Thanks for reading the June edition of TIPS and TOPICS. Welcome
to all the new readers who signed up this month.
Tips:
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
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.
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.
Tips:
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 Why This Generation?
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
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
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.
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.
"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
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.
Have a relaxing time--I will.
David