Is JoinTogether Becoming the Fox News of AOD Prevention?

I have been reading about latest Monitoring the Future 2012 report regarding AOD use by 8^th, 10^th, and 12^th grade high school students from various sources this morning (easily available “all over the web,” but here is the link to the MTF webpage with related info - http://www.monitoringthefuture.org/). Please look at this headline below from JoinTogether, which is at CASA at Columbia and associate with the Partnership for a Drug Free America and compare this to other announcements regarding the report. As you compare, ask yourself: Is JoinTogether becoming the FoxNews of the AOD prevention field?

Survey: Almost One-Fourth of 12th Graders Have Smoked Marijuana in Past Month

December 19, 2012

Almost one-quarter of the nation’s high school seniors say they have smoked marijuana in the past month, and just over 36 percent admit to using the drug in the past year, according to the 2012 Monitoring the Future Survey. View article...

Where most reports on the MTF 2012 findings are meant to suggest the glass is half full, it would appear that JoinTogether saw the glass as half empty…

What do you think?

Dr. Robert

Can the short term benefits of my ability to assuage pain create long term problems of addiction?

Fr. Joseph martin, a well know lecturer in the field of addiction and founder of “Fr. Martin’s Ashley,” an inpatient SUD treatment center in MD, used to argue that, “Pain is God’s greatest gift to mankind.” It is the pain associated with a situation that eventually motivates one to take the necessary steps to affect change. Like the sleeper awakened in the night by the chill autumn air, but is not quite uncomfortable enough yet to get up from a warm bed to close the window, does prescribing enough medication--both the dosage and the number of doses prescribed—to assuage all pain actually delay making proactive changes in one's lifestyle and foster dependence? Does not “managing pain” mean reducing it to a tolerable level rather than assuaging it completely? And because my patient/client “demands” that I do what needs doing to make the pain “go away,” does this necessitate that I prescribe “more” rather than refer to other practitioners who utilize behavioral medicine for analgesic purposes?

If, as Jim Croce crooned back in the 70s, "nobody ever had a rainbow until they had the rain," does "a little bit of pain" remind us that change is needed; change in my behavior as I live my life, not change in yours as a potential writer of prescriptions?

Click on the title below to visit the article and then share your thoughts.

To ReducePrescription Drug Abuse, Focus Less on Patient Satisfaction

Pain management education must help prescribers focus less on patient satisfaction, and more on their functional improvement, according to Sherry Green, the CEO of the National Alliance for Model State Drug Laws.

What do you think?

Dr. Robert

A Serious Look Inside Computer Delivered Interventions (CDI) for College Students: Part II

This post continues a review of the chapter entitled, “Computer Interventions” by Campbell & Hester in the text, College Student Alcohol Abuse: A guide to assessment, intervention, and prevention. As you likely quickly surmised when reading, “Part I” of this review, I found this chapter provocative, informative, and a “must read” for the contemporary student affairs professional and administrator in higher education.

Perhaps this chapter’s greatest significance, at least in this reviewer’s opinion, is a brief section of the article entitled, "commercially available CDIs: summary of empirical findings” (p.260-261) that follows 10 pages of descriptions of each program and a review of their evidence of effectiveness. In this short three-paragraph section we find both a frank review of the limitations of CDI programs as well as an admonishment of caveat emptor and “buyer beware.” As effective as CDI's may be, they are not a panacea for high-risk and dangerous collegiate drinking. Ironically, some CDIs with the greatest price tags and longest completion times perform less effectively then less expensive, briefer programs. More isn't necessarily better. But one point the authors make is that more research on CDIs is necessary, as some have not even received a rudimentary review regarding their effectiveness.

In summarizing this chapter, there are four key points:

1. Most agree that CDI holds great potential for use with heavy drinking collegians. Conversely, they are relatively ineffective at motivating overt change in the drinking behavior of a low-risk, moderate drinking population.
2. Although empirical evidence is available on some CDI programs, this is neither definitive nor universal as regards the different programs that are available.
3. Empirical data that are available on CDI programs result from traditional controlled experiments. It is unknown if the plethora of digital competitors for college student interest will affect either student attention when engaged in a CDI program in a nonclinical environment, i.e., college residence halls, or if its impact will be diminished by other distractions in a controlled, nonclinical environment.
4. Further study is needed to explore adjuncts to simple completion of CDI programs in order to facilitate retention and/or application. For example, involving students in more traditional means of considering the information to which they have been exposed. Further examples include, various means of recording the feedback received from CDI programs and/or literally reading a summary of feedback or information provided by a CDI program.

Recommendations to the field

1.  That administrators employ CDI programs to pursue NIAAA recommended means of intervention with collegians.
2.  That CDI programs be readily available to students by strategically deploying computers with access to such programs to implement a stepped–care approach to campus-wide intervention and prevention.
3. That administrators be mindful of the importance of using CDI programs that students will want to use—the best program will have little impact if students find it tedious, burdensome to use, or simply “not fun.”
4.  That administrators remain mindful of "where" the CDI program will be available. For example, providing for access in controlled, quasi-anonymous environments like classroom buildings, clinical settings, and the like.

Prophesying About the Field

The authors conclude their chapter by prophesying regarding the coming decade. Although it is worth the time to read their complete predictions about the future of CDI programs in their entirety, a preview of their prognostication is warranted:

1.  CDI will continue to improve in scope, in its ability to deliver interventions, and ability to engage collegiate users.
2. CDI programs are in their infancy. As such, they have yet to incorporate all we have learned about effective intervention strategy and traditional face-to-face interventions. In short…stay tuned.
3. The marriage of CDI programs and online social media will likely resemble the proverbial match made in heaven.
4. Merging text messaging capabilities with alternative low-risk collegiate behavior—think "Arab Spring meets Spring Fling.”
5. As smart phones have done to cellular telephones, imagine what CDI will do for interventions with a prevention of high-risk and dangerous collegiate drinking…not to mention other behaviors.
6. Biosensors in cell phones, innovative smartphone apps, perhaps even sensors embedded in clothing able to deliver real-time blood-alcohol level data to gauge personal risk.

In 21 short, easily read pages, including references (three pages) Campbell and Hester have managed to review the role of CDI programs as well as their utility in addressing high-risk and dangerous collegiate drinking. They do this while providing the field with a detailed road map through the commercial minefield of available computer delivered interventions targeting heavy drinkers. This chapter is definitely recommended as a “must read” for any serious student affairs professional or administrator in higher education.

This has been a review, in 2-parts, of “Computer Interventions,” authored by William Campbell and Reid Hester, (chapter #10, pages 246 – 267, in College Student Alcohol Abuse: A guide to assessment, intervention, and prevention, Christopher Correia, James Murphy, and Nancy Barnet editors, copyright 2012, John Wiley & Sons, Hoboken, N.J. ).

What do you think?
Dr. Robert

A Serious Look Inside Computer Delivered Interventions for College Students

As we seem to have entered a profoundly “digital age,” it is no surprise that the availability of alcohol-related information for college students is no exception. Over the past 10+ years we have seen a plethora of computer delivered interventions (CDI) come to market providing innovative approaches to and provocative advertised claims about the delivery of alcohol information and interventions for college students. These claims are often accompanied by creative—and sometime aggressive—marketing, but do such advertised approaches to addressing collegiate drinking work, and if they do, is there a concomitant resulting change in their drinking behaviors?

Included in a new book by Christopher Correia, James Murphy, and Nancy Barnet entitled, College Student Alcohol Abuse: A guide to assessment, intervention, and prevention, copyright 2012 by John Wiley & Sons, Hoboken, N.J., is a chapter that addresses the above questions regarding the use of CDIs with college students among other related issues. Authored by William Campbell and Reid Hester, this chapter (#10 – pages 246 - 267), Computer Interventions, may be the best review I have yet to read on the topic. These authors have managed to review the rather complex literature on CDIs and synthesize a very readable review of ten of the more prominent examples of CDIs, including a very objective review of the empirical evidence supporting (or not) the claims made by those marketing these program. In addition, they include a simple yet thorough matrix that compares and contrasts the ten better known CDIs on six specific criteria: Developer & Contact Information, Purpose, Completion Time, Design & Components, Administrative Features, and cost.

Of particular importance—and one of the more practical reasons that all Student Affairs administrators are recommended to read this chapter—is that this matrix (see pp 252-253) and its accompanying review of the 10 cited CDIs provides an excellent vehicle by which otherwise under-informed administrators can sort through the often hyperbolic PR related to the many computerized products that are commercially available and vying for student affairs dollars. Suffice it to say that a quick review of Campbell and Hester’s chapter suggests that quality and cost are not necessarily positively correlated.

This is but the first of two reviews I will write on this chapter—and considering that the lead editor on the text has asked that I review the entire book, subsequent posts will address other chapters and ultimately the entire text as well. That said, here are some quick reference materials related to both the text and the Campbell & Hester chapter that may be of interest:

1. A link to the text on Amazon: http://www.amazon.com/College-Student-Alcohol-Abuse-Intervention/dp/1118038193
2. A link to the Google Books page on the text: http://bit.ly/Uu9ket (Note: You can “sample” this text and all its chapters at this site). 
3. A Link to the Campbell & Hester chapter: http://bit.ly/TD4UfC (Note: Scroll down to pages 252 – 253 to see the matrix referenced above).

Next Post: Why CDIs are appropriate for consideration in higher education’s quest to address the heavy drinking of some collegians and what the future of CDIs, according to Campbell and Hester, holds…stay tuned!

Understanding Addiction or,

Things are not Always What They Appear to Be

Addiction is nothing if not a contemporary of humans since the dawn of recorded history. During this time, there have been many attempts to explain addiction with most having relied on the behavior exhibited by those identified as addicted in order to explain addiction. This is something like explaining the common cold as congestion, runny-nose, sneezing, and a scratchy throat. Although some or all of these realities may be indicative of the common cold and even descriptive of one who has that condition, they are not, individually or collectively, “the common cold.” If we introduce the construct of viruses—and the rhinovirus in particular—we come closer to operationally defining the common cold. However, even then, the “cold” itself is but a condition where the virus is an organism with the ability to affect its host in a particular way, the result of which is to bring about a condition we call the common cold…and then it is but one of dozens of viruses that result in conditions with “cold-like symptoms.”

Such is the case with addiction. Historically we have looked at the actions and choices of individuals who behave in a particular way and have labeled them as “addicted.” Most frequently, the interpretation of these behaviors has had a decidedly moral bent resulting in describing those “with addiction” as being morally bankrupt or of weak personal character if not the personification of moral turpitude. All of this, based upon the behaviors of an individual whose comportment falls outside the constraints of socially constructed boundaries.

With the advent of contemporary science—and more to the point, the technology that has enabled these scientific advancements—we now know that addiction is more than the behavioral indicators that suggest its presence. In fact, not only is addiction not the result from moral turpitude or a defect of personality, it is more than likely the result of distinct functions of the human brain that make some individuals particularly susceptible to this disorder. Although this susceptibility to addiction is beyond the scope of this brief essay, it is, nonetheless, a “scientific nut” that remains to “be cracked,” and likely sooner on a technological timeline than later.

Explaining addiction requires more than the simple blaming of one’s moral shortcomings and/or personality defects for the continued use of a substance or pursuit of a maladaptive behavior. Recognizing that the characteristic euphoria or “rush” associated with use and the craving that eventually follows both result from normal functions of the brain more than suggests that we revisit our understanding of addictive disorders and our historic approaches to their treatment. That particular regions of the brain associated with the “rush” and “craving” associated with the advent of this disorder suggest its etiology may be more elegant than pejorative.

We know that particular drugs like alcohol and cocaine activate what is referred to as the “reward pathway” in the brain, specifically, the ventral tegmental area (VTA) – nucleus acumbens – prefrontal cortex. Were it not for this unique function of the brain that has evolved so as to ensure that securing food, water, and the desire to continue the species are rewarded, we would literally “not be here.” That drugs like alcohol, cocaine, and behaviors like gambling can activate this pathway by mimicking or compromising the naturally occurring neurotransmitters designed to ensure survival begins to explain the “high” that occurs when engaging in these behaviors; the more one consumes, the greater the high and the greater the desire to repeat the experience. The intensity of the “high” or “rush” is what, in turn, sets the stage for the craving. As one recalls the intense pleasure associated with the addicted behavior, the rush to repeat the experience can preoccupy the individual’s mind to a point that consumption becomes an irresistible urge.

Historically, addiction, or more specifically, the repeated use noted in those with addictions, was thought to be motivated by the negative reinforcement realized when one would seek to assuage the withdrawal symptoms associated by separation from the object of one’s addiction. New research, however, suggests that it is the desire to re-experience the high that is hinge on which the door of addiction swings. The irony is, the very physical system that creates this cascade of events that results in addiction seeks to correct the imbalance created by the flood of neurotransmitters associated with the pleasure pathway by reducing the production of endogenous neurotransmitters. This reduction in neurotransmitters results in a tolerance to an established quantity of use thereby necessitating an increase in drug used or behavior required to ensure satiation. The entire cycle of behavior we have come to refer to as “addiction,” is essentially one’s attempt to recapture the euphoria associated with intoxication. One is not so much addicted to “cocaine” or “alcohol” or “gambling” as he or she is addicted to being intoxicated.

Simply stated, drugs like cocaine and alcohol block the ability to reabsorb the neurotransmitters naturally produced in the brain. As new neurotransmitters are produced to ensure the normal functioning of the brain, a flood of neurotransmitters, for example dopamine, results in continued and over stimulation of the reward pathways. As the body detects this malfunction in the normal flow of neurotransmitters, it reduces the amount of dopamine naturally created. This results in a reduced “high,” which we know as tolerance. Tolerance is met by the consumption of greater quantities of the addictive substance resulting in a spiral so frequently observed in addicted individuals.

If individuals who have an addiction do not have a crisis of character or a dysfunctional personality then to judge them as individuals based on behavior resulting from a discernable physiologic process ceases to make sense. To be blunt, people with an addiction are not bad people who need to learn how to become good; they are individuals with a behavioral health problem who need to get well. Just as there are treatments for individuals with “physical” health problems, so are there treatments for individuals with “behavioral” health problems and in both cases, those treatments work.

What do you think?

Dr. Robert

__________________

Brief Screening for High-Risk Drinking 

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Motivating anyone to rethink an established behavior let along a personal opinion on a controversial topic is a daunting task to say the least. As a matter of fact, when one's drinking (or other drug use) is the object of a motivational intervention, this is often an even greater task. This is nowhere more the case then when a medical professional seeks to engage a patient in a conversation about his or her alcohol (or other drug) use.

For many, both medical professional and patient alike, there seems to be a vicious circle when it comes to considering motivating change where alcohol consumption is involved. This cycle, some might call it the futility cycle, is represented in this graphic courtesy of Dispair, Inc:

Ultimately, the medical professional will simply "stop asking" about use beyond the ubiquitous "do you drink" and if learning, "yes, a couple," leave it at that. Unfortunately, with substance use disorders representing one of the major medical challenges in the 21st century, at least in Western countries, this effectively nullifies early intervention by someone who may, interestingly, have the greatest likelihood of being listened to by a substance using individual...his or her medical professional.

To quickly screen for alcohol-related problems, consider using the four questions that follow (see http://bit.ly/NTuITs for source material).  The first has been suggested as a “single question” capable of determining if further screening, if not a formal assessment, is warranted and is argued in the cited article to be, in and of itself, sufficient to discern if a problem exists or not.

1.      How often do you have eight (or for women, six) or more standard drinks[1] on one occasion?[2]

      

• Monthly or more often suggests a positive screen, indicating that the respondent might benefit from an intervention to help him or her cut back.
• How often in the last 6-months have you been unable to recall some or all of what happened during the previous night’s drinking?
• How often in the past 6-months have you be unable to follow through with normal responsibilities following drinking?
•  How often in the last 6-months have you experienced concern about your drinking expressed by a family member, relative, or friend?

If the answer to the first question is no, and the interviewer believes the response is genuine, consider your screening complete.  If, however, you question the veracity of the response to question #1 or that answer is positive, then questions 2 – 4 make sense to ask.

NOTE #1: You may want to consider “working these in” over the History & Physical rather than risk appearing to conduct an interrogation.

Note #2: Most individuals, especially those who have a substance use disorder (SUD), know how to answer such questions so as to appear “lower, if not a low risk.”  It is therefore recommended to familiarize yourself with these questions so you can “work them into” a conversation with someone being screened.  A secondary approach to conducing this screening, if time permits, is to invite the interviewee to “tell his story” and then answer each question for the interviewee in your mind based on the facts in the reported story.

If the individual does not volunteer needed information necessary to answer each question, use open ended questions to access such.  For example, if the individual’s story does not allow you to answer the question, “How often in the last 6-months have you been unable to recall what happened during the previous night’s drinking?”, try asking, Tell me something about how drinking affects your memory.  If the individual is hesitant or allusive, try something a bit more direct, for example, when drinking, rate your ability to consistently and accurately recall events the next day.

Remember that effective screening necessitates never attacking or simply interrogating an individual.  If the person does not have a problem, such techniques will only serve to alienate the individual while if a problem does exist, it will only alert the individual to your perceived intent…to label and likely show condescension based on that label.

If the results of this brief screening suggest the likely problem with alcohol, ask the individual’s permission to share proactive suggestions about how he or she can pursue the issue further.  If the permission is not forthcoming, then share your concerns for the individual’s health and wellbeing based on the suggested results of the brief screening.

A simple set of follow-up questions include:

1.      What are the good things—and phrase it this way—about drinking?  Note: This is a “throw away question” because everyone will answer it according to personal preferences.  The benefit of this question is that it established your interest in the person and his or her opinion.

2.      The second question is, What are the less good things—and again, state it exactly this way—about drinking.

You will notice that the answer to the second question, which is the important question, will often (always?) mimic the problems that patient associates with drinking.  If, however, the interviewer were to ask, “Tell me about your problem with alcohol” or “What problems do you experience when you drink,” you will likely get something like, “Well, I don’t really have any problems when I drink” or “I don’t have a drinking problem.”

The purpose of this brief intervention is not to get people with alcohol problems to admit that their drinking is a problem.  The purpose is to increase the likelihood that individuals will step outside their comfort zone and look at their drinking from a different perspective.  Just as the answer to the question, “is 2 minutes a long time or a short time” is dependent on the individual’s perspective regarding time.  If, for example, the individual said this is a short amount of time, ask him or her to hold his or her breath for 2-minutes and watch for the reaction.

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[1] A standard drink = 1.5 oz 80 proof spirits, 12-oz domestic beer, 10-oz malt liquor, 5-oz table wine.

[2] Most descriptions of high-risk or what some call binge drinking suggest 5 or more standard drinks for males, 4 or more for females, but this is a controversial bench mark

Collegiate Drinking and the New Academic Year: 

Let the Games Begin...

…no, not the Hunger Games, although at times our work in higher ed may seem like we are perennially selected as competitors for the latest games.

At the start of the new academic year…for those on semesters…it is appropriate to pause and remember that humor can be a useful tool in our efforts to convey information as we seek to move individuals, students in particular, through the stages of readiness to change. For those who have yet to consider that change is a pursuit worth consideration—AKA the Pre-contemplators—humor can serve to capture their attention and invite a further consideration of a message related to revisiting personal behaviors and, hopefully, moving to a contemplative stage of readiness to change.

As with any advertising, it is important to engage the consumer before attempting to sell the  product. As Simon Sinek suggests in his TED lecture on “How great leaders inspire” (see http://bit.ly/PAzvuf), most purveyors of information begin at the outside or more superficial level of explaining “what” a thing is and move on to “how” it works and perhaps, lastly, explain “why” the listener should be interested. “Great leaders” he argues, start with the “why” and move towards the “what,” realizing that once one has been engaged, the issue becomes not motivating them to buy my idea as much as pursue their own values. He repeatedly suggests in this brief clip, “people do not buy what you do; they buy why you do it.” Consequently, “suggesting that collegians revisit their perceptions of alcohol as a substance and drinking as a behavior is a tough sell. As Prochaska pointed out over 30 years ago, pre-contemplators do not think their behavior is the result of a problem; they believe their behavior is the pursuit of a solution.

One of the best ways to invite a pre-contemplator to revisit his or her behavior and increase the likelihood of moving towards becoming a contemplator is consciousness raising activities or helping individuals to look at “the facts” from a different perspective. Challenging individuals to revisit these “facts” as they manifest themselves in their lives will rarely work if our focus is on “their” problem. As my grandfather used to say, “You don’t remove a hornets’ nest from the porch eves by beating it with a stick.” Two strategies that work particularly well regarding consciousness raising are: (1) humor and (2) sensational if not seemingly ludicrous metaphors or examples to illustrate points that force individuals to re-examine assumptions they have made regarding particular behaviors to which they have habituated.

We are all likely familiar with exercises where smoking is translated from cigarettes consumed per day to dollars spent in a year or beers consumed on a Friday night are converted to calories consumed one’s freshman year. These are "classic" examples of consciousness raising activities or strategies designed to get people to look at "the usual" from a different perspective in order to more objectively evaluate its utility. Humor can also serve to get someone’s attention and invite him or her to pause, smile, and rethink—if just for a moment—a behavior or practice that has been repeated so often as to become invisible. Psychologists refer to this as “habituation” and no one changes a behavior that has become so ritualized as to have become invisible in the grand scheme of things in one’s daily life. Take for example this student answer on a physics exam when the required answer was unknown:

Although “funnies” like these make their way around the Internet with regularity, when incorporated into work with students, they can serve to bring poignant issues to the surface for discussion in a non-threatening manner and often open the door to a meaningful discussion about realities without students necessarily  perceiving receipt of the “dad/mom” talk from the practitioner. For example, with the “joke” included above, the practitioner could ask an audience of students what they thought was going through the mind of the test taker. This can easily lead to a discussion about the link between collegiate drinking and its “perceived” consequences, then onto social norms, what factors differentiate between low- and high-risk when drinking, etc. Simalarly, programs can be done using clips from films like Animal House, which are readily available on YouTube. With a little investigating, several clips can be identified, shown, and then discussed regarding what makes them so funny…and then when their humor is exposed refocusing on the risks likely associated with the clip if it were to actually occur on campus.

The examples of humor an "silly" metaphors or examples are endless and only limited by the resourcefulness and creativity of the practitioner who emplys them. My point in this post is to suggst that humor and “creative metaphors” and stories can go a long way to opening the door to conversations with pre-contemplative students about their high-risk behaviors without having the necessarily employ the proverbial “2X4 to get their attention."

Again, and to sum up, citing my grandfather, who used to remind me that, “Whether you rush in the front door or sneak in the back, it is just as warm by the fire." Moral: Pay attention to how you plan to get from where you are to where you want to be.

what do you think?

Dr. Robert