flagstaff medical center wellness program · introduction 2 “a graduate speaks” wellness video...
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Flagstaff Medical Center
Wellness Program
C H R IS TIN E C H IS H O L M , M S W , LC S W
C L I N I C A L MA N A G E R
C R A IG D A V IS , M S W , LA S A C
P R O G R A M C O U N S E L O R
B E N N E TT E D G E R LY , M . A . , LA C
P R O G R A M C O U N S E L O R
P H D S T U DE N T I N C O U N S E L I N G P S Y C H O L O G Y , N A U
D D C S T A T E C O N F E R E N C E M A Y 1 4 , 2 0 1 3
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COL L EAGU ES
AGEND A OVER VIEW
ACTIVITY
Introduction 2
“A GRADUATE SPEAKS”
Wellness Video 3
PANEL DISCUSSION
Philosophy of the
Wellness Concept 4
Philosophy of the Wellness Concept
High failure rate for chemical dependency/substance abuse
treatment programs
Dilemma: If client can’t use AOD while in the DDC program, risk of
relapse is high if client can’t replace the “feel-good” mood altering
and calming neurochemicals in some other way
What legal “feel-good” mood altering and calming neurochemicals
exist? Serotonin (mood) Dopamine(well-being) Endorphins (calming opioids) Norepinephrine (energy/alertness)
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Philosophy of the Wellness Concept
If not accessing calming hormones, one is likely flooded with
stress hormones (cortisol, adrenaline, etc.) Corticotropin-
releasing factor (CRF) in the addicted brain blocks dopamine
receptors. All this lessens ability to:
1. Think clearly 2. Use good judgment 3. Consider consequences of behavior 4. Accurately interpret social cues and interactions 5. Regulate mood and affect including experiencing pleasure 6. Learn new skills!
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Philosophy of the Wellness Concept
How can “feel-good” mood altering and calming
neurochemicals be accessed? Caffeine (Increase Dopamine/wellbeing, Adjusts Serotonin/mood) Sugar (creates peaks/feel good and troughs/feel bad in glucose) Balanced diet stabilizes body chemistry Exercise (produces Endorphins) Mindfulness (increases Serotonin and Dopamine)
What if we designed a program built upon the hypothesis:
If prohibit AOD, need to replace what is missing!
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Wellness Exercise
BREATHING
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Research supporting the FMC Wellness Model
TH R E E C O M P O N E N TS TO TH E F M C W E LLN E S S P R O G R A M .
1. Exercise 2. Nutrition 3. Stress management using Mindfulness-Based Stress Reduction
(MBSR).
Department of Justice Key Components of a Treatment Program.
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Research: The drug-brain paradigm
Addiction is associated with numerous neurobiological and psychosocial variables. But certainly, the neurobiological reinforcement system plays a role.
Often called the “reward center” for dopamine.
Depending on drug used, other neurobiological
reinforcement systems may also be activated:
Serotonergic, opioid, or GABA systems
Drug use typically trumps natural pleasurable activities.
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Research: The drug-brain paradigm
Drug use typically trumps natural pleasurable activities.
“I’m sober…Now what?”
How to replace the feel good component or even just feel normal?
The National Institute of Mental Health (NIMH) maintains
chemical dependence is a brain disorder that is also
responsive to changes in behaviors of exercise and diet.
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Research: Exercise
Exercise as an adjunct for treating dependence to
chemicals is well researched (Brown et al., 2010).
Read and Brown (2003) noted, “The dopaminergic
reinforcement mechanisms in the neural system that
are activated by substances such as alcohol are also
activated during exercise” (para. 3).
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Research: Exercise
Ussher et al. (2004) studied the effect of exercise on
alcohol urges and mood using a quasi-experimental
design with two groups of patients that had just
completed alcohol withdrawal in the hospital (mean of 3
days from detox).
The author’s concluded that a brief bout of moderate intensity
exercise may provide some short-term relief from alcohol urges
during exercise.
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Research: Exercise
Some evidence for positive benefits of exercise in treating
a variety of substances:
Tobacco (Scerbo, et al., 2010);
Marijuana (Buchowski, et al., 2011);
Alcohol (Ussher et al., 2004);
Cocaine (Smith et al., 2008);
Opioids (Weinstock, Wadeson, & Vanheest, 2012);
Methamphetamines (O’dell, Galvez, Ball, & Marshall, 2012).
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Research: Exercise
Williams and Strean (2004) provided guidance on
how to implement exercise into treatment.
6 recommendations for how to include exercise into treatment
program.
Consistent with the FMC approach to implementation.
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Research: Exercise
Other benefits of exercise that indirectly support recovery
from addiction:
Mamen and peers (2011) noted improvement in oxygen uptake, and
reduction in depression, anxiety, social phobia in 33 participants.
Foret and Clemons (1996) that suggests that “Physically
active people maintain and improve their physical
functioning and are also able to handle stress more
efficiently” (para. 2).
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Research: Nutrition
Nutrition therapy as an adjunct to substance abuse
treatment.
Nutrition and substance abuse treatment outcomes
(Grant et al., 2004, Cadogan, 2011; Watts, 2011).
Nutrition interventions are traditionally a missing
component (Roberts, 2011).
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Research: Nutrition
Many people are not nutrition-savy while using
harmful substances.
Some people eat more during abuse (Nolan & Stolze, 2012) ,
while many others do not get sufficient nutrition.
The American Dietetic Association defends
nutrition’s role in recovery.
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Research: Nutrition
How can nutrition be effective?
Abnormal Neurobiochemistry, Neuroplasticity, Neuronal
signaling and Neurophysiology can be improved or
normalized with the help of nutritional interventions and
nutritional therapy (Cadogan, 2011).
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Research: Nutrition
Lingley (2012) offers nutrition therapy for chemical
abuse as a three stage process:
1. Education about the effects of the substance of the body;
2. Teaching proper nutrition and how certain foods support
recovery;
3. Teaching the participant to shop and prepare.
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Research: Nutrition
Chance of recovery is “Significantly increased by
adding nutritional therapy and exercise therapy” to
traditional substance abuse recovery treatment
(Shuman, 2000).
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Research: Stress Management
Diet and exercise are both shown to positively impact
mental health outcomes (Foret & Clemons , 1996),
and are clearly related to the final element of our
treatment program: stress.
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Research: Stress Management
Cognitive level:
Stress increases the risk of developing drug
addiction
Triggering relapse
Changes in the brain’s ability to mitigate stress once
the person begins using (Schwabe, Dickinson, &
Wolf, 2011).
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Research: Stress Management
Sinha, Shaham, & Heilig (2011) maintain that relapse
is often associated with stress exposure, which can
provoke a subjective state of drug craving that can
also be demonstrated under controlled laboratory
conditions.
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Research: Stress Management
Most effective model of stress management
Mindfulness-Based Stress Reduction (MBSR).
Derived from Buddhist Vipassana meditation (Kabat-zinn)
Bowen (2009)
Repeated studies shows significant reductions in participant’s
Self reported stress
Craving to use substances.
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Research: Stress Management
We modeled our MBSR approach
Marcus (2007) studied the effectiveness of a MBSR
approach in a residential chemical dependency
treatment programs.
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Wellness Exercise
RAISIN
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P h a s e I : 3 t ime s a w e e k f or 3 h ou r s
Includes wellness program one a week
P h a s e II : tw ic e a w e e k f or 3 h ou r s
P h a s e III : on c e a w e e k f or 2 h ou r s
Focus on relapse prevention
Treatment Program Structure
O p e n - e n d e d In ta k e
M u l ti - d is c ip l in a r y Tr e a tm e n t Te a m
M ixe d G e n d e r
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Wellness Program Structure
Session 1: Nutrition
Cravings and Nutrition
Session 2: MBSR
Sitting Meditation & Mindful eating of raisin
Session 3: Exercise
Neurobiological basis for recovery
Session 4: MBSR
Body Scan
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Wellness Program Structure
Session 5: Nutrition
Planning a recovery diet
Session 6: MBSR
Mindful Walking
Session 7: Exercise
Stretching/Yoga
Session 8: MBSR
“Seeing” meditation & visualization
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Wellness Program Structure
Session 9: Nutrition
Shopping for recovery diet
Session 10: MBSR
S.T.O.P.
Session 11: Exercise
Examples/Barriers/Plan
Session 12: MBSR
Nonjudgmental Forgiveness
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Sustainability of Program Gains/Behavior Changes
D D C THR EE-PHAS E TR EATMENT PR OGR AM
COMMU NITY PAR TNER S HIPS
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DDC Three-Phase Treatment Program
Nutrition: Phase 1 (3 months) Registered dietitian presentation (3 times) Once a week clients are served a nutritious snack (12 times) Sustainability of gains/behavior change every time client shops
Mindfulness: Phase 1-3 (9 months) Phase I yoga instruction (3 times) Mindful breathing every group Phase 1-3 (72 times) Sustainability of gains/behavior change every time client comes to group
Exercise: Phase 1 (3 months) Once a week 30 minutes Cardiac Rehab Gym (12 times) Sustainability of gains/behavior change in question Need for Community Partnership
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Community Partnerships: Sustainability of Exercise Gains/Behavior Change
Partnership with Flagstaff Family YMCA resulted in a
no cost or reduced cost for a nine month membership
for the client and family members living in the home
(duration of DDC program). For most clients it is at no
cost.
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Community Partnerships: Sustainability of Exercise Gains/Behavior Change
Benefits:
Continued opportunity for exercise and yoga instruction
Family involvement addressed child care issues
Opportunity for pro-social behavior in the community
Northern Arizona College Resource Center (resume and
scholarship application help)
Funding source: Private donations to YMCA and FMC
Foundation (each pays 50% cost)
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Community Partnerships: Health Improvement
Need to insure safety exercising in Cardiac Rehab Gym
Health Risk Appraisal Form is completed
Health issues are reported
Need for medical clearance for exercise by a Primary Care Provider
Client is linked to a Primary Care Provider for medical care
FMC forms partnerships with community-based health care providers for no or low cost medical care
(Native Americans for Community Action, Sacred Peaks, Poore Clinic)
Integration of Behavioral and Physical Health allows for improved health for both client and the community
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Wellness Exercise
BODY SCAN
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Practical Applications Panel Discussion
PR ACTICAL EXER CIS ES THAT CAN BE U S ED
COL L ABOR ATE
S OL ICIT COMMU NITY S U PPOR T
IMPR OV ED COMMU NITY WEL L NES S
Our dream/hope reduces cost globally, while maximizing use of existing providers/resources.
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References
Buchowski, M. S., Meade, N. N., Charboneau, E., Park, S., Dietrich, M. S., Cowan, R. L., & Martin, P. R. (2011). Aerobic Exercise Training Reduces Cannabis Craving and Use in Non-Treatment Seeking Cannabis-Dependent Adults. Plos ONE, 6(3), 1-6. doi:10.1371/journal.pone.0017465
Brown, R. A., Abrantes, A. M., Read, J. P., Marcus, B. H., Jakicic, J., Strong, D. R., & ... Gordon, A. A. (2010). A pilot study of aerobic exercise as an adjunctive treatment for drug dependence. Mental Health And Physical Activity, 3(1), 27-34. doi:10.1016/j.mhpa.2010.03.001
Cadogan, O. (2011). Perspectives on the neurobiochemistry of addiction and implications for nutritional management. In M. Watts (Ed.) , Nutrition and addiction: A handbook supporting recovery from food and substance misuse with nutritional and lifestyle interventions (pp. 21-50). Brighton: Pavilion Publishing (Brighton).
Grant, L. P., Haughton, B., & Sachan, D. S. (2004). Nutrition education is positively associated with substance abuse treatment program outcomes. Journal of the American Dietetic Association, 104(4), 604–610.
Mamen, A., Pallesen, S., & Martinsen, E. W. (2011). Changes in mental distress following individualized physical training in patients suffering from chemical dependence. European Journal Of Sport Science, 11(4), 269-276. doi:10.1080/17461391.2010.509889
Marcus, M. (2007). Behavioral Therapies Trials: A Case Example. Nursing Research, 56(3), 210-216. Nolan, L. J., & Stolze, M. R. (2012). Drug use is associated with elevated food consumption in college students. Appetite, 58(3), 898-906.
doi:1 0.1016/j.appet.2012.02.014 O'dell, S. J., Galvez, B. A., Ball, A. J., & Marshall, J. F. (2012). Running wheel exercise ameliorates methamphetamine‐induced damage to dopamine and
serotonin terminals. Synapse, 66(1), 71-80. doi:10.1002/syn.20989 Read, J. P., & Brown, R. A. (2003). The role of physical exercise in alcoholism treatment and recovery. Professional Psychology: Research and Practice, 34(1),
49–56. Roberts, M. (2011). Nutrition and drug treatment: An overview of drug policy. In M. Watts (Ed.) , Nutrition and addiction: A handbook supporting recovery from
food and substance misuse with nutritional and lifestyle interventions (pp. 7-19). Brighton: Pavilion Publishing (Brighton). Scerbo, F., Faulkner, G., Taylor, A., & Thomas, S. (2010). Effects of exercise on cravings to smoke: the role of exercise intensity and cortisol. Journal Of Sports
Sciences, 28(1), 11-19. doi:10.1080/02640410903390089 Shuman, S. (2000, June). Research into the place of nutritional therapy and exercise therapy in a program of recovery from substance addiction and process
addiction. Dissertation Abstracts International, 60, Ussher, M., Sampuran, A. K., Doshi, R., West, R., & Drummond, D. (2004). Acute effect of a brief bout of exercise on alcohol urges. Addiction, 99(12), 1542-1547.
doi:1 0.1111/j.1360-0443.2004.00919.x Watts, M. (2011). Nutrition and addiction: A handbook supporting recovery from food and substance misuse with nutritional and lifestyle interventions.
Brighton: Pavilion Publishing (Brighton). Weinstock, J., Wadeson, H. K., & VanHeest, J. L. (2012). Exercise as an Adjunct Treatment for Opiate Agonist Treatment: Review of the Current Research and
Implementation Strategies. Substance Abuse, 33(4), 350-360. doi:10.1080/08897077.2012.663327 Williams, D. J., & Strean, W. . (2004). Physical Activity as a Helpful Adjunct to Substance Abuse Treatment. Journal Of Social Work Practice In The Addictions,
4(3), 83-100. doi:10.1300/J160v04n03_06
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