Addiction: Identification & Treatment

1. Addiction: Identification & Treatment Ken Roy, MD, FASAM Addiction Recovery Resources of New Orleans River Oaks Hospital Tulane Department of Psychiatry www.arrno.org kenroymd@bellsouth.net

2. The Diagnosis of Addiction • Bums and bad people? • No!

3. 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

4. Criteria for Substance Dependence (DSM-IV) • 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

5. 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

6. Substance Dependence Shorthand • Compulsion • Loss of control • Continued use in the face of adverse consequences

7. 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?”

8. 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?”

9. “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?”

10. Models of Treatment • Based on assumptions about etiology • Moral Model • Learning Model • Self Medication Model • Disease Model • Integrative Models

11. Moral 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

12. Learning 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

13. Self 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

14. Disease 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

15. Integrative 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

16. Philosophy of Treatment • Disease Concept • Genetic Predisposition • Environment • Abstinence • only rational goal of treatment • Multivariant Treatment Model • use all the tools • individualize interventions

17. Equation for Illness • Genetics + Environment = Disease

18. Genetic 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

19. Contribution of Environment • Similarity to TB • Impact of Using on Emotional Development • Other Diagnoses • Psychoses • Mood Disorders, Anxiety Disorders, Others

20. Abstinence • Similarity to Diabetes • AA/NA/GA/RR not MM • Common Experiences • Fellowship • Impact on Emotional Development • Use of Medications • Importance to Relapse

21. Elements • Multiaxial Diagnostic Assessment • Abstinence • Level of Care • Education, Cognitive Restructuring • Identification • Support System Involvement • Discharge Planning

22. Multiaxial Diagnostic Assessment • Medical Assessment • Laboratory & Imaging • Family History • Psychological Assessment • Mental Status Examination • Social Assessment

23. Levels 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

24. Education and Identification • AA/NA/GA Materials • Workbook • Lectures • Group • Community

25. Support System Involvement • Co-addiction • Anger and Frustration • Communication • Single Family to Multifamily

26. Discharge Planning • Time • Integration • Treatment should “generalize” • Motivation • Relapse Support

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. Problem Patients & Problem Prescriptions • Potential problem patients • Problem prescriptions • Classes of addicting drugs

39. Potential Problem Patients • Family history of alcoholism • External locus of control • Pain persistent or out of proportion • Litigation • Multiple meds

40. Problem Prescriptions • Soma, Fiorinal, Valium, Xanax • Ritalin, Adderall • Vicodin, Percodan, Ultram, OxyContin

41. Classes of Addicting Drugs • Related to the specific reinforcing pathway • Three main classes • Sedative hypnotics and opioids are the vast majority of problem prescriptions

42. Sedative Hypnotics • Active in the GABA system • Alcohol • Benzodiazepines (Rohypnol) • Barbiturates (Fiorinal) • Hypnotics (Ambien Sonata) • Muscle Relaxants (Soma)

43. Opiates • Active in the endorphin systems • Vicodin, other oxy & hydro codones • Especially ES formulations & OxyContin • Stadol, Fentanyl, Buprenorphine • Ultram • Methadone

44. Stimulants • Active in the dopamine system • Amphetamines (Adderall) • Others (Ritalin, Cylert) • *Decongestants