CAPTASA 2012

1. CAPTASA2012 OUR EXPERIENCE WITH OPIATE SUBSTITUTION FOR OPIOD DEPENDENCE AND STIMULANT THERAPY FOR ADHD “CAVEAT EMPTOR” LLOYD J. GORDON MD FASAM DABAM

2. WHY CAN’T WE JUST SHUT UP AND GO ALONG • GIVING A PHARMACEUTICAL AND TALKING ABOUT DOSES IS MUCH EASIER THAN TALKING ABOUT BELIEFS, FEELINGS, BEHAVIORS, AND THE DIFFICULTY OF CHANGE

3. WHAT A MOST ESTEEMED ADDICTIONIST AND MY BEST FRIEND FROM SAN FRANCISCO SAYS • THE PARTY WAS GOING GREAT AND NOW YOU WANT TO THROW A TURD IN THE PUNCH BOWL

4. GOOD THINGS ABOUT BUPRENORPHINE • LESS EUPHORIA • SATURATED ALL OPIOD RECEPTORS AT NON TOXIC DOSE • LESS RESPIRATORY DEPRESSION-LITTLE CHANCE OF OVERDOSE • LESS ABUSE POTENTIAL • NO MORNING AT THE CLINIC-MOST PHYSICIANS COULD USE IT

5. WHAT DO WE DO ABOUT IT? • IN MEDICINE THE QUESTION WE ASK IS OFTEN MUCH MORE IMPORTANT THAN THE ANSWER (TO THE WRONG QUESTION) • WHY? (DOES A PATIENT HAVE IT) • WHERE? (DID IT COME FROM) • WHAT? (CAUSED IT) • HOW? (DO WE TREAT/STOP IT

6. OPIATE MAINTENANCE FOR OPIATE ADDICTION • IS NOT NEW • IF IT WORKED LONG TERM WE WOULD HAVE HAD EVERYONE ON METHADONE YEARS AGO • ORIGINALLY MEANT TO REDUCE CRIME • TEMPORARY MEASURE-STOP GAP-HARM REDUCTION

7. WHAT AA SAYS • “YOU CAN’T THINK YOURSELF INTO RIGHT (HEALTHY) BEHAVIOR, BUT YOU BEHAVE (ACT) YOURSELF INTO RIGHT THINKING”

8. SYMPTOM VS CAUSE • A SYMPTOM IS A PHYSIOLOGIC OUTWARD MANIFESTATION OF THE DISEASE • A SYMPTOM IS NOT THE DISEASE • “COUGH” IS A SYMPTOM OF MANY DIFFERENT DISEASES • WE CAN TREAT COUGH FOR INSTANCE WITH COUGH MEDICINE OR SUPPRESSANT AND IT MAY GO AWAY

9. SYMPTOM VS CAUSE • IF THE DISEASE CAUSING THE COUGH I.E. A VIRUS IS SELF LIMITED THE PATIENT WILL GET WELL • IF THE DISEASE IS NOT SELF LIMITED I.E. BRONCHITIS, PNEUMONIA, TB, CANCER, COPD, FIBROSIS, FUNGUS THE COUGH WILL ONLY GO AWAY TEMPORARILY AND WILL COME BACK. THE COUGH WILL REQUIRE EVER INCREASING DOSES OF MEDICINE TO SUPPRESS IT

10. SYMPTOM VS CAUSE • “CRAVING” IS A SYMPTOM OF THE DISEASE OF ADDICTION. IT IS A FEELING. • “CRAVING” IS CAUSED BY NOT ENOUGH NEUROTRANSMITTER AT RECEPTOR SITES THAT HAVE BEEN DOWN REGULATED. THIS DOWN REGULATION IS IN RESPONSE TO YEARS OF THE USE OF THE CHEMICAL AND HAS BECOME HARD WIRED IN PATIENTS WITH A GENETIC PREDISPOSITION. PATIENT BELIEFS, PERCEPTIONS, AND ATTITUDES CONNECTED (AMYGDALA) TO THE DRUG USE NOW INITIATE THE DOWN REGULATION

11. SYMPTOM VS CAUSE • SUPPLYING MORE STIMULATION OF MU OPIATE RECEPTORS WITH OPIOD SUBSTITUTION TEMPORARILY RELIEVES THE PROBLEM BUT DOES NOTHING ABOUT CHANGING OR TREATING THE DISEASE STATE • THIS IS WHAT THE PATIENT HAS DONE ON THEIR OWN OVER THE YEARS DEVELOPING ADDICTION

12. HAIL TO THE KING!!!AMYGDALA • FEELING ARE CAUSED BY MANY NATURAL STATES OR CONDITIONED STATES • HUNGER, THIRST, LIBIDO ARE ALL FEELINGS CAUSED BY OUR BRAIN. YOU WON’T DIE OF A FEELING • THINK HOW UNCONFORMTABLE THE FEELING OF HUNGER CAN BE AND THE BEHAVIORS IT STIMULATES

13. HAIL TO THE KING!!!AMYGDALA • HUNGER AND THIRST CAN BE SYMPTOMS OF TYPE 1 DIABETES • DIABETES IS THE DISEASE AND TREATING THE SYMPTOMS (FEELINGS) DOES NO GOOD • HYERGYCEMIA IS ANOTHER SYMPTOM OF DIABETES. DESPIT THE EXCELLENT MEDICINES AVAILABLE TODAY THAT LOWER THE BLOOD SUGAR THE DISEASE CAUSES INCREASED RISK OF HEART DISEASE, STROKE, RENAL FAILURE, LOSS OF VISION AND AN EARLIER DEATH

14. SYMPTOM VS CAUSE • THE DISEASE WILL CONTINUE TO PROGRESS UNLESS WE ADDRESS THE HARD WIRING AND THE PATIENT BEGINS TO CHANGE THEIR BELIEFS, BEHAVIORS, PERCEPTIONS, AND ATTITUDES AND THEY BECOME UNATTACHED TO THE DRUGS • THIS WILL EVENTUALLY BEGIN TO ADDRESS THE NEUROTRANSMITTER, DOWN REGULATED RECEPTOR, AND HARD WIRING PROBLEM (THE DISEASE) AND IF YOU WILL REWIRE-REPROGRAM THE PATIENT.

15. Definition of Insanity: Doing the same thing over and over and expecting different results

16. Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are people who cannot or will not give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way. They are naturally incapable of grasping and developing a manner of living which demands rigorous honesty. Their chances are less than average. There are those, too, who suffer from grave emotional and mental disorders, but many of them do recover if they have the capacity to be honest. Bill Wilson Alcoholics Anonymous 1939

17. REBT • One of the fundamental premises of REBT is that humans, in most cases, do not merely get upset by unfortunate adversities, but also by how they construct their views of reality through their language, evaluative beliefs, meanings and philosophies about the world, themselves and others.[3] In REBT, clients usually learn and begin to apply this premise by learning the A-B-C-model of psychological disturbance and change. The A-B-C model states that it normally is not merely an A, adversity (or activating event) that contributes to disturbed and dysfunctional emotional and behavioral C, consequences, but also what people B, believe about the A, adversity. A, adversity can be either an external situation or a thought or other kind of internal event, and it can refer to an event in the past, present, or future.[4] • BELIEF SYSTEM IS EXTREMELY IMPORTANT

18. Why don’t we just change? • pain, pain ,pain! • emotional uncomfortability • internal conflict • anxiety • If left to ourselves, we will continue to do and think the same as we have all of our lives. • 1-2 months of treatment vs. 10-20 years of old behavior

19. Who am I ? Self Honesty? • a truthful person that occasionally lies vs. a dishonest person who occasionally tells the truth • an humble person with occasional arrogant episodes vs. an arrogant person who occasionally manages humility • a selfless individual who can be selfish vs. a self-centered person who can be other-centered • if I don’t discover this I can not change. I have no valid starting point.

20. Self Honesty Equals (AS BILL SEES IT) • acknowledging (gaining of insight) and accepting (this is who I am) of character defects • emotional honesty (this is how I feel) • boundaries (this is what I need to do for me) • I am defined by a set of defects(and positive qualities) and make changes from there (4th and 5th steps) • I DON’T THINK THIS IS POSSIBLE WHILE STILL ON OPIATES AND/OR STIMULANTS

21. CHANGE ??? • IF WE DON’T HAVE AN ACCURATE STARTING ASSESSMENT OF WHO WE ARE AND OUR CHARACTERLOGICAL MAKEUP (STEPS 4 AND 5) WE CANNOT GET BETTER AND CHANGE. • I WILL NOT “WORK” TO CHANGE THAT WHICH I DON’T RECOGNIZE IN MYSELF (I.E. SELFISHNESS) • I WILL NOT “WORK” TO CHANGE THAT WHICH DOES NOT CAUSE ME TO BE UNCOMFORTABLE IN THE ABSENCE OF THE OF THE DRUG (OR ADDICTIVE BEHAVIORS SUCH AS SEXUAL COMPULSIVITY AND EATING DISORDERS) • I TOOK THE DRUG TO DEAL WITH THE WAY I FELT IN THE FIRST PLACE 21

22. First things first • We can not think ourselves into right behavior, we must act ourselves into right thinking? • Our reality that we base our thinking on is formed by our personality make up (character defects)

23. THE PROCESS • ADDICTION IS NOT A “PEEL OFF” DIAGNOSIS. WE GROW INTO ADDICTION. IT IS THE RESULT OF THOUSANDS OF SMALL CHOICES MADE OVER TIME. IT BECOMES PART OF WHO AND WHAT WE ARE. TO GET IN RECOVERY TAKES THOUSANDS OF SMALL CHOICES OVER TIME FOR RECOVERY. WE HAVE TO GROW OUT OF ADDICTION INTO RECOVERY.

24. CRITERIA FOR STUDY OF OPIATE SUBSTITUTION 1. TWO OR MORE FAILED TREATMENTS 2. DRUG OF CHOICE WAS HEROIN (MAINLY IV) OR OXYCODONE OR HYDROCODONE EQUIVALENT TO 100MG OF HYDROCODONE PER DAY 3. COMMITMENT TO STAY IN HALFWAY HOUSE AND IOP AFTER RESIDENTIAL TREATMENT AND THEN RESIDE IN LOCAL AREA THRU ONE YEAR FROM ADMISSION

25. CRITERIA FOR STUDY USING OPIOD SUBSTITUTION THERAPY 4. SIGNED UNDERSTANDING OF SIDE EFFECTS INCLUDING PHYSICAL DEPENDENCE 5. SIGNED AGREEMENT THAT SHOULD THEY LEAVE WE WOULD NOT CONTINUE TO PRESCRIBE SUBOXONE FOR THEM AND THEY WOULD BE RESPONSIBLE FOR FOLLOW UP

26. CRITERIA FOR STUDY USING OPIOD SUBSTITUTION THERAPY 6. IF THEY WERE THERAPEUTICALLY DISCHARGED WE WOULD NOT BE RESPONSIBLE FOR FOLLOW UP 7. THEY WOULD GET ONE WARNING ON BEHAVIORAL ISSUES AND THEN BEHAVIOR CONTRACT(FAILURE TO KEEP FACILITY RULES AND GUIDELINES AS PUBLISHED AND SIGNED OFF ON IN PATIENT HANDBOOK) 8. ALL ABOVE BEHAVIORAL RULES APPLIED TO CONTROL GROUP ALSO

27. CRITERIA FOR STUDY USING OPIOD SUBSTITUTION THERAPY 9. ALL MEDICAL AND PSYCHIATRIC ISSUES WOULD BE ADDRESSED WITHOUT REGARD TO SUBOXONE AND CARE WOULD BE EQUAL BETWEEN GROUPS 10. ONE PHYSICIAN HANDLED SUBOXONE DOSING AND ALL PATIENTS WERE GIVEN REGULAR STAFFING. IT WAS NOT BLINDED. 11. PATIENTS MADE A COMMITMENT NOT TO TALK ABOUT WHETHER THEY WERE ON SUBOXONE OR NOT WITH OTHER PATIENTS ESPECIALLY NOT DOSES(THIS WAS A JOKE!!!)

28. AGE DISTRIBUTION CONTROL VS SUBOXONE

29. AGE DISTRIBUTION BY PERCENTAGE

30. RELAPSE AND LOST TO FOLLOW UP BY AGE FOR SUBOXONE TREATMENT OF OPIOD DEPENDENCE89% (41/46)

31. RELAPSE AND LOST TO FOLLOW UP BY AGE FOR SUBOXONE TREATMENT OF OPIOD DEPENDENCEBY PERCENTAGE {TOTAL 89% (41/46)}

32. RELAPSE AND LOST TO FOLLOW UP FOR SUBOXONE TREATMENT OF OPIOD DEPENDENCEBY QUARTER89%(41/46)

33. RELAPSE AND LOST TO FOLLOW UP FOR SUBOXONE TREATMENT OF OPIOD DEPENDENCEBY QUARTER89%(41/46)

34. RELAPSE AND LOST TO FOLLOW UP BY AGE FOR CONTROLS WITH OPIOD DEPENDENCE34% (16/47)

35. RELAPSE AND LOST TO FOLLOW UP FOR CONTROLS IN TREATMENT OF OPIOD DEPENDENCE BY QUARTER34%(16/47)

36. RELAPSE AND LOST TO FOLLOW UP FOR CONTROLS IN TREATMENT OF OPIOD DEPENDENCE BY QUARTER AND BY PERCENTAGE{TOTAL 34%(16/47)}

37. SOME CONCLUSIONS • 13% OF CONTROLS LOST IN FIRST QUARTER • 8% OF SUBOXONE GROUP LOST IN FIRST QUARTER • PUT OPIOD DEPENDENT PATIENTS ON LONGER SLOWER DETOX ESPECIALLY HEROIN AND OXYCODONE DEPENDING ON QUANTITY USED I.E. 2-3 WEEKS

38. SOME CONCLUSIONS • PLEASE HEAR THIS IF YOU DON’T HEAR ANYTHING ELSE. THE 18-25 YEAR OLD AGE GROUP(ENTITLED) THAT HAS ACCOMPLISHED NOTHING IN THEIR LIVES BUT DRUG USE AND SOME SCHOOL ON AND OFF, WHO HAVE THE EMOTIONAL MATURITY OF TEEN AGERS DO “ABYSMALLY”ON SUBOXONE.

39. SOME CONCLUSIONS • IN SUBOXONE GROUP WE LOST 2/4 IN THE 46-55 AGE GROUP OR 50% • IN THE CONTROL GROUP WE LOST 4/6 IN THE 46-55 AGE GROUP OR 66% • IF THERE IS A GROUP THAT DOES BETTER OR AS GOOD AS CONTROLS ON SUBOXONE, IT IS THE MIDDLE AGED OR OLDER SOCIALLY STABLE (JOB, FAMILY, FINANCES, LEGAL, SUPPORT) THAT HAS BECOME A PRESCRIPTION OPIATE ADDICT (USUALLY STARTED FOR MEDICAL CAUSE, MORE WOMEN THAN MEN)

40. CRITERIA FOR STIMULANT TREATMENT FOR ADHD 1. TWO INTERVIEWERS, USUALY PSYCHIATRIST, PSYCHIATRIC NURSE PRACTIONER, AND/OR PSYCHOLOGIST AGREE PATIENT HAS DX OF ADHD EITHER HYPERACTIVE, INATTENTIVE, OR COMBINED TYPE 2. THERE COULD HAVE BEEN SOME STIMULANT ABUSE IN THE PAST BUT IT COULD NOT BE THEIR DRUG OF CHOICE

41. CRITERIA FOR STIMULANT TREATMENT FOR ADHD 3. NO MORE THAN 25% OF THOSE TREATED WITH STIMULANTS COULD HAVE ABUSED STIMULANTS IN THE PAST 4. INITIALLY POOR OUTCOMES ON ADDERALL LEAD US TO SWITCH TO LONG ACTING PREPARATIONS LIKE CONCERTA OR PRO DRUG LIKE VYVANSE

42. CRITERIA FOR STIMULANT TREATMENT FOR ADHD 5. ONE PSYCHIATRIST SAW ALL PATIENTS FOR PROGRESS AND DOSAGE ADJUSTMENTS 6. PATIENTS AGREED TO NOT DISCUSS DOSAGES, DRUG USED, OR INTERVIEWS WITH PSYCHIATRIST WITH OTHER PATIENTS. 7. ONE OR MORE FAILED TREATMENTS

43. CRITERIA FOR STIMULANT TREATMENT FOR ADHD 8.COMMITMENT TO STAY IN HALFWAY HOUSE AND IOP AFTER RESIDENTIAL TREATMENT AND THEN RESIDE IN LOCAL AREA THRU ONE YEAR FROM ADMISSION 9.SIGNED AGREEMENT THAT SHOULD THEY LEAVE WE WOULD NOT CONTINUE TO PRESCRIBE STIMULANT FOR THEM AND THEY WOULD BE RESPONSIBLE FOR FOLLOW UP 10. ONE VERBAL WARNING ON BEHAVIOR PROBLEMS THEN WRITTEN BEHAVIOR CONTRACT AND THEN THERAPEUTIC DISCHARGE.

44. CRITERIA FOR STIMULANT TREATMENT FOR ADHD 11. ALL PATIENTS HAD ADHD WORK BOOKS WITH ASSIGNMENTS ON BEHAVIORAL INTERVENTIONS FOR ADHD 12. ALL PATIENTS PARTICIPATED IN SPECIAL ADHD GROUPS LED BY PYSCHIATRIST AND PYSCHIATRIC NURSE PRACTIONER

45. AGE DISTRIBUTION CONTROL VS STIMULANT

46. AGE DISTRIBUTION CONTROL VS STIMULANT BY PERCENTAGE

47. RELAPSE AND LOST TO FOLLOW UP BY AGE FOR STIMULANT TREATMENT OF ADHD100%(43/43)

48. RELAPSE AND LOST TO FOLLOW UP BY AGE FOR STIMULANT TREATMENT OF ADHD BY PERCENTAGE100%(43/43)

49. RELAPSE AND LOST TO FOLLOW UP FOR STIMULANT TREATMENT OF ADHDBY QUARTER100%(43/43)

50. RELAPSE AND LOST TO FOLLOW UP FOR STIMULANT TREATMENT OF ADHDBY QUARTER AND BY PERCENTAGE{TOTAL (43/43) 100%}