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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. Addiction Defined, Part 1. Primary, chronic disease of Brain reward Motivation Memory
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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
Addiction Defined, Part 1 • Primary, chronic disease of • Brain reward • Motivation • Memory • Related circuitry
Addiction Defined, Part 2 • Leading to dysfunction • Biological • Psychological • Spiritual • Social
Addiction Defined, Part 3 • Resulting in • Inability to abstain • Impairment in behavioral control • Craving • Trouble in recognizing significance of behavior • Dysfunctional emotional response
Two Broad Categories of Addiction • Substance Use Disorders (SUD), or chemical addiction • Process or behavioral addiction
Examples Substance Process Gaming Gambling Food • Alcohol • Heroin • Tobacco
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)
Damage to the prefrontal cortex means • Decreased ability in solving problems • Increased likelihood of making poor decisions • Higher probability of acting without thinking
People struggling with addiction • Lose their ability to manage their own behavior • Impaired autonomy
Is choice involved? • Of course! • But what starts as a choice • Can become a compulsion
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
Even the language is different “Traditional” Model Disease Model Person with Addiction Flare-Up Recovery Recovery Management • Addict • Relapse • Sobriety • Relapse Prevention
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%)
An important difference between • ADDICTION • Inability to stop use • Failure to meet obligations • MAYBE tolerance and withdrawal • PHYSICAL DEPENDENCE • Tolerance • Withdrawal
Diagnostics Using the DSM-5 • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
Substance-Related and Addictive Disorders • Substance Use Disorders • Substance-Induced Disorders • Substance Intoxication and Withdrawal • Substance/Medication-Induced Mental Disorders
Ten Categories of Substances • Alcohol • Caffeine • Cannabis • Hallucinogen • Inhalant • Opioid • Sedative/Hypnotic/Anxiolytic • Stimulant • Tobacco • Other (or Unknown)
DSM-5 Diagnostic Criteria Groups • Impaired Control (Criteria 1-4) • Social Impairment (Criteria 5-7) • Risky Use (Criteria 8-9) • Pharmacological (Criteria 10-11)
DSM-5 Diagnostic Criteria Severity • Mild: Presence of 2-3 symptoms • Moderate: Presence of 4-5 symptoms • Severe: Presence of 6 or more symptoms
What needs to be said here? • Money better spent on prevention • But people are suffering • Major assumption • People want relief from suffering
People use • To get high/intoxicated • To get symptom relief • E.g., from pain (emotional or physical) • Stress • To avoid withdrawal symptoms
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?
AND • Determine • Level • Of • Patient • Motivation
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
TTM Stages • Precontemplation • Contemplation • Preparation • Action • Maintenance
Treatment options depend on • Availability • Provider preferences • Patient choice (most important)
Four choices • Medication-assisted treatment (MAT) • Other professional-partnered treatment • Community support treatment • Combination of any of the above
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)
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
Commonly-Used Formulations, Part 2 • Acamprosate (Campral) for alcohol • Disulfiram (Antabuse) for alcohol • Naltrexone (including Vivitrol injections) for alcohol • Topiramate (Topamax) for alcohol
Commonly-Used Formulations, Part 3 • Nicotine replacement therapies • Transdermal nicotine patch • Nicotine spray • Nicotine gum • Nicotine lozenges
Commonly-Used Formulations, Part 4 • Bupropion hydrochloride (Zyban, Wellbutrin) for nicotine • Varenicline (Chantix) for nicotine
Notice how nicotine was included? • Part of a nationwide effort toward tobacco-free treatment facilities • CKF started in August 2018 with promising results
MAT means just that: • Medication that is • Prescribed • Dispensed • Managed • Under supervision from a qualified med provider
Any MAT-related treatment • Should include • Behavioral health (BH) interventions • Provided by • Qualified BH practitioner(s)
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
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
What is a realistic goal? • Abstinence? • Harm reduction?
It depends. • On the patient • On the practitioner • On the context
Know your values • Know your practice location and its strengths/limitations • Know your referral sources
Once that goal is set • A recovery management plan can be developed • Realistic • Actionable
Recovery Management Plan (RMP) • Similar to managing other chronic diseases • Requires thinking and planning • Involves others • Family • Friends • Specialists
Development of a good RMP • Self-awareness and reflection • Flare-ups (relapse) as a process vs. an event • Recognition requires willingness to learn
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