Treatment Track, National Rx Drug Abuse Summit, April 2-4, 2013. Treatment Options for Juveniles
presentation by Michelle Lipinski and Dr. Marc Fishman.
1. Treatment
Op+ons
for
Juveniles
Michelle
Lipinski,
MeD
Principal,
Northshore
Recovery
High
School,
and
Principal/Founder,
icanhelp
Program
Dr.
Marc
Fishman,
MD
Medical
Director,
Maryland
Treatment
Centers,
and
Assistant
Professor,
John
Hopkins
University
Department
of
Psychiarty
2. Learning
Objec+ves
1. Define
dependency
and
depriva+on.
2. Iden+fy
states
of
the
World
of
Abnormal
Rearing
(WAR)
cycle.
3. Explain
clinical
interven+ons
to
break
the
cycle
of
addic+on.
4. Plan
how
to
collaborate
with
law
enforcement
and
the
medical
community
to
bring
support
to
juveniles.
3. Disclosure
Statement
• Michelle
Lipinski
has
no
financial
rela+onships
with
proprietary
en++es
that
produce
health
care
goods
and
services.
• Dr.
Marc
Fishman
has
no
financial
rela+onships
with
proprietary
en++es
that
produce
health
care
goods
and
services.
4. Do
They
Know
We
Can
Help?
Michelle
Lipinski,
M
Ed
April
2
–
4,
2013
Omni
Orlando
Resort
at
ChampionsGate
7. The
Adolescent
Brain
Back
of
brain
matures
before
to
the
front
of
the
brain
sensory
and
physical
ac+vi+es
favored
over
complex,
cogni+ve-‐demanding
ac+vi+es
propensity
toward
risky,
impulsive
behaviors
• group
sengs
may
promote
risk
taking
poor
planning
and
judgment
ac+vi+es
with
high
excitement
and
low
effort
are
preferred
poor
modula+on
of
emo+ons
(hot
emo+ons
more
common
than
cold
emo+ons)
heightened
interest
in
novel
s+muli
8. Adolescent
Brain
Development,
Decision-‐Making,
and
Risk
We
begin
with
these
basic
facts:
• The
adolescent
brain
is
not
developed
as
fully
as
the
adult
brain
–
impulse
behaviors
are
less
controlled.
• Immaturity
of
cogni+ve
processing
may
lead
to
risky
decisions.
• The
presence
of
peers
influences
decision-‐making.
• Strong
emo+ons
may
override
ra+onal
decision-‐making.
• Risk-‐taking
may
facilitate
adolescent
transi+ons.
The
above
are
true
for
all
adolescents
–
but
are
o`en
magnified
for
adolescents
with
learning
disabili+es.
Source:
Reviewed
in:
Dahl,
RE
(2004)
Ann.
N.Y.
Acad.
Sci.
1021:
1-‐22
9. Psychosocial
Impact
on
Adolescents
with
LD
The
normal
psychosocial
pressures
that
adolescents
face
are
magnified
for
those
with
learning
disabili+es:
• Peer
culture
and
pressure
–
social
clusters
• Isola+on
• Intolerance
• Low
self-‐esteem
• Hormones
• Environmental
differences
–
home
life,
trauma,
social
connectedness,
etc.
Source:
Substance
abuse
and
learning
disabili+es:
peas
in
a
pod
or
apples
and
oranges?
(September
2000),
retrieved
from
hcp://www.casacolumbia.org
10. Low
Self-‐Esteem
• Low
self-‐esteem
is
considered
by
many
researchers
to
be
one
of
the
leading
influencers
for
substance
use
and
misuse
among
adolescents.
• Adolescents
who
have
a
nega+ve
self-‐image
and
feel
that
they
are
incompetent
are
more
vulnerable
to
peer
pressure
and
more
prone
to
turn
to
alcohol
and
drugs
for
comfort
and
acceptance.
• Adolescents
with
learning
disabili+es
are
par+cularly
suscep+ble
to
low
self-‐esteem
and
its
nega+ve
consequences.
Source:
Substance
abuse
and
learning
disabili+es:
peas
in
a
pod
or
apples
and
oranges?
(September
2000),
retrieved
from
hcp://www.casacolumbia.org
11. Social-‐Connectedness
• Adolescents
with
learning
disabili+es
o`en
experience
difficulty
and
frustra+on
dealing
with
others.
• They
are
less
likely
to
be
involved
in
extracurricular
ac+vi+es.
• According
to
the
2011
NSDUH,
youths
that
reported
par+cipa+ng
in
1
or
fewer
ac+vi+es
also
reported
higher
use
of
illicit
drugs
(15.7%
vs
9.4%),
high
use
of
marijuana
(13.3%
vs.
7.3%),
were
almost
twice
as
likely
to
smoke
cigareces
(15.4%
vs.
6.7%)
and
reported
more
binge
use
of
alcohol
(10.9%
vs.
7.1%).
Source:
2011
NSDUH
12. Academic
Difficulty
or
Failure
• Youth
with
learning
disabili+es
have
a
higher
incidence
of
academic
difficul+es,
which
also
make
them
more
vulnerable
to
substance
use
and
abuse.
• According
to
the
2011
NSDUH,
youth
who
reported
geng
a
“D”
or
lower
the
last
reported
grading
period
when
compared
to
students
who
received
higher
grades
were
3
+mes
more
likely
to
use
illicit
drugs
(27.1%
vs.
9.5%),
use
marijuana
(22.4%
vs.
7.5%),
smoke
cigareces
(25.2%
vs.
7.0%)
and
binge
drink
(16.8%
vs.
7.2%).
Source:
2011
NSDUH
13. Substance
Use
Among
High
School
Drop-‐
outs
Past
Month
Substance
Use
among
12th
Grade
Aged
Youths,
by
Dropout
Status:
2002
to
2010
14. Overlap
of
Substance
Abuse
Risk
Factors
and
LD
CharacterisUcs
SUD
Risk
Factors
LD
CharacterisUcs
Low
self-‐esteem
Low
self-‐esteem
Academic
failure
Academic
Failure
Depression
Depression
Desire
for
acceptance
Peer
rejec+on
Source:
Substance
abuse
and
learning
disabili+es:
peas
in
a
pod
or
apples
and
oranges?
(September
2000),
retrieved
from
hcp://www.casacolumbia.org
15. ADHD
&
Substance
Abuse
Acen+on
deficit
hyperac+vity
disorder
(ADHD)
has
a
prevalence
of
3–9%
in
the
general
childhood
popula+on
and
1–5%
in
the
general
adult
popula+on.
ADHD
affects
between
11
and
35%
of
“substance-‐abusing”
adults,
o`en+mes
complica+ng
treatment
response.
¹
Childhood
onset
ADHD
has
not
only
been
associated
with
an
increased
risk
of
substance
abuse,
but
has
also
been
linked
to
behaviors
that
are
indica+ve
of
more
severe
pacerns
of
substance
use,
such
as
earlier
onset,
longer
substance
use
careers,
poorer
treatment
reten+on,
and
higher
relapse
rates.²
Source:¹
hcp://informahealthcare.com/doi/abs/10.1080/10826080500294858;
²Biederman
et
al,
1995;
Wilens,
2006;
Sullivan
&
Rudnik-‐Levin,
2001,
as
cited
in
Torok,
et
al.
(2012)
Acen+on
deficit
disorder
and
severity
of
substance
use:
the
role
of
comorbid
psychopathology.
Psychology
of
Addic+ve
Behaviors,
Vol.
26,
No.
4,
974-‐979
18. Youth
do
not
realize,
We
Can
Help
Them
We
are
not
reaching
our
youth
who
need
help
The
youth
do
not
know
they
have
a
problem
22. Our
Words,
Our
Ac+ons,
Our
Compassion
“Too often we underestimate the power of a touch, a
smile, a kind word, a listening ear, an honest
compliment, or the smallest act of caring, all of which
have the potential to turn a life around.”
― Leo Buscaglia
22
23. Where
does
it
begin?
• More
than
half
of
new
illicit
drug
users
begin
with
marijuana.
Next
most
common
are
prescrip+on
pain
relievers,
followed
by
inhalants
(which
is
most
common
among
younger
teens).
24. Just
Weed
• AXer
alcohol,
marijuana
has
the
highest
rate
of
dependence
or
abuse
among
all
drugs.
In
2011,
4.2
million
Americans
met
clinical
criteria
for
dependence
or
abuse
of
marijuana
in
the
past
year—more
than
twice
the
number
for
dependence/abuse
of
prescrip+on
pain
relievers
(1.8
million)
and
four
+mes
the
number
for
dependence/abuse
of
cocaine
(821,000).
25. Crea+ng
a
Bridge
to
Services
The
icanhelp
program
builds
help-‐seeking
and
early
engagement
by
establishing
“safe”
places
for
adolescents
to
develop
a
trus+ng
rapport
with
adults
in
the
community
25
26. icanhelp
Essen+al
Components
Follow-‐Up
Awareness
Help-Seeking
Link
to
Resources
Identi9ication
Engagement
Strengthen
Build
Resources
26
27. Build
Awareness
of
the
icanhelp
Program
Let
youth
and
young
adults
Awareness
know
who
to
contact
related
to
the
icanhelp
program
• icanhelp
logos
• icanhelp
posters
Iden+fy
icanhelp
Representa+ves
• icanhelp
presenta+ons
using
icanhelp
Logos
• The
presence
of
the
icanhelp
logo
signals
that
this
is
a
safe
person
• Logos
are
reserved
for
people
who
have
been
trained
and
are
members
of
the
icanhelp
team
27
28. icanhelp
Posters:
Facilita+ng
the
Conversa+on
If you’re thinking these thoughts... If you’re thinking these thoughts...
you may need help. you may need help.
Look for the I CAN HELP sticker Look for the I CAN HELP sticker
to find a safe person to talk to. to find a safe person to talk to.
www.icanhelp.me www.icanhelp.me
28
biopsychosocial
issues
addic+ve
behavior
and
issues
29. Support
Youth
So
They
Seek
Help
Youth
are
more
likely
to
seek
help
if…
• The
adults
around
them
have
posi+ve
atudes
about
help
seeking
Help-Seeking
• They
think
adults
will
respond
• They
are
willing
to
overcome
Youth
are
more
likely
to
seek
help
from
informal
supports
such
as
peer
secrecy
requests
(help-‐
friends,
family
or
mentors
rather
seeking
for
friend)
than
professionals.
• They
think
exis+ng
resources
When
they
seek
professional
help,
can
help
them
they
usually
go
to
someone
familiar
• They
are
engaged
in
school
such
as
primary
care,
school
nurse
or
29
counselor.
30. Why
Target
Adolescents?
• Mental
health
and
substance
use
problems
o`en
start
in
adolescents
– About
half
the
adults
with
mental
health
problems
report
experiencing
their
first
episode
during
adolescence
• Adolescents
do
not
know
that
they
have
a
mental
health/
substance
use
problem
– There
are
so
many
changes
taking
place
it
is
hard
for
the
youth
and
caregivers
to
know
that
there
is
a
problem
• Youth
do
not
know
the
route
to
safe
and
suppor+ve
care
– S+gma
and
lacking
of
knowing
how
to
get
care
leaves
youth
to
their
own
methods
Identi9ication
31. Being
a
Person
Who
Youth
Go
To
For
Help:
Communica+on
Style
• Start
where
the
student
is
at
• Frame
ques+ons
in
a
nonjudgmental
way
• Building
an
alliance
with
youth
so
they
feel
safe
and
welcome
• Strength-‐based
vs.
puni+ve
approach
• Youth
need
encouragement,
• Including
the
student
in
decisions,
valida+on
and
support
for
encourage
open
and
honest
expressing
their
opinions
bidirec+onal
discussions
• Empower
the
student
to
take
responsibility
for
seeking
solu+ons,
and
build
incrementally
on
small
successes
Engagement
31
32. Find
Build
Resources
• In
a
crisis
or
urgent
situa+on,
you
want
to
have
resources
readily
available
• Develop
a
community
resource
guide
• Make
the
guide
as
comprehensive
as
possible
–
divide
and
conquer
–
complete
it
as
a
team
Strengthen
Build
Resources
32
33. Supports
within
Schools
• Special
educa+on
• Social
worker,
psychologist
• Resource
officer
• Crisis
response
team
• Guidance
department
• Nurse/health
center
• Administra+on
Strengthen
Build
• Truancy
official
Resources
• ASOST
supports
• GSA
• Alateen
33
34. Supports
within
Communi+es
• Treatment
providers
for
mental
health
addic+ve
disorders
• Recovery
supports
• Self-‐help
groups
• Parent
supports/groups
• Primary
Care/ER/Healthcare
• Drug
free
communi+es
• Reproduc+ve
health
Strengthen
Build
• Economic
supports/food
banks
Resources
• GED/educa+on
supports
• Social
services
• DCF:
when
to
file
a
51A
• DMH
• Workforce
investment
board
• Courts/juvenile
jus+ce/family
services
• When
to
file
a
CHINS/CP
34
35. Supports
Online
• Resource
database
• hcp://icanhelp.me
• Community
• hcp://icanhelp.me/community/
• Wiki
• Blog
• and
more
• Training
Portal
Strengthen
Build
• Facebook
Resources
• hcp://www.facebook.com/icanhelp.me
• Future
services
• icanhelp
newslecer
mailing
list
• Expanded
search
op+ons
for
resource
database
35
36. Contribute
to
Online
Resources
Let
others
benefit
from
your
effort.
• Share
your
resource
guide
• Load
the
contact
informa+on
into
the
online
icanhelp
resource
database
36
37. Follow
Up:
Why
Services
Don’t
Always
Work
Follow-‐Up
• Youth
or
family
not
always
ready
to
receive
services,
personal
factors
related
to
mental
and
cogni+ve
func+oning
of
individual
or
family
• No
service
available
within
a
reasonable
distance,
dropped
services
• Prac+cal
factors
such
as
insurance,
cost,
transport,
child
care,
eligibility
rules
or
program
scheduling
• Cultural
factors
such
as
language,
ci+zenship
and
status
• Nega+ve
experience/bad
rapport
with
provider
• S+gma
and
labeling
• Lack
of
cultural
competency
37
38. SOAP
• A
two
week
intensive
a`er-‐school
program
designed
to
meet
the
specific
needs
of
teens
and
young
adults.
SOAP
provides
a
safe
place
for
teens
and
young
adults
to
spend
their
a`er
school
hours
where
they
can
learn
and
develop
skills
to
support
recovery
from
substance
use
disorders.
49. What
should
we
do
with
this
case?
• 17
M
• Onset
prescrip+on
opioids
15,
progressing
to
daily
use
with
withdrawal
within
8
months
• Onset
nasal
heroin
16,
injec+on
heroin
6
months
later
• 3
episodes
residen+al
tx,
2
AMA,
1
completed
• Suboxone
treatment
(monthly
supply
Rx
x
4),
took
erra+cally,
sold
half
• Presents
in
crisis
seeking
detox
(“Can
I
be
out
of
here
by
Friday?”)
52. 6%
12
to
17y
18
to
25y
26y
5%
4%
Percent
3%
2%
1%
0%
2002
2003
2004
2005
2006
2007
The
NSDUH
report
February
2009
53. Conceptual
underpinnings
• Use
as
many
effec+ve
tools
as
are
available
• One
size
does
not
fit
all:
as
many
doors
as
possible
• A
full
con+nuum
of
care:
mul+ple
services
with
flexible
responses
• Ins+tu+onal
affilia+on
and
longitudinal
care
promotes
engagement
• Expecta+on
of
relapsing/reming
course
• Expecta+on
of
variable
and
shi`ing
treatment
readiness
• Recovery
as
a
gradual
process,
not
an
overnight
event
-‐-‐
expecta+on
of
incremental
progress
54. Elements
of
treatment
model
• Emphasis
on
ongoing
engagement
from
detox
to
next
levels
of
care
(the
revolving
door
should
lead
somewhere)
• Specialty
care
• Longitudinal
follow-‐up
and
management
• Integra+on
of
relapse
preven+on
medica+on
as
standard
of
care
– Buprenorphine
– Extended
release
naltrexone
• Co-‐occurring
(dual
diagnosis)
treatment
57. CTN
Youth
Buprenorphine
Study
Opioid
Posi+ve
Urines:
12
weeks
Bup
vs
Detox
(Woody et al, JAMA 2008)
58. Percent of confirmed opioid-free weeks (cumulative)
Krupitsky et al. Lancet. 2011
59. Buprenorphine
induc+on
method
• Residen+al
detox
using
bupe
taper
• Interrup+on
of
taper,
switch
to
steady
dose,
or
• Comple+on
of
taper,
later
resume
bupe
• Alterna+ve
induc+on
as
outpa+ent
(minority)
• Outpa+ent
maintenance
60. Buprenorphine
maintenance
• Start
weekly
prescrip+on
supply
• Expecta+on
of
counseling
acendance
• Frequent
urine
monitoring
• Increase
dura+on
of
Rx
dura+on
over
+me,
used
as
con+ngency
management
• Op+onal
tools
for
med
supervision
– Prescrip+ons
le`
for
counselor
to
distribute
– Monitored
distribu+on
and/or
administra+on
by
families
– Direct
med
administra+on
up
to
daily
61. XR-‐NTX
Induc+on
• Residen+al
detox
using
bupe
taper
• 7
day
abs+nence
by
confinement
• NTX
induc+on
with
4
d
oral
dose
+tra+on
– 6.26,
12.5,
25,
50
mg
(liquid)
• 1st
dose
injectable
XR-‐NTX
prior
to
residen+al
discharge
• Outpa+ent
maintenance
63. Why
XR-‐NTX
MAR?
• Failure
of
other
treatments
• Pa+ent
preference
• Family
preference
• History
of
poor
treatment
engagement
and
adherence
• Problems
with
acceptability
of
agonist
pharmacotherapies
• More
tools
in
the
toolbox
64. Why
buprenorphine
MAR?
• Pa+ent
preference,
esp
if
previous
experience
• Failure
of
other
treatments
• Intrinsically
reinforcing
• Growing
posi+ve
reputa+on
of
bupe
• Anxiety
about
NTX,
or
poor
tolerance
• More
tools
in
the
toolbox
65. Medica+ons,
mischief,
and
monkey
business
• Diversion
• Non-‐compliance
• Inconsistency
• Other
substances
66. Case
• 18
F
injec+on
heroin,
mul+ple
failed
treatments
• Inpa+ent
treatment,
recovery
house,
con+nua+on
suboxone
• Made
connec+on
to
NA
for
the
first
+me
• Abs+nent
x
6
months
• Told
at
NA
mee+ng
“not
really
clean”
stopped
Rx
• Relapse
• 6
months
later
back
on
suboxone
• New
stance
towards
Rx
“don’t
ask,
don’t
tell”
• 2
years
abs+nence
67. Case
• 18
F
onset
injec+on
heroin
16,
occasional
street
suboxone
• Outpa+ent
suboxone
maintenance
but
would
take
it
only
intermicently
when
heroin
unavailable
• Clarified
goal:
not
ready
to
quit,
suboxone
stopped
but
MET
con+nued
• 2
months
later
Rx
restarted
under
mother’s
supervision
with
new
commitment
-‐-‐
6
months
abs+nence
68. Bricany
• 15
yo
WF
• 1
yr
hx
prescrip+on
opioids,
recent
progression
to
injec+on
heroin,
parents
didn’t
know
extent
of
dependence,
shocked
to
discover
a
needle
• Parents
compelled
by
idea
of
xr-‐ntx
69. Jennifer
• 17
yo
from
the
suburbs,
injec+on
heroin
x
2
years,
2nd
episode
detox
• Uses
street
bupe
intermicently
• Strong
parental
and
juvenile
jus+ce
pressures,
ambivalent
about
quing
• “If
I
wake
up
there
is
heroin
suboxone
on
the
table
-‐-‐
I’ll
use
heroin
every
+me”
• Agrees
to
trial
of
xr-‐ntx
70. Machew
• 19
M,
3
yr
hx
injec+on
heroin
• 4
previous
episodes
detox,
2
previous
episodes
of
failure
with
bupe
outpt
treatment
• Wants
to
try
bupe
again
• Parents
make
xr-‐ntx
a
condi+on
of
returning
home
71. Greg
• 16
M
prescrip+on
opioid
dependence
• Residen+al
detox,
XR-‐NTX
induc+on
• Abs+nent
x
3
months
• Family
vaca+on,
out
of
town,
dose
#4
delayed
• While
at
beach
started
deliberate
plan
to
use,
diver+ng
few
dollars
at
a
+me
to
prevent
detec+on
• On
return,
told
parents
he
was
headed
to
treatment,
went
to
get
drugs
instead,
missed
XR-‐NTX
• Relapse
x
3
weeks
• Brief
residen+al
detox
• Restart
XR-‐NTX
with
new
level
of
parental
involvement
72. Features
of
youth
treatment
• Family
leverage
• Pushback
against
sense
of
parental
dependence
and
restric+on
• Salience
of
burdens
of
treatment
• Prominence
of
co-‐morbidity
• Family
mobiliza+on
–
“Medicine
may
help
with
the
receptors,
you
s+ll
have
to
parent
your
difficult
teenager”
73. Challenges
• Atudes,
misunderstanding
and
s+gma
• Adherence
• Monitoring
and
supervision
• Range
of
op+ons
may
be
limited
– Limited
treatment
capacity
– Limited
insurance
coverage
– Limited
availability
of
inpa+ent
• Clock
is
+cking
in
inpa+ent
seng
• Tensions
in
involving
family,
esp
older
youth
74. Challenges
• Goals
of
treatment
re
other
substances
• Diversion
of
bupe
• Need
for
more
intensive
management
op+ons
with
bupe
• Limited
(and
false)
info
about
xr-‐ntx
75. Youth
opioid
treatment
chart
review
• Retrospec+ve
review
of
133
pa+ents
entering
outpa+ent
youth
opioid
track
at
Mountain
Manor
in
Bal+more
• 4/07
–
1/10
• Intake
to
26
weeks
• All
the
usual
limita+ons
of
messy
clinical
charts
76. Youth
opioid
treatment
chart
review
Pa+ent
characteris+cs
Age, mean 18.2 years (range 14-21)
Gender, male 53%
Race, caucasian 94%
Duration of opioid use 2.8 years
Rate of heroin use 80%
Rate of injection use 61%
In school 23%
Current psych Rx 38%
Justice system involvement 68%
83. Addi+onal
Factors
Medica+on
vs.
No
Medica+on
Cross-‐sec+onal
reten+on
at
26
weeks
50% Medication
No
40% Medication
30%
20%
10%
0%
84. Conclusions
(I)
• Treatment
with
relapse
preven+on
medica+ons(XR-‐
NTX
and
buprenorphine)
for
youth
with
opioid
dependence
is
well
tolerated
and
well
accepted
by
pa+ents
and
families,
and
can
be
prac+cally
implemented
as
a
standard
treatment
in
a
community
treatment
program.
• Medica+ons
are
easily
integrated
with
counseling
as
part
of
a
comprehensive
treatment
approach
• Use
of
medica+ons
for
relapse
preven+on
is
associated
with
increased
reten+on
and
treatment
u+liza+on,
and
decreased
drug
use.
85. Conclusions
(II)
• Not
surprisingly,
medica+on
compliance
seems
to
be
related
to
effec+veness.
•
Although
pa+ents
dri`
in
and
out
of
treatment,
there
are
substan+al
rates
of
return
to
treatment
following
dropout,
and
re-‐cessa+on
of
drug
use
following
lapse/
relapse.
• Our
experience
suggests
the
benefits
of
a
more
longitudinal
medical
management
model
of
care
as
compared
to
a
more
tradi+onal
model
of
discrete
episodes
of
care.
86. Next
steps
-‐
clinical
• Improved
family
involvement
• How
to
manage
medica+on
discon+nua+on
• Longer-‐term
engagement
strategies
• More
opera+onaliza+on
of
stepped
care
• Broader
coverage
and
reimbursement,
including
XR-‐NTX
• Differen+al
strategies
for
pa+ents
in
early
stages
of
change
in
rela+on
to
other
substances
87. Next
steps
–
Research
agenda
from
the
field
• Longer
term
outcomes?
• Appropriate
dura+on
of
treatment?
• Different
medica+on
discon+nua+on
strategies?
• Bupe
vs
XR-‐NTX?
• Post-‐relapse
strategies
–
s+ck
or
switch?
• Outpa+ent
vs
inpa+ent
induc+on
• Dosing
of
counseling
88. Case
(1)
16
F
injec+on
heroin
and
depression
• Ini+al
Rx
oral
NTX,
ineffec+ve
2º
non-‐adherence
despite
close
parental
monitoring,
even
went
as
far
as
liquid
• Received
8
doses
XR-‐NTX,
substan+al
improvement
(despite
sporadic
lapses)
• Extreme
conflict
with
mother,
moved
in
with
heroin-‐using
boyfriend
• Insisted
on
stopping
XR-‐NTX
2º
injec+on
site
pain
• 5
d
oral
NTX
then
immediate
relapse
and
dropout
89. CASE
(2)
• 1
yr
later
(now
18)
presented
back
to
us
a`er
stabilized
on
methadone
1
month,
re-‐ini+ated
psychotherapy
and
Rx
for
depression
•
A`er
4
months
abs+nent
on
methadone,
switched
to
bupe
• Erra+c
course
over
4
months
with
sporadic
medica+on
non-‐
compliance
and
lapses
leading
to
progressive
full
relapse
• Work
with
family
to
arrange
inpa+ent
treatment
and
detox
with
plan
for
switch
back
to
NTX
• Surrep++ous
use
of
bupe
and
cheeking
of
NTX
at
residen+al
program
• Precipitated
withdrawal
when
given
NTX
90. Case
(3)
• Course
of
XR-‐NTX
for
6
months
• Half
way
house
and
strong
engagement
in
12
step
fellowship
• Titra+on
of
an+-‐depressant
with
gradual
remission
of
depression
and
anxiety
• Switch
to
oral
naltrexone
for
2
months,
but
“+red
of
meds”
• Oral
naltrexone
back-‐up
as
needed
but
rarely
used
• 24
months
sober
• Working,
pregnancy,
living
with
baby’s
father,
recurrence
of
depression,
break-‐up,
living
independently
92. A
sprint
or
a
marathon?
Early:
I
agree
I
was
out
of
control
with
the
dope,
but
I
can
s+ll
use
a
licle
oxy
on
the
weekends.
Middle:
I’m
a
heroin
addict,
not
an
alcoholic.
I
just
need
to
stop
using
heroin.
A
few
beers
is
fine.
Later:
When
I
get
drunk,
I
end
up
using
heroin
again.
Maybe
I
need
to
stop
drinking
too.
But
taking
a
licle
xanax
when
I’m
stressed
is
no
big
deal.
(sigh)