Addiction: Identification & Treatment

Ken Roy, MD, FASAM

Addiction Recovery Resources of New Orleans

River Oaks Hospital

Tulane Department of Psychiatry

www.arrno.org

kenroymd@bellsouth.net

The Diagnosis of Addiction

Bums and bad people?

No!

Criteria for Substance Dependence (DSM-IV)

A maladaptive pattern of use, leading to significant impairment or distress as manifested by three (or more) of the following seven criteria, occurring at any time in the same twelve month period Tolerance, as defined by:

A need for increased amounts to achieve effect Markedly diminished effect from using the same amount

Withdrawal, as manifested by: Characteristic withdrawal syndrome The same substance is used to avoid or relieve withdrawal

symptoms The substance is taken in larger amounts or over a longer

period than was intended There is a persistent desire or unsuccessful efforts to cut

down or control use

Criteria for Substance Dependence (DSM-IV)

A great deal of time is spent in activities necessary to obtain or use the substance or recover from it’s effects

Important social, occupational, or recreational activities are given up or reduced because of substance use

The substance use is continued despite knowledge of having a persistent or recurring physical or psychological problem that is likely to have been caused or exacerbated by the substance (ulcer, depression, etc.)b

Criteria for Substance Dependence (DSM-IV)

Substance Dependence Shorthand

Compulsion

Loss of control

Continued use in the face of adverse

consequences

C A G E Cut down

“Have you ever tried to stop or cut down on your drinking?” Angry

“Do you get angry when someone talks to you about your drinking?”

Guilt “Have you done things while drinking that you wish that you

hadn’t, that you feel guilty about?” Eye opener

“Have you had a drink (or a drug) to prevent or cure a hangover?”

T A C E Tolerance

“Can you drink more than your friends?”

Anger “Do you get angry when someone talks about your drinking?”

Cut down “Have you ever tried to stop or cut down on your drinking?”

Eye opener “Have you ever had a drink (or a drug) to prevent or cure a

hangover?”

“G A T E S” Guilt

“Have you done things while drinking that you wish that you hadn’t, that you feel guilty about?”

Anger “Do you get angry when someone talks about your drinking?”

Tolerance “Can you drink more than your friends?”

Eye opener “Have you ever had a drink (or a drug) to prevent or cure a

hangover?” Stop

“Have you ever tried to stop or cut down on your drinking?”

Models of TreatmentModels of Treatment

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

Moral ModelMoral Model Still Current

Teen Challenge, etc. Goals

from evil to good, weak to strong Advantages

Moral inventory & responsibility for consequences

Liabilities therapist is judgmental, punitive & blaming

Learning ModelLearning Model

Inadvertently learned bad habits Goals

from uncontrolled to controlled from bad habits to good habits

Advantages stresses new learning, pt. responsible for

learning Liabilities

emphasis on control can increase denial

Self Medication ModelSelf Medication Model

Using is a coping mechanism for psychological lesions common in psychiatric programs

Goals from needing to use to not needing to use

Advantages stresses dx & tx of psychopathology

Liabilities psychopathology seen as etiology

Disease ModelDisease Model

Recently dominant model based on genetic predisposition

Goals from sick to well, from using to recovering

Advantages self care rather than self control

Liabilities minimizes coexistent pathology

Integrative ModelsIntegrative Models

AA Moral + Disease Models

Dual Diagnosis Both are primary learning theory effective

Biopsychosocial individualizes these three domains

Multivariant most of the modern effective programs

Philosophy of TreatmentPhilosophy of Treatment

Disease Concept Genetic Predisposition Environment

Abstinence only rational goal of treatment

Multivariant Treatment Model use all the tools individualize interventions

Equation for IllnessEquation for Illness

Genetics + Environment = Disease

Genetic PredispositionGenetic Predisposition

What is inherited? Tolerance - Schuckit Endogenous Opiate system - Gianoulakis

Revia Dopamine Reward Systems - Nestler

Why is it important? reduces shame explains ineffectiveness of willpower

Contribution of EnvironmentContribution of Environment

Similarity to TB Impact of Using on Emotional Development Other Diagnoses

Psychoses Mood Disorders, Anxiety Disorders, Others

AbstinenceAbstinence

Similarity to Diabetes AA/NA/GA/RR not MM

Common Experiences Fellowship Impact on Emotional Development

Use of Medications Importance to Relapse

ElementsElements

Multiaxial Diagnostic Assessment Abstinence

Level of Care Education, Cognitive Restructuring Identification Support System Involvement Discharge Planning

Multiaxial Diagnostic AssessmentMultiaxial Diagnostic Assessment

Medical Assessment Laboratory & Imaging Family History Psychological Assessment

Mental Status Examination Social Assessment

Levels of CareLevels of Care

Least invasive level necessary to achieve & maintain abstinence Medically Managed Inpatient Treatment

Medical/Surgical Hospital Psychiatric Hospital

Medically Supervised Inpatient Treatment Partial Hospitalization Intensive Outpatient Program Residential Treatment Program

Education and IdentificationEducation and Identification

AA/NA/GA Materials Workbook Lectures Group Community

Support System InvolvementSupport System Involvement

Co-addiction Anger and Frustration Communication Single Family to Multifamily

Discharge PlanningDischarge Planning

Time Integration

Treatment should “generalize” Motivation Relapse Support

Distinction From Other Psychiatric Treatment

Distinction From Other Psychiatric Treatment

Not Necessarily Dual Diagnosis Theory of Genetic Drift

Not Incompetent Do Not Meet Psychiatric Admission Criteria

High Functioning Low tolerance For Infantalizing Interactions

Level of Care = Abstinence and Attendance Not Protection of Self or Others

WHAT IS A.A.? Fellowship of men and women who have

had a “drinking problem” Nonprofessional Self-supporting Nondenominational Multiracial, Multicultural Apolitical Available almost everywhere

WHAT DOES A.A. DO?

A.A. members share their experience with anyone seeking help with a drinking problem

Members voluntarily give person-to-person assistance or “sponsorship” to an alcoholic coming to A.A. from any source

WHAT DOES A.A. DO?

The A.A. program, set forth in the Twelve Steps and Twelve Traditions, offers the alcoholic a way to develop a satisfying life without alcohol

This program is discussed at A.A. group meetings

WHAT A.A. DOES NOT DO

Furnish initial motivation for alcoholics to recover

Solicit members Engage in or sponsor research Keep attendance records or case

histories

WHAT A.A. DOES NOT DO

Join “councils” of social agencies Follow up or try to control its members Make medical or psychological

diagnoses or prognoses Provide drying-out or nursing services,

hospitalization, drugs, or any medical or psychiatric treatment

WHAT A.A. DOES NOT DO

Offer religious services Engage in education about alcohol Provide housing, food, clothing, jobs,

money, or any other welfare or social services

WHAT A.A. DOES NOT DO Provide domestic or vocational

counseling Accept any money for its services, or

any contributions from non-A.A. sources

Provide letters of reference to parole boards, lawyers, court officials, social agencies, employers, etc

Expectations of Some Professionals

AA’s are somehow paid to or “have to” help them with their drunks

Once they notify AA that they have a “live one,” someone will come take them away and motivate them

Expectations of Some Professionals

AA is professional treatment, and professional treatment is AA

One meeting is a course of treatment, and drinking after one meeting is failed treatment

AA (or treatment) is only necessary after Cirrhosis or Seizures

Solution

Send your patient to AA, NA CA, etc. Identify treatment professionals in your

area who can accept those unable to get well (abstinent & in recovery) in AA alone

Refer to or consult treatment professionals like any other specialty

Problem Patients & Problem Prescriptions

Potential problem patients Problem prescriptions Classes of addicting drugs

Potential Problem Patients

Family history of alcoholism

External locus of control

Pain persistent or out of proportion

Litigation

Multiple meds

Problem Prescriptions

Soma, Fiorinal, Valium, Xanax

Ritalin, Adderall

Vicodin, Percodan, Ultram, OxyContin

Classes of Addicting Drugs

Related to the specific reinforcing

pathway

Three main classes

Sedative hypnotics and opioids are the

vast majority of problem prescriptions

Sedative Hypnotics

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

Opiates

Active in the endorphin systems Vicodin, other oxy & hydro codones

Especially ES formulations & OxyContin

Stadol, Fentanyl, Buprenorphine

Ultram

Methadone

Stimulants

Active in the dopamine system Amphetamines (Adderall)

Others (Ritalin, Cylert)

*Decongestants