In the Doctor's Office - Dawn Farm Education Series - 2012

8/2/2019 In the Doctor's Office - Dawn Farm Education Series - 2012

1/16

3/19/2012

Physicians Office: Friend or Foe

Dawn Farm Education SeriesMarch 20, 2012

Mark A. Weiner, MDPain Recovery Solutions, PC

In theDoctors OfficeRecovery Friend or Foe?


2/16

3/19/2012

This guycan be

dangerous

too!

Initiation rates for nonmedical pain relieveruse continue to be second only tomarijuana rates, with 2 million or morenew nonmedical pain reliever users eachyear since 2002.

The number of persons nation-widereceiving specialty substance usetreatment within the past year for misuseof pain relievers more than doubled: from199,000 in 2002 to 406,000 in 2010.

www.oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.htm

A national survey of residencyprogram directors found only 56% of the programs require training in

substance use disorders. Even whentraining is required, very little isprovidedmedian curriculum hoursranged from 3 to 12.

www.hazelden.org/web/public/document/bcrup_0903.pdf

In a study of third-year medicalstudents, only 19% recognizedalcoholism during a mock chart reviewexamination, even though thealcoholism diagnosis, a family historyof alcoholism, and a 10-year history of extensive alcohol use were includedprominently throughout the chart.

www.hazelden.org/web/public/document/bcrup_0903.pdf


3/16

3/19/2012

94% of primary care physicians failedto diagnose substance abuse whenpresented with early symptoms of alcohol abuse in an adult patient.

www.centerforhealthandjustice.org/BOSUDsandPrimaryCare.pdf

29.5% of patients (in treatment for

substance abuse) said theirphysicians knew about theiraddiction and prescribedpsychoactive drugs such as sedativesor Valium.

www.centerforhealthandjustice.org/BOSUDsandPrimaryCare.pdf

Public Policy Statement on Measures toCounteract Prescription Drug Diversion, Misuse

and Addiction - ASAM BOD, 01/25/12.

Studies have shown that physicians have notreceived adequate education about thepotential psychiatric and addictionconsequences of the decision to prescribescheduled medication. Most practicingphysicians have had little if any formal trainingin addiction. Few physicians demonstrate

understanding of the etiology of addiction. . ...

Policy statement, ASAM 2012 Although issues of tolerance and withdrawal

are understood to exist, most physicians are notaware of the mechanisms and the behavioralconsequences of these phenomena, or therelationship of these phenomena to addiction.Confusion still exists whereby some cliniciansmistake physical dependence (tolerance andwithdrawal) for addiction. Rarely are craving andreward seeking behaviors appreciated byprescribers as being potential consequences of theirprescribing of opioid and sedative medications. ...

Policy statement, ASAM 2012

But there is emerging data to suggest thatwhen primary care physicians are targeted forfocused education regarding pain, painmedication prescribing, and assessing patientsfor risk prior to the initiation of opioidanalgesic therapy, trends in opioid overdosedeaths can be reversed.

http://www.asam.org/docs/publicy-policy-statements/1-counteract-drug-diversion-1-12.pdf


4/16

3/19/2012

FeelingCrappy?

Headaches

Insomnia Depression Anxiety Stomach

problems

Back pain Attention

problems

Even if heknows yourean addict and

really wants tosupport your

recovery,whats his firstquestion likely

to be?

Sobriety Based Symptoms of Addiction

Restless Irritable Discontent Physical Manifestations

Abstinence

Recovery

Recovering People ShouldPlan Ahead

Decision making can beimpaired when we experienceacute discomfort

Safe,

NewMeds?


5/16

3/19/2012

So

The doctors office can be a dangerousplace for recovering people

Dawn Farm has been working onconnecting clients with recoverycompetent primary care and talking toprimary care providers and medicalstudents about addiction and recovery

ARE WE THINKING ABOUTADDICTION TREATMENTAPPROPRIATELY?

Treatment for Hypertension:High symptoms reduced symptoms symptoms return

Treatment Status Over Time

B l o o d P r e s s u r e :

m m

H g

No Tx Tx Tx Tx No Tx


6/16

3/19/2012

Did treatment work?

Treatment Status Over Time

A l c o

h o

l C o n s u m p t i o n

No Tx Tx Tx Tx No Tx

Treatment for Alcoholism:

Did addictiontreatment work? Acute care model

vs.

Chronic illness

management model

IS ADDICTION TREATMENT AS

EFFECTIVE AS TREATMENT FOR

OTHER HEALTH PROBLEMS?

How doesHow doesasthma compare?asthma compare?

Medication compliance: 30%

Relapse Rate: 60 to 80%


7/16

3/19/2012

How doesHow doeshypertensionhypertension

compare?compare?

Medication

And Diet

Compliance: 30%

Relapse Rate: 60-80%

How doesHow doesdiabetes compare?diabetes compare?

Medication, diet

and foot care

Compliance:


8/16

3/19/2012

What happenswhen we treataddiction as a

chronic illness???People like

this guy findrecovery!

Long term residential treatmentfollowed by

Long term outpatientfollowed by

Long term recovery monitoring

With sober social support

How do we give this kindof care to everyone else?

1. Theyre different!

2. Too expensive! 4. Theyre hopeless!

3. You have no stick!

DawnFarm hasgottenprettygood atthis, but

It takes about 5 years foralcoholism relapse rates to drop

below 15% and about 7 years foropiate addiction relapse rates todrop below 15%


9/16

3/19/2012

Make ThisGuy an Ally

Preventmedicationrelatedrelapses

Pain plan Recovery-

informed care

Make ThisGuy an Ally

Long termrecoverysupport andmonitoring

Recoverycheck ups

Rapid re-stabilization

Declarations of PotentialConflicts of Interest

I have no financial relationship with anypharmaceutical company

The content of this presentation is non-commercial and does not represent anyconflict of interest or commercial bias

I will mention the use of medications for indications that are not FDA approved (but

you will be informed when that happens)

Special Thanks Herb Malinoff, MD Carl Christensen, MD, PhD Edward Covington, MD Doug Gourlay, MD Howard Heit, MD Donald Kurth, MD Edwin Salsitz, MD

Michigan Pain Specialists The Medical Staff at St. Joseph Mercy Hospital

The many patients who have entrusted me with their care

Objectives

Learn how drugs act on our brains Very, very basic neurobiology of relapse

Be able to tell your doctor you are inrecovery Discuss issues regarding pain, insomnia,

anxiety and depression in addiction LOTS of time for Q & A


10/16

3/19/2012

1

Basic Neurobiology of Addiction

Addiction requires activation of the

pleasure center circuit This is a normal useful part of the brain

with enhances our survival It make us feel good when we do things

that keep us alive or reproducing (food,sex, shelter, etc)

Involved in SALIENCE

Basic Neurobiology of Addiction

It is a very powerful modulator of memory,

emotions, motivation and logic In addiction, this center is high-jacked and

results in harm Once activated by addiction, its response

is permanently altered It can be easily reactivated by drugs, cues

and stress

What is Salience

Important That which is remembered most Meaningful Example of normal salience [ripe fruit ->

good to eat -> color, location, season]

VTA

Ventral TegmentalArea (midbrain)

Pleasure Circuit

VTA

NANucleus

Accumbens(striatum)


Pleasure Circuit

VTA

NANucleus

Accumbens(striatum)


Pleasure Circuit


11/16

3/19/2012

VTA

NucleusAccumbens(striatum)


Pleasure Circuit

VTA



Pleasure CircuitCortex(logic)

Hippocampus (memory)

Amygdala (emotions)

Ventral Pallidum (motivation)

VTA

NANucleus

Accumbens(striatum)


Pleasure CircuitAmphetamineCocaineOpiatesCannabinoidsPhencyclidineKetamine

OpiatesEthanolBarbituratesBenzodiazepinesNicotineCannabinoids

VTA

NANucleus

Accumbens(striatum)




Cortex(logic)


Amygdala (emotions)


VTA





Amygdala (emotions)


VTA





Amygdala (emotions)

AmphetamineCocaineOpiatesCannabinoidsPhencyclidineKetamine


DOPAMINEDOPAMINE



12/16

3/19/2012

1

VTA





Amygdala (emotions)



DOPAMINEDOPAMINE


VTA





Amygdala (emotions)



DOPAMINEDOPAMINE


VTA

NANucleus

Accumbens(striatum)




Cortex(logic)


Amygdala (emotions)


Abnormally Salient

SO Important -> essential for life LONGEST LASTING MEMORIES As important as oxygen A Description of Abnormal Salience

Are Prescription Drugsa Drug Problem

YES!


13/16

3/19/2012

1

How to Tell Your Doctors YouAre In Recovery

Tell them early

Doc, I am in recovery from drugs andalcohol. I need your help by notprescribing drugs that are addictive. Doyou know enough about addiction to keepme safe?

Repeat yourself Repeat yourself

Should Addicts and Alcoholics BeDenied Treatment

NO!

An addict or alcoholic, especially in earlyrecovery, deserves the exact same careand relief of pain, insomnia, depression,anxiety, etc

Ignoring these symptoms creates anunstable situation (likelihood for relapse)

The care is different (can be better in some ways)than the care of the non-addict

Why Do People In Recovery GoTo The Doctor

The same reason everyone does: Pain (back, joint, headache, teeth => dentist) Sleep problems Concentration problems Depression Anxiety Colds, coughs, etc.

What is Narcotic / Non-Narcotic?

Not a very useful term A controlled substance (legal)? A prohibited drug (legal)? Causes sleep (ancient term)?

Tramadol / Ultram Carisoprodol / Soma

Take Home Point: Non-narcotic does NOT mean non-addictive!

Types of Problematic Medications

Opiates Vicodin, Vicoprofen, Norco, Lorcet, Percocet, Morphine, rx cough

syrup

Benzodiazepine Sedatives Xanax, Ativan, Valium, Restoril, Ambien, Lunesta, Sonata Other sedatives

Fiorocet, Benedryl, many antihistamines

Dissociatives OTC cough syrup, dextromethorophan, DXM

Steroids prednisone???


Stimulants Adderal, Concerta, Ritilan

Alcohol Containing Medication / Items NyQuil 25% alcohol = 50 proof Listerine 26.9%, Scope 18.9%, Signal 14.5%,

Cepacol 14.0%, Listermint 6.6% Beer 4-6% Wine 13-15% Brandy 35%


14/16

3/19/2012

1


Natural and Herbal

Does not mean it is safe Valerian Root Kava Kava Anything that makes one sleepy, awake, changes

mood or energy level is suspect

Treating Pain In Addiction

Fallacy: The best pain meds are opiates

and we are saving them for the non-addicts

The pain relieving effects of opiatesinvolve direct action on the brain

Many other drugs are more effective atcontrolling pain (naproxen, Tylenol)without CNS effects


The use of opiate pain medications(including tramadol) can lead to extremecravings in addicts/alcoholics no matter how long they have been sober

Patients who have had both experiencestell me the craving is far more miserablethan any physical pain

Acute pain Treatment NSAIDs Motrin, Naproxen, Torodol Other Tylenol 8 hour Ice Rest, splint

Chronic Pain Buprenorphine? --- not necessarily safe, but

definitely safer if opiates are being considered


Anxiety In Addiction

Social anxiety is nearly universal Newly recovering addicts have lost many

friends and feel alone The drugs and alcohol were an effective

coping mechanisms (with deadly sideeffects)

This anxiety usually goes away with time


We should not ignore the fact that 2-5% of people have generalized anxiety disorder

Many primary care doctors andpsychiatrists will prescribe addictivesedatives

Benzodiazepines (Xanax, Klonopin, Ativan) often produce extreme cravings for alcohol


15/16

3/19/2012

1


There are MANY safe and non-addictive

treatments for anxiety disorder Sedatives are slowly falling out of favor as

even psychiatrists see the problems of abuse and dependence without relief of sx

The symptoms of benzo withdrawal areindistinguishable from anxiety disorder

May require assessment from andaddiction psychiatrist

Insomnia

Very common in early recovery

Natural sleep centers are not functioningproperly

Improves universally without medicine butmay take a long time

Most common sleeping medications canactivate the addiction center

May require assessment from andaddiction psychiatrist

Insomnia

If problems persist and are interfering with job, responsibilities, etc., there are manysafe alternatives

Unfortunately many doctors believe thatsome very addictive sleeping meds aresafe (ambien, lunesta, sonata)

Some natural supplements can be helpful(melatonin)

Depression

Essentially universal in early recovery Often resolves quickly with full

engagement in 12-step recovery If persistent, counseling or psychiatric

assessment is warranted Medications may be necessary but often

are not

Depression

Without an understanding of addiction,many psychiatrists arguably overprescribeleading to overmedication and poorer cognitive and social functioning

Is There Such Thing As A DrugOf Choice?

Any substance that activates the addictioncenter can cause relapse

Generally the memory centers will drivethe addict to a specific reinforcing drug

Shark Tank Example


16/16

3/19/2012

Is There Such Thing As A DrugOf Choice?

The fact is that most alcoholics, for reasons yet

obscure, have lost the power of choice in drink.Our so-called will power becomes practically nonexistent. We are unable, at certain times, tobring into our consciousness with sufficient force the memory of the suffering and humiliation of even a week or a month ago. Weare without defense against the first drink.

- Alcoholics Anonymous p. 24

So What Do I Do Now?

Be very careful about medication use

Consult with a board certified AddictionMedicine doctor

Call your Addiction Medicine doctor PRIOR to taking any new pills for pain,insomnia, sleep, depression, etc

So What Do I Do Now?

It is probably not a good idea to get adviceon whether to start or stop any medicationfrom your sponsor or recovery supports

What is Tradition 10?Alcoholics Anonymous has no opinionon outside issues ; hence the A.A. nameought never be drawn into public controversy.

Q&A

How to Contact Me

Pain Recovery Solutions, PCYpsilanti, MI

734 [email protected]

The End

Documents

In the Doctor's Office - Dawn Farm Education Series - 2012