NIDA Enters College by CASAT/UNR

Funding for this module was provided by a grant from the National Institute on Drug Abuse (NIDA) Science Education Drug and Alcohol Partnership Awards (SEDAPA) #1 R25 DA 020472-01A1. Find resources at http://casat.unr.edu/necp.html

NIDA ENTERS COLLEGE PROJECT DEVELOPMENT TEAM

Nancy A. Roget, MS, Michelle Stupfel-Berry, MBA, Wendy L. Woods, MA, Paula Riggs, MD, Joyce A. Hartje, PhD, Michael Wilhelm, BA, Andrea Vicente, BA,

Principal Investigator Co-Investigator/Project Manager Co-Investigator/Project Manager Scientific Advisor Evaluator Media Specialist Operations Coordinator

This material is based on work supported by a Science Education Drug Abuse Partnership Award (SEDAPA) from the National Institute on Drug Abuse (NIDA), a component of the National Institutes of Health, Department of Health and Human Services under Contract Number 1 R25 DA 020472-01A1. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the view of the funding agency. Published in 2010 by the University of Nevada, Renoâ&#x20AC;&#x2122;s Center for the Application of Substance Abuse Technologies (UNR/CASAT) with all rights reserved. You have the permission of UNR/CASAT to reproduce items in this module for classroom education and professional training purposes only. For permission for any other uses, please obtain written authorization by contacting Center for the Application of Substance Abuse Technologies, 800 Haskell St., Reno, NV 89509; www.casat.org; 775-784-6265. Recommended citation for this project: Roget, N.A., Hartje, J.A., Berry, M.S., Riggs, P., Wilhelm, M.A., & Woods, W.L. (2011). The NIDA Enters College Project: A Research-based Curriculum that Examines the Neuroscience of Addiction. Reno, NV: University of Nevada, Reno/Center for the Application of Substance Abuse Technologies.

Table of Contents Project Research & Using the Curriculum..... 3 Module 1............................................................ 6 Module 2............................................................ 49 Module 3............................................................ 56 National Institute on Drug Abuse.................... 98

Project Research The overall purpose of the NIDA Enters College Project Curriculum Infusion Package (NECP-CIP) is to increase studentsâ&#x20AC;&#x2122; knowledge and understanding of the disease model of addiction and decrease stigma related to inaccurate beliefs about addiction and individuals suffering from substance use disorders (SUDs). The NECP-CIP is designed to introduce the neuroscience of addiction to students planning professional careers in which they will likely deal directly with the public health consequences of substance abuse/addiction (e.g., Counseling, Criminal Justice, Nursing, and Social Work). The goals for the Curriculum are as follows: Goal 1: Elicit pre-conceived attitudes and beliefs about addiction, and examine whether those attitudes and beliefs are inaccurate and contribute to stigma. Goal 2: Present scientific knowledge based on research about addiction and effective prevention, intervention, treatment, and recovery approaches. Goal 3: Evaluate whether the scientific content of the Curriculum changed inaccurate, stigmatizing attitudes and beliefs about addiction and individuals suffering from SUDs. To evaluate the impact of the brief, intensive research-based NECP-CIP on studentsâ&#x20AC;&#x2122; knowledge and attitudes about addiction, the Curriculum was integrated into existing introductory criminal justice, nursing, and social work courses at the University of Nevada, Reno. Two sections of each disciplinespecific introductory course were offered during the Fall 2007 and 2008 semesters. One section in each discipline was designated as the implementation (curriculum infusion) group (N = 205) and one section as the non-implementation (control) group (N = 324). Pre-test and post-test knowledge and attitude surveys based on Curriculum objectives were developed and administered to students in both the implementation and control groups. The combined results for the two years of the study showed that a total of 366 students completed pre- and post-test surveys (implementation group: n = 103; control group: n = 263). In both years of the study, results showed significant increases in knowledge about the neuroscience of addiction and decreases in stigmatizing attitudes towards individuals with SUDs between 1) the implementation vs. non-implementation groups; and 2) the implementation group pre-test vs. post-test measures.* These results lend support to the effectiveness of infusing the NECPCIP into existing undergraduate courses on changing knowledge and stigmatizing attitudes, and could hold long-term implications for preparing future professionals to work with individuals who have SUDs. The NECP-CIP is designed to expose students to the neurobiology of addiction so they begin seeing addiction as treatable like other chronic diseases. As they begin to comprehend the concepts presented, students will gain a better understanding of the problems associated with establishing recovering and a drug/alcohol-free lifestyle. Therefore, the Curriculum does not simply educate but also changes the way students think about addiction, and can be an effective teaching tool for preparing the next generation of practitioners to effectively work with individuals with SUDs.

* Study results are available on request.

The three 50-minute modules contain all of the materials needed to present the neuroscience of

Using the NECP Curriculum addiction and can be adapted to the specific teaching format in which you are working (i.e., online or traditional classroom; 1-, 2-, or 3-hour sessions). In addition, the exercises included in each module provide opportunities to apply new knowledge about addiction and replace inaccurate perceptions with new attitudes/beliefs that are more grounded in current research-based addiction science. MODULE 1: Working Definition, Prevalence, Risk/Protective Factors, and Public Health Impact of Addiction • What is addiction? • Why do people become addicted? • Who is at risk for developing addiction? • What protects people from becoming addicted? • Can people become addicted even if they have no or few risk factors? • What is the public health impact and cost of addiction? MODULE 2: Neurobiology of Addiction • How do people become addicted? • What is the biological/neurobiological basis of addiction? Module 3: Prevention, intervention, treatment, and recovery • Can addiction be prevented? • Can interventions be performed to interrupt the course of addiction? • Can treatment and recovery services help people?

Instructions Each module has been created in .pdf and PowerPoint formats to facilitate your preferred presentation method. In order to maintain the fidelity of Curriculum content, the presentation slides have been created in a format that cannot be edited. However, the slides can be rearranged to facilitate integration into your course. The following describes three ways that can be used to present the Curriculum, including how to show the Module 2 and 3 videos. Option 1: Using the .pdf Files. The easiest way to present the Curriculum is to use the .pdf files, as the videos are embedded in the .pdf and require no special A-V equipment to play. Insert the CD into your computer, click on the .pdf file for the module you are presenting and YES to make the make it full screen. Pages advance on the mouse click and videos will play automatically. Option 2: Using the PowerPoint Files and Manually Inserting Video Files. The video files are not embedded in the PowerPoint slides. The DVD included with these materials contains all video files, which are located in separate chapters on the DVD Menu. First, save the video files to a location on your computer. To insert the videos, go to the Insert tab at the top of the PowerPoint navigation page, then click Movie, choose the appropriate video from the file list, and click Insert or OK. You will be given the option to have the video play automatically or when you click the mouse. Option 3: Using the PowerPoint and Video Files Separately. If you do not want to insert the videos as described in Option 2, show the PowerPoint slides up to the point where the videos are to be shown, then switch to the video files located on the DVD. Download updates and order replacement materials at http://casat.unr.edu/necp.html Funding for this module was provided by a grant from the National Institute on Drug Abuse (NIDA) Science Education Drug and Alcohol Partnership Awards (SEDAPA) #1 R25 DA 020472-01A1. Find resources at http://casat.unr.edu/necp.html

NIDA Enters College: Introduction

Exploring our beliefs about Addiction

Slide 1.1: Introduction

The NIDA Enters College Project (NECP) contains three 50-minute modules designed to teach students planning careers in the helping professions such as criminal justice, nursing, and social work about the neuroscience of addiction and its relevance to substance abuse prevention, treatment, and recovery. You may want to use the pre/post-test surveys included in this package to gauge the impact of the Curriculum on student knowledge and attitudes related to addiction and individuals who have substance use disorders.. If you decide to use these instruments, it is recommended that you administer the pre-test one week prior to starting Module 1 if possible. The following questions can be used to engage students in discussions as a means of introducing the Curriculum. • How many of you know someone who has had problems with alcohol or drugs? • How many of you think that alcohol and drug use are a problem on our campus? Throughout our state? • What do you think the likelihood is that you will someday be working with people who have substance abuse / addiction problems?

Students also may be curious about who developed the course: • University of Nevada, Reno’s Center for the Application of Substance Abuse Technologies (http://casat.unr.edu/) • This project was funded by a grant from the National Institute for Drug Abuse (NIDA). Information about NIDA can be found at the end of this manual and by going to the following website (http://www.nida.nih.gov/nidahome.html)

1.2

Slide 1.2: Overall Goal

It is important for people in our field to have an understanding of addiction in order to be effective in working with individuals with substance use disorders (SUDs). For example... (it would be helpful to use disipline-specific examples of where the students may encounter the impact of addictions as professionals.) Slides at the end of Module 1 provide discipline-specific data that may help make the link between addiction and helping professions. This Curriculum has three modules designed to educate students about: • the neuroscience of addiction, • its relevance for working with individuals with substance use disorders (SUDs), and • evidence-based principles of addiction prevention, intervention, treatment, and recovery.

Notes:

1.3

Slide 1.3: Curriculum Objectives

The goals for this Curriculum are: 1. Elicit pre-conceived attitudes and beliefs about addiction, and examine whether these attitudes and beliefs are inaccurate and contribute to stigma. 2. Present scientific knowledge based on research about addiction and effective prevention, intervention, treatment, and recovery approaches.

3. Evaluate whether the scientific content of the Curriculum changed inaccurate, stigmatizing attitudes and beliefs about addiction and individuals suffering from SUDs. Module 1 provides students the opportunity to: • examine pre-conceived ideas about what defines addiction, as well as attitudes and beliefs about the people who become addicted and their behavior; • develop a practical “working” definition of addiction based on the way scientists and researchers define it; • learn some of the key developmental risk factors that increase the vulnerability to addiction; and • discuss the prevalence, costs, and public health impact of addiction. Module 2 is biology-based and sets the stage for teaching students about the neuroscience of addiction through the use of a video in which NECP Scientific Advisor Dr. Paula Riggs presents an overview of: • the major regions of the brain and their main functions; • the role of receptors, neurotransmitters, neurons, synaptic connections as the way in which these different brain regions communicate; • the brain reward pathway and its central role in the neurobiology of addiction; • dopamine as the key neurotransmitter in the brain reward pathway and addiction; and • how drugs and alcohol change the brain. Module 3 builds on what is learned in Modules 1 and 2 to help students understand: • the chronic relapsing nature of the illness; • the need for continuing care and long-term recovery services and support; and • apply those principles to effective prevention, intervention, treatment, & recovery from SUDs. At the end of the 3-hour Neuroscience of Addiction Curriculum, students will be able to: • cite the working definition of addiction • describe the prevalence & public health impact of addiction • identify risk and protective factors that can impact an individual’s vulnerability to addiction • understand the brain reward pathway & its central role in the neurobiology of addiction • recognize research-based principles of addiction prevention & treatment

1.4

Slide 1.4: Introduction to Module 1

This slide marks the beginning of Module 1, which is designed to provide students with a foundation for understanding the neurobiology of addiction. The goal of Module 1 is to identify pre-conceived ideas and biases underlying the stigma associated with addiction and individuals who suffer from this chronic disease, and begin challenging erroneous beliefs using advances in science-based research that have added to our understanding of the neuroscience of addiction. Module 1 includes classroom activities designed to facilitate studentâ&#x20AC;&#x2122;s exploration of: 1) their preconceived ideas about addiction; 2) definitions of addiction; 3) factors that make a person more or less likely to develop an addiction (i.e., risk and protective factors); and 4) the prevalence, public health impact, and costs associated with addiction. The first step in this process is to examine attitudes, beliefs, and stereotypes that contribute to the stigmatization of individuals with substance use disorders (SUDs). We all have beliefs about addiction that can influence how we interact with individuals who have SUDs, both as students and later as professionals. All too frequently, attitudes, beliefs, and stereotypes based on misinformation serve as a barrier to individuals with SUDs receiving much needed professional treatment services. Thus, it is important to explore our personal beliefs and where they come from before beginning professional practice. Next, understanding SUDs and addiction requires the use of a common definition of the disorder. Students will have the opportunity to develop their own definition of substance dependence (addiction) and compare their definition(s) to the criteria listed in the Diagnostic Statistical Manual-IV-TR (2000). A practical, working definition is identified for the purpose of implementing this Curriculum so that every student understands what is meant when we refer to â&#x20AC;&#x2DC;addictionâ&#x20AC;&#x2122;. The continuum of substance use from experimentation through dependence is then presented, and the risk and protective factor theory used to discuss vulnerability to substance use disorders. Module 1 concludes with national data on the prevalence, public health impact, and costs associated with addiction, and an opportunity for students to discuss the social environment on your campus regarding substance use. If available, you may want to include data on substance use at your college/university.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

1.5

Slide 1.5: Module 1 Learning Objectives In Module 1, students will:

• examine pre-conceived ideas about what defines addiction, as well as attitudes and beliefs about the people who become addicted and their behavior; (Slides 1.6 - 1.10) • develop a practical “working” definition of addiction based on the way scientists and researchers define it; (Slides 1.11 - 1.15) • learn some of the key developmental risk and protective factors that can impact an individual’s vulnerability to addiction; (Slides 1.16 - 1.19) • understand the prevalence of addiction, costs, and public health impact of addiction. (Slides 1.20 - 1.46)

Notes:

1.6

Slide 1.6: Classroom Exercise: What do You Believe About Addiction?

Since many students will respond to these questions based on their personal or family experiences, or religious beliefs, it is important to be non-judgmental when discussing student responses. Certainly, this exercise presents the opportunity to correct inaccurate information. However, the source of that information must be considered when challenging the student’s beliefs. For example, a student may believe that treatment does not work because he/she has a friend/family member who relapsed following treatment. This is a “teachable moment” to explain that although many people do relapse following treatment and that it is a painful occurrence for everyone involved, this Curriculum presents the chronic nature of addiction, the need for on-going support following acute treatment episodes, and data on treatment effectiveness.

Classroom Exercise:

(This activity can also be done with the entire class if time does not allow for small group work.) 1. Have students break into small groups and discuss the questions on this slide. Ask them to record the group’s responses and be ready to share them with the class. 2. As each group reports out, have a student write the responses on the board so that everyone can view them. You may want to use the following in the group discussion to facilitate a discussion about stigma: • What do these beliefs have in common? • How are they different? • Which explanation is the most stigmatizing? Which is the least? • Do you think there are ways to scientifically test prevention/treatment efficacy? 3. Since the questions on this slide will be asked again at the end of the Curriculum, it would be useful to keep these initial responses in order to examine changes in students’ attitudes.

NOTE: This exercise is included at the end of Module 3 and can be used to examine the impact of the Curriculum on students’ beliefs regarding substance abuse/addiction.

1.7

Slide 1.7: Why Do People Use Alcohol & Drugs?

This transition slide poses a question that can be used to set the stage for a class discussion about current societal attitudes and messages about the use of nicotine, alcohol, and illicit drugs (next slide). Frequent responses to this question include: • to get high • to have fun • to escape or change their reality • because their friends use alcohol and/or drugs • to medicate themselves • to decrease stress

Notes:

1.8

Slide 1.8: Glamour, Availability, The Rush, Peers

The following questions can be used to engage students in a discussion of why people use alcohol and drugs based on current societal attitudes and messages about the use of nicotine, alcohol, and illicit drugs. We know our beliefs about addiction come from a number of sources. Sample questions that can be used to facilitate classroom discussion: 1. How do media sources, such as movies and advertisements, glamorize substance use? 2. Do societal messages about legal drugs differ from messages and attitudes about illicit substances such as marijuana, cocaine, and methamphetamine? (For example, nicotine and alcohol are legal for adult use and cause many times greater mortality and morbidity than all other drugs combined.) 3. Are societal messages different for different age groups (e.g., children, adolescents, young adults, older adults)? 4. What are the messages about alcohol/drug use on our college/university campus? 5. In what ways do you think messages and/or attitudes about alcohol/drugs are similar or different at our college/ university campus compared to the nation as a whole? 6. Have messages about some alcohol/drugs changed during your lifetime (e.g., nicotine use; consider whether the substance is legal or illegal)? 7. How does substance availability impact the number of individuals who become addicted to that substance? 8. When do most people who become addicted begin using alcohol/drug? 9. How do people who ‘experiment’ or who use ‘recreationally or socially’ differ from people who become addicted? How are they similar?

Notes:

1.9

Slide 1.9: Classroom Exercises

This slide is a transition into the next set of classroom activities (Slides 1.10 – 1.15) designed to engage students in further discussion about their beliefs and how they define addiction.

1.10

Slide 1.10: Addiction is a choice; they could stop if they really tried. Although this statement is false, it is representative of common beliefs and misconceptions about addiction.

Classroom Exercise: The goal of this exercise is to have students create an actual continuum that demonstrates students’ beliefs about this statement. Once students have placed themselves on the ‘line’, the instructor and students will have visual feedback regarding the level of agreement or disagreement with this statement. This also provides an opportunity to make comments about the continuum (e.g., where the majority of the students are standing; where those beliefs come from; how reflective that might be about societal beliefs). 1. Ask students to decide the extent to which they agree or disagree with this statement. 2. Have students line up at the front of the class in order of agreement with this statement. For example, ask students who strongly agree with statement to stand to your left and students who strongly disagree to stand to your right. Have students who hold less strong opinions position themselves somewhere in between. 3. Use line position to determine group placement for the defining addiction activity on Slide 1.12..

1.11

Slide 1.11: How is Addiction Defined?

This transition slide poses a question that sets the stage for a class discussion about how current societal attitudes and messages about the use of nicotine, alcohol, and illicit drugs are reflected in the way addiction is defined.

1.12

Slide 1.12: How do YOU Define Addiction?

This exercise is designed to continue the discussion about students’ current beliefs and attitudes as reflected in the way they define addiction.

Classroom Exercise: 1. Assign students to small groups according to their line placement from the previous activity. Begin by asking students in the small groups to develop a “consensus” definition of addiction (5 minutes). 2. Ask each small group to report their respective definitions of addiction to the class. Have one student write group responses on the board so that other students can view responses (5 minutes). 3. Use the definitions to facilitate class discussion on the definition of addiction. It is important that during this discussion instructor’s point out the differences and similarities among the students’ definitions of addiction.

1.13

Slide 1.13: How Clinicians & Researchers Define Addiction

The previous activity was a good example of how many different definitions/interpretations of addiction exist. However, a common definition is necessary for interpreting research findings and developing effective prevention, intervention, treatment, and recovery approaches. The discussion will now turn to how addiction is defined in the American Psychiatric Associationâ&#x20AC;&#x2122;s Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR). Instructors may want to comment about the DSM-IV-TR and its use by medical and other helping professionals to accurately diagnose and treat individuals who have mental disorders. For example, the manual helps to distinguish between someone with depression from someone with an anxiety disorder, and allows professionals to accurately diagnose mental disorders using agreed upon criteria developed by experts. If unfamiliar with this manual it will be helpful to review it (either text version or online) in order to familiarize yourself with it.

Notes:

1.14

Slide 1.14: Substance Use Disorders (DSM-IV-TR)

Review the definition of substance abuse and dependence (addiction) as specified by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR). Highlight the differences in the definitions for abuse compared to dependence, and that dependence is also referred to as addiction. The final bullet point (continued, compulsive use despite negative consequences) provides a good summative definition of addiction. Compare and contrast the studentsâ&#x20AC;&#x2122; attitudes/beliefs/definitions identified in the previous discussions with the research-based information presented here. If unfamiliar with the substance use and dependence criteria, it may be important to review it before teaching this model. Basically, substance abuse disorders are less serious than substance dependence disorders. Individuals are diagnosed by substance, so some could be diagnosed with an alcohol dependence disorder and a marijuana abuse disorder.

Notes:

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

1.15

Slide 1.15: Working Definition of Addiction For the purpose of this Curriculum, “continued use despite negative consequences” will be the working definition of addiction used for the remainder discussions and activities. Looking at this definition… • What types of negative consequences could occur? • Why do you think people continue to drink or use drugs when they risk consequences like going to jail, losing their job, or having their children taken away? [Engaging students in a discussion about why experiencing negative consequences would not be a deterrent to substance use/abuse could provide additional insight into existing attitudes about addiction and individuals who have SUDs.]

Notes:

1.16

Slide 1.16: How Do People Become Addicted?

This transition slide can be used to set the stage for upcoming discussions on the downward spiral of addiction (Slide 1.17), and risk and protective factors associated with addiction (Slide 1.18 - Slide 1.19). These discussions also will provide an opportunity to contrast the attitudes and beliefs identified earlier with the research-based information presented in the following slides.

Notes:

1.17

Slide 1.17: The Downward Spiral of Addiction

This slide depicts the downward spiral of behavioral and negative consequences that characterize the progression from experimental use to dependence. This progression can be conceptualized as more frequent use accompanied by increasing negative consequences. For example, at the Regular Use Stage, the individual may drink or use drugs on the weekend. Occasionally, the person may overindulge and experience some negative consequences. Perhaps he/she acted in an embarrassing manner or engaged in high risk sexual behavior while under the influence. At the Misuse Stage, these consequences may become more frequent and/or may be more serious (e.g., missing work or school, getting into arguments with friends or loved ones), and tend to modify the drinking and drugging behavior, at least temporarily. However, many individuals continue to use alcohol and drugs no matter the seriousness of the consequences. For example, do you know someone who got a DUI but continued to drink alcohol? [Ask the class this question and discuss their responses.] Individuals who do not have an SUD will end their alcohol and drug use as the consequences get more severe. Individuals with the disorder will continue to use no matter what the consequences are. The Abuse and Dependence (Addiction) Stages are defined by the criteria in the DSM-IV-TR (refer back to Slide 1.14). Research shows that 47% of all teenagers have used illicit substances before leaving high school, 72% have used alcohol, and 55% have been drunk. However, most of these young people do not become addicts (Johnston, O’Malley, Bachman, & Schulenberg, 2007; Winters & McLellan, 2008).

We know that people don’t become addicted to substances the first time they sip a beer or use a drug, and that some people are able to drink socially without getting into trouble. However, for people who do get into trouble there is a fairly predictable pattern that starts with Casual/Experimental (Recreational) use. Then, with more regular use there are occasional problems and ongoing use despite these problems. Misuse of a Substance is ongoing use with more serious problems, like getting a DUI, and then Addiction is the ongoing use despite problems in multiple areas (e.g., job, school, family, repeat DUIs, and an inability to cut back or stop). Notes:

Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2008). Monitoring the future national survey results on drug use 1975-2007: Volume I secondary school students . (NIH Publication No. 08-6418A). Bethesda, MD: National Institute on Drug Abuse. http://monitoringthefuture.org/pubs/monographs/vol1_2007.pdf Winters, K. C., & McLellan, A. T. (2008, January). Adolescent brain development and drug abuse. Treatment Research Institute Science Over Addiction.

1.18

Slide 1.18: Risk Factors

Research has helped determine what factors increase risks and protect against development of a substance use disorder. The primary domains of developmental risk (Slide 1.18) and protective factors (Slide 1.19) for substance abuse and dependence (addiction,) are based on the Risk and Protective Factor theory developed by Hawkins, Catalano, and Miller (1992). This theory identifies “contextual factors” that increase or reduce the likelihood of alcohol, tobacco, and other substance use among adolescents. Risk factors are those things that increase the probability of an individual engaging in substance use (e.g., violence, delinquency, dropping out of school, teen pregnancy, sexually transmitted diseases). The following are examples of risk factors in each of the primary domains of development. [These factors will be referenced again in Module 3 when we discuss prevention.]

Individual Risk Factors • Genetic predisposition • Early and persistent antisocial behavior • Mental Health/Psychiatric disorders • Association with peers/friends who engage in problem behaviors • Early initiation of the problem behavior

Community Risk Factors • Availability of alcohol/drugs • High crimes/community norms that are favorable toward alcohol/drug use • Low neighborhood attachment • Extreme economic deprivation

Family Risk Factors • Family history of problem behavior • Family management problems • Major or frequent family conflict/disruptions • Parental attitudes and substance use/abuse • Crime, violence, abuse/neglect

School Risk Factors • Learning problems/disability • Poor grades/academic performance and academic failure beginning in elementary school • Lack of commitment and behavior problems in school • Expulsion/suspension

Hawkins, J.D., Catalano, R.F., & Miller, J.Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112, 64-105.

Slide 1.18: Risk Factors (Cont.) How can we understand the differences between a high school student who uses alcohol and has no problems and one who becomes addicted to alcohol or drugs? One way is by studying risk factors. Studies have shown that 40-60% of a person’s predisposition to addiction can be attributed to genetics and geneenvironment interactions (the added impact of the environment on how genes function or are expressed). For example, a person has certain risk factors for heart disease such as a family history, smoking, and obesity. While people can’t change their genetic predisposition, they can reduce their risk of heart disease by quitting smoking and losing weight. Similarly, it is hypothesized that changing the non-biological risk factors for substance abuse will reduce the probability that a young person will develop alcohol or other drug problems. Other examples of risk factors that are changeable include: • Untreated mental health problems (e.g., untreated ADHD can increase the risk of substance use); • Peers who use/abuse substances; • Family conflict or parental attitudes and/or substance use; • Learning problems/disabilities that result in poor academic performance. Three additional points should be noted regarding risk factors. First, the more risk factors present in a child’s life, the greater the probability that substance abuse problems will develop. Therefore, when multiple risk factors are present, it makes sense to reduce the ones that can be changed if possible. For example, a child may live in an extremely dysfunctional family. While school personnel cannot do anything about the child’s living situation, they can attempt to reduce school risk factors. Second, the relationship between risk factors and problem behaviors is a correlational not a cause and effect relationship. Therefore, a child with numerous risk factors is not “doomed” to addiction. In other words, “Risk does not equal destiny”. Finally, the absence of risk factors does not mean that a person is “protected” from substance abuse problems. To illustrate this point, imagine a person with no risk factors who uses heroin every day. That person will develop a dependence on heroin. So, we certainly don’t want students to think they can use alcohol and other drugs with impunity if they have few or no risk factors. Thus, the message is that “No risk does not equal total protection”.

1.19

Slide 1.19: Protective Factors

Just as risk factors increase the probability of developing problem behaviors, protective factors provide a barrier. Again, using the analogy of heart disease, we know that proper diet and exercise are protective factors against the development of heart disease. What are the personal and social qualities that help protect against developing an SUD? Some are not changeable, as in the case of genetic predisposition. But there are protective factors that have been shown to be useful in reducing the development of problem behaviors among adolescents, including associating with non-using peer groups, having parents who closely monitor adolescents’ activities and friends, and being successful in school. The interplay between risk and protective factors are not fully understood as someone with many risk factors can avoid developing an SUD. In some cases, children with many risk factors develop a resiliency (Werner, 1993). For people with strong genetic risk for substances, it makes sense to increase protective factors while keeping an eye out for risk factors.

Individual Protective Factors • Activities with non-using peers • Parental monitoring of friends and activities • Resilient temperament • Positive social orientation

Community Protective Factors • Healthy community substance use & behavior norms • Positive community activities/role models • Work • Anti-drug use policies • Policies limiting availability of alcohol

Family Protective Factors • Bonding/attachment to positive family members • Healthy family beliefs • Favorable parental attitudes • Clear standards regarding substance use & behavior • Recognition for positive behaviors, successes

School Protective Factors • Success in school • Parental monitoring of academic performance/ school behavior • Involvement in group activities • Positive recognition for good behaviors, successes

“Developing Healthy Communities: A Risk and Protective Factor Approach to Preventing Alcohol and Other Drug Abuse,” Developmental Research and Program, Inc., 130 Nickerson, Suite 107, Seattle, WA 98109, (800) 736-2630 For additional information on gender-specific differences related to alcohol use/abuse, download the following brochure recently published by the National Institute on Alcohol Abuse and Alcoholism (NIAAA): Women and Alcohol, NIAAA, 2011, http://pubs.niaaa.nih.gov/publications/womensfact womensfact.htm, http://pubs.niaaa.nih.gov/publications/womensfact/womensFact.pdf Werner, E. (1993). Risk, resilience, and recovery: Perspectives from the Kauai Longitudinal Study. Development and Psychopathology, 5, 503-515.

1.20

Slide 1.20: Prevalence, Public Health Impact, & Costs of Addiction

This transition slide marks the beginning of a discussion on the national prevalence (Slides 1.21 - 1.26), and public health impact and associated costs of substance abuse and dependence/addiction (Slides 1.27 - 1.40).

Notes:

1.21

Slide 1.21: In 2009, an estimated 9.0% of Americans aged 12 years and older met the criteria for substance abuse or dependence. According to the 2010 Report on the National Survey on Drug Use and Health, an estimated 9% of Americans (approximately 22 million) aged 12 years and older met the criteria for substance abuse or dependence in 2009. ABOUT THE NATIONAL SURVEY ON DRUG USE AND HEALTH (NSDUH) The National Survey on Drug Use and Health (NSDUH) is an annual nationwide survey involving interviews with approximately 70,000 randomly selected individuals aged 12 and older. The Substance Abuse and Mental Health Services Administration (SAMHSA), which funds NSDUH, is an agency of the U.S. Public Health Service in the U.S Department of Health and Human Services (DHHS). Data from the NSDUH provide national and state-level estimates on the use of tobacco products, alcohol, illicit drugs (including non-medical use of prescription drugs) and mental health problems in the United States. In keeping with past studies, these data continue to provide the drug prevention, treatment, and research communities with current, relevant information on the status of the nation’s drug usage. To assess and monitor the nature of drug and alcohol use and the consequences of abuse, NSDUH strives to: • provide accurate data on the level and patterns of alcohol, tobacco and illicit substance use; • track trends in the use of alcohol and various types of drugs; • assess the consequences of substance use and abuse; and • identify those groups at high risk for substance use and abuse. Many government agencies, private organizations, individual researchers, and the public at large use NSDUH data (e.g., the Centers for Disease Control and Prevention and the Partnership for a Drug-Free America). For instance, many state health agencies use NSDUH data to estimate the need for treatment facilities. Federal, state, and local agencies, such as the White House Office of National Drug Control Policy and the U.S. Department of Justice, use the information to support prevention programs and monitor drug control strategies. To read more about NSDUH, go to https://nsduhweb.rti.org/.

National Survey on Drug Use and Health [NSDUH] (2010). Available at (http://oas.samhsa.gov/NSDUH/2k7NSDUH/tabs/TOC.htm). This is an annual survey conducted by the Substance Abuse and Mental Health Services Administration. The illicit drug use data is past month use of any illicit drug. The substance use disorder data is past year substance abuse or substance dependence. Alcohol use and alcohol use disorders are not included in these data but the trends are similar.

1.22

Slide 1.22: Substance Use Across the Lifespan

This transition slide marks the beginning of a discussion on age-related trends in substance use (Slides 1.23 - 1.26).

Notes:

1.23

Slide 1.23: Past Month Illicit Drug Use among Persons Aged 12 & Older, 2009

According to the 2010 National Survey on Drug Use and Health report, rates of past month illicit drug use varied with age as follows: Rates of past month illicit drug use varied with age. • Adolescent years (ages 12 to 17) • 12 – 13 years of age: 3.6% • 14 – 15 years: 9.0% • 16 – 17 years: 16.7% • 18 – 20 years of age: 22.2% (This age group has the highest rate of use) • 21 – 25 years of age: 20.5% • 26 – 29 years of age: 14.4% • 65 years & older: 0.9%.

From 2008 to 2009, statistically significant increases in the rate of illicit drug use were observed among the following three of the age groups: • Adolescents, aged 16 – 17 years: the rate increased from 15.2 to 16.7% • Young adults, aged 21 – 25 years: the rate increased from 18.4 to 20.5% • Adults, aged 50 – 54 years: the rate increased from 4.3 to 6.9% Notes:

National Survey on Drug Use and Health (SAMHSA, 2010) (http://oas.samhsa.gov/NSDUH/2k9NSDUH/2k9ResultsP.pdf)

1.24

Slide 1.24: Past Month Illicit Drug Use by Age Category, 2009 In 2009, Adults aged 26 or older were less likely to be current drug users than youth aged 12 to 17 or young adults aged 18 to 25 • Adults aged 26 years or older: 6.3% • Adolescents aged 12 – 17 years: 10.0% • Young adults aged 18 – 25 years: 21.2% The rate of past month illicit drug use increased from 2008 to 2009 among: • Adolescents aged 12 to 17 years of age from 9.3% to 10.0% • Young adults aged 18 to 25 years from 19.6% to 21.2% There are two main points for Slide 1.23 and Slide 1.24 that should be emphasized: 1. Drug use and drug use disorders are highest among older teenagers and young adults. Thus, it appears that there is some “maturing out” of illicit drug use with age and as individuals decide that they can no longer drink alcohol and use drugs, and fulfill their work, school, and home obligations. 2. These data show that not everyone who uses drugs develops long term problems. However, since the ratio of drug use to drug use disorders is highest in the younger age groups and drops significantly in the older age group, concerns about illicit drug use among young people is justified as a higher proportion of these users will develop substance use disorders. In addition, many adolescents and young adults injure themselves or others when using alcohol or drugs. So while they might not develop an SUD, their alcohol and/or drug use leads to high-risk behaviors, which may lead to serious health-related issues, disability, or death.

Notes:

National Survey on Drug Use and Health (SAMHSA, 2010) (http://oas.samhsa.gov/NSDUH/2k9NSDUH/2k9ResultsP.pdf)

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Slide 1.25: Alcohol Use across the Lifespan

For the purpose of the National Survey on Drug Use and Health (NSDUH), a “drink” was defined as a can or bottle of beer, a glass of wine or a wine cooler, a shot of liquor, or a mixed drink with liquor in it. The NSDUH report estimates the prevalence of alcohol use primarily at three levels defined for both males and females and for all ages as follows: • Current (past month) use - At least one drink in the past 30 days • Binge use - Five or more drinks on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past 30 days • Heavy use - Five or more drinks on the same occasion on each of 5 or more days in the past 30 days (NOTE: Times when the respondent only had a sip or two from a drink was not considered to be consumption)

The following prevalence rates were reported for individuals ages 12 years and older (NSDUH, 2010): • Current drinkers of alcohol: 51.9% (approximately 130.6 million people) • This finding is similar to the rate of current drinkers reported in 2008 (51.6% or approximately 129 million people) • Binge drinking at least once in the 30 days prior to the survey: 23.7% (approximately 59.6 million people) • This is similar to the rate of binge drinking reported in 2008 (23.3%) • Heavy drinking: 6.8% (approximately 17.1 million people) • This percentage is similar to the rate of heavy drinking reported in 2008 (6.9%) Rates of current alcohol use by age category • Among older age groups, the prevalence of current alcohol use decreased with increasing age, from 66.4% among 26 to 29 year olds to 50.3% among 60 to 64 year olds and 39.1% among people aged 65 or older • These estimates are similar to the rates reported in 2008 Adolescents:

Young adults

• 12 – 13 years of age: 3.5% • 14 – 15 years of age: 13.0% • 16 – 17 years of age: 26.3%

• 18 – 20 years of age: 49.7% • 21 – 25 years of age: 70.2%

National Survey on Drug Use and Health (SAMHSA, 2010) (http://oas.samhsa.gov/NSDUH/2k9NSDUH/2k9ResultsP.pdf)

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Slide 1.26: Research shows that in the United States,...

• approximately half of adolescents experiment with drugs and/or alcohol while they are in school. • 30% of all individuals will develop substance abuse or dependence during their lifetime, most of whom began using when they were adolescents.

The important message to convey here is that, although most individuals who experiment do not go on to develop a substance use disorder, the major concern with that experimentation is doing something while under the influence that they will later regret or could potentially change their life forever, for example: • having unprotected sex that results in an unwanted pregnancy or contracting an STD or HIV/AIDS • getting in a fight • having a car accident while driving under the influence that causes serious injury, disability, or death • participating in a criminal act, such as breaking and entering or burglary Notes:

Hasin, D.S., Stinson, F.S, Ogburn, E., & Grant, B.F. (2007). Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry (July). [Read more at Suite101: Drinking Problems and Americans: Lifetime Prevalence of Alcohol Abuse and Alcohol Addiction http://www.suite101.com/content/ drinking-problems-and-americans-a91617#ixzz1FIOI5iyG]

1.27

Slide 1.27: Public Health Impact & Costs Associated with Addiction This transition slide marks the beginning of a discussion on the public health impact and associated costs of substance abuse and dependence (addiction) (Slides 1.28 - 1.40).

Approximately 1,500 people die every day from alcohol, tobacco and other drugs and thousands more are admitted into hospitals, psychiatric facilities, or jails and prisons, which translates into an estimated $1 trillion per year year in drug-related costs to society. Beyond the raw dollar amounts, there are other costs to society.

Notes:

Califano, J., Jr. (2007). High society: How substance abuse ravages America and what to do about it. Cambridge, MA: Public Affairs. [Read more at Suite101: The Economic Impact of Alcoholism and Drug Abuse: The Costs of Substance Abuse to Business, Consumers, and Taxpayers( http://www.suite101.com/content/the-economics-of-alcoholism-and-drug-abuse-a85770#ixzz11WxkRPsy)]. Centers for Disease Control and Prevention (2005). Annual smoking-attributable mortality: Years of potential life lost, and productivity losses: United States, 1997-2001. Morbidity and Mortality Weekly Report, 54, 625-628. Office of National Drug Policy (2004). The economic costs of drug abuse in the United States: 1992-2002. Washington, DC: Executive Office of the President (Publication No. 207303). Accessible at: http://www.ncjrs.gov/ondcppubs/publications/pdf/economic_costs.pdf Harwood, H. (2000). Updating estimates of the economic costs of alcohol abuse in the United States: Estimates, update methods, and data. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Funding for this module was provided by a grant from the National Institute on Drug Abuse (NIDA) Science Education Drug and Alcohol Partnership Awards (SEDAPA) #1 R25 DA 020472-01A1. Find resources at http://casat.unr.edu/necp.html

1.28

Slide 1.28: Substance Abuse & Addiction Cost

This chart shows the breakdown of the estimated $1 trillion annual cost associated with substance abuse and addiction. The greatest impact (71%) is related to lost productivity, which “reflects a loss of potential resources related to work in the labor market and household production that was never performed” (pg. vii) and includes: • poor job performance • increased employee turnover • illness & absenteeism

• work-related accidents • being a victim of a crime and • incarceration

Roughly 20% of substance abuse/addiction-related cost is associated with such things as: • criminal activity • child abuse/neglect • homelessness Finally, healthcare costs represent roughly 9% of the substance abuse/addiction-related impact include: • emergency department visits • HIV/AIDS and Hepatitis C • Fetal Alcohol Spectrum Disorders caused by prenatal exposure to alcohol/drugs Previous research studies have estimated the economic costs associated with tobacco, drug, and alcohol use/ abuse. Clearly, the costs due to the abuse of legal substances (tobacco and alcohol) far exceed those related to the abuse of illicit drugs. In fact, the costs attributable to alcohol are nearly double those attributable to drug abuse. It should be noted that more than four times as many deaths are caused by alcohol abuse than by illicit drug abuse (annual totals are around 100,000 for alcohol abuse and 23,000 for illicit drug abuse). However, these totals are dwarfed by the deaths caused by tobacco, generally around 400,000 per year. [This is an important point to make with students.] Optional homework assignment: Ask students to do a brief web-based search to find examples of projects that have been or could be developed and implemented for the public good that have costs similar to those associated with drug abuse ($1 trillion). Some examples would be: • Universal health care • Alternative energy • Education reform

• Indigent health care • Housing • Ecological/environmental issues

• School improvement • Rehabilitation program to reduce criminal recidivism

1.29

Slide 1.29: Impact on the Child & Family Assistance System

Substance use impacts not only individuals who have a substance abuse disorder, but also their families and particularly their children. For example, more than 1 in 10 children in the United States under the age of 18 live in homes with a substance abusing or dependent parent (SAMHSA, 2009). According to the SAMHSA report,

• combined data from 2002 to 2007 indicate that over 8.3 million children under 18 years of age (11.9%) lived with at least one parent who was dependent on or abused alcohol or an illicit drug during the year prior to the survey. • Of these, almost 7.3 million (10.3%) lived with a parent who abused or was dependent on alcohol, and about 2.1 million (3.0%) lived with a parent who abused or was dependent on an illicit drug. • Past year substance dependence or abuse by parents involved almost 14% of children aged 5 or younger compared with 12.0% of children aged 6 to 11 and 9.9% of youths aged 12 to 17. • About 5.4 million children under 18 years of age lived with a father who met the criteria for past year substance dependence or abuse, and 3.4 million lived with a mother who met the criteria. These data provide a basis for increased concerns for child abuse and neglect, injuries and deaths related to motor vehicle accidents, and that the children will themselves abuse or become dependent on substances, and highlight the need for substance abuse treatment for the affected adults, as well as prevention and supportive services for the children. [Use the next three slides to help social work students understand the significant role that alcohol and drugs play in child welfare cases, and how important it is for social workers to possess adequate knowledge in this subject area.]

Notes:

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (April 16, 2009). The NSDUH Report: Children Living with Substance-Dependent or Substance-Abusing Parents: 2002 to 2007. Rockville, MD. Retrieved from http://www.oas.samhsa.gov/2k9/SAparents/SAparents.pdf

1.30

Slide 1.30: Substance abuse is shown to be a factor in child abuse and neglect Parents with substance use disorders may not be able to function effectively in a parental role due to: • Impairments (both physical and mental) caused by alcohol or other drugs • Domestic violence, which may be a result of substance use • Expenditure of often limited household resources on purchasing alcohol or other drugs • Frequent arrests, incarceration, and court dates • Time spent seeking out, manufacturing, or using alcohol or other drugs, or recovering from alcohol/drug use • Estrangement from primary family and related support Families in which one or both parents have substance use disorders, and particularly families with an addicted parent, often experience a number of other problems that affect parenting, including mental illness, unemployment, high levels of stress, and impaired family functioning, all of which can put children at risk for maltreatment (National Center on Addiction and Substance Abuse at Columbia University, 2005). The basic needs of children, including nutrition, supervision, and nurturing, may go unmet due to parental substance use, resulting in neglect. Depending on the extent of the substance use and other circumstances (e.g., the presence of another caregiver), dysfunctional parenting can also include physical and other kinds of abuse (HHS, 1999). It is difficult to determine the numbers of child welfare cases that involve substance-using parents since not all child welfare agencies systematically record information on parental substance use disorders, and many substance abuse treatment programs do not routinely ask patients if they have children (Young, Boles, & Otero, 2007). However, it is estimated that in 2004, 22,440 children receiving in-home services for maltreatment and between 128,640 and 211,720 children in out-of-home care had a parent with a substance use disorder in. In that same year, approximately 295,000 parents receiving treatment for substance use had one or more children removed by child protective services.

Sedlak, A.J., Mettenburg, J., Basena, M., Petta, I., McPherson, K., Greene, A., and Li, S. (2010). Fourth National Incidence Study of Child Abuse and Neglect (NIS–4): Report to Congress. Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families. [Online] http://www.acf.hhs.gov/programs/opre/abuse_neglect/natl_incid/index.html Young, N. K., Boles, S. M., & Otero, C. (2007). Parental substance use disorders and child maltreatment: Overlap, gaps, and opportunities. Child Maltreatment, 12(2), 137-149.

1.31

Slide 1.31: Average Length of Time Spent in Out-of-Home Care â&#x20AC;Ś

The child welfare costs associated with substance abuse/addiction are substantial given that children of parents with a substance use disorder may have more severe problems and/or stay in foster care longer than children from other families (HHS, 1999). For example, it has been estimated that roughly 20% ($5.3 billion) of the more than $24 billion spent annually to address substance use-related issues goes to child welfare costs related to substance abuse (National Center on Addiction and Substance Abuse at Columbia University, 2001).

Notes:

[See: http://sparkaction.org/content/impact-substance-abuse-foster-care; http://www.acf. hhs.gov/programs/opre/abuse_neglect/natl_incid/index.html, 2010

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Slide 1.32: Cost Associated with Underage Drinking

In 2007, costs associated with underage drinking totaled approximately $68.0 billion.1 These costs include medical care, work loss, and pain and suffering associated with the multiple problems resulting from the use of alcohol by youth.2 The consequences of underage drinking in the United States include traffic accidents, criminal behavior, and high risk sexual activity.. Costs related to these consequences are shown below. Costs of Underage Drinking by Problem, the United States 2007 Problem

Total Costs (in millions)

Youth Violence

$43,835.8

Youth Traffic Crashes

$10,019.3

High-Risk Sex, Ages 14-20

$4,871.3

Youth Property Crime

$3,178.8

Youth Injury

$2,064.5

Poisonings and Psychoses

$416.2

FASDs among Mothers Age 15-20

$1,227.3

Youth Alcohol Treatment

$2,400.3

Total Underage Drinking Costs

$68,001.5 Billion

Young people who begin drinking before age 15 years are four times more likely to develop alcohol dependence and 2.5 times more likely to become abusers of alcohol than those who begin drinking at age 21.3 In 2007, youth ages 12-20 years represented 9% of all treatment admissions for alcohol abuse, with a total of 62,461 admissions. 1. Report produced by the Pacific Institute for Research and Evaluation (PIRE) with funding from the Office of Juvenile Justice and Delinquency Prevention (OJJDP), November 2009. [Online]: http://www.udetc.org/UnderageDrinkingCosts.asp 2. Levy, D.T., Miller, T.R., & Cox, K.C. (2003). Underage drinking: societal costs and seller profits. Working Paper. Calverton, MD: PIRE. 3. Grant, B.F., & Dawson, D.A. (1997). Age at onset of alcohol use and its association with DSM-IV alcohol abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey. Journal of Substance Abuse 9: 103-110. ALSO: Office of Applied Studies, Substance Abuse and Mental Health Services Administration. Treatment Episode Data Set (TEDS). (2007). Substance Abuse Treatment by Primary Substance of Abuse, According to Sex, Age, Race, and Ethnicity. Available [On-line]: http://apps.nccd.cdc.gov/yrbss. Center for Disease Control (CDC). (2007). Youth Risk Behavior Surveillance System (YRBSS). Available [On-line]: http://www.cdc.gov/nccdphp/dash/yrbs/2001/youth01online/htm. Califano, J., Jr. (2007). High society: How substance abuse ravages America and what to do about it. Cambridge, MA: Public Affairs. [Read more at Suite101: The Economic Impact of Alcoholism and Drug Abuse: The Costs of Substance Abuse to Business, Consumers, and Taxpayers( http://www.suite101.com/content/the-economics-of-alcoholism-and-drug-abuse-a85770#ixzz11WxkRPsy)].

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Slide 1.33: Substance Abuse Impact on the Criminal Justice System

According to the Office of National Drug Control Policy (ONDCP), it was estimated that of the $38 billion spent on corrections in 1996, more than $30 billion was spent incarcerating individuals who had alcohol or drug problems, or committed alcohol or drug related crimes.

1.34

Slide 1.34: Costs Associated with Driving While Intoxicated

According to â&#x20AC;&#x153;The High Cost of Drunk Drivingâ&#x20AC;? (Weisman, 2006), the cost to society from Driving While Intoxicated (DWI) in 2001 was estimated at $230 billion tax dollars due to highway DWI collisions.

Notes:

1.35

Slide 1.35: 2009 Arrest Rates for Drug Violations

These data represent all law enforcement agencies submitting complete reports between 1999 and 2008, and were compiled by the Federal Bureau of Investigation through the Uniform Crime Reporting (UCR) Program. The law enforcement agencies that participate in the data collection process for this program are instructed to count each time a person is taken into custody, notified, or cited for criminal infractions other than traffic violations as one arrest. Thus, annual arrest figures reflect the total number of arrests and not the number of individuals taken into custody since one person could be arrested multiple times during the year for one or more types of offenses. For the purpose of the FBI UCR Program, a juvenile is counted as a person arrested when that juvenile commits an act that would be a criminal offense if committed by an adult. If you remember our earlier discussion about the prevalence of substance use across the lifespan, you can see here that the reported number of drug-related violations corresponds directly with the use patterns shown among these age categories. U.S. Department of Justice, Federal Bureau of Investigation, Uniform Crime Reporting Handbook, 2004, pp. 78-81 [Online]. Available: http://www.fbi.gov/ucr/handbook/ucrhandbook04.pdf Sourcebook of criminal justice statistics [Online] http://www.albany.edu/sourcebook/pdf/t472006.pdf

1.36

Slide 1.36: 46.8% of all arrests for drug abuse violations were persons under the age of 25 This slide further illustrates that almost half (46.8%) of drug-related arrests were individuals under the age of 25, which corresponds with the prevalence data presented earlier in this Module.

1.37

Slide 1.37: Substance Abuse Impact on Worker Productivity

The annual employer cost of alcohol-related injuries to employees and their dependents was reported at $28.6 billion in 2006. This is due to job-related alcohol-involved injuries, commercial motor vehicle crashes in which at least one driver was alcohol-impaired, and job-related alcohol involvement. Zaloshnja, Miller, Hendrie, & Galvin (December, 2006). Employer Costs of Alcohol Related Injuries. American Journal of Industrial Medicine, Wiley-Liss. Inc.

1.38

Slide 1.38: Substance Abuse Impact on the Health Care System

According to the Drug Abuse Warning Network (DAWN), there were 1,631,854 alcohol and drug-related emergency department visits in 2009. While costs vary, drug related E.D. visits alone may cost society $4 billion.

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Drug Abuse Warning Network, 2007: National Estimates of Drug- Related Emergency Department Visits. Rockville, MD, 2010. [This publication may be downloaded from http://DAWNinfo.samhsa.gov or from http://oas.samhsa.gov] Califano, J., Jr. (2007). High society: How substance abuse ravages America and what to do about it. Cambridge, MA: Public Affairs. [Read more at Suite101: The Economic Impact of Alcoholism and Drug Abuse: The Costs of Substance Abuse to Business, Consumers, and Taxpayers (http://www.suite101.com/content/the-economics-of-alcoholism-and-drug-abuse-a85770#ixzz11WxkRPsy)] Consumer Health Ratings.com http://www.consumerhealthratings.com/index.php?action=showSubCats&cat_id=274 Medical Expenditure Panel Survey http://www.meps.ahrq.gov/mepsweb/data_stats/tables_compendia_hh_interactive.jsp?_SERVICE=MEPSSocket0&_PROGRAM=MEPSPGM.TC.SAS& File=HCFY2007&Table=HCFY2007_PLEXP_E&VAR1=AGE&VAR2=SEX&VAR3=RACETH5C&VAR4=INSURCOV&VAR5=POVCAT07&VAR6=MSA&V AR7=REGION&VAR8=HEALTH&

1.39

Slide 1.39: Fetal Alcohol Spectrum Disorders

Prenatal exposure to alcohol or drugs during pregnancy that results in having a child born with one of the FASDs (FAS being the most prevalent), could cost up to $2 million in health care and related specialized services over the course of the childâ&#x20AC;&#x2122;s lifetime. The overall cost to society is estimated to be as high as $6 billion each year, not including costs associated with time lost at work, family burdens, and poor quality of life. http://www.fasdcenter.samhsa.gov/fasdfaqs.cfm#10

1.40

Slide 1.40: An estimated 1 million people in the United States are living with HIV/AIDS The spread of HIV/AIDS and Hepatitis C is associated with sharing drug injection equipment and/or engaging in risky sexual behavior while under the influence of drugs or alcohol

Notes:

1.41

Slide 1.41: Co-Occurring Substance Abuse & Medical Conditions Substance abuse has been shown to be a factor in the development of the following medical conditions: • Lung & cardiovascular disease • Stroke • Cancer • Mental disorders • Nerve cell damage in the brain or peripheral nervous system For more information, see http://www.drugabuse.gov/Infofacts/infofactsindex.html

1.42

Slide 1.42: Co-Occurring Substance Abuse & Mental Health Disorders 1. The majority of mental health problems /psychiatric disorders and substance abuse usually begin during childhood, adolescence or young adulthood 2. The majority of adults with addictive disorders began using substances during adolescence 3. One-half (1/2) of psychiatric disorders begin by age 14 ; three-fourths (3/4) by age 24 4. Co-occurrence of substance use disorders and mental health problems is the rule rather than the exception

1.43

Slide 1.43: National College Survey Data

The primary goal of the next series of slides is to examine results of a national college survey to enhance the personal relevance of the research presented. It is more difficult to sustain erroneous beliefs and attitudes that contribute to the stigma of addiction when the research findings are applied to a more relevant context. You may wish to lead students through the information presented in this series in a manner that facilitates student recognition that: • drug use is highest during the college years • alcohol use is highest during the colleges years • binge drinking rates are highest during the college years • most people mature out of alcohol/drug use. However, drinking/drugging during college can have lifelong negative consequences.

Notes:

1.44

Slide 1.44: National Profile of Substance use among College Students (2006)

In 2006 it was reported that there were approximately 7.2 million college binge drinkers and 2.3 million heavy drinkers. High rates of drinking on college campuses results in roughly: 1,700 alcohol/drug related deaths; 599,000 injuries; 696,000 assaults; 400,000 incidents of engaging in unprotected sex; and 70,000 instances of sexual assault among college students. In addition, the costs associated with alcohol-related vandalism are about $80,000 per college/university. [see Binge Drinking on College Campuses, Center for Science in the Public Interest, December 2008] The CORE Institute at Southern Illinois University developed a survey used by universities and colleges across the United States to determine the extent of substance use and abuse occurring on their campuses. CORE provides comparisons of their aggregate data with each university under contract. The data presented in the next two slides are from the 2006 CORE Institute Survey. If your institution participates in the CORE survey or uses a similar means of collecting substance use data on your campus, you may want to compare those data to the national findings. The main point of this series of slides is to highlight the fact that drug and alcohol use on college campuses is quite high nationally, and make a connection between these data and the earlier prevalence data for this age group.

Notes:

Core Institute, 2006. http://www.core.siuc.edu/ Califano, J., Jr. (2007). High society: How substance abuse ravages America and what to do about it. Cambridge, MA: Public Affairs. [Read more at Suite101: The Economic Impact of Alcoholism and Drug Abuse: The Costs of Substance Abuse to Business, Consumers, and Taxpayers (http://www.suite101.com/content/the-economics-of-alcoholism-and-drug-abuse-a85770#ixzz11WxkRPsy)].

1.45

Slide 1.45: Consequences of Alcohol & Other Drug Use

This graph shows the percentage of students who reported having experienced these substance use-related consequences (CORE Institute Survey, 2006).

Use the following points to elicit responses/facilitate class discussion: • Would students consider items listed as negative consequences of substance use? (Why or why not?) • Would students consider experiencing any or all of the following 6 or more times in a year an example of repeated or continued use of drugs or alcohol despite negative consequences? (Why or why not?) In Module 3, we will talk more about screening tools used in assessing substance use disorders. One of the most widely used and adapted research-based brief screening assessments used by physicians and counselors to screen for problem drug and alcohol use in their patients/clients is the CAGE (Ewing, 1984). The questions on the CAGE are as follows: 1. Have you ever felt the need to Cut down on your drinking? 2. Have you ever felt Annoyed by someone criticizing your drinking? 3. Have you ever felt bad or Guilty about your drinking? 4. Have you ever had a drink first thing in the morning to steady your nerves and get rid of a hangover (Eye-opener)? Answering YES to two or more of the above questions is considered a possible indication of problem substance use and warrants more detailed diagnostic evaluation for substance abuse or dependence (addiction). • Does knowledge of CAGE screening questions and their application change students’ assessment of the substance-related behaviors /experiences on this slide? Other problems associated with substance use? Continued use despite negative consequences? (Why or why not?)

Ewing, JA (1984). Detecting alcoholism: The CAGE questionaire. Journal of the American Medical Association (252), 1905-1907. [ALSO SEE: HTTP://PUBS.NIAAA.NIH.GOV/PUBLICATIONS/ARH28-2/78-79.HTM]

1.46

Slide 1.46: Does our campus social environment promote substance use?

Engage the students in a discussion of the social environment on your campus. Recording comments from students about beliefs and attitudes related to nicotine, alcohol, and drug use/abuse at your institution could be useful in dialogue with other faculty and/or administrators about the campus environment. For example, do beliefs, attitudes and perceptions of students differ from those of faculty and administrators?

1.47

Slide 1.47: Module 1 Take Home Points In Module 1, students have

• examined pre-conceived ideas about what defines addiction, as well as attitudes and beliefs about the people who develop an SUD; • developed a practical “working” definition of addiction based on the way scientists and researchers define it; • learned some of the key developmental risk factors that increase the vulnerability to addiction; and • discussed the prevalence of addiction, costs, and public health impact of addiction. The following slides summarize the key points for Module 1.

1.48

Slide 1.48: Module 1 Take Home Points

Given the variety of definitions/interpretations of addiction that exist, it is important that professionals have a common understanding/definition of addiction in order to provide effective services to individuals who have SUDs. The working definition established for use in this Curriculum is â&#x20AC;&#x153;continued compulsive use despite negative consequencesâ&#x20AC;?.

1.49

Slide 1.49: Module 1 Take Home Points

The majority of high school students experiment with substances without developing a substance use disorder. However, experimentation is a still a major concern given that most individuals who develop SUDs started using during adolescence.

Notes:

1.50

Slide 1.50: Module 1 Take Home Points

Experimentation also is a concern because no one knows all of their RISK FACTORS that can shift experimentation to addiction. Risk factors are those things that increase the probability of an individual engaging in behavior that likely has negative consequences (e.g., substance abuse/dependence, violence, delinquency, dropping out of school, teen pregnancy, sexually transmitted diseases). Risk factors are present in four primary domains of development: Individual, Family, School, and Community. The more risk factors that are present in an individual’s life, the greater the probability that substance abuse problems will develop.

1.51

Slide 1.51: Module 1 Take Home Points

Even those with few risk or protective factors can become addicted by repeatedly using alcohol or drugs. In other words, “Risk does not equal destiny” and “No risk does not equal total protection”.

Notes:

1.52

Slide 1.52: Module 1 Take Home Points

Alcohol & drug problems are prevalent & intricately intertwined with other mental health problems & medical conditions. The public health impact of substance use disorders/addiction includes substantial economic and social costs.

1.53

Slide 1.53: Module 1 Take Home Points

Although most individuals who experiment do not go on to develop a substance use disorder, substance abuse and addiction start early in life and can tragically alter the course of a young personâ&#x20AC;&#x2122;s life. Specifically, the major concern is adolescents doing something while under the influence that they later regret or could have a devastating impact on their lives.

Notes:

1.54

Slide 1.54: Module 1 Take Home Points Addiction does not affect only the individuals who have the SUD, but also impacts their families; businesses, employers, and co-workers; and the health care, human services, and justice systems. In other words, addiction impacts all of us. Notes:

Notes:

Module 2: The Neurobiology of Addiction Slide 2.1: Overview

Slide 2.1: Module Introduction

In Module 1, students had the opportunity to: • examine pre-conceived ideas about what defines addiction, as well as attitudes and beliefs about the people who become addicted and their behavior; • develop a practical “working” definition of addiction based on the way scientists and researchers define it; • learn some of the key developmental risk factors that increase the vulnerability to addiction; and • discuss the prevalence of addiction, costs, and public health impact of addiction.

Module 2 is biology-based and sets the stage for teaching students about the neuroscience of addiction. The majority of the lecture is provided through a video which shows NECP Scientific Advisor Dr. Paula Riggs presenting an overview of: • the major regions of the brain and their main functions; • the role of receptors, neurotransmitters, neurons, synaptic connections as the way in which these different brain regions communicate; • the brain reward pathway and its central role in the neurobiology of addiction; • dopamine as the key neurotransmitter in the brain reward pathway and addiction; and • how drugs and alcohol change the brain. In addition to the presentation by Dr. Riggs, Dr. Gary Fisher, a professor at the University of Nevada, Reno’s Center for the Application of Substance Abuse Technologies, provides a brief overview of the biopsychosocial aspects of addiction. Several talking points are included to engage students in a discussion about the neuroscience of addiction, as well as a classroom exercise that is a useful teaching tool for illustrating everyone’s vulnerability for developing a substance use disorder or addiction.

Notes:

2.2

Slide 2.2: Introduction to Module 2

This slide marks the beginning of Module 2, which is designed to provide students with a basic understanding of the neuroscience associated with addiction. The goal of Module 2 is to increase students’ knowledge and awareness of the structure and function of the brain and how repeated substance use can change it. This will be accomplished through the video contained in this Module, which provides a basic overview of the neuroscience of addiction. The video was produced under the direct supervision of Dr. Paula Riggs, a professor in the Department of Psychiatry at the University of Colorado at Denver Health Sciences Center and Scientific Advisor for this project. In the video, Dr. Riggs reviews what was learned in Module 1, reviews the learning objectives for Module 2, and presents the basic neuroscience of addiction using animated graphics to demonstrate various functions of the brain (e.g., dopamine receptors). As Dr. Riggs explains the basic neuroscience of addiction, she will be using the following terms that may not be familiar to everyone in the class: 1. Dopamine: a chemical in the brain that acts as a messenger between cells. It’s an important chemical messenger because it communicates “pleasure” and is the reason individuals feel “high” when they use drugs. 2. Neurotransmitter: a chemical messenger in the brain—like dopamine 3. Synapse: the connection between nerve cells. In the brain, the synapse is where all the dopamine action happens when people use drugs.

Notes:

2.3

Slide 2.3: Module 2 Learning Objectives At the end of Module 2, students will: • Be able to discuss the general structure and function of the brain • Develop an understanding of the basic neurobiology that underlies addiction • Understand how chronic use of drugs can change the brain

2.4

Slide 2.4: Neuroscience of Addiction Video

The video begins on the next slide... you might want to ask students if they have any questions/comments from the presentation of Module 1 before starting the video.

2.5

Slide 2.5: Neuroscience of Addiction Video

This slide contains the link to the video of Dr. Riggs presenting the neurobiology of addiction and Dr. Gary Fisher talking about the biopsychosocial aspects of addiction. The entire video lasts approximately 18 minutes. You can view the entire video and then use the discussion topics below, or stop the video and discuss the concepts as they are presented in the video. Allow the students to apply the concept of the reward system more broadly in order to solidify their understanding of addiction. It is useful if you can link the video content to their pre-existing knowledge and experiences. Reward system 1. Dr. Riggs mentioned that there is a part of the brain in charge of reward that signals pleasure for things like food and sex. Why would this be a good or adaptive thing?” [ANSWER: Linking pleasure or reward to food and sex makes it more likely that animals will seek out the things that ensure survival of the animal and the species] 2. Other behaviors that increase dopamine are grooming, breastfeeding, and social interactions. a. Do these improve survival?

b. Are these rewarding behaviors?

c. Do any of you use Facebook – do you think that social interaction is rewarding?

3. If drugs increase dopamine, how high do you think it goes? If, for example, you feed a mouse some mouse chow, his brain dopamine goes up 50%. Give him a girlfriend and it goes up 100%. a. How high does it go up for cocaine? [ANSWER: 350%]

b. Amphetamine? [ANSWER: 1,050%]

Route of administration 4. Dr. Riggs mentioned that the route of delivery—smoking or IV compared to pills—has an impact on the amount of dopamine and the addiction potential of a drug. a. What would happen to a drug’s addiction potential if you went from intranasal use to smoking?

b. What is an example of a drug where this is an issue?”

[ANSWER: Cocaine: powder vs. rock cocaine, which is smoked and much higher abuse potential; Crystal methamphetamine is also smoked and therefore more potent than older oral forms; Nicotine, which makes smoking very addictive. Very few people abuse nicotine patches or gum]

2.5

Slide 2.5: Neuroscience of Addiction Video Cont. Brain recovery 5. In the first module and early in the video, we saw that most people with addictions started using when they were adolescents and the brain was still developing. And we know that repeated drug use affects the brain and that long stretches of use can be a problem during adulthood. An important question is: a. Do addicted brains recover?

b. What do you think?

c. How could we measure this?

Notes:

2.6

Slide 2.6: Classroom Exercise

We learned in the video that the structure and function of human brains includes what is referred to as a ‘brain reward pathway’ or circuit that evolved to motivate behaviors that insure our survival and survival of the species (e.g., sex drive; motivation/drive to eat when hungry). We also learned that that alcohol/drugs can hijack the brain reward center and drive compulsive use of drugs/alcohol despite negative consequences (our working definition of addiction). Dopamine is the main chemical messenger of the brain reward system. When dopamine increases, it means we like whatever it is we are doing and motivates us to do it again (continue doing it). Addictive drugs increase dopamine 5-10 times more than “natural reinforcers” (e.g., sex, chocolate) and can ‘hijack’ the brain reward center. The genetic, biological, and environmental risk factors we discussed in Module 1 make some individuals more vulnerable to the reinforcing effects of drugs. Even in individuals without significant risk factors, the repeated use of addictive drugs can cause changes in the brain that drive/motivate the compulsive use of drugs despite negative consequences that is so characteristic of addiction. To illustrate the relationship between genetic predisposition and environmental risk factors that influence addiction, the following “game” is used to demonstrate our own vulnerability to addiction and how we have to “play” the cards we are dealt (i.e., manage and decrease risks for substance abuse/addiction).

Notes:

2.7

Slide 2.7: How Vulnerable are You? Vulnerability Card Game 1. Ask students to get into small groups (4 – 6 per group) 2. Give each group a deck of cards 3. Ask each group to designate one person to deal the cards to the other students in the group (the dealer also participates in the game) 4. Before starting the game, explain the following rules: a. The goal of the game is to get as close to 40 points as possible (without going over) taking the fewest number of cards. [Aces = 1; Number cards = face value; Face cards = 10] b. The Dealer gives each person in the group 2 cards face down. c. Students do NOT look at these cards. These cards represent their genetic predisposition and cannot be turned over until the end of the game. [It is crucial to the experience that students NOT look at these cards until the end of the game.] d. The Dealer then gives each student as many additional cards as he/she wants, face up. e. Remind them that they cannot look at their ‘hold cards’ (face down cards) and are trying to determine how many cards they can take to get to 40 points without knowing the value of the hold cards. f. Optional: Provide an incentive for the students in each group who ‘win’. 5. Begin the game by telling the dealers to deal the hold cards to each member of the group 6. Walking around the room and observing the process can provide interesting group discussion points following the game. 7. Remind students of the goal of the game (get as close to 40 taking the fewest number of cards). 8. When all students have gotten the number of cards they want, instruct them to turn over their hold cards (genetic predisposition cards) and add up their total points. 9. Process with each group who won, who lost, what their hold cards were, how/why they decided on the number of additional cards to take. At the end of the game, explain that the hold cards represent each person’s genetic risk for developing addiction (i.e., risk factors that we do not necessarily know are present) and the number of cards drawn represents environmental factors and other risky behaviors (i.e., factors that can be more easily controlled). Ask students to discuss their reactions to the game.

This activity was adapted from: The brain: Understanding neurobiology through the study of addiction (2000). NIH Publication No. 00-4871. Colorado Springs, CO: BSCS/Videodiscovery, Inc. Funding for this module was provided by a grant from the National Institute on Drug Abuse (NIDA) Science Education Drug and Alcohol Partnership Awards (SEDAPA) #1 R25 DA 020472-01A1. Find resources at http://casat.unr.edu/necp.html

2.8

Slide 2.8-2.9: Module 2 Take Home Points Important points to remember from Module 2: • Repeated use of addictive drugs can cause changes in the brain. • The brain reward center can be high-jacked by addictive drugs because of the increase in dopamine. • Most individuals with an addictive disorder continue to use alcohol and drugs despite negative consequences because they have a chronic relapsing disease of the brain.

2.9

Notes:

2.10 Notes:

Notes:

Module 3: Introduction

Prevention, Screening, Referral, & Treatment

Slide 3.1: Overview In Module 1, students had the opportunity to explore: • examine pre-conceived ideas about what defines addiction, as well as attitudes and beliefs about the people who become addicted and their behavior; • develop a practical “working” definition of addiction based on the way scientists and researchers define it; • learn some of the key developmental risk factors that increase the vulnerability to addiction; and • discuss the prevalence of addiction, costs, and public health impact of addiction. Module 2 was biology-based and set the stage for teaching students about the neuroscience of addiction. The majority of the lecture was provided through a video which shows NECP Scientific Advisor Dr. Paula Riggs presenting an overview of: • the major regions of the brain and their main functions; • the role of receptors, neurotransmitters, neurons, synaptic connections as the way in which these different brain regions communicate; • the brain reward pathway and its central role in the neurobiology of addiction; • dopamine as the key neurotransmitter in the brain reward pathway and addiction; and • how drugs and alcohol change the brain. In Module 3, we will build on what we learned in Modules 1 and 2 to help us understand: • the chronic relapsing nature of the illness; • the need for continuing care and long-term recovery services and support; and • apply those principles to effective prevention and treatment of SUDs and addiction. Notes:

3.2

Slide 3.2: Introduction to Module 3

This is the final module of the NECP curriculum. So far, we have defined addiction, examined the prevalence of substance use nationwide and discussed risk and protective factors associated with addiction. Module 2 presented an overview of the neuroscience and reward system in addiction. This third and final module applies that previous information to prevention and treatment of substance use disorders.

3.3

Slide 3.3: Module 3 Learning Objectives

The information presented in Modules 1 and 2 is essential to understanding substance abuse and addiction. However, that knowledge has little value if not put into practice. Therefore, Module 3 is an opportunity to discuss the practical implications of the neuroscience information presented thus far. Learning Objectives for Module 3: Apply Module 1 & Module 2 concepts to better understand: 1. the principles of effective • Prevention • Screening, Brief Intervention, & Referral to Treatment (SBIRT) • Treatment & Recovery 2. addiction as a chronic medical illness that requires management similar to other chronic diseases (e.g., asthma, diabetes, & hypertension)

3.4

Slide 3.4: Exploring Prevention

In Module 3 we will explore research-based prevention strategies. As you will see, not everything that seems like a good prevention strategy actually works.

3.5

Slide 3.5: Messages once thought to be effective

In Module 1, we talked about societal messages that influence our beliefs and attitudes about substance use. Addiction research has shown that some prevention efforts are effective and others that are not. The ads in the following two slides are examples of social media campaigns intended to reach young people to prevent them from using drugs. What were some of the anti-drug messages used when you were growing up?

Notes:

3.6

Slide 3.6: Your Brain on Drugs Video

Several versions of this video were produced and shown on TV in the 1980s. The message in this video implies that drugs “fry” your brain, which is an inaccurate, non-science based portrayal of drug effects. Exaggerated, inaccurate portrayals of the effects of drugs of abuse on the brain that are designed to scare youth into abstinence have proven to be ineffective. • How many of you have ever seen this ad? • What is your reaction to this ad? • How many think this ad worked to decrease drug use? (Why or Why not?) • Any reasons you can think of why it was not as effective as the creators thought it would be? • Do you think this ad is science-based or more of a scare tactic approach to drug prevention? • In general, scare tactics have not been shown to be very effective in long-term prevention.

Notes:

3.7

Slide 3.7: Your Brain on Heroin Video

This video, produced in 2006, is based on a similar concept to the previous ad but modified to address heroin use. • How many of you have ever seen this ad? • What is your reaction to this ad? • How does the message compare to the previous video? • Do you think this was effective in preventing drug use? (Why or Why not?)

3.8

Slide 3.8: What Have We Learned?

This slide transitions into continued discussion about what we have learned about previous anti-drug efforts.

Notes:

3.9

Slide 3.9: These things don’t work …

Research in prevention has shown that the following criteria must be met for a prevention strategy to work.

• it has to take place in several different places • use multiple methods • target multiple age groups Prevention research also confirms that the risk and protective factors we discussed in Module 1 are important in prevention programs. These factors vary in different places and with different age groups so the prevention strategies have to vary as well.

Notes:

3.10

Slide 3.10: A More Positive Approach

The next three videos were developed using a more positive approach to looking at substance use. The first was created by the Above the Influence Campaign (www.abovetheinfluence.com/). The next two were created by the Most of Us Campaign, which is based in Montana (http://www.mostofus.org/ ). You may want to watch all 3 videos before engaging the students in a discussion about them.

3.11

Slide 3.11: Fitting In Video

This video was produced by Above the Influence Campaign www.abovetheinfluence.com/ Discussion questions are included in the notes following the 3rd video. You can discuss each video individually or after students have viewed all 3 videos.

Notes:

3.12

Slide 3.12: Most of Us - Dogs Know All Video

This video was produced by the Most of Us Campaign http://www.mostofus.org/

3.13

Slide 3.13: Most of Us - Real World Video

This video also was produced by the Most of Us Campaign http://www.mostofus.org/ • What is your reaction to these ads? • How do these messages compare to the previous ones? • Do you think this approach would be more or less effective, or have no impact in preventing drug use? (Why or Why not?)

3.14

Slide 3.14: Evidence-Based Prevention Programs

This slide transitions into a discussion of research-based prevention programs … in other words, what has been shown to be effective in preventing substance use/abuse among adolescents. As noted earlier, not everything that seems like a good prevention strategy actually works. Based on research suggesting that effective programs include specific components, the Center for Substance Abuse Prevention (CSAP) has identified several evidence-based prevention programs that have been shown to be successful. Additional information on evidence-based prevention strategies can be found on SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP) http://www.nrepp.samhsa.gov/ Students could be engaged in a discussion about what types of interventions they think might be useful in preventing substance use/abuse.

3.15

Slide 3.15: … need to be comprehensive, involving all segments of the community

The first component of evidence-based prevention programs as identified by CSAP is that the program must be comprehensive, meaning that effective prevention must involve all segments of the community, and include multiple, evidence-based strategies. It is not logical to expect that a single strategy implemented in a single situation (e.g., a school, drug prevention program) will be effective in preventing drug use. Likewise, different strategies will be appropriate for different age groups. What are some examples of programs in our community that are comprehensive?

3.16

Slide 3.16: Targeted to universal, selected & indicated populations

The second component of evidence-based prevention programs as identified by CSAP is that the program must include strategies that target specific populations. 1. Universal populations are those where selection is not based on the risk for substance abuse. A school program implemented for all sixth graders would be considered universal. Drug prevention commercials target universal populations. 2. Selected populations are those who are chosen based on some criterion that usually involves future risk for substance abuse. A group for children of alcoholics would be an intervention targeted to a selected population. 3. Indicated populations are those who have already demonstrated some type of problem behavior. A drug prevention program for middle school students who have been caught smoking would be an example of a program for an indicated population.

3.17

Slide 3.17: Increase Protective Factors & Reduce Risk Factors

The third component of evidence-based prevention programs as identified by CSAP is that the program must recognize risk and protective factors. As we saw in Module 1, there are a variety of risk and protective factors associated with substance abuse and other problems behaviors. Various neighborhoods or communities may identify some risk factors as more prevalent than others. For example, a community with low neighborhood attachment because of high transience may implement interventions to address this risk factor.

3.18

SLIDE 3.18: Theory Into Practice

Finally, CSAP has identified the following components that must be included for Evidence-based Prevention Strategies to be effective: • Information Dissemination: Imparting information about the dangers of drugs is not effective in isolation from other strategies. • Education: The most effective type of education involves teaching competency enhancement skills (i.e., problem solving, decision making, resistance, self-esteem, self-control, stress and anxiety reduction) • Alternative Activities: This is another strategy that is only effective as part of a comprehensive program, and might include midnight basketball, drug-free dances, and mentoring. • Problem Identification and Referral: This includes student assistance and employee assistance programs. The idea is to target people who are demonstrating problem behaviors before the behaviors become severe, thereby ensuring that the targeted individuals are referred for appropriate assistance. • Community-based Processes: The most common type of strategy involves the formation of community coalitions. These coalitions may strive to improve the nature and delivery of services to the community (comprehensive service coordination) and/or generate community activism to address substance-related problems (community mobilization). These coalitions must include members representing key segments of the community (school, families, business, law enforcement, social services, policy makers, and faith-based groups) • Environmental Approaches: These strategies include the laws, regulations, and policies related to substance use. Excise taxes, licensing of retail outlets, server training, and sting operations to identify underage retail distributors are all examples. Environmental strategies have proven to be effective in reducing underage tobacco and alcohol use. The Substance Abuse and Mental Health Services Administration (SAMHSA) has developed the National Registry of Evidence-Based Programs and Practices (http://www.nrepp.samhsa.gov/). Although it includes evidence-based programs and practices for mental health and substance abuse treatment, most of the programs also involve prevention. The data base can be searched based on any number of variables including risk factor, age, and ethnicity.

Notes:

3.19

Slide 3.19: Exploring Screening& Brief Interventions

This transition slide leads into a discussion regarding screening and brief interventions, and will include definitions and explanations of the process. In general, Screening is a general approach to figuring out who is OK and who needs more attention. Itâ&#x20AC;&#x2122;s similar to the airportâ&#x20AC;&#x201D;everyone gets screened and most everyone who is screened is fine. However, there are a few individuals who are selected to undergo more careful screening/assessment (i.e., brief intervention).

Notes:

3.20

Slide 3.20: What is screening?

An important component of substance abuse prevention and treatment is the process of screening clients to determine the extent to which they use alcohol/drugs for the purpose of getting them into the appropriate level of treatment in a timely manner.

3.21

Slide 3.21: Screening Defined

Screening is defined as follows: a brief procedure to identify individuals with possible alcohol and other drugs problems or who are at risk for developing substance use disorders. It is important to point out that screening cannot substitute for a thorough assessment. Screening is a quick and efficient method to determine if an individual may be at risk for a substance use disorder or should be referred for a comprehensive assessment.

Notes:

3.22

Slide 3.22: Alcohol Use Pyramid

This image illustrates the importance of screening. The Alcohol Use Pyramid was developed by Babor & HigginsBiddle (2001) to explain the prevalence of alcohol use and problem drinking. Based on scores obtained from the AUDIT questionnaire, the largest number of individuals fall into the abstinence or low-risk use categories. The next largest group is those individuals whose alcohol use is at a level that could be causing behavioral, social, and/ or health problems. Individuals at this level of alcohol use (i.e., risky use or problem drinking categories) would benefit from education about the risks associated with alcohol use and referral for treatment. The smallest number of drinkers fall into the harmful use/abuse and alcohol dependence (addiction) categories, and diagnosed as having a substance use disorder (SUD). Individuals at this level need to enter a substance abuse treatment program. The principles of effective treatment will be discussed later in this module. As shown in the diagram, increasing consumption is related to increasing alcohol-related consequences.

Notes:

Babor, TF & Higgins-Biddle, JC (2001). Brief intervention for hazardous and harmful drinking: A manual for primary care. World Health Organization. Available online: http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6b.pdf

3.23

Slide 3.23: Screening Instruments

There are many screening instruments and it is important for screening tools to be efficient, accurate, and appropriate to the population being screened (e.g., adolescents; pregnant women).

3.24

Slide 3.24: AUDIT

One of the most commonly used instruments is the Alcohol Use Disorders Identification Test (AUDIT). The AUDIT is a 10-item screening tool developed by World Health Organization and used in primary healthcare settings. Scoring for each questions is from 0 - 4 points (0 = never, 4 = daily or almost daily). The AUDIT can be administered and scored without training or can be self-administered. Research suggests that the AUDIT is the best screening instrument for the whole range of alcohol problems in primary care, as compared to other questionnaires such as the CAGE and the MAST. More information about the AUDIT can be found in the following publication: Babor, T.F., Higgins-Biddle, J.C., Saunders, J.B., & Monteiro, M.G. (2001). The alcohol use disorders identification test: Guidelines for use in primary care (2nd Ed.). Department of Mental Health and Substance Dependence, World Health Organization. Available online: http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6a.pdf

3.25

Slide 3.25: Screenshot of alcoholscreening.org

This slide shows the home page of a web-based self-screening tool from AlcoholScreening.org, a free service of Join Together which is a project of the Boston University School of Public Health. This tool helps individuals assess their own alcohol consumption patterns to determine if their drinking is likely to be harming their health or increasing their risk for future harm. The screening tool can be found at http://www.alcoholscreening.org/

Another screening tool is the Drug Abuse Screening Test (DAST), which is a 28 item self-test that uses a “yes/no” format to help individuals become aware of possible substance use/abuse problems. The DAST is one of the most widely used screening tests for drug abuse and addiction.

Additional information is available in the following references: http://kc.vanderbilt.edu/addiction/dast.html Gavin DR; Ross HE; Skinner HA. (1989) ‘Diagnostic validity of the Drug Abuse Screening Test in the assessment of DSM-III drug disorders’, British Journal of Addiction 84(3): 301-307. http://counsellingresource.com/quizzes/drug-abuse/index.html Notes:

3.26

Slide 3.26: CAGE

Another commonly used screening tool is the CAGE, which is a four question, very rough screening for alcohol problems. More information on the CAGE can be found at http://pubs.niaaa.nih.gov/publications/arh28-2/78-79.htm

Notes:

3.27

Slide 3.27: If you answered yes …

Answering “Yes” to at least two items on the CAGE indicates a high probability of an alcohol problem. It is important to point out that screening cannot substitute for a thorough assessment. Screening is a quick and efficient method to determine if an individual may be at risk for a SUD or should be referred for a comprehensive assessment. It also is important to point out that screening instruments will have a percentage of false positives (people who are identified as a having a problem but do not) and false negatives (people who are not identified as having a problem but do). Because the content of these screening instruments is obvious, it is easy for an individual with a problem to conceal it. Therefore, it would be expected that there would be more false negatives than false positives.

3.28

Slide 3.28: What is Brief Intervention?

This slide transitions into a discussion about brief interventions and can be used as a discussion question with students. Individuals with moderate or risky levels of substance use may not be diagnosed with a substance use disorder but may still be in need of assistance. This group is responsible for a disproportionate percentage of motor vehicle accidents and other injuries, deaths from substance, poor workplace performance, medical illnesses, marital problems, and family dysfunction. The techniques to engage these clients to change their substance behaviors are called brief interventions.

Notes:

3.29

Slide 3.29: Brief Interventions: Techniques to change the behavior of people who use aod at risky levels before the development of SUDs

Brief interventions frequently are conducted in general healthcare settings, schools, or social service agencies. The procedures can take the form of a five-minute explanation of the harm of substance by a healthcare provider, a mental health counselor encouraging clients to see if they can stop drinking on their own, or a more structured program.

Notes:

3.30

Slide 3.30: Steps of Brief Interventions

A manual on brief interventions developed by the Center for Substance Abuse Treatment (CSAT) describes five basic steps in the brief intervention process. 1. Introduce the issue in the context of the client’s health. This includes building rapport with the client, defining the purpose of the discussion, obtaining the client’s permission to proceed, and helping the client to understand the reason for the brief intervention. 2. Screening, evaluating, and assessing. A screening instrument or interview may be conducted. An individual may be seen as a light or moderate user, at risk, or as requiring treatment. In this case, brief interventions are rarely appropriate and a referral for treatment services is needed (treatment is discussed in the next section of this module). 3. Providing feedback follows screening, evaluating, and assessing. Using information from the preceding step, an interactive discussion of the findings can be conducted. A specific piece of information should be given, followed by a request for client response. In this step, it is important for the helping professional to assess the client stage of change (precontemplation, contemplation, determination, action) in order to determine what to do in the next step. 4. After giving feedback and assessing the client’s stage of change, the possibility of changing behavior and setting goals is discussed. The stage of change is important here. For example, you would meet high resistance if you suggest abstinence to an at-risk drinker in the precontemplation stage. The helping professional can suggest a course of action and then negotiate with the client.

5. The final step is summarizing and reaching closure. This is important so that both the helping professional and the client have a clear understanding of the changes that were agreed upon. Scheduled follow-up is an important part of this step. Depending on the type of brief intervention and the client’s level of use, this follow-up may involve another face-to-face meeting or a telephone call. Research evidence supports the use of brief interventions with nondependent drinkers. Wilk et al. (1997) reviewed studies that randomly assigned heavy drinkers to brief interventions or no interventions. Heavy drinkers who received brief interventions in primary healthcare settings were twice as likely to moderate their drinking as those who did not receive brief interventions. Fleming et al. (2002) found that a brief intervention conducted by primary care physicians with heavy drinkers reduced their drinking behavior, and there was an associated reduction in health problems and alcohol-related motor vehicle accidents. The positive effects of the brief intervention continued for up to four years. Center for Substance Abuse Treatment (1999). Brief interventions and brief therapies for substance abuse (Treatment Improvement Protocol #34). Rockville, MD: Center for Substance Abuse Treatment. Fleming, M.F., Mundt, M.P., French, M.T., Baier-Manwell, L., Stauffacher, E.A., & Lawton-Berry, K.F. (2002). Brief physician advice for problem drinkers: Long-term efficacy and benefit-cost analysis. Alcoholism: Clinical and Experimental Research, 26, 36-43. Wilk, A.I., Jensen, N.M., & Havighurst, T.C. (1997). Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers. Journal of General Internal Medicine, 12, 274-283.

3.31

Slide 3.31: Screening & Brief Intervention can be done as part of routine visits.

It is a common misconception among healthcare providers that screening and brief intervention involves a large amount of time to conduct. However as we will see in the next section, there are many screening tools that are short and take only a few minutes to complete.

Notes:

3.32

Slide 3.32: Exploring Drug Treatment

This transition slide leads into the final segment of this Curriculum, discussing issues related to treatment.\

Notes:

3.33

Slide 3.33: Addiction as a Chronic Medical Illness

Addiction is a chronic medical condition that generally requires more than one treatment episode. As is the case with other chronic diseases (e.g., diabetes, asthma, or hypertension), there is no cure for addiction. However, using a model for the clinical management and treatment of addiction that includes ongoing care can achieve positive treatment outcomes for individuals with SUDs (O’Brian & McLellan, 1996). This slide schematically illustrates the chronic disease model of addiction. Like other chronic illnesses, clients enter treatment demonstrating symptoms of their illness that generally decrease significantly during treatment (e.g., reduced substance use, higher rates of employment, and improved psychosocial and family functioning). Although treatment is effective, clients who do not continue care or discontinue treatment after an acute episode can relapse (i.e., start using again and experience a return of their symptoms). [A chronic disease example to illustrate this would be diabetes. Pre-treatment, the person presents with symptoms of diabetes (e.g., high blood sugar level). During treatment (e.g., diet, exercise, medication), the symptoms are reduced. However, if the person does not continue the prescribed treatment regimen the previous symptoms will return and cause problems.] The following can be said for both addiction and other chronic diseases: • the onset and course of is influenced by genetic, metabolic, and behavioral factors • there are no cures, but effective treatments are available • treatment compliance is necessary to avoid relapse • since relapse is common, treatment and clinical management needs to occur over the course of the lifespan, not as a single treatment episode. • individuals must make significant lifestyle changes (e.g., diet, exercise, treatment regimen compliance) that support long-term maintenance and optimal management of their illness

Notes:

O’Brien, C.P. & McLellan, A.T. (1996). Myths about the treatment of addiction. Lancet; 347: 237-240.

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Slide 3.34: Relapse Rates After Treatment Are Similar to Other Chronic Medical Conditions Since there is no cure for addiction, it is not uncommon for individuals to “slip” or “relapse” following a period of abstinence. A relapse is a return to uncontrolled use following a period of abstinence.

Recovery is a process through which addiction problems are resolved and implies that people impacted by addiction will regain their physical, emotional, spiritual, relational and occupational health (White, Kurtz, & Sanders, 2006). Recovery or sustained abstinence often requires multiple treatment episodes and significant lifestyle changes, follow-up, and excellent clinical management often over the course of a lifetime. In other words, recovery does not happen overnight. This is similar to the treatment and long-term clinical management of other chronic medical conditions, which have relapse rates similar to or that exceed those of addiction. Notes:

White, W. (2008) Perspectives on Systems Transformations. Chicago, IL: Great Lakes ATTC. White, W., Kurtz, E., Sanders, M. (2006) Recovery Management. Chicago, IL: Great Lakes ATTC. White, W. Recovery Management: What if We Really Believed that Addiction Was a Chronic Disorder? (2005) Chicago, IL: GLATTC Bulletin.

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Slide 3.35: Factors associated with addiction relapse are similar to other chronic illnesses: Compliance with follow-up and necessary lifestyle changes are also similar in patients treated for addiction compared to those treated for other chronic medical illnesses.

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Slide 3.36: What are the Principles of Effective Treatment?

Transition slide into a discussion of the principles of effective evidence-based treatment approaches.

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Slide 3.37: NIDA Publications

The National Institute on Drug Abuse (NIDA) publishes booklets focused on evidenced-based principles, methods, and programs in treatment for a variety of populations. These publications are available online at www.nida.nih.gov.

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Slide 3.38: No Single Treatment is appropriate for all individuals

Matching treatment settings, interventions, and services to each individualâ&#x20AC;&#x2122;s particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.

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Slide 3.39: Behavioral therapy is a critical component of effective addiction treatment

In therapy, patients address issues of motivation, build skills to resist drug use, replace drug-using activities with constructive and rewarding nondrug-using activities, and improve problem-solving abilities. Behavioral therapy also facilitates interpersonal relationships and the individual’s ability to function in the family and community.

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Slide 3.40: Effective treatment attends to multiple needs of individuals… not just their drug use

To be effective, treatment must address the individual’s drug use and any associated medical, psychological, social, vocational, and legal problems.

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Slide 3.41: Addicted or drug abusing individuals with co-existing mental health conditions should be receive integrated treatment Because addiction and mental health disorders often co-occur, patients presenting for either condition should be assessed and treated for the co-occurrence of the other type of disorder.

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Slide 3.42: Remaining in treatment for an adequate period of time is critical for treatment effectiveness

The appropriate treatment duration is dependent on an individualâ&#x20AC;&#x2122;s problems and needs. Research indicates that for most patients, the threshold of significant improvement is reached at about three months in treatment. Even after this threshold is reached, additional treatment can produce further progress toward recovery. Thus, programs should include strategies to engage individuals to keep them from leaving treatment prematurely.

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Slide 3.43: Treatment does not need to be voluntary to be effective

Strong motivation can facilitate the treatment process. Sanctions or enticements in the family, employment setting, or criminal justice system can increase significantly both treatment entry and retention rates and the success of drug treatment interventions.

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Slide 3.44: Is recovery possible? Transition slide

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Slide 3.45: Behavioral Change is a process that unfolds over time through a sequence of stages. Notes:

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Slide 3.46: Hesitancy about change is human nature Notes:

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Slide 3.47: Can these changes be reversed?

It is not always clear whether neuropathology in individuals with addiction was pre-existing or caused by drug abuse. However as we learned in Module 2, research clearly shows that repeated use of drugs causes changes in the brain. Fortunately many of these substance-induced changes are reversible, with some recovering relatively soon after abstinence is achieved. However other drug-induced changes (or neuropathology) appear to be long-lasting or may never recover, even with sustained abstinence. This is an extremely important area for future research. The following slides show some of the important research-based evidence and timelines of brain recovery from the chronic effects of drug abuse.

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Slide 3.48: Recovery of Dopamine Receptors with Abstinence

This slide shows a PET scan of the brain of a normal non-addicted individual (top row). The yellow stain is specific for dopamine receptors which are known to be affected by chronic cocaine addiction. Compare the brain of the normal non-addicted individual to that of a chronically cocaine addicted individual abstinent for 10 days (second row) and 100 days (third row) respectively. It appears that there is some increase or recovery of dopamine receptors after 100 days abstinence relative to only 10 days of abstinence. However, the distribution and number of dopamine receptors even after 100 days abstinence are clearly less than that of the normal non-addicted individual. Although some continued level of recovery is likely with even longer periods of abstinence, it is not known whether complete recovery or normalization of dopamine receptors will occur with sustained long term abstinence. There is also some evidence that individuals who are vulnerable to developing addiction may have pre-existing (prior to the onset of drug use) reduced dopamine receptor density compared to individuals with low addiction vulnerability

Notes:

Photo courtesy of Nora Volkow, Ph.D. Volkow ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey, SL. Long-term brain metabolic changes in cocaine abusers. Synapse 11:184-190, 1992; Volkow ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, Schlyer D, Dewey 5, Wolf AP. Decreased dopamine D2 receptor is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177, 1993.

frontal

availability

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Slide 3.49: Dopamine Receptor Recovery in the Adolescent Brain with Abstinence

Little is known about drug-induced changes that occur in the brains of adolescents with addiction or the potential for recovery with treatment. More adolescent research is needed because the majority of adults with addiction started using drugs during adolescence. Perhaps more importantly, adolescentsâ&#x20AC;&#x2122; brains undergo rapid development from early puberty through young adulthood. The brain does not fully mature until well into the mid-twenties or beyond. Some research indicates that the brains of adolescents may be more vulnerable to addiction such that onset of substance abuse during the teenage years may predict longer and more severe course of addiction compared to individuals who do not start using drugs until after adolescence. This slide shows results of a pilot neuroimaging study of 6 adolescents with marijuana abuse or dependence (addiction). All adolescents received neuroimaging scans before and after 16 weeks of cognitive behavioral therapy for drug abuse + medication or placebo for depression. Adolescents were presented with pictures of neutral cues (e.g., chair, table), normal appetitive cues (e.g., hamburgers, french fries, malts) and marijuana cues (e.g., teenagers rolling and smoking â&#x20AC;&#x2DC;jointsâ&#x20AC;&#x2122;) at baseline (before treatment) and after 16 weeks of treatment with antidepressant or placebo + cognitive behavioral therapy (CBT) for their drug abuse. Results indicated that before treatment, brain activation was greater in response to marijuana cues than food cues in the brain reward circuit. After 16 weeks of treatment, brain activation was greater in response to marijuana cues than food cues in the pre-frontal cortex and other areas of the brain involved in cognitive control, motivation and decision-making. Results show that brain activation patterns in response to cues involving their drug of choice may have shifted with treatment from limbic/reward (emotional) regions to areas that can exert cognitive control over limbic/reward circuits. Results must be interpreted with caution due to the small sample size and preliminary nature of results. Additional research is needed in larger samples to determine whether changes in regional brain activation with CBT (if replicated) are associated with strengthening of cognitive control over more emotional, impulsive limbic-driven behavior (e.g., drug use)

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Slide 3.50: Recovery is a long-term process & can require going into treatment multiple times

As noted in an earlier slide, people in recovery often experience what is called a “slip” or an episode of substance use following a period of abstinence. There is no “cure “ for addiction. Recovery or sustained abstinence generally often requires multiple treatment episodes and significant lifestyle changes, medical follow up and excellent clinical management over the course of a lifetime.

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Slide 3.51: Key Take Home Messages

The following slides contain the key messages that students should take away from Module 3, as well as the curriculum as a whole. You may want to use several of these key points to engage the students in discussions about what they learned and possible professional practice implications.

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Slide 3.52: Key Take Home Messages Notes:

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Slide 3.53: Key Take Home Messages

Includes take home messages for Module 3, as well as key points for the 3-hour curriculum.

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Slide 3.54: â&#x20AC;&#x153;...the way clients are spoken to about changing addictive behaviors affects their willingness to talk freely about why and how they might change.â&#x20AC;? These last few slides can be used to encourage students to give some thought as to how what they have learned in this curriculum might be useful to them in their professional career.

Because of the amount of stigma associated with addiction, many clients you work with will be hesitant to talk about their substance use disorder or addiction. As such, the way clients are spoken to can affect their willingness to talk freely about why and how they might change.

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Slide 3.55: Avoid using moral or judgmental statements

It is crucial that as a professional, you be aware of the language you use in talking with your clients about their substance use.

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Slide 3.56: Be supportive & non-judgmental

Most importantly, be supportive and non-judgmental in your interactions.

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Slide 3.57: Members of the allied healthcare community have a professional & ethical responsibility, perhaps even a MANDATE to develop competencies for the detection & early intervention of SUDs

Because not everyone who has a substance use disorder (SUD) recognizes that they have or need help with their addiction, many individuals go undiagnosed and/or untreated. Allied healthcare professionals are in a unique position to identify and intervene with clients who have an SUD in order to offset possible harmful health effects of substance use. Thus, it is imperative that all allied healthcare professionals are knowledgeable about screening, identifying, and referring clients for treatment.

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Slide 3.58: Professional Case Study

If you like, you can use this opportunity to provide students with a case study in which they can apply the concepts learned in this Curriculum. You can use one of the case studies included in this package or develop one of your own.

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Slide 3.59: What Do You Believe About Addiction? Module 1 provides students the opportunity to:

• examine pre-conceived ideas about what defines addiction, as well as attitudes and beliefs about the people who become addicted and their behavior; • develop a practical “working” definition of addiction based on the way scientists and researchers define it; • learn some of the key developmental risk factors that increase the vulnerability to addiction; and • discuss the prevalence of addiction, costs, and public health impact of addiction. Module 2 is biology-based and sets the stage for teaching students about the neuroscience of addiction through the use of a video in which NECP Scientific Advisor Dr. Paula Riggs presents an overview of: • the major regions of the brain and their main functions; • the role of receptors, neurotransmitters, neurons, synaptic connections as the way in which these different brain regions communicate; • the brain reward pathway and its central role in the neurobiology of addiction; • dopamine as the key neurotransmitter in the brain reward pathway and addiction; and • how drugs and alcohol change the brain. Module 3 builds on what is learned in Modules 1 and 2 to help students understand: • the chronic relapsing nature of the illness; • the need for continuing care and long-term recovery services and support; and • apply those principles to effective prevention and treatment of SUDs and addiction. Two main goals of the Curriculum were to: • change science knowledge • assess whether changes in knowledge are associated with changes in attitudes/beliefs This Curriculum has presented the chronic nature of addiction, the need for on-going support following acute treatment episodes, and data on treatment effectiveness. Facilitate class discussion to explore which, if any, ideas, attitudes, and beliefs changed or shifted with the science-based knowledge learned during the 3 hour neurobiology of addiction curriculum. These shifts in attitudes, beliefs, ideas, knowledge can be recorded alongside the initial precurriculum record. NOTE: The questions on this slide were asked at the beginning of Module 1 and can be used to examine the impact of the Curriculum on students’ beliefs regarding substance abuse/addiction.

Slide 3.59: What Do You Believe About Addiction? Cont. Here are the 4 questions we discussed at the beginning of Module 1. Please take 3 minutes in your small groups to discuss and write down your answers on the flip chart. At the end of the 3 minutes, we will come back together and discuss the responses as a class. After responses are recorded, you may want to use the following in the group discussion: • What do these beliefs have in common? • How are they different? • Which explanation is the most stigmatizing? Which is the least? • Do you think there are ways to scientifically test prevention/treatment efficacy?

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Slide 3.60: Addiction impacts us all.

This concludes the NIDA Enters College Project curriculum. Thank you for providing your students with this important information. If you would like to provide feedback on this Curriculum, please send your comments to: Nancy A. Roget, MS, MFT, LADC Principal Investigator, NIDA Enters College Project (NECP) Executive Director, Center for the Application of Substance Abuse Technologies (CASAT) University of Nevada, Reno 800 Haskell St Reno, NV 89509 roget@unr.edu

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NIDA THE NATIONAL INSTITUTE ON DRUG ABUSE

(Retrieved from the National Institute on Drug Abuse Strategic Plan, http://www.nida.nih.gov/PDF/StratPlan.pdf) For the past three decades, the National Institute on Drug Abuse (NIDA) has led the way in supporting research to prevent and treat drug abuse and addiction and mitigate the impact of their consequences, which include the spread of HIV/AIDS and other infectious diseases. To confront the most pressing aspects of this complex disease and to tackle its underlying causes, our strategic approach is necessarily a multipronged one. It takes advantage of research programs in basic, clinical, and translational sciences. This includes genetics, functional neuroimaging, social neuroscience, medication and behavioral therapies, prevention, and health services, including effectiveness and cost-effectiveness research. Our burgeoning portfolio has given us a large and growing body of knowledge that informs our strategic directions for the future. These directions are grouped into four major goal areas: Prevention; Treatment; HIV/AIDS; and Cross-cutting Priorities. These four major goals are summarized in the sections that follow. I. Prevention Strategic Goal: To prevent the initiation of drug use and the escalation to addiction in those who have already initiated use. Our prevention research has led to today’s improved understanding of addiction and has positioned NIDA to build upon solid epidemiological findings and new insights from genetics and neuroscience. Findings have revealed myriad contributors to addiction and the involvement of multiple brain circuits in addiction processes. A major goal of our efforts is to better understand why some people become addicted while others do not. Our prevention efforts encompass both illicit and licit drugs, such as nicotine and prescription medications. We support research that strives to identify the factors that put people at increased risk of drug abuse or protect them from it. Results will lead to more effective counterstrategies, particularly to prevent young people from ever using drugs in the first place. We are applying modern technologies (e.g., genetics and brain imaging tools) to our prevention studies and are devising creative and targeted communications strategies to encourage their use. NIDA’s Prevention Objectives include: • To identify the characteristics and patterns of drug abuse. • To understand how genes, environment, and development influence the various risk and protective factors for drug abuse. • To improve and expand our understanding of basic neurobiology as it relates to the brain circuitry underlying drug abuse and addiction. • To apply this knowledge toward the development of more effective strategies to prevent people from ever taking drugs and from progressing to addiction if they do. II. Treatment Strategic Goal: To develop successful treatments for drug abuse and addiction and improve treatment accessibility and implementation. Given the complex interactions of biological, social, environmental, and developmental factors that underlie drug abuse and addiction, NIDA acknowledges the need to take a “whole systems” approach to treating this disease. We are well-positioned to capitalize on recent discoveries that have uncovered an expanded range of possible brain targets that affect craving, euphoria, motivation, learning, memory, and inhibitory control––key contributors to addiction and relapse. To bring about more customized treatments, our comprehensive therapeutic research portfolio pushes for more effective medication and behavioral therapies. Innovative approaches that consider genetic variation, comorbid conditions (e.g., mental illness, chronic pain), and the addicted person’s changing needs over time will usher in promising medications to counteract drug-induced changes in the brain and enhance behavioral therapies. Effectiveness research helps us optimize strategies for disseminating and implementing research-based treatments in health care and criminal justice settings. This objective requires that we continue to strengthen our productive partnerships with treatment practitioners, state substance abuse programs, and other

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Federal agencies to move proven treatments into clinical practice at the community level.

NIDA

NIDA’s Treatment Objectives include: • To develop effective medications and behavioral interventions to treat drug abuse and addiction and to prevent relapse. • To develop treatments for drug abuse and addiction in association with comorbid conditions. • To develop the knowledge that leads to personalized or customized treatments. • To translate research-based treatments to the community. III. HIV/AIDS Strategic Goal: To diminish the spread of drug abuse-related human immunodeficiency virus (HIV) and minimize the associated health and social consequences, including acquired immunodeficiency syndrome (AIDS). Drug abuse continues to be a major vector for the spread of HIV/AIDS through its connection with other risky behaviors, such as needle sharing and unprotected sex. Our research advances the less-acknowledged link between drug abuse in general and the resulting impaired judgment that can lead to risky sexual behavior and HIV transmission. This linkage highlights the value of drug abuse treatment in preventing the spread of HIV. We plan to continue supporting primary prevention research to find the most effective HIV risk-reduction interventions for different populations. Young people are a major focus for these efforts, prompting strategies that start early and can be adapted as the individuals age. NIDA also supports research to develop effective secondary prevention strategies designed to reduce HIV transmission. This includes seeking out the best ways to incorporate HIV education, testing, counseling, and treatment referral, and supporting research to identify and overcome barriers such as stigma and access to treatment for HIV and drug abuse. NIDA also sponsors research to learn more about the multiple interactions that occur with neurological complications from HIV, substance abuse, and other comorbid psychiatric disorders. This knowledge can inform the development of more responsive counterinterventions. Additionally, we continue to target HIV/AIDS-related health disparities and integrate HIV/AIDS initiatives worldwide. NIDA’s HIV/AIDS Objectives include: • To support research to better understand the etiology, pathogenesis, and spread of HIV/AIDS among drug- abusing populations. • To help prevent the acquisition (primary prevention) and transmission (secondary prevention) of HIV among drug abusers and their partners. • To decrease the health disparities associated with HIV/AIDS. • To support international research on the intertwined epidemics of drug abuse and HIV/AIDS. • To improve HIV treatment and outcomes in drug abusers through a better under-standing of interactions with drugs of abuse, HIV/AIDS disease processes, and the medications used to treat both. IV. CROSS-CUTTING PRIORITIES. Several additional priority areas span NIDA’s portfolio and contribute to our overall mission to prevent or reduce drug abuse and addiction. These areas are highlighted below. • To foster research on other health conditions that may inform, influence, or interact with drug abuse and addiction (e.g., pain, compulsive behavioral disorders). • To decrease health disparities related to drug addiction and its consequences. • To educate a variety of audiences (e.g., criminal justice, medical, and educational systems in the community; media; and legislators) about the science underlying drug abuse. • To train and attract new investigators with diverse experiences–including those from minority or disadvantaged backgrounds––and to actively recruit chemists, physicists, bioengineers, and mathematicians to conduct translational research on drug abuse. • To promote collaborative international research activities that address nicotine addiction, HIV/AIDS, and emerging trends, as well as training and dissemination of science-based information on drug abuse. Funding for this module was provided by a grant from the National Institute on Drug Abuse (NIDA) Science Education Drug and Alcohol Partnership Awards (SEDAPA) #1 R25 DA 020472-01A1. Find resources at http://casat.unr.edu/necp.html

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