1.Psychopharmachology Lecture 7 Psychopharmachology ofAddictionS

2. Adjustment to Living with a DiagnosisS Social impacts: Relationships, energy levels, self-concept andits impact on fxn.S Adjustements to the disease process e.g. changes to dailyrutines, learning new skills (OT and PT), building selfacceptance and dealing with psychological strain.S Grief Stages: 1. Deniel and Isolation, 2. Anger, 3. Bargining, 4.Depression and 5. Acceptance.S Dealing with ablism and identity development. 3. Four types of integration indisability identity development.S (1) "coming to feel we belong" (integrating into society);S (2) "coming home" (integrating with the disability community)S (3) "coming together" (internally integrating our sameness and differentness)S (4) "coming out" (integrating how we feel with how we present ourselves). Four types of integration in disability identity development. Gill, Carol J. Journal of Vocational Rehabilitation, Vol 9(1), Aug 1997, 39-46. doi: 10.1016/S1052-2263(97)00020-2 4. Types of PharmachologicalInterventionsS Disorder based interventions e.g. treat depression with SSRIsand or CBT.S Positive: Multiple symptoms are treated as a cluster.S Negitive: May not reach spacific client needs.S Symptom based interventions e.g. treating sleep problems orpain problems with a more sedating tricyclic medication.S Positive: Treats spacific concerns directly.S Negative: Polypharmacy (or She swallowed the spider to catch the fly. I dont know why she swalllowed the fly) 5. Psychologists as PharmacologyConsultantS Prescribing (Louisianna, New Mexico, Navey)Significant post graduate training.S Colaborating Actively engage with support and dialogabout paitient care and medication selection.S Providing Information Discuss medication information,identify client concers, support adherence, identify sideeffects and communicate concerns with providers.S Each level of engagement in the treatment process hasspecific ethical guidelines. 6. Psychologists asPharmacology ConsultantS Psychologists have begun to realize just how valuable psychopharmacological training can be.S Psychopharmacological training for psychologists is the new face of psychology.S It can prepare the psychologist to S (a) Collaborate with physicians in order to craft the rightpsychopharmacological regimen for their mutual patients. S (b) Recognize which symptoms are likely to benefit from the use ofmedications. S (c) Examine possible drugdrug interactions. S (d) Make sure that the prescription decisions being made are actually inthe best interest of the patient. 7. Working withMedical ProvidersS People become doctors to help. Medical providers wanttheir patients to do well.S Basic Prinicipals of Clinical Consult with MedicalProvider:S Listen to the consulting question.S Be cofortalble with the limits of your knowledge but speakthe providers language.S They are the provider you make a recommendation for amedication evaluation.S Be focused and direct. Say concerns in 3 sentenses or less.S Give suggestions through questions. 8. Medication of the Week PresentationS Describe a medication briefly,S Describe what it is used to treatS Describe its side effectsS Describe other relivent information. 9. Dopamine HypothesisS Dopamine is related to pleasure and thus rewards drug use. S Slot machine argument: We pull the lever on the slot machinebecause it fills us with dopamine and dopamine feels good.S Beyond Dopamine:S Individuals with addiction have lower dopamine response to drug but higher response to drug cues. S Some studies indicate that those with addiction problems fail to habbituate to the reward signals of drug behavior. S Some studies indicate that the under activation in OFC (front brain related to regulation of impulsivity) and ACC (Anterior cyngulate cortex related to compulsivity) mean that poor executive control, emotion regulation and decision making may be central to addiction processes. 10. FRAMES approachS Feedback regarding personal risk or impairment is given to the individual following anassessment of substance use patterns and associated problems.S Responcibiliy for change is placed squarely and explicitly with the individual. Clientshave the choice to either continue their substance use behavior or change it.S Advice about changingreducing or stoppingsubstance use is clearly given to theindividual by the clinician in a nonjudgmental manner.S Menu of self-directed change options andreatment alternatives is offered to theclient.S Empathetic counseling, showing warmth, espect, and understanding, is emphasized.Empathy entails reflective listening.S Self-efficacy or optimistic empowerment is engendered in the person to encourage 11. Stages of ChangeS From Precontemplative to ContemplativeS Create client doubt about the commonly held belief thatsubstance abuse is harmlessS Lead to client conviction that substance abuse is having, orwill in the future have, significant negative results.S From Contemplation to PreparationS Enhance intrinsic and extrinsic motivators for change.S Reexplore the clients values in relation to change.S Clinicians can use decisional balancing strategies to help clients thoughtfully consider the positive and negative aspects of their substance use. 12. Stages of ChangeS From Contemplation to ActionS There appears to be a limited period of time during which change should be initiated.S Sings of readiness: The clients resistance (i.e., arguing, denying) decreases. The client asks fewer questions about the problem.The client shows a certain amount of resolve and may be more peaceful, calm, relaxed, unburdened, or settled. The client makes direct self- motivational statements reflecting openness to change and optimism.S Clinician actions: Remove barriors, elicit social support, and negotiate treatment types. 13. Stages of ChangeS From Action to Maintenance:S Help the client identify and sample substance-freesources of pleasurei.e., new reinforcers.S Support lifestyle changes.S Help the client practice and use new coping strategiesto avoid a return to substance use.S Behavioral Chain Annalysis 14. Case DiscussionS Identify clinical cases for case consult at end of trainingthat have a pharmachologcial and a health component ofcare.S We will have 30 min for case consultation. 15. Alcohol Intoxication and WithdrawalS Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal.S Combination of medical and psychosocial interventions.S Levels of CareS 1. Ambulatory Detoxification Without Extended Onsite Monitoring.S 2. Ambulatory Detoxification With Extended Onsite Monitoring S 3. Clinically Managed Residential Detoxification S 4. Medically Monitored Inpatient Detoxification S 5. Level IV-D: Medically Managed Intensive Inpatient Detoxification. 16. Alcohol Intoxication andWithdrawalS Hallucinations (auditory,S Restlessness, irritability, anxiety,visual, or tactile)agitationS Delusions, usually ofS Anorexia, nausea, vomitingparanoid or persecutoryvarietiesS Tremor, elevated heart rate, increased blood pressureS Grand mal seizures S Insomnia, intense dreaming,S Hyperthermia nightmaresS Delirium/disorientation with S Poor concentration, impairedregard to time, place, person, memory and judgmentand situation; fluctuation inlevel of consciousness S Increased sensitivity to sound, light, and tactile sensations 17. Alchol Withdraw ManagementS Not all individuals with alcohol addiction will need medical attention.S Discomfort and stress often predict a relapse.S Things that might indicate the need for attention are:S 1. Clients who have a history of the most extreme forms of withdrawal,that of seizures and/or delirium. (Immediate attention needed). S 2. Patients who are already in withdrawal and demonstratingmoderate symptoms of withdrawal also require immediate medication. S 3. For those still intoxicated reevaluate need for treatment over thecorse of a day. Higher risk group: longterm use, older age, number ofwithdrawls. 18. Drugs to manage AlcoholWithdrawlS Benzodiazepine: First line treatment. (Four methods: 1.Loading every 2-3 hours a dose, 2. Symptom initiatedtherapy needs clinicians trained to notice symptoms, 3.Gradual Tapering dose, 4. Single Daily Dose).S Problems with benzodiazipine use:S Synergistic effects with alcohol use that could be deadly.S Less evidence that use on sucessive detoxes has sameeffects for preventing siezures.S Benzodiazipines can trigger use. 19. Medications Used in Alcohol WithdrawlS BarbituratesS AnticonvulsantsS Beta blockers/alpha adrenergic agonistsS AntipsychoticsS Benzodiazepine and/or barbiturate intoxication need adifferential assessment 20. Opioid Intoxication and WithdrawalIntoxifacationWithdrawlS SedationS High body temperature,Insomnia, Pain, Vomiting,S Pinpoint pupils Enlarged pupilsS Slowed movement S Abnormally heightened reflexesS Slurred speechS Sweating,Gooseflesh,Increasedrespiratory rate.S Head noddingS Anxiety, Pain. 21. Treatment of Opiod WithdrawlS Non-medically supported withdrawl is contraindicated for opiods.S Methadone is the most common drug:S Blocks -opioid receptor displacing haroin.S Intial dose based on use amount.S Tapered to 5 10 mgs of 3-5 days.S Colidine (Catapres) Lower abuse potentialS Clonidine alleviates some symptoms of opioid withdrawal, it usually is relatively ineffective for insomnia, muscle aches, and drug craving. Intial dose based on use amount. S It has specificity towards the presynaptic 2 receptors in the vasomotor center in the brainstem. This binding decreases presynaptic calcium levels, and inhibits the release of norepinephrine (NE). The net effect is a decrease in sympathetic tone 22. Treatment of Opiod WithdrawlS Buprenorphine (Suboxone, Subutex)S Partial- opiod agonist.S It is a safer medication due to its celingeffect and lower ability to overdose.S It can be administered on an out paitientbasis.S Can be both used for accute detox andmaintenance treatment. 23. Signs of Addiction toPain MedicationS Multiple episodes of lost or stolen prescriptions.S Repeatedly running out of medication earlyS Aggressive complaints about the need for additional prescriptionsS Drug hoarding during periods of reduced symptomsS Urgent calls or unscheduled visitsS Using the medication to achieve euphoric effectsS Unapproved use of prescribed opioid to self-medicate another problem, such as insomnia 24. BenzodiazepineWithdrawlS Benzodiazepine and other sedative-hypnotic abstinencesyndrome managementS Flumazenil (Romazicon) - competitive antagonist that actsas a benzodiazepine (does not work when alch. or otherhypnotic is taken).S Slow taper over weeks and months.S Switching to a slower acting benzodiazipine.S Possible: Imiprimine, depakote, tegratol, trazadone(sedating anti-dep)S Multiple Cog. Techniques support withdrawl along withreducing life stress. 25. Stimulant WithdrawlS Most common stimulants: Cocain and amphetimine.S Stimulant withdrawal symptoms: Depression, Hypersomnia or insomnia,Fatigue, Anxiety, Irritability, Poor concentration, Psychomotor retardation,Paranoia, Drug craving.S No medication exist for stimulant withdrawl.S Siezures can occure during stimulant use/abuse and withdrawl, alch. andstimulants combined can cause heart conditions.S Medications under review: Disulfiram and Amantadine may help reducecocaine use in patients; Modafinil, an anti-narcolepsy agent with stimulant-like action; Antidepressants can be prescribed for the depression thatoften accompanies methamphetamine or other amphetamine withdrawal. 26. Nicotine Withdrawl Agents Used to Treat Nicotine WithdrawNicotine WithdrawS Depressed mood S Bupropion SR S Nicotine Replacement Therapy (NRTS Insomnia S TheophyllineS Anger, irritabilityS Caffeine: StimulantS AnxietyS Tacrine S Imipramine: Tricyclic.S Difficulty concentraiting S Haloperidol: AntipsychoticS Restlessness S PentazocineS Decreased heart rate S Propranolol: Betablocker. S Flecainide:S Increased appitite or wieght S Estradiol:gain. 27. Managing Addiction: AlcoholS Disulfiram (Antabuse): Inhibits bodies ability to brakedown alch. causing increased symptoms and discomfortintended as a punishment paridigm can result in death.No data indicates that it is clearly effective or increasesabstinance rates.S Naltrexone (ReVia): Effects the opiod system(antagonist) effects drinking sequence e.g. reducedcraving, and reinforcement and increased nausia andheadaches.S Acamprosate (Campral): Agonist GABA, Inhibits NMDA(glutamate). Equal in head to head trials to Natroxone. 28. Managing Addiction: OpioidsS Methadone: Requires going to methadone clinic daily.More then 150,000 people are in clinics in US. Bestpractices require sig. psychosocial support along with txmany places do not offer these services.S Buprenorphine (Suboxone and Subutex): Similar tomethadone for outcomes. No need to visit registeredclinic.S Levoalpha Acetyl Methadol (LAAM): Less frequentdosing then methadone, comparable abstinance ratesthe methadone (higher drop out then methadone). 29. Biopsychosocial TreatmentS Medication Adherence: Stages of change for medicationadherence, understanding health beliefs and psychoeducation.(Medication, Education, Motivation)S Developing Social Support: Enhancing current social support,developing new constructive relationships, developing goodrelationship habbits and self-respect.S Cognitive and Affective Support: Developing emotional regulationskills, cognitive skills, healthy self-talk, changing core belifes andgood coping habbits for triggers.S Developing healthy habbits: Eating, sleeping, exercise, healthyfun (hungry angry, lonely, tiered, no exercise).S Treatment Team: Develop and support treatment team and treatcomorbid MH concerns (ACEs). 30. Co-morbidity: Addiction andMental HealthS High comorbidity of MH and and addiction.S Many people have Health, MH and Addiction problems.Each of these can be a trigger for relapse. Treatment teamapproach is vital.S Often MH and Substance Abuse were siloed and there wasno connection with PCP. This lead to a ping-ponging betweenservices and clinicians playing a game of wac-a-mole.S If you are going to remove a coping mechanism a personneeds some coping to put in its place. 31. Co-morbidity: Addiction and Mental HealthS Careful with this kind of thinking:S All mental health symptoms are caused by addiction.S MH symptoms are often missed due to this type of thinking.S Pitfall = Not checking once sobriety is maintained to see if MH symptomspersist.S Treat health, mental health and addiction together. Pull together treatment aspects: Skills, Social, Health and MH.S Assessment:S Include a review of chronologic history, including time frames for onset and continuation of both mental and substance use disordersS include a review of current and previous pharmacotherapy for behavioral disorders effectiveness and problems encountered;S Review family mental health history. 32. Co-morbidity: Addiction andMental HealthS In general medications that treat a MH concern for thosewho have no addiction will also be effective for those withaddiction symptoms.S Considerations:S Synergistic and counter effects effects of medications andstreet drugs e.g. nicotine can reduce the availibility ofantipsychotic medications.S Look for parsimonious treatments e.g. depakote reducesimpulsivity in addiction, treats siezures and bi-polardissorder.S Educate clients about medications, side effects and risks. 33. Co-morbidity: Addiction andMental HealthS Assess for: PTSD, personality dissorders, anxiety anddepression.S Assess risk factors in all those treated for addiction (beable to say if a client is high, medium or low risk for SI orHI).S Right before a relapse there is often an emotional spike(Insular cortex). Increased emotional regulation skills andcapasity for distress tolerance could be vital. 34. CasCase ConsultationS 35. Closing Questions