Lecture 7: Addiction Disorders and Treatment Flashcards
September 18
Brian Greenberg, Ph.D.
Paradigm Shifts in Drug
Treatment?
A change of thinking from one way to another
• Not gradual, but a major shift
• In tech, Disruptive (social networking, tablets &
smartphones, the cloud, search)
The Structure of Scientific Revolutions, Thomas
Kuhn 1962:
• Scientific advancement is not evolutionary, but
revolutionary
• A sort of metamorphosis
Shift: From Lack of Morality to
Lack of Faith…
Rise and Fall of Faith-Based Programs in U.S.
Believers: Less hypertension, less depression, longer survival and less drug abuse and alcoholism (organic religion)
• Religion buffers and insulates
Faith-based programs: No higher success rates (intentional religion)
• However, most programs world wide continue to
be faith-based
Shift: From lack of religion to lack of spirituality… AA:
A Spiritual Program
Step 2: Came to believe that a Power greater than ourselves could restore us to sanity
Prayer could not keep Dr. Robert Smith and Bill Wilson sober
Step 3: God, as we understood him
• 1935, an active religious, or God Lobby
• Step 12: “having a spiritual awakening” may be more explicit
• AA never intended to be a religious program
Shift: Disease Model replaced The Moral Failing Model
old model: Addiction as a failing of discipline and morality
• Deficiencies in character
• Uncaring
• Self centered, little regard for anyone else
new model = Addiction as a Disease
• Characterized by altered brain structure and functioning
• Is irreversible and progressive once acquired
Recovery
Consists of developing and maintaining complete abstinence
• Abstinence completely arrests the disease and keeps it dormant
Reclaiming the addiction field:
Direct Service Professionals
Early Christian Temperance Movement
Salvation Army
Early Split: psych hospitals “discredited” with “drunkard” admissions: concern that here was too much drinking and opium use in psych hospitals
Most of the nation and the world: G-d, Nature, and blended with evidence-based best
practices
Shift: Addiction as a chronic
(rather than acute) condition
Managed rather than treated
A lifelong condition
More than 90 million Americans live with chronic illnesses
Chronic diseases account for 70% of all deaths in the U.S
40% of people with one chronic care condition have at least one other (co-morbidity)
Chronic conditions:
A comparison of relapse rates
It is 40-60% likely that a former drug addict will relapse
Shift: Response to Relapse…
From Discharge to Re-Engagement
1983: Vaillant tracked his patients in an A.A.-based hospital program for 8 years and compared their outcomes with severe alcoholics in several community studies who
received no treatment. He was disappointed:
• It seemed perfectly clear that by moving patients from dependence into hospital treatment and then into AA, I was working for the most exciting alcohol program in the world. But then came the rub. Fueled by our enthusiasm, I and the director tried to prove
our effectiveness. Our clinic followed up our first 100 patients and found compelling evidence that the results of our treatment were no better than the natural history of the disease.”
G.E. Vaillant, The Natural History of Alcoholism, Harvard
Learning from Nicotine Addiction:
A Parallel Process
Eventual success in quitting smoking is associated with multiple treatment attempts
• Smokers most often relapse, but increase length of abstinence with each quit attempt
• Re-treatments can be short and inexpensive (patch, helpful hints)
Keeping smokers engaged or re-engaged in treatment creates a new habit: not smoking
However, persons who return to ETOH, cocaine, and heroin addiction have more severe short term consequences than smokers
Keep ‘em In Treatment
Length of stay in treatment is the single strongest predictor of post-program success
Treatment retention is associated with more favorable post-treatment outcomes:
lower drug & alcohol use, reduced criminal behavior, and increased employment
Methadone
Methadone is the most effective known treatment for heroin addiction.
• Methadone is widely employed throughout the world.
Methadone’s best (and sometimes only) friend is research: most evaluated intervention
4 out of 5 persons who taper relapse back to intravenous drug use
It is difficult to identify who can be maintained without methadone
A brief history of opiate
addiction
Civil War: Widespread opiate addiction
1874: Heroin synthesized
Early 1900’s salesmen, pharmacists, doctors freely sell/distribute all forms of opiates and create 300,000 addicts
—largely an iatrogenic illness
1950’s – Present:
Heroin use intensifies after WWII, and escalates in 1960’s
Then Methadone is Introduced…
Effectiveness of Methadone
Reduction in illicit drug use. Reduction in criminal activity. Improvement in social health. Improvement in health. Retention in drug treatment. Reduction in suicide. Reduction in lethal overdose. Reduction in needle sharing and HIV infection. Reduction in commercial sex work.
Motivation is Not a Pre-Requisite
to a Successful Treatment Episode…
Motivational Enhanced Therapy (MET) or Motivational Interviewing (MI) can help develop and sustain motivation
Clients can progress through stages of change
Expectation of limited initial motivation
The Shifting Literature
Regarding Abstinence and Harm Reduction
Harm Reduction practiced for centuries (heroin in British 19th century)
1980’s needle exchanges
Use Less/Cause less harm
Treatment and Care:
Harm Reduction
Use less
Offered more frequently in OP and Day programs
Pre-Treatment and Treatment Readiness
Lower bar for participation
Treatment and Care:
Abstinence
Abstain from illicit drugs & alcohol
Offered more frequently in residential programs
Private treatment programs
Higher bar for participation
Treatment Capacity Problems
Nationwide:
25 million need treatment
2 million receive treatment
1 in 7 treatment admissions are for marijuana
Mental Health Professionals and
the Addict:
The Stigma Barrier
Too difficult to treat, never get any better, wet brain, impossible to engage
Self-fulfilling prophecy
Stages of Drug Use
Discerning a difference can help to create a disposition/recommendation
• Use
• Abuse
• Dependence = Addiction
Drug “Use”
Use of alcohol or other drugs that does not interfere with home, work, interpersonal relationships or daily functioning
May involve the use of legal or illegal drugs or alcohol
Drug Abuse
A maladaptive pattern of use leading to clinically significant
impairment or distress manifested by 1 or more of the
following:
Recurring use resulting in a failure to fulfill major role
obligations at work, school, or home;
Recurrent use in situations that are physically hazardous (driving);
Recurrent substance-related legal problems;
Continued use despite persistent social or interpersonal problems caused by the effects of substances.
Dependence or Addiction
A maladaptive pattern of use, leading to clinically significant impairment or distress as
manifested by 3 or more of the following:
Tolerance (a need for increasing amounts to achieve intoxication or a diminished effect with same amount);
Withdrawal (stopping or reducing use with symptoms specific to each substance or taking the substance to relieve or avoid withdrawal);
Take more or over a longer period than intended
Addiction: Treatment is Essential
for some
Chronic –A lifelong illness
Progressive—Deterioration with use
Relapsing—For many
Fatal—Ultimately (frequently) ends in death
Common Diagnostic Mistake/Differential
Diagnostic
Males: Onset of schizophrenia between ages of 16–25.
Females: Onset is up to the age of 30.
This is also the age when illicit drug use is most prevalent
Diagnostic difficulty most frequent is differentiating between drug induced psychosis and schizophrenia in this age group (among substance abusers)
Substance Abuse and
Differential Diagnosis
“The ability of psychoactive substances to mimic nearly all the symptoms listed in the DSM-IV further complicates the task of differential diagnosis.”
No definitive way to determine whether or not a particular psychiatric symptom is caused by substance use, but consider…
• Time of onset
• Substance abuse patterns (and periods of non use)
• Consistency of symptoms
• Family history
• Response to treatment
• Stated reason for abuse
How is “remission” defined
Remission can be applied “only after none of the criteria for substance dependence or
substance abuse have been present for at least one month” (DSM IV-TR 2000).
early: less than one year (time only)
sustained: more than a year (time only)
partial: meets at least 1 criteria for dependence or abuse
full: no symptomology evident
Substance Induced Mental
Disorders
Can only be used with intoxication or withdrawal states
A Substance Induced Mental Disorder is NOT diagnosed when “symptoms of pre-existing mental disorders are
exacerbated by substance intoxication or withdrawal”.
Screening Tools:
The CAGE
1 )Have you ever felt you should cut down on your drinking/drug use? Yes No
2 )Have people annoyed you by criticizing your drinking/drug use? Yes No
3 )Have you ever felt bad or guilty about your drinking/drug use? Yes No
4 )Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover, or used drugs early in the day to feel better? Yes No
Score of 2 yeses or higher indicates a problem
Addressing the client:
Strategies for communicating the need for (or notion of) treatment (the ATTITUDE)
Approach to engender a non-defensive response
Join, partner, collaborate with client
Instill hope (the vision thing)
Position the referral as a positive (rather than punitive)
Addressing the client:
Strategies for communicating the need for (or notion of) treatment (the MESSAGE)
People get better
Addiction is treatable like other
conditions
There are many options
Commit to getting information/screening
Voluntary
Treatment can help improve other life problems
What we know about treatment
Cost effective
Doesn’t result in lifetime abstinence for most people (chronic rather than acute)
When substance abuse is reduced, so is criminal behavior
Dropout and relapse is the rule
A recovery rather than a cure
perspective
What we know about the
research:
Most published research is not
randomized/double blind
Initial positive results are frequently difficult to repeat
Evidence-based best practices yield marginally better results (MI, DBT, relapse prevention)
Staff experience determines a lot and is very important
Principles of Treating
Co-occurring Disorders
Abstinence is generally not a prerequisite to beginning or continuing psychotropic medication
Untreated substance abuse disorders negatively impact mental health treatment
A deterioration of psychological well-being is associated with an increase in substance abuse
Relapse, Recovery, and Time
Relapse risk is highest in the first 90 days following treatment
Time in treatment is strongly
associated with outcome
Among people who spend two
years in treatment, 75% remain in recovery after 5 years
One year in treatment, 50%
remain in recovery after 5 years
Relapse Prevention
Relapse happens before the relapse
Identify triggers:
• Internal– thoughts, emotions HALT = hungry, angry, lonely, tired
• External—people, places, things
To avoid relapse:
- Handle day-to-day feelings and problems as they happen
- Keep life in balance… a way to reduce stress
- Gain support and trust
- Identify and plan for high-risk situations
The Treatment Continuum
in San Mateo County, e.g. ……..
Self Help
• 12 Step Fellowship (AA, NA, CA, etc.),
Outpatient
Day Treatment
Residential
Continuing Care
