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Title: 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

6
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!

7
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

9
Detox
  • Intoxication Management
  • Withdrawal Management

10
DETOXIFICATION
  • RESOLUTION OF A TOXIC STATE
  • The Brain has been poisoned
  • Manifestations are changes in behavior and
    changes in physiology

11
Management of Withdrawal
  • Nicotine
  • Alcohol
  • Sedatives
  • Opioids
  • Stimulants
  • Hallucinogens

12
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

13
Nicotine DetoxNicotine Replacement Therapy--NRT
  • Transdermal
  • Oral (buccal)
  • Nasal
  • Inhaled

14
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

15
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

16
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)

17
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)

18
DETOXIFICATION
  • RESOLUTION OF A TOXIC STATE
  • INTOXICATION MANAGEMENT
  • WITHDRAWAL MANAGEMENT

19
TherapeuticsManagement of Intoxication
20
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

21
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)

22
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

23
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!

24
Pediatric Addiction Medicine
  • Alcoholinjuries, sexual assault
  • Cannabisanxiety/panic
  • Hallucinogensanxiety/panic
  • Caffeineanxiety/panic
  • Diet pills (bulimia et al.)anxiety/panic
  • Cocaine and Ecstacyanxiety/panic

25
TherapeuticsManagement of Withdrawal
26
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

27
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

28
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
29
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

30
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

31
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

32
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

33
Alcohol/Sedative Withdrawal
34
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

35
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.

36
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

37
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

38
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)

39
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

40
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

41
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

42
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

43
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

44
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)

45
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

46
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.

47
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.

48
  • BREAK

49
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50
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)

51
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

56
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

61
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

64
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

65
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66
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67
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

70
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

71
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

73
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

74
Management of Cocaine Withdrawal
  • Phase I bromocryptine ????
  • Phase III desipramine ????

75
Opioid Withdrawal
  • Anxiety
  • Irritability
  • Restlessness
  • Insomnia
  • Nausea
  • Abdominal cramps
  • Arthralgias
  • Myalgias
  • Rhinorrhea

76
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

80
  • 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
86
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
88
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

120
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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?
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