Transcript Document

Addiction: Identification &
Treatment
Ken Roy, MD, FASAM
Addiction Recovery Resources of New Orleans
River Oaks Hospital
Tulane Department of Psychiatry
www.arrno.org
[email protected]
The Diagnosis of Addiction
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Bums and bad people?
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No!
Criteria for Substance
Dependence (DSM-IV)
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A maladaptive pattern of use, leading to
significant impairment or distress as
manifested by three (or more) of the
following seven criteria, occurring at any
time in the same twelve month period
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Tolerance, as defined by:
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A need for increased amounts to achieve effect
Markedly diminished effect from using the same amount
Criteria for Substance
Dependence (DSM-IV)
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Withdrawal, as manifested by:
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Characteristic withdrawal syndrome
The same substance is used to avoid or relieve withdrawal
symptoms
The substance is taken in larger amounts or over a longer
period than was intended
There is a persistent desire or unsuccessful efforts to cut
down or control use
Criteria for Substance
Dependence (DSM-IV)
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A great deal of time is spent in activities necessary to obtain
or use the substance or recover from it’s effects
Important social, occupational, or recreational activities are
given up or reduced because of substance use
The substance use is continued despite knowledge of having a
persistent or recurring physical or psychological problem that
is likely to have been caused or exacerbated by the substance
(ulcer, depression, etc.)b
Substance Dependence Shorthand
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Compulsion
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Loss of control
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Continued use in the face of adverse
consequences
CAGE
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Cut down
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Angry
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“Do you get angry when someone talks to you about your
drinking?”
Guilt
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“Have you ever tried to stop or cut down on your drinking?”
“Have you done things while drinking that you wish that you
hadn’t, that you feel guilty about?”
Eye opener
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“Have you had a drink (or a drug) to prevent or cure a hangover?”
TACE
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Tolerance
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Anger
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“Do you get angry when someone talks about your drinking?”
Cut down
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“Can you drink more than your friends?”
“Have you ever tried to stop or cut down on your drinking?”
Eye opener
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“Have you ever had a drink (or a drug) to prevent or cure a
hangover?”
“G A T E S”
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Guilt
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Anger
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“Can you drink more than your friends?”
Eye opener
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“Do you get angry when someone talks about your drinking?”
Tolerance
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“Have you done things while drinking that you wish that you
hadn’t, that you feel guilty about?”
“Have you ever had a drink (or a drug) to prevent or cure a
hangover?”
Stop
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“Have you ever tried to stop or cut down on your drinking?”
Models of Treatment
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Based on assumptions about etiology
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Moral Model
Learning Model
Self Medication Model
Disease Model
Integrative Models
Moral Model
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Still Current
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Goals
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from evil to good, weak to strong
Advantages
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Teen Challenge, etc.
Moral inventory & responsibility for
consequences
Liabilities
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therapist is judgmental, punitive & blaming
Learning Model
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Inadvertently learned bad habits
Goals
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Advantages
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from uncontrolled to controlled
from bad habits to good habits
stresses new learning, pt. responsible for
learning
Liabilities
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emphasis on control can increase denial
Self Medication Model
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Using is a coping mechanism for
psychological lesions
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Goals
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from needing to use to not needing to use
Advantages
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common in psychiatric programs
stresses dx & tx of psychopathology
Liabilities
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psychopathology seen as etiology
Disease Model
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Recently dominant model
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Goals
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from sick to well, from using to recovering
Advantages
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based on genetic predisposition
self care rather than self control
Liabilities
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minimizes coexistent pathology
Integrative Models
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AA
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Dual Diagnosis
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Both are primary
learning theory effective
Biopsychosocial
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Moral + Disease Models
individualizes these three domains
Multivariant
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most of the modern effective programs
Philosophy of Treatment
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Disease Concept
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Abstinence
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Genetic Predisposition
Environment
only rational goal of treatment
Multivariant Treatment Model
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use all the tools
individualize interventions
Equation for Illness
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Genetics + Environment = Disease
Genetic Predisposition
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What is inherited?
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Tolerance - Schuckit
Endogenous Opiate system - Gianoulakis
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Revia
Dopamine Reward Systems - Nestler
Why is it important?
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reduces shame
explains ineffectiveness of willpower
Contribution of Environment
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Similarity to TB
Impact of Using on Emotional Development
Other Diagnoses
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Psychoses
Mood Disorders, Anxiety Disorders, Others
Abstinence
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Similarity to Diabetes
AA/NA/GA/RR not MM
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Common Experiences
Fellowship
Impact on Emotional Development
Use of Medications
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Importance to Relapse
Elements
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Multiaxial Diagnostic Assessment
Abstinence
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Level of Care
Education, Cognitive Restructuring
Identification
Support System Involvement
Discharge Planning
Multiaxial Diagnostic Assessment
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Medical Assessment
Laboratory & Imaging
Family History
Psychological Assessment
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Mental Status Examination
Social Assessment
Levels of Care
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Least invasive level necessary to achieve &
maintain abstinence
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Medically Managed Inpatient Treatment
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Medical/Surgical Hospital
Psychiatric Hospital
Medically Supervised Inpatient Treatment
Partial Hospitalization
Intensive Outpatient Program
Residential Treatment Program
Education and Identification
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AA/NA/GA Materials
Workbook
Lectures
Group
Community
Support System Involvement
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Co-addiction
Anger and Frustration
Communication
Single Family to Multifamily
Discharge Planning
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Time
Integration
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Treatment should “generalize”
Motivation
Relapse Support
Distinction From Other
Psychiatric Treatment
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Not Necessarily Dual Diagnosis
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Not Incompetent
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Do Not Meet Psychiatric Admission Criteria
High Functioning
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Theory of Genetic Drift
Low tolerance For Infantalizing Interactions
Level of Care = Abstinence and Attendance
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Not Protection of Self or Others
WHAT IS A.A.?
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Fellowship of men and women who have
had a “drinking problem”
Nonprofessional
Self-supporting
Nondenominational
Multiracial, Multicultural
Apolitical
Available almost everywhere
WHAT DOES A.A. DO?
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A.A. members share their experience
with anyone seeking help with a
drinking problem
Members voluntarily give person-toperson assistance or “sponsorship” to
an alcoholic coming to A.A. from any
source
WHAT DOES A.A. DO?
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The A.A. program, set forth in the
Twelve Steps and Twelve Traditions,
offers the alcoholic a way to develop a
satisfying life without alcohol
This program is discussed at A.A.
group meetings
WHAT A.A. DOES NOT DO
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Furnish initial motivation for alcoholics
to recover
Solicit members
Engage in or sponsor research
Keep attendance records or case
histories
WHAT A.A. DOES NOT DO
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Join “councils” of social agencies
Follow up or try to control its members
Make medical or psychological
diagnoses or prognoses
Provide drying-out or nursing services,
hospitalization, drugs, or any medical
or psychiatric treatment
WHAT A.A. DOES NOT DO
Offer religious services
 Engage in education about alcohol
 Provide housing, food, clothing, jobs,
money, or any other welfare or social
services
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WHAT A.A. DOES NOT DO
Provide domestic or vocational
counseling
 Accept any money for its services, or
any contributions from non-A.A.
sources
 Provide letters of reference to parole
boards, lawyers, court officials, social
agencies, employers, etc
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Expectations of Some
Professionals
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AA’s are somehow paid to or “have to”
help them with their drunks
Once they notify AA that they have a
“live one,” someone will come take
them away and motivate them
Expectations of Some
Professionals
AA is professional treatment, and
professional treatment is AA
 One meeting is a course of treatment,
and drinking after one meeting is failed
treatment
 AA (or treatment) is only necessary
after Cirrhosis or Seizures
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Solution
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Send your patient to AA, NA CA, etc.
Identify treatment professionals in your
area who can accept those unable to get
well (abstinent & in recovery) in AA
alone
Refer to or consult treatment
professionals like any other specialty
Problem Patients & Problem
Prescriptions
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Potential problem patients
Problem prescriptions
Classes of addicting drugs
Potential Problem Patients
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Family history of alcoholism
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External locus of control
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Pain persistent or out of proportion
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Litigation
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Multiple meds
Problem Prescriptions
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Soma, Fiorinal, Valium, Xanax
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Ritalin, Adderall
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Vicodin, Percodan, Ultram, OxyContin
Classes of Addicting Drugs
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Related to the specific reinforcing
pathway
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Three main classes
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Sedative hypnotics and opioids are the
vast majority of problem prescriptions
Sedative Hypnotics
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Active in the GABA system
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Alcohol
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Benzodiazepines (Rohypnol)
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Barbiturates (Fiorinal)
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Hypnotics (Ambien Sonata)
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Muscle Relaxants (Soma)
Opiates
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Active in the endorphin systems
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Vicodin, other oxy & hydro codones
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Especially ES formulations & OxyContin
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Stadol, Fentanyl, Buprenorphine
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Ultram
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Methadone
Stimulants
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Active in the dopamine system
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Amphetamines (Adderall)
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Others (Ritalin, Cylert)
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*Decongestants