Download 96 Hour Evaluations

CAPTASA
January
2008
96-Hour Assessments
The New Intervention Tool
Michael Wilkerson, MD
Medical Director
Bradford Health Services
96-Hour Assessment
Components
 Internal Medicine Evaluation
 Laboratory Work
 Psychological & Neuropsychiatric Testing
 Psychiatric Evaluation
 Addiction Medicine Evaluation
 Collateral Data
 Therapeutic Community
Internal Medicine Evaluation
History
 Gout
 Peptic Ulcer Disease / Gastritis/ Esophagitis
 Hepatitis C
 Pancreatitis
 Atrial Fibrillation
 Seizures
 Sleep Disturbances
Internal Medicine Evaluation
Physical
 Hypertension
 Palmar Erythema
 Tachycardia
 Needle Marks
 Tremor
 Rosacea
 Hepatomegaly
 Peripheral
 Spider Angiomata
Neuropathy
Internal Medicine Evaluation
Labs
 Transaminitis (i.e îSGOT, SGPT, GGT)
 Hyperlipidemia
 Macrocytosis
 Carbohydrate-Deficient Transferrin
 Drug Screening
 Urine
Drug Screening
 ETG
 Saliva
Testing
 Hair Testing
Neuropsychiatric Testing
 Wechesler Adult Intelligence Scale
 Memory Assessment Scale
 Halstead Reitan Neuropsychological Tests
 Tactual Performance Test
 Finger Tapping Test
 Reitan Indiana Aphasia Screening Test
 Trailmaking Test
Neuropsychiatric Test
Findings
A, B & C…
A.
Split between verbal & performance IQ
 > 10 points
 Usually seen with alcohol,
benzodiazepines, polydrug
 Impaired visual spatial functions &
visual perceptual speed
Neuropsychiatric Test
Findings
B.
Impairments typically seen in the other tests
when addressing patients with a history of
 Alcohol
 Sedative hypnotic, or
 Polydrug abuse
Neuropsychiatric Test
Findings
C. Impairments not typically seen in abusers of
 Opiates
 Amphetamines, or
 Hallucinogens
Psychological Testing
 Minnesota Multiphasic Personality
Inventory –2 (MMPI-2)
 Million Clinical Multiaxial Inventory III
(MCMI-III)
Psychological Findings
Scales to address addiction and
addiction potential document emotional
and personality variables which may
affect treatment.
Psychiatric Evaluation
 Part of the addiction assessment
 Dual Diagnoses Issues…
 Depressive
Disorders
 Anxiety Disorders
 ADD/ADHD
 Bipolar Disorders
 Axis II Diagnosis
Important Issues Addressed in
the Psychiatric Evaluation
 Is the psychiatric diagnosis the primary
issue?
 Medication Management Issues
 Appropriate Level of Care
Addiction Medicine Evaluation
DSM IV Criteria
Generic Criteria for Substance Dependence
The Patient’s maladaptive pattern of substance
use leads to clinically important distress or
impairment shown in a single 12-month period by
3 more of the following:

Tolerance, shown by either of:
 Markedly increased intake of the substance is needed to
achieve the same effect or
 With continued use, the same amount of the substance has
markedly less effect
 Withdrawal, shown by either of:
 The substance’s characteristic withdrawal syndrome or
 The substance (or one closely related) is used to avoid or
relieve withdrawal symptoms
Generic Criteria for Substance Dependence
continued…





The amount of duration of use is often greater
than intended.
The patient repeatedly tries without success to
control or reduce substance use.
The patient spends much time using the
substance, recovering from its effects or trying
to obtain it.
The patient reduces or abandons important
social, occupational or recreational activities
because of use.
The patient continues to use the substance,
despite knowing that it has probably caused
physical or psychological problems.
Generic Criteria for Substance Abuse
 The patient’s maladaptive substance use
pattern causes clinically important distress or
impairment in a single 12-month period by 1 or
more of the following:




Because of repeated use, the patient fails to carry out major
obligations at work or at home.
The patient uses substances even when it is physically
dangerous.
The patient repeatedly has legal problems from substance use.
Despite knowing that it has caused or worsened social or
interpersonal problems, the patient continues to use the
substance.
 For this class of substance, the patient has
never fulfilled criteria for substance
dependence.
Collateral Data
 Assessment Coordinator Directs
 Full Time Position
 Collects information from family, friends and
colleagues
 Coordinator meets with individual daily
 Must be able to ask the “right questions”
 Helps the individual reprocess any new
information
Therapeutic Community
 Housed in apartment complex with
other peers who are in treatment
 Attend groups and 12-Step meetings
 Attend 1st Step presentations
 Can “mirror image” off others in the
community
Additional Assessments
If Indicated
 Pain Evaluation
 Sexual Boundaries Evaluation
Indications for a 96-Hour
Assessment
 Unclear Diagnosis
 Determine Level of Care Needed
 Secondary Intervention
 Confirm Non-diagnosis
 Fit to Return to Duty
 Relapse Issues (not only use but behavior)
96-Hour Assessments
Advantages
 Thorough evaluation done in 4 days
 Therapeutic Community
 Teamwork vs. Splitting
Disadvantages
 Travel
 Cost ($5,000)
 Perceived conflict of interest
Assessment Recommendations
1998-2004
600
500
400
300
200
100
0
1998
1999
2000
2001
96 Hr Assmt.
2002
Tx Rec.
2003
Tx Acpt.
2004
Total
Assessment Recommendations
1998-2004
Totals
96-Hour Assessments
597
Treatment Recommended
333
Percent Tx. Recommended
56%
Treatment Accepted
218
Percent Tx. Accepted
65%
Treatment not recommended
264
Percent Tx. not recommended
44%
Assessment Recommendations
1998-2001
1998
1999
2000
2001
96-Hour Assessments
78
55
74
100
Tx Recommended
47
29
37
60
60%
53%
60%
53%
27
14
24
44
57%
48%
65%
73%
31
26
37
40
40%
47%
50%
40%
% Tx recommended
Tx Accepted
% Tx Accepted
Tx not recommended
% Tx not recommended
Assessment Recommendations
2002-2004
2002
2003
2004
96-Hour Assessments
78
55
74
Tx Recommended
47
29
37
60%
53%
60%
27
14
24
57%
48%
65%
31
26
37
40%
47%
50%
% Tx recommended
Tx Accepted
% Tx Accepted
Tx not recommended
% Tx not recommended
Talbott Recovery Campus
Review of Assessments
1998-2004
 Age and Sex
 The
average age of 597 patients assessed
from 1998 through 2004 was 44.9 years
with a range from 22 years to 84 years.
The average age didn’t vary from year to
year.
 494 patients (82.5%) were male with the
average age of 45.9 years
 103 patients (17.5%) were female with the
average age of 40.5 years
 Occupation
 499 patients (83.7%) – Health Professionals
Health Prof.
Number
Percent
MD
324
64.9%
DDS
72
14.4%
RN
23
4.6%
DO
23
4.6%
RPh
16
3.2%
Med. Student
9
1.8%
RN/PA
6
1.2%
Veterinarian
5
1.0%
LPN
5
1.0%
Medical Tech
3
0.6%
Occupation (cont’d)
Health Prof.
Number
Percent
Chiropractor
2
0.4%
Psychologist
2
0.4%
Physician’s Asst.
2
0.4%
Health Admin
2
0.4%
Social Worker
1
0.2%
Podiatrist
1
0.2%
Nurse Practitioner
1
0.2%
Naturopath
1
0.2%
Paramedic
1
0.2%
 MD Specialty
Specialty
Number
Percent
Gen/Family Practice
70
21.6%
Internal Medicine
59
18.2%
Anesthesia
55
17.0%
Emergency Medicine
23
7.1%
OB/GYN
15
4.6%
Pediatrics
14
4.3%
Psychiatry
14
4.3%
Radiology/Oncology
10
3.1%
Surgery, General
9
2.8%
Surgery, Neurological
9
2.8%
 MD Specialty (cont’d)
Specialty
Number
Percent
Surgery, Plastic
7
2.2%
Surgery, Urology
7
2.2%
Pathology
4
1.2%
Surgery, Cardiothoracic
4
1.2%
Surgery, ENT
4
1.2%
Neurology
3
0.9%
Pain
3
0.9%
Surgery, Ophthalmologic
3
0.9%
Neurology
3
0.9%
Occupational
2
0.6%
 MD Specialty (cont’d)
Specialty
Number
Percent
Surgery, Orthopedic
2
0.6%
Anesthesiology
1
0.3%
Dermatology
1
0.3%
Physical Medicine
1
0.3%
Surgery, Pediatric
1
0.3%
Non-Health Professionals
 98 Patients (16.3%)
 10
attorneys
 32 pilot/flight attendants
Referral Sources
State Medical Boards
PHP, PRN, PAP
44%
21%
Employer
Hospital Authority
Partners
Self
8%
8%
4%
4%
For return to work
Family
Attorney
4%
3%
3%
Wife, Friend
Military
Medical School
2%
1%
1%
Final Diagnoses Categories
Diagnoses Categories
Alcohol Abuse/Dep.
Number
144
Percent
34.8%
Opiate Abuse/Dep.
No Final Diagnosis
Polysub.Abuse/Dep.
86
55
20
20.8%
13.3%
4.8%
Depressive Disorder
Major Depression
Cocaine Abuse/Dep.
Partner Relationship
14
14
8
8
3.4%
3.4%
1.9%
1.9%
Cannabis Abuse/Dep.
Bipolar Disorder
Cognitive Disorder
7
7
7
1.7%
1.7%
1.7%
Final Diagnoses Categories (cont’d)
Diagnoses Categories
Amphet. Abuse/Dep.
Number
6
Percent
1.4%
Occupational Problems
Sed-hypnotic Abuse
Misc.
6
4
5
1.4%
1.0%
1.2%
Dysthymia
Panic Disorder
Benzo. Abuse/Dep.
Pathologic Gambling
4
4
3
3
1.0%
1.0%
0.7%
0.7%
Sexual Disorder
Nitrous Oxide Abuse
Pain Disorder
3
3
2
0.7%
0.7%
0.5%
Drugs of Abuse/Dependence
 Alcohol was first drug of choice (46%)
 61 patients with other diagnoses also
consumed alcohol making it significant
in 63% of all assessments
 Opiates was drug of choice in 41% of
patients.
Drugs of Abuse/Dependence
 Hydrocodone was opiate of choice in 58% of




Opiate Abuse/Dependence cases.
Oxycodone was drug of choice in 17%
Fentanyl was drug of choice in 17%
Other drugs were propoxyphene, codeine,
meperidine, hydromorphone and morphine.
Analgesics butophanol (Stadol) and tramadol
(Ultram) were reported in a few cases-usually
in conjunction with other drugs
Drugs of Abuse/Dependence
 Amphetamines was first drug of choice in 9 cases




(methamphetamine and prescription amphetamines)
Second and third choice drugs in amphetamine
addicts were alcohol, benzodiazepines and opiates
Butalbital was the principle drug of choice in patients
reporting sedative-hypnotic use.
Diazepam, alprazolam, zolpidem and lorazepam
were principal benzodiazepine drugs of choice.
56% of patients reported use of nicotine-containing
products (63% of patients admitted for regular
treatment report use of nicotine-containing products)
Dual Diagnosis
 66% of patients diagnosed with
Abuse/Dependence have one or more
coexisting disorders in diagnostic profile
Dual Diagnosis (Axis 1)
Major Depression/Depressive
Disorder NOS
44%
Addiction to other drug families
43%
Dysthymia/Bipolar Disorder
22%
Cognitive Disorders/Inefficiency
6%
Axis II Diagnostic Patterns
 47% of all assessment patients were
diagnosed with abnormal personality
characteristics.
Axis II Traits/Features
Traits/Features
Number
%-Axis II
Narcissistic
54
28%
Compulsive
32
17%
Histrionic
23
12%
Avoidant
19
9%
Ob-Compulsive
14
7%
Dependent
8
4%
Passive Aggressive
1
0.5%
Axis II Traits/Features (cont’d)
Traits/Features
Number
%-Axis II
Antisocial
5
2.6%
Schizoid
3
1.6%
Cluster B
4
2.1%
Obsessive
3
1.6%
Borderline
2
1.0%
Self Defeating
1
0.5%
Personality Disorder
24
6%
Talbott Recovery Campus
Michael Wilkerson, MD, Medical Director
1-800-445-4232
www.talbottcampus.com
5448 Yorktowne Drive
Atlanta, GA 30349
Lisa Cottrell,MA, LAPC
96-Hour Coordinator