l1 do fobs 2015 addiction and recovery copy

8/17/2019 L1 DO FOBS 2015 Addiction and Recovery Copy

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Addiction and Recovery Addiction and RecoveryOverviewOverview

Mechanisms of Action,Mechanisms of Action, Epidemiology, Genetics,Epidemiology, Genetics,

Diagnosis and TreatmentDiagnosis and Treatment

By Les mith MDBy Les mith MD

Than!s to Brian mart MD, "ar#orview Medical $enter for onThan!s to Brian mart MD, "ar#orview Medical $enter for on


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O#%ectives&O#%ectives&

"ave a #asic 'nderstanding of the #rain(s pleas're"ave a #asic 'nderstanding of the #rain(s pleas're

center)reward systemcenter)reward system

*dentify the diagnostic criteria for s'#stance+related*dentify the diagnostic criteria for s'#stance+related

disordersdisorders

Descri#e the epidemiology of s'#stance+related disordersDescri#e the epidemiology of s'#stance+related disorders

Discern intoication)withdrawal of different s'#stancesDiscern intoication)withdrawal of different s'#stances

Descri#e treatment optionsDescri#e treatment options

Apply the information to clinical cases Apply the information to clinical cases


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'#stance $lasses'#stance $lasses

Alcohol Alcohol

$affeine$affeine

$anna#is$anna#is

"all'cinogens"all'cinogens -$--$- othersothers

*nhalants*nhalants

OpioidsOpioids

edatives, hypnotics,edatives, hypnotics,

and aniolyticsand aniolytics

tim'lantstim'lants

To#accoTo#acco


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.e'ro#iology& Dr'gs of A#'se.e'ro#iology& Dr'gs of A#'se

+Dr'g Addiction is a disease of the #rain and+Dr'g Addiction is a disease of the #rain and

associated #ehavior is the res'lt of #rain tiss'eassociated #ehavior is the res'lt of #rain tiss'edysf'nctiondysf'nction

+Altho'gh the initial target receptor varies, it is+Altho'gh the initial target receptor varies, it is#elieved that ALL dr'gs of a#'se increase#elieved that ALL dr'gs of a#'se increasedopamine concentration in the /entral Tegmentaldopamine concentration in the /entral Tegmental

Area 0/TA1 and .'cle's Acc'm#ens Area 0/TA1 and .'cle's Acc'm#ens

+Dr'gs of A#'se provide longer and larger 02+34+Dr'gs of A#'se provide longer and larger 02+34

fold1 increases in dopamine than nat'ralfold1 increases in dopamine than nat'ralreinforcers s'ch as food or sereinforcers s'ch as food or se


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0

100200

300

400

500

600

700

800

900

1000

1100

0 1 2 3 4 5 hr

% o

f B a s a l R e l e a s e

DADOPACHVA

Accu!e"s

A#he$a%"e

0

100

200

300

400

0 1 2 3 4 5 hr

%

o f B a s a l R e l e a s e

DADOPACHVA

Accu!e"s

Coca%"e

&%e Af$er Dru'

(or#h%"e

0

100

150

200

250

0 1 2 3 hr

&%e Af$er Dru'

% o

f B a s a l R e l e a s e

Accu!e"s

Cau)a$e

*%co$%"e

Di Chiara and Imperato, PNAS, 1988

Effects of Drugs on Dopamine Release

% o

f B a s a l R e l e a

s e

0

100

150

200

250

0 1 2 3 4 5 hr

Accu!e"s

0+5

1+02+510

Dose

mg/kg

mg/kg

mg/kg

mg/kg


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$riteria for '#stance$riteria for '#stance A#'se A#'se

DM+*/DM+*/+Maladaptive pattern of s'#stance 'se,+Maladaptive pattern of s'#stance 'se,leading to impairment or distressleading to impairment or distress

+Manifested #y one or more of the following+Manifested #y one or more of the followingin a 35+month period&in a 35+month period&

6ail're in ma%or role o#ligations6ail're in ma%or role o#ligations -hysically ha7ardo's sit'ations-hysically ha7ardo's sit'ations

Legal pro#lemsLegal pro#lems ocial or interpersonal pro#lemsocial or interpersonal pro#lems


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$riteria for '#stance$riteria for '#stance

DependenceDependence DM+*/DM+*/Maladaptive pattern of 'seMaladaptive pattern of 'seManifested #y 8 or more of the following inManifested #y 8 or more of the following insame 35+month period&same 35+month period&

ToleranceTolerance 9ithdrawal9ithdrawal Larger amo'nts than intendedLarger amo'nts than intended :na#le to c't down or control 'se:na#le to c't down or control 'se

Great deal of time spent 'sing)recoveringGreat deal of time spent 'sing)recovering

*mportant activities given 'p to 'se*mportant activities given 'p to 'se $ontin'ed 'se despite health conse;'ences$ontin'ed 'se despite health conse;'ences


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$hanges from DM+*/ to DM+$hanges from DM+*/ to DM+

22+DM+*/ 'sed A#'se)Dependence dichotomy vs DM+2DM+*/ 'sed A#'se)Dependence dichotomy vs DM+2

mild)moderate)severe contin''m, which is more consistentmild)moderate)severe contin''m, which is more consistent

with o#served #ehavior with o#served #ehavior +Terms s'#stance dependence and physical dependenceTerms s'#stance dependence and physical dependence

ca'sed conf'sion< -hysical dependence one criteria, #'tca'sed conf'sion< -hysical dependence one criteria, #'t

not re;'ired or eno'gh to ma!e diagnosis of '#stancenot re;'ired or eno'gh to ma!e diagnosis of '#stance

Dependence


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'#stance+Related Disorders'#stance+Related Disorders

DM+2DM+25 Gro'ps&5 Gro'ps& '#stance :se Disorders'#stance :se Disorders

= -revio'sly split into a#'se or dependence-revio'sly split into a#'se or dependence

= *nvolves& impaired control, social impairment, ris!y*nvolves& impaired control, social impairment, ris!y

'se, and pharmacological criteria'se, and pharmacological criteria

'#stance+*nd'ced Disorders'#stance+*nd'ced Disorders


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Substance Use Disorder Substance Use Disorder

DSM-5DSM-5+:sing larger amo'nts or for longer time than+:sing larger amo'nts or for longer time thanintendedintended

+-ersistent desire or 'ns'ccessf'l attempts to c't+-ersistent desire or 'ns'ccessf'l attempts to c't

down or control 'sedown or control 'se+Great deal of time o#taining, 'sing, or recovering+Great deal of time o#taining, 'sing, or recovering

+$raving+$raving

+6ail to f'lfill ma%or roles 0wor!, school, home1+6ail to f'lfill ma%or roles 0wor!, school, home1

+-ersistent social or interpersonal pro#lems+-ersistent social or interpersonal pro#lemsca'sed #y s'#stance 'seca'sed #y s'#stance 'se


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'#stance :se Disorder '#stance :se Disorder

DM+2DM+2 0cont10cont1

+*mportant social, occ'pational, recreational+*mportant social, occ'pational, recreational

activities given 'p or red'cedactivities given 'p or red'ced

+:se in physically ha7ardo's sit'ations+:se in physically ha7ardo's sit'ations+:se despite physical or psychological+:se despite physical or psychological

pro#lems ca'sed #y 'sepro#lems ca'sed #y 'se

+Tolerance+Tolerance+9ithdrawal+9ithdrawal 0not doc'mented after repeated 'se0not doc'mented after repeated 'seof -$-, inhalants, hall'cinogens1of -$-, inhalants, hall'cinogens1


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Severity DSM-5Severity DSM-5

everityeverity Depends on > of symptom criteria endorsed+Depends on > of symptom criteria endorsed+

none rated more important or necessary thannone rated more important or necessary than

othersothers

Mild& 5+8 symptomsMild& 5+8 symptoms Moderate& ?+2 symptomsModerate& ?+2 symptoms evere& @ or more symptomsevere& @ or more symptoms


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pecifiers DM+2pecifiers DM+2

pecifierspecifiers *n early remission& no diagnostic criteria*n early remission& no diagnostic criteria

present for 8 months #'t 35 monthspresent for 8 months #'t 35 months0ecept craving which may persist10ecept craving which may persist1

*n s'stained remission& no criteria for 35*n s'stained remission& no criteria for 35

months 0ecept craving1months 0ecept craving1 *n a controlled environment& access to*n a controlled environment& access to

s'#stance restricted 0e< Cail1s'#stance restricted 0e< Cail1


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'#stance+*nd'ced DM+2'#stance+*nd'ced DM+2

+*ntoication+*ntoication

+9ithdrawal+9ithdrawal

+-sychotic Disorder +-sychotic Disorder

+Bipolar Disorder +Bipolar Disorder

+Depressive Disorder +Depressive Disorder

+Aniety Disorder +Aniety Disorder

+leep Disorder +leep Disorder

+Deliri'm+Deliri'm

+.e'rocognitive+.e'rocognitive

+e'al Dysf'nction+e'al Dysf'nction


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*ntoication*ntoication

+Reversi#le s'#stance+specific syndrome+Reversi#le s'#stance+specific syndromed'e to recent ingestion of a s'#stanced'e to recent ingestion of a s'#stance

+Behavioral)psychological changes d'e to+Behavioral)psychological changes d'e to

effects on $. developing after ingestion&effects on $. developing after ingestion& e< Dist'r#ances of perception, wa!ef'lness,e< Dist'r#ances of perception, wa!ef'lness,

attention, thin!ing, %'dgment, psychomotor #ehaviorattention, thin!ing, %'dgment, psychomotor #ehavior

and interpersonal #ehavior and interpersonal #ehavior

+.ot d'e to another medical condition or+.ot d'e to another medical condition ormental disorder mental disorder

+Does not apply to to#acco+Does not apply to to#acco


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$linical pict're of intoication$linical pict're of intoication

depends on&depends on&+'#stance+'#stance

+Dose+Dose

+Ro'te of+Ro'te of Administration Administration

+D'ration)chronicity+D'ration)chronicity

+*ndivid'al degree of+*ndivid'al degree oftolerancetolerance

+Time since last dose+Time since last dose

+-erson+-erson(s epectations(s epectations

of s'#stance effectof s'#stance effect

+$ontet'al varia#les+$ontet'al varia#les


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Dr'g and 'se varia#les thatDr'g and 'se varia#les that

increaseincrease

ris! of a#'seris! of a#'se+ Rapidity of onset+ */, intranasal, orRapidity of onset+ */, intranasal, orsmo!ing prod'ces faster effect


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WithdrawalWithdrawal

+'#stance+specific syndrome d'e to+'#stance+specific syndrome d'e to

stopping or red'cing prolonged 'sestopping or red'cing prolonged 'se

+-hysiological cognitive components+-hysiological cognitive components

+ignificant distress in social, occ'pational+ignificant distress in social, occ'pationalor other important areas of f'nctioningor other important areas of f'nctioning

+.ot d'e to another medical condition or+.ot d'e to another medical condition or

mental disorder mental disorder ++.o.o withdrawal& -$-, other hall'cinogens,withdrawal& -$-, other hall'cinogens,

inhalants Minimal)moderate with canna#is,inhalants Minimal)moderate with canna#is,

stim'lantsstim'lants


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'#stance+*nd'ced Mental'#stance+*nd'ced Mental

Disorder Disorder +-otentially severe, 's'ally temporary, #'t+-otentially severe, 's'ally temporary, #'t

sometimes persisting $. syndromessometimes persisting $. syndromes

+$ontet of s'#stances of a#'se,+$ontet of s'#stances of a#'se,

medications, or toinsmedications, or toins

+$an #e any of the 34 classes of s'#stances+$an #e any of the 34 classes of s'#stances


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'#stance+*nd'ced Mental'#stance+*nd'ced Mental

Disorder Disorder +$linically significant presentation of a+$linically significant presentation of amental disorder mental disorder

+Evidence 0", -E, la#s, prior episode1+Evidence 0", -E, la#s, prior episode1 D'ring or within 3 month of 'seD'ring or within 3 month of 'se $apa#le of prod'cing mental disorder seen$apa#le of prod'cing mental disorder seen

+ Evidence of independent mental disorder + Evidence of independent mental disorder

-receded onset of 'se of s'#stance-receded onset of 'se of s'#stance -ersists for s'#stantial time after 'se 0which-ersists for s'#stantial time after 'se 0which

wo'ld not epect if s'#stance ind'ced1wo'ld not epect if s'#stance ind'ced1


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NeuroadaptationNeuroadaptation&&

Refers to 'nderlying $. changes thatRefers to 'nderlying $. changes that

occ'r following repeated 'se s'ch thatocc'r following repeated 'se s'ch that

person develops tolerance and)orperson develops tolerance and)or

withdrawalwithdrawal -harmaco!inetic adaptation of meta#oli7ing-harmaco!inetic adaptation of meta#oli7ing

systemsystem

-harmacodynamic a#ility of $. to f'nction-harmacodynamic a#ility of $. to f'nctiondespite high #lood levelsdespite high #lood levels


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ToleranceTolerance

.eed to 'se an increased amo'nt of a s'#stance.eed to 'se an increased amo'nt of a s'#stancein order to achieve the desired effectin order to achieve the desired effect

OROR

Mar!edly diminished effect with contin'ed 'se ofMar!edly diminished effect with contin'ed 'se ofthe same amo'nt of the s'#stancethe same amo'nt of the s'#stance

+/aries significantly #y dr'g class+/aries significantly #y dr'g class

+All physiologic tolerances are .OT e;'al+ get+All physiologic tolerances are .OT e;'al+ getm'ch less tolerance to constipation and miosism'ch less tolerance to constipation and miosisthan to other physiologic effects of opioidsthan to other physiologic effects of opioids


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The 8 F$s of AddictionThe 8 F$s of Addiction

3131 $$raving+ a strong desire or 'rge to 'se,raving+ a strong desire or 'rge to 'se,

often precipitated #y specificoften precipitated #y specific

circ'mstances, places, or emotionalcirc'mstances, places, or emotional

states associated with previo's 'sestates associated with previo's 'se0-avlovian10-avlovian1

5151 $$ontin'ed :seontin'ed :se

8181 Loss ofLoss of $$ontrolontrol


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Epidemiology& -revalenceEpidemiology& -revalence

+Recent meas're of prevalence in 5435 for persons greater than 35yo+Recent meas're of prevalence in 5435 for persons greater than 35yowho met criteria for specific 'se disorderwho met criteria for specific 'se disorder in that year


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Epidemiology 0cont


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Epidemiology 0cont


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ER /isits 0.*DAER /isits 0.*DA N41N41

+3


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EtiologyEtiology

+M'ltiple interacting factors infl'ence 'sing+M'ltiple interacting factors infl'ence 'sing

#ehavior and loss of decisional flei#ility#ehavior and loss of decisional flei#ility

+.ot all who #ecome dependent eperience+.ot all who #ecome dependent eperience

it same way or motivated #y same factorsit same way or motivated #y same factors

+Different factors may #e more or less+Different factors may #e more or less

important at different stages 0dr'gimportant at different stages 0dr'g

availa#ility, social acceptance, peeravaila#ility, social acceptance, peer

press'repress're // personality and #iology1personality and #iology1


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EtiologyEtiology

+elf+medication+elf+medication EtO")#en7os + panicP opioids +angerPEtO")#en7os + panicP opioids +angerP

amphetamine + depressionamphetamine + depression

+Genetic 0initially esta#lished with alcohol, #'t+Genetic 0initially esta#lished with alcohol, #'t

appears to #e more general1 ?4+@4K of varianceappears to #e more general1 ?4+@4K of variance

+$onditioning& #ehavior maintained #y its+$onditioning& #ehavior maintained #y its

conse;'encesconse;'ences

Terminate aversive state 0pain, aniety, w)d1Terminate aversive state 0pain, aniety, w)d1 pecial stat'special stat's E'phoriaE'phoria

econdary reinforcers 0e< -araphernalia1econdary reinforcers 0e< -araphernalia1


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Learnin and !hysioloical "asis #orLearnin and !hysioloical "asis #or

DependenceDependence

++ After 'sing dr'gs or when stop leads to a After 'sing dr'gs or when stop leads to adepleted state res'lting in dysphoria and)ordepleted state res'lting in dysphoria and)or

cravings to 'se, reinforcing the 'se of more dr'g


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$omor#idity$omor#idity

:p to 24K of addicts have co+occ'rring:p to 24K of addicts have co+occ'rring

psychiatric disorder psychiatric disorder Antisocial -D Antisocial -D Mood Disorder Mood Disorder Aniety Disorder Aniety Disorder AD"D AD"D


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Typical !resentation and $ourse%Typical !resentation and $ourse%

+-atient may present in ac'te intoication,+-atient may present in ac'te intoication,ac'te)chronic withdrawal or s'#stance ind'cedac'te)chronic withdrawal or s'#stance ind'cedmood, cognitive disorder or medical complicationsmood, cognitive disorder or medical complications

+A#stinence depends on several factors& social,+A#stinence depends on several factors& social,environmental, internal factors 0presence of otherenvironmental, internal factors 0presence of othercomor#id psychiatric illnesses1comor#id psychiatric illnesses1

+Remission and relapses are the r'le 0%'st li!e+Remission and relapses are the r'le 0%'st li!e anyany other other chronic medical illness1chronic medical illness1

+ :p to H4 K event'ally a#le to a#stain or+ :p to H4 K event'ally a#le to a#stain ordecrease 'se s'fficiently to not meet criteriadecrease 'se s'fficiently to not meet criteria


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SUBSTANCE URINE

Alcohol 3-5 days

Amphetamines (except meth) to 3 days!ethamphetamine to 5 days

Ba"#it$"ates (not pheno#a"#ital) to 3 days

%heno#a"#ital 7 $o 14 )a,s

Ben&odia&epines ' to 5 days

Canna#is 28 $o 49 )a,s

Cocaine ' to 3 days

Codeine to 3 days

Cotinine (p"od$ct o nicotine) to days

!o"phine to 3 days*e"oin to 3 days

+S, 2 $o 24 hours


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:R*.E TOQ*$OLOG:R*.E TOQ*$OLOG

:rine toicology:rine toicology screenscreen is initial test 0imm'noassay1,is initial test 0imm'noassay1,

inepensive, #'t ris! of common false positives and falseinepensive, #'t ris! of common false positives and false

negatives


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$a'ses of -otential false$a'ses of -otential false

positive 'rine dr'g screenspositive 'rine dr'g screens


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Options for where to treatOptions for where to treat

+"ospitali7ation++"ospitali7ation+

+D'e to dr'g OD, ris! of severe withdrawal, medical+D'e to dr'g OD, ris! of severe withdrawal, medicalcomor#idities, re;'ires restricted access to dr'gs,comor#idities, re;'ires restricted access to dr'gs,psychiatric illness with s'icidal ideationpsychiatric illness with s'icidal ideation

+Residential treatment 'nit+Residential treatment 'nit

+.o intensive medical)psychiatric monitoring needs+.o intensive medical)psychiatric monitoring needs

+Re;'ire a restricted environment+Re;'ire a restricted environment

+-artial hospitali7ation+-artial hospitali7ation

+O'tpatient -rogram +Low ris! of med)psych mor#idity and+O'tpatient -rogram +Low ris! of med)psych mor#idity andhighly motivated patient< @ month o'tcomes similar tohighly motivated patient< @ month o'tcomes similar toinpatientinpatient


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Treat&ent '(nitial)Treat&ent '(nitial)

Manage *ntoication 9ithdrawalManage *ntoication 9ithdrawal

*ntoication*ntoication= Ranges& e'phoria to life+threatening emergencyRanges& e'phoria to life+threatening emergency

DetoificationDetoification

inpatient& close medical s'pervision)monitoringinpatient& close medical s'pervision)monitoring

o'tpatient& minimal monitoring, preparation foro'tpatient& minimal monitoring, preparation forongoing treatmentongoing treatment


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Treat&entTreat&ent a#ter a#ter ' or i# &ild*' or i# &ild*

durindurin) Deto+) Deto+Behavioral *nterventions 0target internal and eternal re+inforcers1Behavioral *nterventions 0target internal and eternal re+inforcers1

Motivation to change 0M*1Motivation to change 0M*1

Gro'p TherapyGro'p Therapy

*ndivid'al Therapy*ndivid'al Therapy

$ontingency Management$ontingency Management

elf+"elp Recovery Gro'ps 0AA1elf+"elp Recovery Gro'ps 0AA1

Therape'tic $omm'nitiesTherape'tic $omm'nities

6amily *nvolvement)Therapy6amily *nvolvement)Therapy

Twelve+tep 6acilitationTwelve+tep 6acilitation

Relapse -reventionRelapse -revention

0motivational ++interviewing10motivational ++interviewing1

+EBplore desire to stop drin!ing)'sing vs+EBplore desire to stop drin!ing)'sing vs perceived #enefits of ongoing 'seperceived #enefits of ongoing 'se

+Gentle confrontation with ed'cation 0ris!s+Gentle confrontation with ed'cation 0ris!s to health1 ) therape'tic allianceto health1 ) therape'tic alliance

+*nvolve family and friends for s'pport+*nvolve family and friends for s'pport

+Ed'cation a#o't s'#stance dependence+Ed'cation a#o't s'#stance dependence and need for reha#ilitation planand need for reha#ilitation plan


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Treat&entTreat&ent

+-harmacologic *ntervention+-harmacologic *ntervention

+Treat $o+Occ'rring -sychiatric Disorders+Treat $o+Occ'rring -sychiatric Disorders 24K will have another psychiatric disorder 24K will have another psychiatric disorder

+Treat Associated Medical $onditions+Treat Associated Medical $onditions

cardiovasc'lar, cancer, endocrine, hepatic,cardiovasc'lar, cancer, endocrine, hepatic,

hematologic, infectio's, ne'rologic,hematologic, infectio's, ne'rologic,

n'tritional, G*, p'lmonary, renal,n'tritional, G*, p'lmonary, renal,m'sc'los!eletalm'sc'los!eletal


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Treatment, Recovery, RelapseTreatment, Recovery, Relapse

+ As with other chronic diseases, As with other chronic diseases,

discontin'ation of treatment is high ris!discontin'ation of treatment is high ris!

+ Relapse)slip #est viewed as temporaryRelapse)slip #est viewed as temporary

set#ac! d'e to lac! of compliance or c'rrentset#ac! d'e to lac! of compliance or c'rrentineffectiveness of treatmentineffectiveness of treatment

+ Rates of relapse very similar to other chronicRates of relapse very similar to other chronic

diseasesdiseases+ As with other m'ltisystem diseases, a As with other m'ltisystem diseases, a

m'ltimodal approach is often re;'ired


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Stages of ChangeStages of Change

!re-conte&plation!re-conte&plation + needs ed'cation and+ needs ed'cation andenco'ragementenco'ragement

$onte&plation$onte&plation + needs personali7ed feed#ac!+ needs personali7ed feed#ac!

Decision,!reparationDecision,!reparation + needs a plan for how to+ needs a plan for how toproceedproceed ctionction + determine level of treatment needed and+ determine level of treatment needed and

#egin the process of recovery#egin the process of recovery

MaintenanceMaintenance + relapse prevention+ relapse prevention RelapseRelapse + pic! 'p where ever the person has re++ pic! 'p where ever the person has re+

entered the cycleentered the cycle

='!rochas.a / Di$le&ente)


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Identify the stage ofIdentify the stage of

readinessreadiness

+F9hat are yo'r tho'ghts and feelings a#o't+F9hat are yo'r tho'ghts and feelings a#o't

;'itting smo!ingU;'itting smo!ingU

+F"ave yo' tho'ght a#o't %oining the cardiac+F"ave yo' tho'ght a#o't %oining the cardiac

reha# programUreha# programU

+F9hat is yo'r eperience with weight loss+F9hat is yo'r eperience with weight loss

dietsUdietsU


44/50

Identify the stage ofIdentify the stage of

readinessreadiness

+-re+contemplation& .ot am#ivalent and+-re+contemplation& .ot am#ivalent and

does .OT want to changedoes .OT want to change

+$ontemplation& Am#ivalent, may#e yes to+$ontemplation& Am#ivalent, may#e yes to

change, may#e nochange, may#e no

+Decision)-reparation& .ot am#ivalent and+Decision)-reparation& .ot am#ivalent and

DOE wants to changeDOE wants to change

+Action& $ommitted to change< .eeds+Action& $ommitted to change< .eeds

specific plan and reso'rcesspecific plan and reso'rces


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Move one stage at a timeMove one stage at a time

-re+contemplation& *ntrod'ce am#ivalence-re+contemplation& *ntrod'ce am#ivalence

$ontemplation& Resolve am#ivalence$ontemplation& Resolve am#ivalence

Decision)-reparation& Develop an actionDecision)-reparation& Develop an actionplanplan

Action& olve pro#lems Action& olve pro#lems

Maintenance& $onsolidate gainsMaintenance& $onsolidate gains Relapse& *nto action once againRelapse& *nto action once again


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9e#sites9e#sites

+AM"A +AM"A www


47/50

A 82 yo M9M presents to an o'tpatient psychiatrist(s office for an initial eval'ation< 9hen as!ed why he is

there, he initially tells the doctor FMy wife insisted that * #e eval'ated+ she thin!s that * have a pro#lem #eca'se* 'se cocaine some of the time on wee!+ends< "e goes on to say Fshe #ro'ght me here today, #'t * don(t thin!it(s any #ig deal, * %'st do it to rela with friends a co'ple of wee!+ends a month(< "e denies depression or anytho'ghts to harm self or others<

Additional ;'estioning reveals that he& +ometimes misses his !ids sporting events on wee!+ends 0which he had committed to attend1 + stopped 'sing altogether for @ months a year ago in response to his wife(s threats to move o't with the !ids

+ has spent money intended for family vacations to p'rchase cocaine +calls in sic! several Mondays, after he has 'sed cocaine that wee!+end despite important meetings + #ecomes very s'spicio's when he is high on cocaine, pee!ing o't the #linds #elieving that the police havehim 'nder s'rveillance< +has had .O legal or medical pro#lems related to his cocaine 'se<The patient also informs the doctor that he drin!s ?+2 alcoholic #everages on 'nday nights after 'sing cocainein order to Fcalm down and get some sleep< "e will smo!e 8+? cigarettes on days he is 'sing<9hen he is as!ed what he wo'ld li!e to net, the patient says F* !now * need to ;'it, it really is starting to

interfere with more important things, #'t * %'st want to do it on my own,( and Fif * can(t stop on my own, what!ind of help is availa#leU


48/50

31 The psychiatrist(s most appropriateoption at this time wo'ld #e to&

A1 *nsist that the patient chec! himself intoFdeto #eca'se of the potentially life+threatening withdrawal symptoms hewill pro#a#ly enco'nter<

B1 tart an antipsychotic medicine to help

stop the paranoid thin!ing he iseperiencing<

$1 $all the police to ta!e the patient to anemergency room for f'rther eval'ation

D1 $all the patient(s employer to gainadditional leverage in forcing the patient

into treatmentE1 As! the patient if he wo'ld give consent

to allow his wife to come in from thewaiting room to get additionalinformation and disc'ss options<


49/50

51 The most appropriate diagnosis0es1 forthis patient, given that yo' have o#tainedreasona#ly acc'rate information is)are&

A1 -olys'#stance Dependence Disorder B1 $ocaine :se Disorder, severe andTo#acco :se Disorder, moderate $1 $ocaine :se Disorder, moderate D1 -aranoid -ersonality Disorder E1 The patient does not meet criteria for

any '#stance :se Disorder or any otherc'rrently accepted mental illness<


50/50

81 The patient(s Freadiness for changecorrelates most closely with which of thefollowing stages&

A1 -re+contemplationB1 $ontemplation$1 -reparation

D1 Action E1 Relapse

l1 do fobs 2015 addiction and recovery copy

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