ID, Substance Abuse and Recovery

ID, Substance Abuse and Recovery The South Carolina Primary Healthcare Association Clinical Network Retreat, Myrtle Beach, SC 06/12/2011 Ralph Rynes, PhD, NCAC II LRADAC USC School of Medicine and the SC HIV/AIDS Clinical Training Center (803) 545-5356 ralph.rynes@uscmed.sc.edu

None Financial Disclosures

True or False? Addiction is an acute condition that can be effectively treated with detox Treatment should produce a long lasting reduction in symptoms following termination of Tx Relapse should be considered a failure of Tx Relapse can occur before an addict picks up a drink or drug Worrying about others instead of self can trigger relapse Being addicted to prescription drugs is different from being addicted to street drugs Tx doesn t work

The Truth Addiction is a brain disorder THERE IS NO MAGIC PILL / MAGIC BULLET Medications are not always appropriate Specific meds. should be avoided (i.e. benzos) If used, medications must be accompanied by behavioral interventions Interventions must be pt. specific and tailored to that pt. s stage of recovery Addiction is a chronic condition that requires ongoing assessment and Tx TREATMENT WORKS

General ID Risk Factors that Happen to Have a High Correlation with Substance Abuse Hx of ID Poor nutrition High stress & y disorders CrJ Involvement High risk sex practices Overlapping social environments Consider possibility of PTSD

Time Often substance abusers fail to recognize symptoms of disease and seek Tx only when they become acutely ill or emergent, thus prolonging the time they spread infectious conditions to others HIV or Hep C may be asymptomatic for many years (HIV-10 years), (Hep C- 20 years) so many partners may be infected Processing time (denial, etc.)

Most Commonly Abused Drugs in the U.S. Alcohol (combined with cocaine, marijuana, or heroin) Cocaine Marijuana Heroin/morphine Alprazolam (Xanax) Hydrocodone (Vicodin, Lorcet, Lortab) Unspecified benzodiazepines Oxycodone (OxyContin, Percocet, Percodan, Tylox)

Most Commonly Abused Drugs in the U.S. con t. Methadone Clonazepam (Klonopin) Propoxyphene Darvocet N, Darvon ) Amphetamine (Dexedrine) Lorazepam (Ativan) Carisoprodol (Soma) Diazepam (Valium) Methamphetamine (Desoxyn, speed, Tina) Trazodone (Desyrel)

Let s get specific: Crack: May have multiple sex partners while using and may have indiscriminate sex to get drugs or the money to buy them Crack users nationwide have unusually high rates of syphilis infection (often heterosexual men who seek Tx for secondary syphilis and then test + for HIV) Smoking crack degrades oral mucosa, leading to open ulcers. In vitro studies indicate increased HIV replication in 1 the presence of cocaine In recovery, anhedonia impacts rewards of appetite directed behaviors (sleeping, eating) and function directed behaviors (work, responsibilities) 1. Tashkin Journal of Neuroimmunology 2003

How Cocaine Works The neurotransmitter dopamine transmits brain signals by flowing from one neuron across the synapse and attaching to a receptor on another neuron. Normally, dopamine then is recycled back into the transmitting neuron by a transporter molecule on the surface of the neuron. But if cocaine is present, the drug attaches to the transporter and blocks the normal recycling of dopamine, causing an increase of synaptic dopamine levels that leads to euphoria. Source: Swan, N. NIDA Notes Vol. 13 #2; 1998

Cocaine & Sex Functional MRI showing activation of the same brain sites in cocaine addicts watching a cocainecraving-inducing film (left) and non-drugusing subjects watching a film depicting explicit sexual scenes (right). This suggests that cue-induced cocaine craving and sexual excitement are associated with the same brain sites. Source: Zickler, NIDA Notes Vol 16 #2, 2001

Limbic Activation on Cue PET scan shows that limbic regions in the brains of intreatment cocaine users are activated by watching cocaine-related videos. Watching videos of nature scenes does not result in activation of these regions. This suggests that cueinduced craving for cocaine reflects activity in specific regions of the brain. Source: Zickler, NIDA Notes Vol 16 #2, 2001

EtOH Dependence In homeostasis, inhibition and excitation centers are balanced (GABA vs. Glu) EtOH tips the balance to bottom out inhibition (GABA) When a person develops tolerance, EtOH and adaptation mechanisms tend to balance each other During acute withdrawal, the adaptation mechanism (excitation center Glu) bottoms out In post acute withdrawal (which can last a year or more) the excitation centers remain tipped which can lead to extended symptoms like sleep/mood disturbances EtOH increases dopamine levels in the reward pathway

And then there s methamphetamine Hypersexuality Sex marathons Prolonged arousal and long periods of sexual activity cause degradation of genital mucosa

Ecstasy (MDMA)

Ecstasy/MDMA X Methylenedioxymethamphetamine Early 19 th century Merck (1891) Blocks serotonin reuptake and actually induces neurons to pump serotonin into synapses Also blockades norepinephrine and dopamine Hugginess probably due to release of oxytocin

SUD and OCD Both groups have diminished dopaminergic activity in frontal lobe areas This may explain the obsessiveness of addiction and why addicts often have intrusive and obsessional drug-related thoughts that resist their control 1 1. Nora Volkow, McMillan 2003

Abuse vs. Dependence Continue use despite problems Tolerance Physical withdrawal

Mesolimbic Dopamine System Medial Forebrain Bundle Extended amygdala Central nucleus of amygdala Nucleus of the stria terminalis Transition zone (medial shell) of NAcc

Medial Forebrain Bundle Structures ventral tegmental area (VTA) lateral hypothalamus (LH) nucleus accumbens (NAcc) frontal cortex (FC) prefrontal cortex (pfc) orbitofrontal cortex (ofc)

Addiction Centers

Dependence Neurotransmitters Dopamine (DA) Serotononin (SER) Endorphins (END) Gamma-aminobutyric acid (GABA) Glutamate (Glu) - phencyclidine and Ketamine are Glu antagonists @ the NMDA receptor - GABA precursor Acetylcholine (Ach) Enkephalins (opioid pentapeptides; products of proenkephalin geneend in leucine or methionine) Norepinephrine NMDA (N-Methyl D-Aspartate) Activation of NMDA receptors results in the opening of a cation nonselective ion channel. (Na+ and small amounts of Ca2+ ions in and K+ out of the cell). Mimics Glu Cannabinoids Neuropeptide Y (most abundant, specific here to anxiety response, leptin blocks)

Meds. & how they work Acamprosate (Campral) modulates Glu and helps restore GABA/Glu stasis, therefore minimizing LT adverse effects and making abstinence more comfortable Naltrexone (ReVia, Vivitrol) blocks opioid receptors and diminishes some of the + effects of EtOH (May be most effective for heavy drinkers with + family Hx of addiction and pts. compliant w/ Tx) Must be opioid free at initiation and carry ID card Disulfuram (Antabuse) EtOH metabolism antagonist, producing averse effects (severe headache, severe vomiting, diaphoresis, chest pain/palpitations) (May be most effective for pts. with episodic vulnerability to relapse (holidays, etc.) n.b. Any EtOH can trigger reaction (even topicals) Buprenorphine and buprenorphine+naloxone (Suboxone) Used for opioid maintenance Less abuse potential than methadone. Can get 30 day supply so not tied to dispensing center Methadone still Tx of choice for pregnant females

Investigational Tx s Modafinil (Provigil) for stimulant dependence Baclofen (Lioresal) for cocaine dependence Topiramate (Topamax) for EtOH and cocaine dependence Cocaine vaccine failed

Nicotine Dependence Replacement therapies Bupropion (Zyban) Verenicline (Chantix)

Co-occurring Disorders Individuals are said to have COD if they have a Psychiatric Disorder as well as a Substance Use Disorder (SUD) It can be difficult to establish which came first. Why?

Where do You Start? Both disorders must be treated, however it may be more efficacious to treat one before the other Providers must be aware of the complexities of treating co-occurring disorders and MUST rely on their MH or Addictions Tx counterparts to effectively treat (Like MH providers, Addictions Tx providers must carry certification (state at minimum) Acknowledgement of patient s rights and belief in his/her ability to change Cultural competency a must-examples?

No Wrong Door No Wrong Door philosophy is vital. What does this mean, not just for our patients but for us as providers? (Willingness to work with COD, awareness of resources, awareness of scope of practice ASAM requires majority of SUD Tx providers be crosstrained)

Commonly Seen Psychiatric Disorders in PLWHIV (Persons Living with HIV/AIDS) Mood Disorders Depression is most common (clinical or situational?) Adjustment Disorders Anxiety Disorders SUD

Suicidality Assessment Suicide plans, means and intent Delusions and command hallucinations Impulsivity or impaired judgment of cognition History of suicidal or homicidal behavior

Developing Tx Plans for Patients with Significant COD Concentrate on setting limits why? Consider the use of behavioral contracts Make all staff aware of the contract why? Use a healthcare network/team to provide care Focus on long term goals, not immediate rewards Educate staff! Sellers, M. 2010

Consider Possibility of PTSD (Not just HIV but also SUD) Alterations in affect regulation (blocking) Alterations in consciousness (numbing) Alterations in self-perception (dirty) Alterations in relations with others (isolation) Alterations in systems of meaning (church) Proposed in DSM V Alterations in perception of perpetrator

Stages of Change 1. Precontemplation (no awareness of a problem) 2. Contemplation: Awareness of a problem, may seek information but no readiness to commit to change (ambivalent) 3. Preparation: Decided and committed to change but not yet working on the problem 4. Action: Actively initiating changes in themselves and/or environment 5. Maintenance: Changes made but difficulty in maintaining them may occur Source: Prochaska & DiClemente 1982, 1983

Motivational Interviewing A directive, patient-centered milieu for eliciting behavior change by helping patients explore and resolve ambivalence Begins with the supposition that patients come to the process with a basic capacity for actualization of a positive self and are responsible for creating change Provider s role: create conditions shown to enhance likelihood that a patient will engage in efforts to change behavior Source: Rollnick & Miller, 1995

The 4 Parts of Motivational Interviewing 1. Express empathy - reflective listening clarifies and enhances the patient s thinking, helps build a working alliance and supports patient s exploration of his/her ambivalence about change (1) Empathetic provider style has been shown to be a predictor of decreased patient resistance (2) Source: 1. Miller and Rollnick, 1991; 2. Miller et al, 1993

What Empathy Is According to Miller and Rollnick, 1991, empathy is a specifiable and learnable skill for understanding another s meaning through the use of reflective listening, i.e. letting them know you re on the same page by reflecting back what they ve said Communicates respect for and acceptance of patients and their feelings Encourages a nonjudgmental, collaborative relationship Allows you to be supportive Listens rather than tells Sincerely complements rather than put down Gently persuades, keeping the understanding that the decisions about change are the patient s Is NOT identifying with the patient Accepts that ambivalence is normal Example: I don t know why my wife is making such a big deal about this. I don t have a drinking problem -Your wife has some issues with how much you drink

What Empathy is Not Ordering, directing or even giving advice (if I were you, I would think about or maybe you should think about) Trying to persuade with logic, arguing or lecturing Warning or threatening Moralizing, preaching or telling patients their duty Judging, criticizing or blaming Agreeing, approving or praising inappropriately-these can shut down further communication Shaming, labeling Interpreting, analyzing, supplying answers Reassuring, sympathizing or consoling Questioning or probing Withdrawing, or using humor to distract

The 4 Parts of Motivational Interviewing (con t) 2. Develop discrepancy (1) Develop awareness of discrepancy between where patient is and where he/she wants to be (2) Source: Miller and Rollnick, 1991

The 4 Parts of Motivational Interviewing (con t) 3. Roll with resistance (1) Just as empathetic style as been shown to reduce resistance, confrontational style has been shown to not only increase likelihood of resistance but also to be predictive of increased drinking at the end of a 12 month follow up (2) Source: 1. Miller and Rollnick, 1991; 2. Miller et al, 1993

The 4 Parts of Motivational Interviewing (con t) 4. Support self-efficacy (1) Remember that the patient is responsible for choosing and implementing change Develop awareness of supports Talking about how they would go about changing and what it might look like makes patients more likely to view those changes as realistic options (2) Source: 1. Miller and Rollnick, 1991; 2. Miller et al, 1993

Creative Sociopathy We re often forced to sell SA or MH on accepting a given patient, as they often refuse to see him/her b/c of poor assessment of the primary problem Vital to develop No wrong door LRADAC s Solution

ASAM Criteria (PPC-2R) 6 Assessment Dimensions + Levels of Care address degree of direct medical management, degree of structure, safety and security and degree of treatment intensity involved and act as a continuum, making it possible to track progress, setbacks and appropriateness of care across the broad timeline of Tx, recovery and relapse Intensity Rating Scale At least 7 studies (NIH-NIDA + SAMHSA-CSAT) indicating that adherence to ASAM criteria is associated with enhanced Tx retention Source: American Society of Addiction Medicine 2001

Essential Elements of Programs Meeting ASAM Criteria MD and PhD level staff skilled in Dx and referral A majority of staff are cross-trained to deal with SA and MH disorders Psychoeducational components of Tx address both SA and MH disorders A psychiatrist is available on site in acute settings and through coordination in all other settings Medication management is integrated into the Tx plan Counselors and nursing staff are trained to monitor and promote compliance with pharmacotherapies In programs that work with severely mentally ill persons, intensive CM and assertive community Tx services are available

Levels of Care Add -D (Variable Intensity Detox) to Levels I-IV if needed) Level 0.5: Early Intervention OMT: Opioid Maintenance Therapy Level I: Outpatient Tx Level II (II.1-II.5): Intensive Outpatient/Partial Hospitalization Level III (III.1-III.7): Residential/Inpatient Tx Level IV: Medically Managed Intensive Inpatient Tx Source: American Society of Addiction Medicine 2001

The Six Dimensions 1.) Intoxication/Withdrawal Historical: Detox and discharge Current: Link Detox to other addiction and biopsychosocial services. Detox is NOT Tx. Source: David Mee-Lee, MD 2001 and American Society of Addiction Medicine 2001

The Six Dimensions Con t. 2.) Biomedical Conditions/Complications Historical: Tx for complications of addiction only Current: Biomedical care integrated into Tx plan; increase knowledge and understanding of primary care and interventions Source: David Mee-Lee, MD 2001 and American Society of Addiction Medicine 2001

The Six Dimensions Con t. 3.) Emotional/Behavioral/Cognitive Historical: Tx complications and/or underlying y conflicts only Current: Treat any co-occurring problems and integrate with mental health needs Source: David Mee-Lee, MD 2001 and American Society of Addiction Medicine 2001

The Six Dimensions Con t. 4.) Readiness to Change Historical: If not ready for recovery, send away, ignore or nag Current: Motivational strategies and engagement; stages of change Source: David Mee-Lee, MD 2001 and American Society of Addiction Medicine 2001

The Six Dimensions Con t. 5.) Relapse/Continued Use Potential Historical: Ignore or reject from Tx Relapse is learning opportunity in a chronic illness of which relapse is a normal part; prevent drop-out and keep patient in care Source: David Mee-Lee, MD 2001 and American Society of Addiction Medicine 2001

The Six Dimensions Con t. 6.) Recovery Environment Historical: Little or no family or significant other integrated care; programmatic involvement only Current: In-depth assessment, wraps, individualized family care management or IFS Source: David Mee-Lee, MD 2001 and American Society of Addiction Medicine 2001

Considerations When Referring HIV+ Patients into Tx Programs Access to medical care & follow up How will their medications be supplied? If referring PLWHIV out of state, what is that state s ADAP status? Do they have a wait list? Possibility of continuing to receive ART from SC ADAP Possible loss of Medicaid

Predictors of Response to Psychotherapy Socioeconomic Status: + correlation between higher social class and retention in therapy + Correlation between years of education and length of stay in Tx Race: In a study of 17 community mental health centers ethnic minority clients attended significantly fewer sessions than Caucasian clients;(1); Other studies show no correlation (2) Gender: Although women seek Tx more often, there is no significant difference in dropout rates Source: 1.) Greenspan & Kulish, 1985; 2.) Sledge 1990

Predictors of Response to Psychotherapy (con t.) Age: Some studies suggest a relationship between age and retention (1); most suggest no correlation (2) Marital Status: For general psychotherapy, no significant correlation, however for substance abuse therapy + correlation between being married and retention patients who rate their marriages unsatisfactory before Tx fare much worse during and following Tx than those who rated their relationships better (3) Intelligence: Lit. reviews indicate + relationship between higher intelligence and enhanced outcomes. Source: 1.) Greenspan & Kulish (1985); 2.) Sledge et al (1990); 3.) Milton & Hafner (1979); 4.) Luborsky, Singer & Luborsky (1975)

Compliance: It s not Just an AOD Problem 60% of those in AOD Tx drop out in the first month <60% of adult Dx d hypertensives are Tx adherent <50% of patients with DM are Tx adherent <30% of both groups modify their diet/lifestyles as recommended 50% of all amputations and adult onset blindness in US are result of failure to adhere to DM Tx Source: Minkoff, 2003

Relapse Relapse IS NOT treatment failure-it is a learning opportunity Relapse is not an isolated event; it is a process, often taking several weeks, that ultimately leads to the addict returning to AOD use Seemingly unrelated situations, such as being dishonest about issues not related to AOD use, legal violations and worrying about others are often precursors to relapse 1 st 90 days-85% relapse rate; 6 months-1 year - 60% relapse rate; 1-3 years 33% relapse rate; 5 years and after 15%

Gorski s Developmental Model of Recovery 1.) Transition: Recognizes problems but tries to surmount them by controlling substance use 2.) Stabilization: Individual decides to refrain from substance use completely and improves over an extended period of time (6-18 mos.) 3.) Early recovery: Individual becomes comfortable with abstinence Source: Gorski, 1989

Gorski s Developmental Model of Recovery 4.) Middle Recovery: Individual repairs past damages caused to others by AOD use and develops balanced lifestyle 5.) Late Recovery: Individual overcomes barriers to healthy life that stem from childhood experiences 6.) Maintenance: Individual recognizes need for continued growth and balanced life Source: Gorski, 1989

Marlatt s Recovery Model Individual should be able to identify and even anticipate high risk situations Individual must possess the skills needed to effectively cope with those situations Individual should have expectation that using these skills will result in a positive outcome Source: Marlatt, 1993

Marlatt s Recovery Model Relapse Management 1 (End relapse quickly and minimize damage it causes) Consider relapse an unfortunate but isolated incident, not that individual is incapable of recovery Source: 1. Curry & McBride, 1994

Additional Resources www.lradac.org www.daodas.state.sc.us www.nida.nih.gov http://sbirt.samhsa.gov/

OK, So what do they want from us? We as providers can play a role in our patient s recovery, helping them in their process of developing a positive identity as a recovering substance abuser.