Psychopharm lecture 7: Pharmacotherapy and addiction

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  • 1. Psychopharmacholog y Lecture 7 – Psychopharmachology of Addiction S
  • 2. Adjustment to Living with a DiagnosisS Social impacts: Relationships, energy levels, self-concept and its impact on fxn.S Adjustements to the disease process e.g. changes to daily rutines, learning new skills (OT and PT), building self acceptance and dealing with psychological strain.S Grief Stages: 1. Deniel and Isolation, 2. Anger, 3. Bargining, 4. Depression and 5. Acceptance.S Dealing with ablism and identity development.
  • 3. Four types of integration indisability identity development.S (1) "coming to feel we belong" (integrating into society);S (2) "coming home" (integrating with the disability community)S (3) "coming together" (internally integrating our sameness and differentness)S (4) "coming out" (integrating how we feel with how we present ourselves). Four types of integration in disability identity development. Gill, Carol J. Journal of Vocational Rehabilitation, Vol 9(1), Aug 1997, 39-46. doi: 10.1016/S1052-2263(97)00020-2
  • 4. Types of Pharmachological InterventionsS Disorder based interventions e.g. treat depression with SSRIs and or CBT. S Positive: Multiple symptoms are treated as a cluster. S Negitive: May not reach spacific client needs.S Symptom based interventions e.g. treating sleep problems or pain problems with a more sedating tricyclic medication. S Positive: Treats spacific concerns directly. S Negative: Polypharmacy (or… She swallowed the spider to catch the fly. I don’t know why she swalllowed the fly…)
  • 5. Psychologists as Pharmacology ConsultantS Prescribing (Louisianna, New Mexico, Navey) Significant post graduate training.S Colaborating – Actively engage with support and dialog about paitient care and medication selection.S Providing Information – Discuss medication information, identify client concers, support adherence, identify side effects and communicate concerns with providers.S Each level of engagement in the treatment process has specific ethical guidelines.
  • 6. Psychologists as Pharmacology ConsultantS Psychologists have begun to realize just how valuable psychopharmacological training can be.S Psychopharmacological training for psychologists is the new face of psychology.S It can prepare the psychologist to S (a) Collaborate with physicians in order to craft the right psychopharmacological regimen for their mutual patients. S (b) Recognize which symptoms are likely to benefit from the use of medications. S (c) Examine possible drug–drug interactions. S (d) Make sure that the prescription decisions being made are actually in the best interest of the patient.
  • 7. Working withMedical ProvidersS People become doctors to help. Medical providers want their patients to do well.S Basic Prinicipals of Clinical Consult with Medical Provider: S Listen to the consulting question. S Be cofortalble with the limits of your knowledge but speak the providers language. S They are the provider you ―make a recommendation for a medication evaluation.‖ S Be focused and direct. Say concerns in 3 sentenses or less. S Give suggestions through questions.
  • 8. Medication of the Week PresentationS Describe a medication briefly,S Describe what it is used to treatS Describe its side effectsS Describe other relivent information.
  • 9. Dopamine HypothesisS Dopamine is related to pleasure and thus rewards drug use. S Slot machine argument: We pull the lever on the slot machine because it fills us with dopamine and dopamine feels good.S Beyond Dopamine: S Individuals with addiction have lower dopamine response to drug but higher response to drug cues. S Some studies indicate that those with addiction problems fail to ―habbituate‖ to the reward signals of drug behavior. S Some studies indicate that the under activation in OFC (front brain related to regulation of impulsivity) and ACC (Anterior cyngulate cortex related to compulsivity) mean that poor executive control, emotion regulation and decision making may be central to addiction processes.
  • 10. FRAMES approachS Feedback regarding personal risk or impairment is given to the individual following an assessment of substance use patterns and associated problems.S Responcibiliy for change is placed squarely and explicitly with the individual. Clients have the choice to either continue their substance use behavior or change it.S Advice about changing—reducing or stopping—substance use is clearly given to the individual by the clinician in a nonjudgmental manner.S Menu of self-directed change options andreatment alternatives is offered to the client.S Empathetic counseling, showing warmth, espect, and understanding, is emphasized. Empathy entails reflective listening.S Self-efficacy or optimistic empowerment is engendered in the person to encourage
  • 11. Stages of ChangeS From Precontemplative to Contemplative S Create client doubt about the commonly held belief that substance abuse is ―harmless‖ S Lead to client conviction that substance abuse is having, or will in the future have, significant negative results.S From Contemplation to Preparation S Enhance intrinsic and extrinsic motivators for change. S Reexplore the client’s values in relation to change. S Clinicians can use decisional balancing strategies to help clients thoughtfully consider the positive and negative aspects of their substance use.
  • 12. Stages of ChangeS From Contemplation to Action S There appears to be a limited period of time during which change should be initiated. S Sings of readiness: The client’s resistance (i.e., arguing, denying) decreases. The client asks fewer questions about the problem.The client shows a certain amount of resolve and may be more peaceful, calm, relaxed, unburdened, or settled. The client makes direct self- motivational statements reflecting openness to change and optimism. S Clinician actions: Remove barriors, elicit social support, and negotiate treatment types.
  • 13. Stages of ChangeS From Action to Maintenance: S Help the client identify and sample substance-free sources of pleasure—i.e., new reinforcers. S Support lifestyle changes. S Help the client practice and use new coping strategies to avoid a return to substance use. S Behavioral Chain Annalysis
  • 14. Case DiscussionS Identify clinical cases for case consult at end of training that have a pharmachologcial and a health component of care.S We will have 30 min for case consultation.
  • 15. Alcohol Intoxication and WithdrawalS Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal.S Combination of medical and psychosocial interventions.S Levels of Care S 1. Ambulatory Detoxification Without Extended Onsite Monitoring. S 2. Ambulatory Detoxification With Extended Onsite Monitoring S 3. Clinically Managed Residential Detoxification S 4. Medically Monitored Inpatient Detoxification S 5. Level IV-D: Medically Managed Intensive Inpatient Detoxification.
  • 16. Alcohol Intoxication and WithdrawalS Hallucinations (auditory, S Restlessness, irritability, anxiety, visual, or tactile) agitationS Delusions, usually of S Anorexia, nausea, vomiting paranoid or persecutory varieties S Tremor, elevated heart rate, increased blood pressureS Grand mal seizures S Insomnia, intense dreaming,S Hyperthermia nightmaresS Delirium/disorientation with S Poor concentration, impaired regard to time, place, person, memory and judgment and situation; fluctuation in level of consciousness S Increased sensitivity to sound, light, and tactile sensations
  • 17. Alchol Withdraw ManagementS Not all individuals with alcohol addiction will need medical attention.S Discomfort and stress often predict a relapse.S Things that might indicate the need for attention are: S 1. Clients who have a history of the most extreme forms of withdrawal, that of seizures and/or delirium. (Immediate attention needed). S 2. Patients who are already in withdrawal and demonstrating moderate symptoms of withdrawal also require immediate medication. S 3. For those still intoxicated reevaluate need for treatment over the corse of a day. Higher risk group: longterm use, older age, number of withdrawls.
  • 18. Drugs to manage Alcohol WithdrawlS Benzodiazepine: First line treatment. (Four methods: 1. Loading – every 2-3 hours a dose, 2. Symptom initiated therapy – needs clinicians trained to notice symptoms, 3. Gradual Tapering dose, 4. Single Daily Dose).S Problems with benzodiazipine use: S Synergistic effects with alcohol use that could be deadly. S Less evidence that use on sucessive detoxes has same effects for preventing siezures. S Benzodiazipines can ―trigger‖ use.
  • 19. Medications Used in Alcohol WithdrawlS BarbituratesS AnticonvulsantsS Beta blockers/alpha adrenergic agonistsS AntipsychoticsS Benzodiazepine and/or barbiturate intoxication need a differential assessment
  • 20. Opioid Intoxication and WithdrawalIntoxifacation WithdrawlS Sedation S High body temperature, Insomnia, Pain, Vomiting,S Pinpoint pupils Enlarged pupilsS Slowed movement S Abnormally heightened reflexesS Slurred speech S Sweating,Gooseflesh,Increased respiratory rate.S Head nodding S Anxiety, Pain.
  • 21. Treatment of Opiod WithdrawlS Non-medically supported withdrawl is contraindicated for opiods.S Methadone is the most common drug: S Blocks μ-opioid receptor displacing haroin. S Intial dose based on use amount. S Tapered to 5 – 10 mgs of 3-5 days.S Colidine (Catapres) – Lower abuse potential S Clonidine alleviates some symptoms of opioid withdrawal, it usually is relatively ineffective for insomnia, muscle aches, and drug craving. Intial dose based on use amount. S It has specificity towards the presynaptic α2 receptors in the vasomotor center in the brainstem. This binding decreases presynaptic calcium levels, and inhibits the release of norepinephrine (NE). The net effect is a decrease in sympathetic tone
  • 22. Treatment of Opiod WithdrawlS Buprenorphine (Suboxone, Subutex) S Partialμ- opiod agonist. S It is a safer medication due to its celing effect and lower ability to overdose. S It can be administered on an out paitient basis. S Can be both used for accute detox and maintenance treatment.
  • 23. Signs of Addiction to Pain MedicationS Multiple episodes of ―lost‖ or stolen prescriptions.S Repeatedly running out of medication earlyS Aggressive complaints about the need for additional prescriptionsS Drug hoarding during periods of reduced symptomsS Urgent calls or unscheduled visitsS Using the medication to achieve euphoric effectsS Unapproved use of prescribed opioid to self-medicate another problem, such as insomnia
  • 24. BenzodiazepineWithdrawlS Benzodiazepine and other sedative-hypnotic abstinence syndrome management S Flumazenil (Romazicon) - competitive antagonist that acts as a benzodiazepine (does not work when alch. or other hypnotic is taken). S Slow taper over weeks and months. S Switching to a slower acting benzodiazipine. S Possible: Imiprimine, depakote, tegratol, trazadone (sedating anti-dep) S Multiple Cog. Techniques support withdrawl along with reducing life stress.
  • 25. Stimulant WithdrawlS Most common stimulants: Cocain and amphetimine.S Stimulant withdrawal symptoms: Depression, Hypersomnia or insomnia, Fatigue, Anxiety, Irritability, Poor concentration, Psychomotor retardation, Paranoia, Drug craving.S No medication exist for stimulant withdrawl.S Siezures can occure during stimulant use/abuse and withdrawl, alch. and stimulants combined can cause heart conditions.S Medications under review: Disulfiram and Amantadine may help reduce cocaine use in patients; Modafinil, an anti-narcolepsy agent with stimulant- like action; Antidepressants can be prescribed for the depression that often accompanies methamphetamine or other amphetamine withdrawal.
  • 26. Nicotine Withdrawl Agents Used to Treat Nicotine Withdraw Nicotine WithdrawS Depressed mood S Bupropion SR S Nicotine Replacement Therapy (NRTS Insomnia S TheophyllineS Anger, irritability S Caffeine: StimulantS Anxiety S Tacrine S Imipramine: Tricyclic.S Difficulty concentraiting S Haloperidol: AntipsychoticS Restlessness S PentazocineS Decreased heart rate S Propranolol: Betablocker. S Flecainide:S Increased appitite or wieght S Estradiol: gain.
  • 27. Managing Addiction: AlcoholS Disulfiram (Antabuse): Inhibits bodies ability to brake down alch. causing increased symptoms and discomfort intended as a punishment paridigm can result in death. No data indicates that it is clearly effective or increases abstinance rates.S Naltrexone (ReVia): Effects the opiod system (antagonist) effects drinking sequence e.g. reduced craving, and reinforcement and increased nausia and headaches.S Acamprosate (Campral): Agonist GABA, Inhibits NMDA (glutamate). Equal in head to head trials to Natroxone.
  • 28. Managing Addiction: OpioidsS Methadone: Requires going to methadone clinic daily. More then 150,000 people are in clinics in US. Best practices require sig. psychosocial support along with tx many places do not offer these services.S Buprenorphine (Suboxone and Subutex): Similar to methadone for outcomes. No need to visit registered clinic.S Levoalpha Acetyl Methadol (LAAM): Less frequent dosing then methadone, comparable abstinance rates the methadone (higher drop out then methadone).
  • 29. Biopsychosocial TreatmentS Medication Adherence: Stages of change for medication adherence, understanding health beliefs and psychoeducation. (Medication, Education, Motivation)S Developing Social Support: Enhancing current social support, developing new constructive relationships, developing good relationship habbits and self-respect.S Cognitive and Affective Support: Developing emotional regulation skills, cognitive skills, healthy self-talk, changing core belifes and good coping habbits for triggers.S Developing healthy habbits: Eating, sleeping, exercise, healthy fun (hungry angry, lonely, tiered, no exercise).S Treatment Team: Develop and support treatment team and treat comorbid MH concerns (ACE’s).
  • 30. Co-morbidity: Addiction and Mental HealthS High comorbidity of MH and and addiction.S Many people have Health, MH and Addiction problems. Each of these can be a trigger for relapse. Treatment team approach is vital.S Often MH and Substance Abuse were siloed and there was no connection with PCP. This lead to a ping-ponging between services and clinicians playing a game of wac-a-mole.S If you are going to remove a coping mechanism a person needs some coping to put in its place.
  • 31. Co-morbidity: Addiction and Mental HealthS Careful with this kind of thinking: S All mental health symptoms are caused by addiction. S MH symptoms are often missed due to this type of thinking. S Pitfall = Not checking once sobriety is maintained to see if MH symptoms persist.S Treat health, mental health and addiction together. Pull together treatment aspects: Skills, Social, Health and MH.S Assessment: S Include a review of chronologic history, including time frames for onset and continuation of both mental and substance use disorders S include a review of current and previous pharmacotherapy for behavioral disorders effectiveness and problems encountered; S Review family mental health history.
  • 32. Co-morbidity: Addiction and Mental HealthS In general medications that treat a MH concern for those who have no addiction will also be effective for those with addiction symptoms.S Considerations: S Synergistic and counter effects effects of medications and street drugs e.g. nicotine can reduce the availibility of antipsychotic medications. S Look for parsimonious treatments e.g. depakote reduces impulsivity in addiction, treats siezures and bi-polar dissorder. S Educate clients about medications, side effects and risks.
  • 33. Co-morbidity: Addiction and Mental HealthS Assess for: PTSD, personality dissorders, anxiety and depression.S Assess risk factors in all those treated for addiction (be able to say if a client is high, medium or low risk for SI or HI).S Right before a relapse there is often an emotional spike (Insular cortex). Increased emotional regulation skills and capasity for distress tolerance could be vital.
  • 34. CasCase Consultation S
  • 35. Closing Questions