Adolescents and Young Adults
Pornography: Disconnection and Addiction The Psychological Toxicity of Modern Adolescence Connecting to Specialty Addiction and Mental Health Treatment
Strengthening the True Self The Official Magazine of the California Consortium of Addiction Programs and Professionals (CCAPP) April 2018 Vol. 19 | No. 2, $6.95
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CONTENTS
3
Letter from the Editor
22
By Gary Seidler Consulting Executive Editor
Adolescents and Pornography: A Generation of Disconnection and Addiction
CCAPP
Sobering Facts about Sober Living
4
By Pete Nielsen, CADC-II
By Alex Lerza, LMFT, CSAT Presents data on adolescent pornography use, discusses consequences of porn use at a young age, and describes how to address this problem with clients.
6
NACOA
Alcohol Awareness Month: Your Clients’ Sobriety May Hinge on How They Parent
27 Strengthening the True Self in Adolescents and Young Adults By Sandra Felt, LCSW, BCD Defines the “true self,” lists the signs of an underdeveloped self, and provides information on how to strengthen this quality in adolescents and young adults.
By Patricia O’Gorman, PhD
8
Cultural Trends
25I-NBOMe: Hovering Under the Radar
By Maxim W. Furek, MA, CADC, ICADC
Opinion
Eliminating Shame from Addiction Treatment and Recovery
10
By Michael Weiner, PhD, CAP
Wellness
32
The Art of Mentoring
12
By John Newport, PhD
Topics in Behavioral Health Care
The Psychological Toxicity of Modern Adolescence (and What We Can Do about It)
Prescription Drug Misuse and Addiction, Part II: Strategies to Address the Problem
By Stephen S. Ilardi, PhD, & Emily J. Casteen Describes the notion of “diseases of civilization” as it relates to modern adolescence, and lists positive lifestyle changes adolescents can make to counteract mental illnesses.
14
By Dennis C. Daley, PhD
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Counselor Concerns
From the Journal of Substance Abuse Treatment
38
Helping Adolescents Connect to Specialty Addiction and Mental Health Treatment By Ashley Jones, PsyD, Andrea H. KlineSimon, MS, Derek D. Satre, PhD, et al. Presents a study on the effects of SBIRT on specialty addiction treatment, and discusses the importance of pediatric primary care that includes counselors.
The Genesis and Current Status of the Opioid Crisis, and the Interventions That Can Help
By Gerald Shulman, MA, MAC, FACATA
Ask the LifeQuake Doctor
21
By Toni Galardi, PhD
Also in this issue:
Ad Index CE Quiz
2 46
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CE QUIZ INSTRUCTIONS Lifestyle Problems in Relation to Adolescents and Young Adults
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Adolescents and Pornography: A Generation of Disconnection and Addiction Page 22 Presents data on adolescent pornography use, discusses consequences of porn use at a young age, and describes how to address this problem with clients. a. List the consequences of adolescent porn addiction b. E valuate the various studies on pornography use in adolescence and adulthood c. Describe ways adolescents hide their online activity d. A ssess adolescent and/or young adult clients for warning signs of porn addiction
Strengthening the True Self in Adolescents and Young Adults Page 27 Defines the “true self,” lists the signs of an underdeveloped self, and provides information on how to strengthen this quality in adolescents and young adults. a. Analyze the concept of the true self and how it is developed b. D efine “the traumatic disconnect” in relation to adolescents and young adults c. List the ways counselors can tell if the true self is underdeveloped d. Evaluate the consequences of an underdeveloped true self
he Psychological Toxicity of Modern Adolescence T (and What We Can Do about It) Page 32 Describes the notion of “diseases of civilization” as it relates to modern adolescence, and lists positive lifestyle changes adolescents can make to counteract mental illnesses. a. Define the various lifestyle problems facing today’s adolescents b. E xplain the benefits of healthy sleep, sunlight exposure, exercise, and fatty acids c. D escribe the differences between the lifestyles of our ancestors and our lives today d. List strategies for healthy sleep
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Counselor (ISSN 1047-7314) is published bimonthly (six times per 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. Subscription rates in the US are one year $25.95, two years $44.00. Canadian orders add $15 US dollars per year, other international orders add $31 US dollars 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, PO Box 15009, North Hollywood, CA 91615 - 5009 © Copyright 2018, Health Communications, Inc. Printed in the USA. President & Publisher
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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
AD INDEX CCAPP...............................................................................................................5 Debbie Ford.....................................................................................................9 Foundations in Recovery..............................................................................11 Journal of Substance Abuse Treatment...........................................................7 HCI Books......................................................................................................44 Newport Academy...........................................................................Back Cover Toni Galardi.....................................................................................................21 Treatment Management Behavioral Health...............................Inside Back USJT Santa Fe.................................................................................Inside Front
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Counselor | April 2018
LETTER FROM THE EDITOR
A Focused Light on the Opioid Crisis
K
udos to media giants of the past and present— Time magazine and Netflix—for shining a focused and humane light on the worst addiction epidemic in US history: the opioid crisis. According to the Huffington Post, “In 2016, the annual overdose death count reached nearly 64,000, more than three times as many as in 1999. It surpassed the number of fatalities from automobile crashes and homicides, becoming the number one cause of death among Americans age fifty and younger” (Vestal, 2018).
But statistics alone can’t tell the story. Time magazine, for the first time in its ninety-five-year history, devoted an entire issue, “The Opioid Diaries” (March 5, 2018), to one photographer’s work. Veteran conflict photographer James Nachtwey travelled across the country to gather stories from users, families, first responders, and others at the heart of the epidemic. The editors of Time wrote, “We are in the midst of a national emergency that affects every state, every income group, and virtually every age. While the burden has fallen disproportionately on the least-educated Americans, tens of millions of us are no more than one degree of separation from someone struggling with addiction” (Goldberger, Pollack, & Vella, 2018). An equally compelling portrait is the Oscar-nominated original short documentary film Heroin(e), produced by Netflix and cohosted by The Partnership for a Drug-Free America. Heroin(e) chronicles the once bustling industrial town of Huntington, West Virginia that has now become the epicenter of America’s opioid epidemic—with an overdose rate ten times the national average. But within this distressed landscape, Peabody Award-winning filmmaker Elaine McMillion Sheldon (Hollow) shows a different side of the opioid crisis— one of hope. The film highlights three women working to change the town’s narrative and break the devastating cycle of substance use one person at a time. As America’s opioid crisis threatens to tear towns and communities apart, Heroin(e) shows how the chain of compassion holds one town together. Heroin(e) is the film we need now, because it gives us hope; it shows us that individuals, in practicing kindness and in treating this as a health issue, can and will make a difference; and it shows that there are solutions that work in this public health emergency (Feliz, 2018). While “The Opioid Diaries” reflects a national warzone, like Heroin(e) it also shows signs of hope from the people who are dealing with the crisis at street level. As Nachtwey stated, “They are refusing to allow our country to be defined
by this problem. They are helping find solutions. We must join them” (Moakley, & Nachtwey, 2018). And indeed we must. c References Feliz, J. (2018). Partnership cohosts Heroin(e) Netflix documentary film screening in New York City. Retrieved from https://drugfree.org/newsroom/news-item/ partnership-co-hosts-heroine-netflix-documentary-film-screening-new-york-city/ Goldberger, B., Pollack, K., & Vella, M. (Eds.). (2018). Our national crisis. Time. Retrieved from http://time.com/opioid-addiction-epidemic-in-america Moakley, P., & Nachtwey, J. (2018). The opioid diaries. Time. Retrieved from http:// time.com/james-nachtwey-opioid-addiction-america/ Vestal, C. (2018). Overdose deaths fall in fourteen states. Retrieved from https:// www.huffingtonpost.com/entry/overdose-deaths-fall-in-14-states_us_ 5a8ef368e4b05ffbefca1690
Gary Seidler
Consulting Executive Editor Counselor, The Magazine for Addiction & Behavioral Health Professionals, A Health Communications, Inc. Publication
In Memoriam
Dr. Jennifer Leslie Gray Golick, PhD 1976–2018 All of us at U.S. Journal Training, Inc. and Counselor magazine were shocked and saddened to learn of the death of colleague and respected faculty member Dr. Jennifer Golick. The Jennifer Golick Memorial Scholarship has been established by Muir Wood Adolescent and Family Services. Muir Wood founder and Executive Director Scott Sowle speaks for each of us: “We live in an unfortunate reality where unspeakable gun violence is too often overlooked. I want Jennifer’s incredible spirit to remain always in focus. Jennifer was integral in the development and the heart of the program at Muir Wood for many years. I’ve heard from so many boys and families since her passing who are devastated by this loss. Boys have told me that they are alive today because of her. If there is a place where the best of us go after this life, Jennifer is most certainly there.”
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CCAPP
Sobering Facts about Sober Living Pete Nielsen, CADC-II
S
tories of victory over substance abuse are compelling: The high school athlete who turns his life of opiate abuse into a college career, the young mother who reunites with her toddler after overcoming meth abuse, and the famous actor who emerges anew after a rehab stint. These stories reflect the changing paradigm of public sentiment concerning addiction. But as CEO of California’s largest organization representing addiction treatment programs and counselors, and despite positive news coverage about overcoming addiction, I am not jumping for joy. Since the media only tells part of the story, and paparazzi quickly seek the next celebrity du jour, stories of victory actually ignore the incredible shortcomings Californians face when trying to get clean and sober. Addicts show courage for recognizing that they need help, yet thousands of addicts and their loved ones in California are finding out that the incredible act of committing to treatment may be a dead end or at least a battle. 4
Counselor | April 2018
Sadly, those who seek treatment are often sold to the highest bidder, and this is perfectly legal in California. People entering treatment are vulnerable physically and mentally. Their loved ones are often so desperate to end the chaos of addictive behavior that they make excellent targets for scam artists and so called “interventionists” who apply aggressive sales tactics, telling patients and families the addict will die if they do not act upon the referring agent’s directive. Add into these scenarios unscrupulous sober living homes willing to bill individuals and insurers without shame and you have a perfect storm of abuse, waste of resources, and tragically poor recovery rates. Also, addiction counselors in California are not required to have a license to provide private practice in neighborhoods where people could be treated at less severe points of the disease’s progression. Hang a shingle and start treating people the same day. This has led companies with unlicensed facilities in California to provide kickbacks to “junkie hunters” to recruit patients from others states to receive inferior treatment and often guarantee relapse. As I testified before Congress in December 2017, this is a whole-team approach driving the bus for profits. There should
CCAPP be a federal law against patient brokering. Any potential legislation at the federal and state levels must be crafted to support the industry and its good actors, while also weeding out the bad actors. Ultimately, the goal is to have an industry ethical and strong enough to support itself with minimal oversight. CCAPP is a driver of California Assembly Bill 285, introduced last year as the Drugand Alcohol-Free Residences Act. This bill would define a “drug- and alcohol-free residence” as a residential property operated as a cooperative living arrangement to provide an alcohol- and drug-free environment for recovering addicts.
Any potential legislation at the federal and state levels must be crafted to support the industry and its good actors, while also weeding out the bad actors. It would authorize a drug- and alcoholfree residence to demonstrate its commitment to providing a supportive recovery environment by applying and becoming certified by a certifying organization approved by the State Department of Health Care Services. AB 285 declares that a residence housing people committed to recovering from drug or alcohol addiction is presumed to be drug and alcohol free if certified by an approved certifying organization such as CCAPP. This bill makes sense for multiple reasons. It would require an approved certifying organization to maintain an affiliation with a state-recognized national organization; establish procedures to administer the application, certification, renewal, and disciplinary processes for a drug- and alcohol-free residence; and investigate and enforce violations by a residence of the organization’s code of conduct. The bill specifies that an operator seeking a certified residence must submit documentation to an approved certifying organization. A certifying organization would be required to maintain and post online a registry containing specified information of a certified residence pursuant to these
provisions, and would require the state to maintain and post online a registry that contains specified information regarding each residence and operator that has had its certification revoked. This bill would require that a state or county that directs substance abuse treatment—or a judge or parole board that sets terms and conditions for the release, parole, or discharge of a person from custody—first refer that person to a residence on an approved certifying organization’s registry, provided there is availability in such a residence. At some call centers, workers are paid bonuses for how many admissions they sign up, and many use high-pressure sales tactics on desperate callers. It is up to that employee to convince the caller to travel to the treatment center the call center represents, regardless of whether going away from home was the person’s intention and whether the treatment center provides the right therapies and environment for the consumer. Treatment in sunny Florida, especially during cold weather, sounds appealing to someone living in other parts of the country. Making everything public and transparent, through turning bills like AB 285 into law, could put junkie hunters and interventionists out of business. All of our standards, recommendations, and efforts are focused on protecting
the consumer. All of our best practices and efforts exist so that addicts—who are all extremely vulnerable—receive all of our possible protections. The substance use disorder treatment and recovery process is highly complex and, as a result, so is the industry that provides these services. The better trained, organized, and coordinated our industry is, the better our services will be for consumers. CCAPP is promoting common sense legislation to prohibit patient brokering in our state and to provide voluntary certification for recovery residences tied to public referrals and funding. By eliminating kickbacks for referring agents and denying them referrals and public funding, we believe we can stop the “Florida model” from transplanting to California and other states. In doing so we are confident we will save more lives, reunite more families that have been torn apart by untreated or poorly treated addiction, and make more communities safer in the process. c About the Author Pete Nielsen, CADC-II, is the CEO of the California Consortium of Addiction Programs and Professionals (CCAPP). Mr. Nielsen has worked in education as a campus director, academic dean, and an instructor. He has also worked in the SUD field for many years as an interventionist, family recovery specialist, counselor, and administrator.
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NACOA
Alcohol Awareness Month: Your Clients’ Sobriety May Hinge on How They Parent Patricia O’Gorman, PhD
A
pril is Alcohol Awareness Month, a wonderful (and often missed) opportunity to not only help your clients understand how alcohol affects them, but also to help them focus on the messages they’re sending their children. Focus on Parenting
It’s said that children see their self-worth reflected in their parents’ eyes. Ask your clients to consider what their children see when they look into their parents’ eyes when their parents are drunk. This past doesn’t need to predict the future. There are two very different reasons why it’s in your clients’ self-interest to focus on developing parenting skills:
1. Their Children Are at Risk for Addiction
Your clients often live with their children, or at least have contact with them, and children mirror their parents’ actions. Children love and look up to their parents. Their parents are their window into how the world works and into what actions they should take. It’s not surprising when we see toddlers repeating what their parents say after dropping something, even if it’s an expletive. In fact, we think this type of copying is cute. So it shouldn’t surprise us when we see children mimicking their parents in other areas of their life, like numbing their frustrations with school or an unfair teacher or boss, or numbing the pain of a broken heart. We know that parents anesthetizing their frustrations with alcohol and drugs sets the stage for the next generation to do the same. The result for their children can be alcoholism, mental health problems, and even physical health problems. The next reason, though, is one that many haven’t considered.
freedom as a country with parades, memorial services, prayers, flag waving, and family gatherings. With the advent of heavy advertising of alcohol, these classic American celebrations have morphed into drunking days. They are frequently excuses for barbeques where lots of drinking and drug use are the norm, and where your clients’ children are a confused or even terrified captive audience. We’ve just survived St. Patrick’s Day, which has become the fourth most-celebrated drunking day in America after New Year’s Eve, Christmas, and the Fourth of July. Your clients may have participated in a pub crawl, going from bar to bar and getting as drunk as possible as quickly as possible. Some may have had their children in tow. In recovery, particularly during holiday celebrations, your clients will want their children to know that they are highly valued. You can help your clients develop the courage to take steps that will reflect back to their children the unconditional love that they feel inside. One very enjoyable way of doing this is to change how upcoming national holidays are celebrated in the family. Children of those with addiction frequently don’t anticipate a good time as they look forward to these holidays. This means
2. Poor Parenting is a Relapse Trigger
On an immediate and personal level, “Poor parenting is a major relapse trigger for your clients” (O’Gorman & Diaz, 1987, 2004). Your clients’ feelings of anger and frustration (natural to parenting), coupled with guilt for past actions—often intensified by a lack of parenting skills—are a set-up to do what’s familiar: medicating feelings of inadequacy.
You Can Recast Annual Drunking Days
The Fourth of July, Memorial Day, and Veteran’s Day are supposed to be days to celebrate our 6
Counselor | April 2018
Challenge your clients to focus on developing their parenting skills, not only for their children’s sake, but also for their own continuing sobriety.
NACOA that in sobriety your clients now have to figure out how to explain to their children how their desire to “cut loose” and “have fun” may have put them and their children in danger. It also means that this is a golden opportunity to begin to do things differently.
Crisis is an Opportunity
Crisis is an opportunity for changing how your clients lead their families in sober celebrating. To get started, ask your clients: n How they have spent Memorial Day and the Fourth of July in the past n What they liked about their celebrations in the past n What their children liked about those celebrations n What they feel they need to change so that they can stay sober and move their family toward recovery n What traditions they would like to keep n Who can support them in making the needed changes n How they can model for their children having sober fun at family gatherings to begin to teach their children strategies for sober fun This is important because each family is different; each family has different strengths, different traditions, and different priorities.
(O’Gorman, 2014)—into negative self-talk. Their girly thoughts tell them they must be the “good girl” and not make waves by questioning the actions of those they love, even if this leads them to engage in harmful behaviors. Getting drunk on a holiday or at a holiday celebration is one of those harmful behaviors. So if they aren’t going to use on these days, how can they challenge the notion that they aren’t being “bitchy” or a “party pooper” if alcohol isn’t allowed at a party they throw? How do they resist the urge to drink when attending someone else’s party? Here are some ways to utilize this in group work: n Normalize the subtler pressure that women feel
n Have women learn to get support from each other by laughing at how ridiculous the pressure to be a “good girl” really is
Part of the pressure men feel is to have all the answers, to be confident and in control, and to not feel vulnerable. Drinking helps numb this pressure,
One reason women get drunk on days like the Fourth of July is because they have internalized toxic societal messages—which I have named girly thoughts
n Determine where opportunities to be a real hero at these celebrations are by showing friends and children other ways to enjoy this special day Continued on page 16
Offer your patients
GREATER CARE.
Now go deeper. Triggers for use over the holidays are frequently embedded not only in family traditions but also in cultural beliefs about the role of women and men in each family. This translates into how your clients’ children see their parents balancing these subtler expectations of family and friends, some of which directly contribute to the pressure to use.
Tell Women: Don’t Let Girly Thoughts Drive You to Drink
n Discuss how men can distance themselves from a group that’s drinking heavily, and how this has an upside: it can make each man a hero, particularly in the eyes of his children
n Develop ideas for ways to free their daughters and sons from living up to crippling cultural expectations
Help Clients Become Strong, Sober Models of Adulthood
n Normalize the subtler pressure that men feel to be tough and in control n Develop support between men for how painful it is to be confined by gender stereotypes such as “real men can hold their liquor”
n Introduce the concept of girly thoughts
Tell Men: Man Up and Be a Real Hero
and not drinking means standing out from the pack and possibly being challenged. Again, getting drunk on a holiday is one of those harmful behaviors that they can now change, and that change will impact not only their recovery but also their children’s future. So if they aren’t going to use on these days, how can they demonstrate their power when sober? How can they challenge the notion that alcohol is necessary for a celebration without looking like a “wimp” or a “party pooper”? How do they resist the temptation to “be a man” when everyone around them is drinking? In group work,
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CULTURAL TRENDS
25I-NBOMe: Hovering Under the Radar By Maxim W. Furek, MA, CADC, ICADC
A
ccording to the National Institute on Drug Abuse (NIDA), “Alcohol and tobacco are the drugs most commonly abused by adolescents, followed by marijuana. The next most popular substances differ between age groups. Young adolescents tend to favor inhalant substances (such as breathing the fumes of household cleaners, glues, or pens) . . . whereas older teens are more likely to use synthetic marijuana (‘K2’ or ‘Spice’) and prescription medications—particularly opioid pain relievers like Vicodin and stimulants like Adderall” (2014).
Curiously, a cluster of synthetic hallucinogens sold as LSD or mescaline and marketed as “Legal Acid,” “Smiles,” or “25-I” is rarely mentioned. The drug is known as “N-Bomb” because of its unique chemical compositions: 25I-NBOMe, 25C-NBOMe, or 25B-NBOMe. The drug “is an extremely potent synthetic substance that the Drug Enforcement Administration (DEA) considers analogous to LSD” (Martin, 2012). Although the obscure hallucinogenic has hovered under the radar for years, it has netted a cadre of curious drug seekers looking for a psychedelic high.
Voodoo Festival
That curiosity has resulted in tragedy. The overdose death of twenty-one-year old Clayton Otwell of Little Rock, Arkansas, thrust N-Bomb into the spotlight. After a night drinking at the New Orleans Voodoo Festival, Otwell accepted a free dose of 25-I from a stranger. According to Mandie Newell, Otwell’s friend, “the stranger plopped a single drop from a vial into Otwell’s nose” (Martin, 2012). Newell noticed that Otwell immediately started babbling incoherently. “She got him to the medical tent at the festival, but within thirty minutes, Otwell had a seizure and never regained consciousness. Taken to Tulane University Hospital, he was placed on life support” and died three days later, according to The Times-Picayune (Martin, 2012). The Times-Picayune also noted that “Otwell was one of at least three people treated for 25-I overdoses during Voodoo Festival weekend, one local emergency room doctor said” (Martin, 2012). The Drug Enforcement Administration (DEA) wrote that The NBOMe compounds are substantially more potent than other hallucinogenic compounds, and the data suggest that extremely small amounts of these drugs can cause seizures, cardiac and respiratory arrest, and death. Indeed, these compounds have been linked to the deaths of at least nineteen Americans aged fifteen to twenty-nine between March of 2012 and August of 2013 (2013b).
Designer Drug
2C-I-NBOMe has a brief but fascinating history. An article on Heavy.com noted that the substance “. . . is a derivative of the substituted phenethylamine psychedelic 2C-I, discovered in 2003 by Ralf Heim at the Free University of Berlin, and subsequently investigated by a team at Purdue University led by David Nichols. The chemical had no history of human use prior to being sold online as a designer drug in 2010” (Prince, 2015).
Serotonin Receptors
The obscure drug “is derived from mescaline, which occurs naturally in peyote cactus” (Prince, 2015). According to the DEA, 8
Counselor | April 2018
CULTURAL TRENDS “25I-NBOMe, 25C-NBOMe, and 25B-NBOMe were previously investigated as research tools to probe the location of 5-HT2A receptors in the central nervous system of nonhuman mammals” (2013a). Additionally, Vanderbilt University Medical Center (VUMC) stated that “The NBOMe class of drugs was developed for the very specific medical purpose to map serotonin receptors in the brain, but in recent years it has become one of the most frequently abused novel psychoactive substances” (Wood, 2015). The Foundation for a Drug-Free World website acknowledged that “NBOMe creates a hallucinogenic effect similar to LSD at extremely small dosages. Users report the negative effects and after-effects of the drug are worse than that of LSD. It also mimics the effects of methamphetamine” and that “Effects of only a tiny amount of the drug can last for up to twelve hours or longer” (“What is,” 2016). Interestingly, “N-bombs and related substances are known to be more dangerous than other psychedelic drugs, largely because their inconsistent
formulations make them much more difficult to dose. As the DEA put it, even attempting to take ‘safe’ doses is like ‘playing Russian roulette’ ” (Tayag, 2015). Little is known about its pharmacological risks or its interaction with other substances. Even the DEA noted that “synthetic drugs like these have no consistent manufacturing and packaging processes and may contain drastically differing dosage amounts, a mix of several drugs, and unknown adulterants” (DEA, 2013b). The Vaults of Erowid, an online educational and harm-reduction resource, has also cautioned, “25-I-NBOMe is extremely potent. It should not be snorted! 25-I-NBOMe has led to several deaths and a number of hospitalizations” (“25I-NBOMe,” 2015). Another article on NBOMe in the The Times-Picayune stated, “Although little is known about the 25-I, Drug Section Supervisor Rebecca Nugent said it is available on the Internet on research chemical sites. The samples they have seen were traced back to manufacturers in China and India” (McGaughy, 2012).
VUMC warned, The illegal status of classic recreational substances such as cocaine, ecstasy, and cannabis has encouraged drug manufacturers to seek alternative options in order to evade current drug legislation. These substances are usually created by modification to the molecular structures of existing illicit compounds to produce similar effects but offer the advantages of being technically legal, less expensive, readily available, likely undetectable by routine drug abuse screens, or having more desirable and potent pharmacological effects. The substances abused frequently change in response to legislative controls and market demands. It is important for health care providers to remain up-todate on the toxicological effects of these emerging agents (Wood, 2015).
Emergency Scheduling
The crackdown on 25I-NBOMe began several years ago. The Times-Picayune noted, “Around 2009 . . . a number of Continued on page 20
HOW A BELOVED SPIRITUAL TEACHER FOUND RECOVERY “On a warm summer day, I walked out of my last treatment center, knowing that I had tapped into a power and a source that could move mountains, change people’s lives, and lead me to a future that I couldn’t even fathom yet.” —DEBBIE FORD, # 1 New York Times Bestselling Author
Discover the astonishing light within yourself and help others do the same with her new book: YOUR HOLINESS Available Wherever Books and E-Books Are Sold
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9
OPINION
Eliminating Shame from Addiction Treatment and Recovery Michael Weiner, PhD, CAP
I
ntrospection can lead people to look at the pluses and minuses of life. It will cause people to look at things that have been done well and things that could have been done better. It can bring about growth through change. That is the spirit with which this is being written.
As addiction professionals we have helped many, many people. Estimates are that we have helped up to 23.5 million people achieve longterm recovery. It is hard to say how many people with an active addictive disease are still out there. In the lives of addiction professionals, and of people in recovery, the topic of shame comes up frequently. It comes up in treatment settings and in Twelve Step recovery meetings. Very often shame or stigma is talked about as something that is placed upon recovery by the world outside—a world or culture that we cannot control. However, we also learn to focus on what we can control. We can control the shame that we create and we can make it go away. Is it surprising that we create shame? Maybe one reason that it happens is that we are all products of the culture that we accuse of causing the stigma. We grew up in it and have been influenced by it, so maybe we have accepted shame far too easily. It may also be helpful to remember that the recovery movement has been heavily influenced by morality (e.g., the Temperance movement, religion, and the Oxford Group). The dominance of addiction medicine has been more recent. So maybe we are on the brink of eliminating shame from addiction treatment and recovery? First we have to look at our role in creating it. Do we have the “courage to change the things we can?”
Shame: We Did Not Intend to Create It
The first publication created by Behavioral Health of the Palm Beach (BHOP)’s research department was an outcome study published in 2006. At that time the research department consisted of two people: me and Dr. Donald Mullaney. Making the phone calls was painstaking and tedious, but sometimes it was very rewarding. As a result of those phone calls, a few people came back into treatment and got back on track. We did the best we could. We had to trust in people’s honesty. It was often hard to track people down. The result 10
Counselor | April 2018
of our best effort indicated that 53 percent of the people remained substance free one year after leaving residential care at BHOP. We did an honest job. A 53 percent success rate seemed reasonable, and we were pleased with ourselves. We never really paid attention to the finding that 47 percent of the patients we contacted were labeled as “failures.” People were either “successes” or a “failures”; there was nothing in between. After all, it was a study designed to determine our “success rate.” Creating treatment “failure” led me to start thinking about and paying attention to other ways that we may have unintentionally created shame. Unfortunately, I found a few. We have all heard patients say, “I have been to treatment before.” Are they really saying, “I have failed before”? It has to feel bad. It has to feel shameful. I wonder what it feels like to say, “I have been to treatment three times before.” You know what makes me feel worse? When I think about how many times I have asked patients, “How many times have you been in treatment?” What am I really asking? The implication is that I am asking, “How many times have you failed?” Shame, or the expectation of judgment, will keep people from returning for help if a relapse occurs. We may deny that this happens, but take a look at treatment plans for all patients who have returned to treatment multiple times. There is always another First Step and the telling of a story. There is the assumption that people who have not relapsed did not get the First Step. Where in the First Step does it say anything about not drinking? People who have established a period of recovery are not the same as newbies. People who have experienced recovery have learned a thing or two. It is likely that a return to social drinking did not work; that could be a lesson these newbies have yet to learn. People coming back likely know something about Twelve Step recovery, or maybe they know that trying to stay sober without support is really difficult. These are valuable lessons. The language of shame is this: we tell our patients that they have a chronic disease, but we use acute care models. We convey the message that you better get well fast and in the way we want you to do it or we do not want anything to do with
OPINION you. We have made statements like, “Come back when you are ready” or “You need to do more research.” I hate to admit that I have made similar statements to patients. What was I thinking? Would any one of us have made such a statement to someone with any other disorder? Similarly, I have often heard the expression, “I am not going to work harder on your recovery than you are.” On the other hand, we generally expect patients to be in denial and be ambivalent about recovery. But wait . . . we expect patients who are in denial of their disease and probably do not really want to be in treatment in the first place to work hard? We cannot have it both ways. Traditionally, we have relied on one particular therapeutic skill to pull patients out of their denial: confrontation. So if patients are not shamed enough by this time, we yell at them. That is likely to be an overstatement, but not always.
So How Do We Fix It?
Neither the Substance Abuse and Mental Health Services Administration
(SAMHSA; 2012) nor the American Society of Addiction Medicine (ASAM; 2013) includes abstinence from substance use as a measure of recovery. ASAM defines recovery as “A process of sustained action . . . in the direction of consistent pursuit of abstinence.” So, as long as patients are still seeking abstinence, they are still in the game. Why would they not be? Diabetics with unstable blood sugar levels, but still in pursuit of stability, are never considered to be treatment failures. Only we in the addiction field do that! If perfect blood sugar was the criteria for the successful treatment of diabetes, almost every diabetic being treated would be a “failure.” A similar argument could be made for the successful treatment of hypertension. Diabetics and people with hypertension are not considered to be “failures” as long as they are treating their disease. Why not do the same for people with an addictive disease? It does not have to be all or nothing, success or failure. So how do we measure sustained action in the direction of consistent pursuit of abstinence? I think the answer has to do
with keeping people engaged in the process of getting well. We tell patients that we are treating a chronic disease, but traditionally treatment has been heavily loaded on the front end. We can learn something from how other chronic diseases are treated. Diabetics and people with hypertension will be monitored for their entire lives. Can addicts have recovery check-ups (White, 2014) with an addictionologist? Check-ups could be quarterly or semiannual, but it would keep addicts engaged in treatment. There would not be failures. There is something to be said for helping people in their “consistent pursuit of abstinence.” The term “outcome” is inappropriate! If we are treating a chronic disease, we are not measuring an outcome, we are measuring progress at a given point in time. What people have learned “in the consistent pursuit of abstinence” is important and needs to be taken into account when patients with a history in recovery reengage into a higher level of care, assuming that we consider Continued on page 31
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WELLNESS
The Art of Mentoring John Newport, PhD
T
he dictionary defines a mentor as “a trusted counselor or guide” (Merriam-Webster, 2018). We have all been influenced by mentors in our lives—positive role models who have taken a personal interest in us and both inspired and guided us to strive to reach our full potential. Pause for a moment and identify one or two of your own mentors who have had a positive impact on your life. In my own case, I have been inspired by wise friends, counselors, special teachers, bosses, and in recent decades, fellow authors. Mentorship is, indeed, a central theme underlying the successfulness of AA, Al-Anon, NA, and other Twelve Step recovery programs. As addiction professionals, many of you are undoubtedly grateful for the compassionate, tough-minded guidance you received from counselors, sponsors, and other Twelve Steppers who selflessly gave you the loving support and guidance that enabled you to secure a strong foothold in your own recovery. 12
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Personal Experiences with Mentorship
Throughout my teens and adult life I have been blessed with numerous mentors who have helped me along the way. I was pretty messed up from my mid-twenties through a good part of my thirties, and was fortunate to receive compassionate support from gifted therapists and supportive friends who helped me navigate an extremely trying period of my life. Looking back on my high school and college days, I am deeply indebted to a number of truly inspirational teachers. I am particularly grateful for two wonderful professors during my undergraduate years. I took a business writing course from a professor Carl Rosner, whose passion for the subject helped me discover my own talents in that area, and no doubt inspired me to delve more seriously into writing later down the road. Likewise, my business law instructor Dr. Howard Bash was so motivating that half of us wanted to go to law school by the time we finished his class. While I never pursued a legal career—though I was, however, accepted by both Harvard and Columbia law schools—Dr. Bash’s love and passion for his subject matter, and the personal interest he took in his students, was totally inspirational. He somehow roused me to “light a fire inside myself” and sparked
WELLNESS my determination to do something truly worthwhile with my life. Later I developed a friendship with an author, Dr. Steven Farmer, who recognized my own potential as a writer and inspired me to write my first book, The Wellness-Recovery Connection (2004). To this day he remains a constant source of inspiration and encouragement in moving forward with my latest writing ventures. I look back with fondness to Steve Denys, a high-school-era friend back in New York who was like a big brother, providing a much-needed example of a truly grounded and self-reliant person. We both moved westward and lost touch for several decades. About ten years ago we were reunited by a mutual friend who had also relocated to the west. As before, Steve served as a strong friend with a real take-charge attitude. A few years following retirement from my day job, I prevailed upon him to share with me his street-smarts as an “investment junkie.” He took me under his wing and taught me the ins-and-outs of successfully managing retirement investments, an area in which I had previously been blocked by my intimidation. More recently, over the past year and half both my wife and I have become involved in mentoring our young adult granddaughter Amber, who has been staying with us since she moved out here from California. This has been and continues to be an extremely rewarding experience for me, as I have never had any children of my own.
Pointers for Mentoring
Over the past several decades we have increasingly become an overly secular, “me first” society obsessed to the max with personal gain. We are so caught up in the fast lane that we have lost sight of values that are truly important. Far too many people go through each day totally numbed out, devoid of any real sense of purpose in their lives. Advances in electronic communications are in far too many instances eroding the art of face to face communication. Next time you are in a restaurant, look around and see how many couples are busy texting and e-mailing other people while totally ignoring each other. Young people are becoming increasingly isolated and cut
off from meaningful social interaction, as a consequence of their addiction to their smartphones and iPads. At the same time, the rate of depression and suicide among our nation’s youth is truly alarming. In this deeply troubled world there has never been a greater need for mentors to serve as positive role models, while providing inspiration and guidance to others in need of direction. In addition, the rewards of mentoring others yield huge dividends in terms of psychic gratification. Assuming you would like to broaden your involvement in mentoring others, where do you start? I would strongly suggest asking yourself, “What kind of legacy do I want to leave behind?” and let your heart be your guide. It is also important to ask, “What special gifts, talents, and insights do I have to offer, and how can I apply these attributes to help enrich others’ lives?” An example that immediately comes to mind is my wife Ann’s decision to volunteer as a reading tutor at a school in our community. Meeting on a weekly basis with a young male student, she forged a very supportive connection and guided him in writing and illustrating a series of short essays as a term project. As she promised, we assisted him in developing his work into a book. I typed the essays, we incorporated his illustrations, and we even had the University of Arizona Press format his work into a real book with his photo on the cover. In short, through my wife’s caring mentoring, her student made great strides in developing increased self-esteem, together with the confidence that he could really do something with his life. Another area where one can have a deep impact on others is through serving as a health and wellness mentor. If you have successfully recovered from a devastating illness such as a heart attack, stroke, or cancer, you are in a position to serve as a powerful source of inspiration for patients currently struggling with that problem. Health-related agencies in your community, such as the American Heart Association and American Cancer Society, will welcome your assistance in this most important area. Likewise, if you are a former smoker who has successfully kicked the habit, you can provide
valuable support and guidance to others who are struggling to free themselves from nicotine addiction. This is a particularly needed service in the recovery community, as half or more of alcoholics and addicts entering recovery are smokers who have carried this life-robbing addiction over into their recovery. They truly need your help! In this article I discussed severe problems of social isolation, despondency, and lack of purpose plaguing our country’s youth, who are growing up in an increasingly depersonalized and highly competitive society. Teachers are overwhelmed with problems presented by these children and teens, many of whom are products of extremely dysfunctional families. If you are retired, you might consider serving as a much-needed role model for these kids by doing some substitute teaching. Many additional outlets will extend a wholehearted welcome to caring adults who want to serve as role models for troubled youth. Such organizations include youth programs of churches, synagogues, and other religious institutions; community agencies serving troubled youth and their parents; and programs such as Big Brothers and Big Sisters. In short, there are endless opportunities for mentoring others who will benefit from you sharing your life experiences and support. As I alluded to before, the best way to start is to ask yourself what gifts you have to offer and let your heart guide you to those areas where you can truly be of help. As they say in AA, “You’ve got to give it away in order to keep it.” Until next time—to your health! c About the Author John Newport, PhD, is an addiction specialist, writer, and speaker living in Tucson, Arizona. He is author of The Wellness-Recovery Connection: Charting Your Pathway to Optimal Health While Recovering from Alcoholism and Drug Addiction. You may visit his website www.wellnessandrecovery.com for information on wellness and recovery trainings, wellness coaching by telephone, and program consultation services that he is available to provide.
References Merriam-Webster. (2018). Mentor. Retrieved from https://www.merriam-webster.com/dictionary/mentor Newport, J. (2004). The wellness-recovery connection: Charting your pathway to optimal health while recovering from alcoholism and drug addiction. Deerfield Beach, FL: Health Communications.
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TOPICS IN BEHAVIORAL HEALTH CARE
Prescription Drug Misuse and Addiction, Part II: Strategies to Address the Problem Dennis C. Daley, PhD
M
y previous article reviewed data on trends in use, misuse, and addiction to prescription opioids, tranquilizers, sedatives, and stimulants; signs of misuse and addiction; reasons for use, and the effects of drug problems on individuals and families. This article discusses strategies to reduce prescription drug misuse and addiction, and help individuals and families. These are based on reports published by the US government (SAMHSA, 2017; Baker et al., 2017), the Centers for Disease Control and Prevention (CDC, 2016), academic institutions, other organizations, and my extensive experience in clinical care, research, and teaching. A range of education, prevention, early intervention, treatment, and recovery interventions are needed to address this significant public health and safety problem affecting millions of people in the US, their families, and our communities. Education
Providers, patients, families, and communities need education about potential benefits and harms, and alternatives to medications with addictive potential so more informed decisions
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Counselor | April 2018
about treatment can be made. For example, there are nonaddictive medications and nonmedication treatments for pain or anxiety that can help patients manage their conditions. Medical providers need education and training on screening and assessing patients for substance use disorders (SUD), evidence-based interventions for SUDs, and treatment and recovery resources in the community for patients and families. Screening, brief intervention, and referral to treatment (SBIRT) and motivational interviewing (MI) are two strategies that can enhance providers’ ability to identify patients with SUDs, provide brief interventions for less severe problems, or link patients with more severe SUDs to addiction treatment. My surveys and discussions with medical providers show that there is a need for an increase in their knowledge base, skills, and comfort level in working with patients with substance problems. This can help reduce stigma, improve empathy of providers, and lead to better patient care. Medical providers can partner with addiction specialists to implement training programs and design treatment services. Access to ongoing consultation on clinical cases and procedures to develop services such as medication-assisted treatment (MAT) programs in medical settings can also benefit medical staff.
Prevention of Drug Misuse or Addiction
Reducing the number of prescriptions written is one way to reduce the number of individuals who transfer their addiction to illicit street drugs like heroin or fentanyl. SAMHSA and the CDC published clinical guidelines for drug prescribing and pain management. The CDC recommends not using opioids as the first-line therapy for patients with common chronic pain conditions such as low back pain, migraines,
TOPICS IN BEHAVIORAL HEALTH CARE neuropathic pain, osteoarthritis, and fibromyalgia (CDC, 2016). Unless patients have active cancer, need palliative care, or are in end-of-life care, nonopioid medications or nonmedication treatments are recommended. Nonopioid drugs used depend on the specific medical condition and include acetaminophen, NSAIDs, gabapentin/pregabalin, select antidepressants, and topical agents such as lidocaine or capsaicin. Nonmedication treatments include exercise, weight loss, patient education, self-care, cognitive behavioral therapy, physical therapy, and interdisciplinary rehabilitation. Individuals prescribed opioids by physicians and dentists can be advised on ways to safely store medications since individuals with drug problems may find or steal medications from relatives or friends. Individuals who stop taking opioids and family members can be instructed to dispose of unused drugs at take-back locations to reduce access to these drugs by others.
Prevention of Overdose
Given the significant increase in deaths from drug overdose, there is a need for patients, families, concerned others, first responders to emergencies in the community, and medical providers to have access to overdose education and naloxone formulations. For example, hospital patients receiving opioids or with opioid use disorders (OUDs) can be given naloxone prior to hospital discharge and instructed (with or without their family) on how to use this medication. Many overdoses are reversed by drug users helping each other and by first responders. A challenge for first responders is overcoming negative reactions to addicted patients who refuse treatment after an overdose or receive naloxone multiple times for their overdoses.
Pharmacy and Drug Monitoring
Formulary and drug utilization strategies include requiring a prior authorization for opioids, quantity limits, and prospective drug utilization reviews that examine patient use of medications with addictive potential. Drug utilization reviews can identify patients on high morphine equivalent dosages or MEDs (usually 90 or 120 mg or more MEDs), those taking multiple
opioids or receiving prescriptions from more than one provider, length of time taking opioids, or using opioids and concurrent benzodiazepines and/or muscle relaxants. Some reports suggest improving formulary coverage and reimbursement for nonpharmacologic treatments as well as multidisciplinary and comprehensive pain management (NASEM, 2017).
Prescription Drug Monitoring Program (PDMP)
Prescriber registration and use of the PDMP is another helpful tool to monitor drug use and intervene with patients who evidence a problem that may otherwise not be identified (Wunch, Gonzalez, Hopper, McMasters, & Boyd, 2014). Other strategies to take advantage of the PDMP include better integration into electronic health records (EHRs) of patients; enhancing access of PDMP across state lines, since some patients will seek opioids from multiple providers in more than one state; and third-party payer access to PDMP data providing there are proper protections of patient confidentiality. To reduce fraud among providers, there needs to be policies to investigate those who are considered high risk.
Physician Benchmarking
This can be used to compare doctors or practices on opioid prescribing to peer averages within the same medical specialty for nonmalignant, nonterminal conditions. Metrics compared may include prescriptions written per thousand members, average daily MEDs, and percent of total prescriptions written for opioids. Feedback to physicians can help them improve their management and oversight of individuals prescribed opioids for chronic noncancer pain.
Interventions in Medical Systems
Medical providers can screen patients for drug use during clinic visits. Positive screens can lead to a more extensive evaluation at the clinic or with an addiction provider. On-site education, support, brief interventions for drug misuse or mild forms of a drug use disorder, and linkage to specialized treatment for more serious drug use disorders can be provided. Given the low rates of treatment
entry for individuals with SUDs, identification and early intervention in medical settings is needed for more patients with drug problems to receive care and improve their functioning.
Medication-Assisted Treatment (MAT)
More providers are needed to offer MAT to patients with addiction to prescription opioids. Licensed addiction residential programs can address this problem by implementing MAT with patients prior to discharge to the community. Inpatient medical hospital units, emergency departments, consultation and liaison services, and other specialty medical programs need to increase medical staff with waivers to provide buprenorphine. Incentives to initiate MAT during hospital stays or at ED or primary care visits could increase the number of addicted patients who receive MAT. Access to methadone maintenance or buprenorphine with a “warm handoff” to a community provider is essential to get patients engaged in treatment beyond the acute phase of care. Medical systems have to own the problem of SUDs among their patients and use multiple strategies to assess, provide treatment, and/or link them to addiction care or community recovery resources.
Treatment and Recovery for Drug Addiction
There are many treatment and recovery resources for individuals with prescription drug misuse or a SUD and their family members. Information about treatment can be accessed at SAMHSA’s Behavioral Health Treatment Services Locator by entering an address, city, or zip code, or by calling 1-800-662-4357 to receive confidential information in English or Spanish about treatment programs. Most states also have treatment locators, and health plans have care management services to help facilitate identification of treatment services for members in need of treatment for a SUD. Employees with access to an employee assistance program (EAP) can seek help for their own or a family member’s drug problem. EAPs may offer counseling to help people assess drug problems, decide what to do about them, or help families deal with the stress associated www.counselormagazine.com
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TOPICS IN BEHAVIORAL HEALTH CARE with addicted family members. EAPs can also link addicted people or family members to treatment or recovery resources in the community. Medical treatment for physical addiction may include detoxification in a hospital, rehabilitation program, or outpatient clinic. Once individuals are tapered off addictive drugs and their condition stabilizes, they can be connected to ongoing treatment. Methadone (taken daily), buprenorphine (daily pills, sublingual film, or extended release shot given monthly), and buprenorphine combined with naloxone are effective treatments for patients with opioid addiction who comply with their prescriptions and engage in other forms of treatment and/or recovery. Short and long-term residential, partial hospital, intensive outpatient, and outpatient programs can be used based on the type and severity of the drug problem. Treatment programs aim to get people to accept their problems, stop misusing or become abstinent from addictive drugs, and learn ways to meet the challenges of recovery. These include managing cravings, resisting social pressures to use, refuting “addictive thinking,” getting the family involved, finding alternative ways to manage stress, catching early signs of relapse, and developing a support system so that recovery becomes a “we” and not an “I” process. People who actively engage in mutual support programs such as Narcotics Anonymous (NA) often do better than those who do not use these programs (Donovan, Ingalsbe, Benbow, & Daley, 2013). Longterm recovery is one of the best antidotes to addiction. Mutual support programs such as Nar-Anon are also available to help family members or friends affected by a loved ones’ addictions. Other local mutual support programs for family members are available in some areas. Support from peers in recovery can also help individuals with drug problems. Peers may include paid professionals such as peer navigators (PN), peer specialists, recovery coaches, or volunteers who provide services to individuals and in some instances their families. In the medical system in which I am associated, PNs are used in numerous hospitals and ambulatory programs 16
Counselor | April 2018
to screen, assess, refer, and provide brief interventions. This led to more patients engaging in treatment and/or community mutual support programs. PNs have also educated medical staff about treatment and recovery resources in the community.
Harm Reduction
Supervised consumption spaces and needle and syringe programs are used in some communities. While these can help addicted individuals reduce the risk of acquiring or transmitting infectious diseases, or eventually engage in addiction treatment, they are controversial and not accepted by all professionals or others as viable strategies to reduce drug misuse or addiction.
Final Thoughts
Clearly, multiple educational, prevention, treatment, and recovery strategies are needed to address prescription drug misuse and addiction, and the many adverse effects of these problems on individuals and families. Since individuals with prescription drug problems are likely to seek medical care for other reasons, providers who implement evidence-based assessment and treatment and referral strategies can influence patients to address their problems. In my current role in an integrated delivery and finance system, I can attest to many positive outcomes from collaborations between addiction and medical professionals. This has led to increased provider education, training and consultation; increased screening and interventions with medical patients with SUDs; reduction in opioid prescriptions; more providers offering MAT in primary care practices; financial support to first responders and families for overdose education and intervention with naloxone; and better coordination of care for medical patients with SUDs. c About the Author Dennis C. Daley, PhD, served for fourteen years as the chief of Addiction Medicine Services (AMS) at Western Psychiatric Institute and Clinic (WPIC) of the University of Pittsburgh School of Medicine. Dr. Daley has been with WPIC since 1986 and previously served as director of family studies and social work. He is currently involved in clinical care, teaching, and research.
References Baker, C., Bondi, P., Christie, C., Cooper, R., Kennedy, P. J., & Madras, B. (2017). The President’s Commission on Combating Drug Addiction and the Opioid Crisis. Retrieved from https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-1-2017.pdf Centers for Disease Control and Prevention (CDC). (2016). Nonopioid treatments for chronic pain: Principles of chronic pain treatment. Retrieved from https://www. cdc.gov/drugoverdose/pdf/nonopioid_treatments-a.pdf Donovan, D. M., Ingalsbe, M. H., Benbow, J., & Daley, D. C. (2013). Twelve step interventions and mutual support programs for substance use disorders: An overview. Social Work in Public Health, 28(3–4), 313–32. National Academies of Sciences, Engineering, and Medicine (NASEM). (2017). Pain management and the opioid epidemic: Balancing societal and individual benefits and risks of prescription opioid use. Washington, DC: The National Academies Press. Substance Abuse and Mental Health Services Administration (SAMHSA). (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm Wunsch, M. J., Gonzalez, P. K., Hopper, J. A., McMasters, M. G., & Boyd, C. J. (2014). Nonmedical use, misuse, and abuse of prescription medications. In R. K. Ries, D. A. Fiellin, S. C. Miller, & R. Saitz (Eds.), The ASAM principles of addiction medicine (5th ed.) (pp. 513–23). New York, NY: Wolters Kluwer Health.
NACOA
From page 7
Now jump into the deep end and develop a parenting program for your treatment program. Challenge your clients to focus on developing their parenting skills, not only for their children’s sake, but also for their own continuing sobriety—a true win-win! c About the Author Patricia O’Gorman, PhD, is a best-selling author, psychologist, resiliency coach, and international speaker known for her warm presentations. She is the author/coauthor of nine books, three about women. Her latest is The Girly Thoughts 10-Day Detox Plan: The Resilient Woman’s Guide to Saying NO to Negative Self-Talk and YES to Personal Power.
References O’Gorman, P. & Oliver-Diaz, P. (1987). Breaking the cycle of addiction: A parent’s guide to raising healthy kids. Deerfield Beach, FL: Health Communications, Inc. O’Gorman, P. & Diaz, P. (2004). The lowdown on families who get high: Successful parenting for families affected by addiction. Washington, DC: Child and Family Press. O’Gorman, P. (2014). The girly thoughts 10-day detox plan: The resilient woman’s guide to saying no to negative self-talk and yes to personal power. Deerfield Beach, FL: Health Communications, Inc.
COUNSELOR CONCERNS
The Genesis and Current Status of the Opioid Crisis, and the Interventions That Can Help Gerald Shulman, MA, MAC, FACATA
W
hile the use and abuse of opioids (prescribed and illicit) in this country is not new, the magnitude of the current opioid crisis still is very significant. Many people have tried to explain it and the one thing they share in common is their oversimplification. The motivation for the explanations are clear; a desire to bring order out of chaos. The problem is that simple answers to complex problems are almost always wrong. The historical use of opioids is not new. The first written mention of opiates is believed to have come from Mesopotamia in 3400 BCE, when people had discovered that drying the poppy plant’s extracted fluid created a highly powerful drug which become known as the “joy plant,” and later “opium” (PBS, 1998). Following that, different factors served to expedite the use and abuse of opioids: n The hypodermic needle was introduced in 1853 (Bellis, 2017). n The common use of morphine as a painkiller during the Civil War resulted in such a large number of soldiers who became addicted to the opiates given to them for battle injuries that the postwar morphine addiction prevalent among them came to be known as “Soldier’s Disease” (Lewy, 2014). n A community group in the US, the Saint James Society, began a campaign to supply free samples of heroin through the mail to morphine addicts who were trying to give up their habits in the early 1900s (“From the,” 2002). This history alone would not account for today’s opioid crisis. Other, more recent factors have contributed to where we are today. These include: n A cultural belief that we should not be uncomfortable, and if we are, there is some immediate medicinal fix for it n Direct-to-consumer advertising of both OTC and prescription medications, permitted only in two countries, the US and New Zealand (Every-Palmer, 2014) n The consensus statement from the American Pain Society and the American Academy of Pain Medicine in 1997 which stated that there was little risk of addiction and overdose in pain patients, which they claimed as less than 1 percent, now known to be up to 50 percent in nonmalignant chronic pain patients (Højsted & Sjøgren, 2007) www.counselormagazine.com
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COUNSELOR CONCERNS n The huge amounts of money spent by pharmaceutical companies marketing to physicians (Zezima, 2017) n Legislation passed by Congress weakening the DEA’s ability to stem opioid sales (Whitaker, 2017) n The message that pain is “the fifth vital sign” (Keyes, Cerdá, Brady, Havens, & Galea, 2014) n Physician overprescribing n The introduction of illicitly manufactured fentanyl n Treatment and reimbursement of addiction treatment as if it is an acute illness As you can determine from this list, there is no single cause for today’s opioid epidemic, but a series of different, yet related, synergistic circumstances. Let us look more closely at some of these.
An Increase in Prescribing Opioids by Physicians
The federal government began tracking how physicians treated pain, and if doctors and hospitals were not deemed to be giving patients appropriate (i.e., “enough”) pain medication, they did not receive full funding or payment. At this time, pain became the “fifth vital sign” in addition to blood pressure, temperature, pulse rate, and respiration rate (Keyes et al., 2014). Also, pain was determined subjectively by patients using a zero to ten pain scale, but at that time the inclusion of “function” was not used to determine the effects of the chronic pain. Physicians were encouraged to prescribe more narcotics. To give you an indication of prescribing practices, “approximately 80 percent of the global opioid supply is consumed in the United States” and “There was [sic] about 300 million pain prescriptions written in 2015” globally (Gusovsky, 2016). More than 259 million opioid prescriptions were written in 2012 (National Safety Council, 2016). This increase was fueled in part by aggressive marketing and payments to physicians. According to an article in The Washington Post last year, “Researchers at Boston Medical Center found that from 2013 to 2015, 68,177 doctors received more than $46 million in payments from drug companies pushing 18
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powerful painkillers” (Zezima, 2017). One contributing factor is limited and/or absent insurance reimbursement for non-drugtreatment for chronic pain. An unintended consequence of these attempts to control the overprescription of opioids has resulted in the movement to heroin, which is less expensive and more available. These control efforts include no refills on controlled substance prescriptions; limiting the number of pills in a prescription; opioid prescriptions having to be written and physically handed to pharmacies (no electronic transmission), with patients showing ID when dropping off and picking up; limiting opioid prescriptions to seven days; the replacement of short-acting for longacting formulations; prescription drug monitoring programs (PDMPs); and physician and pharmacist training. Another factor adding to the movement from prescription opioids to heroin was that drugmakers in recent years have stepped up efforts to make painkillers difficult to abuse, developing tamper-resistant pills that cannot be crushed, liquefied, or injected (Volkow, 2015). Forty or fifty years ago people addicted to heroin were overwhelmingly male, disproportionately black, and very young (e.g., the average age of first use was sixteen). Most came from poor inner-city neighborhoods. These days, more than half are women, and 90 percent are white. The drug has crept into the suburbs and the middle classes, and although users are still mainly young, the age of initiation has risen: most firsttimers are in their mid-twenties (Cicero, Ellis, Surratt, & Kurtz, 2014).
Social Losses Add to the Crisis
New studies strengthen ties between loss, pain, and drug use such as stagnating wages and fraying ties among people. According to an article in Scientific American, “for every 1 percent increase in unemployment in the US, opioid overdose death rates rose by nearly 4 percent” (Szalavitz, 2017a). The counties with the lowest rates of social capital—including people’s trust in one another and participation in civic matters such as voting— had the highest rates of overdose deaths (Keyes et al., 2014; Szalavitz, 2017b). From 1999 to 2014, research “showed counties with the highest social capital were 83
percent less likely to be among those with high levels of overdose” (Szalavitz, 2017a). Additionally, an article in The Guardian states, “Indeed, this is seen as so important that researchers now see it as a subset of social capital they have labeled ‘recovery capital,’ and study what types of organizations and interventions are most conducive to growing it” (Szalavitz, 2017b).
The Role of Pharmaceutical Companies and Distributors
Spending on Oxycontin marketing went from $11,000 in 1996 (the first full year it was on the market) to $2 million in 2002. While there are doctors who overprescribe pain medication, the distributors (i.e., the link between the pharmaceutical companies and the retail pharmacies) know exactly how many pills go to every drug store they supply. And they are required under the Controlled Substances Act to report and stop what the DEA calls “suspicious orders” such as unusually large or frequent shipments of opioids. But DEA investigators say many distributors ignored that requirement. 60 Minutes reported that “a pharmacy in Kermit, West Virginia, a town of just 392 people, ordered nine million hydrocodone pills over two years” (Whitaker, 2017). Additionally, In 2008, the DEA slapped McKesson, the country’s largest drug distributor, with a $13.2 million dollar fine. That same year, Cardinal Health paid a $34 million fine. Both companies were penalized by the DEA for filling hundreds of suspicious orders—millions of pills. Over the last seven years, distributors’ fines have totaled more than $341 million. The companies cried foul and complained to Congress that DEA regulations were vague and the agency was treating them like a foreign drug cartel (Whitaker, 2017).
Legislation Weakening the DEA’s Ability to Stem Opioid Sales
The Washington Post reported the following: In April 2016, at the height of the deadliest drug epidemic in US history, Congress effectively stripped the Drug Enforcement Administration (DEA) of its most potent weapon against large drug companies
COUNSELOR CONCERNS suspected of spilling prescription narcotics onto the nation’s streets. . . . A handful of members of Congress, allied with the nation’s major drug distributors, prevailed upon the DEA and the Justice Department to agree to a more industry-friendly law, the “Ensuring Patient Access and Effective Drug Enforcement Act,” which undermined efforts to staunch the flow of pain pills, according to an investigation by The Washington Post and 60 Minutes. The DEA had opposed the effort for years. . . . The chief advocate of the law that hobbled the DEA was Rep. Tom Marino, a Pennsylvania Republican (Higham & Bernstein, 2017). Rep. Marino was President Trump’s nominee to be drug czar, a nomination later withdrawn when it was revealed that Rep. Marino received donations from the pharmaceutical industry of almost $100,000 (Higham & Bernstein, 2017).
The Overdose Crisis
The most notable aspect of the opioid crisis is the number of overdoses and resulting deaths: 20,101 from prescription opioids and 12,990 from heroin in 2015 (Rudd, Seth, David, & Scholl, 2016). This rate of overdose has increased because of the increasing availability of illicitly produced fentanyl, which is one hundred times more powerful than morphine. Overdose reversal is accomplished by the administration of naloxone, an opioid antagonist. Naloxone prevents opioid receptors from binding with any further opiates present so that a person who ingested too much of the substance will not experience overdose from toxicity. The drug also completely counteracts the effects of an opioid overdose. In most cases the effect is immediate (within thirty to forty seconds), blocking the effects of the overdose and allowing the person to breathe again. Sometimes multiple doses are required and it is possible that even repeated administrations will not reverse a fentanyl overdose. While available in a number of delivery systems, the most common is the nasal spray Narcan. Narcan must be considered as a tourniquet only, and reversal will often result in the person continuing to use and possibly overdosing again. As valuable as is
our ability to frequently reverse overdose, this is only the beginning (e.g., think of detoxification alone with no treatment follow-up). It is also important for first responders to know that, while fentanyl has a short duration of action (thirty to ninety minutes), it can stay in fat deposits for hours, and patients should be monitored for up to twelve hours after resuscitation.
Medication-Assisted Treatment (MAT)/Pharmacotherapy for Addictive Disorders
There are now evidence-based treatments for opioid dependence, which include methadone (an agonist); buprenorphine, usually combined with naloxone as Suboxone (a partial agonist); and extended release, injectable naltrexone, Vivitrol (an antagonist). These medications should be administered in the context of behavioral counseling and psychosocial supports to improve outcomes and reduce relapse. Two comprehensive Cochrane reviews related to agonists—one analyzing data from eleven randomized clinical trials that compared the effectiveness of methadone to placebo, and another analyzing data from thirty-one trials comparing buprenorphine or methadone treatment to placebo—found that agonist treatment is a safe and effective treatment for drug dependence (Mattick et al., 2003). Methadone and buprenorphine are equally effective and Suboxone and Vivitrol are as well, but there is a problem with induction as Vivitrol requires ten to fourteen days of abstinence from an opioid before it can be administered. Unfortunately, medications approved for the treatment of opioid abuse are underutilized and often not delivered in an evidence-based manner. Fewer than half of private-sector treatment programs offer these medications; and of patients in those programs who might benefit, only a third actually receive it (Knudsen, Abraham, & Roman, 2011).
Recommendations
Recent recommendations to physicians are that opioids be used only for short-term surgical pain and malignant pain, not for chronic pain. One concern is opioid-induced hyperalgesia (OIH), which “is defined as a state of nociceptive sensitization caused by exposure to
opioids. The condition is characterized by a paradoxical response whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to certain painful stimuli” (Lee, Silverman, Hansen, Patel, & Manchikanti, 2011). This could result in increasing use to control the pain. According to an article in The New England Journal of Medicine, “prescribing opioids long-term for their analgesic effects will typically require increasingly higher doses in order to maintain the initial level of analgesia—up to ten times the original dose (Volkow & McLellan, 2016). States and now the federal government have declared the opioid epidemic a public health emergency. States like Maryland have “tightened practices for those prescribing opioids and received a waiver to allow Medicaid to pay for residential drug treatment” (Allen, 2017). Additionally, funding has been made available to purchase Narcan, but there is still insufficient treatment capacity with resultant long waiting lists for treatment and MAT. One solution is to provide buprenorphine for those on wait lists in the interim until they can enter treatment. One attempt to address the opioid crisis in some areas is that after overdose medication is given, the individual is brought to the hospital emergency room for stabilization, where a peer recovery specialist immediately contacts the addict and/or the addict’s family and discusses various available treatments including detoxification, MAT, and the range of psychosocial treatment options. If needed, the peer recovery specialist will drive the patient to the selected, available treatment. The goal is to intervene in the likelihood that the individual will immediately return to use. The combination of MAT, psychosocial treatment of sufficient duration, and case management or recovery support services appears to provide the best opportunity for a positive outcome. Once again, there needs to be sufficient treatment resources for this to work effectively. c About the Author Gerald Shulman, MA, MAC, FACATA, is a clinical psychologist and fellow of the American College of Addiction Treatment Administrators. He has been providing treatment or clinically or administratively supervising the delivery of care to alcoholics and drug addicts since 1962.
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COUNSELOR CONCERNS References Allen, G. (2017). From Alaska to Florida, states respond to opioid crisis with emergency declarations. Retrieved from https://www.npr.org/sections/healthshots/2017/08/11/542836709/from-alaska-to-florida-statesrespond-to-opioid-crisis-with-emergency-declaratio Bellis, M. (2017). Who invented the syringe needle? Retrieved from https://www.thoughtco.com/ who-invented-the-hypodermic-needle-4075653 Cicero, T. J., Ellis, M. S., Surratt, H. L., & Kurtz, S. P. (2014). The changing face of heroin use in the United States: A retrospective analysis of the past fifty years. JAMA Psychiatry, 71(7), 821–6. Every-Palmer, S., Duggal, R., & Menkes, D. B. (2014). Direct-to-consumer advertising of prescription medication in New Zealand. New Zealand Medical Journal, 127(1401), 102–10. “From the beginning: The chronology of heroin use.” (2002). Lodi News-Sentinel. Retrieved from http://www. lodinews.com/news/article_7c508ee4-c2f8-54aa-b92fd9f79060800a.html Gusovsky, D. (2016). Americans consume vast majority of the world’s opioids. Retrieved from https://www.cnbc. com/2016/04/27/americans-consume-almost-all-of-theglobal-opioid-supply.html Higham, S., & Bernstein, L. (2017). The drug industry’s triumph over the DEA. The Washington Post. Retrieved from https://www.washingtonpost.com/graphics/2017/ investigations/dea-drug-industry-congress/?utm_ term=.7946e67b4c1a Højsted, J., & Sjøgren, P. (2007). Addiction to opioids in chronic pain patients: A literature review. European Journal of Pain, 11(5), 490–518. Keyes, K. M., Cerdá, M., Brady, J. E., Havens, J. R., & Galea, S. (2014). Understanding the rural-urban differences in nonmedical prescription opioid use and abuse in the United States. American Journal of Public Health, 104(2), e52–9. Knudsen, H. K., Abraham, A. J., & Roman, P. M. (2011). Adoption and implementation of medications in addiction treatment programs. Journal of Addiction Medicine, 5(1), 21–7. Lee, M., Silverman, S. M., Hansen, H., Patel, V. B., & Manchikanti, L. (2011). A comprehensive review of opioid-induced hyperalgesia. Pain Physician, 14(2), 145–61. Lewy, J. (2014). The Army disease: Drug addiction and the Civil War. War in History, 21(1), 102–19. Mattick, R. P., Ali, R., White, J. M., O’Brien, S., Wolk, S., & Danz, C. (2003). Buprenorphine versus methadone maintenance therapy: a randomized double-blind trial with 405 opioid-dependent patients. Addiction, 98(4), 441–52. National Security Council. (2016). Prescription nation 2016: Addressing America’s drug epidemic. Retrieved from http://www.nsc.org/RxDrugOverdoseDocuments/ Prescription-Nation-2016-American-Drug-Epidemic.pdf PBS. (1998). Opium throughout history. Retrieved from https://www.pbs.org/wgbh/pages/frontline/shows/ heroin/etc/history.html Rudd, R. A., Seth, P., David, F., & Scholl, L. (2016). Increases in drug- and opioid-involved overdose deaths—United States, 2010–2015. Morbidity and Mortality Weekly Report, 65(50–1), 1445–52. Szalavitz, M. (2017a). The social life of opioids. Scientific American. Retrieved from https://www.scientificamerican.com/article/the-social-life-of-opioids/ Szalavitz, M. (2017b). Why social capital could be the key to solving America’s overdose epidemic. The Guardian. Retrieved from https://www.theguardian.com/usnews/2017/aug/16/social-capital-us-opioid-epidemicdrugs-overdose Volkow, N. D. (2015). What is the federal government doing to combat the opioid abuse epidemic? Retrieved
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www.cbsnews.com/news/ex-dea-agent-opioid-crisis-fueledby-drug-industry-and-congress/
from https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/what-federalgovernment-doing-to-combat-opioid-abuse-epidemic
Zezima, J. (2017). Study: Doctors received more than $46 million from drug companies marketing opioids. The Washington Post. Retrieved from https://www.washingtonpost.com/news/post-nation/wp/2017/08/09/studydoctors-received-more-than-46-million-from-drug-companies-marketing-opioids/?utm_term=.2be4f2498482
Volkow, N. D., & McLellan, A. T. (2016). Opioid abuse in chronic pain—misconceptions and mitigation strategies. New England Journal of Medicine, 374, 1253–63. Whitaker, B. (2017). Ex-DEA agent: Opioid crisis fueled by drug industry and Congress. Retrieved from https://
Cultural Trends
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academic research papers were published regarding the pharmacological effects of synthetic compounds. Since then, those so-called ‘research drugs’ have proliferated in the United States . . . in part because of a widespread misconception that they were safe and legal” (Martin, 2012). Soon after, authorities became alarmed after an increase in 25I-related overdoses and deaths. On November 15, 2013, the DEA added 25I-NBOMe to Schedule I using their emergency scheduling powers, making it temporarily in Schedule I for two years. The DEA claimed that “the placement of these synthetic drugs into Schedule I of the CSA is necessary to avoid an imminent hazard to public safety” (2013b). The DEA argued “there is no approved medical use for these particular synthetic drugs, nor has the Food and Drug Administration approved them for human consumption. No published studies exist on their safety for human use” (2013b). Makers, sellers, and other possessors of these synthetic drugs were given a month to rid themselves of their current stocks and to cease making or buying more. The announcement further stated, “These drugs are marketed online and through illicit channels as illicit hallucinogens such as LSD. They have been encountered as powders; liquid solutions; soaked onto blotter paper; and laced on edible items” (DEA, 2013b). By placing these “research drugs” in Schedule I, the DEA has effectively taken another cluster of related chemicals off the streets, making them permanently illegal, and sending a strong message to drug manufacturers intent upon circumventing the law. It is a dauntless task that we will continue to see again and again in the ongoing war on drugs. c
About the Author Maxim W. Furek, MA, CADC, ICADC, has a rich background that includes aspects of psychology, addictions, mental health, and music journalism. His book The Death Proclamation of Generation X: A Self-Fulfilling Prophesy of Goth, Grunge, and Heroin explores the dark marriage between grunge music and the beginning of the opioid crisis. Learn more at shepptonmyth.com.
References “25I-NBOMe.” (2015). Retrieved from https://www. erowid.org/chemicals/2ci_nbome/2ci_nbome.shtml Drug Enforcement Administration (DEA). (2013a). 251NBOMe, 25C-NBOMe, and 25B-NBOMe. Street names: N-Bomb, Smiles, 25I, 25C, 25B. Retrieved from https:// www.deadiversion.usdoj.gov/drug_chem_info/ nbome.pdf Drug Enforcement Administration (DEA). (2013b). Three more synthetic drugs become illegal for at least two years. Retrieved from https://www.dea.gov/divisions/hq/2013/hq111513.shtml Martin, N. (2012). Twenty-one-year-old dies after one drop of new synthetic drug at Voodoo Fest. The TimesPicayune. Retrieved from http://www.nola.com/crime/ index.ssf/2012/11/21-year-old_dies_after_one_dro.html McGaughy, L. (2012). 25-I banned after Voodoo Fest death, legislature to move forward on antidrug laws. The Times-Picayune. Retrieved from http://www.nola. com/crime/index.ssf/2012/11/25-i_banned_after_ voodoo_fest.html National Institute on Drug Abuse (NIDA). (2014). Principles of adolescent substance use disorders treatment: A research-based guide. Retrieved from https:// www.drugabuse.gov/publications/principles-adolescent-substance-use-disorder-treatment-researchbased-guide/frequently-asked-questions/whatdrugs-are-most-frequently-used-by-adolescents Prince, S. J. (2015). N-Bomb killer designer drug: Top ten facts you need to know. Retrieved from http:// heavy.com/news/2013/05/n-bomb-killer-designerdrug-top-10-facts-you-need-to-know/ Tayag, Y. (2015). Why college kids are overdosing on the hallucinogen 25I-NBOMe, ‘N-Bombs.’ Retrieved from https://www.inverse.com/article/8865-why-collegekids-are-overdosing-on-the-hallucinogen-25i-nbomen-bombs “What is N-Bomb?” (2016). Retrieved from http:// www.drugfreeworld.org/drugfacts/synthetic/what-isn-bomb.html Wood, W. (2015). Tennessee poison center warns against designer drug “N-bomb.” Retrieved from https://news.vanderbilt.edu/2015/04/09/ tennessee-poison-center-warns-against-designerdrug-%E2%80%9Cn-bomb%E2%80%9D/