1. Prescription Drug Abuse: Loosening the Knot
J. Patrick Slifka, LCSW & George Young, LCSW

2. Why We’re Here

3. Dealer out of Business?

4. Which is More Dangerous?

5. “Just The Facts” All of these drugs are available – right now.
They do what they’re “advertised to do.”
If your individuals (particularly your adolescent ones) have not been already, they will soon be in a position to make a choice…to use or not to use. Their choice will carry both a benefit and a consequence.

6. “Just The Facts”
Drugs are not inherently evil, bad, or good – they’re simply chemicals.
The Relationship a person forms with a drug becomes the problem – and the problem gets progressively and significantly worse over time.
Remember that not all individuals have the same responses to the same drug or class of drugs. There are idiosyncratic reactions we have to assess and understand.

7. Why We’re Here? Epidemic? Problem?
Attitude is the father of the Action
Ethical Obligation and Competent Practice

8. Jeopardy Time

9. Jeopardy Question #1
The Answer is: Patients leave a doctor’s office with this on 7 out of every 10 visits. What is a Prescription?

10. Jeopardy Question #2
The Answer is: Medicine Cabinets Where do a large number of teens who abuse prescription medications get their drugs?

11. Jeopardy Question #3
The Answer is: Dr. Gregory House and American High School Seniors identify this prescription drug as their favorite. What is Vicodin?

12. Trends and Statistics
The Landscape

13. A View of the Landscape

15. Rates of Rx drug sales, deaths and substance abuse tx admissions

21. 1 in 6 Teenagers

23. Most Commonly Abused Medications Among U. S
Most Commonly Abused Medications Among U.S. High School Seniors (2010 Annual Prevalence)
Source: Monitoring the Future, University of Michigan, December 14, 2010

26. What is Driving the Prevalence?
Misperceptions about safety.
Increasing environmental availability
Varied motivations for their abuse.

27. Other Factors Driving Trend: Pill-Taking Society
Rx medications are all around us…and teens notice.
Patients leave the doctor’s office with a prescription in hand in 7 out of 10 visits.
Direct-to-consumer advertising on TV and in magazines.
Many people don’t know how to safely use these medications or ignore their doctor’s instructions.
Prescription drugs are often a mainstay of treatment for various illnesses including migraine, infections, heart disease, diabetes, depression, arthritis, cancer and many others. TV and print media are also filled with ads for these medications. So teens may come to believe there is a pill for everything. In general, Americans aren’t well informed when it comes to medication safety. Most of us need to be better educated about how to safely use, store and get rid of these medications. We’ll talk about this more later.

28. Common Prescription Drugs of Abuse
Signs, Symptoms and Biopsychosocial Consequences

29. Top 10 Most Dangerous Drugs in America (DAWN database of ER visits)
Xanax
Oxycontin
Vicodin
Methadone
Klonopin
Ativan
Morphine Drugs (opiates)
Seroquel (Antipsychotic)
Ambien
Valium

30. Most Commonly Abused Classes of Prescription Drugs
Opioid Pain Relievers (Opiates, Narcotics)
CNS Stimulants (primarily those used in the tx of ADHD)
CNS Depressants (Sedatives, Hypnotics, Anxiolytics)

31. Key Assessment Point: Effects of Drugs Depend on…
Route of administration
Amount taken at one time
User’s past drug experience
Circumstances under which the drug is taken (the place, the user’s psychological and emotional stability, the presence of other people, simultaneous use of alcohol and other drugs, etc.)

32. Commonly Abused Rx Drugs
How they work
Abused to
Drug names
Strong Pain Relievers
Used to relieve moderate-to-severe pain, these medications block pain signals to the brain
To get high, increase feelings of well being by affecting the brain regions that mediate pleasure
Vicodin, OxyContin,
Percocet, Lorcet, Lortab, Actiq, Darvon, Codeine, Morphine,
Methadone
Stimulants
Primarily used to treat ADHD type symptoms, these speed up brain activity causing increased alertness, attention, and energy that comes with elevated blood pressure, increased heart rate and breathing
Feel alert, focused and full of energy—perhaps around final exams or to manage coursework, lose weight
Adderall, Dexedrine
Ritalin, Concerta
Sedatives or tranquilizers
Used to slow down or “depress” the functions of the brain and central nervous system
Feel calm, reduce stress, sleep
Valium, Xanax, Ativan,
Klonopin, Restoril, Ambien, Lunesta, Mebaral, Nembutal, Soma
Drugs commonly used by teens include:
Strong pain medications that are prescribed to treat moderate-to-severe pain. Teens often go in search of these to get high or feel pleasure. Some street names include: Captain Cody, China Girl, vikes, hillbilly heroin, oxy 80s, OCs, percs, demmies.
Stimulants, or uppers, speed up brain activity, resulting in greater alertness, attention, and energy. Teens turn to these to feel alert and be able to pull all-nighters to stay on top of coursework. Stimulants can make the heart beat faster and put the user at risk for stroke or heart attack. Some popular street names are uppers, vitamin R, Skippy.
Sedatives, or downers, slow down brain activity. The result is a drowsy or calming effect. Other sedatives include tranquilizers and muscle relaxants. Sedatives can reduce heart rate and the body’s response to breathing. Some of street names are candy, downers, tranks, barbs.
Teens also abuse cough medicines and other over-the-counter medicines. They may take any of these with alcohol or other substances.

33. Opioid Pain Relievers (Opiates/Narcotics)

34. What are Opiates?
Opiates are a group of drugs that are used for treating pain. They are derived from opium which comes from the poppy plant.
Opiates go by a variety of names including opiates, opioids, and narcotics. The term opiates is sometimes used for close relatives of opium such as codeine, morphine and heroin, while the term opioids is used for the entire class of drugs including synthetic opiates such as Oxycontin. But the most commonly used term is opiates.

35. Dried Opium Poppy

36. Commonly Used & Abused Opiates
Opium
Codeine …anybody you’re working with taking any of these?
Morphine
Tramadol (Ultram)
Methadone
Buprenorphine (Subutex)
Propoxyphene (Darvocet)
Pethidine (Demerol)
Hydrocodone (Lortab/Vicodin)
Oxycodone (Percocet, Oxycontin)
Hydromorphone (Dilaudid)
Oxymorphone (Opana)
Fentanyl
Heroin (diacetylmorphine)

37. Most Rx’d Opiate in America

38. Oxycontin

39. Opiates
Opiates are highly effective in controlling moderate to severe pain, but they also have a downside. Opiates are highly addictive…and once a person starts abusing them he/she generally becomes dependent (addicted) to them.

40. Opiate Effects Feelings of Euphoria Lowered Body Temperature
Suppression of Pain
Depressed Respiratory Rate
Lowered Heart Rate and Blood Pressure
Lethargy/Drowsiness
Clouded Mental Functioning
Nausea/Vomiting
Lowered Body Temperature
Muscle and Bone Pain
Physical/Psychological Dependence
Severe Withdrawal Symptoms
Mood Swings
Severe Constipation
Unconsciousness
Coma
Death by Overdose

41. Opiates: Long Term Effects
Cause significant changes to the nerochemical, molecular and cellular levels.
Changes brain structure and functioning that lasts well beyond the substance use.
These changes are part of what can trigger drug cravings years after last use.

43. How Do Opiates Work?
Opiates elicit their powerful effects by activating opiate receptors that are widely distributed throughout the brain and body. Once an opiate reaches the brain, it quickly activates the opiate receptors that are found in many brain regions and produces an effect that correlates with the area of the brain involved.

44. How Do Opiates Work?
Two important effects produced by opiates, such as morphine, are pleasure (or reward) and pain relief. The brain itself also produces substances known as endorphins that activate the opiate receptors. Research indicates that endorphins are involved in many things, including respiration, nausea, vomiting, pain modulation, and hormonal regulation.

45. Opiate Agonists
Opiate agonists are drugs that stimulate the opioid receptors in the brain, leading to the high associated with opiate drugs. They include Heroin, Vicodin, Morphine, Codeine and Methadone.
They mimic the effects of naturally-occurring endorphins in the body, and produce an opiate effect by interacting with the opioid receptor sites.

46. Opiate Antagonists
Opiate antagonists block the brain’s opioid receptors, making it impossible for opiate drugs to stimulate them. For example, drugs like Naloxone and Naltrexone make it so that, if the user were to take a drug like heroin afterwards, there would be no high.
These medications are often used to combat the overdose effects of an opiate or to help break an addiction.

47. Partial Opiate Agonists
Partial opiate agonists are drugs that have a “ceiling effect.” In other words, they can only stimulate the opioid receptors to a certain extent. Buprenorphine, the main ingredient in Suboxone, is one of these. No matter how much Suboxone you take, its effects are limited.

48. Sedatives, Hypnotics, and Anxiolytics

49. Sedatives, Hypnotics and Anxiolytics
Drugs that reversibly depress the activity of the central nervous system. Barbiturates, Benzodiazepines, and other sedative-hypnotics have diverse chemical and pharmacological properties that share the ability to depress the activity of all excitable tissue, especially in the arousal center of the brainstem.
Barbiturates (Sedatives): Amytal, Nembutal, Seconal and Phenobarbital.
Benzodiazepines (Anti-Anxiety): Ativan, Halcion, Librium, Valium, Xanax, and Rohypnol.
Other Sedative-Hypnotics (Sleep Inducers): Lunesta, Sonata, Ambien.

50. Barbiturates
In therapeutic doses, barbiturates are effective and are typically used for seizure disorders and anesthesia. Using them to “get high” is extremely dangerous because there is a relatively small difference between the desired dose and an overdose. A small miscalculation, which is easy to make, can lead to coma, respiratory distress (breathing slows or stops) and death. Withdrawal from barbiturates is similar to, and sometimes more severe than, alcohol withdrawal. Seizures are possible and can also lead to death.

51. Common Barbiturates Amytal Nembutal Seconal Phenobarbital
Seconal 100mg
A barbiturate may be prescribed for a variety of reasons, the list is extensive, but the most common use today is as an anesthesia for surgery. This form is hardly ever abused because they cause almost immediate unconsciousness.
Other forms like Phenobarbital are used in treating various seizure disorders as an anticonvulsant. Other uses of this form of barbiturate along with mephobarbital include treating anxiety, insomnia, epilepsy and delirium tremens.

52. Benzodiazepines
The benzodiazepine family of depressants is used therapeutically to produce sedation, induce sleep, relieve anxiety and muscle spasms, and to prevent seizures. In general, benzodiazepines act as hypnotics in high doses, anxiolytics (anti-anxiety) in moderate doses, and sedatives in low doses.
Of the drugs marketed in the United States that affect central nervous system function, benzodiazepines are among the most widely prescribed medications.
Compared to barbiturates, benzodiazepines are much safer. They cause sedation but rarely stop a person’s breathing or lead to death (unless combined with other CNS depressants).

53. Common Benzodiazepines
Ativan
Halcion
Librium
Restoril
Valium
Xanax
Rohypnol (not marketed in U.S.)

54. Other Sedative-Hypnotics: Sleep Aids
This is a newer class of drugs that is used for the short-term treatment of insomnia. They cause the onset of sleep to occur faster and allows for a longer sleep period throughout the night.
These non-benzodiazepines have a short half-life and have less chance of causing dependency, tolerance, and impairment of daytime activities due to carry-over effects.
Again, combining any of these drugs or using them with alcohol (and other depressants) can lead to dangerous effects.

55. Common Sleep Aids/Hypnotics
Ambien/Ambien CR
Sonata
Rozerem
Precedex
Lunesta

56. CNS Stimulants

57. CNS Stimulants
CNS Stimulants are a class of drugs that elevate mood, increase feelings of well-being and increase energy and alertness. Examples include:
Caffeine
*Amphetamines
Cocaine
Methamphetamine
“Bath Salts”

58. Amphetamines
Synthetic psychoactive CNS stimulant drugs including amphetamine, dextroamphetamine and methamphetamine
Medications containing amphetamines are prescribed for narcolepsy, obesity and ADHD (including Adderall, Dexedrine, DextroStat, and Desoxyn).
The basic molecule of amphetamine can be modified to emphasize specific actions (e.g., appetite suppressant, CNS stimulant, cardiovascular actions) for certain medications…including methylphenidate (Ritalin and Concerta).

59. Dexedrine

60. Ritalin

61. Adderall

62. Adderall: The “Study Pill”

63. Amphetamines
Cause release of the neurotransmitters dopamine and norepinephrine – and their reuptake is inhibited.
This influx causes the buildup of NTs at synapses in the brain.
When mixed with other drugs (including alcohol), the effects of prescription amphetamines are enhanced. When the drug is snorted, effects occur within 3-5 minutes. When ingested orally, effects occur within 15 to 20 minutes.

64. Amphetamines: Short-Term Effects
Increased activity/talkativeness
Decreased fatigue/drowsiness
Heightened sense of well-being
Heightened alertness/energy
Euphoria
Release of social inhibitions
Altered sexual behavior
Unrealistic feelings of cleverness, great competence, and power
Hostility or paranoia
Increased body temperature
Irregular or increased heart rate
Increased diastolic/systolic BP
Decreased appetite
Dry mouth
Dilated pupils
Increased respiration
Nausea
Headache
Palpitations
Cardiovascular system failure
Twitching/Tremor of small muscles

65. Amphetamines: Long-Term Effects
Toxic psychosis
Physiological and behavioral disorders
Dizziness
Pounding heartbeat
Difficulty breathing
Mood/Mental changes
Unusual tiredness/weakness
Cardiac arrhythmias
Repetitive motor activity
Ulcers
Malnutrition
Mental Illness
Skin disorders
Vitamin deficiency
Flush or pale skin
Loss of coordination and physical collapse
Convulsions, coma and death.

66. Amphetamines: Potential for Abuse
Rx amphetamines are taken orally and in low doses, drug abuse and addiction are not serious risks.
Abuse of amphetamines can lead to tolerance and physical/psychological dependence characterized by consuming increasingly higher dosages and by the “binge and crash” cycle.
When the binge episode ends, the abuser “crashes” and is left with severe depression, anxiety, extreme fatigue, and a craving for more drugs.
The chronic abuse of amphetamines is characterized by erratic (sometimes violent) behavior – as well as a psychosis similar to schizophrenia.

67. Screening and Evaluation

68. Screening & Assessment: 3 Primary Goals
1. To Obtain Information/Collect a Database 2. To Determine Eligibility for a Particular Service 3. To Engage the Individual/Family in the Treatment Process

69. The Clinical Assessment Interview: Basic Elements
Only One part of a multimodal evaluation
Formally arranged meeting
Has specific purpose
Interviewer chooses topic/broad content
Defined relationships
Interviewer attuned to ALL aspects of interaction - Affect, Behavior, Style (Process) and Content
Questioning techniques/strategies employed to direct the flow of conversation
Acceptance of client's expressions of feelings and factual information without casting judgment
Interviewer makes explicit what otherwise be left unstated
Assessor follows guidelines for confidentiality and disclosure of info.

70. What a Clinical Assessment Interview is NOT...
Ordinary Conversation
"Counseling" Session
Forensic Interview
Survey Interview

71. The Assessment Interview: Assumptions
1. Need for Multiple Data Sources: There is no gold standard for assessing people's functioning. The key to good assessment is to find the conceptual links and relationships between methods and modalities of the assessment. Each form of indirect and direct methods contributes unique elements to solving the puzzle (Wheel of Fortune).

72. Assumptions (Cont.)
2. Situational Variability: Individuals' behaviors are likely to vary across situations and relationships. Good assessment requires identifying patterns of behavior that DIFFER across situations and relationships as well as patterns that REMAIN CONSISTENT, despite variations in situations and relationships.

73. Assumptions (Cont.)
3. Limited Cross-Informant Agreement: There is likely to be only low-to-moderate agreement between informants who are in different situations or in different relationships with the same person (esp. children). Low agreement does not mean that one is right and one is wrong or that one has a "truer" picture. The challenge is to put all these pieces together to form a meaningful picture of the person's functioning under the given circumstances.

74. Assumptions (Cont.)
4. Variations in Interview Structure and Content: The structure and content of clinical interviews should vary in relation to the informant and the goals of the interview. Structured, semi-structured, direct observation, indirect data collection, age/role appropriateness, etc. Clinical interviews need to be tailored to particular informants. The content and questioning strategies are shaped by the kind of informant interviewed and the kind of information sought.

75. Interview Content and Questioning Strategies
1. Semi-Structured: Questions used to query client (and others) about many aspects of functioning. Format is relatively open-ended and flexible to stimulate a natural flow of conversation. MI strategies are used (empathy, reflective listening, summarizing). Probe questions can then be used to obtain more detailed information. 2. Structured: Appropriate for querying individuals/family members about symptoms and criteria for psychiatric disorders. Structured diagnostic interviews have a standardized set of questions and probes focusing on specific problems relevant to diagnoses.

76. Interview Content and Questioning Strategies (Cont.)
3. Behavior-Specific: Questions can be used to query family members parents, teachers, PO's, etc. regarding their current concerns about the individual. More narrow in scope than semi-structured because the focus is on a limited number of specific problem areas. Typically, the main purposes are: a) identify and define problems of concern of others (problem identification) b) examine antecedents and consequences that surround the identified problems (problem analysis) Assessors can also use behavior-specific questions to elicit from individuals their views of particular problems and their understanding of the consequences around the problems.

77. Interview Content and Questioning Strategies (Cont.)
4. Problem-Solving: Focus on others' current concerns with the goal of developing interventions for identified problems. In initial clinical interviews, assessors can use problem-solving questions to explore and gauge others' receptivity to different kinds of interventions prior to implementing any interventions. Can also use problem-solving questions to explore individual’s views of different interventions and to find out which approaches are acceptable to them.

78. Preparation: Master Your Material
Preparation and Mastery increase your confidence and competence. Your goals include...
Understanding and applying all aforementioned material
Learning and knowing intimately all sections (and the purpose for each) of the assessment forms
Mastering the art of Motivational Interviewing
Reading, Studying, Understanding DSM-IV/DSM-5 diagnostic criteria - and applying structured interviewing strategies to rule out and rule in dx
Knowing what you don't know - and learning it

79. Preparation and Mastery: Conceptualizing Your Case
Guided by: Observing, Questioning, Thinking
(repeat ad nauseum)
Study your prelim. Info (Screening Form, etc.) and apply the above...
Begin your studies/research
Generate Questions
Formulate Hypotheses (not conclusions)
Prepare, Prepare, Prepare...

81. Key Terms
Tolerance: (a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect. (b) markedly diminished effect with continued use of the same amount of the substance (DSM-IV TR). Potentiation: Potentiation occurs when two drugs are taken together and one of them intensifies the action of the other. This could be expressed by a +b= B. As an example, - an antihistamine, when given with a painkilling narcotic such as Percocet ,intensifies its effect thereby cutting down on the amount of the narcotic needed.

82. Key Terms
Cross Tolerance and Cross Dependence: Cross tolerance refers to the fact that if a person has developed a tolerance to a drug in a certain classification, such as the depressants, that person is more likely to develop tolerance with another drug in that classification. As an example, people who are dependent upon alcohol show an increased tolerance to barbiturates, synthetic and natural opiate narcotics, and anesthetics. This, of course, means that the person must have a higher dose of the new drug for it to be effective. In cross dependence, the withdrawal symptoms from one drug in a classification can be relieved by another. As an example, many alcoholics are given barbiturates and tranquilizers to prevent withdrawal symptoms. However, the person may soon develop a dependency on the other drug as well.

83. Key Terms
Synergism: Synergism is similar to potentiation. If two drugs are taken together that are similar in action, such as barbiturates and alcohol, which are both depressants, an effect exaggerated out of proportion to that of each drug taken separately at the given dose may occur. This could be expressed by 1+1= 5. An example might be a person taking a dose of alcohol and a dose of a barbiturate. Normally, taken alone, neither substance would cause serious harm, but if taken together, the combination could cause coma or death.

84. Key Terms
Withdrawal:
Withdrawal is a term referring to the feelings of discomfort, distress, and intense craving for a substance that occur when use of the substance is stopped. These physical symptoms occur because the body had become metabolically adapted to the substance. The withdrawal symptoms can range from mild discomfort resembling the flu to severe withdrawal that can actually be life threatening.
Withdrawal from particular substances can be extremely serious and dangerous (potentially life-threatening). Refer to the DSM-IV TR and or DSM-5 for drug-specific withdrawal profiles.

85. Interventions/Best Practices

86. Treatment: Key Components
Established Clinical Model that is evidence-based
Individualized assessment and person-centered treatment planning
Full array of integrated services (MH and SA, etc.)
Individual, Family and Group Therapies
Psychoeducation
Motivational Interviewing/Motivational Enhancement (strengths-based)
Cognitive-Behavioral Interventions
Relapse and Recovery Planning
Connection and Collaboration with Community Resource and Associated Professionals (wrap-around)
Frequent/randomized drug/alcohol screening
Accountability

89. Critical Component of any treatment program
Drug Testing
Critical Component of any treatment program
Urine lab testing
Urine instant
Oral
Hair

90. Pay Attention! What to “watch” for when conducting drug screens
All testing needs to be Observed whenever possible.
Dilution – water loading/adding water to samples
Flushing – ingesting Niacin or Golden Seal (or any of hundreds of other products on the market)
Substituting – synthetic urine or borrowing/storing urine
Mechanical Devices – the “Wizinator,” small bottles or tubes

91. Screening: Other things to Know
Know where your individuals can get tested (and what kind of testing they conduct)
Know what medications your individuals are taking
Connect with a therapist or doctor that conducts drug screens, or make sure you call the lab toxicologist for specific information
You do not have to be the expert on all information, but know where to get the information and be willing to puruse it!

92. Principles of Effective Treatment (National Institute of Drug Abuse, 2012)
Addiction is a complex but treatable disease that affects brain function and behavior.
No single treatment is appropriate for everyone.
Treatment needs to be readily available
Effective treatment attends to multiple needs of the individual, not just his or her substance abuse.

93. Principles of Effective Treatment (cont.)
Remaining in treatment for an adequate period of time is critical.
Behavioral therapies – including individual, family, or group counseling – are the most commonly used forms of drug abuse treatment.
Medications are important element of treatment for many individuals, especially when combined with counseling and other behavioral therapies.

94. Principles of Effective Treatment (Cont.)
An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that is meets his or her changing needs.
Many drug-addicted individuals also have other mental disorders.
Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse

95. Principles of Effective Treatment (Cont.)
Treatment does not need to be voluntary to be effective.
Drug use during treatment needs to be monitored continuously, as lapses during treatment do occur.
Treatment programs should test individuals for the presence of HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases as well as provide targeted risk reduction counseling, linking individuals to treatment if necessary.

96. ASAM Criteria: Case Conceptualization
Wherever the treatment location or circumstances, some guidelines have suggested criteria to consider when treating substance dependence. The following criteria were developed by the American Society of Addiction Medicine (ASAM) to consider in the treatment of dependence:
1. acute intoxication and/or withdrawal potential
2. biomedical conditions and complications
3. emotional, behavioral, or cognitive conditions and complications
4. readiness to change
5. relapse, continued use, or continued problem potential
6. recovery/living environment

97. ASAM Levels of Treatment
Level 0.5 = Early Intervention Services
Level 1 = Outpatient Treatment Services(3 hours a week or less)
Level 2 = Intensive Outpatient/Partial Hospitalization (9
hours per week at least)
Level 3 = Residential/Inpatient Services (24 Hours/Day)
Level 4 = Medically Managed Intensive Inpatient Services
Reference:

98. Opiate Withdrawal and Detoxification

99. Opiate/Narcotic Withdrawal
Opiate addicts avoid treatment because they are afraid of withdrawal, which can be rather unpleasant but rarely fatal. They crave the drug and experience muscle and bone pain, insomnia, restlessness, nausea and vomiting, sweating, involuntary muscle twitches, dry mouth.
Opiate withdrawal will usually peak between hours after the last use. But withdrawal can last much longer, depending on the individual.

100. Detoxification and “Maintenance”
Medications have been developed to lessen the impact of the withdrawal and help addicts rid themselves of the need to use. Principal among these are Methadone and Suboxone, both synthetic opiates themselves, but both act to block the impact of the opiates.

101. Maintenance Therapy
Maintenance therapy with drugs like methadone or Suboxone is helpful because it takes away the severe effects of a heroin or prescription painkiller habit while easing the symptoms of withdrawal.

102. APA Guidelines for Opiate Dependence
The American Psychiatric Association (APA) guideline identified the following 3 treatment modalities to be effective strategies for managing opioid dependence and withdrawal:
1. opioid substitution with methadone or buprenorphine, followed by a gradual taper
2. abrupt opioid discontinuation with the use of clonidine to suppress withdrawal symptoms
3. clonidine-naltrexone detoxification

103. Considering Your Options in Dealing with an Opiate Dependent Individual
Acute opioid-related disorders that require medical management include opioid intoxication, opioid overdose, and opioid withdrawal. Issues pertaining to treatment of chronic opioid abuse include opioid agonist therapy (OAT), psychotherapy, and treatment of acute pain in patients already on maintenance therapy.

104. Intensive Case Management

105. The Importance of Coordinated Intervention
We need an integrated, coordinated community response focused on recovery. This type of approach is more effective in preventing, treating and managing the chronic consequences of substance abuse and addiction than a response that is fragmented or focused primarily on penalties. We need a systematic response that is fast, fluid and flexible…meeting needs as they arise and changing through the continuum of care.

106. Intensive Case Management and Wrap- Around: Who Needs to be Involved?
The prescribing physician
Significant other(s)
Probation or parole (if a part of the case)
Other clinicians (if part of the case)
Other “natural supports” (as part of a high-fidelity wrap around team)
Please make sure you follow all confidentiality regulations under 42 CFR Part 2.

107. Why include these people? What’s the rational?
Liability
Appropriate Service/Treatment Planning
Best Practice

108. Case Study Exercise

109. Case Study: Time to Pick each others’ Brains and Generate some Ideas!

110. “Dedicated Service To Those In Need”
Our strong reputation keeps us increasingly committed to providing high quality services to youth and families in the community.

111. Additional References and Resources
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Johnston, LD, O'Malley, PM, Bachman, JG, & Schulenberg, JE. (2012). Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings, Ann Arbor: Institute for Social Research, University of Michigan. Available at
Levine, DA. (2007). “'Pharming': The abuse of prescription and over-the-counter drugs in Teens.” Current Opinion in Pediatrics. Vol. 19, No. 3, pages
National Institute on Drug Abuse. NIDA InfoFacts: Prescription and Over-the-Counter Medications. Bethesda, MD: NIDA, NIH, DHHS. Published June Retrieved February 2012.
National Institute on Drug Abuse. NIDA Research Report: Prescription Drugs: Abuse and Addiction. NIH Publication No Bethesda, MD: NIDA, NIH, DHHS. Published July Revised October Retrieved February 2012.

112. References and Resources (Cont.)

113. Additional References and Resources
“Epidemic: Responding to America’s Prescription Drug Crisis” 
“Principles of Drug Addiction Treatment: A Research-Based Guide (3rd Edition) 
“Students Seek Competitive Edge…”
“Adderall: The Study Pill”
“PBS NewsHour Excerpt:Prescription Drug Abuse (aired 5/2013)
“Prescription Drug Abuse”
voices.html?emc=eta1#/#1 “In Their Own Words: Study Guides.”