Addiction:%20Identification%20

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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
• kenroymd_at_bellsouth.net

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The Diagnosis of Addiction

• Bums and bad people?
• No!

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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

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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

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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 its 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

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Substance Dependence Shorthand

• Compulsion
• Loss of control
• Continued use in the face of adverse consequences

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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 hadnt, that you feel guilty
  about?
• Eye opener
• Have you had a drink (or a drug) to prevent or
  cure a hangover?

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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?

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G A T E S

• Guilt
• Have you done things while drinking that you
  wish that you hadnt, 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?

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Models of Treatment

• Based on assumptions about etiology
• Moral Model
• Learning Model
• Self Medication Model
• Disease Model
• Integrative Models

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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

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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

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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

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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

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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

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Philosophy of Treatment

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

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Equation for Illness

• Genetics Environment Disease

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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

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Contribution of Environment

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

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Abstinence

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

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Elements

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

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Multiaxial Diagnostic Assessment

• Medical Assessment
• Laboratory Imaging
• Family History
• Psychological Assessment
• Mental Status Examination
• Social Assessment

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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

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Education and Identification

• AA/NA/GA Materials
• Workbook
• Lectures
• Group
• Community

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Support System Involvement

• Co-addiction
• Anger and Frustration
• Communication
• Single Family to Multifamily

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Discharge Planning

• Time
• Integration
• Treatment should generalize
• Motivation
• Relapse Support

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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

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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

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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

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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

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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

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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

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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

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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

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Expectations of Some Professionals

• AAs 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

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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

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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

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Problem Patients Problem Prescriptions

• Potential problem patients
• Problem prescriptions
• Classes of addicting drugs

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Potential Problem Patients

• Family history of alcoholism
• External locus of control
• Pain persistent or out of proportion
• Litigation
• Multiple meds

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Problem Prescriptions

• Soma, Fiorinal, Valium, Xanax
• Ritalin, Adderall
• Vicodin, Percodan, Ultram, OxyContin

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Classes of Addicting Drugs

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

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Sedative Hypnotics

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

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Opiates

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

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Stimulants

• Active in the dopamine system
• Amphetamines (Adderall)
• Others (Ritalin, Cylert)
• Decongestants