W11 Substance-Related and Addictive Disorders (Gee).pdf

Substance-Related and Addictive Disorders Robert Gee, Ed.D. Professor, Behavioral Sciences Assistant Dean, Student Affairs [email protected] ROSS UNIVERSITY SCHOOL OF MEDICINE Changing Environment (Cannabis) ROSS UNIVERSITY SCHOOL OF MEDICINE ROSS UNIVERSITY SCHOOL OF MEDICINE Learning Objectiv...

Substance-Related and Addictive Disorders Robert Gee, Ed.D. Professor, Behavioral Sciences Assistant Dean, Student Affairs [email protected] ROSS UNIVERSITY SCHOOL OF MEDICINE Changing Environment (Cannabis) ROSS UNIVERSITY SCHOOL OF MEDICINE ROSS UNIVERSITY SCHOOL OF MEDICINE Learning Objectives After this lecture, students will be able to: 1. Describe the essential components of the medical model of substance use disorders. 2. Define the purpose and structure of screening, assessment, and treatment. 3. Demonstrate knowledge of substance use disorder treatment standards and the ability to recommend appropriate referrals. 4. Demonstrate knowledge of prescription drug misuse and recognize risk factors for overdose. ROSS UNIVERSITY SCHOOL OF MEDICINE 1. Describe the essential components of the medical model of substance use disorders. Substance Use Involves Multiple Factors Genetics Addiction Behavior Environment Culture American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association. ROSS UNIVERSITY SCHOOL OF MEDICINE 1. Describe the essential components of the medical model of substance use disorders. Classes of Substances Alcohol Caffeine Cannabis Hallucinogens Inhalants Opioids Sedatives Stimulants Tobacco Other (or unknown) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association. ROSS UNIVERSITY SCHOOL OF MEDICINE 1. Describe the essential components of the medical model of substance use disorders. Two Main Groupings SubstanceRelated and Addictive Disorders Substance Use Disorders Substance-Induced Disorders • Substance Intoxication • Substance Withdrawal • Substance/Medication-Induced Mental Disorders American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association. ROSS UNIVERSITY SCHOOL OF MEDICINE 1. Describe the essential components of the medical model of substance use disorders. Substance-Induced Disorders Substance Intoxication • Criterion A: Recent ingestion of [substance name]. • Criterion B: Clinically significant problematic behavior or psychological changes that developed during, or shortly after, [substance name] ingestion. • Criterion C: One (or more) of the following signs or symptoms developing during, or shortly after, [substance name] use. • Criterion D: The signs and symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance. Substance Withdrawal • Criterion A: Cessation of (or reduction in) [substance name] use that has been heavy and prolonged. • Criterion B: One (or more) of the following developing within several hours to a few days after cessation of (or reduction in) [substance name] described in Criterion A: (Symptom list) • Criterion C: The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. • Criterion D: The signs and symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association. ROSS UNIVERSITY SCHOOL OF MEDICINE 1. Describe the essential components of the medical model of substance use disorders. Substance-Induced Disorders (Continued) Other Substance/Medication-induced Mental Disorders • Criterion A: The disorder represents a clinically significant symptomatic presentation of a relevant mental disorder. • Criterion B: There is evidence from the history, physical examination, or laboratory findings of both of the following: 1) The disorder developed during or within 1 month of a substance intoxication or withdrawal or taking a medication; and 2) The involved substance/medication is capable of producing the mental disorder. • Criterion C: The disorder is not better explained by an independent mental disorder (i.e., one that is not substance- or medication induced). Such evidence of an independent mental disorder could indicate the following: 1) The disorder preceded the onset of severe intoxication or withdrawal or exposure to the medication; 2) the full mental disorder persisted for a substantial period of time (e.g., at least 1 month) after the cessation of acute withdrawal or severe intoxication or taking the medication. This criterion does not apply to substance-induced neurocognitive disorders or hallucinogen persisting perception disorder, which persist beyond the cessation of acute intoxication or withdrawal. • Criterion D: The disorder does not occur exclusively during the course of a delirium. • Criterion E: The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association. ROSS UNIVERSITY SCHOOL OF MEDICINE 1. Describe the essential components of the medical model of substance use disorders. Diagnoses Associated with Substance Class Sleep Disorders Sexual Dysfunctions Delirium NeuroCognitive Disorders I/W I/W I/W I/W I/W/P Caffeine I I/W Cannabis I I/W Alcohol Hallucinogens Phencyclidine Other Inhalants Psychotic Disorders Bipolar Disorders Depressive Disorders Anxiety Disorders I/W I/W I/W X X X X X X I X X I I I I X X I I I I I X X I I I X X X X X X X X X X X I I/W Stimulants I/W I/W I/W I/W I/W I/W I/W I/W I/W I/W I/P I/W/P I I W Tobacco Other or Unknown Substance Substance Substance Use Disorders Intoxication Withdrawal I Opioids Sedatives, hypnotics, or anxiolytics ObsessiveCompulsive Disorders I/W I/W I/W I/W I/W X = Ca tegory i s recognized i n the DSM-5. I = The s pecifier “wi th onset during i ntoxication” may be noted for the category. W = The s pecifier “with onset during withdrawal” may be noted for the ca tegory. I/W = The s pecifier “with onset during intoxication” or “with onset during withdrawal” may be noted for the ca tegory. P = The di sorder is persisting. * = Al s o hallucinogen persisting perception disorder (flashbacks). ** = Incl udes amphetamine-type s ubstances, cocaine, and other or unspecified s timulants. I/W X I/W I/W I/W/P X X X X American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association.. ROSS UNIVERSITY SCHOOL OF MEDICINE 1. Describe the essential components of the medical model of substance use disorders. DSM-5 Diagnostic Criteria for Substance Use Disorders 1) [Substance name] is often taken in larger amounts or over a longer period than intended. Impaired Control 2) There is a persistent desire or unsuccessful efforts to cut down or control [substance name] use. 3) A great deal of time is spent in activities necessary to obtain the [substance name] , use [substance name], or recover from its effects. 4) Craving, or a strong desire or urge to use [substance name]. 5) Recurrent [substance name] use resulting in a failure to fulfill major role obligations at work, school, or home. Social 6) Continued [substance name] use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the Impairment effects of [substance name]. 7) Important social, occupational, or recreational activities are given up or reduced because of [substance name] use. 8) Recurrent [substance name] use in situations in which it is physically hazardous. Risky Use Pharmacological 9) [Substance name] use is continued despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated [substance name]. 10) Tolerance, as defined by either of the following: (a) A need for markedly increased amounts of [substance name] to achieve intoxication or the desired effect or (b) Markedly diminished effect with continued use of the same amount of [substance name]. 11) Withdrawal, as manifested by either of the following: (a) The characteristic withdrawal syndrome for [substance name] or (b) [Substance name] (or a closely related substance) is taken to relieve or avoid withdrawal symptoms. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association. ROSS UNIVERSITY SCHOOL OF MEDICINE 1. Describe the essential components of the medical model of substance use disorders. Determining Severity for Substance Use Disorders Mild • 2-3 criteria Moderate • 4-5 criteria Remember the Stages of Changes from the Health Promotion Lecture! Severe • 6 or more criteria American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association. ROSS UNIVERSITY SCHOOL OF MEDICINE 1. Describe the essential components of the medical model of substance use disorders. Science has generated much evidence showing that… • Prolonged drug use changes the brain in fundamental and longlasting ways. • These changes can be both structural and functional. National Institute on Drug Abuse - https://www.drugabuse.gov/ National Institute on Alcohol Abuse and Alcoholism - https://www.niaaa.nih.gov/ ROSS UNIVERSITY SCHOOL OF MEDICINE 1. Describe the essential components of the medical model of substance use disorders. Healthy vs. Diseased Brains Decreased Brain Metabolism in Substance Use Disorder Patient Healthy Brain Diseased Brain/ Cocaine Abuser High Low Decreased Heart Metabolism in Heart Disease Patient Healthy Heart Diseased Heart Fowler, J.S., Volkow N.D., Kassed, C.A., & Chang, L. (2007). Imaging the addicted human brain. Sci Pract Perspect 3(2):4-16. ROSS UNIVERSITY SCHOOL OF MEDICINE 1. Describe the essential components of the medical model of substance use disorders. Structurally… Neuronal Dendrites in the Nucleus Accumbens Robinson, T.E., &, Kolb, B. (1997). Persistent structural modifications in nucleus accumbens and prefrontal cortex neurons produced by previous experience with amphetamine. J Neurosci 17: 8491–8497. Saline Amphetamine ROSS UNIVERSITY SCHOOL OF MEDICINE 1. Describe the essential components of the medical model of substance use disorders. Functionally…. Dopamine Receptors are Decreased by Addiction. DA D2 Receptor Availability Cocaine Methamphetamine Alcohol Heroin Control Addicted ROSS UNIVERSITY SCHOOL OF MEDICINE 1. Describe the essential components of the medical model of substance use disorders. The Films Remember the Stages of Changes from the Health Promotion Lecture! National Institute of Drug Abuse / HBO ROSS UNIVERSITY SCHOOL OF MEDICINE 1. Describe the essential components of the medical model of substance use disorders. Non-Substance-Related Disorders: Gambling Disorder Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12-month period. 1) Needs to gamble with increasing amounts of money in order to achieve the desired excitement. 2) Is restless or irritable when attempting to cut down or stop gambling. 3) Has made repeated unsuccessful efforts to control, cut back, or stop gambling. 4) Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble. Criterion A 5) Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed). 6) After losing money gambling, often returns another day to get even (e.g., “chasing” one’s losses). 7) Lies to conceal the extent of involvement with gambling. 8) Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling. 9) Relies on others to provide money to relieve desperate financial situations caused by gambling. Criterion B The gambling is not better explained by a manic episode. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association. ROSS UNIVERSITY SCHOOL OF MEDICINE 1. Describe the essential components of the medical model of substance use disorders. Addiction Is a Brain Disease • Compulsive behavior • Continued abuse of drugs despite negative consequences • Persistent changes in the brain’s structure and function Volkow, N.D., Chang, L., Wang, G.J., Fowler, J.S., Franceschi, D., Sedler M., et al. (2001). Loss of dopamine transporters in methamphetamine abusers recovers with protracted abstinence. Journal of Neuroscience. Dec 1;21(23):9414-9418. ROSS UNIVERSITY SCHOOL OF MEDICINE 2. Define the purpose and structure of screening, assessment, and treatment. Define the Purpose and Structure of Screening, Assessment, and Treatment Screening • Determines the likelihood that a patient has co-occurring substance use and mental disorders or that his or her presenting signs, symptoms, or behaviors may be influenced by co-occurring issues. • The purpose is not to establish the presence or specific type of such a disorder, but to establish the need for an in-depth assessment. • Screening is a formal process that typically is brief and occurs soon after the patient presents for services. Assessment • Gathers information; engages in a process with the patient that enables the provider to establish (or rule out) the presence or absence of a co-occurring disorder. • Determines the patient’s readiness for change, identifies patient’s strengths or problem areas that may affect the processes of treatment and recovery, and engages the patient in the development of an appropriate treatment relationship. Treatment • Develops a comprehensive set of staged, integrated program placements and treatment interventions for each disorder that is adjusted as needed to take into account issues related to the other disorder. The plan is matched to the individual needs, readiness, preferences, and personal goals of the patient. Center for Substance Abuse Treatment. Screening, Assessment, and Treatment Planning for Persons With CoOccurring Disorders (2006). COCE Overview Paper 2. DHHS Publication No. (SMA) 06-4164 Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services. ROSS UNIVERSITY SCHOOL OF MEDICINE 2. Define the purpose and structure of screening, assessment, and treatment. Screening Using the CAGE • 4 items CAGE Screening • Yes/No responses • Screens for abuse and dependence • Administered through interview • 1 or more positive answer indicates at-risk substance use • Sensitivity = 43-94% • Specificity = 78-96% Ewing, J.A. (1984). Detecting alcoholism: The CAGE questionnaire. JAMA: Journal of the American Medical Association, 252, 1905–1907. ROSS UNIVERSITY SCHOOL OF MEDICINE 2. Define the purpose and structure of screening, assessment, and treatment. Screening Using the CAGE • Have you ever felt that you should Cut down on your drinking? • Have people Annoyed you by criticizing your drinking? CAGE Screening • Have you ever felt bad or Guilty about your drinking? • Have you ever taken a drink first thing in the morning to steady your nerves or get rid of a hangover? (Eye opener) Ewing, J.A. (1984). Detecting alcoholism: The CAGE questionnaire. JAMA: Journal of the American Medical Association, 252, 1905–1907. ROSS UNIVERSITY SCHOOL OF MEDICINE 2. Define the purpose and structure of screening, assessment, and treatment. Assessment: Multidimensional • 1) Acute intoxication and/or withdrawal potential • 2) Biomedical conditions and complications • 3) Emotional, behavioral, or cognitive conditions and complications • 4) Readiness to change American Society of Addiction Medicine (ASAM) • 5) Relapse, continued use, problem potential Six Assessment Dimensions • 6) Recovery/living environment Gastfriend, D.R., & Mee-Lee, D. (2010). “Patient Placement Criteria”, Chapter 4, pp 99-123 in Marc Galanter & Herbert D. Kleber (eds) Psychotherapy for the Treatment of Substance Abuse Treatment (4th ed.). American Psychiatric Publishing, Inc. Washington, DC. ROSS UNIVERSITY SCHOOL OF MEDICINE 3. Demonstrate knowledge of treatment standards and recommend appropriate referrals. Principles of Effective Treatment Addiction is a complex but treatable disease that affects brain function and behavior. No single treatment is appropriate for everyone. Treatment needs to be readily available. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. Remaining in treatment for an adequate period of time is critical. https://findtreatment.samhsa.gov/ National Institute on Drug Abuse. (2012). Principles of drug addiction treatment: A researchbased guide (3rd ed). National Institute on Drug Abuse, National Institutes of Health. ROSS UNIVERSITY SCHOOL OF MEDICINE 3. Demonstrate knowledge of treatment standards and recommend appropriate referrals. Principles of Effective Treatment Behavioral therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. Many drug-addicted individuals also have other mental disorders. https://findtreatment.samhsa.gov/ National Institute on Drug Abuse. (2012). Principles of drug addiction treatment: A researchbased guide (3rd ed). National Institute on Drug Abuse, National Institutes of Health. ROSS UNIVERSITY SCHOOL OF MEDICINE 3. Demonstrate knowledge of treatment standards and recommend appropriate referrals. Principles of Effective Treatment Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. Treatment does not need to be voluntary to be effective. Drug use during treatment must be monitored continuously, as lapses during treatment do occur. Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary. https://findtreatment.samhsa.gov/ National Institute on Drug Abuse. (2012). Principles of drug addiction treatment: A researchbased guide (3rd ed). National Institute on Drug Abuse, National Institutes of Health. ROSS UNIVERSITY SCHOOL OF MEDICINE 3. Demonstrate knowledge of treatment standards and recommend appropriate referrals. Treatment: American Society of Addiction Medicine’s (ASAM) Patient Placement Criteria Level II - Intensive outpatient/partial hospitalization (e.g., 10-15 hours per week) Early intervention (e.g., patient education, prevention efforts, etc.) 0.5 Medicallymanaged intensive inpatient (e.g., detoxification, 214 days) 1.0 Outpatient services (e.g., counseling, 1-2 hours per week) 2.0 3.0 4.0 Residential / Inpatient services (e.g., 1-6 months) Substance Abuse and Mental Health Services Administration - https://www.samhsa.gov/ Mee-Lee, D. (2006). Development and implementation of patient placement criteria. New developments in addiction treatment. Academic highlights. J Clin Psychiatry, 67(11):1805-7. ROSS UNIVERSITY SCHOOL OF MEDICINE 4. Demonstrate knowledge of prescription drug misuse and recognize risk factors for overdose. Misuse of Prescription Drugs Central nervous system depressants Opioids Used to treat pain oxycodone and hydrocodone Used to treat anxiety and sleep disorders tranquilizers, sedatives (alprazolam, diazepam), and hypnotics (zolpidem) Stimulants Used to treat attention-deficit hyperactivity disorder (ADHD) – methylphenidate, dextroamphetamine Mee-Lee, D. (2006). Development and implementation of patient placement criteria. New developments in addiction treatment. Academic highlights. J Clin Psychiatry, 67(11):1805-7 ROSS UNIVERSITY SCHOOL OF MEDICINE 4. Demonstrate knowledge of prescription drug misuse and recognize risk factors for overdose. Misuse of Prescription Drugs: Overview Nearly 200 lives lost to drugs every day in 2019. 86% of all drug overdose deaths involved opioids and/or stimulants. Opioids were found in most deaths involving benzodiazepines, anti-depressants. As of June 2020, the risk of having contracted COVID-19 was10.2x higher for people with an opioid use disorder diagnosis in the prior year and 6.5x higher for those with a prior-year cocaine use disorder diagnosis. Drug overdose deaths nearly doubled from 2010-2019. Wang QQ, Kaelber DC, Xu R and Volkow ND. COVID-19 risk and outcomes in patients with substance Uue disorders: Analyses from electronic health records in the United States. Molecular Psychiatry. 2021;26(1):30-39. doi:10.1038/s41380-020-00880-7 https://nihcm.org/publications/dyingfrom-drugs-a-new-look-at-overdosedeaths-in-the-us Mee-Lee, D. (2006). Development and implementation of patient placement criteria. New developments in addiction treatment. Academic highlights. J Clin Psychiatry, 67(11):18057 2006;67(11):1805-7. ROSS UNIVERSITY SCHOOL OF MEDICINE 4. Demonstrate knowledge of prescription drug misuse and recognize risk factors for overdose. Signs and Symptoms of Prescription Drug Abuse Opioid Painkillers Sedatives and Anti-Anxiety Medications Stimulants Constipation Drowsiness Reduced appetite Nausea Confusion Agitation Feeling high (euphoria) Unsteady walking High body temperature Slowed breathing rate Slurred speech Insomnia Drowsiness Poor concentration High blood pressure Confusion Dizziness Irregular heartbeat Poor coordination Problems with memory Anxiety Increased pain with higher doses (i.e., hyperactivation/opioid-induced hyperalgesia) Slowed breathing Paranoia McCabe S.E., Teter, C.J., & Boyd, C.J. (2006). Medical use, illicit use, and diversion of abusable prescription drugs. J Am Coll Health, 54:269–78. ROSS UNIVERSITY SCHOOL OF MEDICINE 4. Demonstrate knowledge of prescription drug misuse and recognize risk factors for overdose. Other Signs and Symptoms of Prescription Drug Abuse (Continued) Stealing, forging, or selling prescriptions Taking higher doses than prescribed. Displaying excessive mood swings or hostility. Increasing or decreasing sleep. Demonstrating poor decision-making. Appearing to be high, unusually energetic or revved up, or sedated. Continually "losing" prescriptions, so more prescriptions must be written. Seeking prescriptions from more than one doctor. ROSS UNIVERSITY SCHOOL OF MEDICINE 4. Demonstrate knowledge of prescription drug misuse and recognize risk factors for overdose. Overdose Risk Factors Any prescription for an opioid High-dose opioid prescription Recent abstinence (e.g., jail, detox, treatment) Poly-substance use Poverty Age Illness ROSS UNIVERSITY SCHOOL OF MEDICINE Physician’s Role and Associated Healthcare Teams Childcare Services Substance Abuse Services Housing Services Vocational Services Peer Support Services Clinical Management FaithBased Services Financial Services Screening / Assessment Mental Health Services Treatment Pharmacotherapy Family Services Continuing Care Transportation Services Educational Services Legal Services HIV/AIDS Services ROSS UNIVERSITY SCHOOL OF MEDICINE