This document provides an overview of addiction psychiatry including:
- The neurobiology of addiction and how chronic drug use decreases dopamine levels and impacts brain regions responsible for motivation, inhibition and determining importance.
- Dually diagnosed patients often have substance use disorders and psychiatric illnesses which complicate treatment. Integrated treatment is recommended.
- Motivational interviewing and relapse prevention therapy aim to help patients through the stages of change to maintain sobriety.
- Pharmacological interventions for various addictions including opioids, alcohol and cocaine are discussed though more research is still needed on effective medications.
- A case example involves assessing potential prescription opioid misuse or addiction in a chronic pain patient.
This short presentation demonstrates important adverse effects of common anti-psychotic medications in clinical practice and how to effectively manage the adverse events.
This short presentation demonstrates important adverse effects of common anti-psychotic medications in clinical practice and how to effectively manage the adverse events.
Depression is the leading cause of disability world wide and is a major contributor to the overall global burden of diseases .At its worst depression can cause suicide .
There are effective psychological and pharmacological treatments for depression
Depression is the leading cause of disability world wide and is a major contributor to the overall global burden of diseases .At its worst depression can cause suicide .
There are effective psychological and pharmacological treatments for depression
The Physiology of Addiction - February 2012Dawn Farm
"The Physiology of Addiction" was presented on Tuesday February 21, 2012, by Dr. Carl Christensen, MD, PhD, FACOG, CRMO, ABAM. This program explores the differences in neurochemistry between the addicted brain and the normal brain, the progression of physiological changes that occur in people with alcohol/other drug addiction, the mechanisms of physiologic tolerance and withdrawal, and the effects of treatment on the addicted brain. This program is part of the Dawn Farm Education Series, a FREE, annual workshop series developed to provide accurate, helpful, hopeful, practical, current information about chemical dependency, recovery, family and related issues. The Education Series is organized by Dawn Farm, a non-profit community of programs providing a continuum of chemical dependency services. For information, please see http://www.dawnfarm.org/programs/education-series.
A discussion of motivational interviewing: what is it, how does it work, and how can we start to use it with students face forced behavior change in academics?
ADHD and Addiction: Diagnosis and ManagementJacob Kagan
Presentation by Jacob Kagan MD on the diagnosis and management of ADHD and Substance Abuse Disorders, including epidemiology and comorbid conditions,
causality and functional impact, potential explanations for the ADHD/SUD association,stimulant treatment and the risk for SUDs, diversion and misuse of stimulant medications, and treatment recommendations. http://jacobkaganmd.com
Our happy brain chemicals (dopamine, serotonin, oxytocin, endorphin) are inherited from earlier mammals. They did not evolve to make you happy all the time. They are meant to motivate you to go toward things that promote your genes, and warn you to avoid things that threaten your genes. No conscious interest in your genes is involved - these chemicals create such strong impulses that we search for information to make sense of them. That's the job of our big cortex. It's not easy being a mammal, but your ups and downs are easier to manage when you know the job they do in the state of nature.
MRCPsych08 - How To Analyse Diagnostic Test Studies (June08)Alex J Mitchell
This is an educational talk/presentation on the science of diagnostic tests using examples from psychiatry. It was first presented for MRCPsych (Royal College of Psychiatrists UK) June 2008. Now updated in 2009...see newer version
The Psychology and Neurology of Substance Related DisordersRaymond Zakhari
New York City Chapter Men In Nursing Conference 2016 an overview (includes specific information regarding marijuana, stimulants, hallucinogens, depressants)
A PPT of Addiction Counseling by Dr Komal Verma.
Addiction counselors help patients overcome dependence on drugs, alcohol, and destructive behaviors like gambling. Counselors intervene when patients are often at their lowest points in their struggles with addiction. A certified drug and alcohol counselor may also work with the families of addicts to assist the healing process. These professionals may work in outpatient facilities, inpatient rehabilitation centers, halfway houses, or hospitals.
Introduction to the BioPsychoSocial approach to Addictionkavroom
In this 45 minute introductory lecture you will learn about the biopsychosocial approach to addiction
At the end of this session you should:
Have an understanding of the neurological systems that underpin addiction.
Appreciate that the ways addiction is explained has a direct influence upon treatment.
Be aware that there is no unified theory of addition, but that an integrated approach can help explain onset and maintenance of addictive behavior.
Comprehensive Guide to Understanding Addiction.pdfaspirefriscotx
Navigate the complexities of addiction with the 'Comprehensive Guide to Understanding Addiction,' a vital resource for anyone seeking in-depth knowledge about this critical issue. This guide delves into the various types of addictions, from substance abuse to behavioral dependencies, providing a thorough exploration of the causes, effects, and treatments available.
DRUG ABUSE & ADDICTION , IDIOSYNCRASY AND TACHYPHYLAXISsarthak845950
This ppt gives us a clear picture of drug addiction and abuse, illegal drugs, tachyphylaxis, idiosyncrasy, and spare receptors. It also tells us about the most common abusable drugs, the effect of drugs on the brain, ethanol abuse, warning signs of addiction, the effect of drugs on body organs, etc.
The man whose antidepressants stopped workingMajor depress.docxpoulterbarbara
: The man whose antidepressants stopped working
Major depressive disorder is one of the most prevalent disorders we will see in our clinical practice. Treatment options for MDD can vary greatly contingent on the appropriate psychopharmacologic interventions being adopted for our clients.
Medication nonadherence for patients with chronic diseases is extremely common, affecting as many as 40% to 50% of patients who are prescribed medications for management of chronic conditions (Kleinsinger, 2018). Nonadherence isn't a new problem. However, offering clients valuable interventions and education to overcome any potential compliance barriers will help the provider identify any challenges and decide how to achieve mutually agreed-upon goals to improve their health.
Questions
1.
Do you ever feel that taking your medications is a nuisance or inconvenience? Do you have a difficult time remembering to take your medications or forget?
•&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;Developing a medication schedule, It is difficult to come up with a schedule to take medications every day for some patients. Collaboratively we need to come up with a convenient time to take the antidepressant and the other prescribed medication for them to be effective.
2.
Does your prescribed medications and treatment regimen still leave you feeling depressed? Do you have a difficult time adhering to a prescribed regimen?
•&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;The patient discontinued his Effexor although it appeared to be effective. It is essential to find out the patient’s reason for not following the prescribed regimen and come up with a solution together.
•&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;&νβσπ;It is crucial for the patient to take his antidepressants accordingly, as well as not skip or alter the dosage, nor terminate the medication once you start feeling better.
3.
Have the side effects of your medications been difficult to cope with or manage? Do you sometimes stop taking your medications because of the adverse effects?
Sertraline has been prescribed in the past and discontinued several times. The patient experienced side effects of sexual dysfunction and stopped taking. Encourage the patient to monitor any side effects, physical and emotional changes or occurrences.
Stopping medications and treatment regimens prematurely or abruptly have been associated with high relapse rates and can cause serious withdrawal symptoms (Henssler, Heinz, Brandt, & Bschor, 2019).
Important People
Family members and other caregivers bring personal knowledge on the suitability or lack thereof regarding different treatments for the patient's circumstances and preferences (Smith, 2013). The patient is married, so I would address additional questions to his wife. After getting permission to discuss his medical records with his family members, I would ask the wife if she knew what medications her husband was taking? If she knew why he was taking them? Informed and en.
Community Mental HealthLecture 1011OverviewKno.docxtemplestewart19
Community Mental Health
Lecture 10
1
1
Overview
Know what is meant by Mental Health, Mental Disorder, Mental Illness, and DSM-V
Understand examples of mental disorders
Emphasis on stress & suicide
Understand mental health challenges
Understand goals of mental disorder treatment
2
2
Introduction
Mental health: Individual’s social and emotional well-being
Mental disorders: Health conditions characterized by alterations in thinking, mood, or behavior associated with distress and/or impaired functioning (or, disruption of social/emotional well-being)
Mental illness: All diagnosable mental disorders
Diagnosis through DSM-V
3
3
Introduction
Mental health: Individual’s social and emotional well-being
Mental disorders: Health conditions characterized by alterations in thinking, mood, or behavior associated with distress and/or impaired functioning (or, disruption of social/emotional well-being)
Mental illness: All diagnosable mental disorders
Diagnosis through DSM-V
4
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (“DSM-V” or “DSM-5”)
Most influential book in mental health
Published by American Psychiatric Association (APA)
Classifies disorders based on behavioral signs and symptoms rather than definitive tests or measurements of brain or another body system
4
Introduction
Causes of disability for all ages combined (U.S., Canada, & Western Europe, 2000)
5
5
Mental Disorders: Overview
May arise from various causes:
Poor prenatal care; postnatal environment; genetics; environmental factors; brain function impairment; substance abuse; maladaptive family functioning; stress
Various types of mental disorders exist
Focus on some well-known disorders in this class
6
Mental Disorders: Overview
May arise from various causes:
Poor prenatal care; postnatal environment; genetics; environmental factors; brain function impairment; substance abuse; maladaptive family functioning; stress
Various types of mental disorders exist
Focus on some well-known disorders in this class
7
Stress is a contemporary problem in mental health
Stress: Individual’s psychological and physiological response to real or perceived stressors
Acute vs. chronic (by amount of time)
Eustress vs. distress (by nature of influence)
Stressor: Any real or perceived physical, social, or psychological event or stimulus that causes our bodies to react or respond (can be internal/external)
Mental Disorders: Overview
May arise from various causes:
Poor prenatal care; postnatal environment; genetics; environmental factors; brain function impairment; substance abuse; maladaptive family functioning; stress
Various types of mental disorders exist
Focus on some well-known disorders in this class
8
Individuals typically go through three stages when responding to stressors, known as general adaptation syndrome
General adaptation syndrome (GAS)
Alarm (initiate “fight or flight” response)
Resistance (sustained high resistance to stress)
Exhaustion (Bod.
Community Mental HealthLecture 1011OverviewKno.docxjanthony65
Community Mental Health
Lecture 10
1
1
Overview
Know what is meant by Mental Health, Mental Disorder, Mental Illness, and DSM-V
Understand examples of mental disorders
Emphasis on stress & suicide
Understand mental health challenges
Understand goals of mental disorder treatment
2
2
Introduction
Mental health: Individual’s social and emotional well-being
Mental disorders: Health conditions characterized by alterations in thinking, mood, or behavior associated with distress and/or impaired functioning (or, disruption of social/emotional well-being)
Mental illness: All diagnosable mental disorders
Diagnosis through DSM-V
3
3
Introduction
Mental health: Individual’s social and emotional well-being
Mental disorders: Health conditions characterized by alterations in thinking, mood, or behavior associated with distress and/or impaired functioning (or, disruption of social/emotional well-being)
Mental illness: All diagnosable mental disorders
Diagnosis through DSM-V
4
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (“DSM-V” or “DSM-5”)
Most influential book in mental health
Published by American Psychiatric Association (APA)
Classifies disorders based on behavioral signs and symptoms rather than definitive tests or measurements of brain or another body system
4
Introduction
Causes of disability for all ages combined (U.S., Canada, & Western Europe, 2000)
5
5
Mental Disorders: Overview
May arise from various causes:
Poor prenatal care; postnatal environment; genetics; environmental factors; brain function impairment; substance abuse; maladaptive family functioning; stress
Various types of mental disorders exist
Focus on some well-known disorders in this class
6
Mental Disorders: Overview
May arise from various causes:
Poor prenatal care; postnatal environment; genetics; environmental factors; brain function impairment; substance abuse; maladaptive family functioning; stress
Various types of mental disorders exist
Focus on some well-known disorders in this class
7
Stress is a contemporary problem in mental health
Stress: Individual’s psychological and physiological response to real or perceived stressors
Acute vs. chronic (by amount of time)
Eustress vs. distress (by nature of influence)
Stressor: Any real or perceived physical, social, or psychological event or stimulus that causes our bodies to react or respond (can be internal/external)
Mental Disorders: Overview
May arise from various causes:
Poor prenatal care; postnatal environment; genetics; environmental factors; brain function impairment; substance abuse; maladaptive family functioning; stress
Various types of mental disorders exist
Focus on some well-known disorders in this class
8
Individuals typically go through three stages when responding to stressors, known as general adaptation syndrome
General adaptation syndrome (GAS)
Alarm (initiate “fight or flight” response)
Resistance (sustained high resistance to stress)
Exhaustion (Bod.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
2. Outline Definition of addiction Overview of the neurobiology of addiction Dually diagnosed patients; diagnosis and management Motivational Interviewing Relapse Prevention Psychopharm interventions for addiction Case 1
3. DSM-IV criteria for Dependence Although including physiological signs, addiction is largely BEHAVIORAL >3 of the following… Tolerance Withdrawal Using more than intended Unsuccessful attempts to cut down Time spent is excessive Activities are neglected Continued use despite problems developing 2
4. Indications that patients are misusing/abusing prescriptions Early refills, lost Rx, escalating amounts requested, “doctor shopping” – although these can be indications of undertreated pain! Tox screens positive for other substances Patients appear intoxicated in the office What to do… Get collateral: family, pharmacy, other providers, prior providers Get a consult, slow down the pace 3
5. Neurobiology… What happens to the brain when drugs are introduced and what happens over time? Why do people continue to use despite decreasing experience of being high and mounting social/physical problems? How can we use this knowledge to HELP people get sober and maintain – not pathologize 4
6. Dopamine pathways DA neuron cell bodies lie in the VTA (midbrain=meso) Mesolimbic From midbrain to nucleus accumbens; also amygdala and hippocampus Mesocortical From midbrain to the prefrontal cortex, orbitofrontalcortex and anterior cingulategyrus 5
7. Role of Dopamine: Acute drug administration Psychoactive substances may 1) increase DA release, 2) inhibit reuptake, 3) act as DA agonist Acute increases in DA in both the mesolimbic and mesocortical pathways are thought to be essential to the initial “liking” and reinforcement of drug taking (The Reward Pathway) Specifically – Nucleus accumbens is essential to reinforcement, amygdala and hippocampus to cue related learning (setting up cravings) Drugs produce supraphysiological DA release – HIJACKING the normal pathways or what’s important 6
8. Taking drugs Good feeling (Reward Pathway) Hedonistic Theory we keep using b/c it felt good (positive reinforcement) But… Why keep using when the good feeling is gone? (prevent w/d, negative reinforcement) When one’s life has been destroyed? Why relapse after years of sobriety? 7
9. Role of Dopamine: Chronic Administration GLOBAL DECREASE IN DA (hypodopinergic) So what??? Orbital Frontal Cortex: Salience Attribution (Nora Volkow) – responsible for telling us what is important, food/sleep, not drugs! CingulateGyrus: responsible for INHIBITION Dorsolateral Prefrontal Cortex: responsible for MOTIVATION 8
10. With chronic administration… The brain becomes less sensitive to cues that really matter (food), more sensitive to cues involving drugs (including smells, sounds, etc), while simultaneously losing its inherent ability to INHIBIT behavior. We have lose the ability to identify what’s important while becoming markedly more impulsive. 9
11. As if that weren’t bad enough… Corticotropin Releasing Factor (CRF) and the HPA axis (stress response) In response to drug use, and more precisely, activation of the mesolimbic DA system, CRF and the HPA axis are upregulated In acute withdrawal this leads to physiological and psychological withdrawal However, increases in cortisol, CRF, NE in addition to neuropeptide Y, nociceptin, vasopressin are thought to persist weeks/months into sobriety leading to anxiety, dysphoria that we call protracted withdrawal 10
12. Dually diagnosed patients (addiction + psychiatric illness) Prevalence (NCS and NCS-R data) Individuals with psychiatric illness are 2.7 times more likely to have alcohol or substance use disorders (life time prevalence of 29% vs. 19.6%) Lifetime rates of addictive disorders among patients diagnosed with: Schizophrenia: 47% All affective disorders: 32% Bipolar disorder: 56.1% Social anxiety disorder: 22% for alcohol alone ADHD: 12-month prevalence is 15% vs 5% in non-ADHD responders Among those with SUDs, 53% meet criteria for psychiatric illness, 37% among those with EtOHdisorers (Compared to 32% in general population). 11
13. Dual Dx: Clinical Significance SUDs complicate/worsen comorbid psychiatric illness For example… bipolar substance abusers have earlier onset, more hospitalizations, higher rates of rapid cycling/mixed episodes, poorer txresponse In the other direction, psychiatric illness complicates/worsens the course and treatment of SUDs Substance abuse is a well known risk factor for suicide and self-injurious behavior Dual diagnoses increase the risk for violent behavior – often much greater than an additive effect Dual diagnosis pts have higher prevalence of medical comorbidities than either group independently Dually diagnosed pts have higher relapse rates than those w/”straight” addiction 12
14. Dual diagnosis – what to do? Challenges… making the psychiatric diagnosis Psychiatric sxs can be confused with intoxication/withdrawal sxs, including protracted withdrawal Patients who are using or in new sobriety are poor historians Historical approach: Clinicians would wait months/years into sobriety to make the diagnosis and treatment was NOT integrated Given that pts often self-medicate, many would relapse long before a dx was made or treatment started! Current approach: Integrated treatment Decreased threshold for making the psychiatric diagnosis Get a good hx, and collateral! Balance risks of treatment vs risks of not treating (ie are you starting an SSRI or a mood stabilizer?) 13
15. Stages of Change (Prochaska & DiClemente) Precontemplation (Not yet acknowledging that there is a problem behavior that needs to be changed) Contemplation (Acknowledging that there is a problem but not yet ready or sure of wanting to make a change) Preparation/Determination (Getting ready to change) Action (Changing behavior) Maintenance (Maintaining the behavior change) Relapse (Returning to older behaviors and abandoning the new changes) 14
21. Relapse Prevention Therapy (RPT) “Cognitive and behavioral self-efficacy program designed to teach individuals who are trying to maintain changes in their behavior how to anticipate and cope with the problem of relapse.” (Parks & Marlatt) 1) Identify high risk situations/triggers negative emotional states, interpersonal conflict, and social pressure. 2) Teach practical coping skills and cognitive strategies to avoid and manage high risk situations 3) Encourage return to treatment following relapse (relapse leads to guilt which individuals then try to medicate away) 4) Sense of self-efficacy develops with increasing time sober 18
22. Pharmacology Strength of binding (pKa) Determines if an agent can be a blocker Action at binding site (agonist, partial agonist, antagonist) Relates to how a medication “feels” but also safety, “abusability”, treating cravings Time to onset and duration of action The faster the onset, the more a substance can produce euphoria (PO, IN, smoked, IV) 19
23. Pharmacology - Opioids Buprenorphine/naloxone Partial opioid agonist, binds tightly but has ceiling effect Safe and minimal abuse potential, treats cravings and protracted withdrawal Naltrexone Full opioid antagonist (po form of naloxone) Little risk (some hepatic involvement), blocks opioids, but does not tx cravings or protracted withdrawal Methadone Full opioid agonist Administered in a clinic per DEA regulations 20
24. Pharmacology – Alcohol1 Naltrexone Mu-opioid antagonist, attenuates effect of beta-endorphin release, particularly in Nac Good initial efficacy, unclear if long term impact on abstinence and overall small effect size Studies show compliance is significant factor May have more benefit for pts with +FHx, heavy drinkers Some studies show more effective than acamprosate Depot formulations may be more effective (increased compliance) 50mg daily, risk of hepatic dysfxn 21 1 Johnson BA. Update on Neuropharmacological treatments for alcoholism: Scentific basis and clinical findings. 2008. BiochemPharmacol. 75(1):34-56
25. Pharmacology – Alcohol Acamprosate Antagonizes NMDA glutamate receptors Suppresses EtOH induced glut receptor hypersensitivity and cue related cravings Positive European studies led to FDA approval, but US studies have not shown efficacy (COMBINE study) Well tolerated (better than naltrexone) Disulfiram Inhibits aldehydedehydrogenase, resulting in build up of acetaldehyde flushing, nausea, vomiting, palpitation SEs include hepatitis, psychosis, depression, confusional states As mechanism is purely adversive, it does nothing for cravings and pts actually have to take it! 22
26. Pharmacology - Alcohol Topiramate Not FDA approved Multiple mechanisms of action – glutamate antagonist/facilitates GABA 3 RCTs with moderate effect size including recent multisite study showing improvement in self reported drinking outcomes, GGT, some QOL measures Titrate slowly to 200mg; to be cautious as slow as 25mg/week, starting at 25mg qhs (minimizes cognitive dulling, “Dopamax” effect) 23
27. Pharmacology Cocaine Nothing is FDA approved Psychological interventions are the mainstay of treatment (contingency management) Potential medications include modafinil, naltrexone, disulfiram, GABA-ergic agents, N-acetylcysteine 24
28. Case 48 y/o man with a h/o low back pain since an MVA 10 years ago presents for a new pt appointment seeking opioids. You initially prescribe oxycodone, but 6 months later begin to wonder if you are managing addiction vs pain. What could give you more data, and what might be indicators of prescription misuse/addiction? What do we know about how pts with SUDs experience pain? What can be helpful? Get a consult, talk to peers, make treatment as structured as possible, slow down the pace. How might you approach the issue of misuse/addiction with this patient? What options for treatment would you consider? 25