Breakingthecycles.com – Changing the Conversations

by Lisa Frederiksen

NPR’s news program, today, “Commanders Have Ignored Major Mental Health Issues, Army Report Concludes,” reinforces the importance of talking about the connection between substance abuse and mental illness. [Note: substance abuse and addiction are two different things, although both cause changes in the brain.]

Substance abuse (whether it is of alcohol and/or prescription or illegal drugs) causes chemical and structural changes in the brain (see SPECT scan below). Thirty-seven percent of alcohol abusers and fifty-three percent of drug abusers [NOT addicts or alcoholics but drug or alcohol abusers] also have at least one serious mental illness,(1)(2) such as depression, PTSD, bipolar, anxiety, schizophrenia. Often what happens is the person starts to drink or use drugs to self-medicate the mental illness.

When you change the chemical and structural make-up of the brain, you change how the brain works, which in turn, changes how a person thinks, feels and behaves. This is because “neural networks” in the brain control EVERYTHING we think, feel, say and do. “Neural network” is a name for the process by which neurons talk to one another. In the brain, neurons are also known as brain cells. The way our brain cells talk to one another is determined by how our neural networks wire – talk to one another. Drinking too much or abusing drugs interrupts neural networks, which is part of what makes a person unable to think straight or behave “normally.” Repeatedly drinking too much or abusing drugs can cause chemical and structural changes in the brain like those shown in the image on the left, below.

SPECT Surface Scans, Courtesy Amen Clinics, Inc., www.amenclinics.com

LEFT = SPECT Surface Scan confirming substance abuse. RIGHT = SPECT Surface Scan of normal brain.

Now look at SPEC Surface Scans of the brain of a person with ADHD below (for comparisons, look at the bottom, right scan — that’s the same view as the two scans above). As you can see, mental illness also changes the brain.

SPECT Surface Scan Showing ADHD, Courtesy Amen Clinics, Inc., www.amenclinics.com

Looking at scans like these helps one see what substance abuse (such as repeated binge drinking) and  mental illness, such as ADHD, do to the structural make-up of the brain. This in turn can help you appreciate why a person whose brain has experienced these kinds of changes does not “think” or “behave” normally. It helps explain, in part, why suicide can seem like the best option to those who suffer from an undiagnosed, untreated mental illness and a substance abuse problem. A person suffering PTSD or bipolar or anxiety or depression needs help (see Resources below). A person who is abusing substances also needs help (again, see Resources below).

Looking at these kinds of scans also helps us appreciate that just removing the substance – the “coping skill” – without replacing it with something else (such as treatment and/or medication for the mental illness), or treating the mental illness without stopping the substance abuse, is a set-up for failure.

THE BOTTOM LINE: the brain change change. A person can heal their brains with proper treatment. Healing the brain changes how a person thinks, feels and behaves.

RESOURCES:

The Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services offers a Locator database with comprehensive information about mental health services and resources in the United States.

The National Alliance of Mental Illness (NAMI) offers excellent, free self-help programs. Visit www.nami.org for information and locations in your community.

NIAAA’s (National Instittue on Alcohol Abuse and Alcoholism) Rethinking Drinking website can help a person anonymously assess his/her drinking patterns and find tips for cutting down.

NIDA’s (National Institute on Drug Abuse) Info Facts: Science-Based Facts on Drug Abuse and Addiction

Bring Change 2 Mind.org – working to end the stigma associated with mental illness.

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(1) “Factsheet: Dual Diagnosis,” Mental Health America, <http://www.nmha.org/index.cfm?objectid=C7DF9405-1372-4D20-C89D7BD2CD1CA1B9>
(2) “Dual Diagnosis and Integrated Treatment of Mental Illness and Substance Abuse Disorder,” National Alliance on Mental Illness, <http://www.nami.org/Content/ContentGroups/Helpline1/Dual_Diagnosis_and_Integrated_Treatment_of_Mental_Illness_and_Substance_Abuse_Disorder.htm>

The following is a guest post from Eileen and Alisa, mother and daughter, working together to fight the family disease of addiction.

Appropriate addiction treatment is hard to find. Recently I did a web search (google) for best rehabs.  I called the first 800# and told the operator that my husband was using, and we needed him to go to rehab.  I asked, “Where is the best rehab?”

The operator asked, “Private or public?”

I said, “The best.”

She then informed me that I had indeed contacted the best rehab available and that  it was an holistic drug rehab facility offering an addiction treatment program that addresses the four major effects of drug abuse and drug addiction (physical, emotional, spiritual, and mental). She told me that traditional drug rehab centers primarily provide basic medical service that treat withdrawal symptoms associated with drug addiction and a secondary psychological treatment, but that holistic drug rehab programs, on the other hand, go much deeper than this. She explained holistic drug rehab offers an extensive, multi-faceted drug addiction treatment that treats the root of the problem rather than just the symptoms. The operator continued, saying that before anything else, a holistic drug rehab will address the physical aspects of addiction including holistic detox (lots of sleep, water, and organic foods as well as any medications). They also offer talk therapy and behavioral therapy.   Spiritually, she continued, the holistic drug rehab programs offer a safe place to explore what you believe, whether you have specific religious convictions or a more general notion of a higher power. And, she concluded, holistic drug rehab and treatment addresses all mental issues and from mild depression, to serious panic and anxiety, to bipolar disorders, to major depression.

“WOW!” I said. I then explained that many of my family members have gone to many rehabs so I wanted to know their program’s recovery and relapse rates.

She said they have excellent outcomes. [I wasn't sure how that exactly answered my question, but let it go.] I then asked about cost.

She asked, “Insurance or not?”

I said, “No insurance.”

Again I asked for statistics and length of recovery.

She answered by saying their program was 28 days inpatient + 3 weeks outpatient.

I asked, “How much?”

She said, “$40,000.00.”

I explained that $40,000 was more than we could afford and that we would likely need a public rehab program, instead.

She asked me, “What state?”

I said, “Pennsylvania.”

She said, “Hold on.”

Then I was disconnected.

This is but one of the many similar experiences we have had as we’ve tried to unravel addiction treatment programs, costs and outcomes measurements. For $40,000, it does not seem too much to ask to see what their success rates have been! From what we can tell, there does not seem to be a method for determining exactly what a treatment center offers (beyond the fluff of what they all seem to say) — a method that INCLUDES outcomes measurements . And, then, when you add in the cost and the issues of insurance vs no insurance as part of the discussion,  it becomes a new ballgame entirely.

by Lisa Frederiksen

Boy… this seems like a terrific resource for groups wanting to put together coalitions to address underage drinking issues. It was created by the National Association of Governor’s Highway Safety Representatives (NAGHSR) and provides a comprehensive list of organizations that have an interest in or knowledge about underage drinking issues.

Click here to read/print a copy.

This is an excellent, 8-minute video, that includes the voices of parents, teens, addictions’ specialists, a doctor, police officer and others to address one community’s underage drinking problem. It presents many important facts and suggestions for how and why it’s important to address underage drinking.

by Lisa Frederiksen

You have probably been told something like, “Alcoholism / drug addiction is just like any other disease.” After which you have probably said to yourself or to whomever made the statement, “Like *!?!#! it is! People with diabetes or heart disease don’t steal money from me or endanger my children by driving while under the influence!”  And, that’s because diseases like heart disease and diabetes are not brain diseases. They do not cause chemical and structural changes in the areas of the brain a person needs in order to think straight and act responsibly.

Addiction and other diseases, like diabetes and heart disease, share common characteristics true of all diseases:
- They are chronic .
- They have the potential to result in death if untreated.
- There is a genetic influence associated with vulnerability.
- They involve behavioral factors associated with the onset of the disease.
- They have the potential for relapse if treatment recommendations are not followed.

These similarities explain why effective addiction treatment requires a “disease management”   approach, as opposed to an acute care approach (i.e., “28-days and you’re good to go”).  While the components and deliveries will vary, because no single treatment component is appropriate for all individuals at all times,  the overall objectives of a disease management approach to addiction treatment should involve three phases: 1) detoxification/stabilization, 2) rehabilitation and 3) continuing care.

So how did we get so stuck in the acute treatment model?

Secrecy and shame.

How many addicts/alcoholics and/or family members/friends with a loved one who has a problem with substance abuse actually talk about it — talk about it as they would if they or their loved one had cancer?

The founding of AA provided the first wide-spread effort to view excessive drinking as something beyond a “lack of willpower” and to approach treatment from the perspective of abstinence – not drinking any alcohol. Its fellowship viewed alcoholism as a “combination of physical, psychological and spiritual causes,” a combination that made alcoholics different from non-alcoholics.

AA provided a guide for how a member of its fellowship could achieve abstinence and a joyful life through its 12-steps and The Big Book. It proved to be life-changing then and continues to be life-changing now for the millions who grapple with alcoholism – today understood as one of the diseases of addiction. However, AA could not overcome the shame in which society had so thoroughly shrouded the problem, a shame so powerful it forced alcoholics to recover from their disease in anonymity, hence the name, Alcoholics Anonymous.

Treatment options for drug addictions took even longer. Narcotics Anonymous (NA) meetings patterned after AA did not appear until the early 1950s, and its guidebook, Basic Text, was published long after that.

Not until the early 1980s, with the co-founding of the Betty Ford Clinic by Former First Lady Betty Ford, did seeking treatment at a residential facility for alcohol and drug addictions gain public recognition.  Today, there are more than 11,000 addiction treatment programs in the United States, according to the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Awareness Services (SAMHAS). And organizations, such as the American Medical Association, the National Institute on Drug Abuse, the World Health Organization and the National Institute on Alcohol Abuse and Alcoholism, are making significant advances in the prevention and treatment of alcoholism and drug addiction.

Yet, these major inroads have not been enough to overcome the secrecy and shame in which society has so thoroughly shrouded the problem. As a consequence, alcoholism and drug addiction continue to be misunderstood diseases.  They continue to be diseases people try to conquer on their own or to recover from in anonymity for fear of the reprisals they may face socially, at school, in the workplace or within their extended families.

Thankfully, the new brain and addiction-related research is exploding our long-held beliefs about alcoholism and drug addiction being a matter of “choice.” Finally we can end the secrecy and shame! Finally, we can treat addiction (to alcohol or drugs) for what it is — a chronic, often relapsing brain disease. But first, we must TALK ABOUT IT!

The following is an excerpt from a blog post by David Rosenbloom, Director of Join Together, an organization supporting community-based efforts to advance effective alcohol and drug policy, prevention, and treatment since 1991.

…In the early 1900’s negative and hateful stereotypes about who used heroin, cocaine, marijuana and alcohol were codified into law, and it seems to me these stereotypes continue to drive policy. Doctors were actively discouraged from treating people with addiction. Almost any mention or teaching about addiction disappeared from medical training and practice. Since 1914 federal policy has discouraged doctors from treating addiction by…

David Bloom also states that only 15% of those in need reach AA meetings and/or free-standing specialty treatment centers. Clearly we must act now. Read the rest of David Bloom’s piece and do what you can to close the treatment gap.

The following is a reprint of my Guest Opinion appearing in the May 14, 2010, Palo Alto Weekly, copy online. I would love to hear your comments!

There is a relatively new drink on the market. It’s called “four Loko” and it is especially popular with young people. It’s advertised as a “caffeinated alcoholic beverage” and comes in a 23.5-ounce can in a variety of fruit flavors, such as watermelon, lemonade and blue raspberry. They begin to taste like harmless sodas.

What most consumers may not know is that one “four Loko” drink contains almost five standard drinks. Five!

For several years I’ve been giving presentations on alcohol-related issues to a wide variety of groups in the Menlo Park/Palo Alto area and statewide. My main topic was sharing 21st century brain research, especially new findings and science-based answers on why and how alcohol affects the brain and what it is that causes a person to lose control of their drinking.

Time and again, attendees — especially young people — are struck by one of the reasons: measuring alcohol consumption is less about the number of glasses than it is about the number of “standard drinks” in each glass.

A standard drink is usually 5 ounces of table wine, 12 ounces of regular beer, 3.3 ounces of champagne or 1.5 ounces of 80-proof spirits. Thus, a Long Island Iced Tea at one location could contain two or three standard drinks; a vodka on the rocks at another could put a woman into the binge-drinking category; and a “four Loko,” well. …

Additionally, most people do not know what “safe” or “moderate” drinking is all about. No labels; no wonder.

The National Institute on Alcohol Abuse and Alcoholism identifies safe or moderate drinking limits as follows:
For women, seven standard drinks in a week, with no more than three per day.
For men, 14 in a week with no more than four per day.

The weekly-limit recommendation is to help with dietary health (not that a person needs to drink, but if they do …). One standard drink contains about 100 calories and few if any nutrients. The second number is to help a person avoid binge drinking — the kind of drinking that causes a person to lose control of their thinking and engage in drinking behaviors, such as driving while under the influence; having unprotected or unwanted sex; getting into fights with a loved one over how much they’ve had to drink; or starting a fight for a really dumb reason. Binge drinking is defined as four or more standard drinks on an occasion for women and five or more for men.

Why four and five? The reason is that alcohol enters the bloodstream through the wall of the small intestine. Because alcohol dissolves in water, the bloodstream carries it throughout the body (which is 60 percent to 70 percent water) where it is absorbed into body tissue in proportion to the body tissue’s water content.

Alcohol leaves the body through the liver, for the most part. As a very general rule of thumb, it takes the liver about an hour to metabolize the alcohol in one standard drink; four hours for four drinks, and so on.

The brain is mostly water, and it controls everything we think, feel, say and do. When a person drinks more alcohol than their liver can metabolize, the excess alcohol stays in the bloodstream and suppresses certain brain functions. This is why a person can find him/herself engaging in the drinking behaviors previously mentioned.

Even if a person appears as if s/he can “hold their liquor,” the impact is still happening. It still takes their liver about one hour to metabolize one drink; eight hours to metabolize eight drinks.

So, can instituting a standard drink-labeling program change drinking behaviors? Likely. Can we afford not to do something that would cost so little yet potentially accomplish so much? No.

Think about it. We know how many grams of sugar are in a soft drink container and how many calories are in a serving of pasta. We can read the USDA food pyramid on most food product labels. But most of us are not sure how much alcohol is in a drink.

And while the FDA requires we get the nitty-gritty on food contents in the form of a standard label, nowhere can we find out how many “standard drinks” are in our drinks or whether the same drink at another location is really the same.

If it’s important enough to tell consumers about grams of sugar and calories it should be equally important to tell them about their alcohol intake. A lifetime of excess calories may impact a person’s health measurably, but one trip behind the wheel or engaging in any of the other embarrassing, hurtful or dangerous behaviors that can occur after too many drinks could adversely and instantaneously change that person’s and someone’s else’s life forever.

We need legislation that expands existing alcoholic-beverage labels to include the number of standard drinks per serving and per container. The law also should require restaurants and bars do the same on their menus.

Sure, it will mean all bartenders have to pour their drinks as their establishment has labeled them; just like packaged food-serving contents must meet their labels. And yes, some people won’t want to know how much they’re drinking — just like some people don’t want to know how many calories are in the bag of chips they eat.

But with a standard-drink label, the person who wants to keep it to a “couple of drinks” can decide whether to split the “four Loko” with a friend or drink a 24-ounce can of regular beer, instead.

by Lisa Frederiksen

Alcohol use and heavy drinking are common during adolescence and
young adulthood, although the minimum legal drinking age across the
United States is 21 years. Some individuals may start hazardous alcohol
consumption earlier in childhood. The prevalence of problematic
alcohol use continues to escalate into the late adolescent and young adult
age range of 18 to 20 years. Drinking by college-aged students
remains a major issue. Results of recent research that have demonstrated
that brain development continues well into early adulthood1
and that alcohol consumption can interfere with such development2,3
indicate that alcohol use by youth is an even greater pediatric health
concern.

The above is a quote from the American Academy of Pediatrics Committee on Substance Abuse’s, April 12, 2010, “Policy Statement Alcohol Use by Youth and Adolescents: A Pediatric Concern,” published online and available for download. I urge parents, community leaders, policy makers, teachers and school administrators to read this article. It presents the new brain research and study findings as the reasons for Pediatricians to take an ongoing, proactive approach to consulting with their patients about underage drinking. Below are the 16 recommendations Pediatricians and other health care providers who work with children and adolescents are encouraged to do:
1. Become knowledgeable about all aspects of adolescent alcohol, tobacco, and other substance use through participation in training program curricula and/or continuing medical education that provide current best-practices training, including media-literacy training.
2. Obtain a complete family medical and social history at prenatal and health supervision visits to explore potential genetic and family influences regarding alcohol and other substance use.
3. Recognize risk factors for alcohol (as well as other drug) use among youth and be aware of coexisting mental health problems, such as depression, that may occur in this age group.
4. Regularly screen for current alcohol (as well as other drug) use by adolescents and young adults by using nonjudgmental, validated screening methods and appropriate
confidentiality assurances.
5. Assess patients whose screening results are positive for alcohol use to determine the appropriate level of intervention.
6. Use brief intervention techniques in the clinical setting and be familiar with motivational interviewing techniques to work with patients who use alcohol but do not meet criteria for immediate referral. Offer referral to treatment when indicated.
7. Discuss the hazards of alcohol and other substance use with patients as part of anticipatory guidance and patient/parent education at health supervision visits as well as when relevant at acute-problem visits. Anticipatory guidance aligned with key school calendar events, such as proms and graduation, may be especially meaningful.
8. Strongly advise against the use of alcohol, tobacco, and other illicit drugs by youth.
9. Encourage parents to be good role models for healthy life choices and never allow underaged drinking at their home or other property. Empower parents with the realization that their involvement with their adolescents is a powerful deterrent of substance abuse.
10. Be familiar with local resources to which various pediatric-aged patients with alcohol use disorders, their parents, and other family members can be referred for developmentally appropriate treatment.
11. Support adolescents with substance use disorders throughout and after their treatment.
12. Serve as a resource and support for school and other community-based alcohol use prevention programs.
13. Support advocacy efforts to promote appropriate media modeling of alcohol consumption and consequences, including print media, television, film, and the Internet.
14. Support advocacy efforts to promote legislation that reduces alcohol-related morbidity and mortality, such as graduated driver licensing; treatment parity from third-party payers; legal ramifications for parent sponsorship of adolescent drinking; increased alcohol excise taxes; and other prevention and treatment policies recommended in the Surgeon General’s call to action.
15. Support continuation of the age of 21 as the minimum legal drinking age, and support enforcement that decreases access to alcohol for minors.
16. Support further research into prevention, evidence-based screening and identification, brief intervention, and management and treatment of alcohol and other substance use by adolescents.

To better understand what problematic underage drinking is, the following is the CRAFFT Questions suggested for use by Pediatricians.

CRAFFT Questions: A Brief Screening Test of Adolescent Substance Abuse
C Have you ever ridden in a car driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
R Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?
A Do you ever use alcohol or drugs while you are by yourself, alone?
F Do you ever forget things you did while using alcohol or drugs?
F Do your family or friends ever tell you that you should cut down on your drinking or drug use?
T Have you ever gotten into trouble while you were using alcohol or drugs?
Two or more yes answers suggest a significant problem, abuse, or dependence. The CRAFFT questions were developed with grant support from the Robert Wood Johnson Foundation, the National Institute on Alcohol Abuse and Alcoholism, and the Substance Abuse and Mental Health Services Administration.
Source for all of the above:  THE AMERICAN ACADEMY OF PEDIATRICS PEDIATRICS® Volume 125, Number 5, May 2010 1083 Downloaded from www.pediatrics.org on May 11, 2010.

by Lisa Frederiksen

For anyone working to reduce underage drinking, one of the keys to helping coalitions, parents, and young people better understand the “reasons” is to share the new science — the science-based answers now possible due to new imaging technologies that allow neuroscientists and medical professionals to study the live human brain like never before.

Below you will find excerpts from a Fact Sheet by Jack O’Connell, State Superintendent of Public Schools, California Department of Education, issued in January 2009, titled, “The Adolescent Brain and Substance Use.” It is relatively short but has so much important, well-explained information for anyone whose life or career intersects with teens and alcohol use.

Recent research findings on brain development call the adolescent brain “a work in progress.”1 Contrary to earlier wisdom, the brain continues to develop until we reach our early twenties. The areas of the brain that are last to develop are those responsible for decision making, impulse control, learning, and memory. Because teen brains are not yet mature, teens are especially vulnerable to the harmful consequences of substance use.2

A Brief Explanation of Brain Development
Until recently, many believed that the human brain develops by the age of three and matures by around age ten. However, advanced brain imaging techniques now show that brain development is not completed until around age twenty-four.

Between the ages of six and twelve, the brain’s nerve cells that are responsible for thinking and information processing multiply and develop new communication pathways. After this growth in nerve cells, a process of “pruning” occurs in the early twenties, where connections between neurons that are not used die away, and those that are used remain—a “use it or lose it” process.3 At the same time, there is a thickening of the brain’s myelin (a white fatty material that covers parts of the nerve cell and makes transmission of nerve signals faster and more efficient).

Click here to download the PDF of this article and learn more about the timing of various brain regions and their functions, the role puberty plays and how alcohol can hijack the brain of an adolescent.

by Lisa Frederiksen

I like to post stories about collaborative efforts to reduce underage drinking. Here is one on a statewide effort by South Carolina. Quoting from News Channel 7 WSPA  Staff Report, “Statewide Campaign Blitzes Underage Drinking,” appearing on their website, www2.wspa.com:

An “enforcement and education blitz” coordinated by the S.C. Department of Alcohol and Other Drug Abuse Services (DAODAS) resulted in an unprecedented number of activities by local law enforcement and prevention teams that focused attention on the dangers of underage alcohol use.

Through the statewide campaign, South Carolina’s Alcohol Enforcement Teams (AETs) helped direct activities aimed at limiting access to alcohol by young people under the age of 21. The increased enforcement and public education efforts promoted a safe end to the school year and a safe prom season. The campaign – called “Out of Their Hands” – emphasized that it is against the law for anyone under 21 to purchase, possess, or consume alcoholic beverages.

The campaign, which ran April 2-11, resulted in:

32 party-dispersal operations (compared to 3 during the same period in 2009);

759 compliance checks (compared to 115 during the same period in 2009);

71 public safety checkpoints (compared to 14 during the same period in 2009); and

95 “shoulder tap” operations (compared to 0 during the same period in 2009).

These various operations led to 452 cases of charges being filed. During the period of April 2-11, 2009, only 125 cases resulted from similar operations.

To read the rest of the article – click here…