Addiction Identification Treatment Ken Roy MD FASAM Addiction

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

The Diagnosis of Addiction n Bums and bad people? n No!

Criteria for Substance Dependence (DSM-IV) n 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 n Tolerance, as defined by: n n A need for increased amounts to achieve effect Markedly diminished effect from using the same amount

Criteria for Substance Dependence (DSM-IV) n Withdrawal, as manifested by: n n 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

Criteria for Substance Dependence (DSM-IV) n n n 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

Substance Dependence Shorthand n Compulsion n Loss of control n Continued use in the face of adverse consequences

CAGE n Cut down n n Angry n n “Do you get angry when someone talks to you about your drinking? ” Guilt n n “Have you ever tried to stop or cut down on your drinking? ” “Have you done things while drinking that you wish that you hadn’t, that you feel guilty about? ” Eye opener n “Have you had a drink (or a drug) to prevent or cure a hangover? ”

TACE n Tolerance n n Anger n n “Do you get angry when someone talks about your drinking? ” Cut down n n “Can you drink more than your friends? ” “Have you ever tried to stop or cut down on your drinking? ” Eye opener n “Have you ever had a drink (or a drug) to prevent or cure a hangover? ”

“G A T E S” n Guilt n n Anger n n “Can you drink more than your friends? ” Eye opener n n “Do you get angry when someone talks about your drinking? ” Tolerance n n “Have you done things while drinking that you wish that you hadn’t, that you feel guilty about? ” “Have you ever had a drink (or a drug) to prevent or cure a hangover? ” Stop n “Have you ever tried to stop or cut down on your drinking? ”

Models of Treatment n Based on assumptions about etiology n n n Moral Model Learning Model Self Medication Model Disease Model Integrative Models

Moral Model n Still Current n n Goals n n from evil to good, weak to strong Advantages n n Teen Challenge, etc. Moral inventory & responsibility for consequences Liabilities n therapist is judgmental, punitive & blaming

Learning Model n n Inadvertently learned bad habits Goals n n n Advantages n n from uncontrolled to controlled from bad habits to good habits stresses new learning, pt. responsible for learning Liabilities n emphasis on control can increase denial

Self Medication Model n Using is a coping mechanism for psychological lesions n n Goals n n from needing to use to not needing to use Advantages n n common in psychiatric programs stresses dx & tx of psychopathology Liabilities n psychopathology seen as etiology

Disease Model n Recently dominant model n n Goals n n from sick to well, from using to recovering Advantages n n based on genetic predisposition self care rather than self control Liabilities n minimizes coexistent pathology

Integrative Models n AA n n Dual Diagnosis n n n Both are primary learning theory effective Biopsychosocial n n Moral + Disease Models individualizes these three domains Multivariant n most of the modern effective programs

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

Equation for Illness n Genetics + Environment = Disease

Genetic Predisposition n What is inherited? n n Tolerance - Schuckit Endogenous Opiate system - Gianoulakis n n n Revia Dopamine Reward Systems - Nestler Why is it important? n n reduces shame explains ineffectiveness of willpower

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

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

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

Multiaxial Diagnostic Assessment n n Medical Assessment Laboratory & Imaging Family History Psychological Assessment n n Mental Status Examination Social Assessment

Levels of Care n Least invasive level necessary to achieve & maintain abstinence n Medically Managed Inpatient Treatment n n n Medical/Surgical Hospital Psychiatric Hospital Medically Supervised Inpatient Treatment Partial Hospitalization Intensive Outpatient Program Residential Treatment Program

Education and Identification n n AA/NA/GA Materials Workbook Lectures Group Community

Support System Involvement n n Co-addiction Anger and Frustration Communication Single Family to Multifamily

Discharge Planning n n Time Integration n Treatment should “generalize” Motivation Relapse Support

Distinction From Other Psychiatric Treatment n Not Necessarily Dual Diagnosis n n Not Incompetent n n Do Not Meet Psychiatric Admission Criteria High Functioning n n Theory of Genetic Drift Low tolerance For Infantalizing Interactions Level of Care = Abstinence and Attendance n Not Protection of Self or Others

WHAT IS A. A. ? n n n n Fellowship of men and women who have had a “drinking problem” Nonprofessional Self-supporting Nondenominational Multiracial, Multicultural Apolitical Available almost everywhere

WHAT DOES A. A. DO? A. A. members share their experience with anyone seeking help with a drinking problem n Members voluntarily give person-toperson assistance or “sponsorship” to an alcoholic coming to A. A. from any source n

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 n This program is discussed at A. A. group meetings n

WHAT A. A. DOES NOT DO Furnish initial motivation for alcoholics to recover n Solicit members n Engage in or sponsor research n Keep attendance records or case histories n

WHAT A. A. DOES NOT DO Join “councils” of social agencies n Follow up or try to control its members n Make medical or psychological diagnoses or prognoses n Provide drying-out or nursing services, hospitalization, drugs, or any medical or psychiatric treatment n

WHAT A. A. DOES NOT DO Offer religious services n Engage in education about alcohol n Provide housing, food, clothing, jobs, money, or any other welfare or social services n

WHAT A. A. DOES NOT DO Provide domestic or vocational counseling n Accept any money for its services, or any contributions from non-A. A. sources n Provide letters of reference to parole boards, lawyers, court officials, social agencies, employers, etc n

Expectations of Some Professionals AA’s are somehow paid to or “have to” help them with their drunks n Once they notify AA that they have a “live one, ” someone will come take them away and motivate them n

Expectations of Some Professionals AA is professional treatment, and professional treatment is AA n One meeting is a course of treatment, and drinking after one meeting is failed treatment n AA (or treatment) is only necessary after Cirrhosis or Seizures n

Solution Send your patient to AA, NA CA, etc. n Identify treatment professionals in your area who can accept those unable to get well (abstinent & in recovery) in AA alone n Refer to or consult treatment professionals like any other specialty n

Problem Patients & Problem Prescriptions Potential problem patients n Problem prescriptions n Classes of addicting drugs n

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

Problem Prescriptions n Soma, Fiorinal, Valium, Xanax n Ritalin, Adderall n Vicodin, Percodan, Ultram, Oxy. Contin

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

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

Opiates n Active in the endorphin systems n Vicodin, other oxy & hydro codones n Especially ES formulations & Oxy. Contin n Stadol, Fentanyl, Buprenorphine n Ultram n Methadone

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