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TIPS & TOPICS from David Mee-Lee, M.D.
Volume 3, No.3
June 2005
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In this issue
-- SAVVY
-- SKILLS
-- SOUL
-- STUMP THE SHRINK
-- SHAMELESS SELLING
-- Until Next Time

Thanks for reading the June edition of TIPS and TOPICS. Welcome to all the new readers who signed up this month.
SAVVY
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 This past week, I was on three different university campuses in three days. It was fun to be in an environment where young people are just starting out on their career path. In preparation for those presentations, I gained a heightened awareness of some disturbing statistics and issues. This month's SAVVY looks behind the often-seen headlines about a college student who died downing 21 drinks on his twenty-first birthday.

Tips:

  • As distressing as the deaths of young men and women soldiers in Iraq is, as many US college students died from alcohol related accidents in one year as have soldiers died in the whole Iraq war since its beginning.

The stigma of alcohol and other drug problems still exists. It continues to suffer from the Rodney Dangerfield syndrome of "I don't get no respect". Imagine newspaper headlines reporting the death of 4 or 5 college students every day of the year from alcohol-related accidents. And then noting that these deaths are equally present in even the prestigious Ivy League universities as well. There would hopefully be a public outcry rivaling the peace marches and demands for an Iraq exit strategy.

--> The number of unintentional, alcohol-related deaths among US college students rose significantly from 1998 to 2001, prompting researchers to call for expanded screening and treatment for college students with alcohol problems.
--> The number of college students aged 18 to 24 who died accidentally with alcohol as a contributing factor rose from 1,575 in 1998 to 1,717 in 2001.
--> In both 1998 and 2001, more than 500,000 college students were unintentionally injured due to drinking, and 600,000 were assaulted by another student who was drinking.

And it isn't just college students:
--> The number of 18 to 24 year olds who are not college students and died due to alcohol- related, unintentional injury was 5,367 in 2001.

Bottom Line: Our biggest, most deadly drug problems are not methamphetamine, heroin or cocaine, but the legal and most prevalent drugs: alcohol and nicotine.

References:
("Magnitude of Alcohol-Related Mortality and Morbidity Among U.S. College Students Ages 18-24: Changes from 1998 to 2001" in 2005 edition of Annual Review of Public Health. )

  • A significant number of students are seeking better living (and better results) through chemistry - and I don't mean doing their course laboratory work.

A study at a Midwestern university investigated illicit use of stimulant medications:

--> The authors surveyed 179 men and 202 women.
17% of the men and 11% of the women reported illicit use of prescribed stimulant medication.
-->44% of surveyed students stated that they knew students who used stimulant medication illicitly for both academic and recreational reasons.
--> Students reported they experienced time pressures associated with college life. They said that stimulants increased alertness and energy.

In a national survey on prescription stimulant use among US college students (stimulants like Ritalin, Dexedrine or Adderall), here are some findings:

Prevalence rates among US college students
Life-time prevalence was 6.9%
Past year prevalence was 4.1%
Past month prevalence was 2.1%

Past year rates
Past year rates of non-medical use ranged from 0% to 25% at individual colleges.

Profile of Users
Non-medical use was higher among college students who were male, white, members of fraternities and sororities and earned lower grade point averages.

Regional Rates
These were higher at colleges located in the Northeastern region of the US plus colleges with more competitive admission standards.

Other Behaviors of Users
Non-medical prescription stimulant users were more likely to report use of alcohol, cigarettes, marijuana, ecstasy, cocaine and other risky behaviors.

Bottom Line:
While there certainly are people whose functioning is compromised by untreated adult Attention Deficit Hyperactivity Disorder (ADHD), not every student who wants stimulants is seeking relief from a lifelong ailment. It may just be seeking a boost for a short-term examination.

Reference:
Hall KM, Irwin MM, Bowman KA, Frankenberger W, Jewett DC (2005): "Illicit use of prescribed stimulant medication among college students." J Am Coll Health. Jan-Feb;53(4):167-74. Human Development Center, University of Wisconsin- Eau Claire, 54702, USA.

McCabe SE, Knight JR, Teter CJ, Wechsler H. (2005): "Non-medical use of prescription stimulants among US college students: prevalence and correlates from a national survey. Addiction. Jan;100 (1):96-106.

  • Heavy episodic drinking and alcohol use disorders are youth phenomena as well as college phenomena. Prevention campaigns targeted at all youth are needed to supplement interventions conducted at the campus level.

The 2001-02 National Epidemiologic Survey on Alcohol and Related Conditions (N = 43,093)
A sub sample of U.S. adults 18-29 years of age (N = 8666; 4849 female) was interviewed.

Objective of Study
To estimate rates of heavy episodic drinking, alcohol abuse and alcohol dependence among U.S. adults 18- 29 years of age plus--
To determine the relationship of these rates to student status and place of residence.

Results:
Of all adults 18-29 years of age
73.1% reported any drinking in the past year
39.6% reported any heavy episodic drinking
21.1% reported heavy drinking more than once a month
11.0% reported heavy drinking more than once a week.

Past-year drinkers
Rates of 54.3% for any heavy episodic drinking
28.9% for heavy drinking more than once a month
15.0% for heavy drinking more than once a week.

Rates of heavy episodic drinking
Rates were slightly higher for college students than for noncollege students (p < .01). Differences between the 2 groups related more to their place of residence than their student status- whether a college student or non-college student.

Diagnostic Criteria
Overall, 7.0% of adults ages 18-29 met the DSM-IV criteria for alcohol abuse in the past year.
9.2% met the criteria for alcohol dependence.

Highest abuse
The prevalence of abuse was highest among students living off campus (p < .01).

Highest Dependence
Rates of dependence were highest among students living on campus (p < .01).

Bottom Line:
Alcohol and other substance use disorders are equal-opportunity illnesses to be screened for, prevented and intervened with in all general and behavioral healthcare populations.

Reference:
Dawson DA, Grant BF, Stinson FS, Chou PS. (2004): "Another look at heavy episodic drinking and alcohol use disorders among college and noncollege youth." J Stud Alcohol. 2004 Jul;65(4):477-88.


SKILLS
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 As I was reviewing these studies, it occurred to me that all 3 of my children are in this exact age population. My oldest daughter is 24; my son just turned 21 and is now "legal"; and my youngest daughter is 19 having just completed her first year of college. All 3 have been part of that 73.1% who reported any drinking in the past year.

So for a little light summer reading (at least for our northern hemispheric readers), here are some observations, perhaps clinical applications, you can make from the current experiences and challenges facing our 19 to 24 year old cohort.

Tips:

  • The 20's early life crisis is as real as midlife crises.

Only recently have I become aware of what has been coined "quarterlife" crisis. I am always a little skeptical about new terms and phenomena, wondering if it is a marketing ploy. Observing my daughter's wrestling with life questions, relationships, career choices, decision-making of all sorts - and witnessing how engrossing it is- convinces me that there is more to this than a fad.

As you deal with twentysomethings in your clinical practice and/or family, here is some of what I found on the internet:

Turbulent 20s
Dr. Drew Pinsky, former co-host of MTV's Loveline has been a trusted source of information and advice for millions of young adults over the last 18 years. Dr. Drew says he is seeing an alarming number of young adults who seem "anchorless" and disconnected.

This has been a problem for a long time. 18 to 22 is always considered one of the most difficult life transitions, and now the heat is up on this transition both by virtue of the disconnect and the expectations.

"Disconnected is the code word for this generation." - Oprah Winfrey

Why This Generation?
Alexandra Robbins and Abby Wilner, authors of Quarterlife Crisis say young adults are facing an epidemic of indecision, self-doubt and devastating pressure. They discuss the differentiation between a quarterlife crisis and a midlife crisis.

This group leaves college full of dreams and high hopes. Instead of finding fulfillment, this generation is telling us they feel lost. Many twentysomethings are burning out, melting down and losing hope.

From the Book
"We've all heard of adolescent angst and the midlife crisis - but no one really talks about the challenges of the period in between. Though these are supposed to be among the best years of our lives, the truth is that being a twentysomething in the "real world" isn't easy. Twentysomethings face an overwhelming number of choices regarding careers, finances, living situations, and relationships. This period is, in fact, a whirlwind of new responsibilities and freedoms that can make young people feel helpless, indecisive, and panicked.

Quarterlife Crisis is the first book to name and document this phenomenon. It includes the personal stories of more than 100 twentysomethings who describe their struggles to:
-->figure out a direction
-->carve out a personal identity
-->resolve self-doubts
-->cope with decision making
-->balance the many demanding aspects of personal and professional life

This book offers guidance and comfort to recent - and not-so-recent - graduates, and helps families, friends, colleagues, and advisors understand the nature of an often dizzying period. With its wealth of information and startlingly candid anecdotes, Quarterlife Crisis compellingly addresses the most difficult questions facing twentysomethings today."

Resources Book:
Quarterlife Crisis: The Unique Challenges of Life in Your Twenties by Alexandra Robbins & Abby Wilner: www.quarterlifecrisis.

Web site: Visit Dr. Drew's web site at www.drdrew.com.
From the show: Turbulent Twenties

  • Balance limit-setting, incentives, success experiences, responsibility and accountability.
When my then 18 year-old daughter, Mackenzie, went off to college last year in Santa Barbara, CA, we had visions (or maybe nightmares) of an historically party-school overwhelming a newly "free" college student. Would we see poor grades, risky behavior? And all funded by my hard earned dollars! Whether involved with emancipating adolescents in your family or clinical work, the dilemmas are the same:

-->How do you set limits and expectations without rigid controls that stunt the exercise of responsibility and accountability?
E.G. We did not want to have such tight control over her money that she would not learn how to budget. We wanted her to "benefit" from mistakes of running out of money after an impulsive spending spree. We also did not want to provide such ready access to funds that she could spend freely with "daddy's" credit card.

-->How does one create incentives and opportunities for success experiences which still challenge the young person to stretch, grow and push the limits of their abilities?
E.G. We did not want to expect a Grade Point Average (GPA) so high that she would feel hopeless, and not experience the joy of doing well in school. But we also did not want to expect a GPA so low that she could reach that goal with minimal preparation, study and discipline.

The Agreement
I was happy to support her college freshman experience so long as she found a successful balance between work and play. After researching a reasonable GPA to expect together with the appropriate amount of extracurricular activities to complement rigorous, but not ridiculous, amounts of study, we set out the conditions.

We would pay for everything each semester so long as she maintained a certain GPA and either played soccer for the school team or worked a part-time job. For every point above the minimum GPA, there would be a $100 bonus. If she fell below these conditions, then for that semester, she would initiate a college debt. She would need to repay all tuition and living costs for that period of her time at school.

It was with some trepidation that we set those conditions. I wondered if we were being too rigid, not understanding enough of transitions into college life. Her two older siblings who had been there, done that, reassured me we were being reasonable, given the easy distractions of college freshman year. The focus and structure would be good for her.

The Results
First semester had her exceeding her GPA goal and receiving a bonus, as well as contributing significantly to the school soccer team. Second semester she exceeded her GPA goal by three points and gained $300 She gained much self-esteem plus positive feedback from a part-time job. In addition, she noticed a few lessons she had learned in the process:

--> By having certain expectations for success, she studied more consistently than previously in high school where we did not structure her as much.
-->The study and discipline paid off in better grades. This in turn gave her confidence that she may be smarter than she used to think. She also experienced the sweet taste of success.
-->Knowing she had certain goals for school and other work, she found herself structuring her time more efficiently than her roommates. They frequently slouched on the couch glued to TV for hours. Not one of them came close to her GPA, even though they theoretically had much more time to study.
-->Even with the structure and expectations, she still found plenty of time to play since she budgeted her time and resources more carefully now.

Bottom Line:
Finding that right balance between limits, incentives, autonomy, responsibility, accountability and creating success experiences is a challenge. But collaboratively constructing the conditions can open up opportunities for reaping the rewards of self discipline, self esteem and success.


SOUL
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 My apologies to readers who don't have children. It can be a pain in the neck to hear people talking about their kids all the time, and showing you photos you really don't want to see---sort of like someone wanting to show you their surgical scars. But since May-June had both Mothers' Day and Fathers' Day (in Australia, Fathers' Day is in September), kids are on my mind.

When my son was younger and at various stages into baseball, soccer and throwing a football, I felt somewhat inadequate. I grew up in Australia where those weren't the sports of the day. Not being a sports jock anyway (unless you include tennis and table tennis) I was not the ideal dad who could coach the Little League or soccer team, or throw an impressive, arcing, spiraling football. I know my son would have liked that. I was good at watching games and cheering him on. But table tennis was the only game I could have been competitive with the other dads---and that doesn't compare with the soccer, baseball and football dads!

I'm sure all concerned parents wonder how good their past and present parenting really is. So when my son, who is doing his junior year of college at the University of Bologna, Italy, e-mailed an artfully crafted electronic Fathers' Day card, it touched my heart---especially around this sensitive part about sports-dads. Here's a part of what he said:

"You have always been there for me in my life, no matter where you were, what time it was, or how difficult my situation. That type of love means more to me than any amount of financial support, coaching of a little league team, or throwing a football. I have learned from you that being a good father is so much more than signing checks---Thank you so much for supporting my travels, my music, and always being there when I need you. I love you, Taylor"

My point in sharing this slice of my family life is the old and often-said advice to be yourself. Looking back on those sports days with my son, I could have inflicted less stress on myself had I remembered that more. No one has it all. But what we do have, and who we are, shines through if untarnished by self-doubt, "shoulds and "oughts" and "if onlys". I'm gratified that apparently, despite myself, my son experienced, and saw that light shining through even though I didn't coach the team.

P.S. If you would like to "meet" my son, you can log onto his developing website and listen to some of his songs at www.taylormeelee.com.


STUMP THE SHRINK
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 Here is a question to do with Dimension 6, Recovery Environment in the Revised Second Edition of the ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, ASAM PPC-2R, published in April, 2001.

"Our staff has been struggling with how to interpret Dimension 6 issues as illustrated below.

I'm meeting with a 40-year old, married, father of two with two previous treatment episodes and a history of involvement with AA who is requesting admission to our outpatient treatment program, having been unable (for a third time) to keep the abstinence commitment he made to his wife. His wife (ACOA - Adult Child of an Alcoholic) has been to some counseling and is willing to attend our family group and to attend Al-Anon. His employer (where he is in generally good standing) appears supportive of his goals. He has a strong connection to a local church where he serves on several committees and sings in the choir. He has two (particular) friends from previous treatments/AA with whom he has regular contact.

Here's our Level of Care placement dilemma:

His environments are not dangerous and appear supportive of his recovery goals. (Suggesting Level I, Outpatient Services) He's continued to (be able to) drink despite the existence of this support system. (Suggesting a more intensive intervention)

What are your thoughts on:
a) how to interpret the situation; and
b) where to record that interpretation in our six- dimensional summary?

Thanks for any thoughts you might have."

Michael R. Hollen MA, CADCIII
Coordinator
PSV OP Chemical Dependency Services
Portland, OR
503-216-2747

The Answer:
Michael:
You are correct there are some good Dimension 6 supports, and that Level I would be appropriate for any Dimension 6 services needed. When it comes to what service intensity and level of care needed for Dimension 5 relapse issues, it depends on the assessment of why he can't remain sober.

I'd recommend you look at Appendix C in ASAM PPC- 2R (2001) to look at more specific assessment of his Dimension 5, and then see what services and strategies would assist him. If those services/strategies can safely be tried in OP, then that is where to do it. If not, then the treatment would need to be in a more intensive level of care.

For example--
If he continues to drink because he has poor skills to deal with cravings and/or negative affects, that may respond to an educational and coping skills group and an individual session that can be tried in OP. If he keeps using despite increased OP sessions and daily AA attendance and active participation with sponsors and reaching out to people for whom he has many names and numbers, then he may need more structure as in Intensive OP or day treatment. If he continues to use because of continued ambivalence about how severe a problem he has (Dimension 4, Readiness to Change issues), then OP motivational work might be needed with family sessions with wife to clarify what her level of frustration is, and how firm are any limits she may set.

In other words, you can't think about level of care until you know clearly what is behind the continued use; and what strategies might work; and what dose and intensity of those services are needed. That will tell you where the treatment plan can be safely and efficiently provided.

Come back at me if this doesn't make sense.
David


SHAMELESS SELLING

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 New! ASAM PPC-2R Assessment System

The new ASAM PPC-2R Assessment Software complements the ASAM PPC-2R text. The software directs the clinician in a structured interview process, stages clinical severity according to the ASAM six dimensions and suggests levels of care. Once you conduct a structured assessment and upload the information via the internet, you receive back an immediate ASAM multidimensional severity profile and level of care recommendation, which you can override if necessary using your clinical judgment.

If your managed care company agreed to receive the same information at the same time, they could authorize admission in almost real time if they agreed with the assessment and recommendation. The software is based on the Adult Criteria of ASAM PPC- 2R.

You can download the Assessment Software and try it free for three months by going to www.ppcassessment.com/portal.

This website will increasingly become THE major website for information on all things to do with the ASAM Patient Placement Criteria. This new software was based on ten years of research under the leadership of David Gastfriend, M.D. recently Director, Addiction Research Program, Massachusetts General Hospital, Boston, MA.


Until Next Time
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 Because we will be on vacation for half the month of July, I will continue our tradition of combining two of the summer month editions of TIPS and TOPICS. The next edition will be a combined July/August edition to arrive in early August. If you get lonely in July, you could always look at reruns on the homepage of www.dmlmd.com and click on Back Issues!

Have a relaxing time--I will.
David


Contact Information
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phone: 530-753-4300
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