When Mental Health Issues Emerge in My Patient Population From an Addiction Perspective

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "When Mental Health Issues Emerge in My Patient Population From an Addiction Perspective"

Transcription

1 When Mental Health Issues Emerge in My Patient Population From an Addiction Perspective Joseph N. Ranieri, DO, FAAFP, FASAM Diplomate-American Board Of Addiction Medicine Medical Director Bridgeton, NJ Westfield, PA Cherry Hill, NJ Northfield, NJ Morristown,NJ 1 The Presenter, Dr. Joseph N. Ranieri, has declared an interest for speaking engagements with Alkermes Ironwood Pharmaceutical entity. Physician is an employee of Seabrook House. 2 May 4-7,

2 History of present illness: Patient is a 30-year-old female presents to the office with a history of interstitial cystitis diagnosed approximately 15 years ago with periods of exacerbation and remission. Other medical problems include Gastroparesis, Anxiety / Panic, MDD-Depression, PTSD-relationship verbal abuse, Nephrolithiasis Medications include: Oxycodone (Daily range mg), Hydromorphone 8-12mg / day, Buprenorphine-Suboxone-( 12-16mg/ day ) ( i.e. and other opiate medications B & O suppositories ) at various interval times. Other medications include: Diazepam intravaginal suppositories, Klonopin 0.5 mg twice a day, Soma 350 mg 4 times a day as needed, Seroquel 50 mg at bedtime, Remeron 30 mg at bedtime, Zoloft 50mg daily, B & O Suppositories Substance Abuse History / Alcohol use history-unremarkable DAST-21 Questionnaire + one question for experimenting with drugs yrs ago. Mother is present during the history and physical as an advocate Review of symptoms; other 10 point review of symptoms were negative except for Patient Comfort Assessment Form, Anxiety Rating Scale Zung, PHQ-9 Depression Questionnaire. Allergies: Compazine, Reglan, Phenergan, nonsteroidal anti-inflammatory medications ( upset stomach dyspepsia ). 3 Social history; divorced with associated verbal /emotional abuse. Occupation, teacher. Patient ; + nicotine ½ ppd x 16 yr. started age 14 Family history father with kidney cancer Urine drug screen positive for buprenorphine, benzodiazepines. Vital signs include pulse 114, temperature 98.1, blood pressure 99/81. Physical exam unremarkable. Assessment and plan: 1. Chronic pain syndrome secondary to interstitial cystitis-prescribe buprenorphine off FDA- label for pain management 8 mg twice a day 2. Gastroparesis-proton pump inhibitor-prilosec, recent Gastric Device Placed. 3. Anxiety/depression, history of trauma, emotional-verbal, medications include Remeron, clonazepam, diazepam, Seroquel, d/c -Soma, Oxycodone,-140mg/ day d/c Marinol ( patient claims filled but not taken ) 4. Chronic Nephrolithiasis-asymptomatic 5. Recommend support management via support group, interstitial cystitis, recommend meetings for recovery awareness at our office. 6. Coordination of care-with other providers psychiatrist, Uro-Gyn, holistic provider to limit / eliminate Psychoactive Medications, Sedatives, Muscle relaxers, Opiates 7. Review NJ RX Reporting System monitoring,!2 step recovery, CBT 8. Coordinated Care amongst specialist to minimize duplication of medications. 9. Transdermal Pain Cream-Tertracaine, Lidocaine, Baclofen, Clonidine, Neurotin, ibuprofen, Elavil 4 May 4-7,

3 Patient has 3 different Uro-Gynecologists- 1. Dr A. Rx B & O Suppositories & Lyrica 2. Dr B. Rx Vaginal Diazepam & Oral Diazepam, Various Opiates. 3. Dr C. Rx. Multiple Opinions Patient Has 1 primary care provider & Multiple Urgent Care Centers ( Rx Antibiotics ) Patient Has Holistic Medicine Provider Rx. Soma Patient Has 2 Ob-Gyn Providers Patient Has Psychiatrist Rx Clonazepam, Remeron, Seroquel, Zoloft. Patient Has a Therapist which she underutilizes. Patient now Has an Addiction Specialist Rx Suboxone for Pain Management of Substance Use Disorder ( Patient in denial ) Goal is to eliminate duplications of medications in the same pharmacologic class and engage patient in the Bio-Psychosocial aspect of the Disease Treatment of Dependence Pain & Addiction. 5 Fill Date Product, STR, Form Quantity Days Pt ID 10/17/2014 Diazepam Suppository 2MG 1 daily Patient use 1or 2 per day /23/2014 Suboxone 2MG, 8 MG, Film, Soluble I twice a day /02/2014 Clonazepam, 0. 5 MG, Tablet Patient use 2 per day /02/2014 B & O Suppository Patient use for exacerbation most 10 per month May 4-7,

4 Fill Date Product, STR, Form Quantity Days 09/24/2014 Suboxone, 2MG, 8 MG, Film, Soluble -1 twice a day /18/2014 Diazepam Suppository 2MG -1 daily Patient use 1 or 2 per day 9/10/2014 B & O Suppository Patient uses 10 per month 9/6/2015 Oxycodone 10mg /325 Patient use one q6hr x 3 days, holding suboxone 09/05/2014 Clonazepam, 0.5 MG Tablet- Patient use 2 per day 9/4/2015 Lyrica 150mg Patient uses as needed 1-2 per day exacerbations 09/01/2014 Dronzabinol, 2.5 MG, Capsule 1 daily Prescription filled but not used for Gastroparesis 8/20/2014 Diazepam, 2MG, suppository Patient use 1-2 per day /24/2014 Suboxone 8mg Film 1 twice a day /12/2014 Clonazepam, 0.5mg, tablet Patient uses 2 per day 8/12/2015 B & O Suppository Patient use 10 per month 7/19/2014 Soma 350mg Patient uses as needed /29/2014 Suboxone, 2MG, 8MG, Film, Soluble /18/2014 Clonazepam, 0.5mg, tablet Patient uses 1-2 per day Fill Date Product, STR, Form Quantity Days 7/2/2014 Oxycodone 10mg/325 Patinet used 1 q6hr prn x 2 days 07/2/2014 Diazepam, 2MG, TaBlet Patient uses in addition to vaginal supposoitory 07/01/2014 Clonazepam, 0.5MG, Tablet Patient use 2 per day /28/2014 Suboxone, 2 MG; 8 Mg, Film, Soluble /05/2014 Carisoprodol, 350 MG, Tablet /05/2014 Oxycotin 40mg Patient used for 5 days, holding suboxone 06/04/2014 Clonazepam, 0.5 MG, Tablet Patient uses 2 per day 05/24/2014 Diazepam, 2MG, Tablet Patient use as needed in addition to Vaginal suppository 05/21/2014 Suboxone, 2MG; 8MG, Film, Soluble Patient using one daily 05/09/2014 Clonazepam, 0.5 MG, Tablet Patient uses 2 per day 05/05/2014 Oxycotin 40mg Patient uses one twice a day /01/2014 Alprazolam,.25 MG, tablet /22/2014 Suboxone, 2MG; 8 MG, Film, Patient uses as needed /13/2014 Oxycodone 5, 325mg acetaminiphen May 4-7,

5 Fill Date Product, STR, Form Quantity Days 04/08/2014 Alprazolam, 0.5 MG, Tablet /08/2014 Oxycodone Hydrochloride, 15 MG, Tablet /08/2014 Oxycotin, 40 MG, Tablet, Film Coated, Extended Release /04/2014 Oxycodone Hydrochloride, 30 MG, Tablet /04/2014 Lorazepam, 0.5 MG, Tablet /30/2014 Hydromorphone Hydrochloride, 2MG, Tablet /15/2014 Lorazepam, 0.5 MG Tablet /11/2014 Suboxone, 2MG, 8 MG, Film, Soluble /08/2014 Carisoprodol, 350 MG, Tablet /10/2014 Carisoprodol, 250 MG, Tablet /10/2014 Suboxone, 2Mg, 8 Mg, Film, Soluble /27/2014 Suboxone, 2Mg, 8 Mg, Film, Soluble /08/2014 Clonazepam, 1 MG, Tablet /30/2013 Oxycodone and Acetaminophen, 325 Mg, 5 Mg, Tablet Fill Date Product, STR, Form Quantity Days 12/30/2013 Suboxone, 2MG;8MG, Film, Soluble /24/2013 Clonazepam, 1MG, tablet /16/2013 Suboxone, 2MG;8MG, Film, Soluble /13/2013 Oxycodone and acetaminophen, 325 Mg; 5MG, Tablet /09/2013 Suboxone, 2MG;8MG, Film, Soluble /01/2013 Suboxone, 2MG;8MG, Film, Soluble /30/2013 Suboxone, 2MG;8MG, Film, Soluble /25/2013 Suboxone, 2MG;8MG, Film, Soluble /23/2013 Clonazepam, 1 MG, Tablet /14/2013 Suboxone, 2MG;8MG, Film, Soluble /01/2013 Oxycodone Hydrochloride, 30 MG, Tablet /31/2013 Carisoprodol, 350 MG, Tablet May 4-7,

6 Major Gaps exists between the Diagnosis and Treatment of Addiction (i.e. Substance Use Disorders Alcohol Use Disorders), Substance-Medication induced mood disorders, Primary Mental Illness (i.e. Any Mental Illness and Serious Mental Illness e.g. Anxiety, Depression, Mood Disorders), SUD & Co- Occurring Disorders in The United States. Screening tools exist to aid the clinician in proper diagnosis. The PRISM is a semi-structured clinician administered interview that measures DSMIII, DSMIIIR, and DSMIV diagnoses (current and past) of alcohol, drug, and psychiatric disorders and continuous measures of severity, organic, etiology, treatment, and functional impairment. ( 1-3 hrs ). Another tool is the Addiction Severity Index that measures severity of Addiction. ( 1 hr+ ). More Practical PHQ-9 for Depression, Zung Anxiety Rating Scale, and Mood Questionnaire Scale for Bipolar Disorder. Further screening tools consist of the DAST-Drug Abuse Screening Test, AUDIT- Alcohol Screening Test which are examples of SBIRT (Screening Brief Intervention Referral Tools) can be used initially and periodically once treatment initiated. Often psychiatric illnesses are present as Substance-Alcohol Induced Mood Disorders or a combination of both Substance and /or Alcohol Use Disorders along with Co-Occurring Mental Illness. Chronicity of the Substance and /or Alcohol use is imperative in relation to the Diagnosis of the Mental Disorder as a component of evaluation and management. An invaluable test, often not thought off during the initial evaluation and management presentation of the constellation of mental illness symptoms is the consideration of a Urine Drug Screen (i.e. for drugs of abuse and Ethyl Glucuronide for alcohol abuse). Often, Addiction is a disease of denial and Patients are not forthright. Dependence, with aberrant behaviors, also fall into a category of denial & lack of honesty at times. 11 Mental health issues are frequently unrecognized and even when diagnosed are often not treated adequately 8,14 Recognition and treatment of mental illness are significant issues for primary care physicians, who provide the majority of mental health care. 15,16 8.Callahan EJ, Jaén CR, Crabtree BF, Zyzanski SJ, Goodwin MA, Stange KC. The impact of recent emotional distress and diagnosis of depression or anxiety on the physician-patient encounter in Any Mental Illnessly practice. J Fam Pract. 1998;46(5): Tiemens BG, Ormel J, Simon GE. Occurrence, recognition, and outcome of psychological disorders in primary care. Am J Psychiatry. 1996;153(5): Gallo JJ, Coyne JC. The challenge of depression in late life: bridging science and service in primary care. JAMA. 2000; 284(12): Williams JW Jr. Competing demands: Does care for depression fit in primary care? J Gen Intern Med. 1998;13(2): May 4-7,

7 Identifying Substance Use Disorder, Dependence with Aberrant Behaviors, Substance / Medication Use Disorder, Co- Occurring Disorder & Primary Mental Disorders. Psychoactive Medication Discontinuation Syndrome Disorders 13 Abuse-Misuse - use in a manner other than what the prescribing physician / medical provider intended. Dependence - a physiologic process, which is a predictable event in the prescription of opioids, benzodiazepines, barbiturates and stimulants. Dependence is dose-, time- and potency-related and may result in tolerance (to side effects and to therapeutic effects) and withdrawal. Physiologic dependence is not necessarily addiction. Understanding the differences among these terms helps physicians/ medical providers understand the liability risks and helps patients overcome the stigma of getting hooked on a legitimately used controlled substance as well as recent introduction Of CDC Opioid Prescribing Guidelines for Chronic Pain. Addiction: Part II. Identification and Management of the Drug- Seeking Patient, April 15th American Family Physician 14 May 4-7,

8 Brain Reward Center: Median Forebrain Nucleus Accumbens Ventral Tegmental Area Dopamine Addiction is a primary, chronic disease of brain reward, motivation, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control craving, diminished recognition of significant problems with one s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. WITHOUT TREATMENT or engagement in recovery activities, addiction is progressive and can result in disability or premature death. THE ASAM CRITERIA, Treatment Criteria For Addictive, Substance-Related and Co- Occurring Conditions, American Society Of Addiction Medicine, Third Edition, May 4-7,

9 Dr. Howard Markel author of "An Anatomy of Addiction: Sigmund Freud, William Halsted, and the Miracle Drug Cocaine" For most patients with opioid use disorder, the use of medications (combined with psychosocial treatment) is superior to withdrawal management (combined with psychosocial treatment), followed finally by psychosocial treatment on its own (2). This Is true for both agonist,partial agonist, and antagonist medications (1) Evidence suggests that methadone maintenance treatment is superior to withdrawal Management alone and significantly reduces opioid drug use. Further, mortality is lower in patients on methadone, as compared to those not in treatment. Methadone also lowers the risk of acquiring or spreading HIV infection (1). In clinical studies, evidence favors buprenorphine, compared to no treatment, in decreasing heroin use and improving treatment retention (1). Finally, evidence supports the efficacy of both oral naltrexone and extended-release injectable naltrexone versus placebo for the treatment of opioid use disorder (1). Comprehensive Opioid Response with the Twelve Step ( Medication Assisted Treatment ) Approach Model offered By Hazelden / Betty Ford is paving the way to Introduction of MAT Buprenorphine & Injectable Naltrexone for 0-18 months in selected patients in Abstinence Based Treatment Facilities they have recognized that one size does not fit All. 1. ASAM Treatment Guidelines page Primary mode treatment at the majority of facilities in the United States is a complete abstinence model on discharge. 18 May 4-7,

10 New Jersey Prescription Monitoring Program 1. Required to Consult PMP First time a DEA scheduled II medication is prescribed to a new patient for acute or chronic pain 2. Required when you continue to prescribe a regimen of DEA scheduled II medications for acute or chronic pain quarterly during the regimen. 19 Q: What is required of prescribers? A: Once the new PDMP is fully operationalized, prescribers are required to query the system: 1. For each patient the first time the patient is prescribed a controlled substance; or 2. If a prescriber believes or has reason to believe, using sound clinical judgment, that a patient may be abusing or diverting drugs. Once the new PDMP is fully operationalized, prescribers are required to indicate the information obtained from the system in the patient s medical record if: 1. The individual is a new patient; or 2. The prescriber determines a drug should not be prescribed a furnished to a patient based upon the information from the system 20 May 4-7,

11 Addiction Severity Index-Non-Practical for primary care PHQ-9 for Depression Zung Anxiety Rating Scale Mood Questionnaire For Bipolar Disorder Jasper Goldberg Adult Add Questionnaire Psychiatric Research Interview for Substance and Mental Disorders ( PRISM)-Non Practical for primary care ( Addiction & Co-occurring Mental Illness) Drug Abuse Screening Tool-21 Audit Screening Tool- Alcoholism Current Opioid Misuse Measure (COMM) Opioid Risk Tool ( ORT ) May 4-7,

12 23 24 May 4-7,

13 DSM-5 does not separate the diagnosis of substance abuse and dependence as in DSM-IV, rather, criteria are provided for substance use disorder, accompanied by criteria for intoxication, withdrawal, substance/medication-induced disorders, and unspecified substance-induced disorders. DSM-5 substance use disorder criteria are nearly identical to DSM-IV substance abuse and dependence criteria combined into a single list with two exceptions. The DSM-IV recurrent legal problems, has been deleted, and a new criterion, craving or strong desire to use a substance, has been added. In addition, the threshold for substance use disorder in DSM-5 is a set of 2 or more criteria, in contrast DSM-IV, 1 or more criteria for substance abuse, 3 or more criteria for dependence Severity criteria: 2-3 mild, 4-5 moderate, 6 or more severe. Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) released at the American Psychiatric Association s Annual Meeting in May A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12 month period: 1. Impaired Control: Opioids are often taken In larger amounts over a longer period then was intended.* 2. Impaired Control: There is a persistent desire or unsuccessful efforts to cut down or control opioid use.* 3. Impaired Control: A great deal of the time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.* 4. Impaired Control: Craving, or strong desire or urge to use opioids.*** 5. Social Impairment: Recurrent opioid use resulting in a failure to fulfill major role operations at work, school, or home.** 6. Social Impairment: Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.** 7. Social Impairment: Important social, occupational, or recreational activities are given up or reduced because of opioid use.* 8. Risky Use: Recurrent opioid use in situations in which it is physically hazardous.** 9. Risky Use: Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.** 10. Tolerance, as defined by either for the following: * a) A need for markedly increased amounts of opioids, to achieve intoxication or desired effect. b) A markedly diminished effect with continued use of the same amount of an opioid. Note: This criterion is not considered to be met for those taking opioids, solely under appropriate medical supervision 11. Withdrawal, as manifested by either of the following: * a) The Characteristic opioid withdrawal syndrome. b) Opioids are taken to relieve or avoid withdrawal symptoms. Note: This criterion is not considered to be met for those individuals take opioids solely under appropriate medical supervision. Severity criteria: 2-3 mild, 4-5 moderate, 6 or more severe * DSM-IV Dependence **DSM-IV Abuse ***DSM-5 addition ( Formerly DSM-IV Abuse-recurrent substance related legal problems) Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) released at the American Psychiatric Association s Annual Meeting in May May 4-7,

14 Deaths from drug overdose have been steadily rising over the past two decades and have become the leading cause of injury death in the United States. Every day in the United States, 120 people die as a result of drug overdose & another 6,748 are treated in the ER for misuse or abuse. Nearly 9 out of 10 poisoning deaths are caused by drugs. Drug Overdose was the leading cause of injury death in Among people 25 to 64 years of age,drug overdose caused more deaths than motor vehicle traffic accidents. In 2013 drug overdose deaths, approximately 51% were related to pharmaceuticals drugs. Even with acute low dose opioids (1 36 mg/day morphine equivalent dose or MED), patients are at increased risk for developing opioid use disorder (OUD). The likelihood of developing OUD ranges from a 3-fold increase for acute low dose opioids, to a 122-fold increase for chronic high dose opioids ( 120mg/day MED) compared to patients who are not prescribed opioids. Over a median follow-up of 299 days, opioids were dispensed to 91% of patients after an overdose, 7% of the patients had a repeated opioid overdose. after the index overdose the following occur: 1. After 2 years, the cumulative incident of repeated overdose was 17% for patient s receiving high dosages of opioids 2. 15% for those receiving moderate dosages opioids 3. 9% for those receiving low dosages opioids 4. 8% of those receiving no opioids pain patients,dunn KM et al Ann Intern Med Jan Overdose and prescribed opioids: Associations among Chronic non-cancer Edlund MJ, Martin BC, Russo JE, DeVries A, Braden JB, Sullivan MD. The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of opioid prescription. Clin J Pain 2014;30: Opioid prescribing after non- fatal overdose and Association with repeated overdose: A Cohart 27 Study Annals of Internal Medicine January 2016, volume 164, No 1 1. In the 1980s and 1990s, however, both the substance abuse and mental health communities found that a wide range of mental disorders were associated with substance abuse, not just depression (e.g., De Leon 1989; Pepper et al. 1981; Rounsaville et al. 1982b; Sciacca 1991). 2. During this period, studies conducted in substance abuse programs typically reported that 50 to 75 percent of clients had some type of co-occurring mental disorder (although not usually a severe mental disorder). 3. Studies in mental health settings reported that between 20 and 50 percent of their clients had a co-occurring substance use disorder. (See Sacks et al. 1997b for a summary of studies and Compton et al for a more recent study.) 28 May 4-7,

15 COD (replaces dual diagnosis disorders-dd) refers to cooccurring substance-related and mental disorders. Clients said to have COD have one or more substance-related disorders as well as one or more mental disorders. At the individual level, COD exists when at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from a single disorder. Definitions and Terms Relating to Co-Occurring Disorders. Tech. no. Overview Paper 1. Substance Abuse and Mental Health Services Administration, n.d. Web. 19 Jan < Coming to be thought of as an outdated term Overlap with Substance Use Disorders ( Addiction Disorders ) & Co- Occurring Mental Disorders. Traditionally 2 systems (not 2 diagnoses or even a diagnosis at all) Influenced by the biases, perspectives, experience and training of the evaluator Substance / Medication Induced Mental Disorders can cause Diagnostic Confusion ( Chronicity / Timeline important ) Psychoactive Medication Discontinuation Symptoms can cause further Problems and Diagnostic Confusion. Extremely Difficult To Treat in Primary Care or for that matter for Addiction Medicine Specialists & Psychiatrists. May 4-7,

16 Drug Disorder Cocaine and Methamphetamine Stimulants LSD, Ecstasy & psychedelics Alcohol, sedatives, Sleepaids & narcotics PCP & Ketamine Schizophrenia, paranoia, anhedonia, compulsive behavior Anxiety, panic attacks, mania and sleep disorders Delusions and hallucinations Depression and mood disturbances Antisocial behavior Drug States Withdrawal Acute Protracted Intoxication Chronic Use Symptom Groups Depression Anxiety Psychosis Mania Rounsaville 90 May 4-7,

17 Antidepressants: Withdrawal symptoms (FINISH syndrome): Flu-like symptoms, Insomnia, Imbalance, Sensory disturbances, Hyper arousal. Symptoms usually begin & peak within one week, last one day to three weeks, & are usually mild. Antipsychotics: Recurrence of neuropsychiatric symptoms. Withdrawal symptoms (best-documented with clozapine): sweating, salivation, runny nose, flu-like symptoms, paresthesia, broncho-constriction, urination, gastrointestinal symptoms, anorexia, vertigo, insomnia, agitation,anxiety, restlessness, movement disorders, psychosis. Clonidine: Withdrawal syndrome: rebound hypertension, headache, restlessness, anxiety, insomnia, sweating, tachycardia, tremor, muscle cramps, hiccups, nausea, salivation; rarely encephalopathy, stroke, death. ( Prescribers Letter March 2016 Common Oral Medications That Need Tapering ) 34 Reeves and Brister VA Med Center Jackson, MS April 2007 SMA Journal May 4-7,

18 MENTAL DISORDERS Schizophrenia Bi-polar Schizoaffective Major Depression Borderline Personality Post Traumatic Stress Social Phobia others ADDICTION DISORDERS Alcohol Use Disorder Cocaine/ Amphetamine Opiates Use Disorder Cannabis Use Disorder Sedative Hypnotic Poly-substance combinations Prescription drugs Dependence Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health 38 May 4-7,

19 Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health 39 Up to half of people living with mental illness also have substance abuse issues.1,2,3 The highest rates of substance use disorders occur in the late teens and the twenties1,2,3 1. Director s Blog: Mental Health Awareness Month: By the Numbers. National Institute of Mental Health Web site. health awaren ess month by the numbers.shtml. Accessed January 27, Dual Diagnosis. National Alliance on Mental Illness Web site. More/Mental Health Conditions/Related Conditions/Dual Diagnosis. Accessed January 27, American Society of Addiction Medicine. Drug Testing: A White Paper of the American Society of Addiction Medicine (ASAM). source/publicy policy statements/ drug testing a white paper by asam.pdf?sfvrsn=2; page 66. Published October 26, Accessed January 27, May 4-7,

20 Hall 77 Poor out-pt attendance, discontinue Rx Alterman 85 More mood changes, intensive staffing Solomon 86 More noncompliance, arrests Safer 87 Over twice hosp. rate and criminal behav Drake 89 More hostility, noncompliance Barbee 89 More psych symptoms Lyons 89 More noncompliance, ER, jail, rehosp. Chen 92 Worse treatment course Risk Factor Cocaine use Major Depression Alcohol use Separation or Divorce NIMH/NIDA Increased Odds Of Attempting Suicide 62 times more likely 41 times more likely 8 times more likely 11 times more likely ECA EVALUATION May 4-7,

21 Bio Mental Illness Labs-UDS Meds (anti-depressants, etc.) Alcohol-Substance Use Labs-UDS Meds (withdrawal, craving, etc.) Psych Social Psychotherapy Education groups Process groups Couples conf. D/C planning housing, Matrix family program etc. Step work Groups AA Meetings Intervention Sober housing May 4-7,

22 Urine Drug Testing What took me so Long? 46 How do you or would you introduce UDT to your patients? Aids in screening, assessing and diagnosing a substance use disorder. Can affect clinical decisions on a patient s substance use that effects other medical conditions. Increases the safety off prescribing medications by identifying the potential for overdose or serious drug interactions. Can affect clinical decisions about pharmacotherapy, especially with controlled substances. Prevents dangerous medication interactions during surgery or other medical procedures. Identifies the risks for women, who want to become pregnant, and are using drugs and alcohol. Verifies, contradicts, or aids to a patient s self-report or family members report of substance use. Identifies of relapse to substance use. Helps clinicians with risk stratification to assess patient s for chronic pain management compliance and current concomitant use of other medications or drugs. ( Clinical Drug Testing Primary Care Tap 23 ) May 4-7,

23 Urine drug testing is a standard part of care for all my patients prescribed certain medications. It s necessary to help make sure this treatment is as safe as possible for you. Gourlay DL, Heit HA, Caplan YH. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care. Edition ; PharmaCom Group, Inc. Substance Abuse and Mental Health Services Administration. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, Substance Abuse and Mental Health Services Administration. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA , NSDUH Series H-50). Rockville, Maryland: Substance Abuse and Mental Health Services Administration. September, May 4-7,

24 CDC ,329 died from drug overdose / , Opiate overdose deaths 16, Pharmaceutical drugs 22,134 deaths 3. Oxycodone, Hydrocodone & Methadone16, Benzodiazepines ( anti-anxiety ) 30 % involved in 6,497 anti-psychotic drugs 6 % 1, Deaths involving more than one drug or drug class are counted multiple times and therefore are not mutually exclusive. 6. Patients with mental health or substance use disorders are at increased risk for nonmedical use and overdose from prescription painkillers as well as being prescribed high doses of the drugs. Appropriate screening identification and clinical management by healthcare providers are essential parts of both behavioral health and chronic pain management CDC Director, Tom Frieden, MD MPH. Opioids drive continued increase in drug overdose deaths Drug overdose deaths increase for 11th consecutive year MMWR weekly Jamuary 1, 2016 / 64(50); Many patients do not take medication as prescribed 1. Side effects 2. Lack Of Efficacy 3. High Out-Of-Pocket expense 4. Non-Compliance ( Discontinuation ) 5. Self Adjustment Of Dose / Misuse 6. Inconsistent Adherence Mitchel AJ and Selmes T. Why don t patients take their medicine? Reasons and solutions in psychiatry. Adv Psych Treatment. 2007;13: May 4-7,

25 Symptomatic relapse 1. Relapse risk is 5 times higher in those discontinuing antipsychotic drug therapy Negative impact on functioning and course of illness 1. Increased use of emergency psychiatric services, hospitalizations, arrests, violence, suicide. Higher overall health care costs. 1. Robinson D, Woerner MG, Alvir JM, et al. Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder.arch Gen Psychiatry. 1999; 56(3): Higashi K, Medic G, Littlewood KJ, Diez T, Granström O, De Hert M. Medication adherence in schizophrenia: factors influencing adherence and consequences of nonadherence, a systematic literature review. Ther Adv Psychopharmacol. 2013; 3(4): The clinician must choose testing method based on the needs dictated by the patient s history, presentation, community factors and treatment plan goals. The clinician s rationale for test and the analytes ordered must be documented in the patient s medical record. May 4-7,

26 1. Center for Substance Abuse Treatment. (2012).Clinical drug testing in primary care. Technical Assistance Publication (TAP) Series, 32. DHHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration. Available: May 4-7,

27 218,927 specimens; 23 analysts Laboratory immunoassay (IA) screen with reflex of positives to quantization (only IA positives are sent for more definitive testing) Direct definitive testing/quantitative (DQ) approach Kirsh K et al. An Analysis of Laboratory Immunoassay Screen with Reflex of Positives to Quantification Versus Definitive Laboratory Quantitation Methodologies for Medication Monitoring. Poster presented at International Conference on Opioids, June 2014, Boston, MA. The high clinical false negative rate associated with testing by immunoassay followed by reflex of positives to confirmation may lead to: Missed opportunities for intervention Missed relapses for those with substance abuse Less effective treatment and treatment decision making Higher risk for drug interactions Greater potential for increased side effects for patients Kirsh K et al. An Analysis of Laboratory Immunoassay Screen with Reflex of Positives to Quantification Versus Definitive Laboratory Quantitation Methodologies for Medication Monitoring. Poster presented at International Conference on Opioids, June 2014, Boston, MA. May 4-7,

28 Numerous factors may contribute to unexpected UDT results1,2,3: Patient medication use Time of the last dose Undiscovered or unknown over-the-counter or prescription medication use Type of testing Pharmacogenetics Drug-drug interactions 1. Gourlay DL, Heit HA, Caplan YH. Urine Drug Testing in Clinical Practice: the Art and Science of Patient Care. PharmaCom Group, Inc. Accessed March 14, Christo PJ, Manchikanti L, Ruan X, Bottros M, et al. Urine Drug Testing in Chronic Pain. Pain Physician. 2011; 14: Reisfield GM,Goldberger, BA, Bertholf RL. False positive and false negative test results in clinical urine drug testing. Bioanalysis (5): Indicates how long after administration a person excretes the drug and/or its metabolite(s) at a concentration above a specific test cutoff concentration 1 to 3 days for most drugs and metabolites Gourlay DL et al. Urine Drug Testing in Clinical Practice. 4th ed Pharmacon Group, Inc. SAMHSA. Clinical Drug Testing in Primary Care. Technical Assistance Publication (TAP) 32. HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, May 4-7,

29 Benzodiazepines Stimulants Anti-epileptics Tricyclic Antidepressants SSRIs and SNRIs Antipsychotics Alcohol/AlcoholMetabolites Barbiturates Natural& Semi-Synthetic Opioids Synthetic Opioids Muscle Relaxants Illicit Drugs Synthetic Cannabinoids (Spice) Cathinones (Bath Salts) Other Over 100 drugs and metabolites (over 400 brand name medications). Industry leader in offering tests for newer drugs of abuse, including synthetic agents. Millennium, Quest, Labcorp Oral fluid testing is also a viable choice for medication monitoring Collection almost anywhere Easier to observe collection Reduced risk for adulteration or substitution Turn Around time for results 5-7 days Heltsley R, Depriest A, Black DL, et al. Oral fluid drug testing of chronic pain patients. II. Comparison of paired oral fluid and urine specimens. J Anal Toxicol Mar;36(2): May 4-7,

30 SAMHSA recommends to consider drug testing when assessing a patient presenting with mood or behavior changes to: Aid in diagnosis Help determine whether the psychiatric symptoms are substance use or withdrawal related Help identify a co-occurring SUD Monitor for recent use of controlled medications 1. Substance Abuse and Mental Health Services Administration. (2012). Clinical drug testing in primary care. Technical Assistance Publication (TAP) 32. HHS Publication No. SMA Rockville, MD: Substance Abuse and Mental Health Services Administration. It is appropriate to consider periodic random drug testing for all psychiatric patients, and especially young patients and those with a history of substance use disorders, particularly when they have been prescribed Psychoactive Medications and Benzodiazepines. American Society of Addiction Medicine. Drug Testing: A White Paper of the American Society of Addiction Medicine (ASAM). source/publicy po licy statements/drug testing awhitepaper by asam.pdf?sfvrsn=2; page 66. Published October 26, Accessed January 27, May 4-7,

31 About 1.6 million people in the U.S. are current non-medical users of stimulants1 Over 10% of teenagers have misused or abused prescription stimulants Medication adherence may be less than 12% in adult ADHD patients taking stimulant medications Data suggests more than 50% of true amphetamine positives missed by POC 1. Substance Abuse and Mental Health Services Administration. Behavioral Health Trends in the United States: Results from the testing National Survey on Drug Use and Health (HHS Publication No. SMA , NSDUH Series H 50). Rockville, Maryland: Substance Abuse and Mental Health Services Administration. September, The Partnership Attitude Tracking Study.. Partnership for Drug Free Kids.. Teens & Parents uploads/2014/07/pats 2013 FULL REPORT.pdf. Accessed January 29, O Callaghan P. Adherence to stimulants in adult ADHD. Atten Defic Hyperact Disord. 2014; 6(2): Millennium Health, Primary Care Practice Profile, About 30% of drug overdoses involve benzodiazepines, often in combination with opioids Alprazolam (Xanax ) is one of the top three diverted prescription medications in the U.S. Benzodiazepine treatment center admissions nearly tripled between 1998 and High cutoff levels and lack of sensitivity with POC tests may prevent detection of therapeutic doses and identification of specific benzodiazepines 1. Opioids drive continued increase in drug overdose deaths. CDC Newsroom. Published February 20, ths.html. Accessed January 29, DEA Fact Sheet. Benzodiazepines. January Accessed January 29, Substance Abuse Treatment Admissions for Abuse of Benzodiazepines. The Treatment Episode Data Set. Published June 2, Accessed January 29, May 4-7,

32 Anxiety disorders Antidepressants (most) Buspirone (Buspar) Anticonvulsants (valproic acid [Depakene], gabapentin [Neurontin]) Selected antihypertensives (beta blockers) Atypical neuroleptics (olanzapine [Zyprexa], quetiapine [Seroquel], risperidone [Risperdal])-No Indication for anxiety / Consider Avoiding / Recommend Psychiatric Consult. ( Can cause Metabolic Syndrome ) Insomnia Sedating antidepressants Trazodone (Desyrel) Doxepin (Sinequan) Amitriptyline (Elavil) Mirtazepine (Remeron) Antihistamines Avoid Any Benzodiazepine including Atypical ( Ambien etc. ) Pharmacologic Alternatives to controlled Drugs Presenters Opinion 66 Attention-deficit disorder Pemoline (Cylert) Bupropion (Wellbutrin) Desipramine (Norpramin) Venlafaxine (Effexor) Clonidine (Catapres) Selective serotonin reuptake inhibitors Pain Nonsteroidal anti-inflammatory drugs Topical Compounding Creams ( avoid Ketamine ) Acetaminophen Antidepressants Corticosteroids Muscle relaxants Pharmacologic Alternatives to controlled Drugs Presenters Opinion 1 67 May 4-7,

33 Why Should I Care? Excessive alcohol use is the 3 rd leading cause of preventable death in the US. Tobacco is the leading cause of preventable death in the US. Illegal drug use is alarmingly prevalent: Around 9% of the population aged 12 or older reports using illegal drugs within the past month (SAMHSA 2010). Approximately 8.9% of the population over 12 met DSM-IV criteria for substance abuse or dependence (substance use disorder in DSM-5) Why should you make this change to your practice? SBIRT is an evidence-based best practice that is strongly supported in the literature. For example, in one study, 6 months following SBIRT interventions: Rates of illicit drug use were 67.7% lower (p<0.001). Rates of heavy alcohol use were 38.6% lower (p<0.001). Success was seen across clinic settings, gender, race/ethnic, and age subgroups. (Madras et al. 2009) 69 May 4-7,

34 Failure to inform patients of the risk of driving while taking a medication, such as a Benzodiazepine / Opioid / Stimulant may lead to a claim of negligence against the prescribing Physician / Medical Provider. Given the liability risks, Providers should apprise patients of these concerns and document this in the medical record. FORMULATE & UTILIZE A TREATMENT CONTRACT Routinely Use The Prescription Monitoring Program for Your State. Addiction: Part II. Identification and Management of the Drug-Seeking Patient, April 15th American Family Physician & APA Position Editorial Feb When a controlled substance is being considered as a treatment option, patients should be informed of the potential for physical dependency and the possibility of mild to moderate rebound effects even with gradual tapering. The physician / medical provider should carefully review the benefits and risks of the chosen medications, as well as other treatment choices. Formulate a Treatment Contract for all controlled drugs. Addiction: Part II. Identification and Management of the Drug-Seeking Patient, April 15th American Family Physician & APA Position Editorial Feb May 4-7,

35 Dea Scheduled Monitoring contract 72 Dea Scheduled Monitoring contract 73 May 4-7,

36 Dea Scheduled Monitoring contract 74 Dea Scheduled Monitoring contract 75 May 4-7,

37 Patients who abuse prescription drugs may exhibit patterns, such as: escalating use drug-seeking behavior doctor shopping Physicians / Medical Providers must say NO and stick with it when patients exert pressure to obtain a prescription drug. Medical Providers who overprescribe can be characterized by the four Ds : Dated Duped Dishonest Disabled Maintaining a current knowledge base, documenting the decisions that guide the treatment process and seeking consultation are important risk management strategies that improve clinical care and outcomes. Routinely utilize the States Prescription Monitoring Program. ( NJ is Mandatory ) and Urine Drug Testing. Addiction: Part II. Identification and Management of the Drug-Seeking Patient, April 15th American Family Physician 76 The street value of controlled prescription drugs has been estimated by the DEA to be second only to the street value of cocaine, and greater than the street value of marijuana and heroin. Paradox for Physicians/ Medical Providers: the desire to relieve pain, anxiety and other discomfort must be weighed against the fear of creating addiction, of being investigated by law enforcement or licensing authorities, and of being scammed by the occasional patient who abuses opioid analgesics, sedative hypnotics or psychostimulants. These competing concerns often leave Providers feeling uncomfortable about prescribing controlled substances, to the detriment of the majority of patients who suffer legitimate illnesses and are often left undertreated or feeling stigmatized. Addiction: Part II. Identification and Management of the Drug-Seeking Patient, April 15th American Family Physician 77 May 4-7,

38 The patient who has been diagnosed with Substance Use Disorder / Alcohol Use Disorder should be referred to an ADDICTION MEDICINE SPECIALIST / Inpatient or Outpatient treatment center. These steps give the patient a solid start on the recovery process. * If It is possible to detoxify the patient on an outpatient basis. The patient then can be referred to Alcoholics Anonymous or Narcotics Anonymous for sustained follow-up support. * Whatever treatment the patient undergoes, it is important for the family physician / medical provider to be supportive of the patient and the family in recovery. Physicians / Medical Providers should be careful about prescribing Mind & Mood-Altering Drugs. The Medical Practitioner can play a pivotal role by dealing with the patient and family in a Nonjudgmental Manner. All Patients with Opiate use disorders, Dependent on Opiates for Non-Cancer Chronic Pain should have a Narcan-naloxone antidote kit to reverse and prevent Opiate Overdose. *( Based on ASAM placement Criteria ) Addiction: Part II. Identification and Management of the Drug-Seeking Patient, April 15th American Family Physician George M. is a 37-year-old divorced male who was brought into the emergency room intoxicated. His blood alcohol level was.152, and the toxicology screen was positive for cocaine. He was also suicidal ( I'm going to do it right this time! ). He has a history of three psychiatric hospitalizations (lasting 3 days each -all AMA) and two inpatient substance abuse treatments. Each psychiatric admission was preceded by substance use. George M. has never followed through with mental health care. He has intermittently attended Alcoholics Anonymous, but not recently. True or False 1. Question: Does George M, have Alcohol Use Disorder with Co-Occurring Mood Disorder? 79 May 4-7,

39 1. Answer: False For example, if George M.'s psychiatric admissions were 2 or 3 days long, usually with discharges related to leaving against medical advice, decisions about diagnosis and treatment would be different (i.e., it is likely this is a substance-induced suicidal state and referral at discharge should be to a substance abuse treatment agency rather than a mental health center) than if two of his psychiatric admissions were 2 or 3 weeks long with clearly defined manic and psychotic symptoms continuing throughout the course, despite aggressive use of mental health care and medication (this is more likely a person with both bipolar disorder and alcohol dependence who requires integrated treatment for both his severe alcoholism and bipolar disorder) Teresa G. is a 37-year-old divorced female who was brought into a detoxification unit 4 days ago with a blood alcohol level of.150. She is observed to be depressed, withdrawn, with little energy, fleeting suicidal thoughts, and poor concentration, but states she is just fine, not depressed, and life was good last week before her relapse. She has never used drugs (other than alcohol), and began drinking alcohol only 3 years ago. However, she has had several alcohol-related problems since then. She has a history of three psychiatric hospitalizations for depression, at ages 19, 23, and 32, All responded to various antidepressant. After Discharge from the Detoxification unit, she reports to her primary care provider 8 weeks later, claiming she has been sober. Her symptoms include becoming increasingly depressed, with anhedonia, and associated sleep disturbances, passive thoughts of despair and if she should drink again, she wants her next binge drinking episode to be "I just to fall asleep forever. " Also, she is unmotivated to continue her employment. These symptoms have been for the past 8 weeks since Alcohol Cessation. 24 True or False 2. Teresa G, Diagnosis has Alcohol Use Disorder (in early remission with recent acute relapse) with Co-Occurring Major Depression. 81 May 4-7,

40 Answer: True 2. Teresa G. had become increasingly depressed and withdrawn over the past 8 weeks, and had for 8 weeks experienced disordered sleep, poor concentration, and suicidal thoughts, she would be best diagnosed Alcohol Use Disorder (in early remission with recent acute relapse) with Co- Occurring Major Depression. rather than substance-induced mood disorder secondary to her alcohol relapse True or False 3. Urine Drug screening could be an effective tool in determination of proper diagnosis of Substance Induced disorders with or without Mental Illness. Ethyl Glucuronide a metabolite of ethanol is often included in the panel ordered. 83 May 4-7,

41 Answer: False 3. When ordering urine drug screen panels, often Ethyl Glucuronide needs to be specifically ordered. Also, You need to familiarize your-self with the various panels offered for urine drug screens. Opiate ( immunoassay ) screens for morphine heroin,codeine and metabolites but not oxycodone, tramadol, fentanyl. 84 May 4-7,

Identifying and Addressing Addiction in Medical Practices Joseph N. Ranieri, D.O.

Identifying and Addressing Addiction in Medical Practices Joseph N. Ranieri, D.O. Identifying and Addressing Addiction vs Dependence in Medical Practices Joseph N. Ranieri, DO, FAAFP, Diplomate-American Board Of Addiction Medicine Medical Director Bridgeton, NJ Westfield, PA Cherry

More information

Opiate Use Disorder and Opiate Overdose

Opiate Use Disorder and Opiate Overdose Opiate Use Disorder and Opiate Overdose Irene Ortiz, MD Medical Director Molina Healthcare of New Mexico and South Carolina Clinical Professor University of New Mexico School of Medicine Objectives DSM-5

More information

Appendix F Federation of State Medical Boards

Appendix F Federation of State Medical Boards Appendix F Federation of State Medical Boards Model Policy Guidelines for Opioid Addiction Treatment in the Medical Office SECTION I: PREAMBLE The (name of board) recognizes that the prevalence of addiction

More information

GUIDELINES FOR THE USE OF PSYCHOACTIVE MEDICATIONS IN INDIVIDUALS WITH CO-OCCURRING SUBSTANCE USE DISORDERS

GUIDELINES FOR THE USE OF PSYCHOACTIVE MEDICATIONS IN INDIVIDUALS WITH CO-OCCURRING SUBSTANCE USE DISORDERS City and County of San Francisco Mayor Gavin Newsom Department of Public Health Community Behavioral Health Services 1380 Howard Street 5 th Floor San Francisco, CA 94103 GUIDELINES FOR THE USE OF PSYCHOACTIVE

More information

Overview of Opioid Use Disorder

Overview of Opioid Use Disorder Overview of Opioid Use Disorder Doug Burgess, MD Medical Director of Outpatient Services, Truman Medical Centers Assistant Professor of Psychiatry, University of Missouri- Kansas City Objectives History

More information

Treatment Alternatives for Substance Use Disorders

Treatment Alternatives for Substance Use Disorders Treatment Alternatives for Substance Use Disorders Dean Drosnes, MD, FASAM Associate Medical Director Director, Chronic Pain and SUD Program Caron Treatment Centers 1 Disclosure The speaker has no conflict

More information

Safe Prescribing of Drugs with Potential for Misuse/Diversion

Safe Prescribing of Drugs with Potential for Misuse/Diversion College of Physicians and Surgeons of British Columbia Safe Prescribing of Drugs with Potential for Misuse/Diversion Preamble This document establishes both professional standards as well as guidelines

More information

Opioid Abuse in Iowa Rx to Heroin. Iowa Governor s Office of Drug Control Policy March 2016

Opioid Abuse in Iowa Rx to Heroin. Iowa Governor s Office of Drug Control Policy March 2016 1 Opioid Abuse in Iowa Rx to Heroin Iowa Governor s Office of Drug Control Policy March 2016 2 National Rx Painkiller Trends CDC, 2013 3 National Rx-Heroin Trends NIH, 2015 4 National Rx-Heroin Trends

More information

Serious Mental Illness and Opioid Use Disorder

Serious Mental Illness and Opioid Use Disorder Serious Mental Illness and Opioid Use Disorder Serious Mental Illness and Opioid Use Disorders Arthur Robin Williams, MD MBE Columbia University, Department of Psychiatry Nick Szubiak, MSW, LCSW Director,

More information

Intro to Concurrent Disorders

Intro to Concurrent Disorders CSAM-SCAM Fundamentals Intro to Concurrent Disorders Presentation provided by Jennifer Brasch, MD, FRCPC Psychiatrist, Concurrent Disorders Program, St. Joseph s Healthcare There are all kinds of addicts,

More information

Tapering Opioids Best Practices*

Tapering Opioids Best Practices* Tapering Opioids Best Practices* Chuck Hofmann, MD, MACP 5 th Annual EOCCO Office Staff and Provider Summit September 28, 2017 Disclosure No Conflicts of Interest to report Learning Objectives Understand

More information

DSM-5 AND ASAM CRITERIA. Presented by Jaime Goffin, LCSW

DSM-5 AND ASAM CRITERIA. Presented by Jaime Goffin, LCSW DSM-5 AND ASAM CRITERIA Presented by Jaime Goffin, LCSW MODULE 1: GOALS & OBJECTIVES What is your experience with using ASAM and DSM 5 criteria? What are your learning expectations for today? GOAL FOR

More information

Prepared by: Dr. Elizabeth Woodward, University of Toronto Resident in Psychiatry

Prepared by: Dr. Elizabeth Woodward, University of Toronto Resident in Psychiatry Prepared by: Dr. Elizabeth Woodward, University of Toronto Resident in Psychiatry In broad terms, substance use disorders occur when a substance is used in a compulsive manner with a lack of control over

More information

substance use and mental disorders: one, the other, or both?

substance use and mental disorders: one, the other, or both? substance use and mental disorders: one, the other, or both? Stephen Strobbe, PhD, RN, PMHCNS-BC, CARN-AP Dawn Farm Education Series St. Joe s Education Center, Ypsilanti, MI Tuesday, January 27, 2015

More information

Opioid Management of Chronic (Non- Cancer) Pain

Opioid Management of Chronic (Non- Cancer) Pain Optima Health Opioid Management of Chronic (Non- Cancer) Pain Guideline History Original Approve Date 5/08 Review/Revise Dates 11/09, 9/11, 9/13, 09/15, 9/17 Next Review Date 9/19 These Guidelines are

More information

ADVANCED BEHAVIORAL HEALTH, INC. Clinical Level of Care Guidelines

ADVANCED BEHAVIORAL HEALTH, INC. Clinical Level of Care Guidelines The Clinical Level of Care Guidelines contained on the following pages have been developed as a guide to assist care managers, physicians and providers in making medical necessity decisions about the least

More information

Medication Assisted Treatment of an Opioid Use Disorder. J. Craig Allen, MD. Medical Director, Rushford

Medication Assisted Treatment of an Opioid Use Disorder. J. Craig Allen, MD. Medical Director, Rushford Medication Assisted Treatment of an Opioid Use Disorder J. Craig Allen, MD. Medical Director, Rushford Learning objectives At the conclusion of this activity, participants will be able to: Understand

More information

Attitudes Toward Medication-Assisted Treatment Within a Drug Court Program. Caroline Allison. Dr. Kathleen Moore, Ph.D.

Attitudes Toward Medication-Assisted Treatment Within a Drug Court Program. Caroline Allison. Dr. Kathleen Moore, Ph.D. Running Head: MEDICATION-ASSISTED TREATMENT ATTITUDES Attitudes Toward Medication-Assisted Treatment Within a Drug Court Program Caroline Allison Dr. Kathleen Moore, Ph.D. Department of Mental Health Law

More information

Bree Collaborative AMDG Opioid Prescribing Guidelines Workgroup. Opioid Prescribing Metrics - DRAFT

Bree Collaborative AMDG Opioid Prescribing Guidelines Workgroup. Opioid Prescribing Metrics - DRAFT Bree Collaborative AMDG Opioid Prescribing Guidelines Workgroup Opioid Prescribing Metrics - DRAFT Definitions: Days Supply: The total of all opioid prescriptions dispensed during the calendar quarter

More information

Substance Abuse Protracted Withdrawal

Substance Abuse Protracted Withdrawal Substance Abuse Protracted Withdrawal Overview 1. Acute and Protracted Withdrawal 2. Withdrawal Potential Kate Speck, PhD, MAC, LADC 3. Recovery Reinforcers 1 2 3 Addiction Addiction is a primary, chronic,

More information

OPIOID WITHDRAWAL UW PACC BY SARA HAACK, MD, MPH INTEGRATED CARE TRAINING PROGRAM FELLOW UNIVERSITY OF WASHINGTON UW PACC

OPIOID WITHDRAWAL UW PACC BY SARA HAACK, MD, MPH INTEGRATED CARE TRAINING PROGRAM FELLOW UNIVERSITY OF WASHINGTON UW PACC Psychiatry and Addictions Case Conference UW Medicine Psychiatry and Behavioral Sciences OPIOID WITHDRAWAL BY SARA HAACK, MD, MPH INTEGRATED CARE TRAINING PROGRAM FELLOW UNIVERSITY OF WASHINGTON OBJECTIVES

More information

Chronic Pain, Opioids, & Addiction: Assessing and Managing Risk

Chronic Pain, Opioids, & Addiction: Assessing and Managing Risk Chronic Pain, Opioids, & Addiction: Assessing and Managing Risk Randy Brown MD, PhD, FASAM Associate Professor, Dept of Family Medicine Director, Center for Addictive Disorders, UWHC Director, UW Addiction

More information

THE MEDICAL MODEL: ADDICTION IS A BRAIN DISEASE. Judith Martin, MD Medical Director of Substance Use Services San Francisco Dept.

THE MEDICAL MODEL: ADDICTION IS A BRAIN DISEASE. Judith Martin, MD Medical Director of Substance Use Services San Francisco Dept. THE MEDICAL MODEL: ADDICTION IS A BRAIN DISEASE Judith Martin, MD Medical Director of Substance Use Services San Francisco Dept. Public Health disclosures Dr. Martin has no conflict of interest to disclose.

More information

Opioid Use and Other Trends

Opioid Use and Other Trends Opioid Use and Other Trends National Overview Across the nation communities are struggling with a devastating increase in the number of people misusing opioid drugs, leading many to identify the current

More information

Testing for Controlled Substances

Testing for Controlled Substances Testing for illicit drugs Testing for Controlled Substances 1 Purposes: Employment Sports Screening medical eval. Legal Monitoring Treatment Probation Prescribing controlled substances Forensics 2 Drug

More information

Soma (carisoprodol), Soma Compound (carisoprodol and aspirin), Soma Compound w/ Codeine (carisoprodol and aspirin and codeine)

Soma (carisoprodol), Soma Compound (carisoprodol and aspirin), Soma Compound w/ Codeine (carisoprodol and aspirin and codeine) Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.75.07 Subject: Soma Page: 1 of 7 Last Review Date: September 15, 2017 Soma Description Soma (carisoprodol),

More information

OPIOID DEPENDENCE. DR. SHILPA ADARKAR Associate Professor Dept Of Psychiatry & Deaddiction Centre, Seth GSMC & KEMH

OPIOID DEPENDENCE. DR. SHILPA ADARKAR Associate Professor Dept Of Psychiatry & Deaddiction Centre, Seth GSMC & KEMH OPIOID DEPENDENCE DR. SHILPA ADARKAR Associate Professor Dept Of Psychiatry & Deaddiction Centre, Seth GSMC & KEMH What is opioid? Opium, derived from the ripe seed capsule of the opium poppy (Papaver

More information

Mood Disorders for Care Coordinators

Mood Disorders for Care Coordinators Mood Disorders for Care Coordinators David A Harrison, MD, PhD Assistant Professor, Dept of Psychiatry & Behavioral Sciences University of Washington School of Medicine Introduction 1 of 3 Mood disorders

More information

Revised 9/30/2016. Primary Care Provider Pain Management Toolkit

Revised 9/30/2016. Primary Care Provider Pain Management Toolkit Revised 9/30/2016 Primary Care Provider Pain Management Toolkit TABLE OF CONTENTS 1. INTRODUCTION Page 1 2. NON-OPIOID SERVICES &TREATMENTS FOR CHRONIC PAIN Page 2 2.1 Medical Services Page 2 2.2 Behavioral

More information

Based on Tip 54. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders KAP KEYS FOR CLINICIANS

Based on Tip 54. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders KAP KEYS FOR CLINICIANS Based on Tip 54 Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders KAP KEYS FOR CLINICIANS KAP Keys Based on TIP 54 Introduction KAP Keys were developed to accompany the Treatment

More information

Substance Use Disorders in Primary Care

Substance Use Disorders in Primary Care Substance Use Disorders in Primary Care Jin Hee Yoon-Hudman, MD Assistant Vice President, Medical Director, Behavioral Health Healthfirst Fall Symposium Prevention as a Priority in Value-Based Healthcare,

More information

Some newer, investigational approaches to treating refractory major depression are being used.

Some newer, investigational approaches to treating refractory major depression are being used. CREATED EXCLUSIVELY FOR FINANCIAL PROFESSIONALS Rx FOR SUCCESS Depression and Anxiety Disorders Mood and anxiety disorders are common, and the mortality risk is due primarily to suicide, cardiovascular

More information

The Trifecta: Kids, Pot, & Opiates. Drug Overdose Death Rates Never Higher. Adolescent Opiate Overdoses Increased. Eric A.

The Trifecta: Kids, Pot, & Opiates. Drug Overdose Death Rates Never Higher. Adolescent Opiate Overdoses Increased. Eric A. The Trifecta: Kids, Pot, & Opiates Eric A. Voth, MD, FACP Drug Overdose Death Rates Never Higher. Nationally 16 % increase in deaths from opioid pain relievers 2013-2014 to18,893. 200% increase in opioid

More information

Medication for the Treatment of Alcohol Use Disorder. Pocket Guide

Medication for the Treatment of Alcohol Use Disorder. Pocket Guide Medication for the Treatment of Alcohol Use Disorder Pocket Guide Medications are underused in the treatment of alcohol use disorder. According to the National Survey on Drug Use and Health, of the estimated

More information

Mayors Opioid Summit PATTERNS AND TRENDS OF THE OPIOID EPIDEMIC IN BROWARD COUNTY TYPES OF OPIOIDS DEFINITION OF OPIOID. Pill Press from China

Mayors Opioid Summit PATTERNS AND TRENDS OF THE OPIOID EPIDEMIC IN BROWARD COUNTY TYPES OF OPIOIDS DEFINITION OF OPIOID. Pill Press from China The Opioid Epidemic In Broward County 8/24/217 Mayors Opioid Summit PATTERNS AND TRENDS OF THE OPIOID EPIDEMIC IN BROWARD COUNTY Jim Hall Senior Epidemiologist Center for Applied Research on Substance

More information

FY17 SCOPE OF WORK TEMPLATE. Name of Program/Services: Medication-Assisted Treatment: Buprenorphine

FY17 SCOPE OF WORK TEMPLATE. Name of Program/Services: Medication-Assisted Treatment: Buprenorphine FY17 SCOPE OF WORK TEMPLATE Name of Program/Services: Medication-Assisted Treatment: Buprenorphine Procedure Code: Modification of 99212, 99213 and 99214: 99212 22 99213 22 99214 22 Definitions: Buprenorphine

More information

Treatment Approaches for Drug Addiction

Treatment Approaches for Drug Addiction Treatment Approaches for Drug Addiction NOTE: This fact sheet discusses research findings on effective treatment approaches for drug abuse and addiction. If you re seeking treatment, you can call the Substance

More information

Conflict of Interest Disclosure

Conflict of Interest Disclosure Patient Rx Drug Misuse and Abuse: Compliance Toxicology Monitoring in Clinical Practice Toxicology Staff Andrea Terrell, Ph.D., DABCC Chief Scientific Officer George Behonick, Ph.D., DABFT, Manager, FBU

More information

Aetna s Initiative on the Opioid Epidemic

Aetna s Initiative on the Opioid Epidemic Aetna s Initiative on the Opioid Epidemic Christopher James D.O., M.P.H. Medical Director, BH- Mid-Atlantic Territory (JamesC1@aetna.com) July 23, 2017 HHS Data on Epidemic Every Day in the U.S. More than

More information

Guidelines for the Utilization of Psychotropic Medications for Children in Foster Care. Illinois Department of Children and Family Services

Guidelines for the Utilization of Psychotropic Medications for Children in Foster Care. Illinois Department of Children and Family Services Guidelines for the Utilization of Psychotropic Medications for Children in Foster Care Illinois Department of Children and Family Services Introduction With few exceptions, children and adolescents in

More information

Medication Assisted Treatment. MAT Opioid dependence/addiction Opioid treatment programs OTP Regulation of OTP Office Based Treatment

Medication Assisted Treatment. MAT Opioid dependence/addiction Opioid treatment programs OTP Regulation of OTP Office Based Treatment Medication Assisted Treatment MAT Opioid dependence/addiction Opioid treatment programs OTP Regulation of OTP Office Based Treatment Opioid Drugs Opium Morphine Heroin Codeine Oxycodone Roxycodone Oxycontin

More information

Kari A. Stephens, PhD & Wayne Bentham, MD Psychiatry & Behavioral Sciences University of Washington. Approach for doing differential diagnosis of PTSD

Kari A. Stephens, PhD & Wayne Bentham, MD Psychiatry & Behavioral Sciences University of Washington. Approach for doing differential diagnosis of PTSD IN PRIMARY CARE June 17, 2010 Kari A. Stephens, PhD & Wayne Bentham, MD Psychiatry & Behavioral Sciences University of Washington Defining and assessing Approach for doing differential diagnosis of Best

More information

Biological Addictions Treatment. Psychology 470. Many Types of Approaches

Biological Addictions Treatment. Psychology 470. Many Types of Approaches Many Types of Approaches Biological Addictions Treatment Psychology 470 Introduction to Chemical Additions Steven E. Meier, Ph.D. Listen to the audio lecture while viewing these slides Detoxification approaches

More information

Anxiety Disorders. Fear & Anxiety. Anxiety Disorder? 26/5/2014. J. H. Atkinson, M.D. Fear. Anxiety. An anxiety disorder is present when

Anxiety Disorders. Fear & Anxiety. Anxiety Disorder? 26/5/2014. J. H. Atkinson, M.D. Fear. Anxiety. An anxiety disorder is present when Anxiety s J. H. Atkinson, M.D. HIV Neurobehavioral Research Center University of California, San Diego Department of Psychiatry & Veterans Affairs Healthcare System, San Diego Materials courtesy of Dr.

More information

PRESCRIPTION DRUG ABUSE: THE NATIONAL PERSPECTIVE

PRESCRIPTION DRUG ABUSE: THE NATIONAL PERSPECTIVE PRESCRIPTION DRUG ABUSE: THE NATIONAL PERSPECTIVE September 20, 2013 Association of State and Territorial Health Officials Annual Meeting R. Gil Kerlikowske Director of National Drug Control Policy National

More information

Addiction. Concept of Addiction R. Corey Waller MD, MS, FACEP, FASAM Director, Center for Integrative Medicine

Addiction. Concept of Addiction R. Corey Waller MD, MS, FACEP, FASAM Director, Center for Integrative Medicine Addiction Concept of Addiction R. Corey Waller MD, MS, FACEP, FASAM Director, Center for Integrative Medicine Twitter: @rcwallermd Objectives Understand the Concept of Addiction Survival FOOD WATER DOPAMINE

More information

Gold Standard for Urine Drug Testin Urine Drug Testing Why U rine? Urine?

Gold Standard for Urine Drug Testin Urine Drug Testing Why U rine? Urine? Gold Standard for Urine Drug Testing Developed by TRMC Pain Management Center Jill Duffy, RN,BC Pam Kennell, RN, BC Heidi Beisch, RN Urine Drug Testing A DIAGNOSTIC tool For an OBJECTIVE test Based on

More information

The Role of Primary Care Teams and the Medical Neighborhood in Addressing the Opioid Crisis in Maine. March 10, 2016

The Role of Primary Care Teams and the Medical Neighborhood in Addressing the Opioid Crisis in Maine. March 10, 2016 The Role of Primary Care Teams and the Medical Neighborhood in Addressing the Opioid Crisis in Maine March 10, 2016 Objectives Review current state of opioid crisis in Maine Briefly review physiology of

More information

GOALS AND OBJECTIVES

GOALS AND OBJECTIVES SUBOXONE AND VIVITROL: ARE THERE DISPARITIES SURFACING IN MEDICATION ASSISTED TREATMENTS? P R E S E N T E D B Y D R. K I AM E M AH A N I A H & D R. M Y E C H I A M I N T E R - J O R D AN GOALS AND OBJECTIVES

More information

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

Session 2: Mental Health A: Alcohol Dependency: The Pharmacist s Role in Detox and Treatment 1:45pm - 2:45pm 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 107-000-12-015-L01-P

More information

Treatment Options for Bipolar Disorder Contents

Treatment Options for Bipolar Disorder Contents Keeping Your Balance Treatment Options for Bipolar Disorder Contents Medication Treatment for Bipolar Disorder 2 Page Medication Record 5 Psychosocial Treatments for Bipolar Disorder 6 Module Summary 8

More information

The role of behavioral interventions in buprenorphine treatment of opioid use disorders

The role of behavioral interventions in buprenorphine treatment of opioid use disorders The role of behavioral interventions in buprenorphine treatment of opioid use disorders Roger D. Weiss, MD Harvard Medical School, Boston, MA, McLean Hospital, Belmont, MA, USA Today s talk Review of studies

More information

Medical Assisted Treatment of Opioid

Medical Assisted Treatment of Opioid Medical Assisted Treatment of Opioid Dependence with XR-NTX(Vivitrol) Michael McNamara DO, FACN Medical Director Mental Health Center of Greater Manchester Manchester NH Outline Overview of Opioid Dependence

More information

Patient-Centered Urine Drug Testing. Douglas Gourlay, MD, MSc, FRCPC, FASAM

Patient-Centered Urine Drug Testing. Douglas Gourlay, MD, MSc, FRCPC, FASAM Patient-Centered Urine Drug Testing Douglas Gourlay, MD, MSc, FRCPC, FASAM Declaration of Potential Conflict of Interest The content of this presentation is non- commercial and does not represent any conflict

More information

Clinical Guidelines and Procedures for the Use of Naltrexone in the Management of Opioid Dependence Abbreviated Version

Clinical Guidelines and Procedures for the Use of Naltrexone in the Management of Opioid Dependence Abbreviated Version Clinical Guidelines and Procedures for the Use of Naltrexone in the Management of Opioid Dependence Abbreviated Version Clinical Guidelines and Procedures for the Use of Naltrexone in the Management of

More information

SUBOXONE Film, SUBOXONE Tablets, and SUBUTEX Tablets. Risk Evaluation and Mitigation Strategy (REMS) Program

SUBOXONE Film, SUBOXONE Tablets, and SUBUTEX Tablets. Risk Evaluation and Mitigation Strategy (REMS) Program SUBOXONE Film, SUBOXONE Tablets, and SUBUTEX Tablets Risk Evaluation and Mitigation Strategy (REMS) Program Office-Based Buprenorphine Therapy for Opioid Dependence: Important Information for Prescribers

More information

Pain Management and Addiction: Clinical Challenges

Pain Management and Addiction: Clinical Challenges Pain Management and Addiction: Clinical Challenges MMS Pain Management Forum March 12, 2010 Associate Professor of Medicine Boston University School of Medicine Boston Medical Center Conflicts of Interest

More information

Topics of today s training

Topics of today s training Extended Release Naltrexone Vivitrol Christopher J Davis D.O. CAADC, FASAM Medical Director, Brightwater Landing Medical Director, Pyramid Healthcare Diplomate of The American Board of Addition Medicine

More information

Subject: Pain Management (Page 1 of 7)

Subject: Pain Management (Page 1 of 7) Subject: Pain Management (Page 1 of 7) Objectives: Managing pain and restoring function are basic goals in helping a patient with chronic non-cancer pain. Federal and state guidelines require that all

More information

Presentation is Being Recorded

Presentation is Being Recorded Integrated Care for Depression & Anxiety Psychotropic Medication Management for Primary Care Providers Los Angeles County Department of Mental Health September 20, 2011 Presentation is Being Recorded Please

More information

FROM MEDICATION TO MINDFULNESS: NEW INSIGHTS INTO THE WORLD OF ANXIETY

FROM MEDICATION TO MINDFULNESS: NEW INSIGHTS INTO THE WORLD OF ANXIETY 13 th Pearl Leibovitch Clinical Day November 18th, 2014 Mounir H. Samy, MD, FRCP(C) Associate Professor of Psychiatry McGill University (ret.) FROM MEDICATION TO MINDFULNESS: NEW INSIGHTS INTO THE WORLD

More information

9/16/2016. I would feel comfortable dispensing/prescribing varenicline to a patient with a mental health disorder. Learning Objectives

9/16/2016. I would feel comfortable dispensing/prescribing varenicline to a patient with a mental health disorder. Learning Objectives The Smoking Gun: for Smoking Cessation in Patients with Mental Health Disorders BRENDON HOGAN, PHARMD PGY2 PSYCHIATRIC PHARMACY RESIDENT CTVHCS, TEMPLE, TX 09/23/2016 I would feel comfortable dispensing/prescribing

More information

Best Practices in Prescribing Benzodiazepines. Michael Carlisle, DO Medical Director University Hospitals Geauga Medical Center

Best Practices in Prescribing Benzodiazepines. Michael Carlisle, DO Medical Director University Hospitals Geauga Medical Center Best Practices in Prescribing Benzodiazepines Michael Carlisle, DO Medical Director University Hospitals Geauga Medical Center Objectives To review current practice guidelines in benzodiazepine prescribing

More information

Recommendations in Opioid Prescribing Guidelines for Chronic Pain

Recommendations in Opioid Prescribing Guidelines for Chronic Pain Recommendations in Opioid Prescribing Guidelines for Chronic Pain The use of opioids for treating chronic pain has been increasing. 1 In 2010, an estimated 20% of patients presenting to physician offices

More information

Strategies in Managing Opioid and Benzodiazepine Co-Prescribing

Strategies in Managing Opioid and Benzodiazepine Co-Prescribing Strategies in Managing Opioid and Benzodiazepine Co-Prescribing Scott Endsley, MD Associate Medical Director, Quality Partnership HealthPlan of California October 25, 2016 Audio Instructions To avoid echoes

More information

Poisoning Deaths vs. Motor Vehicle Related Injury Deaths, MA Residents ( )

Poisoning Deaths vs. Motor Vehicle Related Injury Deaths, MA Residents ( ) Source: National Vital Statistics Poisoning Deaths vs. Motor Vehicle Related Injury Deaths, MA Residents (1997 2008) The source of the data is: Registry of Vital Records and Statistics, MA Department of

More information

Psychotropic Medication

Psychotropic Medication FOM 802-1 1 of 10 OVERVIEW The use of psychotropic medication as part of a child s comprehensive mental health treatment plan may be beneficial and should include consideration of all alternative interventions.

More information

Tennessee. Prescribing and Dispensing Profile. Research current through November 2015.

Tennessee. Prescribing and Dispensing Profile. Research current through November 2015. Prescribing and Dispensing Profile Tennessee Research current through November 2015. This project was supported by Grant No. G1599ONDCP03A, awarded by the Office of National Drug Control Policy. Points

More information

Where to from Here? Evidence-Based Strategies for Treatment of Refractory Depression

Where to from Here? Evidence-Based Strategies for Treatment of Refractory Depression Where to from Here? Evidence-Based Strategies for Treatment of Refractory Depression Michael D. Jibson, MD, PhD Professor of Psychiatry University of Michigan Major Depression #1 WHO cause of disability

More information

Pediatric Psychopharmacology

Pediatric Psychopharmacology Pediatric Psychopharmacology General issues to consider. Pharmacokinetic differences Availability of Clinical Data Psychiatric Disorders can be common in childhood. Early intervention may prevent disorders

More information

Chapter 29. Caring for Persons With Mental Health Disorders

Chapter 29. Caring for Persons With Mental Health Disorders Chapter 29 Caring for Persons With Mental Health Disorders The Whole Person The whole person has physical, social, psychological, and spiritual parts. Mental relates to the mind. Mental health and mental

More information

Urine Drug Testing. Methadone/Buprenorphine 101 Workshop. Ron Joe, MD, DABAM December 10, 2016

Urine Drug Testing. Methadone/Buprenorphine 101 Workshop. Ron Joe, MD, DABAM December 10, 2016 Urine Drug Testing Methadone/Buprenorphine 101 Workshop Ron Joe, MD, DABAM December 10, 2016 Learning objectives Clarify the purpose of urine drug testing (UDT) Distinguish between UDT for detection of

More information

Opioid Prescribing for Acute Pain. Care for People 15 Years of Age and Older

Opioid Prescribing for Acute Pain. Care for People 15 Years of Age and Older Opioid Prescribing for Acute Pain Care for People 15 Years of Age and Older Summary This quality standard provides guidance on the appropriate prescribing, monitoring, and tapering of opioids to treat

More information

Vermont. Prescribing and Dispensing Profile. Research current through November 2015.

Vermont. Prescribing and Dispensing Profile. Research current through November 2015. Prescribing and Dispensing Profile Vermont Research current through November 2015. This project was supported by Grant No. G1599ONDCP03A, awarded by the Office of National Drug Control Policy. Points of

More information

Opioid Overdose Best Practices Guideline. Table of Contents. A. General description: B: Typical signs and symptoms:

Opioid Overdose Best Practices Guideline. Table of Contents. A. General description: B: Typical signs and symptoms: Opioid Overdose Best Practices Guideline Table of Contents A. General description B. Typical signs and symptoms C. Expected course D. Making the diagnosis E. Recommended treatment F. Criteria for hospital

More information

Antidepressant Medication Strategies We ve Come a Long Way or Have We? Who Writes Prescriptions for Psychotropic Medications. Biological Psychiatry

Antidepressant Medication Strategies We ve Come a Long Way or Have We? Who Writes Prescriptions for Psychotropic Medications. Biological Psychiatry Antidepressant Medication Strategies We ve Come a Long Way or Have We? Joe Wegmann, PD, LCSW The PharmaTherapist Joe@ThePharmaTherapist.com 504.587.9798 www.pharmatherapist.com Are you receiving our free

More information

Understanding Addiction: Why Can t Those Affected Just Say No?

Understanding Addiction: Why Can t Those Affected Just Say No? Understanding Addiction: Why Can t Those Affected Just Say No? 1 The Stigma of Addiction There continues to be a stigma surrounding addiction even among health care workers. Consider the negative opinions

More information

MINOR TRANQUILIZERS CHAPTER TWO : MINOR TRANQUILIZERS

MINOR TRANQUILIZERS CHAPTER TWO : MINOR TRANQUILIZERS MINOR TRANQUILIZERS 76. The term 'minor tranquilizers' was introduced into the scientific literature in the 1950s to distinguish the medicines prescribed to reduce anxiety and tension from the major tranquillizers,

More information

Legal 2000 and the Mental Health Crisis in Clark County. Lesley R. Dickson, M.D. Executive Director, Nevada Psychiatric Association

Legal 2000 and the Mental Health Crisis in Clark County. Lesley R. Dickson, M.D. Executive Director, Nevada Psychiatric Association Legal 2000 and the Mental Health Crisis in Clark County Lesley R. Dickson, M.D. Executive Director, Nevada Psychiatric Association Civil action: Civil Commitment Definition a legal action to recover money

More information

Division of Mental Health and Addiction Services

Division of Mental Health and Addiction Services Division of Mental Health and Addiction Services A DAM BUCON, LSW DMHAS Mission DMHAS, in partnership with consumers, family members, providers and other stakeholders, promotes wellness and recovery for

More information

Best Practices in Prescribing Opioids for Chronic Non-cancer Pain

Best Practices in Prescribing Opioids for Chronic Non-cancer Pain Best Practices in Prescribing Opioids for Chronic Non-cancer Pain Disclosures S C O T T S T E I G E R, M D, F A C P, D A B A M A S S I S T A N T C L I N I C A L P R O F E S S O R D I V I S I O N O F G

More information

Guideline for the Diagnosis and Management of Generalized Anxiety Disorder for Primary Care Physicians

Guideline for the Diagnosis and Management of Generalized Anxiety Disorder for Primary Care Physicians MAGELLAN BEHAVIORAL HEALTH/ BLUE CROSS BLUE SHIELD OF NORTH CAROLINA Guideline for the Diagnosis and Management of Generalized Anxiety Disorder for Primary Care Physicians This guideline includes recommendations

More information

DEMENTIA and BPSD in PARKINSON'S DISEASE. DR. T. JOHNSON. NOVEMBER 2017.

DEMENTIA and BPSD in PARKINSON'S DISEASE. DR. T. JOHNSON. NOVEMBER 2017. DEMENTIA and BPSD in PARKINSON'S DISEASE. DR. T. JOHNSON. NOVEMBER 2017. Introduction. Parkinson's disease (PD) has been considered largely as a motor disorder. It has been increasingly recognized that

More information

A Brief Overview of Psychiatric Pharmacotherapy. Joel V. Oberstar, M.D. Chief Executive Officer

A Brief Overview of Psychiatric Pharmacotherapy. Joel V. Oberstar, M.D. Chief Executive Officer A Brief Overview of Psychiatric Pharmacotherapy Joel V. Oberstar, M.D. Chief Executive Officer Disclosures Some medications discussed are not approved by the FDA for use in the population discussed/described.

More information

Antidepressants for treatment of depression.

Antidepressants for treatment of depression. JR3 340 1 of 9 PSYCHOTROPIC MEDICATIONS PURPOSE The use of psychotropic medication as part of a youth's comprehensive mental health treatment plan may be beneficial. The administration of psychotropic

More information

Disclosures. Objectives 2/5/2018. Women and opioid use disorder: Optimizing care during pregnancy and beyond

Disclosures. Objectives 2/5/2018. Women and opioid use disorder: Optimizing care during pregnancy and beyond Women and opioid use disorder: Optimizing care during pregnancy and beyond Susanne Astrab Fogger, DNP, PMHNP-BC, CARN-AP, FAANP Ashley L. Hodges, PhD, CRNP, WHNP-BC Disclosures Dr. Fogger has nothing to

More information

Medications for Borderline Personality Disorder

Medications for Borderline Personality Disorder Medications for Borderline Personality Disorder Sarah Roff MD, PhD Attending Psychiatrist, DBT Unit, Oregon State Hospital Assistant Professor, Public Psychiatry, OHSU sarah.roff@dhsoha.state.or.us Skills

More information

Dr. Smith. Roneet Lev, MD FACEP Chief, Emergency Department Scripps Mercy Hospital Chair, San Diego Prescription Drug Abuse Medical Task Force

Dr. Smith. Roneet Lev, MD FACEP Chief, Emergency Department Scripps Mercy Hospital Chair, San Diego Prescription Drug Abuse Medical Task Force Dr. Smith Roneet Lev, MD FACEP Chief, Emergency Department Scripps Mercy Hospital Chair, San Diego Prescription Drug Abuse Medical Task Force 1 1 How We Got Here 2 The Epidemic 3 4 San Diego Death Diaries

More information

Substance and Alcohol Related Disorders. Substance use Disorder Alcoholism Gambling Disorder

Substance and Alcohol Related Disorders. Substance use Disorder Alcoholism Gambling Disorder Substance and Alcohol Related Disorders Substance use Disorder Alcoholism Gambling Disorder What is a Substance Use Disorder? According to the DSM-5, a substance use disorder describes a problematic pattern

More information

Substance Abuse Level of Care Criteria

Substance Abuse Level of Care Criteria Substance Abuse Level of Care Criteria Table of Contents SUBSTANCE ABUSE OUTPATIENT: Adolescent... 3 SUBSTANCE ABUSE PREVENTION: Adult... 7 OPIOID MAINTENANCE THERAPY: Adult... 8 SUBSTANCE ABUSE INTERVENTION:

More information

ASAM Criteria, Third Edition Matrix for Matching Adult Severity and Level of Function with Type and Intensity of Service

ASAM Criteria, Third Edition Matrix for Matching Adult Severity and Level of Function with Type and Intensity of Service 1: Acute Intoxication and/or Withdrawal Potential Risk Rating: 0 1: Acute Intoxication and/or Withdrawal Potential Risk Rating: 1 1: Acute Intoxication and/or Withdrawal Potential Risk Rating: 2 The patient

More information

Opioids Research to Practice

Opioids Research to Practice Opioids Research to Practice CRIT/FIT 2016 April 2016 Daniel P. Alford, MD, MPH Associate Professor of Medicine Assistant Dean, Continuing Medical Education Director, Clinical Addiction Research and Education

More information

The Prescription Drug Overdose Epidemic

The Prescription Drug Overdose Epidemic The Prescription Drug Overdose Epidemic Rita Noonan, PhD National Center for Injury Prevention and Control Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division

More information

COMMONLY PRESCRIBED PSYCHOTROPIC MEDICATIONS NAME Generic (Trade) DOSAGE KEY CLINICAL INFORMATION Antidepressant Medications*

COMMONLY PRESCRIBED PSYCHOTROPIC MEDICATIONS NAME Generic (Trade) DOSAGE KEY CLINICAL INFORMATION Antidepressant Medications* COMMONLY PRESCRIBED PSYCHOTROPIC MEDICATIONS NAME Generic (Trade) DOSAGE KEY CLINICAL INFORMATION Antidepressant Medications* Bupropion (Wellbutrin) Start: IR-100 mg bid X 4d then to 100 mg tid; SR-150

More information

Bipolar Disorder Clinical Practice Guideline Summary for Primary Care

Bipolar Disorder Clinical Practice Guideline Summary for Primary Care Bipolar Disorder Clinical Practice Guideline Summary for Primary Care DIAGNOSIS AND CLINICAL ASSESSMENT Bipolar Disorder is categorized by extreme mood cycling; manifested by periods of euphoria, grandiosity,

More information

Updated: 08/2017 DMMA Approved: 11/2017

Updated: 08/2017 DMMA Approved: 11/2017 Request for Prior Authorization for Therapy to Treat Binge Eating Disorder Website Form www.highmarkhealthoptions.com Submit request via: Fax - 1-855-476-4158 All requests for medications to treat Binge

More information

Dr. Renner receives honoraria from Reed Medical Education

Dr. Renner receives honoraria from Reed Medical Education Substance Use Disorders Symposium on Men s Health Massachusetts Medical Society June 17, 2010 John A. Renner, Jr., M.D. John A. Renner Jr., MD DISCLOSURES Johnson & Johnson Stock Holder Dr. Renner receives

More information

MANAGEMENT OF VISCERAL PAIN

MANAGEMENT OF VISCERAL PAIN MANAGEMENT OF VISCERAL PAIN William D. Chey, MD, FACG Professor of Medicine University of Michigan 52 year old female with abdominal pain 5 year history of persistent right sided burning/sharp abdominal

More information

Pharmacotherapy for opioid addiction. Judith Martin, MD Medical Director BAART Turk Street Clinic San Francisco

Pharmacotherapy for opioid addiction. Judith Martin, MD Medical Director BAART Turk Street Clinic San Francisco Pharmacotherapy for opioid addiction Judith Martin, MD Medical Director BAART Turk Street Clinic San Francisco Disclosure slide No commercial conflicts to disclose. Gaps in current treatment of opioid

More information