sherry larkins, ph.d
TRANSCRIPT
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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5
10
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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
f Bas
al R
elea
se
Accumbens
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ETHANOL
00
100100
150150
200200
250250
00 11 22 3 hr3 hrTime After NicotineTime After Nicotine
% o
f Bas
al R
elea
se%
of B
asal
Rel
ease
NICOTINENICOTINE
Time After Methamphetamine
% B
asal
Rel
ease
METHAMPHETAMINE
0 1 2 3hr
1500
1000
500
0
Accumbens
00
100100
200200
300300
400400
Time After CocaineTime After Cocaine
% o
f Bas
al R
elea
se%
of B
asal
Rel
ease
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
n Sc
ores
Comparison (n=80) Meth (n=80)
Control> MA
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MA > Control
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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)
0
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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-0.1
-0.05
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0.05
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0.2
-0.07
0.15
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, [email protected]