998, p. 19–20).

And that’s my fear. That’s why I changed my mind and became a religious agnostic or heretic.

I resist the idea that people know, actually know, what God wants from us or His will for us other than in the most general way: God wants us to be loving and kind.

People have ideas about God, fine.

People have opinions about how to live the spiritual life, fine. People have insights into the life of Jesus or other holy men and women, fine. But when they say that they “know,” I want to run for the hills. I particularly want to run for the hills when they say that they “know” what God wants for and from me.

An article or column cannot do justice to the themes we have touched upon, and so I hope that those of you who are interested in this topic will check out my books The Happy Heretic (2012) and When God Becomes a Drug (1998). c About the Author Leo Booth, a former Episcopal priest, is today a Unity minister. He is also a recovering alcoholic. For more information about Leo Booth and his speaking engagements, visit www.fatherleo. com or e-mail him at fatherleo@ fatherleo.com. You can also connect with him on Facebook: Reverend Leo Booth.

References Booth, L. (1998). When God becomes a drug: Understanding religious addiction and religious abuse.

London: SCP Ltd. Booth, L. (2012). The happy heretic: Seven spiritual insights for healing religious codependency. Deerfield Beach, FL: Health Communications, Inc. Booth, L. (2015). Spirituality vs. religious extremism, part I. Counselor, 16(4), 22–3.

Mother Teresa. (2009). Mother Teresa: The private writings of the saint of Calcutta. New York, NY: Penguin.

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