Zoned, Stoned And Blown Pain Psych R X And C D Cady At Oliver

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Review by Louis B. Cady, MD (Cady Wellness Institute) of the interdigitation between psychiatric disorders, chemical dependency and issues in treatment and recovery. This presentation reviews the enormous intertwinement between untreated ADHD and the development and maintenance of substance use and chemical dependency, examining both biological and psychodynamic influences. It concludes with tips from the recovery community and recommendations on how treatment teams can collaborate with each other.

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  • Thank you so much, Ms Johnson!
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  • I thought this was a very informative and accurate presentation to share on ADHD - the whole spectrum - especially how many who suffer from this neurobiological condition, along with co-existing problems, seek very unhealthy self-medicating substances to deal with problems because they do not realize their true condition or they have been told that ADHD, depression, etc, is not real or not their problem. (Both ARE real, for those who still do not believe, there is entirely too much medical and scientific evidence to support their existence, from imaging techniques to genes that have been identified to EEG readings studied within control groups using scientific data.) Follow the resources listed at the end of the presentation. There are many, many more like this on Slideshare and other research sites.
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  • ADHD is a heterogeneous disorder associated with considerable disability and comorbidity that, in many cases, persists into adulthood. 1 Mood, anxiety, and substance use disorders are the most common comorbid disorders in adults with ADHD. 2 ADHD in adults is more prevalent than once thought. The National Comorbidity Survey found the estimated lifetime prevalence of ADHD in adults to be 8.1%. 3 According to DSM-IV criteria, adults diagnosed with ADHD must have had childhood onset and persistent and current symptoms, although allowance is made for partial remission. 4 Due to the great syndromatic continuity between childhood and adult ADHD, much of the medication management of adults with ADHD can be based on the experience gained from treating children and adolescents. 5 Barkley RA, Fischer M, Smallish L, Fletcher K. The persistence of attention-deficit/hyperactivity disorder into young adulthood as a function of reporting source and definition of disorder. J Abnormal Psychol. 2002;111:279-289. Biederman J, Faraone SV, Spencer T, et al. Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. Am J Psychiatry . 1993;150:1792-1798. Kessler RC, Berglund P, Demler O, Jin R, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry . 2005;62:593-602. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders . 4th ed. ( DSM-IV  ). Washington, DC: American Psychiatric Association; 1994:78-85. Dodson WW. Pharmacotherapy of adult ADHD. J Clin Psychol . 2005;61:589-606.
  • 237 boys 6 to 17 years old were followed prospectively for 4 years and into mid-adolescence Information on smoking history was determined using the Diagnostic Interview for Children and Adolescents/Parents’ version at the 4-year follow-up assessment only [Milberger 1997 p39] Information on frequency of cigarette smoking, age at onset/offset of smoking, and associated impairments were determined by trained interviewers blind to the subjects’ clinical status [Milberger 1997 p39] ADHD is a significant predictor of early smoking in adolescence At the end of 4 years 19% of ADHD boys were smoking compared with 10% of controls ( P =0.003)
  • The incidence of drug abuse was compared in 56 medicated ADHD patients, 19 non-medicated ADHD patients, and 137 non-ADHD control subjects [Biederman 1999 pe21] Non-medicated ADHD patients were at a significantly higher risk for substance abuse than controls or medicated ADHD patients [Biederman 1999 pe22-23] There was no significant difference between medicated ADHD patients and controls (chi-squared=3.7, P =0.15) [Biederman 1999 pe22-23] Medication is associated with an 85% reduction in the risk of substance abuse in ADHD patients [Biederman 1999 pe22-23] Poor compliance is often a more significant problem than addiction [Garland, 1998 p 387-388]
  • Onset of substance abuse in subjects with ADHD averaged 3 years earlier than controls (late adolescence/early adulthood) ADHD was a significant risk factor independent of comorbid diagnoses
  • An examination of the distinguishing features of ADHD and BPD shown on the slide will aid in diagnosing either of the disorders or the comorbidity. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders . 4th ed. ( DSM-IV  ). Washington, DC: American Psychiatric Association; 1994:78-85, 350-363.
  • Studies comparing methylphenidate, dextroamphetamine, and pemoline have demonstrated equivalent efficacy. However, there is much individual variability in response to any one particular psychostimulant. That is, a particular patient may not respond to methylphenidate, but may respond well to an amphetamine medication. This slide shows results of a meta-analysis of six controlled within-subject comparisons of methylphenidate and amphetamine. Of the 174 subjects, 28% responded best to amphetamine, 16% responded better to methylphenidate, while the remaining 41% responded equally well to either stimulant. The response rate for any one particular stimulant medication is approximately 70%. No predictors of response have been identified; that is, there is no way to know whether a patient will respond to one stimulant vs. another. Because patients may have a preferential response to one stimulant medication, different stimulants should be tried before considering a patient to be a stimulant nonresponder.
  • As a consequence of his close contact with alcoholics (and he saw thousands in his lifetime), Dr. Silkworth believed that "something more than human power is needed to produce the essential psychic change" vital to sustained sobriety. Nor did he "hold with those who believe that alcoholism is entirely a problem of mental control." For instance, he said, he had treated many men who had worked assiduously on an important business deal, only to have it fall apart because they picked up a drink. "Then the phenomenon of craving at once became paramount to all other interests. These men (by 1937 he would include women) were not drinking to escape; they were drinking to overcome a craving beyond their mental control." When the chips are down, Dr. Silkworth concluded, "the only relief we have to suggest is entire abstinence."
  • Zoned, Stoned And Blown Pain Psych R X And C D Cady At Oliver

    1. 2. Zoned, Stoned and Blown: The Emotional Tsunami of Psychiatric Disorders Coupled with Pain Disorders & Chemical Dependency Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute Adjunct Professor – University of Southern Indiana Adjunct Clinical Lecturer – Indiana University School of Medicine Department of Psychiatry Child, Adolescent, Adult & Forensic Psychiatry – Evansville, Indiana
    2. 3. ADD – inattentive, without Rx ADD – inattentive, on Adderall Images courtesy of Daniel Amen, MD – Amen Clinics, Inc., Newport Beach, CA
    3. 4. Never mind the pictures. Adult ADD isn’t real, is it? <ul><li>Study of 24 ADHD adults vs. 18 controls </li></ul><ul><li>Comparable on age, SE status, sex, handedness, education, IQ and achievement tests </li></ul><ul><li>MRI on 1.5 T Siemens scanner; image parcellation of neocortex into 48 gyral based units </li></ul>Seidman LJ, et al. Biol Psychiatry. 2006 Nov 15;60(10):1071-80
    4. 5. Volumetric Adult ADHD study, cont. <ul><li>Relative to controls, ADHD adults had: </li></ul><ul><ul><li>Significantly smaller overall cortical gray matter </li></ul></ul><ul><ul><li>Smaller prefrontal cortex </li></ul></ul><ul><ul><li>Smaller anterior cingulate cortex </li></ul></ul><ul><li>CONCLUSIONS: </li></ul><ul><ul><li>Adults with ADHD have volume difference in brain regions in areas involved in attention and executive control. </li></ul></ul><ul><ul><li>These data, largely consistent with studies of children, support the idea that adults with ADHD have a valid disorder with persistent biological features. </li></ul></ul>Seidman LJ, et al. Biol Psychiatry. 2006 Nov 15;60(10):1071-80
    5. 7. Kids and Adults – Differences in HYPERACTIVE domain <ul><li>AS A CHILD: </li></ul><ul><li>Squirming, fidgeting </li></ul><ul><li>Cannot stay seated </li></ul><ul><li>Cannot wait turn </li></ul><ul><li>Runs/climbs excessively </li></ul><ul><li>Cannot play quietly </li></ul><ul><li>On the go/driven by motor </li></ul><ul><li>Talks excessively </li></ul><ul><li>Blurts out answers </li></ul><ul><li>Intrudes, interrupts others </li></ul><ul><li>AS AN ADULT: </li></ul><ul><li>Work inefficiencies </li></ul><ul><li>Can’t sit through meetings </li></ul><ul><li>Cannot wait in line </li></ul><ul><li>Drives too fast </li></ul><ul><li>Self-selects very active job </li></ul><ul><li>Cannot tolerate frustration </li></ul><ul><li>Talks excessively </li></ul><ul><li>Makes inappropriate comments </li></ul><ul><li>Interrupts others </li></ul>Sources: DSM-IV (TR). APA 2000:85-93) Weiss MD, Weiss JR. J Clin Psychiatry 2004;65(Suppl 3):27-37.
    6. 8. Horrigan J, et al. Presented at 47 th Annual AACAP Meeting: October 24-29, 2000. New York, NY.
    7. 9. Persistence of ADHD Into Adulthood <ul><li>ADHD is a heterogeneous disorder associated with considerable disability and comorbidity that, in many cases, persists into adulthood 1 </li></ul><ul><ul><li>Some studies have found persistence as high as 36.3% 2 </li></ul></ul><ul><li>Mood, anxiety, and substance use disorders are the most common comorbid disorders in adults with ADHD 3 </li></ul><ul><li>Current prevalence of ADHD persistent into adulthood 4.4% 4 </li></ul><ul><li>Much of the treatment of adult ADHD can be based on experience in treating children/adolescents 5 </li></ul><ul><li>Barkley et al. J Abnorm Psychol . 2002;111:279-289. </li></ul><ul><li>Kessler RC et al. Biol Psychiatry 2005 June;57(11):1442-51. [retrospective review of 3,197 14-44 yo respondents in NCS-R] </li></ul><ul><li>Biederman et al. Am J Psychiatry . 1993;150:1792-1798. 4. Kessler et al. Am J Psychiatry. 2006;163(4):716-23 . 5. Dodson WW. J Clin Psychol . 2005;61:589-606. </li></ul>
    8. 10. Psychiatric disorders (lifetime) in adults with ADHD [multiple sources, % is estimated; N.B. – this is WITHOUT TREATMENT GROWING UP ] <ul><li>Substance use disorders (all) 50% </li></ul><ul><li>Anxiety disorders 40% </li></ul><ul><li>Major depression 35% </li></ul><ul><li>Learning disabilities 20% </li></ul><ul><li>Bipolar disorder 10% </li></ul><ul><li>Antisocial disorder 10% </li></ul>
    9. 11. % of patients with ADHD presenting with OTHER psychiatric disorders [“Reverse comorbidity”] <ul><li>Major depression: 20% have ADHD </li></ul><ul><li>Bipolar disorder: 15% have ADHD </li></ul><ul><li>Generalized anxiety disorders: 20% have ADHD </li></ul><ul><li>Substance abuse: 25% have ADHD </li></ul><ul><ul><li>Sources: Alpert, et al. Psychiatry Res. 1996;62:213. Nierenberg et al. Presented at the 157 th Annual Meeting of the APA 2002. Faraone S et al. J . Affect Disorder 2000; 58:99. Wilens. Psych Clinic N. Am 2004. </li></ul></ul>
    10. 12. Earlier Initiation of Smoking with ADHD 237 6 to 17-year-old boys 0.6 0.5 0.4 0.3 0.2 0.1 0 Smoking probability 0 2 4 6 8 10 12 14 16 18 20 22 24 P <0.003 ADHD n=128 Control n=109 Milberger S, et al. J Am Acad Child Adolesc Psychol. 1997;36:37-44. 4 year follow-up
    11. 13. SUD’s in Adolescents with ADHD <ul><li>75% - non medicated ADHD (n=19) [p<.001] </li></ul><ul><li>25% - medicated ADHD (n=56) </li></ul><ul><li>18% - Non-ADHD control (n=137) </li></ul>Biederman et al Pediatrics 1998; 104:e20
    12. 14. Pharmacotherapy Significantly Reduces Substance Abuse in Adults with ADHD Biederman J, et al. Pediatrics. 1999;104:e20-e25. 40 30 20 10 0 % of study population Unmedicated ADHD Medicated ADHD Control 32 12 10 P <0.001 (N=56) (N=19) (N=137) 3-fold!
    13. 15. Increased Lifetime Substance Abuse in Untreated Adults with ADHD Biederman, et al. Biol Psychiatry. 1998;44:269-273. Lifetime rate of substance abuse in referred ADHD adults 0 10 20 30 40 50 60 55% Control (n=268) ADHD (n=239) 27% P <0.001
    14. 16. The 3 Big Reasons for substance abuse – Louis B. Cady, M.D. <ul><li>Looking for help </li></ul><ul><ul><li>Something to make their minds work better </li></ul></ul><ul><ul><li>Looking for something to CALM DOWN with </li></ul></ul><ul><li>Looking for Mr. Good-Drug </li></ul><ul><ul><li>Something to take AWAY the pain of failure and lack of performance, or just THE PAIN </li></ul></ul><ul><li>Hanging with the WRONG CROWD </li></ul><ul><ul><li>“ like attracts like”; “losers attract losers” </li></ul></ul>
    15. 18. ADHD vs. BPD in Adults <ul><li>ADHD </li></ul><ul><li>Constant </li></ul><ul><li>Lifelong </li></ul><ul><li>Moods triggered </li></ul><ul><li>Moods congruent </li></ul><ul><li>Instantaneous shifts </li></ul><ul><li>Thoughts “jump” </li></ul><ul><li>Family Hx of ADHD </li></ul><ul><li>Bipolar </li></ul><ul><li>Cyclical </li></ul><ul><li>Later onset (mean, 26 yrs) </li></ul><ul><li>Moods untriggered </li></ul><ul><li>Moods incongruent </li></ul><ul><li>Gradual shifts </li></ul><ul><li>Thoughts “race” </li></ul><ul><li>Family Hx of bipolar </li></ul>STEP-BD reports at least 19% comorbidity of bipolar disorder and ADHD. STEP-BD = Systematic Treatment Enhancement Program for Bipolar Disorder. American Psychiatric Association. DSM-IV ; 1994:78-85, 350-363.
    16. 19. ADHD Comorbidity with bipolar disorder – how to tell’em apart <ul><li>Adults with ADHD </li></ul><ul><ul><li>Lack severe mood lability symptoms </li></ul></ul><ul><ul><li>Moderate impairment in functions </li></ul></ul><ul><li>Adults with ADHD + BPD </li></ul><ul><ul><li>Prominent mood lability (think “rage-aholic”) </li></ul></ul><ul><ul><li>High rates of hyperactive/impulsive symptom </li></ul></ul><ul><ul><li>Episodicity of mood and overall symptoms </li></ul></ul><ul><ul><li>Severe impairment in function </li></ul></ul><ul><ul><li>Wilens et al. Biol Psychiatry 2003;54:1 </li></ul></ul>
    17. 20. LOW ENERGY – frequently occurring with depression. A “no duh,” KNOWN finding. <ul><li>People with depression have LOW ENERGY…. </li></ul><ul><li>So you…. </li></ul>Prescribe (&quot;SIG:&quot;) &quot;E - caps&quot;!!
    18. 21. Depression & Anxiety Dx in 1 Easy Lesson <ul><li>DEPRESSION SIG: E- CAPS! </li></ul><ul><li>Sleep </li></ul><ul><li>Sadness </li></ul><ul><li>Interest loss </li></ul><ul><li>Guilt </li></ul><ul><li>Energy </li></ul><ul><li>Concentration </li></ul><ul><li>Appetite </li></ul><ul><li>Psychomotor Sx </li></ul><ul><li>Suicidal thinking </li></ul><ul><li>Gen. ANXIETY D.O. </li></ul><ul><li>Somatic Sx (“ energy ”,etc.) </li></ul><ul><li>WORRY </li></ul><ul><li>Irritability </li></ul><ul><li>Concentration </li></ul><ul><li>Keyed up </li></ul><ul><li>Insomnia (“sleep”) </li></ul><ul><li>Restlessness </li></ul>SWICKIR is Quicker: Worry + 3 = GAD (Baughman) 5of 9 with 1 of 2 x 2 weeks
    19. 22. Depression & Anxiety By the Numbers: <ul><li>Depression </li></ul><ul><li>2 – 4 % of US population/year </li></ul><ul><li>Lifetime: </li></ul><ul><ul><li>21% of women </li></ul></ul><ul><ul><li>13& of men </li></ul></ul><ul><li>ANXIETY </li></ul><ul><li>4-8% of US population/year </li></ul><ul><li>60% with anxiety disorder come in with somatic symptoms! </li></ul>Adapted from Katon, W. Journal Clin Psych, 1990, Depression & Chronic Mental Illness; and - Kessler, R et al. Lifetime & 12 Month Prevalence of DSM-IIIR Psychiatric Disorders in the U.S. (Ntl Comorb. Study). Arch Gen Psych, Jan 1994, 8-19. Myers, Weissman, Tischler. Six month prevalence of psychiatric disorders in three communities. Arch Gen Psych 1984; 41:959-967. Goldberg, Bridges. The diagnosis of anixety in primary care settings. Br J Clin Pract Symp, 1985; 38 (suppl):28-33
    20. 23. Overlapping Symptoms of Depression and GAD Major Depressive Disorder (MDD) Generalized Anxiety Disorder (GAD) Depressed mood Anhedonia Appetite disturbance Worthlessness Suicidal ideation DSM-IV-TR. Washington, DC: American Psychiatric Association. 2000. Sleep disturbance Psychomotor agitation Concentration difficulty Irritability Fatigue Worry Anxiety Muscle tension Palpitations Sweating Dry mouth Nausea
    21. 24. Adrenal Burnout
    22. 28. How do you spell RELIEF? Diagnosis Symptoms Substance/Abuse Depression Sleep problems Downers, pain Rx EtOH Depression Concentration Uppers, stimulants Depression FATIGUE Uppers, stimulants Anxiety Worry, tension Downers, pain Rx, EtOH Adrenal fatigue FATIGUE Uppers, stimulants
    23. 29. Diagnostic Pearls - Cady <ul><li>How’s work? </li></ul><ul><ul><li>How has your employment history been? </li></ul></ul><ul><li>How’s your mood? Your marriage (relationship)? </li></ul><ul><li>How was school for you? </li></ul><ul><li>Are people nervous driving with you? </li></ul><ul><li>Are there periods of time when you have too much energy for no particular reason ? </li></ul><ul><li>Do you ever have to have a beer at the end of the day to relax? </li></ul><ul><ul><li>[gently lead in to other substances, especially stimulants that may have a CALMING effect] </li></ul></ul><ul><ul><li>“ Have you ever taken any of your child’s ADD Rx?” </li></ul></ul>
    24. 31. An Higelian Dialectical blend of therapeutic alternatives - Cady <ul><li>Thesis: “you can’t be treated if you are using .” </li></ul><ul><li>Anti-thesis: “ Doc, I can’t stop using unless you can do something for me.” </li></ul><ul><li>Synthesis: “Let’s see if we can work something out.” </li></ul><ul><ul><ul><li>“ crossover titration” or replacement of illicit substance with RATIONAL alternative (e.g. – cocaine with Bupropion or atomoxetine; marijuana with clonazepam or Oxycarbazepine (Trileptal ®). Must be willing to ‘GET SOBER.’ </li></ul></ul></ul><ul><ul><ul><ul><li>REFINEMENT of pharmacotherapy as case unfolds </li></ul></ul></ul></ul><ul><ul><ul><li>Willingness to get into AA/NA and GET A SPONSOR, and WORK STEPS – if appropriate. </li></ul></ul></ul><ul><li>If you don’t want to fool with it, REFER, don’t just brand them as “hopeless” or untreatable. </li></ul>
    25. 32. Current “medications” available for Adult ADHD <ul><li>Atomoxetine Nov. 2002 </li></ul><ul><li>Mixed amphetamine salts XR August 2004 </li></ul><ul><li>D-methylphenidate XR June 2005 </li></ul><ul><li>Methylphenidate OROS June 2008 </li></ul><ul><li>Lisdexamfetamine June 2008 </li></ul>
    26. 34. Response to Psychostimulants - Arnold et al. J Attention Dis. 2000;3:200. Best Response (Percent) AMP MPH Equal response to either stimulant Meta-analysis of Within-Subject Comparative Trials Evaluating Response to Stimulant Medications 28% 16% 41% AMP=Amphetamine (Adderall ® , Dexedrine ® , Dextrostat ® ); MPH=methylphenidate (Ritalin ® , others).
    27. 35. Concepts in Recovery and Sobriety Maintenance co-developed with Lisa Seif, LCSW, CADAC, CSAMS – CWI Therapist
    28. 36. “ The phenomenon of craving” William Duncan Silkworth, MD
    29. 37. People at Risk <ul><li>High Risk/High Need </li></ul><ul><li>Middle stages of CD </li></ul><ul><li>Unemployment </li></ul><ul><li>UnEMPLOYABLE </li></ul><ul><li>Undereducated </li></ul><ul><li>Few law-abiding friends </li></ul><ul><li>No stable relationship </li></ul><ul><li>Hopelessness, homelessness </li></ul><ul><li>Low risk/low need </li></ul><ul><li>Early stages </li></ul><ul><li>Employed </li></ul><ul><li>Good support system </li></ul><ul><li>Has a vision of the future </li></ul><ul><li>Spiritual foundation </li></ul><ul><li>Able to conceptualize recovery concepts </li></ul><ul><li>Motivation to change </li></ul>
    30. 38. People at risk – legal woes <ul><li>Legal </li></ul><ul><ul><li>Repeat drunk driving </li></ul></ul><ul><ul><li>Repeat drug offenses </li></ul></ul><ul><ul><li>“ Petition to revoke” </li></ul></ul><ul><ul><li>Failed urine drug screens </li></ul></ul><ul><ul><li>Antisocial behaviors (driving on suspended license, etc.) </li></ul></ul>
    31. 39. Psychosocial: <ul><ul><li>History of “ODD”, conduct problems as child </li></ul></ul><ul><ul><li>“ terminally unique” </li></ul></ul><ul><ul><li>Impatient (low impulse control – ADHD?!) </li></ul></ul><ul><ul><li>Resistant to change </li></ul></ul><ul><ul><li>No life purpose </li></ul></ul><ul><ul><li>no family support </li></ul></ul><ul><ul><li>No goals </li></ul></ul><ul><ul><li>No purpose </li></ul></ul><ul><ul><li>No pleasure </li></ul></ul>
    32. 40. Risky behaviors <ul><li>“ people places and things” </li></ul><ul><li>“ lying, cheating, and stealing” </li></ul><ul><li>Failure to follow through on recovery maintenance activities </li></ul><ul><li>Never grasping “step #1” in AA </li></ul><ul><li>Not dealing with dual diagnosis issues (medication noncompliance) </li></ul>
    33. 41. Patients at risk <ul><li>Family biology/genetics </li></ul><ul><ul><li>(psychiatric AND/or addictive disorders) </li></ul></ul><ul><li>Unenlightened, “un-shrunk” state: </li></ul><ul><ul><li>“ euphoric recall” never dealt with </li></ul></ul><ul><ul><li>“ Dry” but not “Sober.” (Not in recovery.) </li></ul></ul><ul><li>“ Hard wired” issues - Learning disabilities </li></ul><ul><li>Isolation – social, psychological, emotional </li></ul>
    34. 42. RELAPSE PREVENTION STRATEGIES <ul><li>“ Alcoholism doesn’t go away, like diabetes heart disease, cancer, blindness, paralysis… sooner or later you have to accept that you have no control over the PHYSICAL abnormalities. Counseling and support groups can’t change the way our bodies metabolize drugs, alcohol, and substances.” </li></ul><ul><li>- Cady and Seif </li></ul>
    35. 43. Step ONE!! <ul><li>“ We admitted that we were [are?] powerless over alcohol – and that our lives had become unmanageable.” </li></ul>
    36. 44. What happens when you slip?
    37. 45. Key concepts of relapse prevention <ul><li>Alcoholism/ CD don’t go away </li></ul><ul><li>Don’t treat a SYMPTOM with a medication or mind-altering substance that’s not designed to work for it. </li></ul><ul><li>Ongoing recovery is great but a drink can undo it. </li></ul><ul><li>Need to ACCEPT no control over this “physical allergy” (Silkworth) </li></ul>
    38. 46. Medication strategies (Cady) CONDITION CONFOUNDS APPROPRIATE INAPPROPRIATE ADHD Prev. Meth, Cocaine Strattera, Intuniv, Bupoprion Ritalin, Adderall, Stimulants ADHD EtOH, MJ , pain RX – to calm down Stimulant? sedatives Anxiety, Depression, ADHD Alcohol, MJ, PAIN RX TREAT THE PROBLEM, NOT THE SX – eg., SSRI’s, focused Rx for ADHD which can cause anxiety, detc. “ brain dead benzo’s” (Xanax, Klonopin) Bipolar Mood stabilizers, (?) atypicals (?) “ downers”(BZD’s) Chemically dependent Uppers/downers: Red Bull, etc.
    39. 47. Know When to Fold’Em
    40. 48. Team Approach <ul><li>COMMUNICATION between members: </li></ul><ul><ul><li>Physician (frequently not a psychiatrist) </li></ul></ul><ul><ul><li>Social worker/therapist </li></ul></ul><ul><ul><li>Probation/parole officer (judge) </li></ul></ul><ul><ul><li>School or supervisor, if appropriate </li></ul></ul><ul><li>Cross training: </li></ul><ul><ul><li>MD’s should know about recovery issues </li></ul></ul><ul><ul><li>CD workers – should know about Rx </li></ul></ul><ul><li>TIPS: </li></ul><ul><ul><li>Release of information’s need to be signed </li></ul></ul><ul><ul><li>Maintenance of collegiality </li></ul></ul>
    41. 49. &quot;If I hadn't believed it, I wouldn't have seen it.&quot; - Yogi Berra Personal collection Louis B. Cady, M.D.
    42. 50. “ For me, the practice of medicine has opened the door to the greatest adventure in life. Medicine is like a hallway lined with doors, each door opening into a different room, and each room opening into another hallway, again lined with doors. Medicine is always wonderful and never will be finished. ” - Charles H. Mayo, M.D.
    43. 51. Thanks for coming! Please fill out evaluations!  Contact info: Louis B. Cady, MD – 812-429-0772 ( [email_address] )

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