**II. Session Instructions**

**Family Education Sessions Overview**

+---+--------------+----------+---------------------------------------+
| * | **Session**  | **Type   | **Content**                           |
| * |              | of       |                                       |
| N | **Title**    | S        |                                       |
| o |              | ession** |                                       |
| . |              |          |                                       |
| * |              |          |                                       |
| * |              |          |                                       |
+===+==============+==========+=======================================+
| 1 | Triggers and | Po       | Participants learn about the chemical |
|   | Cravings     | werPoint | basis of pleasure and reward in the   |
|   |              | pres     | brain and how triggers and cravings   |
|   |              | entation | relate to addiction.                  |
+---+--------------+----------+---------------------------------------+
| 2 | Alcohol and  | Po       | Participants learn about the nature   |
|   | Recovery     | werPoint | and prevalence of alcohol use,        |
|   |              | pres     | including the dangers it poses to     |
|   |              | entation | health and recovery.                  |
+---+--------------+----------+---------------------------------------+
| 3 | Recovery     | Panel    | Participants learn about the benefits |
|   |              | pres     | and challenges of recovery from       |
|   |              | entation | others in recovery. Participants also |
|   |              |          | learn about 12-Step programs and      |
|   |              |          | mutual-help groups.                   |
+---+--------------+----------+---------------------------------------+
| 4 | Met          | Po       | Participants learn about the nature   |
|   | hamphetamine | werPoint | and prevalence of methamphetamine and |
|   | and Cocaine  | pres     | cocaine, including the dangers they   |
|   |              | entation | pose to health and recovery.          |
+---+--------------+----------+---------------------------------------+
| 5 | Roadmap for  | Po       | Participants learn what relapse risks |
|   | Recovery     | werPoint | they will face in each of the four    |
|   |              | pres     | stages of recovery.                   |
|   |              | entation |                                       |
+---+--------------+----------+---------------------------------------+
| 6 | Coping With  | Mul      | Participants explore feelings and     |
|   | the          | tifamily | needs of one another with respect to  |
|   | Possibility  | group    | relapse and learn strategies for      |
|   | of a Relapse | di       | coping with relapse.                  |
|   |              | scussion |                                       |
+---+--------------+----------+---------------------------------------+
| 7 | Opioids and  | Po       | Participants learn about the nature   |
|   | Club Drugs   | werPoint | and prevalence of heroin and club     |
|   |              | pres     | drugs. They also learn about the      |
|   |              | entation | dangers to health and recovery posed  |
|   |              |          | by heroin, GHB, Rohypnol, LSD, and    |
|   |              |          | ecstasy.                              |
+---+--------------+----------+---------------------------------------+
| 8 | Families in  | Po       | Participants learn about the process  |
|   | Recovery     | werPoint | of recovery and how they can work     |
|   |              | pres     | together to avoid relapse.            |
|   |              | entation |                                       |
+---+--------------+----------+---------------------------------------+
| 9 | Rebuilding   | Mul      | Participants explore the important    |
|   | Trust        | tifamily | role that trust plays in recovery and |
|   |              | group    | how they can begin to repair damaged  |
|   |              | di       | relationships.                        |
|   |              | scussion |                                       |
+---+--------------+----------+---------------------------------------+
| 1 | Marijuana    | Po       | Participants learn about the nature   |
| 0 |              | werPoint | and prevalence of marijuana,          |
|   |              | pres     | including the dangers it poses to     |
|   |              | entation | health and recovery.                  |
+---+--------------+----------+---------------------------------------+
| 1 | Living With  | Mul      | Participants explore the ways in      |
| 1 | an Addiction | tifamily | which recovery can affect family life |
|   |              | group    | and discuss challenges and            |
|   |              | di       | strategies.                           |
|   |              | scussion |                                       |
+---+--------------+----------+---------------------------------------+
| 1 | C            | Mul      | Participants explore the important    |
| 2 | ommunication | tifamily | role that communication plays in      |
|   | Traps        | group    | healthy relationships and about the   |
|   |              | di       | problems that can hamper              |
|   |              | scussion | communication.                        |
+---+--------------+----------+---------------------------------------+

**Session 1: Triggers and Cravings (PowerPoint Presentation)**

**Overview**

***Goals of Session***

-   Help participants understand the relationship between the pleasure
    and reward system in the brain and addiction.

-   Help participants identify the process of addiction.

-   Help participants understand the development and progression of
    craving.

-   Help participants recognize the relationship of triggers to craving.

-   Help participants develop ways to address triggers and cravings.

***Handouts***

-   FE 1A---A Definition of Addiction: American Society of Addiction
    Medicine

-   FE 1B---Thought Stopping

***PowerPoint Presentation (40--45 minutes)***

The counselor presents the PowerPoint slides, encouraging participants
to ask questions at any time. The Presentation section below contains
talking points for each slide. The counselor should add examples and
explain concepts in a way that is appropriate for the audience.

***Focused Discussion (30 minutes)***

The counselor facilitates discussion of the material presented and asks
open-ended questions such as

-   What did you hear that was new information? What surprised you?

-   How does the information relate to your experience?

-   How will this information affect the way your family copes with
    recovery?

-   What questions do you have about this information?

***Open Discussion (15--20 minutes)***

The counselor allows time for participants to ask general questions and
to bring up any pressing issues they may have.

**Presentation**

The bulleted points presented below concisely state the information the
counselor should cover for each slide. The PowerPoint slides can be
downloaded from www.kap.samhsa.gov by clicking on Products, clicking on
Resource Documents & Manuals, and then clicking on the Matrix icon.

***Slide 1-1---Triggers and Cravings***

-   This presentation begins with an overview of addiction and
    dependence and then focuses on the development of addiction and
    cravings and the relationship of environmental and internal triggers
    for craving.

-   Understanding this process allows both clients and families to view
    substance use disorders in a new, more understandable way and to see
    what is behind much of the advice given to clients in treatment.

-   In short, triggers lead to cravings, and cravings lead to using
    drugs or drinking alcohol.

-   Common sense suggests that being around people, places, or
    situations that have resulted in past substance use can increase the
    chances of using or drinking again.

-   The influence that triggers have on the brain makes the advice to
    avoid triggers more than just a good idea; there is no other
    reliable way to avoid cravings and relapse.

***Slide 1-2---Changes in the Brain***

-   Addiction is a neurobehavioral disorder. To understand what this
    means, we must look at two important areas of the brain: the
    prefrontal cortex and the limbic system.

-   In a healthy brain, the prefrontal cortex, or outside portion of the
    brain, is responsible for rational thinking. It is the
    decisionmaker, the onboard computer of the human being.

-   Underneath the cortex is a much older, more primitive part of the
    brain's anatomy, the limbic system.

-   To a greater or lesser degree this lower part of the brain is
    involved in all forms of addiction. It is where the pleasure and
    reward system is located and where most, if not all, survival
    mechanisms originate.

-   Pleasure is a powerful biological force for survival. If you do
    something pleasurable, the brain is wired in such a way that you
    tend to do it again.

-   Unlike the cortex, the limbic system is not under conscious, or
    voluntary, control. The powerful effects of drugs and alcohol on
    this and other parts of the brain can lead to addictive use,
    lessening normal, rational restraints on behavior.

-   Prolonged drug use changes the brain in fundamental and long-lasting
    ways. These changes are a major component of the addiction itself.

-   Accepting addiction as a complicated relationship between the brain
    and behavior is a step toward recovery.

***Slide 1-3---Conditioning***

-   The part of the brain affected by mood-altering substances is the
    same part of the brain that makes us seek food when we are hungry
    and water when we are thirsty and is responsible for our sexual
    drive.

-   Hunger, thirst, sexual desire, and the need for nurturing are
    natural cravings. Satisfying these cravings promotes our survival as
    individuals and as a species. When a craving is not satisfied (e.g.,
    when a person has not eaten for a long time), satisfying the craving
    overpowers all other concerns.

-   When long-term drug or alcohol use occurs, the brain can become
    rewired and adapt to these substances as if survival depends on
    them.

-   There is a demonstration that reflects the power of drugs on the
    brain and behavior:

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-   If you release a caged mouse and it has the option to run into a
    well-lighted area or a dark area, it always will run into the dark.

-   Mice and other small rodents have been conditioned to seek out the
    dark automatically, because darkness protects them from predators.
    This ingrained survival mechanism evolved over millions of years in
    this species.

-   If the mouse is given doses of cocaine in the lighted area, the
    mouse will go into the lighted area each time it is released from
    its cage. This classic experiment demonstrates "conditioned place
    preference," reversing the conditioning that took place over
    millions of years.

***Slide 1-4---Pavlov***

-   To understand the relationship of triggers to craving, it is
    important to understand a bit about a process called conditioning.

-   I.P. Pavlov, a Russian scientist, received the Nobel Prize for a
    series of experiments he conducted on the physical processes of
    digestion.

-   These experiments were continued by some of his students, and the
    conclusions from these experiments became known as the principles of
    classical conditioning.

***Slide 1-5---Pavlov's Dog***

-   Pavlov would feed the dogs and ring a bell at the same time.

-   The dogs saw and smelled the food that then stimulated, or
    triggered, a part of their brain, causing them to produce saliva and
    secrete stomach acid in anticipation of eating.

-   In a relatively short time, Pavlov and his colleagues rang the bell
    *without* the presence of food, and the dogs still produced saliva
    and stomach acid as if food were present.

-   The dogs connected the sound of the bell, the **trigger**, with
    anticipation of eating and responded (involuntarily) physically to
    the powerful trigger, or stimulus, of the bell.

-   Once a dog had been conditioned in this way, no matter how smart or
    well trained the dog was, it continued to produce fluids at the
    sound of the bell. It had no choice; the only way that Pavlov's dogs
    could avoid drooling was by avoiding the bell.

-   The dogs had developed a conditioned response to the bell.

-   The human brain responds in much the same way to conditioned drug
    and alcohol triggers that produce cravings.

-   Drugs and alcohol produce changes in the brain, which result in
    feelings of pleasure. Events that people experience or surroundings
    that people are in when they use are like Pavlov's bell; they cause
    people to experience cravings (like the dogs' physical response to
    the bell, salivating) even when they are not using. The brain may
    even trigger physical reactions that are similar to those initially
    created by the drug itself.

-   For example, if participants were to think about sucking on a lemon,
    they probably would pucker their lips without even meaning to. This
    response is based on their experiences of tasting a lemon in the
    past.

-   This sort of response to drug triggers occurs regardless of whether
    a person intends to use. The dependent person can prevent his or her
    brain's reaction only by avoiding triggers.

-   Triggers and cravings are hallmarks of addiction.

***Slide 1-6---A Definition of Addiction***

-   Handout FE 1A provides a definition of addiction developed by the
    American Society of Addiction Medicine.

-   Primary means that addiction is not just a symptom of another
    disease or disorder; it is a disease in and of itself.

-   Chronic means that the disease continues over time and can be
    treated but not cured. Examples of other chronic diseases include
    diabetes and heart disease.

-   The definition states that genetic, psychosocial, and environmental
    factors may influence the development and manifestations (symptoms)
    of the disease.

-   "Genetic" means that some people are born with certain
    susceptibilities to becoming addicted to drugs or alcohol.

-   "Psychosocial and environmental factors" means that a person's
    emotional, mental, and social life as well as his or her family,
    peers, living situation, employment or school situation, and other
    life circumstances can affect whether addiction develops and how it
    develops.

-   These psychosocial and environmental factors are important to
    consider when looking at a person's triggers for drug or alcohol
    use.

***Slide 1-7---The Addictive Process***

-   The rest of this session looks at the process of developing
    addiction over time, focusing on craving and the triggering of
    craving.

-   The process of addiction can be looked at in terms of four phases:
    the introductory phase, the maintenance phase, the disenchantment
    phase, and the disaster phase.

-   During each phase, people experience increasing levels of obsessive
    thinking, craving responses, use, and consequences resulting from
    their substance.

-   Although the slides are methamphetamine specific, the process of
    addiction is virtually the same for other addictive drugs and
    alcohol.

***Slide 1-8---Addictive Process (Introductory Phase)***

-   Methamphetamine (or another drug or alcohol) use is relatively
    infrequent during the introductory phase of the process of
    addiction.

-   Use may be limited to a few times a year, by chance, or on special
    occasions.

-   The positives of drug or alcohol use appear to outweigh the
    negatives.

***Slide 1-9---Conditioning Process During Addiction (Introductory
Phase)***

-   Unknowingly, persons who use drugs or alcohol are conditioning their
    brains every time they use, but they experience only a mild
    association between people, places, or events and drug or alcohol
    use.

***Slide 1-10---Development of Obsessive Thinking (Introductory
Phase)***

-   During this phase, drug or alcohol use is only one small component
    of a person's overall thought process.

***Slide 1-11---Development of Craving Response (Introductory Phase)***

-   The craving response is the combined experiences of drug or alcohol
    triggers activating the limbic system and the continuing thoughts
    about using drugs or alcohol associated with these triggers.

-   During this introductory phase, the limbic system is activated
    *directly* by drugs or alcohol and, depending on whether the
    substance is a stimulant or a depressant, physiological arousal
    either increases or decreases (for example, methamphetamine causes
    the heart and respiration to speed up, whereas heroin causes the
    heart and respiration to slow down).

***Slide 1-12---Addictive Process (Maintenance Phase)***

-   During the maintenance phase of the addictive process, the frequency
    of drug or alcohol use increases to perhaps monthly or weekly.

-   The scales begin to lean away from the positives.

***Slide 1-13---Conditioning Process During Addiction (Maintenance
Phase)***

-   Conditioning is progressing. The people, places, and things
    associated with drug and alcohol use have become triggers.

-   Exposure to these triggers causes thoughts about drug and alcohol
    use.

-   These thoughts produce moderate physiological reactions leading to a
    drive to find and use drugs and alcohol.

***Slide 1-14---Development of Obsessive Thinking (Maintenance Phase)***

-   Thoughts of drug and alcohol use occur more frequently.

***Slide 1-15---Development of Craving Response (Maintenance Phase)***

-   A mild physiological *arousal* occurs in situations closely
    associated with drug and alcohol use.

-   As the person encounters drug and alcohol triggers, the limbic
    system is activated, and drug and alcohol cravings occur.

-   When drugs and alcohol finally are ingested, a concurrent
    physiological state occurs.

***Slide 1-16---Addictive Process (Disenchantment Phase)***

-   During the disenchantment phase, the scales tip from the positive to
    the negative.

-   The consequences of drug and alcohol use are severe, and the
    person's life becomes unmanageable.

-   At this point the rational decision is to stop using, but the cortex
    part of the brain is no longer in control.

-   Thinking, evaluating, and decisionmaking may appear to be happening,
    but behavior is not always based on rational thinking.

-   People may resolve sincerely to quit using yet may find themselves
    out of control at the first thought of drugs and alcohol, at the
    first encounter with someone they used with, at the availability of
    cash, or with other potent triggers.

***Slide 1-17---Conditioning Process During Addiction (Disenchantment
Phase)***

-   At this point people usually cross the line into addiction,
    continuing to use in spite of serious negative physical and social
    consequences.

-   Triggers in this phase produce a strong physiological response that
    drives people to acquire and use drugs and alcohol.

***Slide 1-18---Development of Obsessive Thinking (Disenchantment
Phase)***

-   During the disenchantment phase, the frequency of drug and alcohol
    thinking increases, crowding out most thoughts about other aspects
    of life.

***Slide 1-19---Development of Craving Response (Disenchantment
Phase)***

-   In this phase, the craving response is powerful.

-   People feel an overpowering physical reaction in situations further
    and further removed from drugs or alcohol.

-   The craving response is almost as powerful as the actual physical
    reaction to drugs and alcohol.

***Slide 1-20---Addictive Process (Disaster Phase)***

-   In the disaster phase, the drug and alcohol use is often automatic.

-   People cannot restrain themselves from using drugs or alcohol.

-   People's behavior in the phase is much like the behavior of addicted
    laboratory animals that use drugs until they die.

***Slide 1-21---Conditioning Process During Addiction (Disaster
Phase)***

-   In this phase, addicted persons are using either daily or in binges,
    which most likely are interrupted only by physical collapse,
    hospitalization, or arrest.

-   The constant overpowering craving from the limbic system overwhelms
    the cortex.

***Slide 1-22---Development of Obsessive Thinking (Disaster Phase)***

-   Thoughts of drug and alcohol use dominate the person's
    consciousness.

***Slide 1-23---Development of Craving Response (Disaster Phase)***

-   In the disaster phase, cravings can create powerful physiological
    effects that even can begin to mimic the initial physiological
    effects of actually ingesting the drug.

***Slide 1-24---Trigger--Thought--Craving--Use***

-   Craving can be activated by external triggers.

-   Triggers can cause thoughts, which can turn into cravings and lead
    to use.

***Slide 1-25---Interruption***

-   The earlier this chain of events is interrupted, the more likely
    relapse will be avoided.

-   An effective technique for coping with triggers and cravings is
    thought stopping.

***Slide 1-26---Thought Stopping***

-   Simply put, thought stopping interrupts the usual process that
    culminates in using or drinking.

-   The usual reaction to thoughts about using "argue" with the
    developing thought/craving. The argument usually results in the
    addiction winning.

-   Arguing precedes negotiation, compromise, justification, and,
    possibly, relapse.

-   Thought stopping ends this process before relapse begins, usually
    stopping cravings in their tracks.

-   If thought stopping works, but the thoughts frequently keep coming
    back, people in recovery may have to change their immediate
    environments or engage in tasks that require full concentration.

-   Thought stopping techniques include

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-   Visualization

-   Rubberband snap

-   Relaxation

-   Calling someone

***Slide 1-27---Visualization***

-   When people experience thoughts of using drugs or alcohol, they can
    visualize a switch or lever and imagine actually moving it from ON
    to OFF to stop the drug- or alcohol-using thoughts.

-   It is important to have another thought ready to replace the drug-
    or alcohol-using thoughts.

-   It should be a pleasurable or meaningful thought and one that does
    not involve drug or alcohol use.

***Slide 1-28---Rubberband Snap***

-   The rubberband behavioral technique helps people in recovery "snap"
    their attention away from thoughts of using drugs or alcohol.

-   People who are addicted simply put a rubberband loosely around their
    wrists.

-   When a craving or using thought occurs, people snap the rubberband
    lightly against their wrists and say "NO" (either aloud or not,
    depending on the situation) to the drug- or alcohol-using thoughts.

-   As with visualization, people need to have another thought ready to
    replace the drug- and alcohol-using thoughts.

-   This technique works best if people leave the rubberband on all the
    time.

***Slide 1-29---Relaxation***

-   Cravings often create feelings of hollowness, heaviness, and
    cramping in the stomach.

-   These feelings often can be relieved by breathing in deeply (filling
    the lungs with air) and slowly breathing out three times in a row
    and by focusing on relaxing the body as much as possible for a few
    minutes.

-   This process can be repeated as often as necessary whenever the
    feelings return.

***Slide 1-30---Calling Someone***

-   Talking to another person provides an outlet for feelings and allows
    people to "hear" their own thinking process.

-   Recovering people should carry the phone numbers of supportive
    people with them *always,* so they can call whenever support is
    needed.

-   Handout FE 1B provides a list of thought-stopping suggestions.

**Session 2: Alcohol and Recovery (PowerPoint Presentation**)

**Overview**

***Goals of Session***

-   Provide participants with factual information about alcohol.

-   Provide participants with information about the risks that alcohol
    poses to recovery.

-   Provide an opportunity for participants to talk about their
    experiences (or the experiences of their family member) with alcohol
    and recovery.

***Handout***

-   FE 2---Fact Sheet: Alcohol

***PowerPoint Presentation (40--45 minutes)***

The counselor presents the PowerPoint slides, encouraging participants
to ask questions at any time. The Presentation section below contains
talking points for each slide. The counselor should add examples and
explain concepts in a way that is appropriate for the audience.

***Focused Discussion (30 minutes)***

The counselor facilitates discussion of the material presented and asks
open-ended questions such as

-   What did you hear that was new information? What surprised you?

-   How does the information relate to your experience?

-   How will this information affect the way your family copes with
    recovery?

-   What questions do you have about this information?

***Open Discussion (15--20 minutes)***

The counselor allows time for participants to ask general questions and
to bring up any pressing issues they may have.

**Presentation**

The bulleted points presented below concisely state the information the
counselor should cover for each slide. The PowerPoint slides can be
downloaded from www.kap.samhsa.gov by clicking on Products, clicking on
Resource Documents & Manuals, and then clicking on the Matrix icon.

***Slide 2-1---Alcohol and Recovery***

-   This session focuses on alcohol.

-   Because alcohol is such a significant and pervasive part of U.S.
    culture, *not* drinking presents a particular challenge for a person
    recovering from stimulant dependence.

-   People in recovery must understand how alcohol can affect their
    bodies, behaviors, and recoveries.

-   Although many people use alcohol occasionally and without problems,
    alcohol is a powerful substance that can seriously damage people's
    bodies and lives.

***Slide 2-2---Alcohol in the Brain***

-   Alcohol affects many chemical systems in the brain.

-   A delicate balance exists between chemical systems that *stimulate*
    and chemical systems that *inhibit*, or slow down, functions of the
    brain and body.

-   Alcohol interferes with and changes this delicate balance.

***Slide 2-3---Adaptation***

-   If people drink alcohol frequently and steadily, their brains adapt
    over time to the presence of alcohol.

-   They do this by producing naturally stimulating chemicals in larger
    quantities than normal.

-   As the brain and body adapt, the person can become dependent on
    alcohol to maintain a chemical balance.

-   If a person who is dependent on alcohol stops drinking all at once,
    the high level of stimulating chemicals can cause withdrawal
    symptoms because the depressant effect of alcohol is absent.

-   Withdrawal symptoms vary depending on how much alcohol and how long
    a person has been drinking.

***Slide 2-4---Withdrawal Symptoms***

-   Withdrawal symptoms can include

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-   Seizures

-   Tremors (shakiness)

-   Nausea

-   Auditory or visual hallucinations (hearing or seeing things that
    aren't there)

-   Insomnia

-   Agitation (extreme nervousness and irritability)

-   Confusion

***Slide 2-5---Delirium Tremens***

-   Alcohol withdrawal can be life-threatening.

-   Delirium tremens (DTs) is a dangerous withdrawal condition.

-   Without treatment, as many as 1 out of every 20 people who develop
    its symptoms die.[^1]

-   Symptoms of DTs include

    -   Rapid heart rate

    -   Increased body temperature

    -   Increased blood pressure

    -   Abnormally fast breathing

    -   Sweating

    -   Tremors

    -   Loss of ability to control muscle movement

    -   Altered mental status

    -   Hallucinations

    -   Cardiovascular collapse and death

***Slide 2-6---Incidence***

-   Most people older than 21 can drink moderate amounts of alcohol
    without developing problems.

-   The 2003 National Survey on Drug Use and Health reports that about
    half of Americans ages 12 and older report drinking alcohol.[^2]

-   The National Institute on Alcohol Abuse and Alcoholism estimates
    that about 3 in 10 (30 percent) American adults drink at levels that
    increase their risk for physical, emotional, and social
    problems.[^3]

-   Of these heavy drinkers, about one in four currently has an alcohol
    use or dependence disorder.[^4]

***Slide 2-7---Incidence by Gender and Age***[^5]

-   In general, more men report being current drinkers than do women: in
    2003, 57 percent of men ages 12 and older reported past month
    alcohol use compared with 43 percent of women.

-   The rate of alcohol *dependence* is also lower for women than it is
    for men.

-   Estimates indicate that about one-third of those dependent on
    alcohol are women.

-   The incidence of heavy alcohol use is highest among young adults
    between ages 21 and 29 and lowest among adults ages 65 and older.

***Slide 2-8---Initial Effects of Alcohol***

-   When people first begin to drink, they experience

    -   Feelings of well-being or euphoria

    -   Talkativeness and increased sociability

    -   Lowered inhibitions (people may do or say things they otherwise
        would not do or say)

***Slide 2-9---Later Effects***

-   As people continue to drink, they begin to feel sedated and drowsy
    and may

    -   Have trouble with balance

    -   Experience impaired peripheral vision (the ability to see to the
        sides)

    -   Experience delayed reaction time

    -   Slur their words

    -   Vomit

    -   Fall asleep

    -   Black out and not remember anything that happened for a period
        while under the influence

***Slide 2-10---Long-Term Effects***

-   Heavy drinking can cause significant damage to organ systems in the
    body.

-   "Heavy" drinking can be defined as binge drinking on five or more
    occasions in the past month.

-   Binge drinking is drinking five or more drinks on one occasion at
    least once in the past month.

-   When alcohol is consumed, it enters the bloodstream and is
    distributed throughout the body.

-   Although heavy drinking is most commonly associated with liver
    damage, it also can affect the digestive, cardiovascular, immune,
    endocrine, and nervous systems.

***Slide 2-11---Liver***

-   The liver is the primary site of alcohol metabolism (breaking down
    the alcohol into other chemicals and eliminating it from the body),
    yet a number of the chemicals produced by this process are toxic
    (poisonous) to the liver itself.

-   These toxins add up over time, leading to alcohol-induced liver
    damage.

-   This damage can take the form of either inflammation (alcoholic
    hepatitis) or scarring (cirrhosis).

-   Often both types of damage exist in the same person.

-   Alcohol dependence is the leading cause of liver-related deaths in
    the United States.

-   It is estimated that more than 2 million people experience some form
    of alcoholic liver disease.

***Slide 2-12---Digestive System***

-   Alcohol also affects the digestive system.

-   Excessive drinking has been shown to cause chronic inflammation of
    the esophagus (the passageway to the stomach), which can lead to
    esophageal cancer.

-   Enlarged blood vessels in the esophagus (esophageal varices) can be
    caused by liver disease.

-   These blood vessels can rupture; when this happens, it is often
    fatal.

-   Heavy alcohol use has been linked to pancreatitis (inflammation of
    the pancreas) and cancers in the throat, colon, and rectum.

***Slide 2-13---Cardiovascular System***

-   Although moderate alcohol intake (one drink per day for women; two
    drinks for men) has been shown in some studies to be heart
    protective, heavy alcohol use is associated with serious heart
    disease:

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-   It interferes with the pumping action of the heart, causing
    irregular and/or weak heartbeats.

-   It causes high blood pressure, which can increase the risk of
    stroke.

    -   Blood platelets, involved in blood clotting, also are damaged,
        causing an increased risk of bleeding.

***Slide 2-14---Immune System***

-   Alcohol can seriously affect the body's immune system (the system
    that protects the body from disease) by damaging white and red blood
    cells.

-   People who drink heavily experience more infectious diseases than do
    people who drink only moderately.

-   Alcohol can damage the immune system to a level where the immune
    system attacks the body. This can result in, or worsen,
    alcohol-induced organ damage such as alcoholic liver disease.

***Slide 2-15---Endocrine System***

-   The body's endocrine system (the hormone-controlling system) can be
    damaged by long-term alcohol use.

-   The balance of the hormones insulin and glucagon, which regulate
    blood sugar levels, is disrupted; diabetes is common among people
    who drink heavily.

-   Drinking alcohol can alter the release of reproductive hormones,
    growth hormone, and testosterone.

-   The effects of alcohol on hormone systems include decreased testicle
    and ovary size and disrupted sperm and egg production.

-   Alcohol-induced changes in hormone concentrations are associated
    with sexual dysfunction in both men and women.

***Slide 2-16---Nervous System***

-   Heavy use of alcohol may damage the nervous system. This damage may
    include

    -   Peripheral neuropathy, resulting in numbness and tingling in the
        legs, arms, and/or hands

    -   Wernicke's syndrome, resulting in disordered eye movements, very
        poor balance, and difficulty walking

    -   Korsakoff's syndrome, resulting in severely affected memory,
        preventing new learning from taking place

        -   In addition to these nervous system disorders, most people
            who drink heavily have some loss of mental function, reduced
            brain size, and changes in the function of brain cells.

***Slide 2-17---Behavioral Effects***

-   Drinking can cause behavioral and physical problems.

    -   Alcohol use is associated with domestic violence, child abuse,
        and assault.

    -   Use is associated with all types of accidents.

    -   The more heavily a person drinks, the greater the potential for
        problems at home, at work, with friends, and even with
        strangers. These problems may include

> -- Arguments with or separation from spouse and other family members
>
> -- Strained relationships with colleagues
>
> -- Absence from or lateness to work with increasing frequency
>
> -- Loss of employment because of decreased productivity
>
> -- Committing or being the victim of violence
>
> -- Auto crashes and/or arrests for driving under the influence (DUI)

***Slide 2-18---Alcohol and Women***[^6]

-   Drinking affects women differently than it affects men:

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-   Over the long term, women develop alcohol-related disease more
    quickly and after drinking less alcohol than men do.

-   Women develop alcoholic liver disease more quickly and after
    drinking less alcohol than men do. Women are more likely than men to
    develop alcoholic hepatitis (liver inflammation) and to die from
    cirrhosis.

-   Women are more vulnerable than men to alcohol-induced brain damage.

-   Among people who drink heavily, men and women have similar rates of
    alcohol-related heart disease, even though women drink less alcohol
    over a lifetime than men do.

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-   For some women, even moderate drinking can slightly raise the risk
    of breast cancer.

***Slide 2-19---Alcohol and Pregnancy***

-   A woman who drinks when she is pregnant puts her baby at risk of
    serious problems.

-   Babies born to mothers who drank during pregnancy may have mental
    retardation or other learning and behavioral problems.

-   Research has not found *any* amount of alcohol to be safe during
    pregnancy.

***Slide 2-20---Fetal Alcohol Spectrum Disorders***

-   The most serious risk is fetal alcohol spectrum disorders (FASD).

-   FASD is the leading known cause of preventable mental retardation in
    the United States.[^7]

***Slide 2-21---Fetal Alcohol Spectrum Disorders (Cognitive and
Behavioral Impairments)***[^8]

-   Although the effects of FASD vary, children with the syndrome have
    cognitive and behavioral impairments.

-   Behavioral and neurological problems associated with FASD may lead
    to poor academic performance and legal and employment difficulties
    in adolescence and adulthood.

***Slide 2-22---Fetal Alcohol Spectrum Disorders (Craniofacial
Features)***

-   Children with severe FASD usually have distinctive facial and head
    features, such as

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-   Skin folds at the corner of the eyes

-   A low nasal bridge

-   A short nose

-   An indistinct philtrum (the groove between the nose and upper lip)

-   A small head circumference

-   A small eye opening

-   A small midface

-   A thin upper lip

***Slide 2-23---Total Abstinence***

-   Heavy alcohol use has obvious damaging effects.

-   However, occasional, light drinking can have a damaging effect on a
    person in recovery, even if the person has never experienced any
    problems with alcohol.

-   Clients in Matrix treatment are asked to stop using all illicit
    drugs *and* alcohol, no matter what drug or drugs brought them into
    treatment.

***Slide 2-24---Alcohol Triggers Are Everywhere***

-   A person in recovery who is trying to stop using alcohol faces a
    difficult struggle.

-   External triggers bombard people in recovery; consumption of alcohol
    may be assumed to be the norm, especially at social functions and
    celebrations.

-   Drinking often accompanies certain activities: wine with dinner, a
    beer at the game, a drink after work.

-   It is hard for a person in recovery to go through a typical day
    without coming across many reminders---both cultural and
    personal---of alcohol.

-   Advertisements, movies, and TV shows link drinking with being happy,
    popular, and successful.

-   Recovering people encounter colleagues, friends, and family members
    with whom they used to drink and pass by bars or liquor stores that
    they used to frequent.

-   Alcohol is integral to celebrations such as parties and weddings.

-   A person in recovery who is not drinking may feel left out of the
    fun or less cool.

***Slide 2-25---Internal Triggers***

-   Internal triggers also pose problems:

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-   Depression, anxiety, and loneliness are all characteristic of
    recovery.

-   These emotional states and others, such as stress, anger, and guilt,
    are cues to drink for many people.

-   Facing the emotional fallout from quitting other substances, people
    in recovery may feel justified in turning to alcohol to "relieve"
    their mental state.

***Slide 2-26---Relapse Warning***

-   However, in spite of the difficulty, it is critical that people
    recovering from stimulant dependence abstain from alcohol.

-   One big reason for this is that studies show that people who use
    stimulants are *eight times* more likely to relapse to stimulant use
    if they use alcohol than if they don't drink.[^9]

***Slide 2-27---Relapse***

-   Drinking lowers a person's inhibitions and makes the person more
    likely to act impulsively on any using thoughts they may have.

    -   Because alcohol affects the rational, reasoning part of the
        brain, people who are drinking are ill equipped to cope with any
        triggers for stimulant use they encounter.

    -   In addition, people who are drinking are more likely to
        encounter triggers than are individuals who are not drinking.
        For example, drinking may

        -   Put people in recovery into contact with other people who
            use stimulants

        -   Put people in recovery into a "party" atmosphere that can
            trigger the desire to use stimulants

        -   Trigger a desire for the stimulant high

***Slide 2-28---Other Reasons for Abstaining***

-   There are other reasons for abstaining from alcohol. When people are
    learning to handle problems without resorting to stimulants, using
    alcohol to numb the uncomfortable learning process is
    counterproductive for two reasons:

    -   Drinking alcohol prevents people from directly confronting their
        stimulant use problem.

    -   Drinking puts people in recovery at risk of becoming dependent
        on alcohol while they are trying to overcome their dependence on
        stimulants.

***Slide 2-29---Plan Not To Drink***

-   It is important for people in recovery to *plan* not to drink,
    rather than wait until they are confronted with a trigger or urge to
    drink. For example, people in recovery can

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```
-   Think about other ways of celebrating

-   Avoid being around others who are drinking

-   Think about ways of spending time with friends that don't involve
    alcohol

-   Make friends with others who are in recovery

-   Practice saying "no thank you"

-   Avoid going to bars and parties

-   Ask family members not to drink in their presence or keep alcohol in
    the house

***Slide 2-30---Plan To Cope***

-   A person in recovery should develop a plan for coping with the
    uncomfortable feelings that arise during recovery. This plan could
    include

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-   Regularly attending 12-Step or mutual-help group meetings

-   Discussing feelings openly in Matrix group sessions

-   Obtaining a 12-Step sponsor

-   Regularly practicing relaxation techniques

-   Practicing HALT (not becoming too hungry, angry, lonely, or tired)

-   Developing a way to remember that uncomfortable feelings are normal
    in recovery and will pass

-   Obtaining help from a therapist if feelings become too overwhelming

    -   Handout FE 2---Fact Sheet: Alcohol summarizes the information
        presented in this session.

**Session 3: Recovery (Panel Presentation)**

***Goals of Session***

-   Provide an opportunity for participants to hear stories of
    successful recovery.

-   Provide an opportunity for participants to ask questions of
    individuals in recovery.

-   Provide important information about the recovery process in a
    personal way that engages participants.

***Handouts***

-   FE 3A---Guidelines for Graduate Panel Participants

-   FE 3B---Guidelines for Family Member Panel Participants

-   FE 3C---Guidelines for Recovery Panel Participants

***Preparation***

At least 1 week before the session, the counselor identifies, invites,
and orients four or five panel participants. The panel should comprise a
mix of program graduates who are stable in their recovery and actively
involved in a 12-Step program or mutual-help group and family members of
program graduates who are working on their own program of recovery in
Al-Anon or a mutual-help group. If the counselor is unable to identify
appropriate graduates, he or she should contact the local Alcoholics
Anonymous (AA) or Narcotics Anonymous (NA) Intergroup Office's Hospitals
and Institutions or Treatment Facilities Committee for help in
identifying local individuals who are in recovery and would be willing
to participate on the panel.

The counselor ensures that graduate panel participants receive a copy of
handout FE 3A---Guidelines for Graduate Panel Participants and that
family member panel participants receive a copy of handout FE
3B---Guidelines for Family Member Panel Participants before the session.
If the counselor is using AA or NA members, the counselor should give
these participants a copy of FE 3C---Guidelines for Recovery Panel
Participants as they arrive at the facility.

Just before the session, the counselor should remind panel participants
that they will have about 10 minutes to tell their stories, using the
guidelines listed on the handouts.

***Presentation (45 minutes)***

The counselor introduces panel participants and facilitates each
presentation to ensure that each participant stays on track and does not
take too much time. The counselor may ask a panel member a question from
the handouts if he or she seems to be having difficulty staying on
topic. The counselor should have extra copies of the handouts available
for panel participants to refer to as needed.

***Question-and-Answer Period (30 minutes)***

The counselor encourages group members to ask questions of panel
participants and facilitates discussion. When the discussion winds down,
the counselor thanks panel members and dismisses them.

***Open Discussion (15 minutes)***

The counselor allows time for participants to ask general questions and
to bring up any pressing issues they may have.

**Session 4: Methamphetamine and Cocaine (PowerPoint Presentation**)

**Overview**

***Goals of Session***

-   Provide factual information about how methamphetamine and cocaine
    act in the brain.

-   Provide factual information about the psychological and physical
    effects of methamphetamine.

-   Provide factual information about the psychological and physical
    effects of cocaine.

-   Provide an opportunity for participants to talk about the effects
    stimulant drugs have had on them or their family member.

***Handouts***

FE 4A---Fact Sheet: Methamphetamine

FE 4B---Fact Sheet: Cocaine

***PowerPoint Presentation (40--45 minutes)***

The counselor presents the PowerPoint slides, encouraging participants
to ask questions at any time. The Presentation section below contains
talking points for each slide. The counselor should add examples and
explain concepts in a way that is appropriate for the audience.

***Focused Discussion (30 minutes)***

The counselor facilitates discussion of the material presented and asks
open-ended questions such as

-   What did you hear that was new information? What surprised you?

-   How does the information relate to your experience?

-   How will this information affect the way your family copes with
    recovery?

-   What questions do you have about this information?

The counselor may want to break the discussion into two parts, stopping
between the presentation on methamphetamine (slides 4-10--4-28) and the
presentation on cocaine (slides 4-29--4-44).

***Open Discussion (15--20 minutes)***

The counselor allows time for participants to ask general questions and
to bring up any pressing issues they may have.

**Presentation**

The bulleted points presented below concisely state the information the
counselor should cover for each slide. The PowerPoint slides can be
downloaded from www.kap.samhsa.gov by clicking on Products, clicking on
Resource Documents & Manuals, and then clicking on the Matrix icon.

***Slide 4-1---Methamphetamine and Cocaine***

-   This session focuses on methamphetamine (meth) and cocaine.

-   Both are highly addictive stimulant drugs that are similar in many
    ways, although there are significant differences as well.

***Slide 4-2---Differences Between Cocaine and Methamphetamine***

-   Cocaine and methamphetamine differ in that cocaine is processed out
    of the body much faster than is methamphetamine, so the effects, or
    high, of cocaine don't last as long.

-   The effects of cocaine last for only 1 to 2 hours, whereas the
    effects of methamphetamine last 8 to 12 hours.

-   Withdrawal from methamphetamine also can last longer, and the
    symptoms of withdrawal may be more intense than those of cocaine
    withdrawal.

***Slide 4-3---Dopamine***

-   The effects of both meth and cocaine are caused by the drugs'
    effects on *dopamine*, a chemical that is always present in the
    brain.

-   Dopamine plays an important role in

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-   Body movement

-   Thinking

-   Motivation and reward

-   Pleasure responses

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-   Dopamine also plays an important role in addiction to any drug.

***Slide 4-4---Example of Dopamine's Effect***

-   When a person engages in natural activities like eating, drinking,
    and sex, dopamine is released by cells in the brain and creates
    immediate (though short-lasting) feelings of pleasure by stimulating
    other cells in the brain.

-   These feelings reward the basic activities of eating, drinking, and
    sex and motivate people to repeat them, ensuring survival.

***Slide 4-5---Dopamine Imbalance***

-   When the natural balance of dopamine is upset (by a drug, for
    example), a person can experience negative effects:

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-   Too *much* dopamine may produce nervousness, irritability,
    aggressiveness, fears that are not based on reality, and bizarre
    thoughts.

-   Too *little* dopamine is associated with low mood, fatigue, and the
    tremors and the inability to control movement that is part of
    Parkinson's disease.

***Slide 4-6---Dopamine and Stimulant Drugs***

-   When a person uses meth or cocaine, too much dopamine becomes
    available in the brain.

-   Although each drug increases the amount of dopamine in the brain in
    a different way, many of the effects are the same.

-   When a person first starts taking meth or cocaine, he or she will
    experience primarily pleasurable effects but will also experience
    some negative effects that are caused by too much dopamine.

***Slide 4-7---Dopamine and Stimulant Use Over Time***

-   As a person continues to use meth or cocaine, the brain's dopamine
    system becomes damaged.

-   As the damage increases, the person will continue to experience some
    pleasurable effects but also will experience substantial negative
    effects from meth or cocaine.

***Slide 4-8---Use--Depression--Craving--Use***

-   When the stimulant and euphoric effects of meth or cocaine wear off,
    dopamine levels may decrease to levels that are below normal, and
    the person experiences an abrupt drop in mood and energy levels.

-   Symptoms of fatigue and depression are common.

-   These negative feelings often create a strong desire (craving) in
    the person to take the drug again.

-   Over time (often, very little time), this
    use--depression--craving--use cycle leads to addiction.

***Slide 4-9---Route of Administration***

-   How a drug is taken influences

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-   How quickly it produces an effect

-   The strength of the drug's effects, both positive and negative

-   The negative effects a person will experience

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```
-   Both meth and cocaine are available in various forms that can be

    -   Injected

    -   Snorted

    -   Smoked

***Slide 4-10---Methamphetamine***

-   The first stimulant drug we will discuss is meth, a synthetic drug
    that is manufactured from common chemicals.

***Slide 4-11---Street Names***

-   Methamphetamine is known on the street as

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-   Meth

-   Ice

-   Glass

-   Crank

-   Crystal

-   Speed

-   Chalk

-   Tweak

***Slide 4-12---Popularity of Meth***[^10]

-   The 2004 National Survey on Drug Use and Health (NSDUH) estimated
    that 12 million people ages 12 and older had used meth at least once
    in their lifetime.

-   Some evidence shows that meth use has stabilized. The number of
    people using meth and the number of people trying it for the first
    time remained constant in 2002, 2003, and 2004.

-   From 2002 to 2004, the average age of first use increased by more
    than 3 years, from 18.9 years to 22.1 years.

***Slide 4-13---Who Uses Meth?***

-   Although the overall rate of meth use may not be increasing, use
    remains a significant problem.[^11]^,^[^12]

-   The number of people dependent on meth more than doubled between
    2002 and 2004.[^13]

-   Once confined to certain areas of the country, particularly Hawaii
    and west coast cities, meth use has spread throughout the country
    and among different populations.[^14]

-   People who use meth have traditionally been Caucasian, male,
    blue-collar workers.

-   Meth use spread to the party and club scene (raves, etc.).

-   Meth use is increasing among Hispanics and young people who are
    homeless.

-   Use among women has increased.

-   More women use meth than use cocaine or heroin; near-equal numbers
    of men and women now use the drug.

-   Meth is used increasingly in the workplace; it has long been used by
    long-haul truck drivers, but use is spreading on construction sites
    and in manufacturing.

-   People in the entertainment, sales, retail, and legal professions
    also increasingly are using meth.

***Slide 4-14---Immediate Psychological Effects***

-   The immediate *psychological* effects of methamphetamine include

    -   Euphoria

    -   Alertness or wakefulness

    -   Feelings of increased strength and renewed energy

    -   Feelings of invulnerability (feeling that nothing bad can happen
        to you)

    -   Feelings of increased confidence and competence

    -   Intensified feelings of sexual desire

    -   Decreased feelings of boredom, loneliness, and shyness

***Slide 4-15---Immediate Physical Effects***

-   The immediate *physical* effects of methamphetamine include

    -   Increased

> -- Heart rate
>
> -- Pupil size
>
> -- Sensitivity to sound and stimulation
>
> -- Blood pressure
>
> -- Breathing rate
>
> -- Body temperature

-   Decreased

> -- Appetite
>
> -- Reaction time
>
> -- Sleep

***Slide 4-16---Toxic Effects***

-   These effects may not sound bad, or they even may sound desirable.

-   However, meth can cause serious long-term psychological and physical
    damage (toxic effects).

-   Although many toxic effects go away in time, even after a person
    stops using meth, some effects can be permanent.

-   Most negative effects begin fairly soon with regular meth use.

***Slide 4-17---Chronic Psychological Effects***

-   Chronic *psychological* effects ("chronic" means that these effects
    may begin later in a person's use cycle and last a long time) of
    meth use include increased

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-   Confusion

-   Loss of ability to concentrate and organize information

-   Loss of ability to feel pleasure without the drug

-   Paranoia (persistent feelings that one is being watched, is being
    followed, or is about to be harmed)

-   Insomnia and fatigue

-   Mood swings

-   Irritability and anger

-   Depression

-   Anxiety and panic disorder

-   Depression when *not* using meth, called "crashing"

-   Reckless, unprotected sexual behavior

***Slide 4-18---Severe Psychological Effects***

-   Particularly severe *psychological* effects can include

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-   *Tactile* hallucinations (the person feels as if things are crawling
    on him or her) or *auditory* hallucinations (the person hears things
    that aren't there)

-   Severe depression that can lead to suicidal thoughts or attempts

-   Episodes of sudden, violent behavior

-   Severe memory loss that may be permanent

***Slide 4-19---Chronic Physical Effects***

-   Chronic *physical* effects of use include

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-   Tremor (shakiness)

-   Weakness

-   Dry mouth

-   Weight loss and malnutrition

-   Increased sweating

-   Oily skin

-   Sores caused by oily skin and by the person picking at his or her
    skin, a common effect of meth use

-   Headaches

-   Severe problems with teeth and gums caused by teeth grinding,
    decreased blood flow to the mouth, and decreased saliva

***Slide 4-20---Severe Physical Effects***

-   Particularly severe *physical* effects can include

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-   Seizures

-   Damage to small blood vessels in the brain, which can lead to stroke

-   Damaged brain cells

-   Irregular heartbeat that can cause sudden death

-   Heart attack or chronic heart problems, including the breaking down
    of the heart muscle

-   Kidney failure

-   Liver failure

-   "Tweaking," movements that a person can't control that are repeated
    regularly

-   Infected skin sores that can cause severe scarring

***Slide 4-21---Meth Is Not Just Meth***

-   Because meth is manufactured by amateur "cooks," it is often full of
    impurities, such as lead acetate or mercury, which can lead to heavy
    metal poisoning, and various acids created in the process.

-   In addition, meth is "cut," or diluted, before it is sold to
    maximize profits.

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```
-   The substances used to cut meth can cause problems of their own.

-   Meth purity tends to range from 40 to 70 percent, meaning 30 to 60
    percent of what a person injects, snorts, or smokes is *not*
    meth.[^15]

***Slide 4-22---Injecting Meth***

-   The ways in which a person can take meth create special problems as
    well. *Injecting* meth can cause

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-   Blood clots

-   Skin abscesses

-   Kidney failure

-   Pneumonia

-   Heart inflammation

-   HIV, tuberculosis, or hepatitis C virus exposure from sharing
    needles and other works or from unprotected sex

***Slide 4-23---Snorting Meth***

-   *Snorting* meth can cause

    -   Sinus infection

    -   Nosebleeds

    -   Holes in the septum, the cartilage between nostrils

    -   Hoarseness

***Slide 4-24---Smoking Meth***

-   *Smoking* meth can cause

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-   Throat problems

-   Burned lips

-   Lung congestion

-   Severe coughing with black mucus

-   Chronic lung disease

***Slide 4-25---Meth Dose and Effects***

-   The dose and frequency of meth use affect the level of toxic
    effects, as well.

-   The higher the dose and the more frequent the use, the higher the
    likelihood of toxic effects.

-   People who use meth tend to develop *tolerance* for the drug,
    meaning that it takes a higher dose to get the desired effect as
    people continue to use meth.

***Slide 4-26---Pregnancy and Meth***

-   A woman who uses meth while she is pregnant may harm her fetus.

-   Fetuses of mothers who use meth are at higher risk of having a
    stroke or brain hemorrhage, often causing death, before delivery.

-   Meth use during pregnancy also can cause premature birth.

-   Fetuses also may be exposed to HIV or hepatitis if the mother is
    infected with these viruses.

    -   Babies of mothers who used meth during pregnancy may have

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    -   Abnormal reflexes

    -   Extreme irritability

    -   Trouble eating and digesting food

***Slide 4-27---Other Effects on Children***

-   Children are affected by meth in other ways:

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-   Although increasing amounts of meth are being imported from Mexico,
    home-based labs for making meth remain common in the United States;
    often children are in these homes.

-   When children live with parents who manufacture meth, the children
    are exposed to toxic chemicals used in the process.

-   Meth labs are dangerous places for children and adults.

-   Fires, explosions, chemical spills, and toxic fumes are common.

-   The chemicals used to make meth give off fumes that are strong
    enough to burn lungs; can damage the brain, kidneys, or liver; and
    even can be fatal.

-   Children of people who use meth may be neglected or abused.

-   In 2001, 700 children who were present in meth labs that were raided
    by the Drug Enforcement Administration tested positive for toxic
    chemicals.[^16]

***Slide 4-28---Other Problems With Meth Labs***

-   Labs where meth is made cause serious problems for other people and
    for the environment:

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-   Toxic fumes released from the chemicals used to make meth go into
    the walls and carpets and remain there for a very long time, putting
    everyone in the house at risk.

-   Even people moving into a home that once housed a meth lab are at
    risk.

-   Making meth creates solid waste as well.

-   For every pound of meth produced, 5 to 6 pounds of toxic waste are
    created.[^17]

-   This waste usually is dumped on the ground, dumped into local
    waterways, or flushed into sewer or septic systems, contaminating
    the surrounding area.

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-   Handout FE 4A summarizes these meth facts.

***Slide 4-29---Cocaine***

-   The next stimulant to be discussed is cocaine, a drug that is made
    from the leaves of the coca plant.

***Slide 4-30---Street Names***

-   Powdered cocaine (cocaine hydrochloride, a salt) is known on the
    street as

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-   Coke

-   Snow

-   Flake

-   Blow

***Slide 4-31---Crack Cocaine***

-   Crack cocaine is cocaine that has been processed from cocaine
    hydrochloride into a rock crystal form that can be smoked.

-   It gets its name from the cracking sound it makes when heated.

-   Crack is sometimes called "rock" or "freebase."

-   When people process cocaine hydrochloride themselves and smoke the
    result, it often is called "free basing."

***Slide 4-32---Popularity of Cocaine***[^18]

-   The 2004 NSDUH survey estimated that nearly 34 million Americans
    have used cocaine at some time in their lives.

-   The same survey estimated the following:

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-   About 2 million people in the United States currently use cocaine.

-   Some 2.5 percent of young people ages 12 to 17 reported that they
    had used cocaine at least one time. Nearly 9 percent of 18 year olds
    reported using cocaine at least once.

-   Among young adults ages 18 to 25, 16 percent reported using cocaine
    at least one time.

***Slide 4-33---Who Uses Cocaine?***[^19]

-   Adults 18 to 25 years old have a higher rate of current cocaine use
    than those in any other age group.

-   Overall, men have a higher rate of current cocaine use than do
    women.

***Slide 4-34---Immediate Psychological Effects***

-   The immediate *psychological* effects of cocaine are similar to
    those of meth and include

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```
-   Euphoria

-   Increased energy

-   Increased talkativeness

-   Increased mental alertness

-   Increased sensitivity to sensations of sight, sound, and touch

-   Increased confidence

-   Intensified feelings of sexual desire

***Slide 4-35---Immediate Physical Effects***

-   The immediate *physical* effects of cocaine include

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-   Constricted blood vessels

-   Dilated pupils

-   Increased heart rate

-   Increased temperature

-   Increased blood pressure

-   Decreased appetite

-   Decreased sleep

***Slide 4-36---Warning***

-   In rare instances, sudden death can occur with cocaine use, even the
    first time someone uses the drug.

-   Drinking alcohol with cocaine increases this risk.

-   The liver combines cocaine and alcohol and manufactures a third
    substance, cocaethylene.

-   Cocaethylene intensifies cocaine's euphoric effects, while
    increasing the risk of sudden death.

***Slide 4-37---Chronic Psychological Effects***

-   Chronic *psychological* effects of cocaine use include

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-   Irritability

-   Depression

-   Increasing restlessness

-   Paranoia

-   Auditory hallucinations

-   Possible bizarre and/or violent behavior (with high doses)

-   Damaged ability to feel pleasure without the drug

-   Exposure to HIV or hepatitis C virus through reckless, unprotected
    sex

***Slide 4-38---Chronic Physical Effects***

-   Chronic *physical* effects of cocaine use include

    -   Cardiovascular effects, such as

        -   Disturbances in heart rhythm

        -   Heart attacks

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-   Respiratory effects, such as

    -   Chest pain

    -   Bronchitis and pneumonia

    -   Respiratory failure

-   Neurological effects, such as

    -   Strokes

    -   Seizures

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    -   Headaches

    -   Loss of appetite over time leading to significant weight loss
        and malnutrition

***Slide 4-39---Injecting Cocaine***

-   Like meth, the way in which cocaine is used may cause particular
    problems. People who regularly *inject* cocaine may experience

    -   Abscesses (infected sores) at injection sites

    -   Allergic reactions, either to the drug or to some additive in
        street cocaine, which can result in death

    -   Exposure to HIV and hepatitis C virus

***Slide 4-40---Snorting Cocaine***

-   Regularly *snorting* cocaine can lead to

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-   Loss of sense of smell

-   Nosebleeds

-   Problems with swallowing

-   Hoarseness

-   Overall irritation of the nasal septum leading to a chronically
    inflamed, runny nose

-   Deviated septum

***Slide 4-41---Smoking Crack***

-   *Smoking* crack cocaine can lead to

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-   Throat problems

-   Burned lips

-   Lung congestion

-   Severe coughing

-   Chronic lung disease

***Slide 4-42---Cocaine Dose and Effects***

-   As with people who use meth, people who use cocaine regularly
    develop tolerance for the effects of the drug and use higher and
    higher doses to get the same euphoric effect.

-   Higher doses and more frequent use increase the likelihood of toxic
    effects.

***Slide 4-43---Pregnancy and Cocaine***

-   Using cocaine during pregnancy may cause serious problems for a
    woman's fetus.

-   The drug passes through the placenta, enters the fetus' bloodstream,
    and passes through the fetal brain barrier.

-   Babies born to mothers who used cocaine during pregnancy may[^20]

    -   Be born prematurely

    -   Have low birth weights

    -   Have smaller than normal heads

    -   Be shorter than normal

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-   Babies also may be exposed to HIV or hepatitis virus if the mother
    is infected.

***Slide 4-44---Cocaine-Exposed Children***

-   Fetal cocaine exposure does not seem to cause as serious and
    long-lasting problems as was once thought.

-   However, as cocaine-exposed children grow up, they may have subtle,
    yet significant, problems later in life in areas that are important
    for success in school, such as[^21]

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-   Paying attention to tasks

-   Thinking things through

-   Learning new information

    -   Handout FE 4B summarizes these cocaine facts.

**Session 5: Roadmap for Recovery (PowerPoint Presentation**)

**Overview**

***Goals of Session***

-   Help participants understand what to expect as clients recover by
    describing a four-stage model of recovery.

-   Help participants recognize the characteristics of each stage of
    recovery.

-   Help participants recognize particular relapse risks clients may
    face in each stage of recovery.

-   Help participants learn more about triggers for drug craving and
    ways both clients and their family members can avoid or cope with
    these triggers.

***Handouts***

-   FE 5A---Daily/Hourly Schedule

-   FE 5B---Relapse Justifications

***PowerPoint Presentation (40--45 minutes)***

The counselor presents the PowerPoint slides, encouraging participants
to ask questions at any time. The Presentation section below contains
talking points for each slide. The counselor should add examples and
explain concepts in a way that is appropriate for the audience.

***Focused Discussion (30 minutes)***

The counselor facilitates discussion of the material presented and asks
open-ended questions such as

-   What did you hear that was new information? What surprised you?

-   How does the information relate to your experience?

-   How will this information affect the way your family copes with
    recovery?

-   What questions do you have about this information?

***Open Discussion (15--20 minutes)***

The counselor allows time for participants to ask general questions and
to bring up any pressing issues they may have.

**Presentation**

The bulleted points presented below concisely state the information the
counselor should cover for each slide. The PowerPoint slides can be
downloaded from www.kap.samhsa.gov by clicking on Products, clicking on
Resource Documents & Manuals, and then clicking on the Matrix icon.

***Slide 5-1---Roadmap for Recovery***

-   This presentation will look at recovery as following a predictable
    course (like a roadmap) through a series of four recovery stages.

-   People in recovery are likely to experience particular physical and
    emotional changes and symptoms in each stage of recovery, and each
    stage brings particular relapse risks. Families are likely to
    witness these changes and symptoms.

-   This does not mean that every person or family will experience
    recovery in exactly the same way; although the general progression
    is predictable, every person in recovery will follow his or her own
    roadmap.

-   A few people will progress from stage to stage smoothly, many will
    become "stuck" for a time in one stage, and others will veer off
    track completely before resuming their progress.

-   Even though there will be variability, being aware of the stages of
    recovery can give people in recovery and their family members a
    basic idea of what to expect during recovery.

-   Knowing what to expect can help people avoid pitfalls and stay on
    the road to recovery.

-   Knowing what to expect also helps family members understand the
    recovery process and allows them to provide more support for the
    person in recovery.

***Slide 5-2---Recovery Stages***

-   Recovery stages we will discuss include

    -   Stage 1: Withdrawal

    -   Stage 2: Early abstinence (sometimes called the "Honeymoon" or
        "pink cloud" stage)

    -   Stage 3: Protracted abstinence (sometimes called "the Wall")

    -   Stage 4: Adjustment and resolution

***Slide 5-3---Stage 1: Withdrawal***

-   The withdrawal stage begins when a person first stops using drugs
    and alcohol.

-   This stage lasts from 1 to 2 weeks.

-   Typical characteristics of the withdrawal stage (particularly for
    those who used methamphetamine or other stimulants) include

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-   Physical detoxification

-   Intense cravings for the drug

-   Depression or anxiety

-   Low energy

-   Irritability or aggression

-   Exhaustion

-   Insomnia *and* extended periods of sleep

-   Disordered thinking

-   Paranoia

-   Memory problems and difficulty concentrating

-   Intense hunger

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-   If people have been using other drugs heavily, such as
    tranquilizers, barbiturates, or heroin, or have been drinking
    alcohol heavily, they may experience symptoms of physical withdrawal
    from those substances, as well.

-   The depression, anxiety, and paranoia people experience when first
    abstaining from stimulants are the direct result of the brain's
    adjusting to the absence of a stimulant drug and, in most cases, are
    temporary.

-   It is important for both people in this stage of recovery and their
    family members to understand that these emotions will pass, but such
    emotions can lead to suicidal thoughts or plans in the short term.
    If the depression, anxiety, or paranoia persists or is very severe,
    a psychiatric consultation may be recommended.

-   In addition to experiencing the characteristics/symptoms listed,
    people in recovery may need medical attention for problems resulting
    from their drug use, such as

    -   Seizures

    -   Infections at injection or skin popping sites

    -   Cardiovascular problems

    -   Severe weight loss

    -   Vitamin deficiencies

    -   Respiratory problems

    -   HIV/AIDS

    -   Hepatitis C

***Slide 5-4---Withdrawal (Relapse Risk Factors)***

-   During the withdrawal stage, people tend to feel out of control of
    their lives.

-   Symptoms such as paranoia, depression, fear of withdrawal, and
    disordered sleep patterns contribute to vulnerability to cravings.

-   Unstructured time and proximity to triggers increase the risk of
    relapse.

***Slide 5-5---Withdrawal (Structure)***

-   The concept of *structure* is an important part of Matrix treatment.

-   People in outpatient treatment, with the help of their family
    members, must learn to design their own structure because outpatient
    treatment does not provide the structure of an inpatient facility.

-   Creating structure by scheduling their time can help people in
    recovery feel more in control of life.

-   Self-designed structure

    -   Helps eliminate avoidable triggers by providing a *plan* to
        avoid them

    -   Makes the concept of "one day at a time" concrete

    -   Reduces anxiety

    -   Counters the drug-using lifestyle

    -   Provides a basic foundation for ongoing recovery

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-   Matrix clients learn to schedule their time outside treatment.

-   Family members can help by supporting clients' scheduling efforts.

***Slide 5-6---Building Blocks of Structure***

-   With the help of their counselor and family members, people in
    recovery create structure by organizing and planning their time
    using schedule sheets.

-   Handout FE 5A---Daily/Hourly Schedule provides an example of a form
    that can be used to help clients structure their time.

-   The building blocks of a person's structure should incorporate new
    drug-free behavioral options, such as

    -   Time scheduling

    -   Treatment activities

    -   Attending 12-Step or mutual-help group meetings

    -   Physical exercise and sports

    -   Interest in new or long-dormant recreational/leisure activities

    -   Work, school, or volunteer activities

    -   Family-related events

    -   Activities with friends who are drug free

    -   Spiritual activities

    -   "Island building" (planning specific events or "islands" of
        rest, relaxation, or fun to look forward to)

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-   The end result is a daily plan for activities that promotes recovery
    and reduces the possibility of boredom, impulsive decisionmaking,
    exposure to triggers, and relapse.

***Slide 5-7---Scheduling Pitfalls***

-   Scheduling should be a positive experience, but sometimes scheduling
    can become tedious or stressful.

-   Some scheduling problems that a person in recovery can encounter
    include

    -   Unrealistic schedules (for example, working 8 hours, taking
        children to an afterschool activity, attending a Matrix group
        session, attending a 12-Step meeting, and exercising---all in 1
        day)

    -   Unbalanced schedules (not enough or too much leisure time, for
        example)

    -   Imposed schedules (allowing others to tell one what to do and
        when to do it, for example, rather than choosing activities
        oneself)

    -   No support from significant others

    -   Holidays, illness, and other changes that can disrupt one's
        schedule

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-   It is important that clients in Matrix treatment work closely with
    their counselor to learn how to schedule appropriately and to plan
    for coping with unusual events that disrupt the schedule.

-   It is equally important that family members support clients' efforts
    to schedule their time.

-   Scheduling and creating structure in one's life is a skill that
    needs to be practiced.

***Slide 5-8---Stage 2: Early Abstinence***

-   The early abstinence stage is sometimes called the Honeymoon or pink
    cloud stage because it is the stage in which people often feel much
    better and start to think that their problems with substances are
    solved.

-   This stage usually lasts for about 4 weeks.

-   Typical characteristics of the early abstinence stage (particularly
    for those who used methamphetamine or other stimulants) include

    -   Increased energy and optimism

    -   Overconfidence

    -   Difficulty concentrating

    -   Continued memory problems

    -   Concerns about weight gain

    -   Intense feelings

    -   Mood swings

    -   Other substance use

    -   Inability to prioritize

    -   Mild, continuing paranoia

***Slide 5-9---Early Abstinence (Relapse Risk Factors)***

-   During this stage, people's moods typically improve, they have more
    energy, cravings diminish, and confidence and optimism increase.

-   This increased energy leads some people to become overinvolved with
    their work; "workaholism," in turn, may lead to relapse as
    recovering people

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-   Decrease their involvement in treatment and other recovery
    activities

-   Neglect self-care

-   Become overtired and stressed

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-   Overconfidence also may cause problems; people in recovery may start
    to believe "I've got this substance problem licked." This belief can
    lead them to think that they

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-   No longer need treatment

-   Can safely be around friends and family members who still are using
    drugs or go to places where they used drugs

-   Can safely use a drug other than their "problem" drug or drink
    alcohol

    -   Exposure to triggers and using secondary drugs or alcohol often
        may lead to relapse to methamphetamine or other stimulant use.

    -   People in this stage also may experience

-   Concerns over weight gain

-   Resistance to continued behavior change

-   An inability to prioritize

-   Occasional paranoia

-   Anxiety about changes in sexual behavior

    -   People in recovery in this stage need to

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    -   Recognize the risks in this stage of recovery

    -   Learn to channel Honeymoon energy toward specific recovery
        tasks, putting together a solid structure of activities to build
        momentum that will carry them through subsequent recovery stages

        -   Family members, too, need to recognize that, although people
            in recovery appear to be better and more optimistic, they
            still need support and encouragement to

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        -   Attend all treatment activities

        -   Attend 12-Step or mutual-help group meetings

        -   Avoid people and places associated with drug use

        -   Abstain from all drugs and alcohol

        -   Continue careful scheduling of their time

        -   Participate in regular physical exercise

***Slide 5-10---Early Abstinence (Triggers and Thought Stopping)***

-   No matter how carefully people in recovery schedule their time, it
    is likely that they will encounter a person, place, situation, or
    emotional state that triggers thoughts about using.

-   People in the early abstinence stage of recovery need to understand
    the concepts of triggers and thought stopping. Family members also
    need to understand this concept.

-   To people in recovery, the trigger--thought--craving--use sequence
    can feel as if all parts of the sequence happen simultaneously.

-   In fact, recovering people can learn to interrupt the sequence at
    any point.

***Slide 5-11---Interruption***

-   Another way to envision this process is to see the
    trigger--thought--craving--use sequence as moving down a steep
    slide.

-   The time to use thought stopping is right after one recognizes the
    first thought of using.

-   At that point, the urge to use, as shown by the small circle moving
    toward the figure, is still relatively small and containable.

-   It still is possible to stop this process when it reaches the
    craving stage, but then it is much more difficult. When a person is
    in the craving mode, the small circle has become enormous---a huge
    force that is nearly out of control.

-   The person in recovery may not want to use and may attempt to
    deflect the cravings, but more often than not, the cravings are so
    powerful that they propel the person into relapse.

-   A first step toward learning to interrupt the
    trigger--thought--craving--use sequence is to understand what
    constitutes a trigger and to learn to recognize a trigger as quickly
    as possible.

***Slide 5-12---Types of Triggers***

-   Triggers can relate to

    -   People

    -   Places

    -   Things

    -   Times

    -   Emotional states

***Slide 5-13---Triggers (People)***

-   Triggers related to *people* may include

    -   Friends who use drugs

    -   Drug dealers

    -   Voices of friends who use drugs/dealers (for example, on phone
        calls)

    -   Absence of a significant other (loneliness)

    -   Partners in meth-related sexual activity

    -   People discussing drug use in a positive way

***Slide 5-14---Triggers (Places)***

-   Triggers related to *places* may include

    -   Drug dealer's home

    -   Bars and clubs

    -   Drug use neighborhoods

    -   Work

    -   Some street corners

    -   *Anyplace* associated with use

***Slide 5-15---Triggers (Things)***

-   Triggers related to objects or *things* may include

    -   Drug paraphernalia

    -   Sexually explicit magazines and movies

    -   Money/ATMs

    -   Certain music associated with using

    -   Movies and TV shows about or depicting drug and alcohol use

    -   Using a drug other than the identified problem drug or drinking
        alcohol

***Slide 5-16---Triggers (Times)***

-   Triggers related to particular *times* include

    -   Idle time

    -   Stressful times

    -   After work

    -   Paydays

    -   Holidays

    -   Friday and Saturday nights

    -   Birthdays, anniversaries, and other special occasions

***Slide 5-17---Triggers (Emotional States)***

-   The reality for most recovering people is that *any* emotional
    state, positive or negative, can be a trigger if it has been
    associated with drug or alcohol use.

-   Triggers related to emotional states include

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-   Anxiety

-   Fatigue (or fear of becoming fatigued)

-   Depression

-   Anger

-   Boredom

-   Frustration

-   Fear

-   Sexual arousal, deprivation, or anxiety about performance

-   Concern about weight gain

***Slide 5-18---Thought Stopping***

-   Thought-stopping techniques can be used to interrupt the
    trigger--thought--craving--use cycle.

-   The first step in successfully using thought-stopping techniques is
    to recognize thoughts about using ("using thoughts") as soon as they
    occur.

-   People new to recovery don't always realize when they are having
    using thoughts, but they can learn to do so by consciously focusing
    on their thought processes.

-   Once people recognize a using thought, they can choose to interrupt
    the thought by using one of these thought-stopping techniques:

    -   Visualization

        -   When people experience thoughts of using drugs or alcohol,
            they can visualize a switch or lever and imagine actually
            moving it from ON to OFF to stop the drug- or alcohol-using
            thoughts.

        -   It is important to have another thought ready to replace the
            drug- or alcohol-using thoughts.

        -   The thought should be a pleasurable one or one that is
            meaningful to the person and does not involve drug or
            alcohol use.

    -   Rubberband snap

        -   The rubberband technique helps recovering people "snap"
            their attention away from thoughts of using drugs or
            alcohol.

        -   People simply can put a rubberband loosely around their
            wrist.

        -   When a craving or using thought occurs, people snap the
            rubberband lightly against their wrist and say "NO" (either
            aloud or not, depending on the situation) to the drug or
            alcohol thoughts.

        -   As with visualization, people need to have another thought
            ready to replace the drug- and alcohol-using thoughts.

        -   This technique works best if people leave the rubberband on
            all the time.

    -   Relaxation

        -   Cravings often create feelings of hollowness, heaviness, and
            cramping in the stomach.

        -   These feelings often can be relieved by breathing in deeply
            (filling the lungs with air) and slowly breathing out,
            repeating the process three times, and focusing on relaxing
            the body as much as possible for a few minutes.

        -   This process can be repeated as often as the feelings
            return.

    -   Calling someone

        -   Talking to others provides an outlet for feelings and allows
            people to "hear" their thought process.

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        -   People in recovery should carry the phone numbers of
            supportive people, including family members, with them so
            they can call someone whenever support is needed.

***Slide 5-19---Nontrigger Activities***

-   If thought stopping works, but the thoughts frequently keep coming
    back, people in recovery may have to change their immediate
    environments or engage in tasks that require full concentration.

-   A few examples of nontrigger activities include

    -   Exercise

    -   Activities in the person's faith-based or spiritual community

    -   12-Step/mutual-help group meetings

    -   Meditation or prayer

    -   New recreational activity or hobby

    -   Structured/monitored periods (time with family or friends who do
        not use, for example)

    -   Eating or sleeping

    -   Non--drug-oriented movies

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    -   A person in recovery should keep a list of such activities handy
        for times when they may be needed.

***Slide 5-20---Stage 3: Protracted Abstinence***

-   The protracted abstinence stage typically lasts for about 3 to 4
    months.

-   This stage (sometimes called the Wall) brings a shift back from the
    high of the Honeymoon phase to a period of low energy and an
    emotional state often characterized by apathy, depression, and
    anhedonia (inability to experience pleasure).

-   This shift is likely even though people in recovery are continuing
    to make positive changes in their lives and are beginning to reap
    the benefits of recovery.

-   Common characteristics of this stage of recovery include

    -   Continued lifestyle changes

    -   Positive benefits from abstinence

    -   Anger and depression

    -   Emotional swings

    -   Episodes of paranoia or suspicion

    -   Unclear thinking

    -   Isolation

    -   Concerns about loss of sex drive, difficulties with sexual
        performance, and reduction in sexual activity

    -   Weight gain

    -   Family adjustment and conflict

    -   Return of cravings

    -   Return to old behaviors

-   It is important for people in recovery and their family members to
    know that the changes of this stage are the result of a continuing
    healing process in the brain and that, if people remain abstinent,
    their brain chemistry will stabilize and the negative emotions and
    the low energy of this stage will pass.

***Slide 5-21---Protracted Abstinence (Relapse Risk Factors)***

-   Relapse factors common to this stage include

    -   Increased emotionality

    -   Breakdown of structure

    -   Behavioral "drift"

    -   Interpersonal conflict

    -   Decreased ability to feel pleasure

    -   Loss of motivation

    -   Concern about weight gain

    -   Sexual anxieties

    -   Poor self-care

    -   Insomnia

    -   Low energy/fatigue

    -   Paranoia

    -   Secondary drug or alcohol use

    -   Relapse justification

-   The person in recovery is particularly vulnerable to relapse during
    the protracted abstinence stage because the person often perceives
    that the negative emotional states and low energy common to this
    stage will persist indefinitely.

-   The person in this stage of recovery may begin to think that if
    recovery feels this bad, it may not be worth it.

-   This thinking, and the low energy and fatigue, can lead to
    behavioral drift, a gradual letting go of the structure (including
    treatment activities and 12-Step or mutual-help group meetings) and
    other behavioral changes the person has worked hard to achieve.

-   As structure breaks down, the person may experience more thoughts
    about using drugs or alcohol and begin to create justifications for
    use.

-   It is critical that the person in recovery anticipate the Wall and
    understand it is a temporary phase.

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-   It is critical that a person in recovery remain in treatment and
    continue the behavioral changes already made to this point to avoid
    a sequence of inertia, boredom, loss of recovery focus, relapse
    justification, and, finally, relapse.

-   Good self-care, particularly regular exercise, and the understanding
    and support of family members can greatly help a person negotiate
    this phase successfully.

***Slide 5-22---Secondary Drugs and Alcohol***

-   It is quite common for people in all stages of recovery to entertain
    at times the idea of using drugs other than those they consider to
    be their primary problem drug (called "secondary drugs") or alcohol.

-   The use of secondary drugs is a particular relapse risk in the
    protracted abstinence stage of recovery because of the uncomfortable
    emotional states common to the stage and the tendency for decreasing
    supportive structure.

-   People in recovery may begin to tell themselves, "My problem is with
    methamphetamine; I've never had a problem with pot. I just need to
    relax a little."

-   Using a secondary drug or alcohol is a bad idea and may lead quickly
    to relapse to using one's primary drug in a number of ways:

    -   **Cortical disinhibition.** Using a secondary drug or alcohol
        can cause the prefrontal cortex, the part of the human brain
        responsible for rational decisionmaking, to become disinhibited
        (less active), thus paving the way for a return to the primary
        drug use. This effort is especially likely if secondary drug use
        exposes people to triggers associated with their use of the
        primary drug (buying from a dealer, for example).

    -   **Stimulant craving induction*.*** Studies at the Matrix
        Institute have shown that, if cocaine or amphetamines are the
        drugs of choice, a return to alcohol use will increase the risk
        of relapse to stimulants by 800 percent. A return to the use of
        marijuana will do the same by 300 percent. This result remains
        true even if the client was not addicted to alcohol or
        marijuana.

    -   **12-Step group philosophy conflict.** If people in recovery use
        a secondary drug or alcohol, they are unlikely to continue to
        attend 12-Step groups, groups that are vital to recovery,
        because using any illicit drug or alcohol is contrary to 12-Step
        group philosophy and people will be increasingly uncomfortable
        in meetings.

    -   **Abstinence violation effect.** There is a strong tendency for
        people to begin thinking, "Well, I'm drinking again; I might as
        well use a little meth, too."

    -   **Interference with new behaviors.** Using a secondary drug or
        alcohol to cope with problems or life stresses will interfere
        with learning new coping behaviors, which are necessary to
        ensure long-term recovery.

***Slide 5-23---Protracted Abstinence (Relapse Justification)***

-   Relapse justification occurs when the addicted brain attempts to
    provide a *seemingly* rational reason (justification) for behavior
    that moves a person in recovery closer to a slip.

-   It is critical that people in recovery and their family members
    learn to recognize a relapse justification as soon as it arises.

-   Most relapse justifications are based on the faulty premise that
    people in recovery have no choice about whether to use drugs or
    remain in recovery.

-   Although at some point, using does become inevitable (for example,
    once people are at their dealer's house, they probably no longer
    have a choice; the craving is then in control), they *can* choose
    not to put themselves in risky situations.

-   Relapse thoughts gain power when they are not recognized or
    discussed openly.

-   Relapse justifications can take many forms:

    -   Other people made me do it.

    -   I needed it for a specific purpose.

    -   I was testing myself.

    -   It wasn't my fault.

    -   It was an accident.

    -   I felt bad.

***Slides 5-24 through 5-29---Relapse Justifications***

-   Handout FE 5B---Relapse Justifications identifies the excuses for
    using on slides 24 through 29 and discusses the process of relapse
    justification.

***Slide 5-30---Stage 4: Adjustment and Resolution***

-   The adjustment/resolution stage typically lasts for about 4 to 6
    months.

-   Although a person is well past physical withdrawal and may have
    mended from many or most of the physical effects of substance use,
    recovery is far from complete.

-   There often is a great feeling of accomplishment at having passed
    the Wall stage.

-   This feeling can result in a false sense that, finally, one's life
    can return to pretreatment normalcy.

-   People in recovery who successfully cope with this stage (and their
    family members) must recognize that the lifestyle and relationship
    changes made are now the new definition of "normal."

-   Once people have completed treatment, they need to shift from
    learning new skills to

    -   Maintaining a balanced lifestyle

    -   Recognizing and accepting that recovering from addiction is a
        life-long process

    -   Monitoring for relapse signs

    -   Developing new areas of interest

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-   Because of increasing emotional stability in this stage, the person
    may be ready to address significant, and sometimes volatile,
    underlying issues that were avoided or had not emerged before.

***Slide 5-31---Adjustment and Resolution (Relapse Risk Factors)***

-   Because cravings occur less often and feel less intense by this
    stage of recovery, people may

    -   Believe that they now can use a secondary drug safely

    -   Relax their vigilance for relapse signs

    -   Relax the recovery structure they have created, putting
        themselves in high-risk situations

    -   Return to relationships with people who use stimulants

    -   Neglect recovery activities, losing the momentum of recovery

    -   Neglect exercise and other self-care activities

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-   People in recovery and their families also may struggle with
    acceptance of the addiction and the life-long nature of recovery.

-   Emerging or reemerging emotional or relationship issues may cause
    distress and a desire to use drugs or alcohol; these issues need to
    be addressed in a counseling or treatment setting to avoid possible
    relapse.

***Slide 5-32---Adjustment and Resolution (Balance)***

-   A critical task for this stage of recovery (and in the future) is
    developing balance in one's life.

-   This representation of a recovery pie illustrates the lifestyle
    balance necessary to sustain ongoing abstinence and sobriety.

-   Every individual needs to find the optimal balance that works.

-   Families can help people in recovery find and maintain this balance
    in their lives.

**Session 6: Coping With the Possibility of a Relapse (Multifamily Group
Discussion)**

***Goals of Session***

-   Help participants explore their feelings and fears about relapse.

-   Help clients and their family members better understand one
    another's fears and needs.

-   Help participants share ideas for coping with relapse.

***Handouts***

-   FE 6A---Coping With the Possibility of Relapse: For the Person in
    Recovery

-   FE 6B---Coping With the Possibility of Relapse: For Family Members
    of the Person in Recovery

-   FE 6C---Family Members and Recovery

***Introduction (2--3 minutes)***

The counselor explains that

-   Today's session provides an opportunity for clients and their family
    members to discuss issues and fears related to the possibility of
    relapse.

-   Relapse to drug or alcohol use can occur only after abstinence is
    achieved.

-   Many people experience relapse at some point. Recovery is like
    learning any difficult skills; most people are not able to acquire
    the skills of recovery without making mistakes.

-   However, relapse is not inevitable. Some people achieve long-term
    recovery without relapsing.

-   Family members can relapse, too; those who have learned new,
    healthier ways of communicating and behaving can relapse to old
    behavior and ways of communicating and can stop taking care of
    themselves when the family member in recovery relapses to drug or
    alcohol use.

-   It is normal for people in recovery and their family members to fear
    relapse.

***Handout Review (10--15 minutes)***

The counselor

-   Gives clients a copy of handout FE 6A---Coping With the Possibility
    of Relapse: For the Person in Recovery and asks them to read the
    information and carefully consider and write down their answers to
    the questions

-   Gives family members a copy of handout FE 6B---Coping With the
    Possibility of Relapse: For Family Members of the Person in Recovery
    and asks them to read the information and carefully consider and
    write down their answers to the questions

-   Tells participants that their answers to the questions are to guide
    discussion; no one will see their responses

***Focused Discussion (50--55 minutes)***

The counselor

-   Facilitates discussion, using the questions on the handouts to
    provide structure

-   Reinforces good ideas for coping with relapse that are brought up in
    the discussion

***Summary (2--3 minutes)***

The counselor

-   Summarizes the ideas for effectively coping with relapse that were
    discussed by the group

-   Gives family members handout FE 6C---Family Members and Recovery

-   Explains that the handout contains some concepts that are important
    for family members of a person in recovery to remember and that
    referring to it from time to time may be helpful

***Open Discussion (15 minutes)***

The counselor allows time for participants to ask general questions and
to bring up any pressing issues they may have.

**Session 7: Opioids and Club Drugs (PowerPoint Presentation)**

**Overview**

***Goals of Session***

-   Familiarize participants with the nature and prevalence of two
    groups of drugs: opioids (e.g., heroin, oxycodone, and morphine) and
    club drugs (e.g., ketamine, LSD, and ecstasy).

-   Familiarize participants with the dangers to health and to recovery
    posed by opioids and club drugs.

***Handouts***

-   FE 7A---Fact Sheet: Opioids

-   FE 7B---Fact Sheet: Club Drugs

***PowerPoint Presentation (40--45 minutes)***

The counselor presents the PowerPoint slides, encouraging participants
to ask questions at any time. The Presentation section below contains
talking points for each slide. The counselor should add examples and
explain concepts in a way that is appropriate for the audience.

***Focused Discussion (30 minutes)***

The counselor facilitates discussion of the material presented and asks
open-ended questions such as

-   What did you hear that was new information? What surprised you?

-   How does the information relate to your experience?

-   How will this information affect the way your family copes with
    recovery?

-   What questions do you have about this information?

***Open Discussion (15--20 minutes)***

The counselor allows time for participants to ask general questions and
to bring up any pressing issues they may have.

**Presentation**

The bulleted points presented below concisely state the information the
counselor should cover for each slide. The PowerPoint slides can be
downloaded from www.kap.samhsa.gov by clicking on Products, clicking on
Resource Documents & Manuals, and then clicking on the Matrix icon.

***Slide 7-1---Opioids and Club Drugs***

-   This presentation offers an overview of opioids and club drugs,
    including what they are, who uses them, their effects on the body,
    and the risks they pose to recovery.

-   Handouts FE 7A---Fact Sheet: Opioids and FE 7B---Fact Sheet: Club
    Drugs summarize the information that is discussed during this
    session.

***Slide 7-2---The Importance of Total Abstinence***

-   For treatment to work, people in recovery should be totally
    abstinent. Abstaining from *all* psychoactive substances greatly
    increase the chances of a successful recovery.

-   If people are in treatment for abusing stimulants, they must give up
    alcohol and all illegal drugs, including drugs such as marijuana
    that some people believe are harmless, to ensure a successful
    recovery.

***Slide 7-3---What Are Opioids?***

-   Opioids are a group of drugs that act on the opiate receptors in the
    brain. Opioids can be made from natural sources (e.g., poppy plants)
    or synthetically.

-   Natural opioids (like morphine and heroin) and synthetic opioids
    (like meperidine and oxycodone) have similar effects.

-   Opioids treat pain effectively because they dull sensation and
    relieve the anxiety that comes from anticipating pain.

-   People abuse opioids because they provide a powerful feeling of
    euphoria or a "rush."

***Slide 7-4---Physical Effects of Opioids***

-   Once opioids enter the brain, they take effect in a matter of
    minutes.

-   The physical signs of opioid use are constricted pupils, flushing of
    the skin, and a heavy feeling in the limbs. People on heroin are
    described as "nodding" because they look as if they are about to
    fall asleep.

-   The rush of euphoria is followed by a drowsy state. Breathing and
    heart rate slow during this time. Headaches and dizziness are
    common. These immediate effects fade a few hours after the drug is
    taken.

***Slide 7-5---Opioids and Tolerance***

-   As people continue to use opioids, higher and higher doses are
    required to achieve the same effect. This is called "tolerance."

-   Eventually, a person's tolerance for opioids means that the drug is
    taken mainly to stave off withdrawal, not to get high.

***Slide 7-6---Dependence Versus Addiction***

-   Repeated use of opioids can result in dependence and addiction.

-   People who take opioids that have been prescribed by their doctors
    to treat pain rarely become addicted.

-   With long-term use, even people who take medication as prescribed
    can become dependent on opioids.

-   These people must stop taking opioid pain medication gradually or
    they will have withdrawal symptoms.

-   Addiction is marked by physical dependence accompanied by a
    compulsive urge to take the drug, even if negative consequences
    result.

***Slide 7-7---Withdrawal From Opioids***

-   A person who is dependent or addicted will go through withdrawal if
    opioids are discontinued suddenly. Symptoms of withdrawal include
    restlessness, severe muscle and bone pain, insomnia, diarrhea,
    vomiting, cold flashes, and goose bumps (the origin of the phrase
    "going cold turkey," used to describe going into withdrawal).

-   Withdrawal can take up to a week to run its course. It is rarely
    fatal to healthy adults, but it can result in early labor or
    miscarriage in a woman who is pregnant.

***Slide 7-8---Abuse of Prescription Opioids***

-   The main prescription opioids that people abuse are codeine,
    oxycodone (OxyContin^®^, Percodan^®^, Percocet^®^, Tylox^®^),
    hydrocodone (Vicodin^®^), meperidine (Demerol^®^), and hydromorphone
    (Dilaudid^®^).

-   We will focus on oxycodone in the next few slides. OxyContin is the
    strongest form of oxycodone available.

***Slide7- 9---Oxycodone (Use Patterns)***

-   Oxycodone abuse appears to be increasing.

-   According to the 2004 National Survey on Drug Use and Health, more
    than 10 percent of people in the United States ages 18 to 25 have
    used oxycodone nonmedically. The number of people abusing oxycodone
    has increased every year since the drug was introduced in 1995.[^22]

-   Most of the people who abuse oxycodone are older than 30.[^23]

-   In 2004, 5 percent of high school seniors reported using oxycodone
    at least once.[^24]

***Slide 7-10---Oxycodone (Facts)***

-   Oxycodone is a timed-release tablet that is prescribed for people
    with long-lasting pain, such as pain from cancer or back pain.

-   People obtain oxycodone illegally by pretending to be in pain,
    forging prescriptions, and robbing pharmacies.

-   To defeat the timed-release action, people who abuse oxycodone crush
    the tablet and then swallow or snort it or dissolve it in water and
    inject it.

-   When taken in these ways, oxycodone produces a euphoric high like
    that of heroin.

-   Oxycodone's street names include oxy, OC, kickers, killers, blue,
    and hillbilly heroin.

***Slide 7-11---Oxycodone (Dangers)***

-   OxyContin contains a much larger dose of opioid than do other
    oxycodone formulations, such as Percodan or Percocet.

-   When tablets are crushed before they are taken, the risks of
    dangerously slow breathing, heart attack, and overdose increase.

-   People who dissolve the tablets and inject the solution face
    diseases such as hepatitis and HIV/AIDS that are linked with dirty
    needles.

-   Like all opioids, oxycodone is highly addictive when abused.

***Slide 7-12---Heroin (Use Patterns)***

-   The main natural opioids that people abuse are heroin and morphine.
    We will focus on heroin in the next few slides.

-   Some 1.6 percent of people 12 years and older have used heroin. More
    than 3.1 percent of high school students have used heroin.[^25]

-   As many as 1 million people in the United States may be addicted to
    heroin.[^26]

-   Among Caucasians, Hispanics, and all people younger than 26, heroin
    is linked to more deaths than any other substance except
    alcohol.[^27]

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-   Heroin is connected with 15 percent of all visits to emergency rooms
    in the United States.[^28]

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-   Most people who use heroin are Caucasian males older than 30 who
    live in urban areas.[^29] The age at which people start using heroin
    had dropped from the middle twenties in 1990 to the early twenties
    in 2000.[^30]

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-   Increasing use among younger people is partly attributable to the
    purer forms of heroin that have become cheaper and more widely
    available in recent years. This purer heroin can be smoked or
    snorted, rather than injected.

-   Smoking or snorting heroin has increased in popularity because
    people mistakenly assume that smoking or snorting heroin will not
    lead to addiction. Fear of using needles also has contributed to
    increasing use of these routes of administration.

***Slide 7-13---Heroin (Facts)***

-   Heroin is made from morphine, which is derived from poppy plants. It
    was used widely as a pain remedy in the late 19th and early 20th
    centuries. Because it is highly addictive and other painkillers were
    available, heroin was banned in 1914.

-   Pure heroin is a white powder. Heroin purchased on the street varies
    in color from white to dark brown and usually is mixed with other
    substances such as sugar, powdered milk, starch, or poisons such as
    strychnine.

-   Heroin is known by many street names, including smack, horse, big H,
    junk, dope, skag, and poison.

# Slide 7-14---Heroin (Dangers)

-   People who use heroin often become so focused on obtaining the drug
    that they neglect most other aspects of their lives.

-   Some experience weight loss, dehydration, and malnutrition. Some
    become impoverished and turn to crime.

-   Because the purity of heroin varies, accidental overdose is a
    prominent danger.

***Slide 7-15---Heroin (Disease Risks)***

-   Most people who use heroin regularly inject it. Those who start out
    smoking or snorting heroin often progress to injection because it
    provides a quicker and more intense rush.

-   Injection drug use is estimated to be a factor in one-third of all
    HIV cases and more than one-half of all hepatitis C cases in the
    United States.

-   Injecting heroin can lead to collapsed veins, clogged blood vessels,
    bacterial infections of the heart and blood vessels, pneumonia,
    tuberculosis, and liver or kidney disease.

***Slide 7-16---What Are Club Drugs?***

-   Club drugs include a wide variety of substances, many of which are
    mistakenly thought to be relatively safe. They include gamma
    hydroxybutyrate (GHB), Rohypnol, ketamine, lysergic acid
    diethylamide (LSD), and MDMA or ecstasy.

-   Club drugs are used primarily by people younger than 30 who are
    Caucasian; high school and college students show highest levels of
    use.

-   Club drugs are used at college fraternities, dance clubs, bars,
    concerts, and all-night dance parties known as raves.

***Slide 7-17---GHB (Use Patterns)***

-   Most people who use GHB are between ages 18 and 30. Most are
    Caucasian, middle-class males.[^31]

-   GHB use rose precipitously during the 1990s. There were 56 emergency
    room reports connected with GHB use in 1994; in 2002 there were
    nearly 5,000 such reports. That represents a 9,000-percent increase
    over 8 years.[^32] Emergency room reports involving GHB have
    declined since 2002.[^33]

-   Approximately 2 percent of high school seniors used GHB at least
    once in 2004.[^34]

***Slide 7-18---GHB (Facts)***

-   GHB is manufactured in illegal labs from inexpensive ingredients. It
    is a light-colored powder that dissolves easily in liquid. When
    mixed with liquid it is clear, odorless, and tasteless.

-   At clubs, it often is sold in liquid form from a water or sports
    drink bottle, by the capful.

-   GHB is known by the street names soap, easy lay, vita-G, and Georgia
    home boy.

***Slide 7-19---GHB (Physical Effects)***

-   GHB produces euphoric and hallucinogenic states, accompanied by loss
    of control of balance, coordination, and speech. GHB takes effect 15
    to 30 minutes after a dose is ingested. The effects last 3 to 6
    hours.

-   At high doses, dangerously slow breathing, unconsciousness, coma,
    and overdose can occur. If GHB is mixed with alcohol, death can
    result.

-   Since 1990, there have been nearly 16,000 cases of GHB overdose and
    70 deaths from GHB.[^35]

***Slide 7-20---Rohypnol (Use Patterns)***

-   Most people who use Rohypnol are 13 to 30 years old and male.[^36]

-   Rohypnol use seems to be decreasing in most parts of the country.

-   Rohypnol is popular with some youth because it is cheaper than other
    club drugs.

-   Some 1.6 percent of high school seniors used Rohypnol at least once
    in 2004.[^37]

***Slide 7-21---Rohypnol (Facts)***

-   Rohypnol is the trade name of a drug that is legal in Mexico and
    Europe, where it is used to treat insomnia; it has never been legal
    in the United States.

-   Rohypnol tablets often are sold in their original packaging, which
    can make people think the drug is legal.

-   Rohypnol is a depressant like Halcyon, Xanax, and Valium, but it is
    many times stronger.

-   Rohypnol is known by the street names roofies, rophies, roche, rope,
    and the forget-me pill.

***Slide 7-22---Rohypnol (Physical Effects)***

-   Like GHB, Rohypnol produces euphoria and hallucinations in those who
    take it.

-   The effects of Rohypnol begin 15 to 20 minutes after it is taken and
    can last more than 12 hours.

-   Rohypnol's effects include decreased blood pressure, slurred speech,
    impaired judgment, and difficulty walking.

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-   Rohypnol can cause headaches, nightmares, tremors, muscle pain,
    digestive problems, aggressive behavior, and blackouts that can last
    24 hours.

***Slide 7-23---Ketamine (Use Patterns)***

-   Ketamine is popular with students and young adults who go to
    nightclubs and raves.

-   Ketamine use has been slowly but steadily decreasing.

-   Some 1.9 percent of high school seniors used ketamine at least once
    in 2004.[^38]

***Slide 7-24---Ketamine (Facts)***

-   Ketamine is an anesthetic first used on battlefields because of its
    fast action. Today it is used almost exclusively by veterinarians.
    Veterinary clinics are robbed specifically for ketamine.

-   Ketamine is produced as a liquid but usually is dried into a white,
    odorless, tasteless powder before it is sold illegally. It can be
    added to drinks, snorted, or smoked with marijuana or tobacco.

-   Ketamine has no smell or taste, so it is hard to detect.

-   Ketamine is known by the street names special K, vitamin K, kit kat,
    super acid, and jet.

***Slide 7-25---Ketamine (Physical Effects)***

-   Ketamine produces altered perceptions and hallucinations and can
    induce amnesia.

-   At low doses, altered perceptions include a pleasant feeling of
    floating or being outside one's body.

-   High doses can lead to terrifying feelings of near total sensory
    deprivation known as the K-hole.

-   The effects of ketamine begin a few minutes after it is taken and
    usually fade within an hour although people report not feeling fully
    normal again for 24 to 48 hours.

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-   At high doses, ketamine can cause heart attack, stroke, and oxygen
    starvation---all of which can lead to coma and death.

***Slide 7-26---Club Drugs and Date Rape***

-   Along with GHB and Rohypnol, ketamine can render people confused and
    helpless, leaving them vulnerable to crime, especially rape.

-   People who take these drugs may be unable to resist sexual acts.

-   Rohypnol is tasteless and odorless and can be dissolved easily in
    drinks at a club.

-   Newer Rohypnol tablets turn blue in a drink to increase visibility
    and decrease its use as a date rape drug.

***Slide 7-27---LSD (Use Patterns)***

-   LSD is used primarily by students and young adults at clubs, raves,
    and concerts.

-   Approximately 10 percent of people 12 and older have tried LSD; 0.2
    percent used LSD at least once in 2003.[^39]

-   Use of LSD by adults has been decreasing in recent years.

-   In 2004, 2.2 percent of high school seniors reported using LSD at
    least once in the previous year.[^40]

***Slide 7-28---LSD (Facts)***

-   LSD is one of the most powerful mood- and perception-altering drugs.
    It has no medical use.

-   LSD is sometimes sold in tablet form but most often is dissolved
    onto blotter paper that is divided into squares. It is odorless but
    has a slightly bitter taste.

-   LSD is known by the street names acid, blotter acid, battery acid,
    window pane, microdot, sunshine, and zen.

***Slide 7-29---LSD (Physical Effects)***

-   The first effects of LSD are felt 30 to 90 minutes after it's taken.
    Physical changes include increased heart rate and blood pressure,
    sweating, nausea, dry mouth, loss of appetite, numbness, and
    trembling.

-   At low doses, LSD produces rapid emotional swings and heightened
    sensations.

-   At high doses, LSD induces distortions of perception: shapes change,
    time slows down, and sensations seem to blend. These hallucinations
    are called a trip.

-   A bad trip can be a terrifying experience that causes confusion,
    panic, and fear. People experiencing LSD hallucinations have had
    fatal accidents.

-   A trip can last up to 12 hours and often is followed by fatigue and
    depression.

    -   One of the most dangerous aspects of LSD is its
        unpredictability. Its effects depend on the dose, the mood of
        the person taking it, and the environment in which it's taken.

    -   People who use LSD regularly are prone to flashbacks in which
        they suddenly experience hallucinations without having taken the
        drug.

    -   LSD may contribute to long-term depression or schizophrenia.

***Slide 7-30---MDMA ("Ecstasy") (Use Patterns)***

-   The chemical MDMA, ecstasy, is used most heavily by Caucasian and
    upper middle-class students and young adults.[^41]

-   Originally used mostly in clubs, ecstasy has spread to other social
    settings.

-   Nearly 5 percent of people 12 and older have tried ecstasy; 1
    percent used it at least once in 2003.[^42]

-   Some 4 percent of high school seniors used ecstasy at least once in
    2004; this number appears to be decreasing.[^43]

***Slide 7-31---Ecstasy (Facts)***

-   Ecstasy was used in psychotherapy in the 1970s, but it has no
    medical value and was banned.

-   Pure ecstasy is a white powder, but it can be combined with other
    drugs or substances before it is sold, usually in pill form.

-   Ecstasy is the drug's main street name, but it is also known as XTC,
    X, E, Adam, clarity, hug drug, and love drug.

***Slide 7-32---Ecstasy (Physical Effects)***

-   The physical effects of taking ecstasy include increased heart rate
    and blood pressure, nausea, loss of appetite, jaw tightness, and
    compulsive chewing and teeth clenching.

-   After getting an initial rush from taking ecstasy, people experience
    calm, positive feelings that last 3 to 6 hours; this process is
    called "rolling."

-   Ecstasy also produces increased energy, desire for visual
    stimulation, and heightened awareness of and response to sensory
    input.

-   Because ecstasy increases feelings of well-being and tolerance for
    others, many people mistakenly consider it a harmless drug.

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-   Ecstasy can raise the body temperature to dangerous levels (as high
    as 109 degrees); these high fevers lead to dehydration, which has
    killed people on ecstasy.

-   Because dehydration is a known risk, people who have taken ecstasy
    sometimes drink too much water, which can lead to a dangerous and
    potentially fatal condition called hyponatremia.

-   Ecstasy is neurotoxic---it kills nerve cells in the brain. Studies
    in rats and monkeys have shown that even a few doses of ecstasy
    cause damage that is not repaired 7 years later.

**Session 8: Families in Recovery (PowerPoint Presentation)**

**Overview**

***Goals of Session***

-   Help family members and people in recovery better understand
    substance use and recovery.

-   Help family members understand how they can support recovery.

***Handouts***

-   FE 8A---Anticipating and Preventing Relapse

-   FE 8B---Relapse Justifications

-   FE 8C---Avoiding Relapse Drift

***PowerPoint Presentation (40--45 minutes)***

The counselor presents the PowerPoint slides, encouraging participants
to ask questions at any time. The Presentation section below contains
talking points for each slide. The counselor should add examples and
explain concepts in a way that is appropriate for the audience.

***Focused Discussion (30 minutes)***

The counselor facilitates discussion of the material presented and asks
open-ended questions such as

-   What did you hear that was new information? What surprised you?

-   How does the information relate to your experience?

-   How will this information affect the way your family copes with
    recovery?

-   What questions do you have about this information?

***Open Discussion (15--20 minutes)***

The counselor allows time for participants to ask general questions and
to bring up any pressing issues they may have.

**Presentation**

The bulleted points presented below concisely state the information the
counselor should cover for each slide. The PowerPoint slides can be
downloaded from www.kap.samhsa.gov by clicking on Products, clicking on
Resource Documents & Manuals, and then clicking on the Matrix icon.

***Slide 8-1---Families in Recovery***

-   In this session, we are going to talk about the people who are most
    important to you. All attendees are here because they care about a
    family member.

-   People in recovery are here because they care enough about
    themselves and their families to seek treatment; family members are
    here because they want to offer encouragement and support.

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-   When a family is coping with a loved one who abuses stimulants, life
    can be frustrating and chaotic. The person who is using can behave
    self-destructively; the family members can resort to desperate
    measures just to cope.

-   Often, it's hard for all involved to understand how they got to this
    point. How did things get this bad? Evaluating a situation when you
    are in the middle of it can be difficult.

-   In this session we will look at how people become dependent on a
    substance and how they and their families recover from dependence.
    The hope is that by better understanding the processes of dependence
    and recovery, family members will be better able to provide support.

***Slide 8-2---Who Makes Up a Family?***

-   It is important to think of family in the broadest possible terms.

-   Family includes immediate family and extended family, friends,
    mentors, partners, colleagues from work---all of these people are
    part of your family when it comes to treatment. If someone you are
    close to is supportive, that person is part of your family.

***Slide 8-3---What Is Addiction?***

-   Addiction is a complicated physical and emotional process that takes
    place in the brain. As a result of drug use, the brain changes and
    people engage in behavior that affects themselves and their
    families.

-   Addiction is a medical disorder. It is counterproductive to recovery
    to think of addiction as representing a personal failing, a lack of
    willpower, or a moral downfall.

***Slide 8-4---Development of Addiction***

-   The development of addiction involves two different areas of the
    brain: the prefrontal cortex and the limbic system.

-   The prefrontal cortex is the intelligent, rational, thinking part of
    the brain. It is the decisionmaker, the brain's computer. The
    prefrontal cortex constantly directs our behavior and evaluates both
    the positives and negatives of any situation to make a decision.

-   The limbic system is made up of smaller parts of the brain below the
    prefrontal cortex. The limbic system's involvement in emotion and
    motivation drives addiction. Each dose of a substance---especially
    stimulants---activates the limbic system. Eventually, the system
    becomes overactivated to the point where normal, rational restraints
    on behavior are lost.

-   One way to understand the process of addiction is as a struggle
    between the rational part of the brain (the prefrontal cortex) and
    the emotional part of the brain (the limbic system).

-   For most people who use meth, the rational part of their brain keeps
    their meth use in check at first. However, with continued use,
    meth's effects on the parts of the brain that govern emotion and
    motivation begin to override reason and clear thinking.

***Slide 8-5---Development of the Craving Response***

-   Craving is the physical and emotional desire for a drug.

-   Three separate processes converge to create a craving for a drug:

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-   The cognitive process

-   The conditioning process

-   Obsessive thinking

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-   The cognitive process is how the rational part of the brain (the
    cortex) copes with substance use.

-   The conditioning process is the involvement of the emotional part of
    the brain (the limbic system) in addiction.

-   Obsessive thinking is the struggle between the rational and
    emotional responses to substance use.

***Slide 8-6---Cognitive Process (Beginning Stages of Addiction)***

-   In the beginning stages of addiction, meth use occurs occasionally,
    often at a party or on a special occasion.

-   Use gradually increases, but the rational part of the brain is in
    control and decides that using meth is justifiable because of the
    supposed benefits it provides.

-   The positives seem to outweigh the negatives. The facts that meth is
    illegal and extra money is spent to buy it do not carry as much
    weight.

***Slide 8-7---Cognitive Process (Disenchantment)***

-   The person who continues to use meth eventually becomes
    disenchanted, as the negative consequences of meth use clearly
    outweigh the positives.

-   Some people are able to stop using when it becomes apparent that
    meth use is damaging their lives. Those who can't stop are addicted.

-   A powerful hunger for meth becomes stronger than the rational part
    of the brain.

-   The rational decision not to use and willpower are not enough to
    deter the craving for meth that has taken root in the emotional part
    of the brain. The rational, decisionmaking process is severely
    impaired, and the addicted brain's demands are imperative.

***Slide 8-8---Conditioning Process (Mild Cravings)***

-   While the cognitive process is taking place in the prefrontal
    cortex, a parallel progression of events takes place in the limbic
    system of someone who is using meth. This is the conditioning
    process.

-   Conditioning is a type of learning that occurs by association. Every
    time people take meth, they strengthen a mental link between the
    drug and its pleasurable effects. This link conditions the brain to
    want more meth.

-   At first, meth use is so infrequent that there is no automatic
    response to the people, places, or situations associated with meth.

-   Over time, this link becomes stronger and more general, so that not
    only taking meth, but thinking of things associated with the drug
    (money, a dealer's house, certain friends) can induce cravings for
    meth.

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-   Things that are associated with meth use and that initiate desire
    for the drug are called triggers.

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-   Craving is a desire for meth that is intensified by the activation
    of the brain's emotional center and by obsessive thoughts about meth
    use.

-   Developing a craving for a substance is a process. Repeated uses of
    meth "build" a craving for the drug in a person's mind.

-   At first, purchasing and using the drug activate the brain's
    emotional and motivational centers in the limbic system. This
    results in euphoria and physiological arousal: increased breathing
    and heart rate, adrenaline effects, and increased energy.

-   The brain begins to form an association between meth and pleasure.

***Slide 8-9---Conditioning Process (Strong Cravings)***

-   As the mental connection between meth and the pleasure it produces
    grows stronger, things other than the drug itself increasingly
    trigger craving, and the craving becomes stronger.

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-   A person who continues using meth will feel an overpowering physical
    response to meth in situations further and further removed from the
    drug itself.

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-   In the later stages of addiction, thinking about meth will set off
    powerful cravings. For a person who is dependent on meth, thinking
    about meth or about using meth produces a powerful arousal similar
    to actual effects of meth.

-   Triggers initiate an automatic craving to use meth, and this feeling
    drives people to find and take meth.

# Slide 8-10---Conditioning Process (Overpowering Cravings)

-   Soon, triggers proliferate, and the mental links between the
    triggers and drug use become overpowering. Addiction---the loss of
    rational control to the emotional part of the brain---has set in.

-   As the addiction becomes severe, people use either daily or in
    binges that are interrupted only by physical collapse.

-   The rational brain is totally overwhelmed by the constant, powerful
    craving from the addicted brain. People who are addicted cannot be
    stronger than the conditioned response that has been forged in the
    brain. They can be only smarter.

***Slide 8-11---Development of Obsessive Thinking (Early Use)***

-   When a person starts using meth, very little time or thought is
    invested in it. Meth use is just a small part of the person's life.

-   If the person keeps using, decisions about whether to use, where to
    get money to buy drugs, and how to conceal the evidence of using
    begin to take more time and thought.

-   These thoughts of using intrude more and more because the links
    formed in the emotional part of the brain between meth and enjoyment
    have begun to exert their influence.

***Slide 8-12---Development of Obsessive Thinking (Continued Use)***

-   With continued use, thoughts about meth crowd out other aspects of
    life. For the most part, the emotional part of the brain is given
    over to addiction and meth dominates the person's thoughts.

-   People using meth become so obsessed with meth that their
    relationships may begin to crumble. There is little room in their
    lives for a relationship with anyone or anything except meth.

-   This overwhelming preoccupation does not mean that family members
    mean less to people than meth does. It means that the brain changes
    caused by meth make the desire to use meth all but irresistible.

***Slide 8-13---Progressive Phases of Addiction***

-   Now we turn to the family members' responses as they watch the
    person they care about become dependent on meth. We can trace family
    members' responses through four progressive stages of addiction:

    -   Introductory

    -   Maintenance

    -   Disenchantment

    -   Disaster

***Slide 8-14---Family Members' Response to Meth Use (Introductory
Phase)***

-   During the introductory phase of a person's meth use, family members
    are probably not affected very much. They may be completely unaware
    of the meth use.

-   Family members may see behaviors that stem from occasional meth use
    but not associate them with a drug problem.

-   Family members may wonder why the person occasionally neglects
    responsibilities and fails to meet obligations.

***Slide 8-15---Family Members' Response to Meth Use (Maintenance
Phase)***

-   Often, during the maintenance phase of a person's addiction, family
    members realize that a problem exists and attempt to solve it.

-   Family members may give financial assistance. They may make up
    excuses for thoughtless behavior that results from meth use. They
    even may try to take on all the responsibilities for earning money,
    taking care of the family, keeping up friendships, and maintaining
    the household.

-   These efforts help only temporarily because the real problem is the
    meth use and its consequences.

-   The problems continue to mount as long as the meth use continues.
    Family members want to help, so they pick up the slack for their
    loved one who is using.

-   This behavior does more harm than good. It helps the person stay
    addicted by covering up the consequences of meth use. Such
    activities give the person more time, energy, and money to continue
    using and cover up the fact that meth use must stop.

***Slide 8-16---Family Members' Response to Meth Use (Disenchantment
Phase)***

-   By the time the person reaches the disenchantment phase of
    addiction, family members often are angry and have given up trying
    to solve the problem.

-   Recognizing that none of the attempted solutions is working, family
    members try to ignore what is going on.

-   When they are unable to avoid being confronted with the consequences
    of the person's behavior, family members tend to blame either the
    person who is using or themselves.

-   The person's dependence on meth makes all members in the family feel
    guilty and ashamed of what is happening and of their inability to
    control the situation.

***Slide 8-17---Family Members' Response to Meth Use (Disaster Phase)***

-   During the disaster phase, family members often end up separating
    from the person who is using to save themselves. As a result of the
    emotional and physical separation, family members feel a sense of
    failure and hopelessness.

-   When family members stay with the person, they learn to behave and
    think in ways that preserve the peace but often are not healthy for
    individual or family well-being.

-   Children in such an environment learn ways of behaving that can
    interfere with their ability to have healthy relationships later in
    life.

***Slide 8-18---Benefits of Family Involvement***

-   It is important for family members to be involved in treatment.
    Studies show that treatment works better when at least one
    supportive family member is engaged in the treatment.

-   Family members who participate in treatment have a better
    understanding of what the person in recovery is going through. They
    also learn about the stages of recovery so that they can anticipate
    the difficulties the person in recovery will face and be aware of
    problems that may arise.

-   The person in recovery is responsible for quitting meth and working
    on recovery. But family members who have been interacting with the
    person in recovery during the progression of the drug dependence
    have been affected by the process and need to make changes of their
    own to undo the damage that has been done.

    -   Handout FE 8A---Anticipating and Preventing Relapse discusses
        family members' roles in recovery.

***Slide 8-19---Stages of Recovery***

-   People who stop taking a substance they are dependent on usually go
    through predictable stages during their recovery.

-   The timetable for recovery varies for each person, but the stages
    usually don't vary.

-   Knowing that there is a pattern to recovery and knowing what to
    expect in each stage often provide encouragement to family members
    and help them better support the person in recovery.

***Slide 8-20---Withdrawal***

-   The withdrawal stage usually lasts 1 to 2 weeks.

-   During this stage, the most severe symptoms are craving and
    depression. Many people also experience low energy, difficulty
    sleeping, increased appetite, and difficulty concentrating.

***Slide 8-21---Honeymoon***

-   The Honeymoon stage lasts about 4 weeks.

-   It is characterized by increased energy, enthusiasm, and optimism.

-   Many people think this is the end of the recovery process and that
    things will remain positive from here on. Unfortunately, the hardest
    part of the recovery is still to come.

***Slide 8-22---The Wall***

-   The Wall is the hardest stage of recovery and one of the longest. It
    lasts about 12 to 16 weeks.

-   The Wall brings with it some troublesome emotional and thinking
    difficulties. The optimism of the Honeymoon stage gives way to the
    full realization of the difficulty and sheer effort involved in
    recovery.

-   People in recovery experience depression, irritability, difficulty
    concentrating, low energy, and a general loss of enthusiasm. Risk of
    relapse is very high during this stage.

-   This stage is almost always a struggle for people in recovery, but
    with the support of family members and the recovery strategies they
    learn in treatment, clients get past the Wall.

***Slide 8-23---Readjustment***

-   The readjustment stage is when the individual begins to adjust to an
    ongoing state of abstinence.

-   During this stage, the Wall has been surmounted and the person in
    recovery and family members begin to return to a more normal
    lifestyle.

-   During the readjustment stage and after, individual and family
    issues can benefit from psychotherapy and family counseling.
    Treatment for meth dependence often does not address issues of
    long-term importance.

***Slide 8-24---Goals for Withdrawal***

-   The main goal for the person in recovery during the withdrawal stage
    of treatment is stopping meth use.

-   In group sessions that focus on early recovery skills, the person in
    recovery learns specific techniques for reducing cravings and
    avoiding relapse.

-   The person in recovery also begins to learn about the process of
    addiction and how drugs, such as meth, affect brain chemistry and
    the rest of the body.

-   When the person in recovery is in the withdrawal stage of treatment,
    family members have one major decision to make: whether they are
    willing to be part of the recovery process.

-   Family members will find it is easier to be involved if they view
    the meth use, not the person in recovery, as the problem and if the
    meth use is recognized as a medical condition, regardless of how it
    began.

***Slide 8-25---Goals for the Honeymoon***

-   During the Honeymoon stage of recovery, people in recovery work on
    improving their physical health and outlook on recovery by
    exercising and staying active.

-   People in recovery also begin to identify personal triggers and
    relapse justifications and to use targeted techniques to stay
    abstinent.

-   Often, persons in recovery feel as if they are "cured" during this
    period. It is important for people in recovery to continue to work
    on their recovery and to avoid testing themselves by being around
    drugs.

-   Family members can be very helpful during the Honeymoon stage,
    working with the person in recovery to support the primary goal of
    abstinence.

-   Although family members are not responsible for the loved one's
    recovery, their behavior and attitudes during this time can
    significantly increase or decrease the chances of the person in
    recovery achieving and maintaining abstinence.

-   Family members need to recognize and discontinue triggering
    interactions.

***Slide 8-26---Goals for the Wall***

-   By the time people in recovery reach the stage known as the Wall,
    they have been abstinent for several months. They continue to work
    on maintaining abstinence by putting relapse prevention techniques
    they have learned into practice.

-   The person in recovery also focuses on repairing relationships with
    family members and friends and developing support networks to cope
    with the problems that arise during recovery.

-   The Wall can be a frustrating and difficult part of recovery. The
    person in recovery needs support and encouragement from many
    sources. Working on developing new interests and staying active also
    are important to recovery.

-   Also important are recognizing and addressing dangerous emotions.

-   While the person in recovery is in the stage known as the Wall,
    family members need to guard against expressing anger toward the
    person.

-   As much as possible, family members need to move past resentment and
    work to support the person in recovery. Family members who are
    committed to this support need to begin trusting the loved one's
    recovery.

-   Family members should relearn how to take care of themselves by
    beginning to return to the normal routines of life and pursuing
    activities that are rewarding and self-nourishing.

-   It also is important at this stage to explore how family members
    communicate, how poor communication may have led to problems, and
    how communication can be improved.

-   Handout FE 8B---Relapse Justifications helps family members
    understand how relapses can start.

***Slide 8-27---Goals for Readjustment***

-   By the time people in recovery reach the readjustment stage of
    recovery, they know which behaviors they need to engage in to keep
    their recovery strong and which behaviors place their recovery at
    risk.

-   The task for people in recovery during this stage---and for the rest
    of their lives---is to monitor their recovery, ensuring that they
    engage in those behaviors that will help them avoid relapse.

-   Because people in recovery often will be confronted with the
    opportunity and desire to use, they need to be aware of those
    situations and thoughts that put them at risk of relapse. For this
    reason, they need to anticipate troublesome situations and have
    detailed plans for how to address them. The most important aspect of
    maintaining abstinence is knowing how to avoid relapse.

-   During the readjustment stage, the person in recovery works on
    forming new, healthy relationships and on strengthening existing
    friendships. The person in recovery also begins to examine long-term
    life goals.

-   When the person in recovery reaches the readjustment stage, the
    family has been with him or her through about 4 months of recovery.
    The person in recovery and the family members have learned a lot
    about what it takes to support the recovery and to make the family
    function well.

-   The readjustment stage is marked by a return to a more predictable,
    more normal lifestyle for everyone in the family. Family members
    should be mindful that many of the changes they have made in their
    lives to offer support for recovery will need to continue and become
    permanent.

-   It is important for family members to accept limitations of living
    with a person in recovery; maintain a balanced, healthy lifestyle;
    and avoid relapsing to former behaviors.

-   Patience with the process of recovery is crucial.

-   Handout FE 8C---Avoiding Relapse Drift helps family members
    understand how they can support the person in recovery.

***Slide 8-28---Key Relapse Issues for People in Recovery***

-   The person in recovery and the family members need to evaluate which
    lifestyle and attitude changes are important for each of them
    individually and as a family. After this point in recovery, the
    person in recovery will receive less support in the form of
    treatment.

-   Some of the support role will be taken up by 12-Step or mutual-help
    groups and by friends, but family members will be a major source of
    support for the person in recovery.

-   Families need to decide which adaptations they have made during
    recovery should become permanent in their lives.

-   When making these decisions, families should bear in mind the most
    common relapse issues for people recovering from meth use. All of
    the six issues listed on this slide may not be a problem for the
    person in recovery, but the family needs to find out which issues
    might be troublesome for the person in recovery.

-   Family members should have an open discussion with the person in
    recovery about how best to support his or her recovery.

***Slide 8-29---Key Relapse Issues for Family Members***

-   Whereas the person in recovery needs to be on the alert for relapse
    to meth use, family members need to be careful not to return to
    their former ways of behaving, thinking, and communicating.

-   This slide lists common problems that can precede a slip back into
    old behaviors for family members.

-   Just as it helps people in recovery to anticipate situations that
    might lead to relapse, so it will help family members to be on guard
    for ways in which they might slip back into behaviors that will
    destroy recovery and the family.

**Session 9: Rebuilding Trust (Multifamily Group Discussion)**

***Goals of Session***

-   Provide an opportunity for participants to think about and discuss
    the role that trust plays in relationships.

-   Provide an opportunity for participants to address the loss of trust
    that can come from stimulant use, including family members' ongoing
    suspicions of substance use by clients.

-   Provide an opportunity for participants to begin to repair damaged
    relationships.

***Handout***

-   FE 9---Rebuilding Trust

***Introduction (2--3 minutes)***

The counselor explains that today's session provides an opportunity for
participants to discuss the loss of trust that can come with stimulant
use and ways to rebuild that trust in family relationships.

***Handout Review (15--20 minutes)***

The counselor

-   Gives participants a copy of handout FE 9---Rebuilding Trust and
    asks them to read the information and carefully consider and write
    down their answers to the questions

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-   Tells participants that their answers to the questions are to guide
    discussion; no one will see their responses

***Focused Discussion (50--55 minutes)***

The counselor facilitates discussion, using the questions on the handout
to provide structure.

***Summary (2--3 minutes)***

The counselor summarizes the ideas for rebuilding trust among family
members that were discussed by the group.

***Open Discussion (15 minutes)***

The counselor allows time for participants to ask general questions and
to bring up any pressing issues they may have.

**Session 10: Marijuana (PowerPoint Presentation)**

**Overview**

***Goals of Session***

-   Familiarize participants with the nature and prevalence of marijuana
    use.

-   Familiarize participants with the dangers to health and to recovery
    posed by marijuana use.

***Handout***

-   FE 10---Fact Sheet: Marijuana

***PowerPoint Presentation (40--45 minutes)***

The counselor presents the PowerPoint slides, encouraging participants
to ask questions at any time. The Presentation section below contains
talking points for each slide. The counselor should add examples and
explain concepts in a way that is appropriate for the audience.

***Focused Discussion (30 minutes)***

The counselor facilitates discussion of the material presented and asks
open-ended questions such as

-   What did you hear that was new information? What surprised you?

-   How does the information relate to your experience?

-   How will this information affect the way your family copes with
    recovery?

-   What questions do you have about this information?

***Open Discussion (15--20 minutes)***

The counselor allows time for participants to ask general questions and
to bring up any pressing issues they may have.

**Presentation**

The bulleted points presented below concisely state the information the
counselor should cover for each slide. The PowerPoint slides can be
downloaded from www.kap.samhsa.gov by clicking on Products, clicking on
Resource Documents & Manuals, and then clicking on the Matrix icon.

***Slide 10-1---Marijuana***

-   This presentation offers an overview of marijuana, including what it
    is, the short- and long-term effects its use has on the mind and
    body, and the risks it poses to recovery.

***Slide 10-2---The Importance of Total Abstinence***

-   For treatment to work, people in recovery should be totally
    abstinent. This means that regardless of why people are in
    treatment, they should abstain from *all* psychoactive substances.

-   A person in treatment for abusing stimulants must give up alcohol
    and all illegal drugs, even drugs such as marijuana that many people
    believe are harmless, to ensure a successful recovery.

-   The use of any substance can jeopardize recovery from stimulant
    dependence.

***Slide 10-3---Is Marijuana Harmless?***

-   Many people wrongly believe that marijuana is not dangerous,
    especially when compared with drugs such as heroin, cocaine, crack,
    meth, or club drugs.

-   Marijuana is the most widely used illegal drug, which may contribute
    to the perception that it is harmless. Each year, about 25 million
    Americans ages 12 and older use marijuana. That is more than 1 out
    of every 10 Americans.[^44]

-   More young people go into treatment for marijuana use than for all
    other illegal drug use combined.[^45]

-   Marijuana use poses significant health hazards. It affects nearly
    every organ system in the body.[^46]

-   In addition to its physical effects, marijuana can have a profound
    impact on people's education, employment, and personal life.

***Slide 10-4---Marijuana Prevalence***

-   Each year about 2.6 million people try marijuana for the first time.
    Two-thirds of those first-time users are younger than 18. The
    average age when people first try marijuana is 17.[^47]

-   Two out of every five Americans have tried marijuana. One in ten has
    used marijuana in the last year. One in a hundred has used marijuana
    at least 300 days in the last year.[^48]

# Slide 10-5---What Is Marijuana?

-   Marijuana is a greenish gray mixture of dried and shredded parts of
    the hemp plant, *Cannabis sativa.* The mixture may consist of
    leaves, stems, flowers, and seeds.

-   It is usually smoked in hand-rolled cigarettes or pipes. Sometimes
    cigars are sliced open, and the tobacco inside is replaced with
    marijuana.

-   Marijuana's more concentrated forms are a resin called hashish and a
    black liquid called hash oil.

***Slide 10-6---Street Names***

-   Marijuana is known by many street names that vary by region of the
    United States. Some of the more common names are pot, weed, bud,
    herb, ganja, hash, grass, Mary Jane, chronic, and cannabis.

-   Marijuana cigarettes are known as joints or nails. Pipes are called
    bongs. Cigars packed with marijuana are called blunts.

***Slide 10-7---History***

-   Marijuana is grown in all 50 States. The main foreign sources for
    marijuana are Mexico, Canada, Colombia, and Jamaica.

-   Marijuana is a Schedule I controlled substance, like heroin and LSD.

-   Nonmedical use of marijuana has been illegal in the United States
    since 1937.

***Slide 10-8---Medical Marijuana***

-   Marijuana has been used to treat

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-   Loss of vision due to glaucoma

-   Nausea experienced by patients receiving treatment for HIV/AIDS and
    cancer

-   Pain associated with the multiple sclerosis

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-   In 1985, the U.S. Food and Drug Administration approved Marinol, an
    oral capsule that includes marijuana's active ingredient.

-   Marinol is available by prescription to treat the nausea and
    vomiting that can accompany cancer chemotherapy and the weight loss
    seen in patients with AIDS.

-   Other countries, including Canada and the United Kingdom, have
    approved an aerosol form of marijuana that is delivered with an
    inhaler to treat pain in patients who have multiple sclerosis.

***Slide 10-9---Active Ingredient***

-   The active ingredient in marijuana is the
    delta-9-tetrahydrocannabinol (THC).

-   THC is responsible for the effects that produce the marijuana high.

-   Over the past two decades, THC levels in marijuana have increased.
    Today's marijuana contains three times as much THC as marijuana from
    the 1970s and 1980s, making it three times stronger.

***Slide 10-10---Short-Term Effects***

-   When someone smokes marijuana, THC rapidly goes from the lungs to
    the bloodstream to the brain. THC causes nerve cells in the brain to
    release the neurotransmitter dopamine.

-   The release of dopamine is responsible for the person feeling
    "high," a relaxed, euphoric feeling.

-   THC can also impair short-term memory, disrupt balance and
    coordination, slow reaction time, increase heart rate, distort
    perception, and result in disorientation, confusion, and panic.

-   The immediate effects of marijuana can last from 1 to 3 hours.

-   After the high subsides, a person may feel sleepy or depressed.
    Feelings of panic, anxiety, and distrust are common.

***Slide 10-11---Long-Term Effects***

-   Marijuana can have long-term effects on memory and learning.

-   People who use marijuana regularly have trouble learning and
    remembering even 30 days after they stop using the drug.[^49]

-   Students who smoke marijuana regularly get lower grades in high
    school and college than those who don't.[^50]

-   Marijuana impairs so many skills that influence learning that people
    who use it regularly may be functioning at a reduced intellectual
    level all of the time.

-   Workers who use marijuana are more likely than their colleagues to
    have problems on the job, including accidents, absence, lateness,
    and job loss.[^51]

-   People who use marijuana at least 300 days a year are more likely to
    be unemployed than those who use it less often or not at all.[^52]

# Slide 10-12---Cancer Risks

-   People who smoke marijuana are exposed to lung damage just as people
    who smoke tobacco.[^53]

-   Regular use of marijuana can cause frequent chest colds, bronchitis,
    and emphysema.[^54]

-   Marijuana smoke has five times more tar and carbon monoxide and up
    to 70 percent more carcinogens than does tobacco smoke.[^55]

-   Smoking marijuana may increase the risk of lung cancer more than
    does smoking tobacco.[^56]

-   Studies suggest that smoking marijuana increases the chances of
    developing cancer of the head or neck.[^57]

***Slide 10-13---Risk of Infection and Disease***

-   The active ingredient in marijuana, THC, hampers the immune system's
    ability to fight off infection and disease.

-   Studies have shown that immune system cells exposed to marijuana
    ingredients have a reduced ability to prevent infections and
    tumors.[^58]

***Slide 14---Marijuana and Driving***

-   Because it impairs balance, coordination, and decisionmaking,
    marijuana is associated with all kinds of accidents.

-   Studies show that up to 11 percent of fatal accident victims have
    THC in their bodies.[^59]

-   Driving under the influence of marijuana is dangerous.

-   Even low doses of marijuana significantly reduce drivers'
    performance on road tests. Combining marijuana with alcohol further
    impairs drivers' abilities.[^60]

-   Drivers' coordination and reaction time are impaired for several
    hours after the high from marijuana use has faded.

-   After alcohol, marijuana is the substance most frequently found in
    drivers involved in fatal car crashes. Seven percent of fatal
    crashes involve marijuana.[^61]

-   Studies estimate that more than one in seven high school seniors
    drive under the influence of marijuana.[^62]

***Slide 10-15---Marijuana and Pregnancy***

-   A woman who uses marijuana during pregnancy exposes her fetus to a
    variety of dangers.

-   Low birth weight and problems with neurological development have
    been linked to marijuana use.

-   Later in life, babies exposed to marijuana during pregnancy may have
    trouble concentrating, learning, and making decisions. These
    problems are compounded if the mother continues to use marijuana
    after the child is born.

-   Breast-feeding mothers who use marijuana can pass THC to their
    babies. THC in breast milk is very concentrated and has been linked
    to problems with motor development in children.

***Slide 10-16---Marijuana Addiction***

-   One of the reasons people think of marijuana as a "safe" drug is
    that they think it is not addictive.

-   Although people may not develop physical dependence on marijuana,
    they can become psychologically addicted to marijuana. They cannot
    imagine living without the drug.

-   Addiction means using a drug even though it interferes with family,
    school, work, and other important aspects of life.

-   For those who are psychologically addicted, withdrawal from
    marijuana use can include cravings for the drug, anxiety,
    irritability, and sleeplessness.

# Slide 10-17---Marijuana and Other Drugs

-   People who use marijuana at least 300 days a year are more likely to
    drink heavily and use illicit drugs than people who occasionally use
    marijuana or those who never use it.[^63]

-   The younger people are when they start using marijuana, the more
    likely they are to use heroin and cocaine and become dependent on
    drugs as adults.[^64]

-   Because it is so integrally linked with other substance use,
    marijuana use poses a particular risk to people in recovery from
    meth use.

***Slide 10-18---Marijuana and Relapse***

-   Research suggests that people recovering from cocaine or meth use
    who continue to use marijuana have relapse rates two to three times
    higher than people who abstain from marijuana.[^65]

***Slide 10-19---Marijuana and Families***

-   People may use marijuana as a way to cope with boredom, anxiety, and
    depression.

-   Marijuana can be used to escape, rather than address, serious
    problems in a family.

-   In addition to making recovery from meth harder, marijuana use can
    contribute to the deterioration of personal and family life.

-   More than half of adult men who are arrested used marijuana in the
    past year. Two out of five men who are arrested test positive for
    marijuana at the time of their arrest.

**Session 11: Living With an Addiction (Multifamily Group Discussion)**

***Goals of Session***

-   Provide an opportunity for participants to think about and discuss
    the ways in which recovering from addiction will affect family life.

-   Provide an opportunity for participants to share concerns *and*
    solutions with others in the group.

***Handout***

-   FE 11---Living With an Addiction

***Introduction (2--3 minutes)***

The counselor explains that

-   Making a commitment to recovery requires recognizing and accepting
    certain realities.

-   Recovery brings all sorts of questions: What happens after the drug
    and alcohol use stops? Does life eventually go back to normal? Can a
    person in recovery lead the same lifestyle as a person who has never
    been addicted?

-   Today's session provides an opportunity for participants to discuss
    issues and concerns related to living with addiction and recovery
    from the perspectives of both people in recovery and their family
    members.

***Handout Review (10--15 minutes)***

The counselor

-   Asks participants to read the information on the handout and
    carefully consider and write down their answers to the questions

-   Tells participants that their answers to the questions are to guide
    discussion; no one will see their responses

***Focused Discussion (50--55 minutes)***

The counselor facilitates discussion, using the questions on the handout
to provide structure.

***Summary (2--3 minutes)***

The counselor summarizes the issues and ideas for effectively living
with addiction and recovery that were discussed by the group.

***Open Discussion (15 minutes)***

The counselor allows time for participants to ask general questions and
to bring up any pressing issues they may have.

**Session 12: Communication Traps (Multifamily Group Discussion)**

***Goals of Session***

-   Provide information about communication styles, techniques, and
    traps.

-   Provide an opportunity for participants to consider and discuss
    family communication issues.

-   Encourage participants to practice new communication skills.

***Handouts***

-   FE 12A---Communication Traps

-   FE 12B---Improving Communication

-   FE 12C---Contract: Commitment To Practice Communication Skills

***Introduction (2--3 minutes)***

The counselor explains that

-   People in families coping with substance use disorders often feel
    guilty, angry, hurt, and defensive.

-   These feelings can affect seriously the way family members
    communicate with one another; negative patterns of interacting often
    become automatic.

-   Understanding that positive communication involves skills that can
    be *learned* is an important first step in improving family
    relationships.

-   This session focuses on communication traps (communication behaviors
    that are not productive) and the skills necessary for improving
    family communication.

-   Paying attention to communication issues and learning new skills
    help families improve their communication.

-   Clear, positive interactions allow people to increase self-esteem
    and confidence and pave the road to committed, trusting
    relationships.

-   Recovery from substance use disorders is a difficult process for
    both the person in recovery and his or her family.

-   Positive and trusting family relationships support *everyone* in the
    recovery process.

***Focused Discussion and Handout Review (55--60 minutes)***

The counselor facilitates discussion of communication and recovery by
asking participants the following questions:

-   In what ways do you think improving communication could improve your
    family relationships?

-   In what ways has communication in your family changed during
    recovery?

The counselor

-   Gives participants a copy of FE 12A---Communication Traps

-   Provides examples of each communication trap (one example for each
    communication trap is provided in Communication Traps: Sample
    Scenarios below; the counselor may want to add examples)

-   Facilitates discussion of each communication trap, asking questions
    such as

    -   How do you think the situation in the example could have been
        avoided?

    -   Do you recognize this communication trap from your own family
        interaction? Would you be willing to share an example?

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-   Provides examples of positive "fixes" for each communication trap if
    they were *not* brought up in discussion (one example for each
    communication trap is provided in Communication Traps: Sample
    Scenarios; the counselor may want to add examples)

After discussion of FE 12A---Communication Traps, the counselor

-   Gives participants a copy of FE 12B---Improving Communication

-   Goes over each point

***Summary (15 minutes)***

The counselor

-   Summarizes the issues and ideas related to communication in
    recovering families that were discussed by the group

-   Gives participants handout FE 12C---Contract: Commitment To Practice
    Communication Skills and allows about 5 minutes for participants to
    complete the contract using the techniques listed on FE 12B

-   Suggests that participants keep the contract in a place that will
    remind them to practice these skills regularly

***Open Discussion (15 minutes)***

The counselor allows time for participants to ask general questions and
to bring up any pressing issues they may have.

**Communication Traps: Sample Scenarios**

**1. Are You Assuming?**

*The scenario*

Nancy asked her husband Pete, "Will you be coming home right after
work?" Pete exploded, "You don't have to check up on me every 5 minutes!
Do you want a urine sample, too?" Nancy responded angrily, "Well, you've
sure given me enough reasons to check up on you." The conversation then
became a full-fledged fight about the past. Pete assumed that Nancy was
suspicious when she asked whether he was coming right home from work and
felt frustrated and angry that she wasn't trusting him or noticing the
changes he'd made in recovery. What Nancy was *really* wondering when
she asked the question was whether Pete would be able to pick up the dry
cleaning before the shop closed or whether she needed to make plans to
leave work early.

*Example of a communication "fix"*

Pete could have avoided the fight by not assuming that he knew what
Nancy was thinking. He could have answered, "Yes, why do you ask?" in a
neutral tone of voice or answered directly and waited for her response.

**2. Are You Hinting?**

*The scenario*

Ricardo, a 17-year-old in recovery, was playing a video game when his
mother, Rosa, walked by and said, "Ricardo, the kitchen trash can is
getting full." Ricardo responded, "Uh huh," and continued to play his
game. Half an hour later, Rosa noticed that Ricardo hadn't emptied the
trash. She angrily confronted Ricardo for not taking the trash out right
away. Ricardo responded to her anger by loudly saying, "Hey, I'll do it
when I'm good and ready!"

*Example of a communication "fix"*

Instead of hinting that she wanted Ricardo to take out the trash right
away, she could have asked him directly by saying, "Ricardo, I need you
to take out the trash in the next 15 minutes; I'll be starting dinner
soon and will have a lot of vegetable scraps." Ricardo would then have
known that she meant "now" and not "sometime."

**3. Are You Giving Double Messages?**

*The scenario*

Tanya asked her husband, Andre, "Do you mind if I go fishing with
Sharonne Saturday?" Andre had been planning to spend time with Tanya on
the weekend and didn't want her to go with Sharonne. However, he replied
"Sure, go ahead." As he said this, his arms were stiffly crossed across
his chest and he didn't look directly at Tanya. Tanya felt uneasy and
said, "You're really OK with it?" Andre responded angrily, "I said I
was, didn't I?" The discussion escalated into an argument.

*Example of a communication "fix"*

Andre could have been honest with Tanya about his feelings, instead of
showing them indirectly. He could have said, "Well, I was hoping we
could spend some time together Saturday. I've been working too much and
I miss seeing you." Tanya would then have understood clearly what his
needs were and either changed her plans or negotiated a way to spend
time with him.

**4. Can You Admit a Mistake?**

*The scenario*

Bob forgot that it was his and Catherine's fifth wedding anniversary. A
coworker invited him to bowl a few frames after work, and he accepted.
When he arrived home, he discovered the table set for two and Catherine
in tears. She had left their children with her sister and prepared a
romantic dinner, now drying out in the oven. When she confronted Bob
about being so late, he responded defensively, "You know I have trouble
remembering these things; you should have reminded me! How am I supposed
to know you were planning a special dinner?" Catherine responded, "How
could you forget our anniversary?" Bob was feeling guilty at this point,
but not wanting to admit he was wrong, defensively replied, "Listen,
Catherine, we've been married 5 years now; what's the big deal?"
Catherine locked herself in the bedroom.

*Example of a communication "fix"*

When Bob realized that he had forgotten their anniversary, he could have
simply admitted his mistake and apologized sincerely. Although the
ensuing discussion still would have been difficult, it may not have
escalated.

**5. Do You Use "I" Statements?**

*The scenario*

Pam, a senior in high school, was out on a date. Her curfew was
midnight, and she was rarely late. When Pam arrived home at 1 a.m., her
mother, Emily, was extremely worried. Emily greeted Pam at the door
saying, "You're late! You could have picked up a phone and called;
you're always so inconsiderate!" Pam responded angrily, "I am *not*
always inconsiderate!" A fight ensued.

*Example of a communication "fix"*

Emily could have used an "I" statement, saying something like "I really
worry that something has happened when you're late and I don't hear from
you. Please give me a quick call if you'll be late." Emily would have
directly addressed an important issue in a calm way, and Pam would not
have felt the need to defend herself aggressively. Pam also may be more
likely to call her mother the next time she is late.

[^1]: Tevisan, L.; Boutros, N.; Petrakis, I.; and Krystal, J.H.
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[^13]: See note 1.

[^14]: See note 2.

[^15]: See note 3.

[^16]: See note 3.

[^17]: See note 3.

[^18]: Substance Abuse and Mental Health Services Administration
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[^19]: National Institute on Drug Abuse. *Research Report Series:
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[^20]: See note 9.

[^21]: See note 10.

[^22]: Substance Abuse and Mental Health Services Administration
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[^23]: Office of National Drug Control Policy. *Pulse Check: Trends in
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[^25]: Substance Abuse and Mental Health Services Administration
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[^26]: Office of National Drug Control Policy. *Fact Sheet: Heroin*.
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[^28]: See note 5, p. 4.

[^29]: See note 5, p. 2.

[^30]: See note 6, p. 10.

[^31]: Office of National Drug Control Policy. *Fact Sheet: Gamma
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[^33]: Substance Abuse and Mental Health Services Administration
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[^34]: See note 11.

[^35]: See note 10.

[^36]: Office of National Drug Control Policy. *Fact Sheet: Rohypnol*.
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[^37]: See note 3, p. 43.

[^38]: See note 3, p. 43.

[^39]: See note 4.

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[^41]: Center for Substance Abuse Prevention. *Ecstasy: What's All the
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[^42]: See note 4.

[^43]: See note 3, p. 43.

[^44]: Substance Abuse and Mental Health Services Administration
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[^45]: Office of National Drug Control Policy. *Fact Sheet: Marijuana*.
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[^47]: See note 2, p. 1.

[^48]: See note 2.

[^49]: Center for Substance Abuse Prevention. *Marijuana: Weeding Out
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[^50]: National Institute on Drug Abuse. *NIDA InfoFacts: Marijuana*.
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[^51]: See note 7.

[^52]: See note 1.

[^53]: See note 2, p. 3.

[^54]: See note 2, p. 3.

[^55]: See note 7, p. 3.

[^56]: See note 7, p. 3.

[^57]: See note 7, p. 3.

[^58]: See note 7, p. 3.

[^59]: National Institute on Drug Abuse. *Research Report Series:
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[^60]: See note 7, pp. 3, 4.

[^61]: See note 6, p. 19.

[^62]: See note 2, p. 4.

[^63]: See note 1.

[^64]: See note 2, p. 1.

[^65]: Rawson, R.A.; Shoptaw, S.J.; Obert, J.L.; McCann, M.J.; Hasson,
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