Transcript Document

ADDICTION MEDICINE:
STATE OF THE ART 2003
`
Integrating:
12-Step Spirituality,
21st Century Psychopharmacology,
Addiction Psychiatry,
and
Dual Diagnosis Concepts
In Addiction Treatment Settings
By
GARRETT O’CONNOR, M.D.
The Radisson-Miyako Hotel
San Francisco
October 8-11, 2003
`
ADDICTION
IS A
BRAIN
DISEASE
THE
RE-ENTRY
OF PSYCHIATRY
INTO THE
ADDICTION
TREATMENT FIELD
`
ADDICTION IS A
`
CUNNING
POWERFUL
BAFFLING
DANGEROUS
DEVIOUS
UGLY
&
HIDDEN
DISEASE
`
BUT
MORE THAN
A
DISEASE,
ADDICTION IS
A
WAY OF LIFE
`
RECOVERY
IS
ALSO
A
WAY
OF LIFE
ADDICTION
`
IS
THE GREAT IMITATOR
OF
ALL DISEASES
(Especially Psychiatric
Ones)
• INTOXICATION CAN MIMIC
OR OBSCURE:
•
•
•
•
•
•
Panic Disorder
Anxiety Disorder
Major Depression
Psychotic Disorder
Bipolar Disorder
Drug-Induced Organic
State
• Obsessive Compulsive
Disorder
• Chronic Alcohol/Drug Use
• Attention Deficit Disorder
`
DUAL DIAGNOSIS
The Co-occurrence of a
Substance Use Disorder
and a
Psychiatric Disorder
(Major Mental Illness
Or Severe Personality
Disorder
In the same Person)
`
DUAL DIAGNOSIS
Is Important Because of: `
• Its Arguably High
Prevalence,
(b) Its Prognostic
Significance
(c) The Important Rx.
Implications of
Making a Correct
Diagnosis
THE
DIFFERENTIAL
`
DIAGNOSIS
BETWEEN
CO-OCCURRING
PSYCHIATRIC
DISORDERS
AND
ADDICTIVE DISEASE
IS A
VITAL CLINICAL
DETERMINATION!
DANGER!
• Prescribing Psychotropic
Medications for the Wrong
Diagnosis
• Failure to Prescribe
PsychotropicMedications
for the Right Diagnosis
`
A MISTAKE
`
EITHER WAY
CAN LEAD TO
EVENTUAL RELAPSE
AND EVEN
DEATH!
INTEGRATING
TWO POTENTIALLY
ANTI-THETICAL MODELS
“12-STEP” (BPSS)
ABSTINENCE, SPIRITUALITY
SERVICE,
HIGHER POWER,
BIG BOOK AUTHORITY,
GROUP CONSCIENCE.
“PSYCHIATRIC”
DUAL DIAGNOSIS,
MEDICAL AUTHORITY,
PRESCRIPTION AUTHORITY,
PSYCHOTHERAPY,
PSYCHIATRY AS HIGHER POWER.
`
I2-STEP ORIENTED
TREATMENT
PROGRAMS MUST
NOT
ALLOW
BIOLOGICAL
PSYCHIATRY,
SCIENCE,
AND
PSYCHOTROPIC
MEDICATIONS TO
BECOME THEIR
HIGHER POWER
`
A
BALANCED
APPROACH
IS
ESSENTIAL
`
IT’S
REALLY
AN
ORGANIZATIONAL
CULTURE
PROBLEM!
`
CULTURE:
Shared beliefs and
values of a group: The
beliefs, customs,
practices, and social
behavior of a
particular nation, class
or group of people.
`
INTEGRATING
FIVE CULTURES
`
ACTIVE ADDICTION
ABSTINENCE-BASED
TREATMENT
AND
12-STEP SPIRITUAL
RECOVERY
COGNITIVE-BEHAVIORAL
TREATMENT
DYNAMIC PSYCHIATRY
BRAIN RESEARCH &
BIOLOGICAL PSYCHIATRY
EACH ONE
OF
`
THESE FIVE
CULTURES
HOLDS DIFFERENT,
AND OFTEN
CONFLICTING,
BELIEFS ABOUT
THE NATURE OF
ADDICTION, AND
HOW IT SHOULD BE
TREATED
THEREFORE,
THE NATURE, TASK, ROLE,
BOUNDARIES,
AND AUTHORITY
OF EACH CULTURE
MUST BE DEFINED,
UNDERSTOOD,
AND ACCEPTED
`
FOR EXAMPLE,
DIFFERENTIATE
TREATMENT
FROM
RECOVERY!
`
DIFFERENTIATE
ABSTINENCE
FROM
HARM REDUCTION
FROM
CONTROLLED
DRINKING
`
`
SOME
“DIFFICULT”
ELEMENTS
OF
12-STEP
SPIRITUALITY
THE
SPIRITUAL CONCEPT
OF A
HIGHER POWER
`
`
ACCEPTANCE
AND
SURRENDER
THE
INFLATED
ALCOHOLIC
EGO
MUST BE
DEFLATED
AT DEPTH
(Bill W.)
`
`
SELECT
AND
SUBMIT
TO A
SPONSOR
SERVICE IN AA
COMMITMENTS
12-STEP WORK
WORK WITH
NEWCOMERS
H&I
G.S. REPRESENTATIVE
SPONSORSHIP
CENTRAL OFFICE
`
SOBRIETY
IS AN
UNNATURAL
STATE
FOR
ADDICTS
`
SOBRIETY
IS
THE
#1
CAUSE
OF RELAPSE
`
GIFTS FOR RECOVERING
ALCOHOLICS
(Opportunities for Spiritual
Growth)
•Suffering!
•Humiliation!
•Disappointment!
•Disillusionment!
•Betrayal!
•Loss!
•Extreme Guilt & Shame!
•Abandonment!
•Failure!
•Success!
`
THE
SPIRITUAL
VALUE
OF
SUFFERING
`
`
THE
RE-ENTRY
OF PSYCHIATRY
INTO THE
ADDICTION
TREATMENT FIELD
`
ABOUT
50%
OF
ALCOHOLIC/ADDICTS
ADMITTED
TO
THE BETTY FORD
CENTER
ARE ALREADY ON
PSYCHOTROPIC
MEDICATIONS
PRESCRIBED BY PCP’S
OR PSYCHIATRISTS,
OFTEN WITHIN 3-6
MONTHS PRIOR TO
ADMISSION
`
•SCIENTIFIC EVIDENCE FOR
ADDICTION AS A BRAIN
DISEASE
• NEW EMPHASIS ON THE
DUAL DIAGNOSIS CONCEPT
• AGGRESSIVE TV AND
OTHER MASS MARKETING OF
SSRI AND OTHER
PSYCHOTROPIC DRUGS;
BENZO’S ETC.
• AWARENESS OF
POPULATIONS NEEDING
TREATMENT. E.G., LICENSED
PROFESSIONALS,
URBAN HOMELESS ETC.
`
• PSYCHIATRY
AND PHARMACEUTICAL
COMPANIES
BELIEVED THEY COULD
ENHANCE THE
EFFECTIVENESS OF
12-STEP
TREATMENT & RECOVERY
• FROM LATE 80’S,
MAJOR ADDICTION MEDICINE
SOCIETIES
(AAPA; ASAM; CSAM; Etc.)
ACCEPTED “EDUCATIONAL”
MONIES FROM DRUG
COMPANIES
`
• DRAMATIC
BREAKTHROUGHS!
• NEW FRONTIERS!
• REVOLUTIONARY
ADVANCES!
• EVIDENCE-BASED
TREATMENT APPROACHES
`
DRUGS USED AFTER
DETOXIFICATION IN
TREATMENT OF ADDICTION
•
•
•
•
•
•
•
•
•
Disulfiram
Naltrexone
LAAM
Acamprosate
Methadone
Buprenorphine
Mood Regulators
Anti-depressants
Sedative-hypnotics (Rarely, if
ever)
• Anti-psychotics (When indicated)
`
•DUAL
DIAGNOSIS
• PSYCHOTROPIC
MEDICATIONS
IN RECOVERY
• BOO-HOO FOR
12-STEP!
(NO “SCIENTIFIC”
EVIDENCE!)
`
ON THE CONTRARY,
RECENT RESULTS
FROM
PROJECT MATCH
SUGGEST THAT
AA
MAY BE THE MOST
EFFECTIVE
APPROACH
FOR
LONG-TERM
ABSTINENCE
AND
SOBRIETY
`
POTENTIALLY
USEFUL & VALID
NEW
TECHNOLOGIES
MAY BE
EXPERIENCED
BY STAFF AS
THREATS
TO THE
12-STEP CULTURE
`
AFTER DETOXIFICATION, `
PSYCHOTROPIC
MEDICATIONS SHOULD
BE
PRESCRIBED
FOR ALCOHOLICS AND
OTHER ADDICTS
IN RECOVERY
ONLY WHEN THE
DIAGNOSIS
OF DUAL DISORDER
HAS
BEEN
CONFIRMED
NEGATIVE ATTITUDES IN AA
ABOUT
PSYCHIATRISTS/PSYCHOTHERAPY
•
•
•
•
•
•
•
•
•
•
•
•
INSENSITIVE
DANGEROUS (ANTI-AA)
ARROGANT
DRUG-ORIENTED
IGNORANT ABOUT
ADDICTION
ABUSIVE
NON-SPIRITUAL
MINIMIZE IMPACT OF
ALCOHOL
MONEY-GRUBBING
COMPETITIVE
CONTEMPTUOUS
THREATENING
`
NEGATIVE ATTITUDES OF
PSYCHIATRY TOWARDS AA
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
SUBSTITUTE DEPENDENCY
AA IS “ADJUNCTIVE”
A FOLK MOVEMENT
RELIGIOUS BIBLE THUMPING
A CULT
FOSTERS DEPENDENCY IN
MEMBERS
NO FOLLOW-UP
NO CONTROLLED RESEARCH
EFFICACY NOT PROVED
DISORGANIZED
HOSTILE TO PSYCHIATRY
LACKS ACCOUNTABILITY
UNCOOPERATIVE
COMPETITIVE
NON-INTELLECTUAL
FREE
`
POSITIVE ATTITUDES IN AA
ABOUT PSYCHIATRISTS,
PSYCHOTHERAPY
AND COUNSELORS
• GRATITUDE
(38% OF AA MEMBERS SAY
THEY WERE REFERRED TO THE
PROGRAM BY PSYCHIATRISTS OR
OTHER THERAPISTS)
MANY AA MEMBERS EXPRESS
GRATITUDE TO PSYCHIATRISTS
FOR SUPPORT AND FOR
PRESCRIPTIONS OF ANTIDEPRESSANTS OR SSRI’S WHICH
THEY SAY “GOT THEM
THROUGH”,“TOOK THE EDGE
OFF”, OR “MADE IT POSSIBLE FOR
THEM TO STAY SOBER”.
`
POSITIVE ATTITUDES IN
PSYCHIATRY ABOUT AA
•
•
•
•
•
•
•
•
•
SUPPORTIVE
LIFE-SAVING
INDISPENSABLE
DIVINELY INSPIRED
COOPERATIVE
COMPLEMENTARY
REVOLUTIONARY
ADMIRATION
GRATITUDE
`
NEGATIVE 12-STEP ATTITUDES
TOWARD MEDICATIONS
•
•
•
•
•
•
•
•
•
•
`
A Crutch
Easier Softer Way
Impede Spiritual Recovery
Foster Dependency
Substitute for Higher
Power
Violate AA Traditions
Bad Example for
Newcomers
Ill-Trained Physicians
Stupid Physicians
Criminal Conduct by Docs
UNDERSTANDING RECOVERY
AND ADDICTION (M.BEAN)
•THE NATURE OF ADDICTION
•THE THINKING DISORDER
(“STINKIN THINKIN”)
•THE MECHANICS &
DYNAMICS
OF RECOVERY
•THE ALCOHOLIC IDENTITY
•THE RECOVERING IDENTITY
•THE ROLE OF SPIRITUALITY
IN RECOVERY
•AA IS NOT “AN ADJUNCT” TO
PSYCHOTHERAPY
`
`
SHAME
PERSONAL,
PROFESSIONAL,
AND
MEDICAL
SHAME
`
PRINCIPLES FOR INTEGRATING
12-STEP AND DUAL DIAGNOSIS
PROGRAMS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Needs Assessment
Establish Vision & Mission
Survey Staff Attitudes
Create Policies and Procedures
Educate Referents
Adequate Staff Education
Cross-Training for Staff
Capability for Longer Stay
Double Trudger’s Groups
Integrated or Segregated
Treatment Tracks?
11. Expert Differential Diagnosis
12. Drug-free Observation Period
13. Experienced Medical and
Psychiatric Direction
`
CRF
`
ANTAGONISTS
MAY
INTERRUPT STRESS
CYCLES,
BLOCK DOMINO
EFFECTS,
AND
PREVENT
BIOLOGICAL CASCADING
INTO
DEEPER LEVELS
OF
STRESS
IN THE MEANTIME,
EVERY ONE HOPES
THAT
SOMETHIHG
ALREADY OUT THERE
(a drug, that is)
WILL
BE FOUND
TO BE
EFFECTIVE!
`
URGENT
NEED
TO FORMALLY
ADDRESS THESE
CULTURAL
DIFFERENCES
WITHIN THE
FIELD TO
FACILITATE
BENCH TO BED
TO COMMUNITY
TRANSLATIONAL
INITIATIVES
`
THE SERENITY PRAYER
`
God grant me the
serenity to accept the
things I cannot change
The courage to change
the things I can
And the wisdom to
know the difference