1. Exploring opiate addiction and options for treatment
Ken Hartenstein, MS, LPC, SAC
Lead therapist, Opioid Addiction intensive outpatient program with medication assisted treatment (MAT)
Rogers Memorial Hospital–Brown Deer
CMSA Madison Area Chapter Meeting
March 12, 2018

2. What is addiction? Physical dependence Addiction
If I stop using the drug I will get sick (withdrawal)
Addiction
The continued use of a substance despite negative consequences

3. “…But I continue to take it anyway.”
“My life is falling apart because of this drug…
“…But I continue to take it anyway.”

4. Natural brain rewards
Oxytocin
Dopamine
Serotonin
Endorphin

5. Addiction attacks the brain’s survival system
The brain gives a reward for things we do to help us or the species survive…
Helping others
Nutrition
Exercise
Accomplishments
Sex

6. The takeover
Addiction results when the brain’s natural reward pathways become paved by powerful connections between drug use and feeling high.
The brain becomes fooled by the drug thinking getting high is necessary for survival so it makes it the top priority.

7. Once the drug takes over…
The brain is convinced that getting and using the drug is more important than:
Shelter
Food
Family & loved ones

8. Triggers
Triggers are powerful cues for drug use that, if the drug is not present, result in in overpowering cravings for the drug.

9. Conditioning
Dr. Ivan Pavlov

10. Pavlov’s dog

11. The stages of addiction
Addiction is a progressive disease with four distinct stages:
Introductory Phase
Maintenance Phase
Disenchantment Phase
Disaster Phase

12. Stage 1: Introductory phase
Positives:
Negatives:
Relief from:
Depression
Anxiety
Loneliness
Insomnia
Euphoria
Increased status
Increased energy
Increased sexual/social confidence
Increased thinking ability
May be illegal
May be expensive
May cause missing work

13. Stage 1: Introductory phase
Triggers:
Parties
Special Occasions

14. Stage 1: Introductory phase
Development of obsessive thinking
FOOD SPORTS
SCHOOL GIRLFRIEND TV
FAMILY OPIATES JOB
EXERCISE PARTIES HOBBIES

15. Stage 2: Maintenance phase
Positives:
Negatives:
Depression relief
Confidence boost
Boredom relief
Sexual enhancement
Social lubricant
Employment/school disruptions
Some relationship concerns
Some financial problems
Beginnings of physiological dependence

16. Stage 2: Maintenance phase
Triggers:
Parties
Special occasions
Friday or Saturday nights
Friends
Alcohol
Sexual situations
“Celebrations”

17. Stage 2: Maintenance Phase
Development of obsessive thinking
FOOD OPIATES
SCHOOL GIRLFRIEND TV
FAMILY OPIATES JOB
EXERCISE PARTIES HOBBIES

18. Stage 3: Disenchantment phase
Positives:
Negatives:
Sociability
Occasional euphoria
Relief from fatigue
Relief from stress
Withdrawal depression
Paranoia
Relationship disruptions
Family distress
Impending job loss

19. Stage 3: Disenchantment phase
Triggers:
Fatigue
All friends
Stress
Boredom
Anxiety
Free time
Sexual arousal
Loneliness

20. Stage 3: Disenchantment phase
Development of obsessive thinking
FOOD OPIATES
OPIATES GIRLFRIEND TV
FAMILY OPIATES JOB
OPIATES PARTIES OPIATES

21. Stage 4: Disaster phase Positives: Negatives:
Brief relief from fatigue
Brief relief from stress
Brief relief from depression
Weight loss / poor health
Alarming appearance
Loss of family
Severe depression
Unemployment
Bankruptcy

22. Stage 4: Disaster phase Triggers Day Night Any emotion Sleep
Being awake
Everything

23. Stage 4: Disaster phase Development of obsessive thinking
OPIATES OPIATES
OPIATES OPIATES OPIATES
OPIATES OPIATES OPIATES
OPIATES OPIATES OPIATES

24. The stages of recovery
Recovery can be broken down into four distinct stages:
Withdrawal
The Honeymoon
The Wall
Adjustment/Resolution

25. Stage 1: Withdrawal Features: Relapse risk factors:
Physical detoxification
Intense cravings
Intense illness
Depression/Anxiety
Low energy
Irritability
Exhaustion
Insomnia
Hopelessness
Powerful cravings
Wanting to use to ease withdrawal symptoms
Poor sleep
Depression
Fear

26. Stage 2: The Honeymoon Features: Relapse risk factors: Optimism
Feeling good
Positive feelings about recovery
Positive feelings about treatment program
Intense feelings
Mood swings
Overconfidence
Trying to get everything done at once
Frustration
Secondary drug or alcohol use
Minimizing the addiction

27. Stage 3: The Wall Features: Relapse risk factors: Anhedonia
Disillusionment with recovery
Disillusionment with treatment
Isolation
Return to “normal” life
Emotional swings
Unclear thinking
Decreased ability to feel pleasure
Behavioral “drift”
Loss of motivation
Discontinuation of treatment
Secondary drug and alcohol use

28. Stage 4: Adjustment / Resolution
Features:
Relapse risk factors:
Feelings of accomplishment
Fulfillment
Acceptance of recovery
Living simply as “someone who doesn’t use”
Discontinuation of frequent drug thoughts
Secondary drug and alcohol use
Feeling “cured”
Less vigilant for relapse cues
Reemergence of underlying emotional issues

29. Assessment The first step is to get an assessment.
Initial screening may be done by phone followed by an in- person assessment.
The assessment will determine if an inpatient stay is necessary.
Alcohol and benzodiazepine withdrawal can be fatal. Always check with a professional.

30. Withdrawal management (detox)
If the withdrawal symptoms are deemed to require an inpatient stay the patient will typically stay in the hospital 3-5 days.
He/she will be medically monitored, provided appropriate medication for symptoms, and be expected to attend groups.

31. Residential treatment
Approximately 4 to 6 weeks, but can be more or less depending on progress.
Patients live at the facility full-time without leaving campus.
Treatment involves group and individual therapy, therapeutic activities, and some healthy recreation.
Cost prohibitive and most insurance won’t cover for initial treatment. Medicaid won’t cover at all.

32. Partial hospitalization and intensive outpatient programs
Intensive treatment primarily consisting of group therapy but incorporating individual sessions and family therapy.
Partial hospitalization (PHP)
Average length of the program is three to four weeks
Groups meet six hours per day, five days a week
Intensive Outpatient (IOP)
Typically runs four to eight weeks.
Groups meet three hours per day, four to five days per week..

33. Medication assisted treatment (MAT)
The utilization of medications designed to reduce drug cravings and block any euphoric affects of any illicit use along with therapeutic counseling is an evidence based practice that has proven to be one of the most effective modalities in treating opiate use disorders.
The use of medications such as Suboxone is not trading one addiction for another.
Remember: the essence of addiction is the use of a substance despite NEGATIVE consequences. Suboxone use does not meet that criteria.

34. Suboxone

35. Individual outpatient therapy
After an intensive outpatient program (IOP), all patients should see a therapist at least weekly to begin.
Too often patients complete an IOP and stop there. Continued treatment for at least one year is essential as patients face new challenges in their young recovery.

36. Support groups Run by and for those seeking a life of sobriety.
Should attend one a week minimum for years.
AA and NA in particular have lots of fun events and 24 hour meetings on holidays.