Pain Medications Work by blocking pain signals going to the brain of by interfering with - PowerPoint Presentation

Slide1

Pain Medications

Work by blocking pain signals going to the brain of by interfering with the brain’s interpretation of the signals

Most painkiller use isn’t

misuse

Effective to treat residual pain after surgery, as well as chronic pain

Highly habit-forming

Deadly at high doses or in conjunction with other drugsSlide2

Pain Medications

Celebrex (celecoxib): Arthritis, short term pain, painful menstruation

Ultram (tramadol): schedule IV controlled substance (low potential for abuse; limited physical or psychological dependence—as compared to other substances in other classifications)

Demerol (meperidine

HCl

)

Lorcet

(hydrocodone

bitartrate

& acetaminophen)

Vicodin (hydrocodone & acetaminophen)Slide3

Pain Medications

Norco (hydrocodone

bitartrate

& acetaminophen)

Percocet (oxycodone & acetaminophen)

Percodan (aspirin & oxycodone hydrochloride)

Oxycontin

(oxycodone

HCl

)

Opana

(

oxymorphone

)/

Opana

ERSlide4

Pain Medications

MS

Contin

(morphine sulfate)

Fentanyl (

Actiq

)

Dilaudid

(hydromorphone)Slide5

Pain Medications

More than 1 in 3 American adults – 35%-- were given painkiller prescriptions by medical providers last year.

More American adults used prescription painkillers than cigarettes, smokeless tobacco or cigars

combined

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 menSlide6

Pain Medications

Opioid painkillers killed nearly 19,000 Americans in 2014

That number is greater than the number of Americans murdered in 2015 (15,809)

2008: Americans consume about 80% of global opioid supply and 99% of supply of hydrocodoneSlide7

Reason for Using Prescription Pain

Relievers

Easy to get from parents' medicine cabinets--62%

Available everywhere--52%

They are not illegal drugs--51%

Easy to get through other people's prescriptions--50%

Teens can claim to have a prescription if caught--49%

They are cheap--43%

Safer to use than illegal drugs--35%

Less shame attached to using--33%

Easy to purchase over the Internet--32%

Fewer side effects than street drugs--32%

Can be used as study aids--25%

Parents don't care as much if you get caught--21%Slide8

Prescription Drug Monitoring Program

Beaver County

2015

2016

2017

Patients

35,945

35,830

30,819

Scripts

105,883

96,737

87,946

Pills

6,696,522

6,924,917

6,271,031Docs3,9853,8173,513

22.76% of adult population received a prescription for opioids46 pills per adult203 pills per patient per year

2017Slide9

Herbal Products

Ginkgo Biloba: improve cognitive functioning and blood flow

St. John’s Wort: anxiety and depression

Ephedra: weight-loss “herbal fen-

phen

”; decongestants, bronchodilators and stimulants, “herbal

ecstacy

”—euphoric state and heightening of awareness & sexual sensations

Ginseng: strengthen normal body functions, increase resistance to stress & improve sexual function

Kava: antianxiety & calming effectsSlide10

Herbal Products

HERBAL PRODUCT

SIDE EFFECTS

Ginkgo biloba

Bleeding

St. John's wort

Gastrointestinal disturbances, allergic reactions, fatigue, dizziness, confusion, dry mouth, photosensitivity

Ephedra (ma huang)

Hypertension, insomnia, arrhythmia, nervousness, tremor, headache, seizure, cerebrovascular event, myocardial infarction, kidney stones

Kava

Sedation, oral and lingual dyskinesia, torticollis, oculogyric crisis, exacerbation of Parkinson's disease, painful twisting movements of the trunk, rashSlide11

Herbal Products

HERBAL PRODUCT

INTERACTING DRUGS

Ginkgo biloba

Aspirin, warfarin (Coumadin), ticlopidine (Ticlid), clopidogrel (Plavix), dipyridamole (Persantine)

St. John' s wort

Antidepressants

Ephedra

Caffeine, decongestants, stimulants

Ginseng

Warfarin

Kava

Sedatives, sleeping pills, antipsychotics, alcoholSlide12

Herbal Products

Are you taking an herbal product, herbal supplement or other “natural remedy?”

If so, are you taking any prescription or nonprescription medications for the same purpose as the herbal product?

Have you used this herbal product before?

Are you allergic to any plant products?

Are you pregnant or breast-feeding?Slide13

Medication-assisted treatment

Medication

Counseling

Support

Often the best option for today’s opioid addictionSlide14

Intervention

Medication Assisted Treatment Availability

MAT Availability: 

Total: 16 MAT facilities

Total: 1,775 treatment slots

MAT Coverage for adult population with OUD: 345%Slide15

Medication-Assisted Treatment (MAT)

Opioids

Methadone/

Buphrenorphine

Acts

on the same targets in the brain as heroin and morphine; suppresses withdrawal symptoms and relieves cravings

Naltrexone

Blocks the effects of opioids at their receptor sites in the brain

Should only be used in patients who have already been detoxedSlide16

MAT

Methadone

Daily methadone dose determined by the program physician based upon a physical exam and the individual’s history

Administered only in oral form and dosing is initially observed by medical staff

Each individual must receive a minimum of 2.5 hours of counseling/month

12-month minimum treatment recommended for maintenanceSlide17

MAT

Buprenorphine

Physicians must request a special certification to prescribe

Subutex

: primarily for pregnant woman

Suboxone

(Buprenorphine & Naloxone)

Buprenex

(injectable available)

Butrans

(7 day transdermal patch)Slide18

Buprenorphine O

verdose

The risk of overdose and death is increased when

suboxone

is combined with other drugs, such as 

alcohol and benzodiazepines

, to give a more intense high.

Seek immediate medical treatment if you experience the following symptoms

:

Profound drowsiness.

Intermittent loss of consciousness.

Lack of coordination.

Slurred speech.

Vision problems.

Slowed breathing.

Sluggish reflexes.Slide19

FDA approves non-opioid for opioid withdrawal symptoms

May 17, 2018 

by Gary A.

Enos

, Editor

The

Food and Drug Administration (FDA) this week approved the first non-opioid medication for the treatment of opioid withdrawal symptoms, after an advisory panel overwhelmingly 

recommended approval

 of the medication earlier this year.

Lucemyra

(generic name:

lofexidine

) was shown to result in less severe withdrawal symptoms and to facilitate completion of a withdrawal protocol in two placebo-controlled studies.

Lucemyra

, which suppresses the neurochemical surge that produces troubling symptoms of opioid withdrawal that include muscle spasms, stomach cramps and heart pounding, is expected to be available in the U.S. market in August.

Officials at drug maker US

WorldMeds referred to the FDA's action as a “milestone approval,” given that the challenge of opioid withdrawal often can get overlooked in discussions of how to address the opioid crisis. The fear and pain associated with withdrawal symptoms often sends individuals back to opioid use. The FDA reviewed the drug application for Lucemyra under its priority review procedures.Lucemyra is seen as having significant potential for patients seeking to be initiated on injectable naltrexone treatment for opioid dependence, as this requires a patient to be completely opioid-free prior to initiation.Lucemyra is designed to be used during the period of peak withdrawal symptoms, usually occurring five to seven days after last use of opioids. The medication is given as three 0.18 mg tablets taken four times a day at intervals five to six hours apart.The most common side effects associated with Lucemyra in clinical trials included low blood pressure, lightheadedness, slow heart rate, sleepiness and dry mouth.Slide20

MAT

Naloxone

Revia

(daily pill)

Vivitrol

(monthly injection)Slide21

MAT

Alcohol

Naltrexone: Blocks opioid receptors that are involved in the rewarding effects of drinking and in the craving for alcohol

Acamprosate

(

Campral

): May reduce symptoms of long-lasting withdrawal, such as insomnia, anxiety, restlessness and dysphoria

Disulfiram (Antabuse): Interferes with the breakdown of alcohol. Leads to unpleasant reactions that include flushing, nausea, and irregular heartbeat if the patient drinks alcoholSlide22

Slide23

Naloxone (Narcan

)

Opioid overdose reversal

Opioid antagonist: binds to opioid receptors and can reverse and block the effects of other opioids

Can restore normal respiration to someone whose breathing has slowed or stopped as a result of overdosing

Injectable or Nasal Spray

Standing Order in PASlide24

Medical MarijuanaSlide25

Approved Diagnoses

Amyotrophic Lateral Sclerosis.

Autism.

Cancer.

Crohn’s Disease.

Damage to the nervous tissue of the spinal cord with objective neurological indication of intractable spasticity.

Epilepsy.

Glaucoma.

HIV (Human Immunodeficiency Virus) / AIDS (Acquired Immune Deficiency Syndrome).

Huntington’s Disease.

Inflammatory Bowel Disease.

Intractable Seizures.

Multiple Sclerosis.

Neuropathies.

Parkinson’s Disease.

Post-traumatic Stress Disorder.Severe chronic or intractable pain of neuropathic origin or severe chronic or intractable pain in which conventional therapeutic intervention and opiate therapy is contraindicated or ineffective.Sickle Cell Anemia.Slide26

Approved Forms of Use:

Pill

Oil

Topical forms, including gel, creams, or

ointments

A form medically appropriate for administration by vaporization or nebulization, excluding dry leaf or plant

form

Tincture

LiquidSlide27

Cresco Yeltrah-Butler

201

Pillow St

Bulter

, PA

724-276-0069

http

://www.cydispensary.com/Slide28

Allegheny County Dispensary Facility

2114 Penn

Avenue

Pittsburgh, PA

**Opening:

TBASlide29

Special PopulationsSlide30

Children & Adolescents

Many medications used to treat children and adolescents with mental illness are safe and effective. However, some medications have not been studied or approved for use with children or adolescents

.

Still, a doctor can give a young person an FDA-approved medication on an "off-label" basis. Slide31

Children & Adolescents

Children may have different reactions and side effects than adults

.

Some

medications have current FDA warnings about potentially dangerous side effects for younger patients

. Slide32

Older Adults

People over 65 have

a

higher risk for experiencing bad drug interactions, missing doses, or overdosing

.

Older adults also tend to be more sensitive to medications. Even healthy older people react to medications differently than younger people because older people's bodies process and eliminate medications more slowly. Slide33

Older Adults

Older adults purchase

more than 30 percent of all prescription medication and more than 40 percent of over the counter (OTC) medicines. Estimates are that as many as 90 percent of seniors use either herbal remedies or vitamins

.

S

eniors

take an average of four to five medications on a daily basis.Slide34

Women Who Are Pregnant or Who May Become Pregnant

The research on the use of psychiatric medications during pregnancy is

limited

There are different

risks

depending

on which medication is

taken

and at what point during the pregnancy the medication is

takenSlide35

Women Who Are Pregnant or Who May Become Pregnant

Most women should avoid certain medications during pregnancy. For example

:

Mood stabilizers are known to cause birth defects.

Benzodiazepines

and lithium have been shown to cause "floppy baby syndrome," in which a baby is drowsy and limp, and cannot breathe or feed well.

Benzodiazepines

may cause birth defects or other infant problems, especially if taken during the first trimester

.Slide36

Women Who Are Pregnant or Who May Become Pregnant

According

to research, taking antipsychotic medications during pregnancy can lead to birth defects, especially if they are taken during the first trimester and in combination with other drugs, but the risks vary widely and depend on the type of antipsychotic taken. The conventional antipsychotic haloperidol has been studied more than others, and has been found not to cause birth defects. Research on the newer atypical antipsychotics is ongoing.Slide37

Women Who Are Pregnant or Who May Become Pregnant

Antidepressants, especially SSRIs, are considered to be safe during pregnancy. However, antidepressant medications do cross the placental barrier and may reach the fetus. Birth defects or other problems are possible, but they are very rare. The effects of antidepressants on childhood development remain under study

.Slide38

Women Who Are Pregnant or Who May Become Pregnant

Studies have also found that fetuses exposed to SSRIs during the third trimester may be born with "withdrawal" symptoms such as breathing problems, jitteriness, irritability, trouble feeding, or hypoglycemia (low blood sugar). Most studies have found that these symptoms in babies are generally mild and short-lived, and no deaths have been reported. Risks from the use of antidepressants need to be balanced with the risks of stopping medication; if a mother is too depressed to care for herself and her child, both may be at risk for problems.Slide39

Women Who Are Pregnant or Who May Become Pregnant

Women

who nurse while taking psychiatric medications should know that a small amount of the medication passes into the breast milk. However, the medication may or may not affect the baby depending

on

the medication and when it is taken

. Slide40

Members Of Specific Cultural Groups

Certain

ethnic groups respond differently to medication, though more research is needed.

African

 Americans and some Asian Americans, for instance, metabolize some medications more slowly than Caucasians. They are thus at increased risk of certain side effects and may benefit from lower dosages. 

For many ethnic groups treatment is also complicated by language barriers, socio-economic stresses, lack of minority health care professionals and

stigma.Slide41

Managing Meds

M

edication

must be actively

managed, particularly in

respect

to coping

with side effects. Difficulty coping with unpleasant side-effects is a common reason for people coming off their

medication.

To guard against an interaction, make a list of all medications, vitamins and herbal

remedies.

Beside

each medication, write the contact information of the physician who prescribed the

medicine.Slide42

Who Should Prescribe Mental Health and/or Pain Medications

Primary Care Physician (PCP)

Psychiatrist

Pain Specialist

AddictionologistSlide43

Managing Meds

Avoid Pharmacy

Shopping

Poly-pharmacy, the “technical” name for pharmacy shopping, is often a source of confusion and drug interactions. 

Throw Away Outdated

Medicines

Borrowing or Lending

Medicine

Prescription medication should never be taken by anyone else than for whom it was intended. Other individuals have special medical histories and may also be taking other medicines that can cause serious drug

interactions.Slide44

Managing Meds

Don’t Skip Doses to Save Medication

Check, Check, and

Recheck

Before taking a medication, double-check the label to be sure that you are taking it according to your doctor’s

instructions

Try to take your pills at the same time each day and pick a time when you are almost always home (for example, when you wake up in the morning or when you go to sleep at night

).Slide45

Managing Meds

Set automated reminders. You can set a daily alarm on your cell phone or computer. Many free online calendars allow you to set daily email or text message alerts (e.g., Google Calendar).

Carry

a record of your medications with you by using our 

Medication Wallet Reminder Card.Slide46

Talking to Your Doctor

If

you are prescribed a medication, be sure that you:

Tell the doctor about all medications and vitamin supplements you are already taking

.

Remind your doctor about any allergies and any problems you have had with medicines

.

Understand how to take the medicine before you start using it and take your medicine as instructed

.

Don't take medicines prescribed for another person or give yours to someone else

.

Call your doctor right away if you have any problems with your medicine or if you are worried that it might be doing more harm than good. Your doctor may be able to adjust the dose or change your prescription to a different one that may work better for you.Slide47

Compliance

In the past when doctors treating mental health conditions were seen

as

the authority

figures,

they used to use the term “compliance” to describe how good a patient was at taking their medication. It is now

recognized

that compliance tends to be a problem for all people with long-term medical conditions whether their conditions are mental or physical

.

Studies have shown that compliance with medication is no worse in mental health conditions like schizophrenia than it is in long term physical ailments such as asthma or high blood

pressure.

D

emographic

factors such as whether you are single or in a relationship are more likely to play a role in your compliance.Slide48

1. Get on to the right medication for you.

Doctors have a range of medications available to them and different drugs will work in different ways. If the side effects

with

the drug are so serious that they are making life unpleasant then discuss

the

possibility of changing to a different medicine.Slide49

2. Change the dose of the medication

T

he

aim with medication is to always be taking the

optimum dose

: that is the dose that gives you the maximum beneficial effect with the fewest side effects. If the side effects are making life

unpleasant, consider asking

your doctor to try reducing the dose for a trial period to find out if the side effects can be reduced without the symptoms

returning

.Slide50

3. Keep on taking the medication

It

may sound paradoxical but coming off your medication without first planning it with your doctor can actually lead to an increase in side effects.

It

is important that you continue to take this low dose even when you are feeling fine and are symptom free. If you stop taking the maintenance dose you will risk a relapse and would then need to be treated with a much higher dose which in turn would have much worse side effects than the maintenance dose.Slide51

4. Treat the side effects of the medication

Many

side effects can be successfully overcome by treating them with other drugs.

A

nxiety

can be treated with anti-anxiety drugs called

anxiolitics

N

ausea

can be treated with over-the-counter

anti-sea

sickness

preparations

S

leep

disruption can be eased with one of the sedating antihistaminesMen with sexual side effects may be treated with medications such as Viagra.Some people also find traditional herbal remedies Slide52

4. Treat the side effects of the medication

If your medicine upsets your 

stomach

, ask your doctor if you should take it with a meal or if the risk may be less with a brand rather than a generic form of a drug

.

If your 

medicine

 makes you sleepy during the day or keeps you awake at night, ask your doctor what time of day you should take it. By taking your medicine first thing in the morning or right before bed, you might diminish some of the unwanted effects

.

Don't take 

psychotropic medicine

s

 with alcohol. Alcohol can affect how well the medicine works, cause sedation, and possibly worsen 

depression

, anxiety and other mental health issues.Slide53

Priapism: A Painfully Hard Topic

C

ondition

in which a penis remains erect for hours in the absence of stimulation or after stimulation has endedSlide54

5. Find out as much as you can about your diagnosis

The

more you know about a problem the better you will be able to cope with it. Slide55

6. Join a support group

This

is one area where support groups can prove very useful. Joining a support group for people with similar problems will give you the chance to talk about side effects with other people who have also experienced them and have found their own way of coping.Slide56

Cognitive Behavioral Therapy (CBT) for Improved Med Compliance

Inquire as to patients’ previous experience with medication.

Ask about prior history

Why was it prescribed?

Was it helpful?

Under what conditions was it terminated?

Did they take med as prescribed?Slide57

CBT for Improved Med Compliance

Address patients' concerns about medication

.

Listen

carefully for any concerns, misunderstandings, or prejudices about taking medication and address these rapidly and assertively. 

 These may include misconceptions about expected medication effects, time needed to experience the effect, side effects, dosing, and interactions with

other substances. 

Therapists should provide clarification in clear, familiar terms and frequently check back with patients to be sure they understand.Slide58

CBT for Improved Med Compliance

P

atients

should be encouraged to expect gradual rather than all-or-nothing

change from medication.

Explaining

the gradual emergence of medication effects provides an opportunity for the therapist to emphasize that 

patients should not expect to benefit from an entirely passive stance regarding

treatment

 simply because they are taking medication

.

Mastery and implementation of coping skills remain an essential and important part of treatment; medication may be an additional, useful adjunct or tool.Slide59

CBT for Improved Med Compliance

Assess medication compliance since last session

.

Close, consistent, and careful monitoring is one of the most effective strategies for enhancing compliance with medications. Thus, a portion of each session should be devoted to evaluating medication compliance and working through any difficulties that might arise.Slide60

CBT for Improved Med Compliance

Praise medication

compliance

Therapists should also convey confidence in the medication and inform patients of the likely benefits. Therapists should be strongly on the side of compliance and praise patients' compliance enthusiastically and genuinely.Slide61

CBT for Improved Med Compliance

Relate patients' clinical improvement to compliance and lack of improvement to noncompliance

.

A crucial role of the therapist is to establish and stress the connection between medication compliance, psychotherapy sessions, and improvement. Therapists should make explicit causal links between patients' compliance and improvement in

appropriate

target symptoms. Conversely, therapists might tie poor compliance to failure to improve.Slide62

CBT for Improved Med Compliance

Use a problem solving strategy for noncompliance

.

When patients are not compliant with medication, therapists should take a practical, objective approach. They should try to help patients clarify reasons or obstacles to compliance and generate practical solutions.

In

all of these discussions, therapists should be nonjudgmental and

nonconfrontational

. Efforts should be made to help patients feel ownership of the plan. This can be done by having them take the primary role in developing the plan, rather than having therapists telling them what to do.Slide63

Motivational Interviewing

Assess Stage of Change

Express empathy

Support self-efficacy

Highlight discrepancies between the patient’s current health behaviors & core values

Roll with resistanceSlide64

Disclosure

Doesn’t have

to be

all or

nothing

Weigh

the risks and benefits involved with telling certain people.

We don’t always share with everyone about medical issues, like diabetes or hypertension. Mental health issues should be considered in the same manner.Slide65

Disclosure at Work

Americans

with Disabilities Act (ADA), passed in 1990, prohibits discrimination in hiring and firing decisions based on physical and

mental disabilities

and entitles people to “reasonable accommodations” from their employers.

In

the case of mental disabilities, these fixes may include flexible working hours, access to a quiet area and additional feedback from supervisors. In many cases, the modifications cost little to no money and can make a big difference to employee happiness and productivity.Slide66

Disclosure at Work

The ADA protections are not ironclad, however. Many managers are not familiar with the details of the law, and people who experience discrimination often lack the resources to bring their case to

court.

D

iscrimination

is difficult to prove: about 90 percent of plaintiffs who bring suits under the ADA lose their cases.Slide67

Disclosure at Work

A critical consideration is the

workplace climate

.

T

ry

to gauge your employer's response ahead of time by looking for certain signs. Those with a history of hiring people from diverse backgrounds may be more understanding. But supervisors may frown on your disclosure if you hold a job with stringent requirements, such as security

clearance.Slide68

Disclosure at Work

Researchers suggest that employees considering broaching a mental health concern should know what they hope to gain.

If

your work has started to suffer, disclosing a mental illness may help you explain the situation and get assistance.

On

the other hand, if you are getting along fine, offering this sensitive information is probably not worth the risk.Slide69

Should You Tell Your Kids about Your

Mental

Illness?

Research shows that if parents don’t tell children about their mental illness, children develop misinformation and worries which can be worse than the

reality.

Strike a

balance

.

There’s a

fine balance between revealing the truth to your kids and overwhelming them.

P

revent

passing on any shameful connotation of mental

illness; Discuss

it

openly (as is age appropriate) and without judgment.Slide70

Should You Tell Your Kids about Your Mental Illness?

Take age and maturity into account

. How you talk to your kids will largely depend on their age and maturity level.

Be open to their questions

. Your kids may have a variety of questions, especially as they get

older.

Teens may fear that they’ll also struggle with mental illness. Younger kids may ask if they caused the illness and wonder how they can fix it. Slide71

Should You Tell Your Kids about Your

Mental Illness?

See your talk as a learning opportunity

.

P

arents

with mental illness

have

a special opportunity to teach their kids one of life’s most important lessons: Everyone has their

baggage. It’s

not so important what the baggage is, but how it’s handled

.

Give

children the language for talking about mental health, feelings, emotional wellbeing and

mood.

Help them understand that mental health is a vital part of health, wellbeing and family life. Stress to your kids the importance of taking good care of

themselves. Talk to them about wellness, sleep, exercise and nutrition. If they’re older, you can talk about the red flags of mental illness, as well.Slide72

Should You Tell Your Kids about Your Mental Illness?

Be reassuring

.

Kids

may become preoccupied with worry about their parents’ wellbeing or their own future mental

health.

Reassure your kids that you love them, that you’re getting help, and “that someone will always be there to meet their

needs.”

Consider counseling for your kids

.

Counseling

can help educate, build coping skills and give kids another venue for emotional

support.Slide73

Disclosure at 12-Step MeetingsSlide74

The A.A. Member—

Medications & Other Drugs

“From

the earliest days of Alcoholics Anonymous it has been clear that many alcoholics have a tendency to become dependent on drugs other than alcohol. There have been tragic

incidents

of alcoholics who have struggled to achieve sobriety only to develop a serious problem with a different drug. Time and time again, A.A. members have described frightening and sobriety-threatening episodes that could be related to the misuse of medication or other drugs.

Experience

suggests that while some prescribed medications may be safe for most

nonalcoholics

when taken according to a doctor’s instructions, it is possible that they may affect the alcoholic in a different way. It is often true that these substances create dependence as devastating as dependence on alcohol. It is well known that many sedatives have an action in the body similar to the action of alcohol. When these drugs are used without medical supervision, dependence can readily develop.

Many

A.A.s who have taken over-the-counter, nonprescription drugs have discovered the alcoholic’s tendency to misuse. Those A.A.s who have used street drugs, ranging from marijuana to heroin, have discovered the alcoholic’s tendency to become dependent on other drugs. The list goes on and will lengthen as new drugs are developed. Always consult your doctor if you think medication may be helpful or needed

.”Slide75

The A.A. Member—

Medications & Other Drugs

“Note

to medical

professionals:

Cooperation with the professional community has been an objective of Alcoholics Anonymous since its beginnings. Professionals who work with alcoholics share a common purpose with Alcoholics Anonymous: to help the alcoholic stop drinking and lead a healthy, productive life.

As

noted in the introduction, some A.A. members must take prescribed medications. However, our experience indicates that the misuse of prescription medication can threaten the achievement and maintenance of sobriety. The suggestions provided in our introduction are offered to help A.A. members find the right balance and minimize the risk of relapse

.”Slide76

Friendship is a wildly underrated medication.

--Anna

Deavere

Smith

actress, playwright & professor