An NASW Online Webinar Series Presented by: Dr. Joseph Hunter, - - PowerPoint PPT Presentation

An NASW Online Webinar Series Presented by:

• Dr. Joseph Hunter, LCSW, Ph.D.

• 1. Introduction and Problem Overview
• 2. Etiology: Genetics, Neurobiology

and Psychosocial Factors

• 3. Co-Occurring Disorders
• 4. Levels of Care, Addiction Medicines

and Therapies

1.

Participants will understand how existing theories seek explain how opiate addiction starts, spreads and sustains its grip in the US population and local communities.

• 2. Participant will learn the neurological

mechanisms of opiate addiction.

• 3. Participants will learn of the genetic,

biological and epigenetic factors associated with opiate addiction.

• What do you hope to gain from this

webinar today?

• Please write this on your

worksheet and post it in the chat (if you wish)

Although I am an employee of both Veterans Affairs (VA) and The University of Southern California (USC), this presentation is done independently of those positions. The views expressed in this presentation are those of the author and do not necessarily reflect the opinion, position or policy of the VA, the US Government or USC. In addition, although I am recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers (#324), this training is offered under NASW’s approved provider number.

• 61.8 million smoked cigarettes
• 175.8 million people drank alcohol
• 36.0 million people used marijuana
• 4.8 million people used cocaine
• 828,000 people used heroin
• 1.5 million people used lysergic acid diethylamide

(LSD)

• 2.6 million people used Ecstasy
• 1.8 million people used inhalants
• 1.7 million people used methamphetamine

[compare to 12.5 million misusers of prescription pain killers]

AGAIN

• Drug overdose is the leading cause of

accidental death in the US

• 52,404 lethal drug overdoses in 2015
• Opioid addiction is driving this epidemic
• 20,101 overdose deaths on prescription

pain relievers

• 12,990 overdose deaths on heroin in 2015

• Suggests that people take drugs to experience

variety

• self-exploration
• religious insights
• altering moods
• escape from boredom or despair
• enhancement of creativity, performance, sensory

experience, or pleasure

• Because people enjoy variety, then it can be

understood why they repeat actions that they enjoy (positive reinforcement)

• Suggest also that the desire to experience pleasure is another

explanation

• Drugs are chemical surrogates of natural reinforcers such as

eating and sex.

• Dependent behavior with respect to the use drugs is

maintained by the degree of reinforcement the person perceives as occurring

• Drugs may be perceived as being more powerful reinforcers

than natural reinforcers and set the stage for addiction

• Individuals who become addicted are unable to control the

reward system in their lives and that addiction may be considered a disorder of compulsive behavior very similar to

• bsessive compulsive disorder.

• Learning models are closely related and somewhat
• verlap the explanations provided by cognitive-

behavioral models.

• Learning theory suggests that drug use results in a

decrease in uncomfortable psychological states such as anxiety, stress, or tension, thus providing positive reinforcement to the user.

• This learned response continues until physical

dependence develops

• The aversion of withdrawal symptoms becomes a

reason and motivation for continued use (as suggested too by CB Theory)

• Psychodynamic models link addiction to ego

deficiencies, inadequate parenting, attachment disorders, hostility, homosexuality, masturbation, and so on.

• Substance abuse can be viewed as symptomatic
• f more basic psychopathology.
• Difficulty with an individual’s regulation of

affect can be seen as a core problem or difficulty.

• Disturbed object relations may be central to the

development of substance abuse.

• Attachment Theory: Insecurely attached children feel that

there is no help during negative affect states, which then creates a feeling of disorganization and overwhelms them.

• The use of alcohol and drugs can become the always-available

attachment figure or object, used for self-soothing/affect regulation.

• Self Psychology: Lack idealized parent to learning self-

soothing so the addictive object (drugs/alcohol) becomes a substitute soothing self object.

• Object Relations Theory: "Situation-in-person" - what is
• utside (via object relations) begets the way a person grows,

thinks and feels (the inside)

• The addict has internalized an addicted parent and is

repeating the behavior with his/her own family.

• A major theme of the behavioral model is, that

within the context of the family, there is a member (or members) who reinforces the behavior of the abusing family member.

• For example, a spouse may make excuses for the

family member or even prefer the behavior of the abusing family member when that family member is under the influence of alcohol or another drug.

• Some family members may not know how to relate

to a particular family member when he or she is not “under the influence.”

• These focus on the way roles in families interrelate
• Some family members may feel threatened if the person with

the addiction shows signs of wanting to recover

• Often rigid and enabling roles are formed that enable the

family to function to the extent possible – hero, scapegoat, lost child and joker are examples of these.

• The possibility of adjusting roles could be so anxiety

producing that members of the family begin resisting all attempts of the “identified patient” to shift relationships and change familiar patterns of day-to-day living within the family system.

• Addiction is viewed as a primary disease rather than

being secondary to another condition

• Offers that there is a progression of the disease of drug

addiction across stages: prodromal, middle or crucial, and chronic that are not reversible

• Consistent with this concept of irreversibility is the

belief that addictive disease is chronic and incurable.

• There is no treatment method that will enable the

individual to use again without the high probability that the addict will revert to problematic use.

• The articulation of addiction as a disease removed the

moral stigma attached to addiction and replaced it with an emphasis on treatment of an illness

• SPT is concerned with the social evolution of

humans and suggests that human identity is inextricably linked to social belongingness

• Suggests people are innately driven to be active

contributors to the wellbeing of their social groups of belonging

• Suggests that when one is utilizing his/her strengths

to contribute to a social group or passion of his her preference, a perception of having life meaning and purpose results

• Perceived life meaning and purpose is reinforced

when one can see the unique benefits of one’s contribution and receives affirmation for the same

• Self-Directed violence is highly influenced by one’s

perception of lacking mutually beneficial belongingness and a missing sense of social contribution

• Implication: Adolescents can align life pursuits to

establish a sense of life meaning and purpose (habilitation)

Goal-Directed Action Strengths Passions M & P Me Us All of Us Figure I. Self-Preserving Orientation ªM & P refers to life meaning and purpose. Benefits Reinforced by visible benefit & positive feedback

Goal- Directed Actions Strengths Passions Me Us All of Us M & P Psychological Dissonance Social Dissonance Figure II. Self-Serving Orientation, Example A ªM & P refers to life meaning and purpose. Benefits Reinforced by by success in achieving desired benefit.

• Addictive substances cause disruptions in the brain

that:

• Enable substance-associated cues to trigger

substance seeking (i.e., they increase incentive salience)

• Reduce sensitivity of brain systems involved in the

experience of pleasure or reward, and heighten activation of brain stress systems

• Reduce functioning of brain executive control

systems, impacting the ability to make decisions and regulate one’s actions, emotions, and impulses

• All addictive substances produce feelings of

pleasure.

• These “rewarding effects” positively reinforce their

use and increase the likelihood of repeated use.

• The rewarding effects of substances involve activity

in the nucleus accumbens, including activation of the brain’s dopamine and opioid signaling system.

• Studies have shown that neurons that release

dopamine are activated, either directly or indirectly, by all addictive substances

• Binge/Intoxication: the stage at which an

individual consumes an intoxicating substance and experiences its rewarding or pleasurable effects

• Withdrawal/Negative Affect: the stage at which an

individual experiences a negative emotional and physiological state in the absence of the substance

• Preoccupation/Anticipation: the stage at which
• ne seeks substances again after a period of

abstinence

• This is a group of structures located at the base of

the forebrain.

• They connect to the cerebral cortex, thalamus and

brainstem, and play an important role in keeping body movements smooth and coordinated.

• They are also involved in learning routine behaviors

and forming habits.

• Two specific subregions are affected by substance

abuse:

• The nucleus accumbens, which is involved in

motivation and the experience of reward

• The dorsal striatum, which is involved in forming

habits and other routine behaviors

• The extended amygdala and its subregions, located

beneath the basal ganglia, regulate the brain’s reactions to stress-including behavioral responses like “fight or flight” and negative emotions like unease, anxiety, and irritability

• This region also interacts with the hypothalamus,

an area of the brain that controls activity of multiple hormone-producing glands, such as the pituitary gland at the base of the brain and the adrenal glands at the top of each kidney

• These glands, in turn, control reactions to stress

and regulate many other bodily processes

• The prefrontal cortex is located at the very

front of the brain and is responsible for complex cognitive processes described as “executive function.”

• organize thoughts and activities
• prioritize tasks
• manage time
• make decisions
• regulate one’s actions, emotions, and

impulses

• Scientists recorded the electrical activity of dopamine-

transmitting neurons in animals that had been exposed multiple times to a neutral (non-drug) stimulus followed by a drug.

• At first, the neurons responded only when they were exposed to the

drug.

• However, over time, the neurons stopped firing in response to the

drug and instead fired when they were exposed to the neutral stimulus associated with it.

• This means that the animals associated the stimulus with the

substance and, in anticipation of getting the substance, their brains began releasing dopamine, resulting in a strong motivation to seek the drug.

• The “reward circuitry” of the basal ganglia (i.e., the nucleus

accumbens), along with dopamine and naturally occurring

• pioids, play a key role in the rewarding effects of substances

and the ability of stimuli, or cues, associated with that substance use to trigger craving, substance seeking, and use.

• As the substance use progresses, repeated activation of the

“habit circuitry” of the basal ganglia (i.e., the dorsal striatum) contributes to compulsive substance seeking

• The involvement of these reward and habit neurocircuits

helps explain the intense desire for the substance (craving) and the compulsive substance seeking that occurs as part of the relapse process

• This stage of addiction involves a decrease in the

function of the brain reward systems and an activation

• f stress neurotransmitters, such as CRF and

dynorphin, in the extended amygdala.

• Together, these phenomena provide a powerful

neurochemical basis for the negative emotional state associated with withdrawal.

• The drive to alleviate these negative feelings

negatively reinforces alcohol or drug use and drives compulsive substance taking.

• This stage of the addiction cycle is characterized by a

disruption of executive function caused by a compromised prefrontal cortex

• The activity of the neurotransmitter glutamate is increased,

which drives substance use habits associated with craving, and disrupts how dopamine influences the frontal cortex

• The over-activation of the Go system (which helps

people make goal-directed decisions that involve focused attention and planning) in the prefrontal cortex promotes habit-like substance seeking

• The under-activation of the Stop system (which

controls the brain’s stress and emotional systems) of the prefrontal cortex promotes impulsive and compulsive substance seeking

• There is a gene-based vulnerability to opiate

addiction but more studies across race groups are needed.

• Studies have shown consistent contribution
• f variation within the DRD2, OPRM1, OPRD1,

and BDNF genes towards the development of

• pioid dependence.
• Genetic susceptibility to opioid dependence

in combination with environmental factors play an important role in this disorder.

• The brain’s opioid system includes naturally
• ccurring opioid molecules:
• Endorphins
• Enkephalins
• Dynorphins
• As well as three types of opioid receptors:
• Mu
• Delta
• Kappa
• These play a key role in mediating the

rewarding effects of addictive substances

• Activation of the opioid system by these

substances stimulates the nucleus accumbens directly or indirectly through the dopamine system.

• Brain imaging studies in humans show

activation of dopamine and opioid neurotransmitters during alcohol and other substance use (including nicotine).

• Other studies show that antagonists, or

inhibitors, of dopamine and opioid receptors can block drug and alcohol seeking in both animals and humans

Risk Factors Domain Protective Factors

Early Aggressive Behavior Individual Self-Control Lack of Parental Supervision Family Parental Monitoring Substance Abuse Peer Academic Competence Drug Availability School Anti-drug Use Policies Poverty Community Strong Neighborhood Attachment

• Sensation seeking behaviors
• Experimentation
• Self medicating
• Peer influence

• Rebelliousness
• Seeking disinhibition (“liquid

courage”)

• Belongingness
• Worthiness
• Existential boredom
• Novelty seeking

• Parental addiction
• Genetic predisposition
• Social learning
• Prescription drugs (access)
• Relatives, friends or doctor prescribed
• Opiates, benzodiazepines, ADHD meds

(Ritalin), etc.

• Over-The-Counter
• Cough syrup, energy drinks, hand sanitizer, etc.
• Huffing (whip-its, glue, gas), mushrooms, etc.

• Neighbors, relatives or friends (access and

social influence)

• Parents’ unsupervised liquor cabinet or

refrigerator (access)

• “Gateways” – chewing or smoking tobacco
• Gambling
• Internet (other electronics) addiction

• Social constructions
• Who determines what’s important?
• Developmental freedoms… (my path and my life)
• Experiential void
• Access, access and access
• Personality vulnerabilities
• Predispositions (social/emotional, genetic, social and

experiential)

• Social and emotional vulnerabilities
• Lack of opportunities (work, school, community, etc.)
• Disillusioned by what is seen, heard and experienced

(including trauma)

Age/Developmental Stage (consider family, peer group school, etc.) Chemical Use Severity ( consider

• rientation

to change) Unique Characteristics (consider ethnicity/culture, age, gender, etc.) Special Needs (consider COA/SA, MI, Conduct, etc.)

• Adolescents are less internally motivated for

treatment than adults and are more likely to enter treatment as a result of external influences, such as legal or family pressure

• Unlike adults, adolescents (typically) don’t have a

long history of negative drug and alcohol experiences that foster a growing sense that they may have a drug

• r alcohol problem.
• Therefore, adolescents may have less insight into

the severity and potential consequences of their substance use behavior and related issues.

• Heroin can be injected, inhaled by snorting or

sniffing, or smoked.

• All three routes of administration deliver the

drug to the brain very rapidly.

• Users report feeling a surge of euphoria

(“rush”) accompanied by dry mouth, a warm flushing of the skin, heaviness of the extremities, and clouded mental functioning.

• Following this initial euphoria, the user goes

“on the nod,” an alternately wakeful and drowsy state.

• When it enters the brain, heroin is

converted back into morphine, which binds to molecules on cells known as

• pioid receptors.
• Opiate receptors are located in many areas
• f the brain (and in the body), especially

those involved in the perception of pain and in reward.

• Including the brain stem, which controls

automatic processes critical for life, such as blood pressure, arousal, and respiration.

• Heroin overdoses frequently involve a

suppression of breathing.

• This can affect the amount of oxygen that

reaches the brain, a condition called hypoxia.

• Hypoxia can have short- and long-term

psychological and neurological effects, including coma and permanent brain damage.

• Miosis (small pupils; except with Demerol

use which causes paralysis of the ciliary body and pupils dilate)

• Nodding
• Hypotension
• Depressed respiration
• Bradycardia (slow heart rhythm)
• Euphoria
• Floating feeling

• Builds tolerance: more of the drug is needed to

achieve the same intensity of effect.

• Fosters dependency: the need to continue use of

the drug to avoid withdrawal symptoms.

• Deteriorates the brain’s white matter
• Impairs decision-making abilities
• Impairs the ability to regulate behavior
• Affects responses to stressful situations.
• Opioid overdose is now the second leading cause
• f accidental death in the United States

Increases risk of the following:

• Fatal overdose
• Spontaneous abortion
• Infectious diseases like hepatitis and

HIV

• Chronic users may develop collapsed veins,

infection of the heart lining and valves, abscesses, constipation and gastrointestinal cramping, and liver or kidney disease.

• Pulmonary complications, including

various types of pneumonia, may result from the poor health of the user as well as from heroin’s effects on breathing.

• Street heroin often contains toxic

contaminants or additives that can clog blood vessels leading to the lungs, liver, kidneys, or brain, causing permanent damage to vital organs.

• These symptoms can begin as early as a few

hours after the last drug administration

• Restlessness, muscle and bone pain,

insomnia, diarrhea and vomiting, cold flashes with goose bumps (“cold turkey”), and kicking movements (“kicking the habit”)

• Users also experience severe craving for the

drug during withdrawal, which can precipitate continued abuse and/or relapse

Withdrawal Intoxication

• Ordinarily, heroin withdrawal is not life

threatening

• However, there are risks for unborn babies
• Heroin withdrawal can lead to spontaneous abortion
• Heroin abuse during pregnancy (together with

related factors like poor nutrition and inadequate prenatal care) is also associated with low birth weight, an important risk factor for later delays in development.

• The infant may be born physically dependent on

heroin and could suffer from neonatal abstinence syndrome (NAS).

• Change in friends
• Excuses (not good enough)
• Easily angered/upset
• Withdrawal from usual family bonding,

routines and activities

• Violation of rules
• Dishonesty
• Lack of motivation

• Dropping school grades and/or skipping classes
• Neglect of personal hygiene
• Stealing money, alcohol or valuables
• Personality:
• disrespect to authority
• manipulation
• secretive phone calls
• alienated and disinterested
• Health and appearance
• Drug paraphernalia

• Physical appearance
• Small pupils
• Decreased respiratory

rate

• Non responsiveness
• Drowsy
• Loss or increase in

appetite

• Weight loss or weight

gain

• Intense flu-like

symptoms (nausea, vomiting, sweating, shaky hands, feet or head, large pupils)

• Wearing long-sleeves or

hiding arms

• Change in attitude

and/or personality

• Tendency to avoid

contact with family and/or friends

• Change in friends,

hobbies, activities and/or sports

• Drops in grades or

performance at work

• Isolation and

secretive behavior

• Moodiness,

irritability, nervousness, giddiness

• Tendency to steal

• Missing medications
• Burnt or missing spoons and/or bottle caps
• Syringes
• Small bags with powder residue
• Missing shoe laces and/or belts

1.

Participants will learn the unique warning signs of opiate addiction, including symptoms

• f withdrawal.
• 2. Participants will understanding the

psychological, social and physical effects of

• piate use disorder.
• 3. Participants will learn how to diagnosis opiate

addiction.

• 4. Participants will learn how opiate addiction

typically co-occurs with medical and mental health disorders.

• Approximately 7.9 million adults in the United

States had co-occurring disorders in 2014.

• People with mental health disorders are more

likely than people without mental health disorders to experience an alcohol or substance use disorder.

• Undiagnosed, untreated, or undertreated co-
• ccurring disorders can lead to a higher

likelihood of experiencing homelessness, incarceration, medical illnesses, suicide, or even early death.

• One study noted that as many as fifty-five percent
• f adolescents presenting for substance abuse

treatment had at least one psychiatric diagnosis in addition to a substance use disorder

• Poorer post-treatment outcomes have been

identified for adolescents with co-occurring mental health disorders

• Youth with higher levels of emotional problems

associated with their substance abuse are more likely to leave treatment early

Those with past-year substance use disorders were four times more likely to have made a suicide plan than those with SUDs (3.4% vs. 0.8%) and nearly seven times more likely to have attempted suicide (2.0% vs. 0.3%)

• PICM - Uses chances to win cash prizes instead of

vouchers.

• Participants supplying drug-negative urine or breath

tests draw from a bowl for the chance to win a $1-$100 prize

• Draws for attending counseling sessions and

completing weekly goal-related activities are used.

• The number of draws starts at one and increases with

consecutive negative drug tests and/or counseling sessions attended; resets with positive urine.

• Although raised as a criticism, studies examining this

concern found that Prize Incentives CM did not promote gambling behavior.

• Buprenorphine is used in medication-assisted

treatment (MAT) to help people reduce or quit their use of heroin or other opiates, such as pain relievers like morphine.

• Like most partial agonists, it has a safer profile than

that of a full agonist.

• Once a certain receptor occupancy desired dosage

level has been achieved, additional dosing does not produce additional effects (i.e., ceiling effect)

• Including eliminating the typical possible
• piate overdose effects of respiratory depression

and/or death

• Suboxone combines Buprenorphine (an

Opiate) with Naloxone (an Opiate Blocker).

• It is an orange colored film taken sublingually

(under the tongue) daily and requires regular physician supervision.

• To treat opiate addiction, doctors must take an

8-hour class on addiction treatment and then apply for a special DEA number.

• Once they obtain the privige they are limited

to treating only 30 patients at a time.