Transcript 0 - THD Internal Medicine Training Program

Ms. Alvarez is a 45 year old Latin-American
female with a history of multiple episodes of
alcoholic pancreatitis. She presents to the
ER complaining of epigastric abdominal pain
and nausea for 2 days. The ER physician
picks up her chart, rolls his eyes after
recognizing her name, and mumbles to
himself in disgust, “Why in the hell is she
here again? What do you want me to
do…why doesn’t she just stop drinking?”
He barges into her room, says a few words,
smashes on her abdomen until she screams,
and rushes out of the room. He orders a
CBC, chem-14 and lipase, and starts IVF.
The lipase is only mildly elevated, but she is
admitted with a diagnosis of pancreatitis. She
tells the hospitalist that she quit drinking 9
months ago, but he does not believe her.
She is made NPO, and given IVF and
morphine prn.
Overnight, her abdominal pain worsens, and
she continues to ask for more pain medicine.
Her nurse reluctantly gives her more
morphine. At the nursing station, she is
referred to as “the alcoholic lady in 742,” and
the nurses talk about how many times they
have taken care of her. When her admitting
physician makes rounds the next morning,
her nurse is annoyed and comments, “This
one kept me up all night.”
He examines the patient, and notes that her
abdomen is much more tender, and she now
has rebound tenderness. Her temperature is
101º and her WBC is 22K. He obtains a CT
of the abdomen and a surgical consult. The
CT shows an inflamed gallbladder with a
surrounding fluid collection. She develops
obvious peritoneal signs, and she is taken to
the operating room. The surgeon finds a
perforated gallbladder.
Points to Ponder….
 All of us have admitted patients with poorly controlled
diabetes mellitus. We pardon their morbid obesity,
poor dietary habits, and noncompliance, and we
continue to treat them with respect. So, why do we
excuse noncompliant diabetics BUT we stigmatize
noncompliant or relapsing patients with substance
abuse disorders?
 How often do we treat the medical complications but
never address the underlying substance abuse
disorder? If it were that simple, writing “stop drinking”
on the discharge sheets would actually work.
Update on Substance Abuse
Disorders
Nilam J. Soni, MD
Overview
1.
2.
3.
4.
5.
6.
Epidemiology
Neurobiology of Addiction
Definitions
Screening for Substance Abuse
Brief Interventions and Motivational Interviewing
Alcohol
a.
b.
7.
Opioids
a.
b.
8.
Inpatient Management
Outpatient Management
Inpatient Management
Outpatient Management
Resources
Epidemiology
Epidemiology
 In 2002, approximately 19.5 million
Americans, or 8.3% of the population ages 12
or older, were current illicit drug users [ 2002 National
Survey on Drug Use and Health (NSDUH), SAMHSA]
 53% of students have tried an illicit drug by
the time they finish high school
 In 2003, 4.5% of 12th graders used Oxycontin
in the past year and 10.5% used Vicodinmaking Vicodin the second-ranked drug after
marijuana (University of Michigan, 2003 Monitoring the Future Study)
Any Illicit Drug Including Inhalants:
Trends in Lifetime Use
(8th, 10th, and 12th Graders)
Percent Who Ever Used
70
65
60
55
50
45
40
35
30
25
20
'91
'92
'93
'94
Twelfth Grade
'95
'96
'97
'98
Tenth Grade
'99
'00
'01
'02
'03
Eighth Grade
Source: Monitoring the Future Study, 2003, NIDA
Mr. and Mrs. Smith come to see you in the
clinic. Mrs. Smith is very angry about her
husband’s drinking, but he doesn’t feel like he
has a problem. His father was an alcoholic,
but Mr. Smith adamantly says, “There is no
way that I am.” Mrs. Smith says, “I think that
he is just weak, mentally that is, and he just
needs to strengthen his will power. After all,
isn’t alcoholism just a matter of will power.”
How would you respond to her?
Neurobiology of
Addiction
(National Institute on Drug Abuse)
Advances in science have revolutionized our
fundamental views of drug abuse and addiction
This is your brain on drugs…..
YELLOW shows
areas of brain
stimulated by
cocaine (striatum)
1-2 Min
3-4
5-6
6-7
7-8
8-9
9-10
10-20
20-30
Disease Model for Drug Addiction
 Genes


CYP 2A6 levels and tobacco dependence
Mu-receptor and heroin addiction
 Environment




Early physical/sexual abuse
Witnessing violence
Stress
Drug availability
 Dopamine and Serotonin Pathways
Dopamine Receptor Levels and Response
to Methamphetamine
Subjects with low
dopamine receptor
levels found
methamphetamine
pleasant while
those with high
dopamine receptor
levels found
methamphetamine
unpleasant
Thus, drugs have
variable effects on
the brain which
determine a
pleasant from an
unpleasant
response.
2.5
unpleasant response
0
pleasant response
Dopamine Pathways
Serotonin Pathways
striatum
frontal
cortex
hippocampus
substantia
nigra/VTA
Functions
•reward
(motivation)
•pleasure, euphoria
•motor function
•compulsion
•perseveration
nucleus
accumbens
raphe
Functions
•mood
•memory
processing
•sleep
•cognition
Accumbens
1100
1000
900
800
700
600
500
400
300
200
100
0
AMPHETAMINE
Accumbens
% of Basal Release
400
DA
DOPAC
HVA
250
1
2
3
4
Time After Amphetamine
NICOTINE
200
Accumbens
Caudate
150
100
0
0
1
2
3 hr
Time After Nicotine
COCAINE
DA
DOPAC
HVA
300
200
100
0
5 hr
% of Basal Release
0
% of Basal Release
% of Basal Release
Effects of Drugs on Dopamine Release
250
0
1
Accumbens
2
3
4
Time After Cocaine
5 hr
MORPHINE
Dose (mg/kg)
0.5
1.0
2.5
10
200
150
100
0
Source: Di Chiara and Imperato
0
1
2
3
4
Time After Morphine
5hr
Development of Addiction
Genetic Predisposition
↓
Environmental Stress
↓
Drug Abuse
(Initiation of drug use, pleasurable experiences, hazardous use)
↓
Drug Addiction
(Neurochemical brain changes, uncontrollable drug use)
Amygdala
Nature Video
Cocaine Video
Anterior Cingulate
Prolonged drug use→ development of pathways that cause
craving
Cocaine Craving
Population (cocaine addicts vs. controls) x Films (cocaine, erotic)
Signal Intensity (AU)
Cingulate
Ant Cing
Cocaine Film
Erotic Film
Controls
IFC
Cocaine Addicts
Garavan et al A .J. Psych 2000
Effects of
Abstinence
Abstinence from
methamphetamine
for 24 months
demonstrated
some recovery,
but not complete
normalization.
Therefore, addicts
are always at risk
for relapse.
[C-11]d-threo-methylphenidate
Normal Control
Methamphetamine Abuser
(1 month detoxification)
Methamphetamine Abuser
(24 month abstinent)
Volkow, N.D. et al., Journal of Neuroscience, 21(23), pp. 9414-9418, December 1, 2001.
Summary
Normal
(at risk)
Drug Use
Addiction
Treatment
Definitions
Spectrum of Substance Use
Substance Use
Disorders
Dependent
Abuse
Hazardous
Low Risk
Abstinence
Drug Abuse
DSM IV Criteria
1 or more adverse effects over 12
months:
1. Recurrent use resulting in failure to fulfill
major role obligations
2. Recurrent use in hazardous situations
3. Recurrent substance-related legal problems
4. Continued use despite interpersonal or
social problems related to use
Drug Dependence
DSM IV Criteria
3 or more in 12 months
Tolerance
Withdrawal
Much time obtaining, using, recovering
Activities given up or reduced
More or longer than intended
Unable to cut down or control
Use despite knowledge of health
consequences
(Preoccupation and compulsion addressed
in 3-7)
1.
2.
3.
4.
5.
6.
7.
What is Addiction?
 Compulsive substance use without medical
purpose in the face of negative consequences
 A different neurobiological state; the addicted
brain is different from the non-addicted brain
 A condition involving activation of the brain’s
mesolimbic dopamine system; a common
denominator in the acute effects of drugs of
abuse
Leshner AI. Science-based views of drug addiction and its treatment. JAMA. 1999;282:1314-1316.
Alcohol Use in Primary Care Setting
Adults > 18
Low-risk
Drinkers
38%
Hazardous
Drinkers 9%
Alcohol
Abuse 8%
Alcohol
Dependent 5%
Abstainers
40%
Manwell, et al, 1997
Case
A 36 year old white male presents to your clinic for the
first time. He reveals that he smoked marijuana
occasionally in high school. Currently, he drinks
“socially” and does not use any drugs. You
investigate his drinking further. He reports drinking a
6-pack with friends on Friday night and 6-pack while
watching sports on Saturday or Sunday. His drinking
has never interfered with his daily activities.
Are his drinking habits consistent with hazardous
drinking, alcohol abuse, or alcohol dependence, OR
is his drinking of no concern?
Screening for
Substance Abuse
Screening for Alcohol Abuse
Alcohol Use
None
Light
Moderate
Heavy
Hazardous
Low Risk
Abuse
Dependent
Severe
Moderate
Small
None
Alcohol Problems
NIAAA Guidelines
 Low risk drinking



Men: < 14 drinks/wk; < 4 drinks/occ
Women:< 7 drinks/wk; < 3 drinks/occ
No use in risky situations
 Hazardous (at risk) drinking


Men: >14 drinks/wk; >4 drinks/occ
Women & over 65:

>7 drinks/wk; >3 drinks/occ
National Institute on Alcohol Abuse and Alcoholism. Physicians’ Guide to
Helping People with Alcohol Problems, 1995,2003
What is a Standard Drink?
1 can of
ordinary
beer or ale
12 oz.
single shot of
spirits, gin,
whiskey,
vodka, etc..
1.5 oz.
glass
of wine
5 oz.
small
glass of
sherry
4 oz.
small
glass of
liqueur
or aperitif
4 oz.
Screening Instruments
Common in Practice
 Quantity & frequency
 CAGE
 AUDIT-C
Other Screens
 MAST (25 items)
 S-MAST
 AUDIT (10 items)
 TWEAK (pregnancy)
 T-ACE (pregnancy)
Piccinelli ‘97, Bradley ‘98, ‘03, Reid ‘99,
Knight ‘01, Isaacson ‘94, Brown ‘95
 CRAFFT (adolescent)
 POSIT (adolescent)
 CAGE-AID (drugs)
CAGE Questions
 Cut down on your drinking?
 Annoyed at others’ criticism of your drinking?
 Guilty about something that happened when
you were drinking?
 Eye-opener (drink 1st thing in the morning)
Cut- off point: > 2 positive
Mayfield, et al; Am J Psychiatry 131:1121-1123, 1974
CAGE > 2 Positive Responses
 Sensitivity 77 - 94%
Limitations:
 Specificity 76 - 96%
 Lifetime use
 Positive predictive
 More reliable for alcohol
value: 55-75%,
assuming 20%
prevalence
abuse and dependence
 Not as sensitive for:



women
elderly
African-Americans
Summary of Screening
ASK about alcohol use
CAGE
consumption (per week, per occasion)
if >14 drinks/week or >4/occasion (men)
>7/week or >3/occasion (women)
or
CAGE 1 or more
ASSESS for alcohol-related problems
medical, behavioral, social
alcohol dependence
alcohol-related problems
at risk for developing problems
Summary of Screening
alcohol dependence
alcohol-related problems
at risk for developing problems
advise to abstain
refer to a specialist
advise to cut down
set a drinking goal
Monitor patient progress
Detection Time in Urine
 1-3 days

marijuana, heroin, cocaine, codeine, morphine
 2-4 days

Amphetamine, methamphetamine, shortacting barbiturates, methadone
 Up to 30 days


chronic marijuana or PCP use
long-acting benzodiazepines
Case
A 36 year old white male present to your clinic for the
first time. He reveals that he smoked marijuana
occasionally in high school. Currently, he drinks
“socially” and does not use any drugs. You
investigate his drinking further. He reports drinking a
6-pack with friends on Friday night and a 6-pack
while watching sports on Saturday or Sunday. His
drinking has never interfered with his daily activities.
Are his drinking habits consistent with hazardous
drinking, alcohol abuse, or alcohol dependence, OR
is his drinking of no concern?
Brief Interventions and
Motivational Interviewing
Readiness to Change Model
Precontemplation
Contemplation
Relapse
Determination
Maintenance
Action
Motivational Interviewing
Motivational interviewing is a
directive, client-centered counseling
style for eliciting behavior change by
helping clients explore and resolve
ambivalence.
Stephen Rollnick, William R. Miller, 1995
Rollnick, S., & Miller, W. R. What is motivational interviewing? Behavioral and Cognitive
Psychotherapy. 1995;23:325-334.
Motivational Interviewing
Techniques
 Develop discrepancy
 Avoid argumentation
 Role with Resistance
 Express Empathy
 Support Self-efficacy
Miller WR, Rollnick S, Conforti K. Motivational Interviewing, Second Edition: Preparing People for
Change. New York: Guilford Press; 2002.
Brief Intervention
 5-15 minute counseling session
 Four components




State your concerns about patient’s use of
alcohol/drugs
Make explicit recommendation for change in
behavior
Discuss patient’s reaction
Review treatment options; negotiate plan
Case
A 42 year old Navajo male is brought by EMS to
the ER with altered mental status. He ended
a 7-day alcohol binge 1 day ago. His blood
alcohol level is negligible, and he is admitted
for alcohol withdrawal. He is given 4mg of
lorazepam IV in the ER followed by 2mg upon
arrival to the floor. He receives scheduled
lorazepam, 2mg IV every 6 hours. Over the
next 12-16 hours, he becomes progressively
more agitated. His nurse calls you, and you
give him a booster of lorazepam 4mg IV.
Case
She calls you back in 1 hr and tells you that he
is still very agitated with a pulse of 140 bpm
and BP of 185/100. You give him an
additional 4mg of lorazepam. The nurse calls
you after 30min and says that he is “out-ofcontrol.” He is pulling fiercely at his
restraints, screaming, and complaining of
insects on the wall, and his BP and pulse are
still elevated. You give him 4mg more of
lorazepam, but he does not improve.
What should you do next?
Management of
Alcohol Abuse
Inpatient and Outpatient Management
Alcohol Withdrawal
 Onset 5-10 hrs, peak 2-3 days, resolve 4-5 days
 Signs and symptoms ( ≥ 2 by DSM IV criteria)
 Autonomic hyperactivity (sweating, tachycardia, ↑ BP)
 Tremor
 Nausea/vomiting
 Anxiety
 Psychomotor agitation
 Anxiety
 Grand mal seizures
 Hallucinations (tactile, visual, auditory)
Management of Alcohol Withdrawal
ASAM Guidelines
 Symptom-triggered (q1h when severe)



Chlordiazepoxide 50-100 mg
Diazepam 10-20 mg
Lorazepam 2-4 mg
 Fixed Schedule (q6h for 4/8 doses + prn)



Chlordiazepoxide 50mg/25mg
Diazepam 10mg/5mg
Lorazepam 2mg/1mg
Mayo-Smith and ASAM working group JAMA 1997;278:144-51
Saitz and O’Malley Med Clin N A 1997;81:881-907
Management of Alcohol Abuse or
Addiction (Inpatient or Outpatient)
1. Detoxification (inpatient vs. outpatient)
2. Social Services (psychological, medical,
3.
4.
5.
6.
employment, and legal problems)
Removal from drinking environment
Mutual/self-help groups (AA, NA, cocaine
anonymous, etc.)
Counseling (cognitive-behavioral, family,
psychotherapy,etc.)
Pharmacotherapy
Disulfiram
 Relevant mechanism
 Inhibits ALDH allowing acetaldehyde to accumulate
 Desired effects (take qd or before risky situation)
 Flushing, tachycardia, nausea, vomiting, hypotension,
blurred vision, confusion, dizziness (30 minutes)
 Side effects
 Lethargy, neuropathy, liver toxicity, psychosis, HTN
Disulfiram (DS)
 Multicenter RCT, 12 month follow-up, N=605
 DS 250 mg, 1 mg, or none
 More abstinence in those adherent to DS (43% vs.
8%, p<0.001)
 Fewer drinking days in the 162 who were assigned to
DS, adhered, and completed follow-up, compared
with the other 2 groups (p=0.05)
***Need supervised administration and involvement of
counselor***
Fuller RK et al. JAMA 256:1449, 1986
Supervised Disulfiram: randomized studies
Author,
Year
Followup
Disulfiram
Abstinence
Gerrein,
‘73
85%
39%
Supervised
Unsupervised
40 %
7%
Azrin,1976
90%
Supervised
Unsupervised
90-98 %
55 %
Azrin,1982
100%
Supervised
Unsupervised
73% *
47% *
Liebson,’78
78%
Supervised
Unsupervised
98%
79%
Length of follow-up was as follows: Gerrein 1973: 8 weeks; Azrin 1976: 2 years, Azrin
1982: 6 months; Liebson 1978: 6 months. * Thirty-day abstinence at 6-months
Naltrexone
 Relevant mechanism
 Blocks endogenous opioids release due to dopamine
release in reward center
 Desired Effects
 Less pleasurable effect of alcohol, reinforcement
 Side Effects
 Nausea, dizziness, hepatotoxicity, difficult pain
management
 Contraindications
 Opiate dependence, pregnancy, active liver disease
Naltrexone for Alcohol Dependence
Combined analysis from Volpicelli (1992) and O’Malley’s (1992) studies, N=186. Taken from
O'Brien CP, McLellan AT. Lancet 1996;347:237-240.
Naltrexone: Initial and
Maintenance Treatment
STUDY 1: Initial Naltrexone Treatment
Randomized (n = 197)
10 weeks
Received CBT + NTX
(n = 97)
STUDY 2. CBT Naltrexone Maintenance
Responders randomized (n = 60)
24 weeks
Received CBT +
NTX (n = 30)
Received PCM + NTX
(n = 93)
STUDY 3. PCM Naltrexone Maintenance
Responders randomized (n = 53)
24 weeks
Received CBT + PLA
Received PCM + NX
Received PCM + PLA
(n = 30)
(n = 26)
(n = 27)
O'Malley SS et al. Arch Intern Med 2003;163:1695 - 1704.
Naltrexone: Initial and
Maintenance Treatment
CBT
(n=97)
PCM
(n=93)
Primary Outcomes
Responder (n, %)
Percentage of days abstinent
77 (79.4%)
79.9 + 31.4
74 (79.6%)
77.9 + 30.9
3.3 + 5.6
60 (61.9%)
43 (44.3%)
3.3 + 4.7
52 (55.9%)
31 (33.3%)
-43.1 + 75.3
-37.9 + 65.7
8.0 + 5.4
8.2 + 5.8
Secondary Outcomes
Drinks per drinking day
No relapse to heavy drinking
Continuous Abstinence (n, %)
GGT end point change
from baseline (mean + SD)
OCDS total score
Therapy (mean + SD)
Acamprosate
 Relevant mechanism: unclear; GABA
analogue
 Desired effects: unclear
 Side effects: diarrhea
 Increased abstinence, decreased drinking
days
 Not available (yet) in the US
Management of Opioid
Abuse and Addiction
Inpatient and Outpatient Management
Opioids
Natural (opiates),
Semisynthetic,
and synthetic
Opioid Intoxication
 Altered level of consciousness
 Respiratory rate <12 breaths per minute
 Direct effect on brainstem respiratory center
 Reduction of responsiveness to CO2
 Miotic pupils
 Response to naloxone
Opioid Overdose Treatment
 Adequate ventilation

Observation until normal level of consciousness
 Inadequate ventilation

Ventilate with 100% O2

Naloxone 0.2-0.4 mg IV, SQ, or IM, repeat with 1-2 mg if
no improvement in 5-7 minutes

Observe for 2-3 hours for complications or re-sedation

3-7% complicated by pneumonia, pulm edema
 No prospective clinical trials comparing IV vs IM vs. SQ
or different doses
Opioid Overdose Treatment
 Higher doses may be required for semi-synthetic oral
opioids
 Small rate (6 of 453 patients) of complications with
naloxone treatment*

Seizure, arrhythmias, pulmonary edema and severe
agitation with violent behavior

All complications occurred within 10 minutes
 Complication rate similar to flumazenil treatment for
benzodiazepine overdose
Osterwalder JJ. J Toxicol Clin Tox 1996
Naloxone
 Opioid antagonist at mu, kappa and delta receptors
 No agonist activity
 Absorbed IV, IM, SQ and endotracheal
 Rapid onset IV but offset by time to place IV
 Orally inactivated by hepatic metabolism
 Highly lipid soluble

Onset of action: 1-2 minutes

Peak Action: 15 minutes

Duration of action: 45-90 minutes
Opioid Withdrawal
Hours Grade
after use
4-6
6
8-12
12-72
Symptoms / Signs
0
Anxiety, Drug Craving
1
Yawning, Sweating, Runny nose, Tearing eyes, Restlessness
Insomnia
2
Dilated pupils, Gooseflesh, Muscle twitching & shaking, Muscle &
Joint aches, Loss of appetite
3
Nausea, extreme restlessness, elevated blood pressure, Heart
rate > 100, Fever
4
Vomiting / dehydration, Diarrhea, Abdominal cramps, Curled-up
body position
Short-term Treatment
 Methadone
or buprenorphine (more expensive)
 Other
Clonidine (hyperadrenergic state)
+ NSAIDS (muscle cramps and pain)
+ Benzodiazepines (insomnia)
+ Dicyclomine (abdominal cramps)
+ Bismuth subsalicylate (Diarrhea)
Heroin versus Methadone
Methadone Hydrochloride
 Full opioid agonist available in tablets, oral
solution, parenteral
 PO onset of action 30-60 minutes
 Duration of action


24-36 hours to prevent opioid withdrawal
6-8 hours analgesia*
 Proper dosing
 Acute withdrawal 20-40 mg
 Chronic withdrawal >80 mg
Inpatient Methadone Dosing Guidelines
 Start with 20 mg of methadone
 Reassess q 2-3 hours, give additional 5-10 mg
until withdrawal signs abate
 Do not exceed 40 mg in 24 hours
 Monitor for CNS and respiratory depression
Inpatient Methadone Dosing Guidelines
 On following day, give total dose QD
 20 - 40mg QD
 10 - 20 mg q12
 Goal is to alleviate acute withdrawal
 Patient will continue to crave heroin
 **Referral for long-term substance abuse treatment**
 Allows 24-36 hour withdrawal-free period after
discharge
Long-term Goals
 Detoxification Program (<15% success)
 Medically supervised withdrawal, a tapering of
an approved drug to a medication-free state.
 Maintenance Program
 Sustained administration of an approved
opioid medication at stable doses
 Residential Program
 Outpatient counseling
 Narcotics Anonymous (NA)
Maintenance Programs
1. Methadone Maintenance Program
2. Buprenorphine and Buprenorphine/Naloxone
Treatment Program
3. Naltrexone
Methadone Maintenance Treatment
 Daily methadone dosing
 Daily nursing assessment
 Weekly individual and/or group counseling
 Random supervised toxicology screens
 Psychiatric services
 Medical services
 Acupuncture
Methadone Effect
 Methadone 20-40 mg

Treats acute withdrawal
 Methadone >80 mg

Treats chronic withdrawal (craving, insomnia)

Blocks effects of other opioids (e.g. heroin)
Methadone Dose Response
Acute w/d
Chronic w/d
MMT: Decrease Drug Use Over Time
MMT: Relapse After Leaving Treatment
Methadone Maintenance Treatment
The “Gold” Standard
 In a Comprehensive Rehabilitation Program…







Improves overall survival
Increases retention in treatment
Decreases illicit opioid use
Decreases seroconversion of hepatitis and HIV
Decreases criminal activity
Increases employment
Improves birth outcomes
Buprenorphine Treatment Program
 Partial agonist

Ceiling effect on respiratory and CNS
depression
 Antagonizes effect to full agonists
Buprenorphine Treatment Program
 Retention rates comparable to methadone
 Efficacy comparable to methadone (80mg)
 Milder withdrawal syndrome
 Very low risk for overdose
 Decreased risk of abuse and diversion
(Buprenorphine/Naloxone)
 Available in Primary Care Settings
Buprenorphine Precipitated Withdrawal
 Displaces a full agonist off the mu receptors
 Buprenorphine only partially activates receptors
 Net decrease in activation occurs and withdrawal
develops (must be in withdrawal to start)
100
90
80
70
Full Agonist (e.g. heroin)
A Net Decrease in Receptor Activity if
a Partial Agonist displaces Full Agonist
60
%
50
Mu Receptor
Intrinsic 40
Activity 30
20
10
0
Partial Agonist (e.g. buprenorphine)
no drug
low dose
DRUG DOSE
high dose
Naltrexone
 Opioid antagonist
 Low interest among “street addicts”
 No better than placebo except in highly motivated
patients
 Impaired physicians > 80% abstinence at 18
months
Resources
Resources
Resources
 National Institute on Drug Abuse


www.nida.nih.gov
www.drugabuse.gov
 Presbyterian Hospital MHMR


Inpatient and outpatient treatment programs
Pat Tally (214) 345-7196
 Greater Dallas Council on Drug and Alcohol
Abuse

(214) 522-8600