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So there are treatment approaches to deal with all of these and patients have different contributions of these. So the patient who goes for pleasure really needs their motivation enhanced but the person who is reinforced because of withdrawal like many IV heroin addicts I see they need an adequate duration of detox in addition to these other things, otherwise they’re sitting ducks for relapse.
Where there is a habit conditioned to positive or pleasure reinforcement, we need an intervention that takes away the pleasure of getting high or the associated pleasure and the cues. For instance, maybe somebody shouldn’t pick up their paycheck and cash it themselves. Maybe the spouse should cash the paycheck because the role of money starts to remind them of having a straw and having a straw starts to feel good and makes them fidgety and it’s very hard to resist that once the dopamine is starting to fly.
The genetic model. Here’s the genetic model in action. This bartender’s saying to this guy, “Your mom wants to buy you a drink.” I also like this because it typifies the isolation in addicted families but maybe I’m reading too much into it. Well, when we do and the one point you should take a look at in the outline is the genetic model is not just a model. Canadian pharmacy viagra 100 mg. There’s proof of it. In alcoholism it is quite strong. At least 50% of the vulnerability to becoming alcoholic is genetically transmitted and there are now good laboratory models in rats that have been recombinantly inbred, even genes being identified that support this. So it’s quite true and it’s important to teach patients about it because it helps them accept that the disease truly is a disease and not a moral weakness.
So there are these models. Take a look at the social model in the outline but what do we do with all that? Well we have to deliver some form of treatment and at the bottom of page 280 you’ll see this list of stages of change. Now, I assume many people have heard of the stages of change. How many people have heard of at least the idea of stages of change? Good. This is really taking hold not just in the world of addiction treatment but in psychotherapy in preventive medicine. It’s having a lot of benefit because it teaches us that it’s not just that somebody’s motivated to change or unmotivated, they’re in a process. It’s a transition from “I don’t even think I have a problem” to “I have a problem, I don’t know what I should do.” “I know what I should do but I need to get going on it. I’m doing what I need to do.” “I did it. I think of it once in awhile and I need to be careful.” Then perhaps relapse. Canadian cialis online.
So stages of change please be familiar with the terminology. Precontemplation. It’s exactly what it says. Before the patient is even thinking about it and the goal of the therapist is to say, “Did you ever think five years ago that this is where you’d be today?” That’s a very upsetting question to a heroin addict with cellulitis, hospitalized with diabetes in their arms and the patient that night, hopefully after a consultation, will sit with that and be upset as they lie on their pillow and the next day as you come back for followup they’ll be thinking, “Gee, that really bugged me when that guy said that to me. Things aren’t really going well for me at all.”
Now the patient’s in contemplation. Thinking about it but doesn’t know what to do or if he can even do something about it and we have to promote a concept that yes you can change. There is something called self efficacy that can be enhanced especially with support so we say to the patient, “Well, where do you want to be five years from now? “What would you like to be in your life? I realize you’re worried you’re going to lose your house. Your kids aren’t in your custody but what do you wish could be?” Then you say, “Well, what supports have you ever used to try and achieve that goal of five years and let’s talk about what you could have at your disposal.” At that point the patient will have some determination or preparation to act and we have to think, well, what’s the best action. So that’s where treatment planning comes in and we’re going to talk about that in the next slide.
Slightly more complex is dependence and the dependence criteria. There are seven different categories but only three criteria to make the diagnosis. So the first two are physiologic – tolerance and withdrawal – but the others are strictly behavioral. You need to know that only three of the behavioral ones can be sufficient to make the dependence diagnosis. You don’t have to have withdrawal. You don’t have to have tolerance.
I have a lovely woman who tells me, “I never get drunk. I do not have increasing use of alcohol. I can control my alcohol. I never have more than three or four drinks and nobody ever says it’s a problem.” “So why are you here?” “Well, my doctor thinks that my diabetes is off the wall and blames my drinking and it’s true my weight is up. He says I’m tremulous from it. So what if I am.” So we make the diagnosis, she substantially cuts down but is not completely abstinent on a more than two week basis at a time but what she notices is that her golf game has shaved ten points so she says, “Gee, there must be something to that.” So it does not have to be a physiologic syndrome to make the diagnosis. Canadian pharmacy with special discounts.
By the way, is there anybody familiar with absolute or relative tolerance? The meaning of those terms. Let me just clarify that because that is something that it’s not nit picking. There is a meaning to it. Absolute tolerance is to get a certain high that I’m seeking I have to drink two drinks initially, then after I’m a full member of the fraternity I have to drink four drinks and by the time I’m an officer I have to drink a six pack or two. That’s absolute tolerance. Relative tolerance is when I joined the fraternity I was drinking two beers, I got tipsy, I was all over the place. I threw up once. I was very sensitive to it. Now I drink two beers nothing happens to me. I don’t even notice it. That’s relative tolerance. We haven’t increased the quantity but the effects on the body have become tolerant.
Another thing to review for the boards is on page 280, that table at the top of urine toxicology. One of these years I gave this lecture and one of the questions was how do you know how long the substances last in the urine? It’s a beautiful board’s question so take a look at that and circle these two items. Phencyclidine which can last up to week, phencyclidine PCP and the last one in the cannabinoid group, the principal active ingredient in marijuana delta-9-THC circle because that can be found in chronic users for up to a month. Hgh online at online canadian pharmacy.
There are a number of models to try and explain addiction and also to clue us into good treatment and these models are in some cases conflicting, in other cases contributory. Since the conceptual understanding of all the different drugs of abuse unifies them, it’s good to understand what that means. The first model I want to condemn and that is the addictive personality. There is no evidence that there is a single developmental fixation that leaves people with an oral phase gratification need that promotes alcoholism or addiction. No evidence to support that. The self medication hypothesis, we’ll talk more about that tonight in the seminar but I’ll just say the data does not support that as an etiology. However, it is relevant clinically in that patients explain or rationalize their substance use in the sense of self medication. So it has some value in our clinical work but on the boards, not substantiated by the data.
What is substantiated by data? The behavioral model is extremely powerful. It’s a laboratory model and it teaches us not just how all the drugs of abuse tend to be similar but also routes to treating. So if we look at pleasure, most of the drugs of abuse make us feel good. That’s positive and so we do it again and again. That’s reinforcement. That’s all we mean by positive reinforcement. Many drugs of abuse, though not all, have a withdrawal syndrome that’s upsetting and painful. Some are physiological painful like alcohol withdrawal, others are emotionally painful like cocaine withdrawal but during the withdrawal it feels bad, therefore I keep doing that substance. So that’s negative. It feels bad therefore I keep doing the substance. So that’s negative. I feel bad. Reinforcement. I keep doing it. That’s all there is to self medication in the sense of negative reinforcement. Drugs information
Often people quit using the substances but they still have an urge, a habit. Think of smokers who like to fidget with their fingers or do something with their mouth. Why do they do that? There’s an important reason and it comes from behavioral theory. Fidgeting with the fingers in a smoker is a conditioned positive “it makes me feel good” reinforcement. Therefore I’d like to do it again. Other habits are when the weekend comes I have many patients who find it’s very hard to resist doing drugs. The weekdays when they’re working and busy they don’t have time to think about it, they do great. But the free time of the weekend is a disaster. Why? I feel bad. I’m lonely. I’m bored. Maybe I might not have a date. That is a conditioned cue. It’s not a drug if you don’t have a date but it is connected to the urge to use the drug because then you don’t care if you have a date and you are reinforced to use.
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