in the doctor's office - dawn farm education series - 2012
TRANSCRIPT
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Physicians Office: Friend or Foe
Dawn Farm Education SeriesMarch 20, 2012
Mark A. Weiner, MDPain Recovery Solutions, PC
In theDoctors OfficeRecovery Friend or Foe?
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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
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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
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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?
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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
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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%
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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:
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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%
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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
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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)
Ventral TegmentalArea (midbrain)
Pleasure Circuit
VTA
NANucleus
Accumbens(striatum)
Ventral TegmentalArea (midbrain)
Pleasure Circuit
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VTA
NucleusAccumbens(striatum)
Ventral TegmentalArea (midbrain)
Pleasure Circuit
VTA
NucleusAccumbens(striatum)
Ventral TegmentalArea (midbrain)
Pleasure CircuitCortex(logic)
Hippocampus (memory)
Amygdala (emotions)
Ventral Pallidum (motivation)
VTA
NANucleus
Accumbens(striatum)
Ventral TegmentalArea (midbrain)
Pleasure CircuitAmphetamineCocaineOpiatesCannabinoidsPhencyclidineKetamine
OpiatesEthanolBarbituratesBenzodiazepinesNicotineCannabinoids
VTA
NANucleus
Accumbens(striatum)
Ventral TegmentalArea (midbrain)
Pleasure CircuitAmphetamineCocaineOpiatesCannabinoidsPhencyclidineKetamine
OpiatesEthanolBarbituratesBenzodiazepinesNicotineCannabinoids
Cortex(logic)
Hippocampus (memory)
Amygdala (emotions)
Ventral Pallidum (motivation)
VTA
NucleusAccumbens(striatum)
Ventral TegmentalArea (midbrain)
Pleasure CircuitCortex(logic)
Hippocampus (memory)
Amygdala (emotions)
Ventral Pallidum (motivation)
VTA
NucleusAccumbens(striatum)
Ventral TegmentalArea (midbrain)
Pleasure CircuitCortex(logic)
Hippocampus (memory)
Amygdala (emotions)
AmphetamineCocaineOpiatesCannabinoidsPhencyclidineKetamine
OpiatesEthanolBarbituratesBenzodiazepinesNicotineCannabinoids
DOPAMINEDOPAMINE
Ventral Pallidum (motivation)
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VTA
NucleusAccumbens(striatum)
Ventral TegmentalArea (midbrain)
Pleasure CircuitCortex(logic)
Hippocampus (memory)
Amygdala (emotions)
AmphetamineCocaineOpiatesCannabinoidsPhencyclidineKetamine
OpiatesEthanolBarbituratesBenzodiazepinesNicotineCannabinoids
DOPAMINEDOPAMINE
Ventral Pallidum (motivation)
VTA
NucleusAccumbens(striatum)
Ventral TegmentalArea (midbrain)
Pleasure CircuitCortex(logic)
Hippocampus (memory)
Amygdala (emotions)
AmphetamineCocaineOpiatesCannabinoidsPhencyclidineKetamine
OpiatesEthanolBarbituratesBenzodiazepinesNicotineCannabinoids
DOPAMINEDOPAMINE
Ventral Pallidum (motivation)
VTA
NANucleus
Accumbens(striatum)
Ventral TegmentalArea (midbrain)
Pleasure CircuitAmphetamineCocaineOpiatesCannabinoidsPhencyclidineKetamine
OpiatesEthanolBarbituratesBenzodiazepinesNicotineCannabinoids
Cortex(logic)
Hippocampus (memory)
Amygdala (emotions)
Ventral Pallidum (motivation)
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!
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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???
Types of Problematic Medications
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%
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Types of Problematic Medications
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
Treating Pain In Addiction
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
Treating Pain In Addiction
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
Anxiety In Addiction
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
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Anxiety In Addiction
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
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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
The End