Kratom Fatalities

Title: Unintentional Fatal Intoxications with Mitragynine and O-Desmethyltramadol from the Herbal Blend Krypton

Citation: Kronstrand, R., Roman, M., Thelander, G., & Eriksson, A. (2011). Unintentional Fatal Intoxications with Mitragynine and O-Desmethyltramadol from the Herbal Blend Krypton. In Journal of Analytical Toxology, vol 35. Retrieved from http://jat.oxfordjournals.org/content/35/4/242.long

Summary: This article talks about case studies on the effects of a drug called Kratom. I had not heard of this drug until recently, and to be honest it scares me. Preliminary research says that on the one hand the drug is a safer alternative to opiates; on the other kratom can lead to relapse on heroin and it is also addictive.

This particular article talked about 9 cases of fatal kratom use. All was observed in previous drug users and usually related to breathing difficulties similar to when you cannot breath after using heroin and pass away. Luckily, narcan can help with a kratom overdose similar to how it helps with a heroin overdose.

The article mentions that at low doses kratom has a stimulant effect and at higher doses has a similar effect to heroin. The “loud” version of kratom is called krypton and has an added receptor to help increase the buzz. The article ultimately concluded that the addition of that receptor contributed to deaths from the substance.

Limitations: This article only has 9 case studies, so there is not experimental or control group. The studies could have been handpicked to show certain results. In addition, most of the cases were male and were prior drug users. This could be a trend worth noting, or it could be selection of the study in order to show increased harmful effects.

Usefulness in practice: This article definitely hammered home some of the effects of kratom. I feel sick thinking about how clients could be using this substance without it showing up in testing all the while experiencing the bad effects. I’m definitely going to be on the lookout for this substance with opioid using clients.

Strengths within clients

This exercise asks to come up with strengths seen in specific clients and answer some questions about each strength. I am going to use generic strengths that I have seen in my clients and in others in my life.

1. Maintains positive attitude

How does a client express this strength? – they come to treatment every day with a smile even though they are frustrated.

How does this strength help the client?- It allows them to build positive relationships with the people they work with and the people around them, leading to better outcomes over all.

Affirmation: You are able to maintain a positive attitude despite some setbacks.

2. Works to keep family housed and fed.

How does a client express this strength?- they dedicate time to work, put work first.

How does this strength help the client?- it allows them to feel needed and depended on, allows them some responsibility in order to maintain sobriety. It allows them activity to do to spend time on something sober.

Affirmation: You really prioritize your family. They are important to you and you make sure to meet obligations to them.

3. Has good communication with case manager.

How does the client express this strength?- they text and call case manager when they will be late, they ask questions, they tell the truth to the case manager, they ask for help when they need it.

How does this strength help the client- allows client to build rapport with case manager. Builds communication skills outside of drug court.

Affirmation: You really make it clear to other people what you intend to do, and then you follow through.

Writing Open-ended questions

In this exercise we were asked to write two open-ended questions to comments that clients make. I will again use one or two examples from the book but come up with my own to share here.

1. Im really tired of dealing with all this crap. I just can’t do it anymore.

What would need to change in order to help you deal with it?

What brings you to this conclusion?

2. I’m thinking of moving out of my house and living with my mother.

How would this decision change things for you?

What is it like for you to consider making this change?

3. I just really don’t want to be non-compliant. That judge makes me scared shitless.

Tell me about why you think you are non-compliant.

What is something that could help you to stay out of non-compliance?

4. These meetings aren’t helpful to me. Recovery is about going to meetings and not about coming here and talking to you.

What would need to change in order for these meetings to help you?

Tell me more about what recovery means to you.

What’s your understanding of why you’re here?

5. I’m here because of my P.O. They said I have a problem but I only got one DUI in my life. I’ve never been in trouble before that. Ever.

What do you think makes them think you have a problem?

Tell me about something that you want to address while we’re here.

 

Usefulness in practice: I feel as if I’m not very good at coming up with questions. Half of these sound accusitory in nature even though I don’t intend them to be. When I was doing the questions in the book I really struggled to think up good responses. This is one skill where I will need additional practice.

Converting Closed Question

This exercise goes with Ch 4 of the Motivational Interviewing skills workbooks. All the exercise asks is that we convert common closed questions to open-ended questions. I will use ones that I came up with as well as one or two from the book.

1. How much do you drink on a typical drinking occasion?

Tell me about a day of drinking for you

What does a typical drink look like for you?

2. Do you use with your friends?

Tell me about a situation when you are likely to use.

Tell me about your friends.

3. Do you have a sponsor?

Tell me a little bit about your support system.

What has your experience with twelve-step programs been like?

4. When was the last time you used?

Tell me about the last time you used.

5. How often did you used to use?

Tell me about what it was like for you to use when you were using.

What was it like for you when you were using regularly?

OARS

Title: Building Motivational Interviewing skills

Citation: Rosengren, D. B. (2009). Building motivational interviewing skills: A practitioner’s workbook. New York, NY: The Guilford Press.

Summary: Chapter four of this workbook focuses on OARS: Open-ended questions, affirmations, and summaries. (The R is for reflective listening).

The first part focuses on open-ended questions. The ratio of reflective statements to questions should be 2:1, something that most trainees fall short of immensely. The reason for this is that questions are often considered one of the roadblocks to a good assessment/session, as they can allow the therapist to fall into the question answer trap.

The “key question” is one that talks about where the person will go next. What they will do next and what their upcoming goals are. You should respond to this answer with reflections.

The next part of the chapter goes over affirmations. Part of the therapist’s job is to instill hope in clients that they can complete treatment, that they can progress. Affirmations are a way to do that, but they are tricky as they can often be confused with compliments. For an affirmation, use “you” language, not “I” language. Focus on specific behaviors and goals, not on things that are intrinsic to a person. Do not focus on the lack of something as an affirmation but instead something positive.

The last part of the chapter goes over summaries. The creators of MI talk about three types of summaries: collecting, linking, and transitions. Collecting is when you gather information your client has presented to you and give it back to them in succinct form. This can help clients to organize their experiences. Linking is similar however it seeks to compare and contrast rather than just to present back. The book reiterates something I have heard before: do not use “but” instead use “and.” Transitional summaries are used to change the direction of the session. The book talks about transitioning between “phase 1 and phase 2” of MI, but I don’t know exactly what it is talking about.

Limitations: I liked this chapter, it really delved into some of the specifics about how to use these tools effectively. It also provided ample examples and some exercises at the end to test my knowledge.

Usefulness in practice: I do intend to use these tools in practice, but I’m realizing steadily that it is very easy to forget things I have learned previously. Therefore I will have to go back and reread some old blog posts in order to assist with my memory. I did not know about the question ratio and I feel that I am not meeting that goal. It does worry me that I only have 30 minutes to use these skills and so much information to find out. I know that these skills are supposed to be used in short treatments though, so there’s no excuse for why these cannot work for me.

Reflective Listening Deepens

Here is another reflective listening exercise from the workbook. In order to preserve the contents of the book I will only use a couple examples out of the many they have provided, and I will change some of them.

The point of the exercise is to use amplified, simple, double-sided, and affective reflective listening. The book gives some statements and we must come up with ways to respond to those statements in each manner.

1. I know I could do some things differently, but if she would just back off, then the situation would be a whole lot less tense; then these things wouldn’t happen.

paraphrase: You feel that there are a few different ways to prevent this.

amplified: She is responsible for starting and preventing these situations.

Double sided: On the one hand you feel that she bears responsibility for these events, on the other you feel that you could play a part in making things better yourself.

Affective: You’re angry with her.

2. I’ve been depressed lately. I keep trying things other than drinking to help myself feel better, but nothing seems to work except having a couple of drinks.

paraphrase: You’re finding that your other coping skills aren’t working for you right now.

amplified: Drinking is the only thing between your life now and everything taking a turn for the worse

Double sided: On the one hand you don’t think drinking is the best solution; on the other you aren’t able to see another option right now.

Affective: You feel helpless.

3. He’s just on me all the time about recovery; I feel like he’s my dad.

paraphrase: He’s really keeping tabs on you.

amplified: He monitors you 24/7.

Double sided: On the one hand he is taking an interest in your recovery; on the other he’s overdoing it.

Affective: You feel smothered.

4. Working with a sponsor is going better than I thought. I just don’t think it’s helpful to me. I don’t need one.

paraphrase: You’ll work with a sponsor but you don’t know if it’s something of value for you.

amplified: You don’t feel that your sponsor will have anything of value to help you or teach you.

Double sided: On the one hand you don’t feel that a sponsor will be helpful; on the other you don’t mind it as much as you thought you would.

Affective: You’re ambivalent about having a sponsor.

5. Case management isn’t recovery for me. AA meetings are recovery. Talking with my sponsor is recovery. These meetings aren’t helpful.

paraphrase: You don’t feel like your time is being spent valuably.

amplified: Case management serves no purpose.

Double sided: On the one hand you don’t identify CM as a part of your recovery. On the other you realize the importance of coming to stay compliant with the court.

Affective: You’re frustrated that this is required.

 

I feel like this exercise has been very useful. These are all statements that I often find in clients, those who I see or not. And writing down some reflective statements helps me to think about their words in a different way as well as think about what I can say to them in a different way. I definitely feel like I understand some of those statements better now that I have really thought about the emotion and meaning behind them.

Reflective Listening Exercise

I tried a reflective listening exercise tonight with my friend, trying to use the skills I learned from the Motivational Interviewing book. The exercise was to see how long I could go in session without asking a question but instead using reflective listening statements. With this particular friend it was easy because I know him so well. I’d like to try with someone I know less well in order to see if I’m on the right track.

It was easy to not ask any questions, and I noticed a few types of reflection that I used. I used double-sided reflection a few times and I used simple reflection many times. It’s easy to use both of those because they are clear cut- you just repeat back what someone has said to you. Amplified reflection is also useful but it’s hard for me to go into deep reflectiv listening. I feel that I was able to do it a couple times with my friend but again only because I know him so well.

I plan to use this exercise with my clients. See how long I can go- most likely about 10 minutes, without asking a single question. This might be harder to do in case management where the goal is to gather information, but I think that it will make me a better case manager to be able to use this skill.

Leadership and Collaboration

Today we attended a presentation on how to be effective collaborators at work. I think this counts as a learning experience and I thought writing about it would cement what I took away from it in my mind.

1. We need to think about the entire organization instead of just our little teams

This came to me while we were doing our exercise and we got competitive with the other teams. I think that we do tend to focus on our own office more than the entire whole, and I’m thinking that we could use a little more comraderie, one way to solve it would be to have every person visit every single office. What are things that we can take away from the other offices and bring to our own?

2. We need to remain teachable

This was a point brought up by someone at another table and I think it pertains to me. I keep telling myself that I am teachable but how teachable am I really? I find myself being resistant to being taught more often than not simply because of fear and pride. I need to learn how to put those things aside. I can learn whether or not I’m into the job for a year or five years. I need to learn in order to grow.

3. Remain positive

4. 50% of speech is in body language

This is especially important for all counselors to remember. I feel like I am not communicating with symmetry in my tone and my body language and my words. I always say what I mean to say but I don’t know if I convey it correctly thought body language. This is a good question for supervision. What more could I do to work on my body language, something that I knowI struggle with?

Favorite Teacher Exercise

Exercise: think about your favorite teacher or supervisor (in my case I will use my favorite therapist). Consider what characteristics he or she had or what he or she did that inspired you to learn and to excel. Then answer these questions:

1. What is his or her name?

S. K.

1. What characteristics did he or she have?

She was kind, and she was always ready to listen. She made some suggestions about how I could change my behavior and never expected me to follow through, but she was always willing to give me more tools to help me through.

1. What inspired you to do or be your best?

I don’t think she inspired me to be my best. I think I felt inspired by myself to be my best. It helped to be able to get all of my emotions and my thoughts out to someone who was willing to listen in a safe, confidential environment.

1. How did you respond to his or her efforts?

I responded by feeling like I was getting better. I don’t know how much of it was her but I do remember that she was a really great therapist. And I give her credit for much of my current recovery. However the funny thing is I can’t even remember accurately what she was like as a p

Building MI skills

Title: Motivational Interviewing- practicioner’s workbook

Citation: Rosengren, D. (2009). Building motivational interviewing skills. New York, NY: The Guilford Press.

Summary: This first chapter talked about what motivational interviewing is and the key concepts.

R- resist the righting reflex. This means that you don’t argue with your clients, instead you start with a well-crafted reflective-listening statement.

U- understand your client’s motivation

L- Listen to your client

E- empower your client.

The basic form of MI is geared towards eliciting change talk. There is an example at the end of the chapter followed by several exercises. I will be doing those exercises as part of this blog in order to facilitate my learning.