1. Substance Abuse &
Assisting Those With
Substance Dependence
Presented by:
Mitch Kerns
Meth Specialist
IDHS
mkerns@dhs.state.ia.us
515-956-2590
June 18, 20 & July 9, 2007

2. The Impact of Addiction Can Be Far
Reaching
•Cardiovascular disease
•Stroke
•Cancer
•HIV/AIDS
•Hepatitis B and C
•Lung disease
•Obesity
•Mental disorders

3. The initial decision to take drugs is mostly voluntary.
However, when drug abuse takes over, a person's ability to
exert self control can become seriously impaired. Brain
imaging studies from drug-addicted individuals show
physical changes in areas of the brain that are critical to
judgment, decision making, learning and memory, and
behavior control. Scientists believe that these changes alter
the way the brain works, and may help explain the
compulsive and destructive behaviors of addiction.
Continued drug abuse- a voluntary behavior?

4. How Does the Brain Become Addicted?
Typically it happens like this:
•A person takes a drug of abuse, be it marijuana or cocaine or
even alcohol, activating the same brain circuits as do behaviors
linked to survival, such as eating, bonding and sex. The drug
causes a surge in levels of a brain chemical called dopamine,
which results in feelings of pleasure. The brain remembers this
pleasure and wants it repeated.
•Just as food is linked to survival in day-to-day living, drugs
begin to take on the same significance for the addict. The need to
obtain and take drugs becomes more important than any other
need, including truly vital behaviors like eating. The addict no
longer seeks the drug for pleasure, but for relieving distress.

5. •Eventually, the drive to seek and use the drug
is all that matters, despite devastating
consequences.
•Finally, control and choice and everything that
once held value in a person's life, such as
family, job and community, are lost to the
disease of addiction.
How Does the Brain Become Addicted?

6. Repeated drug exposure changes brain function. Positron emission tomography (PET) images are illustrated showing similar brain
changes in dopamine receptors resulting from addiction to different substances - cocaine, methamphetamine, alcohol, or heroin. The
striatum (which contains the reward and motor circuitry) shows up as bright red and yellow in the controls (in the left column), indicating
numerous dopamine D2 receptors. Conversely, the brains of addicted individuals (in the right column) show a less intense signal,
indicating lower levels of dopamine D2 receptors.

7. Source: From the laboratories of Drs. N. Volkow and H Schelbert
Addiction is similar to other diseases, such as heart disease.
Both disrupt the normal, healthy functioning of the
underlying organ, have serious harmful consequences, are
preventable, treatable, and if left untreated, can last a
lifetime.

8. No single factor determines whether a person
will become addicted to drugs
Scientists estimate that genetic factors account for 40-60% of a person’s
vulnerability to addiction including the effects of environment on these factors
The influence of the home environment is usually most important in childhood.
Parents or older family members who abuse alcohol or drugs, or who engage in
criminal behavior, can increase children's risks of developing their own drug
problems
The earlier a person begins to use drugs the more likely they are to progress to
more serious abuse
Method of administration. Smoking a drug or injecting it into a vein increases its
addictive potential
Some people will never develop diabetes because they never go over a certain
weight –much like some people will never become drug dependent because they
never try drugs. If they did they would in both cases

10. Does drug abuse cause mental disorders, or vice versa?
Drug abuse and mental disorders often co-exist. In
some cases, mental diseases may precede
addiction; in other cases, drug abuse may trigger or
exacerbate mental disorders, particularly in
individuals with specific vulnerabilities.

11. 2004 National Survey on Drug Use and Health found that
the percentage of the nation's estimated 600,000 monthly
meth users who met the criteria for dependence rose from
27.5 percent (164,000) in 2002 to 59.3 percent (346,000)
in 2004

12. • The first meth epidemic occurred in Japan following
WWII when the government released large stockpiles of
meth that had been held for use by factory workers during
the war
• Amphetamines were used by Allied and Axis armed forces
during WWII and 1991 Operation Desert Storm
• In Japan, meth use has surpassed that of all other drugs
-meth users exceed users of all other substances combined
• Worldwide, amphetamine and methamphetamine are the
most widely abused illicit drug after cannabis- more use
than cocaine or heroin
• From the WHO- over 35 million individuals regularly
use/abuse amphetamine/meth
• As of 2003, according to the National Survey on Drug Use
and Health, 12.3 million Americans had tried meth at least
once -up nearly 40% over 2000 and 156% over 1996

14. % Iowa Adults in Treatment w/Meth
as Primary Drug of Abuse
FY ‘96–‘03 (Iowa Dept Public Health)
The proportion of Iowa drug treatment clients citing meth as
their primary substance of abuse rose to an all-time high of 15.8
% in 2004 and dropped only slightly in 2005.
Prairie Ridge reports 28% of clients used meth.

15. Methamphetamine – The Drug
• Speed, Ice, Meth, Crystal, Crank
• Clandestine labs
• Easily synthesized
• Readily obtainable
• Sold through networks
• Abusers range widely in age, educational level,
socioeconomic status and ethnic background

16. Forms of Meth
Speed usually comes in the form of white or yellow powder
People usually sniff it through the nose (snort), smoke or inject it.
It can also be swallowed, in the form of tablets or capsules
Speed is often mixed or ‘cut’ with other things that look the same to make the
drug go further
Some mixed-in substances can have unpleasant or harmful effects

17. •Making ice, the smokable form of methamphetamine, from standard quality
methamphetamine HCl is essentially a purification process. Methamphetamine HCl is
added slowly to water that has been heated 80-100°C until a supersaturated solution is
obtained. When the slurry is cooled, pure HCl salt of methamphetamine (ice)
precipitates. Methamphetamine HCl, unlike cocaine HCl, is volatile and can be
smoked. Other solvents, such as isopropanol, have been used in place of water to
speed the process. Uncontrolled variations of this process can result in unreliable
removal or addition of impurities. The physical characteristics of the final product
depend on the quality and type of reagents used and on contaminants that may have
been introduced. The lack of significant further processing of methamphetamine HCl
has resulted in increased availability and popularity of smoking the drug.
•One reason for the popularity of smoked methamphetamine is the immediate
clinical euphoria that results from the rapid absorption in the lungs and deposition
in the brain.
•Smoking methamphetamine HCl powder, crystals, or ice occurs first by placing
the substance into a piece of aluminum foil that has been molded into the shape
of a bowl, a glass pipe, or a modified light bulb and heating it over the flame of a
cigarette lighter or torch. Then, the volatile methamphetamine fumes are inhaled
through a straw or pipe.
From emedincine.com
ICE

18. Methamphetamine
• Toxicity: Moderate
• Flammability: Low
• Reactivity: Very Low
• Powerful CNS
stimulant
• Highly addictive
• Usually smoked or
injected
• “High” lasts longer
than cocaine
• Prescribed for weight
loss, ADD-type
behaviors
CHCHNHCH
3
OH
CH
3
EPHEDRINE
CH
3
CH CHNHCH
32
METHAMPHETAMINE

19. Atlanta DEA Seizes Record
Amount of Crystal Meth
…large-scale Mexican drug ring with
members believed to be in the Atlanta
area, involving importation and
distribution of multi-kilogram quantities
of methamphetamine and cocaine from
Mexico, moved through California and
Texas, distributed into the United States…
…41 kilograms of suspected cocaine and
in excess of 187 pounds of suspected
crystal methamphetamine…

20. How is Methamphetamine Used?
• May be smoked, snorted, orally ingested,
injected or used rectally or vaginally
• Alters moods in different ways depending
on how it is taken

21. Acute Positive Effects of Meth
• Well-being to Euphoria
• Increased Energy
• Enhanced Mental Activity
• Increased Sex Drive
• Decreased Need for Sleep
• Decreased Appetite
• Increased Sensory Awareness and Alertness
• Feeling of Omnipotence
• Intensify Emotions
• Alter Self-esteem
• Increased aggressiveness

22. • Easily Available (strongest reason)
66% females 59% males
• 2nd reported reason
Females: to be more productive
Males: curiosity
• Males more likely because parents use drugs
Reasons for First Use of Methamphetamine
March 1998- Nov 1998
Review article M. Cretzmeyer, et al J. Substance Abuse Treatment
24(2003) 267-277

23. Binge Pattern of Abuse Cycle
NORMAL
RUSH
(5-30 Min.)
HIGH (4-16 hrs.)
BINGE (3-15 Days )
TWEAKING
(4-25 Hours)
NORMAL
(2-14 Days)
WITHDRAWAL
(30-90 DAYS)
CRASH

24. Meth vs. Cocaine
• Man-made
• Daily use
• Longer binges
• Smoking produces a
high that last 8-24
hours
• 50% of the drug is
removed from the
body in 12 hours
• Plant-derived
• Recreational use
• Intermittent binges
• Smoking produces a
high that lasts 20-30
minutes
• 50% of the drug is
removed from the
body in 1 hour

25. Meth vs. Cocaine Effects on the Brain
Cocaine
Methamphetamine

26. Measuring Pleasure
Stimulants boost the normal brain levels of the neurotransmitter
dopamine, which produces feelings of pleasure and increases
energy. Methamphetamines causes an excessive spike in
dopamine. Scientists say the excessive release contributes to the
drug's destruction of the brain.
Dopamine Index
Cheeseburger 1.5
Sex 2.0
Nicotine 2.0
Cocaine 4.0
Methamphetamine 11.0
Source: UCLA Integrated Substance Abuse Programs. Michael Mode/The Oregonian

27. Effects of Methamphetamine Use on the Brain
• Direct dopamine effects:
– Changes in mood
– Excitation
– Intensification of
emotions
– Elevation of self esteem
– Sensory perception
– Decreased appetite
– Elevation of libido
– Unusual motor
movements
– Paranoia
• Suspected serotonin effects:
– Increase feelings of
empathy
– Feelings of closeness
– Bizarre mood changes
– Psychotic behavior
– Aggressiveness
– Bruxism
– Lack of appetite
– Inability to sleep

28. Depleted dopamine
transporter levels in
methamphetamine
abusers show recovery
after prolonged
abstinence.
In these brain scans,
high dopamine
transporter levels appear
as red, while low levels
appear as yellow/green.
Dr. Nora Volkow, Director of
NIDA
(National Institute on Drug
Abuse)

30. Brain Changes with Meth Use
PET scans comparing control, Meth users with 6 mo-5 years
abstinence, and patients with Parkinson’s Disease, showing
decreased dopamine transporter activity in the caudate and
putamen. 25% decrease for Meth users, and 60% for PD.
(McCann 1998)

31. Cognitive Deficits
• Axons don’t always grow back correctly
• Different parts of brain recover at different rates
• Impairment of word and picture recall
• Impaired ability to manipulate information
• Ignore information
• Inability to filter irrelevant information
• Studies show impairment worse at 12 weeks
of non-use than is evident in current user
• Word recall gets worse, picture recall gets
better

32. Neurotransmitter Depletion

33. Behavior Changes –
Psychotic Features
• Paranoia
• Visual and auditory hallucinations
• Mood disturbances
• Delusions (ex. The sensation of insects creeping on
the skin)
• Homicidal thoughts
• Suicidal thoughts
• Out of control rages
• Can persist for years after use discontinued

34. Other Effects of Chronic Meth Use
• Tooth decay
• Hepatitis B and C
• STD’s : sexually transmitted disease
• HIV : associated with needle use and unprotected sex
• Sexual Impotence
• Cognitive impairment (reduced ability to process
information)
• Unplanned pregnancy, victims of domestic violence

35. Cognitive Impairment in Individuals Currently
Using Methamphetamine
Active MA users demonstrate impairments in:
– the ability to manipulate information
– the ability to make inferences
– the ability to ignore irrelevant information
– the ability to learn
– the ability to recall material
Matrix Institute on AddictionsMatrix Institute on Addictions

36. Effects of Methamphetamine Use -
Addiction
• Chronic, relapsing disease
• Characterized by compulsive drug-seeking and
drug use
• Functional and molecular changes in the brain
• Stronger potential for addiction
– rapid-acting routes of administration
– higher dosages
– higher purity

37. Effects of Methamphetamine Use - Tolerance
• Take higher doses
• Dose more frequently
• Change their method of drug intake
• “Run” - forego food and sleep while binging
• No tolerance for effects on judgment,
impulsivity, aggression, and susceptibility to
paranoia, delusions, and hallucinations –
opposite reaction

38. Effects of Methamphetamine Use - Withdrawal
• Physical:
Polyphagia (excessive hunger)
Hypersomnolence (sleepiness)
• Psychological:
Depression
Anxiety/agitation “Free floating” anxiety
Delusional state lasting up to a week
Fatigue/malaise
Paranoia
Hallucinations
Aggression
Intense craving for the drug

39. Abstinence Syndrome
After awaking from the crash, symptoms continue:
Psychological/Behavioral Symptoms
• Dysphoric mood--that may deepen into clinical depression
and suicidal ideation
• Persistent and intense drug craving
• Anxiety and irritability
• Impaired memory
• Anhedonia--loss of interest in pleasurable activities
• Interpersonal withdrawal
• Intense and vivid drug-related dreams

40. Abstinence Syndrome
Physiological symptoms
• Thin, gaunt appearance with reported weight loss
or anorexia
• Dehydration
• Fatigue and lassitude, with lack of mental or
physical energy
• Dulled sensorium
• Psychomotor lethargy and retardation--may be
preceded by agitation
• Hunger
• Chills
• Insomnia followed by hypersomnia

41. Special Issues for Women and
Methamphetamine
• Affordable
• Available
• Appetite suppressor
• Energy enhancer
• Weight loss
• Mood elevator
• Libido enhancer
• The growing illicit drug of choice among young
women
• 47% of those presenting for meth treatment females,
other substances 20-25% females

42. The impact on children may be connected to the
fact that women are more likely to use meth than
other illegal drugs.
For one thing, the drug is associated with weight
loss.
One federal survey of people arrested for all
crimes found that 11.3 percent of women had used
meth within the prior month compared with 4.7
percent of men.

43. Parenting Issues with Meth Involvement
• Neglect during long periods of sleep
• Inconsistent, paranoid behavior
• Irritability, short fuse, potentially leading to
physical abuse
• Exposure to violence, unsavory characters
• Generally poor parenting skills
• Mental health issues

44. Substance Abuse Affects Parenting
[Blending Perspectives and Building Common Ground, A Report to Congress
on Substance Abuse and Child Protection, April 1999]
• Impaired judgment and
priorities
• Inability to provide the
consistent care, supervision
and guidance children need
• Substance abuse is a critical
factor in child welfare

45. Children of Parents
with Substance Abuse Problems
• Have poorer developmental outcomes
(physical, intellectual, social and emotional)
than other children
• Are at an (eight-fold) increased risk of
substance abuse themselves

46. Substance Abuse and Child Abuse and Neglect
• Substance abuse causes or exacerbates 7 out
of 10 cases of child abuse and neglect
• Children whose parents use drugs and alcohol
are:
– 3x more likely to be abused
– More than 4x more likely to be neglected

47. Basic Meth Patient Treatment Considerations
Many stimulant dependent individuals demonstrate…
1. Low Impulse Control
2. Low Tolerance for Frustration
3. High Likelihood of Psychiatric Complications
(paranoia, delusions, agitated depression)
4. High Risk for Explosive, Violent Behavior
5. High Risk of Depression and High Risk of Suicide
6. Very Strong Craving
7. Cognitive and Memory Impairment
8. Brief Attention Span

48. What doesn’t work?
I. Shame: The addiction is a disease. You cannot scare a disease
away, you cannot threaten a disease away, and you cannot shame a
disease away. Much like you cannot scare, threaten or shame
diabetes away. These are people with a disease that must learn to
control the disease throughout the rest of their lives.
II. Try to avoid statements such as “if you wanted it bad enough, you
would quit.” “if you loved your children you would quit.” The
addict probably already has a lot of guilt and shame.
III. Heavy front-loading of services. The client is coming out of a
chaotic world with an impaired sense of intellectual functioning and
will not be able to accommodate effectively all the services that may
eventually be called for if they are all provided early in the case.
Don’t try to address all the deficiencies simultaneously.
IV. There are no quick fixes in working with meth and drug using cases,
in fact it appears the longer the client is engaged in services the
better the outcome.

49. What does work?
The first and foremost thing to remember is that meth addicts
can become clean and sober and live a life of recovery.
However, there are a few things to try with meth addicts that
may help them get into recovery quicker.
Treat them with respect, listen to their concerns and reasons for
continued or reuse even though they may not seem logical to
us in the beginning. It is important to meet our clients where
they are at emotionally and intellectually, not where we are at.

50. Use encouragement with the addict. Continue to
tell them that they can do it. If we believe in
them, they will hopefully start to believe in
themselves. Clients have to be held accountable
and have to face consequences for their actions
but our job is also to help them work through why
they made those choices and what can be done so
they have different options next time.
Have as much contact as you can work into your
schedule with the primary substance abuse
counselor. It is very important that you and the
counselor become a team in helping the client in
recovery. Both have an important part of the
puzzle and those pieces must be put together.
What does work?

51. I. Often when we become involved in a ‘meth’ case
there are a lot of issues that need to be addressed.
Find a way to prioritize what needs to be worked on
first. Try to think of it as a marathon and not a sprint.
In most cases, sobriety and then recovery is the most
critical obstacle. Without sobriety and recovery,
parenting skills, employment, housing, etc. will not
happen. Try not to frontload services. Find two or
three things to address initially so that the client can
be successful and then move on to the rest of the list.
II. Drug testing is also very important as a recovery tool.
Many recovering addicts have indicated that drug
testing and fear of random drug testing played a
major tool in their recovery.
What does work?

52. Visits with children are very important. This cannot be
stressed enough. Do your best to line up visits immediately,
preferable within a couple of days if the children are removed.
It is very important to the addict and more importantly for the
children that they have contact with their parents. These visits
can be supervised by a professional, family member or
unsupervised if the case warrants. The point is no matter what
the issues are; please look for a way to have safe visits for the
children early and often.
Trust is a very big issue with addicts. Be honest and upfront
with them from the beginning. Chances are they are looking
for an excuse not to trust in you and the system. If you say
that you are going to do something, do it. If you make a
promise, keep it.
What does work?

53. Support of self-help and 12-step groups can
help maintain a clean and sober lifestyle
Addressing cultural, ethnic, or language
issues and sensitivity to spiritual beliefs and
values improves success
Avoid an assumption that retention problems
reflect a lack of cooperation
Examine and address issues that can create
barriers to treatment success, among them:
transportation, childcare, health, and support
or sabotage from a partner or other family
member

54. Using family team meetings is a helpful way to help address
what needs to be looked at first. It is a great way to help the
client process what needs to be accomplished right away and
also what issues will need to be addressed at a later date. They
are effective in providing organization where there was only
chaos. FTMS are also an excellent way to develop a safety
plan in case of relapse or reuse that the parents have some say
in that also ensures the child’s safety. Keep it simple and
doable.
Family and 12-step and mutual support groups (MOM or
DAD) can be great supports especially early in recovery.
What does work?

55. Implications for practice
Try to find time for a quick phone call or a quick little note
of reassurance and encouragement. This will go a long way
in helping the addict be successful and will help the case
move quicker towards safe case closure.
You can take exception to the person’s behavior but you
must accept the person in order to make progress.
Determine the priorities for intervention in a case and then
move slowly forward to implementation.
Provide parent/child visitation
Provide support and encouragement
If we take away their only solution to life’s problems we
need to follow that up with some other means of coping.

56. Can addiction be treated successfully?
Yes. Addiction is a treatable disease. Discoveries in the
science of addiction have led to advances in drug abuse
treatment that help people stop abusing drugs and
resume their productive lives.
Can addiction be cured?
Addiction need not be a life sentence. Like other
chronic diseases, addiction can be managed
successfully. Treatment enables people to counteract
addiction's powerful disruptive effects on brain and
behavior and regain control of their lives.

57. Relapse rates for drug-addicted patients are compared with those suffering from diabetes,
hypertension, and asthma. Relapse is common and similar across these illnesses (as is adherence
to medication). Thus, drug addiction should be treated like any other chronic illness, with relapse
serving as a trigger for
Relapse rates for drug-addicted patients are compared with those suffering from
diabetes, hypertension, and asthma. Relapse is common and similar across these
illnesses (as is adherence to medication). Thus, drug addiction should be treated
like any other chronic illness, with relapse serving as a trigger for renewed
intervention.

58. People Can and Do Recover from Meth Addiction
Outcomes data provided by SSAs confirm that people can and do recover from meth
addiction. Examples include:
• Colorado’s Alcohol and Drug Abuse Division reported in FY 2003 that 80% of
meth users were abstinent at discharge.
• Iowa’s Division of Behavioral Health and Professional Licensure found, in a 2003
study, that 71.2% of meth users were abstinent 6 months after treatment.
• Tennessee’s Bureau of Alcohol and Drug Abuse reported in a 2002-2003 study that
over 65% meth clients were abstinent 6 months after discharge.
• The Texas Department of State Health Services examined outcomes data for
publicly funded services from 2001-2004 and found that approximately 88% of
meth clients were abstinent 60 days after discharge.
• Utah’s Division of Substance Abuse and Mental Health reported that in State
Fiscal Year 2004, 60.8% of meth clients were abstinent at discharge.
National Association of State Alcohol and Drug Abuse Directors, Inc.

59. September 2005 Report
Iowa Consortium for Substance Abuse Research and Evaluation,
University of Iowa based
meth addicts who received treatment had higher abstinence rates six
months later than any other group, including alcohol, cocaine and
marijuana users.
• Meth users -abstinence rate of 65.4 percent
(they hadn't taken meth or any other substance six months
after treatment)
• Marijuana –abstinence rate of 49.3 percent
• Alcohol –abstinence rate of 47.1 percent
• Cocaine –abstinence rate of 50.1 percent
"Compared to marijuana or alcohol, the people who are on meth tend
to do better," says Stephan Arndt , the group's director.

60. “Statewide in Iowa our methamphetamine addicts have a better
outcome than any other drug of primary choice," said Kermit
Dahlen, president and CEO at Jackson Recovery Centers say that 82
percent of meth addicts who complete treatment are still sober six
months later. Dahlen credited the adoption of evidence-based
practices for the success.
Jackson's Women and Children's Center has a 73-percent completion
rate, said program director Janelle Tomoson. "Some do come
through more than one time. Relapse is part of the learning process
and part of the disease. It's a chronic disease," she said, adding that
women tend to do better in gender-specific programs.
"The moms not only learn to get sober, but many of these women
have never had an opportunity to learn how to parent," said Dahlen.
"They do love their children. Our programs show them they are not
a bad person and are capable of loving their children and are capable
of providing them with a good home."

61. Matrix Model -Treatment That Works
Key Elements
Relies primarily on group therapy
Therapist functions as teacher/coach
Not confrontational ( positive, encouraging relationship)
Time planning and scheduling
Accurate information
Relapse prevention
Family involvement
Self help involvement
Urinalysis/Breath testing
Relapse Prevention
Family and Group Therapy
Motivational Interviewing
12- Step Involvement
Psychoeducation
Social Support

63. Pre-Recovery Behaviors/Excuses
Occur with Increased Frequency
• Old playmates and
old playgrounds
• Person not following
through with AA/NA
meetings or recovery
steps
• Cross-addictions
• “I will just stop over at
Jim’s and if they have
drugs, I will just
leave”
• “I’m too busy/tired to
got to a meeting,”
• I don’t have a problem
with alcohol so it is
OK for me to drink.”

64. Reuse
• can be the use of a drug “out of the blue”
• person may be working an excellent
recovery program
• may have had a long period of sobriety
• may be avoiding the old friends and old
playgrounds
• They may be doing everything right but still
have used

65. Reuse is very much a concern,
but different than Relapse……
• It is tends to be an isolated action
• Can be the “shock” to one’s system that
demonstrates the recovering person’s
continued vulnerability
• Could show them that recovery is a life-
long process
• Studies support that reuse often is part of
recovery (depending on how it is addressed)

66. Back to Basic Questions….
• Are they willing to increase AA/NA/
MOM/DAD support group meetings?
• Are they willing to resume or stay in formal
treatment services longer?
• Is the family cooperating with Family Team
Meetings and complying with Service Plan?
• Revisit the Safety Plan.

67. Relapse Prevention Steps
• Self-knowledge and identification
warning signs. This process teaches
clients to identify the sequence of
problems that has led from stable
recovery to chemical use in the past, and
then to synthesize those steps into future
circumstances that could cause relapse.

68. Step 2
• Coping skills and warning sign
management. This process involves
teaching relapse-prone clients how to
manage or cope with their warning signs as
they occur.

69. Step 3
• Change and recovery planning.
Recovery planning involves the
development of a schedule of recovery
activities that will help clients recognize
and manage warning signs as they occur
in sobriety.

70. Step 4
•Awareness and inventory training.
Inventory training teaches relapse-prone
clients to do daily inventories that monitor
compliance with their recovery program
and check for the development of relapse
warning signs.

71. Step 5
• Maintenance and relapse prevention plan
updating. Ongoing treatment is necessary
for effective relapse prevention. Even
highly effective short-term inpatient or
primary outpatient programs will be unable
to interrupt long-term relapse cycles
without the ongoing reinforcement of some
type of outpatient therapy until sustained
recovery is achieved.

72. Types of Relapse-Prone Clients
• Transition- does not accept/recognize their
addiction and are not able to accurately perceive
reality due to chemical effects.
• Unstabilized- lacks addiction interruption skills,
recovery program support, and positive lifestyle
change.
• Stabilized- is aware of their addiction and the
necessity for ongoing recovery program to
maintain abstinence. However, they tend to
develop dysfunctional symptoms over time
leading back to substance usage.

73. Relapse or Reuse?
• It is important to distinguish relapse from
reuse. They are two different things.
• Relapse is a progressive psychological and
behavioral change
• Can start hours, days, weeks or months
before a person uses mood-altering
chemicals

74. Relapse ≠ Treatment Failure
Recurrence of substance use can happen at
any point during recovery
Recognize the difference between a lapse (a
period of substance use) and relapse (the
return to problem behaviors associated with
substance use)
Work with the client to re-engage in
treatment as soon as possible

75. Part of effecting long-term change includes
working with clients to identify the specific
factors that preceded their substance use—
What were the emotional, cognitive,
environmental, situational, and behavioral
precedents to the relapse?
Relapse ≠ Treatment Failure

76. One element in the process of recovery is to
develop a relapse prevention plan and strategies to
avoid relapse
Plan for the potential of relapse and for ensuring
safety of the child(ren)
Parents who learn triggers can become empowered
to plan proactively for the safety of their children
and to seek healthy ways to neutralize or mitigate
the trigger
Relapse prevention includes: “What can a client do
differently?”
Relapse ≠ Treatment Failure

77. Implications for Practice
• Make sure factors critical for recovery are
addressed by making client accountable.
• Relapse does not necessarily mean the
discontinuation of visitation. Don’t stop visits as
punishment if the child’s safety and well-being
can be assured.
• Provide client with accurate information about
relapse process and the means to avoid it.
• Encourage client through motivational
interviewing and affirmations

78. Readiness for Change
Ambivalence about change allows exploration of costs of
status quo, and benefits of change versus costs of change
and benefits of status quo.
Readiness to change factors:
• Perception of need to change
• Belief that change is possible and can be positive
• Sense of self-efficacy to make the change
• Stated intention to change

81. Use of support groups may have greater benefits
for women. In a study of pregnant addicted
women, support group participation resulted in
better outcomes for mothers and their infants
Participation in group counseling appears to
influence a lower rate of relapse for women. In
addition more intense participation in treatment is
related to lower rates of relapse

82. Often women in treatment have low self-esteem,
little self-confidence, and feel powerless. It is
important to address these issues to improve
treatment effectiveness.
Since women appear to become addicted more
rapidly than men, by the time they enter
treatment, their addiction may be more severe,
which affects the level and intensity of treatment
needed.

83. In the general population, women have twice the
rate of depression as men, one-third of
women who enter SA treatment have
experienced clinical depression in the past year
30-60% of persons in treatment have a
co-occurring mental disorder, including panic
attack and other anxiety disorders; it is critical
that women’s treatment identify and incorporate
mental health services as needed
.

84. Help identify and coordinate the various services needed
to help reduce barriers to recovery and treatment success
Helping develop aftercare step-down services is a
valuable support that can help sustain recovery
Child visitation - Rather than a blanket rule regarding
visitation between parent and child, it may be more
appropriate to look at the factors affecting a specific case
to make an individual determination
Freedom and stability of recovery are benefits that persons
in recovery have identified as important, helping a client
understand how his or her life is better is an important
support for recovery

85. Women in treatment relapse less frequently than men
more likely to engage than men, particularly in group
counseling
One study of women cocaine users found that when
women relapse, they were more likely than men to report
negative emotions or interpersonal problems before the
relapse
Women appeared more impulsive in their return to use
Men were more likely to report positive feelings and a
belief they could control their drug use prior to relapse

86. Treatment Tips
Use behaviorally oriented groups that stress problem solving and
group building
role plays
practice solving real life experiences
Creates excitement, focus, and has them do the work of their own
recovery
Remember:
Many started using alcohol and drugs at a very early age
May be developmentally immature
Come from homes and environments where there is little
support for recovery
may not know what a healthy sponsor or positive recovery
oriented group should look like

87. www.drugfreeinfo.org
Iowa's 24/7 Drug and Alcohol Help Line: Toll
free 1-866-242-4111
Iowa Resources
Agencies, Studies, Statistics
Directory of Services Lists types of services,
population served, and links to
each provider

88. Resources
TIP series from SAMHSA Substance Abuse and Mental
Health Services Administration
under Publications at
www.samhsa.gov/index.aspx
NCSACW National Center on Substance Abuse and Child Welfare
www.ncsacw.samhsa.gov
Children of Alcoholics Foundation
www.coaf.org

89. MATRIX MODEL
4-month, manualized, intensive outpatient abstinence-based
program
Counselor’s Treatment Manual
Counselor’s Family Education Manual
Client Handbook
Client Treatment Companion
ORDER FREE AT:
http://ncadistore.samhsa.gov/catalog/SC_Itemlist.aspx

92. RESOURCES COLLECTED FROM THE FOLLOWING
• http://www.health.org/govpubs/PHD861
• Kci.org (Formerly Koch Crime Institute)
• Lifeormeth.org
• Methabuse.net
• Dr. Rizwan Shaw, Medical Director Regional Child Protection Center
• Dr. Resmiye Oral U of I Child Protection Program & Child Health Specialty Clinic
• SAMHSA http://www.ncsacw.samhsa.gov/files/understandingSAGuide.pdf
• Judy Murphy -Meth Specialist Cedar Rapids Area Iowa DHS
• Dr. Joyce Gilbert Medical Effects of Meth on Children -Idaho DEC Conference 2004
• Brian Reed Decontamination of Meth Contaminated Residences -Idaho DEC Conference 2004
• Dr. John Martyny Ph.D., CIH National Jewish Medical and Research Center Chemical Exposures
Associated with Clandestine Meth Labs -Idaho DEC Conference 2004
• Dr. Kathryn Wells & Dr. Wendy Wright Medical Summit -Idaho DEC Conference 2004
• Captain Clark Rollins Idaho State Police Investigations Michelle Britton Regional Director Department
of Health and Welfare DEC Successes -Idaho DEC Conference 2004
• Dr. Kiti Freier Associate Professor Psychology & Pediatrics Loma Linda University, Associate
Director, Center for Prevention Research Andrews University Psychological and Social Needs of the
Drug Endangered Child -Iowa DEC Conference 2005
• CC Nuckols PhD Methamphetamine Addiction: “Speed” Still Kills Counselor Magazine January 03
• Iowa Division of Narcotics Enforcement
• Matrix Institute www.matrixinstitute.org
• Iowa Drug Endangered Children Program www.iadec.org
• Iowa DHS
• North Carolina Division of Social Services

97. Brain Changes with Meth Use
• Rhesus and Vervet monkey studies
• Given 3-6 months meth doses equivalent to
humans
• Decreased dopamine levels in the caudate
by 80% immediately after stopping meth
and up to 6 months later
(Seiden 1975, Woolverton 1989, Melega 1996 and 1997)

98. Implications for practice
If we take away their only solution to life’s problems we need
to follow that up with some other means of coping.
The result of that is that often we end up with parentified
children who are used to taking care of themselves and their
siblings. They may not respond to direction and consequently
are problems in school because they have been making
decisions themselves and have learned that adults aren’t going
to take care of them or can’t be trusted. We label them with
some DSM IV diagnosis rather than understanding where they
are coming from.
The original home environment was characterized by chaos and
disorder. Some sense of order and routine must be established
which may interfere with what household members are used to
and how they liked to behave.
There will be some turmoil because of some role changes as a
result of sobriety.

99. Motivational Interviewing
five general principles:
Express empathy through reflective listening
Develop discrepancy between clients’ goals or
values and their current behavior
Avoid argument and direct confrontation
Adjust to client resistance rather than opposing it
directly
Support self-efficacy and optimism

100. Treatment Tips
Tell clients symptoms they are experiencing are common at given
stage of abstinence
Avoid 60 minute didactic sessions –meth addicts struggle to
maintain focus also may be developmentally too immature to
participate
15-20 minute video or didactic session followed with
questionnaire
what they thought about the presentation
what they learned
how their future behavior will change
Sessions on how to participate in treatment & how to find a self
help group

101. Don’t overload/frontload
Keep lists short
Assist in prioritizing
Safety plan for kids as part of relapse plan
Day planners
Encourage lots of support
Establish “circles of support”
Acknowledge and compliment
See more often shorter time periods
Things to Keep in Mind