Transcript File - Treatment for Addiction & Psychiatric Disorders

Specific Program Issues
Young Adult Addiction
Young Adult Psychiatric
Chronic Disease
• 90 % have had at least 3 interventions.
• 95% have a life long psychiatric or addictive
•
disease.
• Three stages of treatment
Inpatient - Acute stabilization
PHP/IOP - Acceptance and Surrender
Outpatient - Integration and Maintenance
• “First Things First” – Many exceptions to the
rule
Young Adult Addiction
• Once the addict discovers that using a
substance provides pleasure, he has set up a
Biological Conditioned Response.
• Any unpleasant or boring situation - he can
get immediate relief.
• This response overrides any concerns about
the consequences of using this substance
(driving intoxicated, unsafe sex, stealing)
Genetically Prewired
• 10 to 15 percent of the general population meet the
criteria for substance abuse and dependence
• You have to be genetically prewired to drink a fifth of
vodka a day or to be mentally organized, motivated,
and alert on 120mg of Roxycodone per day.
• 18 to 25% of young adults meet the criteria for a
substance use disorder
• Frequent excessive binges in order to deal with
anxiety or depression may be the reason for the
increase but there are other factors
Genetics
• In order to have an addiction you have to have
an assortment of genes very much like playing
a slot machine.
• Three cherries or three sevens (777) are
necessary to hit the jackpot.
• Addiction may skip a generation
• Addiction may be generalized or very specific
such as Polysubstance Dependence or a
specific substance such as Alcoholism
Environmental Factors
Environment Affects the
Expression of the Addiction Genes
• Studies point out that children of alcoholics
who are “genetically prewired” to be an
alcoholic have a lower incidence of being an
alcoholic.
• Unfortunately, the grandchildren have a
higher incidence of active addiction than their
parents.
Grandfathers
• Alfred died 66yo - Alcoholic
• Jack died 54 yo - Alcoholic
• Albert alive at 95 yo – Not Alcoholic
The Parents
Child
Addiction is a Medical Disorder
• the Limbic System does not care about
consequences of actions.
• Its only purpose is to respond to a negative
stimulus before you have time to think.
• The Cortex is that part of our brain that
remembers all past consequences of
behaviors.
• Its purpose is to assess the risk by reviewing
what you have learned before you act.
Immaturity and Impulsivity
• Drugs and alcohol used in high doses
disconnect the cortex from the Limbic system
• The limbic system is totally developed by the
age of 18 yo but the cortex is still maturing
until 25 yo.
• The young adult who is genetically prewired to
be an addict and is active in his addiction, has
limited impulse control for multiple reasons.
• He is an accident ready to happen.
“Imprinting”
• Most opiate addicts can tell you the first time
they experienced their first opiate.
• It takes one pill for the limbic system to
choose opiates as the answer to all problems.
• It takes a year to replace it with recovery.
• The limbic system is the source of primitive
drives and it is in the driver’s seat for an
addicted young adult. The cortex is in the
back seat making suggestions.
Better Opiates for Pain
• Oxycontin in the 90’s was a tremendous
advancement as a more effective pain
medication with less side effects.
• Availability of opiates dramatically increased
giving chronic pain suffers relief.
• As the street price of these drugs have
increased, it is cheaper to use heroin.
• Heroin has become more available with the
increase demand.
Opiate Epidemic
• Dramatic increase in the # of young adults out of
work, not married, unemployed, living with their
parents, loss of purpose.
• Opiates readily available which gives a sense of
wellbeing and stops all worries for 8% of population.
• Young adults with time on their hands plus opiates =
an epidemic
• Over past 10 years opiate use has increased
multifold.
Opiate Dependency is a Lethal
Disease
• 8 patients died after discharge from the
program from 2009 through 2014
• All had diagnosis of Opioid Dependence
• One had done very well in the program and
completed the program and went to a ¾ way
house
• 7 left the program before recommended,
referred to extended care programs, or were
administratively discharged
The Other Drugs
•
•
•
•
•
•
•
•
Marijuana
The Sedatives – Xanax, Klonopin
Alcohol
The Stimulants – Adderall, Cocaine, Meth
MDMA (molly, ecstasy)
The Synthetics – Spice, Bath Salts
Others – DM, Triple C’s, shrooms, LSD
The Dissociatives – PCP, Ketamine
Withdrawal
• Acute Withdrawal Syndrome (3 to 7 days)
- Primary – Alcohol, Benzodiazepines, Opiates
- Other – Marijuana, Stimulants, Ecstasy
Post Acute Withdrawal Syndrome(1 to 6months)
- Sleep, limited Frustration tolerance, anxiety,
depression, cravings, high relapse potential,
“I am never going to feel good again!”
Relapse
• Relapse as a concept
Patients have many relapses in terms of going
back to old addictive behaviors before they
relapse on their substance
• Relapse on the addictive drug
-First use initiates the cravings
-Second use solidifies it
-Third use is large amount – OD and death
• After a relapse do not keep it a secret,
“What are you going to do about it!”
Special Treatment Considerations
Naltrexone and Vivitrol – Opiate and Alcohol
-Cravings
-Minimize Relapse
-Dedication to the recovery process
Klonopin and Xanax
-Withdrawal Seizures – Depakote
-Probable Anxiety Disorder
Chronic Pain
- Cymbalta, Neurontin, Lyrica, Muscle Relax
Eating Disorder – “Dual Diagnosis” Tract
-Bulimia – The substance addiction cannot be
treated unless you are treating the Bulimia
Sexual Addiction
- Multiple sexual encounters
- Pornography/Internet
Post Traumatic Stress Disorder - ? 20%
- <10% Dissociative
Marijuana
• Arrested Development - #1 cause is Marijuana
1 – Social, emotional, and spiritual
2 – Ego development has “pieces” missing
3 – Partially adult and partially adolescent
• Many patients have been using daily for 3 to 5
years.
• You do not have to be genetically prewired to
be a daily user.
• Makes psych problems worse and is
dangerous while in intensive treatment.
Psychiatric Disorder is #1 Relapse
Risk Factor
• 90% of the Addictive patients have a separate
Psychiatric Disorder
• Anxiety is the largest disorder followed by
Depression
• 90% of the addiction patients do not have a
Personality Disorder
• 90% of the patients that say they have ADHD
do not have this disorder.
• Many patients in the program are diagnosed
with a Psychiatric Disorder for the first time.
Hardest to Treat
• Methamphetamine addiction and Crack
-Cravings are hard and constant
- Wellbutrin - Dopamine
-Post Acute Withdrawal symptoms has to
be aggressively managed medically
• Daily Suboxone use greater than 3 months.
• IV heroin use greater than 6 months
Our Population at Ridgeview
Random sample of 50 admissions in 2011
– 35% left AMA or Administratively
– 35% were referred to extended treatment
– 30% completed program and followed
recommendations
– ~70% had primary dx of Opiate Dependency
•
•
•
•
•
•
~1/3 of all patients have dx of Marijuana Dep.
~1/3 - Xanax Dep.
~15 to 20% of patients – Alcohol Dep/Abuse
<10% – All other substances
>50% have at least two or more Drugs
>10% are addicted to anything they can abuse
and they should prob. not be on any
medication unless absolutely necessary
2012 Outcome Study
• Included all patients who completed the
program in 2012. Out of those we could
contact:
• 57% in recovery
• 43% had relapsed at least once
• ~90% had a dual diagnosis
• ~90% had to be “incentivized” to start
Young Adult Psychiatric
(My best guess)
• 10 to 20% stay in Ridgeview residence
• Primary diagnosis is Major Depression and
Generalized Anxiety Disorder
• Next in frequency is Bipolar Disorder I and II
• 15% have Borderline Pers.Dis.
• 10% first Psychotic episode/Schizophrenia
• 30% have criteria for Addiction Dependency
• 10% purge, self-mutilate
• 20% drink alcohol and smoke marijuana
• Aggressive medication treatment
- Relief of symptoms but limited side effect
- Psychosis, suicide, withdrawal may need
inpatient
• We try to manage abuse of drugs, self
mutilation, and purge but -----• Education of parents is critical to be able to do
interventions
September is Suicide Prevention
Month
Tragically, death by suicide is not uncommon.
Every year, more than 800,000 people die by
suicide throughout the world; this roughly
corresponds to one death every 40 seconds.
Suicide is the fifth-leading cause of death among
those aged 30-49, and the second leading cause
of death in the 15-29 age group.
Know the Risk Factors
Add them Together
• Highest risk is a > 50 yo widowed man with a
major medical illness, with an addiction, living
alone, has a chronic mental illness and a
Borderline or a Dependent personality
disorder, Asian, low or middle-income, not
Catholic or Muslim.
• A young adult with a mental illness, addicted,
living alone, a history of suicide, and a
Borderline or Dependent Personality Disorder.
• Suicide rates vary enormously from country to
country.
• India, where it is illegal, has 21 deaths per
100,000 people against a global average of 11.
• ¾ of suicides occur in low- and middle-income
countries with highest numbers in central and
eastern Europe and in Asia.
• Catholic- Muslim countries have lower rates.
• Prior suicide attempt is the biggest risk factor.
• ~75% of suicides are male in Britain
The #1 Cause of Death of
Young Adults
• Opiate Dependency is now probably the #1
cause of death of the 15 to 29 age group.
• The catastrophic increase in overdoses from
opiates over the past 10 years has happened
so fast, that statistics cannot keep up with it.
• Differentiating suicide from overdose is many
times difficult to do.
• Coupled with a major psychiatric illness,
suicide or overdose is an extremely high
probability without treatment.