S U B STA N C E U S E – W H E N YO U ’ R E R EA DY TO C H A N G E BRING BALANCE TO YOUR LIFE A PERSONAL WELLNESS SOLUTION FROM NEW DIRECTIONS © New Directions Behavioral Health, LLC March 2008 Table of Contents Introduction........................................................................................................ 3
Section 1 ‐ Understanding Substance Use Disorder ................................................ 4
Section 2 ‐ I Think I Have a Problem ...................................................................... 9
Section 3 – Getting Ready to Change .................................................................. 14
Section 4 ‐ What about Detox? ........................................................................... 18
Section 5 ‐ Different Types of Help ..................................................................... 22
Section 6 ‐ Families in Recovery ......................................................................... 24
Section 7 ‐ Children and Alcohol ......................................................................... 27
Summary .......................................................................................................... 31
Appendix I ‐ Commonly Misused Substances....................................................... 32
Appendix 2 ‐ The Dangers of Prescription Drug Abuse ......................................... 36
Resources ......................................................................................................... 38 2
Introduction Congratulations! Your decision to read this guidebook means that you realized the health and personal dangers of problem drinking or drug use. As you move through the guidebook, you’ll discover whether you’re ready to make a change and learn ways to put information into action. If you’re still unsure about whether you want to change, this guidebook may start you on the road to learning more about substance use disorders. We’ve written this guidebook to help you develop the confidence that change is possible. If you’ve tried to stop or reduce your substance use before without success, it’s important to remember that every time you take action, you’re more likely to achieve your goal. Our goal is to give you reasons to hope that this time will be the time! The material in this guidebook combines medical, psychological, and practice information. For example, once you know the signs and symptoms of substance use disorder, you’ll be offered structured exercises to help you decide for yourself whether this applies to you. But please note that this guidebook cannot take the place of medical attention. It’s best to have a full evaluation from a physician, psychologist, or psychotherapist experienced with substance use disorders. Creating a healthcare team for yourself and being guided by them will often accelerate your progress in recovery. If you are reading this manual because of concerns for a loved one, including a youngster, we have added information about the role of families in recovery. While it’s not possible to change another person, it is possible to learn as much as you can in order to provide the encouragement for change and to be prepared to do your part when your loved one shows readiness to take action. Thank you for taking the time to read this manual. Gathering information and self‐awareness is an important step in addressing your questions about substance use. We hope this guidebook will prove useful to you. 3
Section 1 ‐ Understanding Substance Use Disorder Everyone says I’ve got to change. How do I know if they’re right? Gathering information about a problem is often the first step in addressing that problem. Whether the problem is diabetes, heart disease, depression, or substance use disorder, getting good information gives you power. Substance use disorder … like the other illnesses mentioned above … is complex and often requires a multifaceted solution. But first, what is substance use disorder? The National Institute for Alcohol Abuse and Alcoholism (NIAAA) states: “Alcoholism is a disease. The craving that an alcoholic feels for alcohol can be as strong as the need for food or water. An alcoholic will continue to drink despite serious family, health, or legal problems.” The Centers for Disease Control defines alcoholism in a similar way: “Alcoholism or alcohol dependence is a diagnosable disease characterized by several factors including a strong craving for alcohol, continued use despite harm or personal injury, the inability to limit drinking, physical illness when drinking stops, and the need to increase the amount drunk in order to feel the effects.” Note that both SAMHSA1 and the DSM2 also use many of the concepts that define alcohol use disorder to define a drug use disorder, such as dependence on cocaine or methamphetamine. Signs of Substance Use Disorder Like all diseases, substance use disorder has its warning signs. Knowing what these are may help you identify whether your use of substances may need to be addressed. • Planning life around the substance • Neglecting other areas of life, including work and relationships • Acting secretive, sometimes because of shame but more often to protect the ability to get the substance Substance Abuse and Mental Health Services Agency
Diagnostic and Statistical Manual of Mental Disorders used by physicians and behavioral health professionals to diagnose alcoholism and
drug abuse
1
2
4
•
•
•
•
Denying the problem when confronted Trying to stop using without success Insisting “I can stop whenever I want to!” Blaming others or events for using the substance Symptoms of Substance Use Disorder Substance abuse consists of one or more of the following problems during a one year period: • Problems at home or at work • Substance use in dangerous situations • Problems with the law because of alcohol use • Continued use when someone close to you asks you to stop Substance dependence consists of three or more of the following problems during a one year period: • Using more and more of the substance to get the same effect • For alcohol use disorder, physical withdrawal symptoms, like the shakes, nausea or weakness • Using more than you wanted to use • Trying to cut down or quit using the substance, but can’t • Giving up things you like to do because of your using • Using even when you know it hurts you How Much is Too Much? Take stock of your use of substances. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) suggests that moderate drinking for women consists of no more than one drink a day. Moderate drinking for men is no more than two drinks a day. The difference is based on the differences between the genders in both weight and metabolism. If you are using illicit substances, remember that they’re against the law for a reason. At the very least, you risk legal difficulties. What Counts as a Drink? ‐ 12 ounces of regular beer ‐ 5 ounces of wine ‐ 1.5 ounces of 80 proof distilled spirits 5
Screening Tests The CAGE screening test was designed to screen adults for alcohol problems. It cannot be used to diagnose, but only suggests that a disorder may be present. • Have you ever felt you ought to CUT down on your drinking or drug use? • Do you get ANNOYED at criticism of your drinking or drug use? • Do you ever feel GUILTY about your drinking or drug use? • Do you ever take an EARLY morning drink (eye‐opener) or use drugs first thing in the morning ("a little hair of the dog that bit you") to get the day started or to eliminate the "shakes"? A person who answers "yes," "sometimes," or "often" to 2 or more of the questions may have a problem with alcohol. The AUDIT questionnaire was developed by the World Health Organization (WHO) to identify persons whose alcohol consumption has become hazardous or harmful to their health. To take the AUDIT online, visit http://www.alcoholscreening.org/. This site will score your questionnaire and provide you with advice about any needed next steps based on the results. Important Facts to Know A great many people use substances without experiencing problems. But how many people experience difficulties with alcohol and/or illicit drugs? Consider these 2006 statistics from Substance Abuse and Mental Health Services Administration: • 17 million American adults are heavy drinkers; about 6.9% of the adult population. • 57 million American adults are binge drinkers, about 23% of the adult population. • About 10.3 percent of youth (ages 12‐17 years) binge drink • About 2.4 percent of youth report heavy drinking • About 12.4 percent of American adults drove under the influence of alcohol at least once in the past year. • Sons of alcoholics have a 25% risk of becoming dependent on alcohol, whether raised with the alcoholic or not. • Alcohol dependence reduces life expectancy by ten to twenty years. 6
•
•
•
More people began using pain relievers for non‐medical reasons than any other illicit drug, about 2.2 million people age 12 or older. About 7.0 million (2.8 percent) people aged 12 or older used prescription‐type psychotherapeutic drugs non‐medically in the past month. Of these, 5.2 million used pain relievers. Marijuana was the most commonly used illicit drug. About 14.8 million people used it in the month preceding the survey. A Genetic Link? It is generally accepted that a significant portion of risk to develop alcoholism and other forms of substance abuse is due to inheriting some genes that make a person susceptible to becoming addicted to alcohol. Adoption studies and twin studies show that this is true for about 25 percent of children of alcoholic fathers. If both parents are alcoholics, the risk is estimated to be 75 percent. In April 2006, the NIAAA issued a press release stating that researchers had identified new genes that may contribute to excessive alcohol use. Working with nine different strains of mice with various inclinations to consume alcohol, they uncovered 4,000 genes that differed between the high alcohol and low alcohol intake mice. Using statistical techniques, they narrowed the field to 75 genes that may be implicated in whether a mouse will drink more or less. It’s important to understand that, although genetic research relating to substance use disorders is progressing, a definitive answer is not yet available. Biology isn’t destiny. While some people may have risk factors that make them more vulnerable to developing a substance use disorder, it’s possible to reduce the risk by abstaining from alcohol or drugs. A person cannot become alcoholic or drug addicted unless exposed to alcohol or drugs. What is the chance that you will develop a problem with alcohol? Consider the drinker’s pyramid on the next page to see the risk in the general population: 7
The Drinkers’ Pyramid
Dependent Drinkers
At-Risk Drinkers
Responsible Drinkers
Abstainers
Summary
Substance use disorders affect a large number of people in our society. Dependence on substances can create difficulties for people by affecting their health, interfering with their ability to work, disrupting relationships, and creating financial and legal difficulties. If you believe you may have a problem with substances, Section 2 will help you evaluate your readiness to change. 8
Section 2 ‐ I Think I Have a Problem The first step in any type of behavior change is to ask about your state of readiness. Ask the question: How much do I want to change? To answer it, give yourself a score from 1 to 10 with 1 being “not at all” and 10 being “start today.” One aspect of whether a person is ready and motivated to change has to do with their view of the problem. If you drink or use illicit drugs, how serious do you think your problem has become? Answer this in two ways: 1. Rate the seriousness of the problem on a scale from 1 to 10, with 1 being “not at all serious” and 10 being “extremely serious.” My score__________ 2. List the problems that you have encountered as a result of drinking or drugging, including problems on the job, in relationships, financial and legal problems, and problems that involve chaotic living. Give yourself a score of “1” for each item you list and then add for your total score. My score__________ 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Do You Want to Drink or Use Less? If you scored more than 5 in both areas in the above exercise, or higher than 6 in one or both, you may be ready to make some changes. If you scored less, you may not have a problem or you may not be ready to change. If you suspect that you’re not ready to change, skip this exercise and go to the next section, “Getting Ready to Change.” 9
If you feel that you are ready to change, the following exercises can help you develop an abstinence or “drink less” plan. This approach is also useful for many other types of lifestyle behavior changes, such as smoking cessation or improved nutrition and fitness. List your reasons for wanting to change. Think about your health, your daily habits such as sleep, your relationships, your job. Maybe you’re concerned about a medication interaction with alcohol or other drugs. Maybe you’ve experienced legal problems. Whatever the reasons for change, list them here: 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
List your reasons to continue drinking or using drugs. What will you lose if you make this change? Consider how substance use makes you feel. What will you do with your time if you’re not using? What about your social circle – will you lose friends if you give up or reduce drinking or drugging? 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 10
List What You Know You already have information about how to make a change in your use of substances. This information may have come to you from many places, including books you’ve read, experiences you’ve had, information you’ve gathered from TV or the Internet. On the following page, list what you believe you already know about abstinence or limiting use of substances. Think in terms of “how to.” 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Use Your Tools to Set a Goal Make a plan to limit or eliminate use of substances. Consider the following steps in goal setting: 1. When will you start to make the change? Set a date to begin and expectations for that date. How much will you drink on that date if anything? 2. What resources do you have for making the change? Think about changes you’ve made in the past and what has helped you. 3. What support do you have for making the change? Who will help you? Who do you trust to give you encouragement and a boost when needed? 4. What might get in the way of making this change? An old Alcoholics Anonymous saying HALT: never get too hungry, angry, lonely or tired. These issues, plus other types of stresses often get in the way of change. 5. Who might sabotage your attempt to change? The question can usually be answered if you have drinking or drugging buddies. Sometimes, your family can get in the way of change. See the section on Families later in this guidebook. 6. What’s your plan to keep moving toward change? This may include small rewards for small victories, taking the change one day (or one hour) at a time, or making social or environmental changes to help you succeed. 11
Use this chart to set your goal: When will I start making the change? What resources do I have for making the change? What support do I have for making the change? What might get in the way of change? Who might sabotage my attempt to change? What’s my plan to keep moving in the direction of change? 12
Jot down which of the above steps you would be prepared to take today to get ready for change. What will you do to achieve a small step toward the goal of readiness? Today’s Date My Goal To Accomplish My Goal, I will Take the Following Steps 13
Section 3 – Getting Ready to Change Not everybody that feels a need to make a change is ready to change. While you may see how drinking or drugging interferes with your life and adds unwanted problems, you may not be ready to change these behaviors. At times, people can feel guilty about not changing, putting them under stress. The more stress they feel, the harder it is to consider a change. This is a “Catch‐22” or “vicious cycle.” I Can’t Change
I Must Change
Guilt and Stress
If you feel that you are “caught” in the cycle of inability to change, several different approaches may be especially helpful to you. Consider trying one or more of the following: Get more information. You will find basically two types of useful information about substance use disorders: • Reasons to change • How to change While you may already have a whole list of reasons to change – maybe given to you by others – you may not think they’re good reasons. Most people, when they’re thinking about a change, need to do a little research themselves and find out what reasons seem good to them. 14
Until you’ve looked at the implications of continuing to use substances, you may not find a “sufficient” reason to change. For some, understanding the long‐term health effects can have a powerful impact. For others, especially those already skirting legal and financial problems, getting the facts about how, for example, your money situation can improve may make sense. Information is power. Even if you decide not to do anything now with the information you put together, it may come in handy at a later time. This is especially true of learning how people change. What do others say about getting sober and staying in recovery? A number of books have been written to give just that type of information, including: • The Harder They Fall: Celebrities Tell Their Real‐Life Stories of Addiction and Recovery, Gary Stromberg, Jane Merrill 2007 • A Bar On Every Corner: Sobering Up in a Tempting World, Jack Erdmann, Larry Kearney, 2001 • Clean: A New Generation in Recovery Speaks Out, Chris Beckman, 2005 • Hit by a Ton of Bricks (Family Issues), John Vawter, 2003 • The Enabler: When Helping Hurts the Ones You Love, Angelyn Miller, 2001 If you are thinking about abstinence, you may want to look at the information offered by one of the 12‐Step Programs such as Alcoholics Anonymous. 15
Change Your Environment Sometimes, people continue behaviors like using because they’re around people who use substances or because they’re experiencing difficult life circumstances. When your environment changes, the root cause of your substance use may decrease, making you feel as though change is possible. While not all environmental factors can be changed, take time to list those you believe you can influence and develop a plan to do so. People, Places, and Situations How I Can Avoid Them If I Can’t Avoid Them, How Can that Trigger Substance Use I Minimize the Impact on Me? 16
Control Your Stress Learn to improve your stress management skills. Life is full of stress, both everyday demands and unexpected changes and loss. Using substances to feel better, to relax or sleep can lead to chemical dependency and the problems that come with it. A better solution is to learn how to control your reactions to stress. Begin with the basics – improve nutrition, exercise every day, get enough rest, and keep your environment quiet and clutter‐free. You may also be interested in some of the relaxation, cognitive behavioral, and resiliency building techniques offered in the following books: The Relaxation & Stress Reduction Workbook, Martha Davis, Matthew McKay, Elizabeth Robbins Eshelman, 2000 Freedom from Stress: How to Take Control of Your Life, David and Karen Gamow, 2006 The End of Stress as We Know It, Bruce McEwen, 2001 Special Stress Resources If you are a young person who has served (or currently serving) in the military, you may have the same vulnerability to using substances that some veterans of the Viet Nam war experienced. You may be interested in taking a look at two books that speak to building resiliency and the importance of controlling stress: U.S. Army Combat Stress Control Handbook, Department of the Army, 2003 Deep Survival, Laurence Gonzales, 2003 Professional Evaluation A professional evaluation can answer some questions for you. By going through the evaluation process, you will gain from another person’s perspective about your situation. You may learn that your substance use is nothing to worry about; you may learn that your use is more serious than you thought. A licensed specialist in the area of alcohol or drug use disorders can help you understand your unique situation and support you through the “get ready to change” process. For a referral, contact employee assistance program or health plan.
17
Section 4 ‐ What about Detox? Learn from this noted addictions expert about the first stage of recovery. We interviewed Jan Campbell, MD, a board certified psychiatrist and board certified addictions psychiatrist with over 20 years working in the field of addictions. Dr. Campbell leads research teams and has published more than 25 articles and abstracts based on her research. In 2001 she received the COMBAT Research Award. She teaches medical students and residents, and currently is Director of the Addiction Fellowship at Kansas University Medical Center, a new initiative at KU. Dr. Campbell also serves as Medical Director of Quality Improvement for New Directions Behavioral Health. NDBH: Dr. Campbell, what is detoxification? DR. CAMPBELL: Detoxification is the process of safely and effectively discontinuing excessive use of drugs or alcohol. The process involves tapering – or gradually reducing ‐‐ the substance or substituting a medication that will reduce the symptoms and signs of withdrawal. Detox usually takes 3 to 7 days, depending on the severity of the substance use. NDBH: You say “use” rather than “abuse” or “dependence.” Is there a reason for that? DR. CAMPBELL: I’m glad you brought that up. Whether you say “use” or “abuse” the real problems to be addressed have to do with the impact of the substance on the person’s life and relationships. The goal for recovery is to get the person back to a healthy lifestyle. NDBH: So does everyone who uses alcohol or drugs need detox? DR. CAMPBELL: No. The primary concern when someone stops using a substance is whether that person develops symptoms. Some symptoms can be dangerous, especially when withdrawing from alcohol use. NDBH: What makes alcohol withdrawal so dangerous? DR. CAMPBELL: When a person stops using alcohol there’s the danger of developing seizures and delirium tremens – a group of symptoms that include confusion, hallucinations, fever, hyper‐responsiveness, hypertension and tachycardia. These symptoms carry a 15% mortality rate, which is unfortunate because alcohol detox is a fairly straightforward process. There’s no reason for not seeking medical attention. NDBH: How would someone know they need medical attention? 18
DR. CAMPBELL: Think of it this way. A person has had a night of heavy drinking, wakes up feeling shaky – having tremors – and gets rid of the tremors simply by taking another drink. Tremor and fast heart rate are the early signs of physical withdrawal. In some people, these symptoms become worse and sometimes lead to seizures. Usually, seizures occur 36 to 48 hours after a person stops drinking. NDBH: And medical detox can prevent this? DR. CAMPBELL: Absolutely. We use Benzodiazepines – Valium, Librium, Ativan or Serax. This group of medications protects the brain during withdrawal and prevents the worst of withdrawal symptoms. NDBH: So if someone wakes up in the morning after drinking and has the shakes, he or she should seek medical attention? DR. CAMPBELL: Yes, it’s a good sign that alcohol has begun to cause physical damage NDBH: What about other drugs? After alcohol, what’s the most commonly used drug you see needing detox? DR. CAMPBELL: In the Kansas City area, probably cocaine. The difference is that withdrawal from cocaine is more behavioral and less physical. Someone in cocaine withdrawal may feel guilty, irritable and dysphoric at the same time. The risk is that the person will become suicidal, and sometimes the impulse is so strong that a suicide attempt results. NDBH: So suicide is the major risk? DR. CAMPBELL: Another risk is craving for cocaine. This can get very severe and many people can’t protect themselves from returning to use. For both these reasons – suicide and cocaine – being around other people in a safe place, even a non‐medical or social detox, works. NDBH: What other kinds of drugs cause withdrawal problems? DR. CAMPBELL: One that we are more and more concerned about is opiate detox. This includes people who are taking pain medications for true indications as well as individuals who use street drugs. If you take opiates continuously for as little as two weeks, you can end up with physical withdrawal symptoms even if you are not psychologically dependent on the medication. NDBH: What drugs are considered opiates? DR. CAMPBELL: Percocet, Dilaudid, morphine, methadone, and Oxycontin are frequently prescribed opiates. Heroin is the most abused illicit opiate. If a person has taken a narcotic 19
medication for pain control continuing for two weeks or more, and if the medication is suddenly stopped, the person will start to experience withdrawal. EAP: What’s involved in opiate withdrawal? DR. CAMPBELL: This kind of withdrawal is simply miserable. You start with anxiety ‐‐ you find it hard to rest and relax. Then you have sweating, nausea, diarrhea, and vomiting. Next – insomnia, muscle and joint aches, like having severe flu. NDBH: It sounds terrible. But can you die from it? DR. CAMPBELL: No, opiate withdrawal doesn’t cause seizures, delirium or any other life threatening symptoms. The problem is that people become so miserable that they just don’t get through it. They go back to using again. Combine this level of misery with cravings, and most opiate dependent people simply can’t control drug use. Most people need medication, support, and protection during the acute stage of withdrawal – this takes about 7 to 10 days to complete. The chronic withdrawal phase – that can take up to 6 months of anxiety, insomnia and body aches. The best treatment is buprenophine (Suboxone) that can be continued as long as it’s needed, sometimes several months or years. NDBH: Getting support would be important during that time. DR. CAMPBELL: Yes, support is critical to getting through opiate withdrawal without giving into the cravings and trying to relieve the misery by using again. NDBH: What about methamphetamine? We hear a lot about that drug. DR. CAMPBELL: This drug is a lot like crack cocaine. It can lead to paranoid psychosis – sometimes with auditory and visual hallucinations. In withdrawal, the person sometimes acts the opposite of how he acts when using. So for example, someone who is hyperactive when using might be inert during withdrawal. NDBH: Inert? Like not moving? DR. CAMPBELL: More than that. The person can’t concentrate, can’t think, can’t put thoughts together. After withdrawal, we usually find out that a person is completely different – maybe bright or funny. If a person uses meth heavily, it can cause irreversible brain damage. NDBH: So this is really a case of “your brain on drugs” like the TV commercial. DR. CAMPBELL: Yes. And speaking of your brain, another drug that we’re concerned about is ecstasy. It’s here. Kids are using it. The message from the scientific community is that it destroys brain cells with the first use, and each progressive use destroys more. 20
NDBH: But the person who stops using can recover, right? DR. CAMPBELL: Unfortunately, we’re not so sure of that. Brain damage may not be reversible. Studies with monkeys show that after taking ecstasy, they lose functional abilities at about the same time that you see reduced brain activity. When you look at these animals six months later, the brain activity hasn’t increased. NDBH: So ecstasy could turn out to be a real problem. DR. CAMPBELL: More than just ecstasy. The high from ecstasy only lasts 3 or 4 hours. What we’re starting to see is multiple drug use – methamphetamine combined with ecstasy combined with alcohol. This causes multiple brain insults. NDBH: You might say the message is “don’t use drugs.” DR. CAMPBELL: It’s important to remember that many drugs have a role to play in medical treatment. What I’d say instead is there’s always a risk involved in ingesting an unknown substance, because the people who sell these drugs are not known for ethical behavior. In addition to the risk of the drug itself, there’s also the risk of whatever the local drug dealer put in it to increase the quantity. NDBH: What about people who are using alcohol or prescription drugs? DR. CAMPBELL: If you’re using a prescription drug or alcohol, and you have any concerns about symptoms between doses or when you quit using, you may need medical assistance to quit. See your doctor. NDBH: It seems we covered the field! DR. CAMPBELL: We did leave out one drug. Marijuana. You know, a variety of psychological risk factors come with marijuana use. But one of the things most people don’t think about is the damage done to the lungs from inhaling an environmental weed, one that may be full of pesticides, PCP, formaldehyde, and dank – also known as embalming fluid. NDBH: What final words would you have for readers? Dr. Campbell: Know your risks for dependence on alcohol, and stay away from illicit drugs. And if you have a problem with drugs or alcohol today, seek medical assistance to stop using. NDBH: That’s a great message to end on. Thank you, Dr. Campbell, for taking the time to give us this interview and this good information. 21
Section 5 ‐ Different Types of Help Once a person has stopped using, what happens next in the recovery process? Clinicians tend to agree that a single, simple approach to treatment doesn’t exist. Substance use disorders are complex, and treatment must be individualized. Following are several different types of self‐help and treatment resources that may be considered: Alcoholics Anonymous and Narcotics Anonymous AA and its spin‐offs, NA (Narcotics Anonymous) and CA (Cocaine Anonymous), are self‐help groups with approximately 100,000 to 200,000 members. AA was started on June 10, 1935 by Dr. Bob. He was soon joined by Bill W. These founders of AA came up with the now famous 12‐steps that starts will an admission of lack of control over alcohol. The official AA site still says: We who are in A.A. came because we finally gave up trying to control our drinking. We still hated to admit that we could never drink safely. Then we heard from other A.A. members that we were sick. (We thought so for years!) We found out that many people suffered from the same feelings of guilt and loneliness and hopelessness that we did. We found out that we had these feelings because we had the disease of alcoholism. AA operates from the premise that only total abstinence will allow the alcoholic to stay in “recovery.” Narcotics Anonymous takes the same approach. Other groups formed around AA, including: • Al‐Anon for the spouses of alcoholics • Ala‐Teen for the adolescent and now pre‐adolescent children of alcoholics • Adult Children on Alcoholics (ACOA) for adults attempting to overcome the long‐term effects of growing up in an alcoholic home Intensive Outpatient Program (IOP) IOPs include education, group therapy, and family involvement in the treatment of substance use. Depending on the IOP, AA or NA may be used as an adjunctive therapy. Getting good information, group therapy with others who have similar problems, and including your family or other support system in the treatment process will enhance your confidence in your ability to change. Integrated group therapy for substance use disorders build awareness, commitment to change, and can be especially helpful in concrete areas, such as a focus on relapse prevention strategies and everyday 22
coping skills. Medication and Cravings Management Individuals with questions about their substance use may want to talk with their physician about medications to help in craving management. In recent years, certain medications have been shown useful in reducing cravings, or the urge to use substances. The physician may need special qualifications or experience to prescribe some of these medications. Although these new medications help people with cravings management, most studies indicate that medication alone is not as effective as medication combined with talk therapy. Cravings management depends on a number of interrelated factors, such as: • Self‐efficacy or a person’s confidence in his/her ability to handle a given situation • Expectations about the future • Cues for substance use in the environment, such as the availability of alcohol • Degree of motivation or how much a person focuses on the positives of change • Coping skills to manage stress, temptation, and impulsive behavior • Emotional states, especially feeling blue or depressed • Social supports to stop using substances A psychotherapist may provide help in all these areas or may recommend group treatment similar to that mentioned above. 23
Section 6 ‐ Families in Recovery When one member of a family uses alcohol or drugs, the whole family shares the problem. Research shows that when a family member abuses alcohol or drugs, everyone in the family suffers. For example, studies conducted in the 1990’s at University of Buffalo’s Research Institute on Addictions and Medical School found that “…chaotic home environments, when compared with non‐alcoholic homes, [were] often characterized by negative parenting behaviors.” While controversy exists about the long term effects of growing up in an alcoholic family, here are some findings to consider: • 50 to 60 percent of all alcoholics have at least one alcoholic parent • 90 percent of child abuse cases involved alcoholism • Children with alcoholic parents are twice as likely to become alcoholics as adults when compared with children from non‐alcoholic homes • Children from alcoholic, multi‐problem families are more likely to have problems with finances, employment and relationships We can point to four areas of “dysfunction” in alcoholic or drug abusing homes. Depending on the number of other problems in the family, these characteristics may be more or less serious. Communication Communication between parents and children in alcoholic homes often results in mixed messages. For example, a parent who drinks may pay attention to children when sober, only to ignore them when drinking. Children don’t see the alcoholic parent as responsible for the inconsistency. Instead, children will strive to gain consistent attention whether the parent is drinking or not. Failure leads children to have low self esteem. Emotions and Beliefs Emotions and beliefs are discounted in alcoholic homes. Children often get the message that expression of negative emotions such as anger or sadness may upset the alcoholic or drug user and “cause” the parent to use. The non‐using spouse is typically too preoccupied with taking care of the user and the consequences of use to help validate feelings and beliefs of the children. In addition, the non‐using spouse may be exercising tremendous control over personal negative emotions in order to “keep on keeping on.” 24
Rules and Roles Rules and roles in alcoholic homes are often inconsistent. Rules may change depending on the mood or lack of sobriety of the user. What was okay yesterday may not be okay today. As for roles, many children act as parents, picking up adult responsibilities such as housework or even earning money to help the family. Family Identity Family identity in alcoholic homes is often lacking. There may be little sense that family members are connected. Time spent together as a family may be minimized and family rituals – holiday meals, for example – may be spoiled by the behavior of the user. Recovery for the family Recovery that focuses only on helping the user to become abstinent fails the family. Without intervention, family members simply keep on following the three, dysfunctional “rules” that appear common in families affected by substance abuse. The “rules” are don’t trust, don’t talk, and don’t feel. What’s the answer? Any good recovery program – whether medical or community based – should include a strong family component. Intervention with the user’s spouse and children helps to realign the family roles and rules in the family, and improve communication. http://www.al‐anon.alateen.org/ provides guidance and support to families affected by alcoholism and alcohol abuse. When You’re Trying to Change a Loved One One important aspect in the area of treating alcohol and drug use disorders is the concept of “ambivalence.” Simply defined, ambivalence means that a person has positive and negative thoughts and feelings about a situation or change. Remember, for example, how you felt when you graduated high school. You probably felt happy about your achievement and also felt more than ready to move on to the next stage of your life. At the same time, you may have felt sad about leaving friends and familiar surroundings, along with some fear about the future. When people feel ambivalence about making an important change, like beginning recovery from substance use, they go back and forth about whether to take action. They can say that they plan to take action today, only to have their resolve disappear tomorrow. While a lot of reasons play into ambivalence, including the complicated workings of physical and psychological dependency, one way to strengthen a person’s refusal to change is for a loved one to take the “positive” side of change. 25
When faced with “you should change because…” people have a tendency to get stuck on the “I’m‐not‐changing” side of ambivalence. The person may become defensive and argumentative or even angry. While you may know all the good reasons for your loved one to take action, the readiness to change needs to come from inside each individual. It can’t – and won’t – come from you. That doesn’t mean you can’t speak your mind. It’s important to say things like, “I’m worried about your health if you keep drinking” or “I’m concerned about how much time you’ve missed at work because of being high.” But while expressing your care and concern, it makes sense to also emphasize your loved one’s personal responsibility to take action. When a person feels troubled by a loved one’s behavior, it sometimes helps to get advice from a third party. A professional in the area of treating substance use disorders, especially one trained in motivational techniques for change, may be able to provide both fresh perspective and techniques for helping a loved one move into readiness. You can also find more information about motivating loved ones to change in the following: • Changing for Good: A Revolutionary Six‐Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward, by James O. Prochaska, John Norcross, and Carlo DiClemente, 1995 • Addiction and Change: How Addictions Develop and Addicted People Recover, by Carlo DiClemente, 2006 • Addiction: Why Can't They Just Stop? by Susan Cheever, John Hoffman, Susan Froemke, and Sheila Nevins, 2007 26
Section 7 ‐ Children and Alcohol Substance use often starts in the pre­teen or teen years. What can parents do to help prevent problems? The following article was adapted from www.recoverymonth.gov Alcohol and drug use disorders can isolate children and adolescents from their friends, family, and community. Once a child starts drinking or using, it becomes difficult to lead a normal, healthy childhood. The Scope of the Problem Youth is a time of experimentation and learning about yourself and your society— and many young men and women who are exposed to drugs and alcohol give in to curiosity or peer pressure with potentially damaging results. The 2002 National Survey on Drug Use and Health conducted by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) found: • Among youths ages 12 to 17, 11.6 percent are illicit drug users, and 19.3 percent • 7.2 million of youths ages 12 to 20 are binge or heavy alcohol drinkers. • One in 5 youths ages 12 to 17 has used marijuana. • Cocaine has been used by 2.7 percent of youths ages 12 to 17. • More than 11 percent of youths have used prescription pain relievers non‐medically. Studies show that the younger a person begins using drugs or alcohol, the greater the chance that he or she will develop an alcohol or drug use disorder that will carry on into adulthood. Other risk factors for developing dependence on drugs or alcohol include family history of alcohol and drug use disorders, early aggressive behavior, lack of parental supervision, drug availability, and poverty. But there are positive signs that many young people are making smarter health decisions. Statistics show that use of marijuana, Ecstasy, LSD, cigarettes, and alcohol decreased significantly from 2001 to 2003 among 8th, 10th, and 12th grade students in U.S. schools, according to the National Institute on Drug Abuse's Monitoring the Future study. 27
Access to Recovery Currently, only 1 in 10 adolescents who has an alcohol or drug problem receives treatment for it—and only 25 percent of those receive adequate treatment to support sustained recovery. Because alcohol and drug use disorders involve almost every aspect of an adolescent's life, the recovery process requires treatment tailored to the individual, taking into account the severity of substance use, presence of co‐occurring disorders, age, level of maturity, cultural background, gender, and family and peer environment. Making a Difference: What Can I Do? If you are a parent, a family member, or guardian, or someone else who spends time with youth regularly, there are things you can do every day—starting today—to touch the lives of the young people around you. Embrace the power of parenting Preventing, identifying, and treating a child's drug or alcohol use starts in the home—and a good relationship with a parent (or guardian) is the most underutilized tool in combating the problem. The National Youth Anti‐Drug Media Campaign recommends that in addition to regularly observing his or her activities and behavior, you may wish to spend quality time with your child, hold family meetings, ensure that your children have some form of supervision between 3 p.m. and 6 p.m. instead of leaving kids alone after school, eat meals together as often as you can, and consistently establish ground rules and expectations. Most important, you can talk to your son or daughter about the dangers of drugs and alcohol. Research shows that youths are less likely to use a substance if they think their parents disapprove of it. Know the signs You know your child best—so if he or she begins to exhibit unusual behavior, take notice. Warning signs that may indicate an adolescent's unhealthy alcohol or drug use include: • Sudden changes in personality with no known cause • Loss of interest in hobbies, sports, or other activities • Sudden decline in performance or attendance at school or work • Changes in friends and reluctance to talk about new friends • Deterioration of personal grooming habits • Forgetfulness or difficulty paying attention • Sudden aggressive behavior, irritability, nervousness, or giddiness 28
•
Increased secretiveness or heightened sensitivity to inquiry Help make the treatment "fit" If you suspect that your child or a young person you know has an alcohol or drug problem, consult a physician or other knowledgeable professional to have the child screened for alcohol and drug use disorders. Then help the young person find an age‐appropriate treatment program. Your health plan or EAP may have helpful information in locating an appropriate program. Additionally, because young people with an alcohol or drug use disorder frequently may have other behavioral health problems, it’s important to recognize the critical need for concurrent mental health treatment, both during and following treatment for their drug or alcohol problem. Lend your ears—and voice Become a friend and mentor to a young man or woman you know. Offer advice, help with problems, act as an advocate, or simply listen to him or her. Children who live in alcohol‐ and drug‐dependent families are particularly vulnerable and learn not to trust adults. By providing assurance and validation, you can counteract much of that mistrust and make a positive impact on a child's life. Peer Pressure – A Special Problem for Parents and Guardians Adapted from the Substance Abuse and Mental Health Services Administration Would you let your teenage son drink beer at his best friend’s birthday party? Would you let your daughter attend a homecoming party where wine is available? What if you knew that the party had adult supervision? In a poll by the American Medical Association, 1 in 10 parents said that it was okay for teens to have alcohol present at prom or graduation parties with a parent present. Twenty percent of 16‐ to 18‐year‐olds report that they have attended a graduation party with underage drinking and parents present, and 5 percent of them had been to a graduation party where the alcohol was actually supplied by parents. While most parents do not allow their underage children to drink and would not buy alcohol for their kids or allow it at a post‐prom party or graduation event, some will. How can you keep your youngster alcohol free? 29
Before the party Talk to the parents hosting the party and get the details. Where is it? What time does it start and end? Who’s invited? What activities are planned? Will there be adult supervision for teenage guests? How many adult supervisors for how many teenage guests? What can I do to help? You’re not being nosy! Think of it as gathering information so that you can make an informed decision. Ask about Alcohol Ask the parents hosting the party if alcohol will be served at the event. If it’s a party with guests over and under age 21 and alcohol will be present, ask about their plans to prevent minors from drinking alcohol. If all of the guests will be under 21, ask about their plans to make sure that no one brings alcohol to the party. Talk to Your Teen Find out from your youngster how she will handle a party where there’s drinking. Let him know that you expect him not to drink! Your teen needs to know to call you right away for a ride home —no matter how late it is. You may want to create a “code word” that your teen can use. A code word gives your youngster a less embarrassing way to communicate with you when surrounded by friends. Too Tough? During the homecoming season, you may need to make difficult choices about what parties your kids attend. It can be hard to tell your teen child “no” when this is the party that “everyone” is going to. Underage drinking is a key factor in the two leading causes of teenage deaths: car accidents and fatal injuries. It also is linked to two‐thirds of all sexual assaults and date rapes of teens, and it increases the chance of contracting HIV or sexually transmitted diseases. So, go ahead, be tough on underage drinking, and be on the lookout for risky situations during teen parties. For the whole article and other helpful resources, visit SAMHSA at http://family.samhsa.gov/teach/parties.aspx 30
Summary This guidebook was designed to introduce you to the process of getting ready to change when struggling with substance use difficulties. At New Directions, we believe that people can prepare themselves for change, no matter the problem, with a tool kit consisting of good information and appropriate support. We also believe that change occurs according to a more or less predictable process. During recovery, people may experience starts, stops, and slips – but with persistence, change can be positive and people can grow to become more resilient as they give up physical and psychological dependency on substances. Finally, we believe that substance use disorders touch entire families, and that everyone in the family – from the oldest to the youngest – should be involved in the recovery process. We hope that our goals – to raise awareness, build commitment, and empower people to change – have been reflected on these pages. To contact New Directions, please email us at [email protected] or call 913‐982‐8400. 31
Appendix I ‐ Commonly Misused Substances The following information is adapted from information found at www.recoverymonth.gov. Alcohol and drug use disorders are complex and include misuse, dependence, or addiction to alcohol and/or legal or illegal drugs. Although each substance carries its own health risks, all have the potential to have a negative impact on the lives of the individuals in need of treatment, but also those of their family members. Prescription Drugs Certain prescription drugs, when abused, can alter the brain's activity and lead to dependence and possibly addiction. Three types of prescription drugs commonly are misused: Opioids Often called narcotics, opioids such as morphine and codeine are used to treat pain from cancer, terminal illness, severe injury, or surgery. Long‐term use of opioids can lead to dependence and uncomfortable withdrawal symptoms when use is reduced or stopped. Withdrawal symptoms include muscle and bone pain, diarrhea, vomiting, cold flashes, and involuntary leg movements. Central nervous system (CNS) depressants These drugs are useful in treating anxiety and sleep disorders. Withdrawal from CNS depressants can be difficult, even dangerous. Because all CNS depressants work by slowing the brain's activity, when an individual stops taking them, the brain's activity can race out of control, possibly leading to seizures, and in some instances, life‐threatening complications. Stimulants Used to increase alertness and physical activity, they often are prescribed to treat narcolepsy, Attention Deficit Hyperactivity Disorder, and obesity. Taking high doses of a stimulant can result in an irregular heartbeat, dangerously high body temperatures, cardiovascular failure, or lethal seizures. Alcohol 32
Consumption of alcohol can increase the risk for certain cancers, especially those of the liver, esophagus, throat, and larynx (voice box). Heavy drinking can cause liver cirrhosis (scarring), immune system problems, brain damage, and harm to the fetus during pregnancy. High levels of alcohol use are strongly correlated with an increased likelihood of using illicit drugs.17 Even drinking at moderate levels can affect driving ability, cause medication interactions, alcohol‐related birth defects, or long‐term health problems. Marijuana Marijuana can be addictive and is much stronger than it was 30 years ago. Levels of the main active ingredient in marijuana, THC (delta‐9‐tetrahydrocannabinol), are five times greater than they were in the 1970s. Marijuana use has the potential to cause problems in daily life or worsen a person's existing problems. Depression, anxiety, and personality disturbances all are associated with marijuana use. The use of marijuana also can produce adverse mental and behavioral changes, such as impaired short‐term memory, verbal skills, judgment, coordination, and balance. Cocaine and "Crack" Cocaine is a powerfully addictive stimulant that directly affects the brain. The medical complications associated with cocaine use include disturbances in heart rhythm and heart attacks, respiratory effects such as chest pain and respiratory failure, and neurological effects such as strokes and headaches. Research has revealed a potentially dangerous interaction between cocaine and alcohol. Mixing the two is the most common two‐drug combination that results in drug‐related death.32 Hallucinogens Hallucinogens, including LSD (lysergic acid diethylamide, mescaline, and psilocybin (also known as magic mushrooms), are drugs that disrupt a person's ability to think and communicate rationally and distort their perception of reality. Drugs such as PCP (phencyclidine) and Ketamine, which were initially developed as general anesthetics for surgery, distort perceptions of sight and sound and produce feelings of detachment—dissociation—from the environment and self.38 In addition to short‐term effects on perception and mood, hallucinogens are associated with psychotic‐like episodes that can occur long after the person has taken the drug, and can cause respiratory depression, heart rate abnormalities, and a withdrawal syndrome.39 33
Heroin Heroin is processed from morphine. Recent studies suggest that people are switching from injecting heroin to snorting or smoking it because of the misconception that these forms of use will not lead to addiction. Heroin use is associated with serious health conditions, including fatal overdose, spontaneous abortion, collapsed veins, and infectious diseases including HIV/AIDS and hepatitis. Methamphetamine Methamphetamine is a powerfully addictive stimulant that affects the central nervous system. It can be taken orally, by intravenous injection, and by smoking or snorting. Although the drug first was used in selected urban areas, high levels of methamphetamine use are now seen in both urban and rural settings and by very diverse segments of the population. Methamphetamine use can cause strokes, convulsions, anxiety, and irregular heartbeat. Its use can result in cardiovascular collapse or death. Ecstasy (also known as MDMA, or methylenedioxymethamphetamine) A synthetic illicit drug that causes both hallucinogenic and stimulant effects, Ecstasy (MDMA) is most
commonly encountered at all-night dance parties (called raves) or at techno parties and nightclubs. MDMA
is generally sold as a tablet taken orally.
Using MDMA can cause confusion, depression, anxiety, sleeplessness, craving for the drug, and paranoia. People who take MDMA also risk dehydration, hyperthermia, and heart or kidney failure if using the drug during physical exertion or in hot environments, ultimately facing the possibility of death. People who have circulatory problems or heart disease face particular risks because MDMA can increase heart rate and blood pressure. Inhalants The term "inhalants" refers to more than 1,000 different household and commercial products that can be intentionally misused by inhaling them through the mouth or nose for an intoxicating effect. These products are composed of volatile solvents and substances commonly found in commercial adhesives, lighter fluids, cleaning solutions, and paint products. There is a positive correlation between the use of inhalants and problems in school, such as failing grades. Inhalant users also tend to suffer physical consequences ranging from nausea and vomiting to damaged lungs, paralysis, and even death.59 34
Anabolic Steroids Anabolic steroids are synthetic derivatives of the male hormone testosterone. They promote the growth of skeletal muscle and increase lean body mass. Steroids can be taken orally or via injection with a needle. Some consequences of steroid use are increased risk of heart attacks and strokes, liver problems, stunted growth, infertility, and testicular shrinkage. Steroids also may increase irritability and aggression. To learn more about alcohol and drug use disorders, treatment, and usage rates, you can access many of the materials cited in this fact sheet by visiting the Substance Abuse and Mental Health Services Administration's (SAMHSA's) Web site at www.samhsa.gov or by contacting an information specialist at SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI) toll‐free at 1‐800‐729‐6686 or 301‐468‐2600. You also can access the Clearinghouse at www.ncadi.gov. 35
Appendix 2 ‐ The Dangers of Prescription Drug Abuse Your doctor gave you a prescription for pain or anxiety. If you follow the doctor’s instructions about when and how much to take, you will less likely develop dependence. Unless you follow medical instructions, you risk overdose, withdrawal symptoms, and physical dependency. Many people misuse prescription medications. According to SAMHSA, about 7.0 million (2.8 percent) people aged 12 or older used prescription‐type psychotherapeutic drugs non‐
medically in the prior to completing the SAMHSA survey. Of these, 5.2 million used pain relievers. These include drugs like morphine, codeine, OxyContin, Vicodin and Demerol, usually prescribed to help reduce pain after surgery or injury. Chronic pain may be a factor in the misuse of pain killers. Over a period of time, the user becomes dependent and will have symptoms of withdrawal when the pain killer is not available. An overdose may cause breathing to slow down and can lead to death. Tranquilizers like Nembutal, Valium and Xanax slow down the central nervous system and help individuals suffering with anxiety, panic, and sleep problems. Some individuals ‐ about 1.3 million people ‐ abuse tranquilizers in an attempt to become more relaxed or to sleep more easily. Sometimes, people use too many tranquilizers because they develop tolerance – it takes more of the medication for the same relaxed effect. Other people combine a tranquilizer with alcohol to intensify the effect. This is extremely dangerous. The combination of alcohol and tranquilizer can slow down breathing and heart rate, and may lead to death. The combination of alcohol, tranquilizers, and pain medication may be especially deadly. Stimulants like Ritalin and Dexedrine power up the central nervous system. Used to treat attention deficit/hyperactivity disorder and narcolepsy, this medication is safe when the user follows doctor’s instructions. A little less than 1 million people abuse stimulants. This group of drugs can be highly addictive due to the user’s sense of increased alertness and energy. Physically, these drugs raise blood pressure, heart rate, and breathing. An overdose may cause heart failure, seizures, or feelings of hostility and paranoia. As a patient, you can prevent prescription drug use by taking the following steps: • Give your doctor a complete medical history • Follow the doctor’s directions when taking a pain killer, stimulant or tranquilizer 36
•
•
•
Do not increase or decrease the medication, and do not stop taking it without talking to your doctor first Be aware of potential interactions with other drugs – when in doubt, talk to your doctor of pharmacist Never use another person’s prescription medication In the past decade, misuse of prescription drugs has grown to epidemic proportions. It’s up to each individual to ensure that the medications prescribed for legitimate medical reasons by a physician end up being used for that reason. 37
Resources Whether you look for information or support online or in­person, it’s incumbent on you to use good judgment. If something doesn’t feel right, it may not be right for you. New Directions does not endorse any particular group, organization, or resource and provides this information for your convenience. You and you alone can decide what will be helpful for you. Organizations National Council on Alcohol and Drug Dependency www.ncadd.org NCADD provides information, education, help and hope to the general public regarding alcoholism and other drug dependence. The organization supports awareness, prevention, treatment, and advocacy programs. Alcoholics Anonymous www.alcoholics‐anonymous.org A fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism. The only requirement for membership is a desire to stop drinking. There are no dues or fees for AA membership. Al‐Anon/Alateen http://www.al‐anon.alateen.org/ Based on the premise that alcoholism is a family illness and that changed attitudes can aid recovery, Al‐Anon offers hope and solutions when you or a youngster has been affected by someone else’s drinking. Narcotics Anonymous www.na.org Similar to AA, NA is a nonprofit fellowship or society of men and women for whom drugs had become a major problem. Meetings are available nationwide. SoberCircle.com www.sobercircle.com SoberCircle.com is an online recovery community that began in December 2006 to allow people in recovery to meet and share through an online medium. The primary goal for the website is to spread recovery to people in need and to promote sober living worldwide. 38
Self‐Help Books Willpower's Not Enough: Recovering from Addictions of Every Kind by Arnold M. Washton and Donn Boundy, 1990 How to Quit Drugs for Good: A Complete Self‐Help Guide, Jerry Dorsman, 1998 Beyond the Influence: Understanding & Defeating Alcoholism, Katherine Ketcham, William F. Asbury, Mel Schulstad, and Arthur P. Ciaramicoli, 2004 First Year Sobriety: When All That Changes Is Everything, Guy Kettlehack, 1998 Sober But Stuck: Obstacles Most Often Encountered that Keep Us from Growing In Recovery, Dan F., 1994
Co‐Dependent No‐More, Melody Beattie, 1992 Our Drink: Detoxifying the Perfect Family, Chris and Toren Volkman, 2004 Under the Influence: A Guide to the Myths and Realities of Alcoholism, James Robert Milam, Katherine Ketcham, 1984 Children’s Books Daddy Doesn't Have to Be a Giant Anymore by Jane Resh Thomas and Marcia Sewall, 1996 An Elephant in the Living Room, The Children's Book, M.H. Typpo and J.M. Hastings, 1984 39