Fundamentals of Alcohol and Drug Abuse for Teacher Education

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1 Fundamentals of Alcohol and Drug Abuse for Teacher Education When Use Becomes a Problem By the end of this lesson, you should be able to: Identify the prevalence of substance use disorders in the U.S; Demonstrate an understanding of six theories of substance dependency; Describe five components of an intervention; Identify the goal of assessments as they relate to substance use; Describe basic treatment philosophies and practices; Discuss the role of personal motivation in treatment; Discuss recovery in regards to treatment programs; and List the characteristics of self-help groups. Up to this point, we have looked at drugs and how they impact student life and learning, as well as developmentally appropriate prevention approaches. Ultimately, what we are trying to prevent is not just a relatively small number of problems, but true dependency on drugs in general. It is dependency, rather than just use, that significantly impairs a person's life, most affects the people around them, and accounts for the greatest costs to society. In your role as an educator, you may encounter students or their family members that are currently struggling or in recovery from a substance use disorder. Having a basic understanding of dependency, intervention, and treatment can help you be a supportive figure in these people s lives. Additionally, treatment is, as we've mentioned, a form of prevention in that its goal is to prevent further use by dependent individuals. According to the 2012 National Survey on Drug Use and Health, it s estimated that 8.5% of the U.S. population aged 12 or older have had a substance use disorder in the past year; this accounts for 22.2 million people. Of those with a substance use disorder, 12.6% were dependent on both alcohol and illicit drugs. 1 Because large-scale surveys of this nature rely on self-reported data, and questions about one's drug use are extremely sensitive, particularly if the drug involved is illegal, absolutely accurate figures are not possible to obtain. When Use Becomes a Problem 91

2 We do know that dependency crosses gender, race, ethnicity, income, and education lines. In other words, no one is immune. That leads us to the question, "Why do some people become dependent when others don't?" While some choose not to use, and avoid the risk of dependency altogether, even among those who do use, it is often a minority of users who actually become dependent. Although research on genetics indicates about 40-60% of risk can be genetic, that still leaves the other 40-60% of the risk from other sources. 2 No one knows for certain what causes dependency, but taking a drug for the first time is a behavior and a deliberate choice. Many theories may explain why this is the case; some of which might already be familiar to you. We ll discuss several of these theories put forth to explain dependency. 1. Society is "screwed up" Proponents of this theory believe that poor societal conditions, such as unemployment and racism, lead to higher rates of dependency. Some may say, "If you lived in a poor neighborhood, you would use heroin, too." They fail to realize that only a small percentage of people living in poor neighborhoods use heroin, and plenty of people living in affluent suburbs use, too. Indeed, when the Iron Range in Northern Minnesota experienced a large increase in When Use Becomes a Problem 92

3 unemployment, increases in diagnosed dependency followed. This theory may explain some of the increases and decreases in dependency rates, but does little to explain dependency itself. 2. Genetic Theory Probably the most attractive theory at the moment is the genetic theory. Proponents point to higher probabilities of dependency among family members of alcoholics and claim a genetic link. Indeed, with the great advances in mapping of human genes, we probably are quite close to identifying one or more genes, or gene defects, that dependent people share. It s estimated that about 50% of alcohol use disorders can be attributed to genetics. 3 Additionally, children of those with an alcohol use disorder are four times more likely to be diagnosed with the same disorder. 4 It s important to keep in mind that any research on the genetic link points to the extreme difficulty of separating nature from nurture. Although the research does conclude that children of parents with an alcohol use disorder are at higher risk, more than half of these children do not go on to become alcoholics. 3 Other risk and protective factors play a significant role. This may explain why one child develops an alcohol use disorder while their sibling doesn t. 3. Personality Theory Proponents of this theory point to lay terms such as an addictive personality or an obsessive personality to indicate that there probably is such a thing as a measurable personality trait that could predict dependency. Indeed, large numbers of personality tests, such as the Minnesota Multiphasic Personality Inventory and California Personality Inventory, have been given to dependent people. They all seem to have similar scales on these tests, which falls outside the normal range of the total population. However, once sober, their test results fall within the normal range. While these tests may be measuring intoxication or perhaps even dependency, it is unlikely that they are measuring a true personality trait. If they did, test results should show consistency before, during, and after the dependency stage. An additional problem of this research is the use of retrospective studies and comparing personalities of current users with personalities of non-users; in both cases it is difficult to determine the extent that differences are a result or a When Use Becomes a Problem 93

4 cause of the drug use. Much time and effort has been spent trying to identify the elusive addictive personality. Personality and substance abuse research has also looked at predisposing characteristics for addiction. The concept is that certain temperaments or characteristics increase the risk for using and abusing substances, given the right set of environmental, community, personal stressors, and personal experiences. For example, studies consistently find that teens with aggressive, nonconforming, and impulsive traits are at a greater risk for abusing alcohol. 5 Keep in mind, while risk factors increase the risk of dependency, it is not a cause of dependency. 4. Deviant Behavior Theory Proponents of this theory point to the fact that people who deviate from the norm often have more attention paid to them, and attention is reinforcing. For example, the best athletes in a school have a great deal of attention focused on them. However, not everyone can become the best athlete. Maybe someone can become the best drug user or the best drug dealer in their school. Some people crave attention so much that any reputation, even a bad one, serves as a reinforcement in their lives. The work of Peter Benson of the Search Institute indicates that most adolescents have less than five minutes of meaningful conversation with an adult per day. 6 In other words, if people aren't paying attention to you, perhaps you can force them by operating outside the norm. These proponents would argue that people use substances as a means of getting attention. As was the case in Personality Theory, although an increase in use results in a higher risk, it doesn t automatically lead to dependency. 5. Cultural Theory Proponents of this theory point to the fact that cultures over time teach you how to use, or not to use, certain drugs. Indeed, well-established cultures usually have strict rules of behavior surrounding certain drugs. For example, alcohol in southern Europe is viewed as a social drug to be consumed with food, not as an intoxicant. Similarly, Native Americans in the Southwest seldom abuse hallucinogenic drugs, which have been used as sacraments for hundreds of years, yet they have a high rate of alcohol abuse. When this population was introduced to alcohol, which had no cultural significance to them, the context of use had not yet been established. Therefore, this contributes to an increased risk of dependence in Native American communities. Cultures with overlaying immigrant, or conquering, populations often lose a dominant cultural message in a mix of conflicting messages brought by multiple immigrant populations. Hence, given our diverse populations, it s more challenging for the U.S. to develop a consistent cultural message around substance use. When Use Becomes a Problem 94

5 6. Learning Theories Learning theories are also used to explain dependency. In behavioral conditioning, one behaves a certain way, is rewarded for that behavior, and repeats the behavior. With drug abuse, this happens in two primary ways. The first is when a trivial behavior elicits a small reward and this behavior is repeated many times. Cigarette smoking would be a good example. One takes a puff on a cigarette a behavior that really is quite insignificant for a small reward. One doesn't fall to the floor delirious for an hour after a single puff. The brain gets a small chemical reward in just a few seconds. This happens about ten puffs, or rewards, per cigarette. If one smokes a pack a day, that is 200 small rewards per day, 1,400 small rewards per week, and more than 70,000 rewards per year. Considered in that light, it s not surprising that smokers have such a difficult time quitting the habit. The second way involves engaging in a trivial behavior that results in a huge, disproportionate reward. For example, sniffing a substance up your nose, such as cocaine, is not a major behavior; however, the reward can be so huge that users may spend a great deal of their lives repeating the experience, even if there is never another reward. It would be similar to a payoff at a slot machine. You might want to keep pulling that handle with the hope of feeling that rush again. As stated earlier, none of these theories fully explains what causes dependency. If one were to speculate, one could assume a multi-causal model, with learning theory, genetic theory, and cultural theory all playing important roles. We will continue to learn more with additional research, but that does not prevent us from applying a great deal of what we know about intervention, assessment, treatment, and aftercare to help move a majority of people who enter treatment into full recovery. When an individual develops a serious dependency problem, sometimes an intervention forces a person into an assessment to determine the extent of a substance abuse problem. An intervention is when all of the key players in a person's life come together to point out the ways in which a drug has significantly interfered with that person's life, and the group insists on a change in behavior. When Use Becomes a Problem 95

6 One of the first professionals to use the term in this sense was Vern Johnson of the Johnson Institute. His book, I'll Quit Tomorrow, was influential in the dependency field during the 1970s. His chapter on interventions is still a classic description of the rules for a successful intervention. Basically, the point is to intervene in a destructive pattern of behavior and attempt to influence a change. 7 An intervention requires a great deal of advance planning and then a confrontation with a person when they are sober. The following steps are characteristics of most, if not all successful interventions: 1. Provide support to the one who intervenes It s important that the individual who is seeking help for the person they are close to gets support. Often it is recommended that this individual talk to a counselor or go to Al-Anon meetings, which is a support system for the spouses, family members and friends of AA members or potential AA members. They will frequently resist the suggestion at first, because they are trying to get help for someone else, not themselves. However, an old television public service spot said it well: "You can see what drinking is doing to your husband, can you see what it is doing to you?" Unless this person is in a position to support the intervention, the intervention will probably fail. Therefore, they need a great deal of support before an intervention is attempted. 2. Seek out all interested parties and rehearse It s important to bring together a group of people who are close to the subject without the subject present. Once the group has been assembled, they should agree on a plan of action and rehearse exactly who will say what and in what order. Sometimes role-playing will be helpful. In other words, walk through the whole intervention so that when it is done for real, it will go more smoothly. An individual should never do an intervention alone. It is too easy for the subject to rationalize that it is that individual who has the problem because nobody else is complaining. 3. Make certain the motive is to help, not to punish Often people have been hurt a great deal by a dependent person's words and actions. The natural reaction is to strike back or to get even. This is not the purpose of an intervention. The whole objective is to help - not to punish - the individual. Therefore, people who have a need to punish should probably not be a part of the intervention group. When Use Becomes a Problem 96

7 4. Be descriptive and specific Each person should be given an opportunity to describe in very specific detail an event or occasion in which a subject's substance-using behavior caused a problem or hurt someone. Frequently, a person starts with an expression of concern, such as "When you are sober you are really a nice person and I really care about you. Lately, however, when you have been drinking your behavior becomes objectionable. Here is a specific example..." The more specific examples that can be delivered by the group with all participating, the less likely that denial will last for the entire intervention. 5. Get a commitment to a plan If the objective is to have the person go in for a professional assessment, then an appointment should be made for a specific date soon after the anticipated intervention. If the objective is treatment, a bed should be reserved. It is easier to cancel than to have someone make a change and then need to wait a month before something happens. Chances are the change will not last the month. It needs to be reinforced as soon as possible. Do not leave the intervention without everyone involved, and especially the subject, fully knowledgeable about the next several steps to be taken and the consequences of failing to accomplish those steps. Interventions are not always successful. Sometimes denial is just too great. Sometimes key players fail to back up the group. One thing is certain: A second intervention will be much harder than the first. Therefore, it is important to carefully plan the initial intervention. Although there is no systematic, populationbased research in this area, interventions seem to work about half the time. When it comes time for a professional to make a formal assessment for a substance use disorder, a structured interview is set up, lasting between 30 and 60 minutes. The counselor asks a series of questions to assess problem areas in the subject's life. The counselor attempts to document only the alcohol or drug-related negative changes in behavior, changes that would not have occurred without the intoxication. In other words, negative behaviors that would have occurred regardless of intoxication do not count as signs of a substance use disorder. It must be stressed that the overall objective is to identify problems and attempt to solve them. It is not to label a person as an alcoholic or addict; doing so would not change his or her behavior. What has led the person into the assessment in the first place? People generally do not suddenly think of scheduling an assessment for themselves while walking down the street. Something is forcing them in. It might be a crisis at work or stress in the family. It might be the result of an intervention or school sanction. The list When Use Becomes a Problem 97

8 of reasons for referral may also include health concerns. It might even be the result of a DWI arrest. The first step of an assessment is talking through the circumstances of the referral to begin piecing together the negative consequences that have resulted from substance use. Those negative consequences may occur at school or work, or within the family or social group. The individual may volunteer some information, but it is extremely important for the assessor to seek information from other first-hand sources, as well. Why? The delusional process of dependency often blinds people to the true effects of their own behaviors. Counselors needs to verify what users are telling them, as well as to better understand how the users behaviors impact the other important people in their lives, such as a parent or spouse. Asking these questions early on in the assessment, as you might expect, tend to result in more truthful answers from the user. Once the assessment has been completed, the counselor will most likely use criteria for substance use disorders from the Diagnostic and Statistical Manual (DSM-V) to determine if a diagnosis is warranted. Each of the 87 counties in Minnesota is required to have independent assessors. These assessors can usually be found through county mental health services departments. Many school districts also have independent assessors on the payroll. Why do we need independent assessors? You wouldn't go to a Ford dealer and expect the dealer to recommend a Toyota. Likewise, an assessor in the employment of a treatment center is likely to make a referral to that treatment center, especially if there are empty beds. Intervention and assessment are two important tools to help people recognize they have a substance use disorder and start to repair their lives. The key goal is to help individuals begin to realize that their lives could be better if they were not using. When Use Becomes a Problem 98

9 Many different treatment options are available to people with substance use disorders, but no one option has proven to be universally successful. Treatment success depends on many variables, not the least of which is the ability to match individual needs with what the treatment system has to offer. Treatment is a Process, not a Place The treatment system has literally saved lives. Grateful clients and families attribute much of the change in their situations to the program they went through. Treatment is and always has been about the program. It can take place in a luxurious setting, or it can take place in a tent. It's the process that is important, not the physical location; always remember this. Just because a program has a tennis court and a swimming pool does not make it any more successful. Many programs are tailored to specific demographics, drugs consumed, cooccurrence of other diagnoses, and age or gender groups. Tailored programs are more effective than more general self-help groups. Just because Uncle Charlie found help with one treatment center does not mean that young Mary will find the same treatment center beneficial; she may have different needs. Typically, people find the most success with a treatment program that meets their demographic needs and provides an individualized treatment plan. For example, if Mary is seeking treatment for alcohol, she will usually make more progress if she s in a group of adolescents who similarly have an alcohol use disorder than with a group of adults seeking treatment for meth. 8 Many people would expect that there are two groups of people in treatment: those who voluntarily sign themselves in and those who don t. Further, one might also expect that the people who voluntarily sign themselves into treatment would have a higher success rate because they are more motivated. However, this is not really the case. No one really enters treatment without feeling forced into it in some way. If it is not the courts, it might be the family, the employer, or an intolerable situation that has prompted them to seek treatment. Someone or something forces them into the process. Most education experts learn early on that motivation is a key to change. In the dependency field, however, motivation is required for reinforcement, but does not necessarily need to be present before change can occur. You can force change, and motivation to sustain those changes catches up. Remember learning multiplication tables in elementary school? Were you motivated by pep rallies and prizes to learn those multiplication tables? No. You When Use Becomes a Problem 99

10 were forced to learn them, and later, as it became clear that they had use in your life, your motivation caught up. If you listen carefully to people in recovery, almost always the conversion experience begins with a dramatic natural consequence experience. This twoby-four between the eyes gets them to realize that they have a problem that cannot be allowed to go on. A DWI arrest and jail time will do it for many. Being fired from a job because of drug use may do it for others. Allowing people to suffer the natural consequences of their actions often forces change. The National Institute on Drug Abuse has developed a research-based guide on the principles of drug addiction treatment. The following sections include content by NIDA and are used here with permission. 8 Why do drug-addicted persons keep using drugs? Nearly all addicted individuals believe that they can stop using drugs on their own, and most try to stop without treatment. Although some people are successful, many attempts result in failure to achieve long-term abstinence. Research has shown that long-term drug abuse results in changes in the brain that persist long after a person stops using drugs. These drug-induced changes in brain function can have many behavioral consequences, including an inability to exert control over the impulse to use drugs despite adverse consequences the defining characteristic of addiction. Understanding that addiction has such a fundamental biological component may help explain the difficulty of achieving and maintaining abstinence without treatment. Psychological stress from work, family problems, psychiatric illness, pain associated with medical problems, social cues, such as meeting individuals from one s drug-using past, or environmental cues, such as encountering streets, objects, or even smells associated with drug abuse, can trigger intense cravings without the individual even being consciously aware of the triggering event. Any one of these factors can hinder sustained abstinence and make relapse more likely. Nevertheless, research indicates that active participation in treatment is an essential component for good outcomes and can benefit even the most severely addicted individuals. What Does Treatment Look Like? Treatment can occur in a variety of settings, take many different forms, and last for different lengths of time. Because drug addiction is typically a chronic disorder characterized by occasional relapses, a short-term, one-time treatment is usually not sufficient. When Use Becomes a Problem 100

11 There are a variety of evidence-based approaches to treating addiction. Drug treatment can include behavioral therapy, such as cognitive-behavioral therapy or contingency management, medications, or their combination. The specific type of treatment or combination of treatments will vary depending on the patient s individual needs and, often, on the types of drugs they use. Treatment medications, such as methadone, buprenorphine, and naltrexone, are available for individuals addicted to opioids, while nicotine preparations, such as patches, gum, lozenges, and nasal spray, and the medications varenicline and bupropion are available for individuals addicted to tobacco. Disulfiram, acamprosate, and naltrexone are medications available for treating alcohol dependence, which commonly co-occurs with other drug addictions, including addiction to prescription medications. Treatments for prescription drug abuse tend to be similar to those for illicit drugs that affect the same brain systems. For example, buprenorphine, used to treat heroin addiction, can also be used to treat addiction to opioid pain medications. Addiction to prescription stimulants, which affect the same brain systems as illicit stimulants like cocaine, can be treated with behavioral therapies, as there are not yet medications for treating addiction to these types of drugs. When Use Becomes a Problem 101

12 Behavioral therapies can help motivate people to participate in drug treatment, offer strategies for coping with drug cravings, teach ways to avoid drugs and prevent relapse, and help individuals deal with relapse if it occurs. Behavioral therapies can also help people improve communication, relationship, and parenting skills, as well as family dynamics. Many treatment programs employ both individual and group therapies. Group therapy can provide social reinforcement and help enforce behavioral contingencies that promote abstinence and a non-drug-using lifestyle. Some of the more established behavioral treatments, such as contingency management and cognitive-behavioral therapy, are also being adapted for group settings to improve efficiency and cost-effectiveness. However, particularly in adolescents, there can also be a danger of unintended harmful effects of group treatment sometimes group members, especially groups of highly delinquent youth, can reinforce drug use and thereby derail the purpose of the therapy. Thus, trained counselors should be aware of and monitor for such effects. When Use Becomes a Problem 102

13 Because they work on different aspects of addiction, combinations of behavioral therapies and medications, when available, generally appear to be more effective than either approach used alone. How Effective is Treatment? In addition to stopping drug abuse, the goal of treatment is to return people to productive functioning in the family, workplace, and community. According to research that tracks individuals in treatment over extended periods, most people who get into and remain in treatment stop using drugs, decrease their criminal activity, and improve their occupational, social, and psychological functioning. However, individual treatment outcomes depend on the extent and nature of the patient s problems, the appropriateness of treatment and related services used to address those problems, and the quality of interaction between the patient and the treatment providers. Remaining in treatment for an adequate period of time is critical. Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment. Recovery from drug addiction is a long-term process and frequently requires multiple episodes of treatment. When Use Becomes a Problem 103

14 Like other chronic diseases, addiction can be managed successfully. Treatment enables people to counteract addiction s powerful disruptive effects on the brain and behavior and to regain control of their lives. The chronic nature of the disease means that relapsing to drug abuse is not only possible but also likely, with symptom recurrence rates similar to those for other well-characterized chronic medical illnesses such as diabetes, hypertension, and asthma that also have both physiological and behavioral components. Unfortunately, when relapse occurs many deem treatment a failure. This is not the case: Successful treatment for addiction typically requires continual evaluation and modification as appropriate, similar to the approach taken for other chronic diseases. For example, when a patient is receiving active treatment for hypertension and symptoms decrease, treatment is deemed successful, even though symptoms may recur when treatment is discontinued. For the addicted individual, lapses to drug abuse do not indicate failure rather, they signify that treatment needs to be reinstated or adjusted, or that alternate treatment is needed. Recovery Treatment researchers learned early on that simply drying out a person for a month and sending that person back home often failed. Many clients were using again within a month after leaving treatment. Programs that recommended weekly attendance at self-help groups meetings, such as AA (Alcoholics Anonymous), found that more of their clients were able to maintain sobriety because they were being reinforced by other recovering peoples experiences. They knew that when a situation arose threatening to sabotage their recovery, they could go to a self-help group meeting and find support. Modern treatment programs have expanded beyond this initial recommendation. They require the client to attend weekly aftercare meetings sponsored by the treatment center and to do so for up to six months. In addition, they can require up to six meetings per week as the client begins to integrate back into a nonusing society. Treatment programs also recognized the importance of family in maintaining recovery: family in this sense is defined as the people who will be around and live with the client after treatment and is not necessarily the biological family. When the client was in a heavy drug-using period, the family also changed to adapt to the unhealthy relationship shared with and the ineffective communication patterns of the dependent person. If the treatment process doesn't help that family recover the supportive skills they had before the person developed a substance use disorder, then they most likely will unwittingly When Use Becomes a Problem 104

15 sabotage the recovery. As one mother said after her son returned from treatment, "I miss the fights we used to have." The fighting had become their relationship norm; attending the family group sessions would allow the mother and son to relearn how to interact with each other in healthy ways and the mother to learn how to most effectively support her son in his recovery. Self-help groups are one of the more successful ways that we supplement modern medical care, especially for diseases and conditions that are not popular, such as alcoholism, gambling, and being overweight. AA is considered to be the prototype of the self-help movement. At any given point in time, it is estimated that more than 2,000 self-help groups are operating in the Twin Cities metropolitan area. The most numerous are AA and AA spin-offs for family and friends, such as Al-Anon and Ala-teen, but there are also cancer groups, such as Reach for Recovery, a support group the Turtles for adolescents wearing braces for scoliosis, and numerous groups for people with various emotional health problems. Self-help groups generally share four common characteristics: 1. Voluntary No one is forced to go to a self-help group. It is entirely voluntary. Once in a while a judge will sentence someone to a self-help group, but that is discouraged. People feel that they are more respected and have more control if they know that they are attending meetings on their own. 2. Stigmatized Conditions People who attend self-help groups share a common stigmatized condition, such as alcoholism or having a sexually transmitted infection. This may also include certain medical or emotional conditions. People often fail to get appropriate help from the health care system and are ashamed about their condition. 3. No Professionals Very few of these groups are run by professionals. The attendees run the group by themselves. Professionals are only allowed to attend if they, too, share the same condition and then only as regular members, as opposed to experts. 4. Anonymous The groups are anonymous in two senses. First of all, the community does not know who is going to meetings. Lists are not posted or kept. Second, the attendees are often anonymous within the meeting. Usually only first names are used. This prevents people from using their name or credentials to impress When Use Becomes a Problem 105

16 people or shift the power dynamics of the group. Everyone there is on a common ground. As we can see from this lesson, substance use disorders are complex and require a comprehensive and individualized approach. Individuals struggling with these issues need compassionate people in their lives to support them in their journeys through the intervention, assessment, treatment, and recovery process. Lesson content created by the Rothenberger Institute in the School of Public Health at the University of Minnesota Regents of the University of Minnesota. All rights reserved. The Rothenberger Institute provides a suite of wellness-based courses focusing on the knowledge and skills students need to lead healthy, productive, and balanced lives. For more information, visit 1 Substance Abuse and Mental Health Services Administration Center (2013, September). Results from the 2012 national survey on drug use and health: Summary of National Findings (NSDUH Series H-46, HHS Publication No. (SMA) ). Rockville, MD: Author. Retrieved May 13, 2014, from indings/nsduhresults2012.htm#ch7 2 National Institute on Drug Abuse (2007, January). Topics in brief: Drugs, brains, and behavior: The science of addiction. Retrieved May 16, 2014, from 3 National Institute on Alcohol Abuse and Alcoholism. (2012, June). A family history of alcoholism: Are you at risk? (NIH Publication No ). Retrieved May 14, 2014, from 4 National Institute on Alcohol Abuse and Alcoholism. (n.d.). Genetics of substance use disorders. Retrieved May 13, 2014, from 5 Zucker, R.A., Donovan, J.E., Masten, A.S., Mattson, M.E., & Moss, H.B. (n.d.) Developmental processes and mechanisms. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. Retrieved May 14, 2014, from 6 Scales, P.C., Roehlkepartain, E.C., & Benson, P.L.(2010). Teen voice: Relationships that matter to America's teens. Minneapolis, MN: Best Buy When Use Becomes a Problem 106

17 Children's Foundation and Search Institute Retrieved from 7 Johnson, V. (1990). I'll quit tomorrow (Revised Edition). San Francisco: Harper Publishing. 8 National Institute on Drug Abuse. (2012, December). Principles of drug addiction and treatment (NIH Publication No ). Rockville, MD: National Institute on Drug Abuse, National Institutes of Health, U.S. Department of Health and Human Services. Retrieved May 14, 2014, from When Use Becomes a Problem 107

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