Download 2 MB 2017 Addiction Introduction - Northeast Ohio Nurse Practitioners

Alcohol and
Other Drug Abuse 101
David L. Brager PMHNP
Addiction Fellow
Northeast Ohio Nurse Practitioner Conference
April 27, 2017
Cleveland, Ohio
1
ACKNOWLEDGENT:
Thank you and special recognition to:
Christina M. Delos Reyes, MD
Medical Consultant
For her assistance and contribution to this
program.
Disclosure Statement:
No conflicts to disclose.
2
Learning Objectives
Part I. What is addiction? What are substance use
disorders?
Part II. What are the drugs of abuse? What are their
effects?
3
4
Explanatory Models of Addiction
Moral  wrong
Spiritual  empty
Psychological  impulse control
Behavioral  habit
Medical  disease
5
Medical model of addiction
 Sick person seeking wellness
 SUDs as chronic diseases
 Biological basis
 Identifiable signs and symptoms
 Predictable course and outcome
 Treatment improves outcomes
 Lack of treatment may lead to morbidity and
mortality
6
Medical model of addiction
 A chronic relapsing disease of the brain
 Drugs change brain structure and function
 Brain changes can be long lasting and lead to
harmful behaviors
 Characterized by compulsive drug seeking and
use despite harmful consequences
7
8
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How Does the Brain Become Addicted?
Typically it happens like this:
 A person takes a drug of abuse, activating the same
brain circuits as do behaviors linked to survival, such
as eating, bonding and sex
 The drug causes a surge in levels of a brain
chemical called dopamine, which results in feelings of
pleasure; the brain remembers this pleasure and
wants it repeated
10
How Does the Brain Become Addicted?
 Just as food is linked to survival in day-to-day living,
drugs begin to take on the same significance for the
addict
 “Survival Salience”
 The need to obtain and take drugs becomes more
important than any other need, including truly vital
behaviors like eating
 The addict no longer seeks the drug for pleasure,
but for relieving distress
11
How Does the Brain Become Addicted?
 Eventually, the drive to seek and use the drug
is all that matters, despite devastating
consequences
 Finally, control and choice and everything that
once held value in a person's life, such as
family, job and community, are lost to the
disease of addiction
12
Influence
Quantity / Frequency
LIFESTYLE CHOICES
Interact With
BIOLOGICAL
FACTORS
Influence
SOCIAL
FACTORS
PSYCHOLOGICAL
FACTORS
13
What brain changes are responsible
for such a dramatic shift?
 (1) Disrupted dopamine activity
 Dopamine release is needed in order to experience
pleasure and motivate our responses to natural
rewards of everyday life, such as food
 Drugs produce very large and rapid dopamine surges
and the brain responds by reducing normal dopamine
activity
 Eventually, the disrupted dopamine system renders
the addict incapable of feeling any pleasure even
from the drugs they seek to feed their addiction
14
What brain changes are responsible
for such a dramatic shift?
 (2) Altered brain regions that control decision- making
and judgment
 Resulting lack of control leads addicted people to
compulsively pursue drugs, even when the drugs have
lost their power to reward
 Drug addiction is insidious because it affects the very
brain areas that people need to "think straight," apply
good judgment, and make good decisions for their lives
 The disease of addiction can develop in people despite
their best intentions or strength of character
 No one wants to grow up to be a drug addict, after all
15
The Reward Circuit
Mesolimbic and Mesocortical Neuronal Pathways
graphic from: Goldstein RZ, Volkow ND,
(2002). Drug Addiction and Its Underlying
Neurobiological Basis. Am J Psychiatry
159:1642–1652
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Addiction is a Brain Disease
 A stress-induced defect in the reward
pathways of the brain
 Drugs achieve “survival salience”
 Mediated by the neurotransmitter dopamine
 Alcohol and other drugs “hijack” the reward
pathway, making usual life pleasures much
less rewarding
17
Factors that contribute to addiction
 Genetic
 Cultural
 Underlying biological deficit in reward circuits
 Repeated engagement in drug use or other
addictive behaviors, causing neuroadaptation in
motivational circuitry
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Factors that contribute to addiction
(cont’d.)
 Cognitive and affective distortions
 Disruption of healthy social supports and
problems in interpersonal relationships which
impact the development or impact of resiliencies
 Exposure to trauma or stressors that overwhelm
an individual’s coping abilities
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Factors that contribute to addiction
(cont’d.)
 Distortion in meaning, purpose and values that
guide attitudes, thinking and behavior
 Distortions in a person’s connection with self,
with others and with the transcendent (referred to
as God by many, the Higher Power by 12-steps
groups, or higher consciousness by others)
 The presence of co-occurring psychiatric
disorders
20
Relationships between Substances of Abuse
and Mental Disorders (Lehman et al.,1989)
 Acute and chronic substance use can produce
psychiatric symptoms
 Substance withdrawal can cause psychiatric
symptoms
 Substance use can mask psychiatric symptoms
21
Relationships between Substances of Abuse
and Mental Disorders (Lehman et al.,1989)
 Psychiatric disorders can mimic symptoms
associated with substance use
 Acute and chronic substance use can
exacerbate psychiatric disorders
 Acute and chronic psychiatric disorders can
exacerbate the recovery process from addictive
disorders
22
Addiction is characterized by:
 The power of external cues
 Persistent risk and/or recurrence of relapse
:
 Significant impairment in executive
functioning
 Addiction is more than a behavioral disorder
23
Emotional changes
Emotional changes in addiction can include:
 Increased anxiety, dysphoria and emotional pain
 Increased sensitivity to stressors associated with brain
stress systems, such that “things seem more stressful” as
a result
 Difficulty in identifying feelings, distinguishing between
feelings and the bodily sensations of emotional arousal,
and describing feelings to other people (sometimes
referred to as alexithymia)
24
The emotional aspects of addiction
are complex
 Reasons to use alcohol or other drugs:
 “Positive reinforcement”
 seeking a positive emotional state (“euphoria”)
 “Negative reinforcement”
 avoiding a negative emotional states (“dysphoria”)
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Progression and Tolerance
 Intoxication ->
• Experience a “high”, or “positive” emotional state
associated with increased dopamine and opioid peptide
activity in reward circuits
• After the “high”, there is a neurochemical rebound,
where reward function does not simply revert to
baseline, but drops below original levels
• Usually not consciously perceptible by the individual and
not necessarily associated with functional impairments
26
Progression and Tolerance
 Over time:
• Repeated experiences with substance use or
addictive behaviors are not associated with ever
increasing reward circuit activity…
• …And are not as subjectively rewarding
27
Progression and Tolerance
 Withdrawal from drug use or comparable
behaviors->
• Agitated, dysphoric and labile emotional
experience, related to suboptimal reward and
the recruitment of brain and hormonal stress
systems
• Associated with abrupt cessation of most
pharmacological classes of addictive drugs
28
Progression and Tolerance
 While tolerance develops to the “high,”
tolerance does not develop to the
emotional “low” associated with the cycle
of intoxication and withdrawal
 Thus, in addiction, persons repeatedly
attempt to create a “high”--but what they
mostly experience is a deeper and deeper
“low”
29
Progression and Tolerance
 While anyone may “want” to get “high”, those
with addiction feel a “need” to use the addictive
substance or engage in the addictive behavior in
order to try to resolve their dysphoric emotional
state or their physiological symptoms of
withdrawal
 Persons with addiction compulsively use even
though it may not make them feel good, in some
cases long after the pursuit of “rewards” is not
actually pleasurable
30
Progression and Tolerance
 Although people from any culture may choose to
“get high” from one or another activity, it is
important to appreciate that addiction is not
solely a function of choice
 As addiction is a chronic disease, periods of
relapse, which may interrupt spans of remission,
are a common feature of addiction
31
Addiction 1 of 3
ASAM Definition (April 2011):

Addiction is a primary, chronic disease of
brain reward, motivation, memory and
related circuitry. Dysfunction in these
circuits leads to characteristic biological,
psychological, social and spiritual
manifestations. This is reflected in an
individual pathologically pursuing reward
and/or relief by substance use and other
behaviors.
32
Addiction 2 of 3
ASAM Definition (April 2011):
 Addiction is characterized by
A
B
C
D
E
inability to consistently abstain,
impairment in behavioral control,
craving,
diminished recognition of significant
problems with one’s behaviors and
interpersonal relationships,
a dysfunctional emotional response
33
Addiction 3 of 3
ASAM Definition (April 2011):

Like other chronic diseases, addiction often
involves cycles of relapse and remission.
Without treatment or engagement in
recovery activities, addiction is progressive
and can result in disability or premature
death.
34
DSM-5 Substance Use
Disorder: 11 Criteria
 Taking the substance in larger amounts or
for longer than you intended
 Persistent desire or unsuccessful efforts to




cut down or control use
Great deal of time spent obtaining, using,
or recovering from effects of the substance
Craving, or a strong desire or urge to use the
substance
Recurrent use resulting in a failure to fulfill
major role obligations at work, school, or
home
Continued used despite persistent social or
interpersonal problems caused or
exacerbated by use
 Giving up or reducing important social,
occupational or recreational activities
because of substance use
 Recurrent use in situations in which it is
physically hazardous
 Use despite knowledge of
persistent/recurrent physical or
psychological problem that is likely to
have been caused or exacerbated by the
substance
 Tolerance* (see next slide)
Need for increased amounts
 Diminished effects with same amounts

 Withdrawal* (see next slide)
 Characteristic withdrawal syndrome

Drug taken to avoid withdrawal
35
*NOTE:
 Tolerance and withdrawal criterion are not
considered to be met for those taking the following
substances solely under appropriate medical
supervision:
 Opioids
 Stimulants
 Sedative-hypnotics
36
Substance Use Disorder (cont’d)
 Rationale continued: Further, studies from clinical and
general populations indicate DSM-IV substance abuse and
dependence criteria represent a singular phenomenon but
encompassing different levels of severity.
 Mild SUD (2-3/11 criteria) will be coded with the DSM-IV
substance abuse code to reflect the intent but not reality of
considering substance abuse less severe than substance
dependence.
 Moderate (4-5/11 criteria) and severe (6+/11 criteria) SUD
will be coded with DSM-IV substance dependence codes.
37
Copyright © 2013. American Psychiatric Association.
Classes of Drugs of Abuse












Alcohol
Stimulants
Caffeine
Nicotine
Cannabis
Opioids
Sedative-hypnotics
Hallucinogens
Dissociative Drugs
Club Drugs - will not be covered
Anabolic Steroids - will not be covered
Inhalants
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What is a Standard Drink?
40
Use
Consequences
Repetition
ABST
NONPROB
USE
-
+
-
ATRISK ABUSE DEP
USE
+
-/+
-
+
+
+
+
++
+
Loss of control, preoccupation, compulsivity, physical dependence +
41
What is “Low-Risk” drinking?
Research shows that people who drink moderately may be less
likely to experience an alcohol use disorder (AUD). To stay low
risk for AUDs, you must keep within both the single-day and
weekly limits.
For men:
No more than 4 drinks on any single day AND no more than 14
drinks per week
For women and men > 65 who are healthy and on no
medications:
No more than 3 drinks on any single day AND no more than 7
drinks per week
42
What is Risky Drinking?




Women: > 3 drinks per occasion; > 7/week
Over 65: > 3 drink per occasion; > 7/week
Men: > 4 drinks per occasion; > 14/week
Any use is risky when:
 Pregnant
 Driving
 Taking certain medications
 Having certain medical conditions
 In recovery from addiction/cannot control drinking
 Hazardous: Pattern that increases risk for adverse consequences
 Harmful: Negative consequences have already occurred
43
What is Binge Drinking?
 A pattern of drinking alcohol that brings blood alcohol
concentration (BAC) to 0.08 grams percent or above
within 2 hours
 For the typical adult this pattern corresponds to
consuming 5 or more drinks (male) or 4 or more
drinks (female) in about 2 hours
44
Learning Objectives
Part I. What is addiction? What are substance use
disorders?
Part II. What are the drugs of abuse? What are their
effects?
45
4646
Stimulants
 Examples:
 Amphetamine (prototype)
 Cocaine (most common, includes “crack”)
 Methamphetamine (“crank,” “ice”)
 MDPV (“bath salts”)
 Methylphenidate
 Ephedrine
 Khat
47
Stimulants
 All have sympathomimetic activity and cause
euphoria
 Routes of administration: Oral, IN, IV, smoked
 Reinforcing effects are predominantly related to
dopaminergic effects in the nucleus accumbens
 Tolerance and cross-tolerance occur
48
Stimulants
 Medical uses
 Attention deficit disorder
 Narcolepsy
 Treatment resistant depression
 Obesity (YIKES!)
 Local anesthesia (cocaine)
49
Stimulant Intoxication and
Withdrawal
 Intoxication:
 Withdrawal
 Euphoria
 Dysphoria
 Agitation and violence
 Lethargy
 Insomnia
 Anorexia
 Decreased dreaming
 Tachycardia, arrhythmia
 Hypertension
 Dilated pupils
 Hypersomnia
 Hyperphagia
 Increased dreaming
 Bradycardia
 Intense craving
 Paranoia, hallucinations
 Hyperthermia
 Seizure, stroke
50
Cocaine
 Tends to be used in a “binge/crash” pattern
 Medical complications:









Nasal congestion
Perforated nasal septum
Cardiac arrhythmias
Seizure, stroke
Psychosis
Cellulitis, endocarditis (IV use)
Hepatitis B and C, HIV infection
Suicide
Homicide
51
Cocaine
 Different forms and routes of administration
 Cocaine HCL: snorted or injected
 “Crack” or freebase: smoked
 Coca leaf: chewed
 Smoking produces high within seconds that lasts 20-
30 minutes
 Intense “crash” as effects of the drug wear off
52
Methamphetamine
 Four percent of the US population has tried
Methamphetamine
 Use formerly restricted to certain areas of the country
(San Diego, Hawaii, Texas)
 Increasing use in rural areas, including Southern Ohio
 Easily synthesized using OTC pills and other readily
available reagents
53
Methamphetamine





Used in “binge/crash” pattern
Rapid onset of action when smoked.
High lasts 12-14 hours
Can cause long-lasting psychosis
Can cause substantial damage to dopaminergic
neurons with prolonged use, even in relatively low
doses
 Severe “crash” after use
54
Caffeine
Intoxication and Withdrawal
 Intoxication
 Anxiety
 Agitation
 Motor restlessness
 Insomnia
 Tachycardia
 Flushed face
 Diuresis
 Withdrawal
 Dysphoria
 Headache
 Fatigue
 Hypersomnia
 Muscle tension
 Nausea
55
Nicotine Intoxication and
Withdrawal
 Intoxication
 Arousal
 “Calm”
 Appetite suppression
 Tachycardia
 Salivation
 Dizziness
 Withdrawal
 Insomnia
 Anxiety
 Irritability
 Hyperphagia
 Bradycardia
 Difficulty concentrating
56
Marijuana
57
Marijuana
 Most widely used illicit drug in the U.S
 At least 30 % of the population has tried marijuana





(80 million people)
Effects are often situation dependent
Route of administration: Smoked, oral
Active ingredient: delta-9-tetrahydrocannabinol
(THC)
Endogenous cannabinoid receptors have been
identified
Mild tolerance may develop, with some cross
tolerance to alcohol
58
Cannabis Intoxication and
Withdrawal
 Intoxication:
 Euphoria
 Sedation
 Antiemetic
 Hyperphagia
 Memory deficits
 Conjunctival injection
 Ptosis
 Tachycardia
 Psychosis
 Withdrawal
 Dysphoria
 Anxiety
 Insomnia
 Nausea
 Anorexia
 Headache
59
Marijuana
Potential Medical Uses
 Treatment of:
 Nausea in chemotherapy patients
 Wasting due to AIDS
 Spasticity
 Glaucoma
 Pain syndromes
60
MARIJUANA IS NOT A HARMLESS
DRUG!!!







Can cause toxic psychosis
Heavy users are more likely to develop schizophrenia
Panic reactions
Accidents: found in 10% of fatal accident victims
Hastens age-related loss of hippocampal neurons
Impairs immune function
Increased risk of heart attack within an hour of
smoking
61
MARIJUANA IS NOT A HARMLESS
DRUG!!!
 Contains more carcinogens than tobacco (and
marijuana smokers inhale deeper and hold longer)
 Bronchitis
 Increased risk of lung, head and neck cancers
 Substantial motivational and cognitive deficits
62
Overview: Synthetic
Cannabninoids
 K2/Spice
63
Synthetic Cannabinoids
 “Spice” first appeared in Europe in 2004
 March 2011 DEA bans 5 chemicals most commonly
found in K2/Spice
 JWH-018, JWH-073, CP-47,497, JWH-200, and
cannabicyclohexanol
 DEA reports that increased use of synthetic
marijuana has led to a surge in ER visits and poisoncontrol centers calls.
 Adverse health effects: seizures, hallucinations,
paranoid behavior, agitation, anxiety, nausea,
vomiting, racing heartbeat and elevated blood
pressure
64
Opioids
 Opioid agonists:
 Morphine
 Heroin
 Meperidine
 Methadone
 Propoxyphene
 Oxycodone (including
Oxycontin)
 Hydrocodone
 Hydromorphone
 Diphenoxylate
 Opioid antagonists
 Naloxone
 Naltrexone
 Mixed
Agonist/antagonist:
 Buprenorphine
65
Opioids
 Opioid medications are invaluable in the
treatment of acute, severe pain
 Opioid abuse and dependence have been
problematic for centuries
 Main classes of opioid abusers:
 Street (usually heroin) abusers
 Medical abusers
 Methadone patients
 Routes of administration: Oral, IV, IM, SC, IN,
Smoking, PR
66
Opioids
 Effects are mediated through endogenous opioid
receptors:
 Mu: Analgesia, euphoria, respiratory depression,
dependence
 Kappa: Sedation, diuresis
 Sigma: Dysphoria, hallucinations
 Delta: Cardiovascular effects, analgesia
 Tolerance and cross-tolerance exist
67
Opioid Intoxication and Withdrawal
 Intoxication
 Euphoria
 Sedation
 Slurred speech
 Constipation
 Analgesia
 Decreased respirations
 Attentional deficits
 Withdrawal
 Dysphoria, anxiety
 Insomnia
 Diarrhea, nausea, vomiting
 Muscle and joint pain
 Diaphoresis
 Chills
 Piloerection
 Tearing
 Yawning
68
Sedative-Hypnotic Drugs
Examples
 Benzodiazepines
 Barbiturates
 Diazepam
 Phenobarbital
 Chlordiazepoxide
 Pentobarbital
 Clorazepate
 Secobarbital
 Oxazepam
 Others
 Lorazepam
 Meprobamate
 Alprazolam
 Chloral Hydrate
 Clonazepam
 Methaqualone
 Temazepam
 Zolpidem
 Triazolam
 Zapelon
 Flurazepam
 Alcohol
69
Sedative-Hypnotics
 Most have clinical utility as hypnotics, anxiolytics,
sedatives or anticonvulsants
 12-20% of American adults use in any give year
 90% of med-surg patients are prescribed these drugs
 2 billion (yes, billion) tablets of diazepam are
prescribed annually in the U.S.
70
Sedative-Hypnotics
 All exert significant activity on GABA
 Prototype: Barbiturates
 Most common: Benzodiazepine (other than
alcohol)
 Major avenue of supply: Physicians
 Route of administration: Oral, IM, IV
 Tolerance and cross-tolerance occur
 Withdrawal can be life-threatening
 Benzodiazepine antagonist: Flumazenil
71
Sedative Intoxication and
Withdrawal
 Withdrawal
 Intoxication
 Dysphoria
 Euphoria (Rising BAL)
 Anxiety, agitation
 Dysphoria (Falling BAL)
 Insomnia
 Sedation
 Tremor
 Slurred speech
 Diaphoresis
 Incoordination
 GI distress
 Nystagmus
 Transient hallucinations
 Cognitive impairment
 Seizures
72
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Hallucinogens
“My surroundings..transformed themselves in more terrifying
ways. Everything in the room spun around, and the familiar
objects and pieces of furniture assumed grotesque,
threatening forms. They were in continuous motion,
animated, as if driven by an inner restlessness…Even worse
than these demonic transformations of the outer world were
the alterations that I perceived in myself, in my inner being.
Every exertion of my will, every attempt to put an end to the
disintegration of my outer world and the dissolution of my
ego, seemed to be a wasted effort. A demon had invaded me,
had taken possession of my body, mind and soul.”
-Albert Hoffman, 1943
(Sandoz Pharmaceuticals)
74
Hallucinogens
 Examples
 LSD [Lysergic acid diethylamide]
 Psilocybin [mushrooms; 4-hydroxyldimethyltryptamine]
 Mescaline [peyote cactus; 3,4,5trimethoxyphenethylamine]
 STP [2,5-Dimethoxy-4-methylamphetamine or
DOM]
75
Hallucinogens
 Examples (cont.)
 Nutmeg [Myristicin]
 Morning glory seeds [LSA, d-lysergic acid amide]
 Bufotenine [toad-licking; 5-hydroxydimethyltryptamine]
76
77
Hallucinogens
 Hallucinogens: include all drugs that cause
hallucinations. Also cause sympathetic arousal.
 Primary mechanism seems to be upon serotonergic
systems, most prominent in cerebral cortex and
locus coeruleus
 Contaminants are common, esp. anticholinergic
 LSD is the most commonly used hallucinogen
 Sold as “microdots,” “window panes,” or “blotter’
 Effects begin 30-90 minutes after ingestion (usually oral)
and last up to 12 hours
 Rapid tolerance can develop
 No withdrawal syndrome reported
78
Hallucinogens-Lasting Effects
 Hallucinogen Persisting Perception Disorder:
 Episodic, spontaneous recurrences of hallucinogen
sensory experiences, visual disturbances, light trails,
flashing lights, etc.
 Commonly referred to as “flashbacks”
 Psychosis:
 Persistent symptoms including mood swings, vivid
visual disturbances and hallucinations
 Can last for years
79
Hallucinogen Intoxication and
Withdrawal
 Intoxication
 Euphoria, anxiety, panic
reactions
 Perceptual
abnormalities
 Incoordination/ tremor
 Tachycardia
 Blurred vision
 Dilated pupils
 Diaphoresis
 Withdrawal
 None described
80
Dissociative Drugs
 Distort visual and auditory perceptions without
genuine hallucinations
 Produce feelings of detachment from environment
 Exert effects via glutaminergic and dopaminergic
mechanisms
 Examples:
 Phencyclidine (PCP)-prototype
 Ketamine
 Dextromethorphan
81
Phencyclidine Intoxication










Unpredictable behavior
Decreased pain perception
Vertical, horizontal and rotatory nystagmus
Dysarthria
Ataxia
Rigidity and bizarre posturing
Hyperacusis
Increased reflexes
Tachycardia, hypertension, hyperpyrexia
Delirium and persistent psychosis
82
Phencyclidine (PCP)
 Initially developed as a general anesthetic
 Never approved for use in humans due to delirium and





profound agitation occurring as patients emerged
from anesthesia
Often used to “lace” other drugs
Route of administration: Oral, smoked, injected
Effects occur within minutes and are unpredictable
Effects last for several hours to several days
No tolerance or withdrawal is described
83
Ketamine
 Slang names: Special K, “K,” Vitamin K, Cat
valiums
 Anesthetic agent used most commonly in
veterinary medicine
 Effects are similar to PCP (NDMA antagonist)
 Can cause neurotoxicity
 Route of administration: Oral, snorted,
smoked, injected
 Less potent than PCP
 “Date Rape” drug
84
Dextromethorphan
 NMDA antagonist
 Available in OTC cough
preparations
 2-4 oz: mild stimulation,
visual disturbances
 > 4 oz: begin to see
dissociative effects
 Antihistamines and
decongestants often also
in DM containing
preparations
85
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Inhalants
 Include various volatile substances






Aerosols
Gasoline
Airplane glue
Paint thinners
Gases
Nitrites
 Inexpensive, readily available, not regulated,
easy to conceal
 Use is most common in teens and pre-teens
who move on to other drugs
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Inhalant Intoxication and
Withdrawal
 Intoxication
 Euphoria
 Ataxia
 Nystagmus
 Diplopia
 Slurred speech
 Depressed reflexes
 Hallucinations
 Withdrawal
 None described
88
Inhalants
 Ways administered:
 “Huffing”
 “Bagging”
 Sniffing or snorting
 Inhaling from balloons filled with Nitrous Oxide
 Rapid onset of intoxication with relatively short
duration
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Inhalants
 Signs of abuse:
 Detectable odor on breath
 Paint or chemical stains on face, hands, clothing
 Hidden bottles of paint, solvents, soaked rags
 Evidence of intoxication
90
Inhalants
Medical Consequences
 Asphyxiation
 Nephrotoxicity
 Suffocation
 Hepatotoxicity
 Choking/Aspiration
 Cardiotoxicity
 Accidental injury
 Bone marrow
 Neurotoxicity
suppression
91
Contact Information
 David L. Brager, CNP
[email protected]
The Centers for Families and Children, Cleveland, OH
Discussion
Treatment Considerations
93