What They Never Taught You in School About Substance Use

What They Never Taught You in School About David Mee-Lee, M.D. Substance Use and Addiction and What to Do About It

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What They Never Taught You in School About Substance Use and Addiction and What to Do About It

David Mee-Lee, M.D. Davis, CA

(530) 753-4300; Mobile (916) 715-5856 [email protected] davidmeelee.com

tipsntopics.com instituteforwellness.com

September 16, 2021 8:30 AM – 10:00 AM Wisconsin Crisis Intervention Conference

A. Why This Topic?

1. Stigma Lack of training in substance use, addiction and treatment is not a neutral experience. In the vacuum of lack of knowledge, flow the predominant attitudes and prejudices of the greater society.

2. Statistics -2019 National Survey on Drug Use and Health (Sept, 2020)

Past Year Substance Use Disorder (SUD) and Any Mental Illness (AMI) among Adults Aged 18 or Older: 2019

Past Year Substance Use Disorder (SUD) and Serious Mental Illness (SMI) among Adults Aged 18 or Older: 2019


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(e) Unmet Need for Addiction Treatment The results of the 2019 National Survey on Drug Use and Health were released in September 2020. https://www.samhsa.gov/data/report/2019-nsduh-annual-national-report Here is the pie chart where a picture is worth a thousand words. Note the tiny sliver of 1.2% of people who felt they needed treatment and made an effort to get it:

• Most people getting antidepressants for depression get them from primary care physicians because

that’s where those with depression often are – not in psychiatrists, psychologists and other therapists’ offices. The same is true for where people with substance use problems and addiction are.

• Impacting addiction will need much more partnership with primary care and health systems, not just behavioral health integration.

Perceived Need for Substance Use Treatment among People Aged 12 or Older with a Past Year Substance Use Disorder (SUD) Who Did Not Receive Substance Use Treatment at a Specialty Facility in the Past Year: 2019


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B. Attitudes about Substance Use and Addiction

1. Experiences Shaping Attitudes • antisocial, self –destructive • non-compliant • out of control

2. Factors Contributing to Negative Attitudes

• past experience with difficult clients • negative societal attitudes • inadequate education and skills training • over exposure to chronic, relapsing clients • lack of exposure to successfully recovering clients • lack of accessible treatment resources

3. Negative Attitudes Towards Substance Misuse

• anger • avoidance • discouragement • fatalism • frustration • futility • hopelessness • judgmentalism

4. Consequences of Negative Attitudes

• at-risk persons not recognized and screened • affected persons not diagnosed and treated • denial of existence of substance use problems • enabling behavior (prescriptions, social supports etc.) • punitive management • patronizing, nagging behavior

C. Key Concepts About Addiction Not Taught in Professional School 1. Addiction is a brain disease and biopsychosocial-spiritual in nature. (a) American Society of Addiction Medicine (ASAM): “Addiction is a treatable, chronic medical disease

involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases.”

https://www.asam.org/resources/definition-of-addiction

(b) Biopsychosocial in etiology, expression and treatment § Addiction is not just a brain disease or behavioral disorder. It is biopsychosocial in the etiology of

addiction; the way addiction manifests itself and affects people and families; and in promoting treatment that is holistic and person-centered that touches the physical, mental, social and spiritual aspects clients.

§ There are genetic and biochemical origins to addiction. But there are psychiatric and psychological underpinnings to addiction as well as public health principles that contribute to addiction e.g., the more available a drug and the lower the price, the more widespread are the health and social costs of addiction to those drugs.

§ Who crosses the line into addictive illness depends on their own recipe of biopsychosocial factors. Some people can have little genetic predisposition and family history of addiction but succumb to overwhelming psychosocial factors. Others can have a strong genetic predisposition, multiple


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family problems and role models for using substances as a way of living; live in a drug “ghetto” with drugs on every corner; and at 20 years old now has a 5-year history of heavy drug problems.

(c) "Over the past three decades, a scientific consensus has emerged that addiction is a chronic but treatable medical condition involving changes to circuits involved in reward, stress, and self-control; this has helped researchers identify neurobiological abnormalities that can be targeted with therapeutic intervention..... Yet the medical model of addiction as a brain disorder or disease has its vocal critics. Some claim that viewing addiction this way minimizes its important social and environmental causes, as though saying addiction is a disorder of brain circuits means that social stresses like loneliness, poverty, violence, and other psychological and environmental factors do not play an important role. In fact, the dominant theoretical framework in addiction science today is the biopsychosocial framework, which recognizes the complex interactions between biology, behavior, and environment." (Volkow, Nora D (2018): “What Does It Mean When We Call Addiction a Brain Disorder?” Scientific American blog March 23, 2018.)

• New breakthroughs in anti-addiction medication, vaccines and biological interventions • Attempts to improve the public’s acceptance of addiction as a primary, chronic disease. • Promoting screening and brief intervention in general health settings. • A change in attitudes away from addiction as willful misconduct.

(d) Drug, Set, and Setting - The Basis for Controlled Intoxicant Use - Norman E. Zinberg, M.D.

(http://www.psychedelic-library.org/zinberg.htm) "Set" is the mental state a person brings to the experience, like thoughts, mood and expectations. "Setting" is the physical and social environment. Social support networks have shown to be particularly important in the outcome of the psychedelic experience. They are able to control or guide the course of the experience, both consciously and subconsciously. Stress, fear, or a disagreeable environment, may result in an unpleasant experience (bad trip). Conversely, a relaxed, curious person in a warm, comfortable and safe place is more likely to have a pleasant experience. (https://en.wikipedia.org/wiki/Set_and_setting) Implications and objectives:

• To ensure active, cooperative, coordinated interdisciplinary team functioning to help clients live free from reliance on drugs.

• To promote respect, trust and good communication between all disciplines needed to treat the whole person--counselors, social workers, volunteers, clergy, recovered alcoholic or chemically dependent persons, physicians, nurses and allied professionals.

• To ensure treatment plans which address the evaluation and treatment strategies for each aspect of the disease so as to minimize continued use or relapse.

• To help establish reimbursement and care management mechanisms which recognize the necessity for psycho-social-spiritual intervention in addition to biomedical detoxification and treatment of physical complications.

• To assist making the spiritual aspect of recovery relevant to clients and patients by relating it to a restoration of values; introduction to the concepts of "higher power" and spiritual recovery prevalent in such self-help groups as Alcoholics Anonymous; and contrasting spiritual recovery with religious affiliation.

2. “Denial/resistance” – Sustain Talk (Motivational Interviewing) is a major sign and symptom characteristic of addiction • conscious lying • organic amnesia • unconscious survival mechanism • implications for history-taking and treatment planning


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(a) From Pathology to Participant • Resistance is often perceived as pathology within the person, rather than an interactive

process; or even a phenomenon induced and produced by the clinician • “Resistance” may be as much a problem with knowledge, skills and attitudes of clinicians as

it is a “patient” problem As a first step to moving from pathology to participant, consider our attitudes and values about

resistance. It is often perceived as pathology that resides within the client, rather than an interactive process or even a phenomenon induced and produced by the clinician.

(b) Models of Stages of Change

* Transtheoretical Model of Change (Prochaska and DiClemente): Pre-contemplation: not yet considering the possibility of change although others are aware of a

problem; no active interest in changing; seldom appear for treatment without coercion; could benefit from non-threatening information and information to raise awareness of a possible “problem” and possibilities for change.

Contemplation: ambivalent, undecided, vacillating between whether he/she really has a “problem” or

needs to change; wants to change, but this desire exists simultaneously with resistance to it; may seek professional advice to get an objective assessment; motivational strategies useful at this stage, but aggressive or premature confrontation provokes strong sustain talk and discord; many Contemplators have indefinite plans to take action in the next six months or so.

Preparation: takes person from decisions made in Contemplation stage to the specific steps to be taken

to solve the problem in the Action stage; increasing confidence in the decision to change; certain tasks that make up the first steps on the road to Action; most people planning to take action within the very next month; making final adjustments before they begin to change their behavior.

Action: specific actions intended to bring about change; overt modification of behavior and

surroundings; most busy stage of change requiring the greatest commitment of time and energy; care not to equate action with actual change; support and encouragement still very important to prevent drop out and regression in readiness to change.

Maintenance: sustain the changes accomplished by previous action and prevent relapse; requires

different set of skills than were needed to initiate change; consolidation of gains attained; not a static stage and lasts as little as six months or up to a lifetime; learn alternative coping and problem-solving strategies; replace problem behaviors with new, healthy lifestyle; work through emotional triggers.

Relapse and Recycling: expectable, but not inevitable setbacks; avoid becoming stuck, discouraged, or

demoralized; learn from relapse before committing to a new cycle of action; comprehensive, multidimensional assessment to explore all reasons for relapse.

Termination: this stage is the ultimate goal for all changers; person exits the cycle of change, without

fear of relapse; debate over whether certain problems can be terminated or merely kept in remission through maintenance strategies.

Implications and objectives:

• To establish history-taking and diagnostic techniques which include family members and significant others to thus gain more accurate and effective data.

• To provide treatment services which address the denial/resistance that can be expected in all phases of recovery. Such treatment planning involves more than telling a patient to discontinue or control drug usage. Active intervention is required to early diagnose and treat these illnesses and to prevent progression.

• To help establish reimbursement, care management and quality improvement mechanisms which recognize the clinical and cost-effectiveness of consultation-liaison and motivational strategies to deal with readiness to change.


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3. The family disease concept of addiction emphasizes that all members of identified

client's social system are affected and in need of active intervention & treatment. • children of parents with alcohol and/or other drug addiction • spouse or significant other • maintain and prolong addiction • affected by addiction • personal recovery

Implications and objectives:

• To involve significant others in diagnosis and treatment to assist the identified client, but also to understand how they have been affected and to take responsibility to begin recovery for themselves.

• To provide services to help the whole family to recover together, adjust to sobriety and learn new ways of functioning, free from the preoccupation with alcohol and other drugs.

• To provide services, which offer hope for the recovery of the significant others even if the identified client refuses treatment specifically.

4. Treatment/Recovery is a process, not an event.

• motivational strategies • relapse policies • levels of care

Implications and objectives: • To provide a broad range of services from self-help to inpatient settings which promote recovery

at the most effective, least intensive, but safe level of care. • To help clients, significant others, reimbursement and regulatory agencies appreciate that

alcoholism and chemical dependence are frequently chronic relapsing illnesses not cured by one treatment event.

• To establish flexible, multiple levels of service in a broad continuum of care. These services facilitate easy movement throughout the continuum of care, depending on response to treatment, degree of readiness to change and motivation.

• To help establish reimbursement and care management mechanisms that recognize and preserve the necessity for a range of services that match a client’s level of functioning.

5. While there are many common diagnostic and treatment factors in substance-

related and addictive disorders, there is also significant individual variability. Implications and objectives:

• To establish sound admission and care management criteria for the range of services described above, to ensure safe assignment of individuals to the appropriate intensity of service.

• To help clients, significant others, providers, reimbursement and regulatory agencies appreciate how variability in readiness to change and motivation, severity of secondary complications, the presence of coexisting physical or psychiatric diagnoses all affect the length of service.

• To provide individualized diagnostic and treatment plans that are targeted and focused, rather than broad and program-based.

• To help establish reimbursement and care management mechanisms that allow and encourage safely matching clients to the appropriate intensity of service.


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D. Screening for Substance Use Disorders

1. Screening Principles • Must have high sensitivity & high specificity to reduce likelihood of false positives and false negatives • Must be simple and non-offensive to clients • Cannot be time consuming since clients will be negative • Must be a valid approach 2. Screening Methods 1. Interview Transition - Make a transition in the interview. Common strategies are to:

• Introduce the next set of questions as routine. First focus on tobacco use, then ask about alcohol and other drugs.

• Ask about family history of other conditions, then alcohol or other drug problems • When taking a diet history, ask about alcohol use. • Ask about stressors and then coping strategies

2. The 4A’s for Alcohol Screening and Brief Intervention

Step 1: Ask about alcohol use – brief screening questions Step 2: Assess – brief assessment to determine the severity of the problems and the appropriate action Step 3: Advise and Assist – brief intervention to advise to cut down or abstain; and to set goals Step 4: Arrange follow-up – monitor the patient’s progress

3. NIAAA Screening Questions and Recommendations a) Do you sometimes drink beer, wine, or other alcoholic beverages? b) How many times in the past year have you had 5 or more drinks in a day (men); 4 or more drinks in a day (women) c) One standard drink – 12 ounces beer; 5 ounces of wine; 1.5 ounces of 80-proof spirits d) Drinking limits: for healthy men to age 65 – no more than 4 drinks/day AND no more than 14 drinks/wk. e) For healthy women and men over 65 – no more than 3 drinks in a day AND no more than 7 drinks/week. f) Recommend lower limits or abstinence as medically indicated e.g., for patients taking medications that interact with alcohol; have a health condition exacerbated by alcohol; or pregnant (advise abstinence) g) Express openness to talking about alcohol use and any concerns it may raise h) Re-screen at every opportunity Nearly one third of U.S. adults engage in risky drinking patterns and thus need advice to cut down or a referral for further evaluation. 12% of U.S. adults aged 18 years or older never have more than 4 (men) or 3 (women) drinks on any one day; and have less than 1 in 100 chance of having an alcohol use disorder. But even occasionally (less than once a week) having 5 or more drinks (men) or 4 or more drinks (women) in any one day increases the chance of an alcohol disorder to 1 in 14 – that’s a 7% chance versus just 1%.

Reference and Resource: This information, along with a lot more detail, is in “Helping Patients with Alcohol Problems -A Health Practitioner's Guide”. The document can be downloaded in its original graphic format at www.niaaa.nih.gov/publications/Practitioner/HelpingPatients-text.htm 4. Use a brief validated screening protocol (a) CAGE Questions –The CAGE questions can apply to many populations, but may be most useful for men who do not use drugs other than alcohol. • Have you ever thought you should Cut down on your drinking (or drugging)? • Have others ever Annoyed you by criticizing your drinking (or drugging)? • Have you ever felt bad or Guilty about your drinking (or drugging)? • Have you ever had a drink (or another drug) in the morning (Eye-opener) to start your day or help you

get over a hangover?

One positive response to the CAGE suggests the need for further assessment. (Reference: Ewing, John A: “Detecting Alcoholism – The CAGE Questionnaire” JAMA 252: 1905-1907, 1984.)


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(b) UNCOPE - Norman G. Hoffmann, Ph.D.

U “In the past year, have you ever drank or used drugs more than you meant to?”* 1,2 Or “Have you spent more time drinking or using than you intended to?”

N “Have you ever neglected some of your usual responsibilities because of using alcohol or drugs?” 2

C “Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?”** 1, 2

O “Has anyone objected to your drinking or drug use?” 3, 1* Or, “Has your family, a friend, or anyone else ever told you they objected to your alcohol or drug use?” 2

P “Have you ever found yourself preoccupied with wanting to use alcohol or drugs?” 2

Or, “Have you found yourself thinking a lot about drinking or using?” E “Have you ever used alcohol or drugs to relieve emotional discomfort, such as sadness, anger, or

boredom?” 2, 1* Two or more positive responses indicate abuse or dependence.

Using this cut score produces sensitivities in a clinical population for alcohol, cocaine, and marijuana of 93%, 94% and 82% respectively. Specificities for this cut-off are 97%, 99%, and 97% respectively.

Four or more positive responses strongly indicate dependence.

Item Sources: 1. Brown, R. L., Leonard, T., Saunders, L. A., & Papasouliotis, O. (1997). A two-item screening test for alcohol and other drug

problems. Journal of Family Practice, 44, (2), 151-160. 2. Hoffmann, N. G. & Harrison, P. A. (1995). SUDDS-IV: Substance Use Disorders Diagnostic Schedule. Smithfield, RI: Evince

Clinical Assessments. 3. Hoffmann, N. G.(1995). TAAD: Triage Assessment for Addictive Disorders. Smithfield, RI: Evince Clinical Assessments.

1* Similar items identified by Brown, et al. as 3rd and 4th best discriminating items. * SUDDS-IV uses two items for this construct. “Have you ever used alcohol or drugs when you didn’t

intend to?”And, “Have you ever continued to use alcohol or drugs longer than you intended?” ** The SUDDS-IV uses a more stringent criteria for this construct in that it requires a failure to restrict or

stop use, not just a desire to do so. The SUDDS-IV questions are: “Have you ever set rules to control your alcohol or drug use that you failed to follow? and “Have you ever wanted to stop using alcohol or drugs but couldn’t?”

E. Diagnostic Strategies DSM-5 – Substance-Related and Addictive Disorders (Gambling Disorder) Substance use disorder is defined by the following criteria in DSM-5.

A. A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least two of the following occurring in a 12-month period:

1. Substance is often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

3. A great deal of time is spent in activities necessary to obtain substance, use, or recover from the

substance’s effects.

4. Craving or a strong desire or urge to use the substance.

5. Recurrent substance use resulting in failure to fulfill major role obligations at work, school, home.

6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.


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7. Important social, occupational, or recreational activities are given up or reduced because of substance use.

8. Recurrent substance use in situations in which it is physically hazardous.

9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of substance to achieve intoxication or desired

effect b. A markedly diminished effect with continued use of the same amount of the substance.

11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for substance. b. Substance is taken to relieve or avoid withdrawal symptoms.

Severity Scale DSM-5 - The Severity of each Substance Use Disorder is based on: - 0 criteria or 1 criterion: No diagnosis - 2-3 criteria: Mild Substance Use Disorder - 4-5 criteria: Moderate Substance Use Disorder - 6 or more criteria: Severe Substance Use Disorder Specify if: In early remission. If after full criteria for SUD were previously met, none of the criteria for SUD have been met for at least 3 months, but for less than 12 months, except for Criterion 4, “Craving or a strong desire or urge to use a specific substance”). In a sustained remission. If after full criteria for SUD were previously met, none of the criteria for SUD have been met at any time during a period of12 months or longer, except for Criterion 4, “Craving or a strong desire or urge to use a specific substance”). F. Engagement and Attracting People into Recovery (a) “Resistant”

* Resistance is often perceived as pathology within the person, rather than an interactive process; or even a phenomenon induced and produced by the clinician * “Resistance” may be as much a problem with knowledge, skills and attitudes of clinicians as it is a “client” problem (b) “Unmotivated” or “Not ready” * All people are “motivated” and “ready” if they are talking to you. But what they are motivated and ready for may not be what you think they should be motivated and ready for. * That is your problem not their problem. We make it their problem and then call them names like “resistant”, “unmotivated”, “help rejecting”, “oppositional”, “self will run riot”, “stinking thinking”. “Thank-you for choosing to come to treatment.” “I didn’t choose you. They made me come.”

“What would happen if you hadn’t come today?” “I’d do more time, or won’t get off probation.”

“Would that be OK with you if that happened?” “Hell no, that’s why I’m here.”

“Well then thank-you for choosing to work with me so I can help you do less time or get off probation.”


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(c) “Treatment compliance” versus “treatment adherence” – In the literature, significant parts of the rest of healthcare have been using “adherence” long before the mental health and addiction treatment field has had their consciousness raised to the implications of using “compliance” versus “adherence” terminology. In this age of empowerment and collaborative service planning, it is not for the expert counselor and professional to develop a plan with which the client must comply. It isn’t for the physician to prescribe the medication with which the patient must demonstrate medication compliance. Webster’s Dictionary defines “comply” as follows: to act in accordance with another’s wishes, or with rules and regulations. It defines “adhere”: to cling, cleave (to be steadfast, hold fast), stick fast. (d) “Clean/dirty urines” versus “negative/positive urines” – Even though we have positive associations to being “clean and sober”, consider whether using “dirty” instead of “negative” urine drug screen results only adds to the stigma of drug users as being dirty. Stick with positive and negative results rather than dirty and clean urines. (e) What to Say to Orient Participants “Thank-you for choosing to enter join Drug Court. The reason you have been given the opportunity to get treatment rather than be incarcerated is that you have addiction that is related to your charges. We believe that if you get addiction treatment and establish recovery, this will not only be good for your life, but society will benefit from increased public safety, decreased crime and spending resources on treatment rather than incarceration, which is much more expensive.

But you are accountable for doing treatment, not time; for working on changing your attitudes, thinking and behavior; not just complying with a program and graduating. (f) What to Say to Check on Progress

“Tell me about your treatment plan.” (Pause to see what the participant says and monitor if they are working on anything in particular to improve functioning for public safety; or whether they are just “doing time” e.g., “I just have to be here and have another three months.”) “What you are working on to change your attitudes, thinking or behavior that has gotten you into trouble with crime, restricted your freedom and threatened public safety?” (g) What to Say to Track Treatment Engagement “What would you like to do in this session or in group today to advance your treatment plan?” (Pause to see what the participant says and monitor if they are working on anything in particular to improve functioning for public safety; or whether they are just “doing time” e.g., “I just have to be here” Or “What do you want me to say?”) What you would hope they would say is: “I don’t have an anger problem, but I am trying to get off probation so I’m going to ask someone to role play with me an angry situation. Others would get into a fist-fight but not me. I have good anger management skills and am going to demonstrate to the group how to handle that in assertive but nonviolent way. You will note that down and let my PO know that I am doing well.”


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(h) What to Say to a Person who says they don’t want to go to Alcoholics Anonymous It is not unusual for a client to object to having to attend AA or other such groups. Here is how to address such clients: “There are AA meetings and groups that appeal to different members in different ways. If you haven’t tried a number of different groups, it may be that just haven’t yet found the meeting that works for you. Now if you are saying you just don’t want to go to AA for whatever reason, I don’t want to push that on you. Maybe you have another self/mutual help group that works better for you. But before you give up on AA, let’s discuss where else can you find a support group where: 1. You can have access to regular meetings every day and even more than once a day if you really need them – and all for free? 2. You can have a coach like an AA sponsor, who is ready to have you call them at all hours of the day and week if you really need them? 3. You can be with a whole group of people and have sober fun while there are temptations and triggers all around you on New Year’s Eve, Mardi Gras, or St. Patrick’s Day? 4. You can have many friends who have been exactly where you have been with addiction; understand what you are going through from deep personal experience; and will be there for you if you reach out?

Maybe you have a group like that at your church, synagogue, community of faith, or some other group. If you get support from that group with all the same effective features of what AA has to offer, then by all means embrace that group. This is about getting you the ongoing support and guidance you need to establish and maintain recovery and well being, not pushing AA on you.” G. Person-first Language

(a) John F. Kelly conducted an experiment that “randomized more than 500 doctoral-level clinicians to receive a vignette describing an individual involved in a drug court situation, who was supposed to maintain abstinence but had used alcohol/drugs and was caught and was about to face the judge again. The vignette was identical except in half of the vignettes, the individual in violation of the court mandate was described as a “substance abuser” and, in the other half, he was described as “having a substance use disorder”; otherwise no difference. These well-educated clinicians, many of whom were addiction specialists, viewed the person described as a “substance abuser” significantly more punitively, as having greater personal responsibility and being more to blame for his problems, and as less deserving of treatment.” (White, 2013; Kelly, Dow & Westerhoff, 2010). (b) Granello and Gibbs studied undergraduate students, adults in a community sample, and professional counselors and counselors-in-training. They used an instrument that measured people’s attitudes towards individuals with diagnosable mental illness. What they found was that when individuals were described as “mentally ill” this evoked attitudes of authoritarianism (treating people as if needing more control and discipline); social restrictiveness (needing to be more isolated from the rest of the community); and less benevolence (less sympathetic, kind feelings and less willing to be personally involved with the individual). In contrast, when the instrument described individuals as “people with mental illness”, there was increased tolerance, benevolence and acceptance of people as being part of the community needing help and assistance rather than control and isolation from others. (Granello & Gibbs, 2016).


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LITERATURE REFERENCES AND RESOURCES

American Society of Addiction Medicine (ASAM) – “The Definition of Addiction” Adopted by ASAM Board of Directors September 15, 2019. https://www.asam.org/resources/definition-of-addiction Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies. Mee-Lee, David with Jennifer E. Harrison (2010): “Tips and Topics: Opening the Toolbox for Transforming Services and Systems”. The Change Companies, Carson City, NV Mee-Lee, David (2005): “Helping People Change – What Families Can Do to Make or Break Denial” Paradigm. Vol. 10, No. 1 Winter 2005. pp. 12-13, 22. http://www.addictionrecov.org/paradigm/P_PR_W05/paradigmW05.pdf Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing - Helping People Change” Third Edition, New York, NY. Guilford Press. National Survey on Drug Use and Health (NSDUH), 2019. Substance Abuse and Mental Health Administration (SAMHSA). Sept. 2020. https://www.samhsa.gov/data/report/2019-nsduh-annual-national-report Prochaska, JO; Norcross, JC; DiClemente, CC (1994): “Changing For Good” Avon Books, New York. Substance Abuse and Mental Health Services (SAMHSA) Definition of Recovery. For further detailed information about the new working recovery definition or the guiding principles of recovery, visit: http://www.samhsa.gov/newsroom/advisories/1112223420.aspx Volkow, Nora D (2018): “What Does It Mean When We Call Addiction a Brain Disorder?” Scientific American blog March 23, 2018. https://blogs.scientificamerican.com/observations/what-does-it-mean-when-we-call-addiction-a-brain-disorder/?wt.mc=SA_Twitter-Share Zywiak, W. H., Hoffmann, N. G., & Floyd, A. S. (1999). Enhancing alcohol treatment outcomes through aftercare and self-help groups. Medicine & Health/Rhode Island 82 (3), 87-90.

CLIENT WORKBOOKS AND INTERACTIVE JOURNALS The Change Companies’ MEE (Motivational, Educational and Experiential) Journal System provides Interactive journaling for clients. It provides the structure of multiple, pertinent topics from which to choose; but allows for flexible personalized choices to help this particular client at this particular stage of his or her stage of readiness and interest in change. The Change Companies at 888-889-8866. changecompanies.net.

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What They Never Taught You in School About Substance Use