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]
Jan 02, 2016
Addiction: Identification & Treatment
Ken Roy, MD, FASAM
Addiction Recovery Resources of New Orleans
River Oaks Hospital
Tulane Department of Psychiatry
www.arrno.org
Criteria for Substance Dependence (DSM-IV)
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 Tolerance, as defined by:
A need for increased amounts to achieve effect Markedly diminished effect from using the same amount
Withdrawal, as manifested by: 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)
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
Criteria for Substance Dependence (DSM-IV)
Substance Dependence Shorthand
Compulsion
Loss of control
Continued use in the face of adverse
consequences
C A G E Cut down
“Have you ever tried to stop or cut down on your drinking?” Angry
“Do you get angry when someone talks to you about your drinking?”
Guilt “Have you done things while drinking that you wish that you
hadn’t, that you feel guilty about?” Eye opener
“Have you had a drink (or a drug) to prevent or cure a hangover?”
T A C E Tolerance
“Can you drink more than your friends?”
Anger “Do you get angry when someone talks about your drinking?”
Cut down “Have you ever tried to stop or cut down on your drinking?”
Eye opener “Have you ever had a drink (or a drug) to prevent or cure a
hangover?”
“G A T E S” Guilt
“Have you done things while drinking that you wish that you hadn’t, that you feel guilty about?”
Anger “Do you get angry when someone talks about your drinking?”
Tolerance “Can you drink more than your friends?”
Eye opener “Have you ever had a drink (or a drug) to prevent or cure a
hangover?” Stop
“Have you ever tried to stop or cut down on your drinking?”
Models of TreatmentModels of Treatment
Based on assumptions about etiology Moral Model Learning Model Self Medication Model Disease Model Integrative Models
Moral ModelMoral Model Still Current
Teen Challenge, etc. Goals
from evil to good, weak to strong Advantages
Moral inventory & responsibility for consequences
Liabilities therapist is judgmental, punitive & blaming
Learning ModelLearning Model
Inadvertently learned bad habits Goals
from uncontrolled to controlled from bad habits to good habits
Advantages stresses new learning, pt. responsible for
learning Liabilities
emphasis on control can increase denial
Self Medication ModelSelf Medication Model
Using is a coping mechanism for psychological lesions common in psychiatric programs
Goals from needing to use to not needing to use
Advantages stresses dx & tx of psychopathology
Liabilities psychopathology seen as etiology
Disease ModelDisease Model
Recently dominant model based on genetic predisposition
Goals from sick to well, from using to recovering
Advantages self care rather than self control
Liabilities minimizes coexistent pathology
Integrative ModelsIntegrative Models
AA Moral + Disease Models
Dual Diagnosis Both are primary learning theory effective
Biopsychosocial individualizes these three domains
Multivariant most of the modern effective programs
Philosophy of TreatmentPhilosophy of Treatment
Disease Concept Genetic Predisposition Environment
Abstinence only rational goal of treatment
Multivariant Treatment Model use all the tools individualize interventions
Genetic PredispositionGenetic Predisposition
What is inherited? Tolerance - Schuckit Endogenous Opiate system - Gianoulakis
Revia Dopamine Reward Systems - Nestler
Why is it important? reduces shame explains ineffectiveness of willpower
Contribution of EnvironmentContribution of Environment
Similarity to TB Impact of Using on Emotional Development Other Diagnoses
Psychoses Mood Disorders, Anxiety Disorders, Others
AbstinenceAbstinence
Similarity to Diabetes AA/NA/GA/RR not MM
Common Experiences Fellowship Impact on Emotional Development
Use of Medications Importance to Relapse
ElementsElements
Multiaxial Diagnostic Assessment Abstinence
Level of Care Education, Cognitive Restructuring Identification Support System Involvement Discharge Planning
Multiaxial Diagnostic AssessmentMultiaxial Diagnostic Assessment
Medical Assessment Laboratory & Imaging Family History Psychological Assessment
Mental Status Examination Social Assessment
Levels of CareLevels of Care
Least invasive level necessary to achieve & maintain abstinence Medically Managed Inpatient Treatment
Medical/Surgical Hospital Psychiatric Hospital
Medically Supervised Inpatient Treatment Partial Hospitalization Intensive Outpatient Program Residential Treatment Program
Education and IdentificationEducation and Identification
AA/NA/GA Materials Workbook Lectures Group Community
Support System InvolvementSupport System Involvement
Co-addiction Anger and Frustration Communication Single Family to Multifamily
Discharge PlanningDischarge Planning
Time Integration
Treatment should “generalize” Motivation Relapse Support
Distinction From Other Psychiatric Treatment
Distinction From Other Psychiatric Treatment
Not Necessarily Dual Diagnosis Theory of Genetic Drift
Not Incompetent Do Not Meet Psychiatric Admission Criteria
High Functioning Low tolerance For Infantalizing Interactions
Level of Care = Abstinence and Attendance Not Protection of Self or Others
WHAT IS A.A.? 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?
A.A. members share their experience with anyone seeking help with a drinking problem
Members voluntarily give person-to-person assistance or “sponsorship” to an alcoholic coming to A.A. from any source
WHAT DOES A.A. DO?
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
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
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
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
Expectations of Some Professionals
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
Solution
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
Potential problem patients Problem prescriptions Classes of addicting drugs
Potential Problem Patients
Family history of alcoholism
External locus of control
Pain persistent or out of proportion
Litigation
Multiple meds
Problem Prescriptions
Soma, Fiorinal, Valium, Xanax
Ritalin, Adderall
Vicodin, Percodan, Ultram, OxyContin
Classes of Addicting Drugs
Related to the specific reinforcing
pathway
Three main classes
Sedative hypnotics and opioids are the
vast majority of problem prescriptions
Sedative Hypnotics
Active in the GABA system Alcohol Benzodiazepines (Rohypnol) Barbiturates (Fiorinal) Hypnotics (Ambien Sonata) Muscle Relaxants (Soma)
Opiates
Active in the endorphin systems Vicodin, other oxy & hydro codones
Especially ES formulations & OxyContin
Stadol, Fentanyl, Buprenorphine
Ultram
Methadone