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Hope for Recovery

Client With Years of Alcohol, Cocaine, And Meth

Oregon Child Welfare 1997-99

• 60% of CW families A&D involved

• 54% of CW families DRUG involved

• 68% of CW DRUG families METH

• #1 reason for termination –

(2)

Oregon Child Welfare 2004

• 875,790 children ages 0-18

• 46,524 reports of suspected abuse

• 10,622 FOUNDED abuse cases

• 9.6% ^ over previous year

• 73.8% ^ since 1994

• 9.4% ^ in POPULATION since 1994

• 50% of removals METH related

Oregon METH Response

• Collaborate & Integrate

• Separation of issues – Labs & Addiction

• Governor’s METH Task Force

• Drug Endangered Child Response

• DEC Teams & OADEC

• Addiction Recovery Teams - ART

(3)

Oregon Child Welfare & Treatment

• 2000 – 87.8% of child welfare parents

h bl d

with A&D problems entered treatment and 6,800 kids are in foster care.

• 2003 – Oregon legislature cuts TX.

• 2006 – 41 5% of child welfare parents

• 2006 41.5% of child welfare parents with A&D problems enter TX and 8,600 kids are in foster care.

DEC - Drug Endangered Child

Team Partners

• DHS Child Welfare

• Local Law Enforcement

• Meth Lab Law Enforcement

• Criminal Prosecuting District Attorneys

• Child Welfare Attorneysy

(4)

DEC Collaboration Issues

• LEA will seek evidence for charges and arrest.

• DA’s will seek prosecution on both drug charges and child maltreatment.

• DEC Collaboration requires CPS to play active role in this process while advocating for the best outcomes for children.

• Can be conflicts in process.

CPS Requirements – On Site

• Focus - on Your CPS Safety Assessment

• Gather Info from Site Safety Officer

• Determine De-Contamination Need/Plan

• Focus - Be the Social Worker, not the Police Officer.

• Stay Behind the Police Barriers

(5)

Addiction Recovery Teams

• DHS & Contract Collaboration

• DHS staff person assigned to A&D

• Contracted A&D Counselor

• Contracted Outreach Worker

• Other Integrated Servicesg

• Must be on site at child welfare

Family Involvement Team

• FIT Team

• Portland – Multnomah County

• A&D CW Services at the court

• On site DHS & A&D at all times

• On site transport & child visitp

• Treatment Program Case Managers

(6)

ADVANTAGES – ART & FIT

• All providers believe in RECOVERY

• Immediate focus on A&D TX needs

• Tracking clients toward recovery

• Relapse response with Outreach

• FIT – services offered at court

• FIT – TX site case management

ADVANTAGES – ART & FIT

• Parent focused service

• Caseworkers feel supported

• Treatment programs OK with CW

• Clients stick with TX

• Recovery modeled – Parent Mentorsy

(7)

ADVANTAGES ART - FIT

• Defense bar buys in

• Judges recommend & mandate services

• Negates punitive casework

• Promotes clinical approaches

• Drug testing seen as interventiong g

• Recovery is modeled to caseworkers

• Meth has changed over time:

– 1940’s pharmaceutical • L-methamphetamine – 1970’s Street Chemist • d/l-methamphetamine • Levorotatory rotates to the left. • Dextrorotatory rotates to the right.

• Drugs that are “right handed” have a greater

• “Prop-dope” – peanut butter – Mid-1980’s

• d-methamphetamine

• Ephedrine reduction

affinity for receptors, and are therefore more potent.

• Some businesses contribute to the methamphetamine problem: the methamphetamine problem:

– Pseudoephedrine producers

– Paraphernalia manufacturers

(8)

12 15 17 18 22 27 31 34 9 0 % 10 0 % 39 42 42 42 38 35 30 25 21 18 17 31 34 39 44 50 4 0 % 5 0 % 6 0 % 7 0 % 8 0 % Smo ki ng I nsuf l at i o n I nj ect i o n O t her 17 14 12 12 11 10 11 13 13 12 10 32 29 28 28 29 28 28 28 27 26 23 0 % 10 % 2 0 % 3 0 % 1 9 9 2 1 9 9 3 1 9 9 4 ` 1 9 9 5 1 9 9 6 1 9 9 7 1 9 9 8 1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2 Source: SAMHSA, TEDS, 2002

How do most use?

How does this differ from other drugs?

(Results: Frequency of Methamphetamine Use) 6 2 3 4 5 75% Daily or near daily 0 1 DAIL Y 2-6X /WEE K 1X/W EEK 1X/2 WEE KS <1X/ MON TH 25% Occasional or Binge

(9)

Oregon vs. National 8thGraders Since 9-11 The next generation?

25.00% 30.00% Alcohol Alcohol 16 00% 18.00% 20.00% DrugsDrugs 10.00% 15.00% 20.00% 6.00% 8.00% 10.00% 12.00% 14.00% 16.00% 2001 2002 2003 2004 0.00% 5.00% 2001 2002 2003 2004 0.00% 2.00% 4.00%

Oregon Healthy Teens, 2004 & Monitoring the Future, 2004

Oregon 8th Graders Alcohol Past 30-day Use continues to rise above the national average (2003-2004)

25.00% 30.00% e gon n Oregon 8th Graders 10 00% 15.00% 20.00% Or e Orego n National National Oregon 8 Graders consume alcohol

54%

higher than the national average.

2003 2004

0.00% 5.00% 10.00%

(10)

Oregon 8thGraders Illicit Drug Use

continues to rise above the national average (2003-2004)

14.00% 16.00%

Oregon

Oregon Oregon 8th Graders

6.00% 8.00% 10.00% 12.00% N ational National Oregon 8 Graders consume illicit drugs at nearly

Double

the national average. 2003 2004 0.00% 2.00% 4.00% N

• Oregon ranks #7 nationally for recent illicit drug use in people 12+

• Oregon ranks #2 in the U.S. for illicit drug use among adults 26+ and 4th in the U.S. for drug

abuse/dependence among 18-25 year olds.

• Oregon ranks 45th in U.S. for treatment access.

• Oregon ranks 49th in U.S. for treatment access

among 18-25 year olds.

(11)

William White

Researcher/Director: Lighthouse Research Institute

Author: Slaying the Dragon: The History of Addiction & Recovery in America, and Critical Incidents

Addiction Addiction + Addiction ++

Oldest onset 16-18 Younger onset 13-15 Youngest onset 9-12

Little/no trauma Trauma Early trauma

Little/no trauma Trauma Early trauma

Believed Immediate intervention Believed Some intervention Not believed And/or No intervention Little to no professional

help Some professional help Lots of professional help

Low psychiatric Symptomology (older onset) High “self-containment” Moderate psychiatric Symptomology (earlier onset) Moderate “self-containment” Acute psychiatric Symptomology (earliest onset) Little “self-containment” “mature-out”

“many roads to recovery”

Single to multiple tx episodes Chronic many tx episodes

• Many many studies have shown that adolescent treatment outcomes are lower than adult outcomes. One of the largest studies showed that clients under 30 had greater

• Numerous addiction studies have shown a division at age 24:

– Tx completion rates were lower for those 24 and under (TEDS, 2000). susceptibility to drug using peer groups (DATOS, 1999).

– Most adolescent substance abusers do not enter treatment until age 24 (NTIES, 1992).

– Clients with poorer outcomes under 24 (Roffman).

– Increasing belief that cigarettes are harmful at 24 (NIDA, 2002).

(12)

Oregon Child Welfare 1997-99

• 60% of CW families A&D involved

• 54% of CW families DRUG involved

• 68% of CW DRUG families METH

• #1 reason for termination –

(13)

• Early onset substance using kids had up to 5 times higher rates of substance

abuse/dependence

• Significantly higher rates of anxiety and depression Up to 5x’s greater Substance abuse/ dependence Higher rates Anxiety and Depression  Adolescence is a period of profound brain maturation.  It was previously believed that brain development was complete during early adolescence

 The maturation process is not complete until about age 24!!!

(14)

Oregon 2001 Amphetamine Treatment Clients: Male to Female Ratios

100% F l 562 1926 3387 3052 861 663 1519 2429 1869 443 0 500 1000 1500 2000 2500 3000 3500 4000 Male Female 0% 20% 40% 60% 80% 11 to 17 18 to 24 25 to 34 35 to 44 55 to 64 Males Females 0 11 to 17 18 to24 25 to34 35 to44 55 to64 0 200 400 600 800 1000 1200 1999 2000 2001 2002 2003 Youth Female Youth Male

Psychoactive Substances and Sexual

Behaviors

100%

• My sexual drive

is increased by the use of the following substance(s) 57% 16% 42% 73% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% 10% Alco hol Op iate Coca ine MA

(15)

Psychoactive Substances and Sexual

Behaviors

• My use of the • My use of the following substance(s) has made me become

obsessed with sex

and/or made my sex 16%

40% 67% 20% 30% 40% 50% 60% 70% 80% 90% 100%

and/or made my sex drive abnormally high. 0% 0% 10% Alco hol Op iate Coc aine MA

Psychoactive Substances and Sexual

Behaviors

• I am more likely to

• I am more likely to

have sex (e.g. intercourse, oral sex, masturbation, etc.) when using the following 47% 4% 41% 71% 20% 30% 40% 50% 60% 70% 80% 90% 100% following substance(s) 0% 4% 10% Alco hol Opiat e Coc aine MA

(16)

Psychoactive Substances and Sexual

Behaviors

• I am more likely to

• I am more likely to

practice “risky” sex under the influence of the following substance(s) (e.g., not use condoms, be

45% 41% 55% 20% 30% 40% 50% 60% 70% 80% 90% 100%

not use condoms, be less careful about who you choose as a sex partner, etc.)

0% 0% 10% Alco hol Op iate Coc aine MA

Psychoactive Substances and Sexual

Behaviors

• I have become involved

• I have become involved in sex acts that are unusual for me when I am under the influence of the following substance(s) (e.g., marathon masturbation, 17% 4% 35% 58% 20% 30% 40% 50% 60% 70% 80% 90% 100% marathon masturbation, go to “peep” shows, cross-dress, voyeurism, expose yourself, etc.)

4% 0% 10% Alco hol Opiat e Coc aine MA

(17)

Medical/Psychiatric Symptoms

Follow-up of 114 MA Users

Treated with Matrix Model – 1 year

Medical/Psychiatric Symptoms Symptoms in Past 30 Days Baseline Follow-up Hallucinations P i 30% % 9% % Paranoia “Psychiatric Problems” Chest Pains Depression Headaches 24% 24% 23% 62% 44% 7% 5% 12% 59% 40%

Research on Cognitive Impairments

of MA addicts

• Ability to manipulate

• Ability to manipulate

information (multi-relational or “synthesis”)

• Ability to make inferences

• Ability to ignore irrelevant

information

• Ability to learn new

information

(18)

“Methamphetamine: Snapshot Phenomenon” Wurscher & Martin

• A 2002 study of 114 methamphetamine users

• A 2002 study of 114 methamphetamine users,

2-5 years after completing treatment:

– 82% no meth past 30 days.

– 54% abstinent 24 months or longer.

– Full time employment increased from 26% to 62%.

• A 2004 controlled multi-site study of 978,

six-th f ll ft t t t l ti

month follow up after treatment completion:

– 66-69% of urinalysis were clean at discharge and follow up.

1. Rawson, R. et al. (2002). Status of Methamphetamine Users 2-5 years after Outpatient Treatment. Journal of Addictive Diseases, vol. 21, no.1, pp. 107 2. Rawson, R. (June 2004). A Multi-Site Comparison of Psychosocial Approaches for the Treatment of Methamphetamine Dependence. Addiction, volume 99, issue 6 3. DSHS Research and Data Analysis Division, Research and Data Analysis Division. Report Number 11.114fs

(19)

Nerve Cell

Dendrites receive messages messages Cell Body (Soma) nourishes cell and keeps it alive Axon transmits messages Synaptic Gap – the space in between all cells

(20)

Neuropharmacology

• Neurotransmitters ti l t i l are tiny electrical and chemical messengers. • Axon (sender) • Dendrite (receiver) • Synaptic Gap • Synaptic Gap (space in-between the cells)

• Lock & Key mechanism.

Most drugs of abuse “mimic”

Most psychoactive drugs of abuse look “similar” to

neurotransmitters. These drugs mimic the action and appearance of neurotransitters.

THC – Anandamide

Opiates – Endorphin Enkephalin

Alcohol, Benzo’s, Barb’s – GABA

(21)

Drugs of Abuse are “Dopaminergic”

Or, in other words, they increase dopamine activity.

EXAMPLE: THC connects with receptors and causes the release of dopamine

The one and only thing…

Marijuana Alcohol Heroin Cocaine Crack Meth Nicotine Nicotine Caffeine www.nida.nih.gov

(22)

200 200 NAc shell NAc shell FOOD FOOD 200 200 a seline) a seline) SEX SEX

Natural Rewards Elevate Dopamine Levels Natural Rewards Elevate Dopamine Levels

0 0 50 50 100 100 150 150 % of Basal DA Output % of Basal DA Output Empty Empty Box Box FeedingFeeding

100 100 150 150 DA Concentration (% B a DA Concentration (% B a 15 15 0 0 5 5 10 10 Copulation Frequen c Copulation Frequen c 0 0 0 0 6060 120120 180180 Time (min) Time (min)

Source: Di Chiara et al. Source: Di Chiara et al.

Mounts Mounts Intromissions Intromissions Ejaculations Ejaculations 0 0 cycy Sample Number Sample Number 1 1 22 33 44 55 66 77 88 9 10910 1111 1212 1313 1414 1515 1616 1717 Scr ScrScrScr Bas

BasFemale 1 PresentFemale 1 Present

Scr Scr Female 2 Present Female 2 Present Scr Scr

Source: Fiorino and Phillips Source: Fiorino and Phillips

600 600 700 700 800 800 900 900 1000 1000 1100 1100 s al R e lease s al R e lease DA DA DOPAC DOPAC HVA HVA Accumbens

Accumbens AMPHETAMINEAMPHETAMINE

300 300 400 400 a l Release a l Release DA DA DOPAC DOPAC HVA HVA Accumbens

Accumbens COCAINECOCAINE

Effects of Drugs on Dopamine Levels Effects of Drugs on Dopamine Levels

0 0 100 100 200 200 300 300 400 400 500 500 600 600 0 0 11 22 33 44 5 hr5 hr Time After Amphetamine Time After Amphetamine

% o f B a s % o f B a s HVAHVA 0 0 100 100 200 200 0 0 11 22 33 44 5 hr5 hr Time After Cocaine Time After Cocaine

% o f B a s a % o f B a s a 250 250 s e s

e AccumbensAccumbens MORPHINEMORPHINEDose (mg/kg)Dose (mg/kg)

250 250 s e s e NICOTINENICOTINE 0 0 100 100 150 150 200 200 0 0 11 22 33 44 5hr5hr Time After Morphine Time After Morphine

% of B asal R e lea s % of B asal R e lea s 0.5 0.5 1.0 1.0 2.5 2.5 10 10 Dose (mg/kg) Dose (mg/kg) 0 0 100 100 150 150 200 200 0 0 11 22 3 hr3 hr Time After Nicotine Time After Nicotine

% of B asal R e lea s % of B asal R e lea s Accumbens Accumbens Caudate Caudate

Source: Di Chiara and Imperato Source: Di Chiara and Imperato

(23)

R t it Up & Down Regulation • Receptor sites can increase and decrease over time, as the nerves assess the need assess the need to do so.

(24)

Addiction Is A Brain Disease

Expressed As Compulsive Behavior

Addiction Is A Brain Disease

Expressed As Compulsive Behavior

Expressed As Compulsive Behavior

Expressed As Compulsive Behavior

Both Developing and

Recovering From It Depend on

i

S

i

C

Both Developing and

Recovering From It Depend on

i

S

i

C

Behavior and Social Context

Behavior and Social Context

Short Term

• Short Term: Delusions chronic meth user with significant reductions in brain activity – Delusions – Memory Problems – Hallucinations: • Tactile • Visual • Auditory • Gustatory • Olfactory

(25)

Psychosis Stories

• Shadow People

• Meth MonstersMeth Monsters

• Police

• Suspicious of Friends

Meth & Aggression

• Animal Studies (rats, monkeys, etc.)

– Increases frequency of

attack-Low doses Super High doses q y

behavior (# of incidents), decreases actual attack-time (actual minutes and seconds of attack behavior)

– Less awareness of submission-behavior of others, oblivious & unacknowledged (keeps attacking after the other has submitted)

– Low to higher doses increase aggression, really high doses produce less aggression (bell curve) becomes disabling. Aggression A g Ag g

• Hierarchy of Primates (on Meth)

– Increases in aggressive behavior seen most prominently in high ranking & low ranking monkeys, with lesser aggression effects on middle-rank monkeys (inverted bell curve).

Low class monkeys High class monkeys g g ression g ression

(26)

Twitch, Tic’s, Grimacing, Jerky muscle movements

Dr. Darryl Inaba, Pharm.D. Haight Ashbury Films

Dental Problems

• ADA rates meth worse illicit drug for your teeth.

• Constricts blood vessels in the mouth, reducing blood flow and immune protection.

• Tooth grinding, bruxism, adds to deterioration of teeth.

teeth.

• Meth users drink a lot of pop.

• Meth users in treatment experience significant pain.

(27)

Discomfort

• Meth users may experience physiologic discomfort from:

– sores

– tooth decay

– loss of REM sleep

– gastrointestinal ulceration's

Increasing numbers of Meth injectors (OD’s rank 9th)

N dl U I f i

Needle Use Infections abscesses septicemia cotton fever hepatitis B & Cp endocarditis embolism

(28)

Street Survey

• Meth is the sameMeth is the same as Rx drugs.

• Rx drugs are “unnatural”.

Route of Meth Administration

ADAM Adult Meth Users

Snort 68% 43% 28% 46% 57%

Los Phoenix Portland San San

Angeles Diego Jose

Smoke 18% 27% 17% 39% 32%

Inject 11% 27% 49% 12% 5%

Other 2% 3% 5% 2% 6%

Oregon OMHAS, CPMS Meth primary treatment Admits had 39% injection Rate in 1999 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1999 2001 2003 Smoking Injection Insuflation

(29)

• Early onset substance using kids had up to 5 times higher rates of substance

abuse/dependence

• Significantly higher rates of anxiety and depression Up to 5x’s greater Substance abuse/ dependence Higher rates Anxiety and Depression

Hope for Recovery

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