CHALLENGING THE FAMILY TO ACT AND ORGANIZE ITSELF

CHALLENGING THE FAMILY TO ACT AND ORGANIZE ITSELF

Test can happen once trust has been built up. The way toward testing should occur in little strides. The advisor's recommendations may come in little measurements, typically confined as far as the skills that relatives have just appeared. By first taking note of that they are capable, he would more be able to effectively push toward testing their reactions to his proposals. The thought of home detoxification ought not be tended to in an express, coordinate way until the point when the relatives are capable and willing to examine the implica-tions of the test. Once more, this requires a development of certainty amongst family and specialist. In a few families, this sort of liking will come right on time over the span of treatment, nearly without exertion or mindfulness. By and large, in any case, building up such an affinity will en-tail a blend of tolerance, determination, and demonstrating by the advisor, with the goal that the errands he in the long run shows can be seen as achievable by relatives. 

The procedure of test is begun by getting the someone who is addicted and other relatives to confer themselves to performing, on a - hone premise, a little undertaking or venture. The errand should address some issue that they are fit for taking a shot at as well as, more critical, one that they will do. The undertakings might be performed either inside the session or at home. An undertaking in the session ought to be a portrayal of what is to occur at home. For instance, on the off chance that one individual from the family is to be a spectator at home, that individual ought to likewise see in the session (i.e., - establishment of the task).1°" Instructions ought to be concrete, obviously engaged, and completely under-remained by the whole family,. The specialist ought to affirm that all individuals acknowledge their piece of the assignment as sensible, regardless of the possibility that they don't completely acknowledge the general arrangement. A dedication by every individual just to his part is very worthy. Every thing must be arranged, with the goal that all individuals know about their own and others' parts. 

By centering, at any rate at first, on a minor as opposed to a huge scale errand, the advisor builds odds of progress later on. A little errand will probably be dealt with ably by the family. This facili-tates promote achievement in consequent undertakings and builds the relatives' trust. A restricted concentration additionally controls the family's desires far from confusing the single undertaking as a panacea or cure-all. At this beginning time in treatment, the advisor ought not enable the family to expect that detoxification will come rapidly or effortlessly. 

At the point when the specialist sets up an underlying assignment, it is not excessively mindful for him to anticipate disappointment. Doing as such guarantees that the out-come, regardless of whether achievement or disappointment, has additionally use in the treatment. In the event that there is disappointment in playing out any part of the assignment, the advisor concentrates on this in checking on it—investigating with the family how this may look like different routes in which they have been unsuccessful. The discourse should then continue from such - shortcomings into ranges where more positive methodologies and arrangements can be created. Victories and recuperations have occurred some place in the family's understanding; these must be evoked, developed, and brought into the administration of treatment. This activity of investigating an underlying disappointment can deliver an extensive sparing of time and exertion in executing the genuine detoxification design.

ENACTAMNT-DURING SESSIONS

OBSERVING SEQUENCES' AND "ENACTAMNT-DURING SESSIONS

Haley65 has placed particular stress on the importance of symptoms in regulating sequences of behavior in the family. As described in Chapter 1, drug taking and related behaviors often occur in response to parental conflict and have the function of pulling the parents back together. The symptomatic behavior of other family members (pa-rents, siblings, grandparents) also has an important regulatory func-tion in these sequences. For example, a mother's depression may serve as a signal that her son has become too independent, or the

father may begin to complain about heart pains when conflict becomes too extreme.

It is best for the therapist to be able to observe these sequences directly, in the session. Videotape is invaluable in this effort, since subtle signals can trigger almost instantaneous changes. Actual drug taking in sessions is rare, but there are frequent examples of drug-related behavior. This includes various forms of acting out, such as impulsive, angry outbursts, leaving the sessions, or threats of shooting up heroin. Equally important is acting incompetent (i.e., depressed, uncommunicative, helpless) or irrelevant. Frequently, we have also

noted behavior by the IP that serves to remind the family that he is a drug addict, such as nodding and scratching.

When these behaviors occur in a session, it is important to formulate hypotheses as to the function they serve in the sequence.

The therapist might want to ask himself, ( I ) -What was happening prior to the symptomr (watching especially for indications of parental conflict, or pressure on a parent to change); or (2) -What new pattern of behavior is produced?” Often in such instances the parents become united against the addict ("detouring attacking-) or attention is diverted into a familiar and unproductive fight between the addict and one parent. Information about events outside the session can be helpful in confirming and elaborating the hypothesized sequence. It is essential to collect factual data about the events both prior to and following drug episodes, since it is unusual for families to be aware of their own sequences. Once a sequence has been tentatively identified, the thera‑pist can move in the session to block its usual run. For example, he can elicit parental conflict and then prevent the addict from interrupting and diverting the parents' attention. Finally, as Hoffman" notes, all aspects of the repetitive sequence may not have to be shifted, but only enough of them to cause the symptom to disappear.

It needs to be emphasized that this therapy is concerned with the repetitive interactional patterns that maintain the drug taking. The thrust of treatment is to alter these sequences. Although it is inter-esting to speculate about the etiology of drug abuse, it is our experience that historical data are generally of very little utility in actually bringing about change.

HOW WE TAKE CAFFEINE

HOW WE TAKE CAFFEINE

COFFEES

The amount of caffeine in a cup of coffee varies tremendously and depends on several factors.

Types of Coffee Beans

Robusta beans are often grown in Africa and may have as much as twice caffeine as arabica beans, which are grown in South America and the Middle East, among other places. Robusta coffees are generally cheaper and are often used in the mass-produced canned coffees sold in grocery stores, though the package label may not indicate what kind of bean it is. Arabica coffees are considered to be of higher grade and to yield a better-tasting cup. Although generally available, they are predominant at specialty coffee retailers and through the rapidly growing mail-order cof­fee businesses. Arabicas are also much more often sold in whole-bean form than are robustas. For purposes of comparison, a typical cup of cof­fee brewed from arabica beans generally has 70 to 100 milligrams of caf­feine, whereas the comparable amount of robusta coffee may have closer to 150 milligrams.

Method of Roasting

Dark-roasted coffee beans contain less caffeine and less acid than lighter‑ roasted ones. Many people think that dark-roasted coffees contain more caffeine because they often have a more powerful taste than the lighter roasts. In fact, the additional roasting associated with the darker product allows more time for caffeine to be broken down in the beans.

Fineness of Grind and Method of Brewing

The method of brewing and the size of the granules of ground coffee interact to have a significant influence on the amount of caffeine per ounce of coffee produced. The finer the grind, the more surface area of ground coffee comes into contact with the brewing water. This creates more opportunity for caffeine to be extracted from the ground beans. As for brewing method, a cup of coffee made using a drip-type coffeemaker generally has about 20 percent more caffeine than a cup made in a perco­lator. French presses, or "plunger pots," can also extract maximal caffeine levels from ground coffee because the grounds are actually soaked in boiling water for several minutes prior to the plunger being lowered to separate them from the water.

Espresso

Espresso is really a different drink from brewed coffee. It is made by pass­ing water rapidly through relatively tightly packed coffee grounds under high pressure. The result is that the oils and other products in the coffee are more fully extracted than under other coffee brewing conditions, and the taste is considerably richer than that of other coffee brews. A typical "cup" of espresso contains about one and a half to two fluid ounces—much less than a cup of coffee. But espresso contains more caffeine per fluid ounce than coffee does. Thus, the amounts of caffeine in a cup of coffee and a cup of espresso are about the same. While an average cup of coffee brewed from arabica beans contains seventy to one hundred milli­grams of caffeine, the average cup of espresso usually contains about sixty to ninety milligrams.

Why do so many people believe that espresso creates more of a "caf­feine buzz" than coffee does? Perhaps because of the higher concentration of caffeine in the espresso. When a drug is more concentrated in a certain solution, it tends to be absorbed more rapidly across the membranes of the stomach and small intestine. So, even though a single espresso (espresso solo) may have the same or less caffeine than a cup of coffee, its more rapid absorption can result in a more rapid onset of the caffeine

effects and a greater feeling of "rush." Of course, a double espresso (or espresso doppio) contains twice as much caffeine.

Other coffee drinks, such as cappuccino, caffe latte, and café mocha, are each generally made by adding a single shot of espresso to other ingre­dients. So, the caffeine content of these drinks should be roughly equal to that of a single espresso, though less concentrated.

Based on this information, it is obviously impossible to present a sim­ple table describing the amount of caffeine in coffee drinks. Remember that these are broad averages based on a survey of the pharmacological and dietary literatures.  

Drink	Milligrams
Dripped robusta coffee (8 oz)	150
Dripped arabica coffee (8 oz)	100
Percolated robusta coffee (8 oz)	110
Percolated arabica coffee (8 oz)	75
Instant coffee (8 oz)	65
Decaffeinated coffee (8 oz)	3
Espresso (and espresso-based drinks) made from arabica beans (1.5-2 oz)	90

With the rise in popularity of specialty coffees and coffee drinks, there are lots of products to choose from. The following table shows the caffeine content of a number of these drinks in their usual serving sizes.

CAFFEINE CONTENT IN SPECIALTY COFFEES^*

Coffee and Origin                                   Amount          Dose (mg)

Espresso coffees

Big Bean Espresso                                                    1 shot                75.8

2 short shots                140.4

2 tall shots                 165.3

Starbucks Espresso, regular, small                         1 shot                     58.1

Hampden Café Espresso                                         2 shots                 133.5

Einstein Bros.^® Espresso, double                            2 shots                 185.0

Brewed Specialty Coffees

Big Bean, regular                                                       16 oz                    164.7

Big Bean Boat Builders Blend,                               1607                     147.6

regular

Big Bean Organic Peru Andes Gold,                      16 oz                    186.0

regular

Big Bean French Roast, regular                              16 oz                    179.8

Big Bean Ethiopian Harrar,                                    1607                     157.1

regular

Big Bean Italian Roast, regular                              16 oz                    171.8

(grown in Brazil)

Big Bean Costa Rican French Roast,                    16 oz                    245.1

regular

Big Bean Kenya AA, regular                                   16 oz                                 204.9

Big Bean Sumatra Mandheling,                             16 oz                    168.5

regular (grown in Indonesia)

Hampden Café Guatemala Antigua                     16 oz                    172.7

Starbucks regular                                                      16 oz                                 259.3

Royal Farms regular                                                 16 oz                                 225.7

Dunkin' Donuts regular                                            16 oz                    143.4

Einstein Bros.^® regular                                              16 oz                                 206.3

*Data taken from the Journal of Analytical Toxicology by permission of Preston Publications.

TEAS

Tea leaves are harvested from bushes that are grown mostly in India, Indonesia, and Sri Lanka. Leaves are of differing qualities, depending upon how far out on the stalk of the bush they grow. Generally, the bud leaves, which are closest to the stalk, are considered to be of the highest quality. The leaves are dried and allowed to ferment, which turns them to  an orange hue. These are used to make black teas. However, some tea leaves are not fermented in this way and remain green. Green teas are brewed from these and are found in most Chinese and Japanese restau­rants in the United States.

In general, a cup of tea will contain less caffeine than a cup of coffee. Although there is more caffeine in a pound of fermented tea than in a pound of coffee, that pound of tea might be used to brew three to four times as many cups as a pound of coffee would. In addition, the amount of tea in a "cup" is often less than the amount of coffee, by tradition. As with coffees, the amount of caffeine in a given cup may vary considerably, depending on several factors. As a general guide, the following are cal feine ranges in teas as found in the food science literature:

Black tea

8 oz

8 oz

14-61 mg

Green tea

24-40 mg

Iced tea                                     8 oz

5-11 mg

There are well-documented positive effects of both green and black teas on health. Studies have shown that people who drink one or two cups of tea per day are more likely to survive a heart attack than those who do not drink tea. It is not clear why there is this protective effect; nor is it clear if it only applies to heart attack survival or to cardiac health in general. But some scientists think the protection comes from the antioxidants con­tained in tea leaves. These compounds may contribute to lowered choles­terol levels, for example, and thus help protect the heart. It's important to know that these positive effects have not been observed for herbal teas. It seems that the tea leaves themselves may be the source of the protective chemicals. They may also be the source of naturally stress-reducing chem­icals. A recent, well-designed study found that people who drank a bever­age that contained the components of black tea daily over a six-week period were more able to manage stress than those who drank a control beverage that was identical to the tea beverage (including the caffeine), except that it lacked the chemicals that are found in the black tea leaves. The researchers even took care to serve the beverages cold to avoid the possible stress-reducing effects of sipping a warm beverage. Importantly, the people who drank the active beverage also had lower levels of the stress hormone cortisol in their blood after stressful events, indicating that the noncaffeine components of black tea leaves can help dampen the body's physical stress reactivity.

SODAS

The consumption of caffeinated sodas in the United States has been on the rise for a number of years. Some people are bothered by the gastric upset that is sometimes associated with the acids in coffees and prefer to drink caffeine-containing soft drinks. In general, the concentration of caffeine per ounce in sodas is considerably lower than in coffees, but the typical serving of soda is twelve ounces, compared to six to eight ounces for coffee. The general range of doses in soft drinks is about twenty to fifty milligrams. The diet drinks contain the same amount of caffeine (though sometimes more) as their nondiet equivalents.

"ENERGY" DRINKS

The term energy drink is not exactly accurate. These caffeinated drinks don't actually produce more energy, but they can generate a feeling of alert­ness, and even a solid buzz, because of their caffeine content. The concen­tration of caffeine in these products is often twice as high as in regular caffeinated sodas, though the serving sizes are smaller (about eight and a half ounces, compared to twelve ounces for a regular soda), and most come in smaller containers. Most of these drinks contain about 50 to 75 milli­grams of caffeine. Interestingly, although these drinks have the reputation of providing a big caffeine blast, they actually contain about the same con­centration of caffeine as coffee—maybe even a bit less. A notable exception is "5-hour Energy," which contains about 200 milligrams in just a two-ounce serving. These drinks also often contain any of a number of addi­tional compounds that fall generally into the category of "supplements," like ginkgo biloba, taurine, ginseng, B vitamins, and sugar. We will not address these in this chapter, but some of them are discussed in other chap­ters, and the energy drinks are also discussed in the chapter on stimulants.

Although energy drinks are relatively new in the US beverage market (Red Bull was introduced into the United States in 1997), their sales grew 60 percent from 2008 to 2012, and in 2012 their total US sales were more than $12 billion (up from $3.5 billion in 2005). They have been marketed aggressively to young people and have obviously been successful. What makes these products so attractive as to have such a big market presence? One element of their popularity may relate to how they are consumed. Unlike caffeinated beverages that are hot and are generally sipped slowly, energy drinks tend to be consumed quickly, thus leading to more rapid  absorption of the caffeine (and other chemicals) and a more rapid buzz. It

is also likely that some of the many other ingredients in these drinks

interact with the caffeine, possibly modulating its effects. This may be

true for taurine (found in Red Bull) in particular, though there have been

very few studies on the interaction between caffeine and taurine.

Combining energy drinks with alcohol has also become popular. Some

people believe that the energy drink enhances the pleasant buzz of the alco­hol and diminishes the depressant effects. 'This is almost certainly incor­rect. As we pointed out in the "Alcohol" chapter, combining caffeine with alcohol does not make a person less impaired—it just makes him more awake. Although this may seem appealing to someone who wants to be drunk but not sleepy, there is a danger. If a person feels as if he is alert and unimpaired he might feel that drinking more alcohol is safe when in fact it may not be. In general, it is always wise to be wary of combining drugs, par­ticularly when there have been few studies of their interactions. Still, the idea of combining alcohol and caffeine into one drink led to the creation of several caffeinated alcoholic beverages. Perhaps the best known (or most notorious!) is Four Loko, which was sold in 23.5-ounce cans and contained 12 percent alcohol and a high dose of caffeine—quite a blast! In fact, it rap­idly gained the nickname "Blackout in a Can" and became very popular on the college drinking scene. Obviously the use of these drinks had little to do with "energy' and everything to do with rapid and sustained alcohol intox­ication. However, after multiple reports of alcohol-related illnesses after its use, Four 1_, oko came under scrutiny by the FDA and was banned on many college campuses. The current product contains no caffeine but retains the alcohol, available in a range of concentrations from 6 to 12 percent.

In addition to energy drinks, per se, there are many "energy formula­tions" on the market. It can be mind-boggling to sift through all of their claims about how they provide energy and good health, but the bottom line is that they rely mostly on caffeine for their effects. One example is guarana, which is sold in capsule form. One formulation on the market provides 250-milligram capsules, each of which contains about 90 milli­grams of caffeine (about as much as a cup of coffee). Guarana comes from the seeds of a South American tree and is often described as an "herbal" energy supplement or a weight loss aid. Although there was a time when it was thought to increase alertness because of something specific to the plant, it is now clear that it's just the caffeine.

Some people also think that it is a good idea to exercise after consum­ing energy drinks. Although the caffeine might make you feel alert and motivated to exercise, it will also promote dehydration that can decrease physical performance. It's important not to confuse these products with sports drinks like Gatorade, which has no caffeine and is rich in electro­lytes that the body needs while exercising and afterward. The following table shows the caffeine content and usual serving size of a number of

energy drinks and sodas. 

Beverage Energy Drinks	Serving Size (oz)	Caffeine (mg/serving)
Red Devil®	8.4	41.8
Sobe® Adrenaline Rush	8.3	76.7
Sobe® No Fear	16	141.1
	8.4	none detected
Hair of the Dog®
Red Celeste	8.3	75.2
E MaxxTM	8.4	73.6
	8.4	69.6
Amp—
Red Bull®	8.3	78
KMXim	8.4	33.3
5-hour Energy	2	207
Cran-Energy	8	70
Full Throttle	8	71
Monster	8	80
Rockstar	8	80
Vault	8	47
Carbonated Sodas
Coca-Cola® Classic	12	29.5
Coca-Cola Zero	12	35
Diet Coke®	12	38.2
Diet Coke® with Lime	12	39.6
Caffeine-Free Diet Coke®	12	none detected

^{8 8} Vanilla Coke^®                                      12                                                                                              29.5

Pepsi^®                                                                 12                      31.7

Diet Pepsi^®                                        12                      27.4

Mountain Dew^®                                                12                      45.4

Mountain Dew^® Live WireTM                        12                      48.2

Dr Pepper^®                                                        12                      36.0

Diet Dr Pepper^®                                12                      33.8

Sierra Mist^TM

12                                                                              none detected

Celestr Cola                                       12                      19.4

Sprite^®                                                                12                none detected

Seagram's^® Ginger Ale                       12                                                                        none detected

Barq's^® Root Beer                                              12                      18.0

Pibb^® Xtra                                          12                      34.6

A&W^® Root Beer                                               12                                                                    none detected

7-Up^®                                                                  12                                                                    none detected

*Data taken from the Journal of Analytical Toxicology by permission of Preston Publications.

OVER^-THE^-COUNTER DRUGS

There are quite a few medicinal preparations that contain caffeine, some in very high amounts. The following table lists some of these.

CAFFEINE CONTENT IN OVER^-THE-COUNTER DRUGS

Brand Name                     Milligrams

per dose

Cold Remedies

Coryban-D                                     30

Dristan                                           16

Triaminicin                                     30

Diuretics
Aqua-Ban	100
Pain Relievers
Anacin	32
Excedrin	65
Goody's Powders	33
Midol	32
Vanquish	33
Stimulants
Caffedrine	200
NoDoz	100
NoDoz Maximum Strength	200
Vivarin	200

CHOCOLATE

Chocolate is made from the bean of the Theobroma cacao bush, which contains a unique xanthine called theobromine. An average cup of cocoa may contain as much as 200 milligrams of theobromine, but this com­pound is much less potent than caffeine as a stimulant. However, choco­late also contains caffeine. For example, a one-ounce bar of baker's chocolate contains about 25 milligrams of caffeine, a five-ounce cup of cocoa may contain 15 to 20 milligrams, a cup of chocolate chips contains about 100 milligrams, and one Foosh energy mint contains 100 milli­grams. On the other hand, a typical eight-ounce glass of chocolate milk generally contains less than 10 milligrams of caffeine, and one Hershey's Kiss contains only 1 milligram.

One final note about chocolate: caffeine and theobromine may not be the only psychoactive compounds in it. A recent report has indicated that one component of chocolate is very similar to the natural chemical in the brain that interacts with our THC receptors—the receptors to which the psychoactive compound in marijuana binds. Although the concentration of this compound is quite low in chocolate (it was estimated that one would have to eat twenty-five pounds of chocolate to stimulate the recep­tors as much as a typical dose of marijuana), it is possible that its presence

could supplement the natural THC-like compound in the brain enough to produce a subtle effect. These results have led some to speculate that the vague sense of well-being and happiness that some people report in response to chocolate may be related to the interaction of the subtle drug effects associated with low-dose caffeine with those associated with acti­vating the natural THC receptors in the brain.

TOXICITY OF CAFFEINE

Overall, caffeine is fairly safe if a healthy person takes it in moderate amounts. The undesirable side effects that most people experience are gastric upset and nervousness or jitteriness. As people age, they tend to have more problems with sleeplessness and often will limit their caffeine consumption in the afternoon and evening. Pills containing fairly hefty amounts of caffeine, however, can result in severe side effects in people who load up on them to stave off sleep (procrastinating students and sleepy truck drivers, for example). It is also important to note that while caffeine may allow you to keep sleep at bay, sleeping is a very important biological need that you should not ignore for long.

Children who take theophylline for treatment of asthma can also expe­rience toxicity if their blood levels get too high. The major symptoms are severe gastrointestinal upset and vomiting, extreme nervousness, and nervous system excitability, which eventually leads to seizures if blood levels get high enough. Remember, too, that people who have other condi­tions that impair their cardiovascular system (obesity, hypertension, etc.) are more vulnerable to anything that affects heart function.