Prescription Drug Abuse: Loosening the Knot

Prescription Drug Abuse: Loosening the Knot

J. Patrick Slifka, LCSW & George Young, LCSW

Why We’re Here

Dealer out of Business? http://www.youtube.com/watch?

v=Cb93lPJB8yw

Which is More Dangerous? http://www.youtube.com/watch?

v=u_nCqak6mYQ

“Just The Facts”

All of these drugs are available – right now. They do what they’re “advertised to do.” If your individuals (particularly your

adolescent ones) have not been already, they will soon be in a position to make a choice…to use or not to use. Their choice will carry both a benefit and a consequence.

“Just The Facts” Drugs are not inherently evil, bad, or good –

they’re simply chemicals. The Relationship a person forms with a drug

becomes the problem – and the problem gets progressively and significantly worse over time.

Remember that not all individuals have the same responses to the same drug or class of drugs. There are idiosyncratic reactions we have to assess and understand.

Why We’re Here? Epidemic? Problem? Attitude is the father of the Action Ethical Obligation and Competent Practice

Jeopardy Time

Jeopardy Question #1The Answer is:

Patients leave a doctor’s office with this on 7 out of every 10 visits.

What is a Prescription?

Jeopardy Question #2The Answer is:

Medicine Cabinets

Where do a large number of teens who abuse prescription medications get their drugs?

Jeopardy Question #3The Answer is:

Dr. Gregory House and American High School Seniors identify this prescription drug as their favorite.

What is Vicodin?

Trends and StatisticsThe Landscape

A View of the Landscape http://www.youtube.com/watch?v=1sdFRJtzI0s

Rates of Rx drug sales, deaths and substance abuse tx admissions

1 in 6 Teenagers

Most Commonly Abused Medications Among U.S. High School Seniors (2010 Annual Prevalence)

Sedatives

OxyContin

Tranquilizers

Ritalin

Amphetamines

Cough Medicine

Vicodin

0 1 2 3 4 5 6 7 8 9

Source: Monitoring the Future, University of Michigan, December 14, 2010

What is Driving the Prevalence? Misperceptions about safety. Increasing environmental availability Varied motivations for their abuse.

Other Factors Driving Trend: Pill-Taking Society Rx medications are all around us…and teens notice.

Patients leave the doctor’s office with a prescription in hand in 7 out of 10 visits.

Direct-to-consumer advertising on TV and in magazines.

Many people don’t know how to safely use these medications or ignore their doctor’s instructions.

Common Prescription Drugs of AbuseSigns, Symptoms and Biopsychosocial Consequences

Top 10 Most Dangerous Drugs in America (DAWN database of ER visits)1. Xanax2. Oxycontin3. Vicodin4. Methadone5. Klonopin6. Ativan7. Morphine Drugs (opiates)8. Seroquel (Antipsychotic)9. Ambien10. Valium

Most Commonly Abused Classes of Prescription Drugs Opioid Pain Relievers (Opiates, Narcotics) CNS Stimulants (primarily those used in the tx

of ADHD) CNS Depressants (Sedatives, Hypnotics,

Anxiolytics)

Key Assessment Point: Effects of Drugs Depend on… Route of administration Amount taken at one time User’s past drug experience Circumstances under which the drug is taken

(the place, the user’s psychological and emotional stability, the presence of other people, simultaneous use of alcohol and other drugs, etc.)

Commonly Abused Rx Drugs How they work Abused to Drug names

Strong Pain Relievers Used to relieve moderate-to-severe pain, these medications block pain signals to the brain

To get high, increase feelings of well being by affecting the brain regions that mediate pleasure

Vicodin, OxyContin,Percocet, Lorcet, Lortab, Actiq, Darvon, Codeine, Morphine,Methadone

Stimulants Primarily used to treat ADHD type symptoms, these speed up brain activity causing increased alertness, attention, and energy that comes with elevated blood pressure, increased heart rate and breathing

Feel alert, focused and full of energy—perhaps around final exams or to manage coursework, lose weight

Adderall, DexedrineRitalin, Concerta

Sedatives or tranquilizers

Used to slow down or “depress” the functions of the brain and central nervous system

Feel calm, reduce stress, sleep

Valium, Xanax, Ativan,Klonopin, Restoril, Ambien, Lunesta, Mebaral, Nembutal, Soma

Opioid Pain Relievers (Opiates/Narcotics)

What are Opiates? Opiates are a group of drugs that are used for

treating pain. They are derived from opium which comes from the poppy plant.

Opiates go by a variety of names including opiates, opioids, and narcotics. The term opiates is sometimes used for close relatives of opium such as codeine, morphine and heroin, while the term opioids is used for the entire class of drugs including synthetic opiates such as Oxycontin. But the most commonly used term is opiates.

Dried Opium Poppy

Commonly Used & Abused Opiates Opium Codeine …anybody you’re working with taking

any of these? Morphine Tramadol (Ultram) Methadone Buprenorphine (Subutex) Propoxyphene (Darvocet) Pethidine (Demerol) Hydrocodone (Lortab/Vicodin) Oxycodone (Percocet, Oxycontin) Hydromorphone (Dilaudid) Oxymorphone (Opana) Fentanyl Heroin (diacetylmorphine)

Most Rx’d Opiate in America

Oxycontin

Opiates Opiates are highly effective in controlling

moderate to severe pain, but they also have a downside. Opiates are highly addictive…and once a person starts abusing them he/she generally becomes dependent (addicted) to them.

Opiate Effects Feelings of Euphoria Suppression of Pain Depressed Respiratory Rate Lowered Heart Rate and Blood Pressure Lethargy/Drowsiness Clouded Mental Functioning Nausea/Vomiting

Lowered Body Temperature Muscle and Bone Pain Physical/Psychological Dependence Severe Withdrawal Symptoms Mood Swings Severe Constipation Unconsciousness Coma Death by Overdose

Opiates: Long Term Effects Cause significant changes to the

nerochemical, molecular and cellular levels.

Changes brain structure and functioning that lasts well beyond the substance use.

These changes are part of what can trigger drug cravings years after last use.

How Do Opiates Work?

Opiates elicit their powerful effects by activating opiate receptors that are widely distributed throughout the brain and body. Once an opiate reaches the brain, it quickly activates the opiate receptors that are found in many brain regions and produces an effect that correlates with the area of the brain involved.

How Do Opiates Work? Two important effects produced by opiates,

such as morphine, are pleasure (or reward) and pain relief. The brain itself also produces substances known as endorphins that activate the opiate receptors. Research indicates that endorphins are involved in many things, including respiration, nausea, vomiting, pain modulation, and hormonal regulation.

Opiate Agonists

Opiate agonists are drugs that stimulate the opioid receptors in the brain, leading to the high associated with opiate drugs. They include Heroin, Vicodin, Morphine, Codeine and Methadone.

They mimic the effects of naturally-occurring endorphins in the body, and produce an opiate effect by interacting with the opioid receptor sites.

Opiate Antagonists Opiate antagonists block the brain’s opioid

receptors, making it impossible for opiate drugs to stimulate them. For example, drugs like Naloxone and Naltrexone make it so that, if the user were to take a drug like heroin afterwards, there would be no high.

These medications are often used to combat the overdose effects of an opiate or to help break an addiction.

Partial Opiate Agonists Partial opiate agonists are drugs that have a

“ceiling effect.” In other words, they can only stimulate the opioid receptors to a certain extent. Buprenorphine, the main ingredient in Suboxone, is one of these. No matter how much Suboxone you take, its effects are limited.

Sedatives, Hypnotics, and Anxiolytics

Sedatives, Hypnotics and Anxiolytics Drugs that reversibly depress the activity of the

central nervous system. Barbiturates, Benzodiazepines, and other sedative-hypnotics have diverse chemical and pharmacological properties that share the ability to depress the activity of all excitable tissue, especially in the arousal center of the brainstem.

Barbiturates (Sedatives): Amytal, Nembutal, Seconal and Phenobarbital.

Benzodiazepines (Anti-Anxiety): Ativan, Halcion, Librium, Valium, Xanax, and Rohypnol.

Other Sedative-Hypnotics (Sleep Inducers): Lunesta, Sonata, Ambien.

Barbiturates

In therapeutic doses, barbiturates are effective and are typically used for seizure disorders and anesthesia. Using them to “get high” is extremely dangerous because there is a relatively small difference between the desired dose and an overdose.

A small miscalculation, which is easy to make, can lead to coma, respiratory distress (breathing slows or stops) and death.

Withdrawal from barbiturates is similar to, and sometimes more severe than, alcohol withdrawal. Seizures are possible and can also lead to death.

Common Barbiturates Amytal Nembutal Seconal Phenobarbital

Seconal 100mgA barbiturate may be prescribed for a variety of reasons, the list is extensive, but the most common use today is as an anesthesia for surgery. This form is hardly ever abused because they cause almost immediate unconsciousness. Other forms like Phenobarbital are used in treating various seizure disorders as an anticonvulsant. Other uses of this form of barbiturate along with mephobarbital include treating anxiety, insomnia, epilepsy and delirium tremens.

Benzodiazepines The benzodiazepine family of depressants is used

therapeutically to produce sedation, induce sleep, relieve anxiety and muscle spasms, and to prevent seizures. In general, benzodiazepines act as hypnotics in high doses, anxiolytics (anti-anxiety) in moderate doses, and sedatives in low doses.

Of the drugs marketed in the United States that affect central nervous system function, benzodiazepines are among the most widely prescribed medications.

Compared to barbiturates, benzodiazepines are much safer. They cause sedation but rarely stop a person’s breathing or lead to death (unless combined with other CNS depressants).

Common Benzodiazepines Ativan Halcion Librium Restoril Valium Xanax Rohypnol (not marketed in U.S.)

Other Sedative-Hypnotics: Sleep Aids This is a newer class of drugs that is used for the

short-term treatment of insomnia. They cause the onset of sleep to occur faster and allows for a longer sleep period throughout the night.

These non-benzodiazepines have a short half-life and have less chance of causing dependency, tolerance, and impairment of daytime activities due to carry-over effects.

Again, combining any of these drugs or using them with alcohol (and other depressants) can lead to dangerous effects.

Common Sleep Aids/Hypnotics Ambien/Ambien CR Sonata Rozerem Precedex Lunesta

CNS Stimulants

CNS Stimulants CNS Stimulants are a class of drugs that

elevate mood, increase feelings of well-being and increase energy and alertness. Examples include:

Caffeine *Amphetamines Cocaine Methamphetamine “Bath Salts”

Amphetamines Synthetic psychoactive CNS stimulant drugs

including amphetamine, dextroamphetamine and methamphetamine

Medications containing amphetamines are prescribed for narcolepsy, obesity and ADHD (including Adderall, Dexedrine, DextroStat, and Desoxyn).

The basic molecule of amphetamine can be modified to emphasize specific actions (e.g., appetite suppressant, CNS stimulant, cardiovascular actions) for certain medications…including methylphenidate (Ritalin and Concerta).

Dexedrine

Ritalin

Adderall

Adderall: The “Study Pill” http://www.youtube.com/watch?

v=1gQNg2f15dk

Amphetamines Cause release of the neurotransmitters dopamine

and norepinephrine – and their reuptake is inhibited.

This influx causes the buildup of NTs at synapses in the brain.

When mixed with other drugs (including alcohol), the effects of prescription amphetamines are enhanced. When the drug is snorted, effects occur within 3-5 minutes. When ingested orally, effects occur within 15 to 20 minutes.

Amphetamines: Short-Term Effects Increased

activity/talkativeness Decreased

fatigue/drowsiness Heightened sense of well-

being Heightened

alertness/energy Euphoria Release of social inhibitions Altered sexual behavior Unrealistic feelings of

cleverness, great competence, and power

Hostility or paranoia

Increased body temperature

Irregular or increased heart rate

Increased diastolic/systolic BP

Decreased appetite Dry mouth Dilated pupils Increased respiration Nausea Headache Palpitations Cardiovascular system

failure Twitching/Tremor of small

muscles

Amphetamines: Long-Term Effects Toxic psychosis Physiological and

behavioral disorders Dizziness Pounding heartbeat Difficulty breathing Mood/Mental changes Unusual

tiredness/weakness Cardiac arrhythmias Repetitive motor activity

Ulcers Malnutrition Mental Illness Skin disorders Vitamin deficiency Flush or pale skin Loss of coordination and

physical collapse Convulsions, coma and

death.

Amphetamines: Potential for Abuse Rx amphetamines are taken orally and in low

doses, drug abuse and addiction are not serious risks.

Abuse of amphetamines can lead to tolerance and physical/psychological dependence characterized by consuming increasingly higher dosages and by the “binge and crash” cycle.

When the binge episode ends, the abuser “crashes” and is left with severe depression, anxiety, extreme fatigue, and a craving for more drugs.

The chronic abuse of amphetamines is characterized by erratic (sometimes violent) behavior – as well as a psychosis similar to schizophrenia.

Screening and Evaluation

Screening & Assessment: 3 Primary Goals

1. To Obtain Information/Collect a Database

2. To Determine Eligibility for a Particular Service

3. To Engage the Individual/Family in the Treatment

Process

The Clinical Assessment Interview: Basic Elements Only One part of a multimodal evaluation Formally arranged meeting Has specific purpose Interviewer chooses topic/broad content Defined relationships Interviewer attuned to ALL aspects of interaction - Affect,

Behavior, Style (Process) and Content Questioning techniques/strategies employed to direct the

flow of conversation Acceptance of client's expressions of feelings and factual

information without casting judgment Interviewer makes explicit what otherwise be left unstated Assessor follows guidelines for confidentiality and disclosure

of info.

What a Clinical Assessment Interview is NOT...

Ordinary Conversation

"Counseling" Session

Forensic Interview

Survey Interview

The Assessment Interview: Assumptions1. Need for Multiple Data Sources: There is no gold standard for assessing

people's functioning. The key to good assessment is to find the

conceptual links and relationships between methods and modalities of the assessment. Each form of indirect and direct methods contributes unique elements to solving the puzzle (Wheel of Fortune).

Assumptions (Cont.)2. Situational Variability: Individuals' behaviors are likely to vary

across situations and relationships. Good assessment requires identifying

patterns of behavior that DIFFER across situations and relationships as well as patterns that REMAIN CONSISTENT, despite variations in situations and relationships.

Assumptions (Cont.)3. Limited Cross-Informant Agreement: There is likely to be only low-to-

moderate agreement between informants who are in different situations or in different relationships with the same person (esp. children).

Low agreement does not mean that one is right and one is wrong or that one has a "truer" picture. The challenge is to put all these pieces together to form a meaningful picture of the person's functioning under the given circumstances.

Assumptions (Cont.)4. Variations in Interview Structure and

Content: The structure and content of clinical

interviews should vary in relation to the informant and the goals of the interview.

Structured, semi-structured, direct observation, indirect data collection, age/role appropriateness, etc. Clinical interviews need to be tailored to particular informants. The content and questioning strategies are shaped by the kind of informant interviewed and the kind of information sought.

Interview Content and Questioning Strategies1. Semi-Structured: Questions used to query

client (and others) about many aspects of functioning. Format is relatively open-ended and flexible to stimulate a natural flow of conversation. MI strategies are used (empathy, reflective listening, summarizing). Probe questions can then be used to obtain more detailed information.

2. Structured: Appropriate for querying individuals/family members about symptoms and criteria for psychiatric disorders. Structured diagnostic interviews have a standardized set of questions and probes focusing on specific problems relevant to diagnoses.

Interview Content and Questioning Strategies (Cont.)3. Behavior-Specific: Questions can be used to query family

members parents, teachers, PO's, etc. regarding their current concerns about the individual. More narrow in scope than semi-structured because the focus is on a limited number of specific problem areas.

Typically, the main purposes are: a) identify and define problems of concern of others

(problem identification) b) examine antecedents and consequences that surround

the identified problems (problem analysis)

Assessors can also use behavior-specific questions to elicit from individuals their views of particular problems and their understanding of the consequences around the problems.

Interview Content and Questioning Strategies (Cont.)4. Problem-Solving: Focus on others' current

concerns with the goal of developing interventions for identified problems. In initial clinical interviews, assessors can use problem-solving questions to explore and gauge others' receptivity to different kinds of interventions prior to implementing any interventions.

Can also use problem-solving questions to explore individual’s views of different interventions and to find out which approaches are acceptable to them.

Preparation: Master Your MaterialPreparation and Mastery increase your

confidence and competence. Your goals include...

Understanding and applying all aforementioned material

Learning and knowing intimately all sections (and the purpose for each) of the assessment forms

Mastering the art of Motivational Interviewing Reading, Studying, Understanding

DSM-IV/DSM-5 diagnostic criteria - and applying structured interviewing strategies to rule out and rule in dx

Knowing what you don't know - and learning it

Preparation and Mastery: Conceptualizing Your Case Guided by: Observing, Questioning, Thinking (repeat ad nauseum) Study your prelim. Info (Screening Form, etc.)

and apply the above... Begin your studies/research Generate Questions Formulate Hypotheses (not conclusions) Prepare, Prepare, Prepare...

Key TermsTolerance:

(a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect.(b) markedly diminished effect with continued use ofthe same amount of the substance (DSM-IV TR).

Potentiation:Potentiation occurs when two drugs are taken together and

one of them intensifies the action of the other. This could be expressed by a +b= B.

As an example, - an antihistamine, when given with a painkilling narcotic such as Percocet ,intensifies its effect thereby cutting down on the amount of the narcotic needed.

Key TermsCross Tolerance and Cross Dependence:Cross tolerance refers to the fact that if a person has developed a tolerance to a drug in a certain classification, such as the depressants, that person is more likely to develop tolerance with another drug in that classification. As an example, people who are dependent upon alcohol show an increased tolerance to barbiturates, synthetic and natural opiate narcotics, and anesthetics. This, of course, means that the person must have a higher dose of the new drug for it to be effective. In cross dependence, the withdrawal symptoms from one drug in a classification can be relieved by another. As an example, many alcoholics are given barbiturates and tranquilizers to prevent withdrawal symptoms. However, the person may soon develop a dependency on the other drug as well.

Key TermsSynergism:Synergism is similar to potentiation. If two drugs are taken together that are similar in action, such as barbiturates and alcohol, which are both depressants, an effect exaggerated out of proportion to that of each drug taken separately at the given dose may occur. This could be expressed by 1+1= 5. An example might be a person taking a dose of alcohol and a dose of a barbiturate. Normally, taken alone, neither substance would cause serious harm, but if taken together, the combination could cause coma or death.

Key TermsWithdrawal:Withdrawal is a term referring to the feelings of discomfort, distress, and intense craving for a substance that occur when use of the substance is stopped. These physical symptoms occur because the body had become metabolically adapted to the substance. The withdrawal symptoms can range from mild discomfort resembling the flu to severe withdrawal that can actually be life threatening.

Withdrawal from particular substances can be extremely serious and dangerous (potentially life-threatening). Refer to the DSM-IV TR and or DSM-5 for drug-specific withdrawal profiles.

Interventions/Best Practices

Treatment: Key Components Established Clinical Model that is evidence-based Individualized assessment and person-centered treatment

planning Full array of integrated services (MH and SA, etc.) Individual, Family and Group Therapies Psychoeducation Motivational Interviewing/Motivational Enhancement

(strengths-based) Cognitive-Behavioral Interventions Relapse and Recovery Planning Connection and Collaboration with Community Resource and

Associated Professionals (wrap-around) Frequent/randomized drug/alcohol screening Accountability

Drug Testing Critical Component of any treatment

program

Urine lab testing Urine instant Oral Hair

Pay Attention! What to “watch” for when conducting drug screensAll testing needs to be Observed whenever possible.

1. Dilution – water loading/adding water to samples

2. Flushing – ingesting Niacin or Golden Seal (or any of hundreds of other products on the market)

3. Substituting – synthetic urine or borrowing/storing urine

4. Mechanical Devices – the “Wizinator,” small bottles or tubes

Screening: Other things to Know Know where your individuals can get tested

(and what kind of testing they conduct) Know what medications your individuals are

taking Connect with a therapist or doctor that

conducts drug screens, or make sure you call the lab toxicologist for specific information

You do not have to be the expert on all information, but know where to get the information and be willing to puruse it!

Principles of Effective Treatment (National Institute of Drug Abuse, 2012)

1. Addiction is a complex but treatable disease that affects brain function and behavior.

2. No single treatment is appropriate for everyone.

3. Treatment needs to be readily available4. Effective treatment attends to multiple

needs of the individual, not just his or her substance abuse.

Principles of Effective Treatment (cont.)5. Remaining in treatment for an adequate

period of time is critical.6. Behavioral therapies – including individual,

family, or group counseling – are the most commonly used forms of drug abuse treatment.

7. Medications are important element of treatment for many individuals, especially when combined with counseling and other behavioral therapies.

Principles of Effective Treatment (Cont.)8. An individual’s treatment and services plan

must be assessed continually and modified as necessary to ensure that is meets his or her changing needs.

9. Many drug-addicted individuals also have other mental disorders.

10. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse

Principles of Effective Treatment (Cont.)11. Treatment does not need to be voluntary to

be effective.12. Drug use during treatment needs to be

monitored continuously, as lapses during treatment do occur.

13. Treatment programs should test individuals for the presence of HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases as well as provide targeted risk reduction counseling, linking individuals to treatment if necessary.

ASAM Criteria: Case ConceptualizationWherever the treatment location or circumstances, some guidelines have suggested criteria to consider when treating substance dependence. The following criteria were developed by the American Society of Addiction Medicine (ASAM) to consider in the treatment of dependence:

1. acute intoxication and/or withdrawal potential 2. biomedical conditions and complications 3. emotional, behavioral, or cognitive conditions and

complications 4. readiness to change 5. relapse, continued use, or continued problem potential 6. recovery/living environment

ASAM Levels of TreatmentASAM Levels

Level 0.5 = Early Intervention ServicesLevel 1 = Outpatient Treatment Services(3 hours a week or less)Level 2 = Intensive Outpatient/Partial Hospitalization (9

hours per week at least)Level 3 = Residential/Inpatient Services (24 Hours/Day)Level 4 = Medically Managed Intensive Inpatient Services

Reference: www.asam.org

Opiate Withdrawal and Detoxification

Opiate/Narcotic Withdrawal Opiate addicts avoid treatment because they

are afraid of withdrawal, which can be rather unpleasant but rarely fatal. They crave the drug and experience muscle and bone pain, insomnia, restlessness, nausea and vomiting, sweating, involuntary muscle twitches, dry mouth.

Opiate withdrawal will usually peak between 48-72 hours after the last use. But withdrawal can last much longer, depending on the individual.

Detoxification and “Maintenance” Medications have been developed to lessen

the impact of the withdrawal and help addicts rid themselves of the need to use. Principal among these are Methadone and Suboxone, both synthetic opiates themselves, but both act to block the impact of the opiates.

Maintenance Therapy Maintenance therapy with drugs like

methadone or Suboxone is helpful because it takes away the severe effects of a heroin or prescription painkiller habit while easing the symptoms of withdrawal.

APA Guidelines for Opiate DependenceThe American Psychiatric Association (APA) guideline identified the following 3 treatment modalities to be effective strategies for managing opioid dependence and withdrawal:

1. opioid substitution with methadone or buprenorphine, followed by a gradual taper

2. abrupt opioid discontinuation with the use of clonidine to suppress withdrawal symptoms

3. clonidine-naltrexone detoxification

Considering Your Options in Dealing with an Opiate Dependent Individual Acute opioid-related disorders that require

medical management include opioid intoxication, opioid overdose, and opioid withdrawal. Issues pertaining to treatment of chronic opioid abuse include opioid agonist therapy (OAT), psychotherapy, and treatment of acute pain in patients already on maintenance therapy.

Intensive Case Management

The Importance of Coordinated Intervention

We need an integrated, coordinated community response focused on recovery. This type of approach is more effective in preventing, treating and managing the chronic consequences of substance abuse and addiction than a response that is fragmented or focused primarily on penalties.

We need a systematic response that is fast, fluid and flexible…meeting needs as they arise and changing through the continuum of care.

Intensive Case Management and Wrap- Around: Who Needs to be Involved?

The prescribing physician Significant other(s) Probation or parole (if a part of the case) Other clinicians (if part of the case) Other “natural supports” (as part of a high-

fidelity wrap around team)

Please make sure you follow all confidentiality regulations under 42 CFR Part 2.

Why include these people? What’s the rational?1. Liability2. Appropriate Service/Treatment Planning3. Best Practice

Case Study Exercise

Case Study: Time to Pick each others’ Brains and Generate some Ideas!

“Dedicated Service To Those In Need”

Our strong reputation keeps us increasingly committed to providing high quality services to youth and families in the community.

Additional References and Resources www.nationalcounselinggroup.com American Psychiatric Association. (2000). Diagnostic and statistical manual

of mental disorders (4th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual

of mental disorders (5th ed.). Washington, DC: Author. Johnston, LD, O'Malley, PM, Bachman, JG, & Schulenberg, JE. (2012).

Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings, 2011. Ann Arbor: Institute for Social Research, University of Michigan. Available at http://monitoringthefuture.org.

Levine, DA. (2007). “'Pharming': The abuse of prescription and over-the-counter drugs in Teens.” Current Opinion in Pediatrics. Vol. 19, No. 3, pages 270-274.

National Institute on Drug Abuse. NIDA InfoFacts: Prescription and Over-the-Counter Medications. http://www.drugabuse.gov/infofacts/PainMed.html). Bethesda, MD: NIDA, NIH, DHHS. Published June 2009. Retrieved February 2012.

National Institute on Drug Abuse. NIDA Research Report: Prescription Drugs: Abuse and Addiction. http://www.drugabuse.gov/ResearchReports/Prescription/Prescription.html. NIH Publication No. 11-4881. Bethesda, MD: NIDA, NIH, DHHS. Published July 2001. Revised October 2011. Retrieved February 2012.

References and Resources (Cont.) http://emedicine.medscape.com/article/1174630-overview http://www.nytimes.com/interactive/2012/06/10/education/stimulants-

student-voices.html http://www.chesterfieldsafe.org www.unifiedpreventioncoalition.com http://www.samhsa.gov/ http://www.nida.nih.gov/nidahome.html http://www.suboxone.com http://www.drugalcoholaddictionrecovery.com http://drugpubs.drugabuse.gov/ http://www.whitehousedrugpolicy.gov/drugfact/juveniles/

juvenile_drugs_ff.html www.erowid.com http://learn.genetics.utah.edu/content/addiction/ http://www.theantidrug.com/drug-information/default.aspx

Additional References and Resources http://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/

rx_abuse_plan.pdf “Epidemic: Responding to America’s Prescription Drug Crisis” 

http://www.drugabuse.gov/publications/principles-drug-addiction-treatment “Principles of Drug Addiction Treatment: A Research-Based Guide (3rd Edition) 

http://www.drugabuse.gov http://www.youtube.com/watch?v=E0ihO1KFxkQ “Students Seek

Competitive Edge…” http://www.youtube.com/watch?v=1gQNg2f15dk “Adderall: The Study Pill” http://www.youtube.com/watch?v=1sdFRJtzI0s “PBS NewsHour

Excerpt:Prescription Drug Abuse (aired 5/2013) http://www.youtube.com/watch?v=_mgQHSCDswQ&NR=1&feature=fvwp

“Prescription Drug Abuse” http://www.nytimes.com/interactive/2012/06/10/education/stimulants-

student-voices.html?emc=eta1#/#1 “In Their Own Words: Study Guides.”