Session 2: Mental Health A: Alcohol Dependency: The Pharmacist s Role in Detox and Treatment 1:45pm - 2:45pm

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1 January 20-22, 2012 Des Moines Marrio, 700 Grand Avenue, Des Moines, IA Session 2: Mental Health A: Alcohol Dependency: The Pharmacist s Role in Detox and Treatment 1:45pm - 2:45pm ACPE UAN L01-P Ac vity Type: Applica on-based 0.1 CEU/1.0 Hr Program Objec ves for Pharmacists: Upon comple on of this CPE ac vity par cipants should be able to: 1. Recognize the signs of addic on 2. List the Stages of Treatment 3. Take appropriate ac on steps when recognizing abuse 4. Discuss confiden ality and other related legisla on 5. Describe the role of pharmacists in office-based treatment of withdrawal from opiate addic on Speaker: Shelia Murphy, MPA, IADC, graduated with a bachelor s degree in Human Services and Psychology from Upper Iowa University and a Master s degree in Public Administra on from Drake University. She is currently cer fied as an Interna onal Alcohol and Drug Counselor. Shelia has an extensive history in the field of Addi on and Human Services. She began her career in 1988 as an addic on counselor. Along the way, she held mul ple posi ons, including Supervisor of Clinical Services at Powell Chemical Dependency Center, a hospital-based treatment facility in Des Moines, Iowa. She has been an adjunct instructor for the Des Moines Area Community College. Currently, Shelia is the Director of Clinical Services for Women Services for Hazelden in Center City Minnesota. Speaker Disclosure: Shelia Murphy does not report any actual or poten al conflicts of interest in rela on to this CPE ac vity. Off-label use of medica ons will not be discussed during this presenta on.

2 Pre-Assessment Questions Alcohol Dependency The Pharmacist s Role in Detox and Treatment Sheila Murphy, MPA, ADCR Director of Clinical Services Hazelden Foundation Center City, MN 1. The American Society of Addiction Medicine (ASAM) developed criteria to diagnosis addiction. Which one of the following is not one of the signs of addiction according to the criteria? a. Using more of the additive substance to reach the same level of intoxication. b. Modifying social and work activities without consequences. c. Attempting to relieve symptoms of withdrawal by using the same or different drug. d. Has tried to quit or reduce use of substance unsuccessfully. 2 Pre-Assessment Questions Pre-Assessment Questions 2. During the first stage of addiction treatment, it is important that the patient understand the culture of recovery. 3. Which of the following is not one of the fastest growing trends in the field of addiction? b. Older Adult Admissions c. Methamphetamine Addiction d. Office Based Treatment 3 4 Pre-Assessment Questions Pre-Assessment Questions 4. Having a positive attitude towards individuals seeking treatment is important There are several treatment philosophies used today in the treatment of addiction. Which of the following is shown to be the most effective? b. 12-Step facilitation c. Multi-modality d. Cognitive-behavioral therapies 6 1

3 Clinical Case Study Learning Objectives 43 year female seen in a primary residential facility for 28 days and stepped down to an outpatient setting for 47 additional days Treated for Benzodiazepine and alcohol addiction Medical history: Gastric bypass surgery age 18 Migraine headaches Obesity Release Open to patient s pharmacy upon discharge script faxed 7 1. Recognize the signs of addiction 2. Understand the Stages of Addiction Treatment 3. Gain awareness of the actions that can be taken when you recognize abuse 4. Discuss confidentiality and related legislation 5. Describe Office Based treatment and the role of the pharmacist 8 Breast Cancer Kills 40,000 Women in the U.S. Each Year Alcohol-related diseases kill 85,000 people in U.S. each year and are the 3 rd leading modifiable cause of death and it gets its own line of KitchenAid appliances to raise awareness Addiction at a Glance Demographics of Addiction In 2009, an estimated 23.5 million Americans are currently addicted to alcohol and or other drugs and are in need of treatment Only 2.6 million received treatment Gap over 20 million

4 Treatment Needs Vary Stages of Addiction Treatment Screening, Assessment & Stabilization Engagement, Education, Awareness, Increase motivation & exposure to culture of recovery Five substances account for 96% of all admissions in Maintenance & Reengaging in life 14 Criteria for Substance Dependency Signs of Addiction Maladaptive pattern of substance use, leading to impairment or distress, as manifested by 3 (or more) of the following, in the same 12-month period 1. Tolerance, as defined by either of the following: A need for markedly increased amounts of the substance to achieve intoxication or desired effect. Markedly diminished effect with continued use of the same amount of the substance. 2. Withdrawal, as manifested by either of the following: The characteristic withdrawal syndrome for the substance. The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms. 15 Criteria For Substance Dependence 3. Substance is taken in larger amount or over a longer period than was intended. 4. Persistent desire or unsuccessful efforts to cut down or control substance use. 5. A great deal of time is spent in activities necessary to obtain the substance, use the substance or recover from its effects. 6. Important social, occupational, or recreational activities are given up or reduced because of substance use. 7. Continues to use despite knowing it has caused ongoing physical or psychological problems. DSM-IV 16 Treatment Philosophy Cognitive-behavioral therapies Motivational Enhancement Therapy Pharmacotherapy's Process groups 12-Step facilitation Matrix Model for Stimulant Addiction Integrated multi-modality approaches 17 Confidentiality & Related Legislation Each State has different law Confidentiality of Substance Abuse Treatment Records (42CFR Part 2) Prescription directly transmitted by physician to pharmacist Restriction on further redisclosure 18 3

5 Need to Know Office Based Treatment Fasted growing trends: Prescription Narcotics Older Adult Admissions Pharmacotherapy Office Based Treatment A New Model of Care Coordination of services by physician s office Opioid-dependent patients Buprenorphine/naloxone Tailored to needs of patient Successful model How to Help Positive attitude The right & responsibility to work with the prescribing physician Prescription Monitoring Program Observing false or altered prescription forms Support or create drop-off programs for expired & unused prescription medication Drugs for Alcohol Withdrawal Benzodiazepines: Short acting: Long acting / active metabolites: - Midazolam (Versed) - infusion only - Alprazolam (Xanax) - Lorazepam (Ativan) - Chlordiazepoxide (Librium) - Oxazepam (Serax) - Clonazepam (Klonopin) - Clorazepate (Tranxene) - Diazepam (Valium) Other Agents Used for Withdrawal Post Assessment Questions Dexmedetomidine (Precedex)- Infusion only Barbiturates (e.g., Phenobarbital) Seizure medications (Carbamzepine, Divalproes, et.al.) Antipsychotics (E.g., Haloperidol) Beta Blockers (e.g., Propranolol) The American Society of Addiction Medicine (ASAM) developed criteria to diagnosis addiction. Which one of the following is not one of the signs of addiction according to the criteria? a. Using more of the additive substance to reach the same level of intoxication. b. Modifying social and work activities without consequences. c. Attempting to relieve symptoms of withdrawal by using the same or different drug. d. Has tried to quit or reduce use of substance unsuccessfully. 24 4

6 Post Assessment Questions Post Assessment Questions 2. During the first stage of addiction treatment, it is important that the patient understand the culture of recovery. 3. Which of the following is not one of the fastest growing trends in the field of addiction? b. Older Adult Admissions c. Methamphetamine Addiction d. Office Based Treatment Post Assessment Questions Post Assessment Questions 4. Having a positive attitude towards individuals seeking treatment is important There are several treatment philosophies used today in the treatment of addiction. Which of the following is shown to be the most effective? b. 12-Step facilitation c. Multi-modality d. Cognitive-behavioral therapies 28 Questions? 29 5

7 2012 Educational Expo Alcohol Dependency: The Pharmacist s Role in Detox and Treatment Shelia Murphy, MPA, IADC Post Assessment Questions 1. The American Society of Addiction Medicine (ASAM) developed criteria to diagnosis addiction. Which one of the following is not one of the signs of addiction according to the criteria? a. Using more of the additive substance to reach the same level of intoxication. b. Modifying social and work activities without consequences. c. Attempting to relieve symptoms of withdrawal by using the same or different drug. d. Has tried to quit or reduce use of substance unsuccessfully. 2. During the first stage of addiction treatment it is very important that the patient understands the culture of recovery. 3. Which one of the following is not one of the fasted growing trends in the field of addiction? b. Older Adult Admissions c. Methamphetamine Addiction d. Office Based Treatment 4. Having a positive attitude towards individuals seeking treatment is important? 5. There is several treatment philosophies used today in the treatment of addiction. Which one of the following is shown to be the most effective? b. 12 Step facilitation c. Multi modality d. Cognitive behavioral therapies

8 Mental Health Alcohol Dependency: The Pharmacist s Role in Detox & Treatment 43 y.o. female, third primary residential treatment. Stayed 28 days primary & 47 days in outpatient tx. Also attended ongoing therapy Medications at Admission: Vicodin prn Flexeril prn Imitrex prn Zorirax 400 mg Celexa 40 mg Gabapentin 1200 Buspar 30 mg daily Lamictal, titration daily Tofranil 10 mg Rozerem 8 mg Serequel 50 mg Also used: Alcohol and Ambien 400 mg 5 x week Treated for Benzodiazepine & Alcohol addiction While in primary TX she contacted her Pharmacy and informed them of her addiction and requested her chart flagged. Release opened to pts. Pharmacy signed at dc and script faxed What went wrong? (Assessment) Patient problems: System problems: Intervention: (Plan) Medical History & Mental Health Gastric bypass age 18 Migraine headaches Obesity Herpes History of Childhood Abuse Diagnosis of Bipolar Disorder Stepped down to an Out Patient level of care at time of discharge medication were: Celexa 40 ml 2 x a day Rozerem 8 ml - bedtime Effexor 37.5 ml daily Neurontin 600 ml oral 3 x a day Discharged Against Staff Advice from Out Pt. Was withdrawing from support Affect changed Dsyphoria 3 weeks prior to leaving

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