1	S. Alex Stalcup, M.D. New Leaf Treatment Center 251 Lafayette Circle, Suite 150 Lafayette, CA 94549 Tel: 925-284-5200 Fax: 925-284-5204 alex@nltc.com www.nltc.com
2	What is a Drug? A drug is a pleasure producing chemical. Drugs activate or imitate chemical pathways in the brain associated with feelings of well-being, pleasure, and euphoria.
3	Neuroadaptation The process by which receptors in the reward and pleasure centers of the brain adapt to high concentrations of neurotransmitters. Under unstimulated conditions (without drugs) there is profound interference with the ability to experience pleasure. The user feels as if s/he is experiencing an unmet instinctive drive: dysphoria anxiety, anger, frustration and craving. Damage caused by neurotransmitter insensitivity leads the user to feel, when sober, the opposite of feeling high. For the user sobriety becomes the opposite of euphoria. Length of use and intensity of the drug are factors predicting the extent of the damage.
4	PRINCIPLES OF ADDICTION BIOLOGY Drugs and alcohol activate the pleasure-producing chemistry of the brain. Over-stimulation of pleasure pathways causes them to neuroadapt, interfering with the normal experience of pleasure. Addiction is a disease of the pleasure-producing chemistry of the brain; neuroadaptation is the mechanism of the disease. Once neuroadaptation occurs, cessation of drug use leads to ‘inversion of the high’; sobriety becomes pleasureless
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6	Definition of Addiction Compulsion: loss of control The user can’t not do it’ s/he is compelled to use. Compulsion is not rational and is not planned. Continued use despite adverse consequences An addict is a person who uses even though s/he knows it is causing problems. The addict can’t not use. Craving: daily symptom of the disease The user experiences intense psychological preoccupation with getting and using the drug. Craving is dysphoric, agitating and it feels very bad. Denial: distortion of perception caused by craving Under the pressure of intense craving, the user is temporarily blinded to the risks and consequences of using.
7	Causes of Craving Environmental cues (Triggers) immediate, catastrophic, overwhelming craving stimulated by people, places, things associated with prior drug-use experiences Withdrawal: inadequately treated or untreated Mental illness symptoms: inadequately treated or untreated Stress equals Craving
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14	Toxic Psychosis DELUSIONS usually of the paranoid type HALLUCINATIONS usually auditory, occurring with intact reality testing or in the absence of intact reality testing, sometimes with DISORGANIZATION of speech and behavior.
15	SAFETY TIPS for APPROACHING TWEAKERS Keep a social distance - preferably a 7 to 10 foot radius. Do not shine bright lights at him/her. Slow your speech and lower the pitch of your voice. Slow your movements. Keep your hands visible. Keep the tweaker talking.
16	Treatment of Toxic Psychosis Observation Vital signs every 2 hours until stable, then 3 times daily for 5 days Seek immediate medical attention if temperature is higher than 102 F Reduce environmental stimuli: darkened room, quiet until stable, then gradually increase activities Medications Intramuscular: combined injection Haloperidol 5 mg + Cogentin 1 mg + Ativan 5 mg Oral: combined dosing every 8 hours Haloperidol 2 mg + Cogentin 0.5 mg + Ativan 2 mg Push Fluids: 500cc over dietary intake every 8 hours
17	Meth Environments Risks for Children Parenting Attachment: inconsistent discipline, irritable response Safety: sexual assault, physical assault, verbal abuse Neglect: poor hygiene, day/night reversal, inconsistent sleep Nutrition: irregular mealtimes, fast food diet Developmental Risks Older children parenting younger children Unintended observation of sexual activity Unintended observation of physical violence Sexualized environment Environmental Risks Exposure to toxic chemicals Exposure to illicit drugs Needle exposure Physical hazards
18	Bio-Psycho-Social Model Predisposition Genetics Childhood Sexual Abuse Mental Illness The Drug / Circumstances of First Use Enabling System
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21	ADHD Medications Stimulant-long acting sustained release methylphenidate Ritalin LA 10 - 40 mg Concerta 18 - 60 mg dextroamphetamine Dexedrine spansules 10-40 mg Non-stimulant atamoxatine Strattera 10-40 mg Antidepressant venlafaxine Effexor XR 75-225 mg bupropion Wellbutrin XL 150-300 mg desipramine Norpramin 100-200 mg
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23	Dual Diagnosis Mental Illness symptoms interact with drug effects. Intoxication: relieves symptoms of mental illness Tolerance: exacerbates symptoms of mental illness Withdrawal: exacerbates symptoms of mental illness
24	Medication Guidelines Consider the use of medications if the client has insomnia, anxiety, or depression that interferes with daily function. 1/3 to 1/2 of patients will require medication during the first weeks of treatment. A therapeutic trial using a flow chart focuses attention on symptom management. Symptom monitoring validates patient distress, and puts a name and boundaries on otherwise generalized unhappiness in early recovery.
25	Medications Disorders of Mood Disorders of Sleep Anhedonia/Anergia Disorders of Thought Mood Stabilizers Antidepressants Sedating Antidepressants Antihistamines Hypnotics Activating Antidepressants Antipsychotics
26	Moment of Clarity Crisis creates a temporary reduction in distortion of thought. Motivation for treatment is increased.
27	Predictors of Treatment Outcome Length of time in treatment Less than 3 months in treatment has no effect. After treatment for 4 - 6 months 35% achieve sobriety (Sobriety = 30 days consecutively methamphetamine-free.) Retention in treatment is the most important factor influencing outcome. Drug Court participation doubles the number of clients retained in treatment.
28	Evidence Based Treatments Cognitive/Behavioral Therapy (CBT) Community Reinforcement Approach (CRA) Contingency Management (CM) Motivational Enhancement Therapy Twelve-step Facilitation Integrated Models: Matrix, Craving Identification & Management (CIM) Project Match-Volume 3 Marlatt & Gordon, Gorski, NIDA CRA manual Higgins, Petry, et. al. Project Match-Volume 2 CSAT Treatment Tip 35 Project Match-Volume 1 CSAT Treatment Tip 33 Stalcup 2005
29	Definition of Addiction Compulsion: loss of control The user can’t not do it’ s/he is compelled to use. Compulsion is not rational and is not planned. Continued use despite adverse consequences An addict is a person who uses even though s/he knows it is causing problems. The addict can’t not use. Craving: daily symptom of the disease The user experiences intense psychological preoccupation with getting and using the drug. Craving is dysphoric, agitating and it feels very bad. Denial: distortion of perception caused by craving Under the pressure of intense craving, the user is temporarily blinded to the risks and consequences of using.
30	Causes of Craving Environmental cues (Triggers) immediate, catastrophic, overwhelming craving stimulated by people, places, things associated with prior drug-use experiences Withdrawal: inadequately treated or untreated Mental illness symptoms: inadequately treated or untreated Stress equals Craving
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32	CIM Treatment Model Craving Identification and Management Relapse Prevention Workshop Individual Counseling Medical Services Alcohol/drug testing
33	Therapeutic Alliance The client and the treatment team are allies toward common goals. Craving is identified as the major barrier to recovery. Counselor maintains a warm, non-judgmental, and positive manner with the client.
34	Role of Sleep in the Treatment of Methamphetamine Abuse Phase 1 Abstinence begins with 3 to 5 days of nearly continuous sleep to correct chronic sleep deprivation. Client may require medication for paranoia to initiate sleep Phase 2 Sleep may become restless, sporadic, disturbed by nightmares and using dreams. Phase 3 Ongoing attentiveness to sleep hygiene is required. Client may require instruction to develop regular, consistent sleep habits.
35	Special Requirements for Treatment of Methamphetamine Dependence Sleep, Food, Exercise Meticulous control of environmental exposure to methamphetamine Prompt treatment of paranoia with antipsychotic medication Antidepressant treatment of prolonged anhedonia and anergia
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37	Relapse Prevention Workshop Principles Addicted persons relapse because of craving. Craving has causes that can be predicted, recognized and analyzed. Craving can be managed with the use of program activities. Essential Questions What is your craving score? Where does your craving come from? Environmental cues Stress Drug withdrawal Mental health problems What are you going to do to take care of yourself? Avoidance strategies Structure Tools Program activities
38	Avoidance Strategies Measures to Protect the Client From Exposure to Environmental Cues Identification of environmental cues Development of avoidance strategies-specific plan to avoid each cue Rehearsal of avoidance strategies Implementation of avoidance strategies changing phone numbers seeking safe housing avoiding old using haunts separating from old using partners/situations plans for handling money Enforced isolation-strict avoidance of conditioned cues and total isolation from the using environment during the first four to six weeks of recovery.
39	Structure Detailed hour-to-hour planning of each day in which the client makes a consistent effort to make the same things happen at the same time each day. H ungry Three regularly spaced, scheduled meals daily A ngry Separate feelings of anger from losing control L onely At least ONE positive social contact daily T ired Daily practice of sleep hygiene-establishing the same bedtime and wake-up time. Initially this may require the judicious use of non- habit forming medications to help with sleep.
40	Tools Behaviors that dissipate craving Exercise: Two 20 minute exercise periods daily Spiritual practices: Meditation Prayer Talk Treatment groups Peer support groups Individual counseling Journal writing Narcotics Anonymous Alcoholics Anonymous Psychological tools Acceptance Letting go Baths/Showers: hot or cold Orgasm: safe sex/self sex Relaxation exercises: using audio tapes or learned behavioral techniques
41	Methamphetamine Treatment Project Number of Subjects CIM Model Matrix Model N=155 N=78 N=77 Mean No. of sessions attended 22/45 (49%) 26/55 (47%) Retention (completed treatment) 42 (54%) 52 (68%) p=0.026 (Chi-square) Methamphetamine free for 30 days discharge 27 (35%) 28 (36%) p=0.82 (Chi-square) 6 months after Intake 29 (37%) 29 (38%) p=0.95 (Chi-square) Craving: the desire to use a psychoactive substance CIM=Craving Identification and Management Model
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