Transcript Pharmacological Issues in Treatment of Co

Addicted, Crazy or Both?
Now What?
Dual Diagnosis in the CD Patient
Mark Menestrina, MD, FASAM
Brighton Hospital / SEMCA
[email protected]
Michigan Judges’ MI 8/2011
Part 1 (the “teaser”)
Addiction Review
 Classification of Mental Disorders
 Review of Common Disorders
Association of Mental Health Disorders
with SUDs


Part 2


Review of Selected Classes of Psychiatric
Medications
 Pharmacology for Recovery
Safe Prescribing for Individuals with SUDs
Addiction Review
WE LIVE IN A MAGICAL
THINKING MEDICATION
SEEKING SOCIETY
USA is 4.7% of the World Population
But we consume almost 50% of the World’s
Drugs and most of the World’s Pain
Medication
Media / TV / Radio flood us with messages…
We are taught not to tolerate any discomfort
without taking something to feel better
ADDICTION IS A BRAIN
CHEMISTRY DISEASE








Involves the Meso-Limbic System (Primitive)
Neurotransmitter Mediated (Not Conscious)
Denial is a Hallmark Feature
Emotional, Physical, Psychological
Chronic, Progressive, potentially Fatal
Affects Family, Community, Society and Schools
~10% are susceptible to Addiction…Treatable Disease
Different than Abuse, anyone can Abuse Drugs or
Alcohol.…Preventable Behavior
IT’S NOT REALLY A
DISEASE…IS IT?





1956 AMA designates Alcoholism as a disease,
Drug Addiction as a disease followed
“But you have a choice”
Like depression 30 years ago, or oncology 40
years ago
Compare to other Chronic Diseases
When we do treat Addiction, we do so Acutely,
and wonder why we have poor results
Can you find the (alleged) future
alcoholic?
12
LACK OF WILLPOWER?
13
IF ADDICTION /
CHEMICAL DEPENDENCE
IS TRULY A
DISEASE….WHY DON’T WE
TREAT IT AS SUCH?
Leading Causes of Death
Data for the U.S. 2007
Age 25-44
Age 15-24
Injury
Cancer
Heart Disease
Suicide
Homicide
HIV
Liver Disease
Stroke
Diabetes
Injury
Homicide
Suicide
Cancer
Heart Disease
Congenital
Stroke
Diabetes
Google:
Alcoholism +
Humor
ADDICTION vs. ABUSE

ALCOHOLISM,
DRUG ADDICTION,
CHEMICAL
DEPENDENCE

A TREATABLE
DISEASE

DRUG ABUSE,
ALCOHOL ABUSE

A PREVENTABLE
BEHAVIOR
THE NEW GATEWAY FOR
MANY YOUNG PEOPLE…
ADDICTION TREATMENT
MADE EASY…. “A” to “B”
NEGATIVE
Consequences: The
job, liver, judge, wife,
boss, friend get the
individual’s attention!
POSITIVE
Reinforcement: The
individual actually
begins to like and
enjoy “recovery”
While this process is achievable, it is not likely to all make sense
to the patient. It may involve 12 step, counseling, treatment of
co-morbid conditions, Medication Assisted Treatments and
other modalities.
HOW TO SPOT A
HUNTER WITH A DUI
CONVICTION….
Co-Occurring Disorders
Psychiatric Illness & Addiction
Generalizations
Both are common problems
Having one increases the risk for having the other
Having one complicates the treatment of the other
when both are present
“Dual Diagnosis” cases are over represented
among homeless and incarcerated
“Dual Diagnosis” have increased risk of HIV and
other serious medical conditions
Classification of Mental
Disorders…DSM-IV-TR



The official classification system of psychiatric
conditions in use in the USA
Criteria in DSM are used to facilitate
communication among professionals, for research
standards, and for 3rd party payor communication
DSM- A mental disorder is a disorder with
significant behavioral or psychological symptoms
associated with present distress, disability or
increased risk of suffering death, pain, disability or
loss of freedom
THE 5 AXES OF DSM





I.
II.
CLINICAL DISORDERS
PERSONALITY DISORDERS and
MENTAL RETARDATION
III. GENERAL MEDICAL CONDITIONS
IV. PSYCHOSOCIAL AND
ENVIORNMENTAL PROBLEMS
V. GAF (Global Assessment of Functioning)
ASAM DIMENSIONS
I.
ACUTE INTOXICATION OR
WITHDRAWAL POTENTIAL
II.
BIOMEDICAL CONDITIONS
III. EMOTIONAL, BEHAVIORAL OR
COGNITIVE CONDITIONS
IV. READINESS TO CHANGE
V. RELAPSE POTENTIAL
VI. RECOVERY/LIVING ENVIORNMENT
DSM at Work…(or not!)
Major Depressive Episode
A.
Five (or more) of the following symptoms have
been present during the same 2-week period and
represent a change from previous functioning; at
least one of the symptoms is either (1) depressed
mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly
due to a general medical condition, or moodincongruent delusions or hallucinations
MD…continued
(1) Depressed mood most of the day, nearly every
day, as indicated by either subjective report (e.g.,
feels sad or empty) or observation made by
others (e.g., appears tearful) Note: In children
and adolescents, can be irritable mood.
(2) Markedly diminished interest or pleasure in
all, or almost all, activities most of the day, nearly
every day (as indicated by either subjective
account or observation made by others)
MD…continued
(3) Significant weight loss when not dieting or
weight gain (e.g., a change of more than 5% of
body weight in a month), or decrease or increase in
appetite nearly every day. Note: In children,
consider failure to make expected weight gains.
(4) Insomnia or hypersomnia nearly every day
(5) Psychomotor agitation or retardation nearly
every day (observable by others, not merely
subjective feelings of restlessness or being slowed
down)
MD…continued
(6) Fatigue or loss of energy nearly every day
(7) Feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or guilt
about being sick)
(8) Diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by
subjective account or as observed by others
MD…continued
(9) Recurrent thoughts of death (not just fear of
dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific
plan for committing suicide.
B.
C.
The symptoms do not meet criteria for a Mixed
Episode (see p. 171)
The symptoms cause clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
MD…continued
D.
E.
The symptoms are not due to the direct
physiological effects of a substance (e.g., a drug
of abuse, a medication) or a general medical
condition (e.g., hypothyroidism)
The symptoms are not better accounted for by
Bereavement, i.e., after the loss of a loved one,
the symptoms persist for longer than 2 months or
are characterized by marked functional
impairment, morbid preoccupation with
worthlessness, suicidal ideation, psychotic
symptoms, or psychomotor retardation.
MD…diagnosis in the real world

S
I
G
E
C
A
P
S
Depressed mood plus….
sleep disturbance
loss of interest or pleasure (anhedonia)
feelings of guilt or worthlessness
low energy
poor concentration or memory
appetite disturbance
psychomotor agitation or retardation
suicidal ideation
REMEMBER THAT DSM
CRITERIA ARE HELPFUL
GUIDELINES…..BUT WE ALL
HAVE A LITTLE (OR A LOT)
IN EACH OF US!!!
REVIEW OF COMMON
DISORDERS







SCHIZOPHRENIA
AFFECTIVE DISORDERS
ANXIETY DISORDERS (including PTSD)
PERSONALITY DISORDERS
ATTENTION DEFICIT
HYPERACTIVITY
EATING DISORDERS
SUBSTANCE RELATED DISORDERS
SCHIZOPHRENIA





Complex illness, characterized by hallucinations,
delusions, behavioral disturbances, disrupted
social functioning, disorganized speech and
‘negative symptoms’
0.5-1% Prevalence
Violent acts no more frequent than the general
population
Reduced life expectancy, 40% attempt suicide, 1020% succeed
Treatment antipsychotic medications
AFFECTIVE DISORDERS~
MOOD DISORDERS
DEPRESSION: common, often missed, not
hard to diagnose when you look for it, often
severe, often recurrent, costly and highly
treatable
 BIPOLAR DISORDERS ~ Depression with
episodes of elevated mood
BIPOLAR I= with at least one manic
episode
BIPOLAR II= with hypomanic episodes

Affective Disorders
DIAGNOSIS
CRITERIA
MDD
Severe Sx, >5 Sx, > 2 Wks
DYSTHYMIA
BIPOLAR I
Less severe, more
persistent
Mania and Depression
BIPOLAR II
Hypomania, Depression?
CYCLOTHYMIA
Less severe, more
persistent
Consequence of Use or
w/d
SUBSTANCEINDUCED
ANXIETY DISORDERS






GENERALIZED ANXIETY DISORDER
SOCIAL PHOBIA
SIMPLE PHOBIAS
PANIC DISORDER
AGORAPHOBIA
PTSD
PERSONALITY DISORDERS
CLUSTER
DESCRIPTION
A
Odd/Eccentric
DISORDERS
Paranoid/Schizoid/
Schizotypal
B
Dramatic/Erratic Antisocial/Borderline/
Histrionic/Narcissistic
C
Anxious/Fearful
Avoidant/Dependent/
Obsessive-Compulsive
ADHD



Inattention, hyperactivity, impulsivity
ADHD does associate with higher risk for
SUDs, but this may be limited to those with
coexisting conduct or bipolar disorder
Treating ADHD with stimulants actually
appears to be associated with a decreased
risk of developing a subsequent SUD
EATING DISORDERS





ANOREXIA: often severely restrict caloric intake
or excessively exercise, are underweight
BULEMIA: often alternate eating with starvation
or purging, are usually normal weight
Both groups may abuse appetite suppressants,
diuretics or laxatives
BULEMICS appear to be at risk for SUDs
One study found ANOREXICS to be at lower risk
for SUDs
SUBSTANCE INDUCED
DISORDERS



These disorders mimic other psychiatric
disorders, but they are in fact caused,
directly or indirectly, by use of substances
This is a tremendous source of
misdiagnosis, and results in ineffective
treatment of the substance disorder
We live in a society where it is more socially
acceptable to be mentally ill than chemically
dependent
Diagnoses Associated with Class of
Substances…..DSM-IV-TR
Depend
Abuse
Intox
W/D
Alcohol
+
+
+
+
Amphetamines
+
+
+
+
Cannabis
+
+
+
Cocaine
+
+
+
+
Opioids
+
+
+
+
Sedatives
+
+
+
+
Substance Induced Mental Disorders
Organic Brain Syndromes
SI Delirium
SI Persisting Dementia
SI Amnestic Disorder
Mimic Axis I Disorders
SI Psychotic Disorder
SI Mood Disorder
SI Anxiety Disorder

Hallucinogen
Persisting Perceptual
Disorder

SI Sexual Dysfunction

SI Sleep Disorder
ASSOCIATION OF MENTAL
DISORDERS WITH SUDs
SUDs include
ADDICTION: a treatable disease
ABUSE: a preventable behavior
2003 National Survey of Drug
Use and Health (NSDUH)

21.3% of Adults with Serious Mental Illness
(SMI) had a Substance Use Disorder (SUD)

7.9% of Adults without SMI had a SUD
Nicotine and Mental Illness
Grant, B.F. et al, 2004
12 MONTH
ODDS RATIO
PREVALENCE
MOOD
DISORDER
21%
3.3
ANXIETY
DISORDER
22%
2.7
PERSONALITY
DISORDER
32%
3.3
Serious Mental Illness and Its CoOccurrence with Substance Use
Disorders, 2002
Epstein, Barker, Vorburger and Murtha, 2004
SAMHSA.GOV
17.5 million Adults with SMI (Serious
Mental Illness) 8.3% of population



18-25yo 13.2%
26-49yo 9.5%
>50yo
4.9%

28.9% used illicit drug/yr

Illicit drug/yr 17.1%
No drug/yr 6.9%





Female
Male
10.5%
6.0%
>1 race 13.6%
Nat Am 12.5%

SMI did not vary by past
year alcohol use

‘Heavy” alcohol/mo 11.1%
vs. 8.1%

Co-Occurrence of SMI & SUD
33.2 million SMI or SUD
13.4 million (40.4%) SMI
15.5 million (47.4%) SUD
4.0 million (12.2%) SMI + SUD
SMI
Both Disorders: 23.2% of
20.4% of SUD
Rates of SMI…….
Without any SUD
7.0%
Alcohol Dependence or Abuse
19.0%
Illicit Drug Dependence or Abuse
29.1%
Alcohol and Drug Use Disorder
30.1%
Lifetime SUD Among Persons with
Mental Disorders….Regier et al, 1990
MENTAL
DISORDER
schizophrenia
LIFETIME
PREV
1.5%
LIFETIME
PREV SUD
47.0%
ODDS
RATIO
antisocial p.d.
2.6%
83.6%
29.6
anxiety disorders
14.6%
23.7%
1.7
OCD
2.5%
32.8%
2.5
affective disorders
8.3%
32.0%
2.6
any disorder
16.2%
28.9%
2.7
4.6
Why the Association??




Common Risk Factors & Etiologies, genetic
or environmental
Addiction might lead to Mental Illness
Psychiatric Illness might lead to
Addiction…the “Self-Treating Hypothesis”
Self-Limiting Acute Effects of a Substance
(or withdrawal from it) may be mistaken for
a psychiatric illness
Affective Disorders…Association
with SUD Regier et.al. 1990
SMI
SUD
ODDS RATIO
Any Affective
Alcohol
1.9
Any Affective
Cocaine
5.9
Any Affective
Opiates
5.0
Any Affective
Barbiturates
6.6
Any Affective
Hallucinogens
5.9
Bipolar Disorder
Any SUD
6.6
Unipolar d/o
Any SUD
1.9
Summary Points






Co-Occurring Disorders are Common
May be difficult to differentiate from Substance
Induced Disorders
Consider “Watchful Waiting” in less definite cases
when degree of impairment is not as severe
Treatment is often Challenging
Both Disorders need to be addressed when both
are truly present
May be “Road Blocked” by Insurance/Funding
Sources
“NEVER DOUBT THAT A
SMALL GROUP OF
DEDICATED CITIZENS CAN
CHANGE THE
WORLD…INDEED IT IS THE
ONLY THING THAT EVER
HAS”
Margaret Meade