Download Treating Co-occurring Disorders

Best Practices in the
Identification and Treatment of
Co-occurring Disorders
Raymond M. Pomm M.D.
Vice President of Medical Services
River Region Human Services
Why Co-Occurring
Diagnosis ?
Because of an overlap,
drugs of abuse
can cause symptoms that
mimic
most forms of mental
illness
Which Develops First
Substance Abuse or Psychiatric
Illness?
It DepenDs….
SUBSTANCE-RELATED
(DSM-5 adds “and
Addictive”)
DISORDERS
The Social Use of
Drugs/Alcohol
Common Drugs of Abuse
•
•
•
•
•
•
Alcohol
Tobacco
Marijuana
Inhalants
Cocaine/Stimulants
K2, Spice
•
•
•
•
•
•
•
Club Drugs ie ecstasy, GHB
Hallucinogens
Opioids
Sedative hypnotics
Sports Drugs ie steroids
Bath Salts
Krokodil (not common yet)
Marijuana
In 2006 Marijuana was the most commonly
used substance for which the most recent
treatment was received in youths aged 12 to
17.
Gateway Drug
Driving Under the Influence
If drunk –
you run the RED lights
If Stoned –
you stop at the GREEN lights
Alcohol and the Teenage Brain
Professor Susan Tapert of the University of
California at San Diego used a MRI to scan
the brains of teens who binge drink—
defined as drinking 4 or 5 (or more) drinks
in a couple of hours. The “white matter” in
their brains was abnormal when compared
with the white matter of teens who do not
binge drink. This could affect thinking,
learning, and memory.
Alcohol and the Teenage Brain
These teens were not alcoholics, and they
did not drink every day. All they did (to be
considered “binge drinkers”) was drink at
least 4 (for females) or 5 (for males) drinks
in 1 sitting, at least 1 time during the
previous 3 months
(April, 2009)
Criteria for Substance Abuse
A. A maladaptive pattern of substance use leading to
clinically significant impairment or distress, as
manifested by one (or more) of the following,
occurring within a 12-month period:
(1) recurrent substance use resulting in a failure
to fulfill major role obligations
(2) recurrent substance use in situations in which
it is physically hazardous
(3) recurrent substance-related legal issues
(4) continued substance use despite having
persistent or recurrent social or interpersonal
problems caused or exacerbated by the
effects of the substance
A Shorter Definition of Substance
Abuse:
When an individual gets into trouble due to
substance use on, at least, 2 different occasions
within a 12-month period of time.
Criteria for Substance Dependence
A. A maladaptive pattern of substance use, leading to
clinically significant impairment or distress, as manifested
by three (or more) of the following, occurring at any time in
the same 12-month period:
(1) tolerance, as defined by eight of the following:
(a) a need for markedly increased amounts of the
substance to achieve intoxication or desired effect
(b) markedly diminished effect with continued use of
the same amount of substance
(2) withdrawals, as manifested by either of the following:
(a) the characteristic withdrawal syndrome for the
substance (refer to Criteria A and B of the
criteria sets for Withdrawal from the specific
substances)
(b) the same (or a closely related) substance is
taken to relieve or avoid withdrawal symptoms
(3) the substance is often taken in larger amounts or
over a longer period than was intended
(4) there is a persistent desire or unsuccessful efforts to
cut down or control substance use
(5) a great deal of time is spent in activities necessary to
obtain the substance (e.g., visiting multiple doctors or
driving long distances), use the substance (e.g.,
chain-smoking), or recover from its effects
(6) important social, occupational, or recreational activities
are given up or reduced because of substance use.
(7) the substance use is continued despite knowledge of
having a persistent or recurrent physical or
psychological problem that is likely to have been
caused or exacerbated by the substance (e.g., current
cocaine use despite recognition of cocaine-induced
depression, or continued drinking despite recognition
that an ulcer was made worse by alcohol consumption)
The Three “C’s” (Classic Symptoms)
• Loss of Control (forgot kid’s game, too tired to
keep plans with spouse, late for work, etc)
• Compulsivity (using more than intended or for a
longer time)
• using despite adverse Consequences
(arguments w/ loved ones, medical
problems, DUI, job)
DSM-5
• Combines many of the Abuse and
Dependence criteria under the heading
“Substance-Related and Addictive
Disorders”
• Specifier difference: early remission is 3 –
12 months; sustained remission is 12 mos.
or longer
• Severity: mild (2-3 sxs); moderate (4-5 sxs);
severe (6 or more sxs)
• Must list the name of each specific drug
Example
_______ Use Disorder, in early/sustained
remission, on maintenance therapy and/or in
a controlled environment,
mild/moderate/severe
Feel
Food
Fluids
Fight or Flight
F lirt
Dopamine Pathways
Serotonin Pathways
striatum
frontal
cortex
hippocampus
substantia
nigra/VTA
Functions
•reward (motivation)
•pleasure,euphoria
•motor function
(fine tuning)
•compulsion
•perserveration
nucleus
accumbens
raphe
Functions
•mood
•memory
processing
•sleep
•cognition
VTA
Amphetamines
Opiates
THC
PCP
Ketamine
Nucleus
Nicotine
accumbens
Alcohol
benzodiazepin
es barbiturates
Dopamine Pathways
Summary
Dopamine – all drugs of abuse; pleasure
Endorphins – all drugs of abuse; reward, pleasure
Norepinephrine – stimulants
Serotonin - hallucinogens
GABA – sedatives, alcohol
Glutamate, NMDA – withdrawal &
stimulation
Schizophrenia and
Other Psychotic
Disorders
DSM-5
Major difference is the title:
“Schizophrenia Spectrum and
Other Psychotic Disorders”
Diagnostic Criteria for Schizophrenia
A. Characteristic symptoms: Two (or more) of the
following, each present for a significant portion of
time during a 1-month period (or less if successfully
treated):
(1) delusions
(2) hallucinations
(3) disorganized speech (e.g., frequent
derailment or incoherence)
(4) grossly disorganized or catatonic behavior
(5) negative symptoms, i.e., affective flattening,
alogia, or avolition
continued
B. Social/occupational dysfunction
C. Duration: Continuous signs of the disturbance persist
for at least 6 months. This 6-month period must
include at least 1 month of symptoms (or less if
successfully treated) that meet Criterion A.
Diagnostic Criteria for 298.8
Brief Psychotic Disorder
A. Presence of one (or more) of the following symptoms:
(1) delusions
(2) hallucinations
(3) disorganized speech (e.g., frequent derailment
or incoherence)
(4) grossly disorganized or catatonic behavior
B. Duration of an episode of the disturbance is at least 1
day but less than 1 month, with eventual full return to
premorbid level of functioning.
Diagnostic Criteria for 295.70
Schizoaffective Disorder
A. An uninterrupted period of illness during which, at
some time, there is either a Major Depressive Episode,
a Manic Episode, or a Mixed Episode concurrent with
symptoms that meet Criterion A for Schizophrenia.
B. Delusions or hallucinations for 2 or more weeks in the
absence of a major mood episode during the
duration of the illness.
C. Symptoms that meet criteria for a major mood episode
are present for the majority of the total duration of the
active and residual portions of the illness,
Bipolar type; Depressive type; specify if with catatonia
*underline are DSM – 5 changes
Specifiers for Delusional Disorder,
Schizophrenia and Schizoaffective Disorder
•
•
•
•
1st episode, currently in acute episode
1st episode, currently in partial remission
1st episode, currently in full remission
Multiple episodes, currently in acute
episode, partial remission or in full
remission
• Continuous
• Unspecified
Specifiers for Delusional Disorder and
Schizophrenia cont’d
Current severity:
Each primary symptom must be rated
for severity within the last 7 days from 0
(not present) to 4 (present and severe)
MOOD
DISORDERS
DSM-5
Heading is broken out into two
types:
1. Depressive Disorders
2. Bipolar and Related Disorders
Depressive Disorders
Major Depressive Disorder
At least five for a two week period
1.
2.
3.
4.
5.
6.
7.
8.
9.
Depressed mood
Anhedonia
Weight loss/gain (anorexia/hyperphagia)
Insomnia/hypersomnia
Psychomotor disturbance
Diminished energy
Diminished self-esteem/guilt
Impaired concentration
Recurrent thoughts of suicide
MDD Specifiers cont’d
• Partial/full remission
• Mild: few, if any sxs, in excess of required.
Minor impairment. Distressing but
manageable
• Moderate: number and intensity of sxs
between mild and severe
• Severe: number of sxs is substantially in
excess of those required. Marked
impairment. Seriously distressing and
unmanageable
MDD Specifiers
• With:

anxious distress

mixed features

melancholic features

atypical features

mood congruent psychotic features

mood incongruent psychotic features

Catatonia

peripartum onset

seasonal pattern (recurrent only)
Dysthymic Disorder as
we know it is mostly
gone!!!!
Persistent Depressive
Disorder (Dysthymia)
This disorder represents a
consolidation of DSM-IVdefined chronic major depressive
disorder and dysthymic disorder.
Persistent Depressive Disorder
(Dysthymia)
A.
Depressed mood for most of the day, for
more days than not, as indicated either by
subjective account or observation by
others, for at least 2 years.
B.
Presence, while depressed, of two (or
more) of the following:
(1) poor appetite or overeating
(2) insomnia or hypersomnia
(3) low energy or fatigue
(4) low self-esteem
(5) poor concentration or difficulty
making decisions
(6) feeling of hopelessness
Persistent Depressive Disorder
(Dysthymia) cont’d
C. During the two year period of the
disturbance , the individual has never been
without the sxs in Criteria A and B for
more than 2 months at a time.
D. Criteria for major depressive disorder may
be continuously present for 2 years
PDD Specifiers
• Partial/full remission
• Early onset (before 21), Late onset (at or
after 21)
• With pure dysthymic syndrome
• With persistent major depressive episode
• With intermittent major depressive
episodes, with current episode
• With intermittent major depressive
episodes, without current episode
PDD Specifiers cont’d
• Mild: few, if any sxs, in excess of required.
Minor impairment. Distressing but
manageable
• Moderate: number and intensity of sxs
between mild and severe
• Severe: number of sxs is substantially in
excess of those required. Marked
impairment. Seriously distressing and
unmanageable
Other Specified Depressive
Disorder
• Recurrent brief depression: 2-13 days at
least one per month for at least 12
consecutive months
• Short-duration depressive episodes: 4-13
days
• Depressive episode with insufficient
symptoms: depressed affect and at least one
of the other 8 symptoms
Unspecified Depressive
Disorder
Used to be called Depressive
Disorder NOS
Bipolar and Related
Disorders
Manic Episode
A. distinct period of abnormally and
persistently elevated, expansive, or
irritable mood, lasting at least 1 week
(or any duration if hospitalization is
necessary).
B.
During the period of mood
disturbance, three (or more) of the
following symptoms have persisted
(four if the mood is only irritable) and
have been present to a significant
degree:
(1) inflated self-esteem or grandiosity
(2) decreased need for sleep (e.g., feels
rested after only 3 hours of sleep)
(3) more talkative than usual or pressure
to keep talking
(4) flight of ideas or subjective
experience that thoughts are racing
(5) distractibility (e.g., attention too
easily drawn to unimportant or irrelevant
external stimuli)
(6) increase in goal-directed activity
(either socially, at work or school, or
sexually) or psychomotor agitation.
(7) excessive involvement in pleasurable
activities that have a high potential for
painful consequences (e.g., engaging in
unrestrained buying sprees, sexual
indiscretions, or foolish business
investments)
Hypomanic Episode
A
Distinct period of persistently elevated,
expansive, or irritable mood and abnormally
and persistently increased activity or energy,
lasting throughout at least 4 consecutive
days and present most of the day, nearly
every day.
B.
During the period of mood disturbance,
three (or more) of the following symptoms
have persisted (four if the mood is only
irritable) and have been present to a
significant degree:
(1) inflated self-esteem or grandiosity
(2) decreased need for sleep (e.g., feels
rested after only 3 hours of sleep)
(3) more talkative than usual or pressure to
keep talking
(4) flight of ideas or subjective experience
that thoughts are racing.
(5) distractibility (e.g., attention to easily
drawn to unimportant or irrelevant external
stimuli)
(6) increase in goal-directed activity (either
socially, at work or school, or sexually) or
psychomotor agitation
(7) excessive involvement in pleasurable
activities that have a high potential for
painful consequences (e.g., the person
engages in unrestrained buying sprees,
sexual indiscretions, or foolish business
investments)
Bipolar I
• What is it?
At least one manic episode. Major
depression is not required, though the vast
majority experience these episodes.
Bipolar I specifiers
Current or most recent episode:
manic, hypomanic, depressed or
unspecified
Mild, moderate or severe
Partial or full remission
Bipolar I specifiers cont’d
• With:

anxious distress

mixed features

rapid cycling

melancholic features

atypical features

mood congruent psychotic features

mood incongruent psychotic features

Catatonia

peripartum onset

seasonal pattern (recurrent only)
Bipolar II
• What is it?
Must meet the criteria for a current or past
hypomanic episode and the criteria for a
current or past major depressive episode.
There must never have been a manic
episode.
Bipolar II specifiers
Specify if current episode is:
Hypomanic or Depressed
Mild, moderate or severe
Partial or full remission
Bipolar II specifiers cont’d
• With:

anxious distress

mixed features

rapid cycling (4 mood episodes in the last 12
months)

melancholic features

atypical features

mood congruent psychotic features

mood incongruent psychotic features

Catatonia

peripartum onset (during pregnancy or in the 4 weeks
following delivery)

seasonal pattern (recurrent only)
Other Specified Bipolar and
Related Disorder
• Short duration hypomanic episodes (2-3
days) and major depressive episodes
• Hypomanic episodes with insufficient
symptoms and major depressive episodes
• Hypomanic episodes without prior major
depressive episode
• Short duration cyclothymia
Unspecified Bipolar and
Related Disorder
Used to be Bipolar Disorder
NOS
Anxiety Disorders
Generalized Anxiety Disorder
DSM IV = DSM-5
A. Excessive anxiety or worry
B. Difficult to control the worry
C. 3 or more for 6 months:
1/ Restlessness/keyed up; 2/ Easily
fatigued; 3/ Decreased conc.; 4/ Irritability;
5/muscle tension; 6/ sleep disturbance
Panic Attacks
Four or more develop abruptly and reach a peak within 10
minutes
Head:
• Lightheaded
• Sweating parethesias
• Hot flashes
Mental:
• Fear of dying
• Fear of going crazy
• Derealization
Neck:
• Choking
Trunk:
• Short of breath
• Chest pain
• Palpitations
• Nausea
• Trembling
Panic Disorder (no longer
attached to Agoraphobia)
• Recurrent unexpected panic attacks
• Concern or worry about additional panic
attacks or their consequences (e.g., losing
control, “going crazy” or having a heart
attack)
or
• A significant change in behavior related to
the attacks designed to avoid having panic
attacks
PTSD
DSM IV – under the category of Anxiety
Disorders
DSM-5 – under the category of Trauma – and
Stress-Related Disorders
PTSD DSM-5 Criteria
A. Exposure: direct, witness, learning about
event occurring to someone close,
experiencing repeated/extreme exposure to
adverse details of the event; i.e. 1st
responders.
B. One of the following: recurrent memories,
recurrent distressing dreams, dissociative
reactions (i.e. flashbacks), intense distress at
exposure to internal or external cue
(symbolizing or resembling the event)
PTSD DSM-5 Criteria cont’d
C. One or both: avoidance of memories;
avoidance of external reminders
D. Two or more: inability to remember
aspects of the event; negative beliefs about
self or others; distorted cognitions about the
cause or consequence (blaming self or
others); negative emotional state; feelings of
detachment or estrangement from others;
inability to experience positive emotions
PTSD DSM-5 Criteria cont’d
E. Two or more: irritable behavior/angry
outbursts; reckless/self-destructive
behavior; hypervigilance; exaggerated
startle response; problems with
concentration; sleep disturbance
F. Duration of B,C,D and E greater than one
month
PTSD DSM-5 specifiers
• With dissociative symptoms:
depersonalization or derealization
• With delayed expression: symptoms full
criteria not met for at least 6 months after
the event
Evaluation of Cooccurring Disorders
Key Factors in Evaluating Dual
Disorders
1. Comprehensive history
2. Phase specific symptoms:
a) Intoxication
b) Use
c) Withdrawal
d) Post acute withdrawal
Focus on duration/sxs of each phase and
timing as it relates to potential psych sxs.
Very Important:
What are the sxs during times of
abstinence and how long has the
individual been abstinent.
Remember acute versus post acute
withdrawal sxs and duration.
• Don’t give definitive dx while intoxicated or
withdrawing. How long should one wait?
• History is critical: 1) family history; 2) look
for “windows” of clean time; 3) beware of
“white knuckles”.
• Psychological testing only at appropriate
time.
• REMEMBER - A DIAGNOSIS CAN
HAVE PERMANENT
RAMIFICATIONS!
PERSONALITY
DISORDERS
The only difference in
behavior between an
alcoholic/addict and a
personality disorder
is_________?
General Diagnostic Criteria for a
Personality Disorder
A. An enduring pattern of inner experience and
behavior that deviates markedly from the
expectations of the individual’s culture. This
pattern is manifested in two (or more) of the
following areas:
(1) cognition (I.e., ways of perceiving and
interpreting self, other people, and event.
(2) affectivity (i.e., the range, intensity, lability,
and appropriateness or emotional
response)
(3) interpersonal functioning
(4) impulse control
Slide 1 of 3
General Diagnostic Criteria for a
Personality Disorder (continued)
B. The enduring pattern is inflexible and
pervasive across a broad range of personal and
social situations.
C. The enduring pattern leads to clinically
significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The pattern is stable and of long
duration and its onset can be traced back at least
to adolescence or early childhood.
Slide 2 of 3
General Diagnostic Criteria for a
Personality Disorder (continued)
E. The enduring pattern is not better accounted
for as a manifestation or consequence of another
mental disorder.
F. The enduring pattern is not due to the direct
physiological effects of a substance (e.g., a drug
of abuse, a medication), or a general medical
condition (e.g., head trauma).
Slide 3 of 3
Borderline
Personality Disorder
Vs.
Behavior
NARCISSISTIC
Personality Disorder
Vs.
Behavior
Antisocial
Personality Disorder
Vs.
Behavior
Don’t Be So Quick to
Diagnose
CANNABIS USE
DISORDER
Cannabis Intoxication
• Clinically significant maladaptive or
psychological changes (e.g., impaired
coordination, euphoria, anxiety, sensation of
slowed time, impaired judgment, social
withdrawal)
Cannabis Intoxication
cont’d
• Two or more of the following within 2
hours of use:
 Conjunctival injection
Increased appetite
Dry mouth
Tachycardia
Cannabis Withdrawal
•
•
•
•
•
•
•
Irritability
Nervousness/anxiety
Insomnia/disturbing dreams
Appetite decrease
Restless
Depressed mood
At least one : abdominal pain, tremors,
sweating, fever chills or headache
ALCOHOL USE
DISORDER
ALCOHOL INTOXICATION
One (or more) of the following signs,
developing during, or shortly after,
alcohol use:
(1) slurred speech
(2) incoordination
(3) unsteady gait
(4) nystagmus
(5) impairment in attention or memory
(6) stupor or coma
Alcohol: Clinical Effects
Stages of Intoxication and Blood Alcohol Concentration
Sober
Euphoria
Excitement
Confusion
Stupor
Coma
Death
100
200
300
400
Blood Alcohol (mg/dl)
500
600
ALCOHOL WITHDRAWAL
A. Cessation or reduction in alcohol use……….
B. 2 or more of the following………:
Autonomic hyperactivity (e.g., sweating or
pulse rate greater than 100), increased hand
tremor, nausea/vomiting, transient
hallucinations (visual, tactile, auditory or
illusions), psychomotor agitation, anxiety,
and/or generalized tonic-clonic seizures
Specify if with perceptual disturbances –
hallucinations occurring with intact reality testing
or in the absence of delirium
Protracted
Withdrawal
SEDATIVE,
HYPNOTIC or
ANXIOLYTIC USE
DISORDER
Sedative, Hypnotic or
Anxiolytic Intoxication
C. One (or more) of the following signs,
developing during, or shortly after,
alcohol use:
(1) slurred speech
(2) incoordination
(3) unsteady gait
(4) nystagmus
(5) impairment in attention or memory
(6) stupor or coma
3
Sedative, Hypnotic or Anxiolytic
Withdrawal
A. Cessation or reduction of use
B. 2 or more of the following: autonomic
hyperactivity (e.g., sweating or pulse rate
greater than 100), hand tremor, insomnia,
nausea/vomiting, transient hallucinations
(visual, tactile, auditory or illusions),
psychomotor agitation, anxiety, grand mal
seizures
Specify if with perceptual disturbances –
hallucinations occurring with intact reality
testing or in the absence of delirium
Protracted
Withdrawal
BEWARE
• T ½ of critical importance
• Interdose withdrawal
• Rapid development of tolerance leading to
chasing the wrong sxs
• Know the difference between resurgence of
premorbid sxs vs. withdrawal sxs
• Dependence is often iatrogenic
Stimulant-Related Disorder
Attached to severity add:
• Amphetamine-type substance
• Cocaine
• Other or unspecified stimulant
Stimulant Intoxication
A. Recent use
B. Clinically significant behavioral or psychological
changes
C. 2 or more of the following: tachycardia or bradycardiapupillary dilation- incr. or decr. B/P- perspiration or
chills- N/V- wgt loss, psychomotor
agitation/retardation-muscular weakness, respiratory
depression, chest pain or cardiac arrhythmia-confusion,
seizures, dyskinesias, dystonias or coma
Specify the specific intoxicant
Specify if with perceptual disturbances
Stimulant Withdrawal
Dysphoric mood + 2 or more of the following:
1. Fatigue
2. Vivid/unpleasant dreams
3. Insomnia/hypersomnia
4. Increased appetite
5. Psychomotor retardation/agitation
Specify the specific substance
Protracted
Withdrawal
Opioid-Related
Disorders
Opioid Intoxication
A. Recent use
B. Clinically significant problematic
behavioral or psychological changes…….
C. Pupillary constriction or dilation (anoxia)
and 1 or more of the following: drowsiness
or coma, slurred speech and or impairment
in attention or memory
Specify if with perceptual disturbances
Locus Coeruleus
Opioid Withdrawal
A. Cessation/reduction in used or
administration of an antagonist
B. 3 or more of the following: dysphoric
mood - N/V- muscle aches - lacrimation or
rhinorrhea - pupillary dilation,
piloerection, or sweating - diarrhea yawning - fever - insomnia
Protracted
Withdrawal
Urine Drug
Screening
There is a Difference and it is VERY
IMPORTANT
• Screening can yield up to a 50% false
negative rate.
• Screening can yield up to a 41% false
positive rate for oxycodone, 22% for
opiates, 21% for marijuana and 11% for
benzodiazepines.
More data is available upon request.
The Difference cont’d
Reasons for false negatives:
• Higher cutoff levels
• Unable to effectively identify some
substances (e.g. Lorazepam)
Reasons for false positives:
• Cross-reactivity
Confirmation Testing
• Either GC-MS or LC-MS/MS are the only
reliable testing methods upon which one can
be assured of the right decision.
• There are no false negatives or false
positives for drugs tested.
The Co-occurring
Picture
Cannabis
• Intoxication: frank psychosis (rare), acute
psychosis more common when eaten,
paranoid ideation, GAD, panic attacks (rare)
• Chronic use: Memory impairment, learning
skills impairment, 8 point IQ drop,
amotivational syndrome
ALCOHOL
Intoxication: mania (stimulant effect) at low
doses; depressant effects at higher doses.
Withdrawal:
Acute: mild (anxiety, insomnia); severe
(agitation, mania, delirium, psychosis)
Sub-chronic: depression
Chronic: MDD, psychosis, dementia
SEDATIVES
Intoxication (use): depressant, amnesia, ataxia
and falling (old), rarely paradoxical
agitation (young/old),
Withdrawal:
Acute: mild (anxiety, insomnia); severe
(agitation, mania, delirium, psychosis)
Sub-chronic & Chronic: depression, anxiety
STIMULANTS
• Intoxication: anxiety, panic attacks, mania,
psychosis
• Withdrawal: prolonged depression,
insomnia, psychosis
OPIOIDS
• Intoxication (use): depressant effect, many
reports of stimulant effects at lower doses
• Withdrawal:
Acute: previous slide, remember half-life
determines length of time
Chronic: depression, irritability, anxiety,
insomnia
Dual Diagnosis
Epidemiology
 29%
of Psychiatric Patients
 38% of Chemical Dependency Patients
…have Co-morbid Disorder (dually dx)
2/3 OF PATIENTS ADMITTED TO
STATE PSYCHIATRIC
HOSPITALS HAD A LIFETIME
DIAGNOSIS OF ALCOHOL OR
SUBSTANCE ABUSE OR
DEPENDENCE
Reason for Hope
Dopamine Density
Questions?