Advances in Addiction & Recovery (Summer 2017)

SUMMER 2017 Vol. 5, No. 2

Treating the Emerging Adult Patient: Rehabilitation or Habilitation?

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PLUS: • Fentanyl: The Third Wave of the Opioid Crisis • Email & HIPAA-Compliance • NAADAC Opioid Position Statement

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CONTENTS SUMMER 2017 Vol. 5 No. 2 Advances in Addiction & Recovery, the official publication of NAADAC, is focused on providing useful, innovative, and timely information on trends and best practices in the addiction profession that are beneficial for practitioners.

NAADAC, the Association for Addiction Professionals, represents the professional interests of more than 95,000 addiction coun­selors, educators, and other addictionfocused health care pro­fessionals in the United States, Canada, and abroad. NAADAC’s members are addiction counselors, educators, and other addiction-focused health care professionals, who specialize in addiction prevention, treatment, recovery support, and education.

Mailing Address 44 Canal Center Plaza, Suite 301

Alexandria, VA 22314 Telephone 800.548.0497 Email naadac@naadac.org Fax 703.741.7698 Managing Editor

Jessica Gleason, JD

Communication Manager

Kristin Hamilton, JD

Graphic Designer

Elsie Smith, Design Solutions Plus

Editorial Advisory Committee

Kirk Bowden, PhD, MAC, NCC, LPC Rio Salado College

Kansas Cafferty, LMFT, MCA, CATC, NCAAC True North Recovery Services National Certification Commission for Addiction Professionals (NCC AP)

Thomas Durham, PhD

NAADAC, the Association for Addiction Professionals

■ F EAT UR ES 17 Troubling New Direction in U.S. Drug Policy By William L. White, MA

Deann Jepson, MS Advocates for Human Potential, Inc.

James McKenna, MEd, LADC I AdCare Hospital

18 Fentanyl: The Third Wave of the Opioid Crisis By Jack B. Stein, PhD & Maureen P. Boyle,

Cynthia Moreno Tuohy, NCAC II, CDC III, SAP

NAADAC, the Association for Addiction Professionals

20 Treating the Emerging Adult Patient: Rehabilitation or Habilitation? By Cardwell C. Nuckols,

Article Submission Guidelines We are interested in accepting any interesting and topical articles that address issues of interest to addiction-focused professionals. Please submit story ideas and/or articles to Jessica Gleason at jgleason@naadac.org.

24 Email & HIPAA-Compliance By Marlene M. Maheu, PhD

For more information on submitting articles for inclusion in Advances in A ­ ddiction & Recovery, please visit www.naadac.org/advances-in-addiction-recovery.

26 Process Addictions: Brain Chemistry Correlates to Chemical Dependencies An Interview with

Disclaimer It is expressly understood that articles published in Advances in Addiction & Recovery do not necessarily represent the view of NAADAC. The views expressed and the ­accuracy of the information on which they are based are the responsibility of the author(s) and represent the wide diversity of thought and opinion within the addiction profession.

PhD, National Institute on Drug Abuse (NIDA) PhD

Darryl S. Inaba, PharmD, CATC-V, CADC III

28 Career Interrupted By Sandra Street, MA, LPC, MAC, AADC-S

■ DEPA R T M EN TS 4

President’s Corner: Crisis in the Substance Use Disorder Workforce: Help Needed Now!

By Gerard J. Schmidt, MA, LPC, MAC, NAADAC President

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From The Executive Director: Addiction in America & Hong Kong: Highlights from the First Asia Pacific Conference on Addiction By Cynthia Moreno Tuohy, NCAC II, CDC III, SAP, NAADAC Executive Director

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Advocacy: NAADAC Position Statement on the Opioid Epidemic

9

Ethics: Virtue Ethics & Personal Relationships By Mita Johnson, EdD, LAC, MAC, SAP, NAADAC Ethic Committee Chair

Advertise With Us For more information on advertising, please contact Elsie Smith, Ad Sales Manager at esmith@naadac.org.

Advances in Addiction & Recovery The Official Publication of NAADAC, the Association for Addiction Professionals ISBN: 978-0-9885247-0-5 This publication was prepared by NAADAC, the Association for Addiction Pro­fes­sionals. Reproduction without written permission is prohibited. For more in­formation on ob­taining additional copies of this publication, call 1.800.548.0497 or visit www.naadac.org.

Printed July 2017

10 Certification: NCC AP Update By Jerry Jenkins, MEd, MAC, NCC AP Chair 11 Membership: Preliminary Schedule for NAADAC 2017 Annual Conference: Elevate Your

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■ PR ES ID ENT ’S CORN E R

Crisis in the Substance Use Disorder Workforce: Help Needed Now!

By Gerard J. Schmidt, MA, LPC, MAC, NAADAC President The current state of the addiction profession is under an extreme strain due to the increased demand for substance use disorders (SUDs) treatment.

Unfortunately, there is no easy fix as the issues that come into play when looking at the increased demand for services compared to the availability of care for these individuals are very complex.

According to Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, released in November 2016, although 20.8 million people in the United States met the diagnostic criteria for a substance use disorder in 2015, only 2.2 million people (10.4%) received any type of treatment. Of those treated, only 63.7% received treatment in specialty substance use disorder treatment programs, in part due to a nationwide shortage of professionals trained to work in this specialty field. The addiction, mental health, and professional workforce must grow and strengthen to be able to manage this increased demand for its vital services, especially in those states that have the highest rate of deaths from drug overdoses. It is more imperative now than ever that we recruit and retain our professional addiction and mental health workforce.

Even as early as 2004, SAMHSA stated in its Report to Congress: “Nationally, addictions treatment capacity is insufficient to accommodate all those seeking services and is substantially inadequate to serve the total population in need. Capacity issues vary by geographic area, population and the type of treatment required. Per capita funding for treatment services also differs by State. Some States are able to invest substantial State and local resources into treatment, whereas others rely primarily on Federal funding. Given limited resources, States and localities are faced with difficult decisions, such as limiting the types or number of services individuals can receive and/or limiting the number of individuals who can receive services. Moreover, in recent years, many States have experienced severe revenue shortfalls that have reduced treatment capacity, despite Federal budget increases.”

The opioid addiction problem has become a national focus and public awareness continues to grow as state and federal initiatives take root. At the same time, and perhaps as a result of this new aware­ness, there is an increased demand for intervention and treat­ment services. During this same period, many states adopted enhanced Medicaid provisions, causing an immediate influx of those with health care coverage to explode across the country. Treatment providers could not expand service delivery fast enough to meet these demands. This, coupled with the aforementioned shortage of skilled substance use disorders treatment professionals, has left many in need waiting for care.

There are several factors that come into play when assessing the current state of the addiction work force crisis: • High staff turnover of all levels of clinicians has, and continues to be, a major factor. There are several issues that come into play here; the first and foremost of which is the inequity in pay for qualified and trained addiction treatment specialists. These specialists are 4

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constantly competing for pay equal to other similarly qualified treatment specialists in behavioral health. The issue becomes further complicated within the specialized addiction service areas such as the adolescent, court ordered, and female populations where providers require an enhanced skill set. The negative effect is even more pronounced in less urban and more rural areas of the country.

• The age of the current work force is another factor as many qualified and specialized addiction treatment providers are reaching or exceeding retirement age and “graying out.” This, combined with the increased demand for services as a result of the Affordable Care Act and Medicaid expansion, has compounded the shortage of addiction professionals and the lack of professionals to meet the current demands for treatment services nationwide.

• Stigma surrounding those with SUDs and the resulting discrimination is another factor that has contributed to lower numbers of people entering the profession as specialized treatment providers. This decrease coupled with unequal pay — as much as $5,000 to $7,000 lower than similar behavioral health service providers — has thwarted the needed increase in addiction service providers.

While there are a multitude of factors that come into play regarding the shortage of qualified addiction treatment professionals, one thing is clear: there are not enough trained and qualified addiction treatment professionals to meet the current demand for services.

Because of this, and the projected increased demand in the coming years, we all need to closely look at what our role can be in attracting more providers to our profession. Consider mentoring new clinicians, speaking to graduate classes, monitoring and mentoring a graduate student, and encouraging your local college or university to develop addiction courses within their schools. We all play an integral part in increasing the number of qualified addiction treatment providers. If we do not act now, we run the risk of not only there not being enough providers to meet the demand, but also abdicating our profession to the unskilled and unqualified as a treatment option for those most in need.

Gerard J. Schmidt, MA, LPC, MAC, is President of NAADAC, the Association for Addiction Professionals and the Chief Operations Officer at Valley HealthCare System in Morgantown, WV. He has served in the mental health and addictions treatment profession for the past 45 years. Publications to Schmidt’s credit include several articles on the development of Employee Assistance Programs in rural areas and wellness in the workplace, addictions practice in the residential settings and an overview of addictions practice in the United States. He has edited Treatment Improvement Protocols for CSAT for several years and has been active with the Mid-Atlantic ATTC. Schmidt had served as Chair of the National Certification Commission for Addiction Professionals (NCC AP) and NAADAC’s Public Policy Committee, and as NAADAC’s Clinical Affairs Consultant.

Awards include the Distinguished Service Award in 2003 and the Senator Harold Hughes Advocate of the Year in 2010. In addition to his national and international work, Schmidt has been active within West Virginia in advocating for and supporting State legislative issues related to addictions and addiction treatment.

■ F R O M T H E E X E C U T I VE DI RE C TOR

Addiction in America & Hong Kong: Highlights from the First Asia Pacific Conference on Addiction

By Cynthia Moreno Tuohy, NCAC II, CDC III, SAP, NAADAC Executive Director Last night I flew in from Hong Kong after having spent the better part of a week with NAADAC’s Asia Pacific Association for Addiction Professionals (APAAP) and the Asia Pacific Certification Commission for Addiction Professionals (APCCAP) at the First Asia Pacific Conference of Addiction Professionals, organized by the Tung Wah Group of Hospitals, Integrated Centre on Addiction Prevention and Treatment, and The Hong Kong Polytechnic University. The APAAP is an international NAADAC affiliate that represents addiction professionals in Mainland China, Hong Kong SAR, and Macau SAR, and provides trainings as a NAADAC Approved Education Provider in the Asia Pacific region. The APCCAP serves as a certifying body for the National Certification Commission for Addiction Professionals (NCC AP) and offers NCAC I, NCAC II, and MAC Certification exams to those that qualify.

Conference Highlights During the presentation “The Syndrome Model of Addiction,” Dr. Howard Shaffer and Dr. Heather Gray from Harvard Medical School discussed the importance of realizing that most people do not become addicted, most people do not need treatment to change, most treatments work about the same as each other, and some treatments do not work well for everyone. They also discussed the conceptual errors on which many treatments focus, including the concept that addiction resides as a latent property, such as in a drug, and focusing on addiction rather than recovery. I encourage you to read “Toward a Syndrome Model of Addiction: Multiple Expressions, Common Etiology” from Harvard Rev Psychiatry, Volume 12, Number 6, pages 367–374 to learn more.

Dr. Delaney Ruston from Stoney Brook University School of Medicine showed her video on “Screenagers: Growing Up in the Digital Age” and discussed the implications of this expression of addiction being added to the addictions we are seeing across the globe. Dr. Thomas Chung from the Faculty of Medicine of the Chinese University of Hong Kong presented on “Supporting Kids and Teens in the Digital Age” and provided the following SAFE ACTS tips: (S) Show the right attitude by practicing what you preach; (A) Aware of the benefits and risks to digital use; (F) Facilitate a balanced life style including outside activities; (E) Empower children to face the challenge. (A) Agree on rules on time and types of digital use together; (C) Communicate openly and honestly; (T) Trust and respect your child; (S) Seek help when needed. We can see these tips are transferrable to other addictions and can be used in creating healthy family systems.

Dr. Martin Kafka from Harvard Medical School spoke on “The Internet and Sexual Addiction: A Guide for Clinicians and Psychopharmacologists,” focusing on the shared psychosocial antecedents of these disorders,

including psychiatric depression, trauma, impulsivity, delinquency, lack of social skills, and poverty. Dr. Kafka echoed the other presenters, who consistently placed the emphasis on the recovery of the person using multidimensional treatments.

Representatives from the Tung Wah Group of Hospitals discussed the history of their organization and their ongoing clinical research projects.

The Tung Wah Group of Hospitals is a system that is over 150 years old and has over 125 clinics and hospitals across Hong Kong. The ongoing research areas include family based interventions for SUD in community based settings, single session therapies with multiple clinicians facilitating, art therapy for families with addictive parents, effectiveness of short-term residential treatment for clients with diverse addictive behaviors, and working with pregnant women with drug use disorders in residential settings.

It was an honor to be the closing plenary speaker and speak about my book, Rein in Your Brain: from Impulsivity to Thoughtful Living in Recovery. I discussed the ten tips to building regulation in the brain and working through the disagreements, trauma and misunderstandings of that happen in our lives in recovery: (1) Stand Still in the Moment; (2) Do Not Assume Intent; (3) Be an Archeologist – Dig Deeper into the Conflict/Hurt; (4) Cultivate Confusion; (5) Understand the Paradox of Control; (6) Dismantle the Wall of Misunderstanding; (7) Create a Blameless Relationship with Yourself; (8) Avoid Premature Forgiveness; (9) Put Down Your Dukes; and (10) Take Responsibility for Self-Fulfilling Prophecies.

Over the course of my week in Hong Kong, I was impressed by and appreciative of the hard work being done by APAAP, APCCAP, the many additional professionals I met at the conference, and the clinicians and researchers in the Tung Wah Group of Hospitals. Witnessing the interactions and sharing of ideas between the Americans and our colleagues in Asia, I was reminded that we are facing the same battles but also making the same strides in research and working with the same diligence and passion to develop effective treatments for those living with substance use disorders.

Together, we are making a difference! Cynthia Cynthia Moreno Tuohy, NCAC II, CDC III, SAP, is the Executive Director of NAADAC, the Association for Addiction Professionals, and has worked as an addiction professional for over 35 years. She has been a trainer in Domestic Violence/Anger Management and Conflict Resolution for over 25 years as well as an international, national and state trainer in a variety of topics.

Moreno Tuohy is also a curriculum writer in addiction screening and evaluation, counseling methods, conflict resolution, co-occurring disorders and medicated assisted treatment and recovery, and has written articles published in national and other trade magazines. She holds a Bachelor’s Degree in Social Work and is certified both nationally and in Washington State.

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■ A D V O C AC Y

NAADAC Position Statement on the Opioid Epidemic

T

he American public contin ues to hear much about the rise of the opioid epidemic and its devastating impact on individuals, families, and communities around the country.

Now more than ever, it is important that we f­ ocus our ­efforts on curtailing this crisis. NAADAC, the Association for Addiction Professionals, will continue to champion treatment and recovery services that are inclusive, holistic, and unique to the individual needs of each affected person. In recognizing that treatment is not one dimensional, nor is there a‘one size fits all’ method, NAADAC encourages the use of comprehensive treatment plans that encompass bio-psycho-social-spiritual needs as one begins his or her road to sustained recovery.

The enormous costs and staggering consequences of America’s substance misuse problem led the U.S. Surgeon General to release a historical report in 2016: Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health. Published by the Department of Health and Human Services, this report sheds further light on the public health impacts of drug and alcohol misuse — the first of its kind to ever do so. We at NAADAC are committed to keeping in perspective the impact of alcohol and other drugs, including marijuana, that are even more devastating in the number of people affected and the number of deaths. However, this Position Paper is specifically focused on the opioid crisis, and highlights NAADAC’s continued support of the prevention, intervention, treatment, and recovery for people who are affected by opioid use, misuse, and addiction, as well as our call to elected officials and policy makers to insure affected individuals have services available that support their desire to obtain and sustain recovery.

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The Enormity of the Problem and the Legislative Response

NAADAC, the Association for Addiction Professionals, will continue to champion treatment and recovery services that are inclusive, holistic and unique to the individual needs of each affected person.

In 2015, an estimated 2 million people in the United States met diag­nostic criteria for substance use disorder related to prescription opioid pain medications, and another estimated 600,000 met diagnostic criteria for opioid use disorder, specifically heroin.1 Whereas heroin addiction was once viewed as the “seedier” end of the addiction spectrum, we now see individuals from all walks of life turning to this less expensive, and often easier to obtain, street drug as prescription opiates become more difficult to access and/or more expensive. Opioid (both prescription and illicit) overdose deaths increased nearly four-fold from 1999 to 20142, and in 2014, 28,647 people died from a drug overdose involving some type of opioid, including prescription pain relievers and heroin3, bringing much government and media attention to what is now termed the “Opioid Epidemic.”

The Comprehensive Addiction and Recovery Act (CARA) of 2016 was signed into law by President Obama.

Many of its provisions address this epidemic, including provisions that: • Improve education for healthcare providers in managing pain and safe prescribing practices; • Create widespread availability of the overdose reversing drug, Naloxone, and training for first responders; • Expand availability of medication assisted treatment to include counseling and urine drug screening; • Increase the availability of prescription drug monitoring programs; • Expand prevention programs, including those aimed at misuse of heroin and other opioids; and • Improve the availability of long term recovery support services.

The Cures Act, which was also passed in 2016, provided funding of $1 billion over two years for many of CARA’s provisions, with special requirements to focus on medication-assisted treatment (MAT) for those with opioid use disorder.

The Importance of Treating the Whole Person MAT is considered evidence-based and a best practice for treatment of opioid addiction, but opioid agonist medications, like buprenorphine and methadone, are not meant to act as stand-alone treatment. As addiction counselors, we know substance misuse and addiction to alcohol and other drugs have oftentimes devastating impacts on multiple life areas for the individual and those around them, including harm to one’s physical, emotional, psychological, and spiritual health, as well as his or her family network, social wellbeing, and work/school life. Opioid agonist medications will hold off withdrawal symptoms and may help to heal some of the impact other drugs have had on brain function, yet a broader approach to treatment is needed. Hal Cohen, the Agency of Human Services Secretary in Vermont, said, “Each patient presents with different and usually complex needs. Physicians who treat patients with opioid addiction in the officebased setting must consider and plan for the full range of their patients’ needs before initiating treatment. Candidates for buprenorphine treatment of opioid addiction should be assessed for a broad array of biopsychosocial needs in addition to opioid use and addiction, and should be treated and/ or referred for help in meeting those needs.”4 NAADAC recognizes the need for treatment approaches that address the biological, psychological, social, and spiritual needs of the individual.

Many national experts support this view.

In its National Practice Guidelines, the American Society of Addiction Medicine (ASAM) states, “Psychosocial treatment is recommended in conjunction with any pharmacological treatment of opioid use disorder. At a minimum, psychosocial treatment should include the following: psychosocial needs assessment, supportive counseling, links to existing family supports, and referrals to community services.”5 SAMHSA’s publication, TIP 40 Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction, dictates, “Pharmacotherapy alone is rarely sufficient treatment for substance use disorders. Treatment outcome literature demonstrates that adding psychosocial treatment to buprenorphine treatment is correlated with better patient outcomes.”6 Federal opioid treatment standards set forth under 42 C.F.R. §8.12 “require that opiate treatment programs (OTP) provide medical, counseling, drug abuse testing, and other services to patients admitted to treatment.”

“In October 2015 President Obama issued a memorandum to all federal departments and agencies that provide, contract for, reimburse or are involved with health benefits. In it he stated, ‘MAT is the use of Food and Drug Administration (FDA)-approved medications, such as buprenorphine, buprenorphine-naloxone combination products, methadone, and naltrexone — in combination with counseling, other behavioral therapies, and patient monitoring — to provide treatment for opioid use disorders.’”7 In 2016, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health credited evidence-based behavioral interventions as influential in “increasing patients’ motivation to change, increase their self-efficacy…, or help them identify and change disrupted behavior patterns and abnormal thinking.”8 The requirement for counseling was even directly stated in the approved product indication: “SUBOXONE sublingual film is indicated for treatment of opioid dependence and should be used as part of a complete treatment plan to include counseling and psychosocial support.”9 This language demonstrates that prescribing buprenorphine products without a comprehensive treatment plan is ‘off label’ use.

Several studies have shown retention rates for medication assisted treatment using buprenorphine to range between 44% and 48.4% for a three to six month time period.10, 11, 12 Retention rates for treatment using methadone were higher, ranging between 55.3% and 74%.13, 14 In both populations, positive urine drug screens for opiate and/or other drugs were over 50%.15 The most frequently given reasons for dropping out of MAT were not unlike reasons why individuals with substance use disorders drop out of other treatment modalities: “craving for drugs; concomitant use of illicit drugs; family/partner influence; lack of motivation; concomitant use of legal drugs; doubt ability to lead a drug-free life; and confident can get along without therapy.”16 In all published guidelines for MAT, the inclusion of a robust program to provide counseling and other behavioral therapies, along with patient monitoring through urine drug screening, is recommended or even required. Despite these recommendations, many patients report they receive only minimal services, if any at all, which may offer some explanation for the reasons given for discontinuing treatment, even though treatment of physical withdrawal and the associated craving are the target of MAT. S U M M E R 2 017 | A d va n ce s i n A d d i c t i o n & R e c o v e r y 7

Important Role of Addiction Specialty Counselors and Aspects of Care NAADAC believes counselors specifically trained and experienced in addressing addiction play a key role in the overall treatment of opioid dependent individuals, as well as those suffering from other types of substance use disorders. Understanding the multi-dimensional components of addiction, as well as the primary nature of the disease process, is paramount in effective treatment. And while we agree with President Obama when he said, “It doesn’t do much good to talk about recovery after folks are dead,”17 NAADAC also believes recovery is about more than overdose prevention.

Addiction counseling helps patients avoid relapse while overcoming the major challenges they face on their road to recovery. ASAM, in summarizing many models of relapse prevention, identified these components to minimize the risk of relapse, or attenuate the severity of a relapse episode: • Identify environmental cues and stressors that act as relapse triggers; • Learn to identify and manage negative emotional states; • Work toward a more balanced lifestyle; • Develop skills to cope with stressful life events; • Understand and manage cravings; • Learn to identify and interrupt lapses and relapses; • Develop a recovery support network, such as joining a self-help group; and • Utilize clinical resources available to patients, such as counseling.18 Licensed and/or certified addiction counselors are uniquely qualified to assist individuals to develop these skills and resources, and should be part of a multi-dimensional treatment approach for those receiving MAT. Addiction counselors also have a responsibility to be trained and competent to work with those individuals seeking recovery with the assistance of medication.

Naloxone for Overdose Prevention The use of naloxone has proven to be a lifesaving medication to prevent death from opioid overdose. Addiction is a chronic disease with the potential for relapse. Those with a history of opioid use disorder who relapse to opioid use have a higher risk of death from overdose. As addiction counselors we have a responsibility to educate our clients about the use of naloxone for overdose prevention and relapse planning. We also recognize the critical importance of naloxone being available to all first responders across the country.

Call for Public Policy to Address Opioid Epidemic As addiction professionals, we bring firsthand knowledge of the nature of addiction and the devastating impact on individuals, families, and communities. We also know the possibilities of recovery and the hope and healing that occurs. We are in a unique position to advocate for public policy and state and federal legislation that will support addiction prevention, treatment, and recovery. Each of us has that responsibility. In the case of the opioid epidemic, NAADAC will call for: • Authorization of expanded funding for CARA; • Maintaining the increased access to quality care the Affordable Care Act, along with the Mental Health and Addiction Treatment Equity Act, have brought to those struggling with substance use disorders; • Strong requirements for, and expanded funding of, comprehensive treatment planning and counseling services by competent licensed/ certified addiction professionals, along with monitoring through urine drug screens, to accompany medication assisted treatment; • Expansion of MAT to reduce waiting lists and provide access, especially in rural areas; 8

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• Funding to educate addiction counselors in MAT and its integration into psychosocial treatment approaches; • Funding to have naloxone in the hands of all first responders; • Inclusion of naloxone, naltrexone and Suboxone in the formularies of approved medications for insurance coverage; and • Good Samaritan legislation that provides a defense to prosecution for an individual who calls for help for him/herself and/or someone else at risk of overdose.

The opioid epidemic has had a devastating effect on our country. Many lives have been lost, but addressing the opioid epidemic is to go beyond preventing overdose. Recovery in all areas of life is possible and what we believe all individuals with opioid use disorder can achieve.

(Endnotes) 1 U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health (p.

1-9). Washington, DC: HHS, November 2016.

2 U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health (p.

1-14). Washington, DC: HHS, November 2016.

3 U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health (p.

1-1). Washington, DC: HHS, November 2016.

4 Knopf, Alison (2015, December). Vivitrol pilot in Vermont focuses on recently released inmates. Alcoholism & Drug Abuse Weekly, 27(46).

5 American Society of Addiction Medicine. (2015). National Practice Guidelines (p. 103).

6 U.S. Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration, KAP Keys For Physicians Based on TIP 40 Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Washington, DC: HHS, 2005.

7 Knopf, Alison (2015, November). President calls for more MAT to fight opioid epidemic.

Alcoholism & Drug Abuse Weekly, 27(42).

8 U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health (p.

ES-14). Washington, DC: HHS, November 2016.

9 Indivior. (2016). SUBOXONE Film, retrieved from: https://www.suboxone.com/treatment/ suboxone-film.

10 Soyka, M., Zingg, C., Koller, G., & Kuefner, H. (2008). Retention rate and substance use in methadone and buprenorphine maintenance therapy and predictors of outcome: results from a randomized study. International Journal of Neuropsychopharmacology Study, 11(5), 641-653.

11 Burns, L., Gisev, N., Larney, S., Dobbins, T., Gibson, A., Kimber, J., Larance, B., Mattick, R., Butler, T., & Degenhardt, L., (2015). A longitudinal comparison of retention in buprenorphine and methadone treatment for opioid dependence in New South Wales, Australia.

Addiction, 110(4), 646-655.

12 Hser, Y.I., Saxon, A.J., Huang, D., Hasson, A., Thomas, C., Hillhouse, M., Jacobs, P., Teruya, C., McLaughlin, P., Wiest, K., Cohen, A., Ling, W. (2014). Treatment retention among patients randomized to buprenorphine/naloxone compared to methadone in a multi-site trial.

Addiction, 109(1), 79-87.

13 Soyka, M., Zingg, C., Koller, G., & Kuefner, H. (2008). Retention rate and substance use in methadone and buprenorphine maintenance therapy and predictors of outcome: results from a randomized study. International Journal of Neuropsychopharmacology Study, 11(5), 641-653.

14 Hser, Y.I., Saxon, A.J., Huang, D., Hasson, A., Thomas, C., Hillhouse, M., Jacobs, P., Teruya, C., McLaughlin, P., Wiest, K., Cohen, A., Ling, W. (2014). Treatment retention among patients randomized to buprenorphine/naloxone compared to methadone in a multi-site trial.

Addiction, 109(1), 79-87.

15 Soyka, M., Zingg, C., Koller, G., & Kuefner, H. (2008). Retention rate and substance use in methadone and buprenorphine maintenance therapy and predictors of outcome: results from a randomized study. International Journal of Neuropsychopharmacology Study, 11(5), 641-653.

16 Soyka, M., Zingg, C., Koller, G., & Kuefner, H. (2008). Retention rate and substance use in methadone and buprenorphine maintenance therapy and predictors of outcome: results from a randomized study. International Journal of Neuropsychopharmacology Study, 11(5), 641-653.

17 Miller, J., (2016). Obama underlines a collective approach to addiction. Behavioral Healthcare, retrieved from https://www.behavioral.net/article/obama-underlinescollective-approach-addiction.

18 Kraus, M., Alford, D., Kotz, M., Levounis, P., Mandell, T., Meyer, M., Salsitz, E., Wetterau, N., & Wyatt, S. (2011). Statement of the American Society of Addiction Medicine Consensus Panel on the Use of Buprenorphine in Office-Based Treatment of Opioid Addiction.

Journal of Addiction Medicine, 5(4), 254-263.

■ E T H ICS

Virtue Ethics & Personal Relationships

By Mita Johnson, EdD, LAC, MAC, SAP, NAADAC Ethics Committee Chair As we are all keenly aware, ethics codes cannot possibly address all the situations that a clinician or service provider (hereinafter referred to as professional) will be exposed to and need to address during his or her tenure as a practitioner. While mandatory ethics give us the rules that are foundational to safe practice, aspirational ethics go above and beyond those rules to seek excellence in conduct that is more than what is minimally required. Virtue ethics define, inform and guide the actor rather than their actions. Virtue ethics require us to address these two questions: “who am I” and “how shall I be” in this situation? As professionals, it is easier to discern our mandatory ethics because they are concrete — and to ignore our virtue ethics. I would like to challenge us to think more holistically about our ethical thinking process and resulting conduct.

Romantic/personal relationships are a great example of where NAADAC’s Code of Ethics addresses and prohibits certain activities, knowing that there are grey areas surrounding these relationships. The principles and codes are designed to protect the client from exploitation and harm, and to protect the professional from conflicts of interest. The following case, which happens more frequently than we might realize, is an example of a grey area that in many ways is not so grey. Consider this case: is it okay for a professional (i.e., Sue) to engage in a romantic/personal relationship with a client (i.e., Bob) who is currently receiving services at her agency/place of employment, but is not a direct client? Bob is working with another professional in the agency but wants to enter into a personal non-professional relationship with Sue. The NAADAC/NCC AP Code of Ethics prohibits romantic/personal relationships with former or current clients — following under the maxim “once a client, always a client.” It is never going to be acceptable for Sue to have a romantic/personal relationship with Bob if Bob was her client, regardless of how long it has been since the relationship was terminated. A personal/romantic relationship is addressed in the NAADAC/NCC AP Code of Ethics. However, NAADAC does not directly address the issue of dating someone who is a client of the agency and works with another therapist. That’s not a problem, right?

Dating a client of the agency is problematic on several levels. As a clinician (Sue) dating someone who is a client of the agency (Bob), Sue is still in a position of access, power, and authority. Bob’s case is likely to be discussed in group supervision or other staffing sessions. Bob’s clinical behavioral health records, psychological assessment and drug testing results, referral information, legal information, health records, etc. may be accessible to Sue — violating Bob’s rights to confidentiality and privileged communication as a client. In addition, there is the potential for a conflict of interest or potential gain on Sue’s part. Before this relationship is pursued, there are questions that need to be answered and discussions regarding policy and procedure that need to be had around risk and liability management.

The agency is charged legally and ethically with securing and protecting Bob’s rights and agency obligations per legal mandates, licensing rules, and Code of Ethics.

Agencies and group/private practices are not dating or social networking sites. If we add a personal layer, what is motivating Sue to consider pursuing a relationship with Bob? Is she willing to reveal to everyone that she is dating a client from the agency? Is there a transference/countertransference

reaction that she is falling prey to? Is she trying to rescue Bob? Is she enabling Bob? Does Bob have something she wants? What does her social network currently look like? What is Sue’s dating history and who is she typically attracted to? Why would it be okay to Sue to comingle professional and personal relationships? Is there any pressure from Bob to date and how did that develop? What about Bob is attractive enough that she is willing to put her career, livelihood and credentials on the line? NAADAC’s Code of Ethics implicitly recommends that counselors and other service providers not engage in personal relationships with clients of the agency, even if they are not the professional’s direct client — due to the nature of the risk. It is incumbent upon the professional to engage in risk management thinking and behaviors that first and foremost protect the client from all actual and potential harm, while also protecting the professional.

Mita M. Johnson, EdD, LAC, MAC, SAP, has a doctorate in Counselor Education and Supervision, a Master’s Degree in Counseling, and a Bachelor’s Degree in Biology. She is a licensed professional counselor, licensed marriage and family therapist, and licensed addiction counselor, along with earning the national Master Addiction Counselor (MAC) and Department of Transportation Substance Abuse Pro­fes­sional (SAP) certifications. Johnson has two supervisory credentials (ACS and AAMFT) and is a NCC. She is a core faculty member at Walden University, and she maintains a private practice where she works with supervisees who are working on credentialing. Johnson is the Past-President of the Colorado Association of Addiction Professionals (CAAP), and is currently NAADAC Treasurer and Ethics Chair. She previously served as NAADAC’s Southwest Regional Vice-President. In Colorado, Johnson is involved in regulatory and credentialing activities as well as workforce recruitment and retention initiatives. She speaks and trains regionally and nationally on a variety of topics. Her passions beyond workforce retention include pharmacology of drugs of addiction, infectious diseases, ethics, motivational interviewing, and clinical supervision.

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■ CER T IF IC AT I O N

NCC AP Update

By Jerry Jenkins, MEd, MAC, NCC AP Chair

The National Certification Commission for Addiction Professionals (NCC AP) continues to work hard to promote national certification and standards of knowledge and professionalism in the addiction profession.

The delivery of healthcare is rapidly changing as the science and technology supporting it advances. Behavioral healthcare is no exception.

Substance use disorder treatment is and will become more integral with value based reimbursement strategies expanding. Examples frequently mentioned in literature include the use of SBIRT (Screening, Brief In­ter­ vention and Referral to Treatment), integrated health care where primary care and behavioral health care are aligned, and Medicaid Health Homes.

All of the preceding need professionals proficient in addressing substance use disorders. This includes professionals to provide assessment as well as treatment or recovery support services regardless the population: adolescents, adults, persons with co-occurring mental illness and substance use disorder, tobacco dependent, persons with English as a second language, etc.

The NCC AP has purposefully sought to develop credentials identifying specialized skills to payers and other treating professionals. The credentials cover the range of employment settings. Now included is the opportunity

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for recognition of persons with lived experience — peers — peers who have taken the additional step of meeting a national standard.

NCC AP will continue to work with NAADAC to promote our respective credentials to payors as recommended and or/preferred credentials for addiction professionals.

Supporting this effort are a hardworking group of professionals who spent May 4–7, 2017 doing the work of the Commission. You can meet us by visiting the new and improved NAADAC website at www.naadac.org/ about-the-ncc-ap. The Commission insures the currency of standards and processes, as well as performs due diligence around the development of new credentials.

Our meeting had invaluable support from Certification Manager Donna Croy, NAADAC Executive Director Cynthia Moreno Tuohy, NCC AP Consultant Kathy Benson, as well as NAADAC Director of Communications Jessica Gleason. The work session reflected the breadth of substance use disorder treatment challenges worldwide: workforce; training and development; specialization; determining competencies for the rapidly expanding work environments in which there is a demand for qualified substance use disorder treatment professionals; as well as staying current on new advances whether that be treatment strategies or technological tools like medications or smartphone applications.

Going forward, the NCC AP wants to hear from readers about how we can improve our processes or ideas for developing new credentials. We are accessible by email and hope to meet many of you at NAADAC’s Annual Conference in Denver where the Commission will be presenting a breakout session on the importance of national credentials.

On the horizon is more collaboration and development of credentialing with the Association for the Treatment of Tobacco Use and De­pen­ dence (ATTUD) and Council for Tobacco Treatment Training Program (CTTTP), as well as the National Center for Responsible Gaming (NCRG).

These collaborations are around identifying professionals trained, experienced and who have met a national standard for treating tobacco use and dependence or gambling related disorders respectively. Again, we are working to develop ways of identifying professionals with special skills.

In closing, please let us know how we can do better at what we are doing. We know you do critical work in the healthcare arena. We want you to be quickly recognizable through your credentials as the “go to” professional to deal with substance use disorders. In the meantime, we will keep you informed of our credentialing initiatives through this column as well as the NAADAC website.

Jerry A. Jenkins, MEd, MAC, has been the Chief Executive Officer of Anchorage Community Mental Health Services since 2003 adding Fairbanks Community Mental Health Services in 2013. He is in his third year as the President of the Alaska Behavioral Health Association. Anchorage/Fairbanks Community Mental Health Services provides behavioral health services across the span of life from ages 2 to 100. As an addiction treatment professional, Jenkins has over 34 years of experience in treating substance use disorders and mental illness. He has worked in and managed community based, outpatient, halfway and residential treatment services. He is an advocate for safe, affordable and accommodating housing for consumers as well as recovery as the expectation for behavioral health care with particular emphasis on being trauma informed.

Join NAADAC for its 2017 Annual Conference: Elevate Your Practice at the Denver Marriott Tech Center in Denver, Colorado from September 22–26, 2017.

Learn about the latest trends and issues that impact all addiction-focused professionals, connect and network, take your national certification test, and build your business against the backdrop of beautiful Denver and the Rocky Mountains.

Register Now! Early Bird Rate Ends August 15th!

Earn up to 34 .75

CE s!

The three-day Annual Conference will take place on September 23–25 and feature daily keynote speakers in plenary sessions, breakout workshops, and unique addiction-specific education experience within these nine tracks: ■ ■ ■ ■ ■

Practice Management & Technology Co-Occurring Disorders Pharmacotherapy Process Addictions Recovery Support

■ ■ ■ ■

Clinical Skills Cultural Humility Education/INCASE Professional Development

The main conference will also include an Awards Luncheon to honor outstanding addiction-focused professionals from around the nation, a special exhibition to celebrate NAADAC’s 45th Anniversary, onsite testing for NCC AP credentials, and special evening events, including an opening reception, movie night, and an auction with entertainment to support the NAADAC Education & Research Foundation (NERF).

In addition, attendees may register to attend one of four full-day pre-conference sessions on September 22, one of two full-day post-conference sessions on September 26, and/or a two-day U.S. Department of Transportation Substance Abuse Professional (SAP) Qualification/Re-Qualification training on September 24–25.

www.naadac.org/annualconference REV.1 062017

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10 Reasons to Attend NAADAC’s 2017 Annual Conference: Elevate Your Practice is a few short months away. Here’s why YOU should attend:

Preliminary Schedule* FRIDAY (SEPTEMBER 22) Up to 7 CEs Available on Friday

1 Onsite NCC AP Testing. Take the test for the NCAC I, NCAC II, or MAC national credential onsite.

7:30 am – 7:00 pm Registration

2 Earn up to 34.75 CEs. Five days of education, training, networking, and capacity building. Get the full schedule online.

7:30 am – 8:30 am Continental Breakfast

3 Two-day SAP Course. Get your U.S. Department of Transportation Substance Abuse Professional (SAP) Qualification/Re-Qualification.

8:30 am – 5:00 pm PRE-CONFERENCE SESSIONS Basics of Addition Counseling: Pharmacology of Psychoactive Substances Use Disorders Thea Wessel, MA, LPC, LAC, MAC, NCAAC

4 Nine Tracks & Over 50 Breakout Sessions. This year’s conference features over 50 breakout sessions in nine different subject tracks.

Basics of Addiction Counseling: Theories, Practices, and Skills Thomas Durham, PhD

5 Network, Connect and Reconnect. Make professional relationships and long-lasting friendships.

Basics of Addition Counseling: Ethical & Professional Issues Deborah Fenton-Nichols, EdD, LPC, LAC

6 Learn from Industry Leaders. Experts and leading academics, practitioners, and clinicians are on the stage and in the audience.

7 Get Inspired. Our speakers and attendees are not only brilliant professionals, but are inspirational in their passion to make long-term positive impacts.

8 Celebrate Your Peers. Join NAADAC in honoring outstanding addiction professionals and organizations from across the U.S. 9 Professional Development. Develop your skills and make yourself more valuable to your employer and clients.

10 Have Fun! Attend receptions, watch an inspiring movie, meet new friends, and re-energize in beautiful Denver.

Thriving with the 21st Century Telehealth & Technology: Seven Legal and Ethical Strategies Marlene Maheu, PhD 10:00 am – 10:15 am Morning Break 12:00 pm – 1:00 pm Lunch (for Pre-Conference attendees only) 2:00 pm – 4:00 pm NAADAC Minority Fellowship Program for Addiction Counselors (NMFP-AC) Orientation 3:30 pm – 3:45 pm Afternoon Break 5:00 pm – 8:00 pm Welcome Reception in Exhibit Hall 9:00 pm – 10:00 pm Mutual Support Meeting

Endorsing and Collaborating Partners

Part of what makes the 2017 Annual Conference unique is the depth and breadth of NAADAC’s partnerships. NAADAC is proud to have 10 national and local partners joining us, including: ■ American Society of Addiction Medicine (ASAM) ■ Colorado Association of Addiction Professionals (CAAP) ■ International Coalition for Addiction Studies Education (INCASE) ■ National Addiction Studies Accreditation Commission (NASAC) ■ National Addiction Technology Transfer Network (NATTC) ■ National Association for Children of Alcoholics (NACoA) ■ National Association of Addiction Treatment Providers (NAATP) ■ National Center for Responsible Gambling (NCRG) *Schedule subject to change without notice.

■ National Council for Behavioral Health For most up-to-date schedule, please visit ■the NIATx Learning Collaborative www.naadac.org/annualconference.

IMAGES: SHUTTERSTOCK & NAADAC FILES

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Do you need to take the NCC AP test for the NCAC I, NCAC II, or MAC national credential? NC C AP is offering onsite testing at NA AD AC’s Annual Conference on Sunday, September 24 for those who qualif y and pre -register

by September 1, 2017.

For more information, ple ase visit ww w.naadac.org/ac17-t esting.

*Schedule subject to change without notice. For most up-to-date schedule, please visit www.naadac.org/ac17-schedule.

Preliminary Schedule* SATURDAY (SEPTEMBER 23)

TRACK: CULTURAL HUMILITY

TRACK: CULTURAL HUMILITY

7:00 am – 4:30 pm Registration

Male-Specific Addiction Counseling Practices Mark Woodford, PhD, LPC, MAC TRACK: EDUCATION/INCASE

Cultural Humility: Reflection on Self and Practice Kathy FitzJefferies, LCSW, LCAS, CCS

Up to 7 CEs Available on Saturday

7:00 am – 8:00 am Continental Breakfast in Exhibit Hall 7:00 am – 4:15 pm Poster Presentations 7:00 am – 4:15 pm Exhibit Hall Open 8:00 am – 9:45 am MORNING KEYNOTE Welcome Charles Smith, PhD; Cynthia Moreno Tuohy, NCAC II, CDC III, SAP; Mita Johnson, EdD, LPC, LMFT, LAC, MAC, SAP My Story Mackenzie Phillips & Johnny McAndrew State of NAADAC Cynthia Moreno Tuohy, NCAC II, CDC III, SAP & Gerard Schmidt, MA, LPC, MAC 9:45 am – 10:00 am Morning Break in Exhibit Hall 10:00 am – 11:30 am BREAKOUT SESSIONS TRACK: PHARMACOTHERAPY

Nicotine Dependence in Psychiatric Disorders: All Smoke?

Veena Kumari, MA, PhD, C Psychol, AFBPsS & Tonmoy Sharma, MBBS, MSc TRACK: CLINICAL SKILLS

Nicotine Dependence as a Primary Health Concern: Implications for Addiction Professionals Diane Ogilvie, MAEd & Finnley M’Kenna, BA TRACK: RECOVERY SUPPORT

Working with Couples in Early Recovery: A Research-Based Approach Robert Navarra, PsyD, MFT, MAC TRACK: CO-OCCURRING DISORDERS

Eating Disorders & Food Addiction: Where Do They Fit? Marty Lerner, PhD TRACK: PRACTICE MANAGEMENT

How to Integrate Clinicians in Primary & Specialty Medical Care Raymond Tamasi, MEd, LCSW, LADC-1 TRACK: PROCESS ADDICTIONS

Six Types of Sex Addiction Treatment & Assessment Douglas Weiss, PhD

Operation Naloxone: Bringing Opioid Awareness and Overdose Prevention to College Campuses Lori Holleran Steiker, PhD, ACSW, CRSS, Lucas Hill, PharmD & Mark Kinzly

TRACK: EDUCATION/INCASE

TRACK: EDUCATION/INCASE

Affiliate Leadership Training HeidiAnne Werner

Instructing the Recovering Student in Addiction Studies Programs Kathy Elson, LPCC-S, LICDC-CS, MAC, SAP TRACK: PROFESSIONAL DEVELOPMENT

NASAC - Accreditation of Addiction Study Programs: Tap 21 and the Standardization of Educational Curricula Diane Sevening, EdD, LAC & John Korkow, PhD, LAC, SAP 11:30 am – 12:30 pm NAADAC REGIONAL CAUCUS MEETINGS Mid-Atlantic Regional Caucus Mid-Central Regional Caucus Mid-South Regional Caucus North Central Regional Caucus Northeast Regional Caucus Northwest Regional Caucus Southeast Regional Caucus Southwest Regional Caucus International Regional Caucus

4:00 pm – 4:15 pm Afternoon Break in Exhibit Hall 4:15 pm – 5:30 pm AFTERNOON KEYNOTE SESSION Addiction and Trauma: Complexities of Treating the Young Adult Claudia Black, PhD 6:30 pm – 8:30 pm Movie Night 7:00 pm – 8:00 pm International Coalition for Addiction Studies Educators (INCASE) Membership Meeting

12:30 pm – 2:30 pm Lunch in the Exhibit Hall

8:00 pm – 10:00 pm International Coalition for Addiction Studies Educators (INCASE) Reception

2:30 pm – 4:00 pm BREAKOUT SESSIONS

9:00 pm – 10:00 pm Mutual Support Meeting

TRACK: PHARMACOTHERAPY

TelePractice Improvement: Training the Workforce on Implementing Effective Technology-Based Services Terra Hamblin, MA & Wendy Woods, MA TRACK: CLINICAL SKILLS

The Rise of Synthetic Drugs Darlene Walker, MA, CATC IV, NACI & Lynda Sanchez, MBA, CATC TRACK: RECOVERY SUPPORT

Female Adult Children of Alcoholics and Offender Populations: Exploring Effective Interventions Valerie McGaha, PhD, LPC, LADC TRACK: CO-OCCURRING DISORDERS

Learned Helplessness, Perceived Control and the Impact on Addiction and Co-Occurring Disorders Susan Shipp, MA, LPC, CACD III, MAC TRACK: PRACTICE MANAGEMENT

How to Get Started in Telemental Health Jay Ostrowski TRACK: PROCESS ADDICTIONS

SUNDAY (SEPTEMBER 24) Up to 6 CEs Available on Sunday 6:30 am – 7:00 am Sunday Religious Services 7:30 am – 4:30 pm Registration

en?

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n, Showcase your institutio gious event by sti pre s thi at organization or adver tising at our exhibiting, sponsoring, r ce. Access not only ove 2017 Annual Conferen ’s AC es, but NA AD 700 conference attende 0, its mailing list of ,00 10 r ove membership of nd new website. over 48,000, and its bra motional opportunities To explore the many pro Smith, Account available, contact Elsie aadac.org or @n ith Executive, at esm y have a few onl We 9.

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Starting the Body Conversation Robyn Cruz, MA

S U M M E R 2 017 | A d va n ce s i n A d d i c t i o n & R e c o v e r y 13

The City With over 300 days of sunshine, a walkable downtown, thriving arts and culture, stunning architecture, award-winning dining, and unparalleled views with the Rocky Mountains as a backdrop, Denver offers an affordable mix of urban sophistication and outdoor adventure.

The Hotel Denver Marriott Tech Center 4900 S. Syracuse Street Denver, CO 80237 USA Main: 303.779.1100 www.denvermarriotttechcenter.com The Denver Marriott Tech Center is offering rooms for a discounted rate of $119 a night (plus applicable taxes) for reservations made by September 5, 2017. Recently redesigned with a Colorado-inspired modern motif, the hotel is close to upscale shopping, ample outdoor recreation, and the Belleview Light Rail station.

Attendees may book their rooms online at aws.passkey.com/e/48995442?utm_ source=2092&utmmedium=email&utm_ campaign=273132800 or by calling 877.303.0104. Please make reference to the “NAADAC Conference” to receive our special group rate.

Reservations are available on a firstcome, first-served basis for the limited number of rooms being held at the discounted rate. Please book your room early as space is limited and will sell out!

Room Reservation Deadline: September 5, 2017

Preliminary Schedule* 7:30 am – 2:00 pm Exhibit Hall Open 7:30 am – 8:30am Continental Breakfast in Exhibit Hall 7:30 am – 2:00 pm Poster Presentations

8:30 am – 10:00 am MORNING KEYNOTE SESSION It's Us, Not Them: How We Are Failing Men in Treatment Dan Griffin

11:45 am – 1:45 pm Lunch in Exhibit Hall

10:00 am – 10:15 am Morning Break in Exhibit Hall 10:15 am – 11:45 am BREAKOUT SESSIONS TRACK: PHARMACOTHERAPY

Clinical Considerations of Psychopharmacology of Opiate Use Disorder Linda Shaffer, MA, EdS, LCAS, MAC TRACK: CLINICAL SKILLS

Reality Therapy Demonstrations: Elevate Recovery with Recent Advances in an Evidence-Supported Practice Robert Wubbolding, EdD, LPCC, BCC TRACK: RECOVERY SUPPORT

RISE (Recovering in Supportive Environments) Kenneth Roberts MPS, LADC, LPCC, Monique Bourgeois, MPNA, LADC & Lindsay Battuello MA, LADC, LPCC TRACK: CO-OCCURRING DISORDERS

Build Confidence in Dealing with Suicidality in Substance Use Disorder Counseling Randi Jensen MA, LMHC, CDP & Terry Markmann RN, MA

TRACK: PROCESS ADDICTIONS

The Fear of Missing Out: The Psychosocial ple On September 22–24, Correlates of Smartphone Overuse are t companies tha Errol Rodriquez, PhD, CRC, MAC to visit and support the or ct, du tion, pro showcasing their institu TRACK: CULTURAL HUMILITY ibit Hall this year. organization in our Exh Social Class Bias in the Clinical Relationct with the exhibitors ship; Does Socio-Economic Status Impact Exclusive time to intera been set aside during Treatment? in the Exhibit Hall has g, n on Friday evenin Anthony Rivas, LAC, MAC & Bita Rivas, LPC, the Welcome Receptio asts, lunches, akf bre the and during NCC, ACS oon cof fee and morning and aftern d Sunday. breaks on Saturday an

A d va n c e s i n A d d i c t i o n & R e c o v e r y | S U M M E R 2 017

TRACK: PROFESSIONAL DEVELOPMENT

All That Glitters Can Be Gold for Recruitment Diane Sevening, EdD, LAC

Protect Your Business Through Trademark, Copyright & Computer Laws Darren Spielman

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Perceptions of Students and Associate Counselors on Preparedness for Substance Use Counseling Shelley Reed, PhD, LPC, CAC II, CPCS, MAC & Tristen Hyatt, APC, NCC, MS

8:00 am – 5:00 pm NAADAC Board of Directors Meeting

TRACK: PRACTICE MANAGEMENT

Hall!

Visit the Exhibitase be sure

TRACK: EDUCATION/INCASE

2:00 pm – 3:30 pm BREAKOUT SESSIONS TRACK: PHARMACOTHERAPY

America Wakes Up: The Opioid Crisis Matthew Feehery, MBA, LCDC TRACK: CLINICAL SKILLS

Use of the MMPI-2 RF in the Assessment and Treatment of Substance Use Disorders Roberto Velasquez, PhD, CADC II TRACK: RECOVERY SUPPORT

Yoga, 12 Steps, and Addiction Recovery Dorothy Greene, PhD, LCSW, LCAS, CCS, RYT TRACK: CO-OCCURRING DISORDERS

A Non-Pharmacologic Approach to Managing Emotion Dysregulation in Addiction Treatment Osvaldo Cabral, MA, LPC, LAC & Bari Platter, MS, RN, PMHCNS-BC TRACK: PRACTICE MANAGEMENT

How Clinicians Can Influence Public Policy Instead of Being a Victim of It Reo Leslie, LMFT, LPC, CAC III, AAMFT Approved Supervisor TRACK: PROCESS ADDICTIONS

Factors Related to the Occurrence and Recovery of Internet Use Disorder An-Pyng Sun, PhD, LCSW & Hilarie Cash, PhD, LMHC, CSAT TRACK: CULTURAL HUMILITY

No Safe Place – The Growing Epidemic of Addiction and Co-Occurring Disorders in the LGBTQ Community Steve Kelly, LPC, CSAT & Brian Lane TRACK: EDUCATION/INCASE

Elevating Education: Experiential Activities to Take Addiction Studies Courses to the Next Level Jennifer Londgren, EdD, LMFT, LADC-S, NCC TRACK: PROFESSIONAL DEVELOPMENT

Why Should National Credentials Matter to You? Jerry Jenkins, MEd, MAC, Kathryn Benson, LADC, NCAC II, QSAP, QSC & NCC AP Commissioners

Preliminary Schedule* 4:00 pm – 4:15 pm Afternoon Break in Foyer 4:15 pm – 5:45 pm AFTERNOON KEYNOTE SESSION Federal Panel Kimberly Johnson, PhD, MBA & Jack Stein, PhD 6:30 pm – 8:30 pm NAADAC Education & Research Foundation (NERF) Auction Mackenzie Phillips & Johnny McAndrew 9:00 pm – 10:00 pm Mutual Support Meeting

MONDAY (SEPTEMBER 25) Up to 7.75 CEs Available on Monday 8:00 am – 4:30 pm Registration 8:00 am – 9:00 am Continental Breakfast in Foyer 8:00 am – 4:00 pm National Certification Commission for Addiction Professionals (NCC AP) Meeting 8:00 am – 4:30 pm U.S. Department of Transportation’s Substance Abuse Professional Qualification/ Requalification Course - Day 1 Mita Johnson, EdD, LPC, MAC, SAP 8:30 am – 9:00 am Q&A with NAADAC President & Executive Director Gerard Schmidt, MA, LPC, MAC & Cynthia Moreno Tuohy, NCAC II, CDC III, SAP 9:00 am – 10:30 am MORNING KEYNOTE SESSION Sexual Addiction: Neuroscience, Etiology and Treatment Stefanie Carnes, PhD, LMFT, CSAT-S 10:30 am – 10:45 am Morning Break 10:45 am – 12:15 pm BREAKOUT SESSIONS TRACK: PHARMACOTHERAPY

We’re Not in Kansas Anymore: The Brave New World of Medication-Assisted Treatment Michael Bricker, MS, CADC-2, LPC TRACK: CLINICAL SKILLS

Helping Men Heal from Addiction and Trauma: Understanding and Treating Men in Addiction Treatment Michael Barnes, PhD, MAC, LPC

TRACK: RECOVERY SUPPORT

TRACK: PRACTICE MANAGEMENT

Rooting Down to Rise Up in Recovery Jessica Smith, LPC, LAC & Keatin Mckenzie, LPC, LAC

Catch the Wave: Why Providers are Flocking to Accreditation – and Why You Should Join Them Jennifer Flowers, MBA

TRACK: CO-OCCURRING DISORDERS

Building Resiliency for Clients with Mental Health, Cognitive and Substance Use Disorders Rick Krueger, MA, LPCC, LADC

TRACK: PROCESS ADDICTIONS

TRACK: PRACTICE MANAGEMENT

Understanding and Treating Co-Occurring Military Sexual Trauma and Substance Use Disorders Melissa Balent, LPC, NBCC, LAC, MAC

A Phenomenological Study of Stress and Burnout Experienced by Licensed Alcohol and Drug Counselors Derrick Crim, EdD, LADC, CPPR, MAPM TRACK: PROCESS ADDICTIONS

Social Gaming to Internet Gambling: The Connection, the Concern, and Recovery Principles Daniel Trolaro, MS TRACK: CULTURAL HUMILITY

Historical Trauma, Substance Use Disorders, and Indigenous Healing Yvonne Fortier, MA, LPC, LISAC TRACK: EDUCATION/INCASE

Developing or Revising an Online Addictions Course in Higher Education Margaret Smith, EdD, MLADC & Vicki Michels, PhD TRACK: PRACTICE MANAGEMENT

Person-Centered and Engaged: Using Shared Decision Making in Substance Use Treatment Services Laurie Curtis, MA, CPRP & Jesse Higgins, RN, MSN, PMHNP 12:30 pm – 2:15 pm President’s Awards Luncheon 2:30 pm – 4:00 pm BREAKOUT SESSIONS TRACK: CLINICAL SKILLS

Motivational Interviewing Methods for Counseling John Ellis, LISW-S, LICDC-CS, ICCS TRACK: CLINICAL SKILLS

The Millennial Path to Recovery: Upgrading Interventions in Addiction Treatment Robin Kleisler, LPC, LAC, MAC & Fatina Cannon, LPC, MAC, CAC II, R-DMT TRACK: RECOVERY SUPPORT

Furthering the Reach with Technology Christine Taylor, LMSW TRACK: CO-OCCURRING DISORDERS

Clinical Education and Interventions for Defense Structures of Co-Occurring Populations Brian Lengfelder, LCPC, CAADC, SAP, MAC

Eating Disorders 101 Malcolm Horn, LCSW, MAC, LAC, SAP TRACK: CULTURAL HUMILITY

TRACK: EDUCATION/INCASE

Project-Based Learning in a Graduate Research Course Therissa Libby, PhD 4:00 pm – 4:15 pm Afternoon Break 4:15 am – 6:00 pm AFTERNOON KEYNOTE & CLOSING CEREMONY The Art and Science of Healing: Finding the Healing Self Inside Cardwell C. Nuckols, PhD Closing Ceremony Cynthia Moreno Tuohy, NCAC II, CDC III, SAP, Gerard Schmidt, MA, LPC, MAC & Johnny McAndrew 9:00 pm – 10:00 pm Mutual Support Meeting

TUESDAY (SEPTEMBER 26) Up to 7 CEs Available on Tuesday 7:00 am – 11:00 pm Registration 7:00 am – 8:00 am Continental Breakfast (for Post-Conference & SAP Course Attendees only) U.S. Department of Transportation's Substance Abuse Professional Qualification/ Requalification Course - Day 2 Kathryn Benson, LADC, NCAC II, QSAP, QSC 8:00 am - 4:30 pm POST-CONFERENCE SESSIONS Clinical Supervision: New Technologies, Proven Approaches Thomas Durham, PhD Motivational Interviewing: A Skills Update Agnieszka Baklazec, MA, LPC, LAC 12:00 pm – 1:00 pm Lunch (for Post-Conference & SAP Course Attendees only)

S U M M E R 2 017 | A d va n ce s i n A d d i c t i o n & R e c o v e r y 15

Registration Form!

Register Now! Early Bird Rate Ends August 15!

Fee Schedule (please check category fee box)

Early Bird (ends 8/15)

Standard (ends 9/15)

Late/On-site (starts 9/16)

❑ $150 ❑ $225 ❑ $175 ❑ $150 ❑ $175

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PRE-CONFERENCE: SEPTEMBER 22 Member Non-Member Organizational Member Staff** Student/Military Member Student/Military Non-Member

THREE-DAY CONFERENCE: SEPTEMBER 23–25 Member Non-Member Organizational Member Staff** Student/Military Member Student/Military Non-Member

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V1 01012017

Troubling New Direction in U.S. Drug Policy

By William L. White, MA

W

hen alarm was raised on the 2016 presidential campaign trail regarding rising rates of opioid addiction and related deaths, then-candidate Donald Trump promised he would stop the flow of drugs coming into the U.S. by building a wall on the U.S.-Mexico border1, yet remained virtually silent on the major roles American pharmaceutical companies and medical practitioners have played, and continue to play, in the current opioid epidemic. No wall will solve America’s drug problems.2 No wall will check America’s seemingly insatiable appetites for psychoactive drugs, nor will any wall counter the greed-fueled ingenuity of the licit and illicit industries that exploit those appetites.

President Trump praised Philippine President Rodrigo Duterte and later invited him for an official state visit to the White House — the same Duterte who has likened himself to Hitler, expressed his desire and intent to “slaughter” his country’s three million drug addicts3, and whose violence-inciting rhetoric and policies are responsible for the extrajudicial killing of more than 9,000 suspected addicts and bystanders in anti-drug raids by police and government-sanctioned vigilante groups4. Duterte’s actions have been universally condemned by human rights groups and leaders throughout the world. Any action by an American president to lend legitimacy to Duterte’s presidency is morally reprehensible and a dark foreshadowing of future directions in American drug policy.

President Trump appointed a new presidential commission on opioid addiction, while virtually ignoring the landmark Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health pre­ pared by the nation’s leading addiction experts and released in late 2016

by Surgeon General Dr. Vivek Murthy.5, 6 Facing Addiction in America is one of the most important policy documents in the history of drug control policy. To ignore the best scientific research and the proposed strategies of America’s leading addiction and public health experts would be a travesty and a critical lost opportunity. The dismissal of Dr. Murthy by the Trump administration adds further insult to injury and marks a deepening loss of national drug policy expertise.

The House of Representatives and Senate versions of the American Health Care Act of 2017 eliminate treatment for substance use disorders7 as a health care benefit. If approved by the Senate and signed by the President in its current form, this legislation would substantially reduce access to substance use treatment in the U.S., including access within key states hardest hit by the opioid epidemic — states that, in a twist that would be ironic if not so tragic, delivered the White House to Donald Trump.

Newly-appointed Attorney General Jeff Sessions just issued a new directive to federal prosecutors calling for maximum sentences and mandatory minimum sentences for non-violent drug offenders and the expanded use of private prisons.8, 9 This marks a return to failed drug policies of the 1980s that spurred the largest experiment in mass incarceration in U.S. history and its broad spectrum of untoward social and economic consequences — including its destructive effects on low-income communities of color.10 This reverses what has been growing bipartisan consensus on the ineffectiveness of these earlier policies in terms of their excessive costs, low rehabilitative outcomes, and their harmful social effects. The larger concern is that prison expansion creates conditions through which addicted Americans become the raw materials required to fuel institutional growth, corporate profit, and secure employment within otherwise economically oppressed (and often white) communities. An ever-growing prison industrial complex has and will serve as a powerful lobbying force for the increased stigmatization, de-medicalization, and criminalization of addiction.

Newly appointed Secretary of Health and Human Services Dr. Tom Price recently commented that treating opioid addiction with medications amounts to “just substituting one opioid for another”11 — a statement contradicted by decades of scientific reports from medical and public health panels and the cumulative clinical experience of addiction treatment practitioners specializing in the treatment of opioid addiction. Any efforts by this administration to de-value medication-assisted treatment of addiction or delegitimize medication-assisted recovery from opioid addiction would be an unthinkable regression.

Dr. Elinore McCance-Katz, Substance Abuse and Mental Health Policy, continued on page 23 ☛

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Fentanyl: The Third Wave of the Opioid Crisis

By Jack B. Stein, PhD & Maureen P. Boyle, PhD, National Institute on Drug Abuse (NIDA)

Y

ou probably know the statistics: 91 people die every day in our country from an opioid overdose.1 For several years, the opioid crisis has dominated the attention of NIDA and other federal agencies that address drug use and its consequences. It began in the late 1990s with the overprescribing of pain relievers like OxyContin, which led to escalating rates of opioid addiction and overdose deaths. An estimated 4–8 percent of people who misuse prescription opioids shift to heroin use within 3–5 years,2, 3 as street opioids are considerably cheaper than their prescription relatives and produce essentially the same effects; this ultimately fueled the second wave of the opioid overdose epidemic. Federal agencies moved to address the crisis by recommending more limited use of prescription opioids by healthcare providers — which can help stem the tide of new opioid use disorders — as well as by recommending increased adoption of medicationassisted treatment and wider use of naloxone to reverse overdoses. But now our country is rapidly being caught up in what is being called a “third wave” of the opioid crisis: a surge in fatalities related to fentanyl, heroin’s much stronger cousin. This is presenting a host of new challenges.

Fentanyl, like heroin and prescription analgesics, is a mu-opioid receptor agonist, but it is considerably more potent than other opioids — 50–100 times more potent than morphine, for example. Adding to its dangers is its high fat solubility, allowing it to enter the central nervous system very rapidly. These properties dramatically increase the risk for addiction and overdose. Just 2 milligrams can be lethal,4 and even police officers and first responders are endangered by accidentally coming into physical contact with or inhaling fentanyl.

Fentanyl is not a new drug. It was first approved by the Food and Drug Administration in the 1960s, and more recently has been approved in various forms including a transdermal patch, a fast-acting lollipop, and a dissolving tablet and film. Because of its high potency, it is a medication mostly reserved for palliative care or surgical pain. Misuse of prescription fentanyl was described first in the 1970s and is still reported some people

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who misuse prescription opioids.5 However, the bulk of the current fentanyl problem is not from misused or diverted prescriptions but from fentanyl illicitly manufactured in China and imported into the U.S., either directly via the mail or via Mexican drug cartels, who smuggle it across the border.6 The suddenness of this new threat is reflected both in seizures by law enforcement and in overdose statistics just over the last few years. The U.S. Drug Enforcement Administration (DEA) reported fewer than 1,000 fentanyl seizures in 2013, rising to 13,000 in 2015.7 Overdose deaths attributed to synthetic opioids tripled from 3,105 in 2013 to 9,580 in 20151; this category is dominated by fentanyl but also includes U-47700 (about 12 times more potent than morphine), acetyl-fentanyl (about 15 times more potent than morphine), butyrfentanyl (more than 30 times more potent than morphine), and carfentanil (used as a large-animal anesthetic in zoos and approximately 10,000 times more potent than morphine), among others. Numbers of known fentanyl deaths likely underestimate the problem, since one fifth of overdose death certificates do not list the specific drug involved, and many medical examiners do not test for fentanyl.8 A NIDA-funded HotSpot study in New Hampshire, the state hardest hit by the fentanyl overdose crisis (in terms of overdoses per capita), found that nearly two thirds of the 439 drug deaths in that state in 2015 were caused by fentanyl.9 Fentanyl’s ease of manufacture from legally obtainable precursor chemicals and its high potency make it enormously profitable to manufacture and distribute, accounting for its rapid expansion in the illicit drug market.

According to the DEA, a kilogram of fentanyl purchased in China for $3,000 to $5,000 can generate over $1.5 million on the black market10 — much more than an equivalent amount of heroin, which is not only much less potent but is more expensive to produce as it must be extracted and processed from opium poppies. Because of its profitability, distributors are eager to put fentanyl in heroin or cocaine powder or in counterfeit prescription drugs. Fentanyl is often sold in capsules or pressed into pills made to look like prescription pain relievers or sedatives like Xanax.

Although many who overdose on fentanyl have taken the drug unwittingly, believing they are taking another drug, a surprising number of people are deliberately seeking it out. In most respects, the population of fentanyl users overlaps that of heroin users. Apart from questions of access and cost, people with opioid addiction may also be drawn to higher potency street products because of the opioid tolerance they have developed.

This also appears to be driving some heroin users to deliberately seek out fentanyl. The NIDA-funded HotSpot study interviewed opioid users in New Hampshire and found that about a third knowingly sought fentanyl because of its reputed high potency: “Some may seek out a certain dealer or product when they hear about overdoses because they think that it must be good stuff.”9 What can be done? The challenges of a public-health and public-safety response to fentanyl are several. People are coming into contact with this drug via their addiction to other drugs. That drug is heroin in many cases, but many have also been hospitalized or killed when their cocaine was laced with fentanyl or when they have purchased tainted counterfeit pills. Thus

general drug prevention efforts are relevant, and the preventive measures being taken to quell the opioid crisis, such as stricter guidelines on opioid prescribing, can help prevent people from developing opioid addictions. To the same end, NIDA is actively funding research to find new treatments for pain. Recently two NIDA-funded research teams have reported success in preclinical research on opioid compounds that reduce pain in animals but are not reinforcing.11 Other avenues such as targeting the endocannabinoid system instead of the opioid system are also being extensively studied, as are nonpharmacological approaches like transcranial magnetic stimulation.

Hopefully in the next decade, physicians will have a wider array of tools to treat pain that do not pose the danger of dependence, addiction, and overdose that opioids do.

Since most fentanyl users are already addicted to heroin or other drugs, harm-reduction and addiction treatment are particularly important prongs in the public health and public safety response to the crisis. The opioid antagonist naloxone is a mainstay of harm-reduction efforts and its wider implementation, facilitated through easier-to-use nasal sprays, has saved many lives in the last few years. But fentanyl’s extremely high potency often renders the usual doses of naloxone ineffective at reversing fentanyl overdose. Emergency departments are reporting increased numbers of cases in which multiple doses of naloxone are required, and there have been case reports of patients requiring intravenous administration.12 Physicians and first responders need to be aware of this possibility and be prepared to administer naloxone in an appropriate dose and for an appropriate duration.

The opioid education and naloxone distribution programs that have been so successful when implemented among opioid users remain crucial, but unless they are expanded to a broader group of drug users they will not help cocaine or sedative users who unknowingly ingest fentanyl or fentanyl-laced drugs; and given the potentially insufficient dose, lay-distributed naloxone may not be effective for opioid users who overdose on fentanyl. There is a clear need for research on overdose-reversal medications that would work better for fentanyl and other high-potency opioids.

An area where NIH-funded research has made some progress, crossing the domains of harm reduction and treatment, is in studying the possibility of vaccines against fentanyl and other opioids.13 Recruiting the body’s own immune system to neutralize drugs in the bloodstream, via antibodies, before they enter the brain has been the subject of investigation for several years. Vaccines against opioids have been found to work in animals, but more research is needed to take these preclinical findings and develop them into products that can be tested in humans as tools to treat addiction or reduce its harms.

Lastly, expanding access to existing, effective addiction treatments, especially medications for opioid use disorders, is more important than ever.

The sooner an opioid user receives buprenorphine or methadone to quell cravings and withdrawal symptoms, the greater the likelihood of averting the worst outcomes of his or her addiction, including overdose death from fentanyl-laced heroin or deliberate escalation from prescription opioids to even more dangerous, higher-potency substances. Unfortunately, fewer than half of private-sector treatment programs offer medications for opioid use disorder, and only a third of patients in those programs actually receive it.14 The fact that effective treatments for opioid use disorders exist but are so little utilized remains the clearest and theoretically most surmountable barrier in addressing this epidemic, which began with the overprescription of pain medications nearly two decades ago. The dire risk of overdose death in the current environment should overwhelm any lingering attitudinal resistance against such treatments held among treatment providers, since an opioid user who dies of an overdose stands no chance of recovery. And

the flood of overdose victims into emergency rooms provides real economic incentive, on top of the moral imperative, for healthcare systems to make sure these effective and cost-effective measures are widely utilized. The fentanyl “third wave” is yet another wakeup call that we must do more to deliver effective addiction treatment to people who need it.

Jack Stein, PhD, MSW, joined the National Institute on Drug Abuse (NIDA) in August 2012 as the Director of the Office of Science Policy and Communications (OSPC). He has over two decades of professional experience in leading national drug and HIV-related research, practice, and policy initiatives for NIDA, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Office of National Drug Control Policy (ONDCP) where, before coming back to NIDA, he served as the Chief of the Prevention Branch.

Maureen Boyle, PhD, is the Chief of the Science Policy Branch in NIDA’s Office of Science Policy and Communications where she works with congress and other stakeholders to promote science based decision making in public health policy. Prior to joining NIDA, Boyle was a Lead Public Health Advisor at the Substance Abuse and Mental Health Services Administration (SAMHSA) where she coordinated efforts to promote the use of technology to improve the delivery of behavioral health care. Boyle received her PhD in neuroscience from Washington University in St. Louis where she studied the genetic and molecular basis of depression and anxiety-related behaviors. She completed a postdoctoral fellowship at the Allen Institute for Brain Science and she received training in science policy through the American Association for the Advancement of Science Science and Technology Policy Fellowship program.

(Endnotes) 1 Rudd, R. A., Seth, P., David, F. & Scholl, L. Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. Morbidity and Mortality Weekly Report 65, 1445-1452, doi:10.15585/mmwr.mm655051e1 (2016).

2 Muhuri, P. K., Gfroerer, J. C., Davies, M. C.; Substance Abuse and Mental Health Services Administration. Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Review, http://www.samhsa.gov/data/2k13/DataReview/ DR006/nonmedical-pain-reliever-use-2013.pdf (August 2013).

3 Carlson, R. G., Nahhas, R. W., Martins, S. S. & Daniulaityte, R. Predictors of transition to heroin use among initially non-opioid dependent illicit pharmaceutical opioid users: A natural history study. Drug and Alcohol Dependence 160, 127-134, doi:10.1016/ j.drugalcdep.2015.12.026 (2016).

4 European Monitoring Centre for Drugs and Drug Addiction. Fentanyl Drug Profile, http:// www.emcdda.europa.eu/publications/drug-profiles/fentanyl and http://www.emcdda. europa.eu/publications/drug-profiles/fentanyl (2015).

5 Substance Abuse and Mental Health Services Administration. National Survey on Drug Use and Health 2015, Detailed Tables (2016).

6 Gladden, R. M., Martinez, P. & Seth, P. Fentanyl Law Enforcement Submissions and Increases in Synthetic Opioid-Involved Overdose Deaths – 27 States, 2013-2014. MMWR Morb Mortal Wkly Rep 65, 837-843, doi:10.15585/mmwr.mm6533a2 (2016).

7 U.S. Department of Justice, Drug Enforcement Administration, Diversion Control Division.

National Forensic Laboratory Information System (NFLIS) 2015 Annual Report. (2016).

8 Trinidad, J. P., Warner, M., Bastian, B.A., Miniño, A. M., & Hedegaard, H. (Dec 20 2016). Using Literal Text from the Death Certificate to Enhance Mortality Statistics: Characterizing Drug Involvement in Deaths. National Vital Statistics Report 65(9), 1-15, (2016, Dec).

9 National Drug Early Warning System (NDEWS) Coordinating Center. New Hampshire HotSpot Report: The Increase in Fentanyl Overdoses, https://ndews.umd.edu/sites/ndews. umd.edu/files/pubs/newhampshirehotspotreportphase1final.pdf (October 14, 2016).

10 Drug Enforcement Administration. Statement of Louis J. Milione, Assistant Administrator, Drug Enforcement Administration before the House Energy and Commerce Committee Subcommittee on Oversight and Investigations, United States House of Representatives, for the hearing Fentanyl: The Next Wave of the Opioid Crisis, http://docs.house.gov/ meetings/IF/IF02/20170321/105739/HHRG-115-IF02-Wstate-MilioneL-20170321.pdf (March 21, 2017).

11 Perlman, B. Promising Advances in the Search for Safer Opioids. NIDA Notes, https://www. drugabuse.gov/news-events/nida-notes/2017/02/promising-advances-in-search-saferopioids (February 23, 2017).

12 Tomassoni, A. J., Hawk, K. F., Jubanyik, K., et al. Multiple Fentanyl Overdoses — New Haven, Connecticut, June 23, 2016. Morbidity and Mortality Weekly Report 66(4):107–111.

DOI: http://dx.doi.org/10.15585/mm6604a4 (February 3, 2017).

13 Bremer, P. T., Kimishima, A., Schlosburg, J. E., Zhou, B., Collins, K. C., & Janda, K. D. Combatting Synthetic Designer Opioids: Active Vaccination Ablates Lethal Doses of Fentanyl Class Drugs. Angewandte Chemie 55(11):3772-3775, doi:10.1002/anie.201511654 (2016).

14 Knudsen, H. K., Abraham, A. J. & Oser, C. B. Barriers to the implementation of medicationassisted treatment for substance use disorders: the importance of funding policies and medical infrastructure. Evaluation and Program Planning 34, 375-381, doi:10.1016/ j.evalprogplan.2011.02.004 (2011).

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Treating the Emerging Adult Patient: Rehabilitation or Habilitation?

E

By Cardwell C. Nuckols, PhD

merging adults 18–25 years old are the fastest growing patient population entering alcohol and drug addiction treatment programs. They typically view treatment as a form of punishment imposed by their family, the legal system, or another outside source. It is important for them to see the process as making a positive personal and healthy choice that is a stepping stone toward maturity.

Emerging adults respond best in a peer-to-peer environment. They often come from backgrounds where there was tremendous peer pressure to use alcohol and other drugs. Their use often started around two years earlier than those raised in more enriched environments.1 Eating disorders, self-injurious behavior and/or sexual promiscuity complicate the clinical picture.

Emerging adults are searching for meaning in life out of the chaos that seems to surround them. They are more open with each other than with older adults. This is why a safe and trusting environment with peer-to-peer support is so necessary for neurological growth. This growth allows for the development of the ability to deal more effectively and efficiently with the world.

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Strong, bright and talented young adults are frequently confused and frustrated by their inability to achieve life goals. At the same time, they generally are not yet able to appreciate the need to change emotional, attitudinal, and behavioral roadblocks to personal success. Treatment methodology utilized with older adults can be seen as an infringement on their independence and an unwanted extension of parental authority.

Programming should be designed to help them overcome barriers to selfdetermination, meaningful employment, and healthy relationships.

Life is not an on-off switch. It is much more like a positive energy dimmer switch. Think of a switch on the wall that if turned clockwise more and more light enters the room. Now think of life in a similar fashion. The more positive energy put toward preparing oneself for a full life ahead, the better the chances of succeeding. By turning the dimmer switch counterclockwise, less energy is put into their recovery. When energy is turned down, feelings of depression and accompanying negative self-talk prevail.

Treatment is an invitation into themselves…to discover more about what they truly want…and to create a launching pad from which they will go forth in the world and meet their personal destiny.

Rehabilitation or Habilitation Rehabilitation means to return one to a former level of successful psychosocial functioning. For example, John graduated from high school and joined the Navy. After deployment, he returned home and married his high school sweetheart. They had two children. John was hired by a local business and was promoted several times. All went well until John’s drinking started causing problems at home and on the job. John’s treatment (rehabilitation) endeavored to return him to a level of functioning where he was a good husband, father and worker. Hopefully, his recovery helped him gain a better spiritual awareness.

The hand that Mary was dealt was different from the experience of John.

She was sexually abused by her father and started drinking and using drugs at the age of twelve years old. During her adolescence, she spent time in a juvenile criminal justice facility and never graduated from high school.

Now at the age of 23 years old, she is entering her third treatment program.

What can Mary be rehabbed to? She has never matured into a formalized thinker capable of dealing with the complexity of the world around her.

Although she is intelligent and talented, there is no history of prosocial functioning and one can imagine what her resume might look like. Mary needs habilitation with “wrap around” services. Without a safe, drug free environment, and without the help of a surrogate family (therapist, sponsor and home group, big brother or sister, church group, mentor, etc.), her chances of maturing into a well-functioning adult are guarded.

Due to Mary’s non-enriched environmental upbringing, the newest area of her brain -- the prefrontal cortex — may not have developed properly. Because of neuroplasticity, exposing her to enriched environments with positive role models can help her develop an adult-like functional prefrontal cortex.

The Neurobiology of Change Beneath the exterior changes in thinking, feeling, and behavior are transformations in neurobiology. These neuroplastic changes in the prefrontal cortex can allow persons such as Mary to have better control over emotions, think in a more adult-like fashion and have an opportunity for healthier relationships. Prefrontal cortical plasticity allows for long-lasting changes to take place in neuronal circuitry and information processing.

These changes are caused by learning and experience.2 The prefrontal cortex is a sophisticated area of the brain and, over time, allows one to think in a formalized fashion utilizing executive functioning.

This area of the brain also allows for the attachment bonds so critical to healthy relationships. Affective or emotional stability is also a key aspect of becoming an adult. In other words, without a well-developed prefrontal cortex maintaining a relationship, raising a family and holding a job will be difficult at best.

In an enriching environment, the prefrontal cortex takes around 25 years to fully develop. When abuse and/or neglect occur during the early formative years, the prefrontal cortex may be immature in its development. Adding alcohol and other drugs of abuse can further complicate development.3 The brain functions best when there is top-down regulation of the impulses and urges of the bottom part of the brain. The desired formula is prefrontal cortex (inhibition) over midbrain and brain stem (excitation).

When the prefrontal cortex is well developed, reasoning can override impulsivity, leading to better choices in life. By reducing impulsivity, the areas of the prefrontal cortex can plan for positive outcomes, allowing for better self-regulation, and the ability to manage the complexities of the world.

There are three areas of the brain that make up what is anatomically termed the prefrontal cortex. These integrated areas are the dorsolateral prefrontal cortex, the orbitofrontal cortex and the anterior cingulate gyrus.

In the following paragraphs, brief descriptions of the functions of these areas along with how such stressors as early life developmental trauma and early onset alcohol and other drug use can lead to disruption of the natural trajectory of prefrontal maturity are described. Clinical suggestions helpful in the facilitation of neurogenesis and maturation are also listed.

NOTE: The dorsolateral prefrontal and the orbitofrontal cortex are pictured above. The anterior cingulate gyrus lies beneath the outer cortex and is not displayed.

The dorsolateral prefrontal cortex is intimately involved in the areas of morality and executive functioning.4 For example, a 7-year-old child cannot solve a pre-algebra problem, whereas an 11- or 12-year-old can usually comprehend an abstract concept such as “x.” Throughout adolescence and young adulthood, one’s capacity to analyze, abstract, make plans, inhibit impulses, and delay gratification are developed and refined.

Developmental immaturity of the dorsolateral prefrontal cortex can impair the ability to perform age appropriate skills such as caring for your family and growing professionally.

In order to aid in the habilitation process, multiple modalities can be utilized to enhance executive functioning. For example, problem solving exercises, reading comprehension practices, and skills development through art and activities therapies, along with the following can be helpful: • Write a job resume and have the group give feedback.

• Practice dressing and interviewing for a job.

• The interviewer will use a standard set of questions which the patient will answer in front of the group.

• Group feedback encouraged.

• Develop skills.

• Experimenting with several opportunities to develop an interest or hobby, such as photography, cooking, painting, drawing, or using multiple mediums.

• Complete puzzles, such as jig saw puzzles or cross word puzzles.

• Play certain computer games that are nonviolent but demand attention, planning and delayed gratification.

• Use puzzles and computer games that are competitive in nature leading to a discussion on winning and losing.

• Utilize cognitive schools of therapy.

S U M M E R 2 017 | A d va n ce s i n A d d i c t i o n & R e c o v e r y 21

• Examine their interpretation of their favorite lyric of their favorite song and discuss in group.

• Have the group make their own instruments and write their own recovery song to be performed at community meeting or graduation.

The orbitofrontal cortex (especially the right hemisphere) allows for topdown control of emotions.5 This area of the brain also weighs risk versus benefit. Is the risk we might take worth the possible positive outcome of our actions? Should I use and get immediate gratification or should I continue to pursue my scholastic development in order to reach life goals?

Affective control and the development of the orbitofrontal cortex can be facilitated utilizing role play, forms of self-regulation, an introduction to spiritual practices, anger management techniques, and development of a behavioral safety plan (a 3 x 5” index card with positive behaviors chosen by the patient that serve as sources of external grounding). Below is an example of a safety plan. When experiencing a craving or other strong negative emotional state, the patient is taught to immediately read his or her card and choose a behavior to implement.

The patient can add a prayer or motivational message to the back of the card. If the patient is externally motivated, a picture representing the motivation can be placed in the upper corner of the card (example: “If I test positive for cocaine again the state will take my child away from me” can become visual as a small photo of the child).

• Spiritual • Each day a patient reads from a chosen passage from a spiritual text of their choice (AA, NA, Bible, Torah, Koran, Bhagavad Gita, Tao, etc.). Group discussion with personalization follows the reading.

• Introduction to meditation and self-regulation practices • Opportunities to experience these practices and the outcomes during group or individual therapy • Qualifying-writing and reading your story-experience, hope and expectations • List triggering behaviors that precipitate anger and/or aggressive behavior and discuss and role play alternate scenarios The anterior cingulate gyrus is a part of the attachment system and is critical for positive relationships such as choosing and maintaining a marriage partner. The structures that make up the middle pre-frontal cortex (the orbitofrontal cortex and the anterior cingulate) make up the social brain.6 Young children need to develop a relationship with at least one primary caregiver in order for their social and emotional development to transpire normally. During the first two years, how parents or caregivers respond to their infant establishes the type of pattern of attachment the child forms.

As an adult, these patterns will guide feelings, thoughts and expectations in future relationships.

Emotional-relational-social experiences processed before the brain structures that can process experience consciously are fully mature (before 2½–3 years of age) are stored in implicit memory. Implicit memory is outside of awareness. Research has proven that attachment patterns become stabilize by 12–18 months of age. Therefore, they are stable before we have any choice in the matter.7 Fortunately, neuroplasticity allows for these patterns and schemas to change secondary to new relational experiences.

Some other opportunities to develop relational skills are as follows: • Group oriented therapeutic exercises • Communication skills building exercises • Ropes course • Equine therapy • Choosing a good sponsor and home group • Transference relationship with their therapist • Genograms exploring family attachment histories When parents are absent and/or abusive, insecure patterns of attachment can develop. The therapeutic relationship and the creation of a therapeutic milieu are the tools used to help the patient experience and form better attachment styles.

NOTE: The card must be with the patient at all times, such as in his or her purse or wallet and on a bedside table at night. Reading and following the instructions on the card causes more blood flow to the orbitofrontal cortex and reduces flow to the amygdala in the midbrain.

Other examples that might be utilized to assist the patient in developing better top down control of emotions include: • Role play • Work on managing potential relapse and craving situations • People, Places and Things (PPT) group • Anger management • Practice saying, “When I get angry I give up control to the person I claim is making me angry.”

• Alternate responses using situational role play

Creating an Enriched Environment

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Fair and consistent relationships within a healing milieu can help the individual experience healthy attachment. This may be the greatest of gifts as most of the patients in need of habilitation have never experienced a predictable, enriched environment. The trust developed within such a setting allows for honest interchange with staff and fellow patients.

Predictability comes from the patients experience of fairness and consistency. It is directly related to the setting of limits. These limits or rules must be fair and all staff members must be consistent in their response to violation of program rules. If staff members are not on the same page, a non-enriched environment (like the one the patient came from) will exist and patients will “act-out” while staff may “burn out.”

Cardwell C. Nuckols, PhD, is described as “one of the most influential clinical and spiritual trainers in North America.” He has served the behavioral medicine field for over 40 years and for the last 25 years is considered one of the leading experts in the world on addiction and recovery. Dr. Nuckols has been a member of NADAC for almost 40 years.

STRICT FAIR LOOSE Rules that are strict and authoritarian can lead to increased patient anxiety and impulsive behavioral acting-out. When limits are too loose, it is very difficult to get the patient under control. A fair and consistent set of limits creates an environment where the prefrontal cortex can resume normal develop along its natural trajectory.

Conclusion Patients in need of habilitation need safety and quality relationships over time to allow for neurogenesis to take place. The process starts in as little as two minutes with the initial development of synapses and dendrites but may require years in order to give the patient the opportunity to develop a mature, fully functional prefrontal cortex. Typically, “wrap around” services such as recovery housing, educational and vocational support are important to the process. The patient now has the opportunity to succeed in the important areas of their lives — personal, professional and relational.

(Endnotes) 1 Waldrop, A. E., Santa Ana, E., Saladin, M., McRae, A. and Brady, K. (2007) Differences in Early Onset Alcohol Use and Heavy Drinking Among Persons with Childhood and Adulthood Trauma. The American Journal on Addictions, 16(6), 439-442.

2 Kuboshima-Amemori, S., & Sawaguchi, T. (2007). Plasticity of the Primate Prefontal Cortex.

The Neuroscientist, 13(3), 229-240.

3 Crews, F., He, J., & Hodge, C. (2007). Adolescent Cortical Development: A Critical Period of Vulnerability for Addiction. Pharmacology, Biochemistry and Behavior, 86(2), 189-199.

4 Boytek, B. (2013, December 11). Neuroanatomy: What are the primary functions of the dorsolateral prefrontal cortex? Retrieved from https://www.quora.com/NeuroanatomyWhat-are-the-primary-functions-of-the-dorsolateral-prefrontal-cortex.

5 Rolls, E. & Grabenhorst, F. (2008). The Orbitofrontal Cortex and Beyond: From Affect to Decision Making, Progress in Neurobiology, 86(3), 216-244.

6 Graham, L (2008). The Neuroscience of Attachment. Retrieved from https://lindagrahammft.net/resources/published-articles/the-neuroscience-of-attachment 7 Ibid.

Policy, continued from page 17

Services Administration’s new Chief Medical Officer, has proposed a focus on enhanced access to inpatient psychiatric treatment and access to psychiatric medications and a decreased emphasis on community education and recovery support services. Her appointment and declared focus could signal potential abandonment, or a marked reduction in, efforts to develop long-term, community-based recovery support systems for persons experiencing mental health and/or substance use disorders.12 Collectively, these eight concerns reflect not the arrival of bold new leadership and innovative ideas, but an erosion of expertise and policy regressions that will exert potentially prolonged harm to individuals, families, and communities. Every effort must be made to resist and counter these policy directions. It is time for the more than 23 million Americans in recovery and their families to speak out on these issues regardless of their broader political affiliations.

William L. White is a Senior Research Consultant at Chestnut Health Systems/ Lighthouse Institute and past-chair of the board of Recovery Communities United. White has a Master’s degree in Addiction Studies and has worked full time in the addictions field since 1969 as a street worker, counselor, clinical director, researcher and well-traveled trainer and consultant. He has authored or co-authored more than 400 articles, monographs, research reports and book chapters and 16 books. His book, Slaying the Dragon – The History of Addiction Treatment and Recovery in America, received the McGovern Family Foundation Award for the best book on addiction recovery. This ­article was originally published as a blog post on www.williamwhitepapers.com on May 16, 2017.

(Endnotes) 1 Colvin, J. (2017, March 29). Trump, Christie Pledge to Combat Nation’s Opioid Addiction.

U.S. News and World Report. Retrieved from https://www.usnews.com/news/best-states/ washington-dc/articles/2017-03-29/christie-trump-to-launch-drug-addiction-task-force.

2 Humphreys, K. (2016, December 8). The big problem with Donald Trump’s big idea for stopping the flow of illegal drugs. The Washington Post. Retrieved from https://www. washingtonpost.com/news/wonk/wp/2016/12/08/the-big-problem-with-donald-trumpsbig-idea-for-stopping-the-flow-of-illegal-drugs/?utm_term=.3b603299885e.

Lema, K. & Mogato, M. (2016, October 1). Philippines’ Duterte likens himself to Hitler, wants to kill millions of drug users. Reuters. Retrieved from http://www.reuters.com/ article/us-philippines-duterte-hitler-idUSKCN1200B9.

4 Church v. state in the Philippines’ war. (2017, May 11). The Economist. Retrieved from https://www.economist.com/news/asia/21721907-state-winning-church-v-statephilippines-war-drugs.

5 O’Donnell, K. (2017, March 29). Opioid Epidemic: Trump to Set Up Commission on Addiction Crisis. NBC News. Retrieved from http://www.nbcnews.com/storyline/americasheroin-epidemic/opioid-epidemic-trump-set-commission-addiction-crisis-sourcessay-n739861.

6 U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health.

Washington DC, HHS, November 2016.

7 Zezima, K. & Ingraham, C. (2017, March 9). GOP healthcare-bill would drop addiction treatment mandate covering 1.3 million Americans. The Washington Post. Retrieved from https://www.washingtonpost.com/news/wonk/wp/2017/03/09/gop-health-care-billwould-drop-mental-health-coverage-mandate-covering-1-3-million-americans/?utm_ term=.c7feb64ad438.

8 Williams, P. (2017, May 12), Attorney General Sessions Orders Tougher Drug Crime Prosecutions. NBC News. Retrieved from http://www.nbcnews.com/news/us-news/ attorney-general-sessions-orders-tougher-drug-crime-prosecutions-n758111.

9 Hopkins, C. (2017, February 23). Private Prisons Back in Mix for Federal Inmates as Sessions Rescinds Order. NPR. Retrieved from http://www.npr.org/sections/thetwo-way/2017/02/ 23/516916688/private-prisons-back-in-mix-for-federal-inmates-as-sessions-rescindsorder.

10 Alexander, M. (2010). The New Jim Crow: Mass Incarceration in the Age of Colorblindness.

New York: The New Press.

11 Eyre, E. (2017, May 9). Trump officials seek opioid solutions in WV. Charleston Gazette-Mail.

Retrieved from http://www.wvgazettemail.com/news-health/20170509/trump-officialsseek-opioid-solutions-in-wv.

12 Keshavan, M. (2017, May 11). Trump’s pick to run mental health is poised to shake things up. Even some liberals can’t wait. STAT. Retrieved from https://www.statnews.com/2017/ 05/11/mental-health-trump-nomination.

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Email & HIPAA-Compliance

By Marlene M. Maheu, PhD

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he convenience of email has made it an attractive way for counselors to communicate with clients both quickly and easily. The HIPAA Omnibus Final Rule1, effective March 26, 2013, states that a healthcare professional is permitted to send health information via unencrypted email if the patient has been advised of the risks of email.

It is recommended that the counselor engage in a thorough discussion about such risks, and obtain a written informed consent agreement from the patient to document the detailed discussion.

Risks of Sending PHI via Unsecured Email There may be several risks involved with sending unsecured email.

The factors may be related to technology, as well as human error or intentional deception. This article will highlight risks to consider that may compromise an individual’s right to privacy by sharing Personal Health Information (PHI):

• Email may be transmitted through many unsecured servers and may be intercepted or misdirected during transmission. The email services may not have security protocols in place for employees with access to email. For example, employees may not have the proper security clearance or training to handle the data.

• Email can be captured electronically en route, lost, delayed, or fail to be delivered.

• Email can be sent to or be accessed by an unintended person, perhaps due to a typing error, selecting the wrong name in an auto-fill list, or malfunctioning hardware/software.

• “Free” email can and often is read by the free email software programs. Such companies often run automated searches of email for words that suggest an interest in products related to potentially confidential topics being discussed. The identity of the parties conducting these searches is unknown.

• Email can be sent prematurely, before the author intended to release it.

• A common error occurs when a sender of an email forgets to remove previous exchanges in the same thread. This information can have a negative impact on vulnerable clients and patients for a wide variety of reasons when there are others using their email box see such past exchanges.

When working with clients, there may be other risks involved in sending PHI through unsecured email. You may be able to think of other scenarios that may have been problematic for you in the past when using email to communicate with family or friends. Although such occurrences with loved ones can be forgivable, sharing PHI in email with a clinical population demands a higher level of professionalism. It is the responsibility of counselors to prevent HIPAA security and privacy violations that can damage the client. Healthcare professionals need to be competent to handle PHI before offering such services to the public.

Securing Connections from Both Sides An electronic transmission should be secured from both sides of the transaction — the patient as well as the healthcare professional. Imagine an email, text, or video message as similar to a handshake, wherein the agreement has to be entered into by each party. To seal the deal, secured code sets have to lock into each other in order to secure the transaction. Without the involvement of both sides, the agreement is not valid.

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HIPAA Email Privacy Compliance Checklist The healthcare practitioner or entity should obtain a written consent from all patients before any communication via email or other technology.

If you should choose to utilize email in your clinical setting, the following are a few hints to guide you: • Include an automatic email signature disclosure to remind patients that email is not secure, and to delete an email not meant for them.

You can find samples of templates at www.exclaimer.com/emailsignature-handbook/10026-101-email-signature-templates to consider when you create your email practice signature statement.

• Assure that the connection between all computers, smart devices and the email server are encrypted. To achieve this goal, conduct fre­quent risk assessment of all devices to be sure that they are in com­pliance with security standards. There is a U.S. Government Security Risk Assessment tool available for downloading at www. healthit.gov/providers-professionals/security-risk-assessment, which produces a report that can be provided to auditors.

• Avoid transmitting diagnoses and sensitive PHI via email or text messaging. When engaged in telehealth of any type, communicate diagnoses and other PHI via telephone or surface mail.

• To increase email privacy and security when transmitting sensitive medical information, consider email programs that offer encryption.

Programs such as Google, Gmail for Work, or Office 365 from Microsoft build the security features into the software, negating the need to log in and out of separate software to check patient email.

Some practice management and videoconferencing platforms build email functions into the interface so that all exchanges with patients are conveniently found in one place.

• Use an email service that provides a HIPAA Business Associate Agreement (BAA). Refer to this the TBHI blog post located at https://telehealth.org/blog/google-agrees-to-sign-baa-as-meansto-hipaa-compliance for details of the Business Associate Agreement and how Google has handled it. There are other companies offering BAAs as well.

• Create unique email passwords and store them in a password manager, such as: Keepass (http://keepass.info), Dashlane (www. dashlane.com), or LastPass (www.lastpass.com).

• Install an antivirus program on every computer that accesses email.

• Enable settings in all email software to block emails that may have viruses.

• Use two-factor authentication for email, without exception. Such authentication prevents hackers from accessing your email, and this feature is available at no cost in programs such as Gmail for Work.

• Be sure to have a written privacy and security policy. Document that all staff members have received and understand it.

• Always update software to the newest version. HIPAA violations have occurred and led to negative publicity and files when outdated software has been used in healthcare settings and hackers have accessed PHI. • Organize a formal training session to educate staff on what is allowed to be sent via email and SMS. Document time and location of training for such HIPAA-compliance policies. One topic that may be included in the training can be on phishing with online training sites such as OpenDNS Phishing Quiz or McAfee Phishing Quiz.

Disclaimer and Caution In summary: Ignorance is no defense in the face of the law. Data protection and legal compliance are your responsibility. The Telebehavioral Health Institute (TBHI) strongly advises you to hire a local telehealth attorney in your state for a thorough document and telehealth process review. If you cannot afford such a service privately, TBHI encourages you to approach your professional association to hire an attorney on behalf of their entire membership.

Marlene Maheu, PhD, is the founder of the Telebehavioral Health Institute.

Focused exclusively on telebehavioral health, she has written four textbooks and trained more than 20,000 clinicians from 60 countries. Recognized as one of the leading experts in telepractice, she is the originator of the Online Clinical Practice Model (OCPM) for ethical telemental health, telepsychiatry, telepsychology, distance counseling and online therapy. As a world-class leader in the field, she offers practical strategies, straightforward solutions and the hands-on wisdom that only develops through time and diligence.

She will be offering a full-day pre-conference workshop in Telebehavioral Health Best Practices at the 2017 NAADAC Annual Conference on Friday, September 22.

(Endnotes) 1 Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules Under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; Other Modifications to the HIPAA Rules, 78 Fed. Reg. 17 (January 25, 2013) (codified at 45 CFR Parts 160 and 164).

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Process Addictions: Brain Chemistry Correlates to Chemical Dependencies An Interview with Dr. Darryl S. Inaba, PharmD, CATC-V, CADC III

T

Interview by Jessica Gleason, JD, NAADAC Director of Communications

his column’s question on process addictions were submitted

by Advances in Addiction & Recovery readers. Submit your questions for Dr. Inaba to jgleason@naadac.org.

NAADAC: Why was problem and pathological gambling moved from being an Impulse Control Disorder in the DSM-IV to a Substance-Related and Addictive Disorder in the DSM-5 and will other impulse control behaviors be reclassified as additions in the future?

DR. INABA: In 2013, gambling though a behavioral process, was fully accepted as an addiction similar to that seen in chemical dependency because brain imaging and other research showed that the 0.4 to 1.0% of U.S. gamblers who developed gambling disorder1 had brain chemical and functional anomalies similar to that seen in drug addictions and especially as that seen with stimulant (methamphetamine or cocaine) use disorders.2, 3, 4 Process Addictions are addictions to processes, activities or behaviors such as gambling, internet use, sex/pornography, eating, romance, even work and possibly many other behaviors where over-involvement and compulsivity with the activity is continued despite the development of severe life consequences.5 Studies on the wide diversity of eating disorders from anorexia/bulimia nervosa to binge-eating and compulsive over-eating are also showing brain anomalies associated with addiction to substances that should result in their being redefined as substance-related and addictive disorders in the near future.6, 7, 8, 9 Internet, romantic love, and sex addiction are also being studied10, 11, 12, 13 and should be included in the future as well. Shopping (really buying), arson, kleptomania, et al. are not being studied as much but I feel that they are also part of this class of psychiatric conditions know as substance-related and addictive disorders and may be included as such in the future when brain imaging and chemistry studies are able to provide convincing evidence that they disrupt vulnerable brains in the same way that addictive substance impact the brain.

NAADAC: Are brain chemical (neurotransmitter) anomalies present in process or behavioral addictions (i.e. gambling, shopping, food, relationships, internet) similar to those that are seen with chemical dependencies like methamphetamine or opiate addiction?

DR. INABA: Process addictions like chemical addictions involve a greater action of the neurotransmitter dopamine in the mesolimbic brain pathway associated with incentive and motivation. I refer to this as the beginning of the brain’s Addiction Pathway where dopamine is released by the Ventral Tegmental Area (VTA) to activate the brain’s survival instincts in the Nucleus Accumbens Septi (NAc), the “go switch”.14 This dopamine connection has been confirmed for all addictive substances and now confirmed in pathological gamblers during a gambling episode when they are engrossed in their wagering behavior.15, 16, 17 The initial activation of this pathway in an individual that is vulnerable to gambling addiction results in much greater NAc activity encouraging more participation in

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the activity which is mistaken as being necessary for their survival. This is exactly what happens when a person vulnerable to a chemical addiction is exposed to a drug. Excessive dopamine release ultimately leads to its depletion in the addiction pathway bringing about the craving and obsession to reactivate its activity in any way possible and as soon as possible. The behaviors that result from this process are observed as addiction regardless of what activates it, either a substance or an activity like eating, internet, or gambling. The other major brain circuit of the addiction pathway is the control circuitry located in the frontal cortex of the brain. Dopamine also

activates this part of the pathway but either has less ability to do so or the control circuit disconnected to the NAc “go switch” in those vulnerable to addiction. The control circuitry of the brain communicates its “stop” message through the neurotransmitters glutamate. Recent studies have looked at targeting this brain chemical to treat addictions including pathological gambling.18 Other neurotransmitters involved with addiction in the brain’s addiction pathway are norepinephrine, endorphins and GABA. Endorphins facilitates the function of saliency providing greater prominence of addiction related brain processes over other processes and GABA is often involved in the withdrawal and craving processes of addiction. Lower levels of norepinephrine transporters in the brain have especially been linked to pathological gambling. These individuals are less bothered by losing than others with normal levels of such transporters and therefore continue to gamble despite horrible losses.19 Process addictions like gambling have the same downward spiraling pattern of life dysfunctions that addiction to drugs induces. They can ultimately result in catastrophic life consequences if unaddressed and not managed. Gambling, internet, eating and other process addictions need to be rigorously addressed to help minimize the impact they have on those

who are vulnerable to such disorders. The good news is that process additions are now being taken much more seriously and there are treatments in development to address the wide diversity of such addictions. Peer support groups are also evolving to encourage a better understanding and acceptance that these are actual biologic processes. Groups like Gambling Anonymous, Overeating Anonymous, Emotions Anonymous, Internet & Tech Addiction Anonymous, etc. provide fellowship and hope that process addictions can be treated and managed by those who accept their vulnerability and participate in treatment.

Darryl Inaba, PharmD, CATC-V, CADC III, is Director of Clinical and Behavioral Health Services for the Addictions Recovery Center and Director of Research and Education of CNS Productions in Medford, OR. He is an Associate Clinical Professor at the University of California in San Francisco, CA, Special Consultant, Instructor, at the University of Utah School on Alcohol and Other Drug Dependencies in Salt Lake City, UT and a Lifetime Fellow at Haight Ashbury Free Clinics, Inc., in San Francisco. Dr. Inaba has authored several papers, award-winning educational films and is co-author of Uppers, Downers, All Arounders, a text on addiction and related disorders that is used in more than 400 colleges and universities and is now in its 8th edition. He has been honored with over 90 individual awards for his work in the areas of prevention and treatment of substance abuse problems.

(Endnotes) 1 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

2 Takahashi, H., Fujie, S., Camerer, C., Arakawa, R., Takano, H., Kodaka, F., Matsui, H., Ideno, T., Okubo, S., Takemura, K., Yamada, M., Eguchi, Y., Murai, T., Okubo, Y., Kato, M., Ito, H., & Suhara, T. (2013). Norepinephrine in the brain is associated with aversion to financial loss.

Molecular Psychiatry, 18, 3-4.

3 Van Holst, R., Van den Brink, W., Veltman, D., & Goudriaan, A. (2010). Brain imaging studies in pathological gambling. Current Psychiatry Reports, 12(5), 418-425.

4 Balodis, I., Kober, H., Worhunsky, P., Stevens, M., Pearlson, G., Potenza, M. (2012).

Diminished Frontostriatal Activity During Processing of Monetary Rewards and Losses in Pathological Gambling, Biological Psychiatry, 71(8), 749–757.

5 Smith, D. (2012). The process addictions and the new ASAM definition of addiction.

Journal of Psychoactive Drugs, 44(1), 1-4.

6 Amen, D., Willeumier, K., & Johnson, R. (2012). The clinical utility of brain SPECT imaging in process addictions. Journal of Psychoactive Drugs, 44(1), 18-26.

7 Frank, G. (2012). Advances in the diagnosis of anorexia nervosa and bulimia nervosa using brain imaging. Expert Opin Med Diagn., 6(3), 235-244.

8 Delvenne, V., Lotstra, F., Goldman, S., Biver, F., De Maertelaer, V., Appelboom-Fondu, J., Schoutens, A., Bidaut, L., Luxen, A., & Mendelwicz, J. (1995). Brain hypometabolism of glucose in anorexia nervosa: A PET scan study. Biological Psychatry, 37(3), 161-169.

9 Wang, G., Volkow, N., Logan, J., Pappas, N., Wong, C., Zhu, W., Netusll, N., & Fowler, J. (2001).

Brain dopamine and obesity. Lancet, 357(9253), 354-357.

10 Zhou, Y., Lin, F., Du, Y., Qin, L., Zhao, Z., Xu, J., & Lei, H. (2011). Gray matter abnormalities in internet addiction: A voxel-based morphometry study. European Journal of Radiology, 79(1), 92-95.

11 Fisher, H., Brown, L., Aron, A., Strong, G., & Mashek, D. (2010). Reward, Addiction, and Emotion Regulation Systems Associated With Rejection in Love. Journal of Neurophysiology, 104(1), 51-60.

12 Estellon, V. and Mouras, H. (2012). Sexual addiction: insights from psychoanalysis and functional neuroimaging. Socioaffective Neurosceince & Psychology, 2, 11814.

13 Amen, D., Willeumier, K., & Johnson, R. (2012). The clinical utility of brain SPECT imaging in process addictions. Journal of Psychoactive Drugs, 44(1), 18-26.

14 Inaba, D., and Cohen, W. (2014). Uppers, Downers, All Arounders: Physical and Mental Effects of Psychoactive Drugs (8th Edition). Medford, OR: CNS Productions, Inc. 15 Anselme, P. and Robinson, M. (2013). What motivates gambling behavior? Insight into dopamine’s role. Behavioral Neuroscience, 7, 182.

16 Joutsa, J., Johansson, J., Niemelä, S., Ollikainen, A., Hirvonen, M., Piepponen, P., et al.

(2012). Mesolimbic dopamine release is linked to symptom severity in pathological gambling. Neuroimage, 60(4), 1992-1999.

17 Linnet, J., Møller, A., Peterson, E., Gjedde, A., & Doudet, D. (2011). Dopamine release in ventral striatum during Iowa Gambling Task performance is associated with increased excitement levels in pathological gambling. Addiction, 106, 383–390 18 Pettorruso, M., De Risio, L., Martinotti, G., Di Nicola, M., Ruggeri, F., Conte, G., Di Giannantonio, M., and Janiri, L. (2014). Targeting the glutamatergic system to treat pathological gambling: Current evidence and future perspectives. BioMed Research International, 2014.

19 Takahashi, H., Fujie, S., Camerer, C., Arakawa, R., Takano, H., Kodaka, F., Matsui, H., Ideno, T., Okubo, S., Takemura, K., Yamada, M., Eguchi, Y., Murai, T., Okubo, Y., Kato, M., Ito, H., & Suhara, T. (2013). Norepinephrine in the brain is associated with aversion to financial loss.

Molecular Psychiatry, 18, 3-4.

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Career Interrupted

By Sandra Street, MA, LPC, MAC, AADC-S

Y

ou don’t think it could happen to you? I didn’t either. I love my job! I’ve been in this field for more than 30 years. Oh, at times I’m disgruntled with the paperwork and long hours, but, all in all, I look forward to working. Until I couldn’t.

When I was asked to share this story, the request came in a kind tone of voice, “A career interruption could happen to any of us at any time.” I make a distinction here — an interruption chosen by me and an interruption which I did not choose — or desire. I did not choose to interrupt my career. It wasn’t planned. In fact, given a choice, I would not have raised my hand or said, “Let it be me.”

My cancer diagnosis came as a complete surprise. I had few symptoms and they were subtle at that. In fact, the week before I was diagnosed, I line danced three times and walked in a 5K to benefit the American Heart Association. I had an appointment with my gynecologist the week following the race.

I was alone when the doctor told me the diagnosis. My husband was on his way to the hospital but they didn’t wait until he arrived.

I don’t have the words to express the shock I felt learning the diagnosis. Of course I had thought about what it would be like to have a life threatening illness (especially when it happened to someone I knew) but imagined and real are two very different things. I asked the emergency room doctor if I were going to die from this and he replied, “We’re all going to die from something.”

I was hospitalized for my first diagnostic surgery to stage the cancer within one or two days. I was glad I didn’t have long to wait but it meant I only had a few hours to notify patients in my private practice, the other professionals I work with on a regular basis, insurances, the contacts for my consulting contracts, and the Boards. In all honesty, I just went through the motions.

I hardly remember what the letter to my clients and my voice mail message said.

When I checked back, there was an

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offer to help clients find another therapist on an interim or permanent basis, a number for a therapist on call for emergencies, instructions for the client considering self-harm, and even an option for the patient who thought he/ she had to speak to me personally. I wrote something about being back in a few months but, truth was, I didn’t know if I would be back then — or ever. I had the Board-required note in my files of who would have access to my files in case of my absence or death.

I had to put signs on my doors, text or email clients who couldn’t be reached (after I had checked to be sure I had the proper consents), inform my medical billing company, and notify the landlord. I even considered if I wanted to give up part of my office space. After all, my income was going to be reduced drastically.

The reactions of my clients and my colleagues was heartwarming — like the one client who had just lost her father to cancer and, in her words, “couldn’t bear” to think about me going through it. I had calls, cards, letters, and flowers, and my friends and colleagues on the state board made a poster that said “miracles happen” and signed it with get well wishes.

Then they face-timed me for the awards banquet at the West Virginia Fall Conference because I was going to miss it — the first one I would miss in more than 20 years.

I had chemo for several months after the staging surgery. I spent full days at the hospital for chemo. Then I had a break from chemo, an extensive de-bulking surgery, another break from chemo while I recovered from the surgery, then another round of chemo. Chemo made me sick; I lost my hair, I got sores in my mouth and on my skin, as well as cellulitis in my arm from the needle sticks, developed an irregular heart beat (another side effect of chemo) and at the end of chemo, I fell and broke my wrist because chemo may have weakened my bones. I recount all this to make a point — the effect of all this on me seemed devastating. I couldn’t see myself as a person let alone a therapist. I questioned how I would ever be able to focus on my clients. Was it even ethical to practice when I was so broken myself? If I hadn’t worked through this, how could I even consider seeing clients? I didn’t return to my practice for several months.

I returned on a very limited basis after 16 months of treatment but I only saw a few clients each week. I returned a different person. I thought I had always been empathetic to my clients. I thought it a strength that I could be with someone and not try to “fix” their problem. But I had gained a new perspective. I compared my powerlessness and unmanageability to that of a person with a substance use disorder. I could relate to their loss of control and anxiety, and their efforts at acceptance. I understood when they talked about the losses they experienced — their job in particular, and when they spoke of not knowing who they were and how they never thought it would happen to them. I empathized when they talked about how the things they built their life on fell apart. My job wasn’t something I did — it was who I was. I felt the sting as they talked about how their family had been affected. I’d watched my family struggle with the seriousness of all this every week as they accompanied me back and forth to the hospital which was an hour drive each way. I became more conscious than I ever was of offering advice or platitudes, like when someone said to me, “God never gives you more than you can handle.” If that were true, I’d pray to be weak. I knew people may not want to hear about staying strong or talk about God at that time — or ever. I was very aware when someone felt dismissed or discounted and when they were offered false reassurance, as I had been by people who were trying to be helpful. The process not only taught me about taking care of myself and saying “no,” but about how hard it is to make changes or do the healthy thing — even when one

knows full well what that is. “Easy does it” and “A day at a time” took on new meaning, as did the Serenity Prayer.

I’m not the same person I was. I am aware that life can change on a dime. The experience still impacts me and my choices. I am still faced with people’s questions and reminders — for example, about my limited hours of private practice based on the fact I still go frequently for checkups, labs, and screens. My stamina is not the same — neither is my patience (but it’s getting better). Some people seeing my struggle encouraged me to retire but I didn’t want to quit working and my focus was clear when I saw patients.

All the years I’d heard people say you couldn’t work in addiction unless you too had a substance use disorder and now I thought the same thing.

How could someone understand how I felt if they hadn’t been there. But it’s as my father said: “You never know what the other guy is going through.

A good reminder to treat everyone with kindness — you don’t know when it could happen to you.”

Sandra Street, MA, LPC, MAC, AADC-S, is a behavioral health consultant in private practice in Wheeling, WV. She has more than 30 years experience in addictions and mental health treatment as a certified psychiatric/mental health nurse, Licensed Professional Counselor-Approved Supervisor, Master Addiction Counselor, Substance Abuse Professional - U. S. Department of Transportation, Employee Assistance Program professional, certified gambling counselor, administrator, and presenter. She has been in private practice since 1992 and currently sees individuals and couples and manages several contracts with area businesses and healthcare agencies. She is a member of the West Virginia Association of Alcoholism & Drug Abuse Counselors, having served for 15 years as a Board member and the Ethics Chair. She currently serves on the National Certification Commission for Addiction Professionals.

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S U M M E R 2 017 | A d va n ce s i n A d d i c t i o n & R e c o v e r y 2 9

Earn 1 CE by Taking an Online Multiple Choice Quiz

Earn one Continuing Education hour by taking a multiple choice quiz on this article now at www.naadac.org/magazine-ce-articles. $15 for NAADAC members and non-members.

1. In her article on virtual ethics and personal relationships, Mita Johnson states, “It is incumbent upon the professional to engage in risk management thinking and behaviors that first and foremost protect the client from all actual and potential harm, while also protecting the professional.” Which of the following is the most accurate statement with regards to protecting both the client and the therapist (professional) from harm? a. Forming a personal relationship with a client can be therapeutically help­ful as a means of gaining trust. b. Forming a personal relationship with a client is unavoidable due to the nature of therapeutic relationships. c. Forming a personal relationship with a client is anti-therapeutic due to the therapist’s position of access, power, and authority. d. Not forming a personal relationship with a client can lead to actual or potential harm to the client.

2. In the NAADAC position statement on the opioid epidemic, medicationassisted treatment (MAT) is mentioned as evidence-based and a best practice for treatment of opioid addiction. Which of the following is most accurate regarding MAT for opioid addiction? a. Opioid agonist medications, such as buprenorphine and methadone, are effective as stand-alone treatment. b. Opioid agonist medications will hold off withdrawal symptoms and may help to heal some of the impact other drugs have had on brain function, yet a broader approach to treatment is needed. c. Because all persons addicted to opioids essentially have the same brain chemistry, one-dimensional treatment is most effective in the use of an opioid agonist. d. The concept of recovery services that are inclusive, holistic, and unique to the individual needs of each client is outdated and no longer deemed effective due to the use of agonist medications.

3. According to Jack Stein and Maureen Boyle’s article about fentanyl, which of the following is most accurate? a. Unlike heroin and prescription analgesics, fentanyl is not a mu-opioid receptor agonist. b. Fentanyl is considered to be twice as potent as morphine. c. Fentanyl’s low fat solubility allows it to enter the central nervous system very rapidly. d. Due to fentanyl’s potency, police officers and first responders are endangered by accidentally coming into physical contact with or inhaling fentanyl.

4. Jack Stein and Maureen Boyle noted that “the opioid antagonist naloxone is a mainstay of harm-reduction efforts and its wider implementation, ­facilitated through easier-to-use nasal sprays, has saved many lives in the last few years.” Which of the following is most accurate with regards to the use of naloxone with individuals who overdose on fentanyl? a. The usual dosage of naloxone, typically used with those experiencing a heroin overdose, is just as effective at reversing fentanyl overdose. b. Due to opioid education and naloxone distribution programs, emergency departments are reporting decreased numbers of cases in which multiple doses of naloxone are required. c. Opioid education and naloxone distribution programs have been expanded to a broader group of drug users thus have raised awareness in the treatment of cocaine or sedative users who unknowingly ingest fentanyl or fentanyl-laced drugs. d. Given the insufficient dose, lay-distributed naloxone may not be effective for opioid users who overdose on fentanyl.

5. In his article on treating the emerging adult patient, Cardwell Nuckols noted that, “the brain functions best when there is top-down regulation of the impulses and urges of the bottom part of the brain.” Which of the following is an example of this process? a. When the prefrontal cortex (inhibition) is regulated by the midbrain and brain stem (excitation). b. When reasoning can override impulsivity, leading to better choices in life.

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c. When impulsivity is increased, leading to better planning for positive outcomes and allowing for better self-regulation. d. When impulsive urges lead to the ability to manage the complexities of the world.

6. Cardwell Nuckols noted that, “Throughout adolescence and young adulthood, one’s capacity to analyze, abstract, make plans, inhibit impulses, and delay gratification are developed and refined.” The development of what part of the brain is responsible for this capacity? a. Dorsolateral prefrontal cortex b. Orbitofrontal cortex c. Anterior cingulate gyrus d. Ventral lateral prefrontal cortex 7. In Marlene Maheu’s article on HIPPAA and the security of e-mail transmissions, she notes several potential risks involved with sending unsecured email. Which of the following is not a risk that may compromise an indi­ vidual’s right to privacy by sharing Personal Health Information (PHI): a. An e-mail with protected information that is captured electronically, lost, delayed, or not delivered. b. An e-mail with protected information sent to or accessed by an un­ intended person, perhaps due to a typing error, selecting the wrong name in an auto-fill list, or malfunctioning hardware/software. c. An e-mail with protected information sent without including any identifying information about the client. d. An e-mail with protected information that is in reply to an earlier message when the sender forgets to remove previous exchanges in the same thread.

8. Marlene Maheu wrote, “The healthcare practitioner or entity should obtain a written consent from all patients before any communication via email or other technology.” Which of the following was not included as a “hint” to guide practitioners in this effort? a. Install an antivirus program on every computer that accesses email. b. Avoid transmitting diagnoses and sensitive personal health information via telephone or surface mail; only use email or text messaging. c. Assure that the connection between all computers, smart devices, and the email server are encrypted. d. Enable settings in all email software to block emails that may have ­viruses.

9. According to Darryl Inaba, why was problem and pathological gambling moved from being an Impulse Control Disorder in the DSM-IV to a substancerelated and addictive disorder in the DSM-5? a. Because brain imaging and other research showed that some gamblers who developed gambling disorder had brain chemical anomalies similar to that seen in drug addictions. b. Because gamblers are often addicted to alcohol or drugs. c. Because gambling is more clearly associated with chemical addiction than process addictions such as sex, internet use, and eating. d. Because all process addictions are now classified as substance-related and addictive disorders in the DSM-5.

10. In the interview with Darryl Inaba, he mentioned that brain chemical (neuro­ transmitter) anomalies are present in process or behavioral addictions (i.e. gambling, shopping, food, relationships, internet). Which of the following is the most accurate statement regarding these anomalies? a. These anomalies are similar to those that are seen with chemical dependencies with the exception of methamphetamine or opiate addiction. b. Process addictions, like chemical addictions, involve a greater action of the neurotransmitter dopamine in the mesolimbic brain pathway asso­ ciated with incentive and motivation. c. The dopamine connection has been confirmed for all addictive substances and most process addictions, but not in pathological gamblers during a gambling episode. d. Though commonalities exist between chemical addiction and process addiction, excessive dopamine release that ultimately leads to its de­ pletion has only been observed in those diagnosed with a chemical addiction.

■ N A A DAC L E ADE RS HI P NAADAC EXECUTIVE COMMITTEE

NAADAC COMMITTEES

Updated 7/1/2017

North Central

STANDING COMMITTEE CHAIRS

President Gerard J. Schmidt, MA, LPC, MAC

(Represents Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota and South Dakota)

Bylaws Committee Chair Ronald A. Chupp, LCSW, LCAC, NCAC II, ICAC II

President Elect Diane Sevening, EdD, LAC Secretary John Lisy, LIDC, OCPS II, LISW-S, LPCC-S Treasurer Mita Johnson, EdD, LPC, LAC, MAC, SAP Immediate Past President Kirk Bowden, PhD, MAC, NCC, LPC National Certification Commission for Addiction Professionals (NCC AP) Chair Jerry A. Jenkins, MEd, MAC Executive Director Cynthia Moreno Tuohy, NCAC II, CDC III, SAP

James “JJ” Johnson Jr. BS, LADC, ICS Northeast (Represents Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island and Vermont)

William Keithcart, MA, LADC Northwest

Malcolm Horn, LCSW, MAC, SAP, NCIP Southeast (Represents Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina and Tennessee)

Angela Maxwell, MS, CSAPC Southwest

Mid-Atlantic

(Represents Arizona, California, Colorado, Hawaii, Nevada, New Mexico and Utah)

Susan Coyer, MAC Mid-Central

(Represents Kentucky, Illinois, Indiana, Michigan, Ohio and Wisconsin)

Julio Landero, PhD, MAC, MSW, LADC, LASAC Organizational Member Delegate Jim Gamache, MSW, MLADC, IAADC

Diane Sevening, EdD, LAC

Finance & Audit Committee Chair Mita Johnson, EdD, LPC, LAC, MAC, SAP

Nominations and Elections Chair Kirk Bowden, PhD, MAC, NCC, LPC Personnel Committee Chair Gerard J. Schmidt, MA, LPC, MAC Professional Practices and Standards Committee Chair Donald P. Osborn, PhD, LCAC Public Policy Committee Co-Chairs Michael Kemp, ICS, CSAC, CSW Sherri Layton, MBA, LCDC, CCS AD HOC COMMITTEE CHAIRS Awards Committee Chair Patricia Greer, LCDC, AAC Adolescent Specialty Committee Co-Chairs Chris Bowers, CSAC, NCAAC Steven Durkee, NCAAC

Mid-South (Represents Arkansas, Louisiana, Oklahoma and Texas)

International Committee Chair Sandra Jones, MS

Matt Feehery, MBA, LCDC, IAADC

Leadership Committee Chair Gerard J. Schmidt, MA, LPC, MAC Membership Committee Chair Margaret Smith, EdD, LADC

Jerry A. Jenkins, MEd, MAC NCC AP Chair Alaska

Product Review Committee Chair Jim Gamache, MSW, MLADC, IAADC Tobacco Committee Chair Diane Sevening, EdD, LAC

Ethics Committee Chair Mita Johnson, EdD, LPC, MAC, SAP

NERF Events Fundraising Chair Ed Olson, LCSW, CASAC

(Represents Alaska, Idaho, Montana, Oregon, Washington and Wyoming)

REGIONAL VICE-PRESIDENTS (Represents Delaware, the District of Columbia, Maryland, New Jersey, Pennsylvania, Virginia and West Virginia)

Clinical Issues Committee Chair Frances Patterson, PhD, MAC

NATIONAL CERTIFICATION COMMISSION FOR ADDICTION PROFESSIONALS (NCC AP)

Student Sub-Committee Chair Diane Sevening, EdD, LAC

James “Kansas” Cafferty, LMFT, NCAAC California

PAST PRESIDENTS 1974-1977 Robert Dorris 1977-1979 Col. Mel Schulstad, CCDC, NCAC II (ret’d) 1979-1981 Jack Hamlin 1981-1982 John Brumbaugh, MA, LSW, CADAC IV, NCAC II 1982-1986 Tom Claunch, CAC 1986-1988 Franklin D. Lisnow, MEd, CAC, MAC 1988-1990 Paul Lubben, NCAC II 1990-1992 Kay Mattingly-Langlois, MA, NCAC II, MAC 1992-1994 Larry Osmonson, CAP, CTRT, NCAC II 1994-1996 Cynthia Moreno NCAC I, CCDC II 1996-1998 Roxanne Kibben, MA, NCAC II 1998-2000 T. Mark Gallagher, NCAC II 2000-2002 Bill B. Burnett, LPC, MAC 2002-2004 Roger A. Curtiss, LAC, NCAC II 2004-2006 Mary Ryan Woods, RNC, LADC, MSHS 2006-2007 Sharon Morgillo Freeman, PhD, APRN-CS, MAC 2007-2010 Patricia M. Greer, BA, LCDC, AAC 2010-2012 Donald P. Osborn, PhD (c), LCAC 2012-2014 Robert C. Richards, MA, NCAC II, CADC III 2014-2016 Kirk Bowden, PhD, MAC, NCC, LPC

Steven Durkee, NCAAC Secretary Kentucky Thaddeus Labhart, MAC, LPC Treasurer Oregon Rose Maire, MAC, LCADC, CCS New Jersey Art Romero, MA, LPCC, LADAC New Mexico Sandra Street, MAC, SAP West Virginia Loretta Tillery, MPA, CPM Public Member Maryland Gerard J. Schmidt, MA, LPC, MAC (ex-officio) West Virginia

NAADAC REGIONAL BOARD REPRESENTATIVES

NORTHEAST NORTH CENTRAL

MID-CENTRAL

Gloria Nepote, LAC, NCAC II, CCDP, BRI II, Kansas-Missouri Therissa Libby, PhD, Minnesota Tiffany Gormley, MS, PLMHP, Nebraska Megan Busch, LAC, LPCC, North Dakota Linda Pratt, LAC, South Dakota

James Golding, MSW, MHS, CAADC, MAC, Illinois Stewart Ball, Indiana Steven Durkee, NCAAC, Kentucky Shannon Rozell, MPA, Michigan Dorothy Hillaire, LSW, LCDC II, Ohio Daniel Bizjak, MSW, ICS, CSAC, Wisconsin

Susan Campion, LADC, LMFT, Connecticut Ruth A. Johnson, LADC, SAP, CCS, Maine Gary Blanchard, MA, LADC, Massachusetts Kelly Reardon, New Hampshire Christopher Taylor, CASAC, LMHC, MAC, SAP, New York John Mann, LADC, Vermont

NORTHWEST Diane C. Ogilvie, MAEd, Alaska Malcolm Horn, LCSW, MAC, SAP, NCIP, Montana Jennifer Velotta, MNPL, NCAC II, CDP, CPP, Washington SueAnne Tavener, MS, LPC, LAT, Wyoming

SOUTHWEST

MID-ATLANTIC

Carolyn Nessinger, MA, LAC, Arizona Thomas Gorham, MA, CADC II, California Thea Wessel, LPC, LAC, MAC, Colorado Kimberly Landero, MA, Nevada J.J. Azua, LADAC, CPSW, New Mexico Shawn McMillen, Utah

Jevon Hicks Sr., BS, ICADC, Delaware Johnny Allem, MA, District of Columbia David Semanco, Virginia Mary Aldrich-Crouch, MSW, MPH, LICSW, MAC, AADC, West Virginia

SOUTHEAST MID-SOUTH Suzanne Lofton, LCDC, ADC, SAP, Texas

Sam Long IV, NCAC I, Alabama Bobbie Hayes, LMHC, CAP, Florida Ewell Herndon, Georgia Tony Beatty, MA, LCAS, CCS, North Carolina James Wilson, NCAC II, MRC, CCS, South Carolina Lori McCarter, LADAC, QCS, Tennessee

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