Published on July 8, 2009
WEEK 14 - Basic Psychopharmacology for Counselors and Psychotherapists – Chapter 13 CHAPTER THIRTEEN: TREATMENT OF CHEMICAL DEPENDENCY AND CO-OCCURRING CONDITIONS.
Instructor: Jeff Garrett Ph.D.
Objective: To explore treatment considerations for people with co-occurring substanceabuse conditions. The dopamine hypothesis and relevant treatment issues are explored with helpful diagnostic instruments and pharmacological suggestions for each substance of concern.
Topics to be addressed:- Co-occurring conditions.- The dopamine hypothesis.- Treatment issues.- Assessment instruments and strategies.- Treatment phases and goals.- Psychopharmacology for dually-diagnosed patients.- Summary and treatment reminders.
CO-OCCURRING CONDITIONS. The clinician is concerned with the following issues:1. Loss of control (cannot stop or limit drug use).2. Tolerance, or the need to use more and more of the substance to avoid withdrawal or to maintain a desired state.3. Impairment in functioning such as failure to work or keep other life obligations.
Substance abuse is a problem for: - 61 percent of those with bipolar disorder.- 47 percent of those with schizophrenia.- 39 percent of those with personality disorders.- 33 percent of those with obsessive-compulsive disorder.- 32 percent of those with an affective disorder..It is not surprising to learn that the majority of patients who have been treated for a substance-abuse condition also meet criteria for another Axis I and/or Axis II diagnosis.- Drugs and behaviors can have addictive effects on the brain.
Three basic types of neurochemical responses are arousal, satiation, or an increase in preoccupation of the desired object (fantasy). 1. Arousal is accompanied by an increase in dopamine and norepinephrine, satiation with GABA, and fantasy with serotonin. Typically, people seeking arousal use drugs that increase arousal (cocaine or amphetamines), or they engage in high-risk behaviors such as gambling; both activities increase dopamine and norepinephrine.
Three basic types of neurochemical responses are arousal, satiation, or an increase in preoccupation of the desired object (fantasy). 2. A sedation and/or satiation response could be achieved with excessive food consumption, television watching, video games, or drugs like benzodiazepines or alcohol
Three basic types of neurochemical responses are arousal, satiation, or an increase in preoccupation of the desired object (fantasy). 3. Fantasy is often the core issue in sexual addiction. Researchers believe that when a person is addicted, the addiction is in fact to a set of behaviors involving a drug or an activity. The behavioral activities themselves can produce chemical changes in the brain similar to those produced by any exogenous drug
THE DOPAMINE HYPOTHESIS - Most drugs of abuse, including cigarettes, increase the concentration of dopamine in the nucleus accumbens and the mesolimbic system (the brain's reward centers).- Over-stimulation exhausts the dopamine system and causes the brain to reduce both the amount of dopamine available and the receptor sites they bind with.- Most abusers start out seeking the high that comes from drug use, later they use drugs to avoid withdrawal.- In withdrawal they experience dysphoria and depression because of an increase in dopamine 3 receptor sites that are craving or looking for dopamine.- Much of the psychopharmacology used in the treatment of patients with co-occurring conditions attempts to address depression, anxiety, and craving to increase the patient's chances of a sustained recovery.
TREATMENT ISSUES - Zero-tolerance model.- Harm-reduction model.- Treatment centers tend to have their own unique philosophies about detox and recovery.- 12-step approach with a spiritual emphasis.- Rational recovery viewpoint, assuming that patients may not buy into a spiritual or religious reason for their use or recovery.- A good treatment center takes all modalities into consideration.
ASSESSMENT INSTRUMENTS AND STRATEGIES 1. The Michigan Alcohol Screening Test (MAST) is a short, 24-item questionnaire in a yes/no format that detects the presence and extent of drinking. A shorter, 13-item version is also available.2. The Substance Abuse Subtle Screening Inventory (SASSI-3) is a 67-item instrument that measures issues like openness, chemical dependency predisposition, and defensiveness.3. The Substance Abuse Life Circumstance Evaluation (SALCE) contains 98 items and may be helpful in identifying triggers for relapse, for example, the patient's levels of stress.4. The MacAndrew Alcoholism Scale of the MMPI-2 is helpful in identifying the potential for drug or alcohol abuse in a patient.
ASSESSMENT INSTRUMENTS AND STRATEGIES 5. The Substance Abuse Problem Checklist consists of 377 items and examines problematic areas such as treatment motivation, health problems, personality issues, social relationships, job problems, leisure issues, legal issues, and spirituality. This checklist is helpful in assessing patients who have co-occurring personality disorders and social concerns.6. The CAGE questionnaire.1. Have you ever felt that you should Cut down on your drinking (or drug use)? 2. Have people Annoyed you by criticizing your drinking (or drug use)?3. Have you ever felt bad or Guilty about your drinking (or drug use)?4. Have you ever had a drink (or used drugs) first thing in the morning (an Eye opener) to steady your nerves or get rid of a hangover?
TREATMENT PHASES AND GOALS A typical first phase involves a complete assessment. In the second phase of treatment, the clinician attempts to determine the special needs of the dually-diagnosed patient. The following questions guide this effort.- Does the patient need medically supervised detox?- Does the patient need psychotropic medication or a psychiatric evaluation?- Does the patient need inpatient observation based on the patient's behaviors or threats?- What is the patient's level of resistance?- What is the patient's potential for relapse?- What, if any, are the environmental issues that affect treatment (i.e., childcare, work, finances, spousal abuse, codependency, enabling issues, etc.)?
TREATMENT PHASES AND GOALS 3. In phase three of treatment, the clincian examines the need for using various medications in the treatment of the patient with co-occurring concerns.- The clinician should carefully weigh the use of psychotropic medications.- In most cases only antidepressants and appropriate antipsychotics should be considered.- The use of pain medications and/or anxiolytics should be avoided, except during the initial stages of detox and only when the clinician determines that their use outweighs the risks.
PSYCHOPHARMACOLOGY FOR DUALLY DIAGNOSED PATIENTSAlcohol Dependence 1. Disulfiram (Antabuse) is used as a form of "aversion" therapy, because it causes a very unpleasant chemical reaction when patients who use it drink alcohol.2. Naltrexone (Revia) mimics the action of naturally occurring opioid neurotransmitters in the brain.3. Nalmefene (Revex), is FDA approved for complete or partial reversal of opioid drug effects and is used primarily in the field of anesthesia.4. Acamprosate (Campral) was approved by the FDA in 2004 for use in patients with alcohol dependence. It has been used in Europe for many years.- Benzodiazepines is typically reserved for detox settings and not recommended for maintenance because of the possibility of developing dependence.- SSRIs, such as fluoxetine (Prozac) or sertraline (Zoloft), are helpful and may reduce alcohol use, but only in patients with a co-occurring affective disorder.- Ondansetron (Zofran) may help reduce carvings for both alcohol and methamphetamine.
Opioid Dependence 1. Methadone (Dolophine) is a synthetic opiate that is taken orally (liquid). While controversial, methadone-maintenance programs have helped many heroin users return to work and maintain family obligations.2. L-alpha-acetyl-methadol or long acting analog methadone (LRAM) has properties that are similar to methadone, but it has been shown to be superior to methadone in reducing intravenous drug use. This medication may not be indicated for cardiac patients per FDA warnings.3. Buprenorphine (Subutex) is a mixed, opioid agonist-antagonist used as an analgesic. Advantages of buprenorphine include a milder withdrawal upon discontinuance and less potential for abuse, because the agonist effects are diminished at higher doses.4. N Naloxone (N Narcan) is used to reverse the effects of an opioid overdose.
Opioid Dependence Cocaine Dependence1. Tricyclic antidepressants like desipramine (Norpramin) have shown some promise in reducing cravings and improving abstinence associated with cocaine abuse, even when depression is not present.2. Bromocriptine (Parlodel), amantadine (Symmetrel), and mazindol (Sanorex/ Mazanor) are dopamine agonists that are given to reduce craving and discomfort in the early stages of cocaine withdrawal.3. Ibogain is derived from the root of the African iboga shrub. This botanical substance is an indole alkaloid that helps to mask cocaine and opioid withdrawal, but it is a potent hallucinogen with a potential for abuse.4. Methylphenidate (Ritalin) has been shown to reduce cocaine relapse, especially in patients with ADHD.5. Buprenorphine (Subutex) is a mixed, opioid agonist-antagonist used as an analgesic. Advantages of buprenorphine include a milder withdrawal upon discontinuance and less potential for abuse, because the agonist effects are diminished at higher doses.
Other Types of Addiction Bupropion(Wellbutrin SR/Zyban) has been FDA approved in the treatment of nicotine addiction.SSRIs often reduce sexual appetite, they may offer some hope to people with sexual addiction and compulsivity. Sexual-addiction disorders often coexist with chemical dependency and frequently trigger relapse.
SUMMARY AND TREATMENT REMINDERS 4. In the fourth or final phase of treatment, the clinician assesses how the patient has progressed and the need for more attention to either the substance-abuse issue or the mental-health issue. - Clinicians need to be sensitive with respect to patients that they refer to Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) groups.- The clinician needs to inquire about the group's composition and send patients only to groups that are sensitive to the medication issues.- "Booster" sessions and stress-reduction groups are excellent ideas.
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