Advances in Addiction & Recovery (Winter 2013) by NAADAC, the Association for Addiction Professionals

WINTER 2013 Vol. 1, No. 4

The Official Publication of NAADAC, the Association for Addiction Professionals

Association Update:

NAADAC President Looks Back on 2013 PAGE 4

Making a Difference:

Working With Legislators to Make Positive Change PAGE 15

Up in Smoke: the Toll of Tobacco PAGE 18

CALLFOR

PRESENTERS

Proposals are due by the close of business on December 11, 2013

Access to third party billing – the how to’s Addiction education Adolescent treatment strategies Brain neurochemistry and recent advances Clinical supervision Cognitive behavioral therapy Co-occurring disorders Comparative effectiveness of addiction treatments Cross-cultural treatment strategies Electronic health records and your services

Ethics Families – history, therapy, courts, recovery HIV/AIDS Integrating addiction, mental health and primary care Lessons to learn from the Affordable Care Act Marijuana and designer drugs Medication Assisted Treatment and Recovery Pain and addiction Post-traumatic stress disorder and addiction Prevention Psychopharmacology related to addiction Recovery oriented practice/Peer recovery support Relapse prevention School-based services Spirituality and recovery Trauma and addiction Veterans and addiction

NAADAC’s Annual Conference will be held in Seattle, Wash., at the DoubleTree Hotel Seattle Airport from September 27–October 1, 2014. NAADAC and its partners are calling for workshop proposals that offer unique educational experiences for addiction focused professionals. How Will Presenters be Selected? The Conference Committee will accept presenter applications until the close of business on December 11, 2013. Applications will be selected according to the following criteria: • All sections of the application are complete. • Presentation description is clearly written. • Learning objectives are clearly stated. • Session structure and organization are clearly defined. • Presenters have sufficient experience and knowledge of the subject matter.

HOW

WHAT

We are seeking current and relevant information addressing:

Scoring Criteria Each presentation will be ranked out of ten points: three points for topic relevance; three points for a compelling description and use of evidence-based practices; three points for unique approach to/or delivery of the subject matter and one point for being a current NAADAC member.

What Resources Will be Available to Presenters? • The conference committee will consider proposals for 90 minute or three hour sessions. Because the conference committee will select a limited number of proposals, please assure that you do not have a scheduling conflict if your proposal is selected. • Presentation rooms will hold between 50-60 people depending on space configuration. • Invited presenters will be granted complimentary admission for the day they are presenting at the conference but will be responsible for their own travel, lodging arrangements and costs. Depending on the schedule, some meals may be provided. (Scholarships may be available through NAADAC. Contact Donovan Kuehn at dkuehn@naadac.org for an application form.) How Will I Know if I’ve Been Selected? The Program Committee will contact chosen presenters by email by February 3, 2014. It is expressly understood that the presentation may be scheduled at any time on any of the conference dates at the discretion of the conference organizers. Please state if you have a day preference and your request will be considered if possible. Other Deadlines/Expectations • All copies of handouts, presentations and any other materials must be submitted by July 24, 2014. If presenters wish to distribute additional materials, they are the responsibility of the presenter. • A photo to be used in the conference program must be submitted in electronic format by July 24, 2014. • Five assessment questions for session participants must be submitted by July 24, 2013. • Presenters will be expected to sign an agreement if chosen to be present at the conference.

READY

To apply, visit www.naadac.org/conferences Proposals are due by close of business on December 11, 2013

HOSTED BY

Conference details at www.naadac.org/conferences

Contents DEPARTMENTS

FEATURES

Children, Trauma & Technology Highlight Annual Conference Atlanta

Meeting Sells Out

MEMBERSHIP: Advocating for Our Profession President and Executive Director Insights

CLINICAL CON SULTATIONS

Your Clients and Suicide

States, Insurance Companies Thwart Use of Medication to Reverse Opioid Epidemic

Addiction Focused Profes- sionals can Create Positive Change

March 2–4, 2014

ADVOCACY: A Case Study: CAAP’s 2013 Legislative Initiative Success

Restores and Enhances Licensure for Alcohol and Drug Counselors

Tackling One of the Toughest Addictions: Nicotine What can we do to help clients quit?

National Drug Facts Week Targets Youth

Educating Teens About Drug Abuse is Crucial

NAADAC

Board of Directors

Seeing Emotion As Information

How do we weather the storms of live in recovery?

WINTER 2013 Vol. 1 No. 4 Advances in Addiction and Recovery, the official publication of NAADAC, is focused on providing useful, innovative and timely information on trends and best practices in the profession that are useful and beneficial for practitioners. NAADAC, the Association for Addiction Professionals, represents the professional interests of more than 75,000 addiction counselors, educators and other addiction-focused 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 Telephone Email Fax

1001 N Fairfax Street, Suite 201 Alexandria, VA 22314 1.800.548.0497 naadac@naadac.org 703.741.7698

Managing Editor

Donovan Kuehn

Graphic Designer

Elsie Smith, Design Solutions Plus

Editorial Advisory Committee

Kirk Bowden, PhD Rio Salado College

Alan K. Davis, MA, LCDC III Bowling Green State University

Carlo DiClemente, PhD, ABPP University of Maryland, Baltimore County

Rokelle Lerner Cottonwood de Tucson

Cynthia Moreno Tuohy, NCAC II, CCDC III, SAP NAADAC, the Association for Addiction Professionals

Robert Perkinson, PhD Keystone Treatment Center

Robert C. Richards, MA, NCAC II, CADC III Willamette Family Inc.

William L. White, MA Chestnut Health Systems

We are interested in accepting any interesting and topical articles that address issues of interest to addiction-focused professionals. Have a story idea or article that you’d like to submit? Contact Donovan Kuehn at dkuehn@naadac.org and share your story idea. Publication Guidelines ● Articles must be the work of the author(s) and not subject to copyright. ● Articles must not contain information that promotes unethical activities or business practices. ● Submissions can be from 500 to 3,000 words. Longer articles can be submitted in consultation with the editor. ● Submitted works must include citations and a bibliography, or be clearly marked as an opinion piece. ● Authors must submit a biography and photo to be appended to the article. Photos need to be at least 300 KB in size and in JPG or PNG format. NAADAC reserves the right to edit or condense any articles.

Welcome to the

latest issue of Advances in Addiction and Recovery! We hope you enjoy it. Donovan Kuehn, Managing Editor

COMMENTARY: Medical Mari- juana and Ethical Di- lemmas for Chemical Dependency Professionals As voter initiatives pass, where does this leave treatment professionals?

Comments?

Send to Donovan Kuehn at dkuehn@ naadac.org

The Mindful Practices of Alcoholics Anonymous Mindfulness is Inseparable From Core Values of Surrender and Acceptance

Advertise With Us NAADAC accepts advertising placements. For more information on advertising, please contact Elsie Smith, Ad Sales Manager at esmith@ naadac.org or Donovan Kuehn at dkuehn@naadac.org. Advances in Addiction and 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 December 2013 STAY CONNECTED

Cover: MATT Antonino | PhotoSpin.com

Advocating For Our Profession Membership

Transformations and Challenges Don’t Stop the Association’s Progress B ob R ichards , MA, NCAC II, CADC III, NAADAC P resident My first year as your president has been both eventful and exciting. Filling the shoes of Immediate Past President Don Osborn was challenging; however, his leadership made the task far less daunting. My first task was to ensure the continuation of the work already begun and bring everything to the table that my knowledge and experience could add. The poor economy has been a challenge in the past and continues to be so. Dramatic changes in health care transformation have only added to our trials. I am comfortable in saying however that NAADAC is, was and, in my opinion, will always be up to those tasks.

Organizational Efficiency Under the leadership of Executive Director Cynthia Moreno Tuohy, the NAADAC staff have worked diligently to improve the way we do business. We are nearing completion of our annual audit and restructuring of the association’s operations continues. We are committed to finding new and innovative business approaches that not only increase efficiency, but also reduce operating costs.

Public Policy We have strengthened, and continue to strengthen, partnerships with other organizations related to our mission, as well as increasing and developing relationships on Capitol Hill. Through our advocacy efforts we are working hard to “level the playing field” so that our profession, our work and the people we serve have an equal voice and consideration by the nation’s political and regulatory leadership.

Our Members and Professionals There is no addiction profession without good, wellpaying jobs. We are working hard to make our voice heard regarding the needs of our workforce. Our number one goal is to sustain and grow the addiction workforce. The keys to helping our professionals are: ■ Understanding and working under the Patient Pro tection and Affordable Care Act (PPACA): Addictionfocused professionals must have the ability to be compensated under the PPACA for a continuum of services that includes prevention, intervention, treatment and recovery support. ■ Insurance parity: Parity regulations must cover substance use disorders to create equal access to care for people who suffer from addictive diseases. ■ Funding and the federal block grant: Addiction touches almost every family in America. Funding should not be a barrier to treatment. Public and pri-

4 Advances in Addiction & Recovery | WINTER 2013

vate funding needs to be available to combat the number one health crisis facing the United States. ■ Loan forgiveness: As student debt rates rise, addiction-focused professionals have been partic ularly impacted. Education programs at every level need to be affordable and supported by loan forgiveness programs for people who need them. ■ Minority fellowship: Culturally accessible services produce stronger outcomes. Addiction professionals are currently left out of the minority fellowship program to the detriment of the clients who would be served. ■ Health information technology (health IT): Reim bursement will be tied to electronic medical records. Without electronic medical records, organizations and agencies will be less competitive. Congress needs to provide HIT resources for infrastructure to addiction-specific agencies. ■ Peer recovery specialists: Peer recovery has been a foundation of the recovery movement. That foundation must be solidified with national standards and scopes of practice. ■ Mentoring: Fifty percent of new professionals leave the field in the first three years of their career. Cre ating systems and programs that transfer knowledge from experienced to new professionals will support a stable workforce and help client care outcomes. A second part of serving the profession is ensuring that our treatment methods stay up-to-date and serve the needs of our clients. Under the leadership of Kathy Benson, the chair of the National Certification Commis sion for Addiction Professionals (NCC AP), our credentialing continues to keep pace with the changes impacting on our profession. I won’t date myself by expounding on how long I’ve worked at this profession. I will say however that I entered the workforce at the grass roots level when substance abuse treatment was struggling to be recognized as a profession. At the time we were called “paraprofessionals.” In some cases that was accurate. I remember some programs where the only qualification required to become a “counselor” was to have graduated from that program as a patient. Out of those beginnings, programs have evolved into the fine treatment options we have today. For years we struggled just to be recognized as “professionals.” Today we are professionals, practicing as a profession. Unfortunately, some of the changes we are facing threaten to set us back decades in that reRichards, continued on page 6 ☛

Membership

NAADAC on the Move in 2013 Partnerships and Collaboration Set the Agenda C ynthia M oreno Tuohy, NCAC II, CCDC III, SAP, NAADAC E xecutive D irector NAADAC Executive Committee and staff have worked to make this year a vital year in the growth and development of the Addiction Profession and in your personal professional development through NAADAC’s Four Pillars. The transition of Past President Don Osborn to new President, Robert “Bob” Richards went smoothly. Bob has many years of service in the Addiction Pro fession, starting at the grass roots level and eventually becoming Executive Director of a multi-service, comprehensive addiction service programs. Bob’s experience and dedication has added to the development of our association and the work we have committed to do. The following are some highlights:

Professional Development ■ Education and training stand at the center of

NAADAC’s efforts to ensure professional development for those who are members and those yet to become members. This year, 75 CEs were made availa ble to NAADAC members at no cost! The webinars offered by NAADAC are world class and range from new evidence-based practices, to new regulations and the Affordable Care Act, to Recovery to Practice. Reduced rates at Affiliate and NAADAC’s Annual Conferences are our commitment to serve your professional needs. ■ Professional standards stand side-by-side with our efforts in education and training. NAADAC continues to support the National Addiction Studies Accredita tion Commission (NASAC) for higher education addiction accreditation. NASAC is growing and gaining recognition in the higher education accreditation world. ■ The National Certification Commission for Addiction Professionals (NCC AP) has grown and developed new standards through certifications and endorsements. As the work of the Affordable Care Act becomes more integrated, NCC AP has developed a Cooccurring Competency Test that can be used at the state level to ensure knowledge and skill levels in treating co-occurring disorders. NCC AP has other new credentials, including Student Assist ance Professionals and Adolescent Certification. In 2014, the NCC AP will also be launching a Peer Recovery Specialist credential. ■ Through our Affiliates throughout the United States, mentorship and professional development for interns and young professionals continue to grow, as well as student/intern malpractice insurance to assist in their protection. Many State Affiliates have free training and other mentor services for budding professionals.

■ NAADAC is changing and growing our training serv

ices to include more online training products and certificate programs. Look for these in the Winter of 2013 and Spring of 2014. ■ NAADAC’s Code of Ethics is in the process of being updated to include the new challenges in telecounseling. Look for more information coming in the next year. ■ NAADAC and the National Council on Behavioral Health engaged in a professional exchange trip to Cuba in December 2012. It was a great exchange between the professionals on the trip as well as with our Cuban colleagues. ■ IC&RC, NCC AP and NAADAC have been in dis cussions to work together to represent the addiction professionals in this time of change and integration. We are working to develop strategies to work to gether to support the workforce and the addictionspecific profession.

Public Engagement ■ NAADAC launched its vibrant and user-friendly web-

site just prior to this year’s Annual Conference. We are proud of our team that has worked to pull this together — your NAADAC staff. ■ More and more members are needed to be engaged in their affiliates, in leadership and in State and Na tional Committees. We have added new recruits and continue to look for more to come. ■ Networking has always been a key benefit to membership in NAADAC and the sharing of information and ideas. We see this from the community level, through to the State and National levels. NAADAC Affiliates have their own conferences, at many of which the National office is represented and working to engage professionals internally and also externally through advocacy. ■ Advocacy is a key component in our public engagement initiatives. NAADAC works at the Federal level with SAMHSA, HRSA, ONDCP, NIDA, NIAAA, HHS and other departments to ensure that your agenda items are being addressed, especially in the workforce arenas.

WINTER 2013 | Advances in Addiction & Recovery 5

Membership

■ NAADAC has given testimony, supported National

Bills released and given recommendations to SAMHSA, HRSA, ONDCP, Veteran’s Committee and legislators on Capitol Hill this past year. ■ NAADAC’s new magazine, Advances in Addiction and Recovery, has become well-known as a great treatment and recovery resource for both those who serve in the addiction and other helping professions and to the clients we serve. The Editorial Advisory Com mittee is working to build this publication in its educational information that will assist all readers to learn and enjoy the magazine. ■ This year, NAADAC has been involved in print and TV media, as well as having a huge increase in social media through Twitter, Facebook and LinkedIn. Our connections at all levels have increased tremen dously. NAADAC is speaking to your issues and getting the message out to the public. ■ NAADAC works with many other associations and organizations including: Recovery Month Partners, Addiction Leadership Group, National ATTC/NIATx, National Council on Behavioral Health, NORC at the University of Chicago, Hispanic and Latino ATTC, National Center for Responsible Gambling, IC&RC, SBIRT ATTC and many others.

Professional Services ■ NAADAC’s 47 State and International Affiliates re-

ceive technical support and professional services: from training and curriculum development, to technical assistance and certification testing to advocacy. NAADAC has worked this year to support state licensure bills, state support of addiction treatment services and support for the addiction professional being seen as the professional to treat and be paid for addiction services. ■ NAADAC has worked to build awareness and education to our State Affiliates in the Center for Medicaid Services (CMS) for consumer sign-ups in the Affor dable Care Act. ■ NAADAC launched the “Professional eUpdate” a weekly e-blast out to over 31,000 professionals adRichards, continued from page 4

gard. That is why it is critical that we all stand up for who we are and advocate for our profession. That is why I am a NAADAC member and that is going to be on the top of my priority list during the coming year and beyond. All in all however, I consider the past year to have been a very good year for us in spite of adverse conditions and I strongly believe that NAADAC will continue to be the leader in advocating for our profession well into the future. Robert C. Richards, MA, NCAC II, CADC III, is the President of NAADAC and served as Executive Director of Willamette Family Inc. which operates eight facilities in Eugene, Springfield and Cottage Grove Ore. During his over 28 years as an addiction professional he has worked as a counselor, clinical supervisor, administrator and educator. He is a past member of CAAP, the Addiction Technology Transfer Center (ATTC) founded Consortium for the Advancement of Addiction Professionals and has been a member of various state and local groups and taskforces including a detoxification taskforce and a heroin task force. He has also served as a peer reviewer during numerous site reviews for the State of Oregon Office of Mental Health and Addiction Services. Richards is an experienced trainer specializing in cultural aspects of addiction, spirituality, advanced counseling skills and other topics. 6 Advances in Addiction & Recovery | WINTER 2013

vising them of training and other relevant news events. In December of 2013, we will be launching “Addiction and Recovery eNews” that will give specific news of the profession. ■ NAADAC’s Approved Training Provider Program is growing and representing more training and education entities throughout the United States. ■ The Substance Abuse Professional qualification through the Department of Transportation program continues to grow and will likely become more important as a result of the Affordable Care Act. We will see these services expanding to online services as well as the current home-study and face-to-face methods that we use currently. ■ NAADAC works with American territories and at the international level, bringing education, training, certification and technical assistance to areas such as Puerto Rico, the Pacific Jurisdictions, Hong Kong, South Korea, Cuba, the Colombo Plan, the World Federation and many others.

Communicate the Mission ■ Recovery Month is a hallmark initiative of NAADAC’s

dating back to l989 with Treatment Works!, when NAADAC started grassroots work to build the image of addiction treatment. This initiative was later taken on by SAMHSA and renamed Recovery Month. This year, we continue to support the mission of Recovery Month to communicate to the public that recovery is possible and there are many pathways to recovery. ■ The Recovery to Practice project, a SAMHSA initiative that NAADAC was a part of, has brought us full circle. The key to this project is communicating the competencies of recovery and providing professional guidelines that provide quality services and hope to those who are in the recovery process. I invite you to review the core principles outlined in the NAADAC webinar series. ■ NAADAC worked in partnership with the State Asso ciations of Addiction Services (SAAS) and Treatment Comm unities of America (TCA) for the 2013 Ad vocacy Leadership Summit — NAADAC’s advocacy conference. Dedicated professionals from across the United States learned about the issues facing the field and then communicated these to their national representatives on Capitol Hill. ■ NAADAC will continue to focus on workforce issues, including loan forgiveness programs, inclusion on reimbursements, employee benefits and salary issues. NAADAC will accomplish this through our Public Policy and public engagement efforts. We will continue to build those efforts as it is an investment in our future. Thank you for the opportunity to serve you! Respectfully submitted, Cynthia Moreno Tuohy

Children,Trauma & Technology Highlight Annual Conference Atlanta Meeting Sells Out B y D onovan K uehn , NAADAC A dvances

Atlanta was at the center of some of the most interesting discussions on a ddictions in October. Hosted by NAADAC at its national conference, some of the best minds focused on a ddiction prevention, intervention and treatment gathered with over 600 participants to address the topics key to addiction-focused professionals. It is impossible to do justice to the dynamic energ y and information shared at the meeting. Here are some of the highlights of the proceedings.

A ddiction

and

R ecover y E ditor

Message from Georgia Gov ernor Nathan Deal On behalf of the State of Georgia , it sure to be a part of your event. Plea is a please allow me to welcome your distinguished guests, addiction counselors, educators, add iction-focused health care professionals, and othe r attendees. I commend NA ADAC for thei r dedication to prevention, inte rvention, qua lity treatment and recovery support. Your mem bers help individuals on a daily basis work towards a life of recovery and continue a life substance-free. Add iction and substance abuse rob our citizens and their loved ones of happy, fulfilling and productive lives. Your effort in combating these dire situations is truly appreciated. I send my best wishes for a succ essful and enjoyable event. Sincerely, Nathan Deal

Dr. Frances Brisbane and Dr. Vincent “Peter” Hayden Dr. Frances L. Brisbane, Dean and Professor of the School of Social Welfare, State University of New York at Stony Brook and Dr. Vincent “Peter” Hayden, CEO of Turning Point, Inc., an African American social services organization with a holistic approach to counseling and treatment located in Minneapolis, Minn., opened the NAADAC conference. They presented a compelling description of how effective prevention and treatment of substance abuse and addiction responds best when the client’s or patient’s culture is factored into the process. They outlined the fact that while most people develop the disease of alcoholism in a general progression medically, the prevention and treatment need to respond to individual and group cultural behaviors, mores, beliefs and other historical and legacy determinants. They felt that being aware and respectful of cultural differences among individuals as well as their sameness, in many ways, makes for good medical and social outcomes.

Jerry Moe The National Director of the Betty Ford Center Children’s Programs, addressed the issue of parental recovery and its impact on children. Moe described to attendees how kids have a unique perspective in viewing the world. While it has long been held that alcoholism and other drug addiction are a family disease, there are few opportunities for young children to be an integral part of the treatment and recovery process. He described how children see addiction in their families and, more importantly, how they embrace the healing process. Moe believes that there is much hope when we treat the whole family. Moe asked the profession to be proactive: “I want to see a study on recovery and how it affects families, not more on how kids are affected by addiction.” Moe, pulling from his sometimes heart-breaking experiences at the Betty Ford Center, had a simple point for clinicians. “Kids don’t care about how much you know until they know about how much you care,” he said. Dr. David Mee-Lee David Mee-Lee, MD, is a board-certified psychiatrist and is certified by the American Board of Addiction Medicine (ABAM) and is also Senior Vice President of The Change Companies. He has led the development of the ASAM Criteria for the Treatment of Substance-

PHOTOS BY DONOVAN KUEHN | NAADAC.ORG

The Leadership Orientation session at the NAADAC Annual Meeting was well attended. The Dancing Mindfulness session, held outdoors, was enjoyed by all who participated.

WINTER 2013 | Advances in Addiction & Recovery 7

Allan Barger Related Diso rders since the late 1980s yor Kasim Reed Ma a ant Atl Allan Barger has 24 years of experience in from and is Chief Editor of A SA M PPC -2R ge ssa Me AC I thank the members of NA AD the alcohol and drug profession, working as (2001) and the new edition of The ASAM help for providing critical services to a research analyst and trainer with Preven Criteria (2013). ng ggli stru individuals and families peo the of tion Re s earch Institute and having worked lf Dr. Mee-Lee described the ASAM Cri beha n n.O with addictio es to as a community volunteer, a Prevention teria — the most widely used and compreple of Atlanta, I extend best wish ting you for a rem ark abl e and exci Specialist in a community Mental Health hensive set of guidelines for assessment, t. even Center, and adjunct faculty at Easte rn s ervice planning and placement in the Sincerely, Kasim Reed Kentucky University teaching courses on treatment of addictive disorders. A new edialcohol and drug problems. tion was released in October 2013. Barger addressed the new reality in which professionals find themHe described the current regulatory environment facing addictionfocused professionals. With the Affordable Care Act (ACA), there will selves with the renewed acceptance of marijuana use, including legalbe many more people eligible for addiction treatment in treatment ization. While the public has come to view marijuana as harmless, a programs, but even more in general healthcare settings where the cus- growing body of research suggests otherwise. He focused on five areas of risk supported in the research: acute impairment; lingering effects; tomers really are. psychosis; dependence and addiction; and life outcomes. Dr. Darryl Inaba Darryl S. Inaba, PharmD, CADC III, is currently the Director of See More Than the Highlights Handouts from most of the presentations can be found online on Clinical and Behavioral Health Service, Addictions Recovery Center, Medford, Ore. and Director of Research and Education at CNS the NAADAC conference page: www.naadac.org/conferences. In addition to the plenary sessions and over 55 workshops, NAADAC Productions, Inc., also in Medford. Dr. Inaba presented the world premiere of his new video Beyond presented its awards to five outstanding professionals and programs. Opiates at the NAADAC conference. Beyond Opiates examines the 3 NA ADAC Conference science of pain and its influence on recovery from opioid dependency. My Experience at the 201 not know what to expect; however did I say st mu Most importantly it presents the new paradigm for understanding I attend the conference I did know that my focus was to chronic pain, showing how the extended use of prescription pain into co-occurring ght with hopes of gaining more insi killers increases the sensitivity of nerve cells thereby magnifying pain ght, I also made insi e mor gain I did disorders. Not only assed my expecsurp (hyperalgesia, hyperpathia, alodynia). new friends and connections that In Dr. Inaba’s closing plenary, he discussed the wide variety of new tations. s of many vendors as In addition to that, the exhibit synthetic and natural chemicals that are recently being abuse. He speakers and staff of the with ns atio well as the consult focused on synthetic cannabinoids, “bath salts,” prescription opiates, to age ired, encour d and confident NA ADAC left me motivated, insp quality care to the dually diagKratom and “shake and bake” methamphetamine, the toxic and g idin continue in my profession prov to the addict ion characteristics of these substances and how they impact ADAC family and I look forward nosed population. I love my NA sh.! recovery and treatment. 2014 conference in Seattle, Wa erience ! Rosalyn Young Thank you for a wonderful exp The hotel courtyard provided the perfect location for a group shot of participants.

8 Advances in Addiction & Recovery | WINTER 2013

Mel Schulstad Professional of the Year Presented for outstanding and sustained contributions to the advancement of the addiction profession. Presented to Ebony Jamillah Stockton, MEd, LCAS, CCDP, CSAC. Residing in the Hampton Roads area of Virginia, Stockton currently works for the Department of Navy, at the Substance Abuse Rehabilita tion Program (SARP) at Naval Medical Center in Portsmouth, Va. Currently serving as the only Dual Diagnosis Counselor at Naval Medi cal Center Portsmouth, she counsels active duty members and their dep endents who suffer from co-occurring disorders with mental health issues and addiction issues. William F. “Bill” Callahan Award Presented for sustained and meritorious service at the national level to the profession of addiction counseling. David “Mac” Macmaster, CSAC, TTS, has been an addiction specialist since 1975 in Iowa and Wisconsin. He has been a certified addic tion counselor, program director and administrator, grant writer, program developer, interpersonal skills trainer and prevention specialist. Mac achieved the Advanced Member in the American College of Addiction Treatment Administrators when he was the director of New Directions at the St. Francis Medical Center in La Crosse, Wisc. Currently, Macmaster is co-founder and managing consultant for the Wisconsin Nicotine Treatment Integration Project (WINTIP) in Mad ison, Wisc. WINTIP is coordinated by the UW School of Medicine’s Center for Tobacco Research and Intervention. Lora Roe Memorial Alcoholism and Drug Abuse Counselor of the Year Presented to a counselor who has made an outstanding contribution to the profession of addiction counseling. Mary Sugden, CADC II, LADC I, began her career at the Berkshire Council on Alcoholism & Addictions working with families, women, local courts, driver alcohol education and extended care. She continued with BCAA after it merged in 1997 with what is known today as the Brien Center for Mental Health and Substance Abuse Services.

Sugden’s career progressed also with a position as a Substance Abuse Clinician III. She provided individual assessment, treatment planning, supervision and relapse prevention — facilitating many groups such as the Second Offender Aftercare, Suboxone and DCF. NAADAC Organizational Achievement Award Presented to organizations that have demonstrated a strong commitment to the addiction profession and particularly strong support for the individual addiction professional. In 1969, when drug addicts walked the streets of Charlotte, N.C., with nowhere to go to begin a journey of recovery, Open House was founded to provide a welcoming starting point. From humble beginnings, with a small staff in a YMCA basement, Open House grew into the McLeod Center of today; the largest treatment center in North Carolina, employing over 300. Lifetime Honorary Membership Award This award recognizes an individual or entity who has established outstanding service through a lifetime of consistent contributions to the advancement of NAADAC, the addiction profession and its professionals. James Martin, MSW, CSW, NCAC II, MAC, CEAP, SAP, has 30 years of experience in mental health and is a former chairperson of the NAADAC National Certification Commission. He has received an award for Outstanding Contribution to the Field from the Governor’s Advisory Board on Substance Abuse and Distinguished Service Awards from the Michigan Association for Alcoholism and Drug Abuse Counselors and NA ADAC, the Association for Addiction Professionals. He has both Bachelors and Masters degrees of Social Work from Madonna College and the University of Michigan, respectively. For full details on NAADAC’s awards, go to www.naadac.org/recognitionand-awards. NA A DAC w ill be hosting its 2014 meeting in Seattle from September 27 to October 1. Visit www.naadac.org/conferences for more information.

WINTER 2013 | Advances in Addiction & Recovery 9

Your Clients and Suicide Clinical Consultations B R C , LCSW, LCAC, NCAC II T D y

Clinical Consultations aims to address real questions and dilemmas that practitioners encounter in their daily practice. Have a question or advice to share? Send your thoughts to Donovan Kuehn, Managing Editor, at dkuehn@naadac.org. The question for this issue:

“ What are the key factors professionals need to identify in suicidal ideation and assessment in our clients? What resources are available to professionals to help?”

hupp

and

urham ,

Suicide and Drinking are Connected First of all, it is important to remember that depression and SUD are often found in the same person. These are two separate, primary illnesses and both need to be treated. A person who has clinical depression will not automatically get over their depression when he or she achieves sobriety, nor will he/she automatically get over their addiction if the depression is successfully treated. A person can relapse on either disease, and ignoring one disease to treat the other will guarantee a relapse on the one you are treating. There are several key factors that professionals need to be aware of in order to identify and assess for suicidal ideation in our clients. When a person talks about suicide, ending their life, wanting to be done with it, etc., this constitutes suicidal ideation and we need to take them seriously. We must assess the person to see if he or she has a plan and/or intent beyond the ideation, and whether they have access to the method in their plan. If they have intent, a plan, and a method available, they need to be hospitalized on a psychiatric unit immediately. A family member, friend, or the police, need to remove any and all potentially suicidal objects the person has in their home before he/she can safely return. Similarly, a person who is intoxicated and talks about suicide needs to be hospitalized. The impairment in reasoning and judgment caused by the intoxication triples the risk that the person will follow through with their ideation. Seventy percent of suicides are committed by people who have been drinking. They are best

Don’t Ignore the Subtle Signs Subtle signs of suicidal ideation are most perceptible when they comprise changes in behavior patterns. Some of these changes may not even appear to be typical of what is expected of someone contemplating suicide. For instance, many who have made the decision to take their lives may show sudden signs of happiness or contentment. I’ll never forget the time that, by chance, I ran into the teenage son of a colleague. The young man seemed overly eager to greet me. We weren’t expected to meet and he was uncharacteristically overjoyed with the chance encounter. Though I liked the kid and was an acquaintance with his father, I thought his behavior a bit strange. Tragically, it became all too clear to me a week later when he committed suicide. It is important to keep in mind that for many who are serious about taking their lives, some plan ahead, get their affairs in order, and make it a point, in their own way, to say their good-byes. When there is no other logical explanation for this type of behavior, it should not be ignored. In fact take it as a bright red flag if such actions follow struggles with major life difficulties, such as divorce, depression, loss of job, etc. The young man who took his life (and this was over 20 years ago) was struggling with his sexual orientation and felt he couldn’t talk about it to anyone (no one had a clue — this came 10 Advances in Addiction & Recovery | WINTER 2013

P h D, LADC

managed in a psychiatric inpatient unit rather than in a detox center, due to the specialized care needed. Another factor that plays a significant role in suicidal behavior is trauma. The vast majority of our addictions clients have a significant trauma history. We not only need to assess for trauma at intake, but develop treatment protocols to address trauma as part of our normal treatment process. When studies show that around 85 percent of people with addictions also have significant childhood trauma, we must do a better job of treating trauma in our addictions programs. Doing so would have a solid impact on reducing suicides. Most counties in the U.S. have a Community Mental Health Center to which we can refer people when they present with suicidal ideation. Many local governments also have a suicide hotline or suicide prevention coa lition we can utilize. The Internet has multiple sites created by experts where professionals can gather a variety of good ideas on how to best help our clients with suicidal ideation and behaviors. Ron Chupp, LCSW, LCAC, NCAC II, has worked in Mental Health and Addictions since 1991. He received a Baccalaureate degree in Social Work from Goshen College in 1993 and his Master’s degree in Social Work from Indiana University in 2005. He works as a Mental Health and Addiction Counselor at Northeastern Center in LaGrange, Ind., and as an adjunct Professor for the Addictions Program in the School of Social Work at Indiana Wesleyan University. Chupp has chaired the Indiana Association for Addiction Professionals (IAAP) Ethics and Bylaws Committees and has trained numerous jail personnel in preventing suicide among inmates.

out after his death through writings he left behind in a journal). When we think about symptoms of suicidal ideation, the obvious signs usually come to mind — it’s the subtle clues that tend to be ignored. Many times, individuals who have suicidal ideation feel trapped with no outlet of relief for the internal turmoil they may be experiencing. Relief can begin with an understanding ear. As therapists we need to be tuned in to the behavioral shifts in our clients that may be indications of such turmoil. An understanding ear can often provide relief from internal turmoil such as what the young man I encountered was likely experiencing. In cases like the tragic suicide of the young man I referred to, having someone he could talk to about his internal turmoil, could have circumvented his tragic death. Thomas Durham, PhD, LADC, brings more than 35 years of experience in behavioral health treatment and has been an educator and trainer for over 20 years delivering a variety of training topics for behavioral health professionals on topics such as clinical supervision, motivational interviewing, co-occurring disorders, ethics, medicated assisted treatment, compassion fatigue and leadership. Dr. Durham is Program Manager of the Prescription Drug Abuse and Overdose Prevention Program at JBS International where he develops curricula and coordinates training programs for physicians and other healthcare professionals.

A Case Study: CAAP’s 2013 Legislative Initiative Advocacy

Success Restores and Enhances Licensure for Alcohol and Drug Counselors B y S usan C. C ampion , LADC, LMFT, P resident

of the

C onnecticut A ssociation

Addiction-focused professionals are facing challenges throughout the nation as the regulatory environment changes. This submission outlines how addiction professionals in Connecticut managed their response to the change. – Editor.

Introduction: A Radical Change Impacts on the Connecticut Addiction Specialists Workforce

PS productions | photospin.com

In 2012, an amendment was added to the Con necticut statute governing Licensure of Alcohol and Drug Abuse Counselors (LADC) on the last day of the sitting of the General Assembly. There was no public hearing or even advance warning to the Connecticut Association of Addiction Professionals (CAAP), stakeholders and/or consumers that the legislation was being considered. This amendment stripped the licensure of its alcohol and drug abuse-specific educational credentials and Master’s degree requirements. The change severely impaired the professional standing of the Master’s level, licensed addiction specialist in meeting national behavioral health credentialing. As a result, the licensing requirements no longer maintained professional parity with the licenses of social workers, marriage and family therapists and professional counselors. The profession, and all those who relied on its services, was in serious jeopardy. By the Spring of 2013, the LADC workforce had begun to experience erosion of employment opportunities across the state. Agencies, which historically recruited LADCs, were recruiting LCSWs, LMFTs and LPCs instead. The result was indisputable: licensed addiction

Former NAADAC Regional Vice President Barbara Fox testifies before the Connecticut Public Health Committee.

A ddiction P rofessionals

specialists had lost professional standing as a key rovider in Connecticut’s behavioral health network of p services. Unless something changed, the weakened license with the amended credentials would also prevent LADCs from future participation in health services offered under the Affordable Care Act.

Taking a Stand: Preparations for Legislative Campaign In late 2012, CAAP reviewed the licensure problem. As Public Policy Chair, I had led the original licensure legislative initiative over a three year period, which culminated in achieving licensure for the state’s master’s level alcohol and drug counselors in 1998. I wanted to build on that experience to help change the new, flawed regulations. CAAP mapped out a strategy educate legislators on the impact of the changes and initiate a positive effort to strengthen the licensure rules. Phase I: The Initiation Phase – Presentation of the Legislative Goals and Objectives From February–April 1, 2013, CAAP worked to create an environment for change. The first step was to create a legislative initiative team consisting of seasoned advocacy campaigners. These experienced hands would help map out a strategy to contact key influencers and legislators to improve the state regulations. The association made a decision to actively advocate for a behavioral health sciences degree requirement in order to gain professional parity with our behavioral health peers. All public and written testimony presented strong evidence that supported this new requirement. At a key Public Health Committee Hearing, CAAP made a strong showing. Questions and comments appeared to render support of the changes to the licensure. In April 1, 2013, CAAP suffered its first major defeat. The licensure bill with the revisions suggested by CAAP was voted out of Committee with only 300 hours of substance use disorders - specif ic education. The Republicans unanimously voted for the new Master’s degree requirement, but the Democrats, including both Chairs, voted for only the restoration of the educational requirements. Ultimately, t he supp or t of t he Republicans would emerge as an important factor in the final days of the legislative session. Phase II: Facing the Challenges and Obstructions to Legislative Passage – Lobbying Campaign From April 1–May 15, 2013, CAAP changed its strategy from diplomatic influencing to aggressive lobbying. The association built a strong e-mail and phone call WINTER 2013 | Advances in Addiction & Recovery 11

Testimony at the Public Health Committee on the legislative changes to the laws regulating addiction counselors in Connecticut.

campaign to leaders of the Senate and House and the Co-Chairs of the Public Health Committee. The message was clear: bring forward legislation with critical educational requirements and make an amendment to include the behavioral health sciences degree. The campaign included an e-mail blast to all state legislators with a simple, strong message emphasizing the impact of the new regulations on their constituents, who were struggling with active addiction. The campaign received a boost when a Senator from the minority party filed the needed amendment to add a behavioral health sciences degree to the licensure regulations in April 2013. In Connecticut the Republicans are the minority party, but this amendment was helpful as symbol of support. The campaign received a critical victory when CAAP met with the leaders of the legislature’s Public Health Committee. The campaigns and research won the support of the two Co-Chairs of the committee, a key victory as they were charged with drafting the Bill with the amendment. Phase III: Racing Against Time May 15–June 4, 2013; historically, all important bills are left to the end of the General Assembly. CAAP had to contend with critical legislative issues like the budget, which was the most hotly contested legislative act in 2013. Time was running out: the legislation had to be voted upon in both chambers by June 5th. To ensure that this important legislation came to a vote, CAAP led a tight, continuous lobbying campaign through e-mail, phone and by face-to-face. With each phase of this initiative, the association gained greater presence and support in the legislature. The asso ciation’s mission was to go around and over every obstacle to pass the legislation. As a part of this campaign, the Senate Co-Chair of Public Policy, who initially opposed the desired changes to the Bill, became one of its strongest advocates for passage. The Bill passed the Senate on June 1, 2013 with a unanimous vote, but this was only half of the battle. Over the next three days, the CAAP team experienced anxiety, dread and joy due to the number of changes in our strategic playbook. The key to our success was flexibility in process, strong communication lines and unrelenting effort. Our focus for the last days was the intense lobbying of the Demo cratic leadership to get the legislation to a vote in the House. 12 Advances in Addiction & Recovery | WINTER 2013

Once again, the House Co-Chair of the Public Health Committee, who initially opposed the Bill, became our greatest champion in the House. She reported that on the last day of the Session the Repub licans were critical because they could bring the process to a halt. Important bills were “traded” for pet legislation to secure a place on the Speaker’s final Call for a Vote List. Because the ranking Republican member of the Public Health Committee had been a strong supporter of the enhanced license since the Public Hearing, he ran the advocacy with the House Republican leaders. A deal for the Bill to be called was reached around 10 p.m.: two hours before the close of the Session. Time was not on our side. At seven minutes before midnight (the end of the session), I received a message. It read “It is going to go.” At three minutes before midnight, a new and enhanced license for LADCs legislation passed the House of Representatives by unanimous consent. The Bill was signed into law on July 12, 2013 by the Governor. The law marked a new era for Connecticut’s workforce of addiction professionals. Licensure’s credentials gain professional parity with their behavioral health peers — LCSWs, LMFTs and LPCs. And most importantly, the new legislation ensures statutory best practice standards for consumers with substance use disorders. The passage of the 2013 legislation was the result of a coalition of addiction specialists, legislators and influential individuals committed to best practice treatment for Connecticut individuals, families and significant others who struggle with substance abuse.

Lessons Learned In looking back at our success, there were some key components that helped us achieve success. These aspects can be adopted by other professionals striving to build relationships and make an impact with their state’s legislators. Develop an Advocacy Team Legislative advocacy was the most important factor in the success of this initiative. The core of the Connecticut Association Addiction Association’s advocacy consisted of individuals who possessed experience in participating in past legislative campaigns. From the outset, the group developed a set of goals for this initiative: unity of message and action; consensus on strategy development and change; inclusive and transparent communication to all members regarding the legislative process; and most importantly a commitment to ensuring that the license ensured best practice standards for state consumers seeking substance abuse services. Communication Strategies The CAAP team established essential tenets of communication for all stages of the initiative: “Speak with One Voice.” The leader of the initiative mapped out participants’ contacts with legislators; engaged new individuals in the advocacy process; approved all electronic messaging; presented supportive documentation and evidence; and coordinated phone lobbying. Team members had witnessed the negative impact of individuals who had “gone rogue” in their previous advocacy experiences. The leader and the team reviewed and approved various forms of lobbying material through group consensus. The CAAP team and their supporters were kept informed in real time. This practice prevented “splitting behaviors” and power struggles that would have threatened the cohesive momentum of the initiative. CT-N images on pages 11/12 are courtesy of the Connecticut Network and are intended for educational purposes only.

Know Your Opposition Before even attempting to construct a legislative campaign, it is crucial to identify the “who, what and why”: legislators, state government agencies, behavioral health providers and others who may have a solid reason to work against the campaign’s goal. As an example, when the Connecticut Federation of Alcohol and Drug Counselors (CAAP’s former name) conducted its initial campaign for licensure in the late 1990s, it took three years. The process was so laborious because the opposition came from many quarters, including alcohol and drug professional organizations and individuals. The opposition from within our own field made it easy for legislators to dismiss the need for a Master’s level license and keep certification as the standard credential. In 1998, the licensure statute was passed, but not without some structural weaknesses, which came back to haunt the field in 2012. In 2013, the opposition was hidden from the public arena. But in the final two months, CAAP identified the opposition. Because the initiative had gained increasing legislative support, negotiations resulted in support of the new license. The Lack of Clear National Credentialing Body Unlike Connecticut licensed LCSWs, LMFTs and LPCs, state licensed alcohol and drug abuse counselors did not have a national credentialing authority. This factor subtly has played into the public and legislative perception that Master’s level addiction specialists are not on a professional par with their behavioral health peers. It reinforced the opposition’s position that the CAAP’s recommended licensure standards would “be too difficult to attain by individuals entering

the field.” The lack of nationally recognized practice requirements was also an impediment to inclusion in private insurance carriers. All Politics Are Personal Due to their previous experience in legislative advocacy campaigns, the CAAP leadership team recognized the importance of keeping all forms of communication short, simple and strong. The old political axiom of “staying on message” was critical. Legislators are being lobbied 24/7 and their attention span on a particular issue is quite limited. As professionals, we have the tendency to become stuck in overly technical and abstract verbal and written evidence to support legislative objectives. The CAAP team worked diligently to communicate in ways that were visceral, direct and clearly connected the 2013 licensure reforms to the welfare of legislators’ constituents, who were struggling with active addictions. While these lessons were applied to a specific initiative, these principles can be implemented in any state, with positive results. No one will advocate on our behalf — we need to stand up and make our presence felt. Susan Campion, LADC, LMFT, is the President of the NAADAC’s state affiliate, the Connecticut Association of Addiction Professionals. For over 30 years, she has provided a blend of managerial, clinical, consulting/training experience to an array of public and private behavioral health programs, social services and educational institutions. Throughout her career, her managerial accomplishments include; administration of a municipal clinical and community services’ department, licensed outpatient psychiatric clinic, substance abuse treatment agency and Community Health Clinic Division Director for Early Intervention/Prevention and Treatment of HIV/AIDS, which was the largest CHC program in Connecticut. She currently provides administrative and clinical consulting to public and private non-profits, as an independent practitioner.

Online. Convenient.

BestCEU.com Take Your Class Today!

WINTER 2013 | Advances in Addiction & Recovery 13

States, Insurance Companies Thwart Use of

Medication to Reverse Opioid Epidemic B y S tuar t G itlow, MD, P resident

of the

A merican S ociety

Drug overdose death rates in the United States have more than tripled since 1990, and today kill more people than traffic crashes, according to the Centers for Disease Control and Prevention. And yet, state governments and insurance companies regularly deny patients access to FDA-approved medications that could help reverse the epidemic of opioid addiction and overdose deaths. A new report released by the A merican Society of Addiction Medicine (ASAM) examined the effectiveness of opioid medications and found these medications to be effective, safe and cost-effective when used for long-term maintenance treatment. The study, by the Treatment Research Institute and The AVISA Group, found that the costs for these medications to treat opioid addiction are roughly comparable to costs for diabetes medications. The study also reviewed restrictions on these medica tions and found that nearly every state and most insurance companies are arbitrarily restricting their use. Restrictions vary widely from state to state and from insurance company to insurance company, with almost none of them adhering to best practices research-based protocols for these medications. The report included a meta-analysis of research on the effectiveness of buprenorphine, including brand names Suboxone and Subutex, Methadone and injectable extended-release naltrexone, including brand name Vivitrol. The report concludes that the disease of opioid addiction is best managed with an appropriate combination of treatments, including family engagement, behavioral interventions and medications. Evidence shows that we could be saving lives and effectively treating the disease of addiction if state governments and insurance companies remove roadblocks to the use of these medications. Treatment professionals need every evidence-based tool available to end suffering from this chronic disease. Medical science supports the use of addiction medications to treat the disease of addiction. This science should be the basis of state policies, insurance coverage and national standards for the treatment of addiction, the report found. Also, the report brings attention to the fact that addiction is a treatable chronic disease with success and relapse rates comparable to other chronic diseases such as diabetes and hypertension.

… state governments and insurance companies regularly deny patients access to FDAapproved medications that could help reverse the epidemic of opioid addiction and overdose deaths.

14 Advances in Addiction & Recovery | WINTER 2013

A ddiction M edicine

None of the medications by themselves should be c onsidered effective treatments for opioid dependence. All medications are designed for use as part of comprehensive treatment strategies that usually include counseling, social supports and behavioral change strategies. But the medications can be vital treatment components that raise treatment success rates, research shows. Whitney Englander, a patient in long-term recovery using buprenorphine, reported she was regularly denied access to medication even after she and her doctor completed exhaustive paperwork for the necessary preauthorization. Ms. Englander told her story at a recent summit on addiction medications. She said she was often forced to pay for her medication out of pocket or risk relapse. Her insurance company, she said, arbitrar ily decided that she shouldn’t receive the dosage of buprenorphine prescribed by her addiction medicine doctor. “This is discrimination — pure and simple,” she said. “Insurance companies would never deny insulin to a person with diabetes. States would never pass laws limit ing Medicaid coverage of medication for hypertension. Yet people with addiction are routinely treated this way.” The report found one of the biggest hurdles to overcoming this arbitrary denial of access is the stigma asso ciated with addiction treatment medications. Many people — including those working in treatment and recovery — believe it is somehow wrong to treat the disease of addiction with medication. However, these medications have shown good success in helping opioid addiction patients recover and lead healthy and productive lives. State governments and insurance companies must recognize that their policies restricting access to FDAapproved opioid addiction medications are causing preventable suffering and death. And treatment professions need to overcome their own prejudices against addiction medications and begin using them in comprehensive t reat ment protocols for t he disea se of addiction. To read the full report, go to http://www.asam.org/ docs/advocacy/Implications-for-Opioid-AddictionTreatment. Stuart Gitlow is the President of the American Society of Addiction Medicine (ASAM) and is board-certified in general, forensic and addiction psychiatry. He is also the Executive Director of the Annenberg Physician Training Program in addictive diseases. Gitlow has earned MD, MPH and MBA degrees, serves as a medical expert to the Social Security Department’s Office of Disability Adjudication and Review and is on the faculty of Dartmouth Medical School and New York City’s Mount Sinai School of Medicine.

March 2â&#x20AC;&#x201C;4

2014

What Will You

GAIN

From Attending Advocacy in Action? Intensive briefings on current issues in addiction policy and how to positively impact their outcome.

Trainings in advocacy techniques and strategy that can be used in communicating with legislators from the national to local level. Connecting with your members of Congress faceto-face, building a relationship and educating them about the importance of treatment and recovery. Continuing education credits and business hours. An opportunity to network with fellow advocates from across the nation.

Building the identity of addiction professionals

SVLUMA & illustration network | photospin.com

and service providers with national decision-makers in Washington, D.C.

WINTER 2013 | Advances in Addiction & Recoveryâ&#x20AC;&#x192; 15

Addiction-Focused Professionals can

CREATE POSITIVE CHANGE WELCOME

GENERAL INFORMATION

This spring, addiction professionals will leave their group therapy sessions and paperwork behind for a new client: the nation’s lawmakers. NAADAC, the Association for Addiction Professionals, will host the Advocacy in Action conference from March 2–4, 2014, in Washington, D.C. NAADAC’s Advocacy in Action conference is designed to educate addiction professionals about current public policy issues in Washing ton, D.C., and bring their day-to-day experiences and stories to decision-makers at all levels of government. The conference will provide the oppor tunity to meet face-to-face with the nation’s lawmakers and help re-shape how they view addiction. Participants will receive training on advocacy strategies to promote effective prevention, treatment and recovery policies and to help them become active, year-round advocates back in their home communities. If members of Congress do not know that addiction is treatable and that people can and do recover, they have no reason to address the problem. This is why active participation and advocacy are essential, especially from the professionals who, on a daily basis, help combat a disease that affects over 23 million Americans. “As addiction professionals, we have a responsibility to educate the public — in cluding those we’ve elected to Congress — about treatment and recovery. Advocacy in Action is so important because it gives us the tools and training to ensure that we are

Advocacy in Action conference, including the agenda, speakers and fees

auremar | photospin.com

can be found at

16 Advances in Addiction & Recovery | WINTER 2013

CONTINUING EDUCATION Participants may earn up to 10.5 Cont inu ing Education (CE) credits and 6 Business Hours. This conference is approved by NAADAC (Approval #189), NBCC (Approval #5703) and NASW (applied), accredited by the American Probation & Parole Association and accepted by OASIS. For more information, visit www.naadac. org/advocacyconference.

More details about the 2014

www.naadac.org/ advocacyconference.

heard and valued by decision-makers,” remarked Robert C . R ichards, NA A DAC President. The sessions in Washington, D.C., are geared to new and returning participants with an introduction to advocacy issues, tips on how to communicate effectively with lawmakers and mentoring sessions for those new to the legislative process. “For many treatment professionals this is their first encounter with their lawmakers. The excitement for most professionals is that they are at the heart of the legislative process, can see events unfold in front of them and become an active participant in the process,” said Gerry Schmidt, NAADAC Public Policy Committee chair. NAADAC members, and NAADAC’s partners in addiction health services, plan to discuss the federal government’s workforce development agenda, adequate and consistent funding for addiction health services and treatment strategies for veterans. “The Advocacy in Action conference is so important to addiction professionals because it gives us the tools to ensure we are heard and understood by decision-makers in government,” added NAADAC Executive Director Cynthia Moreno Tuohy. “We’re the experts on what works and what doesn’t, and we need to educate our representatives.”

If you have any questions about the conference, call NA A DAC at 703.741.7686 or 800.548.0497.

Congressional Appointments Participants will need to make their own arrangements to meet with their legislators on March 4 from 11 am – 4 pm. We suggest you call your Representatives and Senators early to make these arrangements. If you have any quest ions, plea se cont act NA A DAC at 1.800.548.0497 ext. 129 or visit www.naadac. org/advocacy.

Room Reservations March 2-4, 2014 Holiday Inn Hotel & Suites Alexandria– Historic District www.hioldtownalexandriahotel.com 625 First Street, Alexandria, VA 22314 877.504.0047 (hotel toll free reservation line) 703.548.6300 (hotel front desk) Please make reservations by February 24, 2014, to receive preferred rate of $129. Please mention NAADAC when making your reservation over the phone at 877.504.0047. The Alexandria-Historic District Holiday Inn Hotel & Suites provides complimentary shuttle service to and from Reagan National airport (DCA) and King Street metro stop. Please call 703.548.6300 or stop at the front desk to arrange your transportation.

Washington, D.C., Sightseeing The nation’s Capitol has many unique attract ions, including the national monuments, sporting events and museums. For a free visitor’s guide and a comprehensive list of attractions and events, please contact the Washington, D.C., Convention and Tourism Corpor at ion at www.washington.org or call 202.789.7000.

CONFERENCE AGENDA*

REGISTRATION

Sunday, March 2, 2014

2014 Advocacy in Action, March 2–4

4 pm – 7 pm

Registration

5 – 7 pm Opening Reception Kick off the conference with an opportunity to network with other addiction advocates from around the country. Open to all registered participants. Hors d’oeuvres will be served.

Monday, March 3, 2014 8 am – 5:30 pm Registration 8 – 9 am

Continental Breakfast

9 – 9:30 am Greetings and Welcome Introduction by Robert C. Richards, MA, NCAC II, CADC III, NAADAC President 9:30 – 10:30 am Advocacy Training and Issues Briefing This session will put Advocacy in Action 2014 in context by looking at the history of addiction treatment advocacy and its future. The session will also discuss some of the keys to effective advocacy communication and strategy. 10:30 – 11 am

Break

11 am – noon Advocacy Training and Issues Briefing (continued from morning session) Noon – 1:30 pm Luncheon and Keynote Speaker This session will provide in-depth background on issues currently before Congress that affect addiction professionals and treatment providers. Awards will also be given to the Advocate of the Year, Legislator of the Year and Emerging Leader of the Year Healthcare Reform Panel 1:30 – 3 pm This panel will provide an overview of the national health care reform legislation and the Mental Health Parity and Addiction Equity Act and its impact on substance use disorder treatment. Topics will include changes to Medicaid and private insurance, benefits packages, the integration of substance use disorder treatment with mental and physical care and what this all means for treatment providers. Panelists will provide insight from the Federal government perspective and discuss the opportunities and challenges that lie ahead for the addiction treatment field. 3:30 – 5 pm Advocacy Training, Hill Visit Preparation and Wrap Up Participants have the opportunity to practice their visits to Capitol Hill and receive mentorship from experienced advocates. Upon completion of this session, participants will feel comfortable and confident in achieving their goals during visits with members of Congress. 5:30 – 8 pm Advocacy Reception and Auction $35 suggested donation at the registration desk. This event supports public policy initiatives and advocacy efforts for NAADAC. This session is open to all and heavy hors d’oeuvres will be served.

Tuesday, March 4, 2014 8 – 10 am Award Breakfast and Briefing on the Hill This Briefing will focus on state and national issues related to the Substance Abuse Prevention and Treatment Block Grant and the Patient Protection and Affordable Care Act (ACA) to raise awareness and educate the addiction profession to the coming changes as the ACA is implemented. Crossover issues include the continuum of care for patient services. 10 am – 4 pm Capitol Hill Visits Meet with your lawmakers and advocate on behalf of the addiction profession. 3 – 6 pm Capitol Hill Debrief Session at the Holiday Inn Hotel Share your experiences from Capitol Hill with Association staff and enjoy healthy snacks. *Agenda subject to change

Early Bird

Regular

(register by January 31, 2014)

(register after January 31, 2014)

Daily

NAADAC Member

❑ $150

❑ $200

❑ $50

Non-Member

❑ $175

❑ $225

❑ $75

Student/Associate Member/ Active Military NAADAC Member

❑ $125

❑ $50

Student/Associate Member/ Active Military Non-Member

❑ $150

❑ $75

Registration Fees

Includes: Opening reception on March 2, two continental breakfasts (including the March 4 briefing on Capitol Hill), lunch and breaks on March 3 and light refreshments at the March 4 debriefing session.

Attendee Information (please print clearly)

Is this your first NAADAC meeting? ❑ Yes ❑ No This is your first Advocacy event. ❑ Yes ❑ No I am a: ❑ Participant ❑ Presenter NAADAC Member #__________________________________________________________ Name:______________________________________________________________________ Address:____________________________________________________________________ City: _____________________________________________ State: ____ Zip: _________ Phone: ( )________________________________________________________________ Fax: ( )__________________________________________________________________ Email:______________________________________________________________________ ❑ YES, I want to join NAADAC now! Please consult www.naadac.org for membership fees or call 800.548.0497 to enroll. ❑ Please send me additional information about membership.

Payment Options Conference Fees (see fee schedule above)

__________

Ticket for the NAADAC Political Action Committee (PAC) reception __________ (March 3, $35 suggested donation. Corporate checks or credit cards cannot be used to pay for tickets.) Guest Ticket for Legislative Update Lunch & Awards __________ (March 3, $50 per guest. Lunch is included in participant registration.) Guest Ticket for Breakfast Briefing on The Hill (March 4, $30 per guest. Breakfast Briefing on The Hill is included in participant registration.)

__________

Total Amount Enclosed

__________

Please return check or money order (payable to NAADAC) by mail to: NAADAC, 1001 N Fairfax Street, Suite 201, Alexandria, VA 22314 Or pay by credit card: ❑ Visa ❑ MasterCard ❑ American Express Fax to: 800.377.1136 Name as appears on card_ ___________________________________________________ (please print clearly) Credit card number__________________________________________________________ Expiration date ____________ Signature___________________________________________________________________ Conference refund policy: A partial refund of 75% of registration cost is refundable 30 days before the conference. Thereafter, 50% of conference fees are refundable. Interested in Sponsorships or Exhibiting? Contact Elsie Smith, Ad Sales Manager at esmith@naadac.org or call direct to 717.650.1209 for a prospectus. Or you can download it from www.naadac.org/advocacyconference.

Questions? Visit www.naadac.org/advocacyconference or call 1.800.548.0497. WINTER 2013 | Advances in Addiction & Recovery 17

Tackling One of the Toughest Addictions:

Nicotine

What can we do to help clients quit? B y J eff H offman , P h D Earn TWO continuing education credits for reading this article. Visit www.naadac.org/magazineces and learn more.

Over the past two decades, attention has been focused on clients who have two or more behavioral health problems. Programs routinely provide services to meet the treatment needs of clients who have both substance use and mental health disorders. Less attention has been paid to clients who along with other behavioral health problems are also addicted to nicotine.

Smoking Kills — Especially People with Other Behavioral Health Problems Despite declines in the prevalence of cigarette smoking among adults, prevalence remains high among certain subpopulations, particularly persons with behavioral health disorders.1 People with substance use and/or mental health disorders have a substantially greater likelihood of also having tobacco use disorder. They have rates two- to four-fold higher than the general population.2 Half of the people with a behavioral health disorder also have a tobacco use disorder. They are twice as likely to smoke as the general population, and those who smoke tend to smoke more heavily. Adults with behavioral health disorders represent 25 percent of adults but consume 40 percent or more of all cigarettes smoked by adults.3 Smoking-related illnesses cause half of all deaths among people with behavioral health disorders.

Challenges to Quitting Nicotine As is true of all people with nicotine addiction, clients who also have behavioral health disorders experience challenges and barriers to quit. Many fear cravings and withdrawal symptoms, such as poor concentration, restlessness, depressed mood, tension, irritability, and insomnia. Others, especially women, view increased appetite and possible weight gain as barriers. Many clients who want to quit view the lack of enjoyment of smoking as a barrier. But probably the biggest challenge is that smoking cigarettes is a form of self-medication: clients feel that it reduces stress and anxiety, and makes them feel better.

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Debunking Myths Research demonstrates that nicotine is a strongly reinforcing drug that temporarily improves concentration and attention. However, nicotine has been shown to be ineffective as a treatment for mental disorders or symptoms.4 People with behavioral health problems have quit 18 Advances in Addiction & Recovery | WINTER 2013

and

M im L andr y

rates and rates of interest in quitting that are similar to persons without behavioral health problems and they want information about quitting. 5 6 7 Studies show that approximately 70 percent of mentally ill smokers want to quit.8 Among this group, quit rates and readiness to quit are unrelated to the diagnosis, severity, or coexistence of substance use.9 While challenging, research demonstrates that smoking cessation among this group is effective—often better than the general population, especially when treatment is tailored.10 11 12

Tobacco Cessation Does Not Interfere with Recovery Evidence demonstrates that tobacco cessation does not interfere with recovery from mental illness or lead to increased substance use.13 Indeed, smoking cessation during substance abuse treatment appears to protect against relapse and enhance rather than compromise longterm sobriety.14 15 16 In other words, clients can successfully quit smoking at the same time they are quitting other drugs and/or alcohol.

Relationship Between Smoking and Behavioral Health Problems Evidence is emerging that genetic, familial, and psychological factors have a role in higher smoking rates among people with behavioral health problems. Research is suggesting and exploring: (1) shared genetic factors that promote vulnerability to tobacco use disorders and behavioral health disorders, (2) self-medication of clinical symptoms, medication side effects, and cognitive deficits associated with behavioral health disorders, and (3) common environmental factors such as stress that an promote smoking behavior and mental health symptoms.17 18

Treatment Approaches Research demonstrates that there are effective treatments for tobacco use disorder. There are three broad categories of treatment approaches for tobacco use disorder. These are counseling, nicotine replacement, and medications. The approaches below have been approved as being safe and effective in treating tobacco use disorders. Counseling and Therapy. Counseling and therapy have an integral role in smoking cessation treatment, typically in conjunction with medication. These teach clients to recognize high-risk situations, develop coping strategies, manage stress, improve problem solving skills, and increase social support. ■ Individual and Group Therapy. Cognitivebehavioral counseling and therapy, as well as mo-

tivational interviewing with multiple sessions of individual or group counseling can promote smoking cessation. Three types of counseling and therapy approaches have been shown to promote higher abstinence rates. These include (1) providing smokers with problem-solving and skills training, such as avoiding high-risk situations and identifying personal triggers, (2) providing social support as a component of the treatment program, and (3) assisting smokers to obtain social support outside of the treatment program. ■ Telephone Quitlines and Counseling. Research suggests that proactive telephone counseling helps smokers who seek help from quitlines. Telephone quitlines are an important way for smokers to obtain support, and call-back counseling improves their usefulness. Three or more phone calls increases the chances of quitting compared to a minimal intervention such as self-help materials, brief advice, or pharmacotherapy alone. Each state has a quit line, and some have more than one. Call 800-QUIT-NOW (800-784-8669) to identify options in your state.

Questions to consider while reading this article

hat are the 5As that the Surgeon General recommends counselors use with ever y person who uses toba cco and has shown a willingness to quit ?

tudies show that approximately wha t percentage of mentally ill smokers want to quit?

W W

hat are some Nicotine Replacemen t Therapies (NRTs)?

Nicotine Replacement Therapy. hat are the broad categories of Nicotine Replacement Therapy (NRT) can take the form of a nicotine replacement patch, treatment approaches for tobacco gum, lozenge, nasal spray, and inhaler. NRTs relieve withdrawal symptoms and cravings. NRTs use disorder? can be used short term or long term and some require a medical prescription. They produce ike other addictions, tobacco use less severe physiological alterations than tobacco-based systems and generally provide users diso rder is what kind of illness? with lower overall nicotine levels than they receive with tobacco. Behavioral treatments have been shown to enhance the effectiveness of NRTs and improve long-term outcomes. o people with substance use and/or ■ Nicotine Patch. Nicotine patches, such as NicoDerm and Habitrol, delivers nicotine mental health disorders have a through skin and into the bloodstream. A new patch is worn each day. For clients who greater likelihood of also having toba cco are not able to stop smoking after 2 to 3 weeks or so of nicotine patch treatment, work use disorder? with their physician for help to adjust the dose of the patch or adding another medicamoking-related illnesses cause wha tion. t num ber of all deaths among people ■ Nicotine Gum. Nicotine gum, such as Nicorette, delivers nicotine to the blood system with behavioral health disorders? through the lining of the mouth. It is available in a 2mg dose for regular smokers and a 4mg dose for heavy smokers. Nicotine gum provides many smokers with the desired hich non -nicotine medications control over dosage and the ability to diminish cravings. However, some people canmentioned in the article that have not tolerate the taste and the “chewing and parking” approach to allow nicotine to be been approved by the FDA for toba cco gradually absorbed into the bloodstream. use disorder? ■ Nicotine Lozenge. The nicotine lozenge, such as Commit or Nicorette mini-lozenge, disow does Varenicline, marketed as solves in the mouth and delivers nicotine through the lining of the mouth. The lozCha ntrix, work? enges are available in a 2mg dose for regular smokers and a 4mg dose for heavy smokers. Teach clients to place the lozenge between the gumline and check or under ecognizing the importance for the tongue and let it dissolve. Users generally begin with one lozenge every 1 to 2 counselors to enhance their knowlhours and gradually increase the time between lozenges. Nicotine lozenges require edge of tobacco addiction and deve lop a prescription. skills and strategies for tobacco add ic■ Nicotine Nasal Spray. Nicotine nasal sprays, such as Nicotrol NS, are sprayed into each tion counseling, NAADAC develope da nostril, and is absorbed through the nasal membranes into the blood vessels. The nacertification for what? sal spray delivers nicotine more rapidly than lozenges, gum, or the patch, but not as Earn two continuing education cred rapidly as smoking a cigarette. Some users experience nasal irritation. its for read ing this article. Visit www.naadac. ■ Nicotine Inhalers. The nicotine inhaler, such as Nicotrol, is shaped somewhat like a org/magazineces and learn more. cigarette holder. Users puff on the inhaler and it delivers nicotine vapors into their mouth. The nicotine is absorbed through the lining of the mouth and then enters the bloodstream. Some users experience mouth or throat irritation. typical treatment course lasts for seven to ■ E-cigarettes as Potential Quit Tools. E-cigarettes deliver nicotine and mitigate nicotine with12 weeks, with clients stopping smoking drawal. As a result, e-cigarettes are used by many smokers to help their quit attempts. Also, within approximately 10 days. Bupro smokers with no intent to quit tend to smoke less after switching to e-cigarettes. It is pospion may be prescribed along with a sible that e-cigarettes may emerge as a clinical tool to help certain people in certain situnicot ine patch. ations cut back or quit. At this point in time, there is emerging but insufficient evidence ■ Varenicline. Marketed as Chantix, vareniregarding the effectiveness of e-cigarettes for quit attempts and reducing smoking, and cline tartrate is a nicotinic receptor parregarding the safety of e-cigarettes.19 tial agonist. It stimulates nicotine receptors but more weakly than nicotine. As a Medications. partial agonist, it both reduces cravings A few non-nicotine medications have been approved by the FDA for tobacco use disorder, for and decreases the pleasurable effects which are described below. of tobacco products. The FDA has ap■ Bupropion. Marketed as Zyban and other names, bupropion is an antidepressant medicaproved the use of varenicline for up to 12 tion that increases levels of dopamine and norepinephrine, two neurotransmitters that weeks. If smoking cessation is achieved, are also increased by nicotine. It reduces nicotine cravings and withdrawal symptoms. A

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it may be continued for another 12 weeks. Clients are normally advised to begin varenicline 1 week before stopping smoking. ■ Nortriptyline. This tricyclic antidepressant, marketed as Pamelor, has been shown to reduce withdrawal symptoms and smokers stop. It increases the levels of the brain neurotransmitter norepinephrine, one of the neurochemicals increased by nicotine. It is considered a second-line approach and usually recommended if other medications are not effective. Medication Combinations. Research suggests that cessation rates are higher when two medications are used compared to one medication at a time.20 21 22 For this reason, the Department of Health and Human Services suggests such combinations as nicotine patch with the nicotine gum, lozenge, nasal spray or inhaler; or the nicotine patch plus bupropion.23 Medication Plus Counseling. Research demonstrates that nicotine-cessation medication, including NRT, bupropion, and varenicline can help people quit smoking. Research has also examined how much additional benefit is obtained by providing medication plus behavioral approaches, such as counseling and telephone quitlines. Research demonstrates that combining counseling and medication is more effective for smoking cessation than either medication or counseling alone.24 Mutual Support Self-Help Groups. Nicotine Anonymous and Smokers Anonymous are examples of mutual support, self-help groups that are based on the 12-Step Program developed by Alcoholics Anonymous to help people stop smoking. They provide caring support and practical experience for people who wish to live without nicotine. They can and should be part of the recovery plan for clients who wish to stop smoking or using tobacco.

Does Health Care Reform Impact Smoking Cessation Programs? The recent Patient Protection and Affordable Care Act of 2010 addresses disease prevention, including tobacco cessation programs. The health care reform requires private group and individual health plans created since March 2010 to cover all recommended preventive services, including smoking cessation, without cost-sharing. Tobacco cessation services are covered, although the government has not defined which treatment medications and therapies are included. Currently, insurance plans have significant flexibility to meet this requirement. The Mental Health Parity and Addiction Equity Act requires plans to determine which substance use disorders are covered under the plan as long as it complies with state and federal laws and consistent with standards of medical practice. Tobacco use disorder is listed as a mental health diagnosis in the DSM-5. Thus, if a group health plan provides tobacco cessation benefits, they are subject to the parity requirements and must be substantially equivalent to medical and surgical benefits.

Does Medicaid Cover Tobacco Cessation? Health care reform includes new coverage under Medicaid to help beneficiaries quit smoking. All state Medicaid programs must provide a comprehensive cessation benefit for pregnant women with no patient cost-sharing. Also, State Medicaid programs that voluntarily cover all recommended prevention services, including smoking cessation, will receive increased federal reimbursements. Beginning January 1, 2014, state Medicaid programs will no long be able to exclude smok20 Advances in Addiction & Recovery | WINTER 2013

ing cessation medications from their prescription drug coverage. For a list of CPT, & ICD-9 Codes related to tobacco cessation counseling, click on the Ask and Act practice toolkit at www.askandact.org.

What Can Programs Do? Treatment programs can implement a group-based cognitive behavioral psycho-education smoking cessation program. We recommend a group format consisting of approximately eight to 10 clients lasting seven to 12 weeks. Sessions would address prevalence of tobacco use, the properties of nicotine, the health effects of tobacco use, and the addictive properties of nicotine. Sessions would help clients explore the reasons why people and they smoke. Importantly, sessions must teach clients how to quit smoking, medications used for cessation, and how to develop a quit plan. Relapse prevention sessions should teach about internal, external, and sensory triggers; how to defuse triggers; and how to avoid triggers. Pack Up & Quit. For the Center for Substance Abuse Treat ment, Danya developed Pack Up & Quit, a smoking cessation program for clients in recovery from opioid dependence. The program provides the staff of opioid treatment programs with a rich training experience and set of client curriculum so that they can introduce a tobacco-free program to smokers in their clinics. Pack Up & Quit is based on the Stages of Change Model, adult learning principles, and the recognition of the smoker’s central role in his or her success. Danya developed a Trainer’s Guide, a treatment program curriculum, and a toolkit. Danya will soon complete the pilot training and education and will implement the tobacco cessation around the country. Review and Modify Intake Assessments. Review your intake assessments. Ensure that they include standard questions to screen for tobacco use. These questions should assess tobacco use status by asking about current use. Ask about the type of tobacco product, how much used, how often used, and when. Ask about clients’ history of use, prior quit attempts, and level of dependence using the Fagerström Test for Nicotine Dependence scale.25 Ask about clients’ interest in quitting. Act on this information and offer treatment services that are tailored to clients’ needs. Repeat tobacco-related assessments throughout the course of treatment. Tailor Treatment Services Based on Assessments. Tailor behavioral and pharmacological services to the specific needs of clients and their functional level. Use assessments to determine current functional status and stability. Specifically, smoking cessation is most likely when clients are functioning adequately, able to participate in treatment, ready to quit and motivated, and are medically stable regarding their overall medications. Such clients require less tailored services. Less functionally stable clients need greater tailoring and coordinated treatment management. Use the 5As as an Initial Intervention. The Surgeon General recommends counselors use the 5As with every person who uses tobacco and who shows a willingness to quit. These have been shown to increase quit rates in primary care settings and are appropriate for behavioral health treatment settings. ■ Ask—clients about their nicotine use and document this information in their chart —Tell me about your tobacco use over the past week. ■ Advise—clients to quit in a strong, direct, personal, and yet empathic message—As a young mom, quitting now will really help your baby.

■ Assess—clients willingness to make a quit attempt and consider

using motivational interventions for those with low motivation and assist clients who seem ready to quit—On a scale of 10, how willing are you to quit? ■ Assist—quit attempts through counseling, setting quit dates, reviewing challenges, recommending pharmacotherapies, and reviewing psychological treatments—Let me help you make a quit plan. Can we start now? ■ Arrange Followup—to enhance clients’ motivation, support successes, manage relapses, and assess the use and need for medi cations and psychological treatments—Let’s make a follow-up appointment within a week of your quit date. Good job — keep it up! Use an Integrated, Holistic Approach. Like other addictions, tobacco use disorder is a bio-psycho-social-spiritual disorder. Thus, both treatment and recovery should address the biological, psychological, social and familial, and spiritual needs of clients, use an approach that is multicomponent, integrated, and holistic, such as Living In Balance: Moving from a Life of Addiction to a Life of Recovery.26 Begin with solid and comprehensive screening and assessments. With this information, develop a tailored treatment plan with behavioral and pharmacological services to meet the specific needs of your clients and their functional level. Promote a holistic recovery by encouraging the use of exercise, meditation, visualization exercises, yoga, and spiritual exercises and activities.27 Become or Work with a Nicotine Dependence Specialist. NAADAC recognizes the importance for counselors to enhance their knowledge of tobacco addiction and develop skills and strategies for tobacco addiction counseling. For this reason, NAADAC developed certification for a Nicotine Dependence Specialist. Doing so, NAADAC is promoting competency in nicotine dependence treatment by promoting the recognition of nicotine dependence specialist, providing a national standard for nicotine dependence treatment, and establishing and monitoring the knowledge required for certification in this area. More information can be found at www.naadac. org regarding eligibility and application requirements, cost, examination details and schedule, and test preparation materials. Stay Informed. Become and remained informed about issues and approaches related to clients with behavioral health and tobacco use disorders. Review the Toolkit Resources box below. Attend trainings and conferences to remain engaged on relevant issues. For instance, the Central East Addiction Technology Transfer Center (www.ceattc. org) managed by the Danya Institute, will host a Behavioral Health Conference on Tobacco Cessation May 19 –20, 2014 in North Bethesda, Md. It will address such issues as the effect of health reform on tobacco cessation, electronic cigarettes and cessation, and smoking cessation and behavioral health disorders. You can promote recovery and well-being by incorporating nicotine cessation into behavioral health programs — and ultimately — save more lives. Dr. Jeff Hoffman, clinical psychologist, is CEO of Danya International, which provides innovative solutions for social impact and is Chairman of the Board for the Danya Institute. He is coauthor of the substance abuse treatment and relapse prevention program Living in Balance: Moving From a Life of Addiction to a Life of Recovery series; author of Living In Balance: 90 Meditations for Recovery from Addiction; and co-developer of Adolescent Smoking Cessation Escaping Nicotine and Tobacco, which includes a curriculum and the award-winning teen video, The Last Drag, all published and distributed by Hazelden Publishing, Inc.

Toolkit Resources

Dimensions: Tobacco Free Toolkit for Healthcare Provide rs http://smokingcessationlea dership.ucsf.edu/Download s/ dimensions _tobacco_free_ toolkit_ hcp.pdf

Tobacco Treatment for Per sons with Substance Use Dis orders: A toolkit for Substance Abu se Treatment Providers http://smokingcessationlea dership.ucsf.edu/MH_Reso urces.htm Smoking Cessation for Per sons with Mental Illness: A Toolkit for Mental Health Providers http://smokingcessationlea dership.ucsf.edu/MH_Reso urces.htm Tobacco-Free Living in Psy chiatric Settings http://smokingcessationlea dership.ucsf.edu/nasmhpd _ toolkit_ 2010.pdf Tobacco Free Toolkit: For Com munity Health Facilities http://smokingcessationlea dership.ucsf.edu/tf_policy_ toolkit.pdf 2008 U.S. Public Health Ser vice Guideline—Treating Tob acco Use and Dependence http://w ww.surgeongeneral .gov/tobacco Bringing Everyone Along: Res ource Guide http://w ww.tcln.org /bea

Mim Landry is a Senior Public Health Analyst at Danya International. He is the author of Understanding Drugs of Abuse: The Processes of Addiction, Treatment, and Recovery, the online course Helping Clients with Co-occurring Disorders, and chapters from the textbook Review of General Psychiatry. He is co-author of Living in Balance: Moving From a Life of Addiction to a Life of Recovery series. He has written more than 25 journal articles, 25 chapters, and over 40 online courses, curricula, guides, monographs, or books, including serving as Managing Editor and author of the quarterly CSAT/ SAMHSA (Center for Substance Abuse Treatment/Substance Abuse and Mental Health Services Administration) Discretionary Grantee News over the past several years. REFERENCES 1 U.S. Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2004. Available at http://www.cdc.gov/tobacco/data_ statistics/sgr/sgr_2004/index.htm. Accessed September 11, 2013. 2 Kalman D., Morisette S.B., & George, T.P. (2005). Co-morbidity of smoking in patients with psychiatric and substance use disorders. The American Journal on Addictions, 14(2), 106–123. 3 Substance Abuse and Mental Health Services Administration. (2013). The NSDUH Report, March 20, 2013. National Survey on Drug Use and Health, Rockville, Maryland. 4 Prochaska, J.J. (2011). Smoking and mental illness—breaking the link. The New England Journal of Medicine, 365(3), 196–198. 5 Nahvi, S., Richter, K., Li, X., Modali, L., & Arnsten, J. (2006). Cigarette smoking and interest in quitting in methadone maintenance patients. Addictive Behavior 31(11), 2127–2134. 6 Benowitz, N.L. (2008). Neurobiology of nicotine addiction: Implications for smoking cessation treatment. American Journal of Medicine, 121(4), 3. 7 Sullivan, M.A., & Covey, L.S. (2002). Current perspectives on smoking cessation among substance abusers. Current Psychiatry Reports, 4:388–396. 8 Legacy. (2011) A Hidden Epidemic: Tobacco Use and Mental Illness. Legacy, Washington, DC. 9 Hall, S.M., & Prochaska, J.J. (2009) Treatment of smokers with co‑occurring dis orders: emphasis on integration in mental health and addiction treatment settings. Annual Review of Clinical Psychology, 5:409–31. 10 Hall, S.M., & Prochaska, J.J. (2009) Treatment of smokers with co‑occurring disorders: emphasis on integration in mental health and addiction treatment settings. Annual Review of Clinical Psychology, 5:409–31. 11 McFall, M., Saxon, A.J., Malte, C.A., et al. (2010). Integrating tobacco cessation into mental health care for posttraumatic stress disorder: a randomized controlled trial. Journal of the American Medical Association, 304, 2485–2493. 12 Tsoi, D.T., Porwal, M., & Webster, A.C. (2010). Efficacy and safety of bupropion for smoking cessation and reduction in schizophrenia: systematic review and metanalysis. British Journal of Psychiatry, 196:346–53. 13 Hall, S.M., & Prochaska, J.J. (2009) Treatment of smokers with co-occurring disorders: emphasis on integration in mental health and addiction treatment settings. Annual Review of Clinical Psychology, 5:409–31.

WINTER 2013 | Advances in Addiction & Recovery 21

Prochaska, J.J., Delucchi, K., & Hall, S.M. (2004). A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology, 72(6): 1144–1156. 15 Baca, C.T., & Yahne, C.E. (2009). Smoking cessation during substance abuse treatment: What you need to know. Journal of Substance Abuse Treatment, 36, 205–219. 16 Sullivan, M.A., & Covey, L.S. (2002). Current perspectives on smoking cessation among substance abusers. Current Psychiatry Reports, 4(5):388–396. 17 Bjornson, W. (Ed.). Bringing Everyone Along Resource Guide. (2008). Tobacco Cessation Leadership Network, Portland, Oregon. 18 Kalman D., Morisette S.B., & George, T.P. (2005). Co-morbidity of smoking in patients with psychiatric and substance use disorders. The American Journal on Addictions, 14(2), 106–123. 19 Bullen, C., Howe, C., Laugesen, M., McRobbie, H., Parag, V., Williman, J., & Walker, N. (2013). Electronic cigarettes for smoking cessation: A randomized controlled trial. The Lancet, 9 September. 20 Kozlowski, L.T., Giovino, G.A., Edwards, B., DiFranza, J., Foulds, J., Hurt, R., & Ahern, F. (2007). Advice on using over-the-counter nicotine replacement therapy—patch, gum, or lozenge—to quit smoking. Addictive Behaviors, 32(10), 2140–2150. 21 Bohadana, A., Nilsson, F., Rasmussen, T., & Martinet, Y. (2000). Nicotine inhaler and nicotine patch as a combination therapy for smoking cessation: A randomized, doubleblind, placebo-controlled trial. Archives of Internal Medicine, 160(20), 3128. 22 Piper, M.E., Smith, S.S., Schlam, T.R., Fiore, M.C., Jorenby, D.E., Fraser, D., & Baker, T.B. (2009). A randomized placebo-controlled clinical trial of five smoking cessation pharmacotherapies. Archives of General Psychiatry, 66(11), 1253. 23 Fiore, M.C., Jaen, C.R., Baker, T.B., et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. 24 U.S. Department of Health and Human Services. (2008). Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD. 25 Heatherton, T.F., Kozlowski, L.T., Frecker, R.C., & Fagerström, K.O. (1991). The Fagerström test for nicotine dependence: a revision of the Fagerström tolerance questionnaire. British Journal of Addiction, 86:1119–1127. 26 Hoffman, J.A., Landry, M., & Caudill, B.D. (2003). Living in Balance: Moving From a Life of Addiction to a Life of Recovery. Center City, MN: Hazelden Publishing, Inc. 27 Carim-Todd, L., Mitchell, S.H., & Oken, B.S. (2013). Mind–body practices: An alternative, drug-free treatment for smoking cessation? A systematic review of the literature. Drug and Alcohol Dependence, 132(3), 399-410. 14

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National Drug Facts Week

TARGETS YOUTH Educating Teens About Drug Abuse is Crucial B y C arol K rause , MA, C hief, N ational I nstitute

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Adolescence is the focus of drug-abuse education and prevention for several reasons. For one thing, addiction usually emerges in adolescence. Most people with diagnosed substance use disorders receive their diagnosis by age 20 and most begin taking drugs by age 18. Data show that the earlier they start, the greater the likelihood of developing a disorder, which is why we sometimes call addiction a developmental disease. In fact, its contributing risk factors may extend back even to childhood or the prenatal period. Educating teens about drug abuse is crucial, not only because teens are more likely to take drugs but also because this age group is also more likely to be harmed by drug-taking and develop lasting problems as a result — problems beyond addiction. The harms range from the immediate dangers of risky activities like driving under the influence or unsafe sex to long-term impacts on cognition and memory, social functioning, and physical health. The adolescent brain is uniquely vulnerable to being changed by sub stances, even permanently, because it is still undergoing major maturation processes that don’t complete until the mid-20s. New study data from both animals and humans are filling out our picture of the kinds of changes that can occur as a result of drug use during development. Marijuana, for instance, is the most common illicit substance used by adolescents, and last year we learned from a major study in New Zealand that heavy use of this drug in the teen years can produce permanent impairment in intellectual ability. Heavy marijuana smokers who initiated their use as a teen lost an average of 8 IQ points that were not regained even if the individual had quit using in adulthood. Unfortunately, a gradual loss of IQ points — or other known consequences of marijuana use like loss of motivation — are unlikely to be salient or noWINTER 2013 | Advances in Addiction & Recovery 23

ticed by teens, either in themselves or in their peers who smoke marijuana, and thus it is hard to impress upon them the dangers of this drug. A diminishing number of 8th, 10th, and 12th graders perceive that occasional marijuana use may be harmful, a trend that parallels increased use of the drug by these age groups over the past several years. Unfortunately, even drugs like prescription opioids that do frequently claim the lives of abusers are only perceived as dangerous (if taken occasionally) by just over half of high-school seniors. Some drugs’ dangers are offset in teen perception by their supposed benefits. The increasingly abused ADHD drug Adderall is widely perceived by young people as enhancing cognitive performance, although it is quite dangerous when taken not as prescribed and research suggests it does not actually boost cognitive performance in those who don’t have ADHD. The fact that doctors prescribe drugs like ADHD stimulants or pain relievers, and teens often see adults taking them, contributes to the perception of safety. Research shows that when young people perceive drug abuse as harmful, they reduce their level of abuse. Clearly, reaching young people with effective messages that correct the myths about drugs’ supposed benefits and lack of harms is urgently needed—particularly now as state-level marijuana policies shift and a bewildering array of dangerous new synthetic drugs flood the market masquerading as marijuana substitutes, sometimes evading legal controls. One of the ways NIDA attempts to get sound messages across to youth is through National Drug Facts Week (NDFW), a national health observance during which science and health teachers, guidance counselors, social workers, drug prevention programs, and community support programs work together with parents and students to communicate the scientific facts about drug abuse. The wide array of

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possible awareness events includes school assemblies, trivia nights, after school activities and panel discussions with local law enforcement, substance abuse counselors, and individuals affected by drug abuse. All events include the participation of a scientist or adult-supervised discussion of NIDA educational materials. During this week, our daylong Web chat (Drug Facts Chat Day) gives NIDA scientists the chance to directly answer thousands of questions from teens from nearly 100 high schools around the country. More than 500 events are expected to be held in every state during this year’s NDFW, January 27 through February 2, 2014. NIDA provides free materials designed exclusively for teens to planners of these events to help them disseminate sound, scientific information about drugs and drug use to teen participants. Steering teenagers away from experimenting with drugs during this incredibly vulnerable crossroads in their development is worth whatever resources, time, and effort it takes, because it can prevent years of heartache and suffering—or worse—down the road. NIDA encourages NAADAC members to get involved with our NDFW efforts. We provide an online toolkit that provides useful information on how to create an event, publicize it, and obtain free materials to disseminate. Please visit our Web site for more information: http://drugfactsweek. drugabuse.gov/ or e-mail our National Drug Facts Week team at drugfacts@nida.nih.gov. Carol Krause, MA, serves as the Chief, Public Information and Liaison Branch in the Office of Science Policy and Communications at the National Institute on Drug Abuse (NIDA). The National Institute on Drug Abuse is a United States federal-government research institute whose mission is to “lead the Nation in bringing the power of science to bear on drug abuse and addiction.”

The Addiction Profession Loses Dr. David Powell It is with deep sadness and pain that we write to tell you that David Powell, a dear friend of the addiction profession and colleague to many of us over the years, has unexpectedly died. There is no replacement for this expert and icon in the addiction profession, and we ask you to take a moment to mourn this dedicated and beautiful man. For many of us, Dr. David Powell was the person who took the text book of clinical supervision and made it into the real practice of clinical supervision. He mentored many, taught many and will be extremely missed by many. A memorial service for Dr. Powell was held in Connecticut on November 23. For those of you who would like to submit to NAADAC your thoughts, stories, pictures — we are honored to collect these and place them in a memorable booklet to give to his wife, Barbara, and his family. Please send your submissions to mstorie@naadac.org. The NAADAC Executive Committee and staff of NAADAC will be discussing other means to memorialize this amazing professional. We are missing him already! If you wish to connect with the family directly, Barbara Powell’s email is barbarabpowell@yahoo.com.

Seeing Emotion as Information How do we weather the storms of life in recovery? B y M ark Woodfork circuits brings awareness to subtle shifts in our states of mind. This awareness precedes the process of finding the right words to describe our basic emotions and to express one’s needs and values in recovery. When practiced in daily life, this process can strengthen the neural pathways in our brain and body for emotional awareness. The more quickly one is aware of a shift in their emotional state, the more likely they are to be responsive (versus reactive) to various situations and relationships in recovery. Importantly, when we use the word emotion, we are talking about a state of being in a particular moment in time, for example: feeling excited, proud, happy, calm, lonely or some other emotion. These words carry information about what a person needs and/or values in that moment (Panksepp, 2009). The more in tune we are with the emotional state, the more likely we are to be able to express what we value or understand what we need right now. Emotions are information. To use weather as a metaphor to describe this process, as we develop a day-to-day practice of paying attention to our emotional states, we can more accurately delineate between a temporary emotional storm (e.g., a reaction to something someone said that upset us) or a larger emotional weather event that has clouded our consciousness for the day or the week (e.g., a mood that cannot be attributed to an activating event, but none-the-less is causing distress and is in need of some exploration). From a neuroscience perspective, this process connects the energy and information flow between the upper and lower parts of the brain and central nervous s ystem. As Alan Fogel details in The Psycho physiology of Self-Awareness: Rediscovering the Lost Art of Body Sense (2009), this process of attending to our bod ily states increases our “inter oceptive” awareness, which is our ability to feel our in ternal bodily st ates. Emotion, continued on page 27 ☛

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Emotions are information. Fully understanding what this means in recovery takes time and practice. From a knowledge-based standpoint, one can learn that emotional energy flows through our nervous system in our bodies and minds. This flow of energy is essentially an affective, value-based information system (Siegel, 2001). From a practice-based standpoint, if we are tuned into this ancient information system, then we can feel whether acting on impulse is necessary in a given situation or responding after careful consideration is prudent. When we practice paying attention to this flow of emotional energy, we are strengthening neural pathways in the brain and body. From a brain-based perspective, bringing attention to our emotional states focuses our mind both on the flow of neurochemical energy in our bodies and between the layers of our triune brain. This impacts on the brain stem (associated with maintaining basic bodily functions like respiration and heart rate), the limbic region (associated with basic emotions and drives), and the neo-cortex (associated with consciousness and the ability to think and communicate with others) (Siegel, 2007). The flow of emotional energy and information is bi-directional from top to bottom through our brain and body. The practice in recovery of attending to emotional energy takes place largely in the dorsomedial, ventromedial and dorsolateral prefrontal cortices that are located in the forehead area of our brain. These structures are essential to our “executive attentional” processes, and in conjunction with the orbi tofrontal, insula and anterior cingulate cortices that sit slightly back and below the prefrontal cortices, represent the higher executive structures that monitor and modulate the lower midbrain limbic system (emotion and motivation) and the brain stem (associated with basic drives and emot ions) (Siegel, 2007). These structures have been essential to the survival of our species. Focusing the executive attentional

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C O M M E N TA RY

Medical Marijuana and Ethical Dilemmas for Chemical Dependency Professionals As voter initiatives pass, where does this leave treatment professionals? B y Paul R. Weatherly, MA, CDP

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to patients in addiction treatment programs. A qualified health care professional may have discussions with patients who have qualifying terminal or debilitating medical conditions regarding the use of marijuana as part of a therapeutic regimen only after a thorough physical examination that is age and gender appropriate specific to the condition and a history of the failure of standard treatments has been documented in the pat ient’s medical record. These discussions are allowed in regard to the health care professional’s first amendment right of free speech. In other words, a qualified medical marijuana patient does not have to have a prescription to use marijuana, only a recommendation. Because the patient does not have a prescription to use marijuana, addiction treatment providers can determine whether or not they are willing to admit a medical marijuana user into their treatment program. Information that requires consideration by the treatment provider and chemical dependency professionals includes the following: If a program is receiving federal funding to provide addiction treatment services directly or indirectly through distribution by the state, the program is at risk of losing that funding if they admit or allow patients to use medical marijuana. Patients who may be protected under the Americans With Disabilities Act lose their protection if they are known to be using a substance listed on schedule one of the uniform controlled substances act. All medical marijuana patients must be listed with the Washington State Department of Health. There is very little literature that defines the term “therapeutic dose” so a medical marijuana patient determines the amount of the dose and frequency of dosing he or she determines adequate to receive relief from the symptoms of their terminal or debilitating condition. Providers must thoroughly review medical marijuana documentation to assure that the condition being treated is recognized under Washington State law and therefore legitimate documentation. Medical marijuana documentation from other states is not recognized in Washington because the recommender must be licensed to practice in Washington and interstate transportation of a controlled substance is violation of federal law. Finally, Washington State law defines the core competency of a chemical dependency provider to receive specific training that is “all oriented to assist alcoholic and drug addicted patients to achieve and maintain abstinence from mood-altering substances and develop independent support systems.” The NAADAC code of ethics offers five principles that offer implicit but not explicit guidance regarding medical marijuana. They are Trustworthiness, Compliance with The Law, Rights and Duties, krasimira nevenova | photospin.com

Discussions related to medical marijuana and its efficacy treating a variety of medically recognized conditions dominate many meetings with professionals in the addiction treatment community. What is discussed to a lesser degree are the ethical dilemmas related to admitting or choosing not to admit individuals into add ict ion t reat ment pro grams in st ates that allow qualified patients to use marijuana as part of a therapeutic regimen to treat their medical conditions. Ethical dilemmas are created by state laws that recognize a wide variety of medical conditions that may respond positively to medical marijuana that are in conflict with federal laws and ethical guidelines related to the field of addiction counseling. Issues that complicate these ethical dilemmas come from how state laws and regulations vary in determining the amounts of processed and unprocessed marijuana a medical marijuana user may possess during any given time interval, how states may or may not define a therapeutic dose, frequency of dosing and questions regarding use of substances prior to, during or after attending addiction treatment group or individual counseling sessions and how is relapse defined for a medical marijuana patient. Further complications arise regarding conflicts between state law allowing MD, ND, DO or ARNP’s to recommend the use of medical marijuana to their patients and federal law banning sale, production and possession of marijuana, the Uniform Disciplinary Act, t he A mer ic a ns W it h Disa b i l i t ies Act , U. S . Depa r t ment of Transportation rules and regulations, as well as state laws and regulations regarding addiction treatment and the professional responsibilities of addiction treatment providers. This article will look at the issues arising in Washington State. Washington State law specifically creates immunity from prosecution for MD, ND, DO and ARNP’s to have conversations with patients regarding the use of medical marijuana to treat a terminal or debilitating condition. It requires medical marijuana patients with qualifying conditions to be issued documentation allowing them to possess both processed and unprocessed marijuana that may be used as an affirmative defense if they are arrested and/or prosecuted for possession of marijuana. In addition, the law defines what constitutes a terminal or debilitating condition and the process that allows for individuals to petition the state to add non-recognized conditions to this list. State regulations developed by the Washi ngt on State Department of Health determine the amount of processed and unprocessed marijuana a qualified patient may possess during a 60-day time interval. Washington State law also defines the core competencies for chemical dependency professionals and their responsibilities

Preventing Harm and Duty to Care. Subsequently problems arise regarding the admission and treatment of medical marijuana patients. Conflicts between state and federal laws make it difficult for chemical dependency providers to balance compassion for the patient with the consequences of civil disobedience. Because chemical dependency professionals are not on the list of health care providers protected under Washington law they are risk of practicing outside of their scope and jeopardizing the creation of working relationships with their patients. Conflicts in laws and opinions regarding the efficacy of medical marijuana compounded by Federal legal definitions that marijuana has no medical value compromise a chemical dependency provider’s ability to improve the options and choices a medical marijuana patient may have to treat acute medical issues related to addiction to alcohol or other drugs. Lack of knowledge in the chemical dependency provider community about marijuana and its potential for use as a medicine and various risks to the user’s health dependent upon the route of administration complicate the chemical dependency professional’s ability to evaluate the myriad of mixed messages patients and providers receive regarding marijuana. Lastly, the question of what degree does the use of marijuana to relieve symptoms of a recognized medical condition impair a patient’s ability to make progress meeting goals and objectives on a treatment plan and will this ultimately require the termination of the patient/counselor relationship requiring potential life and death decisions to be made by a chemical dependency professional. This overview of the problem does not come without an overview of some basic solutions. Each agency providing addiction treatment services in Washington would be well served to develop policy and procedure for admitting or choosing not to admit qualified medical marijuana patients into their program. For agencies making the choice to do admissions, issues like therapeutic dose verified by testing parameters defining the limits of THC metabolites should be defined. Rules

related to dosing pre-treatment, during treatment and post-treatment should be concretely stated and definitions regarding how the agency defines relapse need to be clearly presented to medical marijuana patients. Finally, expectations and training for providers regarding documentation regarding conditions for admission or referral, progress or lack of progress attaining treatment goals and criteria for discharge would need to be implemented. For chemical dependency professionals, each will need to make decisions regarding the personal values, biases and understandings of their responsibilities as providers of services to alcoholic and drug addicted individuals. These decisions will ideally incorporate the guidelines provided in the NAADAC code of ethics, research and discussions with peers about the implications of attempting to provide addiction treatment services to qualified medical marijuana patients. These decisions will ultimately inform how each individual provider will engage in the discharge of his or her duties providing services to the community of patients requesting addiction treatment services. This article in many ways only scratches the surface of the problem. It poses many more questions than it answers. But in consideration of all the many mixed messages that exist about marijuana as a medicine, recreational diversion, legalization/decriminalization, creator of tax revenues, etc. it is important that conversation begin somewhere. Paul R. Weatherly MA, CDP, is director of the Alcohol/Drug Counseling Program at Bellevue College, located in Bellevue, Washington.

Recognize Greatness: NAADAC 2014 Awards Know someone who should be recognized for their outstanding contribution to the profession? Nominate them for a NAADAC national award!

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Emotion, continued from page 25

Essentially, this process opens up communication of information through the “crossroads” of our brain, i.e., the orbitofrontal, insula, and anterior cingulate cortices, which brings awareness from our bodily sensations into our executive attentional areas, i.e., the dorsomedial, ventramedial and dorsolateral prefrontal cortices. Significantly, the neural pathways related to this level of embodied self-awareness are relatively slower than the pathways related to other intellectual activities (e.g., solving a math problem). This is due to the fact that interoceptive pathways involve unmyelinated nerve fibers (Fogel, 2009). Myelinated nerve fibers speed up transmission of energy and information through neural circuits. Therefore, in considering brain processes, this level of embodied self-awareness is going to be much slower and take more time to develop (particularly in early recovery) than the relatively rapid fire ideas and thoughts about oneself that enter the mind as “self-awareness.” In short, this practice may entail slowing down, taking a deep breath into our body and trusting the information that comes from our physiology (i.e., from our “gut” and our “heart”) — information that can guide our response to an emotional event in recovery (Woodford, 2012). In summary, when the processes of paying attention and increasing emotional awareness are engaged in the middle prefrontal region of the brain, several important functions of the brain are enhanced that are essential for developing a relationship with oneself and others in recovery; namely, attuned communication, empathy, insight and intuition (Siegel, 2007). Although these functions are severely compromised by addiction, when we repeatedly slow down and reflect on our

emotional experiences, we are working out the muscles of our mind to increase our ability to respond well to high-risk situations in recovery. Over time, this process strengthens new neural pathways related to self-regulation and emotional development (Fosha, Siegel, & Solomon, 2009), which is at the heart of developing an integrated sense of self that can weather the storms of life in recovery. Mark S. Woodford, PhD, LPC, MAC, is a Professor and Chairperson of the Department of Counselor Education at The College of New Jersey. Dr. Woodford earned his Bachelor’s and Master’s degrees from The College of William and Mary and his doctorate in counselor education and supervision from the University of Virginia. He is the author of Men, Addiction, & Intimacy: Strengthening Recovery by Fostering the Emotional Development of Boys and Men. References Fogel, A. (2009). The psychophysiology of self-awareness: Rediscovering the lost art of body sense. New York: Norton. Fosha, D., Siegel, D.J., & Solomon, M.F. (Eds.). (2009). The healing power of emotion: Affective neuroscience, development, & clinical practice. New York: Norton. Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the body: A sensorimotor approach to psychotherapy. New York: Norton. Panksepp, J. (2009). Brain emotional systems and qualities of mental life: From animal models of affect to implications for psychotherapeutics. In D. Fosha, D.J. Siegel, M.F. Solomon (Eds.), The healing power of emotion: Affective neuroscience, development, and clinical practice. (pp. 1–26). New York: Norton. Siegel, D.J. (2001). The developing mind: How relationships and the brain interact to shape who we are. New York: Guilford. Siegel, D.J. (2007). The mindful brain: Reflection and attunement in the cultivation of well-being. New York: Norton. Woodford, M.S. (2012). Men, addiction, and intimacy: Strengthening recovery by fostering the emotional development of boys and men. New York: Routledge. WINTER 2013 | Advances in Addiction & Recovery 27

The Mindful Practices of Alcoholic Anonymous

Mindfulness is Inseparable From Core Values of Surrender and Acceptance B y G eorge D u Wors , MSW, LICSW, BCD Alcoholics Anonymous (AA) had its beginnings in 1935 at Akron, Ohio, as the outcome of a meeting between Bill W., a New York stockbroker, and Dr. Bob S., an Akron surgeon. Both were alcoholics.1 Early in 1939, the Fellowship published its basic textbook, Alcoholics Anonymous. The text, written by Bill, explained AA’s philosophy and methods, the core of which was the now well-known Twelve Steps of recovery.2 As AA gained prominence, the spiritual foundation of the 12-Step process has become tied to many faiths. At least three books (Alexander, 1997) (Ash, 1993) (Griffin, 2004) document the integration of Buddhism

and 12-step recovery. Another (Fields, 2008) refers to the compatibility of mindfulness and 12-step recovery. The AA “Big Book” (Anonymous, 2008) and the Twelve Steps and Twelve Traditions (Anonymous, 1981), on the other hand, urge the recovering reader to seek books by those who know far more about meditation and prayer than the founders of Twelve Step Recovery did. What none of these sources do is spell out that AA, as created in the thirties and practiced today, already cultivates mindfulness in so many direct and practical ways. This article highlights many of those ways.

Definitions Thich Nhat Hanh (1975), in The Miracle of Mindful ness, defines his subject as “keeping alive in consciousness the reality of the present moment.” His defining example is given by an American graduate student. This young man realized that “all time is my own time” and he determined to “take an interest and share my presence,” even doing first grade homework with his

Historical Data: The Birth of A.A. and its growth in U.S./Canada, http://www.aa.org/lang/en/ subpage.cfm?page=288, October 23, 2013. 2 Historical Data: The Birth of A.A. and its growth in U.S./Canada, http://www.aa.org/lang/en/ subpage.cfm?page=288, October 23, 2013. 1

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son. Western psychologists such as Jon Kabat-Zinn (1994) (1990) have defined mindfulness as being aware of what you are doing, thinking feeling, as you do, think or feel it. “Staying present” or “seeing clearly” are also brief Western descriptions. Eckhardt Tolle (1997) avoids the term “mindfulness,” while speaking repeatedly of an experience he calls “presence.” Thich Nhat Hanh makes it clear that there is far more to mindfulness than sitting meditation. In fact, he declares that sitting for 45 minutes a day is of little value without continuous practice throughout the day. He describes many tools for doing just that, as does Jon KabatZinn (1994). Kabat-Zinn, Terry Fralich (2007) and other author/ teachers also distinguish between the “formal” practice of mindfulness (sitting meditation) and the “informal” ones applied during everyday life. Most AA practices discussed here would be considered “informal,” even though they would fit comfortably in The Miracle of Mindfulness. So we will start with just an observation or two about formal meditation and the Twelve Steps.

Meditation and Twelve Steps Sitting in meditation can fulfill the Step Eleven “suggestion” for meditation. But the typical AA member is not a Buddhist, and often does not seek formal training. Most sponsors do encourage daily reading of a recovery meditation, reflectively and accompanied by prayer. This is not so far from Thich Nhat Hahn’s “meditation on a fixed object,” (1975) which picks a subject of personal struggle for in-depth reflection. Formal meditation typically comes later in recovery, often drawing on sources outside the program. Meditation skills may develop earlier as more counselors and sponsors engage with mindfulness. And what of the Twelve Step meeting itself? Focusing on the shared struggle to (remember to) abstain, constant emphasis on acceptance, reminders that “it’s alcoholism not alcohol-wasm,” generates a virtual pep rally for giving up egocentricity, practicing loving-kindness and living in the present. The feeling of “we” abates, however briefly, the awful separation which underlies egotism.

Staying out of Results Thich Nhat Hanh teaches “wash the dish just to wash the dish.” (1975) In essence, he suggests focusing on the experience of doing, rather than any future condition of being “done.” Twelve Step members are taught “ just do the footwork and stay out of the results,” and even “the results are none of my business.” Eckhart Tolle (1997) actually traces this practice all the way back to “Karma yoga” of Hinduism. The actual practice appears to consist of withdrawing or setting aside the will for a future outcome as an object of attention and effort, focusing instead on the real-time experience of doing what one is doing. An AA member also learns to “let go and let God” or “turn it over.” The practice of theistic surrender targets the same “evils” of will (to control outcome, to be there, not here) and ego that “washing the dish to wash the dish” would train out of the Buddhist. In fact, living in the present with an attitude of service, is the consistent “fruit” of surrender as an experience and a practice. When we surrender what has already happened and let the same “higher power” decide what will happen, we are left to deal only with the unfolding present. Surrender also replaces both material attachment and aversion with a “higher power.”

Twelve Step Slogans Probably the most obvious and explicit AA mindful practice is the determination to live “one day at a time.” While the bell of mindfulness may call the Buddhist to the living, breathing moment, “one day at a time” guides the sober alcoholic in to the broader boundaries of

a full day. Future-tripping and thinking of worst-case scenarios are short-circuited by: “Wait a minute! What can I do about that today? Have I done it? If the answer is ‘yes’, the rest is irrelevant. If ‘no’, I get to work.” This practice is a simple and powerful way to bring the mind back from the imaginary, high-stress future to its much more manageable present. Abstaining from alcohol, drugs or any other “fix,” the reminder that one only has to deal with one day of “deprivation” g reatly reduces the agonizing specter of life as an endless desert with no oasis. This humble tool of coming back to the present day has kept millions of alcoholics sober. If 10 percent of the people not in 12-step programs embraced “one day at a time,” it might change the course of history. Several other AA slogans also work to bring the recovering alcoholic back to the present. “HALT” (do not get hungry, angry, lonely or tired) is a simple prescription for self-care and relapse prevention. As a practice, it implies monitoring real-time levels of hunger, anger, loneliness and fatigue and then taking real-time action to reduce the threat. “Just do the next indicated thing,” requires attention to the unfolding of life and what it requires at any given moment. Like Hanh’s “washing the dish to wash the dish,” it entails combining alertness for the present moment, as it develops, with an attitude of service. “Easy does it” implies gentleness, slowing down, not straining obsessively to speed up the future and its desired outcome. “Keep coming back,” repeated collectively at the end of each AA meeting, calls members back. And as we have seen, meetings call them back to the present in a number of ways.

Acceptance and Mindfulness For one who started on the addiction side of “behavioral health” in 1971, it has been heartening and just a little ironic, to observe the mental health side of the profession increasingly embrace “acceptance.” “Mindfulness-based Stress Management” (1990), “Acceptance and commitment therapy,” (Batten, 2011) “Radical Acceptance,” (Brach, 2003) Dialectical Behavior Therapy (DBT) (Linehan, 1993) and “mindful eating” (Bays, 2009) dominate the market for clinical books and continuing education credits. For those focused on substance use disorders, the AA “Big Book” (Anonymous, 2008) proclaimed in the 1930s “we have stopped fighting anything or anybody, even alcohol!” The Serenity Prayer — “God, grant me the serenity to accept the things I cannot change….” joined actual meetings and “the 24 hour plan” as a three-legged stool, one which has kept many an alcoholic sober and upright. At an excellent Seattle workshop on integrating “mindfulness and psychotherapy” Dr. Ron Siegel (2001) surveyed issues from anxiety to depression to chronic pain to ADD to PTSD. At times, it seemed like he just kept saying “acceptance is the answer to all our problems,” a sentence that first appeared in the third edition of the “Big Book.” There is probably no principle on which AA and mindfulness are more synchronous than acceptance. This includes acceptance of others and forsaking judgment, “suggested” by Steps Four through Nine and dictated by the lethal impact of resentment on alcoholics and their recovery. Buddhists say, “to resent my enemy is like swallowing rat poison and expecting the rat to die.” Or, as one AA participant put it, “I’ll show you — I’ll swallow a grenade!” The more general principle of “accepting life on life’s terms” takes the AA member to the heart of mindfulness. As Eckhart Tolle (1997) so eloquently put it, the present moment is not just “the most precious thing there is….. it is the only thing.” Alcoholics are not alone in needing to wake up to the fact that the only place we are actually alive is right here, right now. Many of the tools described here help them accept that “life term” and live with it. WINTER 2013 | Advances in Addiction & Recovery 29

The special place of the Serenity Prayer, often referred to as the AA prayer in spite of its earlier origins, also strengthens mindfulness in AA members. Repeated in unison at virtually every meeting, often more than once, this elegant formula cuts to the existential chase of virtually any problem a human being can have. It is a consummate tool for both calming down and for looking. So, what do we have no control over, dictating a path of acceptance? And what might we change if we are to act in the one place Thich Nhat Hanh (1975) says we have “dominion”: the present moment? The serenity prayer is an ad hoc practice for facing the present moment clearly and knowing how to respond to it.

Mindfulness and Maintenance Turning our attention back to the Twelve Steps, the so-called “maintenance steps” also call for mindful practice. Step Ten, “to continue to take inventory and when we are wrong promptly admit it,” involves monitoring real-time reactions, specifically looking for faulty thinking and/or action in self, taking corrective action “promptly.” “Moral inventories” at the end of each day reinforce this practice, as do “spotcheck inventories” when upset about anything, while still upset. Step Eleven is the “prayer and meditation step,” seeking to increase “conscious contact” with the “higher power.” Whatever your position on theism, does anyone doubt that “conscious contact” is an experience that can only be had in real time? And is it possible that the experience of conscious contact is like “pure consciousness” or “no mind?” Eckhart Tolle, for one, urges “conscious contact” with your inner body as the pathway to “Being.” The second part of the step seeks “knowledge of God’s will for us and the power to carry it out.” Again, how could one recognize an “order” from any source if one is not mentally present to receive it, here and now? When else would it arise? Jon Kabat-Zinn, an avowed atheist, lauds the practice of “stopping,” (extracting one’s will for results) by imagining one has just died. He alleges that this cheerful practice gives us “guidance.” No Twelve Step member who “pauses throughout the day,” practicing both Steps Three and Eleven, would argue with him. Finally, Step Twelve calls for “practicing these principles in all our affairs.” This application of principles puts life on a highly intentional basis, one that is only possible if consciousness is focused on the present “affair” and the principle it may call for. The second part of the step, to take this message to those who still suffer, embodies the practice of compassion. At the same time, the very suffering of the newcomer reminds the “messenger” what awaits if s/he forgets s/he is alcoholic for one moment. To paraphrase Thich Nhat Hanh, the function of AA as a whole is to “keep alive in consciousness the reality of still being alcoholic, still being in recovery, still needing to practice these principles in every moment.”

Sponsorship Sponsorship is another side of mindful practice in AA. The Sponsor “gets out of self” and strengthens his or her own learning by sharing intimately, both what he or she has learned, and the suffering from which it arose. The “guru” in mindfulness/Buddhism is one who has practiced “the way” and been transformed. Dharma teachers introduce themselves by listing their “Masters.” That, and personal practice and experience are the credentials. The late Dr. Alan Marlatt and his colleague, Dr. Sara Bowen (2011) would not accept clinicians into their mindfulness-based relapse prevention course who do not have a meditation practice. And they repeat the necessity and value of selfdisclosure in transmitting the technology of acceptance to patients. 30 Advances in Addiction & Recovery | WINTER 2013

In accepting the Buddhist path of transmission, they required the therapist be someone who has “been there.” Not necessarily an alcoholic who has “worked a program.” Rather, a human being, someone who shares his/her own struggle with the ultimate challenge for each of us, the mind. The boundary between Twelve Step helping and mental health treatment, may be coming down, not because AA is coming out, but because therapy is coming in. At the very least, mindfulnessbased therapy appears to move even further away from the “blank screen” of psychoanalysis. Marlatt insisted on a mutual transparency found among Twelve Step members and precious few other places. It is sometimes referred to as “sharing your thought life,” and gives rise to much of the laughter in meetings.

Conclusion The goal of this article is to spell out how mindful practices and principles pervade Alcoholics Anonymous. “Living in the present” seems to be both a tool and a value. The implications of “surrender” for mindfulness will help the clinician who practices and encourages mindfulness to see more clearly how to help AA clients build on the skills and experience they already have. To those in AA, seeing that they have been “doing mindfulness” all along, that mindfulness is inseparable from core values of surrender and acceptance, may help them to embrace a more vigorous meditation practice. For those interested in recovery and mindfulness, perhaps “turned off” by theistic words of AA, a “middle path” may appear. And for those 12-Steporiented counselors who dismiss “mindfulness” for any reason, may this article be a bridge. The author of a well-respected book on addictive relapse, George Duwors facilitates workshops on “motivation for maintenance.” His engagement with mindfulness began in 1995 with Thich Nhat Hahn’s the Miracle of Mindfulness — ultimately changing his job description from “psychotherapist” to “psychosomatic therapist.” A workbook, “Getting It, Building Motivation From Your Own Relapse Experience” is in trial run. You can reach him at george.duwors@frontier.com or www.motivationformaintenace.com. References Alexander, W. (1997). Cool Water:Alcoholism, Mindfulness, and Ordinary Recovery. Boston, MA: Shambhala Publications. Anonymous. (1981). Twelve Steps and Twelve Traditions: An Iinterpretive Commentary on the AA Program by a Cofounder. New York, NY: Alcoholics Anonymous World Services, Incorporated. Anonymous. (2008). Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered from Alcoholism. New York, NY: Alcoholics Anonymous World Services Incorporateed. Ash, M. (1993). The Zen of Recovery. New York, NY: Jeremy P Tarcher/Putnam. Batten, S. (2011). Essentials of Acceptance and Commitment Therapy. London: Sage Publications. Bays, J.C. (2009). Mindful Eating: A Guide to Rediscovering a Healthy and Joyful Relationship With Food. Boston: Shambhala Publications. Bowen, S.C. (2011). Mindfulness-based Relapse Prevention for Addictive Behaviors: A Clinician’s Guide. New York, NY: The Guilford Press. Brach, T. (2003). Radical Acceptance, Embracing Your Life in the Heart of the Buddha. New York, NY: Bantom Books. Fields, R. (2008). Awakening to Mindfulness: Ten Steps for Positive Change. Deerfield Beach, Florida: Health Communications. Fralich, T. (2007). Cultivating Lasting Happiness: A 7-Step Guide to Mindfulness. Eau Claire, WI: PESI. Griffin, K. (2004). One Breath at a Time: Buddhism and the Twelve Steps. USA: St. Martin’s Press. Hanh, T.H. (1975). The Miracle of Mindfulness, Manual on Meditation. Boston, MA: Beacon press. Kabat-Zinn. (1990). Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York, NY: Dell Publishing. Kabat-Zinn. (1994). Wherever You Go There You Are: Mindfulness Meditation in Everyday Life. New York, NY: Hyperion. Linehan, M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York, NY: The Guilford Press. Siegel, R. M. (2001). Back Sense, a Revolutionary Approach to Halting the Cycle of Chronic Back Pain. New York, NY: Broadway Books. Tolle, E. (1997). The Power of Now. Vancouver, BC: Namaste Publishing, Incorporated.

NAADAC BOARD OF DIRECTORS REGIONAL VICE PRESIDENTS Mid-Atlantic (Represents Delaware, the District of Columbia, Maryland, New Jersey, Pennsylvania, Virginia and West Virginia)

Mid-Central (Represents Kentucky, Illinois, Indiana, Michigan, Ohio and Wisconsin)

Stewart Turner-Ball, LMFT, LCSW, LCAC, MAC Mid-South (Represents Arkansas, Louisiana, Oklahoma and Texas)

NAADAC OFFICERS

Sherri Layton, MBA, LCDC, CCS

Updated 10/23/13

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

President Robert C. Richards, MA, NCAC II, CADC III

Diane Sevening, EdD, CDC III

President Elect Kirk Bowden, PhD

Northeast (Represents Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island and Vermont)

Secretary Thurston S. Smith, CCS, NCAC I, ICADC Treasurer John Lisy, LICDC, OCPS II, LISW-S, LPCC-S

Catherine Iacuzzi, PsyD, MLADC, LCS Northwest

Past President Donald P. Osborn, PhD (c), LCAC

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

Greg Bennett, MA, LAT

NAADAC - National Certification Commission Chair Kathryn B. Benson, NCC AP Chair

Nominations and Elections Chair Donald P. Osborn, PhD (c), LCAC

International Committee Chair Paul Le, BA

PAST PRESIDENTS

Personnel Committee Chair Robert C. Richards, MA, NCAC II, CADC III

Leadership Retention & Membership Committee Chair Roger A. Curtiss, LAC, NCAC II

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

Ron Pritchard, CSAC, CAS

NAADAC

Organizational Representative Philip L. Herschman, PhD

NAADAC Public Policy Committee Chair Gerry Schmidt, MA, LPC, MAC

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

NATIONAL CERTIFICATION COMMISSION FOR ADDICTION PROFESSIONALS (NCC AP) Kathryn B. Benson, LADC, NCAC II, QSAP, QSC, NCC AP Chair Nashville, Tenn. lightbeing@aol.com

William S. Lundgren Denver, CO lund1365@msn.com Rose M. Maire Glen Rock, NJ rmmaire@aol.com

Christopher C. Bowers Powhatan, VA chriscbowers@comcast.net

Loretta Tillery, Public Member Lanham, MD ltillery99@yahoo.com

Susan L. Coyer Huntington, WV susan.coyer@prestera.org

Ricki Townsend Fair Oaks, CA ccrtowns@aol.com

Carmen L. Getty Alexandria, VA carmen.getty@alexandriava.gov

James Holder Past Chair Effingham, SC james.holder10@yahoo.com

Tay Bian How Sri Lanka bian.howtay@colomboplan.org

Clinical Issues Committee Frances Patterson, PhD, MAC

Gloria Boberg, LSAC, CAC

National Addiction Studies and Standards Collaborative Committee Chair Donald P. Osborn, PhD (c), LCAC

Adolescent Specialty Committee Chair Christopher Bowers, MDiv, CSAC, ASE

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

Frances Patterson, PhD, MAC

Student Committee Chair Diane Sevening, EdD, CDC III

Awards Sub-Committee Chair Tricia Sapp, BSW, CCJP, CPS

NAADAC STANDING COMMITTEE CHAIRS

(Represents Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina and Tennessee)

Political Action Committee Chair Nancy Deming, MSW, LCSW, CCAC-S

NAADAC AD HOC COMMITTEE CHAIRS

Southeast

Executive Director Cynthia Moreno Tuohy, NCAC II, CCDC III, SAP

Product Review Committee Chair Philip L. Herschman, PhD

Ethics Committee Chair Anne Hatcher, EdD, CAC III, NCAC II Finance Committee Chair John Lisy, LICDC, OCPS II, LISW-S, LPCC-S

Thaddeus S. Labhart John Day, OR tlabhart@hotmail.com

Robert C. Richards, MA, NCAC II, CADC III (ex-officio)

MID-CENTRAL

NORTHEAST

Beverly Jackson, Illinois C. Albert Alvarez, LMHC, LCAC, MAC, CGP, Indiana Michael Townsend, MSSW, Kentucky Shannon Rozell, MPA, Michigan Leon Collins, LICDC, ICADC, ICCS, Ohio Gisela Berger, PhD, Wisconsin

Susan Campion, LADC, LMFT, Connecticut Ruth A. Johnson, LADC, SAP, CCS, Maine Susan O’Connor, Massachusetts Peter DalPra, LADC, New Hampshire Christopher Taylor, CASAC, LMHC, MAC, DOT SAP, New York William Keithcart, MA, LADC, Vermont

NAADAC REGIONAL BOARD REPRESENTATIVES

NORTH CENTRAL

Gloria Nepote, LAC, NCAC II, CCDP, BRI II, Kansas-Missouri James P. Johnson, BS, LADC, ICS, Minnesota Jack Buehler, LADC, Nebraska Kurt Snyder, MMGT, LSW, LAC, North Dakota Jack Stoddard, MA, CCDC III, South Dakota WA

NORTHWEST MT

Steven Sundby, PhD, Alaska Julie Messerly, LAC, Montana Christine Stole, Oregon Greg Bauer, CDP, NCAC I, Washington SueAnne Tavener, MS, LPC, LAT, Wyoming

ND VT

Northwest

North Central

Mid-Central IL

Southwest

NH MA RI

UT CA

MI IA

Northeast

MidAtlantic

VA NC

SOUTHWEST

Del Worley, MC, LPC, LISAC, Arizona Thomas Gorham, MA, CADC II, California Mita Johnson, LPC, LMFT, LAC, MAC, ACS, Colorado Mark C. Fratzke, MA, MAC, CSAC, CSAPA, Hawaii Kimberly Landero, MA, Nevada Michael Odom, LSAC, Utah

Mid-South TX

AL LA

MID-SOUTH

SOUTHEAST

Paula Heller Garland, MS, LCDC, Texas

Southeast

MID-ATLANTIC Jevon Hicks Sr., Delaware Johnny Allem, MA, District of Columbia Moe Briggs, NCC, LCPC, MAC, SAP, Maryland Patrice Porter, LPC, Virginia Susie Mullens, MS, LPC, ALPS, AADC-S, West Virginia

Eddie Albright, MS, Alabama Bobbie Hayes, LMHC, CAP, Florida Diane Sherman, PhD, NCAC II, Georgia Martha Wittig, PhD, CAADC, CCS, Mississippi Angela Maxwell, MS, CSAPC, North Carolina Ernie Kirkland, South Carolina Toby Abrams, LADAC, Tennessee

WINTER 2013 | Advances in Addiction & Recovery 31

Save the Date

NAADAC Annual Conference • Sept. 27–Oct. 1, 2014 • Seattle

Natural Beauty, Unrivaled Education

howard frisk & tim thompson | visitseattle.org

NAADAC, the Association for Addiction Professionals is pleased to announce its 2014 annual conference in Seattle, Washington. A vibrant arts and culture scene, celebrity chef restaurants, live music, farmers markets and an abundance of lakes, mountains and shoreline to explore. Start planning your Seattle adventure while you earn your education credits from the profession’s thought leaders. Interested in attending, presenting, exhibiting or sponsoring at NAADAC’s 2014 annual conference? Get more information at www.naadac.org/conferences.