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JANUARY 2019

A NO TURNING BACK INC. PUBLICATION

New A Jack Eddinger LIFE EARNED Spirit Carl Evans Kindred A

ANSWERING A CALL to help others RECOVER Rob Carter

S E E WHAT WE OF F E R SAF E & AF FORDAB L E SUP POR T S E R V I CE S

S P I R I TUA L I T Y PHY S I CA L /MENTA L HEA LTH FAM I LY S E R V I CE S L I F E S K I L L S

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CONTENTS To send a comment or

question, write to: No Turning Back Inc. 5209 York Road, Suite 20 Baltimore, MD 21212

A NO TURNING BACK INC. PUBLICATION

INTERESTED IN MORE FROM No Turning Back Inc.? To learn more about our resources for

FEATURES 08 ROB CARTER Answering a call to help others recover 12 JACK EDDINGER A new life earned 16 PRESTONMERRITT The long & winding road to recovery IN THE NEWS 20 IT’S INTHE GENES Researchers probe alcohol’s effect on epigenetics 22 CALIFORNIA DREAMING California saves money favoring treatment over incarceration fo drug offenders 24 SCREENTIME Digital treatment therapies show promise in recent trials 28 TALKIN’ BOUTMY GENERATION NIDA researchers develop screening tool for teen substance use 30 THE FEMALE FACTOR Research: Women need different treament options than men

living a healthy lifestyle, visit noturningbackinc.com or call (443) 214-5445

46 CARL EVANS A kindred spirit 50 SHERRITT BUTLER The career chose her 54 ANDRE RHYNE An experienced, clean client uses his know-how to smooth new clients’ transition 32 eHEALTH Opportunites & challenges 34 ITS NOT JUST A BAD HABIT What it means for addiction to be a disease 38 WE GET IT Cultural competency for addiction treatment professionals 40 NOT CHILD’S PLAY Research: Brain changes from childhood trauma make people more susceptible to substance abuse

NTB Magazine is published by CRG Media

Copyright 2016 by CRG Media . No part of this publication may be reproduced in any form or by any means without the prior written permission of the publisher, excepting brief quotations in connection with reviews written specifically for inclusions in magazines or newspapers, or limited excerpts strictly for personal use. Printed in the United States of America. All rights reserved.

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We’ve always prided ourselves on providing excellent facilities, nice places to live and, along with that, providing good counseling services. — Rob Carter, No Turning Back Owner

CARTER ROB Rob Carter’s successful career as founder and executive director of No Turning Back in Baltimore grew out of his own struggles with drug abuse. Born and raised in the Pimlico/Park Heights section

ANSWERING A CALL TO HELP OTHERS RECOVER grant-givers.”Carter was also able to establish a referral relationship with Gaudenzia, one of the largest treatment centers in Maryland, which has two facilities in Park Heights. In 2015, No Turning Back opened its fth transitional housing residence in the Irvington neighborhood, designated and staffed for women in recovery. Several years ago, No Turning Back began providing outpatient substance abuse treatment, and now serves about 200 patients a year. Another big step came several years ago: hiring substance abuse and mental health grant-givers.”Carter was also able to establish a referral relationship with Gaudenzia, one of the largest treatment centers in Maryland, which has two facilities in Park Heights. In 2015, No Turning Back opened its fth transitional housing residence in the Irvington neighborhood, designated and staffed for women in recovery. Several years ago, No Turning Back began providing outpatient substance abuse treatment, and now serves about 200 patients a year. Another big step came several years ago: hiring substance abuse and mental health home in the area and renovated it using a loan from “one of our home in the area and renovated it using a loan from “one of our

treatment to that population,” Carter recalls. “God spoke to me and said ‘I want you to give back to the community where you grew up.’ So, I started looking for properties in the Carter didn’t have to do much looking before he found a ve-bedroom home in the neighborhood, which was in foreclosure. He bought it with his own money, and launched the treatment and recovery program that became No Turning Back. His own participation in the local recovery community made it relatively easy to nd fellow recovering addicts and Before long, “one person came to our program who had access to another property, an eight-bedroom home, also in Park Heights. That became our second property,” Carter says. About a year later, No Turning Back acquired another eight bedroom

Rob Carter’s successful career as founder and executive director of No Turning Back in Baltimore grew out of his own struggles with drug abuse. Born and raised in the Pimlico/Park Heights section of Baltimore, Rob Carter worked as a Baltimore County reman for 27 years until his retirement in 2010. His teenage drinking led to steady marijuana use, then to pills and heroin and cocaine. He experienced “the progression of the disease to the point where I was mentally and spiritually drained, and suicidal.” In 1994, Carter, who had served four years in the U.S. Air Force, went through treatment and got clean at the VA Hospital at Fort Howard, Md. Attending the proverbial “90 meetings in 90 days” helped him establish a solid foundation for long-term recovery. “After I got cleaned up, I felt a passion to go back to the community where I lived and was raised, to offer

Park Heights area.” START OF AN ERA treatment to that population,” Carter recalls. “God spoke to me and said ‘I want you to give back to the community where you grew up.’ So, I started looking for properties in the Park Heights area.” START OF AN ERA Carter didn’t have to do much looking before he found a ve-bedroom home in the neighborhood, which was in foreclosure. He bought it with his own money, and launched the treatment and recovery program that became No Turning Back. His own participation in the local alcoholics in need of supportive housing. recovery community made it relatively easy to nd fellow recovering addicts and lcoholics in need of supportive housing. Before long, “one person came to our program who had access to another property, an eight-bedroom home, also in Park Heights. That became our second

of Baltimore, Rob Carter worked as a Baltimore

County reman for 27 years until his retirement in 2010. His teenage drinking led to steady marijuana use, then to pills and heroin and cocaine. He experienced “the progression of the disease to the point where I was mentally and spiritually drained, and suicidal.” In 1994, Carter, who had served four years in the U.S. Air Force, went through treatment and got clean at the VA Hospital at Fort Howard, Md. Attending the proverbial “90 meetings in 90 days” helped him establish a solid foundation for long-term recovery. “After I got cleaned up, I felt a passion to go back to the community where I lived and was raised, to offer

property,” Carter says. About a year later, No Turning Back acquired another eight bedroom

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counselors to conduct therapy sessions for the residents. “Our staff clinicians are people who have a good deal of experience in counseling for substance abuse, and take a personal interest in serving each one of our clients,” Carter says. “In treatment, we are dealing with people who each have different issues. We want to make sure we dig into those issues.” One example was a client who was not raised by his biological parents but grew up in a foster home. “Part of our focus would be on going back to parenting skills for that individual, because he missed that part of life,” Carter says. A GOOD RUN Looking back at the history of the program he

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attribute that to the fact that we’ve always prided ourselves on providing excellent facilities, nice places to live and, along with that, providing good counseling services.” “Of course, the number one objective for clients is to not use any foreign substance,” Carter says. “Once clients have been able to stop using and we see that they are serious about taking our suggestions and following our program guidelines, that provides a foundation to start dealing with their other issues.” Often, those include mental health issues, as seen in an increasing number of clients who come to No Turning Back with co-occurring addiction and mental health issues. Along with the professional staff, residents play a major role in ensuring a supportive environment for recovery.

“We set up the guidelines and rules here, but it’s really the (recovering client) leaders who make that all come together and make the programs successful,” Carter says. Back? Carter would like to nd a facility large enough to develop a residential treatment facility with 50 to 60 beds. For Carter, the key to success has been the personal touch. “As long as I have had this organization, I’ve always been involved personally. I’ve always made sure to take time out of my schedule to attend group sessions, and anything else that is going on with the program,” Carter says. “Now that we have been doing this for 11 years, we’re really con dent about the future. In the past, we experienced some situations where we didn’t make good (business) decisions, and have learned from those. Moving forward, we have the support of other agencies in Baltimore, and we have a great reputation.” PLAN FOR THE FUTURE What’s next for No Turning

started a decade ago, Carter says he’s “very surprised at what we’ve been able to

do, in terms of positive outcomes. We

We set up the guidelines and rules here, but it’s really the (recovering client) leaders who make that all come together and make the programs successful. — Rob Carter, No Turning Back Owner

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A NEW LIFE EARNED NO TURNING BACK

A GOOD CHILDHOOD Eddinger does not see the source of his struggles with drugs in his upbringing. Raised in what he believes to be a relatively healthy environment, he wasn't running away from abuse at home or school. He wasn't avoiding his family or friends. He was avoiding himself. “I was always uncomfortable in my skin,” he says, noting that drugs were a way for him to get out of his own head. “It was de nitely a kind of way to escape from my inner discontentment with myself.” Beginning in high school, Eddinger started smoking marijuana. He liked it. A curiosity arose and he began experimenting with other substances. “I was always trying to nd something more intense, an escape that would be a bit more high then I was before.” Adderall, an amphetamine stimulant medication prescribed to treat attention-de cit hyperactivity disorder, was the next drug. Prescriptions for Adderall are easy to come by, and easier still is getting Adderall from a friend. Eddinger’s use of the easily accessible stimulant paved the way to cocaine use. “It was fun at rst, obviously,” Eddinger recalls of his younger self. “I always heard about how everybody tells you drugs are destructive. What do you know?” Eddinger began to roll with the highs and avoid the lows. There was no self to avoid, no insecurities to compensate for. Just drugs and more drugs.

Jack Eddinger

Jack Eddinger sized up the jail cell that was to be his for the night. While being arrested for cocaine possession and transported to central booking, he had been in shock. Now, alone in the cell, he broke down. Dropping to his knees, Eddinger pleaded with God. He begged for forgiveness and mercy. He asked for help, a second chance. This arrest, he prayed, would be his awakening. “I’ll do anything if you help me get out of here,” Eddinger bargained. “I need some type of change. I don't know how to do this on my own.” At 3 a.m. the next morning, Eddinger was released from jail. His possessions were returned to him, including some money. He walked out of central booking, went to a drug dealer and purchased crack cocaine. “Crack cocaine is the worst thing I could ever even imagine. I wouldn't wish it on my worst enemy,” Eddinger says now, astonished by the power of the drug and the control it held over his decision-making. “It’s so deceiving.”

“If you want to live a new way of life. If you are tired of the endless cycle of addiction, come to No Turning Back.”

Jack Eddinger No Turning Back client

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—Jack Eddinger No Turning Back client “ You have to put your own e ort into (your recovery), no one can do it for you.”

TUNNELING OUT “Slowly but surely, it became a way of life. I didn't know life without drugs. My life totally centered around getting high,” Eddinger explains. That’s when he began using opioids. He couldn't get enough, trapping himself in a box of his own making. As a result his grades, relationships and health began to suffer. He realized he had a problem. After his one-night-stint in jail, he told himself his life of drug use would stop. The problem was, he still decided to self-diagnose and self-prescribe. Intuitively, he realized his drug problem stemmed from what he perceived to be internal inadequacies. His recourse was to start focusing on external things. He got a job, then another job, started a relationship. It wasn't enough. He still wasn't satis ed. He still wanted more. Slowly, Eddinger’s desire to rely on substances started creeping back into his life. The lack of lasting recovery added further stress. It was another insuf ciency. He sought a way out, choosing drugs, choosing what was familiar to him. To get out of this cycle, Eddinger knew he had to stop going it alone and get help.

TURNING TO NO TURNING BACK After entering and exiting treatment centers that, he observed, “seemed to be more of a business and focused on the money they can make on the clients,” Eddinger turned to No Turning Back. “It's like nothing else I’ve ever been in. The management are so spiritually in touch. It’s very unique and de nitely helps,” Eddinger says of NTB. Though his pursuit of holistic, effective help led him to NTB, he said that he put in plenty of work. “You have to put your own effort into it, no one can do it for you.” At NTB, he’s found peace and love. “I concentrate on inward contemplation on myself and my place in the world and relationships with others,” Eddinger says, adding, “We all love each other.” Eddinger says that, since his time at NTB, triggers to relapse don’t arise often. And even if they do occur, he now has tools to deal with it. “It’s just a feeling,” Edinger says he tells himself, “it's going to pass. The next thing I need to do is tell someone I am feeling this way.” Eddinger thanks NTB Executive Director Rob Carter. “He has a heart of gold,” Eddinger says. “If you want to live a new way of life. If you are tired of the endless cycle of addiction, come to No Turning Back.”

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According to the Substance Abuse and Mental Health Services Administration, 60% Nearly 60% of adults with a mental illness didn’t receive mental health services in the previous year.

Don’t be a statistic.

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T he middle class is being decimated, but not by diabetes, heart disease, cancer or any of the other usual suspects. It’s drugs, alcohol, and suicide that are the primary drivers behind the shocking mortality rates for middle-aged Americans with no more than a high school education. Many of these deaths stem from overdose (opiates), cirrhosis of the liver (alcohol), and suicide. Drinking oneself to oblivion or nodding away the days on pain pills is in itself a form of resignation, not dissimilar from actual suicide. While middle-aged Americans are dying from drugs, alcohol, and suicide, so are young adults overdosing in obscene numbers. The CDC reports that heroin use more than doubled among young adults between the ages of 18-25 in the past decade. And out of this group, 45% were addicted to prescription opioids before making the switch to heroin.

The Addiction DEVASTATION of the Middle Class

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Preston Merritt

“No Turning Back alumni are always welcome to come back and talk to counselors. They don’t cut the cord, which is a big help in maintaining sobriety.” — Preston Merritt, No Turning Back marketing specialist

The Long and Winding Road to Recovery

Fifty-six year old Preston Merritt’s journey to his current position as a marketing specialist at No Turning Back in Baltimore has not always been a smooth one. But in spite of a few detours along the way, it has ultimately proven to be a successful one. Before arriving at No Turning Back in 2011 to undergo 35 days of inpatient care, Preston had failed in 10 previous treatment attempts at getting and staying clean. He had amassed periods of eight and nine years of sobriety that ended each time with relapses. Merritt’s substance use had begun with smoking pot and drinking while in his teens and eventually progressed to sniffing cocaine, and then shooting heroin. “The drug that brought me down was heroin,” Merritt recalls . History of Drug Use At that point, he had a long work history. He had started working as a part-time orderly at New York’s Beth Israel Hospital while still in high school and then going full-time upon graduation from Theodore Roosevelt High School. Due to his drug use, Preston changed jobs fairly frequently, working at four different hospitals over the next decade.

“I would have been able put in 10 years at one place, if not for my drug use,” he says. In between relapses, he had some periods of “substantial clean time.” At one organization, he started as a job coach/job developer for disabled clients, and worked his way up to director of the program in the mid-1990’s. He eventually lost that job because of using. He also held positions as a case manager and counselor at other social service programs in New York. “Anytime I got a job, it was because I was clean.” Along the way, Preston earned his B.A. degree and then a Master's in Public Administration from Metropolitan College in New York. He was able to keep advancing in his hospital career before prescribed pain pills for a post-surgical recovery led to another heroin relapse.

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Final Surrender No Turning Back proved to be the shelter in a storm that Preston Merritt had been looking for. After completing 35 days of inpatient treatment, he moved into transitional housing for six months in a residence with five other recovering clients. “Coming from New York in 2008, I didn’t know anybodyin Baltimore,” says Merritt. “No Turning Back was my first opportunity to meet some people who were doing something positive. They were different from other transitional housing places I had experienced, in that they really monitor you. And it is not just the staff.” Key to the experience was plenty of interaction with fellow residents, which “really helped me, not just in staying away from drugs but in improving my attitudes and behaviors,” Merritt says. “Living so closely with people kind of forces you to interact with each other. You can talk about what you are going through and any

issue you might have in there. And people really stay on top of each other. It’s not just the

staff. The clients are programmed to automatically monitor each other.”

He still returns unofficially to drop in on support groups at his former residence. “When I first left, I would go back at least once a week to make one or two group meetings. (No Turning Back) alumni are always welcome to come back and talk to counselors. They don’t cut the cord, which is a big help in maintaining sobriety,” says Merritt. For the past three years, Preston has been working part time as a marketing specialist at No Turning Back. A major part of his job is visiting jails, hospitals and treatment facilities “educating people as to what resources are available to them out there. A lot of people in that situation don’t know.”

The Power Of Your Story In retrospect, Merritt’s years of running the streets in his previous life are not always pleasant to look back on. But the experience has certainly helped Merritt understand and help clients. “We don’t feel that it’s necessary for counselors to have a personal drug history to help, but we’ve found that some clients are more receptive to counselors who have a history.”

What would Preston Merritt tell other addicts or alcoholics in need of recovery?

“I’d say, ‘You’ve tried everything else. So, why not try to look at (recovery) as a whole new high?’ A lot of people who have been using for so many years really lose touch with reality and what it is to actually feel, because one thing drugs do is cover up feelings. When you get clean, you start to feel again.”

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It’s in the Genes Researchers Probe Alcohol’s Effect on Epigenetics As scientists gain a better understanding of the human genome, one rapidly emerging area of research is the effect of alcohol on epigenetics – external modifications to DNA that turn genes “on” or “off.” Epigenetic changes alter the physical structure of DNA. One example of an epigenetic change is DNA methylation — the addition of a methyl group, or a “chemical cap,” to part of the DNA molecule, which prevents certain genes from being expressed. A recent article in the National Institute on Alcohol Abuse and Alcoholism’s Alcohol Alert reports on a growing body of research showing how alcohol’s influence on epigenetics may be associated with an array of illnesses and disorders. These include fetal alcohol spectrum disorders (FASD), cancer, liver disease and other gastrointestinal disorders, brain development, the body’s internal clock, and immune function. Researchers and clinicians are beginning to explore therapies that might be developed to target the changes occurring through epigenetics.

How alcohol affects epigenetics Alcohol consumption leads to chemical changes within the body that can affect all the epigenetic mechanisms. For one, excessive alcohol consumption interferes with the body’s ability to process and access a chemical called folate. Folate is critical for methylation, a biochemical process that attaches a methyl group to a specific spot on DNA. DNA methylation acts to lock genes in the “off ” position. Chronic alcohol consumption leads to lower-than-normal methylation, or “hypomethylation.” Research also finds that alcohol metabolism leads to an increase in a substance called NADH, which is a byproduct of alcohol metabolism, and through production of reactive

oxygen species (ROS), which are chemically reactive molecules that at high levels can damage cells. Fetal alcohol spectrum disorders Women who drink during pregnancy put their developing fetuses at serious risk for a range of conditions collectively known as FASD. In exploring how epigenetics contributes to FASD, researchers have also begun to investigate two complex enzymes that play a crucial role in cell differentiation during fetal development. One, called polycomb protein, remodels chromatin to turn genes off; the other, called trithorax protein, remodels chromatin to turn genes on. Research suggests that exposure to alcohol may

Researchers and clinicians are beginning to explore therapies that might be developed to target the changes occurring through epigenetics due to alcohol use.

disrupt these two enzyme complexes, altering how cells differentiate during fetal development. Liver disease and the gastrointestinal tract Alcohol affects epigenetics on many levels within the GI tract and liver, where the majority of consumed alcohol is metabolized and cleared from the body. As alcohol enters the liver, it sets off what could be described as a cascade of epigenetic changes that increase the risk of liver disease, liver cancer and immunological problems. In addition, alcohol-associated epigenetic changes may play a role in what researchers call organ “cross talk” between the GI tract, the liver and other organs. For one, epigenetic changes to genes involved in joining the cells lining the intestines may be partially responsible for “leaky gut,” which allows endotoxins to enter circulation and initiate liver damage. Alcohol-associated cancers As suggested above, alcohol-related changes involved in epigenetics can be linked to the development of liver cancer. In particular, research suggests that some epigenetic changes can transform normal liver cells back into stem cells, which then can develop into liver cancer. In addition, alcohol acts indirectly on a receptor that, when disrupted, is involved in the development of liver cancer. Alcohol’s role in changing DNA methylation patterns, leading to hypomethylation, may be one of the main routes between alcohol consumption and liver cancer as well as other types of alcohol-associated cancers. Changes in brain functioning Alcohol’s epigenetic effects within the brain are complex and intertwined. But increasing evidence suggests that they result in adaptations within the brain that ultimately influence addictive behaviors, including tolerance and alcohol dependence. As seen in other disorders, changes in DNA methylation are one of the epigenetic changes in the brain caused by chronic alcohol consumption. Although researchers still are piecing together the details, findings to date suggest that epigenetic changes in gene expression induced by alcohol consumption may underlie the brain pathology and adaptations in brain functioning associated with

alcohol abuse and alcohol dependence, and may contribute to alcohol relapse and craving. Hope for the future As researchers begin to untangle the exact nature of alcohol’s interactions with epigenetics, they will be able to design better medications to treat or alleviate a wide range of alcohol-related disorders, including FASD, alcohol addiction, cancer and organ damage. In addition, researchers can now analyze DNA methylation patterns for the entire human genome. This work could yield comprehensive maps of DNA methylation changes in alcohol-associated cancers. Those maps then could potentially be used to develop pharmacological treatments that target epigenetic markers and develop new markers for cancer detection and prognosis. 

As researchers begin to untangle the exact nature of alcohol’s interactions with epigenetics, they will be able to design better medications to treat or alleviate a wide range of alcohol-related disorders.

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California Dreaming California saves oney favoring treatment over incarceration for

drug offenders Two recent voter-approved measures in California that shift the focus toward treatment for nonviolent drug offenders have saved the state hundreds of millions of dollars—and the savings are expected to continue. Proposition 47, voted into law in November 2014, stands to save the state $150 million to $250 million per year, while the earlier Proposition 36 saved the Golden State $100 million per year in its first two years. Researchers point to these results in California, often a bellwether for the rest of the country, as evidence that treatment is not only more compassionate but more cost effective for nonviolent drug offenders than prison.

Promise of Prop 47 Proposition 47 reduces almost all nonviolent, non-serious drug and property crimes, without intent to sell, from felonies to misdemeanors. The San Francisco Chronicle reported in September 2014 that the measure is projected to save $150 to $250 million per year.The money saved will be funneled into a fund for financing mental health treatment, truancy and dropout prevention, schools and victim compensation programs. Proposition 47 applies retroactively, allowing for people currently incarcerated to apply for resentencing. According to a Los Angeles Times report in September 2014, this means one in five California prisoners will be eligible to be set free. Proposition 47 not only saves “the state hundreds of millions annually while keeping communities safe,” it also prevents “locking people up for minor offenses when they pose no threat to public safety,” writes Allen Hopper of the ACLU of

Northern California in a post on the ACLU website. “We should convert minor offenses from felonies to misdemeanors so that the punishment and its associated cost to taxpayers fit the crime.” Allen notes that “felony sentences should be reserved for serious offenses that truly threaten public safety.” Earlier measure showed results Proposition 47 is not California’s first attempt at saving money by funneling nonviolent drug offenders into treatment. Its predecessor was the Substance Abuse and Crime Prevention Act of 2000 (SACPA). SACPA paroled first- or second time personal drug use offenders on the condition of participation in a licensed substance abuse treatment program. Offender motivation or suitability standards were not required.Those with current non-drug or violent charges were ineligible.

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The Substance Abuse and Crime Prevent Act of 2000 saved California nearly $100 million in its first and second years.

Though voted out in 2012, the measure saved California nearly $100 million in its first and second years, according to the SACPA cost-analysis report conducted at the University of California, Los Angeles in 2006. Of the 42,000 offenders adjudicated under proposition 36, UCLA researchers estimated that California saved an average of $2,300 per offender compared to 42,000 offenders adjudicated during a two-year stretch before SACPA. Prior to SACPA, personal drug use offenders would be re-incarcerated for a post-conviction relapse at an average cost of $11,300. SACPA acknowledged drug use relapse as part of the process of continuing treatment, and using treatment as a solution cost the state $8,300 per offender. Implications for the rest of the country California, the largest and one of the more diverse states in the nation, is often viewed as a bellwether for the rest of the country, which is also moving away from long prison sentences for nonviolent drug offenders. In its 2015 National Drug Control Strategy, the White House’s Office of National Drug Control Policy outlined a transition from law enforcement to rehabilitation.The strategy aims to do so through

preventing drug use in communities, “seeking early intervention opportunities in healthcare; integrating treatment for substance use disorders into health care and supporting recovery; breaking the cycle of drug use, crime and incarceration; disrupting domestic drug trafficking and production; strengthening international partnerships; and improving information systems to better address drug use and its consequences.” President Barack Obama recently said he plans to execute the shift away from law enforcement through investing “in things like state overdose prevention programs, preparing more first responders to save more lives, and expanding medication assisted treatment programs.” We should convert minor offenses from felonies to misdemeanors so that the punishment and its associated cost to taxpayers fit the crime. - Allen Hopper, ACLU of Northern California 

“ ”

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SCREEN TIME Digital treatment therapies show promise in recent trials

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Computerized programs can improve treatment outcomes when they are used to supplement or partially replace in-person behavioral therapy for drug addiction. That was the finding of researchers from the Yale University School of Medicine’s department of psychiatry in recent trials sponsored by the National Institutes of Drug Abuse (NIDA). In one trial, adding Computer-Based Training for Cognitive Behavioral Therapy (CBT4CBT) to standard methadone-maintenance therapy increased abstinence from cocaine among patients who were addicted to both opioids and cocaine. In the other trial, outpatients who interacted with the Therapeutic Education System (TES) in place of attending some in-person therapy sessions had almost twice the odds of abstaining from all drugs and alcohol in the last four weeks of a 12-week trial period.

Digitized cognitive behavioral therapy shows promise CBT4CBT uses a variety of interactive techniques, games, quizzes and short films. The tools teach patients how to recognize triggers for substance use, cope with drug cravings and counter negative thoughts and challenging situations. For example, each of the CBT4CBT films depicts a character in a high-risk situation for substance use. Alternative endings contrast a negative outcome, such as a relapse to drug use, with a positive one resulting from a skill a patient has just learned. CBT4CBT “trains a person’s skills in cognitive control,” by focusing on decision-making skills, problem-solving, and other cognitive, affective, and behavioral self-control strategies, Dr. Kathleen Carroll, a lead researcher, explains. In the trial, 101 adult outpatients dually addicted to cocaine and opioids received daily methadone-maintenance treatment and weekly group therapy. All the patients also met twice a week with a research assistant who monitored their drug use and collected urine specimens to be tested for cocaine and other drugs. At these visits, roughly half also had access to CBT4CBT on a dedicated computer. The patients who used CBT4CBT were twice as likely as those who did not to achieve three consecutive weeks of abstinence from cocaine use (36 percent versus 17 percent). They also provided a higher percentage of completely drug-free urine samples. The difference in abstinence is an important indicator of how patients may fare in the future, Dr. Carroll says. Follow-up interviews and urine screens disclosed that the patients in the CBT4CBT group reduced their cocaine use more than those in the control group for six months after the end of treatment.

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While therapists may stray from the scripted material, the computer always delivers the same content faithfully.

rewards ranging from $1 to $100 for completing modules and submitting negative urine screens. At the end of the 12-week treatment period, the patients who used TES had a 60 percent higher rate of biologically confirmed abstinence from 10 different substances. Among participants who were still using substances when they entered the study, the TES-based intervention nearly doubled the likelihood of achieving abstinence compared with the controls. “The impact of the TES treatment was greatest among those participants who had a more severe problem,” says Dr. Edward Nunes, who led the study at the New York State Psychiatric Institute, based at Columbia University Medical Center. TES also improved treatment adherence. At the end of the treatment period, almost 50 percent of the participants assigned to receive TES were still participating, whereas that proportion had dropped to about 40 percent among the participants assigned to receive only the treatment-as-usual program. Researchers see the TES intervention as a tool clinicians can prescribe to patients to augment the face-to-face therapy provided by most treatment programs for drug abuse, says Dr. Nunes.

Community reinforcement approach works

The TES program is based on the community reinforcement approach for treating drug addiction, covering a wider range of topics than CBT4CBT. For example, some of its 65 interactive modules, which include short films and self-assessment quizzes, are designed to teach patients relationship and employment skills to enable them to elicit and enjoy social support and reintegrate into their communities. A patient’s homework might simply involve taking their family to a movie and reporting back on the experience. In a multisite trial with 10 outpatient treatment program partners, all of the participants received their particular clinic’s standard outpatient therapy, which was usually group therapy. Half spent all of their therapy time in clinician led sessions, and half substituted working independently with TES for approximately two hours per week of clinician-led sessions. To enhance patients’ motivation, TES provided

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At the same time, clinicians are often better at tailoring content to the particular needs of individual patients. “The strengths of computer delivered therapy and those of the human therapist are complementary, and this synergy benefits the patient,” says Dr. Nunes. At the three- and six-month follow-ups, the TES participants no longer showed significantly higher levels of abstinence than the treatment as-usual group, suggesting the need for providing access to the web-based interventions over longer periods of time, and more emphasis on relapse prevention, says Dr. Nunes. 

Pros and cons of digitized therapies

Researchers have noted that it’s challenging to train clinicians to deliver cognitive behavioral interventions in a consistent manner. While therapists may stray from the scripted material, “the computer always delivers the same content faithfully,” Dr. Nunes says. “ The strengths of computer-delivered therapy and those of the human therapist are complementary, and this synergy benefits the patient. “ - Dr. Edward Nunes, New York State Psychiatric Institute

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Talkin’ ‘Bout My Generation Teens’ use of addictive substances often goes undetected by health care providers. But NIDA-supported

NIDA Researchers Develop Screening Tool for Teen Substance Use This article is a condensed version of a piece that originally appeared on the National Institute on Drug Abuse (NIDA) website.

researchers have developed a Brief Screener for Tobacco, Alcohol and other Drugs (BSTAD), to help spot teens’ problematic habits. In a recent study, BSTAD developers Dr. Sharon Kelly and colleagues at the Friends Research Institute in Baltimore examined the frequencies of use likely to qualify a teen for a diagnosis of an alcohol use disorder (AUD), nicotine use disorder (NUD), or cannabis use disorder (CUD). The frequencies proved to be surprisingly low, according to the researchers.

Teen drug substance use revealed For the study, the BSTAD survey employed a few, simple questions about teens’ use of alcohol, tobacco or drugs within the past year.The teens’ BSTAD responses revealed that 22 percent had used alcohol in the past year, 16 percent had used marijuana, 10 percent had used tobacco, and 3 percent had used at least one illicit substance other

than marijuana. (Original article by Eric Sarlin, M.Ed., M.A., NIDA Notes Contributing Writer) 28

“ Health care providers should have a one-on-one discussion with teens who indicate any substance use to assess level of risk, provide brief advice, and, if necessary, recommend further assessment for a treatment intervention. “

-Dr. Sharon Kelly, Friends Research Institute

Analysis of the data showed that almost all teens who reported on the BSTAD that they had consumed an alcoholic beverage on two or more days during the past year had an AUD. Conversely, teens who reported drinking on fewer than two days were unlikely to have this disorder.The corresponding BSTAD cut point for an NUD was nicotine use on two or more days during the past year and for a CUD was marijuana use on two or more days. BSTAD enables early detection Using these cut points, the researchers found that the BSTAD was highly sensitive. Ninety-six percent of teens with an AUD, 95 percent with an NUD, and 80 percent with a CUD would be flagged as likely in need of further assessment for a brief intervention or referral to treatment. BSTAD’s specificity was also high: 85 percent of teens without an AUD, 97 percent without an NUD, and 93 percent without a CUD reported use below the cut points, and so would be correctly classified. “Very low substance use frequencies were found to be optimal in identifying these disorders,” Dr. Kelly comments. The BSTAD does not distinguish

Researchers encourage regular screening Both the World Health Organization and the American Academy of Pediatrics recommend screening all adolescent patients for substance use since problems later in life often originate in adolescence. Still, many providers do not regularly screen their patients for substance abuse. “Providers are extremely busy and need a quick and valid screening measure for identifying teens who use substances,” says Dr. Kelly. She and colleagues developed the BSTAD in response to a NIDA call for new tools to fill this need. To create the BSTAD, Dr. Kelly and colleagues added the questions about tobacco and marijuana to the widely disseminated National Institute on Alcohol Abuse and Alcoholism screen for youth alcohol use. In the validation study, the FRI research team administered the BSTAD in person to half of the participants, and the rest of the participants self-administered the instrument on an iPad. The teens reported a strong preference for the iPad. The iPad version offers the potential extra convenience that results can be automatically transferred into a teen’s electronic medical record. 

the severities of the disorders, she notes, so when it flags a teen, providers need to follow up with questions to determine appropriate interventions or referrals to treatment. Furthermore, Dr. Kelly says, “Health care providers should have a one-on-one discussion with teens who indicate any substance use to assess level of risk, provide brief advice, and, if necessary, recommend further assessment for a treatment intervention.” Providers also should rescreen teens regularly, because onset of substance use can occur abruptly during adolescence. Pediatrics recommend screening all adolescent patients for substance use since problems later in life often originate in adolescence. Both the World Health Organization and the American Academy of

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Before 1990, women were largely left out of addiction clinical trials. As a result, most treatment programs today are based on research done on men. However, advances in biology research make it clear that substance abuse can affect women in profoundly different ways—meaning they may need different treatment protocols than men

The F F e amct a o le r Research: women need different treatment options than men Unique factors for women The National Institutes on Drug Abuse (NIDA) cites the following unique reasons women claim for using drugs: “controlling weight, fighting exhaustion, coping with pain and self-treating mental health problems.” During or after pregnancy, NIDA finds, women find it particularly difficult to seek help “due to possible legal or social fears and lack of child care while in treatment. Women in treatment often need support for handling the burdens of work, home care, child care and other family responsibilities.” Biological distinctions prove just, if not more, impactful. NIDA research found that women use smaller amounts of certain drugs for less time before becoming addicted. Women have more drug cravings and may be more likely to relapse after treatment, two effects that could be associated with the menstrual cycle. Sex hormone differences can make women more susceptible to the effect of some drugs. Women drug users may experience more physical effects on their heart and blood vessels, may experience different brain changes than men and are more likely to go the emergency room or die from an overdose of certain substances. Women who are victims of domestic violence are at a higher risk to use substances.

Faster track to dependence Research done by Harvard Medical School for a 2010 study found women develop alcohol dependence more quickly and that physical effects of alcohol abuse, like brain atrophy and liver damage, occur more rapidly in women. This is because women typically weigh less, contain less pound-for-pound water in their bodies, have more fatty tissue and have lower levels of two enzymes that break alcohol down in the stomach and liver. The reason more fatty tissue and less water matter: fat retains alcohol while water dilutes it, compounding alcohol’s effect in women relative to men. “Telescoping” is a term researchers use to describe an accelerated progression from substance use to dependence. According to a 2004 study by the Alcohol Research Center at the University of Connecticut, women have accelerated addiction progression for alcohol, cannabis and opioids. “Thus,” write Harvard Medical School researchers, “when women enter substance abuse treatment they typically present with a more severe clinical profile (e.g., more medical, behavioral, psychological, and social problems) than men, despite having used less of the substance and having used the substance for a shorter period of time compared with men.”

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Gaps in research persist Outdated societal forces that deemed substance use unfit for a woman also barred women from clinical studies. Basing traditional treatment approaches on research done solely on men, coupled with antiquated social norms of who engages in substance use, led researchers to believe in a wider margin in substance use between the sexes then there might actually be. Take alcohol, the most commonly abused substance in the U.S. A 2010 Harvard Medical School study reports that 7 to 12 percent of women and 20 percent of men abuse alcohol. However, since the 1970’s, the publication attests, the “gender gap has been narrowing, as drinking by women has become more socially acceptable.” Though progress has been made, gaps in research on women’s substance abuse persist. Marijuana use, the Harvard study claims, is an example of one of the many remaining blind spots in women’s addiction research. Little is known outside of findings that men are three times as likely to report daily use as women. More work to be done Social disapproval of women using substances has waned, but women still face unique difficulties and barriers when they seek treatment. New technical breakthroughs, more female doctors and women’s greater equality in biomedical research are not enough to adequately address women’s health needs, experts say. “Even though much has been achieved in addressing issues important to women’s health, critics call for continued innovation in medical theories and practices,” says Stanford University history of science “When women enter substance abuse treatment they typically present with a more severe clinical profile than men, despite having used less of the substance and having used the substance for a shorter period of time compared with men.” -Harvard Medical School researchers

Though progress has been made, gaps in research on women’s substance abuse persist. professor Londa Schiebinger. “In order to translate recent advances in our understanding of the molecular and physiological bases of sex differences into new therapeutics and health practices, sound, sex-specific clinical data are imperative.” 

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OPPORTUNITIES & CHALLENGES for the Alcohol Field e HEALTH for your

Digital health technologies work best in conjunction with traditional methods, including human support, particularly for people with more severe alcohol use problems.

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With data from eHealth devices, researchers and clinicians eventually will be able to predict risky behavior and supply interventions when they can be most effective.

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follow-up and “just-in-time” interventions for patients who have left residential treatment programs or who are trying to remain sober between treatment center visits. However, much research still is needed to develop protocols that are more effective and dynamic enough to retain users over the long term.

This rapidly developing area already is improving the quality of the data researchers and clinicians collect from patients and research subjects by gathering information in real time. Mobile and digital SBIs and treatment protocols also could potentially reach millions of people with AUD who now go untreated, offering

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