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The Many Faces of Methamphetamine: Addiction, The Family and The Community

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Title: The Many Faces of Methamphetamine: Addiction, The Family and The Community


1
The Many Faces of Methamphetamine Addiction, The
Family and The Community
  • Cardwell C. Nuckols, PhD
  • cnuckols_at_elitecorp.org

2
High Rates of Trauma
  • 44 of women and 24 of men entering treatment
    for methamphetamine addiction report childhood
    sexual abuse
  • 32 of women and 34 of men report childhood
    physical abuse
  • 56 reported parental alcohol and/or drug
    problems
  • Multigenerational
  • Brown University Digest of Addiction Theory and
    Application. May 2004

3
Good News
  • Early Life Developmental Trauma is treatable
  • Multigenerational patterns of disorganized
    attachment can be broken
  • Establishing a helping or therapeutic
    relationship is most important variable
  • Spiritual connectedness

4
Bottom Line
  • Its All About Food, Water and Sex!

5
The Rat Brain
  • What turns on the dopamine in a rats brain..
  • SEX-200 increase in dopamine
  • COCAINE-300 increase in dopamine
  • METHAMPHETAMINE-1100 increase in dopamine
  • This explains why rats will kill themselves to
    get more drug-especially methamphetamine

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7
Key Points
  • Address Protracted Recovery Period
  • Address Continuum of Care
  • Understand Age of Onset and its Relationship to
    Trauma History, Psychiatric Symptomatology and
    Prognosis
  • Utilize Research to Develop Guidelines for
    Prevention and Intervention
  • Methamphetamine Addiction Should be Treated in a
    CD Environment

8
Key Points
  • Understand When the Need is Habilitation and
    not Rehabilitation
  • Understand When in the Course of Recovery is the
    Proper Time for Vocational and/or Educational
    Opportunities
  • Better Prepare the Client to Understand the
    Relationship Between Methamphetamine Addiction
    and Relapse From Marijuana and Alcohol.

9
Key Points
  • Reevaluate our Educational Processes
  • Develop a System of Wrap Around Services That
    Create Hope and Opportunity
  • Relate to the Client in Such a Way That We Help
    Them Better Understand Reward and Reinforcement
    in Early Recovery

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12
Frontal (Executive) Cortical Functions
  • Focus attention
  • Prioritize
  • Exclude extraneous information
  • Suppress primitive urges
  • Reduce impulsivity

13
Frontal Cortex (FC)
  • Decisions like choosing immediate gratification
    (using methamphetamine to satisfy craving) vs.
    healthy choices are made in the FC.
  • Addicts tend to make choices without regard for
    punishment or harm
  • Habit and compulsion overrides recognition of
    harm associated with repeated error

14
Non-Addict Response
  • This is dangerous
  • Prefrontal cortex
  • Sends inhibitory signals to the Ventral Tegmental
    Area (VTA)
  • Reduces dopamine release
  • No repetitive methamphetamine use pattern
  • No reinforcement of pleasure

15
Addict Response Pattern
  • Got to have more
  • Cognitive Deficit Model
  • Abnormalities in prefrontal cortex
  • Compromised ability to send inhibitory signal to
    VTA
  • Chronic alcoholics have reduced GABA
  • Neurochemical used in the inhibitory process
  • Meth and Coke may damage this brain loop
  • Frontostriatal loop

16
End Organ Toxicity
  • Central Nervous System
  • Cardiovascular System
  • Pulmonary System
  • Renal System
  • Hepatic
  • Fetal Development

17
Central Nervous System
  • Acute psychosis
  • Chronic psychosis
  • Strokes
  • Seizures

18
Cardiovascular System
  • Myocardial Infarctions
  • Arrhythmias
  • Cardiomyopathy

19
Pulmonary System
  • Acute Pulmonary Congestion
  • Chronic Obstructive Lung Disease

20
Renal/Hepatic Failure
  • Renal failure
  • Hepatic Failure

21
Fetal Development
  • Exposure early in pregnancy
  • Fetal death
  • Small size for gestational period
  • Exposure later in pregnancy
  • Learning Disabilities
  • Poor social adjustment

22
Childhood Exposure
  • 80-90 of children found in homes where
    methamphetamine is being manufactured will test
    positive for the drug. Some are barely over one
    year old.
  • Due to inhaled fumes
  • Direct contact with the drug
  • Second hand smoke
  • Direct ingestion

23
Childhood Exposure
  • Social workers now accompany law enforcement
    during lab seizures where children are involved.
  • Allowing children to be in such an environment is
    considered neglect and/or child abuse.
  • Parents may be charged with second-degree
    criminal mistreatment

24
Childhood Exposure
  • Children are uniquely susceptible because their
    brains are still developing (lead poisoning) and
    because the are very curious
  • Children have greater skin surface area per pound

25
Lab Seizure Locations
  • Most common locations
  • Single family houses
  • Apartments
  • Mobile homes
  • Vehicles
  • Garages
  • Trailers
  • Motels/hotels
  • Businesses

26
Stove Top Labs
  • Cookers make small amounts using household
    equipment and chemicals
  • The active ingredient
  • Ephedrine or pseudoephedrine
  • Chemical ingredients
  • Trichloroethane (gun scrubber)
  • Ether (engine starter)
  • Methanol (gasoline additive)
  • Gasoline
  • Kerosene

27
Stove Top Labs
  • Chemical ingredients
  • Lithium (camera batteries)
  • Anhydrous ammonia (farm fertilizer)
  • Red phosphorus (matches)
  • Iodine (veterinarian product)
  • Muriatic acid
  • Campfire fuel
  • Paint thinner

28
Stove Top Labs
  • Chemical ingredients
  • Acetone
  • Sulfuric acid (drain cleaner)
  • Table salt/rock salt
  • Sodium hydroxide (lye)
  • Sodium metal (can be made from lye)
  • Alcohol (rubbing/gasoline addictive)

29
Household Equipment
  • Coffee filters
  • Rubber gloves
  • Tempered glass baking dishes
  • Glass or plastic jugs
  • Bottles
  • Measuring cups

30
Household Equipment
  • Funnels
  • Blenders
  • Hotplate
  • Strainer
  • Propane cylinder
  • Aluminum foil

31
Toxicity
  • For every unit of methamphetamine manufactured,
    there exists 5 times that amount in toxic waste
  • This waste is dumped in streams, sewers, fields
  • Environment is contaminated especially
    groundwater

32
Toxicity
  • Toxic gases permeate the walls and carpets making
    homes and buildings uninhabitable.
  • The cost to the taxpayer to clean these sites is
    between 2000 and 4000.
  • Sometimes these gases explode and cause fires.

33
Tolerance
  • Brain cells gradually become less responsive
  • More is needed to stimulate the VTA brain cells
  • To cause more release of dopamine in the NAc
  • To produce reward comparable to earlier
    experiences

34
Stimulant Toxicity
  • Increased levels of Norepinephrine and Dopamine
  • Hyper-arousal
  • Pleasure
  • Paranoia
  • Increased levels of Serotonin
  • Reduced hunger
  • Difficulty sleeping

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Stimulant Crash
  • Reduced levels of Norepinephrine and Dopamine
  • Dysphoria
  • Depression
  • Anhedonia
  • Reduced levels of Serotonin
  • Mood swings
  • Sleep disturbances

37
Craving Management (Situational Emotional
Triggers)
  • Situational triggers
  • Environment (People, Places And Things)
  • Initially drug causes release of dopamine
  • After addiction, situations that have a high
    probability of use cause dopamine release
  • Emotional triggers
  • Internal (Hungry, Angry, Lonely, Tired, Reward
    and Bored)

38
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39
Most Common Craving Triggers
  • In presence of
  • Alcohol and drugs
  • Alcohol and drug users
  • Places where used to use or purchase
  • Negative feeling states particularly anger but
    also
  • Boredom
  • Loneliness
  • Fear
  • Anxiety

40
Most Common Craving Triggers
  • Positive feeling states
  • Physical pain
  • Use of mood-altering prescription drugs
  • Suddenly having a lot of cash
  • Complacency
  • Insomnia
  • Sexual functioning

41
Craving Management
  • Psychotherapy
  • Behavior Therapy
  • Structure
  • Recovery Foundation Program
  • Changing patterns
  • Safety Plan
  • Pharmacological
  • Acute
  • Maintenance

42
Changing Patterns
  • 31 yo Nicki-a recovering methamphetamine addict-
    just got her first paycheck. She cashed her check
    and cruised thru the neighborhood where she used
    to score dope. Rock music blared from her
    speakers. Soon she was thinking, "I worked hard
    all week. I deserve a little fun.

43
Behavioral Foundation Program
  • In an inpatient setting the patient schedule
    serves this purpose
  • On an outpatient basis or upon discharge from
    inpatient a recovery plan or contract is
    appropriate
  • Remember that most addicts have little or no
    recent experience living a drug free lifestyle

44
Behavioral Foundation Program
45
Behavioral Foundation Program
  • Carter is 24 yo and just getting out of treatment
    for alcohol and methamphetamine addiction
  • His early A/D history included.
  • Started drinking on Friday nights with friends in
    high school
  • Turned-on to methamphetamine and marijuana by
    friends on weekends
  • Started to buy methamphetamine to sell from a
    distributor on Wed nights

46
Using Early Drug History
47
Behavioral Safety Plan
  • CT Last night I had a dream that I was getting
    ready to get high on crystal-it was all on the
    table in front of me. It was like five minutes
    before I knew it was a dream.
  • TH Congratulations on not using, tell the group
    what you did to deal with the craving.
  • CT I went into the kitchen and wrote in my
    journal everything that happened. Then I said a
    prayer.

48
Behavioral Safety Plan
  • TH What else could you have done?
  • CT I know that I can always call my sponsor or
    my lover. I can also read from a book that I have
    on recovery or a book of affirmations that I
    like.
  • TH Thats great. Now lets make a safety plan
    from what you have discovered.

49
Behavioral Safety Plan On 3x5 Index Card
50
Behavioral Safety Plan On 3x5 Index Card
  • TH On the back of the index card, come up with
    a saying or a prayer that gives you strength.
  • CT I have always liked Lord help me to be
    the best possible person I can be today.

51
Cognitive Therapy

  • Behavior
  • Situation Cognition Physiology

  • Emotion
  • Modulation Ratio

52
Cognitive Therapy
  • Automatic Thoughts
  • I cannot do anything right
  • I fail at everything I do
  • I will never get better
  • No one can help me
  • No one understands me

53
Cognitive Therapy-Dysfunctional Thought Record
54
Cognitive Reframes
  • CT My wife is always angry at me.
  • CT Every time I go to a meeting my husband gets
    angry.
  • Other examples

55
Cognitive Dysfunction and Change
  • Frontal cortex vs. midbrain
  • Approximately 50 entering treatment suffer from
    cerebral (cognitive) dysfunction
  • Less likely to attend continuing care
  • Less likely to be employed
  • Often mistaken as resistant or unmotivated
  • Less able to absorb information
  • Stimulant addicts look like they have
    degenerative brain disease

56
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57
Cognitive Dysfunction and Change
  • Executive and visuospatial functioning problems
    include
  • Recent memory
  • Abstraction
  • Problem solving
  • Cognitive flexibility
  • Planning
  • Rapid Response

58
Cognitive Dysfunction-Stimulant Addicts
  • Long term stimulant abuse causes damage to
    dopamine producing cells and leads to reduced
    levels
  • Stimulant addicts may suffer from poor attention
    and compromised fine motor skills

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60
Cognitive Dysfunction and Change
  • Recovery in neuropsychological functioning
  • Most of treatment is during time of greatest
    dysfunction
  • Recovery is
  • Time-dependent
  • Due to sustained abstinence
  • Experience-dependent
  • Active rehabilitation or repetitive behavior

61
Cognitive Rehabilitation
  • Repetitive recovery-oriented behaviors
  • Repetitive recovery-oriented thoughts

62
Education
  • Why give a methamphetamine addict a 60 minute
    didactic or video?
  • A new format
  • 15-20 minute simple didactic
  • How to participate in treatment
  • 10 minute questionnaire
  • 30 minute discussion group

63
10 Minute Questionnaire
64
Reward and Reinforcement
  • Mesolimbic Reward Center
  • Environment
  • Spirituality

65
Mesolimbic Reward System
  • The next three slides show
  • Slide one-The Reward Pathway
  • Slide two-Localization of Binding Sites
  • Slide three-Dopamine Binding to Receptors and
    Reuptake Pumps in the Nucleus Accumbens

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69
Mesolimbic Reward System
  • The next three slides show
  • Slide four-Cocaine Binding to Reuptake Pumps and
    Inhibiting Dopamine Reuptake
  • Slide five-Increased cAMP Produced in
    Post-synaptic Cell causes abnormal Firing
    Patterns
  • Slide six-Body now Relies on Stimulant to
    Experience Reward as Natural Rewards No Longer
    Pleasurable

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73
Environment
  • Triggers or cues (seeing, smelling, touching,
    tasting , and hearing) that remind the addict of
    some aspect of his/her use increase the desire
    for the reward (craving) without necessarily
    enhancing the pleasure of the reward itself.

74
Environment
  • Living in an enriched environment may reduce
    animals self-administration of drugs
  • Animal studies suggest that environmental
    conditions may affect the activity of dopamine

75
Meth Hurts Moms and Kids
  • Obstetrician-gynecologist Mary Holley, M.D., who
    founded Mothers Against Methamphetamine said the
    following
  • Were seeing devastation. Infant mortality is
    high. The kids who are born wont feed. Theyre
    underweight. Theyre sick. They are going to have
    ADHD almost guaranteed, and they grow up in a
    home with an addicted mother who doesnt care
    about them.

76
Environment
  • Case Management
  • Multisystem Therapy
  • Wrap around services
  • Family and childcare services
  • Housing/Transportation services
  • Financial and legal services
  • AIDS and medical services
  • Addiction and mental health services
  • Vocational and educational services

77
Spirituality
  • 2 major reviews of the literature
  • National Institute for Healthcare Review (1996)
  • Good evidence that involvement in AA is
    associated with enhanced outcomes in both
    inpatient and outpatient care
  • NIAAA and Fetzer Institute (1999)
  • Strong support for the protective nature of
    spirituality and religion (110 studies) of AA
    involvement (51 studies) and spiritual/religious
    intervention (26 studies)

78
Spirituality In Addiction Recovery
  • Spirituality refers to the unique and intense
    experience of a reality greater than oneself or
    an experience of connection with the totality of
    things. Religion is an organized social structure
    in which spiritual experiences are shared,
    ritualized and passed on to future generations

79
Spirituality In Addiction Recovery
  • An individual does not have to be religious in
    order to have a spiritual experience. The
    benefits of spirituality include humility, inner
    strength, sense of meaning and purpose in life,
    acceptance of self and others, sense of harmony
    and serenity, gratitude and forgiveness.

80
Beliefs Of Our Clients
  • Over 90 of Americans believe in God
  • 57 engage in daily prayer
  • 42 attended church in the last week
  • 80 believed that religious faith can aid in
    recovery from illness

81
Beliefs Of Our Clients
  • 63 agreed that doctors should talk to them about
    spiritual issues (McNichol, 1996)

82
Beliefs of Medical Professionals
  • According to Alcohol Medical Scholars Program,
    Spirituality in Substance abuse/Dependence
    Treatment, Marianne Guschwan, MD
  • Most psychiatrists do not believe in God
  • Nurses and medical students in one survey ranked
    spirituality as a low consideration of patients
    treated on a dual-disorder unit

83
Beliefs of Medical Professionals
  • Guschwan continued
  • However, the patients ranked spirituality and
    belief in God as most important to their
    recovery-Interesting incongruence!

84
Alcoholics Anonymous
  • Based on Judeo-Christian principles
  • Mutual self-help program
  • JCAHO mandates discussion of alternatives
  • Secular Organization for Sobriety (SOS)
  • Rational Recovery (RR)
  • Moderation Management (MM)

85
Alcoholics Anonymous
  • 2 year study of 2319 Alcohol-Dependent Men
    (McKellar,2003)
  • People who keep an active connection in AA are
    more likely to recover
  • Cause and effect-What came first AA or reduced
    drinking?
  • Answer-AA
  • Men who showed strong motivation at start were
  • Less likely to remain in AA
  • More likely to have continuous alcohol problems

86
Summary of AA Research
  • 243 studies of AA prior to the year 2001
  • When investigating treatment outcomes AA should
    not be ignored
  • Combination of AA and treatment predicts better
    outcomes
  • Same results found in UK
  • Continuous abstinence is most likely to be
    affected by AA

87
Summary of AA Research
  • AA without professional treatment does not always
    result in better outcomes
  • Treatment based on 12-step approaches are as
    effective as other approaches and may actually
    achieve more sustained abstinence (10th Report to
    US Congress on Alcohol and Health, 2000)

88
Summary of AA Research
  • Project MATCH compared Twelve-Step Facilitation
    Therapy (TFT) with Cognitive Behavioral Therapy
    (CBT) and Motivational Enhancement Therapy (MET)
  • TFT group did at least as well and did better on
    measures of complete abstinence

89
Summary of AA Research
  • Practically speaking (Owens,2003)
  • AA attendance is associated with increased
  • Self-confidence
  • Self-efficacy in regard to avoiding drinking
  • AA friendships and support are positively
    associate with reduction in alcohol and drug use
  • AA participation leads to lifestyle changes that
    lead to greater levels of abstinence

90
Summary of AA Research
  • Practically speaking (Owens,2003)
  • Support from AA members is more important for
    abstinence than support from non-members
  • Internalizing the program-not the number of
    meetings attended-is a positive factor in
    abstinence rates
  • Remember no one program is for everyone

91
Thank You For Attending
  • In the long run, it is better to choose water,
    food and (safe) sex instead of methamphetamine

92
REFERENCES
  • Robinson, Terry E.NEUROSCIENCE Addicted
    RatsScience 2004 305 951-953
  • http//psychiatry.jwatch.org/cgi/content/full/2004
    /722/5
  • American Medical News. July 26,2004,Mary Holley,
    M.D.
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