Transcript Addiction to Alcohol and Other Drugs

Chemical Addictions—General
Overview
Abdullahi Mubarak, MD
Medical Director of Addiction
Services at PEMCO
Chief Medical Officer at
Consortium Clinical Services,
LLC
Objectives
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Understand general terminology
 The disease of Addiction
 Symptoms of the disease
 Stages of change
 Diagnostic tips
 General treatment approaches
Terminology
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Use—drug taking not associated with harm
 Abuse—drug taking associated with harm
 Dependence—adaptation to drug evidenced
by normal functioning and/or withdrawal
syndrome
 Addiction—loss of control, compulsion,
continued use despite adverse consequences
Terminology
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Abuse potential—the likelihood that a
person will abuse a drug based upon it’s
pleasurable effects, toxicity, and society’s
attitude toward the users of the drug
 Addiction potential—the likelihood that a
drug will produce addiction in chronic users
Relative Addiction Potential
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Cocaine (crack, IV, snorted, chewed)
Methamphetamine (smoked)
Nicotine (IV, smoked, chewed)
Opiates (IV, smoked, snorted, chewed, oral)
Alcohol
Sedative-hypnotics
Anabolic steroids
Marijuana
Inhalants
PCP, other hallucinogens (LSD, Special K, )
Disease of Addiction
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Addiction is primarily a function of many
genetically predisposed biological
responses.
 The response and/or lack of the drug
reinforces the repeated use of the drug.
 The environment permits and facilitates the
use of the drug.
 Addiction can be “created” in low risk
patients with chronic use of drugs of high
addictive potential.
Progression of the Disease
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Erratic drug-taking pattern, erratic sleep,
work, eating, grooming, and social habits
 New forms of enjoyment, new “friends”,
ways of relating, isolation, hiding money,
hiding whereabouts, lying
 Legal, financial, marital, social, career, and
lastly physical adverse consequences
Stages of Change
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Pre-contemplation—lacks awareness
Contemplation—ambivalent about change
Preparation—getting information in order to
change
Action—actually committing to sobriety in deed
Maintenance—attaining stability
Recovery—sobriety
Relapse—use leads to return to contemplation
Signs of Aberrant behavior
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Prescription forgery
 Concurrent abuse of illicit drugs
 Selling prescriptions
 Recurrent lost, stolen, or spilled drugs
 Stealing or borrowing from others
 Obtaining drugs from non-medical sources
 Obtaining scripts from multiple doctors
Indicators of Suspicion
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Reluctant to present identification
 “Out of town” patient
 Overly willing to pay cash
 Telephone call in for controlled substances
 Presents when the regular physician cannot
be reached
Indicators of Suspicion
Allergy to NSAIDS, COX-2’s, or codeine
 Intolerant to collateral contacts
 Intolerant to in-depth interviews
 Interested only in the drug, not the
diagnosis
 Reluctant to comply with diagnostic testing,
pill counts, and urine screening
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Factors Less Indicative
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Drug hoarding during periods of decreased
symptoms
 Unsanctioned dose escalation
 Request for specific drugs by name
 Focus on opiate issues during the first three
office visits
Abnormal Physical Signs
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Pupils < 3mm or >6.5mm in room light
 Presence of nystagmus
 Diminished or absent corneal and/or
pupillary light reflex
 Impaired convergence
 Pulse < 60 or > 100/min
 Venosclerosis or needle tracks
 Perforated nasal septum
Characteristics of the Pain
patient
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Appreciates in-depth interviews
Cooperates with attempts to get collateral histories
Cooperates with pill counts and urine drug
screening
Focus is on the diagnosis and the cure
Attempts to reduce medications on their own
Cooperates with diagnostic and therapeutic
interventions
Addressing Aberrancy and
indicators of suspicion
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Obtain an INSPECT report
 Urine drug screen (UDS)
 Use oral salivary testing when urine
screening is unavailable, patient unable to
void, or the UDS is invalid
 Pill counts when appropriate
 Use Axis V outline to clarify your thoughts
 Treat ONLY according to your diagnosis
INSPECT reports
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The report is unconfirmed history until you
confirm what’s in it.
 “Multiple prescribers” means nothing until
you call the providers to find out what they
did, why they did it, and did they know
there were other prescribers
 Keep the interpretation of the report in your
chart
Urine drug screening
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The results only mean what the results say
Using them to make a diagnosis is only part of the
total picture
Refer for addiction consultation, if the results are
aberrant
Negative screens can mean abuse, addiction,
diversion, or pseudo-addiction syndrome
Do not collect without temperature strips on the
cup.
Be sure the reference lab tests for validity and
multiple metabolites
Oral Salivary Testing
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Easy to use, less intrusive
 Shorter window of detection compared to
urine drug screening
 Accuracy comparable to blood testing
 The results only mean what the result says
Pill Counts
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Best when used sparingly or unexpected
Best to clarify negative urine drug screens
Order within 2 days to rule out diversion
Order within 10 days to rule out abuse or
addiction
Pills can be brought to office or the pharmacy they
purchased their pills
Record any markings on the pills for identification
Diagnostic Challenges
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Impaired by lack of knowledge of differential
diagnosis
Impaired by EMOTIONAL reactions to the
“names” of controlled substances
Use Axis V outline to highlight deficiencies in
knowledge or when you are becoming too
emotional
Say “NO”, if the request is inappropriate for the
diagnosis or you have inadequate information to
arrive at a diagnosis
Continue to monitor to confirm or deny your
provisional diagnosis. Being wrong is ok.
Consultation
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Learn the biases of your consultants.
 Psychiatry consultation for benzo and
stimulant prescribing for mood disorders,
ADHD, etc…
 Addiction consultation to evaluate
aberrancy
 Pain management consultation to evaluate
opiate prescribing
General treatment principles
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Foremost goal initially is self-diagnosis
 Educate—Addiction is a disorder in a
person, not the pill
 Medication assistance—diminish drug
craving, withdrawal, and normalize function
 Intensity of treatment related to intensity of
use pattern and/or history of treatment
failures
 Strengthen social/spiritual supports