Instructions attached with the class readings and resources Topic 7: Substance Use Disorder Treatment Issues

Instructions attached with the class readings and resources
Topic 7: Substance Use Disorder Treatment Issues And Pharmacotherapy
Capuzzi, D. & Stauffer, M. (Ed.). (2019). Foundations of addictions counseling (4th ed.). Pearson ISBN-13: 9780135166932
Read Chapters 11 in Foundations of Addictions Counseling.
Explore “Your ATTC” on the Addiction Technology Transfer Center Network website (2022).
Read “Biology of Opiates Affects Prevalence of Addiction, Options for Treatment,” by Miller and Lyon, from Psychiatric Annals (2003). 
Watch “Culturally Responsive Cognitive Behavioral Therapy for Promoting Strengths and Wellness (Session 1 of 6)” from the PsycTHERAPY Database (2012). 
Read the “PTSD and Substance Abuse in Veterans,” section of the U.S. Department of Veterans Affairs website (2019). 
Watch “Psychopharmacology,” from Films on Demand (2001).
Drugs, Brains, and Behavior: The Science of AddictionImage from the ABCD StudyCourtesy of Richard Watts, PhDUniversity of Vermont and Fair Neuroimaging LabOregon Health and Science University
TABLE OF CONTENTSPreface ………………………………………………..2Introduction ………………………………………..3Drug Misuse and Addiction ………………….4Preventing Drug Misuse and Addiction: The Best Strategy ………………11Drugs and the Brain …………………………….14Addiction and Health …………………………..19Treatment and Recovery ……………………..22Advancing Addiction Science and Practical Solutions ………….26Citations ……………………………………………..29PREFACEHow Science Has Revolutionized the Understanding of Drug AddictionFor much of the past century, scientists studying drugs and drug use labored in the shadows of powerful myths and misconceptions about the people with an addiction. When scientists began to study addictive behavior in the 1930s, people with an addiction were thought to be morallyflawed and lacking in willpower. Those views shaped society’s responses to drug use, treating it as a moral failing rather than a health problem, which led to an emphasis on punishment rather than prevention and treatment. Today, thanks to science, our views and our responses to addiction and the broader spectrum of substance use disorders have changed dramatically. Groundbreaking discoveries about the brain have revolutionized our understanding of compulsive drug use, enabling us to respond effectively to the problem.As a result of scientific research, we know that addiction is a medical disorder that affects the brain and changes behavior. We have identified many of the biological and environmental risk factors and are beginning to search for the genetic variations that contribute to the development and progression of the disorder. Scientists use this knowledge to develop effective prevention and treatment approaches that reduce the toll drug use takes on individuals, families, and communities.Despite these advances, we still do not fully understand why some people develop an addiction to drugs or how drugs change the brain to foster compulsive drug use. This booklet aims to fill that knowledge gap by providing scientific information about the disorder of drug addiction, including the many harmful consequences of drug use and the basic approaches that have been developed to prevent and treat substance use disorders. At the National Institute on Drug Abuse (NIDA), we believe that increased understanding of the basics of addiction will empower people to make informed choices in their own lives, adopt science-based policies and programs that reduce drug use and addiction in their communities, and support scientific research that improves the Nation’s well-being.Nora D. Volkow, M.D.Director, National Institute on Drug Abuse
INTRODUCTIONWhy study DRUG USE AND ADDICTION?Use and misuse of alcohol, nicotine, and illicit drugs, and misuse of prescription drugs cost Americans more than $700 billion a year in increased health care costs, crime, and lost productivity.1,2,3 Every year, illicit and prescription drug overdoses cause tens of thousands of deaths (nearly 70,000 in 2018), alcohol contributes to the death of more than 90,000 Americans, while tobacco is linked to an estimated 480,000 deaths per year.4,5 (Hereafter, unless otherwise specified, drugs refers to all of these substances.) People of all ages suffer the harmful consequences of drug use and addiction:•Teens who use drugs may act out and may do poorly in school or drop out.6 Using drugs whenthe brain is still developing may cause lasting brain changes and put the user at increased riskof dependence.7•Adults who use drugs can have problems thinking clearly, remembering, and paying attention.They may develop poor social behaviors as a result of their drug use, and their work performanceand personal relationships suffer.•Parents’ drug use can mean chaotic, stress-filled homes, as well as child abuse and neglect.8 Suchconditions harm the well-being and development of children in the home and may set the stagefor drug use in the next generation.9•Babies exposed to drugs in the womb may be born premature and underweight. This exposure canslow the child’s ability to learn and affect behavior later in life.10 They may also become dependent onopioids or other drugs used by the mother during pregnancy, a condition called neonatal abstinencesyndrome (NAS).How does science provide solutions for drug use and addiction?Scientists study the effects drugs have on the brain and behavior. They use this information to develop programs for preventing drug use and for helping people recover from addiction. Further research helps transfer these ideas into practice in the community.The consequences of drug use are vast and varied and affect people of all ages.MedicalSocialEconomicCriminal Justice
4SCIENCE OFADDICTIONDRUG MISUSE AND ADDICTIONDrug Misuse and AddictionWhat is DRUG ADDICTION?Addiction is defined as a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences.† It is considered a brain disorder, because it involves functional changes to brain circuits involved in reward, stress, and self-control. Those changes may last a long time after a person has stopped taking drugs.11Addiction is a lot like other diseases, such as heart disease. Both disrupt the normal, healthy functioning of an organ in the body, both have serious harmful effects, and both are, in many cases, preventable and treatable. If left untreated, they can last a lifetime and may lead to death.Comparison Subject1 Month After Last Cocaine Use4 Months After Last Cocaine UseSource: Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health Modified with permission from Volkow et al. 1993Note: These PET scans compare the brain of an individual with a history of cocaine use disorder (middle and right) to the brain of an individual without a history of cocaine use (left). The person who has had a cocaine use disorder has lower levels of the D2 dopamine receptor (depicted in red) in the striatum one month (middle) and four months (right) after stopping cocaine use compared to the non-user. The level of dopamine receptors in the brain of the cocaine user are higher at the 4-month mark (right), but have not returned to the levels observed in the non-user (left).Low dopamine D2 receptors may contribute to the loss of control in cocaine users.†The term addiction as used in this booklet is equivalent to a severe substance use disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5, 2013).
Why doPEOPLE TAKE DRUGS?In general, people take drugs for a few reasons:• To feel good. Drugs can produce intense feelings of pleasure. This initial euphoria is followed by other effects, which differ with the type of drug used. For example, with stimulants such as cocaine, the high is followed by feelings of power, self-confidence, and increased energy. In contrast, the euphoria caused by opioids such as heroin is followed by feelings of relaxation and satisfaction.• To feel better. Some people who suffer from social anxiety, stress, and depression start using drugs to try to feel less anxious. Stress can play a major role in starting and continuing drug use as well as relapse (return to drug use) in patients recovering from addiction.• To do better. Some people feel pressure to improve their focus in school or at work or their abilities in sports. This can play a role in trying or continuing to use drugs, such as prescription stimulants or cocaine.• Curiosity and social pressure. In this respect, teens are particularly at risk because peer pressure can be very strong. Adolescence is a developmental period during which the presence of risk factors, such as peers who use drugs, may lead to substance use.If taking drugs makes people feel good or better,WHAT’S THE PROBLEM?When they first use a drug, people may perceive what seem to be positive effects. They also may believe they can control their use. But drugs can quickly take over a person’s life. Over time, if drug use continues, other pleasurable activities become less pleasurable, and the person has to take the drug just to feel “normal.” They have a hard time controlling their need to take drugs even though it causes many problems for themselves and their loved ones. Some people may start to feel the need to take more of a drug or take it more often, even in the early stages of their drug use. These are the signs of an addiction.Even relatively moderate drug use poses dangers. Consider how a social drinker can become intoxicated, get behind the wheel of a car, and quickly turn a pleasurable activity into a tragedy that affects many lives. Occasional drug use, such as misusing an opioid to get high, can have similarly disastrous effects, including impaired driving and overdose.
6SCIENCE OFADDICTIONDRUG MISUSE AND ADDICTIONDo people choose toKEEP USING DRUGS?The initial decision to take drugs is typically voluntary. But with continued use, a person’s ability to exert self-control can become seriously impaired. This impairment in self-control is the hallmark of addiction. Brain imaging studies of people with addiction show physical changes in areas of the brain that are critical to judgment, decision-making, learning and memory, and behavior control.12 These changes help explain the compulsive nature of addiction.Why do some people become addicted to drugs, WHILE OTHERS DO NOT?As with other diseases and disorders, the likelihood of developing an addiction differs from person to person, and no single factor determines whether a person will become addicted to drugs. In general, the more risk factors a person has, the greater the chance that taking drugs will lead to drug use and addiction. Protective factors, on the other hand, reduce a person’s risk. Risk and protective factors may be either environmental or biological.No single factor determines whether a person will become addicted to drugs.
Risk and Protective Factors for Drug Use, Misuse, and AddictionRISK FACTORSAggressive behavior in childhood13, 14Lack of parental supervision14, 16Low peer refusal skills13, 17, 18Drug experimentation14, 20, 21Availability of drugs at school21, 23Community poverty24, 25PROTECTIVE FACTORSSelf-efficacy (belief in self-control)15Parental monitoring and support16 – 18Positive relationships17, 19Extracurricular Activities17, 22School anti-drug policies17Neighborhood resources26
8SCIENCE OFADDICTIONDRUG MISUSE AND ADDICTIONBrain MechanismsAddictionBiology/GenesEnvironmentGeneticsGenderMental disordersChaotic home and abuseParent’s use and attitudesPeer influencesCommunity attitudesLow academic achievementRoute of administration • Effect of drug • Early use • Availability • CostChildren’s earliest interactions within the family are crucial to their healthy development and risk for drug use.
WHAT BIOLOGICAL FACTORS increase the risk of addiction?Biological factors that can affect a person’s risk of addiction include their genes, stage of development, and even gender or ethnicity. Scientists estimate that genes, including the effects environmental factors have on a person’s gene expression, called epigenetics, account for between 40 and 60 percent of a person’s risk of addiction.27 Also, teens and people with mental disorders are at greater risk of drug use and addiction than others.28WHAT ENVIRONMENTAL FACTORSincrease the risk of addiction?Environmental factors are those related to the family, school, and neighborhood. Factors that can increase a person’s risk include the following:• Home and family. The home environment, especially during childhood, is a very important factor. Parents or older family members who use drugs or misuse alcohol, or who break the law, can increase children’s risk of future drug problems.29• Peers and school. Friends and other peers can have an increasingly strong influence during the teen years. Teens who use drugs can sway even those without risk factors to try drugs for the first time. Struggling in school or having poor social skills can put a child at further risk for using or becoming addicted to drugs.30 What other factors increase theRISK OF ADDICTION?• Early use. Although taking drugs at any age can lead to addiction, research shows that the earlier people begin to use drugs, the more likely they are to develop serious problems.31This may be due to the harmful effect that drugs can have on the developing brain.32 It also may result from a mix of early social and biological risk factors, including lack of a stable home or family, exposure to physical or sexual abuse, genes, or mental illness. Still, the fact remains that early use is a strong indicator of problems ahead, including addiction. • How the drug is taken. Smoking a drug or injecting it into a vein increases its addictive potential.33,34 Both smoked and injected drugs enter the brain within seconds, producing a powerful rush of pleasure. However, this intense high can fade within a few minutes. Scientists believe this powerful contrast drives some people to repeatedly use drugs to recapture the fleeting pleasurable state.
10The brain continues to develop into adulthood and undergoes DRAMATICCHANGES DURING ADOLESCENCEOne of the brain areas still maturing during adolescence is the prefrontal cortex—the part of the brain that allows people to assess situations, make sound decisions, and keep emotions and desires under control. The fact that this critical part of a teen’s brain is still a work in progress puts them at increased risk for trying drugs or continuing to take them. Introducing drugs during this period of development may cause brain changes that have profound and long-lasting consequences.Images of Brain Development in Healthy Children and Teens (Ages 5–20)DRUG MISUSE AND ADDICTIONSource: PNAS 101:8174–8179, 2004.As the brain matures, experiences prune excess neural connections while strengthening those that are used more often. Many scientists think that this process contributes to the steady reduction in gray matter volume seen during adolescence (depicted as the yellow to blue transition in the figure). As environmental forces help determine which connections will wither and which will thrive, the brain circuits that emerge become more efficient. However, this is a process that can cut both ways because not all patterns of behavior are desirable or healthy. The environment is like an artist who creates a sculpture by chipping away excess marble; and just like bad artists can produce bad art, environments with negative factors (like drugs, malnutrition, bullying, or sleep deprivation) can lead to efficient but potentially harmful circuits that conspire against a person’s well-being.
Preventing Drug Misuse and Addiction: The Best StrategyWhy is adolescence a critical time for PREVENTING DRUG ADDICTION?As noted previously, early use of drugs increases a person’s chances of becoming addicted. Remember, drugs change the brain—and this can lead to addiction and other serious problems. So, preventing early use of drugs or alcohol may go a long way in reducing these risks. Risk of drug use increases greatly during times of transition. For an adult, a divorce or loss of a job may increase the risk of drug use. For a teenager, risky times include moving, family divorce, or changing schools.35 When children advance from elementary through middle school, they face new and challenging social, family, and academic situations. Often during this period, children are exposed to substances such as cigarettes and alcohol for the first time. When they enter high school, teens may encounter greater availability of drugs, drug use by older teens, and social activities where drugs are used. When individuals leave high school and live more independently, either in college or as an employed adult, they may find themselves exposed to drug use while separated from the protective structure provided by family and school.A certain amount of risk-taking is a normal part of adolescent development. The desire to try new things and become more independent is healthy, but it may also increase teens’ tendencies to experiment with drugs. The parts of the brain that control judgment and decision-making do not fully develop until people are in their early or mid-20s. This limits a teen’s ability to accurately assess the risks of drug experimentation and makes young people more vulnerable to peer pressure.36Because the brain is still developing, using drugs at this age has more potential to disrupt brain function in areas critical to motivation, memory, learning, judgment, and behavior control.12
12Can research-based programs prevent DRUG ADDICTION IN YOUTH?Yes. The term research-based or evidence-based means that these programs have been designed based on current scientific evidence, thoroughly tested, and shown to produce positive results. Scientists have developed a broad range of programs that positively alter the balance between risk and protective factors for drug use in families, schools, and communities. Studies have shown that research-based programs, such as described in NIDA’s Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide and Preventing Drug Use among Children and Adolescents: A Research-Based Guide for Parents, Educators, and Community Leaders, can significantly reduce early use of tobacco, alcohol, and other drugs.37 Also, while many social and cultural factors affect drug use trends, when young people perceive drug use as harmful, they often reduce their level of use.38How do research-basedPREVENTION PROGRAMS WORK?These prevention programs work to boost protective factors and eliminate or reduce risk factors for drug use. The programs are designed for various ages and can be used in individual or group settings, such as the school and home. There are three types of programs:• Universal programs address risk and protective factors common to all children in a given setting, such as a school or community.• Selective programs are for groups of children and teens who have specific factors that put them at increased risk of drug use.• Indicated programs are designed for youth who have already started using drugs.PREVENTING DRUG MISUSE AND ADDICTION: THE BEST STRATEGYNational drug use surveys indicate some children are already using drugs by age 12 or 13.Prevention is the best strategy.
Young Brains Under StudyUsing cutting-edge imaging technology, scientists from the NIDA’s Adolescent Brain Cognitive Development (ABCD) Study will look at how childhood experiences, including use of any drugs, interact with each other and with a child’s changing biology to affect brain development and social, behavioral, academic, health, and other outcomes. As the only study of its kind, the ABCD study will yield critical insights into the foundational aspects of adolescence that shape a person’s future.These brain images show the reward-related circuity in the cortical and subcortical regions of the brain that tend to be more active when a child is successful at achieving a reward. While all of the images show the regions of the brain that are active to reward, the regions in yellow and red are the most active.Courtesy of the ABCD Study. Adapted from Casey et al., 2018 https://doi.org/10.1016/j.dcn.2018.03.001 Economics of PreventionEvidence-based interventions for substance use can save society money in medical costs and help individuals remain productive members of society. Such programs can return anywhere from very little to $65 per every dollar invested in prevention.39
14Drugs and the BrainIntroducing the HUMAN BRAINThe human brain is the most complex organ in the body. This three-pound mass of gray and white matter sits at the center of all human activity —you need it to drive a car, to enjoy a meal, to breathe, to create an artistic masterpiece, and to enjoy everyday activities. The brain regulates your body’s basic functions, enables you to interpret and respond to everything you experience, and shapes your behavior. In short, your brain is you —everything you think and feel, and who you are.How does theBRAIN WORK?The brain is often likened to an incredibly complex and intricate computer. Instead of electrical circuits on the silicon chips that control our electronic devices, the brain consists of billions of cells, called neurons, which are organized into circuits and networks. Each neuron acts as a switch controlling the flow of information. If a neuron receives enough signals from other neurons that it is connected to, it fires, sending its own signal on to other neurons in the circuit.Here’s how people communicate.TransmitterSCIENCE OFADDICTIONDRUGS AND THE BRAINReceptor
The brain is made up of many parts with interconnected circuits that all work together as a team. Different brain circuits are responsible for coordinating and performing specific functions. Networks of neurons send signals back and forth to each other and among different parts of the brain, the spinal cord, and nerves in the rest of the body (the peripheral nervous system). To send a message, a neuron releases a neurotransmitter into the gap (or synapse) between it and the next cell. The neurotransmitter crosses the synapse and attaches to receptors on the receiving neuron, like a key into a lock. This causes changes in the receiving cell. Other molecules called transporters recycle neurotransmitters (that is, bring them back into the neuron that released them), thereby limiting or shutting off the signal between neurons.How do drugsWORK IN THE BRAIN?Drugs interfere with the way neurons send, receive, and process signals via neurotransmitters. Some drugs, such as marijuana and heroin, can activate neurons because their chemical structure mimics that of a natural neurotransmitter in the body. This allows the drugs to attach onto and activate the neurons. Although these drugs mimic the brain’s own chemicals, they don’t activate neurons in the same way as a natural neurotransmitter, and they lead to abnormal messages being sent through the network.Other drugs, such as amphetamine or cocaine, can cause the neurons to release abnormally large amounts of natural neurotransmitters or prevent the normal recycling of these brain chemicals by interfering with transporters. This too amplifies or disrupts the normal communication between neurons.Here’s how brain cells communicate.NeuronNeurotransmitterReceptor
16What parts of the brain areAFFECTED BY DRUG USE?Drugs can alter important brain areas that are necessary for life-sustaining functions and can drive the compulsive drug use that marks addiction. Brain areas affected by drug use include:• The basal ganglia, which play an important role in positive forms of motivation, including the pleasurable effects of healthy activities like eating, socializing, and sex, and are also involved in the formation of habits and routines. These areas form a key node of what is sometimes called the brain’s “reward circuit.” Drugs over-activate this circuit, producing the euphoria of the drug high. But with repeated exposure, the circuit adapts to the presence of the drug, diminishing its sensitivity and making it hard to feel pleasure from anything besides the drug.• The extended amygdala plays a role in stressful feelings like anxiety, irritability, and unease, which characterize withdrawal after the drug high fades and thus motivates the person to seek the drug again. This circuit becomes increasingly sensitive with increased drug use. Over time, a person with substance use disorder uses drugs to get temporary relief from this discomfort rather than to get high.• The prefrontal cortex powers the ability to think, plan, solve problems, make decisions, and exert self-control over impulses. This is also the last part of the brain to mature, making teens most vulnerable. Shifting balance between this circuit and the circuits of the basal ganglia and extended amygdala make a person with a substance use disorder seek the drug compulsively with reduced impulse control. Some drugs like opioids also disrupt other parts of the brain, such as the brain stem, which controls basic functions critical to life, including heart rate, breathing, and sleeping. This interference explains why overdoses can cause depressed breathing and death.SCIENCE OFADDICTIONDRUGS AND THE BRAINBasal GangliaExtended AmygdalaPrefrontal CortexSource: Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health
How doDRUGS PRODUCE PLEASURE?Pleasure or euphoria—the high from drugs—is still poorly understood, but probably involves surges of chemical signaling compounds including the body’s natural opioids (endorphins) and other neurotransmitters in parts of the basal ganglia (the reward circuit). When some drugs are taken, they can cause surges of these neurotransmitters much greater than the smaller bursts naturally produced in association with healthy rewards like eating, hearing or playing music, creative pursuits, or social interaction.It was once thought that surges of the neurotransmitter dopamine produced by drugs directly caused the euphoria, but scientists now think dopamine has more to do with getting us to repeat pleasurable activities (reinforcement) than with producing pleasure directly.How doesDOPAMINE REINFORCE DRUG USE?The feeling of pleasure is how a healthy brain identifies and reinforces beneficial behaviors, such as eating, socializing, and sex. Our brains are wired to increase the odds that we will repeat pleasurable activities. The neurotransmitter dopamine is central to this. Whenever the reward circuit is activated by a healthy, pleasurable experience, a burst of dopamine signals that something important is happening that needs to be remembered. This dopamine signal causes changes in neural connectivity that make it easier to repeat the activity again and again without thinking about it, leading to the formation of habits. Just as drugs produce intense euphoria, they also produce much larger surges of dopamine, powerfully reinforcing the connection between consumption of the drug, the resulting pleasure, and all the external cues linked to the experience. Large surges of dopamine “teach” the brain to seek drugs at the expense of other, healthier goals and activities.Cues in a person’s daily routine or environment that have become linked with drug use because of changes to the reward circuit can trigger uncontrollable cravings whenever the person is exposed to these cues, even if the drug itself is not available. This learned “reflex” can last a long time, even in people who haven’t used drugs in many years. For example, people who have been drug free for a decade can experience cravings when returning to an old neighborhood or house where they used drugs. Like riding a bike, the brain remembers.Simple activities in everyday life can produce small bursts of neurotransmitters in the brain bringing pleasurable feelings. Drugs can hijack that process.
18DRUGS AND THE BRAINSCIENCE OFADDICTIONWhy are drugs more addictive thanNATURAL REWARDS?For the brain, the difference between normal rewards and drug rewards can be likened to the difference between someone whispering into your ear and someone shouting into a microphone. Just as we turn down the volume on a radio that is too loud, the brain of someone who misuses drugs adjusts by producing fewer neurotransmitters in the reward circuit, or by reducing the number of receptors that can receive signals. As a result, the person’s ability to experience pleasure from naturally rewarding (i.e., reinforcing) activities is also reduced. This is why a person who misuses drugs eventually feels flat, without motivation, lifeless, and/or depressed, and is unable to enjoy things that were previously pleasurable. Now, the person needs to keep taking drugs to experience even a normal level of reward —which only makes the problem worse, like a vicious cycle. Also, the person will often need to take larger amounts of the drug to produce the familiar high—an effect known as tolerance.Some drugs target the brain’s pleasure centerBrain reward (dopamine pathways)These brain circuits are important for natural rewards such as food, music, and sex.How drugs can increase dopamineWhile eating foodDopamine TransporterDopamineDopamineReceptorWhile using cocaineDopamine TransporterDopamineCocaineTypically, dopamine increases in response to natural rewards such as food. When cocaine is taken, dopamine increases are exaggerated, and communication is denied.Long-term drug use impairs brain functioning.For more information on drugs and the brain, order NIDA’s Teaching Addiction Science series or the Mind Matters series at www.drugabuse.gov/parent-teacher.html. These items and others are available to the public free of charge.
Addiction and HealthWhat are the other healthCONSEQUENCES OF DRUG ADDICTION?People with addiction often have one or more associated health issues, which could include lung or heart disease, stroke, cancer, or mental health conditions. Imaging scans, chest X-rays, and blood tests can show the damaging effects of long-term drug use throughout the body. For example, it is now well-known that tobacco smoke can cause many cancers, methamphetamine can cause severe dental problems, known as meth mouth, and that opioids can lead to overdose and death. In addition, some drugs, such as inhalants, may damage or destroy nerve cells, either in the brain or the peripheral nervous system (the nervous system outside the brain and spinal cord). Drug use can also increase the risk of contracting infections. HIV and hepatitis C (a serious liver disease) can occur from sharing injection equipment or from unsafe practices such as condom-less sex.40,41 Infection of the heart and its valves (endocarditis) and skin infection (cellulitis) can occur after exposure to bacteria by injection drug use.42Does drug use causeOTHER MENTAL DISORDERS OR VICE VERSA?Drug use and other mental disorders often co-exist. In some cases, mental disorders such as anxiety, depression, or schizophrenia may come before addiction. In other cases, drug use may trigger or worsen those mental health conditions, particularly in people with specific vulnerabilities.43,44Some people with disorders like anxiety or depression may use drugs in an attempt to alleviate psychiatric symptoms. This may exacerbate their mental disorder in the long run, as well as increase the risk of developing addiction.43,44 Treatment for all conditions should happen concurrently.Addiction and HIV/AIDS are intertwined health conditions.
20How can addictionHARM OTHER PEOPLE?Beyond the harmful consequences for the person with the addiction, drug use can cause serious health problems for others. Some of the more severe consequences of addiction are:• Negative effects of drug use while pregnant or breastfeedingA mother’s substance or medication use during pregnancy can cause her baby to go into withdrawal after it’s born, which is called neonatal abstinence syndrome (NAS). Symptoms will differ depending on the substance used, but may include tremors, problems with sleeping and feeding, and even seizures.45 Some drug-exposed children will have developmental problems with behavior, attention, and thinking. Ongoing research is exploring if these effects on the brain and behavior extend into the teen years, causing continued developmental problems. In addition, some substances can make their way into a mother’s breast milk. Scientists are still learning about long-term effects on a child who is exposed to drugs through breastfeeding.THE IMPACT OF ADDICTION CAN BEFAR-REACHINGHeart diseaseStrokeCancerHIV/AIDSHepatitis B and CEndocarditisCellulitisLung diseaseMental health conditionsADDICTION AND HEALTH
• Negative effects of secondhand smokeSecondhand tobacco smoke exposes bystanders to at least 250 chemicals that are known to be harmful, particularly to children.46 Involuntary exposure to secondhand smoke increases the risks of heart disease and lung cancer in people who have never smoked.5 Additionally, the known health risks of secondhand exposure to tobacco smoke raise questions about whether secondhand exposure to marijuana smoke poses similar risks. At this point, little research on this question has been conducted. However, a study found that some nonsmoking participants exposed for an hour to high-THC marijuana in an unventilated room reported mild effects of the drug, and another study showed positive urine tests in the hours directly following exposure.47,48 If you inhale secondhand marijuana smoke, it’s unlikely you would fail a drug test, but it is possible. • Increased spread of infectious diseasesInjection of drugs accounts for 1 in 10 of cases of HIV. Injection drug use is also a major factor in the spread of hepatitis C,49and can be the cause of endocarditis and cellulitis. Injection drug use is not the only way that drug use contributes to the spread of infectious diseases. Drugs that are misused can cause intoxication, which hinders judgment and increases the chance of risky sexual behaviors such as condom-less sex. • Increased risk of motor vehicle accidentsUse of illicit drugs or misuse of prescription drugs can make driving a car unsafe—just like driving after drinking alcohol. Drugged driving puts the driver, passengers, and others who share the road at risk. In 2016, almost 12 million people ages 16 or older reported driving under the influence of illicit drugs, including marijuana.50 After alcohol, marijuana is the drug most often linked to impaired driving. Research studies have shown negative effects of marijuana on drivers, including an increase in lane weaving, poor reaction time, and altered attention to the road.
22Treatment and RecoveryCan addiction beTREATED SUCCESSFULLY?Yes, addiction is a treatable disorder. Research on the science of addiction and the treatment of substance use disorders has led to the development of research-based methods that help people to stop using drugs and resume productive lives, also known as being in recovery.Can addiction beCURED?Like other chronic diseases such as heart disease or asthma, treatment for drug addiction usually isn’t a cure. But addiction can be managed successfully. Treatment enables people to counteract addiction’s disruptive effects on their brain and behavior and regain control of their lives.Brain Recovery with Prolonged AbstinenceSCIENCE OFADDICTIONTREATMENT AND RECOVERYHealthy PersonMeth User: 1 month abstinenceMeth User: 14 months abstinenceThese images showing the density of dopamine transporters in the brain illustrate the brain’s remarkable ability to recover, at least in part, after a long abstinence from drugs— in this case, methamphetamine.51Source: The Journal of Neuroscience, 21(23):9414-9418. 2001
Does relapse to drug use mean TREATMENT HAS FAILED?No. The chronic nature of addiction means that for some people relapse, or a return to drug use after an attempt to stop, can be part of the process, but newer treatments are designed to help with relapse prevention. Relapse rates for drug use are similar to rates for other chronic medical illnesses. If people stop following their medical treatment plan, they are likely to relapse.Treatment of chronic diseases involves changing deeply rooted behaviors, and relapse doesn’t mean treatment has failed. When a person recovering from an addiction relapses, it indicates that the person needs to speak with their doctor to resume treatment, modify it, or try another treatment.52Comparison of Relapse Rates Between Substance Use Disorders and Other Chronic IllnessesSubstance UseDisordersHypertensionAsthma10080604020Percent of Patients Who Relapse040–60% 50–70% 50–70% Source: JAMA, 284:1689-1695, 2000 Relapse rates for people treated for substance use disorders are compared with those for people treated for high blood pressure and asthma. Relapse is common and similar across these illnesses. Therefore, substance use disorders should be treated like any other chronic illness. Relapse serves as a sign for resumed, modified, or new treatment.While relapse is a normal part of recovery, for some drugs, it can be very dangerous —even deadly. If a person uses as much of the drug as they did before quitting, they can easily overdose because their bodies are no longer adapted to their previous level of drug exposure. An overdose happens when the person uses enough of a drug to produce uncomfortable feelings, life-threatening symptoms, or death.
24What are the principles of EFFECTIVE TREATMENT?Research shows that when treating addictions to opioids (prescription pain relievers or drugs like heroin or fentanyl), medication should be the first line of treatment, usually combined with some form of behavioral therapy or counseling. Medications are also available to help treat addiction to alcohol and nicotine. Additionally, medications are used to help people detoxify from drugs, although detoxification is not the same as treatment and is not sufficient to help a person recover. Detoxification alone without subsequent treatment generally leads to resumption of drug use.For people with addictions to drugs like stimulants or cannabis, no medications are currently available to assist in treatment, so treatment consists of behavioral therapies. Treatment should be tailored to address each patient’s drug use patterns and drug-related medical, mental, and social problems.Discoveries in science lead to breakthroughs in drug use treatment.What medications and devices helpTREAT DRUG ADDICTION?Different types of medications and devices may be useful at different stages of treatment to help a patient stop using drugs, stay in treatment, and avoid relapse.• Treating withdrawal. When patients first stop using drugs, they can experience various physical and emotional symptoms, including restlessness or sleeplessness, as well as depression, anxiety, and other mental health conditions. Certain treatment medications and devices reduce these symptoms, which makes it easier to stop the drug use.• Staying in treatment. Some treatment medications and mobile applications are used to help the brain adapt gradually to the absence of the drug. These treatments act slowly to help prevent drug cravings and have a calming effect on body systems. They can help patients focus on counseling and other psychotherapies related to their drug treatment.• Preventing relapse. Science has taught us that stress cues linked to the drug use (such as people, places, things, and moods), and contact with drugs are the most common triggers for relapse. Scientists have been developing therapies to interfere with these triggers to help patients stay in recovery.COMMON MEDICATIONS USEDTO TREAT DRUG ADDICTION AND WITHDRAWALOpioidMethadoneBuprenorphineExtended-release naltrexoneLofexidineNicotineNicotine replacement therapies (available as a patch, inhaler, or gum)BupropionVareniclineTREATMENT AND RECOVERYAlcoholNaltrexoneDisulfiramAcamprosate
How do behavioral therapiesTREAT DRUG ADDICTION?Behavioral therapies help people in drug addiction treatment modify their attitudes and behaviors related to drug use. As a result, patients are able to handle stressful situations and various triggers that might cause another relapse. Behavioral therapies can also enhance the effectiveness of medications and help people remain in treatment longer.• Cognitive-behavioral therapy seeks to help patients recognize, avoid, and cope with the situations in which they’re most likely to use drugs.• Contingency management uses positive reinforcement such as providing rewards or privileges for remaining drug-free, for attending and participating in counseling sessions,or for taking treatment medications as prescribed.• Motivational enhancement therapy uses strategies to make the most of people’s readiness to change their behavior and enter treatment.• Family therapy helps people (especially young people) with drug use problems, as well as their families, address influences on drug use patterns and improve overall family functioning.• Twelve-step facilitation (TSF) is an individual therapy typically delivered in 12 weekly session to prepare people to become engaged in 12-step mutual support programs. 12-step programs, like Alcoholic Anonymous, are not medical treatments, but provide social and complementary support to those treatments. TSF follows the 12-step themes of acceptance, surrender, and active involvement in recovery. AlcoholHow do quality treatment programs help patients RECOVER FROM ADDICTION?Stopping drug use is just one part of a long and complex recovery process. When people enter treatment, addiction has often caused serious consequences in their lives, possibly disrupting their health and how they function in their family lives, at work, and in the community. Because addiction can affect so many aspects of a person’s life, treatment should address the needs of the whole person to be successful. Counselors may select from a menu of services that meet the specific medical, mental, social, occupational, family, and legal needs of their patients to help in their recovery. For more information on drug treatment, see Principles of Drug Addiction Treatment: A Research-Based Guide, and Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide.Treatment must address the whole person.
26Advancing Addiction Science and Practical SolutionsLeading the Search for SCIENTIFIC SOLUTIONSTo address all aspects of drug use and its harmful consequences, NIDA’s research program ranges from basic studies of the addicted brain and behavior to clinical strategies and health services research. NIDA’s research program develops prevention and treatment approaches and ensures they work in real-world settings. As part of this goal, NIDA is committed to research that addresses the vulnerabilities and health differences that exist among ethnic minorities or that stem from gender differences.Bringing Science to REAL WORLD SETTINGS• Clinical Trials Network (CTN): CTN “road tests” research-based drug use treatments in community treatment programs around the country.• The HEALing Communities Study (HCS): Led by NIDA and funded through the NIH HEAL InitiativeSM, HCS is testing the impact of an integrated set of evidence-based practices across health care, behavioral health, justice, and other community-based settings. The goal of the study is to reduce opioid-related overdose deaths by 40 percent over the course of three years. Research sites are partnering with 67 communities highly affected by the opioid crisis in four states to measure theimpact of these efforts.• The Justice Community Opioid Innovation Network (JCOIN): Led by NIDA and funded through the NIH HEAL InitiativeSM, JCOIN is a network of research institutions and SCIENCE OFADDICTIONADVANCING ADDICTION SCIENCE AND PRACTICAL SOLUTIONScenters established to study approaches to increase high-quality care for people with opioid misuse and OUD in justice settings. JCOIN will test strategies to expand effective treatment and care in partnership with local and state justice systems and community-based treatment providers.• The Adolescent Brain Cognitive Development (ABCD) Study: ABCD is the largest long-term study of brain development and child health in the United States. The study is following more than 11,000 healthy children ages nine to 10 and will follow them into early adulthood to observe brain growth.
SHARING FREE INFORMATIONwith the PublicNIDA increases the impact of its research on addiction by sharing free information with professionals and the general public. Special initiatives are intended for researchers, clinicians, educators, students, and parents. Please visit https://drugpubs.drugabuse.gov. NIDA’S SPECIAL INITIATIVESfor Students, Teachers, and ParentsHeads Up: Real News About Drugs and Your Body– A drug education series created by NIDA and SCHOLASTIC INC. for students in grades 6 to 12NIDA for Teens – A website for teens (with resources for educators and parents) that provides age-appropriate facts on drugsNational Drug and Alcohol Facts Week® – A week-long observance that encourages community-based events and dialogue between teens and scientists about drugs and alcoholDrug and Alcohol Facts Chat Day – A web chat between NIDA scientists and teens, held through school computer labs once a year during National Drug and Alcohol Facts Week®
28SPECIAL INITIATIVESfor CliniciansNIDAMED – A collection of resources for health professionals on the causes and consequences of drug use and addiction, and advances in pain management.Publications onPREVENTION AND TREATMENT PRINCIPLESPreventing Drug Use among Children and Adolescents: A Research-Based Guide for Parents, Educators, and Community Leaders – NIDA’s research-based guide for preventing drug use among children and adolescents provides principles based on effective drug-prevention research and includes answers to questions on risk and protective factors as well as on community planning and implementationPrinciples of Drug Addiction Treatment: A Research-Based Guide – This guide summarizes principles of effective treatment, answers common questions, and describes types of treatment, providing examples of scientifically based and tested treatment componentsPrinciples of Adolescent Substance Use Disorder Treatment: A Research-Based Guide – This guide discusses the urgency of treating substance use disorders in teenagers, answers common questions about how young people are treated for drug problems, and describes effective research-based treatment approachesADVANCING ADDICTION SCIENCE AND PRACTICAL SOLUTIONSPrinciples of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide – NIDA’s research-based guide for treating criminal justice-involved people with addiction provides essential treatment principles and includes answers to frequently asked questions as well as resource informationFor more information: All NIDA publications are available at www.drugabuse.gov. Some publications are also available in print, free of charge. To order a publication in print, call the DRUGPubs Research Dissemination Center at 1–877–NIH–NIDA or go to https://drugpubs.drugabuse.gov.Watch NIDA videos (NIDA TV) at www.drugabuse.gov/nida-tv.
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30CITATIONS15. DiClemente CC, Fairhurst SK, Piotrowski NA. Self-efficacy and addictive behaviors. In: Self-Efficacy, Adaptation, and Adjustment: Theory, Research, and Application. The Plenum series in social/clinical psychology. New York, NY, US: Plenum Press; 1995:109-141.16. Hill KG, Hawkins JD, Catalano RF, Abbott RD, Guo J. Family influences on the risk of daily smoking initiation. J Adolesc Health Off Publ Soc Adolesc Med. 2005;37(3):202-210. doi:10.1016/j.jadohealth.2004.08.01417. Guo J, Hawkins JD, Hill KG, Abbott RD. Childhood and adolescent predictors of alcohol abuse and dependence in young adulthood. J Stud Alcohol. 2001;62(6):754-762.18. Brook JS, Brook DW, Gordon AS, Whiteman M, Cohen P. The psychosocial etiology of adolescent drug use: a family interactional approach. Genet Soc Gen Psychol Monogr. 1990;116(2):111-267.19. Duncan GJ, Wilkerson B, England P. Cleaning up their act: The effects of marriage and cohabitation on licit and illicit drug use. Demography. 2006;43(4):691-710. doi:10.1353/dem.2006.003220. Chassin L, Pitts SC, Prost J. Binge drinking trajectories from adolescence to emerging adulthood in a high-risk sample: predictors and substance abuse outcomes. J Consult Clin Psychol.2002;70(1):67-78.21. Sher KJ, Rutledge PC. Heavy drinking across the transition to college: predicting first-semester heavy drinking from precollege variables. Addict Behav. 2007;32(4):819-835. doi:10.1016/j.addbeh.2006.06.02422. National Institute on Drug Abuse. Preventing Drug Use Among Children and Adolescents, A Research-Based Guide for Parents, Educators and Community Leaders Second Edition, 2003. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse, 2003.23. Brook JS, Kessler RC, Cohen P. The onset of marijuana use from preadolescence and early adolescence to young adulthood. Dev Psychopathol. 1999;11(4):901-914.24. Herting JR, Guest AM. Components of satisfaction with local areas in the metropolis. Sociol Q. 1985;26(1):99-116. doi:10.1111/j.1533-8525.1985.tb00218.x25. Hawkins JD, Arthur MW, Catalano RF. Preventing substance abuse. Crime Justice. 1995;19:343-427. doi:10.1086/44923426. Chalk R, Phillips DA. Youth Development and Neighborhood Influences: Challenges and Opportunities. National Academies Press; 1997.27. Bevilacqua L, Goldman D. Genes and addictions. Clin Pharmacol Ther. 2009;85(4):359-361. doi:10.1038/clpt.2009.628. Substance Abuse and Mental Health Services Administration. Mental and Substance Use Disorders. https://www.samhsa.gov/disorders. Published June 20, 2014. Accessed June 4, 2018.29. Biederman J, Faraone SV, Monuteaux MC, Feighner JA. Patterns of alcohol and drug use in adolescents can be predicted by parental substance use disorders. Pediatrics. 2000;106(4):792-797.30. Whitesell M, Bachand A, Peel J, Brown M. Familial, social, and individual factors contributing to risk for adolescent substance use. Journal of Addiction. https://www.hindawi.com/journals/jad/2013/579310/. Published 2013. Accessed June 4, 2018.31. Substance Abuse and Mental Health Services Administration. Mental and Substance Use Disorders. https://www.samhsa.gov/disorders. Published June 20, 2014. Accessed June 4, 2018.32. Lynskey MT, Heath AC, Bucholz KK, Slutske WS, Madden PAF, Nelson EC, Statham DJ, Martin NG. Escalation of drug use in early-onset cannabis users vs co-twin controls. JAMA 289:427-33, 2003. 33. Squeglia LM, Jacobus J, Tapert SF. The influence of substance use on adolescent brain development. Clin Neurosci Soc ENCS. 2009;40(1):31-38.34. Verebey K, Gold MS. From coca leaves to crack: the effects of dose and routes of administration in abuse liability. Psychiatr Annals18:513–520, 1988.
35. Hatsukami DK, Fischman MW. Crack cocaine and cocaine hydrochloride: Are the differences myth or reality. JAMA276:1580-1588, 1996. 36. Krohn MD, Lizotte AJ, Perez CM. The interrelationship between substance use and precocious transitions to adult statuses. J Health Soc Behav 38(1):87-103, 1997. 37. Gogtay N, Giedd JN, Lusk L, Hayashi KM, Greenstein D, Vaituzis AC, Nugent TF 3rd, Herman DH, Clasen LS, Toga AW, Rapoport JL, Thompson PM. Dynamic mapping of human cortical development during childhood through early adulthood. Proc Natl Acad Sci 101(21):8174-8179, 2004. 38. National Institute on Drug Abuse. Preventing Drug Abuse among Children and Adolescents: A Research-Based Guide for Parents, Educators, and Community Leaders (Second Edition) (NIH Publication No. 04-4212[A]). Rockville, MD, 2003. 39. Johnston, LD, O’Malley, PM, Miech, RA, Bachman, JG, & Schulenberg, JE (2014). Monitoring the Future national survey results on drug use: 1975-2013: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, The University of Michigan. 40. Washington State Institute for Public Policy. (2017). Benefit-cost results. Retrieved from http://www.wsipp.wa.gov/BenefitCost?topicId=. Accessed on June 14, 2018.41. El-Bassel N, Shaw SA, Dasgupta A, Strathdee SA. Drug use as a driver of HIV risks: re-emerging and emerging issues. Curr Opin HIV AIDS. 2014;9(2):150-155. doi:10.1097/COH.000000000000003542. Klevens RM, Hu DJ, Jiles R, Holmberg SD. Evolving epidemiology of hepatitis C virus in the United States. ClinInfect Dis Off Publ Infect Dis Soc Am. 2012;55 Suppl 1:S3-S9. doi:10.1093/cid/cis39343. Moss R, Munt B. Injection drug use and right sided endocarditis. Heart. 2003;89(5):577-581.44. Kelly TM, Daley DC. Integrated treatment of substance use and psychiatric disorders. Soc Work Public Health. 2013;28(0):388-406. doi:10.1080/19371918.2013.77467345. Ross S, Peselow E. Co-occurring psychotic and addictive disorders: neurobiology and diagnosis. Clin Neuropharmacol. 2012;35(5):235-243. doi:10.1097/WNF.0b013e318261e19346. Ko JY, Wolicki S, Barfield WD, et al. CDC Grand Rounds: public health strategies to prevent neonatal abstinence syndrome. MMWR Morb Mortal Wkly Rep. 2017;66. doi:10.15585/mmwr.mm6609a247. National Cancer Institute. Secondhand Smoke and Cancer. National Cancer Institute. https://www.cancer.gov/about-cancer/causes-prevention/risk/tobacco/second-hand-smoke-fact-sheet. Published January 12, 2011. Accessed June 4, 2018.48. Röhrich J, Schimmel I, Zörntlein S, et al. Concentrations of delta9-tetrahydrocannabinol and 11-nor-9-carboxytetrahydrocannabinol in blood and urine after passive exposure to Cannabis smoke in a coffee shop. J Anal Toxicol. 2010;34(4):196-203.49. Cone EJ, Bigelow GE, Herrmann ES, et al. Non-smoker exposure to secondhand cannabis smoke. I. Urine screening and confirmation results. J Anal Toxicol. 2015;39(1):1-12. doi:10.1093/jat/bku11650. Zibbell JE, Asher AK, Patel RC, et al. Increases in acute hepatitis C virus infection related to a growing opioid epidemic and associated injection drug use, United States, 2004 to 2014. Am J Public Health. 2018;108(2). https://ajph.aphapublications.org/doi/10.2105/AJPH.2017.304132. Accessed June 4, 2018.51. Center for Behavioral Health Statistics and Quality. Results from the 2016 National Survey on Drug Use and Health: Detailed Tables.Rockville, MD: Substance Abuse and Mental Health Services Administration; 2017.52. Volkow ND, Chang L, Wang GJ, Fowler JS, Franceschi D, Sedler M, Gatley SJ, Miller E, Hitzemann R, Ding YS, Logan J. Loss of dopamine transporters in methamphetamine abusers recovers with protracted abstinence. J Neurosci 21(23):9414-9418, 2001. 53. McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA 284(13):1689-1695, 2000.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESNIH Publication No. 20-DA-5605Printed in April 2007Revised February 2008, August 2010, July 2014, July 2018, June 2020This publication is available for your use and may be reproducedin its entirety without permission from the NIDA. Citation of the source is appreciated, using the following language:Source: National Institute on Drug Abuse; National Institutesof Health; U.S. Department of Health and Human Services.
Topic 7 DQ 1
How would you go about helping the client to address sexual health issues associated with substance use disorders? What would be some high-risk behaviors that would not promote positive health and recovery? What challenges might there be related to the client’s family faith traditions?
 
Topic 7 DQ 2
Select one of the following special topics related to the substance use disorder field that interests you and discuss briefly.
Documentation (SOAP, DAP, case notes, psychotherapy notes, intake and discharge summaries)
Suicidality and the relationship with substance use disorders
Ethics in substance use disorder treatment
CFR 42 law
Biopsychosocial intake
Termination/discharge/transfer
TASC/probation involvement
Insurance, Affordable Care Act, TriCare/ChampVA, benevolence programs, free medicine programs (C15)
PTSD and SUD comorbidity
Handling crisis, dangerous situations, safety measures
Bible-based counseling
Full Terms & Conditions of access and use can be found athttps://www.tandfonline.com/action/journalInformation?journalCode=wsub20Substance AbuseISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/wsub20The role of spirituality in addiction medicine: aposition statement from the spirituality interestgroup of the international society of addictionmedicineMarc Galanter, Helena Hansen & Marc N. PotenzaTo cite this article: Marc Galanter, Helena Hansen & Marc N. Potenza (2021) The role ofspirituality in addiction medicine: a position statement from the spirituality interest groupof the international society of addiction medicine, Substance Abuse, 42:3, 269-271, DOI:10.1080/08897077.2021.1941514To link to this article: https://doi.org/10.1080/08897077.2021.1941514© 2021 The Author(s). Published withlicense by Taylor & Francis Group, LLCPublished online: 02 Jul 2021.Submit your article to this journal Article views: 3113View related articles View Crossmark data
COMMENTARYTheroleofspiritualityinaddictionmedicine:apositionstatementfromthespiritualityinterestgroupoftheinternationalsocietyofaddictionmedicineMarcGalanter,MDa,HelenaHansen,MD,PhDb,andMarcN.Potenza,MD,PhDc,d,e,faDepartmentofPsychiatry,NewYorkUniversitySchoolofMedicine,NewYork,NewYork,USA;bDepartmentofAnthropologyandPsychiatry,UniversityofCaliforniaLosAngelesDavidGeffenSchoolofMedicine,LosAngeles,California,USA;cDepartmentofPsychiatryandtheChildStudyCenter,YaleSchoolofMedicine,NewHaven,Connecticut,USA;dConnecticutCouncilonProblemGambling,Wethersfield,Connecticut,USA;eConnecticutMentalHealthCenter,NewHaven,Connecticut,USA;fDepartmentofNeuroscience,YaleUniversity,NewHaven,Connecticut,USAABSTRACTSpiritualityisaconstructthatisreflectedinadiversityofstronglyfeltpersonalcommitmentsindifferentculturalandnationalgroups.Forpersonswithsubstanceusedisorders(SUDs),itcanserveasacomponentoftherecoverycapitalavailabletothem.Thispositionstatementreviewsempiricalresearchthatcanshedlightonpsychological,social,andbiologicalaspectsofthiscon-struct.Onthisbasis,theSpiritualityInterestGroupoftheInternationalSocietyofAddictionMedicine(ISAM)makesrecommendationsforhowthisconstructcanbeincorporatedintoresearchandclinicalcare.KEYWORDSAddiction;spirituality;physiology;alco-holicsanonymousIntroductionOvermanyyears,actsofdeeplyfeltcommitmenthaveservedasabasisforpeopletryingtogaincontrolovertheirsubstanceusedisorders(SUDs).Giventhemanysettingsinwhichthiscanoccur,andthediverse,culturallydefinedbeliefsuponwhichindividualsmaydraw,thegenerictermofspiritualitycanbeappliedtosuchphenomena.Spiritualityhasbeendefinedwithregardtoclinicalsettingsasacommitmenttotranscendentorexistentialpersonalmeaninginone’slife,typicallyinvolvingaconnectionwithsomethinglargerthanoneself1andisdistinguishedfromthepursuitofmaterialneedsororganizedreligionperse.Additionally,empiricalstudieshavebeenundertakentoassessthedegreeofindividuals’spiritualorientation.2,3TheInternationalSocietyofAddictionMedicine(ISAM)includesaspiritualdimension,inadditiontopsychologicalandbiologicaldimensionsofSUDs,asinitsdefinitionofaddictionandcertificationnote.4Theneedforattentiontoempiricalevidencefortherela-tionshipbetweenspiritualityandSUDshasbeenlongrecog-nized.5ThecurrentdocumentrepresentsapositionstatementadoptedbytheSpiritualityInterestGroupofISAMtoclarifytheroleofspiritualitywithintheaddictionfield,andincludeshowneuroscience,socialscience,andpsychologycanadvanceourunderstandingofspiritualityanditsroleinrecoveryfromaddictionsandprovidesrec-ommendedactions.ItcomplementstheinclusionbytheWorldHealthOrganizationofreligionandspiritualityasadimensionofqualityoflife,6andtheWorldPsychiatricAssociation’sguidelinesforintroducingreligionandspiritu-alityintothepracticeofpsychiatry.7BackgroundDespiteconsiderableadvancesinbothpharmacologicalandbehavioraltreatmentmodalities,thereisaworldwidedeficitintheavailabilityofprofessionaltreatmentforSUDs.Thereisalsoaneedfordevelopingimprovedapproachesforclini-cians8,9topromoteaddictionrecoverytailoredtothediver-sityofrespectivenationalcultures.10Thewaythiscanbedoneisbygenerating,evaluating,andemployingspirituallyorientedapproachesthatmayhelptoaddressthisdeficit.Oneaspectofsecuringsustainedrecoveryisincludedundertheconceptof“recoverycapital,”describingresourcesuponwhichpeoplewithaddictivedisordersmaydraw.ThistermhasbeendefinedbytheWorldHealthOrganizationintheInternationalStandardsfortheTreatmentofDrugUseDisorders6astheinternalandexternalresourcesavailabletoanindividualtopromoteasustainedrecovery,includingpeer-basedandculturallyrelatedsupportfordiscovering“meaningandpurposeinlife.”Inthisrespect,achievinganenhancedspiritualorientationcanprovideincreasedrecov-erycapital,theenhancedabilitytosustainrecoveryfromsubstanceusedisorders(SUDs).ThiscanbevaluableinCONTACTMarcGalanter,MDmarcgalanter@nyu.eduNewYorkUniversitySchoolofMedicine,550FirstAvenue,NBV2211,NewYork,NY,10016,USA.MembersoftheSpiritualityInterestGroupoftheInternationalSocietyofAddictionMedicineare:MarcGalanter,MD(chair),HamadAlGhaferi,MD,PhD,GregoryBunt,MD,John(Calvin)Chatlos,MD,PaulEarley,MD,Nadyel-Guebaly,MD,BelleGavriel-Fried,PhD,HelenaHansenMD,PhD,JagKhalsa,MS,PhD,DonaldKurth,MD,JonathanLee,MD,ClaytonMcClintock,MTS,PhD,LisaMiller,PhD,MarcN.Potenza,MD,PhD,StephenRoss,MD2021TheAuthor(s).PublishedwithlicensebyTaylor&FrancisGroup,LLCThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttribution-NonCommercial-NoDerivativesLicense(http://creativecommons.org/licenses/by-nc-nd/4.0/),whichpermitsnon-commercialre-use,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited,andisnotaltered,transformed,orbuiltuponinanyway.SUBSTANCEABUSE2021,VOL.42,NO.3,269–271https://doi.org/10.1080/08897077.2021.1941514
addingtotheresources,suchaspharmaceuticalorinstitu-tional,onwhichsuchapersoncandraw.ConsequencesofadeficitinthisaspectofrecoverycapitalhavebeenillustratedinananalysisbyCaseandDeaton11incharacterizing“deathsofdespair,”whichtheyspecificallydefineasalcohol-relatedliverdisease,drugoverdose,andsuicide.Aftercon-trollingforobesity,incomeinequality,andpoverty,theyfoundthatindividuals’limitedoptionsforachievinghopeforthefutureweremostcommonindemographicgroupsexperiencingariseinsuchdeaths.Anapproachtoenhancingpersonallyexperiencedspiritual-ity,asembodiedintheavailabilityofculturallysyntonicapproaches,andtherebyimprovingone’srecoverycapital,mayservetoyieldrelieffromthepressuretoturntosubstancemis-useandaddictivebehaviors.Suchapproacheshavebeendocu-mentedindiversesettings,suchasrecoveryfromgambling(anon-substanceuse)disorderinIsrael3andmulti-denomin-ational,Christianity-basedrecoveryprogramming.12Similarapproachesarealsoimplicitinnumerousculturallydefinedset-tingsworldwideforachievingrecovery,includingHinduisminIndia,BuddhisminSouthAsia,andShi’isminIran.PerhapsthemostwidelystudiedofsuchanapproachhasbeenundertakeninresearchonTwelveStepfellowships.Theutilityofthesefellowshipshasrecentlygainedadd-itionalvalidityafterthereleaseofaCochraneReview13thatdemonstratesthesubstantialeffectivenessoffacilitatingpar-ticipationinAlcoholicsAnonymous(AA)andotherTwelveStepprogramsforalcoholusedisorder.Onaclinicallevel,ithasbeenfoundthatself-reportsofspiritualawakeningamongAAmemberspredictedimproveddrinkingoutcomesinsubsequentfollow-up.14AAandNarcoticsAnonymousareself-designated“SpiritualFellowships,”andtheirmembersnumberinthemillionsworldwide.Twoaspectsofthisself-designationareevidentintheimportanceofspiritualityandspiritualawak-eningamonglong-termmemberswhoattributespiritualcommitmenttotheirexperienceofrecovery.Infact,abstin-enceafterdischargefromprofessionaltreatmentwasfoundinonestudytobethreetimesaslikelyamongpatientswhoreportedhavinghadaspiritualawakening.15Studiesthatdelineatebiologicalcorrelatesofspiritualitycanbehelpfulinunderstandingmechanismsofrecoveryfromaddictions.Inonesetofstudies,responsestoaguidedimageryneuroimagingtaskwereevaluated.16,17Spiritualexperienceswerecontrastedwiththoseofneutral-relaxingandstressfulexperiences,andneuraldifferencesbetweentheconditionsweredistinguishablebyusingfunctionalmagneticresonanceimaging.16,17Activationoftheparietalcortexdis-tinguishedthethreeconditions,16resonatingwithpriorstructuralstudieslinkingreligionandspiritualitytoparietalvolumeofthisregion.18Amoresustainedpatternofengagementofaventralfrontotemporalnetworkwasalsospecifictothespiritualcondition,andthedegreeofengage-mentcorrelatedwithself-reportedrobustnessofthespiritualexperienceaswellasintrinsicspirituality,suggestingafunc-tionalneuralnetworkunderlyingspiritualexperiencesandtendencies.17Additionally,measuresofintrinsicspiritualityhavebeenfoundtocorrelateinverselywithcorticalandsubcorticalbrainregionsduringexposuretopersonallystressfulcues.19Giventhatindividualswithearlylifetraumaorthosewithdrugaddictions(particularlywomenwhoaremorelikelytoengageinaddictivebehaviorstoalleviatestressorforothernegativereinforcementmotivations)havebeenfoundtoover-activatetheseregionsduringsimilarexposurestostressfulcues,20,21thefindingssuggestabio-logicalmechanismbywhichspiritualitymaymitigateagainststressandaddictionrisk.Anotherstudy22employedlong-termAAmemberswhohadreportedhavinghadaspiritualawakening.Theywereexposedtoalcohol-relatedimagesafterreadingeitheranAA-relatedprayerorneutralmaterial.Theirresponsesfollowingtheprayercondition,bothonimagingandonsubjectivereport,werecorrelatedwiththesubsequentdiminishedcravingthattheyreported.Suchresearchsuggestsoptionstobepursuedinstudyingneuralnetworksreflectiveofspiritualexperiencesandhowtheymaypromoterecoveryfromaddictions.GardnerandKleinmannotethatanemphasisonbio-logicalresearchandpharmacologicalmanagementhascometopredominateoverstudieson“theinterconnectionsofmind,body,andsociety”23tothedetrimentofpotentiallybeneficialintegrativemodels.Spiritualityisoftenculturallyresonantwiththemedicallyunderserved,includingracial/ethnicminoritygroups,individualsoflowersocioeconomicstatus,andwomen.Engagingspiritualityandrelatedcom-munityorganizationsintreatmentisanimportantaspectofimprovingtreatmentaccess,outcomes,andequityforunderservedgroups.24Gainingabetterunderstandingofhowspiritualityismanifestedindifferentculturesmayalsoaidinbettertailor-ingoftreatmentinspecificsettings.Itmayalsoenrichthewayspatientswithaddictionscanbeapproachedbyclini-cians.Additionally,researchontheneuralmechanismsasso-ciatedwithspiritualexperiencesmayleadtoclarifyingthecomplexityofbrainnetworksthatunderlieneurallybasedschemasassociatedwithaddictionrecovery.Theabove-describedapproachesmayaidindevelopingbetterpersonalizedpsychologicalandbehavioralapproachesforcliniciansandmayhelpkeeppatientsengagedinmedi-cation-focusedtreatmentprograms.Neurobiologicalstudiesmayaidinunderstandingdifferentialresponsesofpeoplewithaddictionstotreatment(bothpositiveornegative)andidentifyingmechanismsunderlyingactiveingredientsoftreatments.Suchinformationhassignificantpotentialtoadvanceinterventionsanddecreasesufferingofindividualsimpactedbyaddictions.RecommendationsInlightoftheabove,weproposethefollowing:1.Thattheclinicalevaluationofapatientwithanaddict-ivedisorder(SUDsorbehavioraladdictionslikegam-blingorgamingdisorders)includeanassessmentoftheroleofspiritualityintheirpersonalhistoryandthecur-rentmanifestationoftheiraddictivedisorder.2.Thatclinicians’treatmentplanningincludeconsiderationofhowissuesrelatedtospiritualitycanbeemployedin270M.GALANTERETAL.
programmingdesignedtoincreasethepatient’srecoverycapitaltofortifytheirrecovery,suchasanexaminationofwhichspirituallyrelatedexperiencesapatientmighthavepreviouslyencounteredandascertainingspirituallyori-entedresourcesintheircommunity.3.Thatspirituallyorientedcommunity-basedresourcesthatareappropriateforagivenpatient(suchascultur-allyorientedfacilities,religiousinstitutions,25andpeersupportgroups,likeTwelveStepfellowships)beconsid-eredforreferral,andsupportingthereferralofpatientstosuchresources.4.Thatresearchbepromotedtoascertainpsychological,cross-cultural,andbiologicalunderpinningsonhowdrawingonspiritualresourcescanplayaroleinrecov-eryfromaddictivedisorders.AcknowledgementsTheauthorsandInterestGroupmembersexpressappreciationtotheBoardofDirectorsoftheInternationalSocietyofAddictionMedicineforreviewingthisdocumentasaPositionStatementfromtheSociety’sSpiritualityInterestGroup.DisclosurestatementTheauthorsandSpiritualityInterestGroupmembershavenoconflictsofinterest.Dr.PotenzadisclosesthathehasconsultedforandadvisedRivermendHealth,GameDayData,AddictionPolicyForum,AXA,IdorsiaandOpiantTherapeutics;receivedresearchsupportfromtheMoheganSunCasino,theConnecticutCouncilonProblemGamblingandtheNationalCenterforResponsibleGaming;consultedfororadvisedlegalandgamblingentitiesonissuesrelatedtoimpulsecontrolandaddictivebehaviors;providedclinicalcarerelatedtoimpulse-controlandaddictivebehaviors;performedgrantreviews;editedjournals/journalsections;givenacademiclecturesingrandrounds,CMEeventsandotherclinical/scientificvenues;andgeneratedbooksorchaptersforpublishersofmentalhealthtexts.AuthorcontributionsThispositionstatementwasconceivedofanddevelopedbythethreecoauthorsandreviewedandapprovedbymembersoftheSpiritualityInterestGroup.ORCIDMarcN.Potenzahttp://orcid.org/0000-0002-6323-1354References[1]PuchalskiCM.Spiritualityandhealth:theartofcompassionatemedicine.HospPhys.2001;37(3):30–36.[2]ZemoreSE.Aroleforspiritualchangeinthebenefitsof12-stepinvolvement.AlcoholClinExpRes.2007;31(10Suppl):76s–79s.[3]Gavriel-FriedB,MorettaT,PotenzaMN.Associationsbetweenrecoverycapital,spirituality,andDSM-5symptomimprove-mentingamblingdisorder.PsycholAddictBehav.2020;34(1):209–217.[4]AbouttheCertification.InternationalSocietyofAddictionMedicine.https://isamweb.org/isam-products/international-certi-fication-addiction-medicine/.AccessedMay10,2020.[5]MillerWR.Researchingthespiritualdimensionsofalcoholandotherdrugproblems.Addiction.1998;93(7):979–990.[6]TheUnitedNationsOfficeonDrugsandCrime.Internationalstandardsforthetreatmentofdrugusedisorders2017.https://www.who.int/substance_abuse/activities/msb_treatment_stand-ards.pdf.AccessedMay10,2020.[7]Moreira-AlmeidaA,SharmaA,JansevanRensburgB,VerhagenPJ,CookCCH.WPApositionstatementonspiritual-ityandreligioninpsychiatry.WorldPsychiatry.2016;15(1):87–88.[8]BalboniMJ,BandiniJ,MitchellC,etal.Religion,spirituality,andthehiddencurriculum:medicalstudentandfacultyreflec-tions.JPainSymptomManage.2015;50(4):507–515.[9]MendolaA,GibsonRL.Addiction,12-stepprograms,andevi-dentiarystandardsforethicallyandclinicallysoundtreatmentrecommendations:whatshouldcliniciansdo?AMAJEthics.2016;18(6):646–655.[10]YelD,BuiA,JobJS,KnutsenS,SinghPN.Beliefsabouttobacco,health,andaddictionamongadultsinCambodia:find-ingsfromanationalsurvey.JReligHealth.2013;52(3):904–914.[11]CaseA,DeatonA.DeathsofdespairandthefutureofCapitalism.Princeton,NJ:PrincetonUniversityPress,2020.[12]BrownAE,ToniganJS,PavlikVN,etal.Spiritualityandconfi-dencetoresistsubstanceuseamongCelebrateRecoverypartici-pants.JReligHealth.2013;52(1):107–113.[13]KellyJF,HumphreysK,FerriM.AlcoholicsAnonymousandother12-stepprogramsforalcoholusedisorder.CochraneDatabaseSystRev.2020;3:1–98.[14]StrobbeS,CranfordJA,WojnarM,BrowerKJ.Spiritualawak-eningpredictsimproveddrinkingoutcomesinaPolishtreat-mentsample.JAddictNurs.2013;24(4):209–216.[15]KaskutasLA,AmmonL,DelucchiK,etal.Alcoholicsanonym-ouscareers:patternsofAAinvolvementfiveyearsaftertreat-mententry.AlcoholClinExpRes.2005;29(11):1983–1990.[16]MillerL,BalodisIM,McClintockCH,etal.Neuralcorrelatesofpersonalizedspiritualexperiences.CerebCortex.2019;29(6):2331–2338.[17]McClintockCH,WorhunskyPD,XuJ,etal.Spiritualexperien-cesarerelatedtoengagementofaventralfrontotemporalfunc-tionalbrainnetwork:Implicationsforpreventionandtreatmentofbehavioralandsubstanceaddictions.JBehavAddict.2019;8(4):678–691.[18]MillerL,BansalR,WickramaratneP,HaoX,etal.Neuroanatomicalcorrelatesofreligiosityandspirituality:astudyinadultsathighandlowfamilialriskfordepression.JAMAPsychiatry.2014;71(2):128–135.[19]McClintockCH,WorhunskyPD,BalodisIM,etal.Howspir-itualitymaymitigateagainststressandrelatedmentaldisorders:areviewandpreliminaryneurobiologicalevidence.CurrBehavNeurosciRep.2019;6(4):253–262.[20]PotenzaMN,HongKA,LacadieCM,etal.Neuralcorrelatesofstress-inducedandcue-induceddrugcraving:influencesofsexandcocainedependence.AmJPsychiatry.2012;169(4):406–414.[21]ElseyJ,CoatesA,LacadieCM,etal.Childhoodtraumaandneuralresponsestopersonalizedstress,favorite-foodandneu-tral-relaxin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Measurement-basedcareusingDSM-5foropioidusedisorder:canwemakeopioidmedicationtreatmentmoreeffective?JohnMarsden1,BettyTai2,RobertAli3,LianHu2,4,A.JohnRush5,6,7&NoraVolkow2AddictionsDepartment,InstituteofPsychiatry,PsychologyandNeuroscience,King’sCollegeLondon,UK,1NationalInstituteonDrugAbuse,NationalInstitutesofHealth,Rockville,MD,USA,2DisciplineofPharmacology,SchoolofMedicine,TheUniversityofAdelaide,SouthAustralia,3TheEmmesCorporation,Rockville,MD,USA,4Duke-NationalUniversityofSingapore,Singapore,5DepartmentofPsychiatry,DukeUniversityMedicalSchool,Durham,USA6andDepartmentofPsychiatry,TexasTechHealthSciencesCenter,TX,USA7ABSTRACTContextandPurposeMeasurement-basedcare(MBC)isanevidence-basedhealth-carepracticeinwhichindicatorsofdiseasearetrackedtoinformclinicalactions,providefeedbacktopatientsandimproveoutcomes.ThecurrentopioidcrisisinmultiplecountriesprovidesapressingrationaleforadoptingabasicMBCapproachforopioidusedisorder(OUD)usingDSM-5toincreasetreatmentretentionandeffectiveness.ProposalTostimulatedebate,weproposeabasicMBCapproachusingthe11symptomsofOUD(DSM-5)toinformthedeliveryofmedicationsforopioidusedisorder(MOUD;includingmethadone,buprenorphineandnaltrexone)andtheirevaluationinoffice-basedprimarycareandspecialistclinics.KeyfeaturesofabasicMBCapproachforOUDusingDSM-5aredescribed,withanillustrationofhowclinicalactionsareguidedandoutcomescommunicated.Forcoretreatmenttasks,weproposethatcravinganddruguseresponsetoMOUDshouldbeassessedafter2weeks,andOUDremissionstatusshouldbeevaluatedat3,6and12months(andexitfromMOUDtreatment)andbeyond.Eachofthe11DSM-5symptomsofOUDshouldbediscussedwiththepatienttodevelopacaseformulationandguideselectionofadjunctivepsychologicalinterventions,supplementedwithinformationonsubstanceuse,andoptionallyextendedwithinformationfromotherclinicalinstruments.Apatient-reportedoutcomemeasureshouldberecordedanddiscussedateachremissionassessment.ConclusionsMBCcanbeusedtotailorandadaptMOUDtreatmenttoincreaseengagement,retentionandeffectiveness.MBCpracticeprinciplescanhelppromotepatient-centredcareinOUD,personalizedaddictiontherapeuticsandfacilitatecommunicationofoutcomes.KeywordsDSM-5,measurement-basedcare(MBC),medicationsforopioidusedisorder(MOUD),opioidusedisorder(OUD),patientreportedoutcome(PRO),psychologicalintervention.Correspondenceto:JohnMarsden,InstituteofPsychiatry,King’sCollegeLondon,AddictionSciencesBuilding,4WindsorWalk,DenmarkHill,LondonSE58AF,UK.E-mail:john.marsden@kcl.ac.ukSubmitted17October2018;initialreviewcompleted5December2018;finalversionaccepted28December2018PURPOSEANDBACKGROUNDInthisAddictionDebatearticle,wedescribetheconcept,clinicalproceduresandprobablebenefitsofasimplemeasurement-basedcare(MBC)approachforopioidusedisorder(OUD[1]).MBCcanbeappliedtoanytreat-mentinthesubstanceusedisordersfield,butwefocusonfirst-linemedicationsdeliveredinprimarycareandspecialistclinics.Thisisbecausethecurrentopioidcrisisanddramaticincreaseinfatalopioid-relatedpoisoningsintheUnitedStates,Canada,AustraliaandseveralothercountriesinEurope[2–5]haveledtoanurgentcalltoincreaseprovisioninprimarycare[6]andanationalinitiativeintheUnitedStatestoincreasethecapacityandintegrationoftreatmentinhospitals,statehealthdepartments,specialistprogrammesandthecriminaljusticesystem[7].MBCisanevidence-basedhealth-carepracticeinwhichdiseasesymptoms,signsorbiomarkersareusedtoinformclinicalactions,withfeedbackgiventopatientsabouttheirprogressintreatmenttoincreaseengagement,adherenceandbeneficialexposuretoevidence-basedther-apies.Physicalhealthconditionsarealmostalwaystreatedlikethis(e.g.hypertensionanddiabetes,inwhichbloodThisisanopenaccessarticleunderthetermsoftheCreativeCommonsAttribution-NonCommercialLicense,whichpermitsuse,distributionandreproductioninanymedium,providedtheoriginalworkisproperlycitedandisnotusedforcommercialpurposes.©2018TheAuthors.AddictionpublishedbyJohnWiley&SonsLtdonbehalfofSocietyfortheStudyofAddictionAddiction,114,1346–1353ADDICTIONDEBATEdoi:10.1111/add.14546
pressureandglycatedhaemoglobin,respectively,arepri-marybiomarkersinclinicalpractice).Inmentalhealth,manyclinicaldecisionsareguidedbythepresenceandseverityofpatient-reportedsymptoms.Forexample,thenine-itemversionofthePatientHealthQuestionnaire(PHQ-9)[8]wasconstructedfromthesymptomsofmajordepressivedisorderinDSM-IV.Follow-ingpivotalrandomizedcontrolledtrialsofantidepressantmedications[9,10],thePHQ-9hasbecomethemostwidelyusedmeasureforMBCindepression[11,12].ThePHQ-9totalscoreinformstheselectionandswitchingofmedications,thepatient’sresponsetopsychologicaltherapyandprovidesastandardmetrictocommunicateoutcomes.WhydoweneedanMBCapproach?PharmacotherapeuticandpsychologicalapproachesforOUDaredeliveredinout-patientclinicsandofficesandin-patienthospitalsettingsandresidentialsettings.OngoingprescriptionsofmedicationsforOUD[MOUD;oralmethadone(MET)andsublingualbuprenorphine(BUP)]arethefirst-linetreatmentsusedinmanycountriesworld-wideandareourfocushere.Meta-analysisofran-domizedcontrolledtrialsconcludesthatMETandBUPareassociatedwiththesuppressionofnon-medicalopioiduseandincreasedperiodsofabstinence[13,14].Observa-tionalfollow-upstudiesoftreatmentroutinelydeliveredshowreductionsindruginjecting[15,16],opioidoverdose[17],blood-borneviralinfections[18]andcrime[19].Recentrandomizedcontrolledefficacytrialshaveshownclinicalbenefitforextended-releaseinjectabledepotformulationsofnaltrexone(anopioidantagonist)andBUP[20–22].Giventhesepositivefindings,whydoweneedMBC?OnecompellingreasonisthattheaveragetreatmenteffectfromMOUDresearchmasksmanypatients’actualexperi-ence.Upto40–50%ofpatientsdiscontinueMOUDtreat-ment,mostwithinamonth[23,24],andmanyfollowarepeatingcycleofre-admissionandearlydiscontinuation[25].InaninfluentialrandomizedcontrolledstudyofMOUDforpeoplewithprescriptionmedicationOUD,RogerWeissandcolleaguesobservedthatmorethanaquarteroftheirsamplewereunabletostopnon-medicalopioiduseafter2weeksofBUP,withthisearlynon-responsestronglypredictiveofdruguse3monthslaterintreatment[26].InEngland,amonganationalcohortof12745patientswhoreceived12–26weeksofMOUD,64%usedheroinon10ofthepast28daysatfollow-up[27].Inafurtherstudyof7719patientswhowerecontinuouslyenrolledinMOUDfor5years,one-seventhmadeearlygains,butthenrelapsedafterapproximately6months,withatendencytouseheroinonapproximatelyhalfthedaysofthemonthpriortoeverysubsequentbi-annualreview[28].TherehasbeenasustainedefforttoimproveMOUDoutcomes,withstudyofadjunctivepsychologicalinterventionsthemostcommonresearchstrategy.However,pooledresultsfromaCochraneReviewof13differentinterventionshavebeeninterpretedtoindicateweakevidence,withnoonemodal-ityjudgedeffective(relativeriskforabstinence=1.03;95%confidenceinterval=0.98–1.07)[29].Muchhasbeenlearnedfromlong-standingeffortsinthealcoholanddrugfieldtodevelopclinicaloutcomemonitoringsystems[30–32].Apatient’sresponsetotreat-mentwillbeinfluencedbyseveralfactors,includingtheirabilityandmotivationtoadheretotheirprescription(e.g.distancetravelledtoreceivedosingandclinicalprac-ticeondirectlyobservedorself-administereddosingandattendance).AnotherreasonthatMBCisneededisbecauserepeatedcallsfortreatmentservicesandsystemstomonitorout-comes[33,34]hasnotledtowidespreadaction.Severalrelativelybriefinstrumentsareinroutineuseinhealth-caresystems,includingtheBriefAddictionMonitordevel-opedfortheUSVeteransAdministration[35]andtheTreatmentOutcomesProfile,thenationaloutcomestan-dardfordrugandalcoholtreatmentservicesinEnglandforthepastdecade[36].However,neitherinstrumentwasdesignedtodiagnosesubstanceusedisorder(SUD)orclassifyremission.Thereisnoconsensusonwhichindica-torsaremostrelevantforMBCandfewserviceswoulddescribethemselvesasMBC-driven.MBCusingDSM-5symptomsTheDSM-5OUDchecklistisusuallycompletedsolelyforadministrativereasons(e.g.toseekinsuranceauthoriza-tionfortreatment)ortodocumenteligibilitycriteriaforaresearchstudy.Surprisingly,thesequestionsarerarelyusedinthecliniceitherasameansofplanningtreatmentorclassifyingremission.Manypractitionersareattunedtotheirpatients’signsandsymptomsandrespondwhenOUDworsensorimproves,buttimepressuresoftenmeanthattreatmentisnotmonitoredclosely.WesuggestthatforOUDthelogicalstartingpointforanMBCorientationdesignedtoincreaseengagementandresponseistofocusonthe11symptomsofthedisorderinDSM-5.AlthoughtheAPAsystemisusedinthemajorityofresearchreports,weacknowledgethatsomereadersworkintreatmentsystemswhichdiagnoseopioiddepen-denceusingtheWorldHealthOrganizationInternationalClassificationofDisease(WHOICD)system.TheproposalsinthisarticleapplyequallywelltothelatestreleaseoftheICD(WHO;ICD-11)[37].ItwillbeinterestingtodeterminewhetherICD-11hasanyadvantagesoverDSM-5forMBC.DSM-5OUDiswidelyusedandknown,butabriefsummaryiswarranted.OUDisalatentconstructwith11symptoms(eachscoredasmetornot-met)whichfallMeasurement-basedcareusingDSM-5foropioidusedisorder:canwemakeopioidmedicationtreatmentmoreeffective?1347©2018TheAuthors.AddictionpublishedbyJohnWiley&SonsLtdonbehalfofSocietyfortheStudyofAddictionAddiction,114,1346–1353
onasingleseveritydimension[38].Sixitemsaddressphys-iologicalandcognitivebehaviouralaspectscausallyrelatedtoneurobiologicalandneurocognitiveadaptationsfollow-ingopioidexposure(i.e.tolerance;withdrawalsymptoms;usingmorethanintended;problemscontrollingconsump-tion;timespentinvolvedwithopioids;anddistressingcrav-ing).Theremainingfiveitemscaptureriskofharmandharmfulsocialconsequencescausedbyopioiduseandin-toxication(i.e.physicallyhazardoususe;usingdespitehealthproblemscausedorexacerbated;failuretomeetroleobligations;continuedusedespitesocialproblems;activi-tiesreducedorgivenup).Conceptually,eachsymptomisaresponse(eitherdirectorindirect)ofexposuretoopioidsorisaharmthatismaintainedorworsenedbychronicuse.ScoringDSM-5OUDisstraightforward:adiagnosisismetifatleasttwosymptomsareexperiencedwithinthesameperiodinthepast12months.OUDseverityisjudgedbythenumberofsymptomsmet:mild,2–3;moder-ate,4–5;orsevere,6–11.TheminimalscoreforsevereOUDmaynotincludeanynegativeconsequences,butahigherlevelofseveritymustinvolvesomehealthand/orso-cialimpairment.ApersondiagnosedwithOUDisclassifiedasbeingin‘earlyremission’ifnosymptomsaremetforatleast3months.Thecravingsymptomisnotcounted,noranitemreferringtotoleranceandwithdrawalifthepersonisenrolledinandfullycompliantwithMOUD.PracticalproposalsforMBCEstablishingaclinicaldiagnosiswillalwaysbeanessentialclinicaltask,butevenminimalprobingforadditionalinfor-mationforeachendorseditemcanprovidevaluableinsightforcareplanning,deliveryandadaptationastreatmentprogresses.Eachsymptomcanbeextensiblewithfurtherprobingquestionsasneeded,includingadministrationofaclinicalinstrumentdevelopedfortreatmentplanning[39].Tothebestofourknowledge,theDSM-5OUDworkinggroupselecteda3-monthpointforevaluationofearlyre-missionbecauseithaslongbeenbelievedthatthisisthepointfromwhichclinicallymeaningfuloutcomesareob-served[40].Wethinkthisissensible,butwealsorecom-mendevaluationat6monthsfromtreatmentinitiation.‘Stableremission’isassignedtosomeonewhohasnoOUDsymptomsforatleast12months(notincludingcrav-inganddiscountingtoleranceandwithdrawal,ifenrolledinandfullycompliantwithMOUD).Aspecifierdenoteswhetherthepersonislivinginacontrolledmedicalorcus-todialsetting.Forthosepatientsretainedinlonger-termtreatment,itwouldseemreasonabletoexpectthataremis-sionstatusevaluationisperformedtwice-yearlyandatexit.Inthefollowingsections,wedescribeabasicMBCap-proachusingtheexampleofMOUDdeliveredinprimarycareandspecialistclinics.Intheseservices,wewillassumethatpatientsareabletoaccessadjunctiveinterventionsdirectlyorbyreferral.Spacelimitationsprecludediscussionof:populationswithcomplexneeds(e.g.severementalhealth;personalityfactors;neurocognitiveimpairment;chronicmedicalconditions);transferprocedurestohospi-talin-patientorresidentialprogrammes;andsystem-levelfactorswhichbearheavilyonaccessandthedeliveryofeffectiveMOUD.By‘basic’wemeanactivitiesthatdonotundulycompetewithtimefordirectcareandhaveaminimaladministrativeburdenonthepatient.Wedonotsummarizemedicalmanagementtoincreaseadherence,butnotethatthisisanimportantpartnerprocedure.Attreatmentinitiationandreview,afocusoneachOUDsymptomhelpstostructurediscussionandhelpstheclinicianandpatienttoformulateatestablehypothesisaboutwhyOUDhasoccurred,howbiological,psychologi-calandsocialfactorsarelinkedtoopioiduseandharmsandtheoptionsavailabletocapitalizeorstrengthenthepatient’sresourcesforrecovery[41].Thereisalogicintargetinginterventionsonthefirst6itemsofOUDtoaddressitsnegativeconsequences.InadditiontoneededadjustmentstoMOUDdosing(i.e.toattenuatedistressingcravingandachieveopioidblockade),earlyclinicaltasksshouldincludeeducationonriskreductionand/oreitherawatchfulwaitingapproachforimprovementsinsocialfunctioningormakinganearlyreferral.Itcanbeexpectedthatreducingandquittinguseofillicitopioids(and/oranalgesicproductscontainingopioidsnottakenasdirectedornon-prescribed)willamelioratenegativeconsequencesbutsomesocialharmsmayendure,oremergeeitherbecauseothercontributingfactorswerenotmodifiedorwereduetonewcauses.Althoughthecravingsymptomisnotusedforremissiondiagnosis,wethinkitisanimportantandactionableitemforMBC,becausedistressingcravingexperiencesmaytriggertheuseofdrugsandthissymptomcanpersistlongintoabsti-nence.Optionally,andaccordingtocapacity,apatientwhodescribesdistressingcravingcouldbeaskedtocom-pleteasingle-itemratingscaleoramulti-dimensionalquestionnaire(e.g.[42]).Evenabriefdiscussioncouldhelptobuildtherapeuticalliance,increasechangemotivationandinteresttoengagewithtreatment.AbasicMBCframeworkissummarizedinTable1.Thethirdcolumnshowsexamplesofhoweachdomaincouldbeoptionallyextendedwithadditionalquestions.Theseareexamples,andtherearenumerouswaysinwhichthisbasicframeworkcouldbeexpanded.Ataminimum,wesuggestthatbasicinformationonsubstanceuseshouldberecorded.InOUD,opioiduse(andtherouteofadminis-trationandfrequency)isanessentialbehaviouraldescrip-torandanindicatorofhealthrisk,soaminimalsetofquestionsshouldalsobeaskedaboutrecentillicitandnon-medicaldruguse.Giventheincreasedriskoffatalpoisoningwhenopioidsareconsumedwithothercentralnervoussystem1348JohnMarsdenetal.©2018TheAuthors.AddictionpublishedbyJohnWiley&SonsLtdonbehalfofSocietyfortheStudyofAddictionAddiction,114,1346–1353
depressants,thepatientshouldalsobeaskedaboutrecentuseofsedativemedicationsandheavyalcoholconsump-tion[43].Cocaineusecouldalsobemonitored,asthisisprevalentinsomepopulationswithOUDandcanmoderateMOUDengagementandresponse[44].Informedbytheresearchliteratureondifferentialresponsetotreatment,wesuggestanearlyassessmentofillicitandnon-medicalopioiduseafterthefirst2weeksofMETorBUPprescribing.Foreverypatientretainedaftertheonsetoftreatment,DSM-5OUDremissionshouldthenbeassessedatthefirstTable1DSM-5opioidusedisorder(OUD)criteriaandexamplesofextendedquestions.DomainClass/type/criterionExampleofquestionsA.SubstanceuseOpioidsSedativesStimulants(e.g.cocaine)Usedinthepast3monthsor6or12months?Ifyes,frequency:everyday;5–6timesaweek;3–4timesaweek;twiceaweek;onceaweek;1–3timesamonth;lessoften.Weredrugsinjected?HeavyalcoholuseUSA:drankmorethan4(women)or5(man)standarddrinksonasingleoccasionof2hoursorlessinthepast3months(sameresponsescaleasaboveforfrequency)?OUDcriterion(notmet/met)ExamplesofquestiontopicsifcriterionmetB.Physiological1.Usualdoseofopioidhasdiminishedeffect,orneedtotakehigherdoseforrequiredeffectaSelf-reportedtypicaldose?useofotheropioids?motivationforseekingdrugeffect?2.Experienceofopioidwithdrawalsymptoms(orusetoavoid)cSettingswhenexperiencedwithdrawalsymptoms;drugstakentoavoid/manageC.Cognitiveandbehaviouralcontrol3.Usingopioidsmoreoften,orforlongerthanintendedTypicalsettingsforobtainingandusing(placesandpeople).Whatwerethethoughtsandbelievesthataccompaniedcompromisedintention?4.UnsuccessfulattemptstoreduceorquitopioidsActionstakentoavoidopioiduseandreasonsforlackofsuccess?b5.Timespentobtaining,using,recoveringfromopioidsHastimespentobtainingopioidscausedproblems?Examplesofnegativeexperiencesduringandafterusing?6.Bothered/distressedbystrongurge(cravings)foropioidscLasttime:strengthofurgetouse(0–10;notatall–extremely).Situations,triggers,feelings,intentions/plans,desistanceexperiences.D.Healthrisksandharms7.UsingopioidsinphysicallyhazardoussituationsWhichhazardoussituations(e.g.driving,usingmachinery)?8.OpioidusedespiteknownpsychologicalorphysicalhealthproblemcausedorexacerbatedWhichproblemsareaffected?Howdoesopioidusemaketheproblemworse?NB:anyscreeningindicatedforcomorbidconditions?E.Negativesocialconsequences9.FailuretomeetmajorroleobligationsbecauseofopioidsRecentspecificexamplesofhowopioidimpactedonpersonalrolesathome,workorineducation?Whohasbeenaffected?Howoftendoesthishappen?10.ContinueduseofopioidsdespitesocialproblemsSpecifycurrentinter-personal(e.g.primaryrelationship;family)oroccupationalconflictsaffectedbyopioiduse.Howoftendoesthishappen?11.ImportantactivitiesreducedorgivenupbecauseofopioidsWhichsocial,occupational,vocational,recreationalactivities?Whatopportunitiesaretheretohelprestart?aItemnotmetifpatientenrolledinopioidsubstitutiontreatmentandisabstainingfromnon-prescribedand/orillicitopioids.bCanalsoassesspatient’smoti-vation,capability/opportunityandpersonalresourcestoaddress.cItemnotmetifthepatientenrolledinopioidsubstitutiontreatmentandistakingmedica-tionsforOUD(MOUD)medicationasdirected.Areviewofadequacyofongoingprescriptiondoseand/ordispensingarrangementsindicatedifthepatientisabstainingfromallnon-medicalopioids(verifiedbyurinedrugscreen)butreportsopioidwithdrawalsymptoms.Scoring:Admission:past12monthsseverity(items4–14):2–3=mild;4–5=moderate;6–11=severe.After3monthsinMOUD:3-monthremission=noitemsmet(itemC6notcounted).After6monthsinMOUD:6-monthremission=noitemsmet(itemC6notcounted).After12monthsinMOUD:1-yearsustainedremission=noitemsmet(itemC6notcounted).Measurement-basedcareusingDSM-5foropioidusedisorder:canwemakeopioidmedicationtreatmentmoreeffective?1349©2018TheAuthors.AddictionpublishedbyJohnWiley&SonsLtdonbehalfofSocietyfortheStudyofAddictionAddiction,114,1346–1353
clinicvisitafter3,6and12months.Forpatientsenrolledinlonger-termMOUD,a6-monthfrequencyofremissionstatusisalsoappropriate.GiventhecausallogicunderpinningDSM-5,ifapatientenrolledinMOUDiscompletelyabstinent,thenthecrite-rionforremissionismet,evenifapsychologicalinterven-tionisstillindicatedfordistressingcraving.Conversely,whileoccasionalopioidusedoesnothaveadirectbearingonOUDstatus,monitoringchangeinconsumptionisvalu-abletothepatientandclinician,andabiochemicalmea-sure(e.g.urinedrugscreen)maybehelpfultoverifyrecentabstinencesothatlapsescanbediscussedandinter-ventionsimplemented.Apatientreportoutcome(PRO)willalsohelptoiden-tifythepatient’sperspectiveandpromotecollaborationwiththemwhenassessingremissionstatus.Withnointer-pretationrequiredfromtheclinician,thisisasimplemea-sureoftheimpactoftreatment(orbroaderprogressthemes)intermsofwhatisimportanttothepatient.PROmeasuresarebeingusedincreasinglyforresearchinsev-eraldisease-specificareas.ComprehensiveOUD-specificmeasureshavebeendevelopedwhichrecordpersonalperceptionsofprogresstowardsrecovery[45]andqualityoflife[46].Iftherearetimepressures,asingleglobalPROforchangeinOUDsymptomsfollowingaperiodoftreatmentcouldbeusedinstead(e.g.verymuchimproved;muchim-proved;alittleimproved;nochange;alittleworse;muchworse;verymuchworse).AdministeringthisPROmeasureaspartoftheassessmentofremissioncouldbeveryinfor-mative,especiallywhenapatient’sOUDstatusandtheirownperceptionofchangedonotmatch.ThismeasureshouldnotreplaceDSM-5monitoringastheprimaryfocus,butwillbeveryinformativelylinkedtoit.TherearemanycombinationsofOUDsymptomsthatdescribenon-response.Incaseswhereremissionisnotattained,thereareseveralkeyquestionstobeasked:IsthereachangeintheseverityofOUD?HasOUDimprovedorhasitworsened?whatdoeschangeinOUDseveritysayaboutresponsetoprecedinginterventions?Howshouldthisinformopportunitiestoadjustthecareplanandaddadditionaltreatment?Checkingwhichsymptomsaremetincomparisonwithintakeassessmentwillhelptoupdatethecaseformulationandcouldpointtoanalterationinthepatient’scareplan.Forexample,earlycontinueduseofillicitopioidsmightpromptanincreaseinmedicationdose,areviewofdosingarrangementsandadiscussionofsafetyissues.Oneormoreheavydrinkingdayscouldpromptprovisionofguidedself-helpinformation.ThenatureofeachDSM-5symptommetcouldalsoinformaspecificpsychologicalinterventionorreferraltoaccessiblemedical,welfareandsocialservicesinthelocalcommunityand/orapeersupportgroup.Screeningfordepression(e.g.thetwo-itemversionofthePHQ-9[47]andtheitemonsuicidality)andphysicalhealthconditions[HIV,hepatitisCvirus(HCV)]isalsoindicated.SomepeoplewithOUDwillhaveco-existingproblems(e.g.withstimulantdrugs)andalsolong-standingsocialproblems(e.g.housinginstability;unemployment;andfamilyconflict).Thesefactorsaddcomplexitytotreatmentplanningandmayriskdiscontinuationandpooroutcome.Theopportunitytorespondherewilldependontimeandresources.Evenifremissioniselusiveorisnotachievedforlong,MOUDmayprovidesomesymptomcontrolandprotectionagainstopioidpoisoning.TheclinicianshouldalsonotbedisheartenedifaMOUD-resistantpatientre-fusesanadjunctiveintervention,astheymayacceptthisofferinthefuture.Ifthereisnoresponseaftercontinuoustreatment,cliniciansmightconsiderwhethertoshifttoan-otherMOUDmedication,astheyhavedifferentpharmaco-logicalpropertiesthatmightbemoresuitableforsomepatientsthanothers.Anotherconsiderationisthetimingoftreatmentinterventionduringongoingcare(earlyver-suslater).Moreresearchisneededtoaddressthecurrentabsenceofevidenceonwhichpatientcharacteristicspre-dictresponsetooneMOUDversusanother.MBCresearchWehopethatpragmaticrandomizedcontrolledtrialswillbeperformedtoevaluatetheeffectivenessofMBCforMOUDandotherOUDinterventions.OurproposalsforMBCcanguideend-pointselectionandanalysisinclinicaltrials(whereDSM-5remissionstatusisnotoftenusedinend-pointevaluations).Attheveryleast,asingle-itemPROmeasurecouldbehelpfullyincludedintreatmenttrialsassecondaryoutcomemeasures.CohortresearchonMBCdeliveryforOUDwithinhealth-caresystemswouldalsoprovideadditionalinsightsonresponsetospe-cificinterventionsreceived,generatingvaluablereal-worldevidenceforthesystemitselfaswellasforthewiderOUDtreatmentcommunity.CONCLUSIONSThecurrentopioidcrisisinmanycountriesprovidesapressingrationaleforadoptinganMBCapproachtoin-creasetreatmenteffectivenessforOUD.Weneedtoactquicklyandeffectivelytoaddressnon-responsetoMOUDinthefaceofunprecedentedlevelsoftreatmentneed.WebelievethatimplementingMBCpracticeprincipleswillpro-motepatient-centredcareinthetreatmentofOUDwithMOUDprimaryandspecialistcare.MBChasthepotentialtostimulatethedevelopmentofpersonalizedaddictiontherapeuticsandimprovepatientengagementandreten-tioninalltreatmentsforOUDsothathealthandsocial1350JohnMarsdenetal.©2018TheAuthors.AddictionpublishedbyJohnWiley&SonsLtdonbehalfofSocietyfortheStudyofAddictionAddiction,114,1346–1353
harmsarereducedorprevented,aswellaspromotingacommonmetricforcommunicatingoutcomes.Itisessen-tialforOUDremissionstatustoberecorded,asabasicmin-imum,sothatprogresscanbemeasuredeffectivelyandconsistently.MBCwillnotsitcomfortablyinthebusyclinicifhealth-careprofessionalsseeitasaburdenthatcompeteswithtimespentwiththepatient;butasDSM-5isrecordedalready,allweareadvocatingisthediscussionofthesesymptomswiththepatientaspartofcareplanning,build-ingandsustainingtherapeuticengagementandadaptingtreatmenttoclinicalresponse.UsingDSM-5forMBCshouldbetheminimumstandardforMOUDtreatment.DeclarationofinterestsDuringthepast3years,J.M.declaresresearchgrantsfromtheNHSEnglandandtheEnglishDepartmentofHealthandSocialCare[prisonsettingmaintenancemedicationforopioidusedisorder(OUD)];theNationalInstituteforHealthResearch(NIHR;randomizedcontrolledtrialofde-potnaltrexoneforOUDandarandomizedcontrolledtrialofacamprosatewithbehaviouralinterventionforalcoholusedisorder)andtheNIHRBiomedicalResearchCentreforMentalHealthatSouthLondonandMaudsleyNHSMentalHealthFoundationTrust(SLaM;randomizedcontrolledtrialofnovelcognitivetherapyforcocaineusedisorder).Hehaspart-timeemploymentasSeniorAcademicAdviserfortheAlcohol,Drugs,TobaccoandJusticeDivision,HealthandWellbeingDirectorate,PublicHealthEngland(PHE)andisaclinicalacademicconsultantfortheUSNationalInstituteonDrugAbuse,CentreforClinicalTrialsNetwork.J.M.declaresanunrestrictedresearchgrantatIoPPNandSLaMfromIndiviorviaActiononAddictionforarandomizedcontrolledtrialoftailoredpsychosocialin-terventionfornon-responsetoongoingmethadoneandbuprenorphinetreatment.HehasreceivedhonorariaandtravelsupportforfromMerc-Serono(2015;oncologymedicaleducation);Reckitt-Benckiser(2016;treatmentofOUDandPCMScientificandMartindalefortheImprov-ingOutcomesinTreatmentofOpioidDependenceconfer-ence(2015–18;contributionsandchairing).Heholdsnostocksinanycompany.A.J.R.declaresconsultingfeesfromAkili,BrainResourceInc.,CompassInc.,CurbstoneConsultantLLC,EliLilly,EmmesCorporation,Liva-Nova,MindLinc.,Sunovion,TakedaUSA,TajMedical;speakingfeesfromLiva-NovaandSing-Health;androyaltiesfromGuilfordPressandtheUniversityofTexasSouthwesternMedicalCenter,Dallas,TX(fortheInventoryofDepressiveSymptomsanditsderivatives).Heisalsonamedco-inventorontwopatents(USPatentno.7795033:MethodstoPredicttheOutcomeofTreatmentwithAntidepressantMedication,Inventors:McMahonF.J.,LajeG.,ManjiH.,RushA.J.,PaddockS.,WilsonA.S.;andUSPatentno.7906283:MethodstoIdentifyPatientsatRiskofDevelopingAdverseEventsDuringTreatmentwithAntide-pressantMedication,Inventors:McMahonF.J.,LajeG.,ManjiH.,RushA.J.,PaddockS.).R.A.hasreceiveduntiededucationalgrantsfromReckittBenckiserandMundipharmaforthepost-marketingsurveillanceofopioidsubstitutiontherapymedicationsinAustralia.HeacknowledgesanuntiededucationalgrantfromReckittBenckiser/Indiviorforastudyonpharmacogeneticpredic-torsofopioidagonistmedicationtreatmentsuccess.Allotherauthorshavenodeclarations.Theviewsexpressedinthisarticlearethoseoftheauthors.References1.AmericanPsychiatricAssociationDiagnosticandStatisticalManualofMentalDisorders,5thedn.Arlington,VA:AmericanPsychiatricAssociationDSM-5;2013.2.HedegaardH,WarnerM,MininoAM.DrugoverdosedeathsintheUnitedStates,1999–2016.CHSDataBrief,no.294.Hyattsville,MD:NationalCenterforHealthStatistics,2017;CentersforDiseaseControlandPrevention.NationalVitalStatisticsSystem,Mortality;CDCWonder,Atlanta,GA:USDepartmentofHealthandHumanServices,CDC,2017.3.WoodE.Strategiesforreducingopioid-overdosedeaths—lessonsfromCanada.NEnglJMed2018;378:1565–7.4.PeningtonInstitute.Australia’sannualoverdosereport2017.Availableat:http://www.penington.org.au/australias-an-nual-overdose-report-2017(accessed7December2018)(Archivedathttp://www.webcitation.org/75XTomrdDon19January2019).5.EuropeanMonitoringCentreforDrugsandDrugAddiction.EuropeanDrugReport2017:TrendsandDevelopments.Luxembourg:OfficeoftheEuropeanUnion,2017.Availableat:http://www.emcdda.europa.eu/publications/edr/trendsdevelopments/2017(accessed17December2018).6.KorthuisP.T.,McCartyD.,WeimerM.,BougatsosC.,BlazinaI.,ZakherB.etal.Primarycare-basedmodelsforthetreat-mentofopioidusedisorder:ascopingreview.AnnInternMed2017;166:268–78.7.NationalInstitutesofHealth.NewsReleases.NIHlaunchesHEALInitiative,doublesfundingtoacceleratescientificsolutionstostemnationalopioidepidemic.Availableat:https://www.nih.gov/news-events/news-releases/nih-launches-heal-initiative-doubles-funding-accelerate-scientific-solutions-stem-national-opioid-epidemic(accessed17December2018).8.KroenkeK.,SpitzerR.L.,WilliamsJ.B.ThePHQ-9:validityofabriefdepressionseveritymeasure.JGenInternMed2001;16:606–13.9.RushA.J.,TrivediM.H.,WisniewskiS.R.,NierenbergA.A.,StewartJ.W.,WardenD.etal.Acuteandlonger-termout-comesindepressedoutpatientsrequiringoneorseveraltreatmentsteps:aSTAR*Dreport.AmJPsychiatry2006;163:1905–17.10.ChakrabortyB.,GhoshP.,MoodieE.E.,RushA.J.Estimatingoptimalshared-parameterdynamicregimenswithapplica-tiontoamultistagedepressionclinicaltrial.Biometrics2016;72:865–76.11.AmericanPsychiatricAssociationPr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JUNE 2019EARN 30 FREE Category 1 CME Creditswww.psychiatrictimes.com/cmeOf Americans 12 and older, 2 million have a substance use disorder (SUD) that involves prescription pain relievers and 591,000 have a SUD involving heroin.1 Withdrawal from opioids is extremely unpleasant and individuals often return to substance use to ame-liorate symptoms. The individual may be interested in stopping opioid use altogether but has no access to FDA-approved treatment or wishes to pursue a more “natural” alterna-tive.In recent years, two agents have gained popularity as off-label opioid alternatives—loperamide and kra-tom. These are readily available at low costs and for these reasons they have at times been referred to as “the poor man’s methadone” and “poor man’s buprenorphine,” respectively. On drug-use websites and online fo-rums, high doses of these agents have been promoted as options for opioid withdrawal management and, less often, for psychoactive effects. LoperamideLoperamide has been approved by the FDA for medical use since 1976. It is part of the World Health Organi-zation’s List of Essential Medicine and is widely available as an inexpen-sive and over-the-counter (OTC) remedy used in managing diarrhea. Loperamide is marketed OTC under the brand name Imodium A-D but is also available as store brands and ge-neric versions. As a piperidine opioid in nature, it was once a schedule V drug. At therapeutic doses, its actions are restricted to the gastrointestinal tissue by poor absorption and active efflux from the CNS by membrane transporter P-glycoprotein. The max-imum daily dose is 8 mg for adults as OTC use and 16 mg by prescription.When larger than recommended doses are taken, CNS penetration oc-curs. This practice of ingestion of large doses (in excess of 70 mg daily) has been gaining popularity among users of opioids to manage withdraw-al symptoms and, less frequently, to achieve psychoactive opioid-like ef-fects.Medication-Assisted Treatment on a Budget: Two You Should KnowDr Stanciu is Assistant Professor, Dartmouth Geisel School of Medicine, Hanover, NH, and Director of Addiction Services, New Hampshire Hospital, Concord, NH; Dr Gnanasegaram is Clinical Instructor, Dartmouth Geisel School of Medicine and Attending Psychiatrist, New Hampshire Hospital; Dr Penders is Affiliate Professor, East Carolina University Brody School of Medicine and Attending Psychiatrist, Walter B. Jones Drug and Alcohol Treatment Center, Greenville, NC.ACTIVITY GOALThe goal of this activity is to provide a compre-hensive understanding of the opioid-like effects of loperamide and kratom and raise awareness of potential dangers associated with use.LEARNING OBJECTIVESAt the end of this CE activity, participants should be able to:• Explain the evolutionary paths of loperamide and kratom• Discuss the mechanisms for the opioid-like effects of loperamide and kratom• Identify the pharmacodynamic/toxicodynamic effects of loperamide and kratomTARGET AUDIENCEThis continuing medical education activity is intended for psychia-trists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.CREDIT INFORMATIONCME Credit (Physicians): This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfi tters, LLC, and Psychiatric Times. CME Outfi tters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.CME Outfi tters designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.Note to Nurse Practitioners and Physician Assistants: AANPCP and AAPA accept certifi cates of participation for educational activities certifi ed for AMA PRA Category 1 Credit™.DISCLOSURE DECLARATIONIt is the policy of CME Outfi tters, LLC, to ensure independence, bal-ance, objectivity, and scientifi c rigor and integrity in all of their CME/CE activities. Faculty must disclose to the participants any relation-ships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CME/CE activity. CME Outfi tters, LLC, has evaluated, identifi ed, and attempted to resolve any potential confl icts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer-review process.The following information is for participant information only. It is not assumed that these relationships will have a negative impact on the presentations.Cornel N. Stanciu, MD, MRO, has no disclosures to report.Samantha A. Gnanasegaram, MD, has no disclosures to report.Thomas M. Penders, MS, MD, has no disclosures to report.Saeed Ahmed, MD (peer/content reviewer), has no disclosures to report.Applicable Psychiatric Times staff and CME Outfitters staff have no disclosures to report.UNLABELED USE DISCLOSUREFaculty of this CME/CE activity may include discussion of products or devices that are not currently labeled for use by the FDA. The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational uses (any uses not approved by the FDA) of products or devices. CME Outfi tters, LLC, and the faculty do not endorse the use of any product outside of the FDA-labeled indications. Medical professionals should not utilize the procedures, products, or diagnosis techniques discussed during this activity without evaluation of their patient for contraindications or dangers of use.For content-related questions email us at editor@psychiatrictimes.com; for questions concerning CME credit call us at 877.CME.PROS (877.263.7767)PREMIERE DATE: June 20, 2019EXPIRATION DATE: December 20, 2020This activity offers CE credits for:1. Physicians (CME)2. OtherAll other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.Cornel N. Stanciu, MD, MRO, Samantha A. Gnanasegaram, MD, and Thomas M. Penders, MS, MD
29PSYCHIATRIC TIMES CATEGORY 1JUNE 2019EpidemiologyEarly studies showed no abuse potential for loper-amide; however, by 2013, reports of recreational use of 70 to 100 mg doses started surfacing.2 Sub-sequently, from 2011 to 2014 a 71% increase in loperamide-related presentations was noted by poison control agencies. In recent years, reports of extremely high doses have emerged.3,4 Users re-port using primarily to ease withdrawal symptoms but also, less often, as a substitute for opioids.2,5 Most users have a history of opioid use with no reports of loperamide as an initial, gateway drug.5 Unfortunately, national surveys do not track use, and the Drug Abuse Warning Network (DAWN) does not monitor loperamide use.PharmacologyA dose-dependent effect is seen with loperamide that determines the anatomical system it acts on. Within the recommended dose of up to 16 mg daily, μ-opioid receptors are agonized at the large intestinal myenteric and submucosal plexi, stimu-lating secretion of inhibitory neurotransmitters to increase non-propulsive contractions thereby de-creasing peristalsis and allowing for fluid and electrolyte absorption. CNS effects are avoided as transporter P-glycoprotein actively pumps it out at the blood brain barrier.6Above recommended doses, P-glycoprotein systems become saturated, and CNS entry occurs. Several agents (including loperamide) such as antineoplastic drugs, steroids, ketoconazole, and qui-nidine, can block the P-glycoprotein system, facilitating CNS entry. (Some users may supplement with these.) CYP 3A4 inhibitors allow loperamide to cir-cumvent first pass effect.Loperamide’s onset of action is 1-hour post-ingestion and reaches peak plasma levels between 3 to 5 hours, with a half-life between 7 to 19 hours. Users typically have to dose every 8 to 12 hours; however, sus-tained benefit of up to 2 days has also been report-ed by some. Doses range from 70 to 400 mg daily. Although use is with the intent of amelioration of withdrawal, in this range there is also potential for euphoric effects that tend to not be as pleasurable as with opioids.2 CNS effects do not include any analgesic benefits.There have been several reports of the develop-ment of tolerance after weeks to months of use, re-sulting in the need to increase the dose by 25% to 50% increments.5,7,8 Withdrawal symptoms are also mentioned, which are similar to opioid withdrawal but milder and less prolonged. Most users report successfully being able to taper with limited symp-toms.8 Unlike buprenorphine or methadone tapers, once loperamide is discontinued, cravings for opi-ates subside.Pharmacodynamic/toxicodynamic effectsAt therapeutic doses, there may be constipation, dizziness, nausea, and abdominal cramps. More serious yet rare adverse effects of long-term use include toxic megacolon, paralytic ileus, an-gioedema, and Stevens-Johnsons Syndrome.9 When administered in supra-therapeutic doses, cardiac life-threatening adverse effects include QTc prolongation, QRS widening, ventricular dysrhythmias, syncope, and sudden deaths.10,11 The FDA has responded by adding a warning to the drug label in 2016 and also has been working with manufacturers to limit the number of doses per package of OTC medication.Routine drug screens do not pick up lopera-mide use; hence, a high degree of suspicion is re-quired to detect abuse. Opioid users often present with respiratory depression, whereas those using supra-therapeutic loperamide doses will present with arrhythmias (ie, long QT, wide QRS) and may be awake and alert. Patients typically have histories of opioid use with recent discontinuation and will present with unexplained syncope and the electrocardiogram abnormalities. Identification of misuse should open discussion regarding the un-derlying reason for use, promoting treatment.KratomKratom, or Mitragyna speciosa, is a deciduous tree related to the coffee family indigenous to Southeast Asia. Historically, its leaves were chewed or brewed as a tea (less commonly smoked) to help cope with the physical demands of laborers by improving endurance and reducing fatigue. In traditional medicine, kratom has also been used as an opium substitute. When used in small amounts (< 5 g), stimulant properties emerge such as increased alertness and stamina; however, in larger doses (>5 g) opioid-like sedative, euphor-ic, and anti-nociceptive properties are seen. Kra-tom leaves contain at least 40 identified alkaloids and various other organic molecules. The active constituents are mitragyine and 7-hydroxymi-tragynine; each leaf contains varied concentra-tions and proportions.In recent years, because of its unique properties and “harmless” perception, kratom has been gain-ing popularity in parts of the Western world. It is available in headshops, health stores, and is some-times grown locally or available over the Internet. Products are available as crushed or powdered leaves; sometimes as extracts or combined with other agents in tinctures or capsules for very low costs.Although commercially available products show a recommended dose, the amount of actual active ingredient present is not certain. Kratom was legal to grow and purchase in all 50 states until 2015 when the Drug Enforcement Adminis-tration identified kratom as a substance of con-cern. As of June 2018, kratom is illegal to buy, sell, and use in Wisconsin, Rhode Island, Vermont, In-diana, Arkansas, Alabama, Washington, DC, as well as in some specific counties. Outside of the US, use and sale of kratom is illegal in Thailand and has been banned in Australia, Poland, Den-mark, Sweden, Malaysia, and Vietnam.EpidemiologyA recent survey suggested that kratom was one of the most widely sold “legal highs,” offered in 44% of online shops. The National Survey of Drug Use and Monitoring the Future survey do not track kratom use and few data exist on the prevalence of kratom use. It is estimated by advocacy organiza-tions that between 3 and 5 million Americans are regular users.12An anonymous online survey of 10,000 current users located through the American Kratom Asso-ciation and search of social media in October 2016 had 8094 responses.13 The majority of users were male (57%), nonhispanic white (82%), aged be-tween 21 and 50 years; 40% disclosed their use to their medical provider; 55% were married; 57% were fully employed; and 82% had a college edu-cation. The most common use was as a dissolved powder (49%) taken with a beverage; 37% used capsules, and 13% used kratom as a prepared tea. The primary reason for use was self-treatment of chronic pain. A similar percentage reported using to relieve depressed or anxious mood. Adverse ef-fects were reported by only 51 users.It is estimated that 55% of regular users be-come dependent on kratom.12 Between 2011 and 2017 the number of calls to Poison Control Centers related to kra-tom exposures increased from one a month to two daily.14PharmacologyIsolation and chemical characteriza-tion of its components has been of in-terest since the 1960s with over 40 dif-ferent alkaloids having been isolated to date, only two of which are active (mi-tragynine, 7-hydroxymitragynine). The composi-tion of the plant varies significantly depending on the environment in which it is grown, breed-ing and harvesting techniques, and age of the plant. For example, a plant from Thailand has on average 66% mitragynine alkaloid content whereas one from Malaysia has approximately 12%; younger plants tend to have greater mi-tragynine content. The various different alkaloids found in the plant have unique properties: an-ti-nociceptive, anti-inflammatory, anti-depres-sant, or muscle relaxant.Its two active constituents display opioid-like properties in vivo and in vitro. The potency at the opioid receptor has been found to exceed that of morphine. Competitive binding studies further ex-amined affinity at the various opioid receptor sub-types and found a preference for the Ʃ receptors (antagonism) followed by μ (partial agonism) and lastly ƣ, which is a similar profile to buprenor-phine.15,16 The highest potency of 7-hydroxymi-tragynine is at the μ receptor.17 Mitragynine also plays a role in noradrenergic and serotonergic pathways where it stimulates postsynaptic Ơ2 ad-renergic receptors and inhibits 5-H2A recep-tors.15,17 These properties explain how kratom counteracts withdrawal in opioid dependent indi-viduals.Loperamide and kratom are readily available at low costs and have been referred to as the poor man’s methadone and buprenorphine.
30PSYCHIATRIC TIMESJUNE 2019CATEGORY 1Mitragynine has a relatively short half-life as well as a large volume of distribution. Individuals using it to counteract opioid withdrawal require dosing as frequent as every 6 to 12 hours with withdrawal symptoms emerging 12 hours after last use and lasting up to 4 days.When it comes to interactions of its multiple constituents with the CYP 450 system, one study found kratom may inhibit 2C9, 2D6, 3A4 isoen-zymes and to some extent 1A2.18,19 This raises concern over the impact kratom use can have on clinical populations prescribed pharmacological agents.Pharmacodynamic/toxicodynamic effectsCase reports document effects such as weight loss, insomnia, constipation and dehydration, skin hy-perpigmentation, and fatigue occurring in chronic use of kratom.20,21 Some acute effects include sei-zures, delusions and hallucinations, respiratory depression, hepatotoxicity, coma, and death. In recent years emergency departments as well as poison call centers across the country have seen an increasing number of presentations related to kra-tom use. According to the State Unintentional Drug Overdose Reporting System, between July 2016 and June 2017, in 8 of the states reporting to the system a total of 25 deaths involved kratom co-ingestion.22 This number could be an underes-timate since kratom testing and assessment for it is not uniform.In one published report, a male patient addicted to hydromorphone attempted to use kratom to pre-vent withdrawal. He was admitted to the hospital after mixing kratom and modafinil and sustaining a generalized tonic-clonic seizure. It was deemed unclear whether the seizure resulted from the kra-tom or the drug combination.Most reported cases involve mixing kratom with other agents or ingesting contaminated kra-tom products (eg, Krypton). In a case series from Sweden, researchers reported 9 cases of Krypton intoxication and death. The product known as “Krypton” is an herbal preparation of dried, crushed kratom leaves mixed primarily with an-other μ-opioid receptor agonist, O-desmethyltra-madol which is known to cause seizures.Abrupt discontinuation of high dose, long-term use of kratom mimics opioid withdrawal: chills, body aches, loose bowels, insomnia, restlessness and irritability, fatigue, anxiety and mood distur-bances, among others. Symptoms begin 12 hours from last use and can last upwards of 4 days. Symptoms are positively correlated to the amount and duration of use; they are uncomfortable both physiologically and psychologically, which prompts return to use. Cravings are also present. In managing withdrawal, the best approach in-volves symptomatic management of a hyperad-renergic state. Use of regulated agents such as methadone and buprenorphine has been hindered from a medico-legal perspective and very few re-ports exist.Kratom use during pregnancy can lead to neo-natal abstinence syndrome in the neonate. Nothing is known about the extent of placental crossing of kratom’s active alkaloids. In two case reports, symptoms such as jitteriness, irritability, feeding intolerance, and vomiting emerged around day 2 postpartum requiring neonatal intensive care unit admission and standard opioid protocol with intra-venous morphine subsequently tapered with oral formulation over 5 days.23,24Screening for kratom has its challenges. Since it is not detected through the standard urine toxi-cology screen, special confirmatory testing is nec-essary. Detection of breakdown products of mi-tragynine can be detected through gas chromatography coupled with mass spectrometry, liquid chromatography with linear ion trap mass spectrometry, or through electrospray tandem mass spectrometry.ConclusionLoperamide and kratom are growing in popularity because of their opioid-like effects. Motives include opioid withdrawal suppression or to taper off opi-oids as well as, less frequently, psychoactive ef-fects. With loperamide, this practice requires above label doses, placing users at risk for cardiotoxicity among other effects. Kratom is concerning because of its variability in alkaloid composition and prepa-rations that contain dangerous additives, as well as its potential for dependence and withdrawal on dis-continuation. Clinicians need to be aware of such substitutional behaviors in those with a history of opioid use to provide proper diagnosis, manage-ment, and patient education.References1. Bose J, Hedden SL, Lipari RN, et al. Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health. 2016. https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NS-DUH-FFR1-2015.htm. Accessed May 7, 2019.2. Daniulaityte R, Carlson R, Falck R. I just wanted to tell you that loperamide will work: a web-based study of extra-medical use of loperamide. Drug Alcoh Depend. 2013;130:241-244.3. Dierksen J, Gonsoulin M, Walterscheid P. Poor man’s methadone. Am J Foren Med Pathol. 2015;36:268-270.4. MacDonald R, Heiner J, Villarreal J. Loperamide dependence and abuse. BMJ Case Repor. 2015. https://casereports.bmj.com/con-tent/2015/bcr-2015-209705. Accessed May 7, 2019.5. Erowid. Documenting the Complex Relationship Between Humans and Psychoactives. https://www.erowid.org. Accessed May 7, 2019.6. Upton N. Cerebral uptake of drugs in humans. Clin Exp Pharmacol Physiol. 2007;34:695-701.7. Bluelight. 2018. Bluelight. http://www.bluelight.org/vb/ threads/296086-Loperamide-(Immodium)-MegathreadWe-have-now-lost-at-least-2-of-our-own-from-Lope /page21. Accessed November 8, 2018.8. Reddit. 2018. Reddit. https://www.reddit.com/r/Drugs/com ments/z2k45/imodium_loperamide_for_opiate_withdra wals_tips/d. Accessed November 8, 2018.9. FAERS. 2016. FDA drug safety communication: FDA warns about serious heart problems with high doses of the antidiarrheal medicine loperamide (Imodium), including from abuse and misuse. http://www.Post-tests, credit request forms, and activity evaluations must be completed online at www.cmeoutfitters.com/PT (requires free account activa-tion), and participants can print their certificate or statement of credit immediately (80% pass rate required). This Web site supports all browsers except Internet Explorer for Mac. For complete technical requirements and privacy poli-cy, visit www.neurosciencecme.com/technical.asp.PLEASE NOTE THAT THE POST-TEST IS AVAILABLE ONLINE ONLY ON THE 20TH OF THE MONTH OF ACTIVITY ISSUE AND FOR 18 MONTHS AFTER.CME POST-TESTHigh doses of these agents have been promoted as options for opioid withdrawal management and, less often, for psychoactive effects.fda.gov/Drugs/DrugSafety/ ucm504617.htm. Accessed November 20, 2018.10. Eggleston W, Marraffa JM, Stork CM, et al. Notes from the field: cardiac dysrhythmias after loperamide abuse. MMWR. 2016;65:1276-1277.11. Marraffa JM, Holland MG, Sullivan RW, et al. Cardiac con-duction disturbance after loperamide abuse. Clin Toxicol (Phila). 2014;52:952957.12. Providers Clinical Support System. (PCSS). Kratom, A Substance of Increasing Concern. 2018. https://pcssnow.org/event/kratom-a-sub-stance-of-increasing-concern/. Accessed May 7, 2019.13. Grundmann O. Patterns of kratom use and health impact in the US: results from an online survey. Drug Alcoh Dep. 2017;176:63-70.14. Post S, Spiller HA, Chounthirath T, Smith GA. Kratom exposures reported to United States poison control centers: 2011–2017. Clin Toxicol. February 2019; Epub ahead of print.15. Stanciu C, Gnanasegaram S, Ahmed S, Penders T.Kratom withdrawal: a systematic review with case series. J Psychoact Drugs. 2018;51:12-18.16. Suhaimi FW, Yusoff NHM, Hassan R, et al. Neurobiology of kratom and its main alkaloid mitragynine. Brain Res Bull. 2019;126:29-40.17. Prozialeck WC, Jivan JK, Andurkar SV. Pharmacology of kratom: an emerging botanical agent with stimulant, analgesic and opioid-like effects. J Am Osteopath Assoc. 2012;112:792-799.18. Hanapi NA, Ismail S, Mansor SM. Inhibitory effect of mitragynine on human cytochrome P450 enzyme activities. Pharmacog Res. 2013;5:241-246.19. Hughes RL. Fatal combination of mitrgynine and quetiapine: a case report with discussion of a potential herb-drug interaction. Foren Sci Med Pathol. 2019;15:110-113.20. Saingam D, Sawitri A, Geater AF, Lerkiatbundit S. Factor analytical investigation of krathom (Mitragyna speciosa Korth.) withdrawal syndrome in Thailand. J Psychoact Drugs. 2016;48:76-85.21. Vicknasingam B, Narayanan S, Goh TB, Mansor SM. The informal use of ketum (Mitragyna speciosa) for opioid withdrawal in the northern states of peninsular Malaysia and implications for drug substitution therapy. Int J Drug Policy. 2010;21:283-288.22. O’Malley Olsen E, O’Donnell J, Mattson CL, et al. Unintentional drug overdose deaths with kratom detected: 27 states, July 2016 to December 2017. MMWR Morb Mortal Wkly Rep. 2019;68:326-327.23. Davidson L, Rawat M, Stojanovski S, Chandrasekharan P. Natural drugs, not so natural effects: Neonatal abstinence syndrome second-ary to kratom. J Neonatal Perinatal Med. 201;12:109-112.24. Mackay L, Abrahams R. Novel case of maternal and neonatal kratom dependence and withdrawal. Can Family Phys. 2018;64:121-122. UNeed Additional CME Credit?Check Out These Free CME Activities—Genetics in the Clinical Setting: The Role of Psychiatric Genetic CounselingJehannine Austin, PhD, CGCExpiration Date: July 20, 2019https://www.psychiatrictimes.com/cme/genetics-clini-cal-setting-role-psychiatric-genetic-counselingLifeline for Pregnant and Postpartum Women Who Are Drowning in Plain SightNancy Byatt, DO, MS, MBAExpiration Date: August 20, 2019https://www.psychiatrictimes.com/cme/lifeline-preg-nant-and-postpartum-women-who-are-drowning-plain-sight
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Drug Abusefrom Encyclopedia of Applied PsychologyView article on CredoDrug abuse, also referred to as substance or chemical abuse, is the recurrent use of a drug despite theexperience of problems caused by the drug use. Difficulties arising in certain areas of a user’s life areof more importance to researchers and treatment professionals than other areas for identification of adrug abuse problem. The following are types of problems that signify drug abuse: impairment meetingmajor responsibilities in life, such as those regarding school, work, or home; difficulties with the law andsocial behavior; and aggravation of physical/medical conditions due to drug use. Drug abuse is to becontrasted with drug (chemical/substance) dependence. With drug dependence, use is consideredcompulsive and beyond the willful control of the user. That is, someone who is drug dependent isaddicted; this is thought to be a more severe condition than drug abuse. Treatment of drug abuse isaccomplished primarily using a variety of counseling and psychotherapeutic techniques employed toassist the abuser to stop using the drug, to develop new behavioral and mental coping skills, and torehabilitate his or her life from the damage caused by the substance abuse.GLOSSARYpharmacologyThe study of the effects of chemical substances on living systems.psychoactiveThe ability of a drug to induce subjective effects on mood and feeling.psychosocialReflecting the combined influences of psychological and social factors.relapseResumption of drug use following a period of abstinence.withdrawalA maladaptive behavior change that occurs when blood or tissue concentrations of a drug decline inan individual.INTRODUCTIONIn the discussion of drug abuse, it would be easy but inaccurate to label any regular use of a substanceas abusive. Drug use in the United States is commonplace. Many people are capable of consumingdrugs without developing problems. Drugs such as caffeine and alcohol, as well as prescriptionpharmaceutical products such as pain killing agents or antianxiety medication, are routinely and openlyconsumed every day in the United States (and in other countries as well). The various drugs affect thebody differently and are used for specific purposes. For example, caffeine is used to remain alert andto enhance concentration, and tranquilizers are used to quell anxiety and for relaxation. However,drugs of abuse all have in common the property that they are psychoactive. For the sake of discussion,drugs may be classified with respect to different properties; one commonly employed system is interms of the effect of the drug on the central nervous system (CNS). The following is one suchclassification system, with examples of drugs in each category:1. CNS stimulants: Cocaine, amphetamine, and caffeine2. CNS depressants: Alcohol, barbiturates, benzodiazepines, and solvent inhalantshttps://lopes.idm.oclc.org/login?url=https://search.credoreference.com/content/entry/estappliedpsyc/drug_abuse/0
3. Psychotomimetics (also known as psychedelics or hallucinogens): Marijuana, LSD, and mescaline4. Narcotics/Opioids: Opium, heroin, codeine, morphine, and methadoneSubstance use typically begins in adolescence. Adolescent substance use does not appear to berandom; that is, it follows a fairly predictable pattern. Adolescents tend to start using substances thatare legal and widely available to adults: alcohol and tobacco. Due to the fact that these drugs are thestarting point for substance use, they are referred to as “gateway drugs.” In 1975, Kandel developed astage model of progression of drug use that has since been revised:1. Beer or wine use2. Hard liquor or cigarette use3. Marijuana experimentation4. Alcohol abuse5. Prescription drug use6. Opiates and other illegal drugsThe vast majority of adolescents experiment with the gateway drugs at least one time. However,although most individuals try alcohol and tobacco, only for a minority of adolescents does use advanceto abusive levels. As the stages advance, progressively fewer adolescents are found in each category.For example, alcohol will be tried by approximately 9 out of 10 students by their senior year in highschool and cigarettes by approximately 6 out of 10 students by senior year. Opiates, at the last stageof the model, will be tried by only 1 out of 100 students by senior year.Due to the high prevalence of substance use in the United States, it should be no surprise thatsubstance-related problems are often encountered by mental health clinicians. The relatively highfrequency with which substance-related problems are encountered by mental health professionalsreflects the influence of the following factors: (i) Drug abuse has the potential to create or worsen allpsychological symptoms, such as anxiety, depression, impulsive behavior, and antisocial behavior; and(ii) people seeking mental health services also tend to be at elevated risk for substance abuseproblems. In other words, drug abuse harms people and contributes to psychiatric symptoms, andpeople experiencing psychological problems are apt to use drugs abusively.RISK FACTORS AND CAUSES OF DRUG ABUSEWith any medical or mental health condition, it is desirable to determine the cause or causes of theaffliction. Identifying the cause(s) helps to develop prevention strategies to limit or eliminate futurecases and treatment strategies for those already affected by the condition. For example, after thediscovery that an absence of insulin was responsible for type 1 diabetes, effective treatment ofdiabetes with externally supplied insulin became possible. In addition, research is under way todevelop early identification tests for intervention strategies to prevent later development of diabetes.This research has led to the isolation of faulty antibodies believed to attack the insulin-producing cellsof the pancreas. The antibodies can be detected before the person is symptomatic for diabetes;experimental treatments are being used in an attempt to prevent the development of diabetes in thesehigh-risk individuals.https://lopes.idm.oclc.org/login?url=https://search.credoreference.com/content/entry/estappliedpsyc/drug_abuse/0
Human behavior is complex and defies easy explanation. Unlike certain physical characteristics (e.g.,eye color) or physical disorders that can be traced to single genes, a disorder such as drug abuse likelyrepresents the interaction of multiple genetic and environmental influences. Complicating thingsfurther, ethics prevents us from conducting experimental studies (involving environmental or geneticmanipulation) that might help us to tease apart various possible influences. One way to attempt toidentify possible causes of substance abuse is to study risk factors. Risk factors are those variablesassociated with increased likelihood of developing a substance use disorder. Classes of risk factorsare listed here with examples in each class:1. Peer: Peer substance use, strong attachment to peers, and positive peer attitudes aboutsubstance use2. Parent/family: Parent substance use, positive attitude about substance use, parent tolerance ofadolescent substance use, and family disruption (e.g., divorce)3. Personal: Early (childhood) behavior problems, poor academic performance, anxiety/depression,and low self-esteem4. Biological: Genetic predisposition to substance use (e.g., a parent is a substance abuser)5. Community/social: Low socioeconomic status, high availability of substances, and deviant normsthat encourage use of substancesRisk factors help us to understand influences to use substances, but we know many more people usethem than become abusers. Therefore, the question as to who will progress beyond experimentationand casual use to the level of abuse is not answered by risk factors alone. It appears that use ofsubstances is more a function of external risk factors, such as peer, social, and family factors; abuse ofsubstances appears to be more a function of personal factors, such as psychiatric, behavioral, andemotional problems.The biopsychosocial disease model is the most widely accepted model of substance abuse andaddiction. It should be clear after reviewing the list of risk factors that biological, psychological, andsocial factors contribute to substance abuse. The biopsychosocial model is sufficiently comprehensiveto include all known contributants to substance abuse.COURSE OF DRUG ABUSEDisease conditions are defined by several common factors, such as having identifiable causes,characteristic symptoms, and established treatments. In addition, diseases have an observable course.It is important to describe the course of an illness in part so that the condition can be identified (i.e., fordiagnostic purposes). Also, if the untreated progression of an illness was not known, there would be noway to judge the effectiveness of treatment. Treatment interventions endeavor, essentially, to changethe course of a disease. Initial attempts to describe and classify the course of alcohol abuse depictedan ever-worsening condition that eventuated in death, unless the drinking was stopped altogether. As itturns out, the long-term outcome of regular alcohol use is not certain death. Some people who usealcohol never develop problems, some who develop problems (alcohol abusers) never becomeaddicted, and a minority of alcohol abusers (approximately one-third) exhibit the progressivedeteriorative pattern of drinking. The same overall trends may be expected with other substances ofabuse as with alcohol. In 1995, Shaffer and Robbins developed a general model to describe the typicalhttps://lopes.idm.oclc.org/login?url=https://search.credoreference.com/content/entry/estappliedpsyc/drug_abuse/0
course of an addiction, consisting of the following stages:1. Initiation: Experimentation with a drug is begun.2. Positive consequences: At this point in the use process, only the pleasurable pharmacological andsocial effects of the substance are experienced.3. Negative consequences: For those individuals who continue to regularly use the substance,eventually negative consequences are experienced in terms of health, relationships, work, school,finances, or the law.4. Turning point: For abusers who continue despite negative consequences, there is somerecognition of the damage the substance is causing in their lives and ambivalence ensues.5. Active quitting: For some abusers, ambivalence is resolved in the direction of stopping use.6. Relapse prevention: For those who have quit, behavior changes are maintained over time toprevent resumption of drug use.ASSESSMENT OF DRUG ABUSEIn order to treat a condition, it must first be determined that a given individual has the condition; inother words, the diagnosis of drug abuse must be made. In medicine, objective tests via technologicallyadvanced equipment (e.g., x-ray and magnetic resonance imagery) are often used to assist the doctorin the diagnostic process. In the evaluation of drug abuse, modern technology is hardly relevant.Biological testing, in the forms of urinalysis and evaluation of saliva and blood samples, may be usedbut are not the mainstay of assessment. Biological testing can determine if a specific drug or drugmetabolite is present in a sample but cannot indicate anything about patterns of use, withdrawalsymptoms, compulsive behavior, or consequences of use, all of which are important aspects to assess.Therefore, biological testing is confined to the role of confirming recent abstinence; this information isespecially important in certain settings (e.g., criminal justice system and workplace) but of limited usein a drug abuse assessment. Since we are more interested in determining whether a pattern of abusivedrug use is present or not, relevant information needs to be gathered. Therefore, the interview is theprimary method by which information is acquired to make the diagnosis of drug abuse. Typically, thediagnostic interview is conducted with the person in question as well as with others in a position toobserve relevant behaviors (most often family members and/or close friends). In addition to theinterview, information is sometimes acquired via self-report, paper-and-pencil tests. The followinginformation is typically obtained during a drug abuse assessment:1. List all substances ever used2. Age of first use of all substances3. How used each substance (e.g., smoke, drink, snort, etc.)4. Age of peak use, and amount used, for each substance5. Number of days use substance per week, for each substance6. Amount of substance used on a typical day of use7. Date of last use of each substancehttps://lopes.idm.oclc.org/login?url=https://search.credoreference.com/content/entry/estappliedpsyc/drug_abuse/0
8. List all negative consequences resulting from use of substancesDiagnosing a drug abuse disorder is only one element of the assessment process. It is also necessaryto determine as part of the evaluation the most appropriate setting in which treatment should takeplace (e.g., outpatient, halfway house, or inpatient); the proper intensity of treatment (e.g., dailytreatment or monthly treatment); whether other treatment needs exist (e.g., medical and/orpsychological disorders); and specific, individual treatment goals for a given person.TREATMENT OF DRUG ABUSEThere is no one treatment for drug abuse. This fact is a reflection of the complexity of the condition andits diverse manifestations, and it highlights the importance of the assessment process, which is criticalin helping determine the best treatment for a given individual. The treatment of drug abuse may occurin different settings, with varying degrees of professional assistance (e.g., self-help/12-step andprofessional help) and different modalities of professional services (e.g., individual therapy, grouptherapy, family therapy, and pharmacological treatment). Drug abuse treatment may be characterizedas specialized treatment with one main goal: to stop the use of the substance. Treatment is primarilytalking therapy—counseling and psychotherapy; in addition, medications may be employed to managedetoxification from some drugs and/or to treat coexisting psychological or medical conditions. However,regardless of the setting of treatment, the intensity of the contact schedule, or who renders thetreatment, it is ultimately talking therapy that takes place. Especially early in treatment, the focus ofdiscussion is on behavior directly related to drug use and stopping the use of the drug. Most programsand professionals recommend complete abstinence from drugs; some have the goal of harm reduction(allowing use to continue while attempting to reduce drug use to less harmful levels), but they are inthe minority. As treatment progresses, and abstinence is achieved and maintained, the emphasisusually broadens to other areas of the person’s life that may need repair, such as their decision-makingskills, coping skills, emotional state, and relationships. In other words, the individual sufferspsychological and social damage from drug abuse and may even have had significant deficits in theseareas prior to his or her drug abuse; treatment is designed to improve the psychosocial functioning ofthe individual once he or she is drug-free.RELAPSE PREVENTIONDrug abuse has been described as a chronic, relapsing disorder. Like all chronic conditions, long-termeffort must be applied for the individual to maintain abstinence from drug use. Nobody would expect theblood sugar levels of someone with diabetes to be in a healthy range if the person only complied withthe prescribed care regimen for 1 month after a visit to the physician. Likewise, if a drug abuser onlyapplies the principles of treatment for a limited period of time, resumption of abusive habits would beexpected. One way to attempt to guard against a backslide into prior behavior is to extend treatment aslong as possible. In addition, teaching relapse prevention skills that an abuser may use going forwardin time is an integral part of drug abuse treatment. Some common elements of relapse preventionprograms include identification of high-risk situations that are likely to lead to relapse, development andpractice of skills to effectively cope with risky situations, enhancement of self-confidence to be able toapply coping skills when needed, learning to limit a slip to an isolated incident rather than allow it to bethe beginning of a process of abuse, drug/alcohol monitoring for abstinence verification, anddeveloping positive behaviors (e.g., working and physical exercise).See Also the Following Articleshttps://lopes.idm.oclc.org/login?url=https://search.credoreference.com/content/entry/estappliedpsyc/drug_abuse/0
Alcohol Dependence ▪ Diagnostic and Statistical Manual of Mental Disorders ▪ Drug Dependence ▪Nicotine AddictionFurther ReadingBukstein, O. (1995). Adolescent substance abuse: Assessment, prevention and treatment. New York:Wiley. Dodgen, C. E.; Shea, W. M. (2000). Substance use disorders: Assessment and treatment. SanDiego: Academic Press. Gold, M. S. (1991). The good news about drugs and alcohol: Curing, treating and preventingsubstance abuse in the new age of biopsychiatry. New York: Villard. Kandel, D. (1975). Stages in adolescent involvement in drug use. Science, 190, 912-914. Schuckit, M. A. (1995). Educating yourself about alcohol and drugs: A people’s primer. New York:Plenum. Shaffer, H. J.; Robbins, M. (1995). Psychotherapy for addictive behavior: A stage-change approach tomeaning making. In Washton, A. M. Psychotherapy and substance abuse: A practitioner’s handbook(pp. 103-123). New York: Guilford. Charles E. DodgenCaldwell, New JerseyUSA © 2004 Elsevier Inc.https://lopes.idm.oclc.org/login?url=https://search.credoreference.com/content/entry/estappliedpsyc/drug_abuse/0
APADodgen, C. E. (2004). Drug abuse. In C. D. Spielberger (Ed.), Encyclopedia of applied psychology.Elsevier Science & Technology. Credo Reference: https://lopes.idm.oclc.org/login?url=https://search.credoreference.com/content/entry/estappliedpsyc/drug_abuse/0?institutionId=5865ChicagoDodgen, Charles E. “Drug Abuse.” In Encyclopedia of Applied Psychology, edited by Charles DonaldSpielberger. Elsevier Science & Technology, 2004. https://lopes.idm.oclc.org/login?url=https://search.credoreference.com/content/entry/estappliedpsyc/drug_abuse/0?institutionId=5865HarvardDodgen, C.E. (2004). Drug abuse. In C.D. Spielberger (Ed.), Encyclopedia of applied psychology.[Online]. Oxford: Elsevier Science & Technology. Available from: https://lopes.idm.oclc.org/login?url=https://search.credoreference.com/content/entry/estappliedpsyc/drug_abuse/0?institutionId=5865[Accessed 8 December 2022].MLADodgen, Charles E. “Drug Abuse.” Encyclopedia of Applied Psychology, edited by Charles DonaldSpielberger, Elsevier Science & Technology, 1st edition, 2004. Credo Reference,https://lopes.idm.oclc.org/login?url=https://search.credoreference.com/content/entry/estappliedpsyc/drug_abuse/0?institutionId=5865.Accessed 08 Dec. 2022.https://lopes.idm.oclc.org/login?url=https://search.credoreference.com/content/entry/estappliedpsyc/drug_abuse/0
A Wiley Periodicals, Inc. publication. wileyonlinelibrary.comATThe National Association of Addic-tion Treatment Providers (NAATP) has released a draft guidebook for comment by its members. The guidebook, when finalized, will be the document treatment centers can use to determine if they are in compliance with the best practices of the organization.The guidebook, scheduled for publication in the fall, is open for comments from NAATP members until May 31. A product of the NAATP’s Quality Assurance Initia-tive (QAI), the guidebook sets a standard for service delivery, iden-tifying nine core competencies in addiction treatment:• Operations• Admissions and Patient ScreeningBottom Line…A federal guide to implementing medication-assisted treatment initiatives in the justice system suggests stronger partnerships with community providers and fewer financial barriers to continuity of care.• Employment, Training and Credentialing• Billing• Discharge and Continuing Care • Outcomes Measures• Community Engagement, Public Relations and Public Policy• Marketing, Advertising and Visibility • EthicsSee StandardS page 2A new federal guide seeks to encourage states to create or expand medication-assisted treat-ment (MAT) initiatives in criminal justice settings, by tapping into diverse revenue sources and by lifting barriers such as lengthy gaps in Medicaid coverage for incarcerated individuals.The publication from the Sub-stance Abuse and Mental Health Services Administration (SAMHSA) places a heavy emphasis on the importance of continuity of care for offenders with opioid use dis-orders (OUDs). “Criminal justice programs that have relationships established with community-based MAT providers can help ensure continuity of care once individuals are no longer under criminal jus-tice oversight,” states the report, titled Medication-Assisted Treat-ment in the Criminal Justice Sys-tem: Brief Guidance to the States.Mark Parrino, president of the American Association for the See MedicationS page 6NAATP releases draft guidebook for residential treatment providersBottom Line…In preparation for its annual meeting, NAATP has prepared a draft version of its guidebook for members that sets the minimum standards of membership for residential treatment programs.SAMHSA guide advises states on ways to extend MAT into justice systems
6even after having received coun-seling while in custody.The publication also lists the most prominent challenges to incorporating MAT in justice set-tings, from prevailing stigma about the medications to fears of drug diversion to cost barriers to a lack of community providers willing to help serve this population. Parrino believes the issue of stigma and ideology still poses the primary challenge. “That battle is still the prominent issue,” he said. “Will we support the use of medications in corrections and drug court?”The guide’s recommended strat-egies for implementing MAT empha-size the presence of multidisciplinary teams of behavioral health and crim-inal justice professionals. “Approach-ing justice-involved individuals with OUD using a medical model of addiction may require a paradigm shift among professionals accus-tomed to ‘abstinence-only’ MedicationS from page 1Treatment of Opioid Dependence (AATOD), told ADAW that his quick read of the guide indicated that the document is on track. More important, its release repre-sents another in a long series of inflection points that signal the best opportunity yet for the feder-ally approved medications for OUD to become integral compo-nents of prison and jail services. Parrino said these developments range from the promising results Rhode Island and Connecticut are achieving with ambitious MAT ini-tiatives to recent court rulings that consider the withholding of these medications from inmates who need them as a violation of federal law (see ADAW, April 8).“For the first time, I am extremely optimistic about the evolution of this issue,” Parrino said. “This is the best environment I have seen in my professional career.”Summary of guideSAMHSA’s guide lays out the numbers that demonstrate the importance of addressing OUD in the justice population — regular use of opioids among 17 and 19 percent of those sentenced to jail or prison, respectively, and 77 per-cent of formerly incarcerated indi-viduals with an OUD relapsing to opioid use within three months “For the first time, I am extremely optimistic about the evolution of this issue. This is the best environment I have seen in my professional career…. That battle [over stigma] is still the prominent issue. Will we support the use of medications in corrections and drug court?”Mark Parrinoapproaches to substance use treat-ment,” the text states.The guide cites as an example of an effective community partner-ship the Medication-Assisted Treat-ment and Directed Opioid Recovery (MATADOR) program within the Middlesex County, Massachusetts, Sheriff’s Office. MATADOR involves participation from 35 community providers that offer continued MAT for individuals leaving custody. Peer navigators to assist with reentry also are an important component.One shortcoming of the MATA-DOR effort is that at present, only extended-release injectable naltrex-one is available to participants, although there are plans to explore including methadone and buprenor-phine in the program. The SAMHSA report states in its general guid-ance, “Consideration of making available all FDA-approved phar-macotherapy based on individual need is encouraged.”opioid use. The article, “Associa-tion Between Long-Term Opioid Use in Family Members and Persis-tent Opioid Use After Surgery Among Adolescents and Young Adults,” was published in JAMA Surgery. In an accompanying com-mentary by Eija Kalso, M.D., Ph.D., and colleagues, caution is urged in the postoperative treatment of pain with opioids. The main point is that there should be an assessment of any pain that lasts longer than three to seven days postoperatively and requires opi-oids: “Is there a surgical complica-tion, or does the patient have difficulties in managing without analgesics because of fear of pain or for some other psychosocial rea-son?” the commentary noted. “Con-tinuity in care is important in preventing postoperative pain man-agement leading to problematic opioid use. Because this ideal may always not be possible, novel solu-tions have been developed. One is the acute pain service outpatient clinic, where patients who have challenging postoperative pain or are at risk for prolonged opioid use or persistent postoperative pain can be admitted. The acute pain service outpatient clinic is an interface between an acute pain service and a multidisciplinary pain clinic. The second of these can also offer thor-ough assessment of the patient and nonpharmacological approaches, such as physiotherapy and psycho-social interventions.” This is the responsibility of the surgeon who is prescribing the pain medication, the researchers wrote. •Continued from page 5
7A Wiley Periodicals, Inc. publication. View this newsletter online at wileyonlinelibrary.comwith pain. “One of our most impor-tant obligations is to protect consum-ers from those who would prey on them with bogus claims and fraudu-lent products,” said FDA Commis-sioner Scott Gottlieb, M.D. “We’re especially focused on those who would exploit Americans harmed by the opioid crisis with the false prom-ise of products that can treat pain or addiction, but that offer no such ben-efit.” He said that “fraud scams like these are inexcusable,” and added that the “false promises” can keep people from seeking treatment that does work, as well as expose them to health-threatening ingredients or contaminants. “We’ll continue our efforts to protect consumers from such false claims, while also working to advance the development of new Briefly notedADHD may be a risk factor for smartphone addictionResearchers have found that attention-deficit hyperactivity disor-der (ADHD) may be a risk factor for developing smartphone addiction, based on the neurobiological sub-strates underlying each separately and those that are shared. The study found a greater than six times likeli-hood that children with ADHD also had smartphone addiction. The study looked at the prevalence of smartphone addiction and its asso-ciation with depression, anxiety, and ADHD symptoms in a total of 4,512 South Korean middle and high school students, who completed surveys. There were 338 subjects (7.5%) in the smartphone addiction Continues on page 8The guide cites Rhode Island’s inclusion of all three medications in its statewide initiative, which has an in-facility opioid treatment program as a working component. Both Rhode Island and Connecti-cut are already seeing reductions in postrelease mortality and recidi-vism rates as a result of their early-stage correctional MAT initiatives, Parrino said.Regarding funding, which Par-rino considers the second most prominent challenge after ideology, SAMHSA states that a number of federal sources (from grants tar-geted to addressing the opioid grants to less restrictive block grants to the states) should be allocated for comprehensive MAT initiatives at the state and local levels. The guide also points out that states that have expanded Medicaid have dem-onstrated higher rates of coverage for justice-involved populations, and therefore “are better able to ensure that participants will be able to afford and continue MAT once in the community.”However, many states termi-nate or suspend individuals’ Med-icaid coverage once they are incarcerated, even though federal Medicaid law does not require this action. The guide suggests that suspension of coverage is at least preferable to termination in order to facilitate reinstatement of bene-fits once a person is no longer in custody. But SAMHSA adds that “even suspension is not working well in some states where reinstat-ing coverage is a tedious and/or paper-based process; and, in prac-tice, many people’s coverage is actually terminated.”Justice and treatment intertwinedRobert Morrison, executive director of the National Associa-tion of State Alcohol and Drug Abuse Directors (NASADAD), told ADAW that the topic of MAT in the justice system has been a popular one for state directors to share experiences on for some time. Speaking to the topic’s overall rel-evance, Morrison said, “From the get-go, 40 percent of referrals to the public are from the justice sys-tem, to start with.”A challenge in funding, how-ever, involves historically stagnant support from the federal Residen-tial Substance Abuse Treatment program, now funded at $30 mil-lion after having hovered around $18 million for years, Morrison said. This program could be piv-otal in helping to support expanded treatment for offenders, but com-pared to the need, “$30 million is not going to do it,” he said.Parrino indicated that advo-cates will be monitoring the prog-ress of two congressional Democrats from New England, Rep. Ann Kuster of New Hamp-shire and Sen. Edward Markey of Massachusetts, as they prepare to introduce legislation that, among other provisions, would authorize $50 million a year for four years at the Department of Justice to boost offender treatment. Parrino said the legislation also is likely to address issues around maintaining Medicaid eligibility and individu-als’ access to medication treat-ments in the community post-discharge. “You can’t induct someone on methadone when they’re in custody if there’s no available facility in the commu-nity,” he said. •group. The odds ratio of the ADHD group compared to the non-ADHD group for smartphone addiction was 6.43, the highest among all vari-ables. The study, “The relationship between smartphone addiction and symptoms of depression, anxiety, and attention-deficit/hyperactivity in South Korean adolescents” is pub-lished in the March issue of the Annals of General Psychiatry. •FDA moves against ‘fraud scams’ marketing claiming to treat addictionLast month, the Food and Drug Administration (FDA) posted a warn-ing letter to Nutra Pharma Corp. for illegally marketing unapproved prod-ucts labeled as homeopathic and claiming to treat addiction, chronic pain and other conditions associated
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