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Addiction: Identification & Treatment Ken Roy, MD, FASAM Addiction Recovery Resources of New Orleans River Oaks Hospital Tulane Department of Psychiatry www.arrno.org [email protected] The Diagnosis of Addiction Bums and bad people? No! 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 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 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 Substance Dependence Shorthand Compulsion Loss of control Continued use in the face of adverse consequences CAGE Cut down Angry “Do you get angry when someone talks to you about your drinking?” Guilt “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 “Have you had a drink (or a drug) to prevent or cure a hangover?” TACE Tolerance Anger “Do you get angry when someone talks about your drinking?” Cut down “Can you drink more than your friends?” “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?” “G A T E S” Guilt Anger “Can you drink more than your friends?” Eye opener “Do you get angry when someone talks about your drinking?” Tolerance “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 “Have you ever tried to stop or cut down on your drinking?” Models of Treatment Based on assumptions about etiology Moral Model Learning Model Self Medication Model Disease Model Integrative Models Moral Model Still Current Goals from evil to good, weak to strong Advantages Teen Challenge, etc. Moral inventory & responsibility for consequences Liabilities therapist is judgmental, punitive & blaming Learning Model Inadvertently learned bad habits Goals Advantages from uncontrolled to controlled from bad habits to good habits stresses new learning, pt. responsible for learning Liabilities emphasis on control can increase denial Self Medication Model Using is a coping mechanism for psychological lesions Goals from needing to use to not needing to use Advantages common in psychiatric programs stresses dx & tx of psychopathology Liabilities psychopathology seen as etiology Disease Model Recently dominant model Goals from sick to well, from using to recovering Advantages based on genetic predisposition self care rather than self control Liabilities minimizes coexistent pathology Integrative Models AA Dual Diagnosis Both are primary learning theory effective Biopsychosocial Moral + Disease Models individualizes these three domains Multivariant most of the modern effective programs Philosophy of Treatment Disease Concept Abstinence Genetic Predisposition Environment only rational goal of treatment Multivariant Treatment Model use all the tools individualize interventions Equation for Illness Genetics + Environment = Disease 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 Contribution of Environment Similarity to TB Impact of Using on Emotional Development Other Diagnoses Psychoses Mood Disorders, Anxiety Disorders, Others Abstinence Similarity to Diabetes AA/NA/GA/RR not MM Common Experiences Fellowship Impact on Emotional Development Use of Medications Importance to Relapse Elements Multiaxial Diagnostic Assessment Abstinence Level of Care Education, Cognitive Restructuring Identification Support System Involvement Discharge Planning Multiaxial Diagnostic Assessment Medical Assessment Laboratory & Imaging Family History Psychological Assessment Mental Status Examination Social Assessment 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 Education and Identification AA/NA/GA Materials Workbook Lectures Group Community Support System Involvement Co-addiction Anger and Frustration Communication Single Family to Multifamily Discharge Planning Time Integration Treatment should “generalize” Motivation Relapse Support Distinction From Other Psychiatric Treatment Not Necessarily Dual Diagnosis Not Incompetent Do Not Meet Psychiatric Admission Criteria High Functioning Theory of Genetic Drift Low tolerance For Infantalizing Interactions Level of Care = Abstinence and Attendance Not Protection of Self or Others 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 WHAT DOES A.A. DO? A.A. members share their experience with anyone seeking help with a drinking problem Members voluntarily give person-toperson assistance or “sponsorship” to an alcoholic coming to A.A. from any source 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 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 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 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 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 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 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 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 Problem Patients & Problem Prescriptions Potential problem patients Problem prescriptions Classes of addicting drugs Potential Problem Patients Family history of alcoholism External locus of control Pain persistent or out of proportion Litigation Multiple meds Problem Prescriptions Soma, Fiorinal, Valium, Xanax Ritalin, Adderall Vicodin, Percodan, Ultram, OxyContin Classes of Addicting Drugs Related to the specific reinforcing pathway Three main classes Sedative hypnotics and opioids are the vast majority of problem prescriptions Sedative Hypnotics Active in the GABA system Alcohol Benzodiazepines (Rohypnol) Barbiturates (Fiorinal) Hypnotics (Ambien Sonata) Muscle Relaxants (Soma) Opiates Active in the endorphin systems Vicodin, other oxy & hydro codones Especially ES formulations & OxyContin Stadol, Fentanyl, Buprenorphine Ultram Methadone Stimulants Active in the dopamine system Amphetamines (Adderall) Others (Ritalin, Cylert) *Decongestants