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Cardwell C. Nuckols, PhD cnuckols@elitecorp.org The Many Faces of Methamphetamine: Addiction, The Family and The Community Cardwell C. Nuckols, PhD cnuckols@elitecorp.org.

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Presentation on theme: "Cardwell C. Nuckols, PhD cnuckols@elitecorp.org The Many Faces of Methamphetamine: Addiction, The Family and The Community Cardwell C. Nuckols, PhD cnuckols@elitecorp.org."— Presentation transcript:

1 Cardwell C. Nuckols, PhD cnuckols@elitecorp.org
The Many Faces of Methamphetamine: Addiction, The Family and The Community Cardwell C. Nuckols, PhD

2 High Rates of Trauma 44% of women and 24% of men entering treatment for methamphetamine addiction report childhood sexual abuse 32% of women and 34% of men report childhood physical abuse 56% reported parental alcohol and/or drug problems Multigenerational Brown University Digest of Addiction Theory and Application. May 2004

3 Good News Early Life Developmental Trauma is treatable
Multigenerational patterns of disorganized attachment can be broken Establishing a “helping” or therapeutic relationship is most important variable Spiritual “connectedness”

4 It’s All About Food, Water and Sex!
Bottom Line It’s All About Food, Water and Sex!

5 The Rat Brain What “turns on” the dopamine in a rats brain…..
SEX-200% increase in dopamine COCAINE-300% increase in dopamine METHAMPHETAMINE-1100% increase in dopamine This explains why rats will kill themselves to get more drug-especially methamphetamine

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7 Key Points Address Protracted Recovery Period
Address Continuum of Care Understand Age of Onset and its Relationship to Trauma History, Psychiatric Symptomatology and Prognosis Utilize Research to Develop Guidelines for Prevention and Intervention Methamphetamine Addiction Should be Treated in a CD Environment

8 Key Points Understand When the Need is “Habilitation” and not “Rehabilitation” Understand When in the Course of Recovery is the Proper Time for Vocational and/or Educational Opportunities Better Prepare the Client to Understand the Relationship Between Methamphetamine Addiction and Relapse From Marijuana and Alcohol.

9 Key Points Reevaluate our Educational Processes
Develop a System of “Wrap Around” Services That Create Hope and Opportunity Relate to the Client in Such a Way That We Help Them Better Understand Reward and Reinforcement in Early Recovery

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12 Frontal (Executive) Cortical Functions
Focus attention Prioritize Exclude extraneous information Suppress primitive urges Reduce impulsivity

13 Frontal Cortex (FC) Decisions like choosing immediate gratification (using methamphetamine to satisfy craving) vs. healthy choices are made in the FC. Addicts tend to make choices without regard for punishment or harm Habit and compulsion overrides recognition of harm associated with repeated error

14 Non-Addict Response “This is dangerous” Prefrontal cortex
Sends inhibitory signals to the Ventral Tegmental Area (VTA) Reduces dopamine release No repetitive methamphetamine use pattern No reinforcement of pleasure

15 Addict Response Pattern
“Got to have more” Cognitive Deficit Model Abnormalities in prefrontal cortex Compromised ability to send inhibitory signal to VTA Chronic alcoholics have reduced GABA Neurochemical used in the inhibitory process Meth and Coke may damage this brain loop Frontostriatal loop

16 End Organ Toxicity Central Nervous System Cardiovascular System
Pulmonary System Renal System Hepatic Fetal Development

17 Central Nervous System
Acute psychosis Chronic psychosis Strokes Seizures

18 Cardiovascular System
Myocardial Infarctions Arrhythmias Cardiomyopathy

19 Pulmonary System Acute Pulmonary Congestion
Chronic Obstructive Lung Disease

20 Renal/Hepatic Failure
Renal failure Hepatic Failure

21 Fetal Development Exposure early in pregnancy
Fetal death Small size for gestational period Exposure later in pregnancy Learning Disabilities Poor social adjustment

22 Childhood Exposure 80-90% of children found in homes where methamphetamine is being manufactured will test positive for the drug. Some are barely over one year old. Due to inhaled fumes Direct contact with the drug Second hand smoke Direct ingestion

23 Childhood Exposure Social workers now accompany law enforcement during lab seizures where children are involved. Allowing children to be in such an environment is considered neglect and/or child abuse. Parents may be charged with second-degree criminal mistreatment

24 Childhood Exposure Children are uniquely susceptible because their brains are still developing (lead poisoning) and because the are very curious Children have greater skin surface area per pound

25 Lab Seizure Locations Most common locations Single family houses
Apartments Mobile homes Vehicles Garages Trailers Motels/hotels Businesses

26 Stove Top Labs Cookers make small amounts using household equipment and chemicals The active ingredient Ephedrine or pseudoephedrine Chemical ingredients Trichloroethane (gun scrubber) Ether (engine starter) Methanol (gasoline additive) Gasoline Kerosene

27 Stove Top Labs Chemical ingredients Lithium (camera batteries)
Anhydrous ammonia (farm fertilizer) Red phosphorus (matches) Iodine (veterinarian product) Muriatic acid Campfire fuel Paint thinner

28 Stove Top Labs Chemical ingredients Acetone
Sulfuric acid (drain cleaner) Table salt/rock salt Sodium hydroxide (lye) Sodium metal (can be made from lye) Alcohol (rubbing/gasoline addictive)

29 Household Equipment Coffee filters Rubber gloves
Tempered glass baking dishes Glass or plastic jugs Bottles Measuring cups

30 Household Equipment Funnels Blenders Hotplate Strainer
Propane cylinder Aluminum foil

31 Toxicity For every unit of methamphetamine manufactured, there exists 5 times that amount in toxic waste This waste is dumped in streams, sewers, fields Environment is contaminated especially groundwater

32 Toxicity Toxic gases permeate the walls and carpets making homes and buildings uninhabitable. The cost to the taxpayer to clean these sites is between $2000 and $4000. Sometimes these gases explode and cause fires.

33 Tolerance Brain cells gradually become less responsive
More is needed to stimulate the VTA brain cells To cause more release of dopamine in the NAc To produce reward comparable to earlier experiences

34 Stimulant Toxicity Increased levels of Norepinephrine and Dopamine
Hyper-arousal Pleasure Paranoia Increased levels of Serotonin Reduced hunger Difficulty sleeping

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36 Stimulant Crash Reduced levels of Norepinephrine and Dopamine
Dysphoria Depression Anhedonia Reduced levels of Serotonin Mood swings Sleep disturbances

37 Craving Management (Situational & Emotional Triggers)
Situational triggers Environment (People, Places And Things) Initially drug causes release of dopamine After addiction, situations that have a high probability of use cause dopamine release Emotional triggers Internal (Hungry, Angry, Lonely, Tired, Reward and Bored)

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39 Most Common Craving Triggers
In presence of: Alcohol and drugs Alcohol and drug users Places where used to use or purchase Negative feeling states particularly anger but also: Boredom Loneliness Fear Anxiety

40 Most Common Craving Triggers
Positive feeling states Physical pain Use of mood-altering prescription drugs Suddenly having a lot of cash Complacency Insomnia Sexual functioning

41 Craving Management Psychotherapy Pharmacological Behavior Therapy
Structure Recovery Foundation Program Changing patterns Safety Plan Pharmacological Acute Maintenance

42 Changing Patterns 31 yo Nicki-a recovering methamphetamine addict- just got her first paycheck. She cashed her check and cruised thru the neighborhood where she used to score dope. Rock music blared from her speakers. Soon she was thinking, "I worked hard all week. I deserve a little fun.”

43 Behavioral Foundation Program
In an inpatient setting the patient schedule serves this purpose On an outpatient basis or upon discharge from inpatient a recovery plan or contract is appropriate Remember that most addicts have little or no recent experience living a drug free lifestyle

44 Behavioral Foundation Program
TASK MON TU WED THU FRI SAT SUN SH TX FUN NUT PEX

45 Behavioral Foundation Program
Carter is 24 yo and just getting out of treatment for alcohol and methamphetamine addiction His early A/D history included…. Started drinking on Friday nights with friends in high school Turned-on to methamphetamine and marijuana by friends on weekends Started to buy methamphetamine to sell from a distributor on Wed nights

46 Using Early Drug History
TASK MON TU WED THU FRI SAT SUN SH X TX FUN NUT PEX

47 Behavioral Safety Plan
CT: “Last night I had a dream that I was getting ready to get high on ‘crystal’-it was all on the table in front of me. It was like five minutes before I knew it was a dream.” TH: “Congratulations on not using, tell the group what you did to deal with the craving.” CT: “ I went into the kitchen and wrote in my journal everything that happened. Then I said a prayer.”

48 Behavioral Safety Plan
TH: What else could you have done? CT: “I know that I can always call my sponsor or my lover. I can also read from a book that I have on recovery or a book of affirmations that I like.” TH: “That’s great. Now let’s make a safety plan from what you have discovered.”

49 Behavioral Safety Plan On 3x5 Index Card
MY PERSONAL SAFETY PLAN Remember that cravings go away I can write in my journal I can call my sponsor ( ) I can call my lover ( ) I can read from my favorite recovery book I can read affirmations

50 Behavioral Safety Plan On 3x5 Index Card
TH: “On the back of the index card, come up with a saying or a prayer that gives you strength.” CT: “ I have always liked ‘Lord help me to be the best possible person I can be today’.”

51 Cognitive Therapy Behavior Situation Cognition Physiology Emotion
Modulation Ratio

52 Cognitive Therapy Automatic Thoughts “I cannot do anything right”
“I fail at everything I do” “I will never get better” “No one can help me” “No one understands me”

53 Cognitive Therapy-Dysfunctional Thought Record
SITUATION AUTOMATIC THOUGHT EMOTION ALTERNATE RESPONSE OUTCOME 1 year anniversary Things should be better Anger frustration Look back a year Things have improved grateful

54 Cognitive Reframes CT: “My wife is always angry at me.”
CT: “Every time I go to a meeting my husband gets angry.” Other examples

55 Cognitive Dysfunction and Change
Frontal cortex vs. midbrain Approximately 50% entering treatment suffer from cerebral (cognitive) dysfunction Less likely to attend continuing care Less likely to be employed Often mistaken as resistant or unmotivated Less able to absorb information Stimulant addicts look like they have degenerative brain disease

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57 Cognitive Dysfunction and Change
Executive and visuospatial functioning problems include: Recent memory Abstraction Problem solving Cognitive flexibility Planning Rapid Response

58 Cognitive Dysfunction-Stimulant Addicts
Long term stimulant abuse causes damage to dopamine producing cells and leads to reduced levels Stimulant addicts may suffer from poor attention and compromised fine motor skills

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60 Cognitive Dysfunction and Change
Recovery in neuropsychological functioning Most of treatment is during time of greatest dysfunction Recovery is; Time-dependent Due to sustained abstinence Experience-dependent Active rehabilitation or repetitive behavior

61 Cognitive Rehabilitation
Repetitive recovery-oriented behaviors Repetitive recovery-oriented thoughts

62 Education Why give a methamphetamine addict a 60 minute didactic or video? A new format 15-20 minute simple didactic How to participate in treatment 10 minute questionnaire 30 minute discussion group

63 10 Minute Questionnaire I THINK……….. I FEEL………….. I LEARNED……
MY FUTURE BEHAVIOR WILL CHANGE…

64 Reward and Reinforcement
Mesolimbic Reward Center Environment Spirituality

65 Mesolimbic Reward System
The next three slides show: Slide one-The Reward Pathway Slide two-Localization of Binding Sites Slide three-Dopamine Binding to Receptors and Reuptake Pumps in the Nucleus Accumbens

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69 Mesolimbic Reward System
The next three slides show: Slide four-Cocaine Binding to Reuptake Pumps and Inhibiting Dopamine Reuptake Slide five-Increased cAMP Produced in Post-synaptic Cell causes abnormal Firing Patterns Slide six-Body now Relies on Stimulant to Experience Reward as Natural Rewards No Longer Pleasurable

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73 Environment Triggers or cues (seeing, smelling, touching, tasting , and hearing) that remind the addict of some aspect of his/her use increase the desire for the reward (craving) without necessarily enhancing the pleasure of the reward itself.

74 Environment Living in an enriched environment may reduce animals self-administration of drugs Animal studies suggest that environmental conditions may affect the activity of dopamine

75 Meth Hurts Moms and Kids
Obstetrician-gynecologist Mary Holley, M.D., who founded Mothers Against Methamphetamine said the following: “We’re seeing devastation. Infant mortality is high. The kids who are born won’t feed. They’re underweight. They’re sick. They are going to have ADHD almost guaranteed, and they grow up in a home with an addicted mother who doesn’t care about them.”

76 Environment Case Management Multisystem Therapy “Wrap around” services
Family and childcare services Housing/Transportation services Financial and legal services AIDS and medical services Addiction and mental health services Vocational and educational services

77 Spirituality 2 major reviews of the literature
National Institute for Healthcare Review (1996) “Good evidence” that involvement in AA is associated with enhanced outcomes in both inpatient and outpatient care NIAAA and Fetzer Institute (1999) “Strong support” for the protective nature of spirituality and religion (110 studies): of AA involvement (51 studies) and spiritual/religious intervention (26 studies)

78 Spirituality In Addiction Recovery
Spirituality refers to the unique and intense experience of a reality greater than oneself or an experience of connection with the totality of things. Religion is an organized social structure in which spiritual experiences are shared, ritualized and passed on to future generations

79 Spirituality In Addiction Recovery
An individual does not have to be religious in order to have a spiritual experience. The benefits of spirituality include humility, inner strength, sense of meaning and purpose in life, acceptance of self and others, sense of harmony and serenity, gratitude and forgiveness.

80 Beliefs Of Our Clients Over 90% of Americans believe in God
57% engage in daily prayer 42% attended church in the last week 80% believed that religious faith can aid in recovery from illness

81 Beliefs Of Our Clients 63% agreed that doctors should talk to them about spiritual issues (McNichol, 1996)

82 Beliefs of Medical Professionals
According to Alcohol Medical Scholars Program, Spirituality in Substance abuse/Dependence Treatment, Marianne Guschwan, MD Most psychiatrists do not believe in God Nurses and medical students in one survey ranked spirituality as a low consideration of patients treated on a dual-disorder unit

83 Beliefs of Medical Professionals
Guschwan continued However, the patients ranked spirituality and belief in God as most important to their recovery-Interesting incongruence!

84 Alcoholics Anonymous Based on Judeo-Christian principles
Mutual self-help program JCAHO mandates discussion of alternatives Secular Organization for Sobriety (SOS) Rational Recovery (RR) Moderation Management (MM)

85 Alcoholics Anonymous 2 year study of 2319 Alcohol-Dependent Men (McKellar,2003) People who keep an active connection in AA are more likely to recover Cause and effect-What came first AA or reduced drinking? Answer-AA Men who showed strong motivation at start were: Less likely to remain in AA More likely to have continuous alcohol problems

86 Summary of AA Research 243 studies of AA prior to the year 2001
When investigating treatment outcomes AA should not be ignored Combination of AA and treatment predicts better outcomes Same results found in UK Continuous abstinence is most likely to be affected by AA

87 Summary of AA Research AA without professional treatment does not always result in better outcomes Treatment based on 12-step approaches are as effective as other approaches and may actually achieve more sustained abstinence (10th Report to US Congress on Alcohol and Health, 2000)

88 Summary of AA Research Project MATCH compared Twelve-Step Facilitation Therapy (TFT) with Cognitive Behavioral Therapy (CBT) and Motivational Enhancement Therapy (MET) TFT group did at least as well and did better on measures of complete abstinence

89 Summary of AA Research Practically speaking (Owens,2003)
AA attendance is associated with increased Self-confidence & Self-efficacy in regard to avoiding drinking AA friendships and support are positively associate with reduction in alcohol and drug use AA participation leads to lifestyle changes that lead to greater levels of abstinence

90 Summary of AA Research Practically speaking (Owens,2003)
Support from AA members is more important for abstinence than support from non-members Internalizing the program-not the number of meetings attended-is a positive factor in abstinence rates Remember no one program is for everyone

91 Thank You For Attending
In the long run, it is better to choose water, food and (safe) sex instead of methamphetamine

92 REFERENCES Robinson, Terry E. NEUROSCIENCE: Addicted Rats Science : American Medical News. July 26,2004,Mary Holley, M.D.


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