Substance Abuse and Crisis Intervention

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Substance Abuse and Crisis Intervention

• Presented by

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Overview of Western Region Grant

• Certifying counties (DHS 34)
• Training
• Stabilization services

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Goals of the grant

• Reduce inappropriate/unnecessary restriction of
  rights by using more restrictive placement than
  needed
• Improve access to community based least
  restrictive options

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Meet our Presenter

• Lorie Goeser is an Independent Clinical
  Supervisor, Clinical Substance Abuse Counselor,
  BA with focus on sociology and criminal justice
  specialty. Ms. Goeser has worked in private
  settings and has a combined 12 years of
  experience with the DHS and County systems,
  treating addiction or working on addiction
  policies and statues.Ms. Goeser has 26 years of
  experience in the addiction field including
  working with clients in acute crisis, dual
  diagnosis, consultation for detoxification
  services, county provider for outpatient and on
  call, as well as working within the hospital and
  institution settings providing program
  development and services for dual diagnosis
  adolescents and adults. Ms. Goeser has provided
  training to MDs and medical staff on how to
  intervene with addicted clients, how to address
  addiction issues in the ER setting, training on
  assessment and referral to a variety of providers
  including social workers, child protection
  workers, law enforcement and addiction
  therapists.

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What do you think addiction is?

• What thoughts do you have about it?
• What prior experience do you have with addiction?
• What knowledge do you have and where did you
  obtain it from?
• Do believe addiction is a brain disease?
• Do think addiction is a problem in WI?

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Debunking Myths about Dependence

• MYTH All someone has to do to overcome
  alcoholism is go to Alcoholics Anonymous (A.A.).
• FACT A.A. doesnt work for everyone (even for
  many people who truly want to stop drinking). For
  most people, A.A. is a gut-wrenching, lifelong
  working of the 12 steps. Scientists theorize that
  people who get better in A.A. are somehow
  learning how to overcome (or compensate for)
  their brain disease.
• MYTH Nicotine and marijuana are not addicting.
• FACT Nicotine is one of the most
  dependence-producing chemicals in existence and
  marijuana has also been proven to create a
  dependence in a percentage of people who smoke it
  regularly.
• Source Dr. Carl Erickson- University of Texas _at_
  Austin

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Debunking Myths about Dependence

• MYTH Anyone who drinks or uses drugs too often
  will become addicted.
• FACT We know this doesnt occur in everyone, any
  more than diabetes occurs in everyone who eats
  too much sugar or food. It now appears that a
  person must have what it takes to become
  dependent on drugs. In many cases, genetics is
  the main risk factor for determining who develops
  the disease.
• MYTH All addicts are criminals.
• FACT Evolving research is demonstrating that
  addicts (people who are dependent on drugs or
  alcohol) are not bad people who need to get good,
  crazy people who need to get sane or stupid
  people who need education. Addicts have a brain
  disease that goes beyond their use of drugs.
• Source Dr. Carl Erickson- University of Texas _at_
  Austin

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Top 10 Addiction Myths and Myth Busters

• Think you know about addiction? Then these common
  myths may sound familiar
• Myth 1 Drug addiction is voluntary behavior. You
  start out occasionally using alcohol or other
  drugs, and that is a voluntary decision. But as
  times passes, something happens, and you become a
  compulsive drug user. Why? Because over time,
  continued use of addictive drugs changes your
  brain - in dramatic, toxic ways at times, more
  subtly at others, but virtually always in ways
  that result in compulsive and even uncontrollable
  drug use.
• Myth 2 Drug addiction is a character flaw. Drug
  addiction is a brain disease. Every type of drug
  - from alcohol to heroin - has its own mechanism
  for changing how the brain functions. But
  regardless of the addiction, the effects on the
  brain are similar, ranging from changes in the
  molecules and cells that make up the brain to
  mood and memory processes - even on motor skills
  such as walking and talking. The drug becomes the
  single most powerful motivator in your life.

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Top 10 Addiction Myths and Myth Busters

• Myth 3 You can't force someone into treatment.
  Treatment does not have to be voluntary. Those
  coerced into treatment by the legal system can be
  just as successful as those who enter treatment
  voluntarily. Sometimes they do better, as they
  are more likely to remain in treatment longer and
  to complete the program. In 1999, over half of
  adolescents admitted into treatment were directed
  to do so by the criminal justice system.
• Myth 4 Treatment for drug addiction should be a
  one-shot deal. Like many other illnesses, drug
  addiction typically is a chronic disorder. Some
  people can quit drug use cold turkey, or they
  can stop after receiving treatment just one time
  at a rehabilitation facility. But most people who
  abuse drugs require longer-term treatment and, in
  many instances, repeated treatments.

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Top 10 Addiction Myths and Myth Busters

• Myth 5 We should strive to find a "magic bullet"
  to treat all forms of drug abuse. There is no
  one size fits all form of drug treatment, much
  less a magic bullet that suddenly will cure
  addiction. Different people have different drug
  abuse-related problems. And they respond very
  differently to similar forms of treatment, even
  when they're abusing the same drug. As a result,
  drug addicts need an array of treatments and
  services tailored to address their unique needs.
  Finding an approach that is personally effective
  can mean trying out several different doctors or
  treatment centers before a match is found
  between patient and program.

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Top 10 Addiction Myths and Myth Busters

• Myth 6 People don't need treatment. They can
  stop using drugs if they really want to. It is
  extremely hard for people addicted to drugs to
  achieve and maintain long-term abstinence.
  Research shows that when long-term drug use
  actually changes a person's brain function, it
  causes them to crave the drug even more, making
  it increasingly difficult to quit without
  effective treatment. Intervening and stopping
  substance abuse early is important, as children
  become addicted to drugs much faster than adults
  and risk greater physical, mental and
  psychological harm
• Myth 7 Treatment just doesn't work. Studies show
  drug treatment reduces drug use by 40 to 60
  percent and can significantly decrease criminal
  activity during and after treatment. There is
  also evidence that drug addiction treatment
  reduces the risk of infectious disease, Hepatitis
  C and HIV infection - intravenous-drug users who
  enter and stay in treatment are up to six times
  less likely to become infected with HIV - and
  improves the prospects for getting and keeping a
  job up to 40 percent.

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Top 10 Addiction Myths and Myth Busters

• Myth 8 No one voluntarily seeks treatment until
  they hit rock bottom. There are many things that
  can motivate a person to enter and complete
  treatment before that happens. Pressure from
  family members and employers, as well as personal
  recognition that they have a problem, can be
  powerful motivators. For teens, parents and
  school administrators are often driving forces in
  getting them into treatment before situations
  become dire.
• Myth 9 People can successfully finish drug abuse
  treatment in a couple of weeks if they're truly
  motivated. For treatment to have an effect,
  research indicates a minimum of 90 days of
  treatment for outpatient drug-free programs, and
  21 days for short-term inpatient programs.
  Follow-up supervision and support are essential.
  In all recovery programs, the best predictor of
  success is the length of treatment. Patients who
  are treated for at least a year are more than
  twice as likely to remain drug free, and a recent
  study showed adolescents who met or exceeded the
  minimum treatment time were over one and a half
  times more likely to stay away from drugs and
  alcohol.

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Top 10 Addiction Myths and Myth Busters

• Myth 10 People who continue to abuse drugs after
  treatment are hopeless. Completing a treatment
  program is merely the first step in the struggle
  for recovery that can last a lifetime. Drug
  addiction is a chronic disorder occasional
  relapses do not mean failure. Psychological
  stress from work or family problems, social cues
  - meeting someone from the drug-using past - or
  the environment - encountering streets, objects
  or even smells associated with drug use - can
  easily trigger a relapse. Addicts are most
  vulnerable to drug use during the few months
  immediately following their release from
  treatment. Recovery is a long process and
  frequently requires multiple treatment attempts
  before complete and consistent sobriety can be
  achieved.
• (Sources National Institute on Drug Abuse,
  National Institute of Health Dr. Alan I.
  Leshner, former director of the National
  Institute on Drug Abuse The Principles of Drug
  Addiction Treatment A Research-Based Guide
  (October 1999) The Partnership for a Drug-Free
  America)

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Addiction- Definition

• Addiction is a health condition in which an
  individual manifests a pathological pattern of
  use of alcohol, tobacco or other drugs that
  interact with brain systems of reward. Genetic,
  psychological, environmental and cultural factors
  influence its onset and progression. Persons
  with addiction have altered motivational
  hierarchies so that they are preoccupied with
  procuring supplies of using substances that early
  in the illness can produce euphoria, and
  substance use persists despite a range of
  medical, family, occupational, legal and other
  consequences. Individuals, families, and
  communities suffer when addiction is prevalent
  and not adequately treated.(Adapted from
  definitions of the American Society of Addiction
  Medicine.)

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Substance Use Definition

• Substance Use refers to the risky, chronic,
  problematic or harmful use of alcohol, tobacco,
  prescription drugs, and controlled substances.
  (Healthiest Wisconsin 2010)

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Why is it important to Address Addiction and
Substance Use?

• Alcohol use is associated with 41 of road
  traffic deaths, 29 of suicides, Suicides and
  road traffic accidents are leading caused of
  death among 15-34 year olds. (WHO Burden of
  Disease Statistics 2001)
• Alcohol misuse is now the leading risk factor for
  serious injury in the United States, and the
  third leading cause of preventable death. It
  accounts for more than 75,000 deaths annually.
  Little has been done to address the misuse of
  alcohol and drugs a major cause of severe and
  repeat injuries among hospitalized trauma
  patients. (CDC-2003 Conference proceedings on
  Alcohol and Other Drug Problems)

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• Excessive alcohol consumption is the third
  leading preventable cause of death in the United
  States it is associated with multiple adverse
  health consequences, including liver cirrhosis,
  various cancers, unintentional injuries, and
  violence. Alcohol-attributable deaths (ADD) is
  approx. 75,766, and 2.3 million years of
  potential life lost (YPLLs). (Source-CDC-AADs
  YPLLs-US, 2001)

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Wisconsin Epidemiological Profile on Alcohol and
Other Drug Use, 2008

• Key Findings
• Consequences of Alcohol and Other Drug
  Consumption
• Many types of mortality, morbidity, and dangerous
  criminal behavior have been linked to the use of
  alcohol and other drugs. Given Wisconsins high
  rate of alcohol consumption, it is not surprising
  that the rates at which Wisconsin experiences the
  consequences associated with alcohol use also
  tend to be higher than the national average.
• Rates of alcohol dependence, alcohol abuse, and
  alcohol-related motor vehicle fatalities are
  higher in Wisconsin than in the United States as
  a whole. Wisconsin has one-and-a-half times the
  national rate of arrests for operating a motor
  vehicle while intoxicated and more than three
  times the national rate of arrests for other
  liquor law violations. Wisconsin also has the
  highest rate in the nation of self-reported
  drinking and driving.

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Wisconsin Epidemiological Profile on Alcohol and
Other Drug Use, 2008

• Wisconsins rate of alcohol-related motor vehicle
  deaths has been decreasing in recent years,
  although more slowly than the overall rate of
  motor vehicle deaths. One surprising finding
  is that Wisconsin has had a lower rate of
  alcohol-related liver cirrhosis than the national
  average, although this difference may be
  disappearing. Wisconsins rate of other
  alcohol- related deaths (other than liver
  cirrhosis and motor vehicle) has increased since
  1999.
• The number of clients receiving publicly funded
  services for alcohol and other drug abuse
  increased 11 between 1997 and 2006, while
  inflation-adjusted public expenditures for those
  services increased just 4.
• From 1999 to 2006, Wisconsins age-adjusted rate
  of drug-related deaths increased the statewide
  rate of drug-related hospitalizations has also
  increased in recent years. Wisconsins rate of
  arrests for drug law violations remains lower
  than the national average but has increased since
  1997.

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Wisconsin Epidemiological Profile on Alcohol and
Other Drug Use, 2008

• Alcohol Consumption
• Wisconsin's rates of alcohol use and misuse are
  among the highest if not the highest in the
  nation. As of 2006, Wisconsin adults continue to
  have the highest rates of alcohol consumption,
  binge drinking and heavy drinking among all U.S.
  states and territories, and Wisconsin rates of
  underage drinking (ages 12-20) exceed national
  levels. As of 2007, Wisconsin high school
  students have a binge drinking rate that is the
  third highest of reported states, and the highest
  rate of current alcohol use.
• In good news, high school students in both
  Wisconsin and the nation are decreasingly likely
  to report they began alcohol use before age 13.
  Also, binge drinking among young adults (ages
  18-24) has declined in Wisconsin since 2000.

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Wisconsin Epidemiological Profile on Alcohol and
Other Drug Use, 2008

• Alcohol Consumption
• Data for the most recent decade consistently show
  that Wisconsin women of childbearing age are more
  likely to drink and to binge drink than their
  national counterparts. This has important
  implications for unplanned pregnancy and infant
  health.

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Wisconsin Epidemiological Profile on Alcohol and
Other Drug Use, 2008

• Other Drug Consumption
• The use of drugs other than alcohol also remains
  a problem in Wisconsin. As a whole, consumption
  patterns of illicit drugs in Wisconsin mirror
  national trends with few exceptions.
• One notable trend was in the use of marijuana. In
  1997, the prevalence of both lifetime and current
  use of marijuana was lower than the national
  average. Over the next four years, however,
  these measures rose until they were nearly
  identical to the national averages.
• Since 2001, both lifetime and current use of
  marijuana in the United States and Wisconsin have
  decreased at similar rates. Both nationally and
  in Wisconsin, the misuse of prescription drugs
  for non-medical purposes has emerged as a
  problem, especially among young adults.

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Wisconsin Epidemiological Profile on Alcohol and
Other Drug Use, 2008

• Conclusion
• Areas of need are clearly identified in this
  report. Wisconsin data for 2006 reflect a higher
  prevalence of alcohol use and binge drinking in
  adults, especially young adults, compared to the
  country as a whole. Underage drinking and
  underage binge drinking also occur at higher
  rates in Wisconsin, as does drinking among women
  of childbearing age. Concerning illicit drug
  use, Wisconsin rates of death and hospitalization
  from drug use have been increasing. From 1996 to
  2006, Wisconsin's arrest rate for liquor law
  violations was more than three times the national
  rate arrests for operating while intoxicated
  also occur at a higher rate in Wisconsin.
• The economic and health costs of substance abuse
  in Wisconsin are great, as are the related costs
  to the community of arrests and criminal
  offenses. Focus on these key areas will be
  useful in guiding the states funding decisions
  regarding which problems to address and which
  interventions to use.

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Wisconsin Epidemiological Profile on Alcohol and
Other Drug Use, 2008

• Consequences of Alcohol Consumption
• In Wisconsin in 2006, at least 1,678 people died,
  5,654 were injured, and 88,000 were arrested as a
  direct result of alcohol use and misuse. Given
  Wisconsins high rate of alcohol consumption, it
  is not surprising that the consequences
  associated with alcohol use also tend to be
  higher than the national average. Rates of
  alcohol dependence, alcohol abuse, and
  alcohol-related motor vehicle fatalities are
  higher in Wisconsin than in the United States.
• Wisconsin has one-and-a-half times the national
  rate of arrests for operating a motor vehicle
  while intoxicated and more than three times the
  national rate of arrests for other liquor law
  violations. Wisconsin has generally experienced
  a lower rate of alcohol-related liver cirrhosis
  than the national average, although this may be
  changing.

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WI EPI Study 2008

• Motor Vehicle Injuries and Fatalities
• Many motor vehicle injuries and fatalities are a
  direct consequence of alcohol use and abuse.
• In 2006, 364 people in Wisconsin died in
  alcohol-related motor vehicle crashes
  according to the national Fatality Analysis
  Reporting System. Approximately 51 of all
  Wisconsin motor vehicle fatalities in 2006 were
  alcohol-related (Figure 3).
• Wisconsins mortality rate from alcohol-related
  motor vehicle crashes has been higher than
  the United States rate since 2000 (Figure 4, page
  15). In 2006, the alcohol-related motor
  vehicle mortality rate was 6.6 per 100,000
  population in Wisconsin and 5.9 per 100,000
  in the United States.
• Between 1997 and 2006, the total number of
  nonfatal alcohol-related motor vehicle injuries
  in Wisconsin dropped 17, from 6,797 to 5,654.
  The rate of nonfatal injuries in alcohol-related
  crashes has also fallen during this period, to a
  low in 2006 of 102 injuries per 100,000
  population (Figure 5, page 15).

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WI EPI Profile 2008

• Non-Medical Use of Prescription Drugs
• Findings from a recent survey report indicated
  that lifetime non-medical use of prescription
  stimulants among college students in the United
  States was approximately 7, and past-year use
  was an estimated 4. The study also found that
  non-medical prescription drug use was associated
  with use of alcohol, cigarettes, marijuana and
  other illicit drugs.
• During 2005-2006, 5 of Wisconsin residents ages
  12 and older reported using pain relievers for
  non-medicinal purposes (Figure 45). This
  percentage has not changed since 2003-2004, and
  is the same prevalence reported nationally. The
  prevalence of use was highest among young adults
  ages 18 to 25 (12, Figure 38).

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WI EPI Profile 2008

• Non-Medical Use of Prescription Drugs
• Other than marijuana, pain relievers and
  psychotropics were the most commonly reported
  drugs consumed for non-medical reasons. During
  2002-2004, 18 of Wisconsin residents age 12 and
  older reported non-medical use of psychotropics
  and 12 reported non-medical use of pain
  relievers at some point in their lifetime (Table
  27, page 64). During the same time period, 6
  reported using psychotropics and 4 reported
  using pain relievers for non- medical reasons
  in the past year(Table 27).
• In 2007, the Youth Risk Behavior Survey found
  that 23 of Wisconsin high school students had
  used prescription pain relievers for non-medical
  purposes at some point in their lives, and 16
  had used other prescription drugs non-medically
  at some point (data not shown). No comparable
  data for earlier years or the United States were
  available.

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WI EPI Study 2008

• Alcohol Use by Women of Childbearing Age
• Alcohol use can impair decision-making and result
  in risk-taking behaviors, including sexual
  behaviors an unplanned pregnancy may be one
  result. Studies also have shown that alcohol use
  during pregnancy can harm the developing fetus.
  The Centers for Disease Control and Prevention
  (CDC) has reported that Wisconsin is among the
  states that report the highest rates of drinking
  among pregnant women and high-risk drinking among
  women of childbearing age.
• Wisconsin women of childbearing age are more
  likely to drink than women nationally (Figure
  35). In 2006, 66 of Wisconsin women ages 18-44
  said they had at least one alcoholic drink in the
  past 30 days this compares with 54 of women in
  the United States.
• Binge drinking is also more prevalent among
  Wisconsin women of childbearing age, compared
  with their national counterparts. In 2006, among
  women ages 18-44, 24 in Wisconsin and 16
  nationally said they had consumed four or more
  drinks on one occasion in the past 30 days
  (Figure 36).

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WI EPI Profile 2008

• Other Alcohol-Related Mortality
• Alcohol use contributes to many different causes
  of death in varying degrees. For example, it
  contributes to 100 of alcohol-related liver
  cirrhosis deaths, but a smaller percentage of
  deaths from stroke. Alcohol-Related Disease
  Impact (ARDI) software from the Centers for
  Disease Control and Prevention identifies
  fractional alcohol-related mortality for a total
  of 63 chronic and acute conditions.
• For each of these 63 conditions, ARDI specifies a
  distinct fraction of cases attributable to
  alcohol. The number of alcohol-attributable
  deaths can be estimated by multiplying the
  number of deaths for each condition by the
  specified alcohol-attributable fraction and
  summing over conditions. This method was used to
  estimate the total number of alcohol- related
  deaths in Wisconsin, as well as the subset of
  other alcohol-related deaths (other than those
  from alcoholic liver cirrhosis and motor vehicle
  crashes).

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WI EPI Profile 2008

• Other Alcohol-Related Mortality
• Alcohol-related causes other than alcoholic liver
  cirrhosis and motor vehicle crashes accounted for
  an estimated 1,075 deaths in Wisconsin in 2006
  (see Figure 1, page 11). The most frequent
  causes of other alcohol-related deaths are
  mental and behavioral disorders due to alcohol,
  alcohol dependence syndrome, unspecified liver
  cirrhosis, homicide, non-alcohol poisoning, and
  suicide.
• The Wisconsin mortality rate from other
  alcohol-related causes increased from 16.0 deaths
  per 100,000 in 1999 to 19.3 deaths per 100,000 in
  2006.
• Based on combined data for 1999-2006 at the
  county level (Table 4, next page), the mortality
  rate from other alcohol-related causes ranged
  between 8.7 per 100,000 in Calumet County to 29.2
  per 100,000 in Marquette and Milwaukee counties.

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Addiction is only one of the Substance-Related
Disorders

• Addiction (Substance Dependence)
• Problem Use (Substance Abuse)
• Intoxication States
• Withdrawal States
• Substance-Induced Medical Problems
• Substance-Induced Psychiatric Problems
• Health Problems linked to Secondary Use
• Codependency and ACOA Syndromes

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Levels and Patterns of Drinking

• Heavy drinking
• For women, more than 1 drink per day on average.
• For men, more than 2 drinks per day on average.
• Binge drinking
• For women, more than 3 drinks during a single
  occasion or 7 drinks in one week
• For men, more than 4 drinks during a single
  occasion or 14 drinks in one week
• Excessive drinking includes both binge drinking
  and heavy drinking.
• (Source- NIAAA)

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Mortality

• Illicit Drugs - 25,000/year USA
• Alcohol - 100,000/year USA
• Tobacco - 450,000/year USA

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Actual Causes of Death,1 United States - 2000
Actual Cause No () in 2000

Tobacco 435,000 (18.1)
Poor diet and physical inactivity 365,000 (15.2)
Alcohol Consumption 85,000 (3.5)
Microbial agents 75,000 (3.1)
Toxic agents 55,000 (2.3)
Motor vehicle 43,000 (1.)
Firearms 29,000 (1.2)
Sexual behavior 20,000 (0.8)
Illicit drug use 17,000 (0.7)
1Actual causes of death are the major external (nongenetic) modifiable factors that contribute to death in the United States 1Actual causes of death are the major external (nongenetic) modifiable factors that contribute to death in the United States
Mokdad AH, Marks JS, Stroup DF, Gerberding JL.
JAMA (2004). 291238-45 Mokdad AH, Marks JS,
Stroup DF, Gerberding JL. (2005). JAMA
19293293-4.
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Assessing Quantity Backwards

• 6 pack -- 12 pack -- 18 pack -- 24 pack
• 1/2 pt -- pint ---1/5 gal (27 oz or 18 drinks)
• 4/5 quart of wine -- 1/2 gal of wine
• 1.75 liters 57 oz ( 12 drinks of wine, 38
  drinks of 80-proof, 48 drinks of 100-proof)
• HOW MANY DO YOU BUY PER WEEK?

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Alcohol Intoxication
Blood Alcohol Level Clinical Picture
20-100mg percent Mood and behavior changes
Reduced Coordination
Impaired ability to drive a car
101-200mg percent Reduced coordination
Speech Impairment
Trouble walking
General impairment in thinking and judgment
201-300mg percent Marked impairment of thinking, memory, and coordination
Marked reduction in level of alertness
Memory blackouts
Nausea, vomiting, blackouts
5 TIP45 Training Curriculum Module 1-5
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Alcohol Withdrawal

• Restlessness, irritability, anxiety and agitation
• Anorexia, nausea, and vomiting
• Tremors, elevated heart rate, and increased blood
  pressure
• Insomnia, intense dreaming, and nightmares
• Poor concentration, impaired memory, and judgment
• Increased sensitivity to sound, light, and
  tactile sensations
• Hallucinationsauditory, visual, or tactile
• Delusions
• Grand mal seizures
• Hyperthermia
• Delirium
• TIP45 Training Curriculum
  7
• 
  Module 17

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Intoxication and Withdrawal from Heroin and Other
Opioids

• Fast Facts
• Opioids are highly addicting.
• Chronic use of opioids leads to withdrawal
  symptoms that, although not medically dangerous,
  can be highly unpleasant and produce intense
  discomfort.

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Opioid Intoxication

• Opioid Intoxication Signs
• Slow pulse
• Low blood pressure
• Low body temp
• Sedation
• Pinpoint pupils
• Slowed movement
• Slurred speech
• Head nodding

• Opioid Intoxication Symptoms
• Euphoria
• Imperviousness to pain
• Calmness

TIP45 Training Curriculum
8

Module 18
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Intoxication and Withdrawal from Heroin and Other
Opioids

• Opioid Withdrawal Signs Symptoms
• Fast Pulse, Abdominal cramps, High body
  temperature, Vomiting, Enlarged pupils, Nausea,
  Sweating, Diarrhea, Increased respiratory rate,
  Anxiety, Yawning, Bone and muscle pain, High
  blood pressure, Insomnia, Abnormally heightened
  reflexes, Gooseflesh, Tearing (as in crying),
  Runny nose

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Intoxication and Withdrawal from Heroin and Other
Opioids

• Management of Withdrawal from Heroin and Other
  Opioids
• It is not recommended that clinicians attempt to
  manage significant opioid withdrawal symptoms
  without effective detoxification agents.
• The management of opioid withdrawal with
  medication is most commonly achieved through the
  use of methadone.
• The initial dose requirements for methadone are
  determined by estimating the amount of opioid use
  and gauging the patients response to
  administered methadone.
• Methadone can be given once daily and generally
  tapered over 3 to 5 days in 5 to 10mg daily
  reductions.
• Clonidine can also be used to treat opioid
  withdrawal, but it is usually ineffective for
  common symptoms such as insomnia, muscle aches,
  and drug craving.

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Intoxication and Withdrawal from Cannabis
(Marijuana)

• Fast Facts
• Marijuana and hashish are the two substances
  containing THC (delta-9-tetrahydrocannabinol)
  commonly used today.
• The THC abstinence syndrome usually starts within
  24 hours of cessation. The amount of THC that one
  needs to ingest in order to experience withdrawal
  is unknown. It can be assumed, however, that
  heavier consumption is more likely to be
  associated with withdrawal symptoms.
• Symptoms of Cannabis Intoxication
• Impaired short term memory
• Impaired attention, judgment, and other cognitive
  functions
• Impaired coordination and balance
• Increased heart rate

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Intoxication and Withdrawal from Cannabis
(Marijuana)

• Cannabis Withdrawal Symptoms
• Anxiety
• Restlessness
• Irritability
• Sleep disturbance
• Change in appetite
• Tremor
• Sweating
• Elevated heart rate
• Nausea, vomiting, diarrhea
• Management of Withdrawal From Cannabis
• There are no medical complications of withdrawal
  from THC, and medication is generally not
  required to manage withdrawal.
• Screening the patient for suicidal ideation or
  other mental health problems is warranted.
• The patient should be encouraged to maintain
  abstinence from THC as well as other addictive
  substances.

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Intoxication and Withdrawal From Other Drugs An
Overview

• Nicotine
• Two issues regarding tobacco smoking merit
  consideration by staff of substance abuse
  detoxification programs. The first is the program
  managements desire to establish a smoke-free
  treatment environment to comply with workplace
  ordinances and to safeguard the health and
  comfort of patients from exposure to second hand
  smoke. The second issue is the patients
  dependence on nicotine as a drug of abuse.
• Drugs That Do Not Produce a Withdrawal Syndrome
• Chronic use of PCP can cause toxic psychosis that
  takes days or weeks to clear however, PCP does
  not have a withdrawal system. LSD and ecstasy do
  not produce physical dependence.

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Intoxication and Withdrawal From Other Drugs An
Overview

• Polydrug Use
• People who abuse substances rarely use just one
  substance. Typical combinations and preferred
  modes of treatment are as follows
• Alcohol and stimulant Treat alcohol abuse.
• Cocaine and opiate Treat opiate dependence
• Cocaine and amphetamine No detoxification
  protocol is known.

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Assessment

• Quantity / Frequency Questions
• Standard Drink
• 0.6 oz of 100 ethanol 13 gm.
• 12 oz of 5 beer
• 5 oz of 12 wine
• 1.5 oz of 80-proof liquor

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Assessment for detox

• Considerations
• History of previous delirium tremens or
  withdrawal seizures
• No Capacity for informed consent
• Suicidal/homicidal/psychotic condition
• Able/willing to follow tx recommendations
• Co-occurring medical conditions
• Supportive person

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TIDBITS

• Ask if any other herbals or substances taken
• Bring any medications to hospital or assessment
  appt.
• List of providers prescribing medications
• Who is supportive contact
• Evaluate-Stabilize- Readiness-Referral

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Options to access services

• EAP contact
• Primary MD
• Call on medical insurance card
• Call National Tx Directory for service provider
  in your area- 1-800-662-HELP
• Yellow pages for providers of MH and SA in your
  area
• Substance Abuse Counseling services for your
  county

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CAGE Questions

• CCut Down (Have you ever felt you ought to Cut
  Down on your drinking or--did you ever try to
  reduce your drinking but found you were unable to
  do so?)
• AAnnoyed (Have people Annoyed you by criticizing
  your drinking?)
• GGuilty (Have you ever felt bad or Guilty about
  your drinking?)
• EEye-Opener (Have you ever had a drink the first
  thing in the morning to steady your nerves or get
  rid of a hangover?)

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Other screens available

• DAST- Drug Abuse Screening Test
• MAST-Michigan Alcohol Screening Test
• AUDIT-Alcohol Use Disorders Identification
  Test-WHO
• GAIN Short Screen-www.chestnut.org
• Many are available on-line to self-administer

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Tips for addressing a concern

• Be respective and non-reactive
• Open ended questions
• Remember cognitive thinking distortions are a
  part of Addiction
• Keep in mind-most people are aware of the
  probable problem
• Addiction is a brain disease like any other
  chronic progress disease
• Change is a process
• Never underestimate the effect you can have by
  just asking about possible SA/Addiction
• Need to hit bottom a myth-Not True!
• Do not glamorize binge, heavy, or excessive
  drinking
• Alcohol any type or drugs any type-it does not
  matter any can be a problem
• Be aware of your own biases and patterns of use

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Prochaska and DiClementes Stages of Change Model

• The stages of change are
• Precontemplation (Not yet acknowledging that
  there is a problem behavior that needs to be
  changed)
• Contemplation  (Acknowledging that there is a
  problem but not yet ready or sure of  wanting to
  make a change)
• Preparation/Determination (Getting ready to
  change)
• Action (Changing behavior)
• Maintenance (Maintaining the behavior change) and
  
• Relapse (Returning to older behaviors and
  abandoning the new changes)

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Where to learn more

• Numerous resources- internet helpful
• Websites by Federal agencies handout
• www.nattc.org
• www.hbo.com/addiction
• www.cdc.gov
• www.who.org
• www.jointogether.org

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Additional resources

• Ordering Information
• TIP 45
• Detoxification and Substance Abuse Treatment
• Three Ways to Obtain FREE Copies of All TIPs
  Products
• Call SAMHSAs National Clearinghouse for Alcohol
  and Drug Information (NCADI) at 800-729-6686, TDD
  (hearing impaired) 800-487-4889.
• Visit NCADIs Web site at www.ncadi.samhsa.gov.
• You can also access TIPs online at
  www.kap.samhsa.gov.

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Contact Information

• Lorie Goser
• Email lorie.pcpa_at_centurytel.net
• Email lagoeser_at_btsmailbox.com
• Phone [phone]-clinic
• Phone [phone]-work cell
• Poynette Counseling Psychotherapy Associates
  Inc.
• 415 N. Main Street Suite 3, Poynette, WI 53948
• Locations- Baraboo, Mauston, Monona, Poynette