Chemical Addictions — General Overview

1. Chemical Addictions—General Overview Abdullahi Mubarak, MD Medical Director of Addiction Services at PEMCO Chief Medical Officer at Consortium Clinical Services, LLC

2. Objectives • Understand general terminology • The disease of Addiction • Symptoms of the disease • Stages of change • Diagnostic tips • General treatment approaches

3. Terminology • Use—drug taking not associated with harm • Abuse—drug taking associated with harm • Dependence—adaptation to drug evidenced by normal functioning and/or withdrawal syndrome • Addiction—loss of control, compulsion, continued use despite adverse consequences

4. Terminology • Abuse potential—the likelihood that a person will abuse a drug based upon it’s pleasurable effects, toxicity, and society’s attitude toward the users of the drug • Addiction potential—the likelihood that a drug will produce addiction in chronic users

5. Relative Addiction Potential • Cocaine (crack, IV, snorted, chewed) • Methamphetamine (smoked) • Nicotine (IV, smoked, chewed) • Opiates (IV, smoked, snorted, chewed, oral) • Alcohol • Sedative-hypnotics • Anabolic steroids • Marijuana • Inhalants • PCP, other hallucinogens (LSD, Special K, )

6. Disease of Addiction • Addiction is primarily a function of many genetically predisposed biological responses. • The response and/or lack of the drug reinforces the repeated use of the drug. • The environment permits and facilitates the use of the drug. • Addiction can be “created” in low risk patients with chronic use of drugs of high addictive potential.

7. Progression of the Disease • Erratic drug-taking pattern, erratic sleep, work, eating, grooming, and social habits • New forms of enjoyment, new “friends”, ways of relating, isolation, hiding money, hiding whereabouts, lying • Legal, financial, marital, social, career, and lastly physical adverse consequences

8. Stages of Change • Pre-contemplation—lacks awareness • Contemplation—ambivalent about change • Preparation—getting information in order to change • Action—actually committing to sobriety in deed • Maintenance—attaining stability • Recovery—sobriety • Relapse—use leads to return to contemplation

9. Signs of Aberrant behavior • Prescription forgery • Concurrent abuse of illicit drugs • Selling prescriptions • Recurrent lost, stolen, or spilled drugs • Stealing or borrowing from others • Obtaining drugs from non-medical sources • Obtaining scripts from multiple doctors

10. Indicators of Suspicion • Reluctant to present identification • “Out of town” patient • Overly willing to pay cash • Telephone call in for controlled substances • Presents when the regular physician cannot be reached

11. Indicators of Suspicion • Allergy to NSAIDS, COX-2’s, or codeine • Intolerant to collateral contacts • Intolerant to in-depth interviews • Interested only in the drug, not the diagnosis • Reluctant to comply with diagnostic testing, pill counts, and urine screening

12. Factors Less Indicative • Drug hoarding during periods of decreased symptoms • Unsanctioned dose escalation • Request for specific drugs by name • Focus on opiate issues during the first three office visits

13. Abnormal Physical Signs • Pupils < 3mm or >6.5mm in room light • Presence of nystagmus • Diminished or absent corneal and/or pupillary light reflex • Impaired convergence • Pulse < 60 or > 100/min • Venosclerosis or needle tracks • Perforated nasal septum

14. Characteristics of the Painpatient • Appreciates in-depth interviews • Cooperates with attempts to get collateral histories • Cooperates with pill counts and urine drug screening • Focus is on the diagnosis and the cure • Attempts to reduce medications on their own • Cooperates with diagnostic and therapeutic interventions

15. Addressing Aberrancy and indicators of suspicion • Obtain an INSPECT report • Urine drug screen (UDS) • Use oral salivary testing when urine screening is unavailable, patient unable to void, or the UDS is invalid • Pill counts when appropriate • Use Axis V outline to clarify your thoughts • Treat ONLY according to your diagnosis

16. INSPECT reports • The report is unconfirmed history until you confirm what’s in it. • “Multiple prescribers” means nothing until you call the providers to find out what they did, why they did it, and did they know there were other prescribers • Keep the interpretation of the report in your chart

17. Urine drug screening • The results only mean what the results say • Using them to make a diagnosis is only part of the total picture • Refer for addiction consultation, if the results are aberrant • Negative screens can mean abuse, addiction, diversion, or pseudo-addiction syndrome • Do not collect without temperature strips on the cup. • Be sure the reference lab tests for validity and multiple metabolites

18. Oral Salivary Testing • Easy to use, less intrusive • Shorter window of detection compared to urine drug screening • Accuracy comparable to blood testing • The results only mean what the result says

19. Pill Counts • Best when used sparingly or unexpected • Best to clarify negative urine drug screens • Order within 2 days to rule out diversion • Order within 10 days to rule out abuse or addiction • Pills can be brought to office or the pharmacy they purchased their pills • Record any markings on the pills for identification

20. Diagnostic Challenges • Impaired by lack of knowledge of differential diagnosis • Impaired by EMOTIONAL reactions to the “names” of controlled substances • Use Axis V outline to highlight deficiencies in knowledge or when you are becoming too emotional • Say “NO”, if the request is inappropriate for the diagnosis or you have inadequate information to arrive at a diagnosis • Continue to monitor to confirm or deny your provisional diagnosis. Being wrong is ok.

21. Consultation • Learn the biases of your consultants. • Psychiatry consultation for benzo and stimulant prescribing for mood disorders, ADHD, etc… • Addiction consultation to evaluate aberrancy • Pain management consultation to evaluate opiate prescribing

22. General treatment principles • Foremost goal initially is self-diagnosis • Educate—Addiction is a disorder in a person, not the pill • Medication assistance—diminish drug craving, withdrawal, and normalize function • Intensity of treatment related to intensity of use pattern and/or history of treatment failures • Strengthen social/spiritual supports