1. health and fitness
2. addiction

Generation Y Not
Young Adults and Substance Abuse
# YOLO
Stephen A. Wyatt, DO
Medical Director, Addiction Medicine
Carolinas HealthCare System
Charlotte, NC
Objectives
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Review Primary Influences of Onset of SUD
Identify GenY Drugs of Choice
Describe assessment strategies
Identify techniques for approaching a young adults
Identify Treatment Options
Understand a Recovery Plan for this Population
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“We live in a decadent age. Young people no
longer respect their parents. They are rude
and impatient. They frequent taverns and
have no self-respect.”
Inscription on Egyptian tomb
circa 3000 B.C.
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Genetic Variation
• 40-50% of the risk of having a substance problem is genetic.
– Alcohol liking or disliking is linked to families/nations through a two specific enzymes, alcohol
and aldehyde dehydrogenases
• GWAS are able to identify SNPs
– Nicotine receptor subunit doubles the risk for addiction, the area is influential in risk of
disease. (Thorgeirsson et al. 2008)
– Phenotype of impaired inhibitory control (Ersch et al 2012)
• impaired prefrontal regulation of the dorsal striatum in drug addiction
• Epigenectic – opening the genetic window.
– COMT gene variants predict prevalence of psychosis in adolescents exposed to cannabis.
• Pharmacogenetics
– Effect of naltrexone treatment for alcohol in individuals with a specific gene varient, Asp40.
(Oslin et al 2003)
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Genetic Variation
– Alcohol liking or disliking is linked alcohol and aldehyde
dehydrogenases
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Exposure to Parental SUDs
• Familial environment is a significant risk factor in the development of
adolescent risk for SUDs
– Worse in high risk children, e.g. ADHD, Mood d/o (Biedermann,et.al., 2000)
• Parental psychoactive substance use disorder puts adolescents at significant
risk of becoming embedded in a cycle of drug use, associations with drug
using peers, and poor family relations. (Hoffman/Su, 2002)
• History of SUDs in both fathers and mothers increases abuse potential.
– Contributors to abuse potential differed in fathers and mothers (Ammerman, et.al.,
1999)
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Early Environmental Effects ACEs
• Severe childhood adversity place individuals at life-long risk for
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–
–
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Problems related to mental health,
physical health,
employment,
and legal difficulties (Putnam 2006).
• Five or more adverse childhood events (ACEs; i.e., emotional,
physical, or sexual abuse; domestic violence; and household
dysfunction) are 7–10 times more likely to report illicit drug use
and addiction. (Anda et al. 2006).
• Studies of individuals seeking treatment for alcohol use disorders
show a high prevalence of childhood adversity and PTSD.
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• 62 percent having been victims of childhood physical or sexual abuse
(Grice et al. 1995).
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Trauma and Substance Use Disorder
• Youth have the highest rate for being the victim of a violent crime. (3x adults)
– Rape – highest rate in adolescent girls
• Three correlates with SUD
– Substance use asso with exposure
• Substance use with high risk behavior
• Substance use before committing violence
• Risk of violent victimization and severe injury/loss of friends related to
substance use
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Cortisol Releasing Factor
Amygdala
Pituitary
Sympathetic response
Medulla
oblongata
Cardiovascular
Cardiac Output
Blood Pressure
Heart Rate
Stomach
Adrenal Glands
Epinephrine
Blood Glucose
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Gastric secretions
Gastric emptying
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Age of Onset
•
Risk of drug dependence problems significantly greater for adolescent
recent-onset users compared to adult recent-onset users. (Chen, et.al.,
2009)
• The rates of lifetime dependence declined from more than 40% age of onset
14 or younger to approx. 10% age of onset 20 and older.
• Odds of dependence decreased by 14% with each increasing year of age at
onset of use, and the odds of abuse decreased by 8% (Grant/Dawson,
1997)
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Link between Violence and PTSD/Mood d/o
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SUDs
Reckless Behavior
High risk sexual behavior
Gang participation
Disturbance of academic function
Development issues in appraisal of danger
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Cultural Parameters
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Risk of trauma and exposure
Trauma responses
Risk of SUD
Strength and resilience factors in family peer group and community
Help seeking behavior
Attitudes toward intervention components
Youth culture (around specific drugs)
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Developmental Influences
• Proximal and distal development
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Relying on security of protection by parents and caregivers
Emotional regulation
Specific learning task – reading
Making a best friend
Self efficacy in the face of danger
Understanding human motivation
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Drug Use
•
Monitoring the Future – 8th,10th,12th Grade (n=40k+)
– Use of alcohol, cigarettes, and a number of illicit drugs has declined
– Lowest since 1975
•
Strong association between perception of harm and level of use.
• Those in school use less
• White seniors use > Hispanic > Black
• Peak drug use late 1970s – 1981 and 1996-7
•
College Campus
– Binge Drinking
– Stimulants
– Designer Drugs
•
Dependent population – predictors unchanged
Monitoring the Future” Study: NIDA, University of Michigan
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Long Term Annual Trends in Prevalence
60
50
Monitoring
The
Future
Study
40
12th
30
10th
8th
20
10
0
1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Perceived Risk of Marijuana Smoked Occasionally
70
60
50
40
12th
30
10th
8TH
20
10
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0
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011
2013
2014
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Drug Use - Nicotine
•
Cigarettes
– Has been the “gateway drug”
– 90% start prior to 19th birthday
– down to 8% percent in 2014 Monitoring the Future
– substantial reduction in students who say cigarettes are easy for them to get
– increased perception that smoking carries a "great risk”
– Easy screening tool (18% of adult population)
• 80% of SUD patients 8% of population = 6%
• 60% of significant BH d/o patients 20% of population = 12%
• Significant overlap between SUD and MI populations
• Tobacco Products
– Pockets of smokeless use
– Vapor
• Dilutants
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• +-
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Drug Use - Inhalants
• Solvents
– industrial or household
– art or office supply
• Gases
– in household or commercial products
– household aerosol propellants
– medical anesthetic gases
• Nitrites
– aliphatic nitrites
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Drug Use - Inhalants
• ACUTE:
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anesthesia, intoxication, quick “drunk”
initial excitement turns to drowsiness
disinhibition, lightheaded, agitation, HA
ataxia, dizzy, disoriented, dysarthria, weakness, nystagmus, loss of
consciousness
• CHRONIC:
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weight loss
muscle weakness
general disorientation
inattentiveness
lack of coordination
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Drug Use - Inhalants
• POTENTIALLY REVERSIBLE:
- Renal toxicity
- Hepatotoxicity
- Respiratory distress
- Hematologic: methemoglobenemia
• IRREVERSIBLE:
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Hearing loss
Peripheral neuropathies or limb spasms
CNS or brain damage
Hematologic: dyscrasias
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Drug Use - Alcohol
• Binge remains a problem but is declining
• Strong genetic predisposition
• Not infrequently the drug that becomes the problem follow less severe other
drug misuse.
• Chronic Illness making all other Chronic Illness worse.
• Alcohol use is also down MoF Study
– binge drinking remains a problem
– peer disapproval of binge drinking has been rising since 2000
– declines in availability may be another contributing factor to the drops in teen drinking.
• there has been a fair decline in all three grades in saying that alcohol is easy to get.
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Drug Use - ILLICIT DRUGS
• Synthetic marijuana greatest decline MoF
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cannabinoid products first constructed in the lab.
often associated with contaminants
increased rates of disassociation
students still do not recognize as a dangerous class of drugs
• although the proportion of 12th-graders reporting it as dangerous to use did rise significantly in 2014
• efforts at the federal and state levels to close down the sale of these substances may be having an effect.
– decline in12th-graders reporting use of synthetic marijuana in the prior 12 months
• 11 percent in 2011 to 6 percent in 2014.
• "Bath Salts” Methadrone
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a stimulant derivative with hallucinogenic properties
first introduced in Europe
down to less than 1 percent.
students see synthetic stimulants as more dangerous
efforts to make them illegal probably have reduced their availability
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Drug Use - ILLICIT DRUGS
• Marijuana
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variable response relaxant vs. stimulant
long term use more highly associated with paranoia
clear addictive potential (10%)
rise in the general population – changing USA ethical stance
after five years of increasing among teens declined slightly in 2014
• use in the prior 12 months declining from 26 percent to 24 percent for the three grades combined.
– potential harm belief of regular marijuana use continues to fall among youth
• do not seem to explain the change in use this year contrary to the science to this point
– personal disapproval of use is also down some in 8th and 12th grades.
– reported availability is down significantly since 2013 in the two lower grades
• may explain the modest decline
– current daily or near-daily marijuana use—declined some in 2014;
• 1 in every 17 high school seniors in 2014 (5.8 percent) is a current daily or near-daily marijuana
user, which is down from 6.5 percent in 2013.
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Drug Use - ILLICIT DRUGS
• Ecstasy (MDMA)
– stimulant derivative with mild hallucinogenic properties
– primary problem associated with electrolyte imbalance
– statistically significant decline in 2014.
• use in the prior 12 months dropped from 2.8 percent in 2013 to 2.2 percent in 2014.
• In 2001, peak year of use, 6 percent.
• Salvia (hallucinogen)
– has fallen to quite low levels of use
• used in the prior 12 months
• 12th-graders in 2009 = 5.7% and 2014 = 2%.
• Hallucinogens other than LSD
– continuing a longer-term decline.
– availability of these drugs has fallen since 2001
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Drug Use - ILLICIT DRUGS
• Prescription drug misuse includes use of narcotics, sedatives, tranquilizers,
and/or amphetamines
– substantial increase in use in the 1990s,
– 12th-graders statistically significant decline between 2013 and 2014, from 16% to 14% saying
that they used one or more of these prescription drugs in the past 12 months
• Narcotic drugs other than heroin—among the most dangerous of the prescription
drugs
– leading cause of injury death in the United States
– daily 120 people die, and 6,748 are treated in emergency departments
– declined in use by 12th-graders
• in the prior 12 months. 2009 = 9% to 2014 = 6%. Use of these drugs is reported only for 12th grade;
students are reporting that these drugs are increasingly difficult to obtain.
• Use in the prior 12 months of OxyContin declined
– peaked among adolescents around 2009
– The 2014 reports of use in the past 12 months stand at 1.0 percent, 3.0 percent and 3.3 percent in grades 8,
10 and 12, respectively.
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Crude rate per 100,000
6
Source: Paulozzi, CDC, Congressional testimony, 2007
600
500
400
5
300
4
3
200
2
100
1
Sales in mg/person
Deaths per 100,000 related to
unintentional overdose and annual sales of
7prescription opioids by year, 1990 - 2006
8
Deaths per 100,000
Opioid sales (mg per person)
0
0
'90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06
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Drug Use - ILLICIT DRUGS
• Cough and cold medicines (dextromethorphan DXM)
– glutamate antagonist – neurotoxicity
– class of drugs available over-the-counter
– taken in large quantities to get high, can be dangerous
– abuse of these drugs falling among teens since 2006
• 2014 annual prevalence 3.2 percent (MoF)
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Drug Use
• Use of the other illicit drugs unchanged between 2013 and 2014
including;
– most dangerous heroin, crack, methamphetamine.
– the Rx stimulants Ritalin and Adderall
– a variety of other drugs LSD, inhalants, powder cocaine, tranquilizers,
sedatives and anabolic steroids.
– all are well below their recent peak levels of use.
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Gen Y
Summary Drugs Abused
• After marijuana and alcohol, prescription drugs are the most commonly
abused substances by Americans age 14 and older.
• Teens abuse prescription drugs for a number of reasons,
– to get high,
– to stop pain,
– think it will help them with school work.
• Most teens get prescription drugs they abuse from friends and relatives,
sometimes without the person knowing.
• Gender differences;
– boys are more likely to abuse prescription stimulants to get high,
– girls tend to abuse them to stay alert or to lose weight.
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Assessment
Privacy and Confidentiality
• Provider-patient-family trust triangle
• Breach of confidentiality
– Presents harm to self or others
– Required by law
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TRUST RELATIONSHIP
Provider
privacy
communication
confidentiality
Parent
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Child/Young Adult
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SCREENING & ASSESSMENT
• Interview: relate and just ask
• Tools: mnemonics and questionnaires:
– CRAFT, TWEAK
• Refer for specific assessment and testing
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URINE DRUG SCREEN
• Thorough psychosocial history is vital
• Confidentiality and informed consent
• Indications
– identify user for treatment referral
– monitor drug use while under treatment
– emergency diagnosis for altered states
• Random, covert or parent requested testing
– AAP, AAFM, ASAM and AOAAM oppose
– adversarial, breaches trust and alliance
– does not identify pattern or dependency
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URINE DRUG SCREEN
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Knowledge of techniques, limitations
Urine collection under observation
Urine temp, pH, specific gravity
Legal or forensic
– confidentiality, chain of command
– careful labeling, storage
– confirmatory testing - GC/MS
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URINE DRUG SCREEN
DURATION OF DETECTION
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Cocaine metabolites
Inhalants or LSD
Marijuana
Methadone
Short acting Opiates
Phencyclidine
Amphetamines/
methamphetamines
2-4 days
undetectable
3-30 days
3-14 days
2 days
1 week
<48 hours
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SYNTHESIS AND PROCESS
• PATIENT NOT USING
– Affirm decision not to use
– Anticipatory guidance
• PATIENT USING/LOWER RISK
– State your concern
– Elicit patient’s understanding of use. Dispel myths
– Assess readiness to change
– Negotiate plan and follow up
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SYNTHESIS AND PROCESS
• PATIENT USING/HIGHER RISK
– State your concern
– Elicit patient’s understanding of use. Dispel myths
– Assess readiness to change
– Prepare patient/family for referral
– Negotiate plan and follow up
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Treatment
BRIEF INTERVENTION
An interpersonal interaction whose primary impact
is motivational, working to trigger a decision and
commitment to change
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ELEMENTS OF EFFECTIVE
BRIEF INTERVENTIONS
F: Feedback to patient
R: emphasize patient’s Responsibility
A: clear Advice
M:offer Menu of options
E: be Empathetic!
S: reinforce patient’s Self-efficacy
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Stages of Change
• Six Stages of Change:
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Precontemplation -denial
Contemplation – ambivalence
Preparation – making plans for change
Action – acting on the plan to change behavior
Maintenance – ongoing commitment to changed behavior
Relapse – Slip back into earlier using behavior stage
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MOTIVATIONAL INTERVIEWING
• A particular way to help people recognize and do
something about their present or potential behavioral
problems, including AoDA use
• Motivates a person to resolve ambivalence and to get
moving along the path of change
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PRINCIPLES OF
MOTIVATIONAL INTERVIEWING
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Express empathy
Develop discrepancy
Avoid argumentation
Roll with resistance
Support self-efficacy
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Referral to Treatment
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Practitioner uncertain or inexperienced
Frequent, regular or compulsive use
Concurrent psychopathology
Impaired function: school, legal, work or social
Certain circumstances: imminent health risk, behavior presents
danger to self or others
• Inability to use with in “healthy guidelines” or maintain
abstinence
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NIAAA Guidelines
• Men
– Not more than 14 drinks in a week
– Not more than 4 drinks at a single setting
• Women
– Not more than 7 drinks in a week
– Not more than 3 drinks at a single setting
• A standard drink is 14grams of or alcohol
• 12 oz beer
• 5 oz wine
• 1.5 oz liquor
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Assessment
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Assessment
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WHAT’S A STANDARD DRINK?
What’s a Standard Drink?
• In the U.S., a standard drink is any drink that contains about
14 grams of pure alcohol (about 0.6 fluid ounces or 1.2
tablespoons).
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TREATMENT MODALITIES
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Detoxification
Methadone and Buprenorphine programs
Inpatient programs
Therapeutic communities
Outpatient programs
Self-help
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TREATMENT MODALITIES
• Detoxification
– mostly outpatient
– initial step only
• Methadone and Buprenorphine
– treatment of choice - narcotics
– stable: no euphoria, tolerance
– long-acting, oral, semi/synthetic opiates
– combine with broader therapy
– should be > 16 years old
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TREATMENT MODALITIES
• Inpatient programs
– short-term in hospital/CD unit
– highly structured environments
– continuing aftercare essential
• Therapeutic community
– longer-term residential: 6 - 18 months
– drug-free setting for resocialization
– intense, structured, group process
– ex-addict staff plus counseling
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TREATMENT MODALITIES
Outpatient programs
– counseling, family therapy, aftercare (case management),
structured day treatment
– motivated/cooperative patient and family
– free of serious med/psych problems
Self-help: protype is AA
– 12-step approach, adult model
– adapt to teen development
– free, readily available
– “sponsor,” peers in recovery
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TREATMENT OUTCOME
• Best predictor = retention in treatment
• Improved success when
– parents actively participate
– patient active in aftercare
– social and coping skills training
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PROVIDER’S OBLIGATION
• Refer and refer again when indicated
• Reassess progress throughout treatment
• Monitor for potential relapse
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lifelong risk
expect if peer group using
likely if dual diagnosis untreated
expect if teen tries “moderation”
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SUBSTANCE ABUSE
GENERAL ISSUES
• Young People more often abuse multiple drugs
– smorgasbord vs. drug of choice
• Multiple drug use/overdose effects are more difficult to interpret
and treat
• Street drugs often misrepresented
– OD on other than alleged drug
– OD represents drug combination
– OD on concentrated opioids in naïve youth
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Hypertention
Tx
Works!
120
100
80
60
40
20
0
Hypertention
Pre
week 1 Week 2 Week 3 Week 4 Post
Sustance Use Problem
120
100
80
60
40
20
0
Tx
Doesn’t
Work!
While in Treatment
Pre
Sustance Use
Problem
Just Like
Hypertension,
Addiction Is A
Chronic Disease
That
Requires
Continued Care—
but the RESULTS
are usually
measured AFTER
THE TREATMENT
CONDITION HAS
BEEN
WITHDRAWN!
Week 1 Week 2 Week 3 Week 4 Post
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Source: McLellan, AT, Addiction 97, 249-252, 2002.
Questions?
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Some Resources
www.drugabuse.gov/ NIDA
 Provider clinical support system for medication www.NIAAA.nih.gov/ NIAAA
assisted treatments
www.naabt.org
Buprenorphine advocate site
 www.aoaam.org
 www.pcssmat.org
 Amer. Osteo. Acad. of Addiction Medicine
 www.asam.org
 Amer. Soc. Of Addiction Medicine
Provider locator
www.buprenorphine.samhsa.gov/
Provider locator