Chemical AddictionsChemical Addictions——General General OverviewOverview

Abdullahi Mubarak, MD

Medical Director of Addiction Services at PEMCO

Chief Medical Officer at Consortium Clinical Services,

LLC

ObjectivesObjectives

Understand general terminologyThe disease of AddictionSymptoms of the diseaseStages of changeDiagnostic tipsGeneral treatment approaches

TerminologyTerminology

Use—drug taking not associated with harmAbuse—drug taking associated with harmDependence—adaptation to drug evidenced

by normal functioning and/or withdrawal syndrome

Addiction—loss of control, compulsion, continued use despite adverse consequences

TerminologyTerminology

Abuse potential—the likelihood that a person will abuse a drug based upon it’s pleasurable effects, toxicity, and society’s attitude toward the users of the drug

Addiction potential—the likelihood that a drug will produce addiction in chronic users

Relative Addiction PotentialRelative Addiction Potential Cocaine (crack, IV, snorted, chewed) Methamphetamine (smoked) Nicotine (IV, smoked, chewed) Opiates (IV, smoked, snorted, chewed, oral) Alcohol Sedative-hypnotics Anabolic steroids Marijuana Inhalants PCP, other hallucinogens (LSD, Special K, )

Disease of AddictionDisease of AddictionAddiction is primarily a function of many

genetically predisposed biological responses.

The response and/or lack of the drug reinforces the repeated use of the drug.

The environment permits and facilitates the use of the drug.

Addiction can be “created” in low risk patients with chronic use of drugs of high addictive potential.

Progression of the DiseaseProgression of the Disease

Erratic drug-taking pattern, erratic sleep, work, eating, grooming, and social habits

New forms of enjoyment, new “friends”, ways of relating, isolation, hiding money, hiding whereabouts, lying

Legal, financial, marital, social, career, and lastly physical adverse consequences

Stages of ChangeStages of Change Pre-contemplation—lacks awareness Contemplation—ambivalent about change Preparation—getting information in order to

change Action—actually committing to sobriety in deed Maintenance—attaining stability Recovery—sobriety Relapse—use leads to return to contemplation

Signs of Aberrant behaviorSigns of Aberrant behavior

Prescription forgeryConcurrent abuse of illicit drugsSelling prescriptionsRecurrent lost, stolen, or spilled drugsStealing or borrowing from othersObtaining drugs from non-medical sourcesObtaining scripts from multiple doctors

Indicators of SuspicionIndicators of Suspicion

Reluctant to present identification“Out of town” patientOverly willing to pay cashTelephone call in for controlled substancesPresents when the regular physician cannot

be reached

Indicators of SuspicionIndicators of Suspicion

Allergy to NSAIDS, COX-2’s, or codeineIntolerant to collateral contactsIntolerant to in-depth interviewsInterested only in the drug, not the

diagnosisReluctant to comply with diagnostic testing,

pill counts, and urine screening

Factors Less IndicativeFactors Less Indicative

Drug hoarding during periods of decreased symptoms

Unsanctioned dose escalationRequest for specific drugs by nameFocus on opiate issues during the first three

office visits

Abnormal Physical SignsAbnormal Physical SignsPupils < 3mm or >6.5mm in room lightPresence of nystagmusDiminished or absent corneal and/or

pupillary light reflexImpaired convergencePulse < 60 or > 100/minVenosclerosis or needle tracksPerforated nasal septum

Characteristics of the PainCharacteristics of the Pain patientpatient

Appreciates in-depth interviews Cooperates with attempts to get collateral histories Cooperates with pill counts and urine drug

screening Focus is on the diagnosis and the cure Attempts to reduce medications on their own Cooperates with diagnostic and therapeutic

interventions

Addressing Aberrancy and Addressing Aberrancy and indicators of suspicionindicators of suspicion

Obtain an INSPECT reportUrine drug screen (UDS)Use oral salivary testing when urine

screening is unavailable, patient unable to void, or the UDS is invalid

Pill counts when appropriateUse Axis V outline to clarify your thoughtsTreat ONLY according to your diagnosis

INSPECT reportsINSPECT reports

The report is unconfirmed history until you confirm what’s in it.

“Multiple prescribers” means nothing until you call the providers to find out what they did, why they did it, and did they know there were other prescribers

Keep the interpretation of the report in your chart

Urine drug screeningUrine drug screening The results only mean what the results say Using them to make a diagnosis is only part of the

total picture Refer for addiction consultation, if the results are

aberrant Negative screens can mean abuse, addiction,

diversion, or pseudo-addiction syndrome Do not collect without temperature strips on the cup. Be sure the reference lab tests for validity and

multiple metabolites

Oral Salivary TestingOral Salivary Testing

Easy to use, less intrusiveShorter window of detection compared to

urine drug screeningAccuracy comparable to blood testingThe results only mean what the result says

Pill CountsPill Counts Best when used sparingly or unexpected Best to clarify negative urine drug screens Order within 2 days to rule out diversion Order within 10 days to rule out abuse or

addiction Pills can be brought to office or the pharmacy they

purchased their pills Record any markings on the pills for identification

Diagnostic ChallengesDiagnostic Challenges Impaired by lack of knowledge of differential

diagnosis Impaired by EMOTIONAL reactions to the “names”

of controlled substances Use Axis V outline to highlight deficiencies in

knowledge or when you are becoming too emotional Say “NO”, if the request is inappropriate for the

diagnosis or you have inadequate information to arrive at a diagnosis

Continue to monitor to confirm or deny your provisional diagnosis. Being wrong is ok.

ConsultationConsultationLearn the biases of your consultants. Psychiatry consultation for benzo and

stimulant prescribing for mood disorders, ADHD, etc…

Addiction consultation to evaluate aberrancy

Pain management consultation to evaluate opiate prescribing

General treatment principlesGeneral treatment principlesForemost goal initially is self-diagnosisEducate—Addiction is a disorder in a

person, not the pillMedication assistance—diminish drug

craving, withdrawal, and normalize function

Intensity of treatment related to intensity of use pattern and/or history of treatment failures

Strengthen social/spiritual supports