Facts In 2008, an estimated 20.1 million Americans aged 12 or older were current (past-month) illicit drug users. (8.0% of the population) million persons w12 or older needed treatment for illicit drug or alcohol use (9.2% of the population) (2008 SAMSHA National Survey on Drug Use and Health report) 2.3 million received treatment at a specialty facility (0.9%) Substance use disorders affect 45% of patients who present for medical care but are routinely unrecognized by healthcare providers. The use of structured screening and assessment strategies (e.g. CAGE Questionnaire) is essential in the assessment of substance use disorders Staging the severity of addiction, calibrating patients’ readiness to change behaviors, and willingness to access professional help are crucial Patients are more likely to follow plans that are negotiated in partnership with treaters and renegotiated at follow-up visits. Sustained recovery requires many resources. To achieve treatment goals, physicians should become comfortable referring patients to resources such as self-help groups, professional treatment programs, and psychiatrists to treat co-morbid psychiatric disorders.

Drugs & the Brain Structures Brain stem Limbic system Cerebral cortex Brain communication How drugs work in the brain? Long term affects

DSM IV TR Criteria- Abuse A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one (or more) of the following, within a 12-month period: Recurrent substance use resulting in failure to fulfill major role obligations at work, school or home related to use; substance-related neglect of children or household Recurrent use in situations in which it is physically hazardous Recurrent substance-related legal problems (DUI, disorderly conduct) Continued use despite persistent or recurrent social or interpersonal problems caused or worsened by effects of the substance.

DSM IV TR Criteria- Dependence Addiction (dependence, per APA): maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by three (or more) of the following, within a 12-month period: Tolerance Withdrawal Substance taken in larger amounts or over a longer period than intended Persistent desire or unsuccessful efforts to cut down or control use. Great deal of time spent obtaining, using or recovering from use. Important social, occupational or recreational activities are given up or reduced to accommodate use. Use despite knowledge of persistent physical or psychological problems are likely to have been caused or worsened by use. Can occur with or without physiological symptoms of tolerance & withdrawal (psychological addiction)

High index of concern for substance use in persons with: Family history of substance use disorder Recent stressful life events and lack of social supports Chronic pain or illness, trauma Mental illness (e.g., depression, bipolar disorder, etc.) Drug-seeking behaviors Physical and cognitive disabilities Started alcohol use before age 15 Medical condition associated with substance use

Addiction & Disease THIQ & alcohol Opiates & serotonin Cocaine & reward system Cross addiction

Levels of Care Detox versus treatment 28 day programs 25-35% of people who complete addiction treatment will be readmitted to treatment within 1 year & 50% will be readmitted within 5 years Community based treatment programs

Relapse & Recovery First 3-6 months greatest likelihood of relapse, HOWEVER people can relapse at any time, even after many years Recovery/sobriety is not just an absence of symptoms Relapse is not fully stabilized until 4-5 years of sustained recovery. Interview w/ someone in recovery ault.htm

Screening & Assessment: General observations Behavior Mood Co-occurring mental illnesses, dual diagnosis Daily routine

Screening & Assessment: If it SOUNDS like and excuse, it IS an excuse Checklist Handout Questions and follow-up The most reliable info is in response to our follow-up questions Red Flags AA/NA: The program and the excuses

Now that we have additional info, how do we apply it to find best interest? Impact of parental/caretaker substance abuse on children; the importance of environment.

Impact on kids at every age & stage- psychological & physical

8.3 million (11%) children live w/ at least one parent in need of treatment 1 in 4 kids under 18 lives in a home where alcohol & drug abuse is a fact of daily life Children whose parents abuse alcohol & drugs are 3 times more likely to be verbally, physically or sexually abused & 4 times more likely to be neglected

Resources NIDA.gov SAMHSA.gov ault.htm