Transcript Assisted Treatment for Opiate Dependency and

CAPTASA
2012
OUR EXPERIENCE WITH OPIATE
SUBSTITUTION FOR OPIOD DEPENDENCE
AND STIMULANT THERAPY FOR ADHD
“CAVEAT EMPTOR”
LLOYD J. GORDON MD FASAM DABAM
WHY CAN’T WE JUST SHUT UP
AND GO ALONG
• GIVING A PHARMACEUTICAL AND
TALKING ABOUT DOSES IS MUCH
EASIER THAN TALKING ABOUT
BELIEFS, FEELINGS, BEHAVIORS,
AND THE DIFFICULTY OF CHANGE
WHAT A MOST ESTEEMED ADDICTIONIST
AND MY BEST FRIEND FROM SAN
FRANCISCO SAYS
• THE PARTY WAS GOING GREAT
AND NOW YOU WANT TO THROW A
TURD IN THE PUNCH BOWL
GOOD THINGS ABOUT
BUPRENORPHINE
• LESS EUPHORIA
• SATURATED ALL OPIOD
RECEPTORS AT NON TOXIC DOSE
• LESS RESPIRATORY DEPRESSIONLITTLE CHANCE OF OVERDOSE
• LESS ABUSE POTENTIAL
• NO MORNING AT THE CLINIC-MOST
PHYSICIANS COULD USE IT
WHAT DO WE DO ABOUT IT?
• IN MEDICINE THE QUESTION WE ASK IS
OFTEN MUCH MORE IMPORTANT THAN
THE ANSWER (TO THE WRONG
QUESTION)
• WHY? (DOES A PATIENT HAVE IT)
• WHERE? (DID IT COME FROM)
• WHAT? (CAUSED IT)
• HOW? (DO WE TREAT/STOP IT
5
OPIATE MAINTENANCE FOR
OPIATE ADDICTION
• IS NOT NEW
• IF IT WORKED LONG TERM WE
WOULD HAVE HAD EVERYONE ON
METHADONE YEARS AGO
• ORIGINALLY MEANT TO REDUCE
CRIME
• TEMPORARY MEASURE-STOP GAPHARM REDUCTION
WHAT AA SAYS
• “YOU CAN’T THINK YOURSELF INTO
RIGHT (HEALTHY) BEHAVIOR, BUT
YOU BEHAVE (ACT) YOURSELF
INTO RIGHT THINKING”
SYMPTOM VS CAUSE
• A SYMPTOM IS A PHYSIOLOGIC
OUTWARD MANIFESTATION OF THE
DISEASE
• A SYMPTOM IS NOT THE DISEASE
• “COUGH” IS A SYMPTOM OF MANY
DIFFERENT DISEASES
• WE CAN TREAT COUGH FOR
INSTANCE WITH COUGH MEDICINE
OR SUPPRESSANT AND IT MAY GO
AWAY
SYMPTOM VS CAUSE
• IF THE DISEASE CAUSING THE
COUGH I.E. A VIRUS IS SELF LIMITED
THE PATIENT WILL GET WELL
• IF THE DISEASE IS NOT SELF
LIMITED I.E. BRONCHITIS,
PNEUMONIA, TB, CANCER, COPD,
FIBROSIS, FUNGUS THE COUGH
WILL ONLY GO AWAY TEMPORARILY
AND WILL COME BACK. THE COUGH
WILL REQUIRE EVER INCREASING
DOSES OF MEDICINE TO SUPPRESS
IT
SYMPTOM VS CAUSE
•
•
“CRAVING” IS A SYMPTOM OF THE DISEASE OF
ADDICTION. IT IS A FEELING.
“CRAVING” IS CAUSED BY NOT ENOUGH
NEUROTRANSMITTER AT RECEPTOR SITES
THAT HAVE BEEN DOWN REGULATED. THIS
DOWN REGULATION IS IN RESPONSE TO
YEARS OF THE USE OF THE CHEMICAL AND
HAS BECOME HARD WIRED IN PATIENTS WITH
A GENETIC PREDISPOSITION. PATIENT
BELIEFS, PERCEPTIONS, AND ATTITUDES
CONNECTED (AMYGDALA) TO THE DRUG USE
NOW INITIATE THE DOWN REGULATION
SYMPTOM VS CAUSE
• SUPPLYING MORE STIMULATION OF
MU OPIATE RECEPTORS WITH
OPIOD SUBSTITUTION
TEMPORARILY RELIEVES THE
PROBLEM BUT DOES NOTHING
ABOUT CHANGING OR TREATING
THE DISEASE STATE
• THIS IS WHAT THE PATIENT HAS
DONE ON THEIR OWN OVER THE
YEARS DEVELOPING ADDICTION
HAIL TO THE KING!!!
AMYGDALA
• FEELING ARE CAUSED BY MANY
NATURAL STATES OR CONDITIONED
STATES
• HUNGER, THIRST, LIBIDO ARE ALL
FEELINGS CAUSED BY OUR BRAIN.
YOU WON’T DIE OF A FEELING
• THINK HOW UNCONFORMTABLE
THE FEELING OF HUNGER CAN BE
AND THE BEHAVIORS IT
STIMULATES
HAIL TO THE KING!!!AMYGDALA
• HUNGER AND THIRST CAN BE SYMPTOMS OF
TYPE 1 DIABETES
• DIABETES IS THE DISEASE AND TREATING
THE SYMPTOMS (FEELINGS) DOES NO GOOD
• HYERGYCEMIA IS ANOTHER SYMPTOM OF
DIABETES. DESPIT THE EXCELLENT
MEDICINES AVAILABLE TODAY THAT LOWER
THE BLOOD SUGAR THE DISEASE CAUSES
INCREASED RISK OF HEART DISEASE,
STROKE, RENAL FAILURE, LOSS OF VISION
AND AN EARLIER DEATH
SYMPTOM VS CAUSE
• THE DISEASE WILL CONTINUE TO
PROGRESS UNLESS WE ADDRESS THE
HARD WIRING AND THE PATIENT BEGINS TO
CHANGE THEIR BELIEFS, BEHAVIORS,
PERCEPTIONS, AND ATTITUDES AND THEY
BECOME UNATTACHED TO THE DRUGS
• THIS WILL EVENTUALLY BEGIN TO ADDRESS
THE NEUROTRANSMITTER, DOWN
REGULATED RECEPTOR, AND HARD WIRING
PROBLEM (THE DISEASE) AND IF YOU WILL
REWIRE-REPROGRAM THE PATIENT.
Definition of Insanity: Doing the same thing over
and over and expecting different results
Rarely have we seen a person fail who has thoroughly
followed our path. Those who do not recover are people
who cannot or will not give themselves to this simple
program, usually men and women who are constitutionally
incapable of being honest with themselves. There are such
unfortunates. They are not at fault; they seem to have been
born that way. They are naturally incapable of grasping and
developing a manner of living which demands rigorous
honesty. Their chances are less than average. There are
those, too, who suffer from grave emotional and mental
disorders, but many of them do recover if they have the
capacity to be honest.
Bill Wilson Alcoholics Anonymous 1939
REBT
• One of the fundamental premises of REBT is that humans, in most
cases, do not merely get upset by unfortunate adversities, but also
by how they construct their views of reality through their language,
evaluative beliefs, meanings and philosophies about the world,
themselves and others.[3] In REBT, clients usually learn and begin to
apply this premise by learning the A-B-C-model of psychological
disturbance and change. The A-B-C model states that it normally is
not merely an A, adversity (or activating event) that contributes to
disturbed and dysfunctional emotional and behavioral C,
consequences, but also what people B, believe about the A,
adversity. A, adversity can be either an external situation or a
thought or other kind of internal event, and it can refer to an event in
the past, present, or future.[4]
• BELIEF SYSTEM IS EXTREMELY IMPORTANT
17
Why don’t we just change?
 pain, pain ,pain!
 emotional uncomfortability
 internal conflict
 anxiety
If left to ourselves, we will continue to do
and think the same as we have all of our
lives.
1-2 months of treatment vs. 10-20 years
of old behavior
Who am I ? Self Honesty?
q a truthful person that occasionally lies vs. a
dishonest person who occasionally tells the truth
q an humble person with occasional arrogant
episodes vs. an arrogant person who occasionally
manages humility
q a selfless individual who can be selfish vs. a selfcentered person who can be other-centered
q if I don’t discover this I can not change. I have
no valid starting point.
Self Honesty Equals (AS BILL SEES IT)
q acknowledging (gaining of insight) and
accepting (this is who I am) of character defects
q emotional honesty (this is how I feel)
q boundaries (this is what I need to do for me)
q I am defined by a set of defects(and positive
qualities) and make changes from there (4th and
5th steps)
q I DON’T THINK THIS IS POSSIBLE WHILE STILL
ON OPIATES AND/OR STIMULANTS
CHANGE ???
 IF WE DON’T HAVE AN ACCURATE STARTING ASSESSMENT
OF WHO WE ARE AND OUR CHARACTERLOGICAL MAKEUP
(STEPS 4 AND 5) WE CANNOT GET BETTER AND CHANGE.
 I WILL NOT “WORK” TO CHANGE THAT WHICH I DON’T
RECOGNIZE IN MYSELF (I.E. SELFISHNESS)
 I WILL NOT “WORK” TO CHANGE THAT WHICH DOES NOT
CAUSE ME TO BE UNCOMFORTABLE IN THE ABSENCE OF
THE OF THE DRUG (OR ADDICTIVE BEHAVIORS SUCH AS
SEXUAL COMPULSIVITY AND EATING DISORDERS)
 I TOOK THE DRUG TO DEAL WITH THE WAY I FELT IN
THE FIRST PLACE
21
First things first
We can not think ourselves into
right behavior, we must act
ourselves into right thinking?
Our reality that we base our
thinking on is formed by our
personality make up (character
defects)
THE PROCESS
• ADDICTION IS NOT A “PEEL OFF”
DIAGNOSIS. WE GROW INTO
ADDICTION. IT IS THE RESULT OF
THOUSANDS OF SMALL CHOICES
MADE OVER TIME. IT BECOMES
PART OF WHO AND WHAT WE ARE.
TO GET IN RECOVERY TAKES
THOUSANDS OF SMALL CHOICES
OVER TIME FOR RECOVERY. WE
HAVE TO GROW OUT OF ADDICTION
INTO RECOVERY.
CRITERIA FOR STUDY OF OPIATE
SUBSTITUTION
1. TWO OR MORE FAILED TREATMENTS
2. DRUG OF CHOICE WAS HEROIN (MAINLY
IV) OR OXYCODONE OR HYDROCODONE
EQUIVALENT TO 100MG OF HYDROCODONE
PER DAY
3. COMMITMENT TO STAY IN HALFWAY
HOUSE AND IOP AFTER RESIDENTIAL
TREATMENT AND THEN RESIDE IN LOCAL
AREA THRU ONE YEAR FROM ADMISSION
CRITERIA FOR STUDY USING
OPIOD SUBSTITUTION THERAPY
4. SIGNED UNDERSTANDING OF SIDE
EFFECTS INCLUDING PHYSICAL
DEPENDENCE
5. SIGNED AGREEMENT THAT
SHOULD THEY LEAVE WE WOULD NOT
CONTINUE TO PRESCRIBE SUBOXONE
FOR THEM AND THEY WOULD BE
RESPONSIBLE FOR FOLLOW UP
CRITERIA FOR STUDY USING
OPIOD SUBSTITUTION THERAPY
6. IF THEY WERE THERAPEUTICALLY
DISCHARGED WE WOULD NOT BE
RESPONSIBLE FOR FOLLOW UP
7. THEY WOULD GET ONE WARNING ON
BEHAVIORAL ISSUES AND THEN BEHAVIOR
CONTRACT(FAILURE TO KEEP FACILITY RULES
AND GUIDELINES AS PUBLISHED AND SIGNED
OFF ON IN PATIENT HANDBOOK)
8. ALL ABOVE BEHAVIORAL RULES APPLIED
TO CONTROL GROUP ALSO
CRITERIA FOR STUDY USING
OPIOD SUBSTITUTION THERAPY
9. ALL MEDICAL AND PSYCHIATRIC ISSUES
WOULD BE ADDRESSED WITHOUT REGARD TO
SUBOXONE AND CARE WOULD BE EQUAL
BETWEEN GROUPS
10. ONE PHYSICIAN HANDLED SUBOXONE
DOSING AND ALL PATIENTS WERE GIVEN
REGULAR STAFFING. IT WAS NOT BLINDED.
11. PATIENTS MADE A COMMITMENT NOT TO
TALK ABOUT WHETHER THEY WERE ON
SUBOXONE OR NOT WITH OTHER PATIENTS
ESPECIALLY NOT DOSES(THIS WAS A JOKE!!!)
AGE DISTRIBUTION CONTROL VS SUBOXONE
AGE DISTRIBUTION BY PERCENTAGE
RELAPSE AND LOST TO FOLLOW UP BY AGE
FOR SUBOXONE TREATMENT OF OPIOD
DEPENDENCE
89% (41/46)
RELAPSE AND LOST TO FOLLOW UP BY AGE
FOR SUBOXONE TREATMENT OF OPIOD
DEPENDENCE
BY PERCENTAGE {TOTAL 89% (41/46)}
RELAPSE AND LOST TO FOLLOW UP FOR
SUBOXONE TREATMENT OF OPIOD
DEPENDENCE
BY QUARTER
89%(41/46)
RELAPSE AND LOST TO FOLLOW UP FOR
SUBOXONE TREATMENT OF OPIOD
DEPENDENCE
BY QUARTER
89%(41/46)
RELAPSE AND LOST TO FOLLOW UP BY AGE
FOR CONTROLS WITH OPIOD DEPENDENCE
34% (16/47)
RELAPSE AND LOST TO FOLLOW UP FOR
CONTROLS IN TREATMENT OF OPIOD
DEPENDENCE BY QUARTER
34%(16/47)
RELAPSE AND LOST TO FOLLOW UP FOR
CONTROLS IN TREATMENT OF OPIOD
DEPENDENCE BY QUARTER AND BY
PERCENTAGE
{TOTAL 34%(16/47)}
SOME CONCLUSIONS
•
•
•
13% OF CONTROLS LOST IN FIRST
QUARTER
8% OF SUBOXONE GROUP LOST IN
FIRST QUARTER
PUT OPIOD DEPENDENT PATIENTS ON
LONGER SLOWER DETOX ESPECIALLY
HEROIN AND OXYCODONE
DEPENDING ON QUANTITY USED I.E. 23 WEEKS
SOME CONCLUSIONS
•
PLEASE HEAR THIS IF YOU DON’T
HEAR ANYTHING ELSE. THE 18-25
YEAR OLD AGE GROUP(ENTITLED)
THAT HAS ACCOMPLISHED NOTHING
IN THEIR LIVES BUT DRUG USE AND
SOME SCHOOL ON AND OFF, WHO
HAVE THE EMOTIONAL MATURITY OF
TEEN AGERS DO
“ABYSMALLY”ON SUBOXONE.
•
•
•
SOME CONCLUSIONS
IN SUBOXONE GROUP WE LOST 2/4 IN THE
46-55 AGE GROUP OR 50%
IN THE CONTROL GROUP WE LOST 4/6 IN
THE 46-55 AGE GROUP OR 66%
IF THERE IS A GROUP THAT DOES BETTER
OR AS GOOD AS CONTROLS ON
SUBOXONE, IT IS THE MIDDLE AGED OR
OLDER SOCIALLY STABLE (JOB, FAMILY,
FINANCES, LEGAL, SUPPORT) THAT HAS
BECOME A PRESCRIPTION OPIATE ADDICT
(USUALLY STARTED FOR MEDICAL CAUSE,
MORE WOMEN THAN MEN)
CRITERIA FOR STIMULANT
TREATMENT FOR ADHD
1. TWO INTERVIEWERS, USUALY
PSYCHIATRIST, PSYCHIATRIC NURSE
PRACTIONER, AND/OR PSYCHOLOGIST
AGREE PATIENT HAS DX OF ADHD EITHER
HYPERACTIVE, INATTENTIVE, OR COMBINED
TYPE
2. THERE COULD HAVE BEEN SOME
STIMULANT ABUSE IN THE PAST BUT IT
COULD NOT BE THEIR DRUG OF CHOICE
CRITERIA FOR STIMULANT
TREATMENT FOR ADHD
3. NO MORE THAN 25% OF THOSE
TREATED WITH STIMULANTS COULD
HAVE ABUSED STIMULANTS IN THE
PAST
4. INITIALLY POOR OUTCOMES ON
ADDERALL LEAD US TO SWITCH TO
LONG ACTING PREPARATIONS LIKE
CONCERTA OR PRO DRUG LIKE
VYVANSE
CRITERIA FOR STIMULANT
TREATMENT FOR ADHD
5. ONE PSYCHIATRIST SAW ALL PATIENTS
FOR PROGRESS AND DOSAGE ADJUSTMENTS
6. PATIENTS AGREED TO NOT DISCUSS
DOSAGES, DRUG USED, OR INTERVIEWS WITH
PSYCHIATRIST WITH OTHER PATIENTS.
7. ONE OR MORE FAILED TREATMENTS
CRITERIA FOR STIMULANT
TREATMENT FOR ADHD
8. COMMITMENT TO STAY IN HALFWAY HOUSE AND IOP
AFTER RESIDENTIAL TREATMENT AND THEN RESIDE IN
LOCAL AREA THRU ONE YEAR FROM ADMISSION
9. SIGNED AGREEMENT THAT SHOULD THEY LEAVE WE
WOULD NOT CONTINUE TO PRESCRIBE STIMULANT FOR
THEM AND THEY WOULD BE RESPONSIBLE FOR FOLLOW
UP
10. ONE VERBAL WARNING ON BEHAVIOR PROBLEMS
THEN WRITTEN BEHAVIOR CONTRACT AND THEN
THERAPEUTIC DISCHARGE.
CRITERIA FOR STIMULANT
TREATMENT FOR ADHD
11. ALL PATIENTS HAD ADHD WORK
BOOKS WITH ASSIGNMENTS ON
BEHAVIORAL INTERVENTIONS FOR
ADHD
12. ALL PATIENTS PARTICIPATED IN
SPECIAL ADHD GROUPS LED BY
PYSCHIATRIST AND PYSCHIATRIC
NURSE PRACTIONER
AGE DISTRIBUTION CONTROL VS STIMULANT
AGE DISTRIBUTION CONTROL VS STIMULANT
BY PERCENTAGE
RELAPSE AND LOST TO FOLLOW UP BY AGE
FOR STIMULANT TREATMENT OF ADHD
100%(43/43)
RELAPSE AND LOST TO FOLLOW UP BY AGE
FOR STIMULANT TREATMENT OF ADHD BY
PERCENTAGE
100%(43/43)
RELAPSE AND LOST TO FOLLOW UP FOR
STIMULANT TREATMENT OF ADHD
BY QUARTER
100%(43/43)
RELAPSE AND LOST TO FOLLOW UP FOR
STIMULANT TREATMENT OF ADHD
BY QUARTER AND BY PERCENTAGE
{TOTAL (43/43) 100%}
RELAPSE AND LOST TO FOLLOW UP BY AGE
FOR CONTROLS WITH ADHD
31% (12/39)
RELAPSE AND LOST TO FOLLOW UP BY AGE
FOR CONTROLS WITH ADHD BY PERCENTAGE
31% (12/39)
RELAPSE AND LOST TO FOLLOW UP FOR
CONTROLS IN TREATMENT OF ADHD
BY QUARTER
31% (12/39)
RELAPSE AND LOST TO FOLLOW UP FOR
CONTROLS IN TREATMENT OF ADHD BY
PERCENTAGE BY QUARTER
31% {TOATAL (12/39)}
SOME CONCLUSIONS
• STIMULANT THERAPY WITH CLASS II
STIMULANTS SUCH AS ADDERALL,
CONCERTA, RITALIN(METHYLPHENIDATE),
VYVANSE(DEXEDRINE) FOR ADHD DOES
NOT WORK IN THE FIRST YEAR OF
TREATMENT (PROBABLY NOT EVER) FOR
SUBSTANCE DEPENDENCE. ABOUT 25% OF
THE STIMULANT GROUP HAD ABUSED
STIMULANTS IN THE PAST AND ABOUT 75%
HAD NOT.
SOME CONCLUSIONS
• STRATTERA WAS NOT AVAILABLE
AT TIME OF STUDY
• INTUNIV NOT OUT AT TIME OF
STUDY
• 80-90% OF TREATMENT FOR ADHD
SHOULD BE BEHAVIORAL
• SOME PATIENTS IN CONTROL
GROUP WERE TREATED WITH
BUPROPRION OR CLONIDINE
SOME CONCLUSIONS
• WE HAD A MUCH HIGHER INCIDENCE OF
THERAPEUTIC DISCHARGE FOR
BEHAVIORAL PROBLEMS (FAILURE TO KEEP
RULES AND GUIDELINES) IN THE
STIMULANT GROUP THAN THE CONTROL
GROUP. BOTH HAD EQUALLY SEVERE
ADHD. THIS WAS ESPECIALLY TRUE IN THE
FIRST 3 MONTHS WHICH IS EXACTLY
OPPOSITE OF WHAT WE EXPECTED.