Substance Use Disorders: A Primer on Treatment

1. Substance Use Disorders:A Primer on Treatment Kirk A. Weaver, Ph.D., LCPC, LCAC, MAC, NCC Certified Clinical Mental Health Counselor Director of Clinical Services CKF Addiction Treatment

2. Addiction Defined, Part 1 • Primary, chronic disease of • Brain reward • Motivation • Memory • Related circuitry

3. Addiction Defined, Part 2 • Leading to dysfunction • Biological • Psychological • Spiritual • Social

4. Addiction Defined, Part 3 • Resulting in • Inability to abstain • Impairment in behavioral control • Craving • Trouble in recognizing significance of behavior • Dysfunctional emotional response

5. Two Broad Categories of Addiction • Substance Use Disorders (SUD), or chemical addiction • Process or behavioral addiction

6. Examples Substance Process Gaming Gambling Food • Alcohol • Heroin • Tobacco

7. Today’s focus is on substance addiction.

8. Addiction is a disease of the brain.

9. The addicted brain is damaged in three areas: • Positive motivation and “reward circuit” (basal ganglia) • Emotion modulation and “stress circuit” (extended amygdala) • Executive function and “deliberation circuit” (prefrontal cortex)

10. Damage to the prefrontal cortex means • Decreased ability in solving problems • Increased likelihood of making poor decisions • Higher probability of acting without thinking

11. People struggling with addiction • Lose their ability to manage their own behavior • Impaired autonomy

12. Is choice involved? • Of course! • But what starts as a choice • Can become a compulsion

13. One’s understanding of addiction is important • Lack of willpower? • Solution: more resolve • Lack of faith? • Solution: more spirituality • Lack of conscience? • Solution: more incarceration

14. If addiction is a disease, then treat it as such.

15. Everything changes. Perspective matters.

16. Even the language is different “Traditional” Model Disease Model Person with Addiction Flare-Up Recovery Recovery Management • Addict • Relapse • Sobriety • Relapse Prevention

17. As a disease, addiction must be managed • 2000 issue of Journal of the American Medical Association • The following flare-up rates were compared for patients with • Hypertension (50-70%) • Asthma (50-70%) • Substance use disorders (40-60%)

18. Success rates for CKF are within that range.

19. An important difference between • ADDICTION • Inability to stop use • Failure to meet obligations • MAYBE tolerance and withdrawal • PHYSICAL DEPENDENCE • Tolerance • Withdrawal

20. Diagnostics Using the DSM-5 • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

21. Substance-Related and Addictive Disorders • Substance Use Disorders • Substance-Induced Disorders • Substance Intoxication and Withdrawal • Substance/Medication-Induced Mental Disorders

22. Ten Categories of Substances • Alcohol • Caffeine • Cannabis • Hallucinogen • Inhalant • Opioid • Sedative/Hypnotic/Anxiolytic • Stimulant • Tobacco • Other (or Unknown)

23. DSM-5 Diagnostic Criteria Groups • Impaired Control (Criteria 1-4) • Social Impairment (Criteria 5-7) • Risky Use (Criteria 8-9) • Pharmacological (Criteria 10-11)

24. DSM-5 Diagnostic Criteria Severity • Mild: Presence of 2-3 symptoms • Moderate: Presence of 4-5 symptoms • Severe: Presence of 6 or more symptoms

25. So let’s talk about treatment.

26. What needs to be said here? • Money better spent on prevention • But people are suffering • Major assumption • People want relief from suffering

27. People use • To get high/intoxicated • To get symptom relief • E.g., from pain (emotional or physical) • Stress • To avoid withdrawal symptoms

28. So when you encounter a patient, you must • Determine context and severity of substance use • Examine medical, psychological, social history • Understand treatment history • Factor in your underlying assumptions • Remember our discussion in the first part of this presentation?

29. AND • Determine • Level • Of • Patient • Motivation

30. Most providers in KS utilize a simple rubric • Transtheoretical Model of change (TTM) • Developed by Prochaska and Di Clemente et al. in 1977 • Five-stage model of change based on • Specific stages • Identifiable processes between stages • Decisional balance • Self-efficacy

31. TTM Stages • Precontemplation • Contemplation • Preparation • Action • Maintenance

32. Treatment options depend on • Availability • Provider preferences • Patient choice (most important)

33. Four choices • Medication-assisted treatment (MAT) • Other professional-partnered treatment • Community support treatment • Combination of any of the above

34. MAT • Only available for alcohol, opioid, and nicotine use disorders • “Available” meaning approved by FDA • Alcohol (acamprosate, naltrexone, disulfiram, topiramate) • Opioids (naloxone, buprenorphine, naltrexone, methadone) • Lofexidine hydrochloride (non-opioid)

35. Commonly-Used Formulations, Part 1 • Naltrexone extended-release (Vivitrol injection) for both alcohol and opioids • Methadone hydrochloride (Methadose, Dolophine) for opioids • Buprenorphine (Probuphine injection) for opioids • Buprenorphine/naloxone (Suboxone, Sublocade, Zubsolv, Cassipa, Bunavail) for opioids

36. Commonly-Used Formulations, Part 2 • Acamprosate (Campral) for alcohol • Disulfiram (Antabuse) for alcohol • Naltrexone (including Vivitrol injections) for alcohol • Topiramate (Topamax) for alcohol

37. Commonly-Used Formulations, Part 3 • Nicotine replacement therapies • Transdermal nicotine patch • Nicotine spray • Nicotine gum • Nicotine lozenges

38. Commonly-Used Formulations, Part 4 • Bupropion hydrochloride (Zyban, Wellbutrin) for nicotine • Varenicline (Chantix) for nicotine

39. Notice how nicotine was included? • Part of a nationwide effort toward tobacco-free treatment facilities • CKF started in August 2018 with promising results

40. MAT means just that: • Medication that is • Prescribed • Dispensed • Managed • Under supervision from a qualified med provider

41. Any MAT-related treatment • Should include • Behavioral health (BH) interventions • Provided by • Qualified BH practitioner(s)

42. BH Treatment for SUD Is not Is Providing symptom relief Exploring options to heal Promoting wellness Teaching how to be creative Joint alliance with a definite goal • Ignoring presenting problem(s) • Dictating “the” solution • Focusing solely on deficits • Solving the issue • Non-directional

43. Whatever the BH treatment approach, • The goal is disease management (remember our discussion?) • To manage the disease is to manage the self • People with impaired autonomy need help • The key is to develop a realistic, actionable recovery managment plan • In older parlance, a “relapse prevention” plan

44. What is a realistic goal? • Abstinence? • Harm reduction?

45. It depends. • On the patient • On the practitioner • On the context

46. Know your values • Know your practice location and its strengths/limitations • Know your referral sources

47. Once that goal is set • A recovery management plan can be developed • Realistic • Actionable

48. Recovery Management Plan (RMP) • Similar to managing other chronic diseases • Requires thinking and planning • Involves others • Family • Friends • Specialists

49. Development of a good RMP • Self-awareness and reflection • Flare-ups (relapse) as a process vs. an event • Recognition requires willingness to learn

50. Elements of a good RMP (ADAPT) • Acknowledge early warning signs and triggers • Detail the worst possible scenario(s) and how to cope • Accepthelp from “emergency recovery team” • Play on strengths • Trendhealthward