Transcript problematic use - National Council

Clinical
Management:
Alcohol Use Disorders
December 10, 2015
Arthur Robin Williams MD MBE
American Academy of Addiction Psychiatry
Division on Substance Abuse
Department of Psychiatry, Columbia University
New York State Psychiatric Institute
 NIAAA website has many resources
 http://rethinkingdrinking.niaaa.nih.gov/
 Free 16-page booklets
 http://pubs.niaaa.nih.gov/publications/RethinkingDrinkin
g/OrderPage.htm
AUD Treatment Options
Family
Therapy
Level of Care:
- Outpatient
- Individual
- Program
- Residential
- Inpatient/
Hospital
Other
Psychotherapy
- CRA
- RPT
-TSF
Behavioral
Patient
- CBT
- MI/MET
- CM
- AA/NA
- Self-help
- Smart
Recovery
Medications
(MAT)
AUD Treatment Options
Family
Therapy
Level of Care:
- Outpatient
- Individual
- Program
- Residential
- Inpatient/
Hospital
Other
Psychotherapy
- CRA
- RPT
-TSF
Behavioral
Patient
- CBT
- MI/MET
- CM
- AA/NA
- Self-help
- Smart
Recovery
Medications
(MAT)
- Detoxification
- Aversion
- Anti-Craving
- Substitution
11 Symptoms of Addiction
- Excessive amounts used
- Excessive time spent using/obtaining
- Craving or urges to use
- Unsuccessful attempts
to cut down
- Tolerance
- Withdrawal
Problematic use despite
- Physical hazards
- Health problems
- Missed obligations
- Interference with activities
- Interpersonal problems
Addiction & Problematic Use
• Addiction: chronic disease needs treatment
− Up to 16% of the 12+ population
• Problematic use:
− Substance use that threatens health & safety
− Does not meet addiction criteria
− Up to 32% of the 12+ population
• Both require medical care
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Addiction & Problematic Use
SBIRT: Screening, Brief Intervention, Referral to Treatment
All patients diagnosed with addiction
should receive treatment
All patients with problematic use
should receive a brief intervention
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Alcohol
 Neuropathology
 Anti-glutaminergic
 Potentiates GABA
 Dopamine release
Targeting Symptoms
- Excessive amounts used
- Excessive time spent using/obtaining
- Detox taper
(Librium or
Methadone)
- Craving or urges to use
- Unsuccessful attempts
to cut down
Medication
s
(MAT)
Problematic use despite
- Physical hazards
- Health problems
- Missed obligations
- Interference with activities
- Interpersonal problems
- Tolerance
- Withdrawal
(not all substances)
MAT: Alcohol
Detoxification (Youth typically binge drink and rarely require)
• Use benzodiazepines, phenobarbital
• Outpatient v. inpatient models
Aversion
• Antabuse 250mg or 500mg daily (FDA 1951)
• Start after all alcohol has cleared
• Can dose on site or have observer at home
• Effects for up to 2-3 weeks for some
• Consider as an adjunct to psychosocial therapies
• Monitor liver function every 1-3 months
Targeting Symptoms
-Aversion
(Antabuse)
- Anti-Craving
(Naltrexone)
- Excessive amounts used
- Excessive time spent using/obtaining
- Craving or urges to use
- Unsuccessful attempts
to cut down
Medication
s
(MAT)
Problematic use despite
- Physical hazards
- Health problems
- Missed obligations
- Interference with activities
- Interpersonal problems
- Tolerance
- Withdrawal
(not all substances)
MAT: Alcohol
Anti-Craving
• Campral 666mg TID (FDA 2004)
– Stabilizes neuroexcitability in protracted withdrawal
– Dosing is problematic (but no side effects)
– Better choice for patients with liver disease
• Naltrexone 50mg daily (NTX) (FDA 1994)
– Reduces number of drinks per drinking day and cravings
– Side effects limited (nausea/sedation)
– LFTs should be followed intermittently (every 3 months)
• Vivitrol 380mg IM (XR-NTX) (FDA 2006)
– Long acting monthly injection of naltrexone
Summary: Alcohol
 MAT includes
 Antabuse (disulfiram) 250mg or 500mg daily
 Naltrexone 50mg+ daily or monthly Vivitrol injection
 Acamprosate 666mg PO TID
 Dosing should be observed by family or program
 Check liver function regularly if on naltrexone or
Antabuse
Clinical Tips: Alcohol
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If pill taking not witnessed, assume not taken
Patients often “fail” naltrexone on path to antabuse
Roll with resistance if patients attempt “moderation”
SMART Recovery is an alternative to AA/NA
 Treating anxiety and sleep is key in first few months
 CBT, behavioral treatment: www.cbtforinsomnia.com
 Sedating anti-depressants, gabapentin, etc.
References
 CBT for Insomnia: http://www.med.upenn.edu/cbti/
 Niederhofer, H. and W. Staffen (2003). "Acamprosate and its
efficacy in treating alcohol dependent adolescents." Eur Child
Adolesc Psychiatry 12(3): 144-148.
 Niederhofer, H. and W. Staffen (2003). "Comparison of disulfiram
and placebo in treatment of alcohol dependence of
adolescents." Drug Alcohol Rev 22(3): 295-297.
 Simkin, D. R. and S. Grenoble (2010). "Pharmacotherapies for
adolescent substance use disorders." Child Adolesc Psychiatr Clin
N Am 19(3): 591-608.