Addiction Recovery Management

7/31/2019 Addiction Recovery Management

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!!!!!!

Title&Below&please&list&the&title&of&this&resource.& &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

!Addiction!Recovery!Management!

!Author&Below&please&list&the&author(s)&of&this&resource ."

!Kevin!McCauley,!MD!

!

Citation&Below&please&cite&this&resource&in&APA&style.&For&guidance&on&citation&format,&please&visit&

http://owl.english.purdue.edu/owl/resource/560/01/&

!McCauley!MD,!Kevin.!(2011).!Addiction"Recovery"Management![PowerPoint!slides].!Retrieved!from!

www.instituteforaddictionstudy.com!!

!

Summary&Below&please&provide&a&brief&summary&of&this&resource.&If&an&abstract&is&available,&feel&free&to&copy&and&paste&it&here.&

!This!power!point!presentation!highlights!how!the!disease!of!addiction!works!and!the!brain!functions!and!

reactions!that!accompany!the!disease.!The!slides!go!on!to!explore!the!five!theories!of!addiction.!He!then!

reviews!methods!of!treatment!followed!by!an!exploration!of!recovery!capital,!recovery!management,!

recovery!resource!mapping,!and!recoveryoriented!systems!of!care.!


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Kevin T. McCauley, M.D.The Institute for Addiction Study

Salt Lake City, Utahwww.instituteforaddictionstudy.com

(435) 659-6293


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The most evil disease imaginable

Wouldnt look like a disease at all (nearly invisibleepidemiologically)

Genetic, but with variable penetrance (genotype phenotype) Repulsive symptoms easily confused with willful badness Self-deception as a clinical feature Poor prognosis if untreated, but some will get better (inexplicably) Chronic and relapsing (not acute, nor cured) Culturally & politically divisive (would tap into societys deepest

prejudices, stigma, superstitions and attack its core values)

Maximally economically destructive (solutions based on greed &exploitation)

Would cover its tracks (by blaming other diseases) Would only submit to weird solutions: peer support, patient

accountability, personal evaluation, and spiritual growth (not just amedication or surgery)


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The Key Parts of the Limbic Brain


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Orbitofrontal Cortex (OFC) Decision-making guided by

rewards

Integrates sensory andemotional information fromlower limbic structures

Flexible assignment ofvalue to environmental

stimuli to motivate orinhibit choices & actions

Self-monitoring and socialresponding


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Anterior Cingulate Cortex (ACC)

Works with OFC:decision-making basedon reward values

But also generates newactions based on past

rewards/punishments

Appreciation andvaluation of social cues

MRI: active in tasksrequiring empathy andtrust


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Prefrontal Cortex (PFC) Behavioral regulation Reflective decision-

making Inhibition of socially

inappropriate actions

Emotional and sensoryintegration

Planning complexbehaviors

Personality expression


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Drugs work first inthe


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The Midbrain is the brain Not conscious Acts immediately, nofuture planning or

assessment of long-termconsequences

A life-or-deathprocessing station

for arriving sensoryinformation


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In addiction, the drug hijacks the survival

hierarchy and is so close to actual survival that it

is indistinguishable from actual survival

2. EAT!3. KILL!4. SEX !


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Addiction is a disorder in the brains

Reward (Hedonic) SystemIt is a broken

pleasure sense

in the

brain


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Addiction is a disorder of

5. CHOICE (motivation)

4. STRESS (anti-reward system)

3. MEMORY (learning)

2. REWARD (hedonic system)

1. GENES (vulnerability)


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Five Theories of Addiction

1. Genetic Vulnerability (Schuckit et al)

2. Incentive-sensitization of Reward (Robinson & Berridge)

3. Pathology of Learning & Memory (Hyman, Everitt & Robbins)

4. Stress and Allostasis (Koob & LeMoal)5. Pathology of Motivation and Choice

(Kalivas & Volkow)


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Addiction Neurochemical #1: Dopamine

All drugs of abuse and potential compulsivebehaviors release Dopamine

Dopamine is first chemical of a pleasurableexperience - at the heart of all reinforcingexperiences

DA is the neurochemical of salience (it signalssurvival importance)

DA signals reward prediction error Tells the brain this is better than expected


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Incentive-Sensitization(Robinson & Berridge)

Distinguished between a liking and a wantingrole for Dopamine (its more about wanting)

Created hyper-dopaminergicDopamine Transporterknock-down mice (mice with increased synapticDopamine)

Observed increased intake of reinforcing substancesin these mice and greater thwarting of obstacles to

get them (i.e. more wanting)

But did not observe greater liking of thesesubstances by these mice


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Alcohol & Sedative/Hypnotics Opiates/Opioids Cocaine Amphetamines Entactogens (MDMA) Entheogens/Hallucinogens Dissociants (PCP, Ketamine) Cannabinoids Inhalants Nicotine Caffeine Anabolic-Androgenic Steroids

Food (Bulimia & Binge Eating) Sex Relationships Other People

(Codependency, Control)

Gambling Cults Performance

(

Work-aholism

)

Collection/Accumulation (Shop-aholism)

Rage/Violence Media/Entertainment


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Addiction Neurochemical #2: Glutamate

The most abundant neurochemical in thebrain

Critical in memory formation & consolidation All drugs of abuse and many addicting

behaviors effect Glutamate which preservesdrug memories and creates drug cues

And glutamate is the neurochemical ofmotivation (it initiates drug seeking)


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DOPAMINE (DA) GLUTAMATE (Glu)

All drugs of abuse andpotential compulsivebehaviors INCREASE DA

Reward saliencethis is important!I really want this!Rostral (toward the nose)projections:

PFC < NA < VTA

All drugs of abuse andpotential compulsivebehaviors EFFECT Glu

Drug memoriesDrug seekingOK, Ill rememberFine, go and get itCaudal (toward the tail)projections:

PFC > NA


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The hypofrontal/craving brain state represents

and imbalance between 2 brain drives

Cortico-Striatal Circuit

STOP! Organized, Attentive Sensitive to consequences Well-planned Socially appropriateTHERES TOO LITTLE OF THIS

Amygdalar-Cortical Circuit

GO! Impulsive Non-reflective Poorly conceived Socially inappropriateTHERES TOO MUCH OF THIS


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: Pleasuredeafness(the patient is no longer able to derive normal

pleasure from those things that have beenpleasurable in the past)


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Relapse Three things that are known to evoke relapse in

humans:

1. Brief exposure to drug itself (DA release) 2. Exposure to drug cues (GLU release)

3. Stress (CRF release)

(example of a dangerous relapse-triggering behavior:

talking about drugs (cues) with other newly-soberaddicts in treatment (stressed) while smoking (DA surge)


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Craving / Drug Seeking Not quite as conscious as deliberative acts More automatic - like driving a car home

from work without really thinking about it

I was vaguely aware that what I was doingwas not too smart

There I was again with a drink in my handthinking that this time things would be

different


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damage toOrbitofrontal Cortex (OFC)

Causes a loss of a crucialbehavioral guidance system

Responses are impulsiveand inappropriate

Deficits of self-regulation Inability to properly assign

value to rewards (such as

money vs. drugs)

Tendency to choose small &immediate rewards overlarger but delayed rewards


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damage toAnterior Cingulate Cortex (ACC)

Just as with OFC damage:causes a loss of a crucialbehavioral guidance

system Inflexibility/Inability to

respond to errors in thepast with regard to

rewards/punishments

Deficits in socialresponding due todecreased awareness of

social cues


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damage toPrefrontal Cortex (PFC) Failure of executive

function


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Hypofrontality Bechara: research on pts with vmPFC & OFC lesions Myopia for the future - cognitive impulsiveness- these patients prefer immediate butdisadvantageous rewards over rewards that are

delayed but advantageous in the long run

- their decisions are guided primarily by immediate

prospects and are insensitive to positive or negativefuture consequences (rewards or punishments)

- they deny or are unaware of their problem

Scans of vmPFC patients are similar to Sub Abuse pts


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It fails to take into account The Choice Argument measures addiction

only by the addict

s external It ignores the inner of the patient You dont actually have to have drug use for

the defective physiology of addiction to beactive

The addict cannot choose to not


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So how DO we break the hold

ofcravingandturn the FrontalCortex backon?


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misperception ofthe hedonic aspects ofthe drug

And attribution of survival

salience to the drug onthelevel of the unconscious


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The drug takes onpersonal meaning

The addict develops anemotional relationshipwith the drug

The addict derives theirsense of self and exertsagency through the drug


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1. To give the addict

workable, credible

tools to proactively

2. For each individual

addict,

- and

displace the drug with

it


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Addiction is a disorder of

6. MEANING(spirituality?)

5. CHOICE (motivation)4. STRESS (anti-reward system)

3. MEMORY(learning)

2. PLEASURE (hedonic system)

1. GENES (vulnerability)


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AA: using NON - Rational Concepts (the fellowship of alcoholics) (Bills Story, etc.) (what it was like, what happened, and) (Keep coming back, it works) (The Promises) (the answer to all my problems)


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DSM-IV Criteria for Substance Dependence

(IM A TOWN DRUNK)

NABILITY (to cut down) ORE DRUG USED (than intended) LOT OF TIME (spent obtaining, using &

recovering from using the drug)

OLERANCE LD ACTIVITIES, FRIENDS & FAMILY MEMBERS

(given up in favor of the drug)

ITHDRAWAL EGATIVE CONSEQUENCES (have no effect on the

pattern of drug use)


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ASAM Addiction Definition (Aug 2011)A primary, chronic and relapsing brain disease

of reward (nucleus accumbens),

memory (hippocampus & amygdala),

motivation and related circuitry (ACC, basal

forebrain)

that alters motivational hierarchies such thataddictive behaviors supplant healthy, self-care

behaviors


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Addicts are patients! Addicts have the same rights as all patients All the ethical principles that apply to other

patients now also apply to addicts


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(Is there a group of addicts we dont punish?)


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Things we do for pilots:

Medical Detoxification Inpatient or Residential Treatment Aftercare: Immediately after treatment for

3-5 Years

A.A. Attendance Regular testing (monitoring) Return to duty Personal physician


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Treatment Outcome Variance in Pilots

Treated for Alcoholism:

The United States Navy enjoys a 95-97% return to flying

status rate in its pilots treated for alcoholism.

- Joseph A. Pursch, M.D.

Since the inception of its impaired pilot program inconjunction with the FAA and ALPA EAPs, UAL has an 87%

return to flight status rate in pilots treated for alcoholproblems. - Stanley Mohler, M.D.


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Problems with the Disease (Acute Care) Model

Reductive

Materialistic

Expensive, dramatic, late-stage, disruptive

interventions in lieu of a more preventive

Results in episodic, reactive, fragmented,poorly-targeted care

Cannot address meaning, or spiritual/community solutions

Strips patient of power (and hands that powerto the doctor)

Encourages the sick role (fostersdependency, absolves responsibility)


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Benefits of inpatient care

Medical detoxification

Baseline psychiatric evaluation & treatment

Intensive daily structure

Solidification of abstinence

Removal from codependent family/socialsystem

Incapacitation of usePatient takes it seriously

Finney et al. Addiction 1996 91(12), 1773-1796


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Chronic DiseasesAsthma

Diabetes mellitus

Chronic Obstructive Pulmonary Disease (COPD)

Post-chemotherapy/Cancer

Hepatitis B/C

HIV/AIDS

Major Depression

Chronic Pain

Lupus Erythematosis

Cystic Fibrosis

Alzheimers Disease

Kidney Disease

Heart Disease/Post-MI

Hypertension

Rheumatoid Arthritis

Epilepsy

Irritable Bowel Disease

ADHD

Addiction/Recovery

Migrainosis

Anticoagulation Therapy (post-DVT, AtrialFibrillation)


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advantages of a

Chronic Care

Model

Non-urgent

More efficient and cost-effective

Preventive

Based on continuous, healing relationships

Provides services across the continuum of care forlife

Centralized, local (no aircraft needed)

Family-centered

Informational (EMRs > NHII > research)


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Disease Management

Disease Management is a system of coordinated healthcare interventions and

communications for populations with conditions in which

patient self-care efforts are significant.

Goal: improving quality of life and reducing healthcare costs forindividuals with chronic diseases by preventing or minimizing the

effects of the disease through integrative care


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Disease ManagementTargets people with chronic conditions

Located outside the point of care

Personal communications (usually by telephone)

Multidisciplinary team approach

Linkage with community resources

Patient education and self-management support

Close monitoring of symptoms & reporting to clinical team

Goal is to minimize or prevent complications, relapses, re-hosp.


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examples of Disease Management

Nurse outreach (telephony, home visits)

Action planning, Symptom reporting

Health coach advocacy, encouragement

Remote home monitoring or daily testing

Internet interfaces, questionnaires

Physician practice supportRisk assessment, stratification, targeting of

intervention


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What Disease Management looks like for

Daily Fasting Blood Glucose testing (and recording)

Intensive (Flexible) Insulin therapy with MDI/pump

Periodic Hemoglobin A1C testing to check long-term glycemic control

Annual Ophthalmologic Exam

Periodic Podiatric Exam/Foot Care

Diet, Weight Control, Exercise

Monitoring serum cholesterol and lipid profile

Diabetes patient support groups


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What Disease Management looks like for

Community-based Sober Living/Residential Support

Monitoring (non-random drug testing)

Group Therapy/Cognitive-Behavioral Therapy

Peer-Based Recovery Support Groups (AA, etc)

Addictionologist/Addiction Psychiatrist

Web-based Assessment Tools

Call centers/Phone counseling

Occupational/Vocational Assistance


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Recovery Capital(Granfield & Cloud)

Recovery Capital is the sum total of all thepersonal, social, and community resources a

person can draw on to begin and sustain their

recovery from drug and alcohol problems.


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Recovery Management

www.facesandvoicesofrecovery.org/pdf/White/recovery_monograph_2008.pdf


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The

Blueprint

Studies Dupont RL, McLellan AT, White WL, Carr G, Gendel M,

Skipper GE. How are physicians treated? A national survey

of physician health programs. Journal of Substance Abuse

Treatment 2009 Jul; 37(1): 1-7.

Dupont RL, McLellan AT, White WL, Merlo LJ, Gold MS.Setting the standard for recovery: physicians health

programs. Journal of Substance Abuse Treatment 2009

Mar; 36(2): 159-71.


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Characteristics of Physician Health Programs


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Physician Health Programs (PHPs)

Relapse: 22% had one relapse over five years

Of those, only 26% had a repeat positive test

At the end of five years:

71% were working and licensed 18% were retired, died or licenses revoked

(Dupont RL, McLellan AT, Skipper GE. How are physicians treated? A national survey of physician health programs. J Sub Abuse Tx (2009)37:1-7.


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Tips for the First Year of Recovery

1. Residential Treatment (Inpatient or Residential Day)

2. Immediate Aftercare following Residential Treatment

3. Sober Living Environment

4. Ninety A.A. meetings in ninety days (90x90)

5. Automatic Relapse Plan

6. Testing

7. Rapid but Gradual Return to Duty

8. Addictionologist

9. Medication

10. Fun! (Hedonic Rehabilitation/Pleasure Therapy)


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Relapse Plan

DO NOT PANIC! Have an Automatic Relapse Plan(previously agreed upon/no discussion)

Detox (incapacitation) Return to Treatment (residential vs. outpatient) Review Testing Protocol Validate success


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Daily Testing RegimenCocaineAmphetamine

MethamphetamineTHC

Methadone

BuprenorphineOpiates

Oxycodone

Propoxyphene

PCPBarbiturates

Benzodiazepines

Alcohol (breath-analysis)


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Two Kinds of Tests in Addiction Medicine

SCREENING Tests

Immunoassay

Very sensitive

Not very specific

Not an insignificant false

positive rate

CONFIRMATION Tests

GC/MS

Very, very specific

Not very sensitive

Forensic standard


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Addictionologists

Certified by the American Society ofAddiction Medicine

Understand the special needs of recoveringpatients Not likely to make stupid mistakes Doctors who LIKEaddicts, Offices that are

safe places

www.asam.org www.csam-asam.org


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Controlled Substances Protocol All meds in safe (no loose pills) Safe behind locked door, combination

changed monthly

Med recording sheets/Pill Count sheets Staff tested weekly Communication with prescribing physician

(rationale for Rx known)


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Cost per month (Orange County numbers)1. Therapist $150/session x 4 = $600

2. Addictionologist/Psychiatrist $200/visit x 2 = $400

3. Mens/Womens Therapy Group $60/group x 4 = $240

4. Testing $40/test x 10 = $400 - $500

5. Medications (prn) varies6. Aftercare/Outpatient Program varies (may be free)

7. Sober Living Environment $500 - $1500 (& up) $1500

8. Twelve-step meetings free

$3,000 - $4,000


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National Outcome Measures (NOMs)

Abstinence Employment/Education Crime & Criminal Justice Stability in Housing Access/Capability Retention Social Connectedness Perception of Care Cost Effectiveness Use of Evidence-based Practices


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Population served

Time Period: 2 years Number of Residents: 39 men

Range of Duration of Stay:14 to 267 days

Average Length of Stay: 98.0 days Age distribution: x = 28.9, bimodal


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Performance data: Total Delivery:3619 resident-days Days Positive Test: 81 days (2.3%) Days Intoxicated: 83 (2.3%) Relapsed post-Tx: 48.7% Readmit Rate: 20.5%


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LMM Outcomes

39 residents over two-year period 3615 resident-days of service delivered average length of stay was 96.9 days (range: 14 to 287) 34.4% stayed longer than originally intended 40.6% stayed shorter than originally intended 98% of resident-days were abstinent by drug and alcohol screen 23% re-admission rate (half for relapse, half for relapse prevention) 23% employed on admission 61% employed or in school at time of discharge 48 ROSC linkages created and utilized 2 DUI arrests, no probation violations 90.6% of discharged residents transitioned to stable living situations


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