Turning on Dormant Gene May Hold Key for Correcting a Neurodevelopmental Defect

Finding Shows Therapeutic Potential of Small-Molecule Targeting Strategy

Scientists working in cell culture and in mice have been able to correct the loss of gene activity underlying a rare but severe developmental disorder by turning on a gene that is normally silenced in brain cells. Further testing of the identified compound that activates the gene will determine whether it has potential as a genetically-based treatment for the disorder, Angelman syndrome.

Background

Infants with Angelman syndrome appear normal at birth, but show developmental delays by 6 to 12 months. Features of the disorder include impaired speech, seizures, hyperactivity, and motor difficulties. No effective treatment exists CADC I & II Continuing Education

In the late 1990s, researchers found that the disorder results from changes or deletions in the maternal gene for the enzyme ubiquitin protein ligase E3A (Ube3a). Most genes are inherited in sets of two, one from the mother and one from the father. In some cases, either the maternal or paternal gene is silenced, or prevented from being translated into protein. This normal silencing based on inheritance from a mother or father is called imprinting. The Ube3a gene is an example of genetic imprinting, as the paternal gene is normally silenced in neurons. With the maternal gene out of action, infants with Angelman syndrome lack the enzyme, leading to changes in the brain that underlie the symptoms of the disorder.

This Study

This research is reported online in the journal Nature, and was carried out by scientists at the University of North Carolina School of Medicine at Chapel Hill, led by the labs of Ben Philpot, Bryan Roth, and Mark Zylka. In an effort to restore the absent Ube3a enzyme in neurons, the research team screened thousands of compounds for their ability to “wake up” the paternal Ube3a gene. The investigators used neurons from genetically engineered mice to test whether compounds could activate the gene; the neurons fluoresce if the paternal Ube3a gene is expressed, or translated into protein. The team screened 2,306 candidate small molecules from multiple molecular libraries. If fluorescence was detected, that meant that the test compound activated the Ube3a gene. The screening and access to the molecular libraries was made possible through NIMH’s Psychoactive Drug Screening Program, funded by contract to perform pharmacological and functional screening of novel compounds. Bryan Roth at UNC Chapel Hill is the project director and a coauthor of the Nature paper.

The investigators found that a class of compounds—topoisomerase inhibitors—could unsilence the paternal gene. They chose one, topotecan, and tested it to see whether it could do the same thing in vivo in a mouse. They administered topotecan directly into the brain and later into spinal fluid; in both cases it was able to activate paternal Ube3a. Activation persisted for 12 weeks after delivery of the compound had stopped.

Significance

"This is the first time anyone has used a small molecule to successfully target activation of a disease-relevant gene," said senior author Benjamin Philpot. "The work demonstrates that turning on a dormant gene could represent a therapeutic intervention for Angelman syndrome."

NIMH helped to fund this project and has issued a grant to the UNC team to continue studies of topotecan, initially in mice. Although topotecan is already in use in both children and adults as a cancer chemotherapeutic agent, further testing is essential to determine the dosage of the agent that would be needed to be effective, the best means of administering the medication, and whether side-effects at the necessary dosage level are within a range that make it feasible to use. The authors emphasize that much work remains before this or related agents can or should be used for treatment of this condition.

Reference

Huang, H.-S., Allen, J., Mabb, A., King, I., Miriyala, J., Taylor-Blake, B., Sciaky, N., Dutton, J. Jr., Lee, H.M., Chen, X., Jin, J. Bridges, A., Zylka, M., Roth, B., Philpot, B. Topoisomerase inhibitors unsilence the dormant allele of Ube3a in neurons. Nature. Published online ahead of print December 21, 2011, doi: 10.1038/nature10726.


This image shows Ube3a staining in a neurotypical mouse brain and its absence in the Angelman syndrome model mouse brain.

Source: Ben Philpot, Ph.D., University of North Carolina School of Medicine

Holiday Drinking Can Kill, Experts Warn

Drunk-driving accidents, heart problems, home injuries are preventable, say U.S. emergency doctors.

WEDNESDAY, Nov. 24 (HealthDay News) -- Excessive alcohol consumption -- a common problem during the holiday season -- can lead to serious injury and death, warns the American College of Emergency Physicians (ACEP).
The group urges people to use good judgment when they get together with family and friends.
"Very few things are more heartbreaking than to see a family suffer the loss of a loved one because of an alcohol-related tragedy, and during the holidays, people take risks. A fun holiday celebration can turn into a nightmare in the blink of an eye, and it can happen to anyone, and we don't want that to happen," Dr. Sandra Schneider, ACEP president, said in a society news release.
Each year in the United States, 79,000 deaths and many more injuries occur as a direct result of excessive alcohol consumption, according to the U.S. Centers for Disease Control and Prevention.
"Alcohol-related injuries are not always driving-related incidents like some may assume. Emergency physicians have treated patients who have been seriously injured while decorating a home for the holidays," Schneider said.
These injuries can occur from falls while stringing lights on roofs, climbing ladders and using power tools incorrectly because of intoxication.
"These activities are dangerous under any circumstances. When you add alcohol to the mix, all of a sudden cognitive skills are lessened, personal judgments change, and your ability to think coherently is decreased," Schneider said. Heavy drinking at this time of year can also cause "holiday heart syndrome," which is an irregular heartbeat in otherwise healthy people. But the major concern during the holidays, and throughout the year, is drunk driving. "Drunk driving is 100 percent preventable. Don't get behind the wheel of a car if you've had too much to drink. You are not only a danger to yourself, but also to everyone else on the road," Schneider said. Alcoholism and Substance Abuse Dependency CEU Continuing Education
More information
The U.S. Centers for Disease Control and Prevention has more about alcohol and public health.

(SOURCE: American College of Emergency Physicians, news release, Nov. 9, 2010)

A Snapshot of Annual High-Risk College Drinking Consequences

A Snapshot of Annual High-Risk College Drinking Consequences
The consequences of excessive and underage drinking affect virtually all college campuses, college communities, and college students, whether they choose to drink or not.

•Death: 1,825 college students between the ages of 18 and 24 die from alcohol-related unintentional injuries, including motor vehicle crashes (Hingson et al., 2009).


•Injury: 599,000 students between the ages of 18 and 24 are unintentionally injured under the influence of alcohol (Hingson et al., 2009).


•Assault: 696,000 students between the ages of 18 and 24 are assaulted by another student who has been drinking (Hingson et al., 2009).


•Sexual Abuse: 97,000 students between the ages of 18 and 24 are victims of alcohol-related sexual assault or date rape (Hingson et al., 2009).


•Unsafe Sex: 400,000 students between the ages of 18 and 24 had unprotected sex and more than 100,000 students between the ages of 18 and 24 report having been too intoxicated to know if they consented to having sex (Hingson et al., 2002).


•Academic Problems: About 25 percent of college students report academic consequences of their drinking including missing class, falling behind, doing poorly on exams or papers, and receiving lower grades overall (Engs et al., 1996; Presley et al., 1996a, 1996b; Wechsler et al., 2002).


•Health Problems/Suicide Attempts: More than 150,000 students develop an alcohol-related health problem (Hingson et al., 2002), and between 1.2 and 1.5 percent of students indicate that they tried to commit suicide within the past year due to drinking or drug use (Presley et al., 1998).


•Drunk Driving: 3,360,000 students between the ages of 18 and 24 drive under the influence of alcohol (Hingson et al., 2009).


•Vandalism: About 11 percent of college student drinkers report that they have damaged property while under the influence of alcohol (Wechsler et al., 2002).


•Property Damage: More than 25 percent of administrators from schools with relatively low drinking levels and over 50 percent from schools with high drinking levels say their campuses have a "moderate" or "major" problem with alcohol-related property damage (Wechsler et al., 1995).


•Police Involvement: About 5 percent of 4-year college students are involved with the police or campus security as a result of their drinking (Wechsler et al., 2002), and 110,000 students between the ages of 18 and 24 are arrested for an alcohol-related violation such as public drunkenness or driving under the influence (Hingson et al., 2002).


•Alcohol Abuse and Dependence: 31 percent of college students met criteria for a diagnosis of alcohol abuse and 6 percent for a diagnosis of alcohol dependence in the past 12 months, according to questionnaire-based self-reports about their drinking (Knight et al., 2002). Alcoholism and Substance Abuse Dependency CEU Course
MFT CE Requirements
Last reviewed: 7/1/2010


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Silence Hurts. Alcohol Abuse and Violence Against Women

Silence Hurts
Alcohol Abuse and Violence Against Women
Formal Specialized Treatment
For some adults, pretreatment approaches may prove quite effective. This is especially true for late-onset drinkers and prescription drug abusers with strong social support and no mental health comorbidities. Followup brief interventions and empathic support for positive change may be sufficient for continued recovery. There is, however, a subpopulation who will need more intensive treatment.

Despite the resistance that some problem drinkers or drug abusers exert, treatment is worth pursuing.In determining a formal course of treatment, some important considerations include:

•Whether adequate efforts have been made to help the client to reduce alcohol use to safe levels
•Whether abstention or harm reduction is the goal of treatment
•The attitudes of staff and philosophy of the program
•The availability of required modes of treatment (e.g., detoxification, inpatient, intensive outpatient, outpatient)
•The availability of aftercare or continued involvement
Types of treatment include:

•Cognitive-behavioral approaches
•Group-based approaches
•Individual counseling
•Case management, community-linked services, and outreach
Not every approach will be necessary for every client. Instead, the program leaders can individualize treatment by choosing from this menu to meet the needs of the particular client. Planning information comes from:

•Interviews
•Mental status examinations
•Physical examinations
•Laboratory, radiological, and psychometric tests
•Social network assessments
•Other sources (see Module 7 for more on assessments)
Cognitive-Behavioral Approaches
As a prelude to cognitive-behavioral therapy, a therapist might use motivational counseling. This is a more intense process than the motivational interviewing that may take place during a brief intervention. Motivational counseling acknowledges differences in readiness to change and offers an approach for "meeting people where they are."

Motivational counseling has proven effective with adults.1 An understanding and supportive counselor:

•Listens respectfully and accepts theadult's perspective on the situation as a starting point
•Helps the individual identify the negative consequences of drinking
•Helps the person shift perceptions about the impact of drinking or drug-taking habits
•Empowers the individual to generate insights about and solutions for his or her problem
•Expresses belief in and support for the adult's capacity for change
Motivational counseling is an intensive process that enlists patients in their own recovery by:

•Avoiding labels
•Avoiding confrontation (which usually results in greater defensiveness)
•Accepting ambivalence about the need to change as normal
•Inviting clients to consider alternative ways of solving problems
•Placing the responsibility for change on the client
This process also can help offset the denial, resentment, and shame invoked during an intervention.2 It falls somewhere between brief interventions and pretreatment interventions.

Types of Cognitive-Behavioral Approaches
There are three broad categories of cognitive-behavioral approaches: behavior modification/therapy, self-management techniques, and cognitive-behavioral therapies. Behavior modification applies learning and conditioning principles to modifying overt behaviors, which are those behaviors obvious to everyone around the client.3,4 Self-management refers to teaching the client to modify his or her overt behaviors as well as internal or covert patterns. Cognitive-behavioral therapy involves altering covert patterns or behaviors that only the client can observe.

Cognitive-behavioral techniques teach clients to identify and modify self-defeating thoughts and beliefs.5,6 This is intended to improve mood and reduce the probability of drinking as a method of coping, especially in the face of relapse pressures. These pressures include negative emotional states, such as depression, anger, and frustration; peer pressure; and interpersonal conflicts with spouse, family, a boss, and others.

The Drinking Behavior Chain
The cognitive-behavioral model offers an especially powerful method for targeting problems or treatment objectives that affect drinking behavior. Together, provider and client analyze the behavior itself, constructing a "drinking behavior chain." The chain is composed of:

•The antecedent situations, thoughts, feelings, drinking cues, and urges that precede and initiate alcohol or drug use
•The drinking or substance-abusing behavior (e.g., pattern, style)
•The positive and negative consequences of use for a given individual
When exploring the latter, it is particularly important to note the positive consequences of use: those that maintain abusive behavior. Cognitive-behavioral therapy is ideally suited to individuals who are slow to learn because of residual impairment of cognitive functioning. This is because this method breaks down information into small manageable units and repeats them until understanding is ensured.

Researchers have developed an instrument that can elicit by interview the individual's drinking or drug use behavior chain.7 Immediate antecedents to drinking include feelings such as anger, frustration, tension, anxiety, loneliness, boredom, sadness, and depression. Circumstances and high-risk situations triggering these feelings include marital or family conflict, physical distress, and unsafe housing arrangements, among others.Alcohol use is often a form of "self-medication, a means to soften the impact of unwanted change and feelings.

For the patient, new knowledge of his or her drinking chain often clarifies for the first time the relationship between thoughts and feelings and drinking behavior. This method provides insight into individual problems, demonstrates the links between psychosocial and health problems and drinking, and provides the data for a rational treatment plan and an explicit individualized prevention strategy.

Breaking drinking behavior into the links of a drinking chain serves treatment in other ways, too. It suggests elements of the community service network that may be helpful in establishing an integrated case management plan to resolve antecedent conditions (e.g., housing, financial, medical problems). Involvement from the community may be needed beyond the treatment program (see Case Management section).

Behavioral Treatment in Group Settings
Behavioral treatment can be used withadults individually or in groups, with the group process particularly suited towomen with abuse and addiction issues(see Group-Based Approaches). Equipped with the knowledge of the individual's drinking or drug abuse behavior chain, the group leader:

•Begins to teach the client the skills necessary to cope with high-risk thoughts or feelings
•Teaches theperson to initiate alternative behaviors to drinking, then reinforces such attempts
•Demonstrates through role-playing alternative ways to manage high-risk situations, permitting the client to select coping behaviors thatshe feels willing and able to acquire
•Asks for feedback from the group and uses that feedback to work gradually toward a workable behavioral response specific to the individual
The behaviors are rehearsed within the treatment program until a level of skill is acquired. The patient is then asked to try out the behaviors in the real world as "homework." For example, a client who has been practicing ways to overcome loneliness or social isolation may receive a community-based assignment in which to carry out the suggested behaviors.

After practicing, the individual reports to the group. Then the therapist and group members provide feedback and reinforce the individual's attempt at self-management (whether or not the outcome was a success). This process continues until the individual develops coping skills and brings the antecedents for abuse under self-control or self-management. Typically, as patients learn to manage the conditions (thoughts, feelings, situations, cues, urges) that prompt alcohol abuse, abstinence can be maintained.

Posttreatment Issues
Defining drinking behavior antecedents is also useful for determining when a client is ready for discharge. When the individual can successfully use coping behaviors specific to his or her drinking antecedents, the treatment team might assist the person in gradually phasing out of the program. Discharge that takes place before the client has acquired specific coping behaviors is almost certain to result in relapse, probably very soon after discharge.

Studies comparing early- and late-onsetproblem drinkers showed great similarity between these two groups' antecedents to drinking and treatment outcomes.8 Another study described a behavioral regimen that included psychoeducation, self-management skills training, and marital therapy. Studies recommend that treatment focus on:

•Teaching skills necessary for rebuilding the social support network
•Self-management approaches for overcoming depression, grief, or loneliness
•General problem solving9

Group-Based Approaches
Group experiences are particularly helpful to women in treatment. They provide the arena for:

•Giving and sharing information
•Practicing skills, both new and long-unused
•Testing the clients' perceptions against reality
Perhaps the most beneficial aspect of groups for older adults is the opportunity to learn self-acceptance through accepting others and in return being accepted. Guilt and forgiveness are often best dealt with in groups, where people realize that others have gone through the same struggles.

Special groups may also deal with the particular problems of aging. The group format can help patients learn skills for coping with many of the life changes that can put one at risk for substance abuse, including:

•Bereavement and sadness
•Loss of friends, family members, social status, occupation and sense of professional identity, hopes for the future, ability to function
•Social isolation and loneliness
•Reduced self-regard or self-esteem
•Family conflict and estrangement
•Problems in managing leisure time/boredom
•Loss of physical attractiveness (especially important for women)
•Physical distress
•Insomnia
•Sensory deficits
•Reduced mobility
•Cognitive impairment and change
•Impaired self-care
•Reduced coping skills
•Decreased economic security or new poverty status
•Dislocation
Therapy Groups
Therapy groups can be effective ways to provide peer support, particularly if AA meetings are not accessible. They focus on building new social and coping skills. They also encourage connections with peers or others, adding to the social network. Social contacts outside of formal meetings are usually encouraged.

Some therapy groups engage in behavioral interaction, others in more psychodynamic therapy. Both types of groups allow clients to test the accuracy of their interpretations of social interactions, measure the appropriateness of their responses to others, and learn and practice more appropriate responses. Groups provide each client with feedback, suggestions for alternative responses, and support as the individual tries out and practices different actions and responses.

Some people may need help in entering the group, particularly if they are used to isolation. This help could include individual counseling sessions in which the counselor explains how a group works. The counselor could also answer the client's questions about confidentiality.

The client's entry into the group may be eased by joining in stages, at first observing, then over time moving into the circle. The counselor may formally introduce the new person to the members of the group so that upon entering the group, he or she is at least somewhat familiar with them.

Older adults grew up before psychological terms had been integrated into everyday language. Therefore, therapy groups for older adults should avoid the use of jargon, acronyms, and "psychspeak." If leaders do use such terms, they should begin by teaching the group their meanings. If a participant uses an unfamiliar term, the leader should explain it. It may be helpful to develop a vocabulary list on a chart and for any individual notebooks.

Similarly, manyindividuals were raised not to "air their dirty laundry." Therefore, they should never be pressured to reveal personal information in a group setting before they are ready. Nor shouldpatients be pressured into role-playing before they are ready.

Educational Groups
Educational groups are an integral part of addiction and domestic violence treatment. Patients need information about addiction, the substances, their use, and their impact. Women also benefit from shared information about:

•The developmental tasks of each stage of life
•Support systems
•Medical aspects of aging and addiction
•The concepts and processes of cognitive-behavioral techniques
Educational units can be designed to teach practical skills for coping with any aspect of daily life, such as safety, nutrition, household management, and exercise.

Some basic principles for designing educational groups follow:

•Traumatized women can receive, integrate, and recall information better if they are given a clear statement of the goal and purpose of the session and an outline of the content. The leader can post this outline and refer to it during the session. The outline may also be distributed for use in personal note taking and as an aid in review and recall. Courses and individual sessions should be conceived as building blocks that are added to the base of theadult's life experience and needs. Each session should begin with a review of previously presented materials.
•Members of the group may range in educational level from functionally illiterate to postgraduate degrees. Manywomen are adept at hiding a lack of literacy skills. These individuals need to be helped in a way that maintains their self-respect. Group leaders should choose vocabulary carefully based on clients' communication skills.
Alcoholics Anonymous and Other Self-Help Groups
Many treatment programs refer patients to Alcoholics Anonymous (AA) and other self-help groups as part of aftercare. AA is a grassroots peer-assistance approach that has had the greatest impact on the treatment of chemical dependency. It addresses living without alcohol through working a Twelve Step program.

AA requires attending regularly scheduled meetings. This may be a problem for women who have transportation needs, although a sponsor in the chapter may be able to assist.

Providers should warnpatients that these groups might seem confrontational and alienating. The referring program should tell patients exactly what to expect. Group discussions may include profanity and younger members' accounts of their antisocial behavior.

To orient clients to these groups, the treatment program may ask that local AA groups provide an institutional meeting as a regular part of the treatment program. Other options are to help clients develop their own self-help groups or to facilitate the development of independent AA groups for older adults in the area.

Avoiding future problem drinking may depend on continuing affiliation with a recovering peer group. Some model programs have created volunteer alumni groups to allow continued affiliation after requirements for treatment, such as court supervision, end.
MFT Continuing Education http://www.aspirace.com
Individual Counseling
Because of current interpersonal conflicts and the underlying feelings of shame, denial, guilt, or anger, psychotherapy may be appropriate. It can occur in conjunction with other treatment methods such as AA or hospital-based treatment programs. Grief counseling can support the process of healing losses.

Individual counseling is especially helpful to the older substance abuser in treatment's beginning stages, but the counselor often must overcome clients' worries about privacy. Subjects that many older adults are loath to discuss include their relationships with their spouses, family matters and interactions, sexual function, and economic worries.

It is essential to assure the client that the sessions are confidential. In addition, the therapist should conduct the sessions in a comfortable, self-contained room where the client can be certain the conversation will not be overheard.

Older clients often respond best to counselors who behave in a nonthreatening, supportive manner and whose demeanor indicates that they will honor the confidentiality of the sessions. Clients frequently describe the successful relationship in familial terms: "It is like talking to my son, or, "It is as though she were my sister." Older clients value spontaneity in relationships with the counselor and other staff members. A counselor's appropriate self-disclosure often enhances or facilitates a beneficial relationship with the patient.

Because receiving counseling may be a new experience for the client, the provider should explain the basics of counseling and clearly present the responsibilities of the counselor and the client. Summarizing at the beginning of each session helps to keep the session moving in the appropriate direction. Summarizing at the end of a session and providing tasks to be thought about or completed before the next session help reinforce any knowledge or insights gained. They also contribute to the older client's feeling that he or she is making progress.

In individual sessions, counselors can help clients prepare to participate in a therapy group, building their understanding of how the group works and what they are expected to do. Private sessions can also be used to clarify issues when the individual is confused or is too embarrassed to raise a question in the group. As the client becomes more comfortable in the group setting, the counselor may decide to taper the number of individual counseling sessions. Likewise, the client may prepare for discharge by reducing the frequency or length of sessions, secure in the knowledge that more time is available if needed.

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Case Management, Community-Linked Services, and Outreach
Case management is the coordination and monitoring of the varied social, health, and welfare services needed to support anadult's treatment and recovery. Case management starts at the beginning of treatment planning and continues through aftercare. One person, preferably a social worker or nurse, should link all staff who play a role in the client's treatment. This person should also coordinate with other important individuals in the client's social network.

The case/care manager develops the treatment plan, reviews progress, and revises the treatment plan as needed. There is a process for monitoring success in achieving the goals of treatment. The case manager serves as an advocate, representative, and facilitator of links to other agencies to procure services for the client.

The multiple causes of abused and addicted women's problems require multiple linkages to community services and agencies. The treatment program that seeks to be the sole source of all services for itsclients is likely to fail. Even in very isolated areas, programs can strengthen their services for women through linkages to local resources such as the faith community.

The case manager will likely refer the client to a combination of several community resources in response to the issues associated with the substance abuse problem. Case managers must have strong linkages through both formal and informal arrangements with community agencies and services such as:

•Medical practitioners, particularly mental health providers
•Medical facilities for detoxification and other services
•Home health agencies
•Housing services for specialized housing
•Public and private social services providing in-home support
•Faith community (e.g., churches, synagogues, mosques, temples)
•Transportation services
•Social activities
•Vocational training andemployment programs
•Community organizations that place clients in volunteer work
•Legal and financial services
If a program includes outreach services, case management may offer the best means of providing them.10,11 Case managers may, for example, initiate outreach services for homebound clients, although it is important to maintain continuity and assign only one case manager to an older client. If clients in a treatment program become seriously ill or dysfunctional and temporarily require services at home, a case manager may be the ideal staff person to broker services on their behalf. (Comprehensive case management for substance abuse treatment is described in detail in TIP 27.)

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References
1.Miller, W.R., and Rollnick, S. Motivational Interviewing. New York: Guilford Press, 1991.
2.Ibid.
3.Powers, R.B., and Osborne, J.G. Fundamentals of Behavior. New York: West Publishing Co., 1976.
4.Spiegler, M.D., and Guevremont, D.C. Contemporary Behavior Therapy. Pacific Grove, CA: Brooks/Cole, 1993.
5.Dobson, K.S., ed. Handbook of Cognitive-Behavioral Therapies. New York: Guilford Press, 1988.
6.Scott, J.; Williams, J.M.G.; and Beck, A. Cognitive Therapy in Clinical Practice: An Illustrative Casebook. London, UK: Routledge, 1989.
7.Dupree, L., and Schonfeld, L. Assessment and Treatment Planning for Alcohol Abusers: A Curriculum Manual. FMHI Publication Series, Number 109. Tampa: Florida Mental Health Institute, University of South Florida, 1986.
8.Schonfeld, L., and Dupree, L.W. Antecedents of drinking for early- and late-onset elderly alcohol abusers. Journal of Studies on Alcohol 1991, 52:587-592.
9.Schonfeld, L., and Dupree, L. Older problem drinkers: Long-term and late-life onset abusers: What triggers their drinking? Aging 1990, 361:5-9.
10.Graham, K.; Saunders, S.J.; Flower, M.C.; et al. Addictions Treatment for Older Adults: Evaluation of an Innovative Client-Centered Approach. New York: Haworth Press, 1995.
11.Fredriksen, K.I. North of Market: Older women's alcohol outreach program. Gerontologist 1992, 32:270-272.

Planning required when serving alcohol at holiday parties

DHS news release

Note: This guest opinion is by Karen Wheeler, addictions policy manager, Oregon Department of Human Services

Planning required when serving alcohol at holiday parties



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By Karen Wheeler


The winter holidays are a time for celebratory gatherings of family and friends, food and drink, and high spirits. But there's one ingredient that can quickly spoil the holiday cheer -- alcohol.


Give serious thought to the food and drinks you're serving; consider keeping the party alcohol-free.


However, if you decide to add alcoholic beverages to your holiday menu, a bit of planning and preparation can keep your event merry and bright.


If offering liquor, be responsible. Prepare for that relative who tends to imbibe too much. At the same time, make arrangements for non-drinkers and young people. This kind of planning will ensure that your guests have fun and don't turn into party problems or, worse yet, holiday statistics.


Traffic studies tell us that an average of four persons a year for the past 10 years have died on Oregon roads during the Christmas holiday. When New Years statistics for the decade are added in, we learn that 41 percent of the fatal holiday highway crashes involved alcohol. For all of 2005, 33.8 percent of Oregon's motor vehicle fatalities involved alcohol. And last Christmas alone, Oregon State Police arrested 59 persons for driving under the influence of intoxicants.


Keeping alcohol out of the hands of young people is always the way to go -- and it's the law. During holiday parties, keep an eye on the liquor cabinet or punchbowl when kids are around. Research tells us that one place youth procure alcohol is at parties where parents and other adults have left them unsupervised.


Instead, offer teen guests challenging games, activities like a white elephant gift exchange, fun beverages and good food. That way you won't be adding to the eye-popping statistics of Oregon's serious underage drinking problem.


For example, about 30 percent of eighth graders and 45 percent of 11th graders consumed alcohol in the past month, according to DHS reports. One in four older teens said they drank five or more alcoholic beverages within several hours (binge drinking). And more girls than ever are drinking, up from 26.4 percent in 1999 to 33.9 percent in 2006.


There's something else to remember: In Oregon, it's illegal for anyone to serve more alcohol to someone who is showing signs of having too much to drink. And, there's the third party liability law, which means that if you allow an intoxicated person to leave your party, you may be liable for any damages or injuries your guest causes to others on the way home.


Here are some tips for holiday party givers:

Avoid making alcohol the main focus of social events. Entertain guests with music, dancing, games, food and conversation. Many adults prefer non-alcoholic beverages, so offer plenty of alcohol-free choices such as sparkling water, ciders and juice drinks, and sodas.
Provide guests with nutritious and appealing foods to slow the effects of alcohol. High protein and carbohydrate foods such as cheese and meats stay in the stomach much longer, which slows the rate at which the body absorbs alcohol. Avoid salty foods that encourage people to drink more.

Measure the correct amount of liquor into drinks (no doubles) and don't serve anyone who is under age or appears to be impaired. Don't serve alcoholic punch or other beverages that make it hard to gauge how much alcohol one consumes. Don't force alcoholic drinks on guests or rush to refill empty glasses.

Stop serving alcoholic beverages at least one hour before the end of the event. Serve coffee, alcohol-free beverages and desserts at that time. Before the party, recruit people who won't be drinking to help ensure that everyone has a safe ride home.

Karen Wheeler is addictions policy manager for the Oregon Department of Human Services

Social Worker, LSW, LISW, and LCSW Continuing Education http://www.aspirace.com

OxyContin® Abuse and Addiction Continuing Education CEUs

The media have issued numerous reports about the apparent increase in OxyContin® abuse and addiction. Some of these reports include the following:

• In Madison, Wisconsin, a task force reported a dramatic increase in OxyContin cases since 2003. Most OxyContin making its way onto the streets of Madison and nearby communities was believed to have been stolen from local pharmacies.1
• The police chief in Billerica, Massachusetts, reported a “dramatic increase in OxyContin abuse.”2
• The distribution of OxyContin in Virginia was reported to be well above the national average. In the counties of far southwest Virginia, where the hard physical labor of coal mining and farming leads to a higher incidence of injuries, OxyContin prescriptions were generally 500 percent above the national average.3
• Sixty-nine percent of police chiefs and sheriffs said they have witnessed an increase in the abuse of painkillers such as OxyContin. The areas most affected are eastern Kentucky, New Orleans, southern Maine, Philadelphia, southwestern Pennsylvania, southwestern Virginia, Cincinnati, and Phoenix.4

These reports may reflect some of your experiences: We know many of you are treating clients addicted to OxyContin.

OxyContin has been heralded as a miracle drug that allows patients with chronic pain to resume a normal life. It has also been called pharmaceutical heroin and is thought to have been responsible for a number of deaths and robberies in areas where its abuse has been reported. Patients who legitimately use OxyContin fear that the continuing controversy will mean tighter restrictions on the medication. Those who abuse OxyContin reportedly go to great lengths—legal or illegal—to obtain the powerful drug.

At the Center for Substance Abuse Treatment (CSAT), we are not interested in fueling the controversy about the use or abuse of OxyContin. As the Federal Government’s focal point for addiction treatment information, CSAT is instead interested in helping professionals on the front line of substance abuse treatment by providing you with the facts about OxyContin, its use and abuse, and how to treat individuals who present at your treatment facility with OxyContin concerns. Perhaps these individuals are taking medically prescribed OxyContin to manage pain and are concerned about their physical dependence on the medication. Perhaps you are faced with a young adult who thought that OxyContin was a “safe” recreational drug because, after all, doctors prescribe it. Possibly changes in the availability or quality of illicit opioid drugs in your community have led to abuse of and addiction to OxyContin.

Whatever the reason, OxyContin is being abused, and people are becoming addicted. And in many instances, these people are young adults unaware of the dangers of OxyContin. Many of these individuals mix OxyContin with alcohol and drugs, and the result is all too often tragic.

Abuse of prescription drugs is not a new phenomenon. You have undoubtedly heard about abuse of Percocet®, hydrocodone, and a host of other medications. What sets OxyContin abuse apart is the potency of the drug. Treatment providers in affected areas say that they were unprepared for the speed with which an OxyContin “epidemic” developed in their communities.

We at CSAT want to make sure that you are prepared if OxyContin abuse becomes a problem in your community. This revised issue of the original Substance Abuse Treatment Advisory on OxyContin will help prepare you by

• Answering frequently asked questions about OxyContin
• Providing you with general information about semisynthetic opioids and their addiction potential
• Summarizing evidence-based protocols for treatment
• Providing you with resources for further information

For more information about OxyContin abuse and treatment, see our resource boxes and end of this document. Feel free to copy the information in the Substance Abuse Treatment Advisory and share it with colleagues so that they, too, can have the most current information about this critically important topic.

OxyContin® Frequently Asked Questions

Q: What is OxyContin?

A: OxyContin is a semisynthetic opioid analgesic prescribed for chronic or long-lasting pain. The medication’s active ingredient is oxycodone, which is also found in drugs like Percodan® and Tylox®. However, OxyContin contains between 10 and 80 milligrams (mg) of oxycodone in a timed-release tablet. Painkillers such as Tylox contain 5 mg of oxycodone and often require repeated doses to bring about pain relief because they lack the timed-release formulation.

Q: How is OxyContin used?

A: OxyContin, also referred to as “Oxy,” “O.C.,” and “Oxycotton” on the street, is legitimately prescribed as a timed-release tablet, providing as many as 12 hours of relief from chronic pain. It is often prescribed for cancer patients or those with chronic, long-lasting back pain. The benefit of the medication to people who suffer from chronic pain is that they generally need to take the pill only twice a day, whereas a dosage of another medication would require more frequent use to control the pain. The goal of chronic pain treatment is to decrease pain and improve function.

Q: How is OxyContin abused?

A: People who abuse OxyContin either crush the tablet and ingest or snort it or dilute it in water and inject it. Crushing or diluting the tablet disarms the timed-release action of the medication and causes a quick, powerful high. Those who abuse OxyContin have compared this feeling to the euphoria they experience when taking heroin. In fact, in some areas, the use of heroin is overshadowed by the abuse of OxyContin.

Purdue Pharma, OxyContin’s manufacturer, has taken steps to reduce the potential for abuse of OxyContin and other pain medications. Its Web site lists the following initiatives: funding educational programs to teach healthcare professionals how to assess and treat patients suffering from pain, providing prescribers with tamper-proof prescription pads, developing and distributing more than 1 million brochures to pharmacists and healthcare professionals to help educate them about medication diversion, working with healthcare and law enforcement officials to address prescription drug abuse, and endorsing the development of State and national prescription drug monitoring programs to detect diversion. In addition, the company is attempting to research and develop other pain management products that will be more resistant to abuse and diversion. The company estimates that it will take significant time for such products to be brought to market. For more information, visit Purdue Pharma’s Web site at www.purduepharma.com or call the company at 203–588–8069.

Q: How does OxyContin abuse differ from abuse of other pain prescriptions?

A: Abuse of prescription pain medications is not new. Two primary factors, however, set OxyContin abuse apart from other prescription drug abuse. First, OxyContin is a powerful drug that contains a much larger amount of the active ingredient, oxycodone, than other prescription pain relievers. By crushing the tablet and either ingesting or snorting it, or by injecting diluted OxyContin, people who abuse the opioid feel its powerful effects in a short time, rather than over a 12-hour span. Second, great profits can be made in the illegal sale of OxyContin. A 40-mg pill costs approximately $4 by prescription, yet it may sell for $20 to $40 on the street, depending on the area of the country in which the drug is sold.5

OxyContin can be comparatively inexpensive if it is legitimately prescribed and if its cost is covered by insurance. However, the National Drug Intelligence Center reports that people who abuse OxyContin may use heroin if their insurance will no longer pay for their OxyContin prescription because heroin is less expensive than OxyContin that is purchased illegally.6

Q: Why are so many crimes reportedly associated with OxyContin abuse?

A: Many reports of OxyContin abuse have occurred in rural areas that have housed labor-intensive industries, such as logging or coal mining. These industries are often located in economically depressed areas, as well. Therefore, people for whom the drug may have been legitimately prescribed may be tempted to sell their prescriptions for profit. Substance abuse treatment providers say that the addiction is so strong that people will go to great lengths to get the drug, including robbing pharmacies and writing false prescriptions.

Q: What is the likelihood that a person for whom OxyContin is prescribed will become addicted?

A: Most people who take OxyContin as prescribed do not become addicted. The National Institute on Drug Abuse reports: “Long-term use [of opioids] can lead to physical dependence—the body adapts to the presence of the substance and withdrawal symptoms occur if use is reduced abruptly. This can also include tolerance, which means that higher doses of a medication must be taken to obtain the same initial effects. . . . Studies have shown that properly managed medical use of opioid analgesic compounds is safe and rarely causes addiction. Taken exactly as prescribed, opioids can be used to manage pain effectively.”7

One review found, “A multitude of studies indicate that the rate of opioid addiction in populations of chronic pain sufferers is similar to the rate of opioid addiction within the general population, falling in the range of 1 to 2 percent or less.”8

In short, most individuals who are prescribed OxyContin, or any other opioid, will not become addicted, although they may become dependent on the drug and will need to be withdrawn by a qualified physician. Individuals who are taking the drug as prescribed should continue to do so, as long as they and their physician agree that taking the drug is a medically appropriate way for them to manage pain.

Q: How can I determine whether a person who uses OxyContin is dependent on rather than addicted to OxyContin?

A: When pain patients take an opioid analgesic as directed, or to the point where their pain is adequately controlled, it is not abuse or addiction. Abuse occurs when patients take more than is needed for pain control, especially if they take it to get high. Patients who take their medication in a manner that grossly differs from a physician’s directions are probably abusing that drug.

If a patient continues to seek excessive pain medication after pain management is achieved, the patient may be addicted. Addiction is characterized by the repeated, compulsive use of a substance despite adverse social, psychological, and/or physical consequences. Addiction is often (but not always) accompanied by physical dependence, withdrawal syndrome, and tolerance. Physical dependence is defined as a physiologic state of adaptation to a substance. The absence of this substance produces symptoms and signs of withdrawal. Withdrawal syndrome is often characterized by overactivity of the physiological functions that were suppressed by the drug and/or depression of the functions that were stimulated by the drug. Opioids often cause sleepiness, calmness, and constipation, so opioid withdrawal often includes insomnia, anxiety, and diarrhea.

Pain patients, however, may sometimes develop a physical dependence during treatment with opioids. This is not an addiction. A gradual decrease of the medication dose over time, as the pain is resolving, brings the former pain patient to a drug-free state without any craving for repeated doses of the drug. This is the difference between the patient treated for pain who was formerly dependent and has now been withdrawn from medication and the patient who is opioid addicted: The patient addicted to diverted pharmaceutical opioids continues to have a severe and uncontrollable craving that almost always leads to eventual relapse in the absence of adequate treatment. This uncontrollable craving for another “rush” of the drug differentiates the patient who is “detoxified” but opioid addicted from the former pain patient. Theoretically, a person who abuses opioids might develop a physical dependence but obtain treatment in the first few months of abuse, before becoming addicted. In this case, supervised withdrawal (detoxification) followed by a few months of abstinence-oriented treatment might be sufficient for the patient who is not addicted who abuses opioids. If, however, this patient subsequently relapses to opioid abuse, then that behavior would support a diagnosis of opioid addiction. If the patient has several relapses to opioid abuse, he or she will require long-term treatment for the opioid addiction. (See the section titled Treatment and Detoxification Protocols to learn more about treatment options.)

Q: I work at a facility that does not use medication-assisted treatment. What treatment should I provide to individuals addicted to or dependent on OxyContin?

A: The majority of U.S. treatment facilities do not offer medication-assisted treatment. However, because of the strength of OxyContin and its powerful addiction potential, medical complications may be increased by quickly withdrawing individuals from the drug. Premature withdrawal may cause individuals to seek heroin, and the quality of that heroin will not be known. In addition, these individuals, if injecting heroin, may also expose themselves to HIV and hepatitis. Most people addicted to OxyContin need medication-assisted treatment. Even if individuals have been taking OxyContin legitimately to manage pain, they should not stop taking the drug all at once. Instead, their dosages should be tapered down until medication is no longer needed. If you work in a drug-free or abstinence-based treatment facility, it is important to refer patients to facilities where they can receive appropriate treatment. (See SAMHSA Resources.)

Treatment and Detoxification Protocols

OxyContin® is a powerful drug that contains a much larger amount of the active ingredient, oxycodone, than other prescription opioid pain relievers. Whereas most people who take OxyContin as prescribed do not become addicted, those who abuse their pain medication or obtain it illegally may find themselves becoming rapidly dependent on, if not addicted to, the drug.

Two types of treatment have been documented as most effective for opioid addiction. One is a long-term, residential, therapeutic community type of treatment, and the other is long-term, medication-assisted outpatient treatment. Clinical trials using medications to treat opioid addiction have generally included subjects addicted to diverted pharmaceutical opioids as well as to illicit heroin. Therefore, there is no medical reason to suppose that the patient addicted to diverted pharmaceutical opioids is any less likely to benefit from medication-assisted treatment than the patient addicted to heroin.

Some patients who are opioid addicted who have very good social supports may occasionally be able to benefit from antagonist treatment with naltrexone. This treatment works best if the patient is highly motivated to participate in treatment and has undergone adequate detoxification from the opioid of abuse. Most patients who are opioid addicted in outpatient therapy, however, do best with medication that is either an agonist or a partial agonist. Methadone is the agonist medication most commonly prescribed for opioid addiction treatment in this country. Buprenorphine is the only partial agonist approved by the Food and Drug Administration for opioid addiction treatment.

The guidelines for treating OxyContin addiction or dependence are basically no different than the guidelines the Center for Substance Abuse Treatment (CSAT) uses for treating addiction to or dependence on any opioid. However, because OxyContin contains higher dose levels of opioid than are typically found in other oxycodone-containing pain medications, higher dosages of methadone or buprenorphine may be needed to appropriately treat patients who abuse OxyContin.

Methadone or buprenorphine may be used for OxyContin addiction treatment or, for that matter, treatment for addiction to any other opioid, including the semisynthetic opioids. Medication-assisted treatment for prescription opioid abuse is not a new treatment approach. For instance, in 2002, Alaska estimated that 15,000 people abused prescription opioids in the State and that most patients receiving methadone were not addicted to heroin. In addition, a significant percentage of patients in publicly supported methadone programs were not being treated for heroin addiction but for abuse of semisynthetic opioids (e.g., hydrocodone). The Substance Abuse and Mental Health Services Administration (SAMHSA) Drug Abuse Warning Network emergency room data show that both oxycodone and hydrocodone mentions increased dramatically in the United States between 1995 and 2002.9 And when Arkansas opened its first methadone maintenance clinic in December 1993, the vast majority of its clients were not admitted for heroin addiction but for semisynthetic opioid abuse. These individuals had been traveling to other States for treatment because methadone treatment was not available near their homes.

Using the criteria above describing the difference between addiction to and dependence on OxyContin, you may be able to determine whether a patient requires treatment for opioid addiction. If this is the case, methadone or buprenorphine may be used for withdrawal. For certain patient populations, including those with many treatment failures, methadone or buprenorphine is the treatment of choice.10

“As substance abuse treatment professionals, we have the responsibility for learning as much as we can about OxyContin and then providing appropriate treatment for people addicted to it. Appropriate treatment will nearly always involve prescribing methadone, buprenorphine, or, in some cases, naltrexone,” says H. Westley Clark, M.D., J.D., Director of CSAT. “Programs that do not offer medication-assisted treatment will need to refer patients who are addicted to OxyContin to programs that do,” he adds.

It is important to assess an individual’s eligibility for medication-assisted treatment with methadone or buprenorphine to determine whether he or she is eligible for this type of treatment and whether it would be appropriate. The assessment may take place in a hospital emergency department, central intake unit, or similar place. Final assessment of an individual’s eligibility for medication-assisted treatment must be completed by treatment program staff. The preliminary assessment should include the following areas:11

• Determining the need for emergency care
• Diagnosing the presence and severity of opioid dependence
• Determining the extent of alcohol and drug abuse
• Screening for co-occurring medical and psychiatric conditions
• Evaluating an individual’s living situation, family and social problems, and legal problems

“. . . we have the responsibility for learning as much as we can about OxyContin, and then providing appropriate treatment for people who are addicted to it.”

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM
Director, CSAT

Treatment Improvement Protocols (TIPs) and Collateral Products Addressing Opioid Addiction Treatment

TIP 40 Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction BKD500

Quick Guide for Physicians Based on TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction QGPT40

KAP Keys for Physicians Based on TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction KAPT40

TIP 43 Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs BKD524

Quick Guide for Clinicians Based on TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs QGCT43

KAP Keys for Clinicians Based on TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs KAPT43

SAMHSA Resources

To find a substance abuse treatment facility near you, visit the Substance Abuse Treatment Facility Locator at www.findtreatment.samhsa.gov. Call the Substance Abuse and Mental Health Services Administration Substance Abuse Treatment Hotline at 800–662–HELP for substance abuse treatment referral information.

For More Information About Treatment for Opioid Addiction

Sign up for SAMHSA’s Information Mailing System (SIMS) to receive information about the following topics:

• Grant announcements
• Funding opportunities such as competitive contract announcements
• Prevention materials and publications
• Treatment- and provider-oriented materials and publications
• Research findings and reports
• Announcements of available research data sets
• Policy announcements and materials

To sign up for this free service, use one of the following methods to contact SIMS:

Web: http://sims.health.org
Mail: SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI)
Attn: Mailing List Manager
P.O. Box 2345
Rockville, MD 20847–2345
Phone: 800–729–6686
Fax: 301–468–6433
Attn: Mailing List Manager

Three Ways To Obtain Free Copies of All CSAT Products:

1. Call SAMHSA’s NCADI at 800–729–6686; TDD (hearing impaired) 800–487–4889
2. Visit NCADI’s Web site, www.ncadi.samhsa.gov
3. Access TIPs on line at www.kap.samhsa.gov


Substance Abuse Treatment Advisory

Substance Abuse Treatment Advisory—published on an as-needed basis for treatment providers—was written and produced under contract number 270-04-7049 by the Knowledge Application Program (KAP), a Joint Venture of JBS International, Inc., and The CDM Group, Inc., for the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). The content of this publication does not necessarily reflect the views or policies of SAMHSA or HHS.

Public Domain Notice: All material in this report is in the public domain and may be reproduced or copied without permission; citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication: This publication can be accessed electronically through the Internet at www.kap.samhsa.gov. Additional free print copies can be ordered from SAMHSA’s National Clearinghouse for Alcohol and Drug Information at 800–729–6686.

Recommended Citation: Center for Substance Abuse Treatment. “OxyContin®: Prescription Drug Abuse—2006 Revision.” Substance Abuse Treatment Advisory, Volume 5, Issue 1. Rockville, MD: Substance Abuse and Mental Health Services Administration, April 2006.

DHHS Publication No. (SMA) 06-4138
Substance Abuse and Mental Health Services Administration
Printed 2006

Notes

1. WISC-TV. OxyContin: The Good, The Bad, The Deadly. Broadcast transcript. Madison, WI: WISC-TV, February 14, 2006. www.channel3000.com/health/7013912/detail.html [accessed March 2, 2006].
2. Crane, J.P. Drug use by young raises flag. The Boston Globe, February 5, 2006. www.boston.com/news/local/articles/2006/02/05/drug_use_by_young_raises_flag [accessed March 2, 2006].
3. Hammack, L. Painkiller prescriptions up significantly in region. The Roanoke Times, March 28, 2004. www.roanoke.com/roatimes/news/story164817.html [accessed March 2, 2006].
4. Reuters. Powerful painkillers fueling U.S. crime rate. Redmond, WA: MSNBC.com., March 10, 2005. www.msnbc.msn.com/id/7141313 [accessed March 2, 2006].
5. National Drug Intelligence Center. Intelligence Bulletin: OxyContin Diversion, Availability, and Abuse. Johnstown, PA: National Drug Intelligence Center, U.S. Department of Justice, August 2004. www.usdoj.gov/ndic/pubs10/10550/10550p.pdf [accessed March 3, 2006].
6. National Drug Intelligence Center. Pharmaceuticals. In: National Drug Threat Assessment 2004. Johnstown, PA: National Drug Intelligence Center, U.S. Department of Justice, April 2004. www.usdoj.gov/ndic/pubs8/8731/8731p.pdf [accessed March 3, 2006].
7. National Institute on Drug Abuse (NIDA). NIDA Infofacts: Prescription Pain and Other Medications. Washington, DC: NIDA, National Institutes of Health, 2005. www.drugabuse.gov/infofacts/PainMed.html [accessed March 3, 2006].
8. Fisher, F.B. Interpretation of “aberrant” drug-related behaviors. Journal of American Physicians and Surgeons 9(1):25–28, 2004.
9. Substance Abuse and Mental Health Services Administration (SAMHSA). Emergency Department Trends From the Drug Abuse Warning Network: Final Estimates 1995–2002. DAWN Series D-24. DHHS Publication No. (SMA) 03-3780. Rockville, MD: SAMHSA, 2003. dawninfo.samhsa.gov/old_dawn/pubs_94_02/edpubs/2002final [accessed March 2, 2006].
10. Center for Substance Abuse Treatment. Detoxification and Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series 45. DHHS Publication No. (SMA) 06-4131. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2006.
11. Center for Substance Abuse Treatment. Initial screening, admission procedures, and assessment techniques. In: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 05-4048. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005, pp. 43–61.

Substance Abuse and Chemical Dependency Continuing Education CEU

B. Models of Preventive Services

Two well-known models of preventive services are used when referring to behavioral programming for public health or mental health promotion and substance use prevention. They are reviewed briefly here.

for more information on this topic click link below
substance abuse ceus continuing education
The Public Health Model
Public health traditionally defines preventive services as “primary,” “secondary,” or “tertiary.” Primary preventive services, such as immunizations and programs related to tobacco, diet, and exercise, are intended to intervene before the onset of illness to prevent biologic onset of illness. Secondary preventive services include screening to detect disease before it becomes symptomatic, coupled with follow-up to arrest or eliminate the disease. The Pap test and mammography are medical examples of secondary prevention. Tertiary prevention refers to prevention of complications in persons known to be ill. Prevention of stroke through effective treatment of hypertension is an example of tertiary prevention. Much of disease management is tertiary prevention. In the public health model, the three levels of prevention are separate and distinct.

The Continuum of Health Care Model According to the Institute of Medicine (IOM)
When dealing with substance use and other behavioral disorders in clinical settings, the levels of prevention are less distinct than with physical illnesses. The tasks of identifying risk factors and detecting earlystage disease are usually accomplished by patient or family interview. Initial management of both risk and early stage disease is often conducted via patient and family counseling by the primary care provider. Thus, the continuum of the health care model is more practical than the public health model when dealing with preventive behavioral health services.

The continuum of health care model is drawn from a 1994 report of the Institute of Medicine (IOM) (Mrazek & Haggerty, eds., 1994), as originally proposed by Gordon (1983). It differs from the public health model in that it covers the full range of preventive, treatment, and maintenance services. There are three types of preventive services in the IOM model—universal, selective, and indicated. These do not correspond to the primary, secondary, and tertiary services in the public health model. Screening and follow-up preventive behavioral services correspond to secondary prevention within the public health model. Other preventive behavioral services, including most community-based services, correspond to primary or tertiary prevention.

Figure 1. Continuum of Health Care



Source: Reprinted with permission from Reducing Risks for Mental Disorders. Copyright 1994 by the National Academy of Sciences, Courtesy of the National Academy Press, Washington, DC.

In the IOM model, a “universal” preventive measure is an intervention that is applicable to or useful for everyone in the general population, such as all enrollees in a managed care organization. A “selective” preventive measure is desirable only when an individual is a member of a subgroup with above-average risk. An “indicated” preventive measure applies to persons who are found to manifest a risk factor that puts them at high risk (Mrazek & Haggerty, eds., 1994). All these categories describe individuals who have not been diagnosed with a disease.

Universal interventions, on a per-client basis, are relatively inexpensive services offered to the entire population of a lifestage group. They are conducted as a primary prevention or screening to identify sub-populations and individuals who need more intensive screening, preventive, or therapeutic services. A clinical example would be the provision of prenatal care as a universal service for all pregnant women. A behavioral health example would be the use of a simple screening protocol to identify depression in all adult patients at all primary care visits.

Selective interventions are more intensive services offered to subpopulations identified as having more risk factors than the general population, based on their age, gender, genetic history, condition, or situation. For example, more intensive breast cancer screening is provided for women with a family history of breast cancer. A behavioral health example would be offering smoking cessation programming to all smokers.

Indicated interventions are based on higher probability of developing a disease. They provide an intensive level of service to persons at extremely high risk or who already show asymptomatic, clinical, or demonstrable abnormality, but do not meet diagnostic criteria levels yet. Case management and intensive in-home assessment, health education, and counseling are examples of indicated interventions (Mrazek & Haggerty, eds., 1994).

Sometimes a universal service is a screening procedure provided to all, or a primary prevention procedure such as vaccinations for children. The selective service involves diagnostic procedures to confirm or deny a diagnosis, and the indicated service involves much more intensive, individualized services for those at highest risk.

The efficacy and cost-efficiency of preventive services depend on the entire array of universal, selective, and indicated service components. They also depend on the ability of the health care system to target and limit the more costly indicated interventions to those who could most benefit from them.

Appendix C to this report provides a more detailed presentation of the following policy, management, planning, and evaluation issues:

Translation of preventive behavioral research into health care practice
Assessment of the need for preventive services
Assessment of the efficacy of preventive services
Infrastructure and service components for preventive services
“General” vs. “Targeted” Services
Within this monograph, services are also classified into one of two categories, “general” and “targeted,” depending on the evidence base and the nature of the service. Those designated as “general” are supported by the evidence base as being appropriate for universal implementation by all health care systems. Services that are classified here as “targeted” appear to be appropriate for selected populations (e.g., selective or indicated populations if applying the IOM model), or they have a developing research base that is promising. “Targeted” services might also be social or educational interventions that could be provided by nonmedical staff to secure educational and social benefits.

C. Clinical vs. Community Preventive Services

Most preventive behavioral services are delivered in school and community settings, not health care settings (Schinke, Brounstein, & Gardner, 2002; DHHS, 1999). In a 1998 review of indicated preventive behavioral services for children and adolescents, Durlak and Wells (1997) used meta-analysis to review 177 programs—73 percent were in a school setting, compared with 23 percent that were mainly in medical settings. In a similar review published 1 year later by the same authors (Durlak & Wells, 1998), none of the programs was in a medical setting.

This report has been prepared to summarize and analyze the most promising preventive interventions (based on rigorous research studies) for consideration by health care organizations. Only interventions deliverable by health care systems are reviewed in this report. Most community preventive services are oriented toward school-age children, adolescents, and young adults—age groups with relatively low exposure to health care delivery settings. Such services generally are provided by and through schools and community organizations.

Health care settings, however, are effective in reaching pregnant women, infants, adults with major chronic medical illnesses, and those in need of surgical procedures. For example, these settings provide a place to address the behavioral needs of these patients through behavioral screening and preventive services, with follow-up in prescribed regimens of care. In this way, clinical preventive services for depression and substance abuse can reduce emergency room use and hospitalization (Olfson, Sing, & Schlesinger, 1999). Psychoeducational services also can speed recovery of postsurgical patients (Egbert, Battit, Welch, & Bartlett, 1964; Mumford, Schlesinger, & Glass, 1982).

It may not be incumbent upon health care delivery systems to provide highly specialized social and educational support services (Devine, O’Connor, Cook, Wenk, & Curtin, 1988), but health care delivery systems do have a role to play. Through their mental health and social work staff, they maintain working relationships with communitybased, social service, educational, and even correctional agencies to ensure they meet the needs of members of the health care delivery system.

D. Health Care Delivery System Provision of Preventive Behavioral Services

The need for behavioral services is substantial. Many who could benefit from treatment for these disorders do not receive care (Woodward et al., 1997; Harwood, Sullivan, & Malhorta, 2001).

Some of the lack of development of behavioral health services within health care delivery systems may be owing to the perception that mental health and substance use disorder services may be “softer” and therefore less effective than conventional medical therapy. However, the efficacy and cost-efficiency of these services is well established and has been recommended by multiple national organizations since at least the early 1990s (U.S. Preventive Services Task Force [USPSTF], 1996, 2002a, 2003).

The 1994 IOM report was titled Reducing Risks for Mental Disorders—Frontiers for Preventive Intervention Research (Mrazek & Haggerty, eds., 1994). A 1998 follow-up report, Preventing Mental Health and Substance Abuse Problems in Managed Care Settings (Mrazek, 1998), was completed in collaboration with the National Mental Health Association (NMHA). This report recommended widespread implementation of primary preventive programming to address five problem areas within health care systems:

Prevention of initial onset of unipolar major depression across the life span
Prevention of low birthweight and prevention of child maltreatment in children from birth to 2 years of age whose mothers are identified as being at high risk
Prevention of alcohol or drug abuse in children who have an alcohol- or drugabusing parent
Prevention of mental health problems in physically ill patients (comorbidity prevention)
Prevention of conduct disorders in young children
The 1999 Surgeon General Report was titled Mental Health: A Report of the Surgeon General (DHHS, 1999). Although the major focus of this report was care and management of mental disorders, all major preventive services were included.

SAMHSA published two recent prevention-related health care reports. The 2000 literature review titled Preventive Interventions Under Managed Care (Dorfman, 2000) used broader definitions of “prevention” and “mental health services” and recommended six interventions for managed care plans:

Prenatal and infancy home visits
Targeted cessation education and counseling for smokers—especially those who are pregnant
Targeted short-term mental health therapy
Self-care education for adults
Presurgical educational intervention with adults
Brief counseling and advice to reduce alcohol use
This new literature review retains four of the above services and omits numbers three and four on short-term mental health therapy and self-care. The companion document published in 2002 was titled Estimating the Cost of Preventive Services in Mental Health and Substance Abuse Under Managed Care (Broskowski & Smith, 2002). This report provided cost data for each of the services recommended in the 2000 literature review. It also featured, for each set of recommended services, a range of costs and options based on case mix and private versus public insurance coverage. It estimated the cost to managed care organizations (MCOs) to implement recommendations for four possible scenarios ranging from most expensive to least expensive, given drivers such as enrollment mix, staffing, staff salaries, and fixed and variable expenses. This report did not consider savings in other health care expenses. Even with the most expensive of cost profiles, the report did conclude that all six services could be fully implemented at a marginal cost of less than a 1 percent increase in cost, per member per month.

During this period, SAMHSA and the National Committee on Quality Assurance (NCQA)–sponsored Health Employer Data Information Set (HEDIS) program have attempted to bring preventive behavioral services to the attention of the managed care community. In response to market pressures to demonstrate high scores on HEDIS measures, the managed care community has taken giant strides to improve the care of patients with depression and has taken steps to enhance member adherence to prescribed regimens of care for diabetes.

In 1998, SAMHSA’s Center for Substance Abuse Prevention created the National Registry of Effective Programs (NREP) as a resource to help professionals in the field become better consumers of prevention programs (Schinke et al., 2002). NREP reviews and screens evidence-based programs (conceptually sound and/or theoretically driven by risk and protective factors) that, through an expert consensus review of research, demonstrate scientifically defensible evidence. NREP initially focused on substance use prevention but has expanded to include mental health; co-occurring mental health and substance use disorders; adolescent substance use treatment; mental health promotion; and adult mental health treatment. Many programs focus on school and family, but increasingly, programs from community coalitions and environmental programs are being identified as well implemented, well evaluated, and effective.

NREP evaluates programs for substance abuse prevention and treatment, co-occuring disorders, and mental health treatment, promotion, and prevention. After receiving published and unpublished program materials from candidates, NREP reviewers, drawn from 80 experts in relevant fields, rate each program according to 18 criteria for methodological rigor, and they also score programs for adoptability and usefulness to communities (Schinke et al., 2002). Based on the overall scoring, NREP categorizes programs as Model Programs, Effective Programs, Promising Programs, or Programs with Insufficient Current Support. Those wishing to learn more about Model Programs can visit www.modelprograms.samhsa.gov. At this site, there is also a link providing detailed information about NREP and the process for submitting a program for NREP review.

Despite these efforts, behavioral services— both preventive and therapeutic—still are not adequately identified, provided, or arranged by primary care practitioners. They also are not adequately promoted by health care systems. Brief screening instruments for alcohol and drug problems, for example, have been available for a number of years but are not widely used by practicing physicians (Duszynski, Nieto, & Vanente, 1995; National Center on Addiction and Substance Abuse at Columbia University, 2000). In a 2002 review, Garnick et al. (2002) conducted a telephone survey covering 434 MCOs in 60 market areas nationwide and secured useful responses from 92 percent of them. Only 14.9 percent of MCOs required any alcohol, drug, or mental health screening by primary care practitioners. Slightly more than half distributed practice guidelines that addressed mental illness, and approximately one third distributed substance use disorder practice guidelines.

DHHS’s 2003 campaign, Steps to a Healthier U.S., focuses on chronic disease prevention and health promotion with the goals of decreasing both the prevalence of certain chronic diseases and the risk factors that allow conditions to develop. This initiative aims to bring together local coalitions to establish model programs and policies that foster health behavior changes, encourage healthier lifestyle choices, and reduce disparities in health care.

In early 2003, SAMHSA published a review of the delivery of behavioral services by managed care organizations, based on 1999 data. This report, The Provision of Mental Health Services in Managed Care Organizations (Horgan et al., 2003), showed substantial variability from plan to plan, as well as substantial variability among health maintenance organizations (HMOs), pointof- service (POS) plans, and preferred provider organizations (PPOs). All MCOs provided behavioral services, but these services usually had limits and copayments that were more restrictive than for comparable medical services. Fewer than 10 percent required screening for behavioral disorders in primary care settings (Horgan et al., 2003).

Another SAMHSA report, also published early in 2003, offers some insight into discrepancies in coverage, comparing medical to behavioral services and discrepancies in policy and coverage, comparing therapeutic to preventive services. This report, titled Medical Necessity in Private Health Plans: Implications for Behavioral Health Care (Rosenbaum, Kamoie, Mauery, & Walitt, 2003), noted that services are covered by health insurance plans only if they are considered a “medical necessity.” The term medical necessity was defined differently for different services within each health plan, with due consideration given for each of the following five domains:

Contractual scope—whether the contract provides any coverage for certain procedures and treatments, such as preventive and maintenance treatments that are not necessary to restore a patient to “normal functioning.” This dimension preempts any other coverage decision.
Standards of practice—whether the treatment (as judged by the health plan) accords with professional standards of practice.
Patient safety and setting—whether the treatment will be delivered in the safest and least intrusive manner.
Medical service—whether the treatment is considered medical as opposed to social or nonmedical.
Cost—whether the treatment is considered cost-effective by the insurer (Rosenbaum et al., 2003).
The medical necessity report noted that Federal or State regulation is limited in covering how health insurance plans define medical necessity (Rosenbaum et al., 2003). This SAMHSA update is intended to build upon the reports noted above to further enhance implementation of preventive behavioral services in health care settings.

substance abuse ceus

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substance abuse ceus

Alcoholism and Substance Abuse Dependency (15 hours)
Description CH 1-Definitions
CH 2-History
CH 3-DSM Criteria
CH 4-Types of Substance Abuse
CH 5-Prescription Drug Addiction and Dependence
CH 6-Demographic Characteristics
CH 7-Substance Abuse Treatments and Outcomes


Become familiar with clinical and statistical information regarding substance abuse history, DSM criteria, types of abuse, demographic characteristics, treatment, and outcomes.
Define substance abuse and identify its effects.
Become familiar with the medical aspects of alcohol abuse/dependence and other types of chemical dependency.
Apply current theories of the etiology of substance abuse.
Recognize the role of persons and systems that support or compound the abuse.
Become familiar with the major treatment approaches to alcoholism and chemical dependency.
Learn the national legal aspects of substance abuse.
Obtain knowledge of certain populations at risk with regard to substance abuse.
Access community resources offering assessment, treatment and follow-up for the abuser and family.
Learn the process of referring affected persons.

Continuing Education CEUS for MFT, LCSW, and LPC License Renewal

Our Continuing Education courses encompass all areas of mental health practice. Whether you are completing CEUs for your certification or maintain your license, our online continuing education courses provide the fastest, lowest cost, most convenient way to fulfill your CEU requirements. We offer courses in the following subjects:

Aging and Long Term Care CEUs
Alcoholism and Substance Abuse Dependency CEUs
Anger Management CEUs
Anxiety Disorders CEUs
Assessment and Diagnosis CEUs
Bipolar Disorder CEUs
Boundaries CEUs
Boundaries in Marriage CEUs
Child Abuse Assessment and Reporting CEUs
Cognitive Behavioral Therapy CEUs
Conflict Resolution CEUs
Crisis Counseling CEUs
Depressive Disorders CEUs
Family Therapy CEUs
From Panic to Power CEUs
Group Therapy CEUs
HIV and AIDS CEUs
How To Build a Thriving Fee-for-Service Practice CEUs
Human Sexuality CEUs
Law and Ethics CEUs
Managed Care CEUs
Mom's House, Dad's House CEUs
Panic Disorder CEUs
Post Traumatic Stress Disorder CEUs
Psychopharmacology CEUs
Spousal and Partner Abuse CEUs
Step-Wives CEUs

Disaster/Trauma PTSD

Disaster/Trauma
Browse and Read Publications

For more information
on PTSD click here

A Guide to Managing Stress in Crisis Response Professionals (SMA05-4113)
Booklet
Crisis response workers and managers—which include first responders, public health workers, construction workers, transportation workers, utilities workers, and volunteers—are unique in that they are repeatedly exposed to extraordinarily stressful events. This easy-to-use pocket guide focuses on general principles of stress management and offers simple, practical strategies that can be incorporated into the daily routine of managers and workers. It also provides a concise orientation to the signs and symptoms of stress.


After a Disaster: Self-Care Tips for Dealing With Stress (KEN01-0097)
Fact Sheet
Covers things to remember when trying to understand disaster events, signs that adults need stress management assistance, and ways to ease stress.


After a Disaster: What Teens Can Do (KEN01-0092)
Brochure
Provides information for teens to help understand some of their reactions as well as others, to the terrorist events. Suggestions are also provided to help ease the unfamiliar feelings related to the event.


Anniversary Reactions to a Traumatic Event: The Recovery Process Continues (NMH02-0140)
Fact Sheet
Anniversary Reactions to a Traumatic Event: The Recovery Process Continues describes common anniversary reactions among victims of traumatic events and explains how these reactions can be a significant part of the recovery process.


Anxiety Disorders (KEN98-0045)
Fact Sheet
Anxiety disorders range from feelings of uneasiness most of the time to immobilizing bouts of terror. This fact sheet briefly describes generalized anxiety disorder, panic disorder, phobias, and post-traumatic stress disorder. It is intended only as a starting point for gaining an understanding of anxiety disorders.


Center for Mental Health Services Division of Prevention Traumatic Stress and Special Programs Emergency Mental Health and Traumatic Stress Services Branch (KEN95-0011)
Fact Sheet
This fact sheet explains the role of the Emergency Services and Disaster Relief Branch in helping to safeguard the mental health of people affected by disasters, especially those in high-risk groups. Discusses the relationship between the Branch and Federal, State, and local agencies. 1998.1 pp.


Communicating in a Crisis: Risk Communication Guidelines for Public Officials (SMA02-3641)
Booklet
Communicating in a Crisis: Risk Communications Guidelines for Public Officials is a brief, readable primer that describes basic skills and techniques for clear, effective crisis communications and information dissemination, and provides some of the tools of the trade for media relations.


Cómo ayudar a los niños a enfrentar el miedo y la ansiedad (KEN01-0099)
Fact Sheet
En situaciones en que las tragedias afectan a su familia de modo personal o llegan a su hogar por medio de la prensa o televisión, usted puede ayudar a los niños a controlar la ansiedad causada por situaciones de violencia, muerte o desastres.


Creating Trauma Services for Women With Co-occurring Disorders (NMH03-0157)
Article
Many women with co-occurring mental health and substance abuse disorders and histories of trauma are parents who value their roles as mothers and bring skills to the task. Treatment for these women can be optimized by acknowledging their roles as parents and incorporating this reality into service design and delivery.


Crisis Counseling Assistance and Training Program (CCP) (SMA09-4373)
Brochure


Developing Cultural Competence in Disaster Mental Health Programs (SMA03-3828)
Booklet
Designed to supplement information already available through CMHS, SAMHSA, and other sources, Developing Cultural Competence in Disaster Mental Health Programs highlights important common issues relating to cultural competence and to disaster mental health. Disaster mental health providers and workers can use and adapt the guidelines set forth in this document to meet the unique characteristics of individuals and communities affected directly or indirectly by a full range of natural and human-made disasters.


Disaster Counseling (KEN01-0096)
Brochure
Disaster counseling involves both listening and guiding. Survivors typically benefit from both talking about their disaster experiences and being assisted with problem-solving and referral to resources. The following section provides "nuts-and-bolts" suggestions for workers.


Disaster Mental Health: Crisis Counseling Programs for the Rural Community (SMA99-3378)
Booklet
The Emergency Services and Disaster Relief Branch (ESDRB) of the Center for Mental Health Services (CMHS) works in partnership with the Federal Emergency Management Agency in overseeing national efforts to provide emergency mental health services to survivors of Presidentially declared disasters.


Field Manual for Mental Health and Human Service Workers in Major Disasters (ADM90-0537)
Booklet
For mental health workers and other human service providers who assist survivors following a disaster. This pocket reference provides the basics of disaster mental health, with numerous specific and practical suggestions for workers.


Helping Children Cope with Fear and Anxiety (CA-BKMARKR02)
Bookmarker
This bookmark lists ways that parents can help their children cope with fear and anxiety after a tragic event.


Helping Your Child With: Anxiety Disorders (CA-0007)
Fact Sheet
This fact sheet defines anxiety disorders, identifies warning signs, discusses risk factors, describes types of help available, and suggests what parents or other caregivers can do. 1997. 3 pp.


How Families Can Help Children Cope With Fear and Anxiety (CA-0022)
Article
This reproducible drop-in article provides tips for parents to keep the lines of communication with their children open and alerts parents and other caregivers to common signs of fear and anxiety. 2002. 1 p.


How to Deal with Grief (KEN01-0104)
Brochure
This short brochure provides information on grief and how to deal with it.


Major Depression in Children and Adolescents (CA-0011)
Fact Sheet
This fact sheet describes depression and its signs, identifies types of help available, and suggests what parents or other caregivers can do. 1997. 2 pp.


Mental Health All-Hazards Disaster Planning Guidance (SMA03-3829)
Booklet
It is possible, with sound, integrated planning, to fill the new, complex roles of identifying disease outbreaks, integrating health and mental health response, and conducting epidemiological surveillance-all of which are necessary in the new age of bioterrorism threats.


Mental Health Aspects on Terrorism (KEN01-0095)
Brochure
Describes typical reactions to terrorist events and provides suggestions for coping and helping others.


Mental Health Response to Mass Violence and Terrorism, A Field Guide (SMA05-4025)
Booklet


Mood Disorders (KEN98-0049)
Fact Sheet
This fact sheet provides basic information on the symptoms, formal diagnoses, and treatment for bipolar disorder (also known as manic depressive illness) and depression. 1998. 3 pp.


Older Adults (KEN01-0094)
Brochure
Provides suggestions for older adults attempting to understand the recent terrorist events.


Psychosocial Issues for Children and Adolescents in Disasters (ADM86-1070R)
Booklet
The materials discussed in this booklet will give crisis response workers essential information about the impact of disasters on individuals, how the trauma associated with such events impacts children, the unique world of children, and the diversity of family structures in which children reside.


Psychosocial Issues for Older Adults in Disasters (SMA99-3323)
Booklet
This guide to caring for the elderly who survive disasters defines “elderly” and describes what makes older adults vulnerable to disasters. Covers the nature of disasters and human responses to them. Includes a list of resources and a glossary of terms. 1999. 68 pp.


Reaction of Children to a Disaster (KEN01-0101)
Fact Sheet
This fact sheet, which is broken down by age, describes the ways in which children react to a disaster and what adults can do to help.


Recovering Your Mental Health: Dealing With the Effects of Trauma - A Self-Help Guide (SMA-3717)
Booklet
This is one of seven mental health self-help booklets. It focuses on helping individuals cope with traumatic events and makes suggestions of how they can take charge of their own recovery. It also provides a list of additional resources.


Responding to the Needs of People With Serious and Persistent Mental Illness in Times of Major Disasters (SMA96-3077)
Booklet
This manual addresses the need for specialized strategies to ensure that persons with serious mental illness who experience disasters receive services. Designed for State and local mental health administrators, planners, and care providers, it presents practical suggestions for disaster preparedness. Discusses the basic principles of disaster recovery programs and community support systems. 1996. 65 pp.


Self-Care Tips for Emergency & Disaster Response Workers (KEN01-0098)
Fact Sheet
Provides suggestions for those who are at the scene. It outlines facts, indicators of stress, and stress management strategies.


Stress Prevention and Management Approaches For Rescue Workers in the Aftermath of Terrorist Acts (KEN01-0112)
Fact Sheet
This fact sheet provides information for rescue workers on recovering from working at the site of terrorist acts. It also provides a hotline for more information.


Suicide Prevention: National Suicide Prevention Lifeline wallet card (Spanish) (SVP05-0126SP)
Card
Señales de Suicidio


Suicide Prevention: National Suicide Prevention Lifeline Brochure: When It Seems Like Tthere Is No Hope, There Is Help. (SVP06-0141)
Brochure


Tips for Survivors of a Traumatic Event: What to Expect in Your Personal, Family, Work, and Financial Life (NMH02-0139)
Fact Sheet
The Long-term Impact of a Traumatic Event: What to Expect in Your Personal, Family, Work, and Financial Life cites examples of personal uncertainties, family relationship changes, work disruptions, and financial worries that may contribute to the long-term impact of a traumatic event. Also includes tips on how to survive the road to recovery from a traumatic event.


Tips for Talking to Children After a Disaster: A Guide for Parents and Teachers (KEN01-0091)
Fact Sheet
Offers tips to parents on how to talk to children about the terrorist events.


Tips for Talking to Children After a Disaster: A Guide for Parents and Teachers (KEN01-0093)
Brochure
Explains how preschool age, early childhood, and adolescent children may respond to the terrorist events.


Tips for Talking to Children in Trauma: Interventions at Home for Preschoolers to Adolescents (NMH02-0138)
Fact Sheet
Age-specific Interventions at Home for Children in Trauma: From Preschool to Adolescence suggests activities arranged by age group to help children share recovery feelings and experiences at home. Includes activities for preschoolers, elementary age children, and pre-adolescents and adolescents.


Tips for Teachers in Time of Disaster: Taking Care of Yourselves and Each Other (KEN01-0103)
Fact Sheet
Teachers directly deal with children's reactions to disaster. They may also be impacted by the disaster. It is extremely important to recognize for them to recognize that, like children, they are under particular stress and vulnerable to "burnout". This facts sheet provides helpful hints on how to stay mentally healthy.


Training Manual for Mental Health and Human Service Workers in Major Disasters (SMA96-0538)
Pamphlet
This training manual explains how survivors respond to and recover from disasters and highlights the importance of tailoring disaster response to individual communities and populations. Intended for use by instructors, it describes effective interventions for responding to disasters and strategies for stress prevention and management among mental health and human service workers.