Credibility and Community in Addiction Treatment
The Crisis of Credibility Social Determinants of Health Building Recovery Capital Peer Relationships in SUD Treatment The Official Magazine of the California Consortium of Addiction Programs and Professionals (CCAPP) June 2018 Vol. 19 | No. 3, $6.95
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CONTENTS
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Letter from the Editor
22
By Gary Seidler Consulting Executive Editor
The Crisis of Credibility in Addiction Treatment
6
CCAPP
They Don’t Know What They Don’t Know: An Argument for Community Education
By Robert Lynn, EdD Provides an overview of addiction treatment development, lists texts that aided the field, and discusses what treatment needs are today.
By Michael Prichard, MS, LAADC, ICAADC
7
NACOA
A Further Look at Adult Children of Addiction
27 Social Determinants of Health and Behavioral Health Challenges By Pascal Scoles, DSW, LCSW, and Francesca DiRosa, PhD Defines social determinants of health (SDOH), presents the nine guiding principles of SAMHSA, and provides an example of holistic treatment in Philadelphia.
By Tian Dayton, PhD
Ketamine: PCP’s First Cousin
By Maxim W. Furek, MA, CADC, ICADC
Opinion
Closing the Revolving Door: An Intervention to Address Relapse and Readmission
12
By Jessica Noto, LMHC, CADC-II, LADC-I
Wellness
32
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Cultural Trends
Breaking Free from Overwhelment
15
By John Newport, PhD
Strengths Planning for Building Recovery Capital
Topics in Behavioral Health Care
By David Best, MSc, PhD, Michael Edwards, JD, Ivan Cano, MA, MSc, Jeremy Durrance, John Lehman, and William L. White, MA
Addiction and Dental Problems
17
By Richard M. Celko, DMD, MBA, and Dennis C. Daley, PhD
Defines the concept of recovery capital, describes the REC-CAP tool for measuring recovery barriers and strengths, and presents case studies.
Counselor Concerns From the Journal of Substance Abuse Treatment
38
Interpersonal Styles, Peer Relationships, and Outcomes in SUD Treatment
Comprehensiveness and Continuity of Care
19
By Gerald Shulman, MA, MAC, FACATA
Ask the LifeQuake Doctor
21
By Toni Galardi, PhD
Also in this issue:
By Anna J. Harrison, PhD, Christine Timko, PhD, and Daniel M. Blonigen, PhD
Ad Index
Explains interpersonal styles as related to SUDs, presents a study on patients in residential treatment, and provides implications for clinicians.
CE quiz instructions are on page 4
CE Quiz
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GERARD ARMOND POWELL
MY STORY OF ADDICTION My name is Gerard Armond Powell, I was 41 years old, I just sold my latest company for more than $89 million dollars. I had five houses, two airplanes, 23 cars, a boat, a race horse and everything else a human could possibly imagine. And yet, I couldn't figure out why I wanted to commit suicide. I could manifest anything… and yet every new thing that I manifested ultimately made me feel worse about myself. I was using alcohol, drugs, sex and anything else imaginable to mask my pain. I was a miserable human being, a bad father and an even worse husband. After moving to California for a fresh start, I failed again and got divorced. I was miserable and near the end. I undertook thousands of hours of counseling and it simply wouldn't work. And then, I was introduced to Reverend Michael Bernard Beckwith and started going to AGAPE, and for the first time in my life began to have hope. Reverend Beckwith assigned me the most amazing Reverend, Kathleen McNamara, to assist me. And although I saw improvements I was still plagued by unhappiness. I was so far gone that even though the teachings were perfect, and I could understand them, I still could not feel the joy of being alive. I noticed that if I went to mass on Sunday, by the time Wednesday rolled around I was in trouble again. I still wasn't happy. On a vacation in the Philippines I visited with a friend who was a shaman - she had a colleague with similar problems to me and he found a solution. She told me about a plant medicine that was being served in Costa Rica and how it cured her friend. I was honestly near the end of my rope again, so I said what the heck I'll go down and give it a try. So I went to Costa Rica and tried plant medicine. It was a night that changed my life. I spent the evening with God who reaffirmed the metaphysical lessons I learned.
One man’s miraculous, mystical journey from a life of addiction and pain to lasting peace, happiness, and prosperity
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I got to see firsthand that love was holding the universe together, that we were all connected, and witnessed other universal truths directly from source. The next morning, I was a different person. A miracle occurred in my life. I swore that day that I would do the right thing with my wealth and share the secret with as many people as I could. I realized that it wasn't the plant medicine alone but it was the combination of healthy food, metaphysical teachings, colonic cleanses, breathwork, meditation, yoga and plant medicine that brought around this miraculous change in my life.
So I teamed up with my friend Reverend Michael Beckwith, yoga teacher Shiva Rea, and raw food sensation Meg Pearson to start the world's first medically licensed naturopathic spiritual center and everything-included wellness resort that uses ceremonial plant medicines for therapeutic benefit. I purchased a gorgeous luxury resort in beautiful Costa Rica where we collectively designed programs that produce miracles in people's life. Complete life transformations happen every day. Never has there been an establishment like this, where a person can check in and within a week has a new life. I was then joined by the first of many in my co-creative team, Dr. Jeffrey McNairy and Brandee Alessandra. Dr. Jeff was one of my counselors for the six years during my deep struggle and could not believe the change in me. He was so impressed he dropped his lucrative California practice to move to Costa Rica and help bring this project to life. Brandee, the love of my life, and now wife, joined to help bring the vision to reality. It was our goal to provide all of the things that were used to evoke my awakening in one all-inclusive experience. Meaning, you have access to all the things that took me years to find available to you in one week, in one location. We further guaranteed that we would provide these services for one low price. You check in and have no additional charges everything would be covered; spa visits, massage, plant medicine, doctor consultations, counseling, metaphysical classes, farm-to-table organic food, yoga, colonics and more. Visitors never have to spend an additional dollar, not one red cent. Now miracles are happening every single day. More than 90% of the people who check out of the resort cry because they've had a true miracle in their life. Many are booking their next trip before they even leave the resort. Come and visit me, I'm here every day, living my own dream and teaching a class called About Your Miracle, including an introduction to our plant medicine program to ensure your success. If you’re unable to join me, you can learn more about my story and find tips on accessing your miracle through our Rythmic Breath Work in my first book, Sh*t the Moon Said.
...AND A MIRACLE CURE E
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As the Chief Medical Officer of Rythmia Life Advancement Center, located in Guanacaste, Costa Rica, Jeff has committed himself to bridging ancient modalities with western psychology to heal guests.
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Through Dr. McNairy’s intense experience with the most desperate patient populations (addition, acute mental health, and trauma), he has seen that the only real healing can come from within.
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How does the plant medicine help your clients? Having worked at Rythmia since its inception, I have witnessed plant medicine successfully treat many health concerns including trauma, anxiety, and depression. It has effects on mood and thoughtfulness, and activates the frontal and paralimbic regions of the brain. Another interesting component is that it leads to better impulse control and increases long-term planning abilities.
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He has worked in a variety of medical environments and has seen the struggle individuals have experienced when actually trying to heal. The current Western system of heath care is deficient in healing the population. It is more concerned with managing symptoms and using external sources for “change.”
What do you do to ensure safety for guests? During the resort booking process, we conduct a thorough medical questionnaire that addresses medication issues, health concerns, and chronic conditions. Once cleared to attend the Rythmia program, upon admission in Costa Rica, the medical team conducts a full evaluation to ensure that each guest is appropriate to participate in the plant medicine sessions. Every plant medicine session is medically supervised to guarantee safety and clinical appropriateness.
ME
IN
The Western medical model struggles to effectively heal people in relation to addiction, trauma, physical, and mental health conditions. Symptom management is not the answer to health. Finding the root cause of your unhappiness, health concern, and discontent, then resolving it is the only way to truly find peace. I often say, “One plant medicine session conducted in a safe environment that is clinically appropriate can be as effective as 10 years of psychotherapy.” Dr. Jeff McNairy, Psy.D., M.P.H. has been working in the health care field for 25 years.
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How is plant medicine different than the Western model for healing clients?
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Plant Medicine Questions & Answers with Dr. Jeff McNairy, Psy.D., M.P.H.
How do you help guests once they leave the resort? We have an optional after-care program available to our guests so they may continue to be connected to the Rythmia community and our many offerings throughout the week. Further, I host a highly interactive webinar twice a month where former guests can share their experiences and ask questions about how to cope with their new-found clarity.
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CE QUIZ INSTRUCTIONS A Health Communications, Inc. Publication
Credibility and Community in Addiction Treatment The Crisis of Credibility in Addiction Treatment Page 22 Provides an overview of addiction treatment development, lists texts that aided the field, and discusses what treatment needs are today. a. Discuss the various stages of addiction treatment in regards to credibility b. List different texts that helped develop the field in the middle years c. Explain the concept of value-based purchasing d. Analyze the impact of various treatment models on the development of the field
Social Determinants of Health and Behavioral Health Challenges Page 27 Defines social determinants of health (SDOH), presents the nine guiding principles of SAMHSA, and provides an example of holistic treatment in Philadelphia. a. Define social determinants of health (SDOH) b. List SAMHSA’s nine guiding principles c. Clarify the necessary components of a comprehensive behavioral health management approach d. Name the five areas that make up SDOH
Strengths Planning for Building Recovery Capital Page 32 Defines the concept of recovery capital, describes the RECCAP tool for measuring recovery barriers and strengths, and presents case studies. a. Describe recovery capital and its facets b. Explain how the REC-CAP tool works c. List the contents of each block in the REC-CAP tool d. Define the MPE process
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To Complete the Quiz: After reading the indicated feature articles, complete the quiz by filling in one of the multiple choice answer bubbles. Be sure to answer all questions and to give only one response per question. Incomplete questions will be marked as incorrect. Be sure to print clearly and fully complete the information section. For those requiring ADA accommodations, please contact our customer service line at 800-851-9100. The quiz can be submitted within five years of publication date and can only be submitted one time per quiz, per person.
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Advisory Board
Robert J. Ackerman, PhD, Chairman Joan Borysenko, PhD Ralph Carson, PhD Tian Dayton, PhD Bobby Ferguson David Mee-Lee, MD Don Meichenbaum, PhD Pete Nielsen, CADC-II Cardwell C. Nuckols, PhD Mel Pohl, MD Mark Sanders, LCSW David E. Smith, MD
AD INDEX Addictive Studies Institute...........................................................................9 CCAPP.............................................................................................................6 Foundations in Recovery.............................................................................13 Journal of Substance Abuse Treatment..... ...................................................7 HCI Books.....................................................................................................44 Loma Linda.................................................................................................. 11 Newport Academy.........................................................................Back Cover Rythmia..........................................................................................................2 Toni Galardi..................................................................................................21 Treatment Management Behavioral Health.............................Inside Back USJT Calendar..............................................................................Inside Front USJT Newport............................................................................................. 48
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Counselor | June 2018
LETTER FROM THE EDITOR
A Peek into the Future
I
n this issue of Counselor, a forty-year veteran in addiction treatment sounds a sobering alarm. On page 22, Robert “Bob” Lynn, EdD, concludes that our field faces a crisis in credibility. An “independent researcher, professor, and clinical officer in many venues,” Dr. Lynn is an insider who reminds us that our field has evolved through the dedication and caring of “unsung heroes” with little support from mainstream medicine. He explains that “Unless treatment providers and researchers band together to build the bridge from bench to trench, treatment will be dictated by utilization rather than clinical outcomes, and at best the field will fall back into a managed care environment plagued by a crisis of credibility.” Dr. Lynn writes, “What I am saying is that many have been throwing darts with blindfolds on from a questionable foundation.”
First and foremost is the need for research that actually informs care. Outcomes that only promote treatment just add to the confusion and lack of credibility. Furthermore, outcomes that simply measure utilization serve payers more than science and do not result in best clinical practices. “Journals that are dedicated to informing practice based on research are sorely needed,” says Dr. Lynn. He also notes, “We cannot continue to call this a disease and treat it with fifty-year-old practices that are not supported by science. Peer-to-peer support should have a greater role in early engagement and continuing care combined with treatment that is science driven.” “Treatment centers need to reevaluate clinical practice as they may not be poised to meet the needs of the addicted population moving forward,” Dr. Lynn concludes. Much food for thought here. c
He makes a compelling case by citing the following example that many of us can relate to: A while back a close family member requested inpatient treatment for her addiction. After forty-eight years in the field one would believe that this would be an easy task for me—it was anything but. As a scientist I am able to access much of what is proposed to define quality of care. I pride myself on being on top of the research and know many of the treatment centers that have good reputations. All that said, I had no method to determine which program would best suit my family member and no method of determining quality of care related to outcomes. Comparable data was not available, so I chose a place that met the minimum standards I have set for care. A lay person seeking treatment for a loved one is simply lost in the woods and could easily access more information about a vehicle they would like to purchase than reliable information regarding treatment. So what does Dr. Lynn recommend is needed to avert a major correction “much more severe than the managed care correction of the 1980s”? Since there appears to be some consensus that addiction is a chronic, relapsing, biopsychosocial disease, he suggests we begin to guide treatment utilizing the same system that informs medical treatment.
Gary Seidler
Consulting Executive Editor Counselor, The Magazine for Addiction & Behavioral Health Professionals, A Health Communications, Inc. Publication
www.counselormagazine.com
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CCAPP
They Don’t Know What They Don’t Know: An Argument for Community Education Michael Prichard, MS, LAADC, ICAADC
I
t is impossible to overstate the negative impact that substance abuse has on individuals, families, and society. Addiction is arguably the greatest public health threat we face in the US. When training on substance use disorders (SUDs), I describe it as a unique and complex issue in that it is like an octopus that has its tentacles wrapped up in every societal problem. Though not an exhaustive list, substance abuse is strongly implicated in n intimate partner violence n child abuse and neglect n sexual assault n homicide and other violent crimes n roadside injuries/fatalities n unwanted pregnancies n prenatal drug exposure and developmental impairments n the spread of communicable diseases (e.g., STDs, hepatitis C, HIV/AIDS) n mass incarceration n high health care costs and raised taxes
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n underachievement, failure to achieve n unemployment n homelessness n development and perpetuation of dysfunctional family systems In fact, nearly everyone employed in a human service profession will encounter individuals with SUDs, and it seems more and more families are affected irrespective of race/ethnicity, socioeconomic status, or geographic location. Recently, the US opioid crisis has shed light on the dangers of substance abuse as prescription or illicit opioid use was responsible for 66 percent of the 63,632 drug overdoses in 2016 (CDC, 2017). When I entered the SUD counseling profession, I assumed that the public understood SUDs due to the sheer prevalence of the problem. That assumption was wrong. In my early employment in the fields of domestic violence and child welfare, I encountered professionals from a variety of different professions and the general public in the course of my work. I was shocked by the lack of understanding and the misconceptions about SUDs. People know that substance abuse exists and that it has a corrosive effect on society, but there seems to be an enormous knowledge deficit in key areas such as the basic biology of addiction, signs and indicators of substance abuse, functional impairments that are characteristic of SUDs, risk factors that contribute to the development of SUDs, and treatment resources. Continued on page 26
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Counselor | June 2018
NACOA
A Further Look at Adult Children of Addiction Tian Dayton, PhD
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esilient qualities are not only what we are born with, but also the strengths that we build through encountering life’s challenges and developing the personal and interpersonal skills to meet them. The idea of growth through suffering or pain is not a new one, though the systematic study of it is. “Posttraumatic growth” (PTG)—a term coined by Drs. Lawrence Calhoun and Richard Tedeschi, editors of The Handbook of Posttraumatic Growth (2006)—describes the positive self-transformation that people undergo through meeting challenges head on. It refers to a profound, life-altering response to adversity that changes us on the inside as we actively summon the kinds of qualities (e.g., fortitude, forgiveness, gratitude, grit, and strength) that enable us to not only survive tough circumstances, but to thrive. But what factors contribute to our ability to mobilize our own strengths? Is it nature, nurture, or a combination of both? Our framework for understanding trauma has expanded in the past decade to go beyond seeing trauma as a one-time or even a set of repeated painful experiences. We are now understanding that the way in which we are loved by those who raise us can be trauma engendering or can help us build our capacity to deal with and bounce back from life’s inevitable struggles. According to the Adverse Childhood Experience (ACE) studies performed by Robert Anda (2006) and his team at Kaiser Permanente’s Health Appraisal Clinic in San Diego, California, we will all experience four or more serious life stressors that may be traumatizing, and according to positive psychology’s research, most of us will grow from them.
moods and addictions tend to be erratic caregivers. Behaviors in their children that send them through the roof on one day might go completely ignored the next. They are inconsistent at the least and abusive at most, often blaming their children for being the “cause” of their own uncontrollable behavior. For small children, these inconsistent and unpredictable parenting styles—along with
How We are Loved: Attachment, Connection, and Disconnection
Our nervous systems are built to resonate with the nervous systems of others, and to achieve balance within a context of connection (Schore, 1994). The nervous systems of babies are not fully developed at birth, says Alan Schore in Affect Regulation and the Origin of the Self (1994). Rather, each tiny interaction between parents and children actually build the neural networks that children will rely on throughout their lives to attain emotional balance. The cooing and wooing on the part of parents that brings children from the outer edges of crying into a more balanced state, for example, act as an “external regulator” that is slowly absorbed by children and becomes their own ability to soothe themselves when parents are out of reach. Or, it defines their capacity to take in caring from others,
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Does Parental Addiction Play a Role Here?
Growing up with one or more parents who are addicted is one of the childhood ACEs that popped up again and again in Dr. Anda’s research as a predictor of health problems later in life. Children who grow up with parental addiction also tend to grow up inside of a cluster of other forms of abuse and neglect that often become part of addiction’s sad orbit. Parents who are preoccupied with managing their own
experiencing themselves as the cause of parents’ pain, anger, abuse, or neglect— can have long-term resonance in terms of their capacity to form satisfying, nurturing relationships.
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NACOA as a template for mutual regulation has been set into motion. The highest and most evolved system, our social engagement system, is activated by a deep and inborn urge to communicate and cooperate. From the moment of birth, our mind-body reaches out toward our primary attachment figures to establish the kind of connection that will allow us to survive and find our footing in the world. We fall back on our more primitive systems of defense—such as fight, flight, or freeze—only when we fail to find a sense of resonance and safety within this primary connection (Porges, 2004).
How Relational Trauma Disregulates Our Capacity to Connect in Satisfying Ways
“Neuroception,” a term coined by Stephen Porges (2004), former director of the Brain-Body Center at the University of Illinois at Chicago, describes our innate ability to use intricate, meaning-laden, barely perceptible mind-body signals to establish bonds and communicate our needs and intentions. Neuroception is a system that has evolved over time to enable humans (and mammals) to establish the mutually nourishing bonds that we need to regulate ourselves in the context of others. It is also our personal security system that assesses, in nanoseconds, whether or not the situations that we are encountering are safe or in some way threatening (Porges, 2004). According to Porges (2004), our neuroception tells us if we can relax and be ourselves or when we need to self-protect. If the signals we are picking up from others are cold, dismissive, or threatening, that system sets off an inner alarm that is followed by a cascade of mind-body responses honed by eons of evolution to keep us from being harmed. In trauma-engendering interactions, people are not able to use their interactions to regulate their physiological states in relationship, they are not getting anything back from the other person that can help them to remain calm and regulated. Quite the opposite. The other person’s behavior is making them go into a scared, braced-for-danger state. Their physiology is being up regulated into a fight/flight mode (Porges, 2004). 8
Counselor | June 2018
A failure to successfully engage and create a sense of safety and cooperation, or to communicate needs and desires to those people we depend upon for our very survival, can be experienced as a traumatic form of rejection and a hurtful, disequilibrating lack of attunement. Being unwanted or feeling unseen or disliked by a parent or parents we need and love can become a template for seeking out love in all the wrong places. We simply do not know what to look for because we do not have that felt sense of how love feels on the inside, and we also have not learned the easy give and take that is necessary for living comfortably in close connection. We lack the kind of emotional balance and insight into our own behavior that healthy relationships require, and we cannot mentally reverse roles with other people and empathize with them. Therefore, relational trauma can occur at very subtle levels of engagement or a lack there of, as well as in its more obvious forms of living with abuse, neglect, illness, or addiction.
Recover or Repeat
When those we rely on for our basic needs of trust, empathy, and dependency are abusive, unattuned, or neglectful, it constitutes a double whammy. Not only are we being hurt, but the very people we would go to for solace are the ones causing us pain. We stand scared and braced for danger in those moments, prepared by eons of evolution to be ready to flee for safety or stand and fight. If we can do neither, if escape seems impossible because we are children growing up trapped by our own size and dependency within pain engendering families, if we cannot stop waiting for the parents we love to come out from behind their drunken rages and remember that it is us they are yelling at, then something inside of us freezes. Our mind-body fight-or-flight goes on tilt—our thinking mind shuts down whilst our limbic system goes on red alert. As a result, we take in through our limbic/sensory processing system all of the sights, sounds, smells, and so forth in the situation, but our thinking mind, which would make sense of it and create a narrative that might help us to understand what happened, is not functioning properly. We
are left with unconscious hurt and confusion that we do not even know is there until it gets triggered later in life when we try to form our own deep attachments. Partnering, parenting, and simply being in a new family can trigger us in ways we never thought possible. Suddenly, in the blink of an eye, we become that hurt three-year-old standing in our adult body, yelling at our own three-year-old, or we become a wounded five-year-old hurting all over again when our spouse does not respond as we wish and we scream at them, saying what we never said to our parents, because we did not dare or we simply did not know the words. But these dysfunctional patterns of attachment often remain unconscious simply because it is those very relational patterns that wounded us the most deeply, that are the ones we tend to be invested in repressing and disowning. And because there is no narrative attached to them, we may even think they never happened to begin with. ACoAs, in other words, do not know that we do not know. We go through life repeating relational dynamics and behaviors that were learned in the midst of drunkenness and dysfunction, whether or not we ourselves are drinking or using drugs. We imitate dry drunk behavior even when we are perfectly sane and sober. And we think it is the person or circumstance in the present that is causing us the full amount of pain we are in. We cannot feel or see what we are importing from our past that might be fueling our intense reaction of either hurt and rage or avoidance and withdrawal in the present. It is really paying attention to what triggers us the most intensely that can give us the hints we need to illuminate this old, unconscious relational pain. It tends to be through life itself, or role play types of therapy, that this kind of pattern emerges so that we can actually feel and heal it. Until we can somehow come in touch with what pain we are hiding from ourselves, we are at risk for recreating pain-filled relational dynamics from the past in our present relationships. But there is no need to live with or pass along this kind of posttraumatic pain. Therapies have been developed today which are designed to address these sorts Continued on page 14
CULTURAL TRENDS
Ketamine: PCP’s First Cousin Maxim W. Furek, MA, CADC, ICADC
K
etamine, a short-acting, less powerful derivative of phencyclidine (PCP), is used in veterinary hospitals primarily on dogs and cats. Ketamine is used often in conjunction with Valium or other sedatives that relax muscles during medical procedures. Regrettably, the substance is gaining in popularity, worldwide, with club goers and adolescent drug users. Authorities have expressed concern. According to Porrata, Ketamine is a psychedelic anesthetic classified medically as a dissociative anesthetic, discovered by Dr. Cal Stevens of Wayne State University in 1961. Heavily used on
the battlefields of Vietnam, it is used today for short-term surgical procedures in both animals and humans. For human consumption, it is marketed as Ketalar by Parke-Davis (2018). The chapter on PCP and ketamine in Goldfrank’s Toxicologic Emergencies states, Phencyclidine (PCP) and ketamine are dissociative anesthetics that are abused for their psychoactive effects, with ketamine having onetenth the potency. PCP’s popularity peaked during the 1970s. Ketamine gained popularity in the 1990s along with γ-hydroxybutyrate (GHB) and hallucinogenic amphetamines, which remain popular in nightclubs and “raves.” Both xenobiotics [chemical compounds foreign to a given biological system] affect the central nervous system (CNS), producing psychiatric and
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CULTURAL TRENDS medical complications during an “out of body experience” and alteration in sensory perception (Olmedo, 2011). The ketamine drug experience is similar to that of LSD or PCP, but lasts only thirty to sixty minutes, whereas LSD and PCP trips typically last for several hours. Ketamine is less potent than PCP. Consider that 25 mg of PCP will produce a full psychedelic experience while it would require at least 100 mg of ketamine for a similar effect.
Dissociative Drugs
Nora Volkow, MD, the director of the National Institute on Drug Abuse (NIDA), wrote, Hallucinogens and dissociative drugs— which have street names like acid, angel dust, and vitamin K—distort the way a user perceives time, motion, colors, sounds, and self. These drugs can disrupt a person’s ability to think and communicate rationally, or even to recognize reality, sometimes resulting in bizarre or dangerous behavior. . . . Dissociative drugs like PCP, ketamine, dextromethorphan, and salvia divinorum may make a user feel out of control and disconnected from their body and environment (2014). NIDA explains that dissociative drugs act by altering distribution of the neurotransmitter glutamate throughout the brain. Glutamate is involved in perception of pain, cognition (learning and memory), and emotion (NIDA, 2014b). PCP is considered the typical dissociative drug, and the description of PCP’s actions and effects largely applies to ketamine and dextromethorphan as well. Goldfrank’s Toxicologic Emergencies also warns that “The opioid dextromethorphan in high doses has become popular among today’s youth . . . An understanding of the pharmacology and pathophysiology of PCP and ketamine is valuable in the diagnosis, management, and treatment of patients with toxicity from these agents” (Olmedo, 2011). The Monitoring the Future National Survey Results on Drug Use 1975–2016 listed ketamine under “MDMA (Ecstasy, Molly) and Other ‘Club Drugs’ ” (Johnston, O’Malley, Miech, Bachman, & Schulenberg, 10
Counselor | June 2018
2016). The findings revealed the “Annual prevalence for another club drug, ketamine, had also shown significant declines, and was at 0.8 percent, 1.2 percent, and 1.7 percent in 2011” for eighth, tenth, and twelfth graders. Additionally, “Questions about GHB and ketamine use were dropped from the surveys of eighth and tenth graders in 2012. In 2016, annual prevalence among twelfth graders for rohypnol, GHB, and ketamine was 1.1 percent, 0.9 percent, and 1.2 percent, respectively” (Johnston et al., 2016). Ketamine is snorted, swallowed, or injected. A 2007 study published in the Journal of Psychoactive Drugs stated that “Injection drug use among young people has expanded beyond heroin, cocaine, and methamphetamine and into less commonly injectable substances, such as crack, ecstasy, and ketamine” (Lankenau & Sanders, 2007).
Lost in the K-Hole
The dangers associated with ketamine are numerous. Like PCP, the substance is unpredictable and can trigger flashbacks, delirium, impaired motor function, and potentially fatal respiratory problems. Ketamine, odorless and tasteless, can be added to beverages without being detected. Ketamine is considered a date rape drug and has been used to commit sexual assaults due to its ability to sedate and incapacitate unsuspecting victims. Ketamine induces amnesia, preventing victims from recalling events that occurred while under the drug’s influence (NIDA, 2014a). The substance often leaves users in a “K-hole,” a state of massive sensory deprivation. During this “Special K” version of a bad trip, users are detached from reality and unable to speak, move, or experience pain. The drug may be addictive, according to some researchers. The K-Hole produces a lack of awareness to the environment (the effect abusers crave) and an intense psychological and somatic state with dissociative properties that produce a disconnection between users’ bodies and minds (Jansen, 2004). Ketamine has nurtured a cult-like allure on the club scene that includes the Chemical Brothers’s best-selling CD Dig Your Own Hole (1997), a homage to ketamine featuring the song “Lost in the K-Hole.”
According to Porrata, Ketamine may produce pleasant dream-like states, vivid imagery, hallucinations, and possibly extreme delirium. This usually lasts only a few hours. Excitement and visual disturbances can recur days or weeks after exposure to ketamine; the problem with “flashbacks” may be greater with ketamine than with other hallucinogens. It also produces ataxia, slurring of speech, dizziness, confusion, blurred vision, anxiety, and insomnia. It can also cause cessation of breathing, cardiac arrest, brain damage, and death (2018).
World Health Organization
A few years ago the World Health Organization (WHO) rejected a request from China to place ketamine under international control, which would restrict medical access to the drug (Block, 2016). The request was made in March 2015 by China’s United National delegation to the UN Commission on Narcotic Drugs. The Chinese group “argued that ketamine is a health risk to the public when used in a recreational fashion” (Block, 2016). Furthermore, The WHO recently opposed the Chinese request, saying that ketamine abuse does not “pose a global health threat,” while limiting the drug would adversely impact many parts of the world where ketamine is the only widely available anesthetic and analgesic. “The medical benefits of ketamine far outweigh potential harm for recreational use,” the WHO said in a statement (Block, 2016). Because ketamine is also used in hospital settings as an analgesic and anesthetic, and “widely used by veterinarians as an anesthetic for horses . . . the WHO has put ketamine in its ‘Essential Drug List,’ meaning the drug has a minimal medical need for basic health care” (Block, 2016). Back in 2009, Radio Free Asia reported the following: In Hong Kong, the tranquilizer ketamine has already surpassed ecstasy as the most popular drug for youngsters. Of all reported first-time drug users under the age of twenty-one last year, 83 percent were using ketamine, compared with 73.7 percent in 2007. In 2000, ketamine . . . became regulated under Schedule I
CULTURAL TRENDS of Hong Kong’s Chapter 134 Dangerous Drugs Ordinance. It can be used legally only by health professionals, for university research purposes, or with a physician’s prescription (Lee, 2009).
Therapeutic Profile
The therapeutic profile of ketamine is becoming larger. The CSA Schedule III drug is being investigated as a therapy for myriad mental illnesses and neurological conditions including depression and epilepsy. Ketamine has been used in clinical trials to alleviate depression. The treatment appears to work within four hours, while current antidepressants can take weeks to start working. According to an article on CNN, The Food and Drug Administration put the experimental drug esketamine (also known as ketamine) on the fast track to official approval for use in treating major depression, Janssen Pharmaceutical announced. This designated “breakthrough therapy” would offer psychiatrists a new method for treating patients with suicidal tendencies and would qualify as the first new treatment for major depressive disorder in about half a century (Scutti, 2016). Following the lead of researchers overseas, the unique therapeutic value of ketamine is being explored. Research conducted in St. Petersburg, Russia by Dr. Igor V. Kungurtsev utilized ketamine for transpersonal psychotherapy as a treatment for individuals diagnosed with neurotic nonendogenous depression and phobias. Intramuscular injections six to ten times lower than used in surgery were used to induce transpersonal experiences which lasted thirty to forty-five minutes (Kungurtsev, 1992). According to Kungurtsev, “Full liberation from neurotic symptoms is impossible without deep personality alterations. It seems that life values and personality alter only through nonordinary states of consciousness connected with profound experience” (1992). Ketamine treatments include intramuscular injection because of the longer effect (in comparison with intravenous). During the session, patients reclined on a wide bed, listening to music by Kitaro,
Vangelis, and other New Age composers, as the feeling of individual self dissolved. Kungurtsev noted, “The process of losing one’s individuality can be horrifying and felt as a real death. If the subject can relax and let go, this process may be ecstatic. After the loss of the feeling of one’s individual self, the experience is indescribable” (1992). Ketamine is unique among anesthetics. It does not depress critical body vitals and is often used in procedures with burn victims. It produces a dissociative state in the CNS in which amnesia and profound analgesia (loss of pain) are induced, though patients do not appear to be asleep. With newer medical applications of ketamine being researched and developed, authorities need to balance the applications of this drug against its misuse. It is the same old song, one we have heard many times before. c About the Author Maxim W. Furek, MA, CADC, ICADC, is an avid researcher and lecturer on contemporary drug trends. His rich background includes aspects of psychology, addictions, mental health, and music journalism. His latest book, Sheppton: The Myth, Miracle, & Music, explores the psychological trauma of being trapped underground and is available at Amazon.com.
article/464065/?webSyncID=26e0bc45-bd91-577e-c00c605e4a5aa56c&sessionGUID=ae722b95-76b7-8bc262d6-e3aa168d3dd8 The Chemical Brothers. (1997). Dig your own hole [CD]. Hollywood, CA: Virgin. Jansen, K. L. R. (2004). Ketamine: Dreams and realities. Sarasota, FL: MAPS. Johnston, L. D., O’Malley, P. M., Miech, R. A., Bachman, J. G., & Schulenberg, J. E. (2017). Monitoring the Future National Survey results on drug use 1975–2016: 2016 overview: Key findings on adolescent drug use. Retrieved from http://www.monitoringthefuture.org/pubs/monographs/ mtf-overview2016.pdf Kungurtsev, I. V. (1992). Death-rebirth psychotherapy of neuroses with ketamine (ketalar) administration. Retrieved from https://www.maps.org/news-letters/v03n2/03202ket.html Lankenau, S. E., & Sanders, B. (2007). Patterns of ketamine use among young injection drug users. Journal of Psychoactive Drugs, 39(1), 21–9. Lee, K. (2009). Young abusers in Hong Kong. Retrieved from https://www.rfa.org/english/news/china/youngerabusers-11122009130512.html National Institute on Drug Abuse (NIDA). (2014a). Drug facts: Club drugs (GHB, ketamine, and rohypnol). Retrieved from https://www.drugabuse.gov/sites/default/files/drugfacts_clubdrugs_12_2014.pdf National Institute on Drug Abuse (NIDA). (2014b). Hallucinogens and dissociative drugs: Including LSD, PCP, ketamine, psilocybin, salvia, peyote, and dextromethorphan. Retrieved from https://www.drugabuse.gov/sites/ default/files/rrhalluc.pdf Olmedo, R. E. (2011). Phencyclidine and ketamine. In L. S. Nelson, N. A. Lewin, M. A. Howland, R. S. Hoffman, L. R. Goldfrank, & N. E. Flomenbaum (Eds.), Goldfrank’s toxicologic emergencies (9th ed.). New York, NY: McGraw-Hill. Porrata, T. (2018). Ketamine information. Retrieved from http://www.projectghb.org/content/ketamine-information
References
Scutti, S. (2016). Party drug ketamine closer to approval for depression. Retrieved from https://www.cnn. com/2016/08/17/health/ketamine-depressiontreatment/index.html
Block, J. (2016). WHO opposes Chinese request to restrict access to ketamine. Retrieved from https://www.psychiatryadvisor.com/therapies/world-health-organization-ketamine-analgesic-anesthetic-horses-depression-bipolar/
Volkow, N. D. (2014). Hallucinogens and dissociative drugs: From the director. Retrieved from https://www.drugabuse. gov/publications/research-reports/hallucinogens-dissociative-drugs/director
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OPINION
Closing the Revolving Door: An Intervention to Address Relapse and Readmission Jessica Noto, LMHC, CADC-II, LADC-I
Method
I
n the past five years, there has been a greater focus on patients who are readmitted to the hospital within thirty days. This is in part because Medicare is paying less for readmissions and in part because providers want to provide the best care possible. Available literature on thirty-day readmissions focuses primarily on general hospitals and not specialized treatment hospitals. However, what is evidenced in the research for all treatment is that good care lowers readmission rates. 12
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To decrease the frequency of readmissions within thirty days at our own facility, several actions were implemented. A weekly educational and support group for this specific population was created, group members were provided with information on the stages of change and how it applied to them, and members were also given the “Socrates Readiness to Change” questionnaire, which measured which stage of change they were in. The original hypothesis was that the majority of patients in this demographic would be individuals who could not be placed into further treatment or were homeless. This was rapidly proven incorrect. The readmission group tended to be individuals who returned to homes or families that were unsafe for recovery, or individuals who left treatment without a discharge plan. Slowly the educational group morphed into a process group. Patients began sharing with one another about aftercare plans: whether they had made one during their prior admission, and, if they had, what the plan entailed. They also began to discuss their ability to follow the plan, what had caused their relapse, and what they were willing to change during this readmission. Patients reported finding this more helpful than educational sessions. The Socrates questionnaire continued to be filled out by each patient during group. The goal was to establish a baseline Socrates score and compare it to new results weekly in order to measure changes in the scores throughout treatment. Due to an agency-wide emphasis to utilize motivational interviewing (MI) techniques and engagement of the readmitted patients at least four times throughout their treatment, a day-one interview with patients who had been readmitted was also implemented. These interviews were composed of counselor-led discussions of what happened and what would be different this time. Baseline Socrates scores were also established during these interviews. For a period of time, while the group continued to meet weekly, a new element was introduced: current outpatient clients would come and speak with the group about how outpatient treatment helped in their recovery. These clients shared specific information they learned and how the specific tools helped in conjunction with a Twelve Step program or another support network. These patient speakers increased group engagement and increased the number of those who agreed to an outpatient aftercare plan. When our initial assumptions were disproven in May 2013, we began looking at dual-diagnosis and chronic pain issues instead of placement issues. Looking at self-reported patient data, we discovered that most patients had an anxiety and/or depressive disorder. Since these diagnoses were self-reported, it was not possible to discriminate between patients who did not
OPINION meet clinical criteria. Patients with bipolar disorder, schizophrenia, or schizoaffective disorder were identified in the general dual-diagnosis group and tracked separately. These diagnoses are more likely to be given to patients by clinicians, and they were frequently more severe disorders and required medication. The data also revealed that about half of readmitted patients suffered from chronic pain. This is important to be aware of because chronic pain can be a trigger to use either alcohol or opioids. While our facility does offer a chronic pain group to rehabilitation patients, chronic pain is something that should be discussed with the treatment team so that patients have a plan prior to discharge. Recommendations should be shared with other internal departments. In addition, a question about anticipated aftercare was added to the admission intake process and to the phase-one psychosocial assessment completed in detox. The committee wanted all departments throughout the agency mindful of aftercare from the beginning of treatment in hopes that this would increase aftercare plans being made.
Early in 2017 the committee decided that the individual work being done with patients might be more effective than the group. It was decided that committee members would continue to meet with patients on day one of detox, and on day three of their treatment the committee members would meet with both patients and primary counselors in an attempt to have patients, counselors, and committee members on the same page in terms of aftercare planning.
Results
Setting up a concrete aftercare plan can be challenging with this population. Many of our patients had been in treatment before and felt they knew what they needed to do to stay clean and sober. Many patients reported that IOP did not work for them; they had participated in the past and relapsed despite this care. Our treatment team encouraged these patients to consider long-term residential treatment, though frequently it was an option patients were unwilling to consider.
During the first twenty-four hours of treatment, patients tended to be extremely willing to do anything for their recovery. As detox continued and they began to feel better, patients often changed their minds about long-term treatment and decided to return home. In these cases, it is of the utmost importance that primary counselors and group leaders work with patients to enhance their motivation and their stage of change. The majority of patients in the thirtyday readmission group returned to their homes and their families or significant others without an aftercare plan. These living situations may or may not have been safe for patients’ recovery. Combined with refused aftercare, these living situations led to a very high-risk discharge. It is important to note that the initial hypothesis was that a large population of thirty-day readmissions would be from homeless individuals. As previously stated, originally the committee expected there to be more patients who were homeless being readmitted. However, homeless people were only a small portion of this population.
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OPINION Despite work to ensure that every patient was discharged with an aftercare plan, readmissions continued. One possible explanation is that people were readmitted after running out of medications. When patients completed treatment at our facility, they typically left with a thirty-day script for their medications. For a variety of reasons some of our patients seemed unable to obtain a refill from their own providers. A percentage of our patients had never met their primary care physicians (PCP) or did not allow us to schedule a follow-up appointment. To address this issue, we began tracking information related to PCP and psychiatric appointments made at discharge. The tracking revealed low rates of arranging psychiatric appointments. Low rates of psychiatric appointments were the result of several factors. First, there were too few psychiatrists in the area to meet demand. This was compounded by many local agencies requiring two therapy sessions prior to making a psychiatric appointment, forcing patients to wait longer to meet with a psychiatrist. Patient medication may run out before this can happen. Another issue impacting appointment scheduling is patient reluctance. While PCP appointments are easier to schedule prior to discharge, many patients did not want their doctors to know they were in detox. Because of this, patients often did not allow us to make appointments on their behalf. Further still, many patients had not met the PCPs their insurance company assigned them. Perhaps patients’ doctors, after learning about their issues with addiction, had taken them off medications they felt were necessary. These patients may have been unable to make an appointment in a reasonable amount of time and instead were forced to wait for weeks to see their providers. For whatever reason, there seems to be an undercurrent of patients who used their scripts and did not or could not refill them. Being unable to get a refill can precipitate a relapse and often results in a return to treatment. There were several interesting and unanticipated outcomes. We anticipated a younger demographic of primarily opiate users, but our readmits were primarily in the forty- to fifty-year-old range. This remained steady throughout the years of tracking this population. 14
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The separation by gender also remained steady over the study’s lifetime. While the exact numbers and ratio changed, there was a majority of men readmitted in comparison to women. Readmissions tended to wax and wane, with some seasonal differences—for instance, there were fewer readmissions during the summer. At times, a correlation could be observed between a month with fewer aftercare plans being completed and an increase in readmits the next month. While the highs and lows may appear drastic, at most this population is about 5 percent of our hospital’s census. In terms of the substance preferences, alcohol and opiates were used in nearly equal amounts. Additionally, many patients returned for detox from multiple substances. In recent months, the alcohol users outnumbered opioid users, which was unexpected. There had also been a small but steady number of patients who may or may not have continued their benzodiazepine prescriptions while in treatment. The decision to stay on or come off benzodiazepines was based on advice from patients’ medical providers.
Conclusion
Overall it was determined that agencywide change needed to be implemented in order to be successful. The group program’s decision makers expanded to include case management, nursing, counseling, placement staff, and admission staff. Collaboration across departments was vital, as well as cohesion amongst the treatment teams working closest with the patients. This included primary counselors, case managers, physicians, and nursing department. If patients heard the same message from all members of the treatment team, it became easier to create a coherent aftercare plan, which was vital to their success and recovery. The committee has decided to begin follow-up contact shortly. A phone call to patients who have returned home within a week of discharge will be made. The callers will inquire whether or not patients were able to follow-through with their aftercare plans. If they were not able to follow through, they will be asked if we can refer them to aftercare. The committee is also hoping to utilize recovery coaches to help patients in these very early stages of recovery. c
Acknowledgements: I would like to acknowledge my committee, without whom none of this would have been possible: Jan Hughes, Ed O’Brien, Chris Griffin, Josh Master, Tricia Lambert, Jeff Comeau, Pam Daveau, and Jonida Duque.
About the Author Jessica Noto, LMHC, CADC-II, LADC-I, has worked with patients in detox as well as patients in a short-term, stepdown residential program as a primary rehab counselor. Jessica has worked fee-for-service with Adcare outpatient services seeing clients in individual and group therapy. Jessica is currently the program manager for AdCare Hospital in Worcester, Massachusetts.
NACOA
from page 8
of mind-body issues such as neuropsychodrama, EMDR, neurofeedback, and others. Treatment programs increasingly incorporate these new and effective methods and Twelve Step rooms create a self-help container for processing this sort of pain with the support of others. So make friends with what triggers you, find professional help, walk into a Twelve Step meeting room, and become curious about what vibrates underneath. The way out is the way through. c About the Author Tian Dayton, PhD, is the author of sixteen books, including The ACoA Trauma Syndrome; Emotional Sobriety; Trauma and Addiction; Forgiving and Moving On; and The Living Stage. In addition, Dr. Dayton has developed a model for using sociometry and psychodrama to resolve issues related to relationship trauma repair. She is a board-certified trainer in psychodrama, sociometry, and group psychotherapy and is the director of The New York Psychodrama Training Institute.
References Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfeld, C. L., Perry, B. D., . . . Giles, W. H. (2006). The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neuroscience, 256(3), 174–86. Calhoun, L. G., & Tedeschi, R. G. (Eds.). (2006). The handbook of posttraumatic growth: Research and practice. New York, NY: Routledge. Porges, S. W. (2004). Neuroception: A subconscious system for detecting threats and safety. Zero to Three, 24(5), 19–24. Retrieved from https://stephenporges.com/images/neuroception.pdf Schore, A. N. (1994). Affect regulation and the origin of the self: The neurobiology of emotional development. Mahwah, NJ: Lawrence Erlbaum.
WELLNESS
Breaking Free from Overwhelment John Newport, PhD
O
verwhelment occurs when we experience severe overload to the point where we feel mentally, emotionally, physically, and spiritually depleted. While the adage that “God never gives us more than we can handle” may hold true, we mortals are experts in setting ourselves up for truly overwhelming situations. That is particularly true for us obsessive-compulsive types!
is always the same: “Evan, you are by far the best counselor I have, and I assign you these cases because you are the only one I can trust to handle them effectively.”
We all experience periods of overwhelment in our lives. These episodes can be extremely debilitating, particularly when our overwhelment blocks us from effectively dealing with the underlying causes. Learning to effectively deal with overwhelment is an essential component of any recovery program. Common symptoms accompanying overwhelment include severe depression and anxiety, irritability, loss of sleep, and a grossly deflated sense of self-efficacy, to name a few. Overwhelment that is not effectively addressed may cause us to succumb to feelings of despair and helplessness, which feed into a vicious downward spiral. As our sense of being entrapped in unmanageable circumstances persists, we lose sight of effectively taking care of ourselves in the realms of nutrition, physical exercise, sleep hygiene, reaching out to others for social support, and replenishing our spiritual resources through prayer and meditation. Persistent overwhelment poses a real threat of our sobriety and often provides a perfect excuse for relapse to alcohol and drugs, food addiction, and other harmful activities.
I firmly believe that the effectiveness of AA and other Twelve Step programs is in no small way attributable to the program’s steering alcoholics and addicts toward identifying a higher power of their choosing, and developing a personal relationship with that power.
Breaking the Cycle of Overwhelment Identify the Enemy
The first step in breaking the cycle is identifying what you are up against, focusing on precisely what is making you feel overwhelmed, together with other contributing factors that may be at play. Doing some brainstorming on paper can be very helpful. As an illustrative example, let us take the case of Evan, an addiction counselor in a governmentally funded agency
serving indigent clients. Evan suffers from a heavy overload, working tento twelve-hour days, and constantly feeling extremely depleted. While he is committed to helping others suffering from addiction, his job no longer feels rewarding and he dreads coming to
work each morning. His overwhelment has spilled over into his family life, as he is constantly battling with his wife over his long hours, and feels increasingly distant from their three children. At home he spends his limited free time in front of the TV before crashing out of sheer exhaustion. He believes he is being assigned a disproportionate share of the most difficult cases and has brought this to his supervisor’s attention on several occasions. The response
Pray to a Higher Power
While I am not recovering from chemical dependency per se, I have learned to nurture my relationship with a beneficent higher power and turn to that power for counsel, especially when I am feeling overwhelmed.
Apply the Serenity Prayer
As I have stated before, I believe the Serenity Prayer is by far the most powerful stress management tool ever invented. When confronted with an especially www.counselormagazine.com
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WELLNESS challenging situation, I find it helpful to work through the various steps of this prayer on paper. In the “Stress Management” chapter of my book, The Wellness-Recovery Connection (2004), I provide a worksheet for applying the Serenity Prayer to particularly difficult situations. Returning to our friend Evan, as he attempts to focus on those aspects of his situation he believes he cannot change, he notes that he most definitely refuses to budge from his commitment to doing his very best to help his clients. He also recognizes that he cannot change the reality that his agency is currently underfunded, which results in counselors being spread quite thin in carrying out their responsibilities. Next he attempts to identify those aspects that he hopefully can change, or at least significantly influence. He realizes that he could, for example, confront his boss with his growing burnout as a result of his routinely being assigned the most difficult cases. Toward remedying that imbalance, he could offer to mentor other counselors on dealing with difficult clients, provided that his caseload is adjusted to allow him to serve effectively as a mentor. He also decides to share with his boss his thoughts concerning how the agency might secure other sources of funding, perhaps in the form of a foundation grant, while also soliciting donations from community residents and local businesses. Back on the home front, he realizes that he must make the time to talk with both his wife and children concerning the stress his workload is placing on all of them, and elicit their support in attempting to turn that situation around.
Defuse the Sense of Overwhelment
When we are feeling overwhelmed we often compound the problem by obsessively running through our heads a series of worst-case scenarios that make the problem appear worse than it actually is. Years ago in my own therapy I learned a “catastrophic thoughts, rational response” exercise that I often employ to defuse my anxiety in response to highly stressful situations. The first step is to identify the major catastrophic thoughts 16
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you are running through your head. For example, in Evan’s predicament he may be obsessing over his fear that his supervisor will think less of him if he confronts him with his overwhelment relating to his current caseload. More specifically, a key underlying catastrophic thought might be, “Oh my God, Ben thinks I am his best counselor. If I confront him with my overwhelment over my current caseload, he will think I am a wimp! He will lose his respect for me and he might even fire me for being an incompetent counselor!” In this case, appropriate rational responses (RR’s) might include: n RR #1: “Now wait a minute. Anyone would feel overwhelmed with the unreasonably difficult caseload I have been stuck with. Ben seems to be a fairly rational guy. If I directly share my concerns with him, he will hopefully be amenable to working together to come up with a more equitable resolution. By his own admission I am his best counselor; certainly he will want to work out a reasonable adjustment to allow me to maintain my maximum effectiveness.” n RR #2: “By confronting Ben with my growing burnout, combined with my high level of dedication to my clients, I just might set the stage for a constructive dialog concerning how I might more effectively utilize my talents on the job. Who knows, he might be receptive to adjusting my caseload to enable me to spend part of my time mentoring other staff on dealing with difficult clients. Sounds like a win-win situation to me!” Note the upbeat tone that emerges as Evan confronts his catastrophic thinking with empowering rational responses.
Seek Counsel
Returning again to Evan’s efforts to resolve his predicament, he decides to schedule several sessions with a therapist who taught a course in counseling while he was working toward his certification. Through these sessions he obtains valuable support and constructive feedback on increasing his sense of empowerment
and self-efficacy through taking decisive action to counter the sources of his overwhelment.
Take Care of Yourself
As discussed earlier, in freeing ourselves from overwhelment we must make a special effort to take care of ourselves in regard to the physical aspects of wellness, including sound nutrition, regular exercise, and ensuring that we get adequate rest and sleep. As a wise man once said, if you truly believe your body is a temple, do not treat it like a motel! We also need to focus on being easy on ourselves. Quoting from the Desiderata, “Beyond a wholesome discipline, be gentle with yourself ” (Ehrmann, 1952). During this trying time we also need to maintain and utilize a healthy support system—it may be a good time to double up on attending Twelve Step meetings—while replenishing our spiritual resources through prayer, meditation, and seeking appropriate spiritual counsel.
Conclusion
As I mentioned at the outset, we all encounter points in our lives where we experience the devastating effects of overwhelment. In these situations we must either take decisive action to reverse this vicious cycle, or resign ourselves to being held hostage by the devastating circumstances we believe are irreversible. Hopefully this column has provided helpful suggestions for both you and your clients in breaking free from overwhelment. Until next time—to your health! c About the Author John Newport, PhD, is an addiction specialist, writer, and speaker living in Tucson, Arizona. He is author of The Wellness-Recovery Connection: Charting Your Pathway to Optimal Health While Recovering from Alcoholism and Drug Addiction. You may visit his website www.wellnessandrecovery.com for information on wellness and recovery trainings, wellness coaching by telephone, and program consultation services that he is available to provide.
References Ehrmann, M. (1952). Desiderata. Retrieved from http:// mwkworks.com/desiderata.html Newport, J. (2004). The wellness-recovery connection: Charting your pathway to optimal health while recovering from alcoholism and drug addiction. Deerfield Beach, FL: Health Communications.
TOPICS IN BEHAVIORAL HEALTH CARE
Addiction and Dental Problems Richard M. Celko, DMD, MBA, & Dennis C. Daley, PhD
How Alcohol and Drugs Affect Dental Health Alcohol
The acid reflux associated with excessive drinking can cause stomach acids to come into contact with teeth and erode them based on the high acidity content. This can lead to decay on smooth surfaces and around existing fillings.
Tobacco
Use of this drug is associated with dryness of the mouth, oral cancers such as squamous cell carcinoma, and lung and pharyngeal cancers. Smoking cigarettes, cigars, pipes, and marijuana can lead to oral cancer. Dryness and irritation to oral tissues over time causes changes so that the tissue becomes abnormal. These changes could eventually lead to cancer.
Stimulants
A
fter years of continuous recovery from heroin addiction, Daryll had dental surgery and received prescription opioids for postsurgery pain. His addiction was reignited after several days of using the drug. Beth, addicted to methamphetamine, developed “meth mouth,” in which several of her teeth blackened, decayed, or broke off. She also developed gum disease. By the time Mike was in his early forties, he had lost all of his teeth. Several were knocked out during a fight while drunk, and the others were removed due to poor dental care. These are examples of dental problems among individuals with an addiction. Dental problems are caused by poor dental hygiene such as not regularly brushing teeth or flossing; poor eating or health habits such as consuming large amounts of drinks or foods with sugar; the effects of alcohol and other drugs on dental health; and other factors. Teeth can be broken or lost due to physical altercations over drug deals, and fights or accidents when under the influence of drugs or alcohol. Being toothless, missing front teeth, having decaying teeth, gum disease, and poor dental health can impact recovering people’s self-esteem, ability to eat, and even have a negative effect on finding a job.
All amphetamines can cause dehydration, an unusually dry mouth, and cause people to grind their teeth. Meth users may also have cravings for beverages with high sugar content. Over time, amphetamine use can lead to enamel destruction and loss of tooth structure leading to brittle, decayed, and disintegrated teeth. “Meth mouth” is characterized by severe dryness, tooth decay, and periodontal disease. This often causes teeth to break, crack, and/or fall out. Teeth may become blackened, stained, and extensively decayed. A study of 571 meth users found that 96 percent had cavities, 58 percent had untreated tooth decay, and 31 percent had six or more missing teeth (Shetty et al., 2015). The longer people use this drug, the greater the likelihood of severe dental problems, especially among women and cigarette smokers (Shetty et al., 2015).
Marijuana
Use of this drug may cause cannabinoid hyperemesis, whereby vomiting is induced and over time the stomach acid wears the enamel of the teeth away and exposes the tooth structure underneath the enamel, which is known as “dentin,” a yellowish colored, softer material than enamel. Cannabis smoke acts as a carcinogen and can cause premalignant lesions in the oral mucosa (Versteeg, Slot, van der Velden, & van der Weijden, 2008). Additional cannabis-associated oral side effects are xerostomia (dry mouth), leukoplakia (white patches on mucosa), and increased prevalence and thickness of a fungus called candida albicans, also known as a Thrush infection, which usually manifests on the tongue, inner cheek, and inner lip areas.
Heroin
Prolonged heroin use can also cause teeth to become broken down and rotten. When cocaine, heroin, and/or narcotics are www.counselormagazine.com
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TOPICS IN BEHAVIORAL HEALTH CARE taken, there can be dangerous drug interactions with local anesthetics containing vasoconstrictors.
Other Medications
Diuretics, antihistamines, proton pump inhibitors, and antidepressants all can cause xerostomia or dry mouth. When this occurs, the dryness in the mouth permits the bacterial counts to elevate and over time can cause decay on and around the teeth and restorations.
Dental Hygiene, Pain, and Opioids
When patients stop taking care of their oral hygiene, caries (cavities) may develop and then teeth and gums (gingiva) can become infected. These lead to painful conditions and cause some patients to seek relief with opioids. In addition, cough syrups may contain sugar, which when taken over time, can lead to cavities and damage to teeth, especially when oral hygiene and habits are not maintained. When patients get teeth extracted, most commonly performed under general anesthesia, they may be prescribed or request pain medication in addition to antibiotics. The first line of treatment is usually for the dental provider to write a prescription for an opioid for four to seven days postoperatively. Dentists prescribe approximately 12 percent of opioid prescriptions nationally and between 5 to 23 percent are used for nonmedical purposes (Denisco et al., 2011). Opioid-addicted individuals are susceptible to a variety of oral diseases, not least of which are dental cavities and periodontitis. High rates of generalized dental caries, being particularly prevalent on smooth and cervical surfaces, have been widely described in opioid users (Hamamoto & Rhodus, 2008). Opioid analgesics may be used to manage dental pain when acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDS) are not effective in reducing pain (Siegel & Cheung, 2017). When NSAIDS are prescribed following tooth removal or other oral surgery procedures, there are fewer chances for side effects such as nausea and vomiting or constipation, which is a common postoperative experience when patients use opioids. 18
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The long-acting local anesthetic bupivacaine (Exparel) is another nonopioid medicine that can be injected directly into the active surgical site. It has a duration of up to seventy-two hours, which is sufficient time for many cases of acute pain to pass. Limiting the usage of opioids is not only better treatment, it also helps reduce initial exposure to a substance that can contribute to addiction for some individuals (ADA, 2005). Oral health care providers need to be cognizant of how their prescription practices can affect patients’ misuse or addiction to opioids. It is imperative that providers use nationally held standards and make decisions based on best practices and evidence-based outcomes.
is a possibility of systemic issues, such as bacteremia and other cardiac and related conditions that may manifest if oral health is not addressed. Individuals with a history of addiction seeking dental care or oral surgery can be advised to talk with their dentist or oral surgeon about addiction so they can work together to make the best decision about medications to use following a procedure. They can also be advised to talk with sponsors, peers in recovery, or other trusted individuals about strategies to minimize risk of addiction after dental care or oral surgery. Remaining vigilant about the potential for addiction or readdiction following opioid use can help some individuals sustain their recovery. c About the Authors
Dentists prescribe approximately 12 percent of opioid prescriptions nationally and between 5 to 23 percent are used for nonmedical purposes (Denisco et al., 2011). Addiction Providers and Dental Care
Assessment of individuals seeking help for addiction should include a review of dental hygiene habits and dental problems. Current dental problems identified can be incorporated into the treatment plan. Patients with poor dental health can be referred for evaluation and treatment with a dentist as needed. This is not only important to improve dental health, but can also affect self-esteem since patients with bad or missing teeth may feel self-conscious or reluctant to go on a job interview. Providers can offer information and advice on dental hygiene in addition to facilitating treatment of dental problems for patients with an addiction. They can educate patients on types and causes of dental problems, and explain to patients the issues that can occur when oral health and dental hygiene are neglected. There
Richard M. Celko, DMD, MBA, is chief dental officer of the University of Pittsburgh Medical Center, Insurance Division in Pittsburgh. He is a graduate of the University of Pittsburgh School of Dental Medicine. He completed his general practice dental residency at Montefiore Hospital and received his MBA from Indiana University of Pennsylvania. Dennis C. Daley, PhD, served for fourteen years as the chief of Addiction Medicine Services (AMS) at Western Psychiatric Institute and Clinic (WPIC) of the University of Pittsburgh School of Medicine. He has been with WPIC since 1986 and previously served as director of family studies and social work. He is currently involved in clinical care, teaching, and research.
References American Dental Association (ADA). (2017). Policies and recommendations on substance use disorders. Retrieved from https://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/policies-and-recommendationson-substance-use-disorders Denisco, R. C., Kenna, G. A., O’Neil, M. G., Kulich, R. J., Moore, P. A., Kane, W. T., . . . Katz, N. P. (2011). Prevention of prescription opioid abuse: The role of the dentist. Journal of the American Dental Association, 142(7), 800–10. Hamamoto, D.T., & Rhodus, N. L. (2009). Methamphetamine abuse and dentistry. Oral Diseases, 15(1), 27–37. Shetty, V., Harrell, L., Murphy, D. A., Vitero, S., Gutierrez, A,. Belin, T. R., . . . Spolsky, V. W. (2015). Dental disease patterns in methamphetamine users: Findings in a large urban sample. Journal of the American Dental Association, 146(12), 875–85. Siegel, R., & Cheung, J. (2017). Dental schools add an urgent lesson: Think twice about prescribing opioids. Retrieved from https://www.npr.org/sections/healthshots/2017/09/08/549218604/dental-schools-add-an-urgentlesson-think-twice-about-prescribing-opioids Versteeg, P. A., Slot, D. E., van der Velden, U., & van der Weijden, G. A. (2008). Effect of cannabis usage on the oral environment: A review. International Journal of Dental Hygiene, 6(4), 315–20.
COUNSELOR CONCERNS
Comprehensiveness and Continuity of Care Gerald Shulman, MA, MAC, FACATA
I
believe that the development and three subsequent revisions of The ASAM Criteria (Mee-Lee et al., 2013), along with motivational interviewing (MI) and medication-assisted treatment (MAT), have made the greatest contributions to assessment and placement for people with substance use disorders (SUDs). The five levels of ASAM’s withdrawal management—they used to be called “detoxification” because livers do the detoxification and clinicians manage the process, but it was changed to “withdrawal management”—and the eight levels of treatment (including three levels of outpatient care, three levels of residential treatment, and two levels of inpatient treatment) provided the field with a common language and description of the different intensities of treatment. Unfortunately, these levels of care and the programs in each began to be seen as distinct and separate entities by some (Vanderplasschen, De Bourdeaudhuij, & Van Oost, 2002), rather than waypoints in a continuum of care. Some clinicians considered admission to their programs as a discrete event rather than admission into a continuum of care through their program. This has resulted in a series of disconnected treatment services. This is not only true when considering different programs at different sites, but sometimes different levels of care offered by the same program at the same site. This disconnect has implications for both clinical care and costs. Some patients with less severe SUDs may require only a single, low intensive level of care as their total treatment such as Level 1, outpatient. But others may require multiple levels of care, starting with a more intensive level and then moving down in intensity as they make progress. Conversely, some will require an increase in intensity for such things as the development or worsening of a co-occurring medical or mental health problem (e.g., acute suicidality). One current disturbing issue contributing to the disconnect is the practice of treating patients in more intensive levels of care, such as ASAM Level 3.7 in areas far from home followed up by inadequate care when they return. These treatment
programs and their staff view their treatment, whether verbalized or not, and even whether thought consciously or not, as patients’ treatment rather than as only a part of the continuum (Lee et al., 2014). A true continuum of care is characterized by three things: 1. Seamless transfer between levels of care or programs 2. Philosophical congruence between programs
3. Rapid transfer of patient information between levels of care A continuum of care can be provided by multiple providers in some predetermined arrangement that facilitates movement through the continuum, but this is more difficult unless all the treatment providers are in the same geographic area. It can also be accomplished through a single program and when done creatively, costs less to provide and enhance clinical care. I would like to share an example of an acute care, hospital-based, addiction treatment program that provided three levels of withdrawal management services with a twenty-three-hour observation bed, seven levels of treatment, and two levels of transitional care, all at the same site (see Figure 1). A word about names for some of the levels of care in Figure 1. Because this was “new ground” about twenty-five years ago, some of today’s language for levels of care did not quite fit or was cumbersome, so I have included a legend for certain levels’ names.
Figure 1. www.counselormagazine.com
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COUNSELOR CONCERNS Legend
Subacute Detoxification
This was “ambulatory withdrawal management with extended on-site monitoring withdrawal” (ASAM Level 2-WM), combined with supportive housing for those patients who were deemed at risk for using substances overnight when home, for not returning the following day, or whose recovery environment was too toxic to support their recovery.
Superintensive Partial Hospitalization
This was ASAM partial hospitalization Level 2.5 (PHP) combined with supportive housing for those patients who did not require the twenty-four-hour care of a clinically managed, high-intensity residential program or medically monitored intensive inpatient program, but had issues like lack of transportation, homelessness, being at risk for using overnight when home, not returning the following day, or having an environment that was too toxic to support recovery. This model, from twenty-five years ago, is common practice today.
Twenty-Three-Hour Bed
While this does not show on the chart, it was used primarily for assessment prior to the selection of level of care. It was an element that was particularly attractive to payers since the use of the twenty-three-hour bed provided an assessment option that resulted in some patients being admitted to a less intensive level of care that they would have been without the twentythree-hour bed.
Cost-Effectiveness
I previously stated that this could be done at lower costs than would be necessary if each level of care was a discrete program. For example, in this model patients in all three levels of withdrawal management went through their detoxification together, with the patients in inpatient detoxification and those in subacute detoxification remaining in the program overnight while those in ambulatory detoxification went home each evening. Similarly, patients in inpatient rehabilitation, superintensive partial hospitalization, and partial hospitalization 20
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all went through treatment together with those in the PHP program, going home at night and returning the next morning. How did this model reduce costs? It would be very expensive if we had to staff up each level of care separately. However, by combining the different programmatic elements we were able to staff to volume. Interestingly, the hospital was only about 50 percent occupied, which led to severe financial problems. In order to control costs, hospital management required each hospital service to perform a weekly productivity analysis that compared staff expenses with income. The addiction service was the most productive service in the hospital.
Some patients with less severe SUDs may require only a single, low intensive level of care as their total treatment such as Level 1, outpatient. But others may require multiple levels of care, starting with a more intensive level and then moving down in intensity as they make progress. As another example of this approach, we had two evening IOP programs which were well utilized. We received requests to start a day IOP, but our analysis indicated that it would run a census of only three to five patients. With the clinical staff’s input, we rearranged the schedules for the full-day programs so that the people in the day IOP could get program elements they needed in the morning with the other patients and leave at lunch time. Knowing the value of aftercare in helping achieve and maintain positive outcomes, we decided to attempt a one-year aftercare program (Schaefer, Ingudomnukul, Harris, & Cronkite, 2005), but did not know how we were going to fund it. Again, using the clinical staff’s ideas, we reached out to people
we knew who were in counselor training programs or who worked at other SUD treatment programs and offered to provide them with weekly clinical supervision for one year and a certificate of completion at the conclusion of the year if they would provide us with one evening a week for the year to facilitate an aftercare group. One of our clinicians offered to change his schedule to provide the supervision. Our cost was for coffee and cookies for the volunteer facilitators during the group supervision, which occurred after the conclusion of the aftercare groups. I previously stated that this approach also had positive clinical implications. On the fifth floor of the building where the detox and inpatient patients lived there was a nursing station, behind which was a large whiteboard with each patient’s name written in a color that corresponded to their level of care. Patients became motivated to move toward less intensive levels of care and would often ask the nurses, “What do I need to do to get to the next less intensive level of care?” In conclusion, providing a more comprehensive continuum of care, increasing continuity of care, helping motivate patients, and doing all of this at lower costs was a win-win scenario. c About the Author Gerald Shulman, MA, MAC, FACATA, is a clinical psychologist and fellow of the American College of Addiction Treatment Administrators. He has been providing treatment or clinically or administratively supervising the delivery of care to alcoholics and drug addicts since 1962.
References Lee, M. T., Horgan, C. M., Garnick, D. W., Acevedo, A., Panas, L., Ritter, G. A., . . . Reynolds, M. (2014). A performance measure for continuity of care after detoxification: Relationship with outcomes. Journal of Substance Abuse Treatment, 47(2), 130–9. Mee-Lee, D., Shulman, G. D., Fishman, M. J., Gastfriend, D., Miller, M. M., & Provence, S. M. (2013). The ASAM criteria: Treatment criteria for addictive, substance-related, and co-occurring conditions. Carson City, NV: The Change Companies. Schaefer, J. A., Ingudomnukul, E., Harris, A. H., & Cronkite, R. C. (2005). Continuity of care practices and substance use disorder patients’ engagement in continuing care. Medical Care, 43(12), 1234–41. Vanderplasschen, W., De Bourdeaudhuij, I., & Van Oost, P. (2002). Coordination and continuity of care in substance abuse treatment. An evaluation study in Belgium. European Addiction Research, 8(1), 10–21.