sherry larkins, ph.d

Sherry Larkins, Ph.D.

Integrated Substance Abuse ProgramsDepartment of Psychiatry & Biobehavioral Sciences

David Geffen School of Medicine at UCLA

Brief Overview of COD

How Drugs Affect your Brain and Body

General tips for intervening with justice-involved COD patients

NIDA Research Monograph Series, Comorbidity, 20

Past Year SUD and Mental Illness

SAMHSA, NSDUH 2010

Grant et al., 2006; from National Epidemiologic Survey on Alcohol & Related Conditions

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30Any Substance Use Disorder Any Substance Dependence

Use greater treatment resources Have a more complicated course◦ Higher rates of relapse◦ More contact with CJ system◦ Higher rates of re‐hospitalization◦ More frequent ER visits◦ Violence, suicide, homelessness, ◦ Increased morbidity and mortality◦ Poorer treatment compliance

Experts in this field assert that co‐occurring disorders should be the expectation, not the exception in any behavioral health setting.

Past Year Mental Health Care and Treatment for Substance Use Problems among Adults with Co-occurring Disorders

SAMHSA, NSDUH 2010

COD Clients require more complex and expensive care.

COD Clients tend to have more problems of all kinds (medical, legal, social, interpersonal, homelessness, etc.), and more (and more expensive) contacts with agencies and providers (mental health, drug & alcohol, law enforcement, courts, emergency rooms, social welfare, shelters, etc.).

Clients with co‐occurring disorders tend to “fall through the cracks” of the traditional treatment system and develop even worse and more expensive problems.

What effect does substance use have on our brain and behavior?

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To feel goodTo have novel:

FeelingsSensations

ExperiencesAND

To share them

To feel betterTo lessen:Anxiety WorriesFearsDepression HopelessnessWithdrawal

Ivan Petrovich Pavlov

Over time, drug or alcohol use is paired with cues such as money, paraphernalia, particular places, people, time of day, emotions

Through classical conditioning these cues are paired with pleasurable effects of the drug (“high”).

Eventually, exposure to cues alone producesdrug or alcohol cravings or urges that are often followed by substance abuse

Classical Conditioning

Operant Conditioning

ReinforcementPositive Reinforcement

Negative Reinforcement

Punishment

Advances in medicine and scientific techniques have given researchers a clearer idea of what addiction is:◦ Magnetic resonance imaging (MRI)◦ Positron emission tomography (PET) scan◦ Advanced genetic research

MRISPECT

PET

Normal Dopamine Transmission

dopamine reservoir

synapse

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Activating the system with drugsActivating the system with drugs

Drugs and Dopamine

Source: Shoblock and Sullivan; Di Chiara and Imperato

Effects of Drugs on Dopamine Release

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0 1 2 3 4hrTime After Ethanol

% o

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Accumbens

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ETHANOL

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100100

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00 11 22 3 hr3 hrTime After NicotineTime After Nicotine

% o

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asal

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NICOTINENICOTINE

Time After Methamphetamine

% B

asal

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METHAMPHETAMINE

0 1 2 3hr

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Accumbens

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AccumbensAccumbens COCAINECOCAINE

0 1 2 3 4hr

Their Brains

have beenRe-Wired

by Drug Use

Their Brains

have beenRe-Wired

by Drug Use

In other words…In other words…

Prolonged Drug Use Changes

The Brain In Fundamental and

Long-Lasting Ways

We Have Evidence That These Changes Can Be Both

Structural and Functional

We Have Evidence That These Changes Can Be Both

Structural and Functional

AND…AND…

Normal

Cocaine Abuser (10 Days)

Cocaine Abuser (100 Days)Sources: Volkow, et al., Synapse, 11:184-190, 1992

& Volkow, et al., Synapse, 14:169-177, 1993

control addicted

CocaineCocaine

AlcoholAlcohol

Reward Circuits

DA

DA

DA

DA DA

DA

Drug Abuser

DA

DA

DA

DA DADA

DA

Reward Circuits

DADA DADA

DA

Non-Drug Abuser

HeroinHeroin

MethMeth

Dopamine D2 Receptors are Lower in Addiction

Cognitive and Memory Effects

01234567

Word Recall** Picture Recall**

Mea

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ores

Comparison (n=80) Meth (n=80)

Control> MA

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Brain scans were taken while people answered

the question below looking at the following pictures

Which of the two bottom pictures matches the emotion shown on top?

What did their brains

show?

Control Subjects and Methamphetamine Abusers Activate Emotion &

Face Processing Areas

Control Methamphetamine

amygdala amygdala

D Payer et al., Abstr. Soc. Neurosci., 2005

Partial Recovery of Brain Dopamine Transporters in Methamphetamine

Abuser After Protracted Abstinence

Normal Control METH Abuser(1 month detox)

METH Abuser(24 months detox)

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3

ml/gm

Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001.

Drug addiction is a chronic brain disorderDrug addiction is a

chronic brain disorder

The brain shows distinct changes after drug use that can persist

long after the drug use has stopped

Not a single study of the effects of punishment (custody, mandatory arrests, increased surveillance, etc.) has found consistent evidence of reduced substance relapse rates and criminal recidivism.

Multiple studies indicated that a large number of offenders actually become more criminogenic following incarceration

Prison

Criminal Recidivism in 3 Years 68% re-arrested 47% convicted 50% re-incarcerated

Relapse to Drug Abuse in 3 Years 95% relapse

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Reduced Recidivism

Increased Recidivism

CS -.07 (Number of Studies=30) Treatment .15 (Number of Studies=124)

Mean Phi

Most Common Criminogenic Risks• Substance Abuse• Trauma exposure• Criminal onset < 16 years• Prior rehabilitation failures• History of violence• Antisocial Personality Disorder• Familial history of criminal involvement• Criminogenic thinking and sentiment

Provide most intensive treatment to higher‐risk offenders

Intensive treatment for lower‐risk offender can increaserecidivism, and in fact you may just waste your resources (but the results make us feel good)

The most common service need is SUD treatment!

Referral to Treatment: Getting them in the door is the

hardest part!

50% - 67% don’t show for intake 40% - 80% drop out in 3 months 90% drop out in 12 months 70% of probationers and parolees drop

out within 2 - 6 months

Attrition

General Tips

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• One program provides treatment for both disorders• MH & SUD treated by the same clinicians• The clinicians are trained in psychopathology, assessment, and treatment strategies for both disorders

• Treatment is characterized by a slow pace and a long‐term perspective

• Providers offer motivational style counseling• 12‐Step groups are available to those who choose to participate and can benefit from participation

• Pharmacotherapies are indicated according to clients’ psychiatric and other medical needs

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What challenges have you encountered in moving toward the center?

What have you done to overcome these challenges?

BeginningAddiction

Only Treatment

IntermediateAddiction

CODCapable

Fully Integrated

CODIntegrated

IntermediateMental Health

CODCapable

BeginningMental Health

OnlyTreatment

AdvancedAddiction

CODEnhanced

AdvancedMental Health

CODEnhanced

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Common cognitive impairments in COD clients: ◦ Attention & concentration◦ Short-term memory◦ Cognitive flexibility◦ Ability to organize information◦ Abstract reasoning

Compensatory strategies:◦ Repetition◦ Use concrete examples◦ Use handouts, other visual aids◦ Take breaks during sessions

MODIFY TREATMENT PROTOCOLS Decrease length of sessions (attention, memory) Take structured breaks (attention, focus, memory)

(Bates, et al., 2013; Huckans, et al., 2013)

Increase session frequency (practice) Repeat presentations of therapeutic information

(detox, 2 weeks, 4 weeks, 1 month, 3 months, etc.) Multi-modal presentations—audio, visual,

experiential, verbal, hot/cold situations, etc. (Grohman, K. & Fals-Stewart, W., 2003, 2012; Medalia, A. & Revheim,

N., 2003; & Aharonovich, E., et al., 2003, 2005, 2011)

Use memory aids— calendars, planners, phone apps, diagrams

(Bates, et al., 2013; Huckans, et al., 2013)

Teach stress management, breathing, relaxation, and mindfulness meditation skills

(Bates, et al., 2013; Huckans, et al., 2013)

Provide immediate feedback and corrective experiences

Repeat instructions, put things in writing, provide short/direct instructions

To tailor MI to patients with cognitive impairments:◦ Use repetition, concrete verbal interventions with visual aids, handouts, and offer breaks. ◦ Keep open‐ended questions simple and straightforward◦ Use frequent reflections/summaries◦ Affirm patient’s qualities and change efforts and avoid excessive discussion of negative events.

Sherry Larkins, Ph.D.Larkins@ucla.edu