Transcript The Science Based Treatment of Methamphetamine Addiction

The Many Faces of
Methamphetamine: Addiction,
The Family and The
Community
Cardwell C. Nuckols, PhD
[email protected]
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
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”
Bottom Line
It’s All About Food, Water
and Sex!
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
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
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.
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
Frontal (Executive) Cortical
Functions
 Focus attention
 Prioritize
 Exclude extraneous
information
 Suppress primitive
urges
 Reduce impulsivity
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
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
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
End Organ Toxicity
 Central Nervous System
 Cardiovascular System
 Pulmonary System
 Renal System
 Hepatic
 Fetal Development
Central Nervous System
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Acute psychosis
Chronic psychosis
Strokes
Seizures
Cardiovascular System
 Myocardial Infarctions
 Arrhythmias
 Cardiomyopathy
Pulmonary System
 Acute Pulmonary
Congestion
 Chronic Obstructive
Lung Disease
Renal/Hepatic Failure
 Renal failure
 Hepatic Failure
Fetal Development
 Exposure early in pregnancy
 Fetal death
 Small size for gestational period
 Exposure later in pregnancy
 Learning Disabilities
 Poor social adjustment
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
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 seconddegree criminal mistreatment
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
Lab Seizure Locations
 Most common locations
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Single family houses
Apartments
Mobile homes
Vehicles
Garages
Trailers
Motels/hotels
Businesses
Stove Top Labs
 Cookers make small amounts using household
equipment and chemicals
 The active ingredient
 Ephedrine or pseudoephedrine
 Chemical ingredients
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Trichloroethane (gun scrubber)
Ether (engine starter)
Methanol (gasoline additive)
Gasoline
Kerosene
Stove Top Labs
 Chemical ingredients
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Lithium (camera batteries)
Anhydrous ammonia (farm fertilizer)
Red phosphorus (matches)
Iodine (veterinarian product)
Muriatic acid
Campfire fuel
Paint thinner
Stove Top Labs
 Chemical ingredients
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Acetone
Sulfuric acid (drain cleaner)
Table salt/rock salt
Sodium hydroxide (lye)
Sodium metal (can be made from lye)
Alcohol (rubbing/gasoline addictive)
Household Equipment
 Coffee filters
 Rubber gloves
 Tempered glass baking dishes
 Glass or plastic jugs
 Bottles
 Measuring cups
Household Equipment
 Funnels
 Blenders
 Hotplate
 Strainer
 Propane cylinder
 Aluminum foil
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
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.
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
Stimulant Toxicity
 Increased levels of
Norepinephrine and
Dopamine
 Hyper-arousal
 Pleasure
 Paranoia
 Increased levels of
Serotonin
 Reduced hunger
 Difficulty sleeping
Stimulant Crash
 Reduced levels of Norepinephrine and
Dopamine
 Dysphoria
 Depression
 Anhedonia
 Reduced levels of Serotonin
 Mood swings
 Sleep disturbances
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)
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:
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Boredom
Loneliness
Fear
Anxiety
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
Craving Management
 Psychotherapy
 Behavior Therapy
 Structure
 Recovery Foundation Program
 Changing patterns
 Safety Plan
 Pharmacological
 Acute
 Maintenance
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.”
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
Behavioral Foundation Program
TAS
K
SH
TX
FUN
NUT
PEX
MON TU
WED THU FRI
SAT
SUN
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
Using Early Drug History
TAS
K
SH
TX
FUN
NUT
PEX
MON TU
WED THU FRI
SAT
X
SUN
X
X
X
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.”
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.”
Behavioral Safety Plan On 3x5
Index Card
MY PERSONAL SAFETY PLAN
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Remember that cravings go away
I can write in my journal
I can call my sponsor (299-289-5555)
I can call my lover (299-426-1776)
I can read from my favorite recovery book
I can read affirmations
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’.”
Cognitive Therapy
Situation
Cognition
 Modulation Ratio
Behavior
Physiology
Emotion
Cognitive Therapy
 Automatic Thoughts
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“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”
Cognitive Therapy-Dysfunctional
Thought Record
SITUATION
AUTOMATIC
THOUGHT
EMOTION
ALTERNATE
RESPONSE
OUTCOME
1 year
Things
Anger
Look back grateful
anniversa should be frustration a year
ry
better
Things
have
improved
Cognitive Reframes
 CT: “My wife is always angry at me.”
 CT: “Every time I go to a meeting my
husband gets angry.”
 Other examples
Cognitive Dysfunction and Change
 Frontal cortex vs. midbrain
 Approximately 50% entering treatment suffer
from cerebral (cognitive) dysfunction
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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
Cognitive Dysfunction and Change
 Executive and visuospatial functioning
problems include:
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Recent memory
Abstraction
Problem solving
Cognitive flexibility
Planning
Rapid Response
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
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
Cognitive Rehabilitation
 Repetitive recoveryoriented behaviors
 Repetitive recoveryoriented thoughts
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
10 Minute Questionnaire
I THINK………..
I FEEL…………..
I LEARNED……
MY FUTURE BEHAVIOR WILL CHANGE…
Reward and Reinforcement
 Mesolimbic Reward
Center
 Environment
 Spirituality
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
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 Postsynaptic Cell causes abnormal Firing Patterns
 Slide six-Body now Relies on Stimulant to
Experience Reward as Natural Rewards No
Longer Pleasurable
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.
Environment
 Living in an enriched
environment may
reduce animals selfadministration of
drugs
 Animal studies
suggest that
environmental
conditions may affect
the activity of
dopamine
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.”
Environment
 Case Management
 Multisystem Therapy
 “Wrap around” services
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Family and childcare services
Housing/Transportation services
Financial and legal services
AIDS and medical services
Addiction and mental health services
Vocational and educational services
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)
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
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.
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
Beliefs Of Our Clients
 63% agreed that
doctors should talk to
them about spiritual
issues (McNichol,
1996)
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
Beliefs of Medical Professionals
 Guschwan continued
 However, the patients
ranked spirituality and
belief in God as most
important to their
recovery-Interesting
incongruence!
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)
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
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
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)
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
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
Summary of AA Research
 Practically speaking (Owens,2003)
 Support from AA members is more important
for abstinence than support from nonmembers
 Internalizing the program-not the number of
meetings attended-is a positive factor in
abstinence rates
 Remember no one program is for
everyone
Thank You For Attending
In the long run, it is better to
choose water, food and
(safe) sex instead of
methamphetamine
REFERENCES
 Robinson, Terry E.
NEUROSCIENCE: Addicted Rats
Science 2004 305: 951-953
 http://psychiatry.jwatch.org/cgi/content/full/
2004/722/5
 American Medical News. July
26,2004,Mary Holley, M.D.