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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Zoned, Stoned And Blown Pain Psych R X And C D Cady At Oliver
- 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
- 3. ADD – inattentive, without Rx ADD – inattentive, on Adderall Images courtesy of Daniel Amen, MD – Amen Clinics, Inc., Newport Beach, CA
- 8. Horrigan J, et al. Presented at 47 th Annual AACAP Meeting: October 24-29, 2000. New York, NY.
- 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
- 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!
- 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
- 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
- 24. Adrenal Burnout
- 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
- 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).
- 35. Concepts in Recovery and Sobriety Maintenance co-developed with Lisa Seif, LCSW, CADAC, CSAMS – CWI Therapist
- 36. “ The phenomenon of craving” William Duncan Silkworth, MD
- 44. What happens when you slip?
- 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.
- 47. Know When to Fold’Em
- 49. "If I hadn't believed it, I wouldn't have seen it." - Yogi Berra Personal collection Louis B. Cady, M.D.
- 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.
- 51. Thanks for coming! Please fill out evaluations! Contact info: Louis B. Cady, MD – 812-429-0772 ( [email_address] )
Editor's Notes
- 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 &quot;something more than human power is needed to produce the essential psychic change&quot; vital to sustained sobriety. Nor did he &quot;hold with those who believe that alcoholism is entirely a problem of mental control.&quot; 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. &quot;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.&quot; When the chips are down, Dr. Silkworth concluded, &quot;the only relief we have to suggest is entire abstinence.&quot;