1. Treatment: What Y’all Should Know Honorable Peggy Hora (ret.) Steve Hanson NYS Office of Alcoholism and Substance Abuse Services

2. How Treatment Doesn’t Work… You are all Cured!

3. “It’s easy to give up smoking. I have done it a thousand times.” Mark Twain

4. People ask: Does Treatment Work?

5. Treatment Research Institute Outcome In Hypertension Outcome In Hypertension

6. Treatment Research Institute Outcome In Addiction Outcome In Addiction

9. Addiction is like… The dog does not want to let go of the bone (addiction/ denial). It gets excited when it thinks its going to get its bone (craving) It always wants more bones (loss of control) The dog lives in/for the moment. A dog with a bone

10. Treatment is like… You teach the dog’s owner to control the dog. You develop a variety of tools (relapse prevention) to help the dog be obedient. Some dogs are harder to train. Obedience School for the Dog

11. Some Dogs/Addictions are Worse than others

12. What Boomer is Thinking What can I get away with? They won’t test me for another week. Try the second- hand smoke excuse. We can talk our way out of this. I want to get high I WANT TO GET HIGH!!!

14. Early Recovery Issues Loss of lifestyle Loss of Coping Strategy Withdrawal Cognitive deficits related to early abstinence

15. Cognitive Deficits Memory problems- short term loss Difficulty with abstractions Difficulty with impulse control Similar performance to those with brain damage - improves.

16. Treatment Seeks to Enhance Motivation – Why change? Insight – What to change? Skills – How to change?

17. Motivation

18. Motivation Motivation is key to making and sustaining a long term change. Realistically, motivation waxes and wanes Increasing motivation helps prevent relapse Drug Courts provide external (incentives & sanctions) motivators Participants will hopefully become internally motivated (it’s the right thing to do, I feel good when I’m clean, etc.)

19. Motivation How we wish it worked How it really works

20. Changing People Places & Things I can hang out With my old friends And not chase the fox HEY GUYS!! THERE GOES THE FOX!! LET’S GET’EM!

21. Insight You only know what you only know. Participants do not automatically know what to do to stay sober and why. Helping them understand behavioral patterns. Getting them to think outside of their “box”

22. Your Surgeon I’ve never done one of these before. But I did talk about it in group… and I stayed at a Holiday Inn Express!

23. Skill Building Wanting to be able to do something doesn’t mean you can do it. Knowing what to do doesn’t mean you’ll do it (right) when it counts. Keys to skill building: –Practice, practice, practice –Reward the behavior you are trying to encourage - conditioning

24. What Kind of Treatment? Hmmnn.. Outpatient? Inpatient? Residential? Detox? Leeches?

26. Treatment Must Address Behavior Medical / Biological Affect / Emotional Social / Family CognitiveSpiritual

27. “Treatment should be tailored to the needs of the individual and guided by an individualized treatment plan that is developed in consultation with the patient” American Society of Addiction Medicine’s Patient Placement Criteria - Second Edition Revised (ASAM PPC-2R)

28. What Works? Treatment outcome research reveals a number of effective treatment approaches or types to consider when developing a treatment continuum for Drug Courts Treatment outcome research reveals a number of effective treatment approaches or types to consider when developing a treatment continuum for Drug Courts

29. Motivational Approaches  Motivational approaches focus on engaging substance users in considering, initiating and continuing substance abuse treatment while stopping their use of alcohol and other drugs.  “Being where the client is” – what they are motivated by.  Motivational approaches involve combining “motivational interviewing” with a stages-of-change model.  Stages of change include; pre-contemplation regarding change, contemplation, preparation, action, and maintenance

30. New Windows

31. Just one more question. I’m having a hard time understanding why you don’t think your drug use is a problem. You said earlier that you wanted to stop using because your life would be better, and you could keep a job. What exactly is it that you want?

32. Motivation: Sober Me vs. Using Me

33. Sober Me Wants to be sober Doesn’t want to relapse Likes not having hangovers Wants to stay out of jail Likes keeping a job Likes having people trust them.

34. Using Me Likes being high Likes hanging out in fun places Says “One won’t hurt!” Doesn’t mind lying to people Doesn’t really care about job (except for the $$) Doesn’t think they can get caught

36. Cognitive Behavioral Therapy (CBT) Approaches A research review of meta-analyses found that cognitive behavioral approaches consistently appear to be among the most effective treatment therapy for substance abusers (Taxman, 1999). CBT approaches suggest that unless offenders’ faulty thinking is addressed, there is a reduced likelihood of long-term change. The three main cognitive models now utilized by criminal justice agencies are Reasoning and Rehabilitation (R&R), Thinking for a Change and Moral Reconation Therapy (MRT®).

37. Thinking Errors Hanson! I want to see you in my office first thing tomorrow! YOU’RE FIRED!!

38. Community Reinforcement Approach plus Vouchers Uses the community to reward non-using behavior so that the client makes healthy lifestyle changes Uses the community to reward non-using behavior so that the client makes healthy lifestyle changes High levels of satisfaction in drug and alcohol free lifestyles are needed to compete with the reinforcement derived from substance use and the substance-using lifestyle High levels of satisfaction in drug and alcohol free lifestyles are needed to compete with the reinforcement derived from substance use and the substance-using lifestyle The CRA approach is analogous to helping a child conclude—through experience, not talking—that it’s more satisfying to be good than to be naughty. The CRA approach is analogous to helping a child conclude—through experience, not talking—that it’s more satisfying to be good than to be naughty.

39. Rewarding the Behavior

40. Dealing with Relapse

41. Circuits Involved In Drug Abuse and Addiction All of these must be considered in developing strategies to effectively treat addiction STOP GO

42. Go & Stop Craving elicits Go!! Powerful Activity in limbic system not frontal cortex Feeling/reacting vs. thinking/planning Thinking initiates Stop!! Addicts have “bad brakes” – Stop! Hard to stop this fast moving car.

43. Fred Flintstone Brakes

44. Pharmacological Approaches Goals – Provide: –relief from withdrawal symptoms, –prevent drugs from working, –reduce craving, –aversive reactions These actions are helpful in reducing relapse and increasing retention in programs

45. Pharmacological Approaches Methadone – Opiate addiction – reduces craving, mediates withdrawal symptoms, helps restore normal functioning Buprenorphine – similar to methadone, may be prescribed by an MD with special training) Acamprosate – reduction of alcohol cravings Antabuse – produces adverse reaction with alcohol use

46. Pharmacological Approaches Naltrexone/Nalmefene – stops opiates from working, changes alcohol action for some – reduction in relapse Neurontin – helps with insomnia in early recovery Clonidine – reduction of withdrawal symptoms – possible reduction in cravings Baclofen – possible reduction in cocaine cravings

47. AMYGDALAR CONNECTIVITY during brief.5 sec Cocaine Cues Drug 2 amyg conx (n=7) Placebo Baclofen Source: Childress, et al, unpublished Baclofen blunts AMYGDALAR CONNECTIVITY

48. “All you students who skipped school today are suspended!”

49. Responses to Relapse Sanction – If you use this will happen – Directly connects consequences to use Sanction if not honest about relapse – Focus on changing the dishonesty about using Increase treatment intensity – more frequent – residential – etc.

50. Hold Accountable, but: Keep them in treatment More intensive treatment if repeat relapse Keep engaged in supports and other activities (ed/voc, self help, etc.,)

51. When is Enough, Enough? How many strikes?? Is there demonstration of effort? Is this the typical pattern for the individual? Is the team frustrated and want to move on? Is the behavior harming anyone? What are the other participants learning?