Addiction Issues In Critical Care B

1. “Treating Alcohol and Drug Withdrawal

2. “Tips for Taking a Good Alcohol and Drug History”

3. “Office-Based Management: Screening and Brief Intervention”

Sauk Prairie Memorial HospitalSauk Prairie, Wisconsin

September 26, 2006

Michael M. Miller, MD, FASAM, [email protected]

Medical Director, MERITER / NewStartMadison, Wisconsin

Associate Clinical Professor, UW Medical School

President-ElectAmerican Society of Addiction Medicine

Member: AMA, APA, AAAP, ASAM, AMERSANAMI, NCADD, NAATP

mailto:[email protected]

Addiction Medicine

The specialty of medicine devoted to diagnosis, treatment, prevention, education,

epidemiology, research, and public policy advocacy regarding addiction and other substance-

related health conditions

Addiction Medicine

• It’s not just for addiction specialists• There can never be enough addition

specialists to address such prevalent/common conditions

• Every physician encounters patients or family members affected by substance-related conditions

• Every primary care physician needs to know some basics about recognition and referral

Other Resources

http://www.dhfs.state.wi.us/SubstAbuse/INDEX.HTM

The truth is that over 70% of the addiction care provided in the USA is via public funding; knowing public agencies is important in getting your patients’ needs met—the State Bureau of Mental Health and Substance Abuse Services in DHFS; the County Department of Human Services (Dan Brattset, 608-355-4202)

NEW: SBIRT Grant Awarded to Wisconsin DHFS!

http://www.dhfs.state.wi.us/SubstAbuse/INDEX.HTM

Addiction is only one of the Substance-Related Disorders

• Addiction (Substance Dependence)• Problem Use (Substance Abuse)• Intoxication States• Withdrawal States• Substance-Induced Medical Problems• Substance-Induced Psychiatric Problems• Health Problems linked to Secondary Use• Codependency and ACOA Syndromes

Management of Substance-Related Disorders Depends on the

Diagnosis

• Intoxication Management• Withdrawal Management• Management of Psychiatric Complications• Management of Medical Complications• Management of the Primary Disease of

Addiction (‘Substance Dependence’)• Management of the ‘minor syndrome’

called ‘Substance Abuse’

“Detox”

• Intoxication Management

• Withdrawal Management

DETOXIFICATION

• RESOLUTION OF A ‘TOXIC STATE’

• The Brain has been poisoned

• Manifestations are changes in behavior and changes in physiology

Management of Withdrawal

• Nicotine

• Alcohol

• Sedatives

• Opioids

• Stimulants

• Hallucinogens

Basic Principles of Detox• Provide calm environment for the patient, to

reduce anxiety that would amplify symptoms (regardless of the drug class)

• Replace the missing substance with a pharmaceutical that is cross-tolerant with the drug the patient is withdrawing from

• Stabilize the patient• Institute a step-wise graded reduction in the

replacement substance• OR—trick the brain into thinking it’s receiving

more of the ‘missing’ substance

Nicotine DetoxNicotine Replacement Therapy--NRT

• Transdermal

• Oral (buccal)

• Nasal

• Inhaled

Alcohol Detox(Sedative Replacement)

• Benzodiazepines

• Other sedatives will work but have disadvantages—barbiturates, ethanol, paraldehyde

• [ Other sedating drugs that aren’t cross-tolerant with EtOH won’t work, e.g. phenothiazines ]

• Second generation anticonvulsants

Opioid Detox (Opioid Replacement)

• Methadone

• Buprenorphine• Any opioid will work – but all others are

illegal! [except tramadol (Ultram)

• Clonidine (also: guanfacine, lofexidine)

• Supplemental agents for symptom relief for anxiety, insomnia, aches, nausea,

diarrhea, cramping, dehydration

Stimulant Detox(Stimulant Replacement?)

• Replacement, stabilization, and graded step-wise reduction is not recommended for cocaine, amphetamine, psychostimulant (Ritalin, Adderal, Cylert), or ‘designer drug (MDMA, ‘Ecstasy’) users

• Replacement, etc., is useful for persons with caffeine addiction (switch to oral tablets, decrease by 10% per day)

Hallucinogen Detox(Social Detox)

• Replacement strategies do not apply• The problem isn’t ‘withdrawal’, it’s

intoxication, with subsequent anxiety/panic in the wake of unanticipated dissociative symptoms

• ‘Talk Down’ the person on a ‘bad trip’ with psilocybin, LSD, hashish (esp. oral THC)

• ‘Talking Down’ often insufficient for ‘trips’ on PCP or Jimson weed (Datura stramonium)

DETOXIFICATION

• RESOLUTION OF A ‘TOXIC STATE’

• INTOXICATION MANAGEMENT

• WITHDRAWAL MANAGEMENT

Therapeutics:

Management of Intoxication

Intoxication States: Emerging Trends

• Great resource is www.nida.nih.gov, ‘search’ for ‘Club Drugs’

• Ecstacy use: BP, HR, hyperthermia, dehydration, acute renal failure, rhabdomyolysis, hyponatremia, water intoxication, hepatotoxicity, arrhythmia

• GBH use: rapid shifts of level of arousal; ataxia; disinhibition; not in UDT panels

• Ketamine or DM (‘Robo-tripping’) effects are comparable to PCP

http://www.nida.nih.gov/

Pediatric Addiction Medicine

• Become aware of the epidemic of misuse of dextromethorphan (in Robitussin DM and Coricidin Cough & Cold): ‘DXM’ or ‘DM’

• Effects vary widely and, maybe more so than for some agents, are based on ‘expectation of effect’

• 8-24 oz. of syrup is the intoxicating dose

• Consumers/parents are starting to know (www.coricidin.org)

Intoxication Management• For opioids – naloxone

• For ethanol – naloxone!

• For benzodiazepines – flumazenil

• For amphetamines, hallucinogens, PCP:

consider acidification of the urine

• For cocaine – anti-arrhythmics, anticonvulsants, antipsychotics

• For panic/anxiety – ‘talking down’ or/andbenzo’s

Behavioral Management of Intoxication States

• Assure safety of yourself and ER staff• ‘Don’t block egress for the paranoid

patient’ vs. don’t block egress for yourself!• Minimize stimuli / inputs (extraneous

noises/lights, lower volume/rate of speech)• For delirious/disoriented patients,

repeatedly provide orienting information and reassurance—fear fuels anxiety!

Pediatric Addiction Medicine

• Alcohol—injuries, sexual assault

• Cannabis—anxiety/panic

• Hallucinogens—anxiety/panic

• Caffeine—anxiety/panic

• Diet pills (bulimia et al.)—anxiety/panic

• Cocaine and Ecstacy—anxiety/panic

Therapeutics:

Management of Withdrawal

Keys to Withdrawal Management

• Alcohol / Sedative Withdrawal is potentially life-threatening

• Opioid Withdrawal is uncomfortable, but not dangerous

• Opioid Addicts are exquisitely sensitive to subjective discomforts / don’t tolerate them

• Cocaine Withdrawal is insignificant physiologically but can be significant psychiatrically

• Nicotine Withdrawal is common and treatable

Alcohol Withdrawal: Stages

I. Autonomic Hyperactivity / Irritability

II. Hallucinosis

III. Seizures

IV. Delirium[Delirium from any cause looks similar]

[Don’t ignore AWS in the differential]

[Don’t ignore other causes of delirium even in the face of alcohol withdrawal]

Stages of Alcohol and Sedative Withdrawal

General Signs Hallucination

Delirium

Stage 1 mild no no

Stage 2 moderate yesno

Stage 4 severe maybeyes

Stage One - AWS

• Stage One Begins six to eight hours after the last drink

• Increased Sympathetic Autonomic Nervous System Output– Increase Blood Pressure, pulse rate, low

grade elevated temp <100.5– Diaphoresis, exaggerated startle reflex,

headache, nausea, restlessness, easily distracted

Stage Two - AWS

• Worsening symptoms and signs of Stage I

• Defined by presence of Hallucinosis– Visual > Auditory > Tactile

• Typically starts 24 to 72 hours after last drink

• Occurs in 25% of untreated individuals• Patient still cognitively intact

Stage Three - AWS

• Withdrawal Seizures - 5 to 15% of untreated individuals

• Typically within the first 48 hours after the last drink

• Always Grand Mal - short duration of Tonic/Clonic seizure

• Occur in Salvoes• 3% will enter Status Epilepticus

Stage Four - AWS

• Delirium Tremens (DTs) • Begins 48 hours to 14 days after last drink• Profound clouding of the sensorium - ie

Delirious• Paranoid Delusions• Mortality approximately 5 %• Approximately 5 % of untreated individuals

will enter Stage four

Alcohol/Sedative Withdrawal

Severity ofWithdrawal

clinicalassessment

score

Time in Days

long actingbenzodiazepines

stage 4deliriumtremens

stage 2Stage 3

stage 1

0 1 2 3 4 5 6 7 8 9 10

30

20

10

Prognosticators of Severe Withdrawal

• BAC greater than 300mg/dl• Age greater than 35 years• Previous AWS seizure• Concomitant medical or surgical problem• Abnormal liver functions• Other drug use - especially

sedatives/hypnotics

Kindling Phenomenon

• Each subsequent withdrawal episode is worse

• medical management of AWS may prevent the Kindling phenomenon

• Evidence better with anticonvulsants such as valproic acid & carbamazepine than benzodiazepines & barbiturates in blocking progression of the Kindling phenomenon.

Alcohol Withdrawal Management

1. Replace Sedative2. Prevent Advancing to Higher Stages

I II III IV3. Treat hallucinosis4. Consider other causes of seizures,

especially if > 48 hours after falling BAC5. Manage the delirium & co-morbid

medical conditions

Sedative Replacement

• Symptom-triggered

• Standard Assessment

• Standing Order Sets / Protocols

• Benzos (long-acting oral agents if uncomp.)

• DPH loading is passe

• Carbamazepine is effective

• Remember: propofol is a true sed/hypnotic

Standardized Assessment

• CIWA-A(r)• Clinical Institute Withdrawal Assessment• Addiction Research Institute (ARI), Toronto• http://www.agingincanada.ca/CIWA.HTM

C.I.W.A. (SEE-wah)

Global Assessment of Withdrawal

• Nausea/Vomiting• Tremor• Paroxysmal Sweats• Anxiety• Agitation• Tactile Disturbances• Auditory Disturbances• Visual Disturbances

• Headache• Orientation/Clouding

of the Sensorium• All 0 to 7 except

orientation which is 0-4

Treatment

• Benzodiazepine substitution– Long acting superior - diazepam and

chlordiazepoxide• Half life of Valium 20 to 50 hours• Metabolized by hepatic oxidation and

glucuronidation

– Lorazepam not as efficacious - more likely to have breakthrough symptoms.

• Safer profile in patients with hepatic insufficiency• Half life 10-20 hours

Treatment

• Valium 5mg = Ativan 1mg• Valium 5 mg = ‘one standard drink’• Lorazepam can be used PO/IM/IV• Diazepam can be used PO/IV• Phenobarbital may be slightly better with

concomitant Benzodiazepine misuse – Phenobarbital 30mg = Valium 10mg

Diazepam Dosing Symptom Triggered

• 10mg diazepam if CIWA scores 6-11, or diastolic blood pressure >90, or pulse >100

• 20mg diazepam if CIWA scores 12-17, or diastolic blood pressure >100, or pulse >110

• 30mg diazepam if Global scores 18-23, or diastolic blood pressure >110, or pulse >120

• May try 2-4 mg IM lorazepam if CIWA scores higher or if vitals higher than above parameters

Adjunctive Medications

• Haloperidol - use for hallucinosis or delirium. NOTE: This is adjunctive treatment--the patient should still be receiving benzodiazepines

• Beta Blockers and centrally-acting alpha agonists– PRN protracted tremors or elevated pulse– Can ‘mask’ other symptoms of withdrawal– Don’t ‘protect against’ advancing of stages

‘Prophylactic Replacement’

• Replace sedative, assuming that 1 drink =• 5 mg p.o. diazepam• 1 mg p.o. lorazepam

Also—carbamazepine may empirically lower the seizure risk, but it still takes 5 half-lives to reach steady-state (beyond period of maximum risk for withdrawal seizures)

Alcohol Withdrawal Delirium

• Replace Sedative

• Frequent dosing with p.o. if possible

• Intravenous boluses of diazepam vs. continuous infusions of lorazepam/midazolam

• I.M. is not safe/effective, except somewhat for lorazepam I.M.

• Calming via benzo’s; antipsychotics are only for hallucinosis / incoherence / disorientation

ASAM Practice Guidelines

JAMA, 278(2):144-51 July 9, 1997

Michael F. Mayo-Smith, MD MPH, et. al.

Archives of Internal Medicine, 164:1405-12 July 12, 2004

Michael F. Mayo-Smith, MD MPH, et. al.

Patient Safety

• Early recognition of A.W.S.

• Standardized Assessment of A.W.S.

• Protocols / Practice Guidelines for management of sedative replacement and other assessment/treatment in A.W.S.

• Wisconsin Hospital Association et al.

BREAK

Sedatives

• Barbiturates• Benzodiazepines• Sedative-Hypnotics (choral hydrate,

meprobamate—carisoprodol/Soma)• GHB (GBL, 1,4 BD)• Propofol

– And don’t forget Cl- channel agents: Ambien (zolpidem) and Sonata (zaleplon)

Sedative Intoxication

• Ataxia, dysarthria, nystagmus, and somnolence

• Avoid reversal agent – flumazenil– Only use in overdose if a sole benzodiazepine

has been ingested in a non chronic user

• Main treatment is supportive – Charcoal may be helpful– Orogastric intubation and gastric evacuation

maybe useful since GI motility may be slowed

Sedative WithdrawalSymptoms & Signs

• Anxiety• Nausea• Tremor• Hypertension• Tachycardia• Hypersensitivity to

stimuli• Hyperreflexia• Diaphoresis

• Hallucinosis• Depersonalization• Psychosis• Delirium• Seizures• Looks like hypomania

Sedative Withdrawal

• Similar to alcohol withdrawal--though usually not as dramatic or obvious and more variability; often VS are normal

• Dependent on Duration of sedative useDaily amount of sedative useHalf-life of sedative used

Benzodiazepine Duration of Action

• Short-Acting (half life < 3 hours)– Triazolam

• Intermediate-Acting (half life 12-20 hours)– Oxazepam Temazepam Lorazepam– Alprazolam Estazolam

• Long-Acting (half life > 100 hours)– Diazepam Chlordiazepoxide Chlorazepate– Clonazepam Flurazepam

Sedative Withdrawal

• Declining serum levels correlate with emergence of withdrawal symptoms– Shorter acting Bzdz withdrawal begins within

24 hours of cessation & peaks within 1 to 5 days

– Longer acting Bzdz withdrawal begins within 5 days of cessation & peaks within 1 to 9 days

• Duration of withdrawal – 7 to 21 days for shorter acting Bzdz– 10 to 28 days for longer acting Bzdz

Alcohol/Sedative Withdrawal

Severity ofWithdrawal

clinicalassessment

score

Time in Days

long actingbenzodiazepines

stage 4deliriumtremens

stage 2Stage 3

stage 1

0 1 2 3 4 5 6 7 8 9 10

30

20

10

Tapering• Usually SUBSTITUTE with a long-acting

sedative and taper that, not the original agent

• Give the patient a calendar with a tapering schedule

• Write prescriptions that will be filled every day or every other day

• Write the date that the Rx is to be filled

• Use one pharmacy only – discuss plan with the pharmacist

Substitution Agents

• Usually phenobarbital or clonazepam

• Use clonazepam for alprazolam

• Phenobarbital best to use when– High dose of sedatives– Unknown or erratic use

• Phenobarbital intoxication not well liked

• Once steady state achieved, negligible inter-dose serum level variation

Tapering with or without Substitution

• Phenobarbital – on initial dose for two days – If no signs of withdrawal or intoxication begin taper on

day 3• Taper over about a 20 day period• Reduce dose by 30-60mg per day• Final 25% make smaller daily dose reductions

• Benzodiazepine tapering– Provide daily amount in divided doses– About 25% reduction per week of starting dose or

about 1mg clonazepam per week – which ever is less– Final 25% of reduction can/should be slower: 10%

every week

Substitution Dose Conversions

• Phenobarbital 30mg• Diazepam 10mg• Chlordiazepoxide

25mg• Clonazepam 2mg• Flurazepam 15mg• Lorazepam 2mg• Oxazepam 10mg• Temazepam 15mg

• Triazolam 0.25mg• Butalbital 100mg• Meprobamate 400mg• Carisoprodol 700mg• Chloral Hydrate

500mg

Prescriptions

• Write amount to be dispensed out in English and draw a box around this

• Write zero refills• Date prescription today’s date 10/21/04 but then

write fill only on 10/23/04• Number prescriptions in chronological order• Make photostat copies of your prescriptions• If patients make accusations regarding the

pharmacist refer them to the state pharmacy board

Adjunctive Withdrawal Management

• Carbamazepine– 100mg every 6 hours

• 100mg every 8 hours if weight less than 100pounds• 200mg every 8 hours if weight more than 220pounds

– Baseline CBC and hepatic panel

• Divalproex– 250mg every 6 hours

• 250mg every 8 hours if weight less than 100pounds• 500mg every 8 hours if weight more than 220pounds

• On fourth day check pre-dose serum level

Adjunctive Withdrawal Management

• Once therapeutic on anti-convulsant begin taper of sedative dose– 75% pretreatment dose on day one– 50% pretreatment dose on day two– 25% pretreatment dose on day three– On day four give no further sedatives

• Continue anticonvulsant between 30 to 60 days then taper over 4 to 8 days– Recheck hepatic panel and CBC at 1 to 3 week

intervals for Carbamazepine

Sedative Tolerance Test

• Pentobarbital 200mg initially then 100mg every one hour – Assess for signs of intoxication– Convert to phenobarbital at a conversion of

pentobarbital 100mg = Phenobarbital 30mg

• Pentobarbital hard to find

• Need to design a different sedative taper test

Stimulants

• Cocaine• Amphetamines

– Methamphetamine– Dextroamphetamine– Amphetamine sulfate

• Methylated amphetamines (‘designer drugs’) MDMA—Ecstasy MDA, DOM, STP

• Psychostimulants--Methylphenidate (Ritalin)-- Pemoline (Cylert)

• Ephedrine/Pseudo-ephedrine

• Phenylpropanolamine

• Amphetamine Congeners– Benzphetamine– Diethylpropion– Fenfluramine– Phentermine– Phenmetrazine– Phendimetrazine – Mazindol

Absorption & Metabolism

• Cocaine – half-life 40 to 60 minutes– Cocaethylene – intermediate active metabolite

when ethanol used concurrently

• Amphetamine – half-life 6 to 12 hours

• Methylphenidate – half-life 2 hours

Intoxication

• Psychosis – mainly amphetamines– Paranoid ideation with well formed delusional

structure– Hallucinosis– Stereotyped behavior– Can persist for days

• Hyperpyrexia• Seizure Activity• Vasoconstriction

Stimulant Intoxication Management

• Hypertension/Tachycardia– Phentolamine if hypertensive urgency/emergency

• 5-10mg every 10minutes

– Avoid Beta Blockers since may lead to unopposed alpha adrenergic activity

– Avoid Calcium Channel Blockers

• Anxiety/Agitation– Lorazepam

• Psychosis – Haloperidol

Stimulant Intoxication Management

• Seizures– Diazepam– Phenytoin

• Hyperthermia– Cooling techniques

• Elimination– Acidification with ammonium chloride may

help in select cases of acute amphetamine overdose

Cocaine Withdrawal

• Phase one – Crash– Initial - Intense dysphoria & craving– Middle – Desire to sleep, dysphoria, may start

to use other substances or pursue supplies– Late – Hypersomnia and increased appetite –

lasts 3 to 4 days

• Phase two – Withdrawal– Honeymoon – 12 hours to 4 days – reduced

craving, improved mood and sleep pattern

Stimulant Withdrawal

• Phase two – Withdrawal– Dysphoria – depression, lethargy, anhedonia,

reemergence of craving – lasts 6 to 18 weeks

• Phase three – Extinction– Gradual improvement of mood, ability to

experience pleasure, & interest in environment – lasts months

Management of Cocaine Withdrawal

• Phase I: bromocryptine ????

• Phase III: desipramine ????

Opioid Withdrawal

• Anxiety

• Irritability

• Restlessness

• Insomnia

• Nausea

• Abdominal cramps

• Arthralgias

• Myalgias

• Rhinorrhea

Evaluation: Opioid WithdrawalGrade 1

Yawning

Sweating

Lacrimation

Rhinorrhea

Grade 2

Mydriasis

Piloerection

Muscle Twitching

Anorexia

Grade 3

Insomnia

Increased Pulse

Increased Resp Rate

Elevated BP

Abdominal Cramps

Vomiting

Diarrhea

Weakness

* Source: Adapted from TIP #24. A Guide to Substance Abuse Services for Primary Care Clinicians. DHHS (SMA) 97-3139, 1997

Opioid Withdrawal Management

• With clonidine—requires supplemental agents (lorazepam, ibuprofen, Bentyl, antiemetics, antidiarrheals)

• With Ultram (not ‘Scheduled!’)

• With methadone (MUST be in an OTP)

• With buprenorphine (MUST be an ‘approved physician’, but 8 hour courses are available!)

Opioid Discontinuation

• When ‘detox’ isn’t ‘detox’• Opioids prescribed for pain, can be discontinued• Call it ‘therapeutic taper’ or discontinuation• ‘Detox’ has a legal meaning (methadone /

Suboxone regs)• Any doc can taper his/her or another doc’s

treatment regimen, but you can’t ‘taper’ a self-designed ‘plan’ (person using ‘street’ or ‘Internet’ supplies, not ‘authorized medical use’)

Pain and Addiction

• See www.dea.gov for the latest• Attend ASAM “Common Threads, Pain

and Addiction, VII”, in Chicago, October 29• See www.asam.org: Public Policy, TOC,

Medical Aspects of Substance Use and Addiction

• Also: http://www.asam.org/pain/pain_and_addiction_medicine.htm

http://www.dea.gov/

http://www.asam.org/

BREAK

“Treatment”

• Brief Interventions

• Individual/Family Counseling

• Medication Management

• Relapse Prevention

• Case Management

• Intensive Services (“Rehab”)—– Intensive Outpatient/IOP/Day Treatment– Intensive Inpatient: Residential/Hospital

“Assessment”

• Screening/Case Finding

• Interview

• Collateral Interview

• Physical Exam and Labs

• Structured Instruments– For withdrawal: CIWA, COWS– For addiction: CAGE, MAST, AUDIT

What Are We Assessing/Treating?

• A substance USE disorder– Could be alcohol dependence– Could be alcohol abuse– Could be opioid, stimulant, sedative, cannabis

dependence– Could be opioid, stimulant, sedative, cannabis

abuse– Could be nicotine dependence

Range of ‘Use’ Conditions

• Use

• Misuse

• Risky Use

• Problem Use

• Addiction

• Disability

• Death

Relationship Between Alcohol Use and Alcohol Problems

None

LightModerate

Heavy

None

SmallModerate

Severe

Alcohol Problems

Alcohol Use

Low Risk At Risk Problem Dependent

The Spectrum of Alcohol UseThe Spectrum of Alcohol Use

heav

y severe

cons

umpt

ion

none

none

consequences

Risky

Lower risk

Alcohol Use Disorders

Alcohol Use Disorders

Abstinence

Harmful, abuse

Problem

AlcoholismDependence Unhealthy Use

“Broadening the Base of Treatment”IOM Report--1990

“Broadening the Base of Treatment”IOM Report--1990

Leve

ls o

f USE

none

none

TRE

ATM

EN

T INTE

NS

ITY

Risky Use

Use

Abstinence / Non-Use

305.0

Problem Use

303.9

What is Addiction?

Substance use Use behaviors and procurement behaviors persist despite

problems due to use Return to use after periods of abstinence, despite previous

problems Inability to consistently control use Preoccupation with use/procurement; salience of use-related

behaviors Cognitive changes (over-valuation, de-valuation,

minimization/denial) Enhanced cue responsiveness via conditioning and

generalization

Targeted Therapeutic Changes in Addiction Treatment

• BEHAVIORAL CHANGES

• Eliminate alcohol and other drug use behaviors

• Eliminate other problematic behaviors

• Expand repertoire of healthy behaviors

• Develop alternative behaviors

• BIOLOGICAL CHANGES

• Resolve acute alcohol and other drug withdrawal symptoms

• Physically stabilize the organism

• Develop sense of personal responsibility for wellness

• Initiate health promotion activities (e.g., diet, exercise, safe sex, sober sex


• COGNITIVE CHANGES• Increase awareness of

illness• Increase awareness of

negative consequences of use

• Increase awareness of addictive disease in self

• Decrease denial

• AFFECTIVE CHANGES• Increase emotional

awareness of negative consequences of use

• Increase ability to tolerate feelings without defenses

• Manage anxiety and depression

• Manage shame and guilt


• SOCIAL CHANGES• Increase personal

responsibility in all areas of life• Increase reliability and

trustworthiness• Become resocialized:

reestablished sober social network

• Increase social coping skills: with spouse/partner, with colleagues, with neighbors, with strangers

• SPIRITUAL CHANGES• Increase self-love/esteem;

decrease self-loathing• Reestablish personal values• Enhance connectedness• Increase appreciation of

transcendence

What are the options for Addiction Rehab?

• General Outpatient (ASAM Level I)

• Intensive Outpatient (ASAM Level II)

• Day Treatment (ASAM Level II)

• Residential—Medically Monitored Inpatient (Level III)

• Hospital—Medically Managed Inpatient (Level IV)

Addiction is a Chronic Disease

Often Pediatric Onset

Usually Progressive, Sometimes Fatal

Chronic Course:

Relapsing & Remitting

Addiction Must Be MANAGED

• Total lifetime abstinence after an index intervention sometimes occurs

• The rule is that subsequent substance use will occur -- but is that ‘bad’ ?

• Follow - up is the key to success, as for any chronic disease

• Remember: ‘detox’ is NOT treatment of addiction (it’s treatment of intoxication or withdrawal, but not chronic disease mgmt.)

Goals of Chronic Disease Management

• Minimize the frequency and severity of relapses

• Maximize the duration of periods of remission and the quality of life during periods of remission

• Reduce symptoms

• Improve level of functioning

Addiction is Treatable

• But not via detox alone

• But not via acute interventions alone

• But not via treating psychiatric co-morbidities alone

• Compliance = for other chronic illnesses

• Outcomes = for other chronic illnesses

Relapse Rates & Tx Compliance for Medical

Conditions

40

5055

30

70

30

Diabetes Hypertension Asthma

% Relapsed (Mdn) in 1 Yr% Complied w Trt Plan

O’Brien & McLellan, 1996 (The Lancet)

Therapeutic Pessimism

• It’s endemic

• It’s a creation of our own mental models

• What’s the definition of success?

• Is success measured during the application of treatment or is it measured after the withdrawal of treatment?

Evaluation of A Hypothetical TreatmentEvaluation of A Hypothetical Treatment

0

1

2

3

4

5

6

7

8

9

10

Pre During During During Post

Sym

pto

m S

ever

ity

Sym

pto

m S

ever

ity HYPERTENSIONHYPERTENSION

0

1

2

3

4

5

6

7

8

9

10

Pre During During During Post

Stage of TreatmentStage of Treatment

Sym

pto

m S

ever

ity

Sym

pto

m S

ever

ity ADDICTIONADDICTION

Just Like Hypertension,Addiction Is A

Chronic Disease ThatRequires Continued Care

Source: McLellan, AT, Addiction 97, 249-252, 2002.

Source: McLellan, AT, Addiction 97, 249-252, 2002.

Principles of Effective Treatment

1. No single treatment is appropriate for all2. Treatment needs to be readily available3. Effective treatment attends to the multiple needs

of the individual4. Treatment plans must be assessed and

modified continually to meet changing needs


5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness

6. Counseling and other behavioral therapies are critical components of effective treatment

7. Medications are an important element of treatment for many patients


8. Co-existing disorders should be treated in an integrated way

9. Medical detoxification is only the first stage of treatment

10. Treatment does not need to be voluntary to be effective


11. Possible drug use during treatment must be monitored continuously

12. Treatment programs should assess for HIV/AIDS, Hepatitis B & C, Tuberculosis and other infectious diseases and help clients modify at-risk behaviors

13. Recovery can be a long-term process and frequently requires multiple episodes of treatment

- NIDA (1999) Principles of Drug Addiction Treatment

Evidence-Based Components

• Cognitive Behavioral Interventions– Disease education– Life skills– Conflict resolution– Refusal skills– Managing triggers


• Ecological Approaches– Community Reinforcement Approach

(contingencies; token rewards)– Strength-Based Interventions– Multi-systemic Therapy– Case Management


• Twelve-Step Facilitation

Project MATCH used 3 modalities:

• MET

• CBT

• TSF


• Engagement Strategies– Motivational Interviewing– Contingency Management– Childcare– Transportation– Medical Services


• Engagement Strategies– Vocational Training– Employment Services – Role Induction– Seamless Transfer Between Levels of Care– Rapid Intake and Re-intake

The Therapeutic Relationship• Rogerian Skills• Responsiveness• Hope• Openness • Work Experience• Respect

• Self-disclosure• Warmth• Immediacy• Concreteness• Confrontation• Potency


• All clients would have access to all modalities– Adequate Detoxification– Outpatient

• Standard and menu driven• Pharmacologically assisted or not

– Residential• Long and short

– Recovery Homes


• Pharmacological Therapies– Antabuse– Naltrexone (Revia)– Acamprosate (Campral)– Methadone– Buprenorphine– Naltrexone (Trexan)– N.R.T. / bupropion (Zyban)


• Family Therapy– Before Treatment– During Treatment


• Duration would be emphasized over intensity.


• Brief interventions for substance abusers

Treatment of Addiction in the General Medical Setting

• Know what you are treating: DSM-IV Abuse vs. Dependence

• Know what your goals are.• Know what your methods are.• Recognize that if you treat intoxication or

withdrawal well, you’re providing a great medical service, and probably better than your colleagues would.

• Know the referral sites in your community.

Treatment of Addiction: Goals

• What are the treatment goals for a chronic disease?

• Decrease frequency of relapses

• Decrease severity of relapses

• Increase duration of remission

• Optimize level of function during remissions

Treatment of Addiction: Methods

• Psychosocial Interventions

• Pharmacological Therapies

• Alcohol Dependence

• Opiate Dependence

• Nicotine Dependence

Pharmacotherapy of Addiction• Antabuse—for alcohol dependence (and

cocaine!)• Naltrexone, Acamprosate, et al.—for

alcohol dependence• Naltrexone—for opioid dependence• Opioid Agonist Therapies—MMT• O.B.O.T.—Buprenorphine• Nicotine Replacement Therapy• Bupropion—for nicotine dependence

The Trade Names are Suboxone and Subutex

• Buprenorphine in a sublingual tablet

• Strengths are 2 mg or 8 mg

• Combination product contains naloxone in 4:1 ratio

--Suboxone 2/0.5

--Suboxone 8/2

Office-Based Use of Buprenorphine (Schedule III)

• Any pharmacy can dispense Suboxone (up to a 30-day supply) if the prescribing physician has the correct DEA number

• Any physician can obtain the special DEA registration by taking an 8-hour course approved by C.S.A.T.

• ASAM and others offer the courses• All primary care docs and hospitalists should

consider becoming ‘qualified physicians’ for Suboxone Rx-ing

BREAK

Treatment of Addiction in the Primary Care Setting

• The 5 A’s:AskAdviseAssess (Readiness for Change)AssistArrange

Treating Nicotine Dependence in a General Medical Practice

• There are a lot of ‘zebras’ in medical practice.

• In general medical practice, and in general psychiatric practice, nicotine dependence is no ‘zebra’.

• Nicotine replacement therapies work.

• Counseling (individual and family) works.

• Bupropion works.

How to Ask Questions

• Ask questions in professional, systematic manner, dispassionately (without any particular show of affect), they way you’d objectively collect data about any other aspect of the patient’s health status.

• Show interest, like you’re taking this seriously, to convey to patient the sense of the importance of the topic


• Recognize that the patient has lots of shame and guilt and is hesitant to open up with lots of facts that might, in a different context, be ‘self-incriminating’ or ‘something that he could be hit over the head with’

• Recognize that if there is minimization or denial, the patient is lying to himself and not specifically lying to you.

• Don’t take things personally in the information exchange


Allow patient to ‘save face’ and to hold on to some of his/her projection/denial/other defenses:

“When was the time in you life when you were using the most?”

“Has anyone expressed concern about your use?”


“Has your drinking changed lately?”

[this doesn’t ask ‘how much are you drinking now?’, a discrete quantifier that patient may be defensive about/amend the answer; this gives you a sense of trends and gets to the quantity/frequency issue somewhat indirectly]


Don’t ask directly about use; ask instead about the utility of use:

“How has your sleep been? What do you do to try to help with your sleep?”

[possible answers = OTC Rx, alcohol, marijuana, even opioids]

Advise“It’s very important for your health

that you stop smoking”

“I would like you to stop drinking”

Treatment of Addiction in the Primary Care Setting

• The 5 A’s:AskAdviseAssess (Readiness for Change)AssistArrange

Stages of Change

• Pre-contemplation: not seeing a problem

• Contemplation: seeing a problem and considering whether to act

• Preparation: making concrete plans to act soon

• Action: doing something to change

• Maintenance: working to maintain the change

Assist• Refer to specific resources in your

community Professional counselors Addiction Medicine physiciansSelf-Help (AA, NA)

• Provide assistance within the context of your primary care practice

“AA is NOT TREATMENT”

ASAM, AAAP and APA recommend that: • 1. Patients in need of treatment for alcohol or other drug-related

disorders should be treated by qualified professionals in a manner consonant with professionally accepted practice guidelines and patient placement criteria;

• 2. Self help groups should be recognized as valuable community resources for many patients in addiction treatment and their families. Addiction treatment professionals and programs should develop cooperative relationships with self help groups;

• 3. Insurers, managed care organizations and others should be aware of the difference between self help fellowships and treatment;

• 4. Self help should not be substituted for professional treatment, but should be considered a compliment to treatment directed by professionals. Professional treatment should not be denied to patients or families in need of care.

Motivational Enhancement Therapy (M.E.T.)

• Express Empathy

• Support Self-Efficacy • Roll with Resistance

• Develop Discrepancy

Reference: Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational Enhancement Therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.AA

Express Empathy

Empathy involves seeing the world through the client's eyes, thinking about things as the client thinks about them, feeling things as the client feels them, sharing in the client's experiences. Expression of empathy is critical to the MI approach. When clients feel that they are understood, they are more able to open up to their own experiences and share those experiences with others. Having clients share their experiences with you in depth allows you to assess when and where they need support, and what potential pitfalls may need focused on in the change planning process. Importantly, when clients perceive empathy on a counselor's part, they become more open to gentle challenges by the counselor about lifestyle issues and beliefs about substance use. Clients become more comfortable fully examining their ambivalence about change and less likely to defend ideas like their denial of problems, reducing use vs. abstaining, etc. In short, the counselor's accurate understanding of the client's experience facilitates change.

Support Self-Efficacy

As noted above, a client's belief that change is possible is an important motivator to succeeding in making a change. As clients are held responsible for choosing and carrying out actions to change in the MI approach, counselors focus their efforts on helping the clients stay motivated, and supporting clients' sense of self-efficacy is a great way to do that. One source of hope for clients using the MI approach is that there is no "right way" to change, and if a given plan for change does not work, clients are only limited by their own creativity as to the number of other plans that might be tried.

The client can be helped to develop a belief that he or she can make a change. For example, the clinician might inquire about other healthy changes the client has made in their life, highlighting skills the client already has. Sharing brief clinical examples of other, similar clients' successes at changing the same habit or problem can sometimes be helpful. In a group setting, the power of having other people who have changed a variety of behaviors during their lifetime gives the clinician enormous assistance in showing that people can change,

Roll with Resistance

In MI, the counselor does not fight client resistance, but "rolls with it." Statements demonstrating resistance are not challenged. Instead the counselor uses the client's "momentum" to further explore the client's views. Using this approach, resistance tends to be decreased rather than increased, as clients are not reinforced for becoming argumentative and playing "devil's advocate" to the counselor's suggestions. MI encourages clients to develop their own solutions to the problems that they themselves have defined. Thus, there is no real hierarchy in the client-counselor relationship for the client to fight against. In exploring client concerns, counselors may invite clients to examine new perspectives, but counselors do not impose new ways of thinking on clients.

Develop Discrepancy

"Motivation for change occurs when people perceive a discrepancy between where they are and where they want to be" (Miller, Zweben, DiClemente, & Rychtarik, 1992, p. 8). MI counselors work to develop this situation through helping clients examine the discrepancies between their current behavior and future goals. When clients perceive that their current behaviors are not leading toward some important future goal, they become more motivated to make important life changes. Of course, MI counselors do not develop discrepancy at the expense of the other MI principles, but gently and gradually help clients to see how some of their current ways of being may lead them away from, rather than toward, their eventual goals.

Motivational Interviewing

• Identify what the patient wants

• Identify what you want

• Try to get the patient’s goals and the therapist’s goals to align

Motivational InterviewingDisadvantages of the status quo

• What worries you about your current situation?• What makes you think that you need to do something

about your blood pressure?• What difficulties or hassles have you had in relation to

your drug use?• What is there about your drinking that you or other

people might see as reasons for concern?• In what way does this concern you?• How has this stopped you form doing what you want to

do in life?• What do you think will happen if you don’t change

anything?

Motivational InterviewingAdvantages of change

• How would you like for things to be different?• What would be the good things about losing

weight?• What would you like your life to be like 5 years

from now?• If you could make this change immediately, by

magic, how might things be better for you?• The fact that you’re here indicates that at least

part of you thinks it’s time to do something. What are the main reasons you see for making a change?

• What would be the advantages of making this change?

Motivational InterviewingOptimism about change

• What makes you think that if you did decide to make a change, you could do it?

• What encourages you that you can change if you want to?

• What do you think would work for you, if you decided to change?

• When else in your life have you made a significant change like this? How did you do it?

• How confident are you that you can make this change?• What personal strengths do you have that will help you

succeed?• Who could offer you helpful support in making this

change?

Motivational InterviewingIntention to change

• What are you thinking about your gambling at this point?

• I can see that you’re feeling stuck at the moment. What is going to have to change?

• What do you think you might do?• How important is this to you? How much do you

want to do this?• What would you be willing to try?• Of the options I’ve mentioned, which one sounds

like it fits you best?• Never mind the “how” for right now – what do

you want to have happen?• So what do you intend to do?

Asking Open-Ended Questions

• If you continue to drink like this, what could possibly happen?

• What else concerns you about your drinking/drug use?• What are some other reasons why you would want to

change?• Do you remember a time when things were going well for

you? What has changed?• What were things like before you started using drugs?

What were you like back then?• If you stop using drugs, what do you hope might be

different in the future?• How would you like things to turn out for you 10 years

from now?

Urine Drug Testing

• Rapid Tests (kits, TLC, RIA) detect only selected benzodiazepines, and only OPIATES (they will read ‘negative’ for OPIOIDS)

• Natural Opiates = Opium, Codeine, Morphine, Heroin (6-acetyl-morphine)

• Excluded are Oxycodone, Hydrocodone, Hydromorphone, Meperidine, Methadone

• Screening test results should be confirmed by

Gas Chromatography / Mass Spectroscopy• GC/MS can detect almost anything

Guide to Psychotropic Medications

• http://www.mattc.org/information/psychotherapeutic/index.html

Summary: Key Points

• Addiction is a Health Problem

• Addiction is not a desired state

• Use, Intoxication, Withdrawal, and Addiction can all be clinically relevant

• Addiction is usually managed outside of hospitals, and is ideally managed as a CHRONIC DISEASE

Summary: Key Points

• The high-volume, high-need populations are those with alcohol problems and nicotine dependence

• The tools are available—and you now know them: the 5 A’s, brief intervention, motivational enhancement, effective pharmacotherapy

• It’s do-able, and you can ‘make a go of it’

Summary: Key Points

• Alcohol and Sedative Withdrawal are potentially life-threatening, and can be manageable by a general psychiatrist who becomes knowledgeable in assessment and pharmacotherapy of A.W.S.

• A.W.S. has describable STAGES

• Standard Assessment (CIWA) improves clinical results

Summary: Key Points

• Only YOU can learn who the key contacts are in your community and where to refer for specialty services (addiction treatment facilities).

• Buprenorphine is a marvelous advance, and you can become ‘Qualified Physician’ with relative ease. Even if you don’t choose to ‘induce’ patients in your practice, you can receive stable patients from an addictionist so the pateints appear on your 30-patient census.

• ASAM is a resource for ANY PHYSICIAN

Blueprint of Strategies:What to DO In Your Own Practice

• Make sure you have systems in place for effective NICOTINE REPLACEMENT THERAPY (NRT) for all your patients—hospitalized or in your own office practice

• Remember that YOU providing Brief Intervention for nicotine dependence (Ask, Advise, Assist, Arrange follow-up)

may be the most important thing you do for your patients’ long-term health status


• Develop a RESOURCE LIST for referrals to addiction specialty treatment providers—not only who and where, but who is covered by what payment type?

• PARTNER with your hospital Social Service Department and ER to have constantly-updated lists readily-available so you and other docs know how to advise patients about community-based services


• Implement Standardized Rating Scales for Withdrawal Assessment (CIWA) and in-service NURSES on key units if alcohol detox is done on the general psych unit of

your hospital, make sure CIWA is used if you do consultation-liaison psychiatry already and

work on med/surg units, make sure they use CIWA

• “If you wanted the best outcomes, would you have a good detox doctor and a lousy detox nurse, or a lousy detox doctor and a good detox nurse?”

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Addiction Issues In Critical Care B

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