S. Alex Stalcup, M.D.

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S. Alex Stalcup, M.D.

• New Leaf Treatment Center
• 251 Lafayette Circle, Suite 150
• Lafayette, CA 94549
• Tel [phone]
• Fax [phone]
• alex_at_nltc.com www.nltc.com

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Predictors of Treatment Outcome

• Length of time in treatment
• Less than 3 months in treatment has no effect.
• After treatment for 4 - 6 months 35 achieve
  sobriety
• (Sobriety 30 days consecutively
  methamphetamine-free.)
• Retention in treatment is the most important
  factor influencing outcome.
• Drug Court participation doubles the number of
  clients retained in treatment.
• (67 versus 35)

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What is a Drug?

• A drug is a pleasure producing chemical. Drugs
  activate or imitate chemical pathways in the
  brain associated with feelings of well-being,
  pleasure, and euphoria.

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Neuroadaptation

• The process by which receptors in the reward and
  pleasure centers of the brain adapt to high
  concentrations of neurotransmitters.
• Under unstimulated conditions (without drugs)
  there is profound interference with the ability
  to experience pleasure. The user feels as if s/he
  is experiencing an unmet instinctive drive
  dysphoria anxiety, anger, frustration and
  craving.
• Damage caused by neurotransmitter insensitivity
  leads the user to feel, when sober, the opposite
  of feeling high. For the user sobriety becomes
  the opposite of euphoria.
• Length of use and intensity of the drug are
  factors predicting the extent of the damage.

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Principles of Addiction Biology

• Drugs and alcohol activate the pleasure-producing
  chemistry of the brain.
• Over-stimulation of pleasure pathways causes them
  to neuroadapt, interfering with the normal
  experience of pleasure.
• Addiction is a disease of the pleasure-producing
  chemistry of the brain neuroadaptation is the
  mechanism of the disease.
• Once neuroadaptation occurs, cessation of drug
  use leads to inversion of the high sobriety
  becomes pleasureless.

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Definition of Addiction

• Compulsion loss of control
• The user cant not do it s/he is compelled to
  use.
• Compulsion is not rational and is not planned.
• Continued use despite adverse consequences
• An addict is a person who uses even though s/he
  knows it is causing problems. The addict cant
  not use.
• Craving daily symptom of the disease
• The user experiences intense psychological
  preoccupation with getting and using the drug.
  Craving is dysphoric, agitating and it feels very
  bad.
• Denial distortion of perception caused by
  craving
• Under the pressure of intense craving, the user
  is temporarily blinded to the risks and
  consequences of using.

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Physical Dependence

• Physical Dependence
• When the user stops the drug, physical illness
  results.
• Abstinence Syndrome
• Name of the illness caused by withdrawal
  symptoms.
• Tolerance
• Neuroadaptation forces the user to increase the
  dose to maintain the effect of the drug.
• Using an inadequate dose causes withdrawal
  symptoms occur when the amount used is less than
  the tolerance level.

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Causes of Craving

• Environmental cues (Triggers)
• immediate, catastrophic, overwhelming craving
  stimulated by people, places, things associated
  with prior drug-use experiences
• Drug Withdrawal
• inadequately treated or untreated
• Mental illness symptoms
• inadequately treated or untreated
• Stress equals Craving

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Bio-Psycho-Social Model

• Predisposition
• Genetics
• Childhood Sexual Abuse
• Mental Illness
• The Drug / Circumstances of First Use
• Enabling System

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Reward Deficiency Syndrome

• Clinical Presentation
• Substance Abuse Disorders
• Compulsive Disorders
• Attention Deficit Disorder
• Supportive Observations
• All drugs of abuse augment dopamine function.
• Persons with Reward Deficiency Syndrome
  predominantly have the A1, D2 allele.
• Persons with the A1, D2 allele have 20 to 30
  fewer D2 (reward) receptors.
• The A1 allele confers a 74 increase in risk of
  having one or more Reward Deficiency Syndrome
  disorders.
• Adapted from Blum K, Cull JG, Braverman ER,
  comings DE. Reward deficiency syndrome. Am Sci.
  199684132-145.

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Attention Deficit Disorder and Addiction

• Treatment of ADD with medications reduced the
  risk of
• alcohol/drug abuse 84
• Prospective four-year study of 15 year-old boys.
• 75 Unmedicated ADD boys
• started abusing alcohol/drugs (N19)
• 25 Medicated ADD boys
• started abusing alcohol/drugs (N56)
• 18 Non-ADD boys
• started abusing alcohol/drugs (N137)
• Adapted from Biederman J, et al. Pharmacotherapy
  of attention-deficit/hyperactivity disorder
  reduces risk for substance use disorder.
  Pediatrics 104(2)20, 1999

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Dual Diagnosis

• Co-occurrence of
• Mental Illness and Substance Abuse
• Consider dual diagnosis if
• Onset of addictive disease in early or mid-teens
• Indiscriminate poly-substance use
• Frequent drug use despite engagement in treatment
• Client dislikes sobriety
• Mental health symptoms worsen over time.
• Most common mental illness diagnoses are anxiety
  disorders, depression, posttraumatic stress
  disorder (PTSD), and personality disorders.

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Dual Diagnosis

• Mental Illness symptoms interact with drug
  effects.
• Intoxication
• relieves symptoms of mental illness
• Tolerance
• exacerbates symptoms of mental illness
• Withdrawal
• exacerbates symptoms of mental illness

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Promoting Resilience

• Positive relationship with an adult
• Positive peer group activities
• Involvement in faith-based activities
• Participation in pleasurable activities
• Music (playing, singing, dancing)
• Taking care of pets
• Volunteer activities

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Toxic Psychosis

• DELUSIONS usually of the paranoid type
• HALLUCINATIONS usually auditory, occurring with
  intact reality testing or in the absence of
  intact reality testing, sometimes with
• DISORGANIZATION of speech and behavior.

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Treatment of Toxic Psychosis

• Observation
• Vital signs every 2 hours until stable, then 3
  times daily for 5 days
• Seek immediate medical attention if temperature
  is higher than 102 F
• Reduce environmental stimuli darkened room,
  quiet until stable, then gradually increase
  activities
• Medications
• Intramuscular combined injection
• Haloperidol 5 mg Cogentin 1 mg Ativan 5 mg
• Oral combined dosing every 8 hours
• Haloperidol 2 mg Cogentin 0.5 mg Ativan 2 mg
• Push Fluids 500cc over dietary intake every 8
  hours

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Meth EnvironmentsRisks for Children

• Parenting
• Attachment inconsistent discipline, irritable
  response
• Safety sexual assault, physical assault, verbal
  abuse
• Neglect poor hygiene, day/night reversal,
  inconsistent sleep
• Nutrition irregular mealtimes, fast food diet
• Developmental Risks
• Older children parenting younger children
• Unintended observation of sexual activity
• Unintended observation of physical violence
• Sexualized environment
• Environmental Risks
• Exposure to toxic chemicals
• Exposure to illicit drugs
• Needle exposure
• Physical hazards

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Causes of Craving

• Environmental cues (Triggers)
• immediate, catastrophic, overwhelming craving
  stimulated by people, places, things associated
  with prior drug-use experiences
• Drug Withdrawal
• inadequately treated or untreated
• Mental illness symptoms
• inadequately treated or untreated
• Stress equals Craving

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Components of Treatment

• Initiation of Abstinence Stopping Use
• Drug Detoxification Use of medications to
  control withdrawal symptoms
• Avoidance Strategies Measures to protect the
  client from environmental cues
• Schedule Establishing times for arising,
  mealtimes, and going to bed
• Mental Health Assessment and Treatment
• Relapse Prevention
• Drug Detoxification Continued use of medications
  to control withdrawal as needed
• Avoidance Strategies Controlled re-entry to
  cue-rich environments
• Schedule Adherence to a regular daily lifestyle
• HUNGRY Three regularly spaced meals each day
• ANGRY Separate feelings of anger from losing
  control of behavior
• LONELY One positive social contact per day
  minimum
• TIRED Daily practice of sleep hygiene
• Tools Behaviors that dissipate craving
• Exercise Spiritual Practice
  Pleasurable Activities Treatment Groups
  Individual Counseling
• Mental Health Assessment and Treatment

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Predictors of Treatment Outcome

• Length of time in treatment
• Less than 3 months in treatment has no effect.
• After treatment for 4 - 6 months 35 achieve
  sobriety
• (Sobriety 30 days consecutively
  methamphetamine-free.)
• Retention in treatment is the most important
  factor influencing outcome.
• Drug Court participation doubles the number of
  clients retained in treatment.
• (67 versus 35)

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Special Requirements for Treatment of
Methamphetamine Dependence

• Sleep, Food, Exercise
• Meticulous control of environmental exposure to
  methamphetamine
• Prompt treatment of paranoia with antipsychotic
  medication
• Antidepressant treatment of prolonged anhedonia
  and anergia

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CIM Treatment ModelCraving Identification and
Management

• Relapse Prevention Workshop
• Individual Counseling
• Medical Services
• Alcohol/drug testing

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DETOXIFICATION

• Use of medications to treat withdrawal symptoms.

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Medication Guidelines

• Consider the use of medications if the client has
  insomnia, anxiety, or depression that interferes
  with daily function.
• 1/3 to 1/2 of patients will require medication
  during the first weeks of treatment.
• A therapeutic trial using a flow chart focuses
  attention on symptom management.
• Symptom monitoring validates patient distress,
  and puts a name and boundaries on otherwise
  generalized unhappiness in early recovery.

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Medications for Meth Withdrawal

• Disorders of Mood
• Stabilizers Antidepressants
• Lithium 300-1200 mg Effexor XR 75-225 mg
• Abilify 5-20 mg Wellbutrin XL 150-300 mg
• Desipramine 100-200 mg
• Disorders of Sleep
• Trazedone 50-300 mg
• Seroquel 100 mg
• Imipramine 100-200 mg
• Anhedonia/Anergia Disorders of Thought
• Effexor XR 75-225 mg Abilify 5-20 mg
• Wellbutrin XL 150-300 mg Haldol 1-2 mg
• Desipramine 100-200 mg Risperdal 1-3 mg

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Relapse Prevention Workshop

• Essential Questions
• What is your craving score?
• Where does your craving come from?
• Environmental cues
• Stress
• Drug withdrawal
• Mental health problems
• What are you going to do to take care of
  yourself?
• Avoidance strategies
• Structure
• Tools
• Program activities

• Principles
• Addicted persons relapse because of craving.
• Craving has causes that can be predicted,
  recognized and analyzed.
• Craving can be managed with the use of program
  activities.

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Relapse Prevention Guidelines

• Exercise Two 20 minute exercise periods daily.
• Avoidance Strategies Measures to protect the
  client from exposure to environmental cues.
• Structure Detailed hour-to-hour planning each
  day in which the client makes a consistent effort
  to make the same things happen at the same time
  each day.
• Tools Behaviors that dissipate craving.

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Methamphetamine Treatment Project

• Number of Subjects CIM Model Matrix Model
• N155 N78 N77
• Mean No. of sessions attended 22/45 (49) 26/55
  (47)
• Retention (completed treatment) 42 (54) 52
  (68)
• p0.026 (Chi-square)
• Methamphetamine free for 30 days
• discharge 27 (35) 28 (36)
• p0.82 (Chi-square)
• 6 months after Intake 29 (37) 29 (38)
• p0.95 (Chi-square)
• Craving the desire to use a psychoactive
  substance
• CIMCraving Identification and Management Model

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Causes of Craving

• Environmental cues (Triggers)
• immediate, catastrophic, overwhelming craving
  stimulated by people, places, things associated
  with prior drug-use experiences
• Drug Withdrawal
• inadequately treated or untreated
• Mental illness symptoms
• inadequately treated or untreated
• Stress equals Craving

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Components of Treatment

• Initiation of Abstinence Stopping Use
• Drug Detoxification Use of medications to
  control withdrawal symptoms
• Avoidance Strategies Measures to protect the
  client from environmental cues
• Schedule Establishing times for arising,
  mealtimes, and going to bed
• Mental Health Assessment and Treatment
• Relapse Prevention
• Drug Detoxification Continued use of medications
  to control withdrawal as needed
• Avoidance Strategies Controlled re-entry to
  cue-rich environments
• Schedule Adherence to a regular daily lifestyle
• HUNGRY Three regularly spaced meals each day
• ANGRY Separate feelings of anger from losing
  control of behavior
• LONELY One positive social contact per day
  minimum
• TIRED Daily practice of sleep hygiene
• Tools Behaviors that dissipate craving
• Exercise Spiritual Practice
  Pleasurable Activities Treatment Groups
  Individual Counseling
• Mental Health Assessment and Treatment

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Role of Sleep in the Treatment of Methamphetamine
Abuse

• Phase 1
• Abstinence begins with 3 to 5 days of nearly
  continuous sleep to correct chronic sleep
  deprivation. Client may require medication for
  paranoia to initiate sleep
• Phase 2
• Sleep may become restless, sporadic, disturbed
  by nightmares and using dreams.
• Phase 3
• Ongoing attentiveness to sleep hygiene is
  required. Client may require instruction to
  develop regular, consistent sleep habits.

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Special Requirements for Treatment of
Methamphetamine Dependence

• Sleep, Food, Exercise
• Meticulous control of environmental exposure to
  methamphetamine
• Prompt treatment of paranoia with antipsychotic
  medication
• Antidepressant treatment of prolonged anhedonia
  and anergia

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Relapse Prevention Workshop

• Essential Questions
• What is your craving score?
• Where does your craving come from?
• Environmental cues
• Stress
• Drug withdrawal
• Mental health problems
• What are you going to do to take care of
  yourself?
• Avoidance strategies
• Structure
• Tools
• Program activities

• Principles
• Addicted persons relapse because of craving.
• Craving has causes that can be predicted,
  recognized and analyzed.
• Craving can be managed with the use of program
  activities.

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Avoidance Strategies

• Measures to Protect the Client From Exposure to
  Environmental Cues
• Identification of environmental cues
• Development of avoidance strategies-specific plan
  to avoid each cue
• Rehearsal of avoidance strategies
• Implementation of avoidance strategies
• changing phone numbers
• seeking safe housing
• avoiding old using haunts
• separating from old using partners/situations
• plans for handling money
• Enforced isolation-strict avoidance of
  conditioned cues and total isolation from the
  using environment during the first four to six
  weeks of recovery.

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Structure

• Detailed hour-to-hour planning of each day in
  which the client makes a consistent effort to
  make the same things happen at the same time each
  day.
• H ungry Three regularly spaced, scheduled meals
  daily
• A ngry Separate feelings of anger from losing
  control
• L onely At least ONE positive social contact
  daily
• T ired Daily practice of sleep hygiene-establishin
  g the same bedtime and wake-up time.
  Initially this may require the judicious use
  of non-habit forming medications to help the
  client sleep.

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Recovery Tools

• Behaviors that dissipate craving
• Exercise Two 20 minute exercise periods daily
• Spiritual practices Meditation Prayer
• Talk Treatment groups
• Peer support groups
• Individual counseling
• Journal writing
• Narcotics Anonymous
• Alcoholics Anonymous
• Psychological tools
• Acceptance
• Letting go
• Baths/Showers hot or cold
• Orgasm safe sex/self sex
• Relaxation exercises using audio tapes or
  learned behavioral techniques

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Use Episode

• In the community setting the client is constantly
  buffeted by environmental cues.
• Drugs are readily available, and often the client
  has frequent, early use episodes.

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Relapse

• In Relapse the client disappears from treatment
  and returns to using drugs.
• Losing control is not shameful
• Returning to treatment is an act of courage and
  is praise worthy.

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SAFETY TIPS for APPROACHING TWEAKERS

• Keep a social distance-preferably a 7 to 10 foot
  radius. Never try to manage the situation alone.
  Call for help.
• Do not shine bright lights at him/her. The
  tweaker is already paranoid, and if blinded by a
  bright light the likelihood of violence
  increases.
• Slow your speech and lower the pitch of your
  voice. A tweaker already hears sounds at a fast
  pace and in a high pitch. A side effect of the
  drug is a constant electrical buzzing sound in
  the background.
• Slow your movements. This decreases the odds that
  your physical actions will be misinterpreted
• Keep your hands visible. Tweakers are paranoid.
  If you place your hands where s/he cannot see
  them, s/he might feel threatened and could become
  violent.
• Keep the tweaker talking. A tweaker who falls
  silent can be extremely dangerous. Silence often
  means that the paranoid thoughts have overtaken
  reality. Anyone on the scene can become part of
  the tweaker's paranoid delusions.

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