Treating Alcohol and Drug Withdrawal 2. Tips for Taking a Good Alcohol and Drug History 3. OfficeBas

1
Treating Alcohol and Drug Withdrawal2. Tips
for Taking a Good Alcohol and Drug History3.
Office-Based Management Screening and Brief
Intervention

• Sauk Prairie Memorial HospitalSauk Prairie,
  WisconsinSeptember 26, 2006

2

• Michael M. Miller, MD, FASAM, FAPA
• mmiller_at_meriter.com
• Medical Director, MERITER / NewStart
• Madison, Wisconsin
• Associate Clinical Professor, UW Medical School
• President-Elect
• American Society of Addiction Medicine
• Member AMA, APA, AAAP, ASAM, AMERSA
• NAMI, NCADD, NAATP

3
Addiction Medicine

• The specialty of medicine devoted to diagnosis,
  treatment, prevention, education, epidemiology,
  research, and public policy advocacy regarding
  addiction and other substance-related health
  conditions

4
ASAM
5
Addiction Medicine

• Its not just for addiction specialists
• There can never be enough addition specialists to
  address such prevalent/common conditions
• Every physician encounters patients or family
  members affected by substance-related conditions
• Every primary care physician needs to know some
  basics about recognition and referral

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Other Resources

• http//www.dhfs.state.wi.us/SubstAbuse/INDEX.HTM
• The truth is that over 70 of the addiction care
  provided in the USA is via public funding
  knowing public agencies is important in getting
  your patients needs metthe State Bureau of
  Mental Health and Substance Abuse Services in
  DHFS the County Department of Human Services
  (Dan Brattset, 608-355-4202)
• NEW SBIRT Grant Awarded to Wisconsin DHFS!

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Addiction is only one of the Substance-Related
Disorders

• Addiction (Substance Dependence)
• Problem Use (Substance Abuse)
• Intoxication States
• Withdrawal States
• Substance-Induced Medical Problems
• Substance-Induced Psychiatric Problems
• Health Problems linked to Secondary Use
• Codependency and ACOA Syndromes

8
Management of Substance-Related Disorders Depends
on the Diagnosis

• Intoxication Management
• Withdrawal Management
• Management of Psychiatric Complications
• Management of Medical Complications
• Management of the Primary Disease of Addiction
  (Substance Dependence)
• Management of the minor syndrome called
  Substance Abuse

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Detox

• Intoxication Management
• Withdrawal Management

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DETOXIFICATION

• RESOLUTION OF A TOXIC STATE
• The Brain has been poisoned
• Manifestations are changes in behavior and
  changes in physiology

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Management of Withdrawal

• Nicotine
• Alcohol
• Sedatives
• Opioids
• Stimulants
• Hallucinogens

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Basic Principles of Detox

• Provide calm environment for the patient, to
  reduce anxiety that would amplify symptoms
  (regardless of the drug class)
• Replace the missing substance with a
  pharmaceutical that is cross-tolerant with the
  drug the patient is withdrawing from
• Stabilize the patient
• Institute a step-wise graded reduction in the
  replacement substance
• ORtrick the brain into thinking its receiving
  more of the missing substance

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Nicotine DetoxNicotine Replacement Therapy--NRT

• Transdermal
• Oral (buccal)
• Nasal
• Inhaled

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Alcohol Detox(Sedative Replacement)

• Benzodiazepines
• Other sedatives will work but have
  disadvantagesbarbiturates, ethanol, paraldehyde
• Other sedating drugs that arent cross-tolerant
  with EtOH wont work, e.g. phenothiazines
• Second generation anticonvulsants

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Opioid Detox (Opioid Replacement)

• Methadone
• Buprenorphine
• Any opioid will work but all others are
  illegal! except tramadol (Ultram)
• Clonidine (also guanfacine, lofexidine)
• Supplemental agents for symptom relief
• for anxiety, insomnia, aches, nausea, diarrhea,
  cramping, dehydration

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Stimulant Detox(Stimulant Replacement?)

• Replacement, stabilization, and graded step-wise
  reduction is not recommended for cocaine,
  amphetamine, psychostimulant (Ritalin, Adderal,
  Cylert), or designer drug (MDMA, Ecstasy)
  users
• Replacement, etc., is useful for persons with
  caffeine addiction (switch to oral tablets,
  decrease by 10 per day)

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Hallucinogen Detox(Social Detox)

• Replacement strategies do not apply
• The problem isnt withdrawal, its
  intoxication, with subsequent anxiety/panic in
  the wake of unanticipated dissociative symptoms
• Talk Down the person on a bad trip with
  psilocybin, LSD, hashish (esp. oral THC)
• Talking Down often insufficient for trips on
  PCP or Jimson weed (Datura stramonium)

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DETOXIFICATION

• RESOLUTION OF A TOXIC STATE
• INTOXICATION MANAGEMENT
• WITHDRAWAL MANAGEMENT

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TherapeuticsManagement of Intoxication
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Intoxication States Emerging Trends

• Great resource is www.nida.nih.gov, search for
  Club Drugs
• Ecstacy use BP, HR, hyperthermia, dehydration,
  acute renal failure, rhabdomyolysis,
  hyponatremia, water intoxication, hepatotoxicity,
  arrhythmia
• GBH use rapid shifts of level of arousal
  ataxia disinhibition not in UDT panels
• Ketamine or DM (Robo-tripping) effects are
  comparable to PCP

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Pediatric Addiction Medicine

• Become aware of the epidemic of misuse of
  dextromethorphan (in Robitussin DM and Coricidin
  Cough Cold) DXM or DM
• Effects vary widely and, maybe more so than for
  some agents, are based on expectation of effect
• 8-24 oz. of syrup is the intoxicating dose
• Consumers/parents are starting to know
  (www.coricidin.org)

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Intoxication Management

• For opioids naloxone
• For ethanol naloxone!
• For benzodiazepines flumazenil
• For amphetamines, hallucinogens, PCP
• consider acidification of the urine
• For cocaine anti-arrhythmics, anticonvulsants,
  antipsychotics
• For panic/anxiety talking down or/and benzos

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Behavioral Management of Intoxication States

• Assure safety of yourself and ER staff
• Dont block egress for the paranoid patient vs.
  dont block egress for yourself!
• Minimize stimuli / inputs (extraneous
  noises/lights, lower volume/rate of speech)
• For delirious/disoriented patients, repeatedly
  provide orienting information and
  reassurancefear fuels anxiety!

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Pediatric Addiction Medicine

• Alcoholinjuries, sexual assault
• Cannabisanxiety/panic
• Hallucinogensanxiety/panic
• Caffeineanxiety/panic
• Diet pills (bulimia et al.)anxiety/panic
• Cocaine and Ecstacyanxiety/panic

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TherapeuticsManagement of Withdrawal
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Keys to Withdrawal Management

• Alcohol / Sedative Withdrawal is potentially
  life-threatening
• Opioid Withdrawal is uncomfortable, but not
  dangerous
• Opioid Addicts are exquisitely sensitive to
  subjective discomforts / dont tolerate them
• Cocaine Withdrawal is insignificant
  physiologically but can be significant
  psychiatrically
• Nicotine Withdrawal is common and treatable

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Alcohol Withdrawal Stages

• Autonomic Hyperactivity / Irritability
• Hallucinosis
• Seizures
• Delirium
• Delirium from any cause looks similar
• Dont ignore AWS in the differential
• Dont ignore other causes of delirium even in
  the face of alcohol withdrawal

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Stages of Alcohol and Sedative Withdrawal
General Signs Hallucination
Delirium Stage 1 mild no no Stage
2 moderate yes no Stage
4 severe maybe yes
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Stage One - AWS

• Stage One Begins six to eight hours after the
  last drink
• Increased Sympathetic Autonomic Nervous System
  Output
• Increase Blood Pressure, pulse rate, low grade
  elevated temp
• Diaphoresis, exaggerated startle reflex,
  headache, nausea, restlessness, easily distracted

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Stage Two - AWS

• Worsening symptoms and signs of Stage I
• Defined by presence of Hallucinosis
• Visual Auditory Tactile
• Typically starts 24 to 72 hours after last drink
• Occurs in 25 of untreated individuals
• Patient still cognitively intact

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Stage Three - AWS

• Withdrawal Seizures - 5 to 15 of untreated
  individuals
• Typically within the first 48 hours after the
  last drink
• Always Grand Mal - short duration of Tonic/Clonic
  seizure
• Occur in Salvoes
• 3 will enter Status Epilepticus

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Stage Four - AWS

• Delirium Tremens (DTs)
• Begins 48 hours to 14 days after last drink
• Profound clouding of the sensorium - ie Delirious
• Paranoid Delusions
• Mortality approximately 5
• Approximately 5 of untreated individuals will
  enter Stage four

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Alcohol/Sedative Withdrawal
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Prognosticators of Severe Withdrawal

• BAC greater than 300mg/dl
• Age greater than 35 years
• Previous AWS seizure
• Concomitant medical or surgical problem
• Abnormal liver functions
• Other drug use - especially sedatives/hypnotics

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Kindling Phenomenon

• Each subsequent withdrawal episode is worse
• medical management of AWS may prevent the
  Kindling phenomenon
• Evidence better with anticonvulsants such as
  valproic acid carbamazepine than
  benzodiazepines barbiturates in blocking
  progression of the Kindling phenomenon.

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Alcohol Withdrawal Management

• 1. Replace Sedative
• 2. Prevent Advancing to Higher Stages
• I II III IV
• Treat hallucinosis
• Consider other causes of seizures, especially if
  48 hours after falling BAC
• Manage the delirium co-morbid medical
  conditions

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Sedative Replacement

• Symptom-triggered
• Standard Assessment
• Standing Order Sets / Protocols
• Benzos (long-acting oral agents if uncomp.)
• DPH loading is passe
• Carbamazepine is effective
• Remember propofol is a true sed/hypnotic

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Standardized Assessment

• CIWA-A(r)
• Clinical Institute Withdrawal Assessment
• Addiction Research Institute (ARI), Toronto
• http//www.agingincanada.ca/CIWA.HTM
• C.I.W.A. (SEE-wah)

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Global Assessment of Withdrawal

• Nausea/Vomiting
• Tremor
• Paroxysmal Sweats
• Anxiety
• Agitation
• Tactile Disturbances
• Auditory Disturbances
• Visual Disturbances

• Headache
• Orientation/Clouding of the Sensorium
• All 0 to 7 except orientation which is 0-4

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Treatment

• Benzodiazepine substitution
• Long acting superior - diazepam and
  chlordiazepoxide
• Half life of Valium 20 to 50 hours
• Metabolized by hepatic oxidation and
  glucuronidation
• Lorazepam not as efficacious - more likely to
  have breakthrough symptoms.
• Safer profile in patients with hepatic
  insufficiency
• Half life 10-20 hours

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Treatment

• Valium 5mg Ativan 1mg
• Valium 5 mg one standard drink
• Lorazepam can be used PO/IM/IV
• Diazepam can be used PO/IV
• Phenobarbital may be slightly better with
  concomitant Benzodiazepine misuse
• Phenobarbital 30mg Valium 10mg

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Diazepam Dosing Symptom Triggered

• 10mg diazepam if CIWA scores 6-11, or
  diastolic blood pressure 90, or pulse 100
• 20mg diazepam if CIWA scores 12-17, or
  diastolic blood pressure 100, or pulse 110
• 30mg diazepam if Global scores 18-23, or
  diastolic blood pressure 110, or pulse 120
• May try 2-4 mg IM lorazepam if CIWA scores higher
  or if vitals higher than above parameters

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Adjunctive Medications

• Haloperidol - use for hallucinosis or delirium.
  NOTE This is adjunctive treatment--the patient
  should still be receiving benzodiazepines
• Beta Blockers and centrally-acting alpha agonists
• PRN protracted tremors or elevated pulse
• Can mask other symptoms of withdrawal
• Dont protect against advancing of stages

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Prophylactic Replacement

• Replace sedative, assuming that 1 drink
• 5 mg p.o. diazepam
• 1 mg p.o. lorazepam
• Alsocarbamazepine may empirically lower the
  seizure risk, but it still takes 5 half-lives to
  reach steady-state (beyond period of maximum risk
  for withdrawal seizures)

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Alcohol Withdrawal Delirium

• Replace Sedative
• Frequent dosing with p.o. if possible
• Intravenous boluses of diazepam vs. continuous
  infusions of lorazepam/midazolam
• I.M. is not safe/effective, except somewhat for
  lorazepam I.M.
• Calming via benzos antipsychotics are only for
  hallucinosis / incoherence / disorientation

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ASAM Practice Guidelines

• JAMA, 278(2)144-51 July 9, 1997
• Michael F. Mayo-Smith, MD MPH, et. al.
• Archives of Internal Medicine, 1641405-12 July
  12, 2004
• Michael F. Mayo-Smith, MD MPH, et. al.

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Patient Safety

• Early recognition of A.W.S.
• Standardized Assessment of A.W.S.
• Protocols / Practice Guidelines for management of
  sedative replacement and other assessment/treatmen
  t in A.W.S.
• Wisconsin Hospital Association et al.

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• BREAK

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Sedatives

• Barbiturates
• Benzodiazepines
• Sedative-Hypnotics (choral hydrate,
  meprobamatecarisoprodol/Soma)
• GHB (GBL, 1,4 BD)
• Propofol
• And dont forget Cl- channel agents Ambien
  (zolpidem) and Sonata (zaleplon)

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Sedative Intoxication

• Ataxia, dysarthria, nystagmus, and somnolence
• Avoid reversal agent flumazenil
• Only use in overdose if a sole benzodiazepine has
  been ingested in a non chronic user
• Main treatment is supportive
• Charcoal may be helpful
• Orogastric intubation and gastric evacuation
  maybe useful since GI motility may be slowed

52
Sedative WithdrawalSymptoms Signs

• Anxiety
• Nausea
• Tremor
• Hypertension
• Tachycardia
• Hypersensitivity to stimuli
• Hyperreflexia
• Diaphoresis

• Hallucinosis
• Depersonalization
• Psychosis
• Delirium
• Seizures
• Looks like hypomania

53
Sedative Withdrawal

• Similar to alcohol withdrawal--though usually not
  as dramatic or obvious and more variability
  often VS are normal
• Dependent on
• Duration of sedative use
• Daily amount of sedative use
• Half-life of sedative used

54
Benzodiazepine Duration of Action

• Short-Acting (half life
• Triazolam
• Intermediate-Acting (half life 12-20 hours)
• Oxazepam Temazepam Lorazepam
• Alprazolam Estazolam
• Long-Acting (half life 100 hours)
• Diazepam Chlordiazepoxide Chlorazepate
• Clonazepam Flurazepam

55
Sedative Withdrawal

• Declining serum levels correlate with emergence
  of withdrawal symptoms
• Shorter acting Bzdz withdrawal begins within 24
  hours of cessation peaks within 1 to 5 days
• Longer acting Bzdz withdrawal begins within 5
  days of cessation peaks within 1 to 9 days
• Duration of withdrawal
• 7 to 21 days for shorter acting Bzdz
• 10 to 28 days for longer acting Bzdz

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Alcohol/Sedative Withdrawal
57
Tapering

• Usually SUBSTITUTE with a long-acting sedative
  and taper that, not the original agent
• Give the patient a calendar with a tapering
  schedule
• Write prescriptions that will be filled every day
  or every other day
• Write the date that the Rx is to be filled
• Use one pharmacy only discuss plan with the
  pharmacist

58
Substitution Agents

• Usually phenobarbital or clonazepam
• Use clonazepam for alprazolam
• Phenobarbital best to use when
• High dose of sedatives
• Unknown or erratic use
• Phenobarbital intoxication not well liked
• Once steady state achieved, negligible inter-dose
  serum level variation

59
Tapering with or without Substitution

• Phenobarbital on initial dose for two days
• If no signs of withdrawal or intoxication begin
  taper on day 3
• Taper over about a 20 day period
• Reduce dose by 30-60mg per day
• Final 25 make smaller daily dose reductions
• Benzodiazepine tapering
• Provide daily amount in divided doses
• About 25 reduction per week of starting dose or
  about 1mg clonazepam per week which ever is
  less
• Final 25 of reduction can/should be slower 10
  every week

60
Substitution Dose Conversions

• Phenobarbital 30mg
• Diazepam 10mg
• Chlordiazepoxide 25mg
• Clonazepam 2mg
• Flurazepam 15mg
• Lorazepam 2mg
• Oxazepam 10mg
• Temazepam 15mg

• Triazolam 0.25mg
• Butalbital 100mg
• Meprobamate 400mg
• Carisoprodol 700mg
• Chloral Hydrate 500mg

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Prescriptions

• Write amount to be dispensed out in English and
  draw a box around this
• Write zero refills
• Date prescription todays date 10/21/04 but then
  write fill only on 10/23/04
• Number prescriptions in chronological order
• Make photostat copies of your prescriptions
• If patients make accusations regarding the
  pharmacist refer them to the state pharmacy board

62
Adjunctive Withdrawal Management

• Carbamazepine
• 100mg every 6 hours
• 100mg every 8 hours if weight less than 100pounds
• 200mg every 8 hours if weight more than 220pounds
• Baseline CBC and hepatic panel
• Divalproex
• 250mg every 6 hours
• 250mg every 8 hours if weight less than 100pounds
• 500mg every 8 hours if weight more than 220pounds
• On fourth day check pre-dose serum level

63
Adjunctive Withdrawal Management

• Once therapeutic on anti-convulsant begin taper
  of sedative dose
• 75 pretreatment dose on day one
• 50 pretreatment dose on day two
• 25 pretreatment dose on day three
• On day four give no further sedatives
• Continue anticonvulsant between 30 to 60 days
  then taper over 4 to 8 days
• Recheck hepatic panel and CBC at 1 to 3 week
  intervals for Carbamazepine

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Sedative Tolerance Test

• Pentobarbital 200mg initially then 100mg every
  one hour
• Assess for signs of intoxication
• Convert to phenobarbital at a conversion of
  pentobarbital 100mg Phenobarbital 30mg
• Pentobarbital hard to find
• Need to design a different sedative taper test

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Stimulants

• Cocaine
• Amphetamines
• Methamphetamine
• Dextroamphetamine
• Amphetamine sulfate
• Methylated amphetamines
• (designer drugs)
• MDMAEcstasy
• MDA, DOM, STP
• Psychostimulants
• --Methylphenidate (Ritalin)
• -- Pemoline (Cylert)

• Ephedrine/Pseudo-ephedrine
• Phenylpropanolamine
• Amphetamine Congeners
• Benzphetamine
• Diethylpropion
• Fenfluramine
• Phentermine
• Phenmetrazine
• Phendimetrazine
• Mazindol

68
Absorption Metabolism

• Cocaine half-life 40 to 60 minutes
• Cocaethylene intermediate active metabolite
  when ethanol used concurrently
• Amphetamine half-life 6 to 12 hours
• Methylphenidate half-life 2 hours

69
Intoxication

• Psychosis mainly amphetamines
• Paranoid ideation with well formed delusional
  structure
• Hallucinosis
• Stereotyped behavior
• Can persist for days
• Hyperpyrexia
• Seizure Activity
• Vasoconstriction

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Stimulant Intoxication Management

• Hypertension/Tachycardia
• Phentolamine if hypertensive urgency/emergency
• 5-10mg every 10minutes
• Avoid Beta Blockers since may lead to unopposed
  alpha adrenergic activity
• Avoid Calcium Channel Blockers
• Anxiety/Agitation
• Lorazepam
• Psychosis
• Haloperidol

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Stimulant Intoxication Management

• Seizures
• Diazepam
• Phenytoin
• Hyperthermia
• Cooling techniques
• Elimination
• Acidification with ammonium chloride may help in
  select cases of acute amphetamine overdose

72
Cocaine Withdrawal

• Phase one Crash
• Initial - Intense dysphoria craving
• Middle Desire to sleep, dysphoria, may start to
  use other substances or pursue supplies
• Late Hypersomnia and increased appetite lasts
  3 to 4 days
• Phase two Withdrawal
• Honeymoon 12 hours to 4 days reduced craving,
  improved mood and sleep pattern

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Stimulant Withdrawal

• Phase two Withdrawal
• Dysphoria depression, lethargy, anhedonia,
  reemergence of craving lasts 6 to 18 weeks
• Phase three Extinction
• Gradual improvement of mood, ability to
  experience pleasure, interest in environment
  lasts months

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Management of Cocaine Withdrawal

• Phase I bromocryptine ????
• Phase III desipramine ????

75
Opioid Withdrawal

• Anxiety
• Irritability
• Restlessness
• Insomnia
• Nausea
• Abdominal cramps
• Arthralgias
• Myalgias
• Rhinorrhea

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Evaluation Opioid Withdrawal
77
Opioid Withdrawal Management

• With clonidinerequires supplemental agents
  (lorazepam, ibuprofen, Bentyl, antiemetics,
  antidiarrheals)
• With Ultram (not Scheduled!)
• With methadone (MUST be in an OTP)
• With buprenorphine (MUST be an approved
  physician, but 8 hour courses are available!)

78
Opioid Discontinuation

• When detox isnt detox
• Opioids prescribed for pain, can be discontinued
• Call it therapeutic taper or discontinuation
• Detox has a legal meaning (methadone / Suboxone
  regs)
• Any doc can taper his/her or another docs
  treatment regimen, but you cant taper a
  self-designed plan (person using street or
  Internet supplies, not authorized medical
  use)

79
Pain and Addiction

• See www.dea.gov for the latest
• Attend ASAM Common Threads, Pain and Addiction,
  VII, in Chicago, October 29
• See www.asam.org Public Policy, TOC, Medical
  Aspects of Substance Use and Addiction
• Also http//www.asam.org/pain/pain_and_addiction
  _medicine.htm

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• BREAK

81
Treatment

• Brief Interventions
• Individual/Family Counseling
• Medication Management
• Relapse Prevention
• Case Management
• Intensive Services (Rehab)
• Intensive Outpatient/IOP/Day Treatment
• Intensive Inpatient Residential/Hospital

82
Assessment

• Screening/Case Finding
• Interview
• Collateral Interview
• Physical Exam and Labs
• Structured Instruments
• For withdrawal CIWA, COWS
• For addiction CAGE, MAST, AUDIT

83
What Are We Assessing/Treating?

• A substance USE disorder
• Could be alcohol dependence
• Could be alcohol abuse
• Could be opioid, stimulant, sedative, cannabis
  dependence
• Could be opioid, stimulant, sedative, cannabis
  abuse
• Could be nicotine dependence

84
Range of Use Conditions

• Use
• Misuse
• Risky Use
• Problem Use
• Addiction
• Disability
• Death

85
Relationship Between Alcohol Use and Alcohol
Problems
Alcohol Use
None
Light
Moderate
Heavy
At Risk
Problem
Dependent
Low Risk
Severe
Moderate
Small
Alcohol Problems
None
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The Spectrum of Alcohol Use
heavy
Alcohol Use Disorders
severe
Alcoholism Dependence
Unhealthy Use
Harmful, abuse
Problem
consumption
consequences
Risky
Lower risk
Abstinence
none
none
87
Broadening the Base of TreatmentIOM
Report--1990
303.9
Levels of USE
305.0
Problem Use
Risky Use
TREATMENT INTENSITY
Use
Abstinence / Non-Use
none
none
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What is Addiction?

• Substance use
• Use behaviors and procurement behaviors persist
  despite problems due to use
• Return to use after periods of abstinence,
  despite previous problems
• Inability to consistently control use
• Preoccupation with use/procurement salience of
  use-related behaviors
• Cognitive changes (over-valuation, de-valuation,
  minimization/denial)
• Enhanced cue responsiveness via conditioning and
  generalization

89
Targeted Therapeutic Changes in Addiction
Treatment

• BEHAVIORAL CHANGES
• Eliminate alcohol and other drug use behaviors
• Eliminate other problematic behaviors
• Expand repertoire of healthy behaviors
• Develop alternative behaviors

• BIOLOGICAL CHANGES
• Resolve acute alcohol and other drug withdrawal
  symptoms
• Physically stabilize the organism
• Develop sense of personal responsibility for
  wellness
• Initiate health promotion activities (e.g., diet,
  exercise, safe sex, sober sex

90
Targeted Therapeutic Changes in Addiction
Treatment

• COGNITIVE CHANGES
• Increase awareness of illness
• Increase awareness of negative consequences of
  use
• Increase awareness of addictive disease in self
• Decrease denial

• AFFECTIVE CHANGES
• Increase emotional awareness of negative
  consequences of use
• Increase ability to tolerate feelings without
  defenses
• Manage anxiety and depression
• Manage shame and guilt

91
Targeted Therapeutic Changes in Addiction
Treatment

• SOCIAL CHANGES
• Increase personal responsibility in all areas of
  life
• Increase reliability and trustworthiness
• Become resocialized reestablished sober social
  network
• Increase social coping skills with
  spouse/partner, with colleagues, with neighbors,
  with strangers

• SPIRITUAL CHANGES
• Increase self-love/esteem decrease self-loathing
• Reestablish personal values
• Enhance connectedness
• Increase appreciation of transcendence

92
What are the options for Addiction Rehab?

• General Outpatient (ASAM Level I)
• Intensive Outpatient (ASAM Level II)
• Day Treatment (ASAM Level II)
• ResidentialMedically Monitored Inpatient (Level
  III)
• HospitalMedically Managed Inpatient (Level IV)

93
Addiction is a Chronic Disease

• Often Pediatric Onset
• Usually Progressive, Sometimes Fatal
• Chronic Course
• Relapsing Remitting

94
Addiction Must Be MANAGED

• Total lifetime abstinence after an index
  intervention sometimes occurs
• The rule is that subsequent substance use will
  occur -- but is that bad ?
• Follow - up is the key to success, as for any
  chronic disease
• Remember detox is NOT treatment of addiction
  (its treatment of intoxication or withdrawal,
  but not chronic disease mgmt.)

95
Goals of Chronic Disease Management

• Minimize the frequency and severity of relapses
• Maximize the duration of periods of remission and
  the quality of life during periods of remission
• Reduce symptoms
• Improve level of functioning

96
Addiction is Treatable

• But not via detox alone
• But not via acute interventions alone
• But not via treating psychiatric co-morbidities
  alone
• Compliance for other chronic illnesses
• Outcomes for other chronic illnesses

97
Relapse Rates Tx Compliance for Medical
Conditions
OBrien McLellan, 1996 (The Lancet)
98
Therapeutic Pessimism

• Its endemic
• Its a creation of our own mental models
• Whats the definition of success?
• Is success measured during the application of
  treatment or is it measured after the withdrawal
  of treatment?

99
Evaluation of A Hypothetical Treatment
Just Like Hypertension, Addiction Is A Chronic
Disease That Requires Continued Care
Source McLellan, AT, Addiction 97, 249-252,
2002.
100
Principles of Effective Treatment

• 1. No single treatment is appropriate for all
• 2. Treatment needs to be readily available
• 3. Effective treatment attends to the multiple
  needs of the individual
• 4. Treatment plans must be assessed and modified
  continually to meet changing needs

101
Principles of Effective Treatment

• 5. Remaining in treatment for an adequate period
  of time is critical for treatment effectiveness
• 6. Counseling and other behavioral therapies
  are critical components of effective treatment
• 7. Medications are an important element of
  treatment for many patients

102
Principles of Effective Treatment

• 8. Co-existing disorders should be treated in an
  integrated way
• 9. Medical detoxification is only the first
  stage of treatment
• 10. Treatment does not need to be voluntary to be
  effective

103
Principles of Effective Treatment

• 11. Possible drug use during treatment must be
  monitored continuously
• 12. Treatment programs should assess for
  HIV/AIDS, Hepatitis B C, Tuberculosis and other
  infectious diseases and help clients modify
  at-risk behaviors
• 13. Recovery can be a long-term process and
  frequently requires multiple episodes of
  treatment
• - NIDA (1999) Principles of Drug Addiction
  Treatment

104
Evidence-Based Components

• Cognitive Behavioral Interventions
• Disease education
• Life skills
• Conflict resolution
• Refusal skills
• Managing triggers

105
Evidence-Based Components

• Ecological Approaches
• Community Reinforcement Approach (contingencies
  token rewards)
• Strength-Based Interventions
• Multi-systemic Therapy
• Case Management

106
Evidence-Based Components

• Twelve-Step Facilitation
• Project MATCH used 3 modalities
• MET
• CBT
• TSF

107
Evidence-Based Components

• Engagement Strategies
• Motivational Interviewing
• Contingency Management
• Childcare
• Transportation
• Medical Services

108
Evidence-Based Components

• Engagement Strategies
• Vocational Training
• Employment Services
• Role Induction
• Seamless Transfer Between Levels of Care
• Rapid Intake and Re-intake

109
The Therapeutic Relationship

• Rogerian Skills
• Responsiveness
• Hope
• Openness
• Work Experience
• Respect

• Self-disclosure
• Warmth
• Immediacy
• Concreteness
• Confrontation
• Potency

110
Evidence-Based Components

• All clients would have access to all modalities
• Adequate Detoxification
• Outpatient
• Standard and menu driven
• Pharmacologically assisted or not
• Residential
• Long and short
• Recovery Homes

111
Evidence-Based Components

• Pharmacological Therapies
• Antabuse
• Naltrexone (Revia)
• Acamprosate (Campral)
• Methadone
• Buprenorphine
• Naltrexone (Trexan)
• N.R.T. / bupropion (Zyban)

112
Evidence-Based Components

• Family Therapy
• Before Treatment
• During Treatment

113
Evidence-Based Components

• Duration would be emphasized over intensity.

114
Evidence-Based Components

• Brief interventions for substance abusers

115
Treatment of Addiction in the General Medical
Setting

• Know what you are treating
• DSM-IV Abuse vs. Dependence
• Know what your goals are.
• Know what your methods are.
• Recognize that if you treat intoxication or
  withdrawal well, youre providing a great medical
  service, and probably better than your colleagues
  would.
• Know the referral sites in your community.

116
Treatment of Addiction Goals

• What are the treatment goals for a chronic
  disease?
• Decrease frequency of relapses
• Decrease severity of relapses
• Increase duration of remission
• Optimize level of function during remissions

117
Treatment of Addiction Methods

• Psychosocial Interventions
• Pharmacological Therapies
• Alcohol Dependence
• Opiate Dependence
• Nicotine Dependence

118
Pharmacotherapy of Addiction

• Antabusefor alcohol dependence (and cocaine!)
• Naltrexone, Acamprosate, et al.for alcohol
  dependence
• Naltrexonefor opioid dependence
• Opioid Agonist TherapiesMMT
• O.B.O.T.Buprenorphine
• Nicotine Replacement Therapy
• Bupropionfor nicotine dependence

119
The Trade Names are Suboxone and Subutex

• Buprenorphine in a sublingual tablet
• Strengths are 2 mg or 8 mg
• Combination product contains naloxone in 41
  ratio
• --Suboxone 2/0.5
• --Suboxone 8/2

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121
Office-Based Use of Buprenorphine (Schedule III)

• Any pharmacy can dispense Suboxone (up to a
  30-day supply) if the prescribing physician has
  the correct DEA number
• Any physician can obtain the special DEA
  registration by taking an 8-hour course approved
  by C.S.A.T.
• ASAM and others offer the courses
• All primary care docs and hospitalists should
  consider becoming qualified physicians for
  Suboxone Rx-ing

122

• BREAK

123
Treatment of Addiction in the Primary Care Setting

• The 5 As
• Ask
• Advise
• Assess (Readiness for Change)
• Assist
• Arrange

124
Treating Nicotine Dependence in a General Medical
Practice

• There are a lot of zebras in medical practice.
• In general medical practice, and in general
  psychiatric practice, nicotine dependence is no
  zebra.
• Nicotine replacement therapies work.
• Counseling (individual and family) works.
• Bupropion works.

125
How to Ask Questions

• Ask questions in professional, systematic manner,
  dispassionately (without any particular show of
  affect), they way youd objectively collect data
  about any other aspect of the patients health
  status.
• Show interest, like youre taking this seriously,
  to convey to patient the sense of the importance
  of the topic

126
How to Ask Questions

• Recognize that the patient has lots of shame and
  guilt and is hesitant to open up with lots of
  facts that might, in a different context, be
  self-incriminating or something that he could
  be hit over the head with
• Recognize that if there is minimization or
  denial, the patient is lying to himself and not
  specifically lying to you.
• Dont take things personally in the information
  exchange

127
How to Ask Questions

• Allow patient to save face and to hold on to
  some of his/her projection/denial/other defenses
• When was the time in you life when you were
  using the most?
• Has anyone expressed concern about your use?

128
How to Ask Questions

• Has your drinking changed lately?
• this doesnt ask how much are you drinking
  now?, a discrete quantifier that patient may be
  defensive about/amend the answer this gives you
  a sense of trends and gets to the
  quantity/frequency issue somewhat indirectly

129
How to Ask Questions

• Dont ask directly about use ask instead about
  the utility of use
• How has your sleep been? What do you do to try
  to help with your sleep?
• possible answers OTC Rx, alcohol, marijuana,
  even opioids

130
Advise

• Its very important for your health that you
  stop smoking
• I would like you to stop drinking

131
Treatment of Addiction in the Primary Care Setting

• The 5 As
• Ask
• Advise
• Assess (Readiness for Change)
• Assist
• Arrange

132
Stages of Change

• Pre-contemplation not seeing a problem
• Contemplation seeing a problem and considering
  whether to act
• Preparation making concrete plans to act soon
• Action doing something to change
• Maintenance working to maintain the change

133
Assist

• Refer to specific resources in your community
• Professional counselors
• Addiction Medicine physicians
• Self-Help (AA, NA)
• Provide assistance within the context of your
  primary care practice

134
AA is NOT TREATMENT

• ASAM, AAAP and APA recommend that
• 1. Patients in need of treatment for alcohol or
  other drug-related disorders should be treated by
  qualified professionals in a manner consonant
  with professionally accepted practice guidelines
  and patient placement criteria
• 2. Self help groups should be recognized as
  valuable community resources for many patients in
  addiction treatment and their families. Addiction
  treatment professionals and programs should
  develop cooperative relationships with self help
  groups
• 3. Insurers, managed care organizations and
  others should be aware of the difference between
  self help fellowships and treatment
• 4. Self help should not be substituted for
  professional treatment, but should be considered
  a compliment to treatment directed by
  professionals. Professional treatment should not
  be denied to patients or families in need of
  care.

135
Motivational Enhancement Therapy (M.E.T.)

• Express Empathy
• Support Self-Efficacy
• Roll with Resistance
• Develop Discrepancy
• Reference Miller, W. R., Zweben, A., DiClemente,
  C. C., Rychtarik, R. G. (1992). Motivational
  Enhancement Therapy manual A clinical research
  guide for therapists treating individuals with
  alcohol abuse and dependence. Rockville, MD
  National Institute on Alcohol Abuse and
  Alcoholism.AA

136
Express Empathy
Empathy involves seeing the world through
the client's eyes, thinking about things as the
client thinks about them, feeling things as the
client feels them, sharing in the client's
experiences. Expression of empathy is critical
to the MI approach. When clients feel that they
are understood, they are more able to open up to
their own experiences and share those experiences
with others. Having clients share their
experiences with you in depth allows you to
assess when and where they need support, and what
potential pitfalls may need focused on in the
change planning process. Importantly, when
clients perceive empathy on a counselor's part,
they become more open to gentle challenges by the
counselor about lifestyle issues and beliefs
about substance use. Clients become more
comfortable fully examining their ambivalence
about change and less likely to defend ideas like
their denial of problems, reducing use vs.
abstaining, etc. In short, the counselor's
accurate understanding of the client's experience
facilitates change.
137
Support Self-Efficacy
As noted above, a client's belief that change is
possible is an important motivator to succeeding
in making a change. As clients are held
responsible for choosing and carrying out actions
to change in the MI approach, counselors focus
their efforts on helping the clients stay
motivated, and supporting clients' sense of
self-efficacy is a great way to do that. One
source of hope for clients using the MI approach
is that there is no "right way" to change, and if
a given plan for change does not work, clients
are only limited by their own creativity as to
the number of other plans that might be tried.
The client can be helped to develop a belief
that he or she can make a change. For example,
the clinician might inquire about other healthy
changes the client has made in their life,
highlighting skills the client already has.
Sharing brief clinical examples of other, similar
clients' successes at changing the same habit or
problem can sometimes be helpful. In a group
setting, the power of having other people who
have changed a variety of behaviors during their
lifetime gives the clinician enormous assistance
in showing that people can change,
138
Roll with Resistance
In MI, the counselor does not fight client
resistance, but "rolls with it." Statements
demonstrating resistance are not challenged.
Instead the counselor uses the client's
"momentum" to further explore the client's views.
Using this approach, resistance tends to be
decreased rather than increased, as clients are
not reinforced for becoming argumentative and
playing "devil's advocate" to the counselor's
suggestions. MI encourages clients to develop
their own solutions to the problems that they
themselves have defined. Thus, there is no real
hierarchy in the client-counselor relationship
for the client to fight against. In exploring
client concerns, counselors may invite clients to
examine new perspectives, but counselors do not
impose new ways of thinking on clients.
139
Develop Discrepancy

• "Motivation for change occurs when people
  perceive a discrepancy between where they are and
  where they want to be" (Miller, Zweben,
  DiClemente, Rychtarik, 1992, p. 8). MI
  counselors work to develop this situation through
  helping clients examine the discrepancies between
  their current behavior and future goals. When
  clients perceive that their current behaviors are
  not leading toward some important future goal,
  they become more motivated to make important life
  changes. Of course, MI counselors do not develop
  discrepancy at the expense of the other MI
  principles, but gently and gradually help clients
  to see how some of their current ways of being
  may lead them away from, rather than toward,
  their eventual goals.

140
Motivational Interviewing

• Identify what the patient wants
• Identify what you want
• Try to get the patients goals and the
  therapists goals to align

141
Motivational InterviewingDisadvantages of the
status quo

• What worries you about your current situation?
• What makes you think that you need to do
  something about your blood pressure?
• What difficulties or hassles have you had in
  relation to your drug use?
• What is there about your drinking that you or
  other people might see as reasons for concern?
• In what way does this concern you?
• How has this stopped you form doing what you want
  to do in life?
• What do you think will happen if you dont change
  anything?

142
Motivational InterviewingAdvantages of change

• How would you like for things to be different?
• What would be the good things about losing
  weight?
• What would you like your life to be like 5 years
  from now?
• If you could make this change immediately, by
  magic, how might things be better for you?
• The fact that youre here indicates that at least
  part of you thinks its time to do something.
  What are the main reasons you see for making a
  change?
• What would be the advantages of making this
  change?

143
Motivational InterviewingOptimism about change

• What makes you think that if you did decide to
  make a change, you could do it?
• What encourages you that you can change if you
  want to?
• What do you think would work for you, if you
  decided to change?
• When else in your life have you made a
  significant change like this? How did you do it?
• How confident are you that you can make this
  change?
• What personal strengths do you have that will
  help you succeed?
• Who could offer you helpful support in making
  this change?

144
Motivational InterviewingIntention to change

• What are you thinking about your gambling at this
  point?
• I can see that youre feeling stuck at the
  moment. What is going to have to change?
• What do you think you might do?
• How important is this to you? How much do you
  want to do this?
• What would you be willing to try?
• Of the options Ive mentioned, which one sounds
  like it fits you best?
• Never mind the how for right now what do you
  want to have happen?
• So what do you intend to do?

145
Asking Open-Ended Questions

• If you continue to drink like this, what could
  possibly happen?
• What else concerns you about your drinking/drug
  use?
• What are some other reasons why you would want to
  change?
• Do you remember a time when things were going
  well for you? What has changed?
• What were things like before you started using
  drugs? What were you like back then?
• If you stop using drugs, what do you hope might
  be different in the future?
• How would you like things to turn out for you 10
  years from now?

146
Urine Drug Testing

• Rapid Tests (kits, TLC, RIA) detect only selected
  benzodiazepines, and only OPIATES (they will read
  negative for OPIOIDS)
• Natural Opiates Opium, Codeine, Morphine,
  Heroin (6-acetyl-morphine)
• Excluded are Oxycodone, Hydrocodone,
  Hydromorphone, Meperidine, Methadone
• Screening test results should be confirmed by
• Gas Chromatography / Mass Spectroscopy
• GC/MS can detect almost anything

147
Guide to Psychotropic Medications

• http//www.mattc.org/information/psychotherapeutic
  /index.html

148
Summary Key Points

• Addiction is a Health Problem
• Addiction is not a desired state
• Use, Intoxication, Withdrawal, and Addiction can
  all be clinically relevant
• Addiction is usually managed outside of
  hospitals, and is ideally managed as a CHRONIC
  DISEASE

149
Summary Key Points

• The high-volume, high-need populations are those
  with alcohol problems and nicotine dependence
• The tools are availableand you now know them
  the 5 As, brief intervention, motivational
  enhancement, effective pharmacotherapy
• Its do-able, and you can make a go of it

150
Summary Key Points

• Alcohol and Sedative Withdrawal are potentially
  life-threatening, and can be manageable by a
  general psychiatrist who becomes knowledgeable in
  assessment and pharmacotherapy of A.W.S.
• A.W.S. has describable STAGES
• Standard Assessment (CIWA) improves clinical
  results

151
Summary Key Points

• Only YOU can learn who the key contacts are in
  your community and where to refer for specialty
  services (addiction treatment facilities).
• Buprenorphine is a marvelous advance, and you can
  become Qualified Physician with relative ease.
  Even if you dont choose to induce patients in
  your practice, you can receive stable patients
  from an addictionist so the pateints appear on
  your 30-patient census.
• ASAM is a resource for ANY PHYSICIAN

152
Blueprint of StrategiesWhat to DO In Your Own
Practice

• Make sure you have systems in place for effective
  NICOTINE REPLACEMENT THERAPY (NRT) for all your
  patientshospitalized or in your own office
  practice
• Remember that YOU providing Brief Intervention
  for nicotine dependence
• (Ask, Advise, Assist, Arrange follow-up)
• may be the most important thing you do for your
  patients long-term health status

153
Blueprint of StrategiesWhat to DO In Your Own
Practice

• Develop a RESOURCE LIST for referrals to
  addiction specialty treatment providersnot only
  who and where, but who is covered by what payment
  type?
• PARTNER with your hospital Social Service
  Department and ER to have constantly-updated
  lists readily-available so you and other docs
  know how to advise patients about community-based
  services

154
Blueprint of StrategiesWhat to DO In Your Own
Practice

• Implement Standardized Rating Scales for
  Withdrawal Assessment (CIWA) and in-service
  NURSES on key units
• if alcohol detox is done on the general psych
  unit of your hospital, make sure CIWA is used
• if you do consultation-liaison psychiatry
  already and work on med/surg units, make sure
  they use CIWA
• If you wanted the best outcomes, would you have
  a good detox doctor and a lousy detox nurse, or a
  lousy detox doctor and a good detox nurse?