Reducing the Risk of Drinking and Driving
4/26/2015 Pills, Pot & Alcohol Reducing the Risk of DUII John Fitzgerald, PhD, LPC, CAS 6,699 DUII in 2013 105 Alcohol-impaired driving fatalities 77.3% BAC was above .15 FBI Uniform Crime Report 1 4/26/2015 Law Enforcement Prosecutor ODOT Treatment Judicial DMV/OAH OLCC Prevention Law Enforcement Prosecutor ODOT DUII Client OLCC Law Enforcement Treatment Prevention ODOT Treatment Judicial Judicial OLCC OLCC Prosecutor Prevention DMV/OAH DMV/OAH DUII Client DUII Client Prevention 2 4/26/2015 Origins of Addiction 90% ≤ 20 years-old 3 4/26/2015 Substance Use Disorders Begin in Adolescence and Last for Decades OAS, 2002 Dennis & Scott, 2007 4 4/26/2015 Risk Factors Poverty Community attitudes Availability of addictive objects Academic failure Low commitment to school Association with drug-using peers Peer rejection in elementary grades Lack of parental supervision Parental substance abuse & attitudes Chaotic home environment Genetics/Constitutional factors Psychological - Sensation seeking - Lack of impulse control - Early aggressive behavior Mental Health Disorders - Trauma in all forms Risk Factors Poverty Community attitudes Availability of addictive objects Academic failure Low commitment to school Association with drug-using peers Peer rejection in elementary grades Lack of parental supervision Parental substance abuse & attitudes Chaotic home environment Genetics/Constitutional factors Psychological - Sensation seeking - Lack of impulse control - Early aggressive behavior Mental Health Disorders - Trauma in all forms Levels Community School Peer Group Family Protective Factors Supportive Communities Cultural Continuity Prevention & treatment availability Anti-drug use policies Anti-bullying policies Academic success Relational skills Nurturing relationships Parental monitoring and boundaries Developmentally appropriate experiences Impulse control Emotional IQ Early treatment of mental health issues Individual Levels Community School Complex Puzzle Peer Group Family Protective Factors Supportive Communities Cultural Continuity Prevention & treatment availability Anti-drug use policies Anti-bullying policies Academic success Relational skills Nurturing relationships Parental monitoring and boundaries Developmentally appropriate experiences Impulse control Emotional IQ Early treatment of mental health issues Individual 5 4/26/2015 Risk Factors Levels Poverty Community attitudes Availability of addictive objects Protective Factors Supportive Communities Cultural Continuity Prevention & treatment availability Community Academic failure Low commitment to school Anti-drug use policies Anti-bullying policies School Association with drug-using peers Peer rejection in elementary grades GenesComplex X Environment Lack of parental supervision Parental substance abuse & attitudes Chaotic home environment Genetics/Constitutional factors Psychological - Sensation seeking - Lack of impulse control - Early aggressive behavior Mental Health Disorders - Trauma in all forms Peer Group Family Puzzle Academic success Relational skills Nurturing relationships Parental monitoring and boundaries Developmentally appropriate experiences Impulse control Emotional IQ Early treatment of mental health issues Individual Heritable Influences on Addiction Substance/Behavior Heritability Estimates Nicotine 33-71% Alcohol 48-66% Marijuana 51-59% Cocaine 42-79% Opioid 23-54% Gambling 49% Source: Agrawal, A. et al. (2012) 6 4/26/2015 Adverse Childhood Experiences (ACEs) ACE STUDY • San Diego, CA • Kaiser Permanente Study • Begin in Obesity Clinic • Data collected 1995-1997 • 17,000+ participants 7 4/26/2015 Abuse Household Psychological (by parents) Substance Abuse Physical (by parents) Mental Illness Sexual (anyone) Parental Separation/Divorce Emotional neglect Battered Mother Physical neglect Criminal Behavior ACE Score Women Men Total 0 31.3 34.2 32.7 1 24.2 27.3 25.6 2 14.8 16.4 15.5 3 10.4 9.3 9.9 4 6.8 4.8 5.9 5 or more 12.5 8.0 10.5 8 4/26/2015 ACE Score & Alcoholism ACE Score & Smoking “Addiction is not a brain disease, nor is it caused by chemical imbalances or genetics. Addiction is best viewed as an understandable, unconscious, compulsive use of psychoactive materials in response to abnormal prior life experiences, most of which are concealed by shame, secrecy, and social taboo.” Vincent J. Felitti, MD Principle Investigator, Kaiser Permanente 9 4/26/2015 Present-day Stress APA, www.stressinamerica.org, 2014 Coping Responses APA, www.stressinamerica.org, 2014 10 4/26/2015 Disease: Ebola School Killing: Adam Lanza Terror: ISIS Suicide: Hoffman & Williams Public Killing: Holmes & Rodger War: Israel & Palestine 15 to 18 percent of working officers in the United States have undiagnosed symptoms of post-traumatic stress disorder. John Violanti, U. of Buffalo 11 4/26/2015 Varieties of Addiction Experience Why Addiction? Feel Good or Feel Better Dopamine Index Cheeseburger 1.5 Sex 2 Nicotine 2 Cocaine 4 Meth 11 Source: UCLA Integrated Substance Abuse Programs 12 4/26/2015 Broad Universe of Addictive Experience SEX FOOD GAMBLING ALCOHOL ILLICIT DRUGS LICIT DRUGS Fantasy sex Pizza Internet Undistilled Marijuana Nicotine Seductive role Chocolate Video keno Beer Cocaine Bath salts Anonymous Chips Horse & Dog Wine Heroin Inhalants Prostitution Cookie Stocks Sake PCP Rx Drugs Trading sex Ice Cream Dice games Chicha MDMA Snuff Voyeurism French Fries Casino games Distilled Amphetamine eCigarettes Exhibitionism Cheeseburger Sports cards Rum LSD Coffee Intrusive sex Non-diet Soda Games of skill Vodka K2/Spice Cough syrup Pain exchange Cake Bingo Whiskey Club drugs Mushrooms Object sex Cheese Sports Brandy Rx Drugs Diet pills Minor sex Bacon Lottery Powdered Steroids Marijuana Other: Internet, exercise, relationships, working… Broad Universe of Addictive Experience SEX FOOD GAMBLING ALCOHOL ILLICIT DRUGS LICIT DRUGS Fantasy sex Pizza Internet Undistilled Marijuana Nicotine Seductive role Chocolate Video keno Beer Cocaine Bath salts Anonymous Chips Horse & Dog Wine Heroin Inhalants Prostitution Cookie Stocks Sake PCP Rx Drugs Trading sex Ice Cream Dice games Chicha MDMA Snuff Voyeurism Behavioral French Fries Casino games Distilled Cheeseburger Sports cards Rum Intrusive sex Non-diet Soda Games of skill Pain exchange Cake Object sex Cheese Minor sex Bacon Exhibitionism Substance Amphetamine eCigarettes LSD Coffee Vodka K2/Spice Cough syrup Bingo Whiskey Club drugs Mushrooms Sports Brandy Rx Drugs Diet pills Lottery Powdered Steroids Marijuana Other: Internet, exercise, relationships, working… 13 4/26/2015 Sex Licit Drugs Alcohol Illicit Drugs Food Gambling More experimenting at an earlier age 14 4/26/2015 Shift from alcohol and marijuana to opiates as age increases Prescription Opioid Analgesics (pain medicines) Hydrocodone Oxycodone Methadone Fentanyl Morphine Hydromorphone Buprenorphine 15 4/26/2015 Falling Guns Traffic Accidents Drug Overdoses 26,852 deaths 31,672 deaths 33,687 deaths 38,329 deaths * Source: CDC WONDER 2010 data * 30,006 unintentional deaths 16 4/26/2015 Level of Confidence in the Evidence for Adverse Effects of Marijuana on Health and Well-Being Effect Evidence Symptoms of chronic bronchitis High Motor vehicle accidents High Addiction to marijuana and other drugs High Diminished lifetime achievement High Abnormal brain development Medium Progression to abuse of other drugs Medium Schizophrenia Medium Depression or anxiety Medium Lung cancer Low Volkow et al., 2014 TEENS • Interferes with brain development • Relationship problems • Poor academic performance • Increased risk of accidents • Health/mental health problems • High risk sexual behavior • Gateway to other drugs 6.5% daily abusers 17 4/26/2015 When considering legalization… policymakers need to: • Prevent easy access to marijuana by teens • Increase access and funding for adolescent treatment • Consider regulating levels of tetrahydrocannabinol (THC) 1980s – 4% 2012 – 15% 18 4/26/2015 Surveillance of Abuse and Addiction Drug Trends • National Survey on Drug Use and Health (NSDUH) • Monitoring the Future (MTF) • National Forensic Laboratory Information System (NFLIS) Treatment Trends • Treatment Episode Data Set (TEDS) • National Survey of Substance Abuse Treatment Services (N-SSATS) Private Government Drug Trends • The Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS®) System • Street RX • National Addictions Vigilance Intervention and Prevention Program (NAVIPPRO) Behavioral Risk Trends • Behavioral Risk Factor Surveillance System (BRFSS) Consequences 19 4/26/2015 “Drug addiction is a brain disease.” Nora Volkow, MD Director, National Institute on Drug Abuse Molecular Addiction Switch 20 4/26/2015 Cocaine Abuse and Brain Glucose Metabolism Normal subject Cocaine abuser 10 days post Cocaine abuser 100 days post 21 4/26/2015 Percentage Who Relapse Type I Diabetes 30 to 50% 40 to 60% Drug Addiction Hypertension 50 to 70% Asthma 50 to 70% Survival distribution function Proportion abstinent at discharge by primary drug use Time to discharge Sinha, R. (2011) 22 4/26/2015 Addiction Affects Relationships Self Shame You know, I was shameful, and you do stuff that causes disgust, and that’s hard to recover from. You can say, ‘I forgive you’ and all that stuff, but it’s not the same as recovering from it. It’s not coming back. Robin Williams Interview with The Guardian, 2010 23 4/26/2015 Addiction Affects Relationships Others Self Isolation Shame Developmental Stuckness 24 4/26/2015 Addiction Affects Relationships Faith Others Self Ignorance Isolation Shame We live two lives Inner life (Eye Closed) Pure consciousness Outer life (Eye Open) Physical reality Timeless/changeless Time/change Being Doing/action Collective (one) mind Individual (ego) mind 25 4/26/2015 We live two lives Inner life (Eye Closed) Pure consciousness Outer life (Eye Open) Physical reality Timeless/changeless Time/change Being Doing/action Collective (one) mind Individual (ego) mind Risk Reduction 26 4/26/2015 Percentage of Impaired Drivers in Fatal Alcohol-Involved Crash, 1995-2004 Repeat offenders and chronic drunk drivers make up about 1% of all drivers on weekend nights, but account for 50% of all fatal crashes. National Council on Alcoholism and Drug Dependence, 2006 27 4/26/2015 Intervention Pre-Drinking During Drinking PREVENTION • Targeted education/media campaigns ENFORCEMENT • Traffic enforcement • Controlling access of alcohol • Ignition interlock • Alternative transportation • Minor Decoy/Cops in Shops • Checkpoints Post Drinking ADJUDICATION • Sanctions: jail, diversion, fines, DISP • Treatment • Zero-tolerance for minors • Primary care screening/BI Outpatient 90% of patients in care 82% of facilities 14,148 facilities Residential 9% of patients 24% of facilities Hospital 1% of patients 5% of facilities Source: N-SSATS 2013 28 4/26/2015 1,249,629 clients in substance abuse treatment on March 29, 2013 9.9% of those in need receive treatment • 35 billion industry • Unlicensed and non-credentialed staff • Turnover of staff higher than in the fast-food industry • Short-term (< 90 days) 29 4/26/2015 What is effective treatment? Addiction is a pathological disorder, a disease that requires expert treatment. 30 4/26/2015 Addiction is an a pathological adaptive response disorder, toa disease and biology that trauma requiresover expert time, treatment. and may benefit from expert treatment. How motivated… to stop doing what has allowed life to be tolerable? 31 4/26/2015 Depression Pain Suicidal Grief Sex Relationships Acute Homeless • • • Guilt • • Internet • • Stress Bipolar Stigma Suicidal Meth HIV Homeless Intoxicated Smoking Fear Psychoses Medical Relapse Work Developmental Legal Diet Alcohol RESOLVE Cutting Chronic • • • Rage • • Time • • Panic Drugs MANAGE Craving LSD Schizophrenia Pills Antisocial Depression Pain Suicidal Grief Cutting Sex Relationships Addiction • • • Guilt • • Internet • • Stress Bipolar Hopeless Alcohol RESOLVE Drugs Family Obese Ambivalence GHB Craving LSD Schizophrenia Narcissist History Pills Anxiety Loneliness OCD Hungry ADHD Unemployed Numb Gambling Chronic Suicidal • Meth HIV Panic Homeless • Legal Intoxicated • Smoking Fear Rage Psychoses Systems• Evaluation Medical • Time Relapse Work Developmental • Living LegalSituation • Diet Legal PTSD GHB Stigma Debts Shame Addiction Trauma K2 Cocaine ACEs Medical Pot Psychotic Sleep Stress Relationships Food TBI Hep C Lifestyle (Time/$) Health (Diet) Ambivalence Acute Narcissist Loneliness Obese Homeless Gambling Debts Shame Anxiety Addiction Trauma K2 Cocaine ACEsMental Health Medical Pot Psychotic Sleep Stress Relationships Food TBI Hep C Lifestyle (Time/$) Physical Health (Diet) Health PTSD Legal MANAGE Hopeless Antisocial OCD Hungry ADHD Unemployed Numb 32 4/26/2015 Depression Pain Suicidal Grief Sex Relationships Addiction Acute • Suicidal Acute • Homeless Legal Homeless Stigma Stress HIV • Guilt • • Internet • • Bipolar Meth Panic Cutting Chronic • Addiction Chronic • ACEsMental RESOLVE Ambivalence GHB Craving LSD Schizophrenia Narcissist History Pills Loneliness Cocaine •Intoxicated Suicidal •• Smoking Fear Rage •Psychoses Homeless • Systems• •Medical Intoxicated Evaluation•• Time • Relapse Work •Developmental Psychoses • Living •Legal Medical •• Situation Drugs • Alcohol Diet • Developmental • Legal • Family Obese Gambling Shame Debts Anxiety Trauma K2 Health Addiction Medical Pot Psychotic Sleep ACEs Stress Medical Relationships Food TBI Hep C Stress Lifestyle (Time/$) Physical Relationships Health (Diet) Health Legal PTSD OCD Lifestyle (Time/$) Health (Diet) MANAGE Hopeless Antisocial Hungry ADHD Unemployed Numb Talents Strengths Virtues 33 4/26/2015 5 Actions Motivate Evaluate Resolve Manage Create Motivational Interviewing CRAFT Contingency Management Goal Setting Ongoing Systems Evaluation / Outcome Measures Cognitive-Behavioral Relapse Prevention Medications Trauma Therapies (e.g. EMDR) Developmental Brief Interventions Case Management 12-step Facilitation Humanistic Existential Hope Therapy Well-being Therapy Motivational Interviewing CRAFT Contingency Management Goal Setting 5 Actions Motivate Evaluate Ongoing Systems Evaluation / Outcome Measures Right Intervention(s) Relapse Prevention Resolve Cognitive-Behavioral Right Time Trauma Therapies (e.g. EMDR) Medications Developmental Right DoseBrief Interventions Manage Create Case Management 12-step Facilitation Humanistic Existential Hope Therapy Well-being Therapy 34 4/26/2015 Internal Hope Consequences Feeling External MI Mandates CRAFT CRAFT: Helping Families 70 60 50 40 30 20 10 0 CRAFT CRAFT Intervention Intervention Al-Anon Al-Anon 64% 30% 10% 35 4/26/2015 1 Get Past Records 2 Study 3 Get Evaluated CONNECT THE DOTS Mental Health Addiction Sexual trauma Alcohol Depression Pot ADD Food Anxiety Work Physical Health Environmental Obesity Few supportive friends High blood pressure Poor financial resources apnea Sleep Apnea Poor housing situation 36 4/26/2015 “The challenge of [trauma] recovery is to reestablish ownership of your body and your mind.” • Find a way to be calm and focused, even during times where you are reminded of the past • Find a way to be fully alive in the present and engaged with the people around you • Not having to keep secrets from yourself, including secrets about the ways you have managed to survive Mindfulness Practice Mindfulness is not thinking, interpreting, or evaluating; it is an awareness of perception. It is a nonjudgmental quality of mind which does not anticipate the future or reflect back on the past. Any activity can be done with mindfulness. Source: www.contemplativemind.org 37 4/26/2015 Mindfulness Practice Meditation Yoga Mindfulness is not thinking, interpreting, Vipassana Ananda or evaluating; it is an awareness of Zen Ashtanga Chakra It is a nonjudgmental Bikram quality perception. Deep breathing Hatha of mind which does not anticipate Visualization Iyengar the Walking Kripalu future or reflect back on the past. Any Sitting Power activity can be done with mindfulness. Eating Vinyasa Creative Yin Source: www.contemplativemind.org Developmental Catch-up Emotional Age = 12 38 4/26/2015 Chronological Age = 46 Developmental Catch-up Neurosequential Model of Therapeutics (Perry) Emotional Age = 12 Developmentally-based Psychotherapy (Greenspan) Sensorimotor Psychotherapy (Ogden) Three Leverage Points Time (outpatient vs. res) EBP (addiction medications) Coordinated (chronic) Services 39 4/26/2015 Chronic Condition Condition-specific Interventions Shared Interventions Addiction Hypertension Heart Disease Diabetes OpioidBlocker, Methadone Diuretics, Beta-blockers ACE Inhibitors, ARBs Insulin, Diabetes Pills Stress Management Friendship Networks Motivational Interviewing Diet Goal Setting Brief Interventions Sleep Spirituality Collaborative Team Exercise Program Community Supports Helping Relationships 40 4/26/2015 All children are artists. The problem is how to remain an artist once he grows up. Picasso What to Create? 41 4/26/2015 Learn more at www.addictionmanagement.com drjohnfitz@gmail.com 42
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