Back to Basics Substance Abuse_2011 Dr Lau_compressed

Substance Use Disorders REVIEW OF PSYCHIATRY T Lau, MD, FRCPC [psych], Director of Undergraduate Education Faculty of Medicine, Department of Psychiatry, UNIVERSITY OF OTTAWA NOTEABLE QUOTABLES • “It's easy to quit smoking I've done it hundreds of times.” Mark Twain, 1835-1910 • “It provokes the desire but it takes away the performance.” William Shakespeare • “I'm not so think as you drunk I am.” John Squire Pre-Test Questions • What of the following causes pupillary dilation (mydriasis) a) b) c) d) e) Cholinergics Opiates Organophosphates Crystal met Clonidine CASE • 35 year old man whose alcohol consumption started in his teens For many years, he drank alcohol mostly on social occasions • He is not sure what happened first but he began having problems with his wife and his work It was during this time that his alcohol consumption increased • Although he doesn’t drink everyday he often drives to work somewhat intoxicated and his coworkers have noticed that he has not been himself lately • He has been having problems with intimacy with his wife and she had been wondering if it was related to alcohol he had been consuming more of • What is the diagnosis? • What treatment options exist? CASE • 58 year old divorced man with alcohol problems who drinks everyday, needing an “eye opener” to get going in the morning and to avoid feeling shakey He sometimes consumes more than 10 drinks at a time • He has lost several jobs over the years and is estranged from his wife and children largely because of his drinking and behaviour • He has had a heart attack, has hypertension and is obese He saw his family physician who tells him his bloodwork and MRI abdomen is consistent with cirrhosis • What is the diagnosis? • What blood work would be consistent with this picture? • What treatment options would you offer? CASE • 38 year old female who lives with her husband and year old daughter She suffers from chronic pain following a MVA years ago • She was treated at that time with Percocet, however her GP “cut her off” after months of medications and now will only prescribe her NSAIDs • She works as a purchasing agent in the civil service but is getting in trouble at work for repeated work absences • She is currently using 2x80 mg oxycontin which she gets from a friend who refers to them as “oxys” She is paying $80 per day for these narcotics and can’t really afford to continue like this CASE • Based on the history above what is the most likely diagnosis? a) Opiod abuse b) Fibromyalgia c) Dependent personality disorder d) Opiod dependence e) Addictive personality disorder CASE • You ask her when her last “oxy” was and she states 2h ago Which of the following are symptoms of opiod intoxication? a) b) c) d) e) Hypotension Miosis Lacrimation Respiratory depression euphoria CASE • She states that when she doesn’t take the pills she feels sick Which of the following are symptoms of opiod withdrawal a) b) c) d) e) Nausea or vomiting Seizures Myalgias Yawning Rhinorrhea CASE Miscellaneous Notes on Substance use disorders • Death by hyperthermia with MDMA • Inhalants a common cause of cognitive impairment • PCP commonly presents with catatonia • No withdrawal w PCP according to the DSM IV Reasons to suspect an underlying psychiatric disorder… • Sx precede use of substance • Sx persist after discontinuation (eg One month) • Sx out of proportion or unusual for offending substance • Cross sectional, longitudinal, epidemiology, FHx and past tx responsiveness suggest a specific axis pathology Treatment • approaches • Abstinence • Harm reduction • Treatment settings • Outpatient • Residential tx programs • Psychotherapy WHO 2006 Treatment • Motivational Interviewing • Cognitive Behavioural Therapy • Social Skills Training • Contingency Management • Pharmacological therapy - A number of medications have been approved for the treatment of substance abuse These include replacement therapies such as buprenorphine and methadone as well as antagonist medications like disulfiram and naltrexone in either short acting, or the newer long acting form (under the brand name Vivitrol) • Several other medications, often ones originally used in other contexts, have also been shown to be effective including bupropion (Zyban or Wellbutrin), Modafinil (Provigil) and more Change theory STAGES OF CHANGE Precontemplation Contemplation Preparation Action Maintenance Prochaska & DiClemente Psychotherapy • Motivational Interviewing • Focuses on the present interests, concerns and perspectives of the individual • Focuses on the resolution of ambivalence • Elicits and selectively reinforces change talk • Is a method of communicating rather than a set of techniques • It is fundamentally a way of being with and for people“facilitative approach to communication that evokes natural change” • Illicits the persons intrinsic motivation for change Motivational interviewing • Four General Principles Express Empathy • Acceptance facilitates change Develop Discrepancy • Between behaviour and personal goals Roll with resistance • Patient primary resource for solutions • Signal to respond differently Support self-efficacy • Patient responsible for choosing and carrying out change CBT for substance • Cognitive Behavior Therapy for substance has two main components: functional analysis and skills training • Functional Analysis: Working together, the therapist and the patient try to identify the thoughts, feelings and circumstances of the patient before and after they drank or used drugs This helps the patient determine the risks that are likely to lead to a relapse • Functional analysis can also give the person insight into why they drink or use drugs in the first place and identify situations in which the person has coping difficulties • Skills Training: If someone is at the point where they need professional treatment for their alcohol or drug dependence, chances are they are using alcohol or drugs as their main means of coping with their problems The goal of cognitive behavior therapy is to get the person to learn or relearn better coping skills WHO 2006 WHO 2006 ... week the depressive symptoms subsided but she continued to periodically have “flashbacks of the same symptoms she had during her “bad trip” • What is the most likely substance? CASE • 25 year... dangerous related behaviour Substance Dependence • > 3/7 at anytime over a 12 month period T Tolerance W Withdrawal I Increased amount than intended S Substance use despite symptoms (physical or psychological)... this time that his alcohol consumption increased • Although he doesn’t drink everyday he often drives to work somewhat intoxicated and his coworkers have noticed that he has not been himself lately