Question: Given the discussion on brain recovery and stretching out the time expected for clients to start to engage in tx…we use structured graduated responses to continued drug use or missed treatment sessions in our court, and the number of responses/sanctions we have for those problems in our court are limited, so we may be looking at program termination before a client realistically has had the opportunity to overcome some of the brain dysfunction. Any suggestions on how many court responses we should have available and/or when we should realistically look at termination for our clients?
Answer – (from Theresa Lemus) – Clinical withdrawal from most substances of abuse has a fairly predictable set of symptoms that can and should be monitored by knowledgeable medical personnel and or trained clinicians. Once immediate withdrawal (detoxification) subsides and most of the drug has cleared the body, the deficit in neurotransmitters becomes the most immediate concern. During this time, once detoxification is complete the client experiences a complete or near-complete absence of dopamine. Note: It should be obvious that during detoxification- a person absolutely cannot function normally and has limited ability to function much at all.
Remember- all humans produce and utilize dopamine (a neurotransmitter) normally. Dopamine is a neurotransmitter present in regions of the brain that regulate movement, emotion, cognition, motivation, and feelings of pleasure. Dopamine has many receptor sites in an area of the brain nicknamed “the reward center”. One of the reward center’s main functions is to ensure that we will repeat life-sustaining activities and it does this by associating activities with pleasure or reward. So, whenever this reward circuit is activated, the brain notes that something important is happening that needs to be remembered, and teaches us to do it again and again, without thinking about it. Because drugs of abuse stimulate the same circuit (the Reward Center) and because most drugs of abuse target the brain’s reward system by flooding the circuit with dopamine (a neurotransmitter that regulates movement, emotion, cognition, motivation, and feelings of pleasure) drugs have an incredibly positive effect on the brain’s reward center thus– we learn to abuse drugs over and over again.
Also keep in mind that drugs of abuse release 2 to 10 times the amount of dopamine that natural rewards, (i.e. eating, drinking, and nurturing) do. Which means that regular life-sustaining rewards noted above become less a priority to the brain than drugs. In addition, once drugs are stopped- so does the hyper-response of the reward center. The problem is, by now the brain has learned to stop producing dopamine in response to “normal / natural rewards” simply because those rewards are inferior to the drugs.
Now- skip to post-detox when we typically would have a person come into FDC. Based on what you read above- there are a few recommendations:
1) All persons working with an FDC should understand the process described above. Cross Training in Substance Use Disorders and the Science of Addiction (NIDA)
2) Clinicians must carefully assess where the client is in this process and communicate these details to the team in staffing so that the team can customize realistic expectations of the client for where they are at. For instance- client is in active withdrawal (detoxing) and is suffering the withdrawal syndrome for their drug(s) of choice or client completed detox a couple days ago and may continue to present with flat affect, may fail to show “normal” feelings, may not be capable of following directions, and may appear to not care because they are absent of dopamine (a neurotransmitter that regulates movement, emotion, cognition, motivation, and feelings of pleasure). Cross Training in Substance Use Disorders and the Science of Addiction (NIDA), Motivational Interviewing and Trantheoretical Stages of Change and possible Mental Health Evaluation
3) FDC teams should make every effort to understand why a client is breaking the rules and have contingency plans to address the brain dysfunction before terminating them. Do the phases take into account the Science? Do we need to go back and take into account the dysfunction and reduce the tasks assigned to clients in the first phase and/or increase the supports during the time that the client is dopamine-absent or low (early recovery).