Reviewer Quiz BEE Handout PDF

**REVIEWER** - 269 million people between the ages of 15 and 64 used illicit substances at least once in 2018 - 35.6 million people suffer from drug use disorders. - People who suffer from drug use disorder need treatment - An estimated 11.3 million people injected drugs in 2018 -...

**REVIEWER** - 269 million people between the ages of 15 and 64 used illicit substances at least once in 2018 - 35.6 million people suffer from drug use disorders. - People who suffer from drug use disorder need treatment - An estimated 11.3 million people injected drugs in 2018 - About 12.6% of those who inject drugs lives with HIV amounting to 1.4 million people - About 48.5% of PSUDs, or some 5.5 million people, are living with Hepatitis C Global consequences of SUDs are far-reaching and include: - Higher rates of hepatitis and tuberculosis - Lost productivity - Injuries and deaths - Overdose deaths - Suicides - Violence **Diagnostic and Statistical Manual- 5 (DSM-5** - People have had many different ideas about addiction over the centuries. Many people still see addiction as a character flaw, a personality disorder, or a moral failing rather than as a health problem. We now know that substance addiction is not just a lot of drug use: - The environment and lifestyle issues play important roles in development of heart disease. In addition, a person's genetic makeup also plays an important role.The same is true of addiction. For example, the studies of identical twins that as much as half of an individual's risk of becoming addicted to nicotine, alcohol, or other drugs depends on his or her genes. - Another disease term is pathogenesis, or the progression of a disease from its origins through its critical development and expected outcomes. Most diseases, when untreated, follow a generally predictable path of symptom development and biological changes. This is also true of addiction. We'll be talking about the progression of addiction later in the module. For now, let's move on to look at the chronic disease part of the definition of addiction. - Another element of the definition of addiction is chronic disease. Chronic disease is defined as one that is long lasting and that cannot be cured but can be managed.Addiction is defined as a chronic disease because the brain shows distinct changes after substance use that can persist long after the substance use has stopped. And, like diabetes and hypertension, it cannot be cured, but it can be managed with pharmacotherapy and counseling intervention or with counseling intervention alone. - Addiction is considered a brain disease because psychoactive substances change the structure of the brain and how it works. These brain changes can be long lasting and can lead to addiction and the harmful behaviours associated with addiction. - Relapsing is included in the definition because, given the chronic nature of the addiction, relapsing to substance use is not only possible, but common. Relapsing is part of all chronic diseases, not just addiction.Relapse rates for substance use are similar to relapse rates for other chronic diseases such as diabetes and hypertension.The relapse rate for drug addiction is between 40 and 60 percent. The rate for diabetes is just a bit lower, between 30 and 50 percent, and the rates for both hypertension (high blood pressure) and asthma are both even a bit higher than the rates for addiction, at between 50 and 70 percent. - It's important to distinguish between a lapse (sometimes called a slip) and a relapse.A lapse is a brief, often one-time, return to substance use. For example, a person could run into an old friend who still uses. He or she might use with the old friend and then regret it right away. Sometimes lapses are triggered by stress, unhappiness, or fatigue. - A relapse is a complete return to using psychoactive substances in the same way the person did before he or she quit. - Lapses are fairly common in the early stages of recovery. A lapse can lead to relapse, but it doesn't always, and relapse can be avoided. - A neuron sends messages to other cells through its axon tips and receives messages - from other cells at its receptor sites. The cell body directs all activities of the neuron. - Dendrites (the parts that look like tree branches) are short fibers covered with receptor - sites. These receptor sites receive messages from other neurons and relay those messages to the cell body. - The axon is a long single fiber that sends impulses, or messages, from the cell body to - dendrites of other neurons. The axon is covered with a myelin sheath; myelin insulates the axon and increases the speed at which impulses travel. - Networks of neurons pass messages back and forth to different structures within the brain, the spinal column (the central nervous system), and the peripheral nervous system. The peripheral nervous system includes all the nerves going to your arms, legs, hands, and feet---basically all of the nerve systems outside the central nervous system. - These nerve networks coordinate and regulate everything we feel, think, and do. - Each nerve cell in the brain sends and receives messages in the form of chemical - impulses: - These chemicals are called neurotransmitters. - The brain has many different neurotransmitters. - The sending neuron releases a neurotransmitter from its axon terminal across a space between neurons called a synapse or synaptic cleft. - A neurotransmitter attaches to a specialized site on the receiving cell called a receptor.Once the receiving neuron gets and processes the message, it becomes a sender and passes the message to other neurons. - The yellow dopamine is in the sending neuron. - The blue dopamine receptors are on the receiving neuron. - A neurotransmitter and its receptor operate like a key and lock. Each receptor will pass on the appropriate message only after interacting with the correct kind of neurotransmitter. - A neurotransmitter and its receptor operate like a key and lock. Each receptor will pass on the appropriate message only after interacting with the correct kind of neurotransmitter. - Once the dopamine is released from the sending cell, crosses the synapse, and makes contact with its receptors, transporters located on the sending cell recycle the dopamine, bringing it back into the cell that released it. This is called reuptake. - Reuptake stops the signal between neurons once the message has been communicated.Psychoactive substances and brain communication - Psychoactive substances are chemicals that tap into the brain's communication system and mimic or disrupt with the way nerve cells normally send, receive, and process information. - Some psychoactive substances, like marijuana and heroin, can activate neurons because their chemical structure mimics that of a natural neurotransmitter. This similarity in structure fools receptors and allows the substances to lock onto and activate the nerve cells. Meanwhile, the correct neurotransmitters are blocked from communicating with the neuron.Although these substances mimic brain chemicals, they do not activate nerve cells in the same way as a natural neurotransmitter, and they transmit abnormal messages through the network. - Other psychoactive substances, like amphetamine or cocaine, can cause the nerve cells to release abnormally large amounts of natural neurotransmitters or prevent the normal reuptake of these brain chemicals. This disruption produces a greatly amplified message, ultimately disrupting communication channels. - Dopamine (the little orange stars) is released normally from the sending neuron and makes contact with its receptor site (blue ovals) as usual. - But cocaine (green squiggles) has attached itself to the transporters, and the transporters cannot do their job of recycling the dopamine back into the sending cell. - The way the brain communicates is the same throughout the brain. However, different - parts of the brain are responsible for coordinating and performing specific functions, - and certain areas of the brain are more affected by substance use than others. - The areas of the brain most involved in substance effects and addiction are the brain - stem, the cerebral cortex, and the limbic system. - The brain stem controls functions critical to life, such as heart rate, breathing, and - sleeping. - The front part of the cortex, the cerebral cortex or forebrain, processes information - from our senses and is the thinking and judgment center of the brain. It powers our ability to think, plan, solve problems, and make decisions - The limbic system contains the brain's reward circuit. The limbic system links together - a number of brain structures that control emotional memory and regulate the ability to feel pleasure. Feeling pleasure motivates us to repeat behaviors such as eating---actions that are critical to existence. - The limbic system is activated when we perform these activities and by substances - of abuse. In addition, the limbic system is responsible for the perception of other emotions, both positive and negative, which explains the mood-altering properties of many psychoactive substances. - „ The limbic system is divided into areas that control specific functions. Different areas - process information from our senses, enabling us to see, smell, feel, hear, and taste. - The brain's reward circuit, in the limbic system, is critical to the development of addiction. - Our brains are wired to ensure that we repeat life-sustaining activities by associating - those activities with pleasure or reward. - This pleasure or reward is largely related to the neurotransmitter dopamine. Certain survival activities, like eating and sex, stimulate production of dopamine. All psychoactive substances of abuse also directly or indirectly target the brain's reward system by flooding the circuit with dopamine and/or other neurotransmitters.However, substance-induced rewards are much more powerful than natural rewards. When some substances of abuse are taken, they can release 2 to 10 times the amount - of dopamine that natural rewards do. In some cases, this occurs almost immediately (as when substances are smoked or injected). The effects can also last much longer than those produced by natural rewards. - This overstimulation of the reward circuit produces the euphoric effects sought by - people who abuse psychoactive substances and teaches them to repeat the behavior. - Whenever this reward circuit is activated naturally, the brain notes that something important is happening that needs to be remembered and teaches us to do it again and again, without thinking about it. Because psychoactive substances of abuse stimulate the same circuit, people learn to abuse substances in the same way. - The resulting effects on the brain's pleasure circuit dwarfs those produced by naturally rewarding behaviors such as eating and sex. - The effect of such a powerful reward strongly motivates people to take psychoactive substances over and over again. - This overstimulation of the reward system becomes even more complicated, leading the brain to try to compensate and reinstate balance. - The brain adjusts to the overwhelming surges in dopamine (and other neurotransmitters) by producing less dopamine or by reducing the number of receptors that can receive and transmit signals. - As a result, dopamine's impact on the reward system of the brain of a person who abuses substances can become abnormally low, and the ability to experience any pleasure induced by normal stimuli is reduced. This is why the person who abuses substances eventually feels listless and depressed and cannot enjoy things that previously brought pleasure.Now, the person needs to take the substance just to bring the dopamine function back to normal. The person must take larger amounts of the substance than he or she first did to create the dopamine high---an effect known as tolerance. - Just as continued abuse may lead to tolerance (the need for more of the drug to produce the same effect), it may also lead to addiction, which can drive the person to seek out and take psychoactive substances compulsively. - Substance addiction erodes a person's self-control and ability to make sound decisions, while sending intense impulses to take psychoactive substances. Over time, the person spends less time thinking about other areas of his or her life and more time thinking about finding and using psychoactive substances. - At first, the person is using a substance casually or experimentally (the recreational or circumstantial use talked about yesterday). Other interests remain intact and in balance. - At first, the person is using a substance casually or experimentally (the recreational or circumstantial use talked about yesterday). Other interests remain intact and in balance. - Eventually, the person is spending most of his or her energy on finding and using substances (compulsive use or addiction). - The reason is that vulnerability to addiction differs from person to person. In general, the more risk factors an individual has, the greater the chance that taking psychoactive substances will lead to abuse and addiction. - No single factor determines whether a person will become addicted. The overall risk for addiction is affected by both biological and environmental factors and by the interaction between the two. - Gender or ethnicity affects risk, and individuals with mental disorders appear to be at greater risk of substance abuse and addiction than is the general population. - Age is also important. Although taking psychoactive substances at any age can lead to addiction, research shows that the earlier a person begins to use, the more likely he or she will progress to more serious abuse. - Scientists estimate that genetic factors account for between 40 and 60 percent of a person's vulnerability to addiction, including the effects of environment on gene expression and function. There is some evidence that even the likelihood a person will start using a substance may be largely affected by genetic factors. For example, a recent (and large) study found that use of marijuana and alcohol appeared to be affected by common genetic factors. - Genes are functional units that make up our DNA. Each gene is like a book that stores information. A gene contains the information required to make a protein or ribonucleic acid (RNA), the building blocks of life. - Research on the human genome has shown that the DNA sequences of any two individuals are 99.9 percent identical. However, that 0.1 percent variation is profoundly important, contributing to visible differences, like height and hair color, and to invisible differences, such as increased risks for, or protection from, heart attack, stroke, diabetes, and addiction.3 - a strong internal drive to use the psychoactive substance, which is manifested - physiological features of dependence may also be present, including tolerance to the effects of the psychoactive substance, withdrawal symptoms following cessation or reduction in use of the psychoactive substance, or repeated use of psychoactive substance or pharmacologically similar substances to prevent or alleviate withdrawal symptoms. The features of dependence are usually evident over a period of at least 12 months but the diagnosis may be made if psychoactive substance use is continuous (daily or almost daily) for at least 1 month. - Affect the functioning of the central nervous system. ′ - Change how people behave, perceive or feel about what is happening around them. Our brains are protected by a membrane called the blood--brain barrier. This barrier is a series of tightly pressed-together cells that allows for the passage of only certain chemicals. Because the cells of the blood--brain barrier are so tightly pressed together, substances with a large molecular structure and that are water soluble (meaning that they dissolve easily in fluid) can't get through the barrier. Most medications we take, like aspirin or antibiotics, are in this category. However, substances with a small molecular structure and that are fat soluble, as most psychoactive substances are, can easily pass through the blood--brain barrier. In this way, psychoactive substances can have a direct effect on brain functioning. - Absorbs psychoactive substances - Distributes them - Metabolizes them - Eliminates them - Mood-Feeling more alert, Feeling more relaxed, Feeling more or less depressed than usual, Feeling irritable or angry, Feeling more sociable, Feeling "happy" ,Feeling more or less sexual, Feeling fearful - Thoughts-Racing thoughts Inability to plan or make a decision Distorted perceptions Increased clarity of thought Paranoid thoughts Poor judgment - Sensory perceptions-Perceptual distortions ,Changes in temperature perception, Changes in pain perception - Behavior-Decreased or increased activity, Increased risk-taking; dangerous activities ,Behavior not in line with personal values, Aggression or violence Passivity Increased or decreased sexual behavior - The potency of synthetic opioids can be up to 100 times that of morphine or heroin - Only a small amount of synthetic opioids is required to - produce a "high" - They are often added to other drugs (e.g., heroin, - cocaine) and serve as an inexpensive and highly potent adulterant that can have lethal effects - Synthetic opioids are also illegally converted to pills that resemble prescription painkillers Opium is the semidried sap of the plant and is 100 percent natural. - Two of the most prevalent alkaloids (plant compounds with psychoactive properties) in opium are morphine and codeine. - Morphine and codeine can be isolated and processed as separate drugs. - Heroin is a semisynthetic opioid, meaning that it can be synthesized from opium. - Other semisynthetic opioids are hydrocodone, oxycodone, and hydromorphone. - Synthetic opioids are not derived from natural opium but are manufactured to work in similar ways. - Methadone, fentanyl, and meperidine are synthetic opioids. - Opium is most commonly smoked. - Heroin can be smoked, inhaled (either as a powder or liquefied in a nasal spray bottle), or injected (intramuscularly or intravenously). - Other opioids are more commonly taken orally, in tablet form. - When used medically for pain relief, some opioids are administered via slow-release capsules or patches. OxyContin, a slow-release capsule, has become a major problem in some areas of the United States. People break open the capsule, dilute the contents, and inject the solution. Patches are sometimes abused by cutting them open and eating or injecting the contents.How long an opioid high lasts depends on the specific drug. Some opioids are short acting, and some are long acting. The effects of heroin usually last 3 to 4 hours. - Physical pain relief - Emotional numbness - Euphoria, followed by a sense of well-being - Calm drowsiness or sedation - Alternating wakefulness and drowsiness - Dreaminess - Nausea and vomiting - Confusion - Slowed breathing - Constipation - Blurred or double vision - "Pinpoint" pupils - Dizziness, faintness, floating feeling, light-headedness - Uncoordinated muscle movements, rigid muscles - Rash, hives, itching - Facial flushing - Dry mouth - Weakness - Agitation - Headache - Appetite loss - Memory loss - Infection of the heart lining and valves - Liver or kidney disease - Pulmonary complications, including various types of pneumonia, resulting from the poor health of the user as well as from the depressing effects on respiration - Intestinal complications resulting from chronic constipation - Consequences directly associated with injecting, including abscesses and collapsed veins - Spontaneous abortion.Babies born to women who are opioid addicted may have low birth weight and/or go through withdrawal, with symptoms lasting 5 to 8 weeks. Unlike adults, babies can die from opioid withdrawal. - Cold, clammy skin - Weak, floppy muscles - Fluid in the lungs - Greatly lowered blood pressure and heart rate - "Pinpoint" or dilated pupils - Stupor - Coma - Slow and difficult breathing - Bluish-colored fingernails and lips from reduced oxygen intake - Muscle cramping - Restlessness - Severe muscle, joint, and bone pain - Muscle cramping - Sweating and running nose - Rapid pulse - Coughing and yawning - Dilated pupils - Insomnia - Diarrhea and vomiting - Fever and chills with severe shivering and goose bumps - Kicking movements - The cocaine alkaloid is found in the leaves of the coca bush that grows primarily in the Andes Mountains of Peru. - Amphetamines are commercially manufactured; they include Adderall, Dexedrine, and biphetamine. Although not as strong, some amphetamine-like drugs have similar effects and are abused to some extent: methylphenidate (Ritalin), fenfluramine, pemoline, and phentermine. - Methamphetamine is also synthetic. It is commercially manufactured (Desoxyn) but is more typically synthesized in clandestine laboratories. - MDMA (3,4 methylenedioxymethamphetamine), also known as ecstasy, is a synthetic, psychoactive drug that is chemically similar to both the stimulant methamphetamine and the hallucinogen mescaline, but it is generally classified as a stimulant. - Orally - By snorting (inhaled nasally after crushing tables) - By smoking - By injecting after dissolving crushed tablets in water - By inhaling powder (snorting) - By injecting - By smoking - Orally (rarely) - By smoking - By inhaling nasally - By injecting "Desirable" Effects of Stimulants - Euphoria - Increased energy and endurance - Talkativeness - Increased mental alertness - Feelings of happiness and power - Release of social inhibitions - Unrealistic feelings of cleverness, great competence, and power - Enhanced sensations of sight, sound, and touch - Enhanced sexual desire and performance (at low doses) - Heightened feelings of emotional warmth and increased empathy for self and others - Distortions in time perception - Heightened sensation - Visual distortions and hallucinations - Dilated pupils - Increased body temperature, heart rate, and blood pressure - Headaches - Restlessness and insomnia - Anxiety and irritability - Abdominal pain and nausea - Decreased appetite - Increased aggression and violence - Formication: sensations in the skin that feel like crawling bugs - Decreased sexual response (at higher doses) - Feelings of paranoia - Loss of the sense of smell - Chronic nosebleeds - Problems with swallowing - Chronically runny nose - Thirst - Coughing - Hoarseness - Acute cardiovascular or cerebrovascular emergencies, such as a heart attack or stroke, which may cause sudden death - A temporary state of full-blown paranoid psychosis - Severe dental problems, including cracked teeth from extreme jaw clenching when high and severe tooth decay resulting from dry mouth and acidic effects of cocaine or methamphetamine trickling into the mouth from nasal ingestion - Severe bowel gangrene from ingesting cocaine as a result of reduced blood flow - Severe allergic reactions at injection sites - Serious respiratory complications, including pneumonia, hemorrhage, and respiratory failure from smoking - Facial and body sores from scratching, sometimes leading to infections - Extreme weight loss and malnutrition - Strokes - Heart infections - Lung disease - Kidney damage - Liver damage - When used by a pregnant woman, increased risk of: - Placental separation and hemorrhage - Premature birth - Birth defects, including cardiac defects, cleft palate, club foot - Fetal brain hemorrhage and stroke - Overdose risk: - Seizures - Severely elevated body temperature - Stroke - Severe dehydration (especially when mixed with alcohol), leading to heatstroke, muscle damage, and kidney failure - Seizures - In high doses, can interfere with the body's ability to regulate temperature - On rare but unpredictable occasions, can lead to a sharp increase in body temperature, which can result in liver, kidney, and cardiovascular system failure and death - Increased heart rate and blood pressure can cause serious cardiovascular problems in susceptible individuals - Can interfere with its own metabolism (breakdown within the body), allowing potentially harmful levels to be reached by repeated MDMA administration in short periods - Research in animals indicates that MDMA can be harmful to the brain. One study in nonhuman primates showed that exposure to MDMA for only 4 days caused damage to serotonin nerve terminals that was evident 6 to 7 years later. - Extreme lack of energy and motivation and need for sleep - DepressionWithin a few days of abstinence Symptoms lessen - Energy returns Starting within 5 to 7 days of abstinence and lasting for weeks or months - Severe drug cravings - Energy level drops again - Anhedonia (lack of feelings of pleasure) - Increased depression - Loss of motivation, initiative - Vivid, unpleasant dreams - Insomnia - Psychomotor agitation - Increased appetite - To treat anxiety, acute stress reactions, panic attacks, and sleep disorders - To control seizures - As muscle relaxants - In medically managed alcohol withdrawal - As presurgery sedation - Desirable" Effects of Depressants - Relaxation - Decreased anxiety - Decreased inhibitions - Sense of well-being - Mild euphoria - Poor concentration - Muscle weakness - Lack of coordination - Slurred speech - Dizziness - Slowed reflexes - Nausea and vomiting - Impaired judgment - Mental confusion - Memory loss - Emotional blunting - May cause or aggravate depression - Respiratory depression can occur at high doses or when combined with other depressant drugs, particularly alcohol - Those who use benzodiazepines chronically may experience paradoxical effects at high doses; these effects include aggressive behavior, agitation, and lack of inhibition instead of the typical sedation and anti-anxiety effects - Depressants are sometimes primary drugs of abuse. However, they are most commonly abused along with other substances to enhance desired effects or to counter undesirable effects. For example: - Benzodiazepines have effects similar to alcohol, and some people take them when they drink to enhance the effect. This use is highly dangerous because the risk of potentially fatal respiratory depression is greatly increased. - People who abuse stimulant drugs often take a depressant to "come down" from excess stimulation or to sleep following a stimulant binge. This combination is associated with spasms of coronary heart muscle that can damage the heart. - People addicted to heroin often use depressants when they can't get heroin to ease withdrawal symptoms. - Drug craving - Headache - Tremors and muscle twitches - Nausea and vomiting - Anxiety - Restlessness - Yawning - Rapid heart rate and increased blood pressure - Muscle cramps - Sleep problems - Hallucinations - Multiple seizures, which can be fatal - Peyote buttons or psilocybin mushrooms can be chewed or brewed into tea. - Mescaline or psilocybin also can be taken orally in capsule form. - LSD is taken orally. - Heightened sensory experiences (e.g., brighter colors, sharper visual definition, increased hearing acuity, more distinguished taste) - Vivid mental images and distorted vision - Altered space and time perception - Joy, exhilaration - Distorted sense of body (feeling either weighed down or weightless) - Loss of sense of reality; melding past experiences with present - Preoccupation with trivial thoughts, experiences, or objects - Intense emotions - Altered sense of time and self - Synesthesia: Experiences seem to cross over different senses, giving the user the feeling of hearing colors and seeing sounds - Dreaminess - Introspection - Hallucinations Side Effects of Hallucinogens - Intense nausea and vomiting (very common with peyote) - Appetite suppression - Elevated body temperature and sweating - Chills and shivering - Highly adverse reactions ("bad trip"), including frighten in hallucinations, confusion, disorientation, paranoia, agitation, depression, panic, and/or terror - Difficulty focusing, maintaining attention, concentrating, and thinking - Dilated pupils - Increased body temperature - Increased heart rate and blood pressure - Sweating - Loss of appetite - Sleeplessness - Dry mouth - Tremors - Highly adverse reactions ("bad trip"), including frightening hallucinations, confusion, disorientation, paranoia, agitation, depression, panic, and/or terror - Impaired reasoning and loss of judgment leading to extremely dangerous behavior - Worsening symptoms of existing mental illness or causing earlier onset of psychosis in a susceptible individual - Flashbacks or recurrences of certain aspects of the drug experience; flashbacks occur suddenly, often without warning, and may occur within a few days or more than a year after LSD use; in some individuals, the flashbacks can persist and cause significant distress or impairment in social or occupational functioning, a condition known as hallucinogen-induced persisting perceptual disorder - Possible prolonged psychotic state similar to that of paranoid schizophrenia in susceptible individuals - Oral - Sprinkled on marijuana and smoked - Inhaled intranasally - Both are dissociative drugs, meaning that they distort perceptions of sight and sound and produce feelings of detachment (dissociation) from the environment and self - Feelings of strength and power - Relaxation - Mild euphoria **Side Effects of Dissociative Anesthetics** - Mood disturbances: anxiety and depression - Shallow breathing and increased breathing rate - Flushing - Sweating - Numbness in extremities - Nausea and vomiting - Loss of coordination - Decreased pain response - Blurred vision - Delirium (hallucinations or disorientation) - Increased heart rate and blood pressure - Impaired motor function - Numbness - Depression - Dizziness - Anger, aggression, and violence - Seizures - PCP causes symptoms that mimic schizophrenia, such as delusions, hallucinations, paranoia, disordered thinking, and a sensation of distance from one's environment - Because PCP can have depressant effects, interactions with other depressants, such as alcohol and benzodiazepines, can lead to respiratory depression and coma - People who have abused PCP for long periods have reported memory loss, difficulties with speech and thinking, depression, and weight loss; these symptoms can persist up to 1 year after stopping PCP abuse - Severe depression with suicidal thoughts and attempts - Injuries from accidents and fights - Industrial or household products, including paint thinners or removers, degreasers, dry-cleaning fluids, gasoline, and lighter fluid - Art or office supply solvents, including correction fluids, felt-tip marker fluid, electronic contact cleaners, and glue - Aerosols: Sprays that contain propellants and solvents: - Household aerosol propellants in items such as spray paints, hair or deodorant sprays, fabric protector sprays, aerosol computer cleaning products, and vegetable oil sprays - Gases: Found in household or commercial products and used as medical anesthetics: - Household or commercial products, including butane lighters and propane tanks, whipped cream aerosols or dispensers (whippets), and refrigerant gases - Medical anesthetics, such as ether, chloroform, halothane, and nitrous oxide - Nitrites: A special class of inhalants that are used primarily as sexual enhancers - Organic nitrites are volatiles that include cyclohexyl, butyl, and amyl nitrites, commonly known as "poppers" - Sniffing fumes directly from the container - Spraying aerosols directly into the nose or mouth - Placing an inhalant-soaked rag in the mouth - Inhaling fumes from a balloon or a plastic or paper bag that contains the inhalant - Amyl nitrite is still used in certain diagnostic medical procedures - Nitrous oxide is used as an anesthetic, particularly for dental procedures - Desirable" Effects of Inhalants - Euphoria - Giddiness - Lessened inhibition and anxiety - Hallucinations **Side Effects of Inhalants** - Headache - Confusion - Nausea and vomiting - Drowsiness - Slurred speech - Lack of coordination - Hearing loss (spray paints, glues, de-waxers, dry-cleaning chemicals, correction fluids) - Peripheral neuropathies or limb spasms (glues, gasoline, whipped cream dispensers, gas cylinders) - Central nervous system or brain damage (spray paints, glues, de-waxers) - Bone marrow damage (gasoline) - Liver and kidney damage (correction fluids, dry-cleaning fluids) - Blood oxygen depletion (varnish removers, paint thinners) - Smoked (in a pipe or rolled into cigarette papers or cigars). Hashish oil is typically dripped onto dry marijuana to increase potency. The effects of smoking are typically felt within a few minutes and generally wear off within 2 to 3 hours. - Oral (mixed with food or brewed into tea). When substance is eaten, effects typically do not appear for 30 to 60 minutes but can last up to 6 hours. - Physical relaxation, sedation - Exaggerated mood - Heightened empathy for others - Heightened suggestibility - Heightened novelty: even mundane objects seem interesting - Giddiness - Changes in sensory and time perception - "Trailing" phenomenon (seeing afterimages of a moving object) - Increased appetite - Increased heart rate and blood pressure - Bloodshot eyes (resulting from increased blood flow through mucous membranes in the eyes) - Decreased muscular coordination - Poor depth perception and tracking (ability to follow a moving object) - Lung irritation and coughing - Difficulty thinking and solving problems - Panic reactions (pounding heart, extreme anxiety and fear, sweating, dizziness) - Chronic cough and bronchitis - Damaged lung tissue - Increased phlegm production and reduced ability to clear it - Frequent respiratory illnesses - Decreased cognitive/intellectual functioning - Delayed emotional development - Suppressed immune function that can lead to increased susceptibility to viral and bacterial infections and can accelerate progression of HIV/AIDS - Problems with short-term memory and learning that can last for days or weeks after last use - At high doses, acute psychotic reactions in susceptible individuals, including triggering chronic schizophrenia in those genetically predisposed - Long-term use may lead to amotivational syndrome: reduced energy and ability to concentrate, reduced desire to work, reduced interest in social or other activities - At high doses, marijuana may worsen clinical depression - Irritability - Sleeplessness - Decreased appetite - Symptoms begin within about 1 day following abstinence, peak at 2 to 3 days, and subside within 1 or 2 weeks. - Fresh leaves and soft twigs are chewed - Less commonly, it can be consumed as a tea or smoked - Mild euphoria - Alertness - Excitement - Energy - Loss of appetite - Sexual dysfunction - Insomnia - Gastrointestinal problems (such as constipation) - Oral inflammation - Oral cancer - Depression - Increase in severity of psychological problems - If khat is used during pregnancy, the baby may be born smaller than other babies - Chewing khat appears to reduce breast milk production - Minor laziness - Mild depression - Nightmares - Slight tremor - Extreme tiredness and lack of energy - Difficulty performing normal daily activities - Slight trembling several days after having stopped chewing khat **Social Stigma** - Stigma is defined as a mark, a sign, a deeply discrediting and dishonorable attribute that reduces someone from a whole and usual person to a tainted, discounted one. It is an attribute, behavior, or reputation which is socially discrediting in a particular way: - it causes an individual to be mentally classified by others in an undesirable, rejected stereotype rather than in an accepted, normal one. - It is defined as a special kind of gap between virtual social identity and actual social identity. - Stigma can arise when certain social processes co-occur within a power dynamic: - labeling (assignment of social categories - stereotyping (labels are related to stereotypes) - separating (them-us) - It is important to note that, both public and private institutions, including treatment programs, also play a role in building stigma for people using substances. It is therefore of paramount importance that institutions review their practices, reflect on their conceptualizations regarding the population to be served and develop education and training initiatives. - Discrimination, occurs when individuals with SUDs are perceived as less valued and treated unjustly (i.e., discriminated against) by others. Discrimination can occur either when individuals treat another person unfairly, or when institutional practices disadvantage individuals with SUDs. - Social stigma often leads to status loss, discrimination, and exclusion from meaningful participation in society - Stigma tends to arise when the true nature of a condition is not understood. Stigma can interfere with effective treatment of any disease, including substance use disorders (or SUDs). For example: - Stigma is a difficult aspect of addiction, as it becomes more complex for individuals and families to deal with their problems and get the help they need. People who are stigmatized often internalize the rejection that stigma carries, transforming it into shame. - The authors of the University of Nevada study found that people who feel they have to cope with an addiction alone (what they called "secrecy coping") had poorer mental health that appeared to decrease their chances of recovery. - Secrecy coping also can make accessing treatment more difficult. For example, fear often prompts adolescents to hide a substance problem from their parents. When parents do find out, stigma can make them feel guilty and ashamed. They then may find it harder to fight for the care and resources their child urgently needs. - Treatment systems and helpers are not immune from prejudice. Treatment professionals also may unthinkingly stigmatize clients with the language they use and other negative attitudes towards clients.1 - Health professionals generally had a negative attitude towards patients with substance use disorders. They perceived violence, manipulation, and poor motivation as impeding factors in the healthcare delivery for these patients. - Health professionals also lacked adequate education, training and support structures in working with this patient group. - Negative attitudes of health professionals diminished patients' feelings of empowerment and subsequent treatment outcomes. - Health professionals are less involved and have a more task-oriented approach in the delivery of healthcare, resulting in less personal engagement and diminished empathy. - Similarly, terms like "clean" and "dirty" reinforce stigma. When clean is used to describe someone in recovery, it implies that he or she once was dirty. When these terms are used to describe the positive or negative results of a drug test, which should be associated to the symptoms of a disease, they are associated to dirt, reinforcing the stigmatizing language. - One way to avoid using stigmatizing language is to remember to put people first: - Person with a substance use disorder; - Person who injects drugs; or - Person with addiction. - The terms "client" and "patient" describe a person's current status in treatment, and not who they are as individuals. The perception that those with addiction are somehow less than human, or worthless, can: - There are no easy ways to address stigma, but being aware of the effects of stigma and working to recognize and deal with negative thoughts and feelings toward those who are addicted can lead to more positive outcomes for individuals and, eventually, society. - Counselors who work with people with addiction are not immune to feelings of prejudice. Honestly evaluating your own attitudes and feelings can help you work more effectively with your clients.Avoiding Stigmatic Language on SUD Treatment - The terms counselors use to refer to their clients and families matter! Calling someone an "addict" dehumanizes that person and can link a substance use disorder to their individual identity. A person is not defined by their illness or health condition. - Stigmatizing language can negatively influence health care provider perceptions of people with SUD, which can impact the care they provide the way people with SUD see themselves and how they are treated by society as a whole. It is important to remember that a substance use disorder should be treated as a medical condition. - Shifting language to more accurately reflect the nature of the health condition can lead to wider support of life-saving interventions. - Clinicians are typically the first points of contact for a person with an SUD, health professionals should "take all steps necessary to reduce the potential for stigma and negative bias." Take the first step by learning the terms to avoid and use. When talking to people with SUD, their loved ones, and your colleagues, use non-stigmatizing language that reflects an accurate, science-based understanding of SUD and is consistent with your professional role. Some actions to take: - Training physicians, nurses, nurse practitioners, physician assistants, and emergency department staff in providing compassionate care to patients who may display the difficult, sometimes frightening behaviors associated with drug addiction and withdrawal. - To promote awareness of addiction as a chronic relapsing (and treatable) brain disease. - This effort should include promoting understanding of the disease's behavioral consequences as well as of the factors that make certain people particularly vulnerable. Susceptibility to the brain changes leading to compulsive substance use is substantially modulated by genetic, developmental, psychiatric, and social factors, many of which are out of the person's control. - In medicine the term drug refers to any substance with the potential to prevent or cure a disease or the potential to enhance physical or mental well-being - In pharmacology (the study of drugs and drug action), the term refers to any chemical agent that alters the biochemical or physiological processes of body tissues or organisms. - In common usage, the term drug often refers to a substance that is used for - nonmedical (e.g., recreational) reasons. Individuals with addiction may suffer a range of consequences: - Studies have demonstrated that women are more sensitive to the consumption and long-term effects of alcohol and drugs than are men. Women experience an effect called "telescoping," meaning they tend to progress faster than do men from initial use to addiction and to substance-related consequences, even when using a similar - or smaller amount of substances.1 - For example, women who drink are at greater risk than are men for developing cirrhosis and other medical problems, and they develop these problems sooner than do men. One reason for this appears to be that women have less water in their bodies than do men, and they metabolize alcohol in a way that leads to higher blood alcohol levels with comparable intake and body weight. - Much of the research on women has been done regarding alcohol consumption, but newer research suggests that there is a similar pattern of rapid progression with illicit drugs. For example, a study of women in treatment found that women had used opioids and cannabis for fewer years than men did before entering treatment. The women also reported more severe psychiatric, medical, and employment complications than did men. Rockville - Fetal effects generally range from low birth weight to developmental behavioral and cognitive deficits. - Impaired attention, language, and learning skills, as well as behavioral problems, have been seen in children exposed to cocaine and marijuana. - Methamphetamine exposure has been associated with fetal growth restriction, decreased arousal, and poor quality of movement in infants. - Untreated heroin exposure without prenatal care could result in infants needing to go through painful withdrawal after birth. Heroin exposure also has been associated with low birth weight---an important risk factor for delayed development. - Neonatal Abstinence Syndrome(NAS) can be seen with the use of opioids, alcohol, caffeine and some sedatives. - Symptoms of NAS in a newborn can develop immediately or up to 14 days after birth. - Some of these symptoms include blotchy skin coloring, diarrhea, excessive or high pitched crying, fever, increased heart rate, irritability, poor feeding, rapid breathing, seizures, sleep problems, slow weight gain, trembling, vomiting. - Differing Physiological Responses: Youth - Early drug use increases a person's chances of developing substance use-related disorders. - Young people also are particularly vulnerable to physical and social problems related to substance use. Some of this vulnerability is due to the effects of substances on a still-maturing brain and body. - Drug and alcohol abuse can disrupt brain function in areas critical to motivation, memory, learning, judgment, and behavior control. All of these functions continue to mature into adulthood. So, it is not surprising that teens who abuse alcohol and other drugs often have family and school problems, poor academic performance, and health- related problems (including mental health). They may also be involved in the criminal justice system. - One of the brain areas still maturing during adolescence is the prefrontal cortex---the part of the brain that enables us to assess situations, make sound decisions, and keep emotions and desires under control. - The fact that this critical part of an adolescent's brain is still a work in progress puts them at increased risk for making poor decisions (such as trying drugs or continuing drug abuse). - Introducing drugs while the brain and body are developing may have profound and long- lasting consequences. 1. **Cognitive-Behavioral Therapy** - CBT merges two treatment models---cognitive therapy and behavioral therapy. - Cognitive therapy, originally developed by Aaron Beck to treat depression, is based on the theory that people often have beliefs, assumptions, and automatic thoughts that influence their behavior but may be unhelpful and unrealistic. - Cognitive therapy proposes that a person's thoughts and interpretations cause feelings and behaviors. - A core belief in cognitive therapy is that people can improve the way they think (and feel and act), even if the situation does not change. - Behavioral therapy, first conceptualized by Ivan Pavlov and refined by B. F. Skinner and others, treats emotional and behavioral disorders as learned responses that can be replaced by healthy ones with appropriate training. - Behavioral therapy helps people identify behavior that is not helping them and try out new ways of behaving. - Behavioral therapy can include a range of relaxation and coping techniques. - CBT is based on the belief that a client can be helped to recognize and discard learned self-defeating thoughts, emotions, and behaviors that are causing dysfunction in his or her life. - Although other therapy models attempt to address why an individual does what he or she does, the questions that are central to CBT are: - What keeps them doing it? - How do they change? - The what question addresses the reinforcers that maintain patterns of thought, affect, and behavior. The how question relates to building skills. - The CBT approach to treating SUDs focuses on teaching clients skills that help them recognize and reduce risks of relapse, maintain abstinence, solve problems, and - Homework is a major part of CBT approaches. Clients are given reading assignments, asked to keep track of certain behaviors and thoughts, and asked to practice new skills. - CBT also is applied to other challenges in recovery, such as repairing relationships and coping with emotions. - One specific type of CBT approach is cognitive-behavioral coping-skills therapy,originally developed for work with clients with alcohol use disorders. - Coping skills therapy is a structured, manual-based approach. - Each session of coping skills therapy includes discussion of the rationale, specific skill guidelines, behavioral rehearsal role plays, and other practice exercises for a particular topic, including: - Managing thoughts about substances and using; - Solving problems; - Substance refusal skills; - Planning for emergencies and coping with a lapse; and - Seemingly irrelevant decisions - Motivational approaches (motivational interviewing \[MI\] and motivational enhancement therapy \[MET\]) are based on the perspectives that change occurs in stages, motivation for change varies over time, and motivation can be enhanced. - Motivational approaches are based on the principles of motivational psychology and the trans-theoretical model of change, also known as the stages of change model, which was developed by James Prochaska and Carlos DiClemente - Motivational counseling approaches are methods of counseling that are client-centered and use nondirective methods. These approaches use strategies that: - Acknowledge that substances of abuse have rewarding properties that can disguise, at least temporarily, their hazards and negative long-term effects; - Help clients resolve ambivalence about engaging in treatment and stopping substance use; - Use the internal motivation of clients to evoke and sustain rapid change; and Are not focused on a counselor's discovery, interpretation, and guidance. - Motivational approaches operate in the belief that change is created through the - Motivational approaches frequently include other problem-solving or solution-focused strategies that build on clients' past successes. - The counselor acts as a coach or consultant rather than as an authority figure. **Primary techniques** - Through empathic listening and skillful interviewing, the motivational counselor - encourages the client to: - Identify discrepancies between significant life goals and the consequences of SUDs; - Believe in his or her capabilities for change; - Choose among available strategies and options; and - Take responsibility for initiating and sustaining healthful personal behavior. - Counselors pose questions to clients in a way that solicits information while strengthening clients' motivation and commitment to positive change. - FRAMES approach - The FRAMES acronym reminds a motivational counselor of his or her role and responsibilities during treatment. - Decisional balance exercises - is the concept of exploring the pros and cons---or benefits and disadvantages---of change. In the context of recovery from substance use, the client weighs the pros and cons of changing versus not changing substance-using behavior. The purpose of exploring the pros and cons of a substance use problem is to tip the scales toward a decision for positive change. - Identifying discrepancies- One way to enhance motivation for change is to help clients recognize a discrepancy or gap between their future goals and their current behavior. - The counselor might clarify this discrepancy by asking, How does your drinking fit in with having a happy family and a stable job. - Pacing - Every client moves through the stages of change at his or her own pace. - The concept of pacing requires that a counselor meet a client at the client's level and use as much or as little time as is necessary with the essential tasks of each stage of change. For example, some clients may need frequent sessions at the beginning of treatment and fewer later. If a counselor pushes a client at a faster pace than the client is ready to take, the relationship between counselor and client may break down. - Personal contact with clients not in treatment - Motivational interventions can include simple activities designed to enhance continuity of contact between counselor and client and strengthen the relationship. Activities can include personal handwritten letters or telephone calls from counselor to client. Research has shown that these simple motivation-enhancing interventions are effective for encouraging clients to return for another clinical consultation, to return to treatment following a missed appointment, to stay involved in treatment, and to increase treatment adherence. - Motivational Interviewing (MI) is a counseling technique or style that focuses on creating a favorable climate for change. - The essence of motivational interviewing is in its collaborative nature, communicating in a partner-like relationship, where the interviewer seeks to create a positive interpersonal atmosphere. - There are five primary principles in MI. These are not steps, but concepts to be applied at all times to enhance the relationship between the counselor and the client. They are often summarized by the acronym READS: - Roll with resistance; - Express empathy; - Avoid argument; - Develop discrepancy; and - Support self-efficacy. - To carry out these five principles, there are four basic therapeutic skills or methods an - Reflective listening or responding to a client's statement by stating back to her or him the essence or a specific aspect of what was said; - Asking open-ended questions; - Affirming; and - Summarizing. - This approach is also primarily client-centered, but counseling sessions are planned and directed by the counselor. - In SUD treatment, MET counselors seek to alter the harmful use of drugs and alcohol. - In MET problems are viewed as behaviors at least partially under the voluntary control of the client. Thus, they follow the normal principles of behavior change. - Motivational Enhancement Therapy is based on principles of cognitive and social psychology. The MET counselor: - Seeks to help the client perceive a discrepancy between current behavior and significant personal goals; and - Emphasizes the client's self-motivational statements regarding both the desire for and the commitment to change. - Although simple family involvement is not a specific "model" of treatment, research shows that family involvement in treatment enhances outcomes. - Most programs offer family education, family support groups, and family counseling as part of their approach. Some programs, particularly those focusing on adolescent, - Family-based services ensure that family functioning adjusts to and positively influences the recovery of the client. - One main goal of involving families in treatment is to increase family members' understanding of the client's substance use disorder as a chronic disease. - Family-based services can: - Increase family support for the client's recovery. Family sessions can increase a client's motivation for recovery, especially as the family realizes that the client's substance use disorder is intertwined with problems in the family. - Identify and support a change of family patterns that works against recovery. - Relationship patterns among family members can work against recovery by supporting the client's substance use, family conflicts, and inappropriate coalitions. - Prepare family members for what to expect in early recovery. Family members unrealistically may expect all problems to dissipate quickly, increasing the likelihood of disappointment and decreasing the likelihood of helpful support for the client's recovery. - Educate the family about relapse warning signs. Family members who understand warning signs can help prevent the client's relapses. - Help family members understand the causes and effects of substance use disorders from a family perspective. - Take advantage of family strengths. Family members who demonstrate positive attitudes and supportive behaviors encourage the client's recovery. It is important to identify and build on strengths to support positive change. - Encourage family members to obtain long-term support. As the client begins to recover, family members need to take responsibility for their emotional, physical, and spiritual recovery. - While families can be critical to the success of a client with SUDs, some family members may actually need treatment themselves before they can be such a helpful resource for clients. Many clients are from families that are particularly chaotic and dysfunctional or have multi-generational substance use disorders, mental disorders, and other problems. - Behavioral couples therapy (BCT); - Multisystemic therapy (MST) for adolescents; and - Multidimensional family therapy (MDFT) for adolescents. - The spouse or partner gains an active role in the treatment, minimizing the sense of - helplessness that often comes with living with a person with an SUD. - Partners generally attend 15 to 20 hour-long sessions over 5 to 6 months. Sessions - The therapist asks about any substance use since the last session; - The couple discusses compliance with the recovery contract; - The couple presents and discusses homework assigned at the last session; - The couple discusses any relationship problems since the last session; - The therapist presents new material; and - The therapist assigns new homework. - BCT is typically used as an adjunct to other SUD treatment approaches. - MST is an intensive, in- home and in-community approach that focuses on changing the thinking and behavior of both parents and adolescents. - Traveling to the family overcomes the high dropout rates of other treatments, which often occur because of the difficulty caregivers face in getting adolescents to appointments. - The approach primarily uses cognitive-behavioral and social-development (risk and protective factors) strategies. - MST focuses on a family's strengths to facilitate positive change. - Interventions are designed to promote responsible behavior and decrease irresponsible actions by family members. - Interventions focus on the present: what is happening currently in the adolescent's life. Counselors look for action that can be taken immediately, targeting specific, welldefined problems rather than gaining insight or focusing on the past. - Interventions target sequences of behavior within and between the various interacting elements of the adolescent's life---family, teachers, friends, home, school, and community---that sustain the identified problems. - A key developmental emphasis is on building the adolescent's ability to get along well with peers and acquire academic and vocational skills that will promote a successful transition to adulthood. - MST counselors do not label families as resistant, not ready for change, or unmotivated; their approach avoids blaming the family but rather places the responsibility for positive treatment outcomes on the MST team. - Interventions are designed to empower caregivers to address the family's needs after treatment ends. The caregiver is seen as the key to long-term success. - MDFT views adolescent drug use in terms of a network of influences (individual, family, peer, community) and suggests that reducing unwanted behavior and increasing desirable behavior occur in multiple ways in different settings. - Treatment includes individual and family sessions held in a treatment center, in the home, or with family members at schools, courts, or other community locations. - During individual sessions, the therapist and adolescent work on important developmental tasks, such as developing decision-making, negotiation, and problemsolving skills. - Adolescents acquire vocational skills and skills in communicating their thoughts and feelings to deal better with life stressors. - Parallel sessions are held with family members. Parents examine their particular parenting styles, learning to distinguish influence from control and to have a positive and developmentally appropriate influence on their children. - Contingency management (CM) is based on operant conditioning theory and was developed out of applied behavioral analysis and behavior therapy. - Its roots are grounded in the 1950s work that students of B. F. Skinner did when they applied operant conditioning principles to the treatment of serious conditions (for example, those with schizophrenia, juvenile justice populations) using "token economies" - Operant conditioning theory maintains that future behavior is based on the positive or negative consequences of past behavior. - For example, drug use is maintained by the positively reinforcing effects of the drug - Healthier lifestyle; - Employment; - Educational opportunities; and - Maintaining positive relationships. - However, it typically takes a long time before internal rewards are experienced by a client attempting to make such significant behavioral changes. - So, abstinence in and of itself, may not be sufficiently reinforcing to maintain a person's motivation to stop using drugs, particularly in early abstinence. Other rewards must be found that reinforce ongoing abstinence and lifestyle change. - CM motivates clients' behavioral change and reinforces abstinence by systematically rewarding desirable behaviors and ignoring or punishing others. - Reinforcers are typically positive, pleasurable, and rewarding events or objects, but some negative reinforcers also are effective. - Removing a fine or restriction after a client has complied with a specified regimen is an example of negative reinforcement. - Several basic types of incentive programs have been researched: - Contingent access to clinic privileges: In a clinical setting, clients are allowed to use privileges that already exist within that setting; level systems are designed such that once a level is achieved, the client immediately earns all the privileges for that level and the levels lower than it. - Onsite prize distribution: Tangible or material goods are distributed when a desired behavior is exhibited, based on how long the behavior has been exhibited. - Vouchers or some other token economy systems: Points or vouchers, which can be redeemed for goods or privileges, are given for consistently engaging in specific activities or for meeting specific treatment plan goals. - Refunds or rebate: Clients pay a fee on entering treatment, but they receive a refund if they complete treatment and remain abstinent. - A challenge of contingency management programs is to identify a reward for a desired behavior that is both practical and sufficiently powerful---over time---to replace or substitute for the potent, pleasurable, or pain-reducing effects of the drug. The reward also must be available without too much cost or expenditure of staff energy. - One type of contingency management, community reinforcement (CR), uses social, recreational, familial, and vocational reinforcers rather than material rewards or withinprogram privileges to make an abstinent lifestyle more rewarding than substance use. - CR is based on the premise that environmental contingencies can be highly effective in changing substance use behavior. A strong case management component is essential to using the CR approach. - One form of CR, community reinforcement approach plus vouchers, has been documented as an EBP. The original model was an intensive 24-week outpatient therapy for treatment of cocaine and alcohol addiction. There were two primary treatment goals: - To maintain abstinence long enough for clients to learn new life skills to sustain that sobriety; and - To reduce alcohol consumption for clients whose drinking is associated with cocaine use. - In this program, clients attended one or two individual counseling sessions each week focusing on: - Improving family relationships; - Learning a variety of skills necessary for reducing drug and alcohol use; - Receiving vocational counseling; and - Developing new recreational activities and social networks. - Vouchers were also provided for cocaine-negative test samples, and increased in - Clients' engagement in treatment; and - Systematically gain increasing periods of cocaine abstinence. - Medications are available for treating dependence on alcohol, opioids, and nicotine. - These medications generally need to be prescribed by a medical practitioner, though medications for nicotine dependence are available without a prescription. - One of the widest used and best known forms of pharmacotherapy is methadone maintenance therapy for opioid dependence. - Pharmacotherapy is typically used along with counseling and other treatment services, not in place of them. - Treatment that includes medication is often the best choice for opioid addiction. - MAT uses one of three medications---naltrexone, buprenorphine, or methadone---to treat addiction to heroin or other opioid drugs. - Naltrexone blocks all the effects of opioids, preventing a person from getting high. - Client compliance with naltrexone therapy is often a problem, and naltrexone has seldom been used. The newer injectable form of naltrexone (Vivitrol®) was recently approved in the United States for use with opioid dependence, which may increase its use. - Buprenorphine (Subutex®) reduces or eliminates withdrawal symptoms associated with opioid dependence but, at proper doses, does not produce the euphoria and sedation caused by heroin or other opioids. - At high doses, buprenorphine can produce euphoria, so is often combined with naloxone, a medication that blocks these effects, into a formulation called Suboxone®to avoid this potential problem. - Methadone is the best know and most widely used medication for opioid treatment. - Methadone may be used short term, as an aid to withdrawal, or over a long period (maintenance or substitution therapy). - Methadone is on the WHO's list of essential medications. - Maintenance treatment is usually conducted in specialized settings (for example, methadone maintenance clinics). - In some countries, clients who are stabilized on methadone and have participated in counseling services are allowed to receive take-home doses for a few days or a week at a time. - Admitting there is a problem; - Seeking help; - Engaging in a thorough self-examination; - Making a confidential self-disclosure; - Making amends for harm done; and - Helping others who want to recover. - Twelve-Step Facilitation Therapy focuses on helping clients understand AA/NA principles, start working through the 12 steps of recovery, learn about and accept their addiction, achieve abstinence, and become involved in community-based 12-Step groups. - Group work focuses on accepting the disease, assuming responsibility for the recovery process and one's actions, renewing hope, establishing trust, changing behavior, practicing self-disclosure, developing insights into one's behavior, and making amends. - Clients are encouraged strongly to: - Accept their addiction; - Develop or adopt spiritual values; - Develop a sense of fellowship with others in recovery; and - Attend meetings in the community. - Establishing client-facilitator rapport; - Conducting a collaborative assessment of drug abuse (history); - Discussing the client's efforts to stop or control use; - Discussing negative consequences associated with use; - Sharing a diagnosis with the client and attempting to have it be a collaborative decision; - Outlining the program; and - Attempting to get a commitment from the client to give the program and AA/NA a try and to keep an open mind. - Each regular session begins with a 10-minute discussion of the client's "recovery - Any use that occurred; - Any urges to use that the client experienced; - Reactions to recovery tasks and other specific suggestions made at the end of the last session; - Reactions to meetings attended; and - Overall progress in getting active in AA or NA. - Since the program is based on the principles of 12-Step fellowships, the counselor must work within this framework. For example, participation in self-help groups is central and is regarded as the primary agent of change. Specific objectives include: - Attending 90 AA or NA meetings in 90 days; - Getting and using members' phone numbers; - Getting a sponsor; and - Assuming responsibilities within a meeting. - The Matrix model was developed during the 1980s as an effective way to treat people dependent on stimulant drugs, particularly cocaine and methamphetamine. - The model has been modified to include treatment for people who use other drugs, - Matrix is a manual-based program. The manual materials, including handouts for clients that form the basis of therapeutic sessions, were selected through a behavioral analysis of the type of problems encountered by cocaine and methamphetamine users as they proceeded through periods of cocaine abstinence. - The Matrix model integrates several research-based techniques (including cognitivebehavioral, motivational enhancement, education, and family approaches) to target clients' behavioral, emotional, cognitive, and relationship issues. - The Matrix approach includes: - Establishing a strong therapeutic relationship between the client and counselor; - Teaching clients how to structure time and live an orderly and healthful lifestyle; - Providing accurate, understandable information about addiction; - Providing opportunities to learn and practice relapse prevention and coping techniques; - Involving family and significant others in the therapeutic and educational processes to gain their support for---and prevent their sabotage of---treatment; - Encouraging clients to participate in community-based support groups; and - Conducting random urinalyses or breath tests to assess treatment effectiveness. - Detailed treatment manuals contain worksheets for individual sessions; other components include family education groups, early recovery skills groups, relapse prevention groups, combined sessions, urine drug tests, 12-Step program attendance, relapse analysis, and social support groups. - The elements of the Matrix treatment approach are a collection of group sessions (early recovery skills, relapse prevention, family education, and social support) and 3 to 10 individual sessions delivered over a 16-week intensive treatment period. Specifically during those 16 weeks, the Matrix model requires: - Three individual/conjoint family sessions; - Eight early recovery skills group sessions; - Thirty-two relapse prevention group sessions; - Twelve family education group sessions; and - Thirty-six social support group sessions. - Clients can begin attending social support groups, which focus on continuing care, once they have completed the 12-session family education group but are still attending the relapse prevention group sessions. The Matrix program has found that overlapping the social support group attendance with the intensive phase of treatment helps ensure a smooth transition to the 36-week continuing care phase.