SlideShare ist ein Scribd-Unternehmen logo
1 von 93
Downloaden Sie, um offline zu lesen
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	
  	
  
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.	
  
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.	
  	
  
Do	
  They	
  Know	
  We	
  Can	
  Help?	
  
   Michelle	
  Lipinski,	
  M	
  Ed	
  
            April	
  2	
  –	
  4,	
  2013	
  
          Omni	
  Orlando	
  Resort	
  	
  
           at	
  ChampionsGate	
  
Treatment options for_juveniles_final
Treatment options for_juveniles_final
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	
  
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	
  
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	
  
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	
  
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	
  
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	
  
Substance	
  Use	
  Among	
  High	
  School	
  Drop-­‐
                      outs	
  
Past	
  Month	
  Substance	
  Use	
  among	
  12th	
  Grade	
  Aged	
  Youths,	
  by	
  Dropout	
  Status:	
  
2002	
  to	
  2010	
  
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	
  
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	
  
Perceived	
  Risk	
  
What	
  are	
  our	
  children	
  using	
  to	
  get	
  
                       high?	
  
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	
  
Treatment options for_juveniles_final
Treatment options for_juveniles_final
Treatment options for_juveniles_final
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	
  
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).	
  
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).	
  
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	
  
icanhelp	
  Essen+al	
  Components	
  
                                            Follow-­‐Up	



       Awareness	



      Help-­Seeking	

         Link	
  to	
  
                              Resources	

      Identi9ication	



      Engagement	

       Strengthen	
  	
  Build	
  
                              Resources	


                                                             26	
  
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	
  
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	
  
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.	
  
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
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	
  
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	
  
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	
  
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	
  
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	
  
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	
  
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	
  
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.	
  
SOAP	
  Class	
  Rooms	
  
SOAP	
  Ac+vity	
  Room	
  
SOAP	
  Music	
  Room	
  
Treatment options for_juveniles_final
Treatment options for_juveniles_final
Treatment options for_juveniles_final
Treatment options for_juveniles_final
Treatment options for_juveniles_final
icanhelp.me
IntegraUng	
  Relapse	
  PrevenUon	
  
Pharmacotherapy	
  into	
  Treatment	
  of	
  Opioid	
  
         Dependence	
  for	
  Youth	
  
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?”)	
  
Past Year Use Prevalence: 8th and 12th Graders (MTF)

              1.8	
  

              1.6	
                                                                                                         8th	
  Graders	
          12th	
  Graders	
  
              1.4	
  

              1.2	
  
Percent	
  




                 1	
  

              0.8	
  

              0.6	
  

              0.4	
  

              0.2	
  

                 0	
  
                         '91	
   '92	
   '93	
   '94	
   '95	
   '96	
   '97	
   '98	
   '99	
   '00	
   '01	
   '02	
   '03	
   '04	
   '05	
   06	
   07	
   08	
   09	
  
                                                                    hcp://www.monitoringthefuture.org/pubs/monographs/overview2009.pdf	
  	
  
MTF:	
  Annual	
  Use	
  Prevalence	
  12th	
  Graders	
  


              10	
  
                                 12th	
  Graders	
  
                8	
  
Percent	
  




                6	
  


                4	
  


                2	
  


                0	
  
                        '91	
   '92	
   '93	
   '94	
   '95	
   '96	
   '97	
   '98	
   '99	
   '00	
   '01	
   '02	
   '03	
   '04	
   '05	
   06	
   07	
   08	
   09	
  

                                                          hcp://www.monitoringthefuture.org/pubs/monographs/overview2009.pdf	
  	
  
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	
  
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	
  
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	
  
100
                     90                       Full Agonist
                     80                       (Methadone
                                              Heroin, oxycodone)
Intrinsic Activity



                     70
                     60                         Partial Agonist
                     50                         (Buprenorphine)
                     40
                     30
                     20
                     10                      Antagonist (Naloxone)
                      0
                           -9   -8      -7      -6      -5         -4
                                     Log Dose of Medication
Journal of the
American
Medical
Association, 2008
CTN	
  Youth	
  Buprenorphine	
  Study	
  	
  
Opioid	
  Posi+ve	
  Urines:	
  12	
  weeks	
  Bup	
  vs	
  Detox	
  	
  




                                            (Woody et al, JAMA 2008)
Percent of confirmed opioid-free weeks (cumulative)




  Krupitsky et al. Lancet. 2011
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	
  
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	
  
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	
  
XR-­‐NTX	
  Maintenance	
  
•  Monthly	
  injec+ons	
  
•  Expecta+on	
  of	
  counseling	
  acendance	
  
•  Asser+ve	
  dosing	
  reminders	
  
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	
  
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	
  
Medica+ons,	
  mischief,	
  and	
  monkey	
  
                  business	
  
•    Diversion	
  
•    Non-­‐compliance	
  
•    Inconsistency	
  
•    Other	
  substances	
  
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	
  
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	
  
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	
  
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	
  
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	
  
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	
  
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”	
  
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	
  
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	
  
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	
  
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%
Youth	
  opioid	
  treatment	
  chart	
  review	
  
               Medica+on	
  treatment	
  



Treated with:
Any medication                            61%
   Buprenorphine                          39%
   Extended release naltrexone            19%
   Oral naltrexone                        3%
No medication                             39%
Cumula+ve	
  reten+on	
  over	
  26	
  weeks	
  	
  
             by	
  medica+on	
  
26	
  
24	
                                                            subsequent	
  	
  cumula+ve	
  reten+on	
  
22	
                                                            1st	
  episode	
  reten+on	
  
20	
                                                            subsequent	
  	
  cumula+ve	
  reten+on	
  
                 *	
                                                         *	
  
18	
                                          *	
  
               15.8	
                                                      15.9	
  
16	
                                         15.3	
  
14	
                                                                       4.9	
  
                 5.5	
                       5.4	
  
12	
                                                                                             10.3	
  
10	
  
 8	
                                                                                               2.5	
  
 6	
                                                                        11	
  
               10.3	
                         9.9	
  
 4	
                                                                                              7.8	
  
 2	
  
 0	
  
         Any	
  medica+on	
                XR-­‐NTX	
              Buprenorphine	
         No	
  medica+on	
  



                     *	
  =	
  p	
  	
  0.01	
  compared	
  to	
  no	
  medica+on	
  
Reten+on	
  by	
  medica+on	
  


  *	
       *	
      *	
  
Opioid-­‐free	
  weeks	
  over	
  26	
  weeks	
  
                    	
  by	
  medica+on	
  
            Combining	
  urine	
  and	
  self	
  report	
  
                 Opioid	
  free	
  weeks,	
  during	
  intake	
  to	
  week	
  26,	
  n	
  =	
  133	
  
26	
  
24	
  
22	
  
20	
  
18	
  
16	
  
14	
                                               *	
  
                *	
                                                                *	
  
12	
  
10	
  
 8	
  
 6	
                                             13.7	
  
               11.5	
                                                            10.6	
  
 4	
                                                                                                         7	
  
 2	
  
 0	
  
         Any	
  medica+on	
                   XR-­‐NTX	
                Buprenorphine	
              No	
  medica+on	
  
                        *	
  =	
  p	
  	
  0.01	
  compared	
  to	
  no	
  medica+on	
  
Cumula+ve	
  reten+on	
  Propor+ons	
  
   1	
  
0.9	
  
                                                                                                            Meds	
  
0.8	
  
                                                                                                            No	
  meds	
  
0.7	
  
0.6	
  
0.5	
  
0.4	
  
0.3	
  
0.2	
  
0.1	
  
   0	
  
           1	
   2	
   3	
   4	
   5	
   6	
   7	
   8	
   9	
   10	
   11	
   12	
   13	
   14	
   15	
   16	
   17	
   18	
   19	
   20	
   21	
   22	
   23	
   24	
   25	
   26	
  
Cumula+ve	
  Opioid	
  Nega+ve	
  Urines	
  


                                           Opioid Negative Urines
                100%

                90%

                80%                                                    XR-NTX
                                                                       Buprenorphine
% of Patients




                70%
                                                                       No Meds
                60%

                50%

                40%

                30%

                20%

                10%

                 0%
                       Wks 1-4   Wks 5-8       Wks 9-12    Wks 13-16   Wks 17-20       Wks 21-24


                                             Weeks of Treatment
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%
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.	
  
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.	
  	
  
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	
  
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	
  
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	
  
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	
  
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	
  
Pharmacological	
  Treatment	
  
•  Ques+on:	
  
   –  Which	
  is	
  becer	
  -­‐	
  medica+ons	
  or	
  counseling?	
  


•  Answer:	
  
   –  Yes	
  
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)	
  
Hypothe+cal	
  Miracle	
  Cures	
  

Weitere ähnliche Inhalte

Was ist angesagt?

You Are Good Enough - Joe and Angela Clouse - 3-5-16
You Are Good Enough - Joe and Angela Clouse - 3-5-16You Are Good Enough - Joe and Angela Clouse - 3-5-16
You Are Good Enough - Joe and Angela Clouse - 3-5-16DenverCoC
 
Community Violence & Trauma: How to Build Resilience in the Classroom
Community Violence & Trauma:  How to Build Resilience in the ClassroomCommunity Violence & Trauma:  How to Build Resilience in the Classroom
Community Violence & Trauma: How to Build Resilience in the ClassroomPacific Oaks College
 
Acesandkernels 110927145112-phpapp02
Acesandkernels 110927145112-phpapp02Acesandkernels 110927145112-phpapp02
Acesandkernels 110927145112-phpapp02teenaellison
 
Poverty and Mental Illness final paper
Poverty and Mental Illness final paperPoverty and Mental Illness final paper
Poverty and Mental Illness final paperMallory McBlaine
 
A project on CHILD MALTREATMENT
A project on CHILD MALTREATMENTA project on CHILD MALTREATMENT
A project on CHILD MALTREATMENTMehreen Shafique
 
Multicultural presentation
Multicultural presentationMulticultural presentation
Multicultural presentationtariqbahoo
 
Au Psy492 M7 A2 De Priest L
Au Psy492 M7 A2 De Priest LAu Psy492 M7 A2 De Priest L
Au Psy492 M7 A2 De Priest Lodaat444
 
William O. Donnelly - Conversations with adolescents
William O. Donnelly - Conversations with adolescentsWilliam O. Donnelly - Conversations with adolescents
William O. Donnelly - Conversations with adolescentsPlain Talk 2015
 
Current events and childhood paper
Current events and childhood paperCurrent events and childhood paper
Current events and childhood paperStevieHardigree
 
The Child’s Psychological Use of the Parent: A Workshop
The Child’s Psychological Use  of the Parent: A Workshop The Child’s Psychological Use  of the Parent: A Workshop
The Child’s Psychological Use of the Parent: A Workshop James Tobin, Ph.D.
 
The Voices of New Hampshire's Young Adults
The Voices of New Hampshire's Young AdultsThe Voices of New Hampshire's Young Adults
The Voices of New Hampshire's Young AdultsJSI
 
Zhang d lis 560 assignment 1
Zhang d lis 560 assignment 1Zhang d lis 560 assignment 1
Zhang d lis 560 assignment 1Dibiboi
 
Wekerle CIHR Team - Anne Niec - Understanding Child Maltreatment
Wekerle CIHR Team - Anne Niec - Understanding Child MaltreatmentWekerle CIHR Team - Anne Niec - Understanding Child Maltreatment
Wekerle CIHR Team - Anne Niec - Understanding Child MaltreatmentChristine Wekerle
 
Anthropological 193 - disciplinary paper
Anthropological 193 - disciplinary paperAnthropological 193 - disciplinary paper
Anthropological 193 - disciplinary paperOmar Aldama
 
Adolescent Issues in the Media
Adolescent Issues in the MediaAdolescent Issues in the Media
Adolescent Issues in the MediaStevieHardigree
 
Bullying Summary Report_FINAL
Bullying Summary Report_FINALBullying Summary Report_FINAL
Bullying Summary Report_FINALRandell Bailey
 
Multidimensionality of pressure in adolescence
Multidimensionality of pressure in adolescenceMultidimensionality of pressure in adolescence
Multidimensionality of pressure in adolescenceSurabhi Bhargav
 
Projekt anglisht
Projekt anglisht Projekt anglisht
Projekt anglisht irida_2000
 

Was ist angesagt? (20)

You Are Good Enough - Joe and Angela Clouse - 3-5-16
You Are Good Enough - Joe and Angela Clouse - 3-5-16You Are Good Enough - Joe and Angela Clouse - 3-5-16
You Are Good Enough - Joe and Angela Clouse - 3-5-16
 
Community Violence & Trauma: How to Build Resilience in the Classroom
Community Violence & Trauma:  How to Build Resilience in the ClassroomCommunity Violence & Trauma:  How to Build Resilience in the Classroom
Community Violence & Trauma: How to Build Resilience in the Classroom
 
Acesandkernels 110927145112-phpapp02
Acesandkernels 110927145112-phpapp02Acesandkernels 110927145112-phpapp02
Acesandkernels 110927145112-phpapp02
 
Background
BackgroundBackground
Background
 
Poverty and Mental Illness final paper
Poverty and Mental Illness final paperPoverty and Mental Illness final paper
Poverty and Mental Illness final paper
 
A project on CHILD MALTREATMENT
A project on CHILD MALTREATMENTA project on CHILD MALTREATMENT
A project on CHILD MALTREATMENT
 
Multicultural presentation
Multicultural presentationMulticultural presentation
Multicultural presentation
 
Au Psy492 M7 A2 De Priest L
Au Psy492 M7 A2 De Priest LAu Psy492 M7 A2 De Priest L
Au Psy492 M7 A2 De Priest L
 
William O. Donnelly - Conversations with adolescents
William O. Donnelly - Conversations with adolescentsWilliam O. Donnelly - Conversations with adolescents
William O. Donnelly - Conversations with adolescents
 
Current events and childhood paper
Current events and childhood paperCurrent events and childhood paper
Current events and childhood paper
 
The Child’s Psychological Use of the Parent: A Workshop
The Child’s Psychological Use  of the Parent: A Workshop The Child’s Psychological Use  of the Parent: A Workshop
The Child’s Psychological Use of the Parent: A Workshop
 
The Voices of New Hampshire's Young Adults
The Voices of New Hampshire's Young AdultsThe Voices of New Hampshire's Young Adults
The Voices of New Hampshire's Young Adults
 
Zhang d lis 560 assignment 1
Zhang d lis 560 assignment 1Zhang d lis 560 assignment 1
Zhang d lis 560 assignment 1
 
Rebecca Collins, Charlotte Wilson
Rebecca Collins, Charlotte WilsonRebecca Collins, Charlotte Wilson
Rebecca Collins, Charlotte Wilson
 
Wekerle CIHR Team - Anne Niec - Understanding Child Maltreatment
Wekerle CIHR Team - Anne Niec - Understanding Child MaltreatmentWekerle CIHR Team - Anne Niec - Understanding Child Maltreatment
Wekerle CIHR Team - Anne Niec - Understanding Child Maltreatment
 
Anthropological 193 - disciplinary paper
Anthropological 193 - disciplinary paperAnthropological 193 - disciplinary paper
Anthropological 193 - disciplinary paper
 
Adolescent Issues in the Media
Adolescent Issues in the MediaAdolescent Issues in the Media
Adolescent Issues in the Media
 
Bullying Summary Report_FINAL
Bullying Summary Report_FINALBullying Summary Report_FINAL
Bullying Summary Report_FINAL
 
Multidimensionality of pressure in adolescence
Multidimensionality of pressure in adolescenceMultidimensionality of pressure in adolescence
Multidimensionality of pressure in adolescence
 
Projekt anglisht
Projekt anglisht Projekt anglisht
Projekt anglisht
 

Andere mochten auch

Successful strategies for_community_change_part1_final
Successful strategies for_community_change_part1_finalSuccessful strategies for_community_change_part1_final
Successful strategies for_community_change_part1_finalOPUNITE
 
Treatment opioids a_comprehensive_response_final
Treatment opioids a_comprehensive_response_finalTreatment opioids a_comprehensive_response_final
Treatment opioids a_comprehensive_response_finalOPUNITE
 
Successful strategies for_community_change_part3_final
Successful strategies for_community_change_part3_finalSuccessful strategies for_community_change_part3_final
Successful strategies for_community_change_part3_finalOPUNITE
 
Trends in rx_drug_abuse_final
Trends in rx_drug_abuse_finalTrends in rx_drug_abuse_final
Trends in rx_drug_abuse_finalOPUNITE
 
Enabling and intervention_final
Enabling and intervention_finalEnabling and intervention_final
Enabling and intervention_finalOPUNITE
 
Building public safety_public_health_partnerships_final
Building public safety_public_health_partnerships_finalBuilding public safety_public_health_partnerships_final
Building public safety_public_health_partnerships_finalOPUNITE
 
Technologies in preventing_diversion-ne_wweb
Technologies in preventing_diversion-ne_wwebTechnologies in preventing_diversion-ne_wweb
Technologies in preventing_diversion-ne_wwebOPUNITE
 
Realities of addiction_volkow-final
Realities of addiction_volkow-finalRealities of addiction_volkow-final
Realities of addiction_volkow-finalOPUNITE
 
Drug abuse ppt
Drug abuse pptDrug abuse ppt
Drug abuse pptDFC2011
 

Andere mochten auch (10)

Successful strategies for_community_change_part1_final
Successful strategies for_community_change_part1_finalSuccessful strategies for_community_change_part1_final
Successful strategies for_community_change_part1_final
 
Treatment opioids a_comprehensive_response_final
Treatment opioids a_comprehensive_response_finalTreatment opioids a_comprehensive_response_final
Treatment opioids a_comprehensive_response_final
 
Successful strategies for_community_change_part3_final
Successful strategies for_community_change_part3_finalSuccessful strategies for_community_change_part3_final
Successful strategies for_community_change_part3_final
 
Trends in rx_drug_abuse_final
Trends in rx_drug_abuse_finalTrends in rx_drug_abuse_final
Trends in rx_drug_abuse_final
 
Enabling and intervention_final
Enabling and intervention_finalEnabling and intervention_final
Enabling and intervention_final
 
Building public safety_public_health_partnerships_final
Building public safety_public_health_partnerships_finalBuilding public safety_public_health_partnerships_final
Building public safety_public_health_partnerships_final
 
Technologies in preventing_diversion-ne_wweb
Technologies in preventing_diversion-ne_wwebTechnologies in preventing_diversion-ne_wweb
Technologies in preventing_diversion-ne_wweb
 
Realities of addiction_volkow-final
Realities of addiction_volkow-finalRealities of addiction_volkow-final
Realities of addiction_volkow-final
 
Amalgam cavity design
Amalgam cavity designAmalgam cavity design
Amalgam cavity design
 
Drug abuse ppt
Drug abuse pptDrug abuse ppt
Drug abuse ppt
 

Ähnlich wie Treatment options for_juveniles_final

Adolescent palliative medicine
Adolescent palliative medicineAdolescent palliative medicine
Adolescent palliative medicineHilary Flint
 
juvenile delinquency
juvenile delinquencyjuvenile delinquency
juvenile delinquencyMuhammad Afiq
 
Essay On Adhd In Children
Essay On Adhd In ChildrenEssay On Adhd In Children
Essay On Adhd In ChildrenKendra Cote
 
Adolescent Mental Health Presentation (2015)
Adolescent Mental Health Presentation (2015)Adolescent Mental Health Presentation (2015)
Adolescent Mental Health Presentation (2015)Amanda Rostic, MPH
 
Child abuse and maltreatment for merge
Child abuse and maltreatment   for mergeChild abuse and maltreatment   for merge
Child abuse and maltreatment for mergeIsaac Offor
 
Responding to Mental Health Needs of HIV-Positive Pediatric Patients in Resou...
Responding to Mental Health Needs of HIV-Positive Pediatric Patients in Resou...Responding to Mental Health Needs of HIV-Positive Pediatric Patients in Resou...
Responding to Mental Health Needs of HIV-Positive Pediatric Patients in Resou...jehill3
 
Drug Abuse Resistance Education Program Analysis
Drug Abuse Resistance Education Program AnalysisDrug Abuse Resistance Education Program Analysis
Drug Abuse Resistance Education Program AnalysisErin Moore
 
Manadoob a comprehensive presentation website
Manadoob a comprehensive presentation websiteManadoob a comprehensive presentation website
Manadoob a comprehensive presentation websitemanadoob
 
5· Preventing Delinquency after DivorceArtresah Lozier, Ch.docx
5· Preventing Delinquency after DivorceArtresah Lozier, Ch.docx5· Preventing Delinquency after DivorceArtresah Lozier, Ch.docx
5· Preventing Delinquency after DivorceArtresah Lozier, Ch.docxblondellchancy
 
2Source Elrod, P., & R. Scott Ryder (2021). Juvenile justice.docx
2Source Elrod, P., & R. Scott Ryder (2021). Juvenile justice.docx2Source Elrod, P., & R. Scott Ryder (2021). Juvenile justice.docx
2Source Elrod, P., & R. Scott Ryder (2021). Juvenile justice.docxBHANU281672
 
2Source Elrod, P., & R. Scott Ryder (2021). Juvenile justice.docx
2Source Elrod, P., & R. Scott Ryder (2021). Juvenile justice.docx2Source Elrod, P., & R. Scott Ryder (2021). Juvenile justice.docx
2Source Elrod, P., & R. Scott Ryder (2021). Juvenile justice.docxlorainedeserre
 
Autonomy, Dependency, and Attainment of Young Adulthood Tasks in Individuals ...
Autonomy, Dependency, and Attainment of Young Adulthood Tasks in Individuals ...Autonomy, Dependency, and Attainment of Young Adulthood Tasks in Individuals ...
Autonomy, Dependency, and Attainment of Young Adulthood Tasks in Individuals ...beitissienew
 
elementary school suicide prevention training powerpoint.ppt
elementary school suicide prevention training powerpoint.pptelementary school suicide prevention training powerpoint.ppt
elementary school suicide prevention training powerpoint.pptEl Viajero
 

Ähnlich wie Treatment options for_juveniles_final (20)

Adolescent Development
Adolescent DevelopmentAdolescent Development
Adolescent Development
 
Ydm adolescent
Ydm adolescentYdm adolescent
Ydm adolescent
 
Adolescent palliative medicine
Adolescent palliative medicineAdolescent palliative medicine
Adolescent palliative medicine
 
juvenile delinquency
juvenile delinquencyjuvenile delinquency
juvenile delinquency
 
Risk And Protective Factors
Risk And Protective FactorsRisk And Protective Factors
Risk And Protective Factors
 
Youth with Substance Abuse by: MJAC
Youth with Substance Abuse by: MJACYouth with Substance Abuse by: MJAC
Youth with Substance Abuse by: MJAC
 
Essay On Adhd In Children
Essay On Adhd In ChildrenEssay On Adhd In Children
Essay On Adhd In Children
 
Adolescent Mental Health Presentation (2015)
Adolescent Mental Health Presentation (2015)Adolescent Mental Health Presentation (2015)
Adolescent Mental Health Presentation (2015)
 
Child abuse and maltreatment for merge
Child abuse and maltreatment   for mergeChild abuse and maltreatment   for merge
Child abuse and maltreatment for merge
 
Responding to Mental Health Needs of HIV-Positive Pediatric Patients in Resou...
Responding to Mental Health Needs of HIV-Positive Pediatric Patients in Resou...Responding to Mental Health Needs of HIV-Positive Pediatric Patients in Resou...
Responding to Mental Health Needs of HIV-Positive Pediatric Patients in Resou...
 
Drug Abuse Resistance Education Program Analysis
Drug Abuse Resistance Education Program AnalysisDrug Abuse Resistance Education Program Analysis
Drug Abuse Resistance Education Program Analysis
 
Mtsa presentation
Mtsa presentationMtsa presentation
Mtsa presentation
 
Manadoob a comprehensive presentation website
Manadoob a comprehensive presentation websiteManadoob a comprehensive presentation website
Manadoob a comprehensive presentation website
 
5· Preventing Delinquency after DivorceArtresah Lozier, Ch.docx
5· Preventing Delinquency after DivorceArtresah Lozier, Ch.docx5· Preventing Delinquency after DivorceArtresah Lozier, Ch.docx
5· Preventing Delinquency after DivorceArtresah Lozier, Ch.docx
 
2Source Elrod, P., & R. Scott Ryder (2021). Juvenile justice.docx
2Source Elrod, P., & R. Scott Ryder (2021). Juvenile justice.docx2Source Elrod, P., & R. Scott Ryder (2021). Juvenile justice.docx
2Source Elrod, P., & R. Scott Ryder (2021). Juvenile justice.docx
 
2Source Elrod, P., & R. Scott Ryder (2021). Juvenile justice.docx
2Source Elrod, P., & R. Scott Ryder (2021). Juvenile justice.docx2Source Elrod, P., & R. Scott Ryder (2021). Juvenile justice.docx
2Source Elrod, P., & R. Scott Ryder (2021). Juvenile justice.docx
 
Teenage Drug Abuse Essay
Teenage Drug Abuse EssayTeenage Drug Abuse Essay
Teenage Drug Abuse Essay
 
Substance abuse
Substance abuseSubstance abuse
Substance abuse
 
Autonomy, Dependency, and Attainment of Young Adulthood Tasks in Individuals ...
Autonomy, Dependency, and Attainment of Young Adulthood Tasks in Individuals ...Autonomy, Dependency, and Attainment of Young Adulthood Tasks in Individuals ...
Autonomy, Dependency, and Attainment of Young Adulthood Tasks in Individuals ...
 
elementary school suicide prevention training powerpoint.ppt
elementary school suicide prevention training powerpoint.pptelementary school suicide prevention training powerpoint.ppt
elementary school suicide prevention training powerpoint.ppt
 

Mehr von OPUNITE

Dr. Tom Frieden keynote
Dr. Tom Frieden keynoteDr. Tom Frieden keynote
Dr. Tom Frieden keynoteOPUNITE
 
Dr. Francis Collins keynote
Dr. Francis Collins keynoteDr. Francis Collins keynote
Dr. Francis Collins keynoteOPUNITE
 
Kana Enomoto keynote
Kana Enomoto keynoteKana Enomoto keynote
Kana Enomoto keynoteOPUNITE
 
Rx16 claad tue-vision_final
Rx16 claad tue-vision_finalRx16 claad tue-vision_final
Rx16 claad tue-vision_finalOPUNITE
 
Rx16 tpp wed_330_1_stack_2nelson_3roberts_4skinner
Rx16 tpp wed_330_1_stack_2nelson_3roberts_4skinnerRx16 tpp wed_330_1_stack_2nelson_3roberts_4skinner
Rx16 tpp wed_330_1_stack_2nelson_3roberts_4skinnerOPUNITE
 
Web rx16 prev_tues_330_1_lawal_2warren_3huddleston_4pershing
Web rx16 prev_tues_330_1_lawal_2warren_3huddleston_4pershingWeb rx16 prev_tues_330_1_lawal_2warren_3huddleston_4pershing
Web rx16 prev_tues_330_1_lawal_2warren_3huddleston_4pershingOPUNITE
 
Rx16 general session_wed_800_1_volkow copy
Rx16 general session_wed_800_1_volkow copyRx16 general session_wed_800_1_volkow copy
Rx16 general session_wed_800_1_volkow copyOPUNITE
 
Rx16 general session_900_1_botticelli
Rx16 general session_900_1_botticelliRx16 general session_900_1_botticelli
Rx16 general session_900_1_botticelliOPUNITE
 
Web rx16 prev_tues_200_1_bretthaude-mueller_2scott_3debenedittis_4cairnes copy
Web rx16 prev_tues_200_1_bretthaude-mueller_2scott_3debenedittis_4cairnes copyWeb rx16 prev_tues_200_1_bretthaude-mueller_2scott_3debenedittis_4cairnes copy
Web rx16 prev_tues_200_1_bretthaude-mueller_2scott_3debenedittis_4cairnes copyOPUNITE
 
Rx16 treat wed_330_1_barnes_2clarkolsen
Rx16 treat wed_330_1_barnes_2clarkolsenRx16 treat wed_330_1_barnes_2clarkolsen
Rx16 treat wed_330_1_barnes_2clarkolsenOPUNITE
 
Rx16 pdmp wed_330_1_hoppe_2sun_3baumgartner-leichting
Rx16 pdmp wed_330_1_hoppe_2sun_3baumgartner-leichtingRx16 pdmp wed_330_1_hoppe_2sun_3baumgartner-leichting
Rx16 pdmp wed_330_1_hoppe_2sun_3baumgartner-leichtingOPUNITE
 
Rx16 prev wed_330_workplace issues and strategies
Rx16 prev wed_330_workplace issues and strategiesRx16 prev wed_330_workplace issues and strategies
Rx16 prev wed_330_workplace issues and strategiesOPUNITE
 
Web only rx16 pharma-wed_330_1_shelley_2atwood-harless
Web only rx16 pharma-wed_330_1_shelley_2atwood-harlessWeb only rx16 pharma-wed_330_1_shelley_2atwood-harless
Web only rx16 pharma-wed_330_1_shelley_2atwood-harlessOPUNITE
 
Rx16 pdmp wed_330_1_hoppe_2sun_3baumgartner-leichting
Rx16 pdmp wed_330_1_hoppe_2sun_3baumgartner-leichtingRx16 pdmp wed_330_1_hoppe_2sun_3baumgartner-leichting
Rx16 pdmp wed_330_1_hoppe_2sun_3baumgartner-leichtingOPUNITE
 
Rx16 len wed_330_1_ferdinand_2price
Rx16 len wed_330_1_ferdinand_2priceRx16 len wed_330_1_ferdinand_2price
Rx16 len wed_330_1_ferdinand_2priceOPUNITE
 
Rx16 heroin wed_330_1_rader_2lynch-earle
Rx16 heroin wed_330_1_rader_2lynch-earleRx16 heroin wed_330_1_rader_2lynch-earle
Rx16 heroin wed_330_1_rader_2lynch-earleOPUNITE
 
Rx16 clinical wed_330_1_saunders_2wexelblatt
Rx16 clinical wed_330_1_saunders_2wexelblattRx16 clinical wed_330_1_saunders_2wexelblatt
Rx16 clinical wed_330_1_saunders_2wexelblattOPUNITE
 
Web only rx16-adv_tues_330_1_elliott_2brunson_3willis_4dean
Web only rx16-adv_tues_330_1_elliott_2brunson_3willis_4deanWeb only rx16-adv_tues_330_1_elliott_2brunson_3willis_4dean
Web only rx16-adv_tues_330_1_elliott_2brunson_3willis_4deanOPUNITE
 
Rx16 treat wed_200_group_falkinburg_miller
Rx16 treat wed_200_group_falkinburg_millerRx16 treat wed_200_group_falkinburg_miller
Rx16 treat wed_200_group_falkinburg_millerOPUNITE
 
Rx16 tpp wed_200_group
Rx16 tpp wed_200_groupRx16 tpp wed_200_group
Rx16 tpp wed_200_groupOPUNITE
 

Mehr von OPUNITE (20)

Dr. Tom Frieden keynote
Dr. Tom Frieden keynoteDr. Tom Frieden keynote
Dr. Tom Frieden keynote
 
Dr. Francis Collins keynote
Dr. Francis Collins keynoteDr. Francis Collins keynote
Dr. Francis Collins keynote
 
Kana Enomoto keynote
Kana Enomoto keynoteKana Enomoto keynote
Kana Enomoto keynote
 
Rx16 claad tue-vision_final
Rx16 claad tue-vision_finalRx16 claad tue-vision_final
Rx16 claad tue-vision_final
 
Rx16 tpp wed_330_1_stack_2nelson_3roberts_4skinner
Rx16 tpp wed_330_1_stack_2nelson_3roberts_4skinnerRx16 tpp wed_330_1_stack_2nelson_3roberts_4skinner
Rx16 tpp wed_330_1_stack_2nelson_3roberts_4skinner
 
Web rx16 prev_tues_330_1_lawal_2warren_3huddleston_4pershing
Web rx16 prev_tues_330_1_lawal_2warren_3huddleston_4pershingWeb rx16 prev_tues_330_1_lawal_2warren_3huddleston_4pershing
Web rx16 prev_tues_330_1_lawal_2warren_3huddleston_4pershing
 
Rx16 general session_wed_800_1_volkow copy
Rx16 general session_wed_800_1_volkow copyRx16 general session_wed_800_1_volkow copy
Rx16 general session_wed_800_1_volkow copy
 
Rx16 general session_900_1_botticelli
Rx16 general session_900_1_botticelliRx16 general session_900_1_botticelli
Rx16 general session_900_1_botticelli
 
Web rx16 prev_tues_200_1_bretthaude-mueller_2scott_3debenedittis_4cairnes copy
Web rx16 prev_tues_200_1_bretthaude-mueller_2scott_3debenedittis_4cairnes copyWeb rx16 prev_tues_200_1_bretthaude-mueller_2scott_3debenedittis_4cairnes copy
Web rx16 prev_tues_200_1_bretthaude-mueller_2scott_3debenedittis_4cairnes copy
 
Rx16 treat wed_330_1_barnes_2clarkolsen
Rx16 treat wed_330_1_barnes_2clarkolsenRx16 treat wed_330_1_barnes_2clarkolsen
Rx16 treat wed_330_1_barnes_2clarkolsen
 
Rx16 pdmp wed_330_1_hoppe_2sun_3baumgartner-leichting
Rx16 pdmp wed_330_1_hoppe_2sun_3baumgartner-leichtingRx16 pdmp wed_330_1_hoppe_2sun_3baumgartner-leichting
Rx16 pdmp wed_330_1_hoppe_2sun_3baumgartner-leichting
 
Rx16 prev wed_330_workplace issues and strategies
Rx16 prev wed_330_workplace issues and strategiesRx16 prev wed_330_workplace issues and strategies
Rx16 prev wed_330_workplace issues and strategies
 
Web only rx16 pharma-wed_330_1_shelley_2atwood-harless
Web only rx16 pharma-wed_330_1_shelley_2atwood-harlessWeb only rx16 pharma-wed_330_1_shelley_2atwood-harless
Web only rx16 pharma-wed_330_1_shelley_2atwood-harless
 
Rx16 pdmp wed_330_1_hoppe_2sun_3baumgartner-leichting
Rx16 pdmp wed_330_1_hoppe_2sun_3baumgartner-leichtingRx16 pdmp wed_330_1_hoppe_2sun_3baumgartner-leichting
Rx16 pdmp wed_330_1_hoppe_2sun_3baumgartner-leichting
 
Rx16 len wed_330_1_ferdinand_2price
Rx16 len wed_330_1_ferdinand_2priceRx16 len wed_330_1_ferdinand_2price
Rx16 len wed_330_1_ferdinand_2price
 
Rx16 heroin wed_330_1_rader_2lynch-earle
Rx16 heroin wed_330_1_rader_2lynch-earleRx16 heroin wed_330_1_rader_2lynch-earle
Rx16 heroin wed_330_1_rader_2lynch-earle
 
Rx16 clinical wed_330_1_saunders_2wexelblatt
Rx16 clinical wed_330_1_saunders_2wexelblattRx16 clinical wed_330_1_saunders_2wexelblatt
Rx16 clinical wed_330_1_saunders_2wexelblatt
 
Web only rx16-adv_tues_330_1_elliott_2brunson_3willis_4dean
Web only rx16-adv_tues_330_1_elliott_2brunson_3willis_4deanWeb only rx16-adv_tues_330_1_elliott_2brunson_3willis_4dean
Web only rx16-adv_tues_330_1_elliott_2brunson_3willis_4dean
 
Rx16 treat wed_200_group_falkinburg_miller
Rx16 treat wed_200_group_falkinburg_millerRx16 treat wed_200_group_falkinburg_miller
Rx16 treat wed_200_group_falkinburg_miller
 
Rx16 tpp wed_200_group
Rx16 tpp wed_200_groupRx16 tpp wed_200_group
Rx16 tpp wed_200_group
 

Kürzlich hochgeladen

Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 
Microbiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptxMicrobiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptxkitati1
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisSujoy Dasgupta
 
The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?Ryan Addison
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu Medical University
 
Pregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfPregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfMedicoseAcademics
 
General_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingGeneral_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingAnonymous
 
World-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptxWorld-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptxsumanchaulagain3
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 
concept of total quality management (TQM).
concept of total quality management (TQM).concept of total quality management (TQM).
concept of total quality management (TQM).kishan singh tomar
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE Mamatha Lakka
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...Ganesan Yogananthem
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfHongBiThi1
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 
Physiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisPhysiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisNilofarRasheed1
 

Kürzlich hochgeladen (20)

Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 
Microbiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptxMicrobiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptx
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosis
 
The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?
 
Cone beam CT: concepts and applications.pptx
Cone beam CT: concepts and applications.pptxCone beam CT: concepts and applications.pptx
Cone beam CT: concepts and applications.pptx
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu
 
Pregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfPregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdf
 
General_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingGeneral_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_Wellbeing
 
World-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptxWorld-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptx
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 
concept of total quality management (TQM).
concept of total quality management (TQM).concept of total quality management (TQM).
concept of total quality management (TQM).
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 
Physiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisPhysiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid Arthritis
 

Treatment options for_juveniles_final

  • 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  
  • 17. What  are  our  children  using  to  get   high?  
  • 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.  
  • 48. IntegraUng  Relapse  PrevenUon   Pharmacotherapy  into  Treatment  of  Opioid   Dependence  for  Youth  
  • 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?”)  
  • 50. Past Year Use Prevalence: 8th and 12th Graders (MTF) 1.8   1.6   8th  Graders   12th  Graders   1.4   1.2   Percent   1   0.8   0.6   0.4   0.2   0   '91   '92   '93   '94   '95   '96   '97   '98   '99   '00   '01   '02   '03   '04   '05   06   07   08   09   hcp://www.monitoringthefuture.org/pubs/monographs/overview2009.pdf    
  • 51. MTF:  Annual  Use  Prevalence  12th  Graders   10   12th  Graders   8   Percent   6   4   2   0   '91   '92   '93   '94   '95   '96   '97   '98   '99   '00   '01   '02   '03   '04   '05   06   07   08   09   hcp://www.monitoringthefuture.org/pubs/monographs/overview2009.pdf    
  • 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  
  • 55. 100 90 Full Agonist 80 (Methadone Heroin, oxycodone) Intrinsic Activity 70 60 Partial Agonist 50 (Buprenorphine) 40 30 20 10 Antagonist (Naloxone) 0 -9 -8 -7 -6 -5 -4 Log Dose of Medication
  • 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  
  • 62. XR-­‐NTX  Maintenance   •  Monthly  injec+ons   •  Expecta+on  of  counseling  acendance   •  Asser+ve  dosing  reminders  
  • 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%
  • 77. Youth  opioid  treatment  chart  review   Medica+on  treatment   Treated with: Any medication 61% Buprenorphine 39% Extended release naltrexone 19% Oral naltrexone 3% No medication 39%
  • 78. Cumula+ve  reten+on  over  26  weeks     by  medica+on   26   24   subsequent    cumula+ve  reten+on   22   1st  episode  reten+on   20   subsequent    cumula+ve  reten+on   *   *   18   *   15.8   15.9   16   15.3   14   4.9   5.5   5.4   12   10.3   10   8   2.5   6   11   10.3   9.9   4   7.8   2   0   Any  medica+on   XR-­‐NTX   Buprenorphine   No  medica+on   *  =  p    0.01  compared  to  no  medica+on  
  • 79. Reten+on  by  medica+on   *   *   *  
  • 80. Opioid-­‐free  weeks  over  26  weeks    by  medica+on   Combining  urine  and  self  report   Opioid  free  weeks,  during  intake  to  week  26,  n  =  133   26   24   22   20   18   16   14   *   *   *   12   10   8   6   13.7   11.5   10.6   4   7   2   0   Any  medica+on   XR-­‐NTX   Buprenorphine   No  medica+on   *  =  p    0.01  compared  to  no  medica+on  
  • 81. Cumula+ve  reten+on  Propor+ons   1   0.9   Meds   0.8   No  meds   0.7   0.6   0.5   0.4   0.3   0.2   0.1   0   1   2   3   4   5   6   7   8   9   10   11   12   13   14   15   16   17   18   19   20   21   22   23   24   25   26  
  • 82. Cumula+ve  Opioid  Nega+ve  Urines   Opioid Negative Urines 100% 90% 80% XR-NTX Buprenorphine % of Patients 70% No Meds 60% 50% 40% 30% 20% 10% 0% Wks 1-4 Wks 5-8 Wks 9-12 Wks 13-16 Wks 17-20 Wks 21-24 Weeks of Treatment
  • 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  
  • 91. Pharmacological  Treatment   •  Ques+on:   –  Which  is  becer  -­‐  medica+ons  or  counseling?   •  Answer:   –  Yes  
  • 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)