Action is going to the AA meetings, going to the counselor, seeing a psychiatrist for the evaluation of psychiatric symptoms that might promote relapse, maybe day treatment and so forth. That might be a phase of weeks or months or even years but eventually a patient succeeds and more than 70% of our patients succeed and have good recoveries in which their lives are improved and they reintegrate into society.
But that’s not enough because if they don’t practice periodic maintenance actions, they are vulnerable to relapse. When? Well, maybe the next New Year’s party or maybe their next birthday. Maybe the anniversary of one year of sobriety. So we need maintenance steps to help prevent specific risks after the day to day worry about relapse seems to have been effective and is no longer necessary. When people relapse, what’s the trick? Well, help them get back into contemplation quickly. They can cycle through this much more rapidly with less damage, with less severity and quantity of substances so that they can learn quickly “What was the one thing that blind sided me that I need to work harder on for next time?” Ask google!
Well, the different treatments that we have at our disposal fall into about four categories – hospital care, daily medical management but that’s for people with severe withdrawal risks, 24 hour acute medical care needs, maybe because of liver disease or pancreatitis that’s acute and psych or behavioral complications that need 24 hour care for instance suicidality. But it’s not for housing, it’s not because the urges to relapse are strong. We don’t use the hospitals for that. It’s too expensive and not specific. Instead we use medically monitored inpatient care which is simply a residential program where there is some nursing care and maybe a visiting or consulting physician. For this, there still can be some withdrawal risk and some medical monitoring required or psychiatric monitoring required but the patient shouldn’t have the severe containment needs that a hospital provides. Cheap female viagra at online us pharmacy.
Intensive outpatient can be day treatment or partial hospital or a several times a week evening program and patients with all of these types of problems fit in here as long as the medical and psychiatric ones are not severe. For outpatient once a week care, it’s important that we meet the criteria of no severe withdrawals, no severe medical risks, no severe psychiatric risks and the motivation has to be partial at least. The relapse potential has to be manageable in outpatient so if we discharge somebody from the hospital after acute cellulitis and they use heroin on their way home from the hospital the answer is not to put them in Level 1 care. It’s they all come once a week to therapy and we’ll talk about it even if managed care says that’s without proof and we have this problem with managed care.
You know, there’s plenty of evidence of the cost saving benefit of this treatment to society. California did a huge study, tens of thousands of cases analyzed, to see what does one dollar spent on treatment get you. What they found, and this is on page 281 in the middle, that you spend a dollar on inpatient you save four dollars subsequently. If you spend one dollar on outpatient treatment because it’s so inexpensive you save twelve dollars. On average, and this is probably the thing you should write down here because I wouldn’t be surprised to find it on the boards, the average of those two, taking into account all the different sample sizes, is one dollar spent on addictions treatment saves seven dollars mostly in health and crime costs.
So we see a big societal savings and there’s more to it. What about savings on prison treatment? Well prison treatment can reduce relapse to prison short term three-fold. So if we spent the money, what we would buy would be less crime, probably less homelessness, less unnecessary utilization of our Emergency Rooms and ICUs. So the one dollar per seven dollar ratio is important for you to have in mind. Unfortunately this argument is not yet fully bought although there is a big parity debate that they’ll have in Congress this year and I hope it will go to some lengths to cure the crisis that this slide exemplifies. The mental health services drive-thru.
Cheap cialis professional at online Canada pharmacy.
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.
Herbal xanax at Cheap canadian pharmacy.
In a year’s time, we’ve seen a huge increase in the teen use of illicit drugs and the average age is decreasing with kids as young as 16 averaging their start with marijuana. The estimates of use in the U.S. is 14 million Americans are using substances and heroin is increasing in its use because of greater purity and decrease in cost. It’s being marketed by the same people that used to bring you cocaine so cocaine’s desirability is going down. We’re seeing it more in the unglamorous crowds and heroin is part of the glamour crowd. Why is that? We’ll talk about that a little bit later.
Buy hgh online
First I want to cover stimulants even though cocaine is being relegated to female, older and mentally ill chemically abusing populations, MICA, and that concept which we’ll cover more tonight if you attend the dual diagnosis seminar, MICA is primarily psychotic severely disabled mentally ill patients who dabble in substance abuse as opposed to people who have primary substance abuse – the majority of people with a substance abuse problem in the U.S. who have secondary symptoms but we’ll talk about that more tonight. Methamphetamine, big problem in Hawaii, the West Coast. Some East Coast areas now but more in the south. We’re not seeing it really in the Northeast for some reason but easily cooked up in my kitchen and I haven’t tried this by the way so I can’t explain exactly how you do it but I’m told that I can do better than academia.
It does seem to damage dopaminergic and serotonergic terminals in the brain. This is rat brain. We don’t know the clinical significance in humans but it’s important to know that. MDMA, another amphetamine derivative popularly known as ecstasy. Methamphetamine is known as crank, speed, ice. Ecstasy for MDMA. The neurons themselves are damaged in rat brain. We don’t know the clinical significance in humans.
The big problem with heroin is it’s so pure now that inhaled alone is sufficient to make people dependent. It’s not just a gateway anymore that leads them to IV use. It does lead people to IV use but it’s enough to get people so dependent that I’ve had to refer patients who are just heroin smokers or snorters to methadone treatment because they can’t get off the stuff.
Marijuana is now the choice of teenagers throughout the land. It’s been increasing since 1992 and there are lots of combination lacings of marijuana now to improve the marketing. You may have heard of embalming fluid being laced to marijuana and fry is the mixture. Fry. And I think that’s a rye comeback on the advertisement we used to see, “This is your brain on drugs.” You know, it was the egg being fried in the frying pan. Now the kids are saying, “Oh, yeah. Let’s do it.” So this is one of the crises of raising teenagers in America. Mine aren’t quite teenagers and I’m just bracing for the experience.
Club drugs. Rohipnol – the date rape drug. Sedative. GHB, gamma hydroxybutyrate. These are mostly sedatives but LSD is being used, MDMA ecstasy, big rave party drug. Raves are these all night nonstop very crowded sweaty trance-like dance parties with music, I guess, that’s the second generation of disco which really shows you how the taste is going in America.
Pregnancy. 5.5% of pregnant women in studies are found to be using drugs of abuse which is pretty shocking. Almost 20% alcohol and smoking cigarettes despite all that we know about the effects of fetal alcohol syndrome and low birth weight, low head circumference with smoking. So a lot of important trends and epidemiology and we can talk about that maybe in questions if people are particularly interested.
Canadian viagra
But I want to stress that some familiarity with this is important. It can appear on the boards but at least have down the basics of diagnosis. Now, there are many syndromes of psychiatric disturbance that are associated with intoxication or withdrawal and so we want to be familiar with these names. So Roman numeral II on your outline which I think is page 279 has the substance induced syndromes and these are listed separately along with the dependent syndromes.
The two to be most aware of are the delusional or psychotic induced syndrome which many of these substances can induce and delirium and hallucinosis which just about all of the hallucinatory, stimulatory and even the sedative substances can produce delusions, delirium… well, at least delirium and hallucinosis. Sometimes in intoxication, in other cases like a sedative withdrawal or alcohol withdrawal during withdrawal. Of course, not caffeine or nicotine. So an easy point to remember. It can easily show up as a multiple choice test with all of the above. You just have to know that the all of the above probably does include all of the above. Generic viagra pharmacy.
But what is abuse? Separate from these substance induced syndromes, abuse is a very simple problem. It’s just any one persisting problem – role failure, use in hazardous situations or recurrent legal or social problems. So it’s a good diagnosis for the alcohol intoxication driving arrest and the patient says, “This has never happened to me before. I drink when I come home from work. At the bar I stop off with my pals and I make it home fine and this arrest has nothing to do with alcoholism.” Well, that may be true but it is alcohol abuse to drink and then drive. So that’s an easy diagnosis to make.
Recent Comments