Substance Use and Trauma: New Considerations in Co-Occurring Treatment

1. Substance Use and Trauma: New Considerations in Co-Occurring Treatment Dale Yagiela, MA, CAADC, LMSW

2. Today’s Agenda • A Review of Addiction, Its Progression, and Avenues of Treatment • Effects of Marijuana and K2 • The Limits of Conventional Mental Health Diagnoses • A Review of the Work Regarding Trauma and its Connection Drug Use • Developing an Understanding of Trauma Informed Programming and Integrating it into Substance Use Treatment • Specific Evidence Based Clinical Techniques that Show Efficacy in Addressing Trauma

3. Why This Training, Now? • The K2 Scare • 10% of the Public Claim to be Recovering (Used to Say 10% were Alcoholic); Over 13,000 Newborns Need Opiate DeTox at Birth (5 Fold increase in since 2000-One Born Every Hour • Enough Percocet Distributed last Year to give 25 to Every Man, Women and Child in US; 40 Vicadin • Drugs are the New Currency; Drug Dealers are the New Banks • Defacto Legalization Now in Michigan • Public Policy Regarding Co-Occurring Disorders-One Size Fits All

4. Limits In Providing Substance Use Treatment • Psychodynamic Therapy • “Short” Interventions • Outpatient Treatment v. In-Patient/Residential • Increased Regulation and Training Requirements • Ideological Constructs (Co-Occurring Disorders) Cost and Regulation Have Been More Important than Improving Treatment Outcomes

5. When We Talk of Addiction, We Seldom Talk about it From a Treatment Perspective Anymore • When We Do, We typically look at Addiction from a Psychological and SocialPerspective • If We Follow the Work of NIDA and Dr. Valkow, • We need to look at it as a Physiological Occurrence

6. What Do We Know About the Physiology of Addiction? • Brain Structure • Pleasure Circuit and Dopamine • How Various MADs alter Brain Function

7. Brain Has Essentially Three Operating Units • “Reptile” Part of the Brain Deals with Sensation; Connected with Survival (Hunger, Thirst, Procreation, Temperature Regulation); Flight or Fight; Often Referred to as the Primitive Brain • “Mammalian “ Part of the Brain (Amygdala): Emotion and Feelings • Frontal Lobe: Logic and Reason

8. Importance of Dopamine • Primitive Brain Releases Dopamine to Reward Survival Activities (Eating, Drinking, Procreation, Seeking Warmth), Impacting Pleasure Circuit • Dopamine Creates the Reward Response that Reinforces the Our Learning and Sets Us Up to Learn, Act, Respond • Links Primitive Brain, Emotional Memory and Frontal Lobe (Rational Thought) • All Mood Altering Drugs cause a Massive Release of Dopamine and a Firing of the “Pleasure Circuit” in the Brain • Creates the Responses in the Reptilian Part of Our Brains Critical to Survival • Creates the Imprinting of Emotional Memory and Learning • Affects the Development of Cognitive Skills in the Frontal Lobe

9. It is all about the Dopamine

10. All addictive substances send dopamine levels surging in the small central zone of the brain called the nucleus accumbens, which is thought to be the main reward center. Amphetamines induce cells to release it directly; Cocaine blocks its reuptake; Alcohol and narcotics like morphine, heroin and many prescription pain relievers suppress nerve cells that inhibit its release. NYT July, 2011

11. What Drugs Do to the Brain • Researchers now postulate that addiction requires two things. First is a genetic vulnerability, whose variables may include the quantity of dopamine receptors in the brain: • Too few receptors and taking the drug is not particularly memorable, too many and it is actually unpleasant. • Second, repeated assaults to the spectrum of circuits regulated by dopamine, involving motivation, expectation, memory and learning, among many others, appear to fundamentally alter the brain’s workings. NYT, July 2011

12. THE DISEASE CONCEPT INITIALLY, DRUG USE PRODUCES EUPHORIA, MODIFYING THE PLEASURE CIRCUIT THROUGH THE RELEASE OF DOPAMINE Survival Becomes Equated with Pleasure; Euphoria Becomes a Survival Response, Like Satiation after Eating; An Explosive Biochemical Linkage is Made between Feeling Good and Survival Survival Connects to the Primitive Brain, Where Sensation Controls and Dictates Action

13. The Hijacked Brain • Dopamine (Pleasure)= Survival

14. What Drugs Do to the Brain Dr. Volkow’s ( NIDA Director) research and that of others has also shown that even after addicts are successfully detoxed and long clean, their dopamine circuits remain abnormally blunted. Substances that elevate dopamine levels in normal subjects had notably muted responses in ex-addicts. NYT July, 2011

15. THE DISEASE CONCEPT THE BRAIN ATTEMPTS TO READJUST TO THE REDUCTION IN NEUROTRANSMITTERS, TRYING TO RETURN TO “NORMAL” • DEEP EMOTIONAL MEMORY OF THE EUPHORIC EXPERIENCE • CRAVING FOR EXPLOSIVE PLEASURE, BUT DEPLETED CAPACITY • LEADS TO URGES & CRAVINGS • IN SOME INSTANCES, THE BRAIN STATE IS PERMANENTLY ALTERED • THIS “DEPENDENCY” PRODUCES LONG LASTING EFFECTS ON THINKING, EMOTIONS, PERCEPTION, MEMORY & RECALL

16. Use Commenced in Adolescence, But We’re Now Treating an “Adult” • Some Addicts Began Their Use in the Mid to Late 20’s • Have the Skill , Emotional, Intellectual Development Associated with ‘Successful” Adolescence • If Use Began in the their Teens, and They are Now Chronologically Young Adults, They Are Developmentally Delayed, Due to Their Use

17. What About the Adolescent Brain? • Developing Brain • Frontal Lobe not Fully Engaged Until the Mid 20s • Primitive Brain and Emotional Brain Dominate • Neurons “Trimming” Dendrites • Neuropath ways are Developing , Changing • Routinize Over Time • Adolescents Lack the “Executive Functions” to Block and Override the Connection Between the Primitive Parts of the Brain and the Pleasure Circuit; Use High Jacks the Brain

18. Adolescent Substance and Brain Development THE DISEASE CONCEPT • DRUG USE ALTERS NEURAL PATHS • BRAIN BECOMES “MIS WIRED” • The Neural Link, Coupled with the Lack of Frontal Lobe Development “ Between Emotion and Pleasure is Corrupted, Creating the Desire to Use • Euphoric Experience Becomes Deeply Imprinted in the Emotional Memory • Kids Move through the Phases of Addiction Quicker, With More “ Covered” Consequences • They are “Discovered” through Increasing Levels of Consequence , due to no Apparent Capacity to Redirect Themselves-They Look Characterlogical

19. We Find This in Adults that Commenced Use as Adolescents

20. Substance Use and Brain Development • NEUROTRANSMITTER LEVELS MAY NOT COME BACK • RECEPTOR DAMAGE • CAN’T PREDICT IN ADVANCE WHAT WILL CHANGE FOR WHOM, OR LASTING IMPACTS, IF ANY • SOME CHANGES ARE PERMANENT

21. MARIJUANA IS A SPECIAL CONCERN THE DISEASE CONCEPT • ACTIVE AGENT IS THC, IT MODIFIES THE CANNABINOID CIRCUIT, WHICH THEN MODIFIES THE PLEASURE CIRCUIT • SLOWS BRAIN FUNCTION • THC CONCENTRATIONS IN TODAY’S MARIJUANA ARE 15 TO 20 TIMES GREATER THAN 20 YEARS AGO • THC IS FAT SOLUBLE, SETTLING & THICKENING NEURAL WALLS • THC HAS A 72 HOUR HALF LIFE, EVEN MINIMAL USE CAUSES A BUILD UP OF THC THAT HAS LASTING EFFECTS • CREATES DISTRACTABILITY, IRRITABILITY, LACK OF FOCUS, POOR MEMORY • TAKES 60 TO 90 DAYS TO “WITHDRAW” • New Research on Cognitive Impact of Adolescent Marijuana Dependency: Decreases IQ 8-10 Points (NTY, 8.27.12)

22. Marijuana Looks Benign Because of Its Withdrawal Symptoms • Alcohol: 1 Hour • Opiates: 15 to 30 Minutes • Cocaine: 30 minutes to 1 Hour • THC has a Half Life of 24-72 Hours • THC is Fat Soluble, Retained in the Body, In Walls of Neurons, Slowing Neuron Function • Observable Intoxication Diminishes but Impact on Brain Function Continues for 1-2 Days • During this Time, Memory, Focus, Emotions, Perception, Concentration are Impaired • “Pleasure Demand” begins to Dominate Brain Function • Use Occurring Every 2-3 Days Drives THC Levels Up • Can’t Just Cut Down, Because of THC Half Life

23. K2: What It Is • The “Potpourri” that is the K2 Base is often a Dried and Shredded Plants, including Salvia, which has Hallucinogenic Properties. • The Plant base is Coated with a number of Man-Made Chemicals that mimic the Structure of Delta Nine Tetrahydrocannabinol(THC), the active Ingredient found in Marijuana.

24. K2: Addictive and Psycho-Pharmacological Qualities • The Man-Made Chemicals have 5Times greater affinity to fill Cannabinoid Receptors in Brain Neurons than THC, so they activate the Cannabinoid System more Efficiently than standard THC. • In a more Simplified Explanation, as Standard THC is activated, it fills someCannabinoid Receptors in Brain Cells, Triggering the release of the Neurotransmitter Dopamine which produces the “High”. • The Danger of K2 is that it activates a HigherLevel of Dopamine release, which intensifies the high and produces serious Side Effects.

25. K2: Produces Psychosis • Excessive Dopamine levels have been correlated with Psychosis. • Pronounced Psychotic Episodes are a common feature of K2 Use. • Behavioral Markers of Psychosis, according to the DSM IV-TR (the Reference of the American Psychiatric Association used to Diagnose Mental Health and Substance Use Disorders) include Hostility, Suspicion and Paranoia, Delusions and Grandiosity. Thought Disturbances are also quite Common.

26. K2 • K2 is not detectible using standard Drug Screens. A special drug screen is required. • Traceable in Urine for 72 hours after use • Most ERs, Drug Testing Facilities and Labs are not assaying for it • Urine Screens indicate that, contrary to the Package Labeling, the Banned Substances are Present in the Product • No One Starts Out Using K2; Addicted to Marijuana, other Drugs of Choice • K2 Use is a Late Stage Addiction Marker

27. Other Drugs of Choice: • Alcohol • Vicodin, Oxycontin, Ritalin • Benzos (Mostly Young Women) • Heroin • Cocaine, Crack • Methamphetamine • Ecstasy

28. We Don’t See the Addicted Person’s Physiology; We See it Manifested in Abhorrent Behavior, Faulty Thinking, Affect and Social Situations

29. Impact of DependencyOn Development

30. How Do People Using Drugs Deal with the World? • Drugs=Survival • Naïve View (Magical Thinking) • Avoidance (Employ Skills Used to Survive Family) • Emotional Self Regulation Through Drugs, Sex, Cutting, Violence, Withdrawal • Seek Explosive Pleasure • Chronological Age v. Emotional Age • Intellectual Skills (Frontal Lobe) Delayed • Move Through the Phases of Addiction Quicker

31. THE DISEASE CONCEPT • WHEN REGULAR USE BEGINS, EMOTIONAL, SPIRITUAL AND SOCIAL DEVELOPMENT SLOWS, THEN CEASES • KIDS RELY ON DRUGS TO CHANGE MOOD • INTELLECTUAL DEVELOPMENT FOCUSES ON PERFECTING USE AND CREATING “SPACE” TO SATISFY CRAVINGS & URGES • ANY USE INTERFERES WITH DEVELOPMENT • DEPENDENCE DELAYS DEVELOPMENT UNTIL SOBRIETY COMMENCES • Typically, no physical symptoms: See Unmanageable behavior and the inability to learn from consequence

32. PROGRESSION OF USE PROGRESSION & SYMPTOMS Change in Brain State Addiction Harmful Involvement Early Middle Late Experimentation TIME

33. SOCIAL USE PROGRESSION & SYMPTOMS • ALCOHOL IS THE ONLY SOCIALLY ACCEPTABLE DRUG; • IT IS LEGAL FOR ADULTS • SOCIAL USER CEASES USE WHEN LOSS OF CONTROL BECOMES EVIDENT • ALSO LEARNS FROM CONSEQUENCE

34. EXPERIMENTATION PROGRESSION & SYMPTOMS • 5 TO 10 TIMES • LEARNS (DEEP EMOTIONAL LEARINING) – THE EUPHORIC EXPERIENCE (THIS MAKES ME FEEL GOOD EVERY TIME!) • I DIDN’T DIE OR GO CRAZY • I CAN KEEP MOM & DAD IN THE DARK ABOUT THIS • 80% - 95% ADOLESCENTS EXPERIMENT

35. HARMFUL INVOLVEMENT PROGRESSION & SYMPTOMS • REGULAR USE COMMENCES • CLANDESTINELY, BEGINS TO BUILD LIFE AROUND USING • USE IS SECRET TO SIGNIFICANT OTHERS • SLIGHT MOOD, BEHAVIOR, ATTITUDE CHANGES ARE VISIBLE Changes in Friends Changes in Activities Creating Space & Distance • MAY TAKE ONE OR TWO YEARS or One OR TWO DECADES

36. ADDICTION / EARLY STAGE PROGRESSION & SYMPTOMS • CHANGE IN BRAIN STATE (BLACKOUT) • FAMILY CONFLICT • PARALOGICAL REASONING • STILL ABLE TO KEEP USE SECRET OR TO EXPLAIN EVIDENCE AWAY • WORKING TO CREATE SPACE & HAVE OTHERS HANDLE MUNDANE ASPECTS OF DAY-TO-DAY LIFE • FOCUS IS ON USING, EXCITEMENT • MOOD SWINGS, INATTENTIVE, DEPRESSED • EMOTIONAL DEVELOPMENT IMPAIRED • INTELLECT USED TO BECOME “A BETTER ADDICT” • FULL BLOWN LOVE RELATIONSHIP W/ DRUGS • GO TO A THERAPIST-MISDIAGNOSIS / INAPPROPRIATE CLINICAL INTERVENTION

37. ADDICTION / MIDDLE STAGE PROGRESSION & SYMPTOMS • USE NO LONGER A SECRET • MATTERS OF INTEGRITY / HONESTY APPARENT (STEALING, DRUG DEALING, LYING) • IMMUNE TO CONSEQUENCE • DEEPENING MOOD SWINGS, PARALOGICAL THINKING • DEPRESSED MOOD – USE TO FEEL “NORMAL” • NARCISSISM • RUNNING FAMILY, SPLITTING • LEGAL, SCHOOL PROBLEMS ABOUND • MIDDLE STAGE IS WHERE CONSEQUENCES CATCH UP AND INTERVENTION MOST LIKELY TO OCCUR & TAKE HOLD • IF USE IS INTERUPTED, PICKS UP AS IF NEVER STOPPED

38. ADDICTION / LATE STAGE PROGRESSION & SYMPTOMS • TOLERANCE, SEEKING NEW DRUGS, Drugs of Choice are a Marker: Heroin, K2, Prescription Medications (Especially Xanax) • Significant Problems in Social Functioning • Loss of Support System • Suicidal Gestures, Accidental Occurrences and Overdoses • MAY OR MAY NOT HAVE PHYSICAL SYMPTOMS • IF USE COMMENCED AT 14 OR 15, UNABATED, LATE STAGE COMMENCES IN EARLY 20’S, Look Bi-Polar, BPD • CLOSED HEAD INJURIES, BURN VICTIMS • SEVERE PARALOGICAL THINKING – PSYCHOLOGICAL PROBLEMS RESEMBLING CHARACTER DISORDERS • TORMENTED, UNSETTLED • DEATH, PRISON

39. Response: Not Helpful • Expecting Substance Use to Go Away on Its Own • Expect Addicts that are Using to Learn by Consequence • Trying to Talk the Individual into Not Using (Just Say No) • Supporting “Cutting Down” vs. Abstinence • Buying Their Story/Keeping Their Secrets • Enabling Their Behavior(Covering Up, Making Excuses for, Defending, etc.) • Morally Judging Individuals Because They Use (Would Judge Them If They had Diabetes or TB?) • Waiting for Them to Violate or Disappear • Relating to Their Use Through Your Own Experiences • Seeing Kids with Drug Problems as Needing MH Counseling

40. Response: Helpful • Be Informed about Addiction and Recovery • Expect Use and Demand Sobriety; Establish a “Broken Windows” Environment and Inform Parents of the Stand You are Taking; Involve Them in It • Establish Partnerships with Significant Others • Support Co-Dependency Recovery in Families and Families “Bottom Lining” the Impaired Individual • “Time Line” Their Behavior • Have Institutional “Bottom Lines” • Work Towards a “Tipping Point” Based in Recovery

41. Presenting Issues in Assessment: Addiction is not a Conventional Mental Health Issue!!! • Using People Under Report Use to Protect It • Data Needs to Be Collected from Family Members About Evidence of Use • If Data is Public Knowledge, Youth has been Dependent for at Least Two Years • Needs Formal Assessment and Treatment by a Chemical Dependency Specialist, Not a Mental Health Clinician

42. Presenting Issues in Assessment: Addiction is not a Conventional Mental Health Issue Dependency is Often Misdiagnosed by Counselors, Therapists and Psychiatrists • Depression (Sadness, Isolation) • ADHD (Distractibility, Poor Memory, Inability to Concentrate) • Bi-Polar Disorder (Mood Swings) • Suicidal Ideation, Cutting • Parents Would Rather A Have their Kids Diagnosed/Treated with MD than Diagnosed and Treated for a Use Disorder • Dependency Minimized as “Substance Abuse” and a Symptom of Other Psychological or Social Cause, Due to Under-Reporting or Clinical Bias

43. Results from Treating a “Mental Health” Matter While a Person is Addicted to a MAD are Typically Unsuccessful

44. Presenting Issues: ER • Addicted Individiuals will Mix Drugs • Alcohol Poisoning • Hallucinations (LSD, PCP, DMX, Ecstasy) • High Temp, Dehydration (Ecstasy) • Injuries to Fights, Falls, MVA • Withdrawal from Alcohol (Convulsions, Depressed Respiration, Heart Rate) • Opiates (Depressed Respiration, Heart Rate) • Sexual Victimization; Sexual Assault The Severity of Consequence Involved with and ER Admission Usually Means Minimally Two Years of Use and Middle Stage Addiction

45. More Likely “Mental Health” Matters • More Prevalent Dual Diagnosis for Many is Trauma • Tendencies of Borderline Personality Disorders, Often Misread as Bipolar Disorder • Purported that 80% Have Co-Occurring Disorders Where’s the Data? • MH Doesn’t “Firm Up” into the Early 20s (CD, ODD, not BPD, ASPD)

46. Treatment

47. Treating Addiction as a Physiological Occurrence • Addiction is a Medical Disease, not just Psychological • Central to understanding of Addiction as a Physical Ailment is the Belief that Treatment must be continued to avoid Relapse. • Diabetes is not cured after 6 weeks of Medical Management. • When we stop Treatment after 28 days, People Relapse • The Idea that Addiction is a Chronic Disease is slow to take hold in Medical Circles. Doctors struggle to grasp Brain Function (Volkow) • Most People who abuse Substances do not have Psychiatric Problems (Alford, Addiction Residency Program, BUMC) NYT June, 2011

48. Issue#1: If We See Addiction as a Chronic Condition, What Should be the Goal of Treatment? • Harm Reduction (Expects/Accepts Relapse) Discounts Brain Chemistry • Abstinence (Disease in Remission; Establish a Tx. Regimen to Maintain Wellness)

49. Issue# 2 Because we don’t see the Physiological, We Typically ignore it and “Treat” what We see

50. Missed Issues • Developmental Lags • Family Use and Attitudes about Use • People Lie about their Use (Most “Rising to the TOP” Have Used for 3 to 5 Years) • Folks Would Rather Be Diagnosed/Treated with MD than Diagnosed and Treated for a Use Disorder • Few Willingly go to Treatment (Immune to Consequence) • System Investment is in MH