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What Does Effective Treatment Look Like (part 5)


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The treatment of prescription drug and heroin use is one of the most pressing issues facing our country right now. Across the country, opiate related overdose deaths, fueled by prescription pain killers, now takes more lives that car accidents, with nearly 100 Americans dying from an overdose EVERY DAY.

Given the current state of affairs related to opiate use and abuse, current legal, regulatory, and budgetary constraints, federal agencies and the White House have been working hard to develop guidelines for effective treatment  and to generate and direct resource at this epidemic. But, on the frontlines, counselors and treatment professionals are trying to figure out what will really help and what doesn’t.

There is no silver bullet for a disease as complex as opioid addiction. Research does reveal the longer a person is involved in treatment the better the outcomes. There needs to be an alignment of the stars to get all the wheels of treatment and recovery to move in the same direction. It is not impossible but, without the needed resources, it is very difficult. Let’s take a look at what effective treatment looks like.

1. Individualized Treatment Planning
Each individual comes to treatment with a unique set of circumstances. Some are caught in a domestic abuse situation, others at involved with Children and Family Services, yet others are facing serious legal consequences. Most are simply aware that the path they are on will end in death. Because of the myriad variable in each story, effective treatment must be responsive to the individual needs and considerations. That doesn’t mean there aren’t universal skills each person will need, such as relapse prevention skills, it simply means that a cookie-cutter approach isn’t helpful when everybody starts at a different place.

2. Level of Motivation
Besides the unique process that led an individual to seek treatment there is also a unique level of motivation for each that should be considered. Many develop a sense of hopelessness that they can every get this monkey off their back. Others, while drug dependent, haven’t been motivated by the consequences to quit yet. One of the ways humans resolve the cognitive dissonance between what we do and how that impacts our lives and the lives of those we love, is denial. It’s a protective mechanism that keeps us from being overwhelmed with guilt, shame, and remorse, but also enables ongoing drug use. Understanding a person’s level of motivation is key in helping them through the process, when they are motivated.

3. Understanding the Science of Addiction
We have learned so much in the last 10 years about the brain that we struggle with presenting current information because what we are learning is outpacing our ability to integrate it into treatment. But, people desire to know how the brain works and how drugs affect it. The more you understand that science of behavior and addiction and what is happening in the brain the greater the sense of being able to control what is happening. For example, if a person in treatment learned about how the brain is rewired through drug use and what new behaviors will help the brain heal and rewire into healthier behaviors, that is empowering. There is meaning and understanding to the choices they make. Plus, science is cool.

4. Cognitive Behavioral Therapy
There is a direct connection between how we think about ourselves and the world we live in and how we behave. If someone is afraid of flying and they believe planes are unsafe, they will not likely fly anywhere. But, when that thinking is challenged with rational thinking, such as how safe flying actually is, and that you are more likely to be injured in a car accident that have your plane fall from the sky, you are more likely to fly. Good treatment helps the individual challenge and replace irrational thinking and evaluate it in the light of reality. When you live under the fog of addiction you live in survival mode. There is so much deluded thinking that is necessary to navigate that world but is problematic once an individual enters recovery.

5. Wellness
The mind and the body and intricately connected. The benefits of healthy habits are well documented. For the opiate dependent sleep, exercise, and nutrition are essential to quality recovery.

6. Family Engagement
Just because the wind from the storm is over doesn’t mean there still isn’t work that needs done. The family has taken a toll because of their loved one’s addiction. Work needs to occur to rebuild trust and habits of relating to each other. Imaging living with someone and you both speak English (the language of addiction/anger/stress) and then someone goes to treatment or seeks out recovery. In recovery they speak French (recovery, therapy). Now, you have two parties trying to co-exist and they can’t communicate because they speak different languages. Both groups need to be speaking the same language if restoration of relationships is to occur.

7. Accountability
Drug use monitoring is an important part of the recovery process. Drug screens and medication counts help bring accountability to the person in recovery. Because old habits die hard, the need for someone to ask tough questions and to provoke honest dialogue is also necessary. This is most effective when there is trust and rapport between the two parties.

8. Co-occurring Conditions
Many times drug using individuals are self-medicating because of a co-occurring condition, such as PTSD, depression or anxiety. Taking opiates, benzos, or other depressants can give temporary relief to an often debilitating condition. If these conditions are not treated, relapse is imminent.

9. Employment Support
Studies show one of the biggest predictors of sustained recovery is gainful employment. Working gives the individual a sense of purpose, accomplishment, and independence. This can be a challenge if you have a felony record or a spotty work history. Having someone trained to walk alongside you while job seeking can be an indispensable source of encouragement and support.

10. Pro-Social Recreation
Anhedonia is the inability to experience pleasure. This often occurs when the reward center has been hijacked due to years of opiate misuse. When you experience pleasure so off the charts over and over again, the brain rewires to that level as the new default. Anything less than that is no longer experienced as pleasure. Boredom is a HUGE trigger for people early in recovery precisely for this reason. Who wants to live an existence where they experience no or low levels of pleasure in anything. Retraining the brain to enjoy (pleasure) life is also an important part of the recovery process. Developing new hobbies that are not related to using drugs, listening to music without getting high, being sexually intimate without having to use first are all difficult for the person early in recovery.

11. Criminogenic Needs
Do you know what you get when you sober up a horse thief? A sober horse thief. Criminal attitudes and behavior are a part of the lifestyle associated with drug use. The mere fact that someone uses drugs means they are engaged in a criminal act. Along with behaving in a criminal manner means adopting criminal attitudes that support or endorse your behavior. This needs to be undone if someone is going to thrive in recovery.

12. Case Management
Because the person can be caught up in other systems there is a need for effective case management. It is possible that a drug using individual ca be on probation, Children and Family Services, Drug Court, see another therapist for past trauma, or a host of other service, all aimed at helping them get back on the right path. Effectively communicating with these other services is necessary, as is making appropriate referrals to address these needs.

13. Harm Reduction
I won’t say much about this now because I’m designating a future blog to this but Harm Reduction is the idea, that if an individual is not willing or struggling to abstain from drug use, how can we support them where they’re at? For example, providing clean needles is proven to prevent the spread of blood born disease common among IV needle users. This also reduces the associated cost of health care for treating someone, likely without insurance, in the emergency room and ongoing treatment for Hepatitis C, a commonly spread disease among IV needle users. This is a controversial strategy but one that is often misunderstood. We’ll explore this in greater detail.

14. Intersections
Individuals are unique and complex. There are other intersections to consider when providing effective treatment, race, ethnicity, gender, religion, sexual orientation, ability/disability, age, educational levels, and a host of other considerations. All which need to be addressed when providing individualized treatment.

15. Recovery Community
Yes, addiction has biological hooks. The pleasure is such a powerful reward that it draws a user back with powerful cravings. But, more often that not it is reinforced by the community of peers we surround ourselves with when using. Recovery is no different. Creating the community we crave, that was denies by our addiction, is one of the most powerful reinforcers of remaining clean or returning after a relapse. Recovery has more to do with being connected in meaningful ways than just about anything else. The pain of alienation and isolation, the pain of being marginalized and feeling outcast, the deep hurt of feeling utterly unloved and unlovable will drive addiction to dark places we never knew existed. If we are going to heal our those addicted in our communities we must be willing to venture into those dark places and lead them out.

We are constantly learning more about what it means to be a person dependent on opiates every day. In spite of the progress we are making, not everyone who needs treatment can access it when they need it or are motivated to seek it. We’ll address barriers to treatment in our next post. 

Medication Assisted Treatment (part 4)


In our last post we explored the neurological changes that occur in the brain when a person misuses opiates (heroin or prescription pain pills). We learned that the brain’s natural endorphin system shuts down and becomes dependent on an external source, such as heroin or prescription narcotics. We also learned the body requires endorphins to function normally; to manage pain, energy, and mood. So, an individual MUST continue using because it is a physiological necessity.

If a diabetic requires a medication to correct an internal imbalance, they would have the needed support from friends and family to do whatever they needed to do to get better. Yet, there is so much stigma, due to lack of understanding about the nature or opiate dependency, that creates unnecessary barriers to people getting the help they need, especially help that is proven to be the most effective form of treatment for this particular condition.

So how does one break the need to use opiates once these changes occur?

Methadone and Suboxone are both medications that can be prescribed to manage opiate withdrawals and craving while the brain begins the process of rebuilding its internal endorphin workforce.

Methadone is a full agonist opiate, meaning it has the potential to act like any other opiate. It has the potential to satisfy withdrawals and cravings but also has an abuse potential. Suboxone has less risk involved but is expensive and doesn’t work for everyone.

Methadone

Methadone is a synthetic opiate that sits in the brain’s opiate receptors. When prescribed a therapeutic dose, methadone will sit in the opiate receptor and do the necessary jobs of preventing withdrawal, stifling cravings, provide energy, stabilize mood, and manage pain, just like the natural endorphins will eventually begin doing again.

The length of time it takes each person’s brain to fully recovery varies based on many variable, such as; length of time using drugs, quantity and quality of the drugs consumed frequency of consumptions, personal physiology, psychological state, level of physical activity, nutrition, sleep habits, and recovery support.

There is the potential for abuse but if managed well this can be avoided. The methadone clinic providing the medication should always strive for conservative dosing (prevent withdrawal without sedation), random drug screens, diversionary practices, laboratory testing, and ensuring there is adequate recovery capital before allowing take homes.

Methadone tends to work better for individuals with a chronic opiate use disorder. These individuals are more likely to thrive when they have controlled dosing, daily engagement at the clinic, accountability and encouragement, case management and counseling.

Suboxone

Suboxone tends to work better for individuals who already have some measure of recovery capital. These individuals also are more likely to have jobs, transportation, stable housing, and supportive relationships. These individuals are also more likely to have used prescription narcotics vs. street heroin, although some long time users report significant benefits from using Suboxone.

Suboxone is a partial agonist, which means it only does part of the job of an opiate. There are two medications combined to make up Suboxone, the first is Buprenorphine. It will sit in the brain’s opiate receptors but won’t activate the brain’s pleasure/reward center. This is good news because that means there is very little chance of misusing this medication. It also has built in protective factors. There is a ceiling to how much Suboxone you can take. There is a max dose a person can take before they stop receiving benefit from the medication. This reduces the potential for using the medication to “get high”.

There is also naloxone in the medication. This is the same medication they give to someone who overdose on opiates. It is more commonly known as NARCAN. NARCAN, when introduced to the body with “kick” the opiates out of the opiate receptors and reverse an over dose (we’ll talk about NARCAN in greater detail in a future post). If someone on Suboxone tries to misuse this medication or, they try to use other opiates while on the medication, it has the potential to send them into immediate withdrawal. Because of this, there is very little risk that the individual will be able to misuse or abuse the Suboxone.

Because there is less while on Suboxone the consumer has a tendency to stabilize fairly quickly. Methadone takes slightly longer as the individual and treatment team work to establish a therapeutic dose by adjusting the medication over time.

The likelihood of an individual in severe withdrawal engaging in treatment, rebuilding relational trust, or going to work or caring for the kids is very low, if not nearly impossible. There will always be exceptions to this but it is not the norm. The brain will eventually begin to rebuild its own endorphin system and in time, many are able to taper off these medication altogether. There are a number of people who have used in such a way that their brain will never fully recover and will require medication for the remainder of their life.

So, once an individual becomes stable on medication, what does effective treatment for the opiate dependent individual look like. We’ll explore that in our next post.

 

Opiate Tolerance and Withdrawal (part 3)


Tolerance

The struggle that Adam and Eve discovered in the garden, on that fateful day when they ate the apple, was that they learned about something they were never intended to know. Much like the Adam and Eve narrative, when we use opiates our brain learns about something it never knew existed, the increased capacity to experience higher levels of dopamine output. If that sounds too clinical for you then let me make it simple; they (opiate users) discovered a higher, more intense level of pleasure than they ever knew possible. It is so powerful in its reward that it almost immediately sets a new default for pleasure that the brain will always try to attain again.

Our brain is amazing. It is very plastic and adaptive. When it sets its “mind” on something it obsesses on it (cravings/urges) and if we surrender to those cravings we strengthen our connection to that which we are craving.

In the case of the opiate user our brains, the pathways that support the natural endorphin production work just fine but compared to the new superhighway of heroin/prescription narcotics it pales in comparison. The brain is flooded with significantly more endorphins and the brain has to create new pathways and places for them to land. This causes the brain to change and actually grow new endorphin landing sites, which in turn requires more of whatever it is that is flooding the brain with larger amounts of dopamine. Repeat the process. This is called tolerance and the brain is designed to make this happen.

Meanwhile, the old pathways that the naturally produced endorphins use to travel and growing old and less used. Imagine old rural county highways that are overgrown with grass, wore out and crumbled, with cracks and dirt beginning to cover them. They are becoming less traveled because of the nearby superhighway that is allowing more endorphins to travel at higher speeds to the reward center of the brain. In time, nothing will travel on those old roads and if they do it is likely to get lost along the way.

So, what use to give us pleasure; sex, food, relationships, work, recreation, movies, candy, etc. now pale in comparison and no longer deliver what it use to. Now, try to imagine that for a minute…nothing gives you pleasure except the medication your doctor prescribed you for your back pain. You quickly learn the only thing worth pursuing is the next fix, because, as well talk about next, withdrawal is so bad you’ll wish you were dead.

Withdrawal

You’ve been using these pills for several months now. They no longer work like the use to because you’ve developed a tolerance and your doctor is starting to become concerned about the frequency of which you ask for refills and is beginning to talk about not prescribing them anymore. You start to panic and begin visiting different urgent care centers hoping to score some Vicodin.

Instead, you decide to just stop taking the pills. They are costing a fortune and you don’t like the feeling of needing them just to help the kids get ready for school in the morning. So you just stop taking them one day.

REVOLT!

The brain has become dependent on the level of medication you’ve been giving it daily for the last nine months. It shut down its own production of natural endorphins and now relies on you to give it what it needs to function normally, to just get out of bed and not hurt. When the brain revolts like this it makes you feel deathly sick. It is reported that you feel like you’re dying but it never comes.

Common withdrawal symptoms are:

  • Sweating
  • Nausea
  • Muscle cramps
  • Diarrhea
  • Cold sweats/fever
  • Tremors
  • Pain
  • Depression
  • Possible seizures

Your stomach and digestive system has opiate receptors as well and since one of the side-effects of opiate use is constipation, diarrhea would result when in withdrawal. These symptoms are so severe that they would drive you to temporarily suspend your morality and do things you never imagined doing, such as; lying, cheating, stealing, manipulating, breaking the law, becoming violent, all to get money to get more opiates so you won’t be sick any longer. The criminal behavior often associated with drug use is typically a function of the drug use not a personality or character flaw. Stealing and selling possessions, lying or coercing others to get money is simply to not be sick any longer and so they can just get up and take care of their family, house, job, etc.

It is here that sympathies break down. When someone addicted to opiates begins to steal from a loved one we tend to become less empathetic. It’s important to remember at this time that your loved one is suffering from a brain altering dependency on an opiate. Nobody grows up hoping to become a heroin addict.

The brain is a fickle organ. It wants what it wants when it wants it and when it gets it over and over and over again it changes its neurological make-up to accommodate it. This is the nature of a brain disease/disorder that has biological, environmental, behaviors, cognitive, and personality variables influencing the outcome of dependency. At some point the person dependent on opiates loses their ability to choose. They MUST continue to use.

*in our next post we’ll explore the role of medications like methadone and suboxone in helping someone overcome opiate dependency.

This is your brain on opiates (part 2)


What are Opioids?

Opioids are a powerful class of drug that includes the illicit drug heroin as well as the licit pain relievers, such as; oxycodone, hydrocodone, codeine, morphine, and fentanyl.

Our brains have natural opioid receptor hardwired within it. Opioid receptors interact with nerve cells in the brain and nervous system, controlling pain and delivering pleasure. Everyone on the planet does this naturally through our endorphin system.

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When we engage in pleasurable activities the brain releases these feel good chemicals (dopamine/serotonin) and we experience them as a reward. These chemicals are the drive behind every habit we have. We will almost always do what that which gives us the greatest pleasure or has the greatest potential for removing pain or discomfort. We are hedonic seeking creatures. It’s why we eat when we’re hungry, have sex when we’re horny, and take medicine when we’re sick.

Our natural endorphin system has three primary functions; stabilize mood, provide energy/motivation, and control pain. All necessary to live a functional, normal life. Opiate dependent individuals ALL report they stopped using heroin and pain pills to get high within months of starting. They report primarily using just to feel normal, just to get up and go to work, take care of the kids, and not be sick.

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The Anatomy of an Opiate Addict

When we are prescribed or illicitly take opiates our brains hit the jackpot! Not only does this medication already belong in our systems, it’s much more powerful than the stuff we make naturally. If we take the medication or heroin long enough our brain, being a very efficient organ, will reduce or just stop manufacturing the naturally occurring chemicals and rely on you to provide it via drugs. It’s like the brain lays off all the workers and shuts down the factory.

Opiates are highly addictive because the chemical already belong there. The brain would fight off other foreign chemicals such as cocaine or methamphetamines because it sees them as a threat. But with opiates it just says, “Back that truck up and give me as much as you’ve got!” This is called dependency.

Unfortunately, the longer you use opiates the stronger the neural pathways get that support their use. Consequently, the lesser use natural pathways get weaker and less used neural pathways have a tendency to prune themselves to make room for more frequently used neurons/pathways. The brain, fueled by illicit or licit opiate use creates a superhighway that supports that drug use and he old, natural pathways are like rural back roads that aren’t driven anymore, overgrown and broken down. Even if you tried to take the old rural road it would be hard to traverse because of a lack of use.

So, now an individual is completely dependent on opiates and the brain structure has changed to accommodate this drug use. Paying for daily drugs gets expensive quickly as tolerance to the medication increases. This often leads a moral, kind, good person to do awful things they never imagined doing, such as stealing from grandmother, taking money from their kids piggy banks, selling the family jewelry, or robbing someone using physical force. All just to avoid feeling violently ill. All with the intent to make right as soon as they’re feeling better. But, that never comes. There’s always tomorrow and more sickness. The hole just gets deeper. Add to that the growing sense of shame, guilt, and remorse and you have a desperate, self-loathing person and the perfect antidote for feeling sick and hating yourself…use more drugs. Repeat. Repeat. Repeat.

If a person began using prescription pain medication and developed a dependency, it’s a short jump to heroin. Maintaining a pill addiction is very expensive and heroin is a cheaper, more powerful alternative. Once you use a needle to inject heroin, there’s no going back from there. Your life becomes a hopeless cycle of using drugs, getting high, hustling for money, getting high. Repeat. Repeat. Repeat.

Opiate use now becomes the only way for a person to function as a human. Most of the public lacks this understanding and perpetuates the false belief that if someone really wanted it bad enough they’d just stop using. Science tells us it simply does not work that way.

*In our next post we’ll explore the conditions known as tolerance and withdrawal and why quitting cold-turkey rarely works and can even be dangerous.

 

Overview of the Opioid Epidemic (part 1)


Let’s start with a brief overview of the current state of affairs related to the opioid crisis. Some of these number will shock you and some will be hard to believe. As an addiction counselor working exclusively with opioid dependent individuals I can tell you these number don’t surprise me at all. Having worked in this field for a few years now I can attest to the growing number of opioid users, especially among the populations listed below. We’ve also seen a growing number of overdose related deaths due to opioid use. To those of us working in the field, it feels like the problem is growing faster than we can treat it. If this were the Ebola virus and that was happening we would do everything we could to contain its spread without hesitation.

The numbers…

Drug overdose is the leading cause of accidental death in the US, with 47,055 lethal drug overdoses in 2014. Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers, and 10,574 overdose deaths related to heroin in 2014. From 1999 to 2008, overdose death rates, sales and substance use disorder treatment admissions related to prescription pain relievers increased in parallel. The overdose death rate in 2008 was nearly four times the 1999 rate; sales of prescription pain relievers in 2010 were four times those in 1999; and the substance use disorder treatment admission rate in 2009 was six times the 1999 rate. In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of pills. Four in five new heroin users started out misusing prescription painkillers. As a consequence, the rate of heroin overdose deaths nearly quadrupled from 2000 to 2013. During this 14-year period, the rate of heroin overdose showed an average increase of 6% per year from 2000 to 2010, followed by a larger average increase of 37% per year from 2010 to 2013. 94% of respondents in a 2014 survey of people in treatment for opioid addiction said they chose to use heroin because prescription opioids were “far more expensive and harder to obtain.”

Adolescents (12 to 17 years old) 
In 2014, 467,000 adolescents were current nonmedical users of pain reliever, with 168,000 having an addiction to prescription pain relievers. In 2014, an estimated 28,000 adolescents had used heroin in the past year, and an estimated 16,000 were current heroin users. Additionally, an estimated 18,000 adolescents had heroin a heroin use disorder in 2014. People often share their unused pain relievers, unaware of the dangers of nonmedical opioid use. Most adolescents who misuse prescription pain relievers are given them for free by a friend or relative. The prescribing rates for prescription opioids among adolescents and young adults nearly doubled from 1994 to 2007.11

Women

Women are more likely to have chronic pain, be prescribed prescription pain relievers, be given higher doses, and use them for longer time periods than men. Women may become dependent on prescription pain relievers more quickly than men.

48,000 women died of prescription pain reliever overdoses between 1999 and 2010. Prescription pain reliever overdose deaths among women increased more than 400% from 1999 to 2010, compared to 237% among men. Heroin overdose deaths among women have tripled in the last few years. From 2010 through 2013, female heroin overdoses increased from 0.4 to 1.2 per 100,000.

*data from: http://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf

 

Addressing the Heroin/Opioid Epidemic


The United States is in the midst of an epidemic. The small county I work in reports 3-5 calls per day for opiate related overdoses. Treatment programs from around the area have huge wait lists and people are dying every day. Experts at a recent round table discussion on the problem are predicting that it will only get worse as we tighten physician prescribing of opiates, as opiate dependent people will switch to the cheaper, more accessible heroin to fight off withdrawals.

This, and other reasons are why we are designating time and space to exploring this growing concern. Heroin and opiates are not an inner city problem. The largest growing base of new users are 20-something, middle class, Caucasians, especially women. This problem in already in your backyard if you live in the suburbs or a rural community.This is not to say opiates doesn’t affect those in the city but the myth that it’s inner city black males that are the largest consumer and dealer of illicit drugs in not supported by research.

Over the next several months we will explore the following topics related to the opiate epidemic that is sweeping across the nation.

  1. Who? What? Why? Where? – An overview of the current state of this problem
  2. Understanding how opiates change the brain
  3. Tolerance/Withdrawal/Detoxification
  4. Medication Assisted Treatment – Methadone & Suboxone
  5. What does effective treatment look like and what are the barriers to accessing it
  6. Harm Reduction (needle exchanges, narcan, and condoms)
  7. Mass Incarceration and the War on Drugs
  8. Co-occurring Disorders
  9. Family Systems and Substance Use
  10. Intersection of class, race, gender, sexual orientation
  11. Education and Employment
  12. What is the role of the church?

U.S. drug control strategy has largely been focused on law enforcement. Police have done their jobs and have done them well. In the last 20 year we have seen record arrests, drug seizures, and incarceration of drug offenders and yet the drug problem is only getting worse and more deadly, not to mention wasted valuable taxpayer resources. It’s time to collectively create a new way of addressing the drug problem in our country. What we’re doing now clearly isn’t working.

Abuse Defined


If we’re going to dig into this messy and difficult topic then we’re going to need to define what abuse is and identify the different types of abuse a child/young person can experience.

Abuse Defined

Child abuse and neglect are defined by Federal and State laws. The Federal Child Abuse Prevention and Treatment Act (CAPTA) provides minimum standards that States must incorporate in their statutory definitions of child abuse and neglect. The CAPTA definition of “child abuse and neglect,” at a minimum, refers to:

  • “Any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act which presents an imminent risk of serious harm”

The CAPTA definition of “sexual abuse” includes:

  • “The employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or
  • The rape, and in cases of caretaker or interfamilial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children”

Types of Abuse

Nearly all States, the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands provide civil definitions of child abuse and neglect in statute. As applied to reporting statutes, these definitions determine the grounds for intervention by State child protective agencies. States recognize the different types of abuse in their definitions, including physical abuse, neglect, sexual abuse, and emotional abuse. Some States also provide definitions in statute for parental substance abuse and/or for abandonment as child abuse.

Physical Abuse

Physical abuse is generally defined as “any non-accidental physical injury to the child” and can include striking, kicking, burning, or biting the child, or any action that results in a physical impairment of the child. In approximately 38 States and American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the Virgin Islands, the definition of abuse also includes acts or circumstances that threaten the child with harm or create a substantial risk of harm to the child’s health or welfare.

Neglect

Neglect is frequently defined as the failure of a parent or other person with responsibility for the child to provide needed food, clothing, shelter, medical care, or supervision such that the child’s health, safety, and well-being are threatened with harm. Approximately 24 States, the District of Columbia, American Samoa, Puerto Rico, and the Virgin Islands include failure to educate the child as required by law in their definition of neglect. Seven States specifically define medical neglect as failing to provide any special medical treatment or mental health care needed by the child. In addition, four States define as medical neglect the withholding of medical treatment or nutrition from disabled infants with life-threatening conditions.

Sexual Abuse/Exploitation

All States include sexual abuse in their definitions of child abuse. Some States refer in general terms to sexual abuse, while others specify various acts as sexual abuse. Sexual exploitation is an element of the definition of sexual abuse in most jurisdictions. Sexual exploitation includes allowing the child to engage in prostitution or in the production of child pornography.

Emotional Abuse

Almost all States, the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the Virgin Islands include emotional maltreatment as part of their definitions of abuse or neglect. Approximately 32 States, the District of Columbia, the Northern Mariana Islands, and Puerto Rico provide specific definitions of emotional abuse or mental injury to a child. Typical language used in these definitions is “injury to the psychological capacity or emotional stability of the child as evidenced by an observable or substantial change in behavior, emotional response, or cognition,” or as evidenced by “anxiety, depression, withdrawal, or aggressive behavior.”

Parental Substance Abuse

Parental substance abuse is an element of the definition of child abuse or neglect in some States. Circumstances that are considered abuse or neglect in some States include:

  • Prenatal exposure of a child to harm due to the mother’s use of an illegal drug or other substance (14 States and the District of Columbia)
  • Manufacture of a controlled substance in the presence of a child or on the premises occupied by a child (10 States)
  • Allowing a child to be present where the chemicals or equipment for the manufacture of controlled substances are used or stored (three States)
  • Selling, distributing, or giving drugs or alcohol to a child (seven States and Guam)
  • Use of a controlled substance by a caregiver that impairs the caregiver’s ability to adequately care for the child (seven States)

Abandonment

Approximately 17 States and the District of Columbia include abandonment in their definition of abuse or neglect, generally as a type of neglect. Approximately 18 States, Guam, Puerto Rico, and the Virgin Islands provide definitions for abandonment that are separate from the definition of neglect. In general, it is considered abandonment of the child when the parent’s identity or whereabouts are unknown, the child has been left by the parent in circumstances in which the child suffers serious harm, or the parent has failed to maintain contact with the child or to provide reasonable support for a specified period of time.

Building Bridges (pt. 3 – LGBTQ-Related Stress)


In the third part of our series on LGBTQ themes, our research/interviews revealed to us that there are extra layers of stress for LGBTQ students compared to their non-LGBTQ peers.

Growing up as a teen in today’s fast paced culture is hard enough as it is. To compound those struggles with stressors related directly to being an individual that identifies as LGBTQ can be overwhelming. So what are “normal stressors” all you are at risk for experiencing? Let’s take a quick look:

  • puberty/physical changes/body image issues
  • peer comparison
  • performance anxiety (school, athletics, roles at home, church, etc.)
  • pressures to engage in high-risk behaviors, such as; drug use, drinking, and sexual activity
  • academic stressors/college prep/career planning
  • family life/expectations (child care of younger siblings, household chores, etc.)
  • challenges related to managing emotions
  • onslaught of negative messages (self/family, peers, media, culture) and filtering them

Now let’s take a look at specific stressors identified by LGBTQ teens related to being LGBTQ:

  • internal/external homophobia
  • bullying/assault/death
  • stigma
  • social isolation/alienation/minority stress
  • academic struggles due to not feeling safe at school
  • higher risk of depression, self harm,, substance abuse, and suicide
  • fear of or actual rejection from family and friends
  • misconceptions by public related to what it means to be LGBTQ
  • pressure (internal or external) to suppress sexual identity/gender identity
  • incongruent identity
  • intersections, such as; disability, race, gender, gender norms, religious background/beliefs

These lists are probably incomplete but it gives you a clearer picture of what the average LGBTQ student is likely to deal with on any given day. High levels of relentless stress contribute to feeling hopeless and helpless, which is a precursor to suicidal ideation. This alone sets apart LGBTQ youth from their non-LGBTQ peers. This also contributes directly to further alienation and isolation. Regardless of your faith tradition and its respective doctrine about the issue of homosexuality, this kind of collateral damage to God’s beloved children cannot be acceptable to anyone calling themselves followers in the way of Jesus.

So, what might be a better way of engagement?

Building Bridges (part 2 – acceptance/rejection and coming out)


“I was born a female but identify with the male gender. My sexual identity is gay. I am 16 years old and was kicked out of my home recently. Sometimes I think killing myself would save everyone a lot of trouble. I don’t know what else to do or where to go. There is no place that I know of that will accept me as I am. I never wanted this. It’s not like I want to be hated by everyone and all alone. I’m basically on my own now.” – Homeless transgendered teen

In an attempt to better understand the lives of young LGBTQ students I interviewed several teens looking for common themes related to the topics of rejection/acceptance, coming out, LGBTQ-related stress, other intersections of identity, trauma/bullying, mental health/substance use, suicide, community/sense of belonging, and faith and spirituality. What I discovered has changed me and I don’t think I will ever be the same and I’m hoping it will change how the church engages these precious and beloved children of God as well.

During the course of one interview, the student I was talking with used the term “straight privilege”. It stopped me in my tracks. It wasn’t something I’d ever considered, let alone heard of. Those with privilege rarely do consider it. I mean, come on. I get white privilege or male privilege, but straight privilege? How much privilege could one man have? I quickly learned that the world I lived in lent itself to being straight. I have never experienced the stress of coming out or being rejected because I liked the opposite sex. The term “Hetero” has never been used as a derogatory term. Nobody shouts, “Look at that dude, he looks so straight!” or “That shirt is so straight. He must like girls.” I have never had to wonder if me being heterosexual was pleasing to God or if I was damned to hell because I was attracted to the opposite sex. I learned through these interviews that I am biased because of straight privilege and it was preventing me from seeing the world through the eyes of an LGBTQ individual.

Rejection/Acceptance

All of the students interviewed had a sense they were different at a very early age, some reporting as early as 7 or 8 years old. Most had a definitive awareness by 10 – 13 years of age. Most report initially rejecting the notion that they had same-sex attraction and many said they were repulsed by the idea. One teenage boy, who identifies as gender fluid and gay shared that when he was 6 years old he asked his mother if he could like boys.

The most common fear of identifying as gay, lesbian, bisexual, or transgendered was the fear of rejection and all correlated this with not coming out at an earlier age. This shouldn’t surprise anyone reading this but it was an overwhelming majority of LGBTQ students that echoed this sentiment. Mallory, a 22-year-old lesbian told a story about being the center of gossip in her small rural town when she came out. She said repeatedly that her fear was that those closest to her would begin to look at her differently, like a pedophile who intended to steal and eat all of the children in town like a monster.

Coming Out

Most of the students interviewed report coming out to the safest people possible at first. This usually consisted of closest friends and siblings. Ironically, most of them report that the individuals they first came out to already had suspicion that they were not heterosexual. The average age of coming out among those interview was 16-18 years old. They all indicate that the time period between accepting they were gay, lesbian, bisexual, or transgendered and when they came out were the most difficult years. We’ll explore that a little later.

Several indicated that the process of coming out never ends. With each new person they tell the process starts over for them. The fear of rejection and anxiety resets and with each new person they meet for the rest of their lives will likely provoke some measure of anxiety as well.

One young woman shared that she believed there were three layers of coming out; to the first individual, family and friends, and publicly, each with their own unique factors.

Bree, a 20-year-old lesbian reminded me that these are issues I will never have to deal with because I identify as a white, heterosexual, Christian male and since I won’t have to deal with them I am likely biased to expect the rest of the world (including LGBTQ individuals) to experience the world just like I do.

If it’s possible to summarize issues so complex I would say this; the time between when a young person identifies internally that they are gay, lesbian, bi, or trans and when they actually come out to others is the time they are at the greatest risk for substance abuse, depression, self-harm, suicide and other mental health related concerns.

If that is even remotely true it beckons a response. So, then what is the best response(s) from people of faith?

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