Rehab Counseling Rehab Counseling

Substance Abuse Class 05Substance Abuse Class 05

Markus Dietrich LMHC,CRC,CAAPMarkus Dietrich LMHC,CRC,CAAP

Shands HealthcareShands Healthcare

dietrmk@shands.ufl.edudietrmk@shands.ufl.edu

Drug Use-ScopeDrug Use-Scope

In 2001 an estimated 15.9 million Americans 12 In 2001 an estimated 15.9 million Americans 12 or older used illicit drugs. This represents 7.1% of or older used illicit drugs. This represents 7.1% of this population.this population.

This a 0.8% increase from 6.3% in 1999 and 2000.This a 0.8% increase from 6.3% in 1999 and 2000. Increases were noted for:Increases were noted for:Marijuana Marijuana 4.8% to 5.4%4.8% to 5.4%

Cocaine Cocaine 0.5% to 0.6%0.5% to 0.6%

Pain Relievers 1.2% to 1.6%Pain Relievers 1.2% to 1.6%Tranquilizers Tranquilizers 0.4% to 0.6%0.4% to 0.6% National Household Survey 2001National Household Survey 2001

Drugs Use- MarijuanaDrugs Use- Marijuana

Marijuana is the most commonly used drug Marijuana is the most commonly used drug used by 76% of the drug usersused by 76% of the drug users

56% of drug users use only marijuana56% of drug users use only marijuana 20% use Marijuana and another drug.20% use Marijuana and another drug. 24% use illicit drugs but not marijuana.24% use illicit drugs but not marijuana.

Therapeutic Drugs Therapeutic Drugs

Of the 4.8 million users of therapeutic drugs,Of the 4.8 million users of therapeutic drugs, 3.5 million use pain relievers3.5 million use pain relievers 1.4 million use tranquilizers1.4 million use tranquilizers 1 million uses stimulants1 million uses stimulants 0.3 million use sedatives 0.3 million use sedatives

Drugs cont.Drugs cont.

In 2001 an estimated 1.7 million (0.7%) In 2001 an estimated 1.7 million (0.7%) Americans age 12 or older were current Americans age 12 or older were current cocaine users and 406,000 (0.2%) were cocaine users and 406,000 (0.2%) were current crack userscurrent crack users

1.3 million (0.6%) used hallucinogens1.3 million (0.6%) used hallucinogens 957,000 used Oxycontin non medically 957,000 used Oxycontin non medically

(four times as much as 1999)(four times as much as 1999) Heroin use is reported to be 123,000 (0.1%)Heroin use is reported to be 123,000 (0.1%)

Drugs- VariablesDrugs- Variables

Men are more likely to report drug use than Men are more likely to report drug use than women (8.7 vs. 5.5%)women (8.7 vs. 5.5%)

Rates and patterns of drug use vary by age, Rates and patterns of drug use vary by age, peaking among 18-20year oldspeaking among 18-20year olds

Drug use is correlated with education. Rate Drug use is correlated with education. Rate for H.S graduates is 7.6% vs. 4.3 percent for H.S graduates is 7.6% vs. 4.3 percent for four year college graduates, even though for four year college graduates, even though college graduates were more likely to have college graduates were more likely to have tried drugs.tried drugs.

AlcoholAlcohol

109 million ( 48.35%) Americans age 12 or 109 million ( 48.35%) Americans age 12 or older report being current drinkersolder report being current drinkers

Approximately one fifth (20.5%) reported Approximately one fifth (20.5%) reported bingeing at least once in last 30 daysbingeing at least once in last 30 days

5.7%reported heavy drinking5.7%reported heavy drinking

Alcohol variablesAlcohol variables

Age: highest prevalence of alcohol use is Age: highest prevalence of alcohol use is between 18 and 25. Rate drops slightly between 18 and 25. Rate drops slightly between 25 and 60.between 25 and 60.

Men are more likely to drink than womenMen are more likely to drink than women likelihood of drinking alcohol increases likelihood of drinking alcohol increases

with education, however, binge drinking with education, however, binge drinking and heavy drinking were least prevalent and heavy drinking were least prevalent among college graduatesamong college graduates

EmploymentEmployment

Unemployment is highly correlated with drug and Unemployment is highly correlated with drug and alcohol use however,alcohol use however,

6.9% of illicit drug users are full-time employed6.9% of illicit drug users are full-time employed 9.1% of drug users are part-time employed9.1% of drug users are part-time employed Among the 43.9 million adult binge drinkers, 35.4 Among the 43.9 million adult binge drinkers, 35.4

million (81%) are full-time or part-time million (81%) are full-time or part-time employees.employees.

9.8 million (80%) of the heavy drinkers are also 9.8 million (80%) of the heavy drinkers are also employedemployed

Significant OthersSignificant Others

Non-alcoholic members of alcoholic’s Non-alcoholic members of alcoholic’s families use 10 times as much sick leave as families use 10 times as much sick leave as in families where alcohol is not a factor.in families where alcohol is not a factor.

More than half of all family members of More than half of all family members of alcoholics who are employed (80%) report alcoholics who are employed (80%) report their ability to function is impaired as a their ability to function is impaired as a result or living with an alcoholic.result or living with an alcoholic.

Effects on BusinessEffects on Business

decreased productivitydecreased productivity increased on-the-job accidentsincreased on-the-job accidents increased absenteeismincreased absenteeism turnoverturnover increased health care costincreased health care cost

Economic ImpactEconomic Impact

Cost to society associated with drug and Cost to society associated with drug and alcohol abuse is estimated to be $294 alcohol abuse is estimated to be $294 billion.billion.

The largest impact is on lost productivity.The largest impact is on lost productivity. The health care cost for alcohol abuse is The health care cost for alcohol abuse is

about twice that for drug abuse.about twice that for drug abuse.Samsha 2001Samsha 2001

Social ImpactSocial Impact

Alcohol and drug abuse correlate positively Alcohol and drug abuse correlate positively

with:with: Domestic ViolenceDomestic Violence Child abuse and neglectChild abuse and neglect Separation and divorceSeparation and divorce Healthcare costHealthcare cost Criminal behaviorCriminal behavior

TrendsTrends

The NHSDA showed increases among The NHSDA showed increases among Americans in rates of use of several Americans in rates of use of several substances, including marijuana and substances, including marijuana and cocaine and the non-medical use of pain cocaine and the non-medical use of pain relievers and tranquilizers. Alcohol use also relievers and tranquilizers. Alcohol use also increased, although binge drinking and increased, although binge drinking and heavy use remained unchanged between heavy use remained unchanged between 2000 and 20012000 and 2001

Addiction and the BrainAddiction and the Brain

Addiction is a Addiction is a brain disorderbrain disorder

Addiction is an independent disorder Addiction is an independent disorder distinguished from drinking that is merely distinguished from drinking that is merely heavy, problematic, ill advised or socially heavy, problematic, ill advised or socially

unacceptableunacceptable

Abuse - intentional overuse in cases of Abuse - intentional overuse in cases of celebration, anxiety, despair, self-celebration, anxiety, despair, self-medication, other mental health disorders medication, other mental health disorders or ignorance. Tends to decline with or ignorance. Tends to decline with consequences or adequate treatment of consequences or adequate treatment of other mental health disorder.other mental health disorder.

Functional Imaging

SPECT – single photon emission computed tomography

PET – positron emission tomography

fMRI – functional magnetic resonance imaging

Dopamine Pathways – Pleasure pathways

nucleusaccumbens

hippocampus

striatum

frontalcortex

substantianigra/VTA

cocaineheroinnicotineamphetaminesopiatesTHCPCPketamine

heroinalcoholbenzodiazepinsbarbiturates

alcohol

THE RAT BRAINTHE RAT BRAIN

What “turns on” the dopamine in a rats What “turns on” the dopamine in a rats brain…..brain…..– SEXSEX-200% increase in dopamine-200% increase in dopamine– COCAINECOCAINE-300% increase in dopamine-300% increase in dopamine– METHAMPHETAMINEMETHAMPHETAMINE-1100% increase in -1100% increase in

dopaminedopamine

enzymesreceptorsresponses

malfunction MFB

Inherited genes oraltered expression

The explanation for why people respond differently!

Early exposure to drugs

abnormal proteins

Brain of the addicted is Brain of the addicted is fundamentally different:fundamentally different:

Gene expression Gene expression (Liu, Nickolendko 1994; Daunais & (Liu, Nickolendko 1994; Daunais & McGinty 1995)McGinty 1995)

Glucose metabolism Glucose metabolism (Volkow, Gillespie, 1996)(Volkow, Gillespie, 1996)

Responsiveness to Responsiveness to environmental cues environmental cues (O’Brien, Childress, 1993; Kilgus & (O’Brien, Childress, 1993; Kilgus & Pumariega, 1994)Pumariega, 1994)

What’s inherited???What’s inherited???

TemperamentTemperament Initial sensitivity to rewarding or aversive Initial sensitivity to rewarding or aversive

qualities (like or dislike of the drug)qualities (like or dislike of the drug) ToleranceTolerance Rates and routes of metabolismRates and routes of metabolism Taste preferencesTaste preferences Response to memories related to useResponse to memories related to use

Developing brainDeveloping brain

Individuals who begin drinking Individuals who begin drinking before age 15 are 4 times more before age 15 are 4 times more likely to develop alcohol likely to develop alcohol dependence during their lifetimes dependence during their lifetimes than those who begin drinking at than those who begin drinking at age 21.age 21. (Grant & Dawson 1997; Journal of Substance Abuse 9:103-110)(Grant & Dawson 1997; Journal of Substance Abuse 9:103-110)

Earlier drinking more likely to Earlier drinking more likely to result in alcohol dependence result in alcohol dependence independent of family history independent of family history (Grant, 1998)(Grant, 1998)

Your Brain on DrugsYour Brain on Drugs

1-2 Min 3-4 5-6

6-7 7-8 8-9

9-10 10-20 20-30

YELLOW shows places in brain where cocaine goes (Striatum)

PET scan after cocaine PET scan after cocaine useuse

Alcohol 25 yrsAlcohol 25 yrs Cocaine 2 yrsCocaine 2 yrs Marijuana 12 Marijuana 12 yrsyrs

NormalNormal

SPECT

(blood flow)

Assessment and DiagnosisAssessment and Diagnosis

Bio-psycho-social-spiritual Assesment Bio-psycho-social-spiritual Assesment DSM-IVR:DSM-IVR:

Seven CriteriaSeven Criteria

Two dimensions- Two dimensions-

Obsession and Compulsion.Obsession and Compulsion.

Job is last to go!Job is last to go!

AbuseAddiction

Usually self-limitedProgressive course

Likely to stop as consequences progress

Unable to stop because of consequences – loss of control

May have significant consequences

Significant consequences

Frequent character or personality pathology

No specific personality

Normal brain chemistryAbnormal brain chemistry

Bad judgment, poor morals, self will

Cravings, preoccupation

Facilitate ChangeFacilitate ChangeMotivational Enhancement TherapyMotivational Enhancement Therapy

Key Factors for Change for the Counselor:Key Factors for Change for the Counselor: StyleStyle StyleStyle StyleStyle

Key ConceptsKey Concepts

Motivation: the probability that a person Motivation: the probability that a person will enter into, continue and adhere to a will enter into, continue and adhere to a specific change strategy.specific change strategy.

Resistance: the result of interacting with Resistance: the result of interacting with one’s environment- not a characteristic.one’s environment- not a characteristic.

Ambivalence: the heart of the problem, not Ambivalence: the heart of the problem, not pathological.pathological.

Stages of ChangeStages of ChangeProchaska & DeClemente 1982Prochaska & DeClemente 1982

Pre-contemplationPre-contemplationWhat problem?What problem? ContemplationContemplationIs it a problem?Is it a problem? PreparationPreparationWhat can I do?What can I do? ActionActionI am doing somethingI am doing something MaintenanceMaintenanceI am successfulI am successful

Helper TasksHelper Tasks

Pre-contemplationPre-contemplationRaise DoubtRaise Doubt ContemplationContemplationEvoke reasons for changeEvoke reasons for change PreparationPreparationHelp client find best course of actionHelp client find best course of action ActionActionSupport steps toward changeSupport steps toward change MaintenanceMaintenanceRelapse PreventionRelapse Prevention