Alcoholism In The Office SCOTT PAIST, III, M. D.

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1 Alcoholism In The Office SCOTT PAIST, III, M. D.

2 The Dopaminergic Mesolimbic System PFC= Prefrontal Cortex NA=Nucleus Accumbens VTA= Ventral Tegemntal Area A = Amygdala C = Caudate Nucleus

3 The Limbic System or Lizard Brain Mesolimbic dopamine system Ventral Tegmental Area (VTA). This connects to the Nucleus Accumbens. Dopaminergic. Rats in which these connections have been broken no longer show interest in drugs of abuse.

4

5 Limbic Survival The Four F s of survival are mediated via these pathways. Fight Flight Food Procreation

6 Limbic Survival Dopamine flows when we are: Warm Dry Well-fed Safe Satisfied Happy

7 Limbic Survival When dopamine flows, were are more likely to survive as individuals and as a species. This a VERY POWERFULLY driven system. We all seek it via various means: Exercise or athletics Artistic pursuits Work Hobbies

8 At Least as Expensive as cocaine

9 Defective Brain Reward System Substance dependent people have a different brain response to substances of abuse. The reward system in a substance dependent person is abnormal (dysregulated)

10 Testimonials back up the theory I used to do this to get high, now I do it try to feel normal. Long time substance-dependent individuals who get clean/sober describe the return of ability to feel normal. Once an individual relapses, the dysregulated process starts again generally in a more advanced state.

11 Addictive Brain and Genetics A person with one alcoholic parent runs a 25% risk of becoming alcoholic. A person with two alcoholic parents is at a 50% risk of being alcoholic.

12 Case-Finding You must ask! Have you ever had a problem with drugs or alcohol? The next person who speaks, loses (information). Watch for eye movement down and to the left. What do you like to drink? Would you drink, like, a case a day (a 5 th, two bottles, etc.)? If they hesitate, you ve got your answer.

13 Case-Finding CAGE questionnaire 1. Have you ever felt you needed to Cut down on your drinking? 2. Have people Annoyed you by criticizing your drinking? 3. Have you ever felt Guilty about drinking? 4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

14 Addiction in the DSM IV (TR) Definition: (Need 3 or more) Tolerance (Larger amounts or less effect) Withdrawal (syndrome or using to alleviate) Increasing use over time Unsuccessful efforts to stop Excessive time spent using or obtaining Use despite personal harm Important life activities given up

15 Motivational Interviewing Recognizes and accepts the fact that clients who need to make changes in their lives approach counseling at different levels of readiness to change their behavior. Skills needed: the ability to ask open ended questions the capacity for reflective listening the ability to periodically provide summary statements to the client

16 Motivational Interviewing Motivational interviewing is non-judgmental, non-confrontational and non-adversarial. Empathy is very important. Wow, it sounds as though your drinking is really causing you trouble. From what you re telling me, it sounds as though the booze really owns you right now. How s that working out for you? The strategy seeks to help clients think differently about their behavior and ultimately to consider what might be gained through change.

17 Motivational interviewing Motivation to change is elicited from the client, and is not imposed from outside forces It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence Direct persuasion is not an effective method for resolving ambivalence The counseling style is very passive and all information comes from the client

18 Motivational Interviewing The physician is directive only in helping the patient to examine and resolve ambivalence. Readiness to change is not something to wait for in the patient, but a fluctuating result of interpersonal interactions. The therapeutic relationship resembles a partnership or companionship. Don t try to help!!

19 Medications Naltrexone (Revia ; Vivitrol ) Opioid receptor blocker blocks mu-receptors apparently reducing feelings of intoxication and cravings. Has been shown effective in prevention of short term relapse. The data showed one short term relapse was prevented for every five patients treated with naltrexone (i.e., number needed to treat [NNT] = 5). Data from RCT s on long-term relapse are mixed at best.

20 Medications Naltrexone (Revia ; Vivitrol ) Contraindicated in patients with hepatic disease. GGT > triple normal. Oral dose is 50 mg daily. There are no compelling data that show injectable form (Vivitrol ) is superior to oral form Vivitrol costs $1300/month. Oral form costs $117/month.

21 Medications - Disulfiram Good old Antabuse. Inhibits acetaldehyde dehydrogenase. Has been shown to reduce number of drinking days but not relapse rates. Many alcoholics take it in the morning and then drink through it at night. Compliance is low.

22 Medications - Acamprosate Believed to block glutaminergicn-methyl- Daspartate receptors and activate 3- aminobutyric acid type A receptors. Effectiveness is not proven, May be used while drinking. May be used in hepatic disease although not in patients with advanced cirrhosis or renal disease. Diarrhea, usually transient, is only side-effect.

23 Medications - Other SSRI s Topiramate Gabapentin Evidence of effectiveness is mixed at the very best. Many addicts crave gabapentin and it does have a significant street value.

24 The 12 Steps We admitted we were powerless over alcohol--that our lives had become unmanageable. Came to believe that a Power greater than ourselves could restore us to sanity. Made a decision to turn our will and our lives over to the care of God as we understood Him. Made a searching and fearless moral inventory of ourselves. Admitted to God, to ourselves and to another human being the exact nature of our wrongs. Were entirely ready to have God remove all these defects of character.

25 The 12 Steps Humbly asked Him to remove our shortcomings. Made a list of all persons we had harmed, and became willing to make amends to them all. Made direct amends to such people wherever possible, except when to do so would injure them or others. Continued to take personal inventory and when we were wrong promptly admitted it. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

26 12 Steps and Brain Physiology Those boys in 1935 knew some things! Step One speaks directly to the non-verbal Limbic system. We only think we have control over this powerful system. We are powerless when it comes to survivalbased drives.

27 12 Steps and Brain Physiology Prayer and meditation have been shown to activate the limbic system. Despite all of the above, controlled trials have not been definitive. RCT s of behavioral interventions are very hard to design. Many such trials have eliminated all reference to a higher power.

28 What are we left with? Case-finding is important at least to alert the physician to possible health damage in the drinking patient. Referring a patient to AA at least does no harm and has been shown to be better than no intervention. The combination of therapy and naltrexone is better than nothing. PEOPLE DO STOP DRINKING AND STAY SOBER.

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