Jay Weiss, MD Drug Summit Little Rock, Arkansas Sep 9/10, 2014

Transcription

1 Jay Weiss, MD Drug Summit Little Rock, Arkansas Sep 9/10, 2014

2 OVERVIEW Definitions Disease concept Anatomy and neurochemistry Risk Factors Defenses, statistics, comorbidity Professionals and treatment

3 History Civil War 1865 Morphine OTS Heroin and Cocaine 1910 Harrison act 1916 Prescription Authority Prohibition 1918 Doctors in jail 1920 Repeal 1933 War on Drugs today

4 More History Dr. Ruth Fox 1950 Disease versus Character Problem Evaluation, Treatment and Monitoring Not Punishment Open Versus Occult Problem No more Hiding 1974 AMA

5 Dependence (3) Maladaptive Pattern Tolerance Withdrawal Larger Amounts, Longer Time Unable to control or cut down Increasing time spent Important activities given up Physical/ Psychological problems

6 Abuse (1) Maladaptive Pattern Failure to fulfill major role obligations Physical Danger Legal Problems Social/ Interpersonal Problems

7 Types of Addiction (They run in packs) Chemical Alcohol Stimulants Sedatives Opiates Hallucinogens Cannabis Process Gambling Eating Sex Spending Relationships Work

8 Disease Concept Mechanism of action Target tissue/organ Predictable course Treatment options Management Acute or chronic process Toxins

9 Neuroanatomy Limbic system Nucleus accumbens Ventral Tegmental Nuclei Reward Circuitry Dopamine, Survival Reptilian brain

10 Neurochemistry Dopamine Norepinephrine Serotonin Endorphins Enkephalins GABA

11 Dopamine Key neurotransmitter Increases hallucinations and delusions in schizophrenia All drugs of abuse increase dopamine All antipsychotics block dopamine receptors Addictive behavior resembles psychosis

12 Effects of All Addictive Drugs Stimulate limbic system Must have drug to survive Shut down cortex Destroy judgment, values, will Smart people do stupid things Id, Superego, Ego

13 Addictive Defenses Denial Rationalization Projection Passive-Aggressive Distortion Acting out Paranoia

14 Addictive Behaviors Lying and denying Web of lies Wall of deceipt Externalization of blame Victimization Craving and drug seeking Doctor shopping

15 More Behaviors Stealing Fights Confusion Minimization of difficulties Irrational Labile Unpredictable

16 Risk Factors AGENT: Availability, Cost, Rapidity of onset, Efficacy as a tranquilizer ENVIRONMENT: Occupation, Peer Group, Culture, Social Instability HOST: Genetic predisposition, Multiproblem family, Comorbid Psychiatric Disorder

17 Statistics Alcohol Dependence Lifetime Risk is 15% in western societies Drug Dependence and Abuse Lifetime Risk is between 6 and 7% Nicotine Dependence is 25% of US population

18 Dual Diagnosis Addiction and Psychiatric Problem in the Same Patient Very Common Interrelated Dual DX needs Dual TX Chicken or Egg Treat Both

19 Comorbidity If you have a drug disorder, lifetime prevalence of alcohol disorder is 47% and of a psychiatric disorder 53% If you have an alcohol disorder, your chances of a current or prior psychiatric disorder are 37% and life time prevalence of a drug disorder is21%

20 What Works? Identify Intervene Evaluate Detoxify Treatment-AA based Aftercare Monitoring and accountability

21 Identify Difficult Enabling behavior Protection Denial Resistance

22 Intervention Also difficult Coordinate Family, friends, supervisor, boss Unanimous Immediate treatment

23 Treatment Inpatient most effective 12 step: AA, NA, Alanon Inpatient hospital Residential Intensive outpatient (IOP) Outpatient Attend AA on your own

24 Detoxification First step only Insufficient for recovery Best done inpatient AA/Education starts here No quick cure Off all controlled meds Lifelong management

25 Treatment Inpatient most effective 12 step AA/NA works best Inpatient Hospital CD Residential Intensive Outpatient Outpatient Attend AA on own

26 Treatment Success AA and meetings 10-15% 30 day inpatient 30% 60 day inpatient 60% 90 day inpatient 90% Monitor, test, contract Accountability AA based

27 Treatment Success 90 days inpatient best. Why? College semester Military basic training Internalization of learning Sets up permanent behavior change Sets up lifelong management

28 Results 80-95% sober at one year 85% with 5 years monitoring 30 day inpatient treatment with no follow up yields 80% relapse at one year Not an acute problem Chronic disease Lifelong management

29 Chronic Pain Opiates, Sedatives, Alcohol Work well at first Tolerance and withdrawal One week rule Occasional rule Surgery on addicts

30 Professionals Professional training Body of knowledge Serve the public Fiduciary responsibility Licensing board Held to a higher standard Live in a fishbowl

31 Professionals Large data base Judgment Executive function Dynamic situation Powers of observation No margin for error Correct decisions

32 Professionals and CDS Not recommended Potential impairment Side effects: Variable/Unpredictable Danger to patients outweighs any possible benefit to individual professional Dopamine increase

33 Prescriptions for CDS Adderall, Ritalin: ADHD Oxycodone, Methadone, Hydrocodone: Chronic Pain, LBP, Headache Methadone, Suboxone, Subutex: Chronic Opiate Maintenance for Addiction Muscle Relaxants Benzodiazepines: Anxiety, Tremor

34 Impairment Dizzy, drowsy, headache, insomnia, vomiting, anxiety, blurred vision, confusion, decreased attention, fainting, mood swings, mania, depression, paranoia, psychosis, impaired executive function, impaired judgment, jaundice, slurred speech, edema, delirium, withdrawal symptoms Invitation to bad mistakes

35 Professionals and CDS Impairment of executive function Impaired cognition Impaired performance Unpredictable side effects Incompatible with safe practice Choice between safe practice and consumption of CDS

36 Professionals Added exposure (access) = added risk Higher rates of addiction Anesthesia, ER, OR, Recovery Pharmacy Boards, PHP, RNP Higher standards and visibility Higher expectations and pressures

37 Professionals High rate of recovery 85-95% Mandated treatment Close follow-up Monitoring and accountability Random drug and alcohol screens Contingency and consequences

38 FAA Program Similar to OPAP Management Identify, Detox, Evaluate Treatment: Inpatient, outpatient, testing, monitoring, accountability, consequences 2 DWI in 10 years 2 years grounded Satisfactory evidence of recovery

39 Treatment Identification Detoxification and evaluation Treatment and Monitoring Accountability and Supervision Long term Management Contract Licensing action?

40 Summary Widespread Problem No Social Boundaries High Cost, High Mortality No Quick Recovery Chronic Disease Model Lifelong Management, Monitoring Professional programs work