Defining Dual Diagnosis in a Deficient Delivery System. Paul Garcia, MD Chief of Psychiatry Vidant Beaufort Hospital

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1 Defining Dual Diagnosis in a Deficient Delivery System Paul Garcia, MD Chief of Psychiatry Vidant Beaufort Hospital

2 Objectives Review the understanding of dual diagnosis. Review the criteria for substance use disorder in the DSM-5. Review the mechanism of action of addiction. Review statistics associated with substance abuse and the mentally ill. Understand some of the Acute treatment options for addiction. Briefly discuss some commonly abused drugs in the patient setting. 2

3 Which of the following drugs cause the most health problems in the USA today? A. Alcohol B. Cocaine C. Heroin D. Nicotine E. Marijuana 3

4 4

5 Defining Dual Diagnosis Dual diagnosis is co-occurring illness or disease Some units have treated both substance abuse and mental illness Some are mentally retarded (intellectually disabled) and mentally ill Only 12.4% of American adults with substance use disorders are receiving both mental health and addiction treatment Partial treatment involves only treating the disorder that is considered primary (major depression) Sequential treatment involves treating the primary disorder first, and then treating the secondary disorder after the primary disorder has been stabilized (2) 5

6 Dual Diagnosis Parallel treatment involves the client receiving mental health services from one provider, and addictions services from another. [2] Parallel treatment is not recommended because it is fragmented. Even though some psychiatric units do not identify themselves as dual diagnosis they still treat these patients. It is recommended that acute psychiatric units do not view it as a dual diagnosis, but concurrent with a primary and secondary diagnosis. i.e. Primary diagnosis of paranoid schizophrenia with a secondary diagnosis of cocaine use disorder. Primary diagnosis of Cocaine Use Disorder with a secondary diagnosis of paranoid schizophrenia. 6

7 ADATC (Alcohol and Drug Abuse Treatment Center) W.B. Jones R.J. Blackley in Butner, NC Julian Keith in Black Mountain, NC Very few options for inpatient substance abuse services. Especially if you have very few resources. These patients are difficult to place. For a lot of our patients the acute psychiatric hospitalization is only formal treatment they receive for their addiction or substance use disorder. 7

8 Human Addiction Since childhood, humans have always tried to change their consciousness. This is evidence throughout the life cycle. These actions force people in the present moment. 8

9 Substance Abuse A MALADAPTIVE pattern of substance use leading to clinically significant impairment of one or more of the following in a 12 month period. Failure to fulfill major role obligations. Recurrent use in physically dangerous situations. Recurrent legal problems. Continued use despite having recurrent problems in personal and professional life. 9

10 Substance Dependence A MALADAPTIVE pattern of substance use leading to clinically significant impairment or distress as manifested by 3 or more of the following, occurring at anytime during a 12 month period. Tolerance Withdrawal 10

11 Substance Dependence II The substance is taken in larger amounts and/or for longer periods than intended. There is a persistent desire or unsuccessful efforts to cut down or control substance use. A great deal of time is spent attempting to obtain the substance. Important social, occupational, or recreational activates are given up or reduced because of substance use. Continued use despite knowledge of its ramifications. 11

12 Changes in the Diagnostic Criteria Dependence (3 out of 7) 1. Tolerance 2. Withdrawal 3. Trouble controlling amount 4. Persistent desire to cut down 5. A lot of time attaining Rx 6. Persistent problems at work, home 7. Use despite physical problems Abuse (1 or more) 1. Can t fulfill roles 2. Continued use while in hazardous situations 3. Recurrent Legal problems 4. Continued use despite knowing current problems 12

13 DSM-5 for Substance Use Disorder (2 or more) 1. Tolerance 2. Withdrawal 3. Trouble controlling amount 4. Persistent desire to cut down 5. A lot of time attaining Rx 6. Persistent problems at work, home. 7. Use despite physical problems 8. Can t fulfill roles 9. Continue use while in hazardous situations 10. Craving for the substance 11. Continued use despite knowing current problems 13

14 Narcotics Reason narcotics are addictive is because humans have opioid receptors in the brain. 3 types of receptors: mu, kappa, and delta. Narcotics can be extremely addictive. Majority of patients do not abuse their medications. This is evident in PCA studies. Everyone can fall to opioid addiction. 14

15 CDC Findings for Death rates from opioid abuse exceed heroin and cocaine combined. Number of pill mills (illegitimate pain clinics) have increased. In 2008, 36,450 patients died from drug overdoses. 73.8% of those were cause by opioid pain medications. 15

16 Heroin OxyContin aka Hillbilly Heroin Violin Percocet Codeine Opiate Abuse 16

17 Red Flags I have a high tolerance Is well versed on dosages and treatment. Allergic to NSAIDS and Tylenol. Traveling long distances to pain clinics. History of hepatitis B and C. Focusing on narcotics. Appearance does not correlate with professed physical dysfunction. 17

18 Opioid Intoxication Pupil constriction Drowsiness Slurred speech Impaired attention 18

19 Nausea or vomiting Pupillary dilation Insomnia Rhinorrhea Sweating Piloerection Opioid Withdrawal = 3 or More 19

20 Heroin Pathology HIV: 50-66% of IV drug users are HIV positive. Endocarditis Amyloidosis secondary to skin popping Renal failure Pulmonary edema 20

21 Skin Popping 21

22 CDC Findings for Death rates were not exactly related to demographics but to prescribing habits. Death rate today is 3 times the rate compared to In 2009, 1.2 million ED visits were for misuse of narcotics (not including heroin and cocaine). This is up by 98.4% since

23 CDC Findings for In 2007 nearly 100 persons died per day because of a drug overdose. Medicaid population are at greater risk of overdose. 4.8% of the U.S. population have used narcotics for non medical reasons. Narcotics abuse costs insurance companies 72.5 billion dollars annually. 23

24 Narcotic Sold in KG 24

25 Death Rate 25

26 26

27 Acute Treatment 12 Step Program, 12 Step Program, 12 Step Program, 12 Step Program Methadone, only a select few. Suboxone, Zubsolv, Subutex Cognitive Behavioral Therapy Detoxification 27

28 Alcohol or Ethanol 28

29 Alcohol 50% of trauma beds are filled with patients who were under the influence. 3 rd leading cause of death. 80% of cirrhosis is caused by ETOH % of suicides involved alcohol. Why does it appear that the majority of DUI violators survive the trauma, while the victims die? 29

30 Alcohol Level 1 standard drink raises your blood alcohol level (BAL) by.02% A healthy liver will metabolize 0.75 ounces of 80 proof alcohol in an hour. How long would it take for a 160 lb. man who consumed 5 ounces of alcohol to be not legally drunk? 30

31 BAL can be expressed by mg% 50 mg% Slurred speech 80 mg% Legally intoxicated 100 mg% Slurred speech 200 mg% Euphoria 300 mg% Confusion 400 mg% Stupor 500 mg% Coma 600 mg% Resp. paralysis, death Alcohol Level II 31

32 1 drink raises level by 20 mg% Blood Alcohol Level It takes the liver 1 hour to decrease it by 15 mg% In the previous example the gentlemen needs at least 2 hours before he drives. 32

33 Prevalence A national co-morbidity study found the lifetime prevalence for alcohol abuse is 6% for women and 12% for men. For alcohol dependence is 8% for women and 20% for men. 33

34 ETOH Stats 15-18% of men will develop alcohol use disorder. 10% of women will develop alcohol use disorder. If a person drinks more than 2 drinks a day, they are at risk. The lower age a person gets exposed to ETOH, the higher the risk. Most alcoholics had their first drink at age 14. First sign is tremor. 34

35 Physical Addiction A patient with a BAL of 150 mg% who does not appear to be intoxicated is evidence of physical addiction. A BAL of 300 mg% in any awake patient also is a marker for physical addiction. 35

36 Cardiac: increase BP, HR, MI Physical Complications Cancer risk increased: esophageal, head, neck, liver, stomach, colon, and lung. Liver problems: BLEEDING, decreased clotting factors Bone Marrow: decrease platelets Brain: kills brain cells 36

37 Varices 37

38 Another term is delirium tremens. Mortality is 10-15%. The Shakes Confusion, tremor, visual hallucinations, dilated pupils, VS are significantly elevated. i.e. BP 200/120, P=150, temp

39 CAGE questions Screening Have you ever felt the need to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt Guilty about your drinking? Have you drank in the a.m. as an Eye opener? 39

40 A 34-year-old woman presents for routine care. On questioning, she admits to drinking one to two alcohol-containing beverages each evening. On weekends, she may drink two to three each evening. She has not had any legal or social problems related to alcohol use; she has not had any significant withdrawal symptoms and has been consistent in this pattern of use for several years. On CAGE questioning, she denies any effort or interest in cutting back and does not feel guilty about her alcohol use. She denies any history of morning alcohol use, but does note that her husband intermittently encourages her to decrease her alcohol use. 40

41 What is the most appropriate intervention at this point? A. Reassure the patient that there is no evidence of alcohol abuse or dependence. B. Intervene briefly to identify drinking patterns and to set common goals on future use. C. Begin inpatient detoxification. D. Prescribe benzodiazepines for supporting cessation. E. Prescribe disulfiram 41

42 The correct answer is B Recognize and treat at-risk drinking. Critique: This patient meets the criteria for at-risk (heavy) alcohol use, which is defined as greater than 14 drinks/week for men and greater than 7 drinks/wk for women without evidence of abuse or dependence 42

43 Acute Treatment Options 12 Step Program, 12 Step Program, 12 Step Program, 12 Step Program 90 meetings in 90 days. Get a sponsor, if your family is affected inquire about the sponsor. Confrontation of the problem is a goal, NOT an intervention style. 43

44 Treatment Options II Drug Rehab: WBJ, WTC, Fellowship Hall Half Way House Disulfiram Revia Campral 44

45 Alcohol related deaths Divorce Sexual, physical abuse Mental retardation Increase health care costs Decreased productivity Implications 45

46 Coca Leaves 46

47 Crack Cocaine 47

48 Cocaine 48

49 Cocaine Coke Snow Nose candy Flake Blow Big C Lady White Snow birds Rocks Cookies 49

50 Cocaine Coca Leaves: % Pure powdered cocaine: 20-80% Free Base: % Cocaine alkaloid or crack: 50-95% No FDA approved tx*. Some open label trials. 50

51 Cocaine Pathology Crack lung: fever, SOB, CP, pneumonia Seizures Stroke Heart attack Paranoid delusions Hallucinations 51

52 Cocaine Prevalence 12% of the population has at least tried it. 3% has used it in the past year. 1% in the past month. 52

53 Marijuana 53

54 Marijuana Not as benign as once thought. Data is starting to reveal that it is physically addictive. There are identified caniboid receptors in the brain. Can unmask psychosis. 54

55 Take Home Points Alcohol is a drug. 12 Step programs are very effective. If you are in a 12 Step program, get a sponsor. If you are a loved one, ask who is the sponsor. Addiction is a life long illness. Law enforcement do not need a warrant to administer a breath analyzer. 55

56 Take Home Points II Addicts come in ALL shapes and sizes. An addict who states he/she can do it alone, is destined for failure. Marijuana is not a benign drug, data now shows it can be physically addictive. Withdrawal symptoms tend to be the opposite of the drug s mechanism of action. 56

57 Questions? 57

58 Center of Disease Control References Cookie Monster Cartoon by Mark Parisi available at the following: DSM IV-TR, DSM-5 Fiellin DA, Reid MC, O'Connor PG. Outpatient management of patients with alcohol problems. Ann Intern Med. 2000;133: PMID: (View PubMed) - Bradley KA, Boyd-Wickizer J, Powell SH, Burman ML. Alcohol screening questionnaires in women: a critical review. JAMA. 1998;280: PMID: (View PubMed) The Natural Mind by Andrew Weil, MD 58

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