Transcript 10 Buxton Addiction talk

Opiate Misuse and Addiction
Martin Buxton, M.D.,
L.F.A.A.C.A.P, D.L.F.A.P.A.
Objectives
• Identifying substance abuse disordered
patients
• Understanding the basic tenets of
substance use disorders (SUD)
• Management of this patient population
Martin Buxton, M.D.
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Clinical Professor of Psychiatry, MCV/VCU
Chief of Psychiatry, CJW Medical Center
Medical Director, Tucker Pavilion
Medical Director, Family Counseling
Center of Richmond
• President of Insight Physicians
• Consultant to the National Basketball
Association (NBA) for substance
dependencies
Surgery and Addiction
• Rate of opiate dependence and addiction
is 1:10 patients post operation
• 90% of surgeons feel pressure to
prescribe more opiates
• Screening patients post discharge around
pain management: HCAP scores pay
more for procedure if patient satisfied
• Fewer 25% patients discuss of non-opiate
control for pain management
Opiate Dependence After Surgery Its Even Worse Than Physicians Thought (2016).
MD Magazine, Vol 6. Issue 8: 18-20.
DSM V
Substance Use Disorders: patterns of
symptoms resulting from use of a substance
despite problems
•2-3 criteria Mild
•4-5 criteria Moderate
•> 6 criteria Severe
Modifiers: “in early remission”, “in sustained
remission”, “on maintenance therapy”, “in a
controlled environment”
DSM V Criteria
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Taking the substance in larger amounts or for longer than you meant
Wanting to cut down or stop but not able
Spending a lot time getting, using or recovering from use
Cravings and urges to use
Not managing to do what you should at work, home or school
Continuing to use even when it causes problems in relationships
Giving up important social, occupational or recreational activities
Using substances repeatedly even when it could be dangerous
Continuing to use even when you have a physical or psychological
problem that could be worsen by the substance
• Tolerance
• Development of withdrawal symptoms relieved by use
Brain’s Reward Center
http://www.health.harvard.edu/newsletter_article/how-addiction-hijacks-the-brain
SUD and Mental Illness
http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf
The Inherent Challenges
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You can’t be an addict without
being dishonest
The physician is being paid to
NOT trust the patient
Pain and suffering are
prerequisites for Addicts’
recovery
The slippery slope between
helping and “enabling”
Addiction is promiscuous and
not monogamous to the
preferred substance or
behavior
The Challenge of Cross
Addiction
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Colombo Method Of Interviewing
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How many times a year do you get drunk?
Have you or anyone in your family ever been
arrested? e.g. DUI, Drunk in Public, etc.
Anybody in your family have a psychiatric illness
and/or drug and alcohol problem?
How often do you drink or drug?
Have you ever had a seizure?
Have you ever had a consequence from your
drinking or drugging?
Do you have a preferred drink?
Should you be concerned?
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Red Flags Are Up When
• Patient will not allow you to speak with
significant others
• Patient will not give ROI to speak with previous
or other healthcare providers
• Patient will not give a spontaneously requested
drug screen
• The Urine Drug Screen is positive for illicit
substances or medications which are not
prescribed
• Premature refill requests or patient reports loss
of medicines
Relevant Psychopathology of SUD
Patients
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“I want what I want when I want it.”
Child’s sense of time
Lack of harm avoidance
Unreasonable expectations
Oversensitivity to discomfort
All or nothing thinking
Dissonance between patient’s concerns and physician’s concerns
Minimizations, rationalizations and externalizations
– People who worry about becoming addicted don’t become
addicted
– Compartmentalizing
– “Besides that Mrs.Lincoln…”
• Distorted thinking as a result of denial, organicity and/or
intoxification “Do we really speak the same language?”
• Rigidity of thinking “Bend don’t break”
How To Monitor
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PMP on all patients you’re
prescribing controlled
medications
If suspicious, random call back
appointments before refills are
needed and count pills
Urine drug screen when
suspicious and/or randomly
Referral to addiction specialist
when in doubt
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Psychotherapeutic Interventions
as Prelude for Pharmacotherapy
• Manage your life or your life will be managed
• SUD ends 1 of 3 ways:
1. Institutions
2. Recovery
3. Death
• Rules of Engagement
– No unilateral medication changes i.e. increases in dose, decreases in
dose, stopping meds nor sharing meds
– No doctor shopping
• Machete therapy
• Chemically dependent individuals cannot trust their own
thinking regarding medications
Psychotherapeutic Interventions
as Prelude for Pharmacotherapy
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“Hang with dogs and you get fleas”
Observable Ego grossly impaired in SUD
Two psychiatrists…
Modeling and preaching the serenity prayer to manage
countertransferance issues
God grant me the serenity to accept the things I cannot change,
the courage to change the things I can
and the wisdom to know the difference
Family/Relationship Interventions
as Prelude to Pharmacotherapy
• Snow White and & 7 Dwarfs
• Psychoeducation regarding family disease model of SUD (Are
you adopted?)
• Apples don’t grow on orange trees
• Genetic interpretation to help with acceptance of diagnosis
• Accepting the powerlessness i.e. even Michael Corleone can’t
control the illness
• Family Intervention to address denial
• How many psychiatrists does it take to change a light bulb?
• Challenge the family’s and patient’s predilections to see their
drug and alcohol use to “self medicate”
How To Provide Pain
Management for the SUD Patient
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Limited number of pills and no refills
A significant other to hold and dole out addictive meds
Optimally do not discharge SUD patient from Hospital
before weaning them off addictive medications
If ongoing pain management is necessary, monitor
tolerance, refer for none analgesic forms of pain relief,
monitor UDS and d/c if dirty for other substances
Written contract with patient to not seek nor receive pain
management from any other provider
Discuss with the SUD/pain patient the difficult choice of
being in pain and addicted or just being in pain
New prescribing recommendations for pain management
Consider MAT (Medication Assistive Treatment) for the
pain patient who is also addicted
Nonaddictive
Pharmacological Alternatives
• Anxiety: Buspirone, Baclofen, Trazodone, Gabapentin,
Tiagabine, Hydroxyzine, Chlorpromazine, Perphenazine,
Tricyclic Antidepressants, Low dose atypical
antipsychotics, SSRI’s
• Sleep: Sleep Hygiene,TCA’s, Trazodone, Mirtazapine,
Ropinirole, Quetiapine, Olanzapine, Chlorpromazine,
Clonidine, Guanfacine, Melatonin
• ADHD: Use long acting agents vs short acting,
Atomoxetine, Clonidine, Guafacine, Buproprion*,
Lisodexamfetamine, Modafinil, Armodafinil
Final Thoughts
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It takes 2 minutes to write a prescription
for a benzodiazepine but a half hour to say “No”
Recovered SUD individuals are the
healthiest people I know and a pleasure
to work with.
The challenge is helping them get there by
being part of the solution and not the
problem.