4/26/2015
Pills, Pot & Alcohol
Reducing the Risk of DUII
John Fitzgerald, PhD, LPC, CAS
6,699 DUII in 2013
105 Alcohol-impaired
driving fatalities
77.3% BAC was above .15
FBI Uniform Crime Report
1
4/26/2015
Law
Enforcement
Prosecutor
ODOT
Treatment
Judicial
DMV/OAH
OLCC
Prevention
Law
Enforcement
Prosecutor
ODOT
DUII
Client
OLCC
Law
Enforcement
Treatment
Prevention
ODOT
Treatment
Judicial
Judicial
OLCC
OLCC
Prosecutor
Prevention
DMV/OAH
DMV/OAH
DUII
Client
DUII
Client
Prevention
2
4/26/2015
Origins of Addiction
90% ≤ 20 years-old
3
4/26/2015
Substance Use Disorders Begin in
Adolescence and Last for Decades
OAS, 2002
Dennis & Scott, 2007
4
4/26/2015
Risk Factors
Poverty
Community attitudes
Availability of addictive objects
Academic failure
Low commitment to school
Association with drug-using peers
Peer rejection in elementary grades
Lack of parental supervision
Parental substance abuse & attitudes
Chaotic home environment
Genetics/Constitutional factors
Psychological
- Sensation seeking
- Lack of impulse control
- Early aggressive behavior
Mental Health Disorders
- Trauma in all forms
Risk Factors
Poverty
Community attitudes
Availability of addictive objects
Academic failure
Low commitment to school
Association with drug-using peers
Peer rejection in elementary grades
Lack of parental supervision
Parental substance abuse & attitudes
Chaotic home environment
Genetics/Constitutional factors
Psychological
- Sensation seeking
- Lack of impulse control
- Early aggressive behavior
Mental Health Disorders
- Trauma in all forms
Levels
Community
School
Peer Group
Family
Protective Factors
Supportive Communities
Cultural Continuity
Prevention & treatment availability
Anti-drug use policies
Anti-bullying policies
Academic success
Relational skills
Nurturing relationships
Parental monitoring and boundaries
Developmentally appropriate experiences
Impulse control
Emotional IQ
Early treatment of mental health issues
Individual
Levels
Community
School
Complex
Puzzle
Peer Group
Family
Protective Factors
Supportive Communities
Cultural Continuity
Prevention & treatment availability
Anti-drug use policies
Anti-bullying policies
Academic success
Relational skills
Nurturing relationships
Parental monitoring and boundaries
Developmentally appropriate experiences
Impulse control
Emotional IQ
Early treatment of mental health issues
Individual
5
4/26/2015
Risk Factors
Levels
Poverty
Community attitudes
Availability of addictive objects
Protective Factors
Supportive Communities
Cultural Continuity
Prevention & treatment availability
Community
Academic failure
Low commitment to school
Anti-drug use policies
Anti-bullying policies
School
Association with drug-using peers
Peer rejection in elementary grades
GenesComplex
X Environment
Lack of parental supervision
Parental substance abuse & attitudes
Chaotic home environment
Genetics/Constitutional factors
Psychological
- Sensation seeking
- Lack of impulse control
- Early aggressive behavior
Mental Health Disorders
- Trauma in all forms
Peer Group
Family
Puzzle
Academic success
Relational skills
Nurturing relationships
Parental monitoring and boundaries
Developmentally appropriate experiences
Impulse control
Emotional IQ
Early treatment of mental health issues
Individual
Heritable Influences on Addiction
Substance/Behavior
Heritability Estimates
Nicotine
33-71%
Alcohol
48-66%
Marijuana
51-59%
Cocaine
42-79%
Opioid
23-54%
Gambling
49%
Source: Agrawal, A. et al. (2012)
6
4/26/2015
Adverse Childhood
Experiences
(ACEs)
ACE
STUDY
• San Diego, CA
• Kaiser Permanente Study
• Begin in Obesity Clinic
• Data collected 1995-1997
• 17,000+ participants
7
4/26/2015
Abuse
Household
Psychological (by parents)
Substance Abuse
Physical (by parents)
Mental Illness
Sexual (anyone)
Parental Separation/Divorce
Emotional neglect
Battered Mother
Physical neglect
Criminal Behavior
ACE Score
Women
Men
Total
0
31.3
34.2
32.7
1
24.2
27.3
25.6
2
14.8
16.4
15.5
3
10.4
9.3
9.9
4
6.8
4.8
5.9
5 or more
12.5
8.0
10.5
8
4/26/2015
ACE Score & Alcoholism
ACE Score & Smoking
“Addiction is not a brain disease, nor is it
caused by chemical imbalances or
genetics. Addiction is best viewed as an
understandable, unconscious, compulsive
use of psychoactive materials in response
to abnormal prior life experiences, most of
which are concealed by shame, secrecy,
and social taboo.”
Vincent J. Felitti, MD
Principle Investigator, Kaiser Permanente
9
4/26/2015
Present-day Stress
APA, www.stressinamerica.org, 2014
Coping Responses
APA, www.stressinamerica.org, 2014
10
4/26/2015
Disease: Ebola
School Killing: Adam Lanza
Terror: ISIS
Suicide: Hoffman & Williams
Public Killing: Holmes & Rodger
War: Israel & Palestine
15 to 18 percent of
working officers in the
United States have
undiagnosed symptoms
of post-traumatic stress
disorder.
John Violanti, U. of Buffalo
11
4/26/2015
Varieties of
Addiction Experience
Why Addiction? Feel Good or Feel Better
Dopamine Index
Cheeseburger
1.5
Sex
2
Nicotine
2
Cocaine
4
Meth
11
Source: UCLA Integrated Substance Abuse Programs
12
4/26/2015
Broad Universe of Addictive Experience
SEX
FOOD
GAMBLING
ALCOHOL
ILLICIT DRUGS
LICIT DRUGS
Fantasy sex
Pizza
Internet
Undistilled
Marijuana
Nicotine
Seductive role
Chocolate
Video keno
Beer
Cocaine
Bath salts
Anonymous
Chips
Horse & Dog
Wine
Heroin
Inhalants
Prostitution
Cookie
Stocks
Sake
PCP
Rx Drugs
Trading sex
Ice Cream
Dice games
Chicha
MDMA
Snuff
Voyeurism
French Fries
Casino games
Distilled
Amphetamine
eCigarettes
Exhibitionism
Cheeseburger
Sports cards
Rum
LSD
Coffee
Intrusive sex
Non-diet Soda
Games of skill
Vodka
K2/Spice
Cough syrup
Pain exchange
Cake
Bingo
Whiskey
Club drugs
Mushrooms
Object sex
Cheese
Sports
Brandy
Rx Drugs
Diet pills
Minor sex
Bacon
Lottery
Powdered
Steroids
Marijuana
Other: Internet, exercise, relationships, working…
Broad Universe of Addictive Experience
SEX
FOOD
GAMBLING
ALCOHOL
ILLICIT DRUGS
LICIT DRUGS
Fantasy sex
Pizza
Internet
Undistilled
Marijuana
Nicotine
Seductive role
Chocolate
Video keno
Beer
Cocaine
Bath salts
Anonymous
Chips
Horse & Dog
Wine
Heroin
Inhalants
Prostitution
Cookie
Stocks
Sake
PCP
Rx Drugs
Trading sex
Ice Cream
Dice games
Chicha
MDMA
Snuff
Voyeurism
Behavioral
French Fries
Casino games
Distilled
Cheeseburger
Sports cards
Rum
Intrusive sex
Non-diet Soda
Games of skill
Pain exchange
Cake
Object sex
Cheese
Minor sex
Bacon
Exhibitionism
Substance
Amphetamine
eCigarettes
LSD
Coffee
Vodka
K2/Spice
Cough syrup
Bingo
Whiskey
Club drugs
Mushrooms
Sports
Brandy
Rx Drugs
Diet pills
Lottery
Powdered
Steroids
Marijuana
Other: Internet, exercise, relationships, working…
13
4/26/2015
Sex
Licit Drugs
Alcohol
Illicit Drugs
Food
Gambling
More experimenting
at an earlier age
14
4/26/2015
Shift from alcohol and
marijuana to opiates
as age increases
Prescription Opioid Analgesics
(pain medicines)
Hydrocodone
Oxycodone
Methadone
Fentanyl
Morphine
Hydromorphone
Buprenorphine
15
4/26/2015
Falling
Guns
Traffic Accidents
Drug Overdoses
26,852 deaths
31,672 deaths
33,687 deaths
38,329 deaths *
Source: CDC WONDER 2010 data
* 30,006 unintentional deaths
16
4/26/2015
Level of Confidence in the Evidence for Adverse
Effects of Marijuana on Health and Well-Being
Effect
Evidence
Symptoms of chronic bronchitis
High
Motor vehicle accidents
High
Addiction to marijuana and other drugs
High
Diminished lifetime achievement
High
Abnormal brain development
Medium
Progression to abuse of other drugs
Medium
Schizophrenia
Medium
Depression or anxiety
Medium
Lung cancer
Low
Volkow et al., 2014
TEENS
• Interferes with brain
development
• Relationship problems
• Poor academic performance
• Increased risk of accidents
• Health/mental health
problems
• High risk sexual behavior
• Gateway to other drugs
6.5% daily abusers
17
4/26/2015
When considering legalization…
policymakers need to:
• Prevent easy access to marijuana by teens
• Increase access and funding for adolescent treatment
• Consider regulating levels of tetrahydrocannabinol (THC)
1980s – 4%
2012 – 15%
18
4/26/2015
Surveillance of Abuse and Addiction
Drug Trends
• National Survey on Drug Use and
Health (NSDUH)
• Monitoring the Future (MTF)
• National Forensic Laboratory
Information System (NFLIS)
Treatment Trends
• Treatment Episode Data Set (TEDS)
• National Survey of Substance Abuse
Treatment Services (N-SSATS)
Private
Government
Drug Trends
• The Researched Abuse, Diversion and
Addiction-Related Surveillance
(RADARS®) System
• Street RX
• National Addictions Vigilance
Intervention and Prevention Program
(NAVIPPRO)
Behavioral Risk Trends
• Behavioral Risk Factor Surveillance
System (BRFSS)
Consequences
19
4/26/2015
“Drug addiction is a brain disease.”
Nora Volkow, MD
Director, National Institute on Drug Abuse
Molecular
Addiction
Switch
20
4/26/2015
Cocaine Abuse and Brain Glucose Metabolism
Normal subject
Cocaine abuser
10 days post
Cocaine abuser
100 days post
21
4/26/2015
Percentage Who Relapse
Type I Diabetes
30 to 50%
40 to 60%
Drug Addiction
Hypertension
50 to 70%
Asthma
50 to 70%
Survival distribution function
Proportion abstinent at discharge by primary drug use
Time to discharge
Sinha, R. (2011)
22
4/26/2015
Addiction Affects Relationships
Self
Shame
You know, I was shameful, and you do
stuff that causes disgust, and that’s hard
to recover from. You can say, ‘I forgive
you’ and all that stuff, but it’s not the
same as recovering from it. It’s not
coming back.
Robin Williams
Interview with The Guardian, 2010
23
4/26/2015
Addiction Affects Relationships
Others
Self
Isolation
Shame
Developmental Stuckness
24
4/26/2015
Addiction Affects Relationships
Faith
Others
Self
Ignorance
Isolation
Shame
We live two lives
Inner life (Eye Closed)
Pure consciousness
Outer life (Eye Open)
Physical reality
Timeless/changeless
Time/change
Being
Doing/action
Collective (one) mind
Individual (ego) mind
25
4/26/2015
We live two lives
Inner life (Eye Closed)
Pure consciousness
Outer life (Eye Open)
Physical reality
Timeless/changeless
Time/change
Being
Doing/action
Collective (one) mind
Individual (ego) mind
Risk Reduction
26
4/26/2015
Percentage of Impaired Drivers in Fatal Alcohol-Involved Crash, 1995-2004
Repeat offenders and chronic drunk
drivers make up about 1% of all drivers
on weekend nights, but account for
50% of all fatal crashes.
National Council on Alcoholism and Drug Dependence, 2006
27
4/26/2015
Intervention
Pre-Drinking
During Drinking
PREVENTION
• Targeted education/media
campaigns
ENFORCEMENT
• Traffic enforcement
• Controlling access of alcohol
• Ignition interlock
• Alternative transportation
• Minor Decoy/Cops in Shops
• Checkpoints
Post Drinking
ADJUDICATION
• Sanctions: jail, diversion,
fines, DISP
• Treatment
• Zero-tolerance for minors
• Primary care screening/BI
Outpatient
90% of patients in care
82% of facilities
14,148 facilities
Residential
9% of patients
24% of facilities
Hospital
1% of patients
5% of facilities
Source: N-SSATS 2013
28
4/26/2015
1,249,629 clients in substance abuse treatment on March 29, 2013
9.9%
of those in need
receive treatment
• 35 billion industry
• Unlicensed and non-credentialed
staff
• Turnover of staff higher than in
the fast-food industry
• Short-term (< 90 days)
29
4/26/2015
What is effective treatment?
Addiction is a pathological disorder, a
disease that requires expert treatment.
30
4/26/2015
Addiction is an
a pathological
adaptive response
disorder,
toa
disease and
biology
that trauma
requiresover
expert
time,
treatment.
and may
benefit from expert treatment.
How motivated…
to stop doing what
has allowed life to
be tolerable?
31
4/26/2015
Depression
Pain
Suicidal
Grief
Sex
Relationships
Acute
Homeless
•
•
•
Guilt
•
•
Internet
•
•
Stress
Bipolar
Stigma
Suicidal
Meth
HIV
Homeless
Intoxicated
Smoking
Fear
Psychoses
Medical
Relapse
Work
Developmental
Legal
Diet
Alcohol
RESOLVE
Cutting
Chronic
•
•
•
Rage
•
•
Time
•
•
Panic
Drugs
MANAGE
Craving
LSD
Schizophrenia
Pills
Antisocial
Depression
Pain
Suicidal
Grief
Cutting
Sex
Relationships
Addiction
•
•
•
Guilt
•
•
Internet
•
•
Stress
Bipolar
Hopeless
Alcohol
RESOLVE
Drugs
Family
Obese
Ambivalence
GHB
Craving
LSD
Schizophrenia
Narcissist
History
Pills
Anxiety
Loneliness
OCD
Hungry
ADHD
Unemployed
Numb
Gambling
Chronic
Suicidal
•
Meth
HIV
Panic
Homeless
•
Legal
Intoxicated
•
Smoking
Fear
Rage
Psychoses
Systems•
Evaluation
Medical
•
Time
Relapse
Work
Developmental
•
Living
LegalSituation
•
Diet
Legal
PTSD
GHB
Stigma
Debts
Shame
Addiction
Trauma
K2
Cocaine
ACEs
Medical
Pot
Psychotic
Sleep
Stress
Relationships
Food
TBI
Hep C
Lifestyle (Time/$)
Health (Diet)
Ambivalence
Acute
Narcissist
Loneliness
Obese
Homeless
Gambling
Debts
Shame
Anxiety
Addiction
Trauma
K2
Cocaine
ACEsMental
Health
Medical
Pot
Psychotic
Sleep
Stress
Relationships
Food
TBI
Hep C
Lifestyle (Time/$)
Physical
Health
(Diet)
Health
PTSD
Legal
MANAGE
Hopeless
Antisocial
OCD
Hungry
ADHD
Unemployed
Numb
32
4/26/2015
Depression
Pain
Suicidal
Grief
Sex
Relationships
Addiction
Acute
• Suicidal
Acute
• Homeless
Legal
Homeless
Stigma
Stress
HIV
•
Guilt
•
•
Internet
•
•
Bipolar
Meth
Panic
Cutting
Chronic
• Addiction
Chronic
• ACEsMental
RESOLVE
Ambivalence
GHB
Craving
LSD
Schizophrenia
Narcissist
History
Pills
Loneliness
Cocaine
•Intoxicated
Suicidal
••
Smoking
Fear
Rage
•Psychoses
Homeless
•
Systems•
•Medical
Intoxicated Evaluation••
Time •
Relapse
Work
•Developmental
Psychoses
•
Living
•Legal
Medical
••
Situation
Drugs •
Alcohol
Diet
• Developmental
• Legal
•
Family
Obese
Gambling
Shame
Debts
Anxiety
Trauma
K2
Health
Addiction
Medical
Pot
Psychotic
Sleep
ACEs
Stress
Medical
Relationships
Food
TBI
Hep C
Stress
Lifestyle
(Time/$)
Physical
Relationships
Health
(Diet)
Health
Legal
PTSD
OCD
Lifestyle
(Time/$)
Health (Diet)
MANAGE
Hopeless
Antisocial
Hungry
ADHD
Unemployed
Numb
Talents
Strengths
Virtues
33
4/26/2015
5 Actions
Motivate
Evaluate
Resolve
Manage
Create
Motivational Interviewing
CRAFT
Contingency Management
Goal Setting
Ongoing Systems Evaluation / Outcome Measures
Cognitive-Behavioral
Relapse Prevention
Medications
Trauma Therapies (e.g. EMDR)
Developmental
Brief Interventions
Case Management
12-step Facilitation
Humanistic
Existential
Hope Therapy
Well-being Therapy
Motivational Interviewing
CRAFT
Contingency Management
Goal Setting
5 Actions
Motivate
Evaluate
Ongoing Systems Evaluation / Outcome Measures
Right Intervention(s)
Relapse Prevention
Resolve Cognitive-Behavioral
Right
Time
Trauma Therapies (e.g. EMDR)
Medications
Developmental
Right DoseBrief Interventions
Manage
Create
Case Management
12-step Facilitation
Humanistic
Existential
Hope Therapy
Well-being Therapy
34
4/26/2015
Internal
Hope
Consequences
Feeling
External
MI
Mandates
CRAFT
CRAFT: Helping Families
70
60
50
40
30
20
10
0
CRAFT
CRAFT
Intervention
Intervention
Al-Anon
Al-Anon
64%
30%
10%
35
4/26/2015
1 Get Past Records
2 Study
3 Get Evaluated
CONNECT
THE
DOTS
Mental Health
Addiction
Sexual trauma
Alcohol
Depression
Pot
ADD
Food
Anxiety
Work
Physical Health
Environmental
Obesity
Few supportive friends
High blood pressure
Poor financial resources
apnea
Sleep Apnea
Poor housing situation
36
4/26/2015
“The challenge of [trauma] recovery
is to reestablish ownership of your
body and your mind.”
•
Find a way to be calm and focused, even
during times where you are reminded of
the past
•
Find a way to be fully alive in the present
and engaged with the people around you
•
Not having to keep secrets from yourself,
including secrets about the ways you
have managed to survive
Mindfulness Practice
Mindfulness is not thinking, interpreting,
or evaluating; it is an awareness of
perception. It is a nonjudgmental quality
of mind which does not anticipate the
future or reflect back on the past. Any
activity can be done with mindfulness.
Source: www.contemplativemind.org
37
4/26/2015
Mindfulness Practice
Meditation
Yoga
Mindfulness
is not thinking,
interpreting,
 Vipassana
 Ananda
or evaluating;
it is an awareness
of
 Zen
 Ashtanga
 Chakra It is a nonjudgmental
 Bikram quality
perception.
 Deep breathing
 Hatha
of mind
which does not anticipate
 Visualization
 Iyengar the
 Walking
 Kripalu
future
or reflect back on the
past. Any
 Sitting
 Power
activity
can be done with mindfulness.
 Eating
 Vinyasa
 Creative
 Yin
Source: www.contemplativemind.org
Developmental Catch-up
Emotional
Age = 12
38
4/26/2015
Chronological
Age = 46
Developmental Catch-up
Neurosequential Model of Therapeutics
(Perry)
Emotional
Age = 12
Developmentally-based Psychotherapy
(Greenspan)
Sensorimotor Psychotherapy
(Ogden)
Three Leverage Points
Time (outpatient vs. res)
EBP (addiction medications)
Coordinated (chronic) Services
39
4/26/2015
Chronic
Condition
Condition-specific
Interventions
Shared
Interventions
Addiction
Hypertension
Heart Disease
Diabetes
OpioidBlocker,
Methadone
Diuretics,
Beta-blockers
ACE
Inhibitors,
ARBs
Insulin,
Diabetes Pills
Stress
Management
Friendship
Networks
Motivational
Interviewing
Diet
Goal Setting
Brief Interventions
Sleep
Spirituality
Collaborative Team
Exercise
Program
Community
Supports
Helping
Relationships
40
4/26/2015
All children are artists.
The problem is how to
remain an artist once he
grows up.
Picasso
What to Create?
41
4/26/2015
Learn more at www.addictionmanagement.com
[email protected]
42