Chemical AddictionsChemical Addictions——General General OverviewOverview
Abdullahi Mubarak, MDMedical Director of Addiction
Services at PEMCOChief Medical Officer at
Consortium Clinical Services, LLC
ObjectivesObjectives
Understand general terminologyThe disease of AddictionSymptoms of the diseaseStages of changeDiagnostic tipsGeneral treatment approaches
TerminologyTerminology
Use—drug taking not associated with harmAbuse—drug taking associated with harmDependence—adaptation to drug evidenced
by normal functioning and/or withdrawal syndrome
Addiction—loss of control, compulsion, continued use despite adverse consequences
TerminologyTerminology
Abuse potential—the likelihood that a person will abuse a drug based upon it’s pleasurable effects, toxicity, and society’s attitude toward the users of the drug
Addiction potential—the likelihood that a drug will produce addiction in chronic users
Relative Addiction PotentialRelative Addiction Potential Cocaine (crack, IV, snorted, chewed) Methamphetamine (smoked) Nicotine (IV, smoked, chewed) Opiates (IV, smoked, snorted, chewed, oral) Alcohol Sedative-hypnotics Anabolic steroids Marijuana Inhalants PCP, other hallucinogens (LSD, Special K, )
Disease of AddictionDisease of AddictionAddiction is primarily a function of many
genetically predisposed biological responses.
The response and/or lack of the drug reinforces the repeated use of the drug.
The environment permits and facilitates the use of the drug.
Addiction can be “created” in low risk patients with chronic use of drugs of high addictive potential.
Progression of the DiseaseProgression of the Disease
Erratic drug-taking pattern, erratic sleep, work, eating, grooming, and social habits
New forms of enjoyment, new “friends”, ways of relating, isolation, hiding money, hiding whereabouts, lying
Legal, financial, marital, social, career, and lastly physical adverse consequences
Stages of ChangeStages of Change Pre-contemplation—lacks awareness Contemplation—ambivalent about change Preparation—getting information in order to
change Action—actually committing to sobriety in deed Maintenance—attaining stability Recovery—sobriety Relapse—use leads to return to contemplation
Signs of Aberrant behaviorSigns of Aberrant behaviorPrescription forgeryConcurrent abuse of illicit drugsSelling prescriptionsRecurrent lost, stolen, or spilled drugsStealing or borrowing from othersObtaining drugs from non-medical sourcesObtaining scripts from multiple doctors
Indicators of SuspicionIndicators of Suspicion
Reluctant to present identification“Out of town” patientOverly willing to pay cashTelephone call in for controlled substancesPresents when the regular physician cannot
be reached
Indicators of SuspicionIndicators of SuspicionAllergy to NSAIDS, COX-2’s, or codeineIntolerant to collateral contactsIntolerant to in-depth interviewsInterested only in the drug, not the
diagnosisReluctant to comply with diagnostic testing,
pill counts, and urine screening
Factors Less IndicativeFactors Less Indicative
Drug hoarding during periods of decreased symptoms
Unsanctioned dose escalationRequest for specific drugs by nameFocus on opiate issues during the first three
office visits
Abnormal Physical SignsAbnormal Physical SignsPupils < 3mm or >6.5mm in room lightPresence of nystagmusDiminished or absent corneal and/or
pupillary light reflexImpaired convergencePulse < 60 or > 100/minVenosclerosis or needle tracksPerforated nasal septum
Characteristics of the PainCharacteristics of the Pain patientpatient
Appreciates in-depth interviews Cooperates with attempts to get collateral histories Cooperates with pill counts and urine drug
screening Focus is on the diagnosis and the cure Attempts to reduce medications on their own Cooperates with diagnostic and therapeutic
interventions
Addressing Aberrancy and Addressing Aberrancy and indicators of suspicionindicators of suspicion
Obtain an INSPECT reportUrine drug screen (UDS)Use oral salivary testing when urine
screening is unavailable, patient unable to void, or the UDS is invalid
Pill counts when appropriateUse Axis V outline to clarify your thoughtsTreat ONLY according to your diagnosis
INSPECT reportsINSPECT reportsThe report is unconfirmed history until you
confirm what’s in it.“Multiple prescribers” means nothing until
you call the providers to find out what they did, why they did it, and did they know there were other prescribers
Keep the interpretation of the report in your chart
Urine drug screeningUrine drug screening The results only mean what the results say Using them to make a diagnosis is only part of the
total picture Refer for addiction consultation, if the results are
aberrant Negative screens can mean abuse, addiction,
diversion, or pseudo-addiction syndrome Do not collect without temperature strips on the cup. Be sure the reference lab tests for validity and
multiple metabolites
Oral Salivary TestingOral Salivary Testing
Easy to use, less intrusiveShorter window of detection compared to
urine drug screeningAccuracy comparable to blood testingThe results only mean what the result says
Pill CountsPill Counts Best when used sparingly or unexpected Best to clarify negative urine drug screens Order within 2 days to rule out diversion Order within 10 days to rule out abuse or
addiction Pills can be brought to office or the pharmacy they
purchased their pills Record any markings on the pills for identification
Diagnostic ChallengesDiagnostic Challenges Impaired by lack of knowledge of differential
diagnosis Impaired by EMOTIONAL reactions to the “names”
of controlled substances Use Axis V outline to highlight deficiencies in
knowledge or when you are becoming too emotional Say “NO”, if the request is inappropriate for the
diagnosis or you have inadequate information to arrive at a diagnosis
Continue to monitor to confirm or deny your provisional diagnosis. Being wrong is ok.
ConsultationConsultationLearn the biases of your consultants. Psychiatry consultation for benzo and
stimulant prescribing for mood disorders, ADHD, etc…
Addiction consultation to evaluate aberrancy
Pain management consultation to evaluate opiate prescribing
General treatment principlesGeneral treatment principlesForemost goal initially is self-diagnosisEducate—Addiction is a disorder in a
person, not the pillMedication assistance—diminish drug
craving, withdrawal, and normalize functionIntensity of treatment related to intensity of
use pattern and/or history of treatment failures
Strengthen social/spiritual supports