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Integrating Non-Addictive Pharmacotherapy into Abstinence-based Addiction Treatment Programmes

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Consultant Psychiatrist and Medical Director, Dr. Mike McPhillips' presentation for The Neuroscience and Addiction Conference 2009.

Consultant Psychiatrist and Medical Director, Dr. Mike McPhillips' presentation for The Neuroscience and Addiction Conference 2009.

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  • 1. Integrating Non-Addictive Pharmacotherapy into Abstinence-based Addiction Treatment Programmes Dr. Mike McPhillips Consultant Psychiatrist Medical Director
  • 2. Non-addictive medications licensed for the treatment of addiction • Disulfiram (1948 onwards) • Acamprosate (1989 onwards) • Naltrexone (1992 onwards) • Bupropion (1985 onwards) • Varenicline (2006 onwards)
  • 3. Pharmacotherapy The Industry View • An unattractive area for R&D because of: • Low numbers of very heavy users • Stigma and damage to other brands • Poor uptake and compliance • Entrenched opposition from some opinion leaders • Low numbers of qualified medical specialists • High regulation and development costs • Uncertain funding from Government • Perceived need for low cost treatments
  • 4. How many people even try these drugs? • Between 1 and 5% of those who might benefit from them. http://aspe.hhs.gov/health/reports/cocaine/4cases.htm
  • 5. Reasons for Poor Uptake of Meds • Lack of marketing, promotion (disulfiram) • Perceived toxicity/side effects • Lack of awareness (not enough specialists) • Lack of education (mainly among medical staff, nurses) • Entrenched opposition (Fellowships and non-medically trained clinic staff, confusion with addictive meds) • Denial of illness (patients) • High costs of the treatment • High costs of the associated psychotherapies required • Poor compliance with medication and follow-up
  • 6. We Have a Problem... • Our failure to deliver potentially effective medications to the people who need them results in: • Preventable morbidity and mortality • Therapeutic nihilism among staff and patients • Pharmaceutical companies unwilling to research new products for our patients
  • 7. Do Specialists Do Any Better? • Advantages for specialists • More perceived authority • More time spent with each patient • More knowledge and training • A captive audience (inpatients!) • The chance to talk to people while they are sober • Intensive psychological treatment (groups and 1:1)
  • 8. Probably... • Research shows: • More prescribing of all drugs • More confidence with prescribing • More use of combinations and off-label prescribing ❖ Even so, over 50% of patients leave inpatient treatment on no abstinence meds.
  • 9. Methadone is Sticky... • We are much better organized at delivering illicit drug substitutes than we are at delivering abstinence enhancing medicines. • Patients are much more compliant in the taking of substitute opioids like methadone, buprenorphine and diazepam.
  • 10. What can Specialists Do About Poor Uptake and Compliance? • View it as an expected problem rather than an unpleasant surprise • Seek first to engage the patient and foster a positive therapeutic rapport before prescribing • Be champions for a blend of medication with other interventions for the treatment of addiction • Education of ALL staff about what medication has to offer • Make medications available, simple, inexpensive, offer positive feedback for good adherence
  • 11. Public Perceptions of Psychiatry in 1920’s Sir Roderick Glossop, Psychiatrist “(he).. is always called a nerve specialist because it sounds better, but everyone knows he’s a sort of janitor in a looney bin” P.G. Wodehouse, The Inimitable Jeeves, 1923
  • 12. The Relationships of Doctors with the Recovery Movement “...an obsession of the mind that condemns one to drink and an allergy of the body that condemns one to die or go mad if one continues to ingest alcohol.”
  • 13. PMP: Alcohol Withdrawal Lying there in conflict, I dropped into the blackest depression I had ever known. Momentarily my prideful obstinacy was crushed. I cried out, “Now I’m ready to do anything - anything to receive what my friend Ebby has”. Though I certainly didn’t really expect anything, I did make this frantic appeal: “If there be a God, will He show Himself!” The result was instant, electric, beyond description. The place seemed to light up, blinding white. I knew only ecstasy and seemed on a mountain. A great wind blew, enveloping and penetrating me. To me, it was not of air, but of Spirit. Blazing, there came the tremendous thought “You are a free man.” Then the ecstasy subsided. Still on the bed, I now found myself in a new world of consciousness which was suffused by a Presence. One with the universe, a great peace stole over me. I thought, “So this is the God of preachers, this is the Great Reality.” But soon my so-called reason returned, my modern education took over. I thought I must be crazy and I became terribly frightened.
  • 14. Neuropsychiatric Workup, 2009 • Slx: Neuro exam, FBC, WCC, U&E, RCTransketolase, ESR/CRP +/- brain imaging, CXR blood cultures. • DDx: Withdrawal hallucinosis, incipient delirium tremens, risk of Wernicke’s encephalopathy. • Mx: Increase detox. Meds, Parenteral thiamine, small dose of antipsychotic med, +/- anticonvulsant drug.
  • 15. Dr. Silkworth’s Contribution Dr. Silkworth, a medical saint if ever there was one, came in to hear my trembling account of this phenomenon. After questioning me carefully, he assured me that I was not mad, that I had perhaps undergone a psychic experience which might solve my problem. Skeptical man of science though he then was, this was most kind and astute. If he had said “hallucination”, I might now be dead.To him I shall ever be eternally grateful.
  • 16. The Doctor’s Opinion
  • 17. The Doctor’s Opinion “To Whom It May Concern: I have specialized in the treatment of alcoholism for many years. About four years ago I attended a patient who, though he had been a competent business man of good earning capacity, was an alcoholic of a type I had come to regard as hopeless. In the course of his third treatment he acquired certain ideas concerning a possible means of recovery. As part of his rehabilitation he commenced to present his conceptions to other alcoholics, impressing upon them that they must do likewise with still others. This has become the basis of a rapidly growing fellowship of these men and their families. This man and over one hundred others appear to have recovered. I personally know thirty of these cases who were of the type with whom other methods had failed completely. These facts appear to be of extreme medical importance; because of the extraordinary possibilities of rapid growth inherent in this group they mark a new epoch in the annals of alcoholism. These men may well have a remedy for thousands of such situations. You may rely absolutely on anything they say about themselves. Very truly yours, (Signed) WD Silkworth MD.”
  • 18. The Family Doctor • Family friend • Initial diagnosis • “First aid” (sobering up) • Advice • Referral – pastor/Fellowship/psychiatrist • Firm emphasis on the disease model • Persistent support
  • 19. The Psychiatrist Statement on Alcoholism “The American Medical Association identifies alcoholism as a complex disease with biological, psychological and sociological components and recognizes medicine’s responsibility in behalf of affected persons.The Association recognizes that there are multiple forms of alcoholism and treated in an individualized and comprehensive manner.” House of Delegates American Medical Association, 1971
  • 20. Medicine vs. Spirituality in AA • The alcoholic needs a personality • The alcoholic needs a spiritual change reawakening • The patient should be analysed to • The alcoholic should examine his identify the causes of drinking and conscience, make a moral inventory achieve a catharsis • Personality defects must be corrected • Character defects (sins) can be though accurate self knowledge and corrected through acquiring humility, adjustment to reality honesty, tolerance, love • The alcoholic withdraws, becomes • The alcoholic is self-centred, has lost neurotic, anxious. his connection to his fellow men • The alcoholic needs other interests • The alcoholic must replace his disease and pastimes to replace alcohol with service of others, fill up his spiritual life
  • 21. Changes in the Doctor’s Role: Medication • 1933 • 2009 ✤ It’s probably a disease of ✤ It’s definitely a brain the body disease ✤ It can be inherited ✤ It is inherited but we’re still not sure who will get it, how or why ✤ It’s incurable ✤ It’s still incurable ✤ The only treatment is ✤ We still recommend abstinence abstinence, but ✤ Medication is useful only ✤ We now have medicines for detoxification, not that are proven to help prevention with prevention: (antabuse, acamprosate, naltrexone, rimonabant, baclofen, varenicline)
  • 22. The Doctor’s Role: What Stayed the Same? • Skeptical man of science, but open-minded to spirituality • Blames the disease, not his patient for the behavioral symptoms of the condition • Objective, tolerant, non-judgmental, kind • Exemplifies courtesy, politeness, humility at all times • Accepting of remedies that are not scientifically proven, or ever likely to be • Accepts that some patients may never be sober without becoming angry, rejecting or dismissive • Encourages and befriends those who wish to recover and comforts those who cannot
  • 23. Thank You!