1. Rehab Counseling Substance Abuse Class 05 Markus Dietrich LMHC,CRC,CAAP Shands Healthcare dietrmk@shands.ufl.edu

2. Drug Use-Scope In 2001 an estimated 15.9 million Americans 12 or older used illicit drugs. This represents 7.1% of this population. In 2001 an estimated 15.9 million Americans 12 or older used illicit drugs. This represents 7.1% of this population. This a 0.8% increase from 6.3% in 1999 and 2000. This a 0.8% increase from 6.3% in 1999 and 2000. Increases were noted for: Increases were noted for: Marijuana 4.8% to 5.4% Cocaine 0.5% to 0.6% Pain Relievers 1.2% to 1.6% Tranquilizers 0.4% to 0.6% National Household Survey 2001

3. Drugs Use- Marijuana Marijuana is the most commonly used drug used by 76% of the drug users Marijuana is the most commonly used drug used by 76% of the drug users 56% of drug users use only marijuana 56% of drug users use only marijuana 20% use Marijuana and another drug. 20% use Marijuana and another drug. 24% use illicit drugs but not marijuana. 24% use illicit drugs but not marijuana.

4. Therapeutic Drugs Of the 4.8 million users of therapeutic drugs, 3.5 million use pain relievers 3.5 million use pain relievers 1.4 million use tranquilizers 1.4 million use tranquilizers 1 million uses stimulants 1 million uses stimulants 0.3 million use sedatives 0.3 million use sedatives

5. Drugs cont. In 2001 an estimated 1.7 million (0.7%) Americans age 12 or older were current cocaine users and 406,000 (0.2%) were current crack users In 2001 an estimated 1.7 million (0.7%) Americans age 12 or older were current cocaine users and 406,000 (0.2%) were current crack users 1.3 million (0.6%) used hallucinogens 1.3 million (0.6%) used hallucinogens 957,000 used Oxycontin non medically (four times as much as 1999) 957,000 used Oxycontin non medically (four times as much as 1999) Heroin use is reported to be 123,000 (0.1%) Heroin use is reported to be 123,000 (0.1%)

6. Drugs- Variables Men are more likely to report drug use than women (8.7 vs. 5.5%) Men are more likely to report drug use than women (8.7 vs. 5.5%) Rates and patterns of drug use vary by age, peaking among 18-20year olds Rates and patterns of drug use vary by age, peaking among 18-20year olds Drug use is correlated with education. Rate for H.S graduates is 7.6% vs. 4.3 percent for four year college graduates, even though college graduates were more likely to have tried drugs. Drug use is correlated with education. Rate for H.S graduates is 7.6% vs. 4.3 percent for four year college graduates, even though college graduates were more likely to have tried drugs.

7. Alcohol 109 million ( 48.35%) Americans age 12 or older report being current drinkers 109 million ( 48.35%) Americans age 12 or older report being current drinkers Approximately one fifth (20.5%) reported bingeing at least once in last 30 days Approximately one fifth (20.5%) reported bingeing at least once in last 30 days 5.7%reported heavy drinking 5.7%reported heavy drinking

8. Alcohol variables Age: highest prevalence of alcohol use is between 18 and 25. Rate drops slightly between 25 and 60. Age: highest prevalence of alcohol use is between 18 and 25. Rate drops slightly between 25 and 60. Men are more likely to drink than women Men are more likely to drink than women likelihood of drinking alcohol increases with education, however, binge drinking and heavy drinking were least prevalent among college graduates likelihood of drinking alcohol increases with education, however, binge drinking and heavy drinking were least prevalent among college graduates

9. Employment Unemployment is highly correlated with drug and alcohol use however, 6.9% of illicit drug users are full-time employed 6.9% of illicit drug users are full-time employed 9.1% of drug users are part-time employed 9.1% of drug users are part-time employed Among the 43.9 million adult binge drinkers, 35.4 million (81%) are full-time or part-time employees. Among the 43.9 million adult binge drinkers, 35.4 million (81%) are full-time or part-time employees. 9.8 million (80%) of the heavy drinkers are also employed 9.8 million (80%) of the heavy drinkers are also employed

10. Significant Others Non-alcoholic members of alcoholic’s families use 10 times as much sick leave as in families where alcohol is not a factor. Non-alcoholic members of alcoholic’s families use 10 times as much sick leave as in families where alcohol is not a factor. More than half of all family members of alcoholics who are employed (80%) report their ability to function is impaired as a result or living with an alcoholic. More than half of all family members of alcoholics who are employed (80%) report their ability to function is impaired as a result or living with an alcoholic.

11. Effects on Business decreased productivity decreased productivity increased on-the-job accidents increased on-the-job accidents increased absenteeism increased absenteeism turnover turnover increased health care cost increased health care cost

12. Economic Impact Cost to society associated with drug and alcohol abuse is estimated to be $294 billion. Cost to society associated with drug and alcohol abuse is estimated to be $294 billion. The largest impact is on lost productivity. The largest impact is on lost productivity. The health care cost for alcohol abuse is about twice that for drug abuse. The health care cost for alcohol abuse is about twice that for drug abuse. Samsha 2001

13. Social Impact Alcohol and drug abuse correlate positively with: Domestic Violence Domestic Violence Child abuse and neglect Child abuse and neglect Separation and divorce Separation and divorce Healthcare cost Healthcare cost Criminal behavior Criminal behavior

14. Trends The NHSDA showed increases among Americans in rates of use of several substances, including marijuana and cocaine and the non-medical use of pain relievers and tranquilizers. Alcohol use also increased, although binge drinking and heavy use remained unchanged between 2000 and 2001 The NHSDA showed increases among Americans in rates of use of several substances, including marijuana and cocaine and the non-medical use of pain relievers and tranquilizers. Alcohol use also increased, although binge drinking and heavy use remained unchanged between 2000 and 2001

15. Addiction and the Brain

16. Addiction is a brain disorder Addiction is an independent disorder distinguished from drinking that is merely heavy, problematic, ill advised or socially unacceptable Abuse - intentional overuse in cases of celebration, anxiety, despair, self-medication, other mental health disorders or ignorance. Tends to decline with consequences or adequate treatment of other mental health disorder.

17. Functional Imaging SPECT – single photon emission computed tomography PET – positron emission tomography fMRI – functional magnetic resonance imaging

20. Dopamine Pathways – Pleasure pathways nucleus accumbens hippocampus striatum frontal cortex substantia nigra/VTA cocaine heroin nicotine amphetamines opiates THC PCP ketamine heroin alcohol benzodiazepins barbiturates alcohol

21. THE RAT BRAIN What “turns on” the dopamine in a rats 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

23. enzymes receptors responses malfunction MFB Inherited genes or altered expression The explanation for why people respond differently! Early exposure to drugs abnormal proteins

24. Brain of the addicted is fundamentally different: Gene expression (Liu, Nickolendko 1994; Daunais & McGinty 1995) Gene expression (Liu, Nickolendko 1994; Daunais & McGinty 1995) Glucose metabolism (Volkow, Gillespie, 1996) Glucose metabolism (Volkow, Gillespie, 1996) Responsiveness to environmental cues (O’Brien, Childress, 1993; Kilgus & Pumariega, 1994) Responsiveness to environmental cues (O’Brien, Childress, 1993; Kilgus & Pumariega, 1994)

25. What’s inherited??? Temperament Temperament Initial sensitivity to rewarding or aversive qualities (like or dislike of the drug) Initial sensitivity to rewarding or aversive qualities (like or dislike of the drug) Tolerance Tolerance Rates and routes of metabolism Rates and routes of metabolism Taste preferences Taste preferences Response to memories related to use Response to memories related to use

26. Developing brain Individuals who begin drinking before age 15 are 4 times more likely to develop alcohol dependence during their lifetimes than those who begin drinking at age 21. (Grant & Dawson 1997; Journal of Substance Abuse 9:103-110) Individuals who begin drinking before age 15 are 4 times more likely to develop alcohol dependence during their lifetimes than those who begin drinking at age 21. (Grant & Dawson 1997; Journal of Substance Abuse 9:103-110) Earlier drinking more likely to result in alcohol dependence independent of family history (Grant, 1998) Earlier drinking more likely to result in alcohol dependence independent of family history (Grant, 1998)

27. Your Brain on Drugs 1-2 Min3-45-6 6-77-88-9 9-1010-2020-30 YELLOW shows places in brain where cocaine goes (Striatum) PET scan after cocaine use

28. Alcohol 25 yrs Cocaine 2 yrs Marijuana 12 yrs Normal SPECT (blood flow)

29. Assessment and Diagnosis Bio-psycho-social-spiritual Assesment Bio-psycho-social-spiritual Assesment DSM-IVR: DSM-IVR: Seven Criteria Two dimensions- Two dimensions- Obsession and Compulsion.

30. Job is last to go!

31. AbuseAddiction Usually self-limitedProgressive course Likely to stop as consequences progress Unable to stop because of consequences – loss of control May have significant consequences Significant consequences Frequent character or personality pathology No specific personality Normal brain chemistry Abnormal brain chemistry Bad judgment, poor morals, self will Cravings, preoccupation

32. Facilitate Change Motivational Enhancement Therapy Key Factors for Change for the Counselor: Style Style

33. Key Concepts Motivation: the probability that a person will enter into, continue and adhere to a specific change strategy. Motivation: the probability that a person will enter into, continue and adhere to a specific change strategy. Resistance: the result of interacting with one’s environment- not a characteristic. Resistance: the result of interacting with one’s environment- not a characteristic. Ambivalence: the heart of the problem, not pathological. Ambivalence: the heart of the problem, not pathological.

34. Stages of Change Prochaska & DeClemente 1982 Pre-contemplation Pre-contemplation What problem? Contemplation Contemplation Is it a problem? Preparation Preparation What can I do? Action Action I am doing something Maintenance Maintenance I am successful

35. Helper Tasks Pre-contemplation Pre-contemplation Raise Doubt Contemplation Contemplation Evoke reasons for change Preparation Preparation Help client find best course of action Action Action Support steps toward change Maintenance Maintenance Relapse Prevention